Grace Schools v. Sylvia Mathews Burwell ( 2015 )

In the
United States Court of Appeals
For the Seventh Circuit
Nos. 14-1430 & 14-1431
GRACE SCHOOLS, et al., AND DIOCESE OF
FORT WAYNE-SOUTH BEND, INC., et al.,
Plaintiffs-Appellees,
v.
SYLVIA MATHEWS BURWELL, et al.,
Defendants-Appellants.
Appeals from the United States District Court for the
Northern District of Indiana.
Nos. 3:12-cv-00459-JD-CAN and 1:12-cv-00159-JD-RBC —
Jon E. DeGuilio, Judge.
ARGUED DECEMBER 3, 2014 — DECIDED SEPTEMBER 4, 2015
Before MANION, ROVNER, and HAMILTON, Circuit Judges.
ROVNER, Circuit Judge. The district court entered a prelimi-
nary injunction in favor of the plaintiffs, a number of religious,
not-for-profit organizations, preventing the defendants from
applying or enforcing the so-called “contraceptive mandate”
of the Patient Protection and Affordable Care Act of 2010
(“ACA”) to the plaintiffs. See 42 U.S.C. § 300gg-13(a)(4); Pub.
2 Nos. 14-1430 & 14-1431
L. No. 111-148, 124 Stat. 119 (2010). The plaintiffs contend that
the ACA’s accommodations for religious organizations impose
a substantial burden on their free exercise of religion, and that
the ACA and accompanying regulations are not the least
restrictive means of furthering a compelling government
interest, in violation of the plaintiffs’ rights under the Religious
Freedom Restoration Act of 1993 (“RFRA”). See 42 U.S.C. §
2000bb et seq. The defendants, several agencies of the United
States government, appeal. We conclude that ACA does not
impose a substantial burden on the plaintiffs’ free exercise
rights and so we reverse and remand. However, we will
maintain the injunction for a period of sixty days in order to
allow the district court adequate time to address additional
arguments made by the parties but not addressed prior to this
appeal.
I.
The ACA requires group health plans and third-party
administrators of self-insured plans to cover preventive care
for women under guidelines supported by the Health Re-
sources and Services Administration (“HRSA”), a component
of the Department of Health and Human Services (“HHS”). 42
U.S.C. § 300gg-13(a)(4); 45 C.F.R. § 147.130(a)(1)(iv); University
of Notre Dame v. Burwell, 786 F.3d 606, 607 (7th Cir. 2015)
(hereafter “Notre Dame II”); University of Notre Dame v. Sebelius,
743 F.3d 547, 548 (7th Cir. 2014), vacated by 135 S. Ct. 1528
(2015) (hereafter “Notre Dame I”). The relevant guidelines
include “all Food and Drug Administration approved contra-
ceptive methods, sterilization procedures, and patient educa-
tion and counseling for all women with reproductive capac-
ity.” 77 Fed. Reg. 8725-26. The regulations adopted by the three
Nos. 14-1430 & 14-1431 3
Departments implementing this part of the ACA require
coverage of, among other things, all of the contraceptive
methods described in the guidelines. See 45 C.F.R.
§ 147.130(a)(1)(iv) (HHS); 29 C.F.R. § 2590.715-2713(a)(1)(iv)
(Labor); 26 C.F.R. § 54.9815-2713(a)(1)(iv) (Treasury).1
In anticipation of objections from religious organizations to
these requirements, the Departments provided an exemption
from the contraception coverage provision for religious
employers. 45 C.F.R. § 147.131(a). A religious employer is
defined as “an organization that is organized and operates as
a nonprofit entity and is referred to in section 6033(a)(3)(A)(i)
or (iii) of the Internal Revenue Code of 1986, as amended.”
45 C.F.R. § 147.131(a); 26 U.S.C. § 6033(a)(3)(A). That provision
of the Internal Revenue Code, in turn, refers to “churches, their
integrated auxiliaries, and conventions or associations of
churches,” and “the exclusively religious activities of any
religious order.” 26 U.S.C. § 6033(a)(3)(A)(i) and (iii). But the
exemption did not cover religiously-affiliated non-profit
corporations such as schools and hospitals that did not meet
the IRS guidelines for religious employers. The Departments
therefore adopted additional regulations providing accommo-
dations for group health plans provided by these non-profit
1
All three of these regulations have been amended since this suit was filed.
The most recent amendments, which are scheduled to take effect Sept. 14,
2015, address accommodations for closely-held for-profit corporations
whose owners have religious objections to some or all of the contraceptive
coverage requirements of the ACA. See Burwell v. Hobby Lobby, 134 S. Ct.
2751 (2014). Because these most recent amendments are not relevant to the
issues raised here, we will be referring to the version of the regulations in
effect at the time this suit was filed, unless we state otherwise.
4 Nos. 14-1430 & 14-1431
religious corporations, called “eligible organizations” in the
regulations:
(b) Eligible organizations. An eligible organization
is an organization that satisfies all of the following
requirements:
(1) The organization opposes providing coverage for
some or all of any contraceptive services required to
be covered under § 147.130(a)(1)(iv) on account of
religious objections.
(2) The organization is organized and operates as a
nonprofit entity.
(3) The organization holds itself out as a religious
organization.
(4) The organization self-certifies, in a form and
manner specified by the Secretary, that it satisfies
the criteria in paragraphs (b)(1) through (3) of this
section, and makes such self-certification available
for examination upon request by the first day of the
first plan year to which the accommodation in
paragraph (c) of this section applies. The
self-certification must be executed by a person
authorized to make the certification on behalf of the
organization, and must be maintained in a manner
consistent with the record retention requirements
under section 107 of the Employee Retirement
Income Security Act of 1974.
Nos. 14-1430 & 14-1431 5
45 C.F.R. § 147.131(b).2 See also 78 Fed. Reg. 39,874-75.
Eligible organizations are not required “to contract,
arrange, pay, or refer for contraceptive coverage” to which
they have religious objections. 78 Fed. Reg. 39,874. The
government developed a two-page form for eligible organiza-
tions to use to comply with this accommodation, the “EBSA
Form 700 – Certification.”3 The short form requires the eligible
organization to supply its name, the name and title of the
individual authorized to make the certification on behalf of the
organization, and a mailing address and telephone number for
that individual. The form also requires a signature verifying
the statement, “I certify the organization is an eligible organi-
zation (as described in 26 CFR 54.9815-2713A(a), 29 CFR
2590.715-2713A(a); 45 CFR 147.131(b)) that has a religious
objection to providing coverage for some or all of any contra-
ceptive services that would otherwise be required to be
covered.” The organization must then provide a copy of the
certification to the organization’s health insurance issuer or, for
self-insured plans, to its third-party administrator. The insurer
or administrator receiving the certification is obligated to
provide (or arrange for the provision of) contraception cover-
age for the health plan’s participants without cost sharing
through alternate mechanisms established by the regulations.
2
This regulation will also be updated as of Sept. 14, 2015. Again, we cite to
the earlier version.
3
The form can be found at http://www.dol.gov/ebsa/pdf/preventive
serviceseligibleorganizationcertificationform.pdf, last visited September 3,
2015.
6 Nos. 14-1430 & 14-1431
45 C.F.R. § 147.131(c). The insurer4 may not impose a charge of
any variety, either directly or indirectly, on the eligible
organization for the provision of contraception services.5 The
insurer must also inform plan participants that the eligible
organization will not provide or fund any contraception
coverage. 45 C.F.R. § 147.131(d). As we will discuss below,
since the filing of this suit, these regulations have been
amended to allow a second method of objecting to contracep-
tive coverage, by notifying HHS directly of any religiously-
based objection.
The plaintiffs are various religiously-based non-profit
organizations including the Diocese of Fort Wayne-South
Bend, Inc. (“Diocese”); Catholic Charities of the Diocese of Fort
Wayne-South Bend, Inc. (“Catholic Charities”); Saint Anne
Home & Retirement Community of the Diocese of Fort Wayne-
4
From this point forward, when we use the term “insurer,” we mean to
include third-party administrators in those instances where the plan is self-
insured unless we state otherwise.
5
Insurers are expected to recoup the costs of contraceptive coverage from
savings on pregnancy medical care as well as from other regulatory offsets.
See Notre Dame II, 786 F.3d at 609–10; 78 Fed. Reg. 38977-78 (“Issuers are
prohibited from charging any premium, fee, or other charge to eligible
organizations or their plans, or to plan participants or beneficiaries, for
making payments for contraceptive services, and must segregate the
premium revenue collected from eligible organizations from the monies
they use to make such payments. In making such payments, the issuer must
ensure that it does not use any premiums collected from eligible organiza-
tions.”). Third-party administrators may seek reimbursement of up to 110%
of their costs from the government. Notre Dame II, 786 F.3d at 609; 45 C.F.R.
§ 156.50(d)(3).
Nos. 14-1430 & 14-1431 7
South Bend, Inc. (“St. Anne Home”); Franciscan Alliance, Inc.;
Specialty Physicians of Illinois LLC (“Specialty Physicians”);
University of Saint Francis (“St. Francis”); Our Sunday Visitor,
Inc. (“Sunday Visitor”); Biola University, Inc. (“Biola”) and
Grace Schools. The plaintiffs objected below to the regulatory
scheme, which they characterize as a “contraceptive services
mandate,” on numerous grounds. Primarily, they asserted that
the regulations force them to participate in a system that
contravenes their religious beliefs in violation of the RFRA. 42
U.S.C. § 2000bb et seq.6 In particular, they are forced to contract
with insurers or third-party administrators that will provide
their employees (and, in some cases, their students) with
coverage for contraceptives, sterilization, and abortion-
inducing products, all in violation of their deeply held reli-
gious beliefs. The accommodation provides them no relief,
they contended below, because it causes them to trigger and
facilitate the same objectionable services for their employees
and students. A non-complying employer7 who does not meet
6
The plaintiffs also allege that the challenged statute and regulations
violate their rights under the First Amendment and under the Administra-
tive Procedures Act, 5 U.S.C. § 500 et seq. Because the district court issued
the injunction after considering only the RFRA, and because neither side
has briefed the other issues, we will confine our discussion to the RFRA. On
remand, the plaintiffs are free to pursue their other theories for relief and,
in fact, we will leave the injunction in place for a limited time in order to
allow the court to consider those additional claims.
7
The disputed regulations apply equally to employers providing insurance
to employees and to institutions of higher education providing student
health insurance. See 45 C.F.R. § 147.131(f). Some of the plaintiffs provide
(continued...)
8 Nos. 14-1430 & 14-1431
an exemption faces fines of $2000 per year per full time
employee8 for not providing insurance that meets coverage
requirements, 26 U.S.C. § 4980H(c), or $100 per day per
employee for providing insurance that excludes the required
contraceptive coverage, 26 U.S.C. § 4980D, and will face the
risk of other enforcement actions.
The Diocese itself is exempted from challenged require-
ments under the religious employer exemption,9 and the
remaining plaintiffs are subject to the accommodation for non-
profit, religiously-affiliated employers. The government does
not contest the sincerity of the plaintiffs’ religious objections to
the required contraceptive coverage. Moreover, all of the
plaintiffs consider the provision of health insurance for their
employees and students to be part of their religious mission.
7
(...continued)
both employee and student health coverage.
8
When calculating the number of employees for the purpose of assessing
this penalty, the statute directs that thirty employees be subtracted from the
total number of employees, essentially reducing the penalty by $60,000 per
year for affected employers. 26 U.S.C. § 4980H(c)(2)(D)(i).
9
Although the Diocese is itself exempt, the Diocesan Health Plan insures
employees of the non-exempt Catholic Charities. In order to protect
Catholic Charities from having to comply with either the contraceptive
mandate or the accommodation, the Diocese has forgone almost $200,000
annually in increased premiums in order to maintain its grandfathered
status under the ACA. See 42 U.S.C. § 18011. Grandfathered plans are those
health plans that need not comply with the coverage requirements of the
ACA because they were in existence when the ACA was adopted and have
not made certain changes to the terms of their plans.
Nos. 14-1430 & 14-1431 9
Although the plaintiffs concede that they are not required
to pay for the objectionable services, they contended in the
district court that being forced to contract with insurers or
third-party administrators who must then provide those
services makes them a facilitator of objectionable conduct,
complicit in activity that violates their core religious beliefs.
The plaintiffs also asserted below that the government’s
interest in providing contraceptive services is not compelling
and that the means the government employed are not the least
restrictive available to achieve the government’s goals. On
those bases, the plaintiffs sought and received a preliminary
injunction in the district court.
The district court noted that the RFRA prohibits the federal
government from placing substantial burdens on a person’s
exercise of religion unless it can demonstrate that applying the
burden is “in furtherance of a compelling governmental
interest,” and is the “least restrictive means of furthering that
compelling governmental interest.” 42 U.S.C. § 2000bb-1(a) and
(b). The court first considered whether the contraception
regulations create a substantial burden on eligible employers
in light of the accommodation provided by the regulations.
Citing our opinion in Korte v. Sebelius, 735 F.3d 654 (7th Cir.
2013), cert. denied, 134 S. Ct. 2903 (2014), the court noted that
“the pertinent inquiry for the substantial burden test under
RFRA is whether the claimant has an honest conviction that
what the government is requiring or pressuring him to do
conflicts with his religious beliefs and whether the governmen-
tal pressure exerts a sufficiently coercive influence on the
plaintiffs’ religious practice.” Grace Schools v. Sebelius,
988 F. Supp. 2d 935, 950 (N.D. Ind. 2013); Diocese of Fort Wayne-
10 Nos. 14-1430 & 14-1431
South Bend, Inc. v. Sebelius, 988 F. Supp. 2d 958, 972 (N.D. Ind.
2013). The court found that the plaintiffs sincerely believe that
the accommodation compels them to facilitate and serve as a
conduit for objectionable contraceptive services for their
employees and students. If the plaintiffs want to provide
health insurance for their students and employees as part of
their religious mission (and in order to avoid the fines imposed
by the ACA on employers who fail to meet coverage require-
ments), the court reasoned, then they must either provide the
objectionable coverage themselves or comply with the accom-
modation.
And the plaintiffs sincerely believe that invoking the
accommodation facilitates and enables the provision of
contraceptive services to their employees and students; the
accommodation, in short, makes them complicit in the provi-
sion of services to which they possess a religious objection.
That they need not pay for the services provides no relief from
their religious dilemma, the district court reasoned, because
they must violate their religious beliefs by either forgoing
providing health insurance to their employees and students, or
they must take critical steps (i.e. comply with the accommoda-
tion) to facilitate a third party’s provision of the objectionable
coverage. Because failure to take either of these equally
objectionable routes would result in the imposition of large
financial penalties, the district court found that the plaintiffs
demonstrated that the ACA imposes a substantial burden on
their free exercise rights in contravention of the RFRA. The
court then assumed that the government possessed a compel-
ling interest in providing seamless contraceptive services to
women in group health plans, but found that the accommoda-
Nos. 14-1430 & 14-1431 11
tion was not the least restrictive means of accomplishing that
goal. The court therefore enjoined the defendants from
enforcing against the plaintiffs the requirements “to provide,
pay for, or otherwise facilitate access to coverage for FDA
approved contraceptive methods, abortion-inducing drugs,
sterilization procedures, and related patient education and
counseling.” Grace Schools, 988 F. Supp. 2d at 958; Diocese of
Fort-Wayne-South Bend, 988 F. Supp. 2d at 980. The government
appeals.
