# The Roman Catholic Archdiocese of Atlanta v. Secretary of the U.S. Department of Health and Human Services > Court of Appeals for the Eleventh Circuit · February 18, 2016 · 818 F.3d 1122 URL: https://www.frixlaw.com/law-library/cases/3178557 ## Case - **Full name:** ETERNAL WORD TELEVISION NETWORK, INC., Plaintiff-Appellant, State of Alabama, Plaintiff, SECRETARY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, U.S. Department of Health and Human Services, Secretary of the U.S. Department of Labor, U.S. Department of Labor, Secretary of the U.S. Department of the Treasury, U.S. Department of the Treasury, Defendants-Appellees. the Roman Catholic Archdiocese of Atlanta, an Association of Churches and Schools, the Most Reverend Wilton D. Gregory, and His Successors, Archbishop of the Roman Catholic Archdiocese of Atlanta, Catholic Charities of the Archdiocese of Atlanta, Inc., a Georgia Non-Profit Corporation, the Roman Catholic Diocese of Savannah, an Ecclesiastical Territory, the Most Reverend John Hartmayer, and His Successors, Bishop of the Roman Catholic Diocese of Savannah, Et Al., Plaintiffs-Appellees, Secretary, U.S. Department of Health and Human Services, U.S. Department of Health and Human Services, U.S. Department of Labor, U.S. Department of Treasury, Secretary, U.S. Department of Labor, Secretary, U.S. Department of Treasury, Defendants- Appellants - **Court:** Court of Appeals for the Eleventh Circuit - **Decided:** February 18, 2016 - **Citations:** 818 F.3d 1122 - **Precedential status:** Published - **Opinion:** Opinion - **Judges:** Tjoflat, Pryor, Anderson - **Nature of suit:** CON - **Cited by:** 42 later opinions in the Frix Law Library ## Citator (automated) - No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases. - Full citator and citing cases: https://www.frixlaw.com/law-library/cases/3178557 ## How later opinions describe it (automated extraction) - stating that we construe pleadings by pro se litigants liberally ## Opinion text Case: 14-12696 Date Filed: 02/18/2016 Page: 1 of 148 [PUBLISH] IN THE UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT ________________________ No. 14-12696 ________________________ D.C. Docket No. 1:13-cv-00521-CG-C ETERNAL WORD TELEVISION NETWORK, INC., Plaintiff - Appellant, STATE OF ALABAMA, Plaintiff, versus SECRETARY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, SECRETARY OF THE U.S. DEPARTMENT OF LABOR, U.S. DEPARTMENT OF LABOR, SECRETARY OF THE U.S. DEPARTMENT OF THE TREASURY, U.S. DEPARTMENT OF THE TREASURY, Defendants - Appellees. ________________________ Appeals from the United States District Court for the Southern District of Alabama ________________________ Case: 14-12696 Date Filed: 02/18/2016 Page: 2 of 148 ________________________ Nos. 14-12890; 14-13239 ________________________ D.C. Docket No. 1:12-cv-03489-WSD THE ROMAN CATHOLIC ARCHDIOCESE OF ATLANTA, an association of churches and schools, THE MOST REVEREND WILTON D. GREGORY, and his successors, Archbishop of the Roman Catholic Archdiocese of Atlanta, CATHOLIC CHARITIES OF THE ARCHDIOCESE OF ATLANTA, INC., a Georgia non-profit corporation, THE ROMAN CATHOLIC DIOCESE OF SAVANNAH, an ecclesiastical territory, THE MOST REVEREND JOHN HARTMAYER, and his successors, Bishop of the Roman Catholic Diocese of Savannah, et al., Plaintiffs - Appellees, versus SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, U.S. DEPARTMENT OF LABOR, U.S. DEPARTMENT OF TREASURY, SECRETARY, U.S. DEPARTMENT OF LABOR, SECRETARY, U.S. DEPARTMENT OF TREASURY, Defendants - Appellants. 2 Case: 14-12696 Date Filed: 02/18/2016 Page: 3 of 148 ________________________ Appeals from the United States District Court for the Northern District of Georgia ________________________ (February 18, 2016) Before TJOFLAT, JILL PRYOR and ANDERSON, Circuit Judges. JILL PRYOR, Circuit Judge: The plaintiffs in these consolidated appeals challenge the regulations implementing what is known as the “contraceptive mandate” of the Affordable Care Act (“ACA”)—the requirement that employers provide health insurance coverage for preventive care (including contraception) to women. 