United States Court of Appeals

For the Eighth Circuit

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No. 13-3528

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Paul Joseph Wieland; Teresa Jane Wieland

lllllllllllllllllllll Plaintiffs - Appellants

v.

United States Department of Health and Human Services; Sylvia Mathews

Burwell, in her official capacity as the Secretary of the United States Department

of Health and Human Services; United States Department of the Treasury; Jacob J.

Lew, in his official capacity as the Secretary of the United States Department of

the Treasury; United States Department of Labor; Thomas E. Perez, in his official

capacity as the Secretary of the United States Department of Labor1

lllllllllllllllllllll Defendants - Appellees

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 Appeal from United States District Court 

for the Eastern District of Missouri - St. Louis

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 Submitted: September 8, 2014

 Filed: July 20, 2015

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Before WOLLMAN, LOKEN, and MURPHY, Circuit Judges.

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WOLLMAN, Circuit Judge.

Secretary of Health and Human Services Sylvia Mathews Burwell is 1

substituted for her predecessor, Kathleen Sebelius. See Fed. R. App. P. 43(c)(2).
Paul and Teresa Wieland appeal from an order of the district court dismissing

their complaint against the U.S. Departments of Health and Human Services,

Treasury, and Labor and their respective Secretaries (collectively, HHS). The

Wielands argue that the district court erred in concluding that they lacked standing

to challenge certain provisions of the Patient Protection and Affordable Care Act (the

ACA) and its implementing regulations, which they allege require themto obtain, and

provide to their daughters, healthcare coverage for contraceptives, sterilization, and

abortifacients (collectively, contraceptives) in violation of their sincerely held

religious beliefs. We reverse and remand. 

Paul Wieland is a member of the Missouri House of Representatives and

obtains healthcare coverage for himself and his family through the Missouri

Consolidated Health Care Plan (MCHCP), a group healthcare plan made available to

him by his employer, the State of Missouri. Prior to August 1, 2013, MCHCP offered

Paul Wieland an opportunity to opt out of coverage for contraceptives under state

law. But the State and MCHCP discontinued offering the opportunity to opt out of

such coverage following the decision in Missouri Insurance Coalition v. Huff, 947

F. Supp. 2d 1014, 1020 (E.D. Mo. 2013). In Huff, health insurers and insuranceindustry groups sought a declaratory judgment that certain provisions of section

376.1199 of the Missouri Revised Statutes were preempted by the ACA. As relevant

here, section 376.1199 required that health insurers offering plans in Missouri offer

an employer a healthcare plan that excluded coverage for contraceptives if such

coverage was contrary to the employer’s religious beliefs. Huff, 947 F. Supp. 2d at

1017. An individual enrollee in a healthcare plan covering contraceptives was also

permitted to opt out of that coverage based on his religious beliefs. Mo. Rev. Stat.

§ 376.1199.4. The district court in Huff held that these provisions of section

376.1199 were preempted by the ACA under the Supremacy Clause of the U.S.

Constitution. The State of Missouri did not appeal the Huff decision, and on August

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1, 2013, MCHCP placed the Wielands in a healthcare plan that included coverage for

contraceptives. 

2

TheWielands, parents ofthree daughters, are committed to the health and wellbeing of their children and thus seek to ensure that their daughters have

comprehensive healthcare coverage. As devout Roman Catholics, they believe that

they cannot pay for or participate in a healthcare plan that includes coverage for

contraceptives or provide such coverage to their daughters without violating their

sincerely held religious beliefs. 

The Wielands filed a complaint against HHS, generally contending that HHS’s

enforcement or threatened enforcement of certain provisions of the ACA caused

MCHCP to place them in a healthcare plan that includes coverage for contraceptives,

thereby forcing them to provide that coverage to their dependent daughters. The

Wielands challenged provisions of the ACA and its implementing regulationsthat do

not apply to individuals like themselves, but to “group health plan[s] and . . . health

insurance issuer[s] offering group or individual health insurance coverage.” 42

U.S.C. § 300gg-13(a)(4); 75 Fed. Reg. 41726, 41759 (noting application to group

health plans and health insurance issuers offering group or individual health

insurance coverage). They also challenged an interim final rule, which they defined

in their complaint as “the Mandate,” that “requires . . . all ‘group health plan[s]

and . . . health insurance issuer[s] offering group or individual health insurance

coverage’” to provide coverage for contraceptives. 76 Fed. Reg. 46621; 45 C.F.R.

