# U ni te d S ta te s Co ur t of A pp ea ls For the Eig hth Circu it

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No. 1 4- 27 26

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Dor dt Co ll eg e; Co rn ers to ne Uni ve rs it y

ll ll ll ll ll ll ll ll ll ll l Pla in ti

ff s - Ap pe ll ees

v.
Sy lv ia M. Bu rwel l, i n h er o ffi ci al cap aci ty as Sec ret ary of th e Uni te d S ta te s Dep art m en t o f Heal th an d Hu m an Serv ic es ; Th om as Pere z, in hi s o ffi ci al cap aci ty

as Secr et ary of

th e Uni te d S ta te s Dep art m en t o f Lab or ; J ack Lew, in hi s o ffi ci al
cap aci ty as Sec ret ary of

th e Uni te d S ta te s Dep art m en t o f th e Treas ur y ; Un it ed St at es Depa rtment o f Heal th an d Hu m an Serv ic es ; Un it ed Sta te s Dep art m en t o f

Lab or ; Un it ed Sta te s Dep art m en t o f th e Treas ur y

ll ll ll ll ll ll ll ll ll ll l Defe nd

an ts - App el la nt

s

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Am eri can s Un it ed Fo r Sep arat io n o f Ch ur ch an d S ta te ; Am eri can Civ il Lib ert ie s

Uni on ; Am eri can Civ il Lib ert ie s Un io n o f Io wa

ll ll ll ll ll ll ll ll ll ll l

Amici on Beha lf

of App el la nt (s

)

Ass oc ia ti on of Am eri can Ph y si ci an s & Su rg eo ns ; Am eri can Ass oc ia ti on of Pro -Lif e Obs te tri ci an s & Gy

ne co lo gi st s; Ch ris ti an Med ic al Ass oc ia ti on ; Ca th ol ic Med ic al Ass oc ia ti on ; Th e Nat io na l Ca th ol ic Bio et hi cs Cen te r; Al ab am a Ph y si ci an s fo r Life ; Nat io na l As so ci at io n o f Pro Life Nu rs es ; Nat io na l As so ci at io n of Cat ho li c Nur se s

ll ll ll ll ll ll ll ll ll ll l

Amici on Beha lf

of App el le e(s

)

__ __ __ __ __ __App eal fro m Uni te d S ta te s Di st ric t Co ur t fo r th e Nor th ern Dis tri ct of I owa - Sio ux Cit y

__ __ __ __ __ __
Su bm it te d: Decem

be r 10 , 20 14 Fil ed : Se pt em

be r 17 , 20 15

__ __ __ __ __ __
Befo re WOL LMAN, COLLOTON , and BENTON, Circu it Ju dg es

.

__ __ __ __ __ __

W OLLMAN, Circ ui t J ud ge

.

The Dep art m en ts of Heal th an d Hu man Serv ic es (HHS), Lab or (DOL), an d
Treas ur y , as well as th ei r res pe ct iv e Secr et ari es , (co lle ct ive ly
, the gov ern m en t) ap pe al
fro m th e di st ric t co ur t’s or de r gr an ti ng a mo t i on fo r a pr el im in ary in jun ct io n th at 1

en joi ns th e go ve rn m en t fro m en fo rci ng cert ai n pr ov i s i o ns of th e Pat ie nt Pro te ct io n

an d Affo rd ab le Care Act (ACA), 42 U.S.C. § 30 0g g- 13 (a)( 4)
, an d it s im pl em en ti ng
reg u l a t i on s ag ai ns t Dor dt Co ll eg e an d Co rn ers to ne Uni ve rs it y , each of whi ch is a

no np ro fit rel ig io us ed uc at io na l in st it ut io n th at of fers he al th care co ve r a g e to it s

em pl oyees— Dor dt th ro ug h a sel f-i ns ur ed pl an an d Co rn ers to ne th ro ug h a n i ns ur ed pl an

. Th e di st ric t co ur t’s or de r al so en joi ne d th e go ve rn m en t fro m en fo rci ng th e 2

The Hon or ab le Mar k W

. Ben ne tt , Uni te d St at es Dis tri ct Ju dg e fo r th e 1 Nor th ern Dis tri ct of I owa

.
A se lf- in su red em

pl oyer be ars th e fin an ci al ris k of pa y in g i t s e mp l oyees’ 2 he al th -in su ran ce cl ai m s an d of te n hi res a th ird -p art y ad m in is tra to r to m an ag e ad m in is tra ti ve fu nc ti on s li ke pr oc es si ng in su ran ce cl ai m s. An in su red em pl oyer, by

co nt ras t, co nt ract s w ith a se pa rat e in su ran ce co m

pa ny to pr ov id e he al th care co ve rag e, be ar th e f

i n a n c ia l ris k of in su ran ce cl ai m s, an d m an ag e rel at ed ad m in is tra ti ve fu nc ti on s. See, e.g ., 1A St ev en Pl it t, e t a l

. , C o uc h on In su ran ce § 10 :1 n.1 (3 d ed

. 20 13 ).