1 Specifically, the plaintiffs argue that the regulations’ accommodation for nonprofit organizations with a religious objection to providing contraceptive coverage violates the Religious Freedom Restoration Act (“RFRA”), 42 U.S.C. § 2000bb, et seq. They claim that the accommodation substantially burdens their religious exercise in violation of RFRA by forcing them to take actions that cause their health plan administrators to provide contraceptive coverage and to maintain a health plan that serves as a conduit for contraceptive coverage. We reject the 1 We consider in this opinion the following district court orders: Eternal World Television Network, Inc. v. Burwell, 26 F. Supp. 3d 1228 (S.D. Ala. 2014); Roman Catholic Archdiocese of Atlanta v. Sebelius, No. 1:12-cv-03489-WSD, 2014 WL 2441742 (N.D. Ga. May 30, 2014); and Roman Catholic Archdiocese of Atlanta v. Sebelius, No. 1:12-cv-03489-WSD, 2014 WL 1256373 (N.D. Ga. Mar. 26, 2014). The government filed separate appeals from the two orders in Roman Catholic Archdiocese, which were consolidated before this Court. 3 Case: 14-12696 Date Filed: 02/18/2016 Page: 4 of 148 plaintiffs’ claims because we conclude that the regulations do not substantially burden their religious exercise and, alternatively, because (1) the government has compelling interests to justify the accommodation, and (2) the accommodation is the least restrictive means of furthering those interests. Eternal Word Television Network (“EWTN”), the plaintiff in the first appeal, also raises several First Amendment challenges to the accommodation. Because the accommodation is a neutral, generally applicable law that does not discriminate based on religious denomination, we reject EWTN’s challenges under the Establishment and Free Exercise Clauses. We also reject EWTN’s challenge under the Free Speech Clause because, as discussed below, any speech restrictions that may flow from the accommodation are justified by a compelling governmental interest and are thus constitutional. I. BACKGROUND A. The Affordable Care Act and the Contraceptive Mandate Enacted in 2010, the ACA requires group health insurance plans to provide a minimum floor of coverage without imposing cost sharing (such as deductibles, co-payments, or co-insurance) on plan participants and beneficiaries. 42 U.S.C. § 300gg-13(a). If an employer fails to provide such coverage in its group employee health plan, it is subject to penalties in the form of a tax of $100 per day per affected person. 26 U.S.C. § 4980D(b)(1). The Women’s Health Amendment 4 Case: 14-12696 Date Filed: 02/18/2016 Page: 5 of 148 to the ACA added to the minimum coverage requirements a mandate that group health plans provide women with coverage for preventive care and screenings. 42 U.S.C. § 300gg-13(a)(4). The requirement was intended in part to “get[] rid of, or minimiz[e], high copays and high deductibles that are often overwhelming hurdles for women to access screening programs.” 155 Cong. Rec. S11987 (Nov. 30, 2009) (statement of Sen. Mikulski). The ACA tasked the Health Resources and Services Administration (“HRSA”), an agency of the Department of Health and Human Services (“HHS”), with promulgating comprehensive guidelines determining which preventive services and screenings would be required. 42 U.S.C. § 300gg-13(a)(4). HHS commissioned the Institute of Medicine (“IOM”) to assist with HRSA’s development of the guidelines. The IOM released a full report in 2011 detailing its study of various preventive services and its recommendations for coverage under the mandate. Inst. of Medicine, Clinical Preventive Services for Women: Closing the Gaps (2011) (“IOM Report”). The IOM Report discussed at length the positive public health outcomes associated with reducing unintended pregnancies and giving women more control over birth spacing. The United States has a much higher rate of unintended pregnancies—49 percent of pregnancies in 2001—than other developed countries. Id. at 102. Unintended pregnancies correlate with health problems both for women who experience such pregnancies and for children born 5 Case: 14-12696 Date Filed: 02/18/2016 Page: 6 of 148 as a result of them. Id. at 103. And because women may not realize immediately that they are pregnant, “their entry into prenatal care may be delayed[;] they may not be motivated to discontinue behaviors that present risks for the developing fetus; and they may experience depression, anxiety, or other conditions.” Id. Unintended pregnancies also frequently end in abortion. Id. at 102. 