A variety of legislative issues have raised interest in the First Amendment implications of mandatory public health programs, such as the minimum coverage requirements enacted in the Patient Protection and Affordable Care Act or considerations of vaccination programs to prevent an outbreak of serious illness that may arise from potential acts of bioterrorism. Because some religious denominations believe that certain health care measures would violate their First Amendment right to religious freedom, congressional action related to mandatory health care programs must be considered in light of the First Amendment's Establishment and Free Exercise Clauses. This report will discuss the legal issues that arise in the context of religious exemptions for mandatory health care programs. It will discuss constitutional and statutory provisions relating to religious protection and how such laws have been applied in the medical context. The report will also briefly address examples of health care programs that have included religious exemptions. It will analyze whether the U.S. Constitution requires religious exemptions for mandatory health care programs and whether, if not required, the Constitution allows religious exemptions for such programs. The First Amendment of the U.S. Constitution provides that "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof...." These clauses are known respectively as the Establishment Clause and the Free Exercise Clause. Although the U.S. Supreme Court had historically applied a heightened standard of review to government actions that allegedly interfered with a person's free exercise of religion, the Court reinterpreted that standard in its 1990 decision, Employment Division, Department of Human Resources of Oregon v. Smith . Since then, the Court has held that the Free Exercise Clause never "relieve[s] an individual of the obligation to comply with a valid and neutral law of general applicability." Under this interpretation, the constitutional baseline of protection was lowered, meaning that laws that do not specifically target religion or do not allow for individualized assessments are not subject to heightened review under the Constitution. Congress responded to the Court's holding by enacting the Religious Freedom Restoration Act of 1993 (RFRA), which statutorily reinstated the heightened scrutiny standard for government actions interfering with a person's free exercise of religion. When RFRA was originally enacted, it applied to federal, state, and local government actions, but in 1997 the Supreme Court ruled that its application to state and local governments was unconstitutional under principles of federalism. Under RFRA, a statute or regulation of general applicability may lawfully burden a person's exercise of religion only if it (1) furthers a compelling governmental interest and (2) uses the least restrictive means to further that interest. This standard is sometimes referred to as strict scrutiny analysis. The Supreme Court has held that in order for the government to prohibit exemptions to generally applicable laws, the government must "demonstrate a compelling interest in uniform application of a particular program by offering evidence that granting the requested religious accommodations would seriously compromise its ability to administer the program." Some religious doctrines forbid medical treatment or conflict with specific medical procedures. Followers of these religions believe that receiving treatment would violate their First Amendment right to exercise their religion freely. This conflict raises the issue known as forced care—whether patients can be forced to receive medical care to which they object on religious grounds. Legal issues of forced care typically arise in situations where patients lack the capacity to make an informed decision about whether or not to receive care. These situations often involve patients facing death if they do not receive treatment. For example, because some religions have specific teachings regarding matters of life and death, a patient may object to life-saving treatment on religious grounds. However, if that patient lacks the capacity to provide informed consent at the time that care would be provided, a doctor or hospital may not be willing to withhold care based on religious affiliation alone, without an informed discussion with the patient. Federal and state courts have addressed these issues of forced care for patients with religious objections to medical care. Courts have indicated a growing willingness over the past several decades to recognize patients' religious objections to medical care, including life-saving treatments. In the 1960s, a federal court authorized a hospital to treat a patient with what would be an objectionable procedure under her religion. The patient faced death without a blood transfusion, a procedure that her religion prohibited, but due to emergency circumstances, the hospital staff was unable to determine if the patient was making an informed decision when she refused the treatment. By the 1980s, courts were giving greater weight to patients' choices regarding care. In later cases, courts concluded that competent adults with religious objections to procedures cannot be forced to receive care, with one court noting that courts should give "great deference to the individual's right to make decisions vitally affecting his private life according to his own conscience." It is important to note, however, that such deference to patients' objections to care may not be recognized in cases in which parents are claiming objections on behalf of a child. The Patient Protection and Affordable Care Act (ACA; P.L. 111-148 ), enacted in March 2010, creates a requirement that individuals