Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-14-01431/USCOURTS-ca7-14-01431-0/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 

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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 preliminary 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.

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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 Resources 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 contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.” 77 Fed. Reg. 8725-26. The regulations adopted by the three

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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 accommodations for group health plans provided by these non-profit

All three of these regulations have been amended since this suit was filed. 1

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.

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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. 

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Nos. 14-1430 & 14-1431 5

45 C.F.R. § 147.131(b). See also 78 Fed. Reg. 39,874-75. 2

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 organizations to use to comply with this accommodation, the “EBSA

Form 700 – Certification.” The short form requires the eligible 3

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 organization (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 contraceptive 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 coverage for the health plan’s participants without cost sharing

through alternate mechanisms established by the regulations.

This regulation will also be updated as of Sept. 14, 2015. Again, we cite to 2

the earlier version.

The form can be found at http://www.dol.gov/ebsa/pdf/preventive 3

serviceseligibleorganizationcertificationform.pdf, last visited September 3,

2015. 

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6 Nos. 14-1430 & 14-1431

45 C.F.R. § 147.131(c). The insurer may not impose a charge of 4

any variety, either directly or indirectly, on the eligible

organization for the provision of contraception services. The 5

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 contraceptive coverage, by notifying HHS directly of any religiouslybased 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 WayneFrom this point forward, when we use the term “insurer,” we mean to 4

include third-party administrators in those instances where the plan is selfinsured unless we state otherwise.

Insurers are expected to recoup the costs of contraceptive coverage from

5

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 organizations.”). Third-party administrators mayseek 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).

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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. In particular, they are forced to contract 6

with insurers or third-party administrators that will provide

their employees (and, in some cases, their students) with

coverage for contraceptives, sterilization, and abortioninducing products, all in violation of their deeply held religious 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 employer who does not meet 7

The plaintiffs also allege that the challenged statute and regulations

6

violate their rights under the First Amendment and under the Administrative 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.

The disputed regulations applyequally to employers providing insurance

7

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...)

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8 Nos. 14-1430 & 14-1431

an exemption faces fines of $2000 per year per full time

employee for not providing insurance that meets coverage

8

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 requirements under the religious employer exemption, and the 9

remaining plaintiffs are subject to the accommodation for nonprofit, 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. 

 (...continued) 7

both employee and student health coverage. 

When calculating the number of employees for the purpose of assessing 8

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).

 Although the Diocese is itself exempt, the Diocesan Health Plan insures 9

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. 

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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 governmentalinterest.” 42U.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 governmental 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 WayneCase: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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 requirements), the court reasoned, then they must either provide the

objectionable coverage themselves or comply with the accommodation. 

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 provision 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 accommodation) 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 compelling interest in providing seamless contraceptive services to

women in group health plans, but found that the accommodaCase: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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 injunctions for the plaintiffs here, we issued our opinion in Notre

Dame I, where we affirmed the denial of a motion for a preliminary 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 distinguishable 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,

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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 injunction 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 orto comply with the

accommodation by opting out through the use of the EBSA

Form700 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 administrator 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

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Nos. 14-1430 & 14-1431 13

compliance. We denied the university’s motion for an injunction 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 organization's refusal to administer or fund contraceptive

benefits) ... shall be an instrument under which the

plan is operated, [and] shall be treated as a designation 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

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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 administratorsof 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.

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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 theuniversitymust 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 objectionable 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 mandating 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,

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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 holdthemselves 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 contraCase: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
Nos. 14-1430 & 14-1431 17

ceptives. The Government contends that the applicant's health insurance issuer and third-party administrator 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 administrator 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 objection. 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

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18 Nos. 14-1430 & 14-1431

writ of certiorari, having been submitted to Justice

Alito and by him referred to the Court, the application 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 applicable), 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’ ortheir organizations’ 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.

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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 (7 Cir. 2015). In Notre

th

Dame II, we noted that, shortly after filing its suit and immediately before the regulatory deadline, the university signed the

Form 700 and sent it to the insurer of its students and the thirdparty 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 administration 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 provide 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 elsewhere in the health insurance market.

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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 contraceptive 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 government, 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. 

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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 contraception 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 accommodationthat 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

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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 objectionable 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 accompanying 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 requireonly 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

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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 nonparties, 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 government 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 assertionthat 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 Amendment, 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 organizations 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

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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 substantial burden on religious exercise under RFRA and affirming the

denial of a preliminary injunction in one instance and reversing 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 substantial 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 concluding 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 (6 Cir. Aug. 21, 2015) (because objectors

th

ma y o bt a in the a c c o mmoda ti o n fr o m t he

contraceptive-coverage requirement without providing,paying

for, and/or facilitating access to contraception, the contracepCase: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
Nos. 14-1430 & 14-1431 25

tive-coverage requirement does not impose a substantial

burden on their exercise of religion). No court of appeals has 10

concluded that the contraceptive mandate imposes a substantial 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 requirements 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 orlaw “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

 The Sixth Circuit released its opinion a few weeks prior to the issuance

10

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

asupplemental opinion addressing Hobby Lobby. The Sixth Circuit continues

to hold that theACA’s contraception provisions do not impose a substantial

burden under RFRA. Michigan Catholic, 2015 WL 4979692, *6- *15.

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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 regulations 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 government, 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

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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 objectionable 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 premiums to insurance companies orthird 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 status to avoid its plan 11

becoming a conduit for objectionable coverage for the employees 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

“Grandfathered plans” are plans that were in existence when the ACA

11

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.

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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

orthird-party administrators that are authorizedtoprovide 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 thenotificationtriggersorfacilitates

the provision of objectionable services. They practice their

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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

behaviorin 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

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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

courtshaveno 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 (substantiality 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 closelyheld, 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 operated 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 commission of an immoral act by another.” Hobby Lobby, 134 S. Ct at

2778. 

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
Nos. 14-1430 & 14-1431 31

So we defer to the plaintiffs’ sincerely held beliefs regarding 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 plaintiff’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

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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., concurring); 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 administrator of its obligations toprovide 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 contraceptive 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

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Nos. 14-1430 & 14-1431 33

plan participants and beneficiaries to coverage); GenevaCollege,

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 reasonableness 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

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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 accommodate 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 government 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 contracting 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

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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 orthe 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 healthplans 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 contract s with those insurer s to cover

emergency-contraceptive benefits. The latter contracts 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.

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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 insurance 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

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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 employing 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 Catholicplaintiffs). 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

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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 injunctions 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.

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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‐

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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

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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.

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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

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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‐

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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).

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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).

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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.

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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.

Case: 14-1431 Document: 89 Filed: 09/04/2015 Pages: 74
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

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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)).

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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)).

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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).

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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

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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).

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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

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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

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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.

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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).

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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

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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.

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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).

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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.

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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

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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).

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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.

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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.

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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‐

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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

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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

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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

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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)).

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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

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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‐

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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.

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