2 The IOM Report also noted the health consequences of pregnancies occurring too closely together in time. For infants, “[s]hort interpregnancy intervals in particular have been associated with low birth weight, prematurity, and small for gestational age births.” Id. at 103. For women, both pregnancy spacing and the ability to avoid pregnancy may significantly affect their health because, among other reasons, some “women with certain chronic medical conditions (e.g., diabetes and obesity) may need to postpone pregnancy until appropriate weight loss or glycemic control has been achieved.” Id. Pregnancy is also contraindicated for some women with serious medical conditions, for example, pulmonary hypertension or Marfan syndrome. 3 Id. at 103-04. The IOM Report also found 2 A 2013 report from the Centers for Disease Control and Prevention estimated that 18 percent of all pregnancies in the United States ended in abortion and noted that “unintended pregnancy precedes nearly all abortions.” Karen Pazol, et al., Centers for Disease Control & Prevention, Abortion Surveillance—United States, 2010 (Nov. 29, 2013), http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6208a1.htm. The IOM Report noted that in 2001, 42 percent of unintended pregnancies in the United States were terminated by abortion. IOM Report at 102. 3 Marfan syndrome is a genetic disorder that affects the body’s connective tissue. Pregnancy can be difficult for women with the condition because of the additional strain 6 Case: 14-12696 Date Filed: 02/18/2016 Page: 7 of 148 that “greater use of contraception within the population produces lower unintended pregnancy and abortion rates nationally.” Id. at 105. Pursuant to its statutory authority, HRSA released binding guidelines, based on the IOM Report, that require coverage for “[a]ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.” U.S. Dep’t of Health & Human Servs., Health Res. & Servs. Admin., Women’s Preventive Services Guidelines (“HRSA guidelines”), http://www.hrsa.gov/womensguidelines (last visited Feb. 12, 2016); see also 77 Fed. Reg. 8725, 8725-26 (Feb. 15, 2012) (quoting the language in the HRSA guidelines regarding coverage). Implementing regulations developed by the Department of Labor, the Department of the Treasury, and HHS (collectively, the “Departments”) reiterate the contraceptive mandate’s requirement that health plans cover all services listed in the HRSA guidelines. 26 C.F.R. § 54.9815-2713(a)(1)(iv) (Treasury Regulation); 29 C.F.R § 2590.715-2713(a)(1)(iv) (Labor Regulation); 45 C.F.R. § 147.130(a)(1)(iv) (HHS Regulation). 4 pregnancy places on the cardiovascular system. Nat’l Heart, Lung, & Blood Inst., What is Marfan Syndrome? (Oct. 1, 2010), http://www.nhlbi.nih.gov/health/health-topics/topics/mar/. 4 The Departments have jointly developed regulations carrying out the ACA. To be concise, whenever possible we cite only to the regulations issued by HHS, codified at 45 C.F.R. pt. 147, and not to the corresponding identical regulations issued by the Departments of Labor and the Treasury. 7 Case: 14-12696 Date Filed: 02/18/2016 Page: 8 of 148 Mindful of religious freedom and the importance of respect for “the unique relationship between a house of worship and its employees in ministerial positions,” the Departments promulgated interim regulations that gave HRSA discretion to exempt from the contraceptive mandate certain group health plans established or maintained by religious employers. See 76 Fed. Reg. 46621, 46623 (Aug. 3, 2011). The Departments defined “religious employer” by incorporating the Internal Revenue Service’s definition of a church or integrated auxiliary from 26 U.S.C. § 6033(a)(3)(A)(i) and (iii). 45 C.F.R. § 147.130(a)(1)(iv)(B) (2011). The definition also required a religious employer to have a religious purpose and to both serve and employ primarily persons who share the religious tenets of the organization. Id. Exercising the discretion the regulations provided, HRSA amended its guidelines to exempt religious employers from the contraceptive mandate. The guidelines, issued on August 1, 2011, required compliance beginning on August 1, 2012. See id. § 147.130(b)(1). The Departments finalized the implementing regulations in February 2012. See 77 Fed. Reg. 8725. At the same time, the Departments established a temporary safe harbor from the contraceptive