II.
Several months after the district court entered the injunc-
tions for the plaintiffs here, we issued our opinion in Notre
Dame I, where we affirmed the denial of a motion for a prelimi-
nary injunction under strikingly similar circumstances to those
presented by these appeals. The government asserts that our
decision in Notre Dame I controls the result here and requires
that we reverse the preliminary injunctions granted by the
district court. The plaintiffs argue that Notre Dame I is distin-
guishable and that application of the substantial burden test
from Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751 (2014),
and Korte requires that we affirm the preliminary injunctions
here. After this appeal was fully briefed and argued, the
Supreme Court vacated and remanded our opinion in Notre
Dame I “for further consideration in light of Burwell v. Hobby
Lobby Stores, Inc., 134 S. Ct. 2751 (2014).” University of Notre
Dame v. Burwell, 135 S. Ct. 1528 (2015). We recently issued a
new opinion addressing the effect of Hobby Lobby on Notre
Dame’s appeal. See Notre Dame II, 786 F.3d at 615–19. We will
begin our analysis with our original Notre Dame I opinion,
which continues to apply to some of the questions raised here,
12 Nos. 14-1430 & 14-1431
before we turn to Notre Dame II. “We review the district court's
findings of fact for clear error, its balancing of the factors for a
preliminary injunction under the abuse of discretion standard,
and its legal conclusions de novo.” United Air Lines, Inc. v. Air
Line Pilots Ass’n, Int’l, 563 F.3d 257, 269 (7th Cir. 2009). To
obtain a preliminary injunction, a party must establish that it
is likely to succeed on the merits, that it is likely to suffer
irreparable harm in the absence of preliminary relief, that the
balance of equities tips in its favor, and that issuing an injunc-
tion is in the public interest. Smith v. Executive Dir. of Ind. War
Mem’ls Comm’n, 742 F.3d 282, 286 (7th Cir. 2014).
A.
In Notre Dame I, a non-profit Catholic university moved to
enjoin the enforcement of the ACA’s contraception provisions
against it. 743 F.3d at 551. Notre Dame provides health benefits
to its employees and students. The university self-insures the
employees and utilizes a third-party administrator to manage
the plan. It contracts directly with an insurance provider for
the student health plan. 743 F.3d at 549. The ACA requires the
university, as an eligible organization, either to provide
contraceptive coverage for its employees or to comply with the
accommodation by opting out through the use of the EBSA
Form 700 certification (“Form 700"), which we described above.
743 F.3d at 550. The relevant regulations required Notre Dame
to provide the completed Form 700 to its third-party adminis-
trator and to the insurer of the student plan. Notre Dame filed
suit shortly before the deadline for complying with the
accommodation and moved for a preliminary injunction. The
district court denied the motion and Notre Dame appealed,
with fewer than two weeks left to meet the deadline for
Nos. 14-1430 & 14-1431 13
compliance. We denied the university’s motion for an injunc-
tion pending the appeal but ordered expedited briefing. On the
last day to comply with the regulations, Notre Dame signed
the Form 700 and supplied it to its insurer and third-party
administrator. 743 F.3d at 551. The appeal proceeded.
We noted that Notre Dame’s primary objection was to the
regulations surrounding the Form 700 certification. One
regulation provides that:
the copy of the self-certification [EBSA Form 700]
provided by the eligible [to opt out] organization
[Notre Dame] to a third party administrator
[Meritain] (including notice of the eligible organiza-
tion's refusal to administer or fund contraceptive
benefits) … shall be an instrument under which the
plan is operated, [and] shall be treated as a designa-
tion of the third party administrator as the plan
administrator under section 3(16) of ERISA for any
contraceptive services required to be covered under
§ 2590.715–2713(a)(1)(iv) of this chapter to which the
eligible organization objects on religious grounds.
Notre Dame I, 743 F.3d at 552–53 (quoting 29 C.F.R. § 2510.3-16).
Notre Dame interpreted that regulation as if its mailing of the
Form 700 to its insurer and its third-party administrator were
the cause of the provision of contraceptive services to its
employees and students, in violation of its religious beliefs. We
noted that was not the case. Instead, the Form 700 allows the
university to opt out of the provision of objectionable services
entirely and the law then places the burden of providing the
14 Nos. 14-1430 & 14-1431
services on the insurer and the third-party administrator. 743
F.3d at 553.
In assessing the likelihood of Notre Dame’s success on the
merits, we considered and rejected the school’s claim that
filling out and mailing the Form 700 is a “substantial burden”
on the university’s exercise of religion. 743 F.3d at 554. Notre
Dame complained that completing the form and distributing
it to the insurer and third-party administrator triggered
contraceptive coverage for employees and students, making
the university complicit in the provision of objectionable
services and burdening the university’s religious exercise. We
found that the Form 700 self-certification does not trigger,
cause or otherwise enable the provision of contraceptive
services:
Federal law, not the religious organization's signing
and mailing the form, requires health-care insurers,
along with third-party administrators of self-insured
health plans, to cover contraceptive services. By
refusing to fill out the form Notre Dame would
subject itself to penalties, but Aetna [the insurer] and
Meritain [the third-party administrator] would still
be required by federal law to provide the services to
the university’s students and employees unless and
until their contractual relation with Notre Dame
terminated.
Notre Dame I, 743 F.3d at 554. We also rejected Notre Dame’s
argument that its insurer and third-party administrator would
not have been authorized as plan fiduciaries to provide the
contraceptive services until the school executed Form 700.
Nos. 14-1430 & 14-1431 15
743 F.3d at 554–55. The law and the regulations (and not the
Form 700) designate the insurer and third-party administrator
as plan fiduciaries who are then obligated by federal law to
provide the contraceptive services. 743 F.3d at 555. We also
concluded that the contraception regulations do not impose a
substantial burden simply because the university must contract
with a third party willing to provide (at the behest of the
government) the services that Notre Dame finds objectionable.
Because that third party did not object to providing the
services, we called any such claim speculative and not a
ground for equitable relief. We emphasized, in the end, that it
was not the Form 700 or anything that Notre Dame was
required to do by the regulatory accommodation that caused
the university’s employees and students to receive the objec-
tionable coverage; rather it was federal law that authorized,
indeed required, insurers and third-party administrators to
provide coverage. 743 F.3d at 559. Because the true objection
was not to actions that the school itself was required to take
but rather to the government’s independent actions in mandat-
ing contraceptive coverage, we concluded that there was no
substantial burden on the university’s religious exercise.
743 F.3d at 559.
B.
As litigation on the ACA’s contraception requirements has
progressed in other cases and other circuits, new regulations
have been issued in response to interim orders from the
Supreme Court. In Little Sisters of the Poor Home for the Aged,
Denver, Colo. v. Sebelius, 134 S. Ct. 1022 (2014), after a district
court declined to enjoin the operation of the ACA against a
religious organization that did not wish to file the Form 700,
16 Nos. 14-1430 & 14-1431
the Court entered an injunction pending the appeal of that
decision:
If the employer applicants inform the Secretary of
Health and Human Services in writing that they are
non-profit organizations that hold themselves out as
religious and have religious objections to providing
coverage for contraceptive services, the respondents
are enjoined from enforcing against the applicants
the challenged provisions of the Patient Protection
and Affordable Care Act and related regulations
pending final disposition of the appeal by the
United States Court of Appeals for the Tenth Circuit.
To meet the condition for injunction pending appeal,
applicants need not use the form prescribed by the
Government and need not send copies to third-party
administrators. The Court issues this order based on
all the circumstances of the case, and this order
should not be construed as an expression of the
Court's views on the merits.
Little Sisters, 134 S. Ct. at 1022. The order, in short, relieved the
Little Sisters of their obligation to file the Form 700 so long as
they directly notified the government of their objection.
Subsequently, the Court entered a similar injunction in a
case within our circuit. See Wheaton College v. Burwell, 134 S. Ct.
2806 (2014). After essentially repeating the language from the
very short order in Little Sisters, the Court clarified:
Nothing in this interim order affects the ability of
the applicant's employees and students to obtain,
without cost, the full range of FDA approved contra-
Nos. 14-1430 & 14-1431 17
ceptives. The Government contends that the appli-
cant's health insurance issuer and third-party ad-
ministrator are required by federal law to provide
full contraceptive coverage regardless whether the
applicant completes EBSA Form 700. The applicant
contends, by contrast, that the obligations of its
health insurance issuer and third-party administra-
tor are dependent on their receipt of notice that the
applicant objects to the contraceptive coverage
requirement. But the applicant has already notified
the Government—without using EBSA Form
700—that it meets the requirements for exemption
from the contraceptive coverage requirement on
religious grounds. Nothing in this order precludes
the Government from relying on this notice, to the
extent it considers it necessary, to facilitate the
provision of full contraceptive coverage under the
Act.
Wheaton College, 134 S. Ct. at 2807. As with Little Sisters, the
order relieved Wheaton College of its obligation to file Form
700 as long as it notified the government directly of its objec-
tion. But the government was permitted to use this direct
notice to facilitate the coverage required by the ACA.
And finally, after the Third Circuit reversed a temporary
injunction sought by a religious employer and granted by a
district court, the Court again intervened:
The application for an order recalling and staying
the issuance of the mandate of the Court of Appeals
pending the filing and disposition of a petition for a
18 Nos. 14-1430 & 14-1431
writ of certiorari, having been submitted to Justice
Alito and by him referred to the Court, the applica-
tion as presented is denied. The Court furthermore
orders: If the applicants ensure that the Secretary of
Health and Human Services is in possession of all
information necessary to verify applicants’ eligibility
under 26 CFR § 54.9815-2713A(a) or 29 CFR §
2590.715-2713A(a) or 45 CFR § 147.131(b) (as appli-
cable), the respondents are enjoined from enforcing
against the applicants the challenged provisions of
the Patient Protection and Affordable Care Act and
related regulations pending final disposition of their
petition for certiorari. Nothing in this interim order
affects the ability of the applicants’ or their organiza-
tions’ employees to obtain, without cost, the full
range of FDA approved contraceptives. Nor does
this order preclude the Government from relying on
the information provided by the applicants, to the
extent it considers it necessary, to facilitate the
provision of full contraceptive coverage under the
Act. See Wheaton College v. Burwell, 573 U. S. ___
(2014). This order should not be construed as an
expression of the Court’s views on the merits. Ibid.
Justice Sotomayor would deny the application.
Zubik v. Burwell, 2015 WL 3947586 (June 29, 2015) (full text
found at http://www.supremecourt.gov/search.aspx?
filename=/docketfiles/14a1065.htm, last visited September 3,
2015). As a result of these interim orders from the Supreme
Court, the regulations have been amended so that objectors
may now notify HHS directly rather than filing the Form 700.
Nos. 14-1430 & 14-1431 19
And the government may, in turn, facilitate the required
contraceptive coverage based on such notice.
C.
We turn to our recent decisions in Notre Dame II and
Wheaton College v. Burwell, 791 F.3d 792 (7th Cir. 2015). In Notre
Dame II, we noted that, shortly after filing its suit and immedi-
ately before the regulatory deadline, the university signed the
Form 700 and sent it to the insurer of its students and the third-
party administrator of its employee plan. That action left us
wondering what relief Notre Dame sought. Ultimately, we
determined, Notre Dame wanted
us to enjoin the government from forbidding Notre
Dame to bar Aetna and Meritain from providing
contraceptive coverage to any of the university's
students or employees. Because of its contractual
relations with the two companies, which continue to
provide health insurance coverage and administra-
tion for medical services apart from contraception as
a method of preventing pregnancy, Notre Dame
claims to be complicit in the sin of contraception. It
wants to dissolve that complicity by forbidding
Aetna and Meritain—with both of which, to repeat,
it continues to have contractual relations—to pro-
vide any contraceptive coverage to Notre Dame
students or staff. The result would be that the
students and staff currently lacking coverage other
than from Aetna or Meritain would have to fend for
themselves, seeking contraceptive coverage else-
where in the health insurance market.
20 Nos. 14-1430 & 14-1431
Notre Dame II, 786 F.3d at 611. The university’s primary
objection to the ACA was that its contractual relationship with
its insurer and third-party administrator made the school a
conduit for the provision of objectionable services. According
to Notre Dame, the contraception regulations imposed a
substantial burden on it by forcing the university to identify
and contract with a third party willing to provide objectionable
contraceptive services. 786 F.3d at 611–12.
We noted that, although Notre Dame is the final arbiter of
its religious beliefs, only the courts may determine whether the
law actually forces the university to act in a way that would
violate those beliefs. 786 F.3d at 612. The record contained no
evidence to support a conduit theory. Nor is it within our usual
practice to enjoin non-parties such as Notre Dame’s insurer
and third-party administrator. We also rejected Notre Dame’s
claim that the regulation requiring employers to provide Form
700 to its insurers was the cause of the provision of contracep-
tive services; rather the services are provided because federal
law requires the insurers to provide them. Notre Dame II,
786 F.3d at 613–14 (“It is federal law, rather than the religious
organization's signing and mailing the form, that requires
health-care insurers, along with third-party administrators of
self-insured health plans, to cover contraceptive services.”).
Because the insurer must provide the services no matter what
the employer does, we noted that “signing the form simply
shifts the financial burden from the university to the govern-
ment, as desired by the university.” 786 F.3d at 615. See supra
note 5. We thus re-asserted the core reasoning of our earlier
opinion before turning to any effect that Hobby Lobby had on
the case.
Nos. 14-1430 & 14-1431 21
Hobby Lobby, we noted, involved closely-held for-profit
corporations whose owners objected on religious grounds to
the contraceptive mandate. The Supreme Court held that the
RFRA applied to nonreligious institutions owned by persons
with sincerely held religious objections to the ACA’s contra-
ception regulations. Hobby Lobby, 134 S. Ct. at 2776–78; Notre
Dame II, 786 F.3d at 615. The Court noted that the companies’
objections could be addressed by allowing them to invoke the
same accommodation that the government created for religious
non-profit employers, namely signing and filing the Form 700.
134 S. Ct. at 2782. The Court left open the issue of whether the
accommodation that was adequate for nonreligious, for-profit
corporations would be sufficient to protect the rights of
religious non-profit employers. As to that issue, we examined
various alternative schemes that Notre Dame proposed as
possible accommodations and found each of them lacking. We
also noted that the Supreme Court had created an alternative
to Form 700 by allowing employers to notify the government
directly of its objection to the mandate. Notre Dame II, 786 F.3d
at 617–18; Wheaton College, 134 S. Ct. at 2806. We rejected Notre
Dame’s objections to the Wheaton College alternative notice,
citing Bowen v. Roy, 476 U.S. 693 (1986). We noted that the Roy
Court rejected Roy's religious objection to the government's
use of his daughter's Social Security number for its purposes.
