Litigation Challenging Governmental and Health Institution Efforts to Address Health Equity from January 2024 to May 2025

The Public Health Law Watch created a report, with support from Change Lab Solutions, that analyzes litigation surrounding health equity efforts in the United States between January 2024 and May 2025. Our main findings are noted below.

Please download the full report here.

Summary

Between January 2024 and May 2025, 30 lawsuits[1] were identified that challenged governmental and health institution (e.g., hospitals, medical schools) interventions to improve health equity. The identified lawsuits focused on two topic areas: challenges to rules and guidance issued by the Biden Administration to expand civil rights protections for gender identity and sexual orientation (19 lawsuits); and challenges to programs, services, or advisory groups with racial or gender eligibility preferences or requirements (11 lawsuits).

In the 19 gender identity and sexual orientation lawsuits relating to Biden Administration rules or guidance, judicial decisions on the merits were issued in 13, with the rules and guidance enjoined in all of them. In three other lawsuits, some or all of the rules and guidance are not being implemented because of an injunction in another lawsuit or because the Trump Administration rescinded the Biden Administration’s rules and guidance. Two other lawsuits are still pending, and one was dismissed. In the 11 lawsuits against programs, services, or advisory groups with racial or gender eligibility preferences or requirements, seven lawsuits have been dismissed, with six of the seven being dismissed because the race or gender eligibility preferences or requirements were removed. The other four lawsuits are still pending.

This report summarizes the process used to search for lawsuits, the claims made in the lawsuits, judicial decisions about the claims, and limitations. The appendix includes information about the types of claims brought within each lawsuit and provides individual lawsuit summaries.

Process

The research team of lawyers and law students searched several databases and websites for lawsuits that started (i.e., a complaint was filed) between January 1, 2024 and May 31, 2025 that challenged governmental and health institution interventions to improve health equity. Therefore, if a judicial opinion was issued during this time frame, but the complaint was filed prior to January 1, 2024, that lawsuit was not included. While health equity is a broad concept encompassing numerous areas, the research team excluded lawsuits involving reproductive health and the environment as these issues are being tracked by other organizations. Additionally, lawsuits regarding individual employment claims were excluded. Although members of the research team changed during the project, all members met frequently with the faculty advisor to discuss whether lawsuits met the criteria. If a lawsuit met the criteria, the research team reviewed the documents filed in the lawsuit, particularly the complaint, which included the claims made, and any judicial decisions on the claims. The research team did not review judicial decisions on issues that were not on the merits of the claims (e.g., decisions on discovery motions or standing). The databases, websites, and search criteria used are below. Additionally, if the research team found a lawsuit that met the criteria while researching another lawsuit, it included that lawsuit as well.

Bloomberg Law [2]

o Docket searches for lawsuits that met the following criteria: diversity, equity, AND inclusion; “Do No Harm;” Pacific Legal Foundation; and “Pacific Legal Foundation” AND discrimination AND race.[3] (ended 2/28/25)

o Docket alerts for lawsuits that met the following criteria: (race S/ discrimination) S/ (health OR medic! OR doctor); and “health equity” (started 3/1/25)

Westlaw

o Docket searches for lawsuits that met the following criteria (race S/ discrimination) S/ (health OR medic! OR doctor); and “health equity” (started 3/1/25)

Google: searches for the terms “racial balancing;” DEI and health; and DEI and lawsuit

Georgetown O’Neill Institute Health Care Litigation Tracker

o Searches for the terms: diversity, equity, AND inclusion; “Do No Harm;” Pacific Legal Foundation; and “Pacific Legal Foundation” AND discrimination AND race.

o Searches for the terms: (race S/ discrimination) S/ (health OR medic! OR doctor); and “health equity”

Meltzer Center Advancing DEI Litigation Tracker:

o Searches for the terms “Do No Harm;” “health equity;” and “discrimination AND race”

o Searches for lawsuits tagged with “government programs” or “targeted programs” as a topic

Pacific Legal Foundation: Searches for lawsuits listed on the “Equality and Opportunity” issue page