mandate for nonprofit organizations with religious objections to providing contraceptive coverage. See Dep’t of Health & Human Servs., Guidance on the Temporary Enforcement Safe Harbor for Certain Employers, Health Plans & Group Health Insurance Issuers with Respect to the 8 Case: 14-12696 Date Filed: 02/18/2016 Page: 9 of 148 Requirement to Cover Contraceptive Services Without Cost Sharing (Feb. 10, 2012). The safe harbor remained in effect for the 2012 plan year, ending on August 1, 2013. See id. at 2. The Departments intended to use the safe harbor period to “expeditiously develop and propose changes to the final regulations implementing” the contraceptive mandate. 77 Fed. Reg. 16501, 16503 (Mar. 21, 2012). The changes to the regulations needed to “meet two goals—accommodating non-exempt, non- profit religious organizations’ religious objections to covering contraceptive services and assuring that participants and beneficiaries covered under such organizations’ plans receive contraceptive coverage without cost sharing.” Id. In March 2012, the Departments began the rulemaking process and solicited comments on potential regulations that could achieve these two goals. Id. at 16501. At the conclusion of the rulemaking process in July 2013, the Departments promulgated revised regulations that retained HRSA’s authority to exempt religious employers. See 78 Fed. Reg. 39870 (July 2, 2013). The same day, HRSA released revised guidelines that tracked the Departments’ changes to the religious employer exemption. The final regulations simplified the definition of a “religious employer,” making the term coextensive with the IRS’s statutory definition and removing the additional qualifications regarding a religious 9 Case: 14-12696 Date Filed: 02/18/2016 Page: 10 of 148 employer’s mission, programs, and employees. 45 C.F.R. § 147.131(a) (2013); see also 78 Fed. Reg. at 39873-74. Religious employers remained categorically exempt from the contraceptive mandate out of “respect [for] the religious interests of houses of worship and their integrated auxiliaries.” 78 Fed. Reg. at 39874. The Departments noted that the exemption did not undermine their goal of making contraceptive coverage available because religious employers and their integrated auxiliaries “are more likely than other employers to employ people of the same faith who share the same objection, and who would therefore be less likely than other people to use contraceptive services even if such services were covered under their plan.” Id. The revised regulations, which took effect on Aug. 1, 2013, added an accommodation for organizations that do not qualify as religious employers under the exemption. See 45 C.F.R. § 147.131(b) (2013). So long as an organization is a nonprofit entity holding itself out as a religious organization and has a religious objection to providing contraceptive coverage (we refer to such entities as “eligible organizations”), it may opt out of the contraceptive mandate. Id. 5 5 Under 45 C.F.R. § 147.131(b), an organization is eligible for the accommodation if: (1) The organization opposes providing coverage for some or all of any contraceptive items or services required to be covered under § 147.130(a)(1)(iv) on account of religious objections. (2) (i) The organization is organized and operates as a nonprofit entity and holds itself out as a religious organization; or 10 Case: 14-12696 Date Filed: 02/18/2016 Page: 11 of 148 Eligible organizations can take advantage of the accommodation via one of two procedures. The first procedure requires the organization to complete Employee Benefits Security Administration Form 700 (“Form 700”). See EBSA Form 700–Certification (Aug. 2014), http://www.dol.gov/ebsa/preventiveserviceseligibleorganizationcertificationform.doc. 6 To complete the two-page form, the eligible organization must provide its name and the name, title, and contact information of the individual signing the form on behalf of the organization. The person signing the form must certify that the organization “has a religious objection to providing coverage for some or all of any contraceptive services that would otherwise be required to be covered.” Id. (ii) The organization is organized and operates as a closely held for-profit entity, as defined in paragraph (b)(4) of this section, and the organization’s