The Court held “Roy may no more prevail on his religious
objection to the Government's use of a Social Security number
for his daughter than he could on a sincere religious objection
to the size or color of the Government's filing cabinets.” Roy,
476 U.S. at 700. Notre Dame's objection to the government
designating insurers as substitutes to provide contraceptive
22 Nos. 14-1430 & 14-1431
coverage was an analogous challenge to the government's
management of its affairs and, accordingly, Notre Dame had
not demonstrated a substantial burden to its religious exercise.
Notre Dame II, 786 F.3d at 618.
In Wheaton College, we similarly rejected a religious school’s
objections to the contraception regulations under the RFRA,
the First Amendment and the Administrative Procedures Act.
791 F.3d at 801. The college asserted that the government was
using the school’s insurance plan and putting additional terms
into its contracts with insurers in order to provide the objec-
tionable coverage. The college sought an injunction prohibiting
the government’s effort to use Wheaton’s plans as the vehicle
for making contraceptive coverage available to its employees
and students. It objected to notifying its insurers or the
government that it claimed a religious exemption, and also to
providing the government with the names of its insurers so
that the government could then implement the coverage
separate from the college. We noted that the ACA and accom-
panying regulations do not alter any employer’s insurance
plans or contracts. 791 F.3d at 794. Nor is the college being
forced to allow the use of its plan to provide objectionable
services. The ACA and regulations require only that the college
notify either its insurers or the government that it objects,
which takes the school out of the loop. 791 F.3d at 795. As in
Notre Dame II, we rejected the claim that the provision of notice
to insurers or the government somehow triggers or facilitates
the provision of objectionable coverage. 791 F.3d at 796. As was
the case with Notre Dame, Wheaton also objected to being
forced to contract with insurers which, in turn, provided
objectionable services, contending that this made the college
Nos. 14-1430 & 14-1431 23
complicit in the provision of those services. We saw no
complicity in the operation of the law, which makes every
effort to separate religious employers from the provision of
any objectionable services.
We again noted that courts generally do not enjoin non-
parties, and Wheaton had not made its insurers parties to the
suit. Wheaton also expressed a reluctance to identify its
insurers to the government, instead preferring that the govern-
ment discover through its own research the names of the
insurers. But Wheaton made no connection between the means
for identifying the insurers and its religious commitments. We
also noted Wheaton’s assertion that its students and employees
sign a covenant agreeing to abide by the school’s moral
standards, indicating perhaps that Wheaton’s concerns about
the ACA are largely academic because the employees and
students are unlikely to actually use the services offered.
Finally, we rejected Wheaton’s claims under the First Amend-
ment, ERISA and the Administrative Procedures Act, all issues
which were not argued in the instant appeal, and so we will
not address them further. 791 F.3d at 797–800.
Before we move on to the plaintiffs’ objections in this case,
we note that the case law analyzing the contraceptive mandate
is rapidly evolving. Recently, the six other circuits to consider
these same issues have all come to the same conclusion as our
opinions in Notre Dame and Wheaton College, namely, that the
contraceptive mandate, as modified by the accommodation,
does not impose a substantial burden on religious organiza-
tions under the RFRA. See Catholic Health Care System v.
Burwell, — F.3d —, 2015 WL 4665049, *7-*16 (2d Cir. Aug. 7,
2015) (concluding that the accommodation does not impose a
24 Nos. 14-1430 & 14-1431
substantial burden); Little Sisters of the Poor Home for the Aged v.
Burwell, 794 F.3d 1151 , 2015 WL 4232096, *16 (10th Cir. 2015),
petition for cert. filed, 84 USLW 3056 (U.S. July 24, 2015) (No. 15-
105) (concluding that the mandate does not impose a substan-
tial burden on religious exercise under RFRA and affirming the
denial of a preliminary injunction in one instance and revers-
ing the grant of preliminary injunctions in two others); East
Texas Baptist University v. Burwell, 793 F.3d 449, 459 (5th Cir.
2015), petition for cert. filed, 84 USLW 3050 (U.S. July 8, 2015)
(No. 15-35) (holding that the ACA does not impose a substan-
tial burden under the RFRA and reversing the grant of a
preliminary injunction); Geneva College v. Secretary United States
Department of Health & Human Servs., 778 F.3d 422, 442 (3d Cir.
2015), petition for cert. filed, 83 USLW 3894 (U.S. May 29, 2015)
(Nos. 14-1418 & 14A1065), and stay denied by Zubik v. Burwell,
135 S. Ct. 2924, 2015 WL 3947586 (June 29, 2015) (reversing
grant of preliminary injunction and concluding that the
accommodation procedures do not impose a substantial
burden on religious exercise); Priests for Life v. United States
Dep’t of Health & Human Servs., 772 F.3d 229, 256 (D.C. Cir.
2014), petition for cert. filed, 83 USLW 3918 (U.S. June 9, 2015)
(No. 14-1453) (affirming denial of injunctive relief and conclud-
ing that the ACA’s mandate does not impose a substantial
burden on religious exercise); Michigan Catholic Conference v.
Burwell, 755 F.3d 372, 390 (6th Cir. 2014), cert. granted, judgment
vacated and remanded, 135 S. Ct. 1914 (2015), reissued, — F.3d —
2015 WL 4979692 (6th Cir. Aug. 21, 2015) (because objectors
may obtain the accommodation from the
contraceptive-coverage requirement without providing, paying
for, and/or facilitating access to contraception, the contracep-
Nos. 14-1430 & 14-1431 25
tive-coverage requirement does not impose a substantial
burden on their exercise of religion).10 No court of appeals has
concluded that the contraceptive mandate imposes a substan-
tial burden under the RFRA.
D.
After this court issued its opinion in Notre Dame II, we
asked the parties to file position statements addressing the
effect of that opinion on this appeal. We turn now to the
parties’ position statements as well as the arguments raised in
their original briefs. The government, in its original brief,
contended that Notre Dame I was controlling. It argued that the
plaintiffs are permitted to opt out of providing contraceptive
coverage, and that the plaintiffs improperly object to require-
ments imposed by the accommodation on third parties rather
than on themselves. The government also asserted that it is the
province of the court rather than the plaintiffs to determine
whether a particular regulation or law “substantially” burdens
the plaintiffs’ free exercise of religion under the RFRA. Finally,
the government maintained that, even if we were to determine
that the regulations impose a substantial burden on the
plaintiffs under the RFRA, the government’s interest in
10
The Sixth Circuit released its opinion a few weeks prior to the issuance
of Hobby Lobby, but denied rehearing en banc several months later. The
Supreme Court subsequently granted the petition for certiorari, vacated the
opinion and remanded for further consideration in light of Hobby Lobby. The
Sixth Circuit recently reissued and reaffirmed its earlier opinion and filed
a supplemental opinion addressing Hobby Lobby. The Sixth Circuit continues
to hold that the ACA’s contraception provisions do not impose a substantial
burden under RFRA. Michigan Catholic, 2015 WL 4979692, *6- *15.
26 Nos. 14-1430 & 14-1431
providing the coverage is compelling and the regulations are
narrowly tailored to meet that interest.
In its position statement, the government adds that Notre
Dame II rejected all of the arguments raised by the plaintiffs
here. Specifically, the government again notes that the regula-
tions allow the plaintiffs to opt out of providing the mandated
contraceptive services, making them effectively exempt. After
objectors opt out, the government tasks third parties with
providing the coverage. Moreover, the opt-out does not
operate as a trigger or cause for the coverage; rather federal
law imposes on third parties the obligation to provide the
coverage. Nothing in the ACA or regulations makes the
plaintiffs complicit or allows their contracts with insurers or
third party administrators to act as conduits for the provision
of contraceptive services. The government repeats that, even if
the regulations impose a substantial burden on the plaintiffs’
free exercise of religion under the RFRA, the regulations serve
a compelling government interest and are the least restrictive
means of achieving those interests. According to the govern-
ment, our opinion in Notre Dame II demonstrates that the
current regulations are narrowly tailored to achieve the
compelling interest, and that none of the plaintiffs’ suggested
alternatives would be effective.
In their opening brief, the plaintiffs argued, as they did
below, that the contraception regulations impose a substantial
burden on their exercise of religion. The plaintiffs asserted that
they exercise their religion “by refusing to take actions in
furtherance of a regulatory scheme to provide their employees
with access to abortion-inducing products, contraceptives,
sterilization, and related education and counseling.” Brief at
Nos. 14-1430 & 14-1431 27
29. The plaintiffs maintained that submitting Form 700 renders
them complicit in a grave moral wrong because the form has
certain legal effects that facilitate the provision of the objection-
able services. The accommodation, the plaintiffs added,
requires them to amend the documents governing their health
plans to provide the very coverage to which they object. The
plaintiffs also objected to contracting with and paying premi-
ums to insurance companies or third party administrators that
are authorized to provide their employees with contraceptive
coverage. Moreover, the plaintiffs pointed out that if they fail
to comply with the regulations, they will face onerous fines.
The plaintiffs asserted that Notre Dame I is distinguishable on
the facts, and that Notre Dame I did not address the arguments
of the Catholic appellees here that (1) the Diocese is being
forced to forgo $200,000 annually in increased premiums in
order to maintain its grandfathered status11 to avoid its plan
becoming a conduit for objectionable coverage for the employ-
ees of Catholic Charities that are enrolled in the Diocese’s
health plan; and (2) the mandate has the additional effect of
artificially dividing the Catholic Church into a “worship arm”
and a “good works arm.”
The plaintiffs also maintained in their opening brief that the
government’s “substantial burden” analysis incorrectly focuses
on the nature of the actions that the regulations require the
11
“Grandfathered plans” are plans that were in existence when the ACA
was adopted and that have not made certain changes to the terms of the
plans. Grandfathered plans need not comply with the ACA’s coverage
requirements. See 42 U.S.C. § 18011; 26 C.F.R. § 54.9815-1251T. Certain
increases in premiums could cause a plan to lose its grandfathered status
and thus become subject to the ACA’s coverage requirements.
28 Nos. 14-1430 & 14-1431
plaintiffs to take rather than the pressure the government has
placed on the plaintiffs to take those actions. They contended
that the focus of the analysis should be on the intensity of the
coercion applied by the government to act contrary to their
religious beliefs. Finally, they asserted that they object to
actions they themselves must take under the regulations, not
to the actions of third parties.
In their position statement, the plaintiffs contend that Notre
Dame II is distinguishable on the facts, that it is not binding
here, and that it is based on legal errors. Finally, the plaintiffs
argue that the strict scrutiny analysis in Notre Dame II is both
foreclosed by the government’s concession in this case and
inconsistent with circuit precedent.
E.
We turn to the specific objections raised by the plaintiffs
here. They contend that the accommodation does not operate
as a true “opt-out” because it requires them to engage in
numerous religiously objectionable actions. The actions to
which the plaintiffs object fall under two categories: first, the
mandate requires them to contract with insurance companies
or third-party administrators that are authorized to provide the
objectionable coverage and which will provide that coverage
once the plaintiffs communicate their objections. Second, they
must submit the Form 700 or notify the government directly of
their objection. They sincerely believe that the required actions
render them complicit in a grave moral wrong because their
insurance contracts serve as conduits for the provision of the
objectionable services, and the notification triggers or facilitates
the provision of objectionable services. They practice their
Nos. 14-1430 & 14-1431 29
religion, they assert, by refusing to take actions “in furtherance
of” a scheme to provide the objectionable services. And if they
decline to engage in these actions, the mandate subjects them
to onerous fines.
The core of the disagreement between the plaintiffs and the
government lies in how we apply the substantial burden test.
The plaintiffs cite our decision in Korte for the proposition that
the substantial burden test under the RFRA focuses primarily
on the intensity of the coercion applied by the government to
act contrary to religious beliefs. Korte, 735 F.3d at 683. Citing
Hobby Lobby, they also assert that the RFRA allows private
religious believers to decide for themselves whether taking a
particular action (such as filing the Form 700 or contracting
with an insurance company) is connected to objectionable
conduct in a way that is sufficient to make it immoral. Hobby
Lobby, 134 S. Ct. at 2778.
In Korte, we noted that “exercise of religion” means “any
exercise of religion, whether or not compelled by, or central to,
a system of religious belief.” 735 F.3d at 682; 42 U.S.C.
§ 2000cc–5(7)(A). A substantial burden on free exercise may
arise when the government compels a religious person to
perform acts undeniably at odds with fundamental tenets of
that person’s religious beliefs, and also when the government
places substantial pressure on a person to modify his or her
behavior in a way that violates religious beliefs. Korte, 735 F.3d
at 682. “Put another way, the substantial-burden inquiry
evaluates the coercive effect of the governmental pressure on
the adherent's religious practice and steers well clear of
deciding religious questions.” Korte, 735 F.3d at 683. Relying on
Korte and Hobby Lobby, the plaintiffs urge us to engage in a
30 Nos. 14-1430 & 14-1431
two-step analysis of first identifying the religious belief at
issue, and second, determining whether the government has
placed substantial pressure on the plaintiffs to violate that
belief.
The plaintiffs are correct that it is not our province to decide
religious questions. Hobby Lobby, 134 S. Ct. at 2778 (the RFRA
presents the question of whether the mandate imposes a
substantial burden on the ability of the objecting parties to
conduct business in accordance with their religious beliefs, but
courts have no business addressing whether the religious belief
asserted is reasonable); Notre Dame II, 786 F.3d at 612 (an
objector is the final arbiter of its religious beliefs); Little Sisters
of the Poor, 794 F.3d at —, 2015 WL 4232096, at *19 (substantial-
ity does not permit a court to scrutinize the theological merit
of a plaintiff's religious beliefs); Geneva College, 778 F.3d at 436
(courts should defer to the reasonableness of a plaintiff’s
religious beliefs). The plaintiffs in Hobby Lobby were closely-
held, for-profit corporations that were required by the ACA to
provide and pay for health insurance which included coverage
of certain emergency contraceptives that they believed oper-
ated as abortifacients. Similar to the plaintiffs here, they
believed that providing the required coverage is connected to
the destruction of an embryo in a way that is sufficient to make
it immoral for them to provide the coverage. “This belief
implicates a difficult and important question of religion and
moral philosophy, namely, the circumstances under which it
is wrong for a person to perform an act that is innocent in itself
but that has the effect of enabling or facilitating the commis-
sion of an immoral act by another.” Hobby Lobby, 134 S. Ct at
2778.