After the district court entered its order in Huff, the Supreme Court held in 2

Burwell v. Hobby Lobby Stores, Inc., that the Religious Freedom Restoration Act of

1993 prohibited the government from enforcing the ACA and its implementing

regulations that require “closely held corporations [to] provide health-insurance

coverage for methods of contraception that violate the sincerely held religious beliefs

of the companies’ owners.” 134 S. Ct. 2751, 2759 (2014). On remand, the district

court must consider whether Huff remains good law after Hobby Lobby. 

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§ 147.130. The Wielands alleged that HHS’s enforcement or threatened enforcement

of “the Mandate” against them violated their rights under the Religious Freedom

Restoration Act of 1993 (RFRA), 42 U.S.C. §§ 2000bb to 2000bb-4; the Free

Exercise, Free Speech, and Due Process Clauses of the U.S. Constitution; and the

Administrative Procedure Act, 5 U.S.C. § 706, by forcing them to provide their

daughters with coverage for contraceptives. 

TheWielands sought a declaration “that theMandate and [HHS’s] enforcement

of the Mandate against these Plaintiffs” violatestheir rights and “an order prohibiting

[HHS] from enforcing the Mandate against these Plaintiffs insofar as it forces them

to provide, fund or participate in the provision of contraceptives.” They also sought

a temporary restraining order (TRO) and a preliminary injunction “prohibiting [HHS]

from requiring that the Plaintiffs’ health benefit plan contain coverage for

contraceptives.” The Wielands claimed that if the requested relief were granted, the

State and MCHCP would offer them a healthcare plan without coverage for

contraceptives or an opportunity to opt out of such coverage. 

HHS moved to dismiss the complaint for lack of standing. According to HHS,

the Wielands lacked standing because they were challenging provisions of the ACA

that did not apply to them and were seeking an injunction prohibiting HHS from

enforcing the Mandate against MCHCP and, ultimately, the State of Missouri, neither

of which was a party to the case. The district court agreed with HHS, and it

concluded that even if it granted the Wielands the relief they sought, whether the

Wielands would ultimately be offered a contraceptive-free healthcare plan was

“linked with the independent discretionary actions of the State and MCHCP, neither

of which [is a] part[y] to this action or before this Court.” The court recognized that

MCHCP had previously provided an opportunity to opt out of coverage for

contraceptives, but that the provision under which that opt-out had been offered,

section 376.1199, was invalidated in Huff—a decision that the State did not appeal. 

The court also rejected the Wielands’ contention that if it were to enter the requested

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injunction, a different state statute, Missouri Revised Statutessection 191.724, would

require the State and MCHCP to offer a contraceptive-free healthcare plan. 

Because the district court concluded that the Wielands had not met their burden

to establish standing, it dismissed their complaint with prejudice and withoutreaching

the merits. The court also concluded that the Wielands’ failure to establish standing

was fatal to their motion for declaratory and injunctive relief, and it denied that

motion without further analysis. The Wielands filed a notice of appeal from the

district court’s order and also moved for a preliminary injunction pending appeal. 

HHS opposed the motion for a preliminary injunction, and an administrative panel of

this Court denied the motion. 

We review de novo the district court’s grant of a motion to dismiss for lack of

standing, accepting as true all factual allegations in the complaint and drawing all

reasonable inferencesin favor of the nonmoving party. Hastings v. Wilson, 516 F.3d

1055, 1058 (8th Cir. 2008). Although courts generally must ignore materials outside

the pleadings in deciding Rule 12 motions to dismiss, they “may consider some

materials that are part of the public record or do not contradict the complaint, as well

as materials that are necessarily embraced by the pleadings.” Miller v. Redwood

Toxicology Lab., Inc., 688 F.3d 928, 931 (8th Cir. 2012) (citations omitted). 