highest governing body (such as its board of directors, board of trustees, or owners, if managed directly by its owners) has adopted a resolution or similar action, under the organization’s applicable rules of governance and consistent with state law, establishing that it objects to covering some or all of the contraceptive services on account of the owners’ sincerely held religious beliefs. (3) The organization must self-certify in the form and manner specified by the Secretary of Labor or provide notice to the Secretary of Health and Human Services as described in paragraph (c) of this section. The organization must make such self-certification or notice 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 or notice must be executed by a person authorized to make the certification or notice on behalf of the organization, and must be maintained in a manner consistent with the record retention requirements under section 107 of ERISA. 6 Form 700 is included as the appendix to this opinion. 11 Case: 14-12696 Date Filed: 02/18/2016 Page: 12 of 148 The form’s recipient depends on the type of health plan the eligible organization maintains. Employers can provide health benefits either through an insured health plan or a self-insured health plan. 7 See Cong. Budget Office, Key Issues in Analyzing Major Health Insurance Proposals 6 (2008). If the eligible organization has an insured plan, it gives Form 700 to the insurance company that provides its health plan (“plan provider”); if the organization has a self-insured plan, it gives Form 700 to its third-party administrator (“TPA”). The plaintiffs in both cases before us provide health benefits to their employees through self- insured group health plans, and all employ TPAs to administer their plans. Alternatively, an eligible organization may directly notify HHS of its religious objection to complying with the contraceptive mandate. This more recently developed method of taking advantage of the accommodation arose from the United States Supreme Court’s order granting a preliminary injunction in Wheaton College v. Burwell, 134 S. Ct. 2806 (2014). After the regulations concerning the exemption and accommodation procedures were finalized, the Supreme Court in Burwell v. Hobby Lobby Stores, 134 S. Ct. 2751, 2759-60 (2014), extended the accommodation for nonprofit religious organizations to 7 For insured health plans, the employer contracts with an insurance company that administers the group plan and pays claims. For self-insured plans, the financial risk of providing health insurance lies with the organization itself; the organization directly pays for the plan participants’ and beneficiaries’ claims. Usually, organizations with self-insured plans hire a third party to handle administrative tasks, such as developing provider networks and processing claims. 12 Case: 14-12696 Date Filed: 02/18/2016 Page: 13 of 148 closely held for-profit corporations whose owners have religious objections to complying with the contraceptive mandate. Three days after the Hobby Lobby decision was issued, the Supreme Court in Wheaton College granted a request for a preliminary injunction pending appellate review to a plaintiff challenging the accommodation itself under RFRA, the same challenge the plaintiffs mount here. Wheaton Coll., 134 S. Ct. at 2807. The Supreme Court’s order enjoined HHS from enforcing the accommodation procedure against the college, so long as the college “inform[ed] the Secretary of Health and Human Services in writing that it is a non- profit organization that holds itself out as religious and has religious objections to providing coverage for contraceptive services.” Id. The Supreme Court warned, however, that the injunction order “should not be construed as an expression of the Court’s views on the merits.” Id. 8 In response to the order in Wheaton College, the Departments issued interim final regulations in August 2014 to allow an eligible organization to opt out by sending a letter to HHS, instead of giving Form 700 to its plan provider or TPA. 79 Fed. Reg. 51092, 51094-95 (Aug. 27, 2014); see Ctr. for Medicare & Medicaid Servs., Model Notice, https://www.cms.gov/CCIIO/Resources/Regulations-and- 8 The Seventh Circuit recently resolved Wheaton College’s appeal, affirming the district court’s denial of the college’s request for a preliminary injunction. Wheaton Coll. v. Burwell, 791 F.3d 792 (7th Cir. 2015). 