-2

-ch al le ng ed pr ov is io ns ag ai ns t “ an y in su ran ce p ro vi de r (in cl ud in g in su ran ce is su ers

an d th ird -p art y ad m in is tra to rs ) of feri ng he al th in su ran ce to Dor dt or Co rn ers to ne .” D. Ct. Ord er o f May 21
, 20 14
, at 8. Dord t an d C or ne rs to ne rai se d o bjec ti on s t o t he
A C A a n d it s im

pl em en ti ng reg ul at io ns th at are su bs ta nt ia ll y si m il ar to th os e ad dr es se d b y

th is co ur t i n t he op in io n is su ed to da y in Sh arp e Hol di ng s, In c. v. U.S. Dep art m en t of Heal th an d Hum an Serv ic es , No. 14 -1 50 7, sl ip op

. (8 th Ci r. Sep t. 17
, 20 15 ). Fo r pu rp os es of th is op in io n, we pr ov i d e o n l y a b rie f di sc us si on of th e le gi sl at iv e an d ad m in is tr a t iv e ba ck gr ou nd of th e ACA an d it s im pl em en ti ng
reg ul at io ns , as well as an ab br ev ia te d su m m ary of th e arg um en ts rai se d by th e pa rti es

. Fo r a m or e de ta il ed ex am in at io n, we di rect read ers to ou r op in io n in Sh arp e Hol di ng s.

Dor dt an d Co rn ers to ne ch al le ng ed pr ov is ions of the A CA an d it s im pl em en ti ng
reg ul at io ns req ui rin g th em ei th er to pr ov id e their em plo y ees wit h he al th care co ve rag e fo r “ [a]ll Fo od an d Dru g Adm in is tra ti on [(FDA)] a pp ro ve d co nt race pt iv e m et ho ds
, st eri li zat io n pr oc ed ur es , an d pa ti en t ed uc at io n an d co un se l in g fo r al l wom en wit h

rep ro du ct iv e cap aci ty” (t h e co nt race pt iv e m an da te ), or to ap pl y fo r an

acco m m od at io n ex cu si ng th em fro m pr ov id in g su ch co ve rag e. 77 Fed

. Reg

. 87 25
, 8 7 2 5 ( F eb

. 15
, 20 12 ); se e 29 C.F.R. § 25 90 .71 5- 27 13 (a). Alt ho ug h th e AC A

pr ov id es an ex em

pt io n fro m th e co nt race pt iv e m an da te fo r “ gr an df at he red ” he al th pl an s, i.e. , th os e in ex is te nc e at th e ti m e of th e ACA’s ad op ti on , 42 U.S.C. § 18 01 1;
29 C.F.R. § 25 90 .71 5- 12 51
, an d fo r he al th pl an s sp on so red by “ rel ig io us em pl oyers,”
i.e. , “ ch ur ch es , th ei r in te gr at ed au xi li a r i e s , an d co nv en ti on s or as so ci at io ns of ch ur ch es ,” as well as “ th e ex cl us iv el y rel ig io us act iv it ie s of an y rel ig io us or de r,” 45
C.F.R. § 14 7.1 31 (a) (ci ti ng th e In te rn al Rev en ue Co de
, 26 U.S.C. § 60 33 (a)( 3) (A)(i ), (ii i))
, it do es no t pr ov id e a si m il ar ex em pt io n fo r no np ro f

i t rel ig io us or ga ni zat io ns li ke Dord t an d C or ne rs to ne

.