Federal court jurisdiction is restricted to “‘cases’ and ‘controversies.’” Flast

v. Cohen, 392 U.S. 83, 94 (1968). A case or controversy exists only if a plaintiff

“personally has suffered some actual or threatened injury as a result of the putatively

illegal conduct of the defendant.” Gladstone Realtors v. Vill. of Bellwood, 441 U.S.

91, 99 (1979). A plaintiff bears the burden of showing (1) that he has suffered an

“injury in fact” that is “actual orimminent, not ‘conjectural or‘hypothetical’”; (2) that

the injury is causally connected to the defendant’s allegedly illegal conduct and not

to the “independent action of some third party not before the court”; and (3) that “it

[is] ‘likely,’ as opposed to merely ‘speculative,’ that the injury will be ‘redressed by

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a favorable decision.’” Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-61 (1992)

(citations omitted). A plaintiff’s burden to establish standing depends on the stage

of litigation, and “[a]t the pleading stage, general factual allegations . . . may suffice,

for on a motion to dismiss we ‘presum[e] that general allegations embrace those

specific facts that are necessary to support the claim.’” Id. at 561 (citations omitted). 

The Wielands first argue that the district court erred in concluding that they did

not establish a causal connection between their injury and the Mandate sufficient to

satisfy the causation element ofstanding. They argue that their pleadings adequately

alleged a chain of causation that runs directly from the Mandate to their placement

in a healthcare plan that includes coverage for contraceptives. The district court

erred, according to the Wielands, because there was no “independent discretionary

action” by the State or MCHCP—MCHCP placed them in a healthcare plan that

included coverage for contraceptives, thereby causing their injury, as a direct result

of HHS’s threatened enforcement of the Mandate against the State and MCHCP. We

agree.

The Wielands alleged in their complaint that “[b]ecause of the Mandate . . .

MCHCP now states that Mr. Wieland’s insurance plan must provide” coverage for

contraceptives. They also alleged that “upon information and belief,” they “cannot

obtain insurance coverage without coverage for contraceptives . . . from any source.”

Thus, they contended, “[t]he Mandate forces [them] to provide coverage for or

otherwise participate in the provision of” coverage for contraceptives “against [their]

religiously informed consciences.” The crux of these general allegations is that

absent the Mandate, the Wielands would have a contraceptive-free healthcare plan,

whether from MCHCP or from a private insurance issuer.

HHS argues that the Mandate cited by the Wielands asthe source oftheir injury

imposes no direct obligation or requirement on themand that the district court did not

err in concluding that the Wielands failed to satisfy the causation element ofstanding. 

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An injury may be “fairly traceable” to a defendant for causation purposes even when

that defendant’s actions are not “the very laststep in the chain of causation.” Bennett

v. Spear, 520 U.S. 154, 168-69 (1997). “While . . . it does not suffice if the injury

complained of is ‘th[e] result [of] the independent action of some third party not

before the court,’ that does not exclude injury produced by determinative or coercive

effect upon the action of someone else.” Id. at 169 (internal citations omitted). 

Here, the Wielands’ injury is fairly traceable from HHS’s enforcement or

threatened enforcement of the Mandate, to MCHCP, to the Wielands. This is not a

case where the “unfettered choices made by independent actors” operate to sever the

chain of causation. Lujan, 504 U.S. at 562. The Mandate challenged in the

Wielands’ complaint requires group health plans and health insurance issuers to

include coverage for contraceptives in all healthcare plans, and it is the Mandate that

caused the State and MCHCP to eliminate contraceptive-free healthcare plans, to

place the Wielands in a healthcare plan that included this coverage, and thus to cause

injury to the Wielands. 