13 Case: 14-12696 Date Filed: 02/18/2016 Page: 14 of 148 Guidance/Downloads/Model-Notice-8-22-14.pdf (last visited Feb. 12, 2016). 9 There is no prescribed format for the letter, but it must include: the name of the eligible organization and the basis on which it qualifies for an accommodation; its objection based on its sincerely held religious beliefs to coverage of some or all contraceptive services, as applicable (including an identification of the subset of contraceptive services to which coverage the eligible organization objects, if applicable); the plan name and type . . . ; and the name and contact information for any of the plan’s third party administrators and health insurance issuers. 45 C.F.R. § 147.131(c)(1)(ii). The regulations became final, without substantial changes, in a set of new rules effective on September 14, 2015. 80 Fed. Reg. 41318 (July 14, 2015). Under the current rules, if an eligible organization directly notifies HHS of its intent to opt out of the contraceptive mandate, the government then alerts the organization’s health plan provider or TPA that the organization has opted out and describes the plan provider’s or TPA’s resulting obligations. See 26 C.F.R. § 54.9815- 2713A(b)(1)(ii)(B), (c)(1)(ii). For insured plans, once an eligible organization avails itself of the accommodation, the plan provider must (1) “[e]xpressly exclude contraceptive 9 The interim final regulations also removed a provision (known as the non-interference provision) requiring that eligible organizations “‘must not, directly or indirectly[,] seek to interfere with a third party administrator’s arrangements to provide or arrange for separate payments for contraceptive services,’ and ‘must not, directly or indirectly, seek to influence a third party administrator’s decision to make any such arrangements.’” 79 Fed. Reg. at 51095 (quoting 26 C.F.R. § 54.9815-2713A(b)(1)(iii); 29 C.F.R. § 2590.715-2713A(b)(1)(iii)). 14 Case: 14-12696 Date Filed: 02/18/2016 Page: 15 of 148 coverage from the group health insurance coverage” and (2) “[p]rovide separate payments for any contraceptive services required to be covered” for the plan participants and beneficiaries. 45 C.F.R. § 147.131(c)(2)(i). For self-insured plans, the regulations provide that when an eligible organization invokes the accommodation, its TPA is designated as the plan administrator under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1002(16), with respect to contraceptive services. Under the regulations, the TPA is designated as the plan administrator in one of two ways. If the eligible organization provides a copy of Form 700 to its TPA, then the regulations treat the form “as a designation of the [TPA] as the plan administrator” for ERISA purposes. 29 C.F.R. § 2510.3-16(b). If the eligible organization instead notifies HHS of its intent to opt out, then the Department of Labor notifies the TPA that it shall be the plan administrator with respect to contraceptive services for ERISA purposes. Id. Upon receiving notification, the TPA has the option of terminating its contractual relationship with the eligible organization. 10 See 26 C.F.R. § 54.9815- 10 If the TPA terminates the relationship, the organization must (1) contract with a new TPA to administer its self-insured plan, (2) convert to an insured plan by contracting with a plan provider, or (3) administer the plan itself. If the eligible organization contracts with a new TPA, then it remains subject to the mandate and must provide contraceptive coverage, seek an accommodation, or pay a penalty. Alternatively, the organization could restructure its plan and contract with a plan provider that would assume the risk of providing health insurance (that is, change from a self-insured to an insured plan). In this scenario, the organization would have to 15 Case: 14-12696 Date Filed: 02/18/2016 Page: 16 of 148 2713A(b)(2). If it remains as the TPA, then it must provide (or arrange for another insurer to provide) contraceptive benefits to participants and beneficiaries of the self-insured plan. Id.; 29 C.F.R. § 2510.3-16(c). 11 Significantly, plan providers and TPAs “may not impose any cost-sharing requirements (such as a copayment, coinsurance, or a deductible), or impose any premium, fee, or other charge, or any portion thereof, directly or indirectly, on the eligible organization, the group health plan, or plan participants or beneficiaries.” 