In st ead
, th e A C A pr ov id es an “ acco m m od at io n” fo r no np ro fit rel ig io us

or ga ni zat io ns th at ha ve rel ig io us ob jecti on s to th e co nt race pt iv e m an da te bu t do no t

-3

-qu al ify fo r th e rel ig io us -em pl oyer ex em

pt io n. 78 Fed

. Reg

. 39 ,87 0, 39 ,87 1 (J ul y 2,

3
20 13 ); se e al so 29 C

. F

. R

. § 25 90 .71 5- 27 13 A. The acco m m od at io n is in te nd ed to
pr ot ect rel ig io us or ga ni zat io ns “ fro m ha vi ng to co nt ract , arra ng e, pa y , or refe r fo r”

co nt race pt iv e co ve rag e. 78 Fed

. Reg

. at 3 9
, 8 7 2

. I t is av ai la bl e fo r a rel ig io us

or g a n i z a t io n th at (1 ) ha s rel ig io us ob jecti on s to pr ov id in g he al th care co ve rag e fo r

so m e or al l co nt race pt iv e se rv ic es , (2 ) “ is or ga ni zed an d o p e r a t e s a s a no np ro fit

en ti ty,” (3 ) “ ho ld s it se lf ou t as a rel ig io us or ga ni zat io n,” an d (4 ) co m pl ie s wit h a se lfcert ifi cat io n pr oc es s. 29 C.F.R. § 25 90 .71 5- 27 13 A(a). A rel ig io us or ga ni zat io n m ay

se lf- certi fy by co m

pl et in g an d su bm it ti ng di rect ly to it s in su ran ce is su er or th ird -p art y ad m in is tra to r (TPA) an EBSA Fo rm 70 0– Cert ifi cat io n (Fo rm 70 0)
, cert ifyin g th at it is a rel ig io us no np ro fit en ti ty th at ha s rel ig io us ob jecti on s to pr ov id in g co ve rag e fo r

so m e or al l of th e co nt race pt iv es req ui red by th e m an da te , 29 C.F.R. § 2 5 9 0 .71 5-
27 1 3A( a)-( b)
, or by pr ov id in g no ti ce to HHS st at in g th e or ga ni zat io n’s na m e; th e ba si s on whi ch it qu al ifi es fo r an acco m m od at io n; it s re ligio us ob

jecti on s to pr ov id in g

co ve rag e fo r so m e or al l co nt race pt iv es , in cl ud in g th e sp eci fic co nt race pt iv es to whi ch it ob

jects ; it s in su ran ce pl an na m e an d type; an d it s in su ran ce is su er’s or TPA’ s

na m e an d co nt act in fo rm at io n (HHS Not ic e), se e 79 Fed

. Reg

. 51 ,09 2, 5 1
, 0 9 4 -9 5 4

Afte r th e Su p r e me C o u rt’s de ci si on in Bu rwel l v. Hob by Lob by, 13 4 S. Ct

. 3 27 51 (2 01 4)
, th e go ve rn m en t rev is ed th e rel ev an t reg ul at io ns effe ct iv e Sep te m be r 14
, 20 15
, to e xt en d th is acco m m od at io n to cert ai n cl os el y he ld fo r-p ro fit en ti ti es th at ha ve a rel ig io us ob

jecti on to pr ov id in g co ve rag e fo r so m e or al l of th e FDA-ap pr ov ed

co nt race pt iv e m et ho ds . See 8 0 F ed . Reg . 41 ,31 8 (J ul y 14 , 20 15 ).

Sel f-ce rti fic at io n us in g HHS Not ic e was in cl ud ed in th e reg ul at io ns aft er th e 4 Su pr em e Co ur t’s or de r in W he at on Co ll eg e v. Bu rwel l, 13 4 S. Ct

. 28 06 ( 2 01 4)

. W he at on Co ll eg e, a rel ig io us or ga ni zat io n, ch al le ng ed th e acco m m od at io n pr oc es s, arg ui ng th at co m

pl et in g Fo rm 70 0 an d fo rward in g th e Fo rm to it s i n su ran ce is su er

m ad e it co m

pl ic it in th e pr ov is io n of co n t race pt iv e co ve rag e in vi ol at io n of it s rel ig io us b e l i e f

s

. The Su pr em e Co ur t gr an te d in jun ct iv e rel ie f, en

joi ni ng th e go ve rn m en t fro m en fo rci ng th e co nt race pt iv e m an da te whi le th e co ll eg e’s ch al le ng e to th e acco m

m od at io n pr oc es s was pe nd in g, pr ov id e d th at th e co ll eg e in fo rm HHS

-4

-(Au g. 27
, 20 14 ); 80 Fed

. Reg

. 41 ,31 8, 41 ,32 3 (J ul y 14
, 20 15 ); 29 C.F.R. § 25 90 .71 5-

27 13 A (b )(1 )(i i)( B). Afte r HHS rece iv es th e Not ic e, it pr ov id es th e in fo rm at io n to DOL, whi ch se nd s a se pa rat e no ti fic at io n to in fo rm th e rel ig io us or ga ni z a ti on ’s
in su ran ce is su er or TPA of th e or ga ni zat io n’s ob jecti on s to cert ai n co ve rag e. See id

.