Nos. 14-1430 & 14-1431 31
So we defer to the plaintiffs’ sincerely held beliefs regard-
ing questions of religion and moral philosophy. But whether
the government has imposed a substantial burden on their
religious exercise is a legal determination. Notre Dame II,
786 F.3d at 612; Little Sisters of the Poor, 794 F.3d at —, 2015 WL
4232096, at *18; East Texas Baptist University, 793 F.3d at 456–59
& n.33; Geneva College, 778 F.3d at 436; Priests for Life, 772 F.3d
at 247–49; Michigan Catholic, 755 F.3d at 385. And we are not
required to defer to the plaintiffs’ beliefs about the operation
of the law. Notre Dame II, 786 F.3d at 612 (although an objector
is the final arbiter of its religious beliefs, it is for the courts to
determine whether the law actually forces the objector to act in
a way that would violate those beliefs); Little Sisters of the Poor,
794 F.3d at —, 2015 WL 4232096, at *18 (courts need not accept
the legal conclusion, cast as a factual allegation, that a plain-
tiff’s religious exercise is substantially burdened); Geneva
College, 778 F.3d at 436 (courts need not accept an objector’s
characterization of a regulatory scheme on its face but may
consider the nature of the action required of the objector, the
connection between that action and the objector’s beliefs, and
the extent to which that action interferes with or otherwise
affects the objector’s exercise of religion, all without delving
into the objector’s beliefs); Michigan Catholic, 755 F.3d at 385
(although a court may acknowledge that the objectors believe
that the regulatory framework makes them complicit in the
provision of contraception, the court will independently
determine what the regulatory provisions require and whether
they impose a substantial burden on the objector's exercise of
religion). In this instance, and as was the case in Notre Dame I
and II, the plaintiffs misapprehend the operation of federal
32 Nos. 14-1430 & 14-1431
law. As many courts have noted, contraceptive coverage under
the ACA results from federal law, not from any actions
required by objectors under the accommodations. Notre Dame
II, 786 F.3d at 614; and 786 F.3d at 623 (Hamilton, J., concur-
ring); Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096,
at *16; East Texas Baptist, 793 F.3d at 459; Geneva College, 778
F.3d at 437; Michigan Catholic, 755 F.3d at 387.
The first action to which the plaintiffs object is filing the
Form 700. They assert that the Form 700 is far more than a
simple notification or objection, that it instead (1) designates
the third party administrator as plan administrator and claims
administrator for contraceptive benefits; (2) serves as an
instrument under which the plans are operated vis-à-vis
contraceptive services; and (3) apprises the third party admin-
istrator of its obligations to provide contraceptive coverage. We
rejected this very argument in Notre Dame II, holding that
treating the mailing of the Form 700 as the cause of the
provision of contraceptive services is legally incorrect. 786 F.3d
at 613. The Form 700, we noted, has the effect of throwing the
entire administrative and financial burden of providing
contraception on the insurer and the third party administrator.
786 F.3d at 613–14. As a result, the burden is lifted from the
objector’s shoulders. 786 F.3d at 614. “It is federal law, rather
than the religious organization's signing and mailing the form,
that requires health-care insurers, along with third-party
administrators of self-insured health plans, to cover contracep-
tive services.” 786 F.3d at 614. See also Little Sisters of the Poor,
794 F.3d at —, 2015 WL 4232096 at *16 & *22-24 (finding that
plaintiffs do not “trigger” or otherwise cause contraceptive
coverage because federal law, not the act of opting out, entitles
Nos. 14-1430 & 14-1431 33
plan participants and beneficiaries to coverage); Geneva College,
778 F.3d at 437–38 (same); Michigan Catholic, 755 F.3d at 387
(same).
Moreover, the regulations have been amended during this
litigation, and now employers need not file the Form 700.
Instead, consistent with the Supreme Court’s interim orders in
Little Sisters of the Poor and Wheaton College, the plaintiffs may
contact the Department of Health and Human Services
directly, alerting the government that they have a religious
objection to providing contraceptive coverage, and providing
only the name and contact information for their insurers or
third party administrators. 80 Fed. Reg. 41342-47 (July 14,
2015). The burden then falls on the government to make
appropriate arrangements with the insurer or third-party
administrator to provide coverage for contraceptive services.
The plaintiffs object to that action as well, asserting that it also
makes them complicit in the provision of coverage. But that
notification does nothing more than completely remove an
objector from the provision of the objectionable services. See
Geneva College, 778 F.3d at 436 (“While the Supreme Court
reinforced in Hobby Lobby that we should defer to the reason-
ableness of the appellees' religious beliefs, this does not bar our
objective evaluation of the nature of the claimed burden and
the substantiality of that burden on the appellees' religious
exercise.”). As we noted in our Notre Dame opinions, the
plaintiffs are in the strange position of objecting not to the
contraceptive mandate itself but to the accommodation that
relieves them of any involvement in the implementation of the
contraceptive mandate. Notre Dame I, 743 F.3d at 557–58; Notre
Dame II, 786 F.3d at 621 (Hamilton, J., concurring). See also Little
34 Nos. 14-1430 & 14-1431
Sisters of the Poor Home for the Aged v. Burwell, 794 F.3d —, 2015
WL 4232096, *14-15 (10th Cir. 2015) (noting the unusual nature
of a claim that attacks the government's attempt to accommo-
date religious exercise by providing a means to opt out of
compliance with a generally applicable law).
[T]he arrangements the government makes to find
substitutes for those given the benefit of a religious
exemption are imposed as a matter of federal law,
not as a result of the exemption itself. The party
claiming the exemption is not entitled to raise a
religious objection to the arrangements the govern-
ment makes for a substitute.
Notre Dame II, 786 F.3d at 623 (Hamilton, J., concurring). In
short, requiring an employer to notify the government of its
objection to the mandate is no more burdensome than the
government’s use of a girl’s Social Security number in a
benefits program even though her father sincerely believed
that the use of the number would harm his daughter’s spirit.
See Notre Dame II, 786 F.3d at 618–19 (discussing Bowen v. Roy,
476 U.S. 693 (1986)). So too with the plaintiffs here.
The second action to which the plaintiffs object is contract-
ing with insurers and third-party administrators who will then
provide the objectionable coverage, albeit at no cost to, and
without further involvement of, the plaintiffs. The plaintiffs
admittedly want to provide their employees and students with
health insurance; indeed they have said that it is part of their
religious mission to do so. But they wish to provide health
insurance without the objectionable coverage. Yet this is
exactly what the accommodation allows them to do. Notre
Nos. 14-1430 & 14-1431 35
Dame II, 786 F.3d at 621–22 (Hamilton, J., concurring) (once an
employer files the Form 700 or notifies the government directly
of its religious objection, it can avoid contracting, paying,
arranging, or referring for the objectionable contraceptive
care); Wheaton College, 791 F.3d at 795–96 (once the college
notifies its insurer or the government of its religious objections,
the college and its health plans are bypassed). As with the
notification requirement, the plaintiffs believe that their
contracts further the provision of objectionable services. They
assert that the government is using their health plans or
altering the terms of their health plans to provide contraceptive
coverage. But once they have objected, the government does
not use the health plans or contracts at all, much less alter any
terms. See Wheaton College, 791 F.3d at 796 (“Call this ‘using’ the
health plans? We call it refusing to use the health plans.”). As
we noted in Wheaton College:
The upshot is that the college contracts with health
insurers for contraceptive coverage exclusive of
coverage for emergency contraceptives, and the
Department of Health and Human Services con-
t r a c t s w i t h t h o s e in s u r e r s t o c o ve r
emergency-contraceptive benefits. The latter con-
tracts are not part of the college's health plans, and
so the college is mistaken when it tells us that the
government is “interfering” with the college’s
contracts with its insurers. The contracts, which do
not require coverage of emergency contraception,
are unchanged. New contracts are created, to which
the college is not a party, between the government
and the insurers.
36 Nos. 14-1430 & 14-1431
Wheaton College, 791 F.3d at 796. We rejected any notion of
complicity in the provision of contraceptive services arising
from the mere existence of a contract to provide health insur-
ance without any contraceptive coverage. 791 F.3d at 797. See
also Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096 at
*16 (the de minimis administrative tasks required to opt out of
the mandate relieves objectors from complicity); East Texas
Baptist, 793 F.3d at 461 (“Under the accommodation, the
contracts are solely for services to which the plaintiffs do not
object; the contracts do not provide for the insurers and
third-party administrators to cover contraceptives, do not
make it easier for those entities to pay for contraceptives, and
do not imply endorsement of contraceptives.”).
To the extent that the act of opting out causes the legal
responsibility to provide contraceptive coverage to shift from
the plaintiffs to their insurers or third-party administrators,
this feature relieves rather than burdens their religious
exercise. Little Sisters of the Poor, 794 F.3d at —, 2015 WL
4232096 at *16. As our colleagues in the Tenth Circuit noted,
“An opt out religious accommodation typically contemplates
that a non-objector will replace the religious objector and take
over any legal responsibilities.” Little Sisters of the Poor, 794
F.3d at —, 2015 WL 4232096, *16 n.21; East Texas Baptist, 793
F.3d at 461–62 (RFRA does not entitle plaintiffs to block third
parties such as the government or insurers from engaging in
conduct with which the plaintiffs disagree); Geneva College, 778
F.3d at 438 n.13 (the provision of contraceptive coverage is not
dependent upon the objector’s contract with its insurance
company); Michigan Catholic, 755 F.3d at 388 (the government's
imposition of an independent obligation on a third party does
Nos. 14-1430 & 14-1431 37
not impose a substantial burden on an objector’s exercise of
religion).
Finally, the Catholic plaintiffs here (namely, the Diocese,
Catholic Charities, St. Anne Home, Franciscan Alliance,
Specialty Physicians, St. Francis and Sunday Visitor) assert
what they characterize as unique RFRA claims that were not
presented in the Notre Dame appeal and therefore are not
resolved by the Notre Dame opinions. In particular, they argue
that the mandate substantially burdens the Diocese’s religious
exercise by forcing it to forgo almost $200,000 annually in
increased premiums to maintain its grandfathered status so
that it may avoid its health plan becoming a conduit for
objectionable coverage for Catholic Charities’ employees who
are enrolled in its health plan. See note 11 supra. But if the
Diocese were to lose its grandfathered status, it would become
exempt from the ACA’s contraceptive mandate, and Catholic
Charities would be able to opt out of the mandate by employ-
ing the accommodation. As we just concluded, that scenario
would not impose a substantial burden on the free exercise
rights of either the Diocese or Catholic Charities.
The Catholic plaintiffs also contend that the mandate has
the effect of artificially dividing the Catholic Church into a
“worship” arm (the Diocese) and a “good works” arm (the
remaining Catholic plaintiffs). Again, though, groups affiliated
with the Diocese may opt out of providing contraceptive
coverage using the accommodation and thus continue to
provide health coverage under the Diocese’s health plan. Both
arms of the Church are therefore extricated from the provision
of objectionable contraceptive services, albeit through different
means. Moreover, any division is created not by the ACA but
38 Nos. 14-1430 & 14-1431
by the Internal Revenue Code that excepts “churches, their
integrated auxiliaries, and conventions or associations of
churches” from certain requirements. See 26 U.S.C.
§ 6033(a)(3)(A)(i). It is difficult to see how laws and regulations
that grant tax advantages to churches and their integrated
auxiliaries somehow impose a substantial burden on affiliates.
III.
The accommodation does not serve as a trigger or a conduit
for the provision of contraceptive services. Notre Dame II,
786 F.3d at 612–15; Wheaton College, 791 F.3d at 795–97. It is the
operation of federal law, not any actions that the plaintiffs
must take, that causes the provisions of services that the
plaintiffs find morally objectionable. The accommodation has
the legal effect of removing from objectors any connection to
the provision of contraceptive services. As we noted above,
every other circuit court to consider the issue of whether the
mandate imposes a substantial burden on religious exercise
has come to the same conclusion. As a result, the plaintiffs are
not entitled to a preliminary injunction against the enforcement
of the ACA regulations. If they wish to object, they may either
employ the Form 700 or they may notify the Department of
Health and Human Services directly. We extend the injunc-
tions here for 60 days so that the district court may consider in
the first instance the additional arguments that plaintiffs raised
in support of injunctive relief. We reverse the district court’s
judgments and remand for proceedings consistent with this
opinion.
REVERSED AND REMANDED.
Nos. 14‐1430 & 14‐1431  39
MANION, Circuit Judge, dissenting.
The HHS accommodation is the long and winding exten‐
sion  cord  the  government  uses  to  power  its  contraceptive
mandate.  It  winds  through  regulations  and  additions  and
revisions. The court, through a perfunctory examination, in‐
terprets  the  accommodation’s  twisted  framework  and  holds
that  it  frees  the  religious  nonprofits  from  having  to  power
the  mandate  themselves  and,  thus,  does  not  violate  the
RFRA. The  court  is  wrong: A  thorough examination  reveals
that the accommodation’s tangled mess is hiding the fact that
the extension cord gets its power from the nonprofits’ health
plans and must be plugged in before it will work. It also ex‐
poses the fact that  the government  is forcing the  nonprofits
to  plug  in  the  accommodation  themselves  by  signing  the
self‐certification or providing the alternative notice.
This dissent, as long and detailed as it is, reveals that the
accommodation  never  relieves  the  religious  nonprofits  or
their  health  plans  from  the  provision  of  contraceptive  ser‐
vices  which  burdens  their  religious  exercise.  Section  I  ex‐
plains  how  the  court,  as  many  others  have  before  it,  uses  a
caricature of the HHS accommodation to avoid accepting the
nonprofits’ sincerely held religious belief as required by the
Supreme  Court  in  Burwell  v.  Hobby  Lobby  Stores,  Inc.,  134  S.
Ct. 2751 (2014). Section II shows that the nonprofits correctly
understand the accommodation’s operation, so that the court
must  accept  their  sincerely  held  religious  belief  and  hold
that  the  accommodation  imposes  a  substantial  burden  on
their  religious  exercise.  Section  III  demonstrates  that  the
government  has  utterly  failed  to  prove  that  the  HHS  ac‐
40  Nos. 14‐1430 & 14‐1431
commodation  furthers  a  compelling  governmental  interest:
The  government  has  failed  to  establish  any  of  the  causal
links  necessary  to  prove  that  increasing  the  availability  of
contraceptive  services  will  improve  the  health  of  women
generally,  let  alone  that  of  the  nonprofits’  employees.  Fur‐
thermore, the government’s stated interest is overbroad, un‐
derinclusive,  and  marginal  at  best.  Section  IV  demonstrates
that,  even  if  the  government  had  a  compelling  interest,  the
accommodation  is  not  the  least  restrictive  means.  For  these
reasons,  Section  V  concludes  that  the  HHS  accommodation
violates  RFRA,  which  means  the  nonprofits  have  a  signifi‐
cant likelihood of success on the merits of their claim and the
district  court’s  preliminary  injunction  should  be  affirmed.
For the many reasons that follow, I dissent.