26 C.F.R. § 54.9815-2713A(c)(2)(i); 45 C.F.R. § 147.131(c)(2)(ii). 12 Plan providers “must segregate premium revenue collected from the eligible organization from the monies used to provide payments for contraceptive comply with the mandate, seek an accommodation, or pay a penalty. Finally, the organization could continue with its self-insured plan without a TPA, meaning the organization would assume responsibility for administering claims. Although the Departments are unaware of the existence of a single self-insured plan without a TPA, they have created a safe harbor that excuses such a plan from complying with the contraceptive mandate so long as it annually notifies HHS that it has no TPA and plan participants and beneficiaries that contraceptive coverage is not provided. The Departments will provide this safe harbor while considering an additional accommodation. 78 Fed. Reg. at 39880-81. 11 Self-insured plans run by houses of worship and certain organizations controlled by or associated with a house of worship, known as “church plans,” are not subject to the provisions of ERISA unless they elect otherwise. See 26 U.S.C. §§ 410(d), 414(e). The government lacks authority to compel the TPA of a church plan not subject to ERISA to provide contraceptive coverage. See 29 U.S.C. § 1003(b)(2). Nonetheless, the TPA for a church plan may voluntarily provide contraceptive services; the government incentivizes these TPAs to provide the coverage by offering larger reimbursements. See 80 Fed. Reg. at 41323 n.22; 45 C.F.R. § 156.50(d). 12 The government reimburses plan providers and TPAs for providing contraception benefits. Plan providers receive a downward adjustment to the user fees they must pay to the federal government to sell plans on the federally-facilitated health exchanges. The process for TPAs can be more complicated. If the TPA is not itself a participating insurer, then it must contract for contraceptive coverage with a participating insurer, and the insurer then passes on the reimbursement to the TPA. See 80 Fed. Reg. at 41328. 16 Case: 14-12696 Date Filed: 02/18/2016 Page: 17 of 148 services.” 45 C.F.R. § 147.131(c)(2)(ii). A plan provider or TPA also must notify plan participants and beneficiaries (contemporaneously with the delivery of other plan materials, if possible) “that the eligible organization does not administer or fund contraceptive benefits,” but that the plan provider or TPA instead “provides separate payments for contraceptive services.” 26 C.F.R. § 54.9815-2713A(d); 45 C.F.R. § 147.131(d). B. The Parties and Procedural History This opinion addresses two cases: one brought by EWTN and one brought by two Catholic Dioceses and a group of related persons and entities. Below, we briefly discuss the plaintiffs and the procedural history of each case in turn. 1. Eternal Word Television Network Plaintiff-appellant EWTN is a non-profit worldwide Catholic media network founded in 1981 by Mother Mary Angelica, a Catholic nun. EWTN, based in Irondale, Alabama, has approximately 350 employees. The network consists of 11 television feeds and two radio stations that reach 230 million homes in 144 countries and territories. Its programming includes daily Mass, Catholic devotions, coverage of Catholic Church events, documentaries, children’s programs, educational series, and other television and radio shows that support EWTN’s mission of “serv[ing] the orthodox belief and teaching of the Church as proclaimed by the Supreme Pontiff and his predecessors.” Compl. at 5, No. 1:13-cv-00521- 17 Case: 14-12696 Date Filed: 02/18/2016 Page: 18 of 148 CG-C, Doc. 1. EWTN has a self-insured group health plan to provide health insurance benefits to its employees. Blue Cross Blue Shield of Alabama serves as the TPA for the plan. EWTN, together with the State of Alabama, 13 filed a complaint challenging the contraceptive mandate and accompanying regulations under RFRA, the First Amendment, the Due Process Clause of the Fifth Amendment, and the Administrative Procedure Act (“APA”), 5 U.S.C. § 701 et seq. The complaint alleged that “EWTN cannot facilitate access to health care insurance . . . that covers artificial contraception, sterilization, or