Document ID: ./input/supremecourt_opinions/opinions/19pdf/19-431_5i36.pdf
Page Number: 42.0

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LITTLE SISTERS OF THE POOR SAINTS PETER 
AND PAUL HOME v. PENNSYLVANIA 
ALITO, J., concurring 

women, why didn’t Congress mandate that coverage in the 
ACA itself?  Why did it leave it to HRSA to decide whether 
to require such coverage at all? 

Third,  the  ACA’s  very  incomplete  coverage  speaks  vol-
umes.  The  ACA  “exempts  a  great  many  employers  from 
most  of  its  coverage  requirements.”    Hobby  Lobby,  573 
U. S., at 699.  “[E]mployers with fewer than 50 employees
are not required to provide” any form of health insurance, 
and  a  number  of  large  employers  with  “ ‘grandfathered’ ” 
plans  need  not  comply  with  the  contraceptive  mandate. 
Ibid.; see 26 U. S. C. §4980H(c)(2); 42 U. S. C. §18011.  Ac-
cording to a recent survey, 13% of the 153 million Ameri-
cans  with  employer-sponsored  health  insurance  are  en-
rolled  in  a  grandfathered  plan,  while  only  56%  of  small
firms provide health insurance.  Kaiser Family Foundation, 
Employer Health Benefits: 2019 Annual Survey 7, 44, 209 
(2019).  In Hobby Lobby, we wrote that “the contraceptive 
mandate ‘presently does not apply to tens of millions of peo-
ple,’ ” 573 U. S., at 700, and it appears that this is still true 
apart from the religious exemption.10 

Fourth,  the  Court’s  recognition  in  today’s  decision  that
the ACA authorizes the creation of exemptions that go be-
yond  anything  required  by  the  Constitution  provides  fur-
ther  evidence  that  Congress  did  not  regard  the  provision 
of  cost-free  contraceptives  to  all  women  as  a  compelling 
interest. 

Moreover, the regulatory exemptions created by the De-
partments and HRSA undermine any claim that the agen-
cies themselves viewed the provision of contraceptive cov-
erage  as  sufficiently  compelling.    From  the  outset,  the 
church exemption has applied to churches, their integrated 

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10 In contrast, the Departments estimated that plans covering 727,000
people would take advantage of the religious exemption, and thus that 
between 70,500 and 126,400 women of childbearing age would be affected 
by the religious exemption.  83 Fed. Reg. 57578, 57581.