Onc e an in su ran ce is su er or TPA rece iv es Fo rm 70 0 fro m th e r e l i gi ou s

o rg an iz at io n or th e se pa rat e no ti fic at io n fro m DOL it m us t “ pr ov id e or arr a n g e
pa y m en ts fo r co nt race pt iv e se rv ic es ” fo r be ne fi c i a r i e s of th e or ga ni zat io n’s gr ou p he al th pl an ei th er by pr ov id in g th os e pa y m en ts it se lf or by arra ng in g fo r an ot he r pa rty
to do s o

. 2 9 C .F.R. § 25 90 .71 5- 27 13 A(b )(2 ) (TPA); 45 C.F.R. § 14 7.1 31 (c)( 1) (i) (in su ran ce i ss ue r). W it h res pe ct to TPAs, Fo rm 70 0 or HHS no ti ce al so de si gn at es th e TPA “ pl an ad m in is tra to r an d cl ai m s ad m in is tra to r fo r co nt race pt iv e be ne fit s” fo r th e rel ig io us or ga ni zat io n. 78 Fed

. Reg

. at 39 ,87 9; se e al so 29 C.F.R. § 25 10 .3-1 6( b) (p ro vi di ng th at Fo rm

70 0 b eco m es “ an in st ru m en t un de r whi ch th e pl an is op erat ed [an d is ] tre at ed as a de si gn at io n of th e [TPA] as th e pl an ad m in is tra to r un de r se ct io n 3( 16 ) of ERISA[, 2 9 U.S.C. § 10 02 (3 3) ,] for an y co nt race pt iv e se rv ic es req ui red to be co ve red ”); 79 Fed

. Reg

. at 51 ,09 5 (p ro vi di ng th at DOL’ s no ti fic at io n to th e TPA

un de r HHS Not ic e al so op erat es to “ de si gn at e” th e TPA “ as pl an ad m in is tra to r” un de r ERISA fo r co nt race pt iv e be ne fit s)

. The in su ran ce is su er o r TP A must pr ov id e

se pa rat e no ti ce reg ard in g co nt race pt iv e se rv ic es t o p a rti ci pa nt s an d be ne fic ia rie s

en ro ll ed in th e rel ig io us or ga ni zat io n’s gr ou p he al th pl a n

. 2 9 C

. F.R. § 25 90 .71 5-
27 13 A(b )(2 ).

“ in writ in g th at it is a no np ro fit or ga ni zat io n th at ho ld s it se lf ou t as rel ig io us an d ha s rel ig io us ob

jecti on s to pr ov id in g co ve rag e fo r co nt race pt iv e se rv ic es .” 13 4 S. Ct

. at 28 07

. The co ll eg e was no t req ui red to se lf- cert i f y u s i n g Fo rm 70 0. Id

. The Co ur t al so st at ed
, “ Not hi ng in th is or de r pr ecl ud es th e Gov ern m en t fro m rel y in g on th is

no ti c e , to th e ex te nt it co ns id ers it ne ces sa ry , to faci li ta te th e pr ov is io n of fu ll

co nt race pt iv e co ve rag e un de r th e” A CA to W he at on Co ll eg e’s em pl oyees an d
st ud en ts . Id.

-5

-Dor dt an d Co rn ers to ne , in acco rd an ce wit h th ei r si nc erel y he ld rel ig io us

be li efs
, op po se th e u se , fun di ng , pr ov is io n, or sup po rt of abo rti on , an d th ey be li ev e th at cert ai n c on tra cep ti ve s re qu ire d u nd er the co nt race pt iv e m an da te —Pl an B, el la
,
an d co pp er IUDs— are fu nc ti on a l l y e q u iv al en t to ab or ti on

. See Bu rwel l v. Hob by
Lo b b y, 13 4 S. Ct

. 27 51
, 27 62 -6 3 (2 10 4) (n ot in g th at th es e fo rm s of co nt rac e p t i v e

“ m ay h a v e th e effe ct of pr ev en ti ng an al read y fert il iz ed eg g fro m de ve lo pi ng an y fu rth er by i n h i b i t i n g it s at ta ch m en t to th e ut eru s” ). The y br ou gh t su it ag ai ns t th e
go ve rn m en t, arg ui ng th at bo th th e co nt race p t i v e m an da te an d th e acco m m od at io n
pr oc es s im

po se a su bs ta nt ia l bu rd en on th ei r ex erci se of rel ig io n i n v io la ti on of th e Rel ig io us Free do m Res to rat io n Act of 19 93 (RFR A), 42 U.S.C. § 20 00 bb -b b4