HHS contends that it was not the Mandate that caused MCHCP to eliminate

contraceptive-free healthcare plans and to place the Wielands in a healthcare plan that

includes coverage for contraceptives. Rather, HHS argues, it was the State’s

independent and discretionary decision not to challenge the ruling in Huff that caused

MCHCP to eliminate contraceptive-free healthcare plans. We are not persuaded. In

our view, the Huff decision merely put the State and MCHCP on notice that HHS’s

enforcement or threatened enforcement of the Mandate would result in significant

penalties in the event that MCHCP continued offering contraceptive-free healthcare

plans under section 376.1199. Indeed, the MCHCP board of trustees, after

acknowledging that Huff clarified how the ACA would be applied, concluded that

MCHCP could no longer offer contraceptive-free healthcare plans that were “in direct

conflict with the ‘contraceptive mandate’ in the” ACA without “put[ting] MCHCP

and its assets at risk.” Because MCHCP did not qualify for an exemption or

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accommodation under the ACA, the board concluded that MCHCP was “subject to

the same provisions of federal law that require the offering of contraceptives,” that

MCHCP was required to eliminate all contraceptive-free healthcare plans, and that

“affected individuals” must be transferred “from the plan they chose without

contraception to the same plan with contraception.” The Huff decision simply

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clarified for the State and MCHCP that the section 376.1199 opt-out provisions were

preempted by federal law; it was the federal law itself—the Mandate—that was the

but-for cause of the change in the Wielands’ healthcare plan. Moreover, as earlier

stated, the continued validity of the Huff decision is a matter that must be addressed

in light of the Supreme Court’s decision in Hobby Lobby. If Hobby Lobby overruled

Huff, a question we leave for the district court in the first instance, the section

376.1199 opt-out provision would again be available, and MCHCP would be required

to comply with that statutory provision.

MCHCP eliminated contraceptive-free healthcare plans and transferred the

Wielands into a plan including such coverage to avoid violating the Mandate and

“put[ing] . . . its assets at risk.” Keeping in mind that at this stage of the litigation we

“must accept all factual allegations in the complaint as true and draw all inferences”

in favor of the Wielands, we are satisfied that the Wielands have alleged sufficient

facts to show that they were placed in a healthcare plan that includes coverage for

contraceptives, not because of “independent discretionary actions of the State and

MCHCP,” but because of HHS’s enforcement or threatened enforcement of the

Exempted from the Mandate are “grandfathered” plans, 45 C.F.R. § 147.140;

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religious employers, id. § 147.131(a); and employers with fewer than 50 full-time

employees, as long as the employer does not offer any healthcare coverage, see 26

U.S.C. § 4980H. Certain religious nonprofit organizations may also qualify for an

accommodation from the Mandate, 45 C.F.R. § 147.131(b), as may closely held

corporations whose owners have religious objections to the Mandate, see Hobby

Lobby, 134 S. Ct. at 2759-60. MCHCP does not qualify for these, or any other,

exemptions or accommodations and is thus subject to the Mandate. 

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Mandate. There was no discretion involved in the decision. The State and MCHCP

were required by federal law, by the Mandate, to include coverage for contraceptives

in all healthcare plans they offered—including the Wielands’ healthcare plan. The

undeniable effect of the Mandate upon the Wielands isthat their healthcare plan must

now include coverage for contraceptives. We therefore conclude that the Wielands

have established a sufficient causal connection between their injury and HHS’s

enforcement of the Mandate to satisfy the causation element of standing. 

In addition to establishing a sufficient causal connection between the Mandate

and their alleged injury, the Wielands were required to allege facts that, if true, would

show that it is “likely” and not merely “speculative” that their injury would be

redressed if they were granted the remedy they seek. See Lujan, 504 U.S. at 561. The

Wielands claim that an injunction prohibiting HHS from enforcing the Mandate

against MCHCP would result in MCHCP offering them a contraceptive-free

healthcare plan under section 191.724 of the Missouri Revised Statutes. This section

was not challenged by the plaintiffs in Huff, and it apparently remains in effect in

Missouri. We conclude that the Wielands have sufficiently alleged that it is more

than merely speculative that their injury would be redressed if they were granted the

remedy they seek. 

