Little Sisters Of The Poor Saints Peter And Paul Home, v. Pennsylvania

140 S. Ct. 2367 (2020)


The ACA requires covered employers to offer “a group health plan or group health insurance coverage” that provides certain “minimum essential coverage.” A provision of the ACA requires covered employers to provide women with “preventive care and screenings” without “any cost-sharing requirements.” The statute does not define “preventive care and screenings,” nor does it include an exhaustive or illustrative list of such services. Congress stated that coverage must include “such additional preventive care and screenings . . . as provided for in comprehensive guidelines supported by the Health Resources and Services Administration” (HRSA), an agency of the Department of Health and Human Services (HHS). At the time of the ACA’s enactment, these guidelines were not yet written. As a result, no specific forms of preventive care or screenings were (or could be) referred to or incorporated by reference. The Departments began promulgating rules but did not proceed through the notice and comment rulemaking process, which the Administrative Procedure Act (APA) often requires before an agency’s regulation can “have the force and effect of law.” The first relevant IFR indicated that HRSA planned to develop its Preventive Care Guidelines (Guidelines) by August 2011. It released its first set of Guidelines in August 2011. The Guidelines were based on recommendations compiled by the Institute of Medicine (now called the National Academy of Medicine), “a nonprofit group of volunteer advisers.” It included the contraceptive mandate, which required health plans to provide coverage for all contraceptive methods and sterilization procedures approved by the Food and Drug Administration as well as related education and counseling. When the 2010 IFR was originally published, the Departments began receiving comments from numerous religious employers expressing concern that the Guidelines would “impinge upon their religious freedom” if they included contraception. The same day the Guidelines were issued, the Departments amended them. The Departments determined that “it [was] appropriate that HRSA . . . take into account the [mandate’s] effect on certain religious employers” and concluded that HRSA had the discretion to do so through the creation of an exemption. The Departments then determined that the exemption should cover religious employers, and they set out a four-part test to identify which employers qualified. The last criterion required the entity to be a church, an integrated auxiliary, a convention or association of churches, or “the exclusively religious activities of any religious order.” HRSA created an exemption for these employers the same day. In February 2012, before the Guidelines took effect, the Departments promulgated a final rule that temporarily prevented the Guidelines from applying to certain religious nonprofits. Originally the safe harbor covered nonprofits “whose plans have consistently not covered all or the same subset of contraceptive services for religious reasons.” Thus, the nonprofits who availed themselves of this safe harbor were not subject to the contraceptive mandate when it first became effective. Another final rule was issued in 2013. The Departments “simplified” and “clarified” the definition of a religious employer. The Departments provided the anticipated accommodation for eligible religious organizations, which the regulation defined as organizations that “(1) oppose providing coverage for some or all of the contraceptive services . . . on account of religious objections; (2) [are] organized and operate as . . . nonprofit entities; (3) hold [themselves] out as . . . religious organization[s]; and (4) self-certify that [they] satisfy the first three criteria.” The accommodation required an eligible organization to provide a copy of the self-certification form to its health insurance issuer, which in turn would exclude contraceptive coverage from the group health plan and provide payments to beneficiaries for contraceptive services separate from the health plan. The accommodation was to “protect” religious organizations “from having to contract, arrange, pay, or refer for [contraceptive] coverage” in a way that was consistent with and did not violate the Religious Freedom Restoration Act of 1993 (RFRA). The Little Sisters of the Poor (Little Sisters) challenged the self-certification accommodation. Little Sisters “is an international congregation of Roman Catholic women who have operated homes for the elderly poor in the United States since 1868. The Little Sisters hold the religious conviction “that deliberately avoiding reproduction through medical means is immoral.” Little Sisters challenged the self-certification accommodation, claiming that completing the certification form would force them to violate their religious beliefs by “taking actions that directly cause others to provide contraception or appear to participate in the Departments’ delivery scheme.” They alleged that the self-certification accommodation violated RFRA. Under RFRA, a law that substantially burdens the exercise of religion must serve “a compelling governmental interest” and be “the least restrictive means of furthering that compelling governmental interest.” The Court of Appeals rejected their RFRA claim. Many others filed similar suits all with the same result that the accommodation did not violate RFRA. It was determined that “‘contraceptive coverage could be provided to employees, through the insurance companies, without any . . . notice from the religious employers.’” The employers agreed that such an approach would not violate their free exercise rights. The Supreme Court directed the Government to “accommodate petitioners’ religious exercise while at the same time ensuring that women covered by petitioners’ health plans receive full and equal health coverage, including contraceptive coverage.” A host of other entities challenged the contraceptive mandate itself as a violation of RFRA. As the Departments began the task of reformulating rules related to the contraceptive mandate, they did so not only under Zubik’s direction to accommodate religious exercise, but also against the backdrop of Hobby Lobby’s pronouncement that the mandate, standing alone, violated RFRA as applied to religious entities with complicity-based objections. The Departments published a request for information on ways to comply with Zubik but “no feasible approach” had been identified. The Departments maintained their position that the self-certification accommodation was consistent with RFRA because it did not impose a substantial burden and, even if it did, it utilized the least restrictive means of achieving the Government’s interests. In 2017, the Departments promulgated the two IFRs that served as the impetus for this litigation. The first IFR broadened the definition of an exempt religious employer to encompass an employer that “objects . . . based on its sincerely held religious beliefs,” “to its establishing, maintaining, providing, offering, or arranging [for] coverage or payments for some or all contraceptive services.” This definition included for-profit and publicly traded entities. Because they were exempt, these employers did not need to participate in the accommodation process, which nevertheless remained available under the IFR. The Departments invoked §300gg-13(a)(4) as authority to promulgate this “religious exemption,” stating that it “included the ability to exempt entities from coverage requirements announced in HRSA’s Guidelines.” The Departments announced for the first time that RFRA compelled the creation of, or at least provided the discretion to create, the religious exemption. They “concluded that it [was] appropriate to expand the exemption to other . . . organizations with sincerely held religious beliefs opposed to contraceptive coverage.” The second IFR created a “moral exemption” for employers-including nonprofits and for-profits with no publicly traded components-with “sincerely held moral” objections to providing some or all forms of contraceptive coverage. The Departments invoked their authority under the ACA to create this exemption, The Departments requested post-promulgation comments on both IFRs. Pennsylvania (P) filed an action seeking declaratory and injunctive relief. It alleged that the IFRs were procedurally and substantively invalid under the APA. The District Court granted a preliminary nationwide injunction against the IFRs. The Federal Government appealed. The Departments issued rules finalizing the IFRs. They explained that, in the wake of the numerous lawsuits challenging the self-certification accommodation and the failed attempt to identify alternative accommodations after the 2016 request for information, “an expanded exemption rather than the existing accommodation is the most appropriate administrative response to the substantial burden identified by the Supreme Court in Hobby Lobby.” After the final rules were promulgated, the State of New Jersey joined Pennsylvania’s suit claiming the rules as substantively and procedurally invalid under the APA claiming the Departments lacked statutory authority under either the ACA or RFRA to promulgate the exemptions. They claimed the Departments impermissibly used the IFR procedure to bypass the APA’s notice and comment procedures. The District Court issued a nationwide preliminary injunction against the implementation of the final rules. The Federal Government appealed, as did one of the homes operated by the Little Sisters. The Third Circuit affirmed. It held that the Departments lacked authority to craft the exemptions under either statute. The Supreme Court granted certiorari. Ps contend that the 2018 final rules providing religious and moral exemptions to the contraceptive mandate are both substantively and procedurally invalid.