I.  The court refuses to apply RFRA.
RFRA  prevents  the  government  from  substantially  bur‐
dening a person’s religious exercise unless the burden on the
person is the least restrictive means of furthering a compel‐
ling  governmental  interest.  42  U.S.C.  §  2000bb‐1.  The  Su‐
preme  Court  has  made  it  abundantly  clear  that  courts  are
wholly  incompetent  to  decide  whether  a  governmental  ac‐
tion  burdens  a  person’s  religious  exercise.  Rather,  courts
must accept a person’s sincere belief that it is a burden. Hob‐
by Lobby, 134 S. Ct. at 2778–79. Courts determine whether the
burden is substantial, but they do so by examining the level
of  coercion  applied  to  compel  compliance,  not  what  is  re‐
quired by that compliance and to what extent it violates the
person’s  religion.  Id.  at  2779;  Korte  v.  Sebelius,  735  F.3d  654,
683 (7th Cir. 2013). Thus, the proper analysis is to determine
Nos. 14‐1430 & 14‐1431  41
first, that the nonprofits have a sincere belief that compliance
with  the  law  would  violate  their  religion,  and  second,  that
the  pressure  applied  by  the  government  to  coerce  compli‐
ance with the law is substantial. The outcome of a thorough
and  proper  analysis  is  ultimately  simple  and  straightfor‐
ward: As  in  Hobby  Lobby,  the  government  concedes  the  sin‐
cerely  held  religious  belief  and  the  fines  imposed  for  non‐
compliance are “enormous.” Hobby Lobby, 134 S. Ct. at 2779.
So,  following  Hobby  Lobby,  the  accommodation  imposes  a
substantial  burden.  That  the  government  labels  it  an  ac‐
commodation makes no difference to the burden it imposes
on the nonprofits. The analysis remains the same.
The court does not apply these straightforward steps be‐
cause it balks at the idea that we must accept a person’s as‐
sertion that a law burdens their religion. The court fears that
such a rule will allow a person to escape any number of reg‐
ulations, including this brave new world of free and univer‐
sal contraceptives, unless the government can meet the strict
scrutiny  test  laid  down  by  RFRA.1  This  was  the  same  con‐
cern  that  prompted  the  Supreme  Court’s  decision  to  limit
free exercise protections in Employment Div., Dept. of Human
Resources  of  Ore.  v.  Smith,  494  U.S.  872  (1990).  Hobby  Lobby,
134  S.  Ct.  at  2761–62.  Nevertheless,  when  it  enacted  RFRA,
Congress  meant  to  restore  exactly  the  level  of  protection  to
religious exercise that now so concerns the court. Id. at 2761–
1  What  goes  unsaid  by  this  critique  is  the  conclusion  that  the  non‐
profits’  religious  beliefs  are  less  deserving  of  protection  than  the  gov‐
ernment’s scheme to marginally increase the availability of contraceptive
services for certain employees.
42  Nos. 14‐1430 & 14‐1431
62;  Korte,  735  F.3d  at  671–72.  So,  foreclosed  by  the  Supreme
Court, the court rules as it and many others have before: The
court  rejects  the  nonprofits’  sincere  belief  that  compliance
with the HHS accommodation is prohibited by their religion
by holding that the nonprofits misunderstand the manner in
which  the  accommodation  operates.  Then,  acting  as  an  ex‐
pert  theologian,  the  court  holds  that  the  accommodation’s
operation  as  understood  by  the  court  is  not  a  substantial
burden  to  the  nonprofits’  religious  exercise.  Ante,  at  38;  see
also  Wheaton  Coll.  v.  Burwell,  791  F.3d  792  (7th  Cir.  2015);
Univ.  of  Notre  Dame  v.  Burwell,  786  F.3d  606  (7th  Cir.  2015)
(Notre Dame  II);  Michigan  Catholic  Conference  v.  Burwell,  2015
WL  4979692  (6th  Cir. Aug.  21,  2015);  Little Sisters  of  the  Poor
Home for the Aged v. Burwell, 794 F.3d 1151 (10th Cir. Jul. 14,
2015); East Texas Baptist Univ. v. Burwell, 793 F.3d 449 (5th Cir.
Jun. 22, 2015); Geneva College v. Secretary United States Dep’t of
Health & Human Servs., 778 F.3d 422 (3d Cir. 2015); Priests for
Life  v.  United States Dep’t of Health  & Human Servs., 772  F.3d
229  (D.C.  Cir.  2014).  But  cf.  Notre  Dame  II,  786  F.3d  at  626
(Flaum,  J.,  dissenting);  Little  Sisters,  794  F.3d  1151,  2015  WL
4232096, *41 (Baldock, J., dissenting); Priests for Life v. United
States  HHS,  2015  U.S.  App.  LEXIS  8326,  *16  (D.C.  Cir.  May
20, 2015) (en banc denied) (Brown, J. and Kavanaugh, J., dis‐
senting);  Eternal  Word  Television  Network,  Inc.  v.  Sec’y,  U.S.
Dep’t of Health & Human Servs., 756 F.3d 1339, 1340 (11th Cir.
2014) (Pryor, J., concurring).
The court does this by improperly judging the nonprofits’
religious beliefs and ignoring the penalties used for compli‐
ance. Had the nonprofits said that they sincerely believe that
the HHS accommodation violates their religion and left it at
Nos. 14‐1430 & 14‐1431  43
that,  perhaps  the  injunction  would  remain  in  place  because
there would be nothing for the court to attack. But since the
nonprofits  said  that  they  sincerely  believe  that  the  accom‐
modation  violates  their  religion  because  the  accommodation
makes them complicit in the provision  of  contraceptive  ser‐
vices,  the  court  has  attacked  their  claim  that  the  law makes
them complicit. The court is right that  it is  “not required to
defer to the plaintiffs’ beliefs about the operation of the law.”
Ante,  at  31.  Nevertheless,  it  is  the  nonprofits  that  are  right
about the operation of the law, not the court.
II.  The  accommodation  imposes  a  substantial  burden  on
the nonprofits’ religious exercise.
The court denies that the self‐certification and alternative
notice  process  trigger  the  provision  of  contraceptive  cover‐
age.  According  to  the  court,  it  is  federal  law,  not  the  self‐
certification  form  or  alternative  notice,  which  results  in  the
contraceptive  coverage. The  court  says that  self‐certification
throws the burden of contraceptive coverage on to the non‐
profits’  health  insurance  issuers  (insurers)  and  third  party
administrators (TPAs). Ante, at 32. But how does this lift the
burden off the nonprofits when the accommodation imposes
the  “free”  contraceptive  coverage  requirement  only  on  the
insurers and TPAs that the nonprofits have hired? In spite of
that  imposition,  the  court  also  denies  that  the  accommoda‐
tion uses the nonprofits’ health plans to provide the contra‐
ceptive  coverage.  Instead,  it  says  that  the  government  con‐
tracts with the insurers and TPAs to provide the coverage to
only the beneficiaries on the nonprofits’ health plans. Ante, at
35.  But,  given  that  connection  with  the  nonprofits’  health
44  Nos. 14‐1430 & 14‐1431
plans,  how  can  the  provision  of  coverage  be  completely  in‐
dependent of those same plans?
The court can only make such sweeping claims by ignor‐
ing  the  true  operation  of  the  accommodation  and  the  legal
consequences  the  government  has  attached  to  the  self‐
certification and alternative notice. The court may think that
the nonprofits “throw” their burden onto their insurers and
TPAs,  but  it  ignores  who  is  forced  to  do  the  throwing  and
who  ultimately  carries  the  burden  once  thrown.  A  close  ex‐
amination  of  the  manner  in  which  the  regulations  actually
operate reveals that the government’s promise of accommo‐
dation  is  illusory.  The  nonprofits’  claim  that  the  HHS  ac‐
commodation makes them complicit in the provision of con‐
traceptive coverage becomes obvious.
A.  The  self‐certification  form  and  alternative  notice
trigger the coverage of contraceptive services.
The court holds that the self‐certification and alternative
notice are simply signs that the nonprofits have opted out of
providing contraceptive coverage, and once the sign is made
known the law obliges the nonprofits’ insurers and TPAs to
provide  the  unwanted  coverage.  Ante,  at  32–33.  In  reality,
once  the  nonprofits  formally  object,  they  are  opted  in.  The
self‐certification  and  alternative  notice  do  more  than  give
notice of the nonprofits’ objections. And they are much more
than  de  minimis  paperwork  necessary  to  effectuate  the  non‐
profits’ objection. They create the insurers’ and TPAs’ obliga‐
Nos. 14‐1430 & 14‐1431  45
tion  to provide  the  contraceptive coverage.2 For a  nonprofit
with  a  self‐insured  plan,  the  effect  of  the  self‐certification
and  alternative  notice  is  abundantly  clear:  the  government
makes  them  legal  instruments  under  which  the  nonprofit’s
health  plan  is  operated.  This  then  allows  the  regulations  to
treat them as legal designations of the TPA as plan adminis‐
trator and claims administrator for coverage of contraceptive
services under the nonprofit’s health plan.3 Only a nonprofit
can designate its plan administrator.4 The government’s abil‐
ity to define how a plan administrator is designated does not
give it the power to designate who will be a plan administra‐
2 45 C.F.R. § 147.131(c)(2)(i) (“A group health insurance issuer that re‐
ceives a copy of the self‐certification or notification … must … [p]rovide sepa‐
rate  payments  for  any  contraceptive  services  for  plan  participants  and
beneficiaries for so long as they remain enrolled in the plan.” (emphasis
added));  29  C.F.R.  §  2590.715–2713A(c)(2)(i)  (identical  requirement  for
TPAs); 78 Fed. Reg. 39878 (listing among the key elements of the accom‐
modation the need for eligible organizations with insured group health
plans  to  self‐certify  and  that  it  is  the  “issuer  that  receives  a  self‐
certification”  that  must  comply  with  the  accommodation’s  require‐
ments); 78 Fed. Reg. 39880 (“A third party administrator that receives a
copy  of  the  self‐certification  …  must  provide  or  arrange  separate  pay‐
ments for contraceptive services … .”).
3  78  Fed.  Reg.  39879  (“The  self‐certification  …  will  be  treated  as  a
designation of the third party administrator(s) as plan administrator and
claims administrator for contraceptive benefits pursuant to section 3(16)
of ERISA.”); 29 C.F.R. § 2510.3–16 (defining the term plan administrator
to  include  the  regulatory  treatment  of  the  self‐certification  and  alterna‐
tive notice as acts of designation and declaring that each “shall be an in‐
strument under which the plan is operated”).
4 29 U.S.C. § 1102(a)(2).
46  Nos. 14‐1430 & 14‐1431
tor.5 For the TPA to have the necessary authority to provide
coverage  for  contraceptive  services,  the  nonprofit  must  desig‐
nate the TPA as a plan administrator.6 Such an act would ob‐
viously  violate  the  nonprofit’s  religion.  So  the  government
has  loaded  the  self‐certification  and  alternative  notice  with
the legal significance of designating the TPA. It is not the op‐
eration  of  law.  It  is  the  acts  of  self‐certification  and  alterna‐
tive notice that designate the TPA and facilitate the provision
of the unwanted contraception coverage. Without possession
of  the  self‐certification or alternative notice, the TPA cannot
receive  reimbursement  for  the  provision  of  contraceptives.7
In  sum,  the  government  can  only  require  the  nonprofits’
TPAs  to  cover  contraceptive  services  if  the  nonprofits  give
the government the legal authority to do so. The government
has hidden that legal authority in self‐certification and alter‐
native notice.
For insurers the situation is not as clear, but it is not the
less  burdensome.  The  law  requires  insurers  to  include  con‐
traceptive coverage in every health plan they offer.8 (Insurers
will not, however, provide something for which they are not
5 29 U.S.C. § 1002(16)(A).
6  78  Fed.  Reg.  39880  (“The  third  party  administrator  serving  as  the
plan administrator for contraceptive benefits ensures that there is a party
with  legal  authority  to  arrange  for  payments  for  contraceptive  services
and  administer  claims  in  accordance  with  ERISA’s  protections  for  plan
participants and beneficiaries.”).
7 See infra note 18.
8 45 C.F.R. § 147.131(a)(1).
Nos. 14‐1430 & 14‐1431  47
paid.9) The  self‐certification  and  alternative  notice  permit  an
insurer to offer a health plan that appears not to include con‐
traceptive coverage. But this is on the condition that  the in‐
surer  still  provides  the  coverage  itself  in  the  form  of  direct
payments.10 The assertion that it is the operation of law that
designates  an  objecting  nonprofit’s  insurer  as  the  replace‐
ment  is  misleading.  It  ignores  the  fact  that  but  for  the  non‐
profit’s  hiring  of  the  insurer,  and  the  nonprofit’s  continuing
contractual  relationship  with  it,  the  government  (or  the  op‐
eration  of  law)  would  not  make  any  designation.  Without
the objection  and designation  by the  nonprofits,  the  insurer
is  not  required  to  act  at  all,  despite  the  court’s  claim  to  the
contrary. The government has turned the act of objecting into
the act of designating and it cannot escape the consequences
of that conflation by calling it an act of law.
This  is  not  like  the  case  of  a  conscientious  objector  who
objects  and  the  government  finds  a  replacement.  Under  the
regulations,  the  government  does  not  find  the  replacement,
the nonprofit does. The designation does not take place un‐
less the nonprofit either delivers the self‐certification form to
its  insurer  or  TPA,  or  uses  the  alternative  notice  to  inform
the government who its insurer or TPA is and which health
plan  is  at  issue.  By  insisting  that  the  nonprofit  deliver  the
form  or  supply  the  plan  information  for  the  government’s
use,  the  government  uses  the  objecting  nonprofit  to  do  its
9 See infra note 21.
10 See supra note 2.
48  Nos. 14‐1430 & 14‐1431
dirty work. The government has not provided an exit—it of‐
fers a revolving door with only one opening.11
Furthermore,  this  is  not  like  the  case  of  a  conscientious
objector who refuses to object and goes to jail, and the gov‐
ernment still finds a replacement. If the nonprofits refuse to
self‐certify or provide the alternative notice and instead pay
the huge fines, their insurers and TPAs will not automatical‐
ly  provide  the  contraception  coverage.  To  comply  with  the
law, the insurers would refuse to sell plans without the cov‐
erage, while the TPA would refuse to provide their services.
In  spite  of  the  huge  monetary  penalties,  the  nonprofits
would  still  be  prevented  from  providing  health  plans  for
their employees, which they have asserted is also a violation
of  their  religious  beliefs.  So  the  no‐win  substantial  burden
would hit them on both sides.
The  court  has  implied  that  requiring  the  nonprofit  to
identify  its  insurer  (or  TPA)  is  merely  the  most  efficient
means  for  the  government  to  achieve  its  objective,  Wheaton,
791 F.3d at 798, but efficiency does not excuse the substantial
burden  imposed  by  the  requirement.  Identifying  its  insurer
so  that  the  government  can  instruct  that  insurer  to  provide
11  This  is  not  the  case  of  a  conscientious  objector  walking  into  the
draft  board,  voicing  his  objection,  being  excused,  and  walking  out.  For
the analogy to fit the HHS accommodation, the draft board must decide
that every objector will be replaced by the objector’s friend, and the ob‐
jector’s objection is only effective if the objector delivers written notice of
his  objection to  his  friend  or  tells  the  draft  board  who  his  friend  is  and
where  the  board  can  find  him.  Then,  the  objector  must  send  his  friend
money  so  that  that  his  friend  will  remain  his  friend  for  the  purpose  of
being his replacement.