Just Security Litigation Tracker:

o Searches for the terms: diversity, equity, AND inclusion; “Do No Harm;” Pacific Legal Foundation; and “Pacific Legal Foundation” AND discrimination AND race.

o Searches for the terms: (race S/ discrimination) S/ (health OR medic! OR doctor); and “health equity”

Findings and Analysis

Lawsuits challenging governmental and health institution actions to expand civil rights protections for gender identity and sexual orientation

The research team identified 19 lawsuits alleging that civil rights protections for sex-based discrimination should not include gender identity or sexual orientation. Following the Supreme Court’s 2020 decision in Bostock v. Clayton County, which held that an employer violates Title VII of the Civil Rights Act of 1964 by firing an individual for being homosexual or transgender, the Biden Administration issued new rules and guidance to expand discrimination protections. The new rules and guidance were issued across several federal departments and agencies including the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, the Department of Agriculture, the Equal Employment Opportunity Commission, the Department of Education, and the Administration for Children & Families. These new rules and guidance strengthened protections against sex-based discrimination and harassment and clarified protections for LGBTQI+ people under Title IX of the Civil Rights Act of 1964 (which prohibits sex discrimination by educational institutions that receive federal money), the Affordable Care (ACA), and the Americans with Disabilities Act, among other laws. Of the 19 identified lawsuits, 11 were filed against a Department of Education Title IX rule.

The lawsuits often included multiple claims within the complaint. All 19 lawsuits claimed violations of the Administrative Procedure Act, 16 claimed violations of the Constitution’s Spending Clause, 13 claimed violations of the major questions doctrine, 11 claimed First Amendment free speech violations, eight claimed violations under the Constitution’s enumerated powers/separation of powers clauses, and seven claimed violations under the nondelegation doctrine and the Tenth Amendment. Please see the Appendix for a list of additional claims made by the lawsuits that were not as prevalent.

One or more judicial opinions on the claims were issued in 13 of the 19 lawsuits and in all 13, a district or appellate court enjoined the rules and/or guidance from taking effect (one district court denied plaintiffs’ motion for a preliminary injunction, but the appellate court provided an injunction). In striking down the rules or guidance, the courts relied on a variety of grounds, including:

1. That the department or agency didn’t have the statutory authority to issue the rules or guidance,

2. That the rules or guidance were:

a. contrary to law (often citing Title IX),

b. were arbitrary and capricious,

c. violated the major questions and nondelegation doctrines and the Spending Clause, and

d. implicated freedom of speech and freedom of religious expression concerns.

Twelve of the 13 lawsuits with judicial opinions on the claims also referenced the Bostock decision and in all 12 of these, the judicial opinions noted that the defendants’ reliance on that decision was misplaced and/or that they misinterpreted the decision (one district court’s opinion did not hold that the department misapplied or misinterpreted Bostock, but the appellate court did). Of the remaining lawsuits, five are still pending and one was dismissed. In the five pending lawsuits, one lawsuit was stayed because of an injunction in another lawsuit (also in this report) on the same issue, one lawsuit was dismissed against some of the defendants because an department (under the Trump Administration) rescinded the Biden Administration rules and guidance, and one lawsuit was stayed because the plaintiffs are no longer challenging the rule because the Trump Administration issued new guidance stating the Biden Administration rule didn’t carry the force of law. There have been no significant judicial decisions in the remaining two pending lawsuits. The final lawsuit was dismissed because the plaintiff failed to timely serve the defendants.

The Alliance Defending Freedom provided legal representation to plaintiffs in eight of the 19 lawsuits. Please see the Appendix for other organizations that brought lawsuits or provided legal representation.

Due to the time period of the research, the recent U.S. Supreme Court opinion in U.S. v. Skrmetti was not included in this report (the lawsuit was filed in 2023), though it is relevant to some of the lawsuits in this report. In a 6-3 ruling, the Supreme Court upheld the constitutionality of Tennessee's ban on gender-affirming care for minors – holding that the ban did not discriminate on the basis of sex, so is not subject to heightened scrutiny under the Equal Protection Clause. This decision, which is in line with the other lawsuits discussed above, is likely to have a significant impact on gender equity litigation (including the lawsuits in this report that remain pending).