maintain insurance coverage. This individual responsibility requirement (sometimes referred to as an individual mandate) requires that individuals and their dependents maintain "minimum essential coverage" after the effective date of the provision. Individuals who do not maintain the required coverage face financial penalties for the months that they are not covered (a shared responsibility requirement), if they do not qualify for one of the included exemptions. ACA includes a religious conscience exemption, which provides that the individual responsibility requirement does not apply to any individual who has been certified to be "a member of a recognized religious sect or division thereof described in section 1402(g)(1) [of the Internal Revenue Code of 1986] and an adherent of established tenets or teaching of such sect or division as described in such section." Section 1402(g)(1) provides an exemption from self-employment income tax if the individual seeking exemption: is a member of a recognized religious sect or division thereof and is an adherent of established tenets or teachings of such sect or division by reason of which he is conscientiously opposed to acceptance of the benefits of any private or public insurance which makes payments in the event of death, disability, old-age, or retirement or makes payments toward the cost of, or provides services for, medical care.... Thus, there is no list of specific religious groups that qualify for the exemption. Rather, the exemption is general, such that any member of any religious organization with the beliefs described in the provision would qualify. This construction of the exemption appears to conform with the constitutional requirements of the First Amendment, as discussed later in this report. Members of any religious group who can demonstrate conformance with the requirements of Section 1402(g) would therefore be qualified for exemption under ACA. The exemption for religious groups with conscientious objections to medical treatment outside the religious community is typically associated with religious groups such as the Amish, which have historically opposed participation in public social service programs based on their religious beliefs. However, the exception is not specifically offered to that group, and speculation on which religious groups' tenets would qualify for exemption is beyond the scope of this report. Several lawsuits have challenged the constitutionality of the minimum essential coverage requirement on various grounds. Such challenges have included religious freedom claims, with at least one court addressing the merits of those claims. In that case, taxpayers claimed that the requirement violated RFRA by imposing a substantial burden on their religious exercise because obtaining health insurance would indicate a lack of trust as Christians that God would provide for their needs. The U.S. District Court for the District of Columbia noted that, according to the U.S. Supreme Court, a substantial burden would indicate that the government has substantially pressured an individual to modify his or her behavior in violation of his or her religious beliefs. The court held that the burden imposed by the coverage requirement did not rise to the level of a substantial burden because there was insufficient evidence that the individuals would be pressured to modify their behavior and violate their beliefs. The court reasoned that the individuals could opt out of the coverage requirement by paying a shared responsibility requirement instead. Further, the court found the individuals "routinely contribute to other forms of insurance, such as Medicare, Social Security, and unemployment taxes, which present the same conflict with their belief that God will provide for their medical and financial needs." The court concluded that even if it had found a substantial burden on religious exercise, the coverage requirement nonetheless complied with RFRA. According to the court, the requirement served a compelling governmental interest in lowering health insurance premiums and improving access to health care through the least restrictive means, which provided individuals with a choice between the minimum coverage requirement or the shared responsibility requirement. On appeal, the U.S. Court of Appeals for the D.C. Circuit affirmed the district court's opinion, agreeing "that appellants failed to allege facts showing that the mandate will substantially burden their religious exercise." ACA also requires group health plans and health insurance issuers that offer health insurance coverage to provide coverage for certain preventive health services without imposing any cost sharing requirements. The U.S. Departments of Health and Human Services, Labor, and Treasury subsequently issued guidelines and regulations for coverage of a range of preventive health services, including contraceptives and related services. The rules provide authority for an exemption for "religious employers" from the preventive health services guidelines "where contraceptive services are concerned." To qualify as a religious employer, an organization must meet four criteria: (1) The inculcation of religious values is the purpose of the organization; (2) The organization primarily employs persons who share the religious tenets of the organization; (3) The organization serves primarily persons who share the religious tenets of the organization; and (4) The organization is a nonprofit organization as described in section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as amended. The exemption appears to apply to churches, but potentially would not apply to other religiously affiliated institutions such as universities, hospitals, and social service providers.