Nos. 14‐1430 & 14‐1431  49
contraceptive coverage is just as burdensome to the nonprof‐
it  as  if  it  had  to  pick  its  own  replacement,  because  it  has
done just that by hiring its insurer and then objecting to the
coverage requirement. That the nonprofits could not object if
the  government,  on  its  own,  were  to  find  a  replacement  in‐
surer and discover to which employees it had to provide the
coverage is not relevant. Of course the nonprofits would not
have an objection to the government contracting with a third
party  to  provide  the  contraceptive  coverage  to  other  third
parties.  They  believe  the  provision  of  objectionable  contra‐
ceptives is always immoral, but they know they have no le‐
gal  means  to  stop  the  government  from  contracting  with
third  parties.  That  is  not  what  is  happening  here.  The  gov‐
ernment is using the nonprofits, their health plans, and their
contractual  relationships  with  their  insurers  and  TPAs,  to
provide the contraception coverage to which they object.
B.  The  accommodation  uses  the  nonprofits’  health
plans.
The HHS accommodation requires significantly more in‐
volvement  on  the  part  of  the  nonprofits  and  their  health
plans than the court relates. For starters, the accommodation
does not create independent policies or contracts. In fact, as
the  nonprofits  assert,  the  accommodation  relies  wholly  on
the existing contract between the nonprofits and the insurers
and TPAs to provide separate payments directly to the non‐
profits’ health plan beneficiaries.12 The accommodation must
12 78  Fed.  Reg.  39874  (“[T]he  accommodations  established  under
these final regulations do not require the issuance of a separate excepted bene‐
fits individual health insurance policy covering contraceptive services … but
50  Nos. 14‐1430 & 14‐1431
use  the  existing  insurance  contracts  to  issue  payments  be‐
cause  separate  policies  would  violate  insurance  laws.13  The
separate payments are only provided so long as an employ‐
ee  is  enrolled  in  the  nonprofit’s  health  plan,  thus  requiring
the nonprofits’ health plans to determine eligibility.14 The ac‐
commodation also relies on the nonprofits’ health plans’ en‐
rollment  procedures.  The  insurers  and  TPAs  must  provide
notice of the separate payments when they provide notice of
the  other  benefits  under  the  nonprofits’  health  plans.15  The
separate payments can be limited to the same provider net‐
work  as  the  other  plan  benefits.16  The  end  result  is  that  the
instead require a simpler method of providing direct payments for con‐
traceptive services.” (emphasis added)).
13 78 Fed. Reg. 39876 (“As the payments at issue derive solely from a
federal  regulatory  requirement,  not  a  health  insurance  policy,  they  do
not  implicate  issues  such  as  issuer  licensing  and  product  approval  re‐
quirements under state law … ”).
14  45  C.F.R.  §  147.131(c)(2)(i)(B)  (insurers  must  “[p]rovide  separate
payments  for  any  contraceptive  services  …  for  plan  participants  and
beneficiaries for so long as they remain enrolled in the plan.”); 29 C.F.R.
§ 2590.715–2713A(c)(2)(i)(B)  (identical  regulatory  requirements  for
TPAs).
15 78 Fed. Reg. 39881 (“The notice [regarding the provision of contra‐
ceptive  services]  must  be  provided  contemporaneous  with  (to  the  extent
possible), but separate from, any application materials distributed in connec‐
tion  with  enrollment  (or  re‐enrollment)  in  coverage … .”  (emphasis  add‐
ed)).
16  78  Fed.  Reg.  39877  (“[A]n  issuer  …  may  require  that  contraceptive
services be obtained in‐network (if an issuer has a network of providers) in
order  for  plan  participants  and  beneficiaries  to  obtain  such  services
without cost sharing.” (emphasis added)).
Nos. 14‐1430 & 14‐1431  51
contraceptive  services  become  a  de  facto  benefit  under  the
nonprofits’  health  plans.17  The  government  admitted  as
much  when  it  stated  that  it  was  by  design  that  the  accom‐
modation  makes  the  provision  of  contraceptive  coverage
“seamless[]”  with  the  other  plan  benefits.  Gov’t  Supp  and
Reply  Br.,  14.  These  circumstances  sharply  conflict  with  the
court’s conclusion that the accommodation does not use the
nonprofits’ health plans and “makes every effort to separate
religious employers from the provision of any objectionable
services.” Ante,  at  23.  “[E]very  effort”  does  not  disguise  the
fact that the offensive provision is inseparably imbedded in
the nonprofits’ health plan. Id.
A  further  indication  that  the  accommodation  uses  the
nonprofits’ health plans is the fact that the only way an em‐
ployee receives coverage for contraceptive services under the
accommodation  is  to  enroll  in  the  objecting  nonprofit’s
health  plan. An  employee  cannot  reject  coverage  under  the
nonprofit’s plan and still receive coverage under the accom‐
modation.  The  coverage  under  the  accommodation  is  not
separate  from  the  coverage  under  the  nonprofit’s  health
plan.  It  is  the  employee’s  status  as  a beneficiary  of  the  non‐
profit’s health plan, not as an employee, that entitles the em‐
ployee to coverage under the accommodation. Simply being
hired  as  an  employee  is  not  enough  to  receive  coverage;  an
17 78 Fed. Reg. 39880 (“[T]he self‐certification … identifies the limited
set of plan benefits (that is, contraceptive coverage) that the employer re‐
fuses to provide and that the third party administrator must therefore provide
or arrange for an issuer or another entity to provide.” (emphasis added)).
52  Nos. 14‐1430 & 14‐1431
employee must enroll in the nonprofit’s health plan. Cf. Notre
Dame II, 786 F.3d at 617.
C.  The  nonprofits  are  involved  in  the  payment  for  con‐
traceptive services.
Finally, there is the matter of payment. For TPAs, the self‐
certification  and  alternative  notice  act  as  authorizations  for
payment,  without  which  the  TPAs  cannot  receive  reim‐
bursement  from  the  government  for  payments  made  under
the accommodation.18 The government assumed that the re‐
imbursements for TPAs would not be passed on to the non‐
18 Payments for contraceptive services provided by TPAs under the
HHS  accommodation  are  funded  through  an  adjustment  (i.e.,  discount)
to  the  federally‐facilitated  exchange  (FFE)  user  fee.  See  78  Fed.  Reg.
39882. The FFE user fee is paid by insurance issuers that participate in a
federal health care exchange to support the operations of the exchange.
See  78  Fed.  Reg.  15412;  45  C.F.R.  §  156.50(c).  The  amount  of  the  adjust‐
ment  is  equal  to  the  total  amount  of  the  payments  made  for  contracep‐
tive services provided by the TPA plus an allowance of at least 10 percent
for administrative costs. 45 C.F.R. § 156.50(d)(3). To receive the FFE user
fee  adjustment,  a  TPA  must  submit  to  HHS  “[a]n  attestation  that  the
payments  for  contraceptive  services  were  made  in  compliance  with  26
CFR  54.9815‐2713A(b)(2)  or  29  CFR  2590.715‐2713A(b)(2).”  45  CFR  §
156.50(d)(2)(iii)(E). Both the provisions cited by § 156.50 provide that the
TPA will provide the separate payments for contraceptive services “[i]f a
third party administrator receives a copy of the self‐certification from an
eligible  organization  or  a  notification.”  26  CFR  §  54.9815‐2713AT(b)(2)
and  29  CFR  §  2590.715‐2713A(b)(2).  Moreover,  §  156.50  requires  a  TPA
which receives an adjustment to maintain for 10 years and make availa‐
ble upon request “[a] copy of the self‐certification referenced in 26 CFR
54.9815‐2713A(a)(4) or 29 CFR 2590.715‐2713A(a)(4) for each self‐insured
plan  with  respect  to  which  an  adjustment  is  received.”  45  CFR  §
156.50(d)(7)(i).
Nos. 14‐1430 & 14‐1431  53
profits but, as more nonprofits are forced to use the accom‐
modation and more contraceptive services are provided un‐
der the accommodation, that assumption is unlikely to prove
true.19 For insurers there is ostensibly no reimbursement be‐
cause  the  government  claims  the  cost  of  contraceptive  ser‐
vices will be offset by the reduction in unintended pregnan‐
cies.20  Whether  this  claim  is  true  will  be  hard  to  determine
because the regulations allow insurers to recapture costs for
contraceptive  services  provided  under  the  accommodation
through  what  is  called  the  “risk  corridor  program.”21  The
19 The government assumed that the adjustments granted under the
accommodation  for  2014  would  be  small  enough  to  have  no  impact  on
the  fee.  78  Fed.  Reg.  39882.  However,  the  FFE  user  fee  will  have  to  be
increased to cover 1) more adjustments as more nonprofits are forced to
take  advantage  of  this  accommodation,  and  2)  greater  adjustments  be‐
cause the HHS mandate incentivizes more expensive forms of contracep‐
tion. An increase in the FFE user fee will eventually be recouped through
an increase in premiums, albeit an increase across the insurance issuer’s
entire portfolio, but the nonprofits may be in that same portfolio.
20  78  Fed.  Reg.  39877  (“The  Departments  continue  to  believe,  and
have  evidence  to  support,  that,  with  respect  to  the  accommodation  for
insured  coverage  established  under  these  final  regulations,  providing
payments for contraceptive services is cost neutral for issuers.”).
21 78 Fed. Reg. 39878 (“[A]n issuer of group health insurance cover‐
age  that  makes  payments  for  contraceptive  services  under  these  final
regulations  may  treat  those  payments  as  an  adjustment  to  claims  costs
for purposes of medical loss ratio and risk corridor program calculations.
This adjustment compensates for any increase in incurred claims associ‐
ated with making payments for contraceptive services.”). The “risk cor‐
ridor  program”  is  a  complex  cost‐sharing  program  in  which  insurers
with healthier beneficiaries cover the costs of insurers which either failed
to  raise  premiums  or  could  not  raise  premiums  enough  to  cover  more
54  Nos. 14‐1430 & 14‐1431
program  is  temporary,  but  since  the  HHS  accommodation
was enacted during the program’s implementation, it will be
difficult  to  determine  how  the  accommodation’s  separate
payments affect premiums. Nevertheless, if it were true that
payments  for  contraceptive  services  are  cost‐neutral,  then
the  premiums  that  would  otherwise  go  toward  childbirths
are instead used for contraceptive services in order to reduce
costly beneficiaries, including those that received separate payments for
contraceptive  services.  See  45  C.F.R.  §  153.500  et  seq.;  78  Fed.  Reg.  7235
(“Section 1342 of the Affordable Care Act directs the Secretary to estab‐
lish a temporary risk corridors program that provides for the sharing in
gains or losses resulting from inaccurate rate setting from 2014 through
2016 between the Federal government and certain participating plans.”);
see  also  78  Fed.  Reg.  72323  (“In  2014,  HHS  will  also  operationalize  the
premium  stabilization  programs  established  by  the  Affordable  Care
Act—the  risk  adjustment,  reinsurance,  and  risk  corridors  programs—
which  are  intended  to  mitigate  the  impact  of  possible  adverse  selection
and  stabilize  the  price  of  health  insurance  in  the  individual  and  small
group markets.”). The program is supposed to pay for itself, but the reg‐
ulations allow the government to use appropriated funds to cover insur‐
er loses. See 79 Fed. Reg. 30260 (“In the unlikely event of a shortfall for
the  2015  program  year,  HHS  recognizes  that  the  Affordable  Care  Act
requires  the  Secretary  to  make  full  payments  to  issuers.  In  that  event,
HHS  will  use  other  sources  of  funding  for  the  risk  corridors  payments,
subject to the availability of appropriations.”). Perhaps this is why insur‐
ers  do  not  object  to  the  HHS  accommodation.  Insurers  know  that  the
federal government will ultimately bear the burden of covering the costs
for  contraceptive  services  they  are  unable  to  recoup.  The  risk  corridor
program has been criticized as a health insurer bailout program. See No‐
am  N.  Levey,  Critics  call  Obama  funding  plan  for  health  insurer  losses  a
‘bailout’,  L.A.  TIMES,  May  21,  2014,  http://www.latimes.com/nation/la‐
na‐insurance‐bailout‐20140521‐story.html (last visited Sept. 3, 2015).
Nos. 14‐1430 & 14‐1431  55
childbirths  because  the  nonprofits’  premiums  are  the  only
source of funding. This is also an objectionable outcome.
D.  The  proper  substantial  burden  analysis:  the  court
must accept the nonprofits’ sincere belief that the accommo‐
dation  violates  their  religion  because  the  nonprofits  under‐
stand its operation.
The HHS accommodation is a purposely complicated act
of  bureaucratic  legalese  and  accounting  tricks  that  enables
the  government  to  claim  that  the  objecting  nonprofits  have
nothing  to  do  with  the  provision  of  contraceptive  services.
Yet, as shown in much detail above, the accommodation in‐
fects the nonprofits’ health plans with an offensive provision
that  eradicates  their  purpose,  which  is  the  exercise  of  the
nonprofits’  religion.  It  is  the  nonprofits  which  understand
the operation of the HHS accommodation, not the court, and
we must accept their sincere belief that it violates their reli‐
gion. The accommodation imposes a substantial burden be‐
cause  the  nonprofits  have  a  sincere  belief  that  compliance
with the law violates their religion and the penalties applied
by the government to coerce compliance are enormous.
III. The accommodation does not further a compelling gov‐
ernmental interest.
The government must grant the nonprofits an exemption
from the accommodation unless “it demonstrates that appli‐
cation  of  the  burden  to  the  person—(1)  is  in  furtherance  of  a
compelling governmental interest; and (2) is the least restric‐
tive  means  of  furthering  that  compelling  governmental  in‐
terest.”  42  U.S.C.  §  2000bb‐1  (emphasis  added).  “This  re‐
quires us to look beyond broadly formulated interests and to
56  Nos. 14‐1430 & 14‐1431
scrutinize the asserted harm of granting specific exemptions
to particular religious claimants—in other words, to look to
the marginal interest in enforcing the contraceptive mandate
in these cases.” Hobby Lobby, 134 S. Ct. at 2779 (internal quo‐
tation and alteration marks omitted). “RFRA creates a broad
statutory  right  to  case‐specific  exemptions  from  laws  that
substantially burden religious exercise even if the law is neu‐
tral and generally applicable, unless the government can sat‐
isfy  the  compelling‐interest  test.”  Korte,  735  F.3d  at  671.  “In
short, RFRA operates as a kind of utility remedy for the inev‐
itable clashes between religious freedom and the realities of
the  modern  welfare  state,  which  regulates  pervasively  and
touches nearly every aspect of social and economic life.” Id.
at 673.
“Congress’s  express  decision  to  legislate  the  compelling
interest  test  indicates  that  RFRA  challenges  should  be  adju‐
dicated  in  the  same  manner  as  constitutionally  mandated
applications of the test … .” Gonzales v. O Centro Espirita Be‐
neficente Uniao  do Vegetal, 546 U.S.  418, 430  (2006).  Thus, the
government  “must  specifically  identify  an  ‘actual  problem’
in need of solving, and the curtailment of [the right] must be
actually  necessary  to  the  solution.”  Brown  v.  Entmʹt  Merchs.