. The y

co nt en d th at th e go ve rn m en t is co erci ng th em to vi ol at e th ei r rel ig i ou s be li efs by
th reat en in g to im

po se se ve re m on et ary p en al ti es un le ss th ey ei th er di rect ly pro vi de

co ve rag e fo r ob

jecti on ab le co nt race pt iv es th ro ug h t he ir gr ou p he al th pl an s or in di rect ly pr ov id e, tri gg er, an d faci li ta te th a t ob jecti on ab le co ve rag e th ro ug h th e

acco m m od at io n pr oc es s. As st at ed ab ov e, th e di st ric t co ur t gr an te d th ei r req ue st fo r

a pr el im in ary in

jun ct io n to en

joi n en fo rcem en t of th e co nt race pt iv e m an da te an d th e

acco m m od at io n re gu la ti on s ag ai ns t t he m

.

The go ve rn m en t rai se s arg um en ts fo r rev ers al of th e di st ric t co ur t’s or de r th at

are su bs ta nt ia ll y si m il ar to th os e as se rte d by th e go ve rn m en t in Sh arp e Hol di ng s. Sp eci fic al ly, th e go ve rn m en t arg ue s th at t he co nt race pt iv e m an da te an d

ac co m m oda tio n proc es s do no t su bs ta nt ia ll y bu rd en Dor dt an d Co rn er sto ne ’ s ex er ci se of rel ig io n, th at it ha s co m pe ll in g in te res ts in sa feg ua rd in g pu bl ic he al th an d en su rin g
eq ua l a c c e s s to he al th care fo r wom en , an d th at th e co nt race pt iv e m an da te an d

acco m m od at io n pr oc es s are th e le as t res tri ct iv e m ean s to fu rth er th o s e c o mp e ll in g in te res ts

. Fo r th e reas on s se t fo rth in Sh arp e Hol di ng s, we co nc lu de th at by co erci ng Dor dt an d Co rn ers to ne to pa rt ic ip at e in th e co nt race pt iv e m an da te an d

acco m m od at io n pr oc es s un de r th reat of se ve re m on et ary pe na lt y , th e go ve rn m en t ha s

su bs ta nt ia ll y bu rd en ed Dor dt a n d C o r n ers to ne ’s ex erci se of rel ig io n. Als o fo r th e

-6

-reas on s se t fo rth in Sh arp e Hol di ng s, we co nc lu de th at , ev en a s s um in g th at th e

go ve rn m en t’s in te res ts i n s a f eg ua rd in g pu bl ic he al th an d en su rin g eq ua l acce ss to he al th care fo r wom en are co m pe lli ng, the co ntr ac ep tiv e m anda te an d acco m m od at io n
pr oc es s li ke ly are no t th e le as t res tri ct iv e m ean s of fu rth eri ng th os e in te res ts

. Thu s, 5
ba se d o n ou r reas on in g in Sh arp e Hol di ng s, we affi rm th e or de r gr an ti ng in jun ct iv e rel ie f.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Dor dt an d Co rn ers t o ne arg ue th at th e go ve rn m en t’s as se rte d “ co m pe ll in g 5 in te res ts ” are fat al ly un de rm in ed in li gh t of th e ex em pt io ns t o t h e co nt race pt iv e

m an da te an d acco m

m od at io n pr oc es s gr an te d to gr an df at he red he al th care pl an s an d rel ig io us em

pl oyers— ex em

pt io ns th at res ul t in th ou sa nd s of wom en wit ho ut acce ss to co nt race pt iv e co ve rag e th ro ug h th ei r em pl oyers’ h e a l t hc are pl an s. Bec au se we affi rm th e d is tri ct co ur t’s g ran t o f in jun ct iv e rel ie f on th e ba si s t ha t t he go ve rn m en t ha s fai le d to es ta bl is h th at th e co nt race pt iv e m an da te an d acco m m od at io n pr oc es s are th e le as t res tri ct iv e m ean s to acco m pl is h th ei r st at ed co m

pe ll in g in te res ts , we de cl in e to ad dr es s Dor dt an d Co rn ers to ne ’s as se r t i o n s reg ard in g th e in su ffi ci en cy of th e go ve rn m en t’s co m

pe ll in g in te res ts

. See Hob by Lob by, 13 4 S. Ct

. at 27 80 (“ W e wil l

a ss um e th at th e in te res t in gu aran te ei ng co st -fre e acce ss to th e fo ur ch al l e n g e d

co nt race pt iv e m et ho ds is co m pe ll in g wi th in th e m ean in g o f RFR A . . . .”).

-7

-