Lawsuits challenging governmental and health institution programs, services, or advisory groups with racial or gender eligibility preferences or requirements

The research team identified 11 lawsuits in which the plaintiffs claimed that programs, services, or advisory groups with racial or gender eligibility preferences or requirements were illegal. Following the Supreme Court’s 2023 decision in Students for Fair Admissions v. President and Fellows of Harvard College, which held that universities could not consider race in admitting students because it violated the Fourteenth Amendment’s Equal Protection Clause and Title VI of the Civil Rights Act, several groups, including Do No Harm and the Pacific Legal Foundation, started bringing lawsuits aimed at striking down race considerations across a broad swath of sectors, including in health care and public health. In these lawsuits, the plaintiffs generally argue that excluding or disfavoring a white individual from a program because they do not belong to a minority group is not a compelling enough reason to use race as the reason for exclusion. One of the lawsuits raised similar claims pointing to eligibility criteria that prioritized women.

The lawsuits often included multiple claims within the complaint. Of the 11 lawsuits identified, seven claimed violations of the Equal Protection Clause of the Fourteenth Amendment, three claimed violations of the Citizenship Clause of the Fourteenth Amendment, three claimed violations of Section 1981 of the 1866 Civil Rights Act, three claimed violations of state laws, two claimed violations of Title VI of the 1964 Civil Rights Act, and one claimed violations of Section 1557 of the ACA.

Seven lawsuits have been dismissed, while four lawsuits are still ongoing, where no judicial ruling on the claims has been issued. Of the seven dismissed lawsuits, four were dismissed because the defendants worked to change state law to remove eligibility preferences or requirements and two were dismissed because the parties agreed to a stipulation that removed the eligibility preferences or requirements. One lawsuit was dismissed because the plaintiff failed to produce the required discovery documents.

Do No Harm was a plaintiff in eight of the 11 lawsuits and the Pacific Legal Foundation provided legal representation in seven of the 11 lawsuits. Please see the Appendix for other organizations that brought lawsuits or provided legal representation.

Limitations

There are several limitations to this report. First, while numerous databases and websites were used to find lawsuits, the research team may not have captured all relevant lawsuits given the different search criteria and reach of the search strings used. Arguably, the broadest search terms were the ones that the team started using for the Bloomberg Law docket alerts on March 1, 2025. Prior to that, the Bloomberg Law docket search terms were narrower. Moreover, Westlaw was only used starting on March 1, 2025, meaning the team relied primarily on Bloomberg Law as the legal database for the majority of the research period. The changes to expand the Bloomberg Law search terms and to add the Westlaw database were made when there was turnover in the research team and broadening the search terms seemed advisable. Even with the expanded terms, some filings in lower courts may not have been included in the databases used as Bloomberg and Westlaw vary in what state court dockets they include.

A second limitation is the subjectivity involved in both defining the lawsuit criteria and in determining which lawsuits met the criteria. As noted above, health equity is a broad concept, and the research team did not include all lawsuits that impact health equity. For example, while several lawsuits challenging governmental and health institution interventions to improve reproductive health and environmental health were found through research, the research team excluded them because other organizations were tracking them. To limit the subjectivity of which lawsuits met the criteria, the research team reviewed lawsuits with the faculty advisor.

A third limitation is that searching for lawsuits inherently misses threats of litigation that might result in proactive compliance or other resolutions before a lawsuit is filed. For example, the research team did not research demand letters.

[1] In this report, the term “lawsuit” is being used to refer to a single suit or case filed in court and encompasses all documents filed and proceedings in that case, including any appeals to a higher court. For example, if a complaint, answer, and judicial decision were filed in one case, it counts as one “lawsuit.”

[2] Using quotation marks searches for the term in quotation marks as compared to individual words. Using “AND” searches for all the terms in the search string while using “OR” searches for any of the terms used in the search string. Using “S/” searches for terms that occur within the same sentence as the other words in the string. Appending “!” to the end of part of a word searches for all words that share the same root (i.e., medic) but have different endings.

[3] Do No Harm and the Pacific Legal Foundation are organizations that have been involved in bringing or supporting several of these lawsuits.