Assʹn, 131 S. Ct. 2729, 2738 (2011) (citation omitted). This re‐
quires a “high degree of necessity.” Id. at 2741. The govern‐
ment must show a “direct causal link.” Id. at 2738. The gov‐
ernment’s  “predictive  judgment”  is  insufficient,  “and  be‐
cause  it  bears  the  burden  of  uncertainty,  ambiguous  proof
will  not  suffice.” Id.  at  2738–39.  (citation  omitted).  The gov‐
ernment  must  prove  that  what  it  seeks  to  regulate  actually
causes the harm it wishes to prevent; evidence of a correlation
Nos. 14‐1430 & 14‐1431  57
is insufficient. Id. at 2739. “[S]tudies [that] suffer from signif‐
icant,  admitted  flaws  in  methodology”  fail  to  provide  this
proof. Id. If the regulation is underinclusive it is a  sign that
the governmental interest is not compelling. Id. at 2740. Put
another  way,  “only  those  interests  of  the  highest  order  and
those  not  otherwise  served”  can  be  considered  compelling.
Wisconsin v. Yoder, 406 U.S. 205, 215 (1972). But, “a law can‐
not be regarded as protecting an interest of the highest order
when it  leaves  appreciable damage to that  supposedly vital
interest unprohibited.” Church of Lukumi Babalu Aye v. City of
Hialeah,  508  U.S.  520,  547  (1993)  (internal  quotation  and  al‐
teration  marks  omitted).  Finally,  the  government  does  not
have a compelling interest in “[f]illing the remaining modest
gap”  or  in  “each  marginal  percentage  point  by  which  its
goals are advanced.” Brown, 131 S. Ct. at 2741, n.9.
The  government  asserts  the  same  interest  in  furtherance
of  the  HHS  accommodation  that  it  asserts  in  furtherance  of
the  HHS  contraceptive  mandate,  namely,  the  increased
availability of contraceptive services to improve the health of
women. The government also says that it wishes to increase
the availability of contraceptive services to equalize the pro‐
vision of preventive care for women and men so that women
can  participate  in  the  workforce  and  society  on  an  “equal
playing  field  with  men.”  The  latter  interest  boils  down  to  a
concern for women’s health. The government claims that the
inequality  stems  from  the  additional  cost  of  contraception
and  that  the  additional  cost  can  deter  women  from  using
contraceptives,  thus  allowing  the  negative  health  outcomes
that  prevent  women  from  achieving  equal  economic  status.
77 Fed. Reg. 8728.
58  Nos. 14‐1430 & 14‐1431
To  justify  increasing  the  availability  of  contraception  to
improve  the  health  of  women,  the  government  relies  exclu‐
sively on the Institute of Medicine’s 2011 study, Clinical Pre‐
ventive Services for Women: Closing the Gaps (IOM Study). The
IOM  Study  is  a  235‐page  study  of  the  current  preventative
services available for women. Only eight pages of the study
deal  with  the  issue  of  contraceptive  services.  IOM  Study,
102–09.  The  study  does  not  claim  that  contraceptives  im‐
prove  women’s  health  generally,  but  that  they  prevent  cer‐
tain  negative  health  outcomes  associated  with  unintended
pregnancies. See Priests for Life, 772 F.3d at 261 (“A core rea‐
son the government sought under the ACA to expand access
to  contraception  is  that  use  of  contraceptives  reduces  unin‐
tended  pregnancies.”).  The  government’s  interest  advanced
by the accommodation, then, is best identified as increasing
the availability of contraceptive services in order to prevent
the negative health outcomes caused with unintended preg‐
nancies. When put to the test, the government’s interest fails
to prove compelling.22
A.  A  lack  of  available  contraception  and  unintended
pregnancies are not actual problems in need of solving.
The  HHS  accommodation  relies  on  a  lengthy  chain  of
causality:  1)  the  accommodation  will  make  contraceptives
more  available  by  removing  administrative  and  cost  bur‐
dens;  2)  if  contraceptives  are  more  available,  then  more
22 For a comprehensive explanation of how the government’s inter‐
est thoroughly fails the compelling interest test, see generally Helen Al‐
varé,  No  Compelling  Interest:  The  “Birth  Control”  Mandate  and  Religious
Freedom, 58 VILL. L. REV. 379 (2013).
Nos. 14‐1430 & 14‐1431  59
women will use them; 3) if more women use contraceptives,
then  there  will  be  fewer  unintended  pregnancies;  and  4)  if
there  are  fewer  unintended  pregnancies,  then  there  will  be
fewer of the negative health outcomes associated with them.
The government, therefore, must prove more than the exist‐
ence  of  negative  health  outcomes.  It  must  prove  first,  that
unintended  pregnancies  cause  the  negative  outcomes;  sec‐
ond,  that  contraceptive  use  will  cause  fewer  unintended
pregnancies; and third a higher availability of contraceptives
will cause more women to use them. The IOM Study fails to
prove  these  “direct  casual  links.”  Brown,  131  S.  Ct.  at  2738.
Instead, the study shows merely a correlation.
First, the study admits that “for some outcomes [of unin‐
tended  pregnancy],  research  is  limited.”  Id.  at  103.  It  then
proceeds  to  describe the  outcomes  correlated  with  unintend‐
ed pregnancies: outcomes that “may” or “may not” happen,
are “more” or “less likely,” have been “reported,” and have
“increased odds,” or are “associated with.” IOM Study 103.
Second,  the  study  discusses  “evidence  of  [contraceptive]
method  effectiveness,”  but  does  not  prove  that  increasing
the use of even an effective contraceptive causes fewer unin‐
tended  pregnancies.  This  is  because  such  a  simple  correla‐
tion does not take into account the factors that inhibit perfect
use of contraception or the societal changes that result from
increased reliance on contraception.23 Rather than prove that
23 See Alvaré, supra note 22, at 408–411 for a discussion of the “grow‐
ing  body  of  scholarship  …  indicating  that  the  persistence  or  worsening
of high rates of unintended pregnancy, abortion, and sexually transmit‐
ted  diseases,  and  also  our  nation’s  high  rates  of  nonmarital  births  (the
60  Nos. 14‐1430 & 14‐1431
greater contraceptive use causes fewer unintended pregnan‐
cies, the study only states that “evidence exists” that it does.
Id. at 105. The IOM study bases this statement on two other
studies, but they are insufficient to provide the necessary ev‐
idence.24 According  to  the  study,  “[i]t  is  thought  that  greater
use  of  long‐acting,  reversible  contraceptive  methods—
including  intrauterine  devices  and  contraceptive  implants
that  require  less  action  by  the  woman  and  therefore  have
lower use failure rates—might help further reduce unintend‐
ed  pregnancy  rates.”  Id.  at  108  (emphasis  added;  citation
omitted).
Third, the study  fails to prove that  increasing the availa‐
bility  of  contraceptives  will  cause  an  increase  in  their  use,
but concludes that “[t]he elimination of cost sharing for con‐
traception  therefore  could  greatly  increase  its  use,  including
use  of  the  more  effective  and  longer‐acting  methods,  espe‐
cially  among  poor  and  low‐income  women  most  at  risk  for
unintended  pregnancy.”  IOM  Study,  109  (emphasis  added).
However,  the  conclusion  that  eliminating  cost  sharing
“could”  increase  its  use  is  based  on  two  studies,  neither  of
which concerned contraceptive services specifically. The first
concerned preventative and primary care services generally,
and the second concerned mammograms. Id. The final claim
the  study  makes  is  that  “when  out‐of‐pocket  costs  for  con‐
chief  predictor  of  female  poverty),  are  the  ‘logical’  result—in  economic
and psychological terms—of the new marketplace for sex and marriage
made  possible  by  increasingly  available  contraception  (in  some  cases,
combined with available abortion).”
24 Alvaré, supra note 22, at 399‐405.
Nos. 14‐1430 & 14‐1431  61
traceptives  were  eliminated  or  reduced,  women  were  more
likely  to  rely  on  more  effective  long‐acting  contraceptive
methods.” Id. But, a review of the study underlying that con‐
clusion reveals that “[w]e cannot be certain that the changes
in procurement were solely due to the removal of cost to the
patient,  but  there  was  a  shift  toward  prescribing  the  most
effective  methods  ([intrauterine  contraceptives]  and  injecta‐
ble  contraceptives)  and  a  substantial  increase  in  prescribing
of  [emergency  contraceptive  pills].”25  So,  not  only  was  the
study  inconclusive,  it  is  ambiguous  regarding  the  IOM
Study’s  intended  purpose  because  a  substantial  increase  in
emergency contraceptive pills  would seem to follow from  a
decrease  in  regular  contraceptive  use.  On  the  whole,  the
IOM study’s lack of causality renders the government’s claim
that  it  must  increase  the  availability  of  contraceptives  noth‐
ing more than a “predictive judgment.” Brown, 131 S. Ct. at
2738.
Another reason the IOM Study fails to prove “an ‘actual
problem’  in  need  of  solving”  is  because  it  is  overbroad.
Brown, 131 S. Ct. at 2738. The study starts with the estimation
that “[i]n 2001, … 49 percent of all pregnancies in the United
States were unintended,” but the study defines an unintend‐
ed  pregnancy  as  one  that  is  “unwanted  or  mistimed  at  the
time of conception.” IOM Study, 102. This definition includes
pregnancies  that  were  unwanted  at  the  time  of  conception,
but still wanted when the mother discovered she was preg‐
nant,  and  mothers  who  intended  to  become  pregnant,  but
25  Debbie  Postlethwaite,  et  al.,  A  comparison  of  contraceptive  procure‐
ment pre‐ and post‐benefit change, 76 CONTRACEPTION 360, 364 (2007).
62  Nos. 14‐1430 & 14‐1431
did  not  intend  to  become  pregnant  by  the  specific  conjugal
act that resulted in conception. The government has zero in‐
terest  in  preventing  these  pregnancies.  Under  the  study’s
overbroad  definition,  “all  sexually  active  women  with  re‐
productive  capacity  are  at  risk  for  unintended  pregnancy.”
Id. at 103. Aside from the study’s problems with its own def‐
inition,  unintended  pregnancies  are  an  extremely  difficult
thing to quantify.26
Overall,  the  IOM  Study  lacks  the  necessary  quality  and
rigor. It heavily relies on studies from biased organizations,
such  as  the  Guttmacher  Institute  and  the  journal
CONTRACEPTION,  and  offers  no  consideration  of  competing
studies.  Id.  at  102–109.  The  study’s  own  dissenting  opinion
says it best:
Readers  of  the  Report  should  be  clear  on  the
fact  that  the  recommendations  were  made
without  high  quality,  systematic  evidence  of
the  preventive  nature  of  the  services  consid‐
ered.  Put  differently,  evidence  that  use  of  the
services in question leads to lower rates of dis‐
ability  or  disease  and  increased  rates  of  well‐
being is generally absent.
The view of this dissent is that the commit‐
tee  process  for  evaluation  of  the  evidence
lacked transparency and was largely subject to
the preferences of the committee’s composition.
Troublingly,  the  process  tended  to  result  in  a
26 Alvaré, supra note 22, at 396–97.
Nos. 14‐1430 & 14‐1431  63
mix  of  objective  and subjective  determinations
filtered through a lens of advocacy. An abiding
principle in the evaluation of the evidence and
the  recommendations  put  forth  as  a  conse‐
quence  should  be  transparency  and  strict  ob‐
jectivity,  but  the  committee  failed  to  demon‐
strate  these  principles  in  the  Report.  This  dis‐
sent views the evidence evaluation process as a
fatal flaw  of  the Report  particularly in  light of
the  importance  of  the  recommendations  for
public  policy  and  the  number  of  individuals,
both men and women, that will be affected.
IOM Study, 232–33.
The  study  itself  shows  that  the  lack  of  available  contra‐
ceptive services is not a problem in need of solving. Accord‐
ing to the IOM Study, “[c]ontraceptive coverage has become
standard  practice  for  most  private  insurance  and  federally
funded  insurance  programs.”  Id.  at  108.  Further,  “[s]ince
1972,  Medicaid,  the  state‐federal  program  for  certain  low‐
income  individuals,  has  required  coverage  for  family  plan‐
ning in all state programs and has exempted family planning
services  and  supplies  from  cost‐sharing  requirements.”  Id.
Finally,
[C]omprehensive coverage of contraceptive
services and supplies [is] “the current insur‐
ance industry standard,” with more than 89
percent of insurance plans covering contracep‐
tive methods in 2002. A more recent 2010 sur‐
vey of employers found that 85 percent of large
64  Nos. 14‐1430 & 14‐1431
employers and 62 of small employers offered
coverage of FDA‐approved contraceptives.
Id. at 109 (citations omitted). Not only are contraceptive ser‐
vices  already  widely  available,  but  they  are  also  already
widely used: “More than 99 percent of U.S. women aged 15
to  44  years  who  have  ever  had  sexual  intercourse  with  a
male  have  used  at  least  one  contraceptive  method.”  IOM
Study,  103  (citation  omitted).  According  to  the  Centers  for
Disease Control and Prevention, contraceptive use is “virtu‐
ally universal among women of reproductive age.”27
The  study  similarly fails  to  prove  that  there is a need  to
increase  the  availability  of  contraceptives  to  alleviate  “the
increased  risk  of  adverse  pregnancy  outcomes  for  pregnan‐
cies that are too closely spaced” or for “women with certain
chronic  medical  conditions”  who  “may  need  to  postpone
pregnancy”  and  “women  with  serious  medical  conditions”
for whom “pregnancy may be contraindicated.” IOM Study,
103. Amazingly, the study does not even pretend to demon‐
strate a causal link in these circumstances, relying instead on
the  reader  to  make  the  inference  mistakenly.  The  study
hopes the reader ignores the common sense fact that women
in these circumstances have a higher incentive to use contra‐
ceptives if that is their chosen method to prevent these out‐
comes.
27 CDC, “Advance Data No. 350, Dec. 10, 2004: Use of Contraception
and  Use  of  Family  Planning  Services  in  the  United  States:  1982‐2002”,
http://www.cdc.gov/nchs/data/ad/ad350.pdf (last visited Sept. 3, 2015).
Nos. 14‐1430 & 14‐1431  65
The  study  offers  no  evidence  regarding  the  effects  that
extra  paperwork  or  other  administrative  and  logistical  ob‐
stacles would have on contraceptive availability or use. Such
a  finding  is  absolutely  necessary  for  the  government  to  as‐
sert that it has a compelling interest in using the nonprofits’
health  plans  so  that  the  coverage  for  contraceptive  services
will be “seamless.” Instead, the IOM Study’s conclusions are
limited  to  the  elimination  of  cost‐sharing  and  provide  no
reason why a government‐run option would not work equal‐
ly as well as the HHS accommodation.
Finally,  the  IOM  Study  does  not  concern  the  employees
of  the  nonprofits  who  are  less  likely  to  use  contraception
given  their  own  religious  beliefs.  Instead,  its  conclusions
mostly  concern  the  “poor  and  low‐income  women  most  at
risk for unintended pregnancy.” Id. at 109. The study’s hope
is that the elimination of cost sharing for contraception will
induce the poor to use more effective, long‐acting methods,
such  as  IUDs,  implants,  and  sterilization.  Id.  at  108‐109.