HHS argued before the district court that MCHCP’s decision to eliminate

contraceptive-free healthcare plans “would not be illegal under [section] 191.724.2

because that statute does not prohibit employers or insurers from choosing to offer

only a health plan that covers contraception.” The Wielands invoked section

191.724.4, however, which states:

No governmental entity, . . . or entity acting in a governmental capacity

shall discriminate against or penalize an employee, . . . employer, health

plan provider, health plan sponsor, . . . or any other person or entity

because of such employee’s, . . . employer’s, health plan provider’s,

health plan sponsor’s, . . . or other person’s or entity’s unwillingness,

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based on religious beliefs or moral convictions, to obtain or provide

coverage for, pay for, [or] participate in, . . . abortion, contraception, or

sterilization in a health plan.

Mo. Rev. Stat. § 191.724.4. The Wielands contend that under subsection 4, MCHCP,

an entity created by the State and acting in a governmental capacity, is prohibited

from discriminating against them by refusing to offer them a contraceptive-free

healthcare plan despite their religious objections to coverage for contraceptives. 

They argue that if MCHCP offers State employees a healthcare plan that includes

coverage for contraceptives, but refuses to offer a healthcare plan that excludes such

coverage to employees who have a religious objection, “[t]here could be no more

obvious case of discrimination” against the employees with religious objections to

such coverage. Moreover, they argue, because section 191.724.1 states that “[t]he

rights guaranteed under [section 191.724] are in addition to the rights guaranteed

under . . . section 376.1199,” the provision that was invalidated in Huff, section

191.724 provides a separate basis on which MCHCP must provide them with a

contraceptive-free healthcare plan. Thus, the Wielands argue, if the requested

injunction is granted, section 191.724 requires that MCHCP offer the Wielands a

contraceptive-free healthcare plan. 

HHS argues that if section 191.724 required MCHCP to offer contraceptivefree healthcare plans to employees with religious objections, MCHCP would not have

eliminated those plans after the Huff decision invalidated the section 376.1199 optout provision. HHS points to an emergency rescission issued by the MCHCP board

of trustees after the Huff decision stating that after Huff, “there is no longer a state

statutory requirement on which to base” an opt-out opportunity. But the Wielands

argue that MCHCP relied on section 191.724 when it offered them the opportunity

to opt out of coverage for contraceptives. The MCHCP 2013 Open Enrollment

Worksheet, which provided the mechanism for employees to exercise their opt-out

rights, specifically refers to section 191.724 as the provision under which “every

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employee . . . has the right to decline or refuse coverage for contraception” if such

coverage is “contrary to an employee’s religious beliefs.”

We conclude that it is more than merely speculative that the Wielands’ injury

would be redressed if they were granted the injunctive relief they seek. With the

benefit ofthe requested injunction against HHS’s enforcement oftheMandate against

MCHCP, MCHCP would be assured that it could safely proceed under section

191.724 to provide the Wielands with an opportunity to opt out of coverage for

contraceptives. And if Hobby Lobby overruled Huff, the section 376.1199 opt-out

provision would again be available. Before the threatened enforcement of the

Mandate, the State and MCHCP were willing to offer the Wielands a contraceptivefree healthcare plan, which is persuasive evidence that they would do so again if the

Wielands obtain their requested relief. We conclude therefore that the Wielands have

alleged a sufficient basis on which to conclude that it is “likely” and not merely

“speculative” that their injury would be redressed if they were granted the injunctive

relief they seek. 

The judgment of the district court is reversed, and the case is remanded to the

district court for further proceedings consistent with this opinion. We express no

opinion on the merits of the Wielands’ claims. See Red River Freethinkers v. City

of Fargo, 679 F.3d 1015, 1023 (8th Cir. 2012) (“The standing inquiry is not . . . an

assessment of the merits of a plaintiff’s claim.”). 

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