However, “the government must establish a compelling and
specific  justification  for  burdening  these  claimants.”  Korte,
735  F.3d  at  685;  see  also  Hobby  Lobby,  134  S.  Ct.  at  2761.  The
IOM  Study  fails  to  prove  any  connection  whatsoever  with
the  nonprofits’  employees.  In  fact,  there  are  already  a  high
level of access to contraception, a higher rate of use, and an
increased use of  more effective methods  among the women
with  more  income  and  education.28  Simply  put,  the  IOM
study  fails  to  “specifically  identify  an  ‘actual  problem’  in
need  of  solving,”  and,  consequently,  the  government  has
28 Avaré, supra note 22, at 426.
66  Nos. 14‐1430 & 14‐1431
failed to demonstrate a compelling interest. Brown, 131 S. Ct.
at 2738.
B.  The accommodation is underinclusive.
The HHS accommodation’s underinclusiveness is another
sign  that  the  governmental  interest  is  not  compelling.  Id.  at
2740.  The  government  “leaves  appreciable  damage  to  that
supposedly  vital  interest  unprohibited”  by  allowing  reli‐
gious  employers,  grandfathered  plans,  and  employers  with
fewer  than  50  employees  to  avoid  providing  contraceptive
coverage.  Lukumi,  508  U.S.  at  547  (internal  quotation  marks
omitted). Although  more health plans will lose their grand‐
fathered status the longer the ACA is in place, the number of
persons employed by religious employers and organizations
with  fewer  than  50  employees  will  remain  considerable  in
light  of  the  less  than  2,000  covered  employees  concerned
here.
The  accommodation  is  also  underinclusive  because  it
does not account for the other causes of the negative health
outcomes  the  IOM  Study  correlates  with  unintended  preg‐
nancies.  According  to  the  study,  “women  with  unintended
pregnancies  are more  likely  than  those  with  intended  preg‐
nancies  to  receive  later  or  no  prenatal  care,  to  smoke  and
consume  alcohol  during  pregnancy,  to  be  depressed  during
pregnancy,  and  to  experience  domestic  violence  during
pregnancy.”  IOM  Study,  103.  The  study  implies  that  unin‐
tended  pregnancies  cause  these  conditions,  but  there  could
just as well be another cause that causes not only these con‐
ditions, but the unintended pregnancy as well: poverty, lack
of education, abuse, or other causes of risk taking behaviors.
Nos. 14‐1430 & 14‐1431  67
The  HHS  accommodation  addresses  none  of  these  alterna‐
tive causes, focusing solely on unintended pregnancies. Most
notably, the study does not acknowledge the fact that preg‐
nancies resulting from failed contraceptives are also consid‐
ered unintended.
Most  damaging  to  the  government’s  asserted  interest  in
the contraceptive mandate is the fact that those women most
at  risk  for  an  unintended  pregnancy  are  “women  who  are
aged 18 to 24 years and unmarried, who have a low income,
who are not high school graduates, and who are members of
a racial  or ethnic  minority group.” IOM Study, 102 (citation
omitted).  These  women—let  alone  the  nonprofits’  employ‐
ees—are less likely to be served by the HHS accommodation,
or the ACA’s contraception mandate generally, because they
are less likely to have the type of employment that qualifies
them for the health insurance under the ACA. These women
would  not  obtain  contraceptive  services  through  the  HHS
accommodation,  but through  a number of government  pro‐
grams such as Medicaid, 42 U.S.C. § 1396 et seq. (2010), and
the Title X Family Planning Program, 42 U.S.C. § 300 (2006).
“The consequence is that [the HHS accommodation] is wild‐
ly underinclusive when judged against its asserted justifica‐
tion, which … is alone enough to defeat it.” Brown, 131 S. Ct.
at 2740.
C.  Forcing nonprofits to use the accommodation can on‐
ly provide a marginal increase in contraception.
Contraceptive  services  are  already  widely  available  and
their use is virtually universal. The HHS accommodation on‐
ly fills the “remaining modest gap” by making already prev‐
68  Nos. 14‐1430 & 14‐1431
alent  contraceptive  services  free  for  employees  of  religious
nonprofits. Id. at 2741. This “can hardly be a compelling state
interest.”  Id.  Further,  the  “more  focused  inquiry”  of  RFRA
requires the government to demonstrate that it has a compel‐
ling  interest  in  filling  the  gap  made  by  the  less  than  2,000
employees of the nonprofits here. Hobby Lobby, 131 S. Ct. at
2779. This is even less of a compelling interest. Further still,
the accommodation fills in even less of the gap when viewed
from the perspective of unintended pregnancies. This is be‐
cause  the  accommodation  seeks  to  treat  unintended  preg‐
nancies  through  contraceptive  services,  but  contraceptives
are not always effective for a variety of reasons. Even if this
gap  could  be  decreased  by  improving  the  effectiveness  of
contraceptives, “the government does not have a compelling
interest in each marginal percentage point by which its goals
are advanced.” Brown, 131 S. Ct. at 2741, n.9.
D.  A  primary  concern  underlying  the  accommodation  is
cost.
Cost  appears  to  be  a  primary  concern  underlying  the
HHS accommodation. After all, babies are expensive. Of the
IOM  Study’s  eight‐page  discussion  of  contraceptives,  a  sig‐
nificant  portion  is  spent  on  the  cost  savings  to  be  expected
from  their  use  despite  the  study’s  acknowledgement  that
cost considerations are out of scope:
Although it is beyond the scope of the
committee’s consideration, it should be
noted that contraception is highly cost‐
effective. The direct medical cost of unin‐
tended pregnancy in the United States was
Nos. 14‐1430 & 14‐1431  69
estimated to be nearly $5 billion in 2002, with
the cost savings due to contraceptive use esti‐
mated to be $19.3 billion. … It is thought that
greater use of long‐acting, reversible contra‐
ceptive methods—including intrauterine de‐
vices and contraceptive implants that require
less action by the woman and therefore have
lower use failure rates—might help further re‐
duce unintended pregnancy rates. Cost barri‐
ers to use of the most effective contraceptive
methods are important because long‐acting,
reversible contraceptive methods and steriliza‐
tion have high up‐front costs.
IOM  Study,  107–08  (citations  omitted).  The  study’s  primary
conclusion  is  that  the  use  of  contraceptive  services—
particularly  longer‐acting  methods  like  IUDs—will  greatly
increase if they are free, “especially among poor and low‐income
women.” Id. at 109 (emphasis added). The appearance is that
the  government  desires  to  use  contraceptives  that  “require
less  action  by  the  woman”  to  prevent  poor,  unmarried,  mi‐
nority women from having babies, as if babies were a costly
disease.  IOM  Study,  108.  Of  course,  this  appearance  is  less‐
ened by the fact that the government is vigorously enforcing
the HHS contraception mandate on even religious nonprofits
through the accommodation.
Because the government has failed to prove that the HHS
accommodation  furthers  a  compelling  governmental  inter‐
est, it is not allowed to burden the nonprofits’ religious exer‐
cise with the accommodation. 42 U.S.C. § 2000bb‐1. Thus, the
70  Nos. 14‐1430 & 14‐1431
government  must  grant  the  nonprofits  the  same  exemption
that it grants to religious employers. 45 C.F.R. § 147.131(a).
IV. The accommodation is not the least restrictive means.
Even  if  the  government  had  proved  that  the  HHS  ac‐
commodation was in furtherance of a compelling interest, it
would still have to grant the nonprofits’ an exemption from
the  accommodation  because  the  accommodation  is  not  the
least  restrictive  means.  42  U.S.C.  §  2000bb‐1(b)(2).  The  Su‐
preme Court in Hobby Lobby spoke of an obvious means that
would be less restrictive than the HHS accommodation:
The most straightforward way of doing this
would  be  for  the  Government  to  assume  the
cost of providing the [objectionable] contracep‐
tives at issue to any women who are unable to
obtain them under their health‐insurance poli‐
cies  due  to  their  employers’  religious  objec‐
tions. This would certainly be less restrictive of
the  plaintiffs’  religious  liberty,  and  HHS  has
not  shown  …  that  this  is  not  a  viable  alterna‐
tive.
131  S.  Ct.  at  2780.  The  government  argues  that  RFRA  does
not require the government to create entirely new programs
to  accommodate  religious  objections,  but  the  government
provides  no  authority  for  its  position.  The  Court  did  not
hold  that  it  was  so  in  Hobby  Lobby.  Id.  at  2786.  Rather,  the
Court  stated  that  Congress  understood  that  by  passing
RFRA it might cost the government extra to avoid burdening
religion.  Id.  at  2781.  Besides,  the  government  already  main‐
tains  programs,  such  as  Medicaid  and  the  Title  X  Family
Nos. 14‐1430 & 14‐1431  71
Planning Program mentioned earlier, which could be opened
up to the employees of the nonprofits.
The government also argues that a government‐run pro‐
gram is not a valid means because it would create additional
burdens  for  the  nonprofits’  employees  and  RFRA  does  not
protect  religious  exercise  that  “unduly  restrict[s]  other  per‐
sons,  such  as  employees,  in  protecting  their  own  interests,
interests the law deems compelling.” Id. at 2786–87 (Kenne‐
dy,  J.,  concurring).  This  requirement  is  not  found  in  RFRA.
What  the  government  fails  to  acknowledge  is  that  the  pur‐
pose of an inquiry into the burdens on others is to determine
whether  a  particular  religious  accommodation  violates  the
Establishment  Clause.  See  Cutter  v.  Wilkinson,  544  U.S.  709,
719–20  (2005)  (Ginsburg,  J.).  To  determine  whether  a  reli‐
gious  accommodation  under  RFRA  is  compatible  with  the
Establishment Clause “courts must take adequate account of
the  burdens  a  requested  accommodation  may  impose  on
nonbeneficiaries,  and  they  must  be  satisfied  that  the  Act’s
prescriptions are and will be administered  neutrally among
different faiths.” Id. at 712 (citation omitted). A religious ac‐
commodation’s effect on third parties must be examined be‐
cause  “[a]t  some  point,  accommodation  may  devolve  into
‘an unlawful fostering of religion.’” Id. at 714 (quoting Corpo‐
ration of Presiding Bishop of Church of Jesus Christ of Latter‐day
Saints  v.  Amos,  483  U.S.  327,  334‐335  (1987)).  The  Supreme
Court “has long recognized that the government may … ac‐
commodate  religious  practices  …  without  violating  the  Es‐
tablishment Clause.” Id. at 713 (quoting Hobbie v. Unemploy‐
ment Appeals Comm’n of Fla., 480 U.S. 136, 144‐145 (1987)).
72  Nos. 14‐1430 & 14‐1431
Administering a government‐run program for contracep‐
tive coverage in order to relieve the nonprofits of the burden
on their religion imposed by the accommodation would not
“devolve into ‘an unlawful fostering of religion.’” Id. at 714.
A  government‐run  program  would  provide  the  contracep‐
tion coverage on a cost‐free basis. Any burden resulting from
an employee’s participation in the program would be de min‐
imis because it truly would be nothing more than additional
paperwork  (unlike  the  self‐certification  and  alternative  no‐
tice). Furthermore, such a small burden would be no differ‐
ent  than  the  burden  experienced  by  the  many  who  obtain
dental  and  vision  care  benefits  from  different  plans  and  fill
their  prescriptions  at  pharmacies  unassociated  with  their
health care providers. It would be absurd to say that such a
de  minimis  burden  even  came  close  to  the  establishment  of
religion. Finally, any burden would be within the employee’s
power  to  avoid  by  changing  employment  to  an  employer
that  provides  the  coverage.  According  to  the  government,
when  the  contraceptive  services  mandate  was  enacted,  85%
percent  of  large  employers  and  62%  percent  of  small  em‐
ployers  already  covered  contraceptives  services  under  the
health plans. Even more plans will cover contraceptives and
that coverage will be copayment‐free now that the mandate
is in force.
V.  Conclusion
This  dissent  explores  the  road  less  traveled  by.  As  de‐
tailed above, the detour exposes two serious misrepresenta‐
tions.  First,  the  so‐called  accommodation  is  nothing  but  a
mirage.  The  government  strung  together  the  complicated
Nos. 14‐1430 & 14‐1431  73
details  to  create  a  lengthy  and  twisted  extension  cord.  The
end  result  is  the  de  facto  imposition  of  a  provision  offering
“free”  birth  control  into  the  nonprofits’  necessary  health
plans. The unwanted provision is very offensive and contra‐
ry to the nonprofits’ sincerely held religious beliefs. The im‐
position does not occur if the nonprofits refuse to plug in the
extension  cord  by  refusing  to  self‐certify  or  otherwise  indi‐
cate  consent  through  the  alternative  notice.  But  this  refusal
causes  enormous,  existential  monetary  penalties.  So,  there
are substantial burdens at both ends of the accommodation.
Second, deep into the detour is the falsehood behind the
government’s claim that increasing the availability of contra‐
ceptive  services  furthers  a  “compelling  governmental  inter‐
est.”  That  label  is  needed  to  overcome  the  nonprofits’  sin‐
cerely  held  religious  beliefs  that  no  one  disputes.  But,  con‐
traceptive  services  are  already  widely  available  from  the
great majority of employers. And, for the primarily targeted
poor  and/or  unemployed  women,  whom  the  mandate  does
not affect, there are already programs like Medicaid and Ti‐
tle  X  that  offer  free  contraceptive  services. At  its  center,  the
IOM Study recognizes that babies are medically very expen‐
sive,  so  the  government  endeavors  to  reduce  “unexpected”
pregnancies  to  save  money.  In  effect,  the  government  con‐
siders pregnancy a preventable disease.
Aside  from  the  fact  that  the  government  desires  to  sub‐
stantially  burden  the  nonprofits’  religious  exercise  in  fur‐
therance  of  an  exaggerated,  misnamed,  and  misdirected  in‐
terest,  there  are,  no  doubt,  less  restrictive  means  of  further‐
ing its interest. But why even go there? The government cer‐
74  Nos. 14‐1430 & 14‐1431
tainly  has  no  compelling  interest  in  forcing  contraceptive
coverage  into  the  nonprofits’  otherwise  wanted  and  needed
health plans when they unanimously assert they don’t want
the  coverage  and  don’t  need  it.  The  obvious  solution  for
these  plaintiffs  (and  likely  for  the  plaintiffs  involved  in  the
similar—and  similarly  expensive—litigation  in  at  least  six
other federal circuits, see supra p.42) is for the government to
extend  the  religious  employer  exemption  to  all  religious
nonprofits that object to the coverage. 45 C.F.R. § 147.131(a).
The  nonprofits  have  shown  a  likelihood  of  success  on
their claims that the HHS accommodation violates RFRA. 42
U.S.C. § 2000bb‐1. The preliminary injunction granted by the
district court should be affirmed. Korte, 735 F.3d at 666 (“Alt‐
hough  the  claim  is  statutory,  RFRA  protects  First  Amend‐
ment free‐exercise rights, and in First Amendment cases, the
likelihood of success on the merits will often be the determi‐
native factor.” (internal quotation marks omitted)).
For all these reasons, I dissent.