abortion, or related education and counseling, without violating its deeply held religious beliefs.” Compl. at 7, No. 1:13-cv-00521-CG-C, Doc. 1. To EWTN, this means that its religious beliefs prevent it both from providing contraceptive coverage in its health plan and from using the accommodation. As a result, EWTN alleged, the contraceptive mandate “imposes government pressure and coercion on EWTN to change or violate its religious beliefs” because if it does not provide coverage or use the accommodation, it faces fines for non-compliance with the mandate. Id. at 27. EWTN and Alabama moved for partial summary judgment on five of the 17 counts in the complaint, including: Count One, alleging a violation of RFRA 13 Alabama was a party throughout the district court proceedings, but the State did not join EWTN in this appeal. 18 Case: 14-12696 Date Filed: 02/18/2016 Page: 19 of 148 based on the regulations’ burden on religious exercise; Count Two, alleging a violation of the Free Exercise Clause based on the same burden; Count Three, alleging a violation of the Free Exercise Clause based on intentional discrimination among religious organizations; Count Five, alleging a violation of the Establishment Clause based on the selective imposition of a burden on some religious organizations; and Count Nine, alleging a violation of the Free Speech Clause based on compelled speech. Alabama joined in EWTN’s motion and additionally moved for summary judgment on Count Seventeen, which sought a declaration that the contraceptive mandate does not preempt Alabama law. The defendants-appellees—the Departments and their Secretaries—filed a motion to dismiss the complaint or, in the alternative, for summary judgment on all of the plaintiffs’ claims. The district court denied EWTN’s and Alabama’s motions for summary judgment and granted the defendants’ motion for summary judgment as to Counts One, Two, Five, and Nine. On a motion by the plaintiffs, the district court entered a final judgment on those four counts pursuant to Federal Rule of Civil Procedure 54(b) and stayed litigation of the remaining claims pending appeal. EWTN timely appealed. On EWTN’s motion, we issued an injunction pending appeal, preventing the defendants from enforcing the mandate or the 19 Case: 14-12696 Date Filed: 02/18/2016 Page: 20 of 148 accommodation against EWTN. Eternal Word Television Network, Inc. v. Sec’y, U.S. Dep’t of Health & Human Servs., 756 F.3d 1339 (11th Cir. 2014). 2. The Diocesan Plaintiffs, CENGI, and Catholic Charities A group of Catholic entities—the Roman Catholic Archdiocese of Atlanta, the Archbishop of Atlanta, Christ the King Catholic School, Catholic Charities of the Archdiocese of Atlanta (“Catholic Charities”), the Roman Catholic Diocese of Savannah, and the Bishop of Savannah—filed a lawsuit against the Departments and their Secretaries. Both the Archdiocese of Atlanta and the Diocese of Savannah (collectively with the Bishop and Archbishop, “the Dioceses”) are associations of Catholic parishes and organizations, including Catholic schools. Catholic Charities is a nonprofit organization that provides social services, including immigration counseling, mental health counseling, marriage counseling, and pregnancy support services. The second amended complaint added as a plaintiff Catholic Education of North Georgia (“CENGI”) and removed Christ the King Catholic School. CENGI is a nonprofit organization that oversees five Catholic schools in the Atlanta area. The Atlanta Archdiocese operates a self-insured health plan, which covers employees of the Archdiocese, Catholic Charities, and CENGI. The Savannah 20 Case: 14-12696 Date Filed: 02/18/2016 Page: 21 of 148 Diocese operates two self-insured health plans for its employees. Meritain Health serves as the TPA for all three plans. 14 The second amended complaint alleged that the contraceptive mandate and accompanying regulations violate RFRA, the First Amendment, the non-delegation doctrine, 15 and the APA. The plaintiffs alleged that the regulations require them “to provide, pay for, and/or facilitate insurance coverage for abortion-inducing drugs, sterilization, and contraception, in violation of their religious beliefs.” Second Am. Compl. at 6, No. 1:12-cv-03489-WSD, Doc. 56. They alleged that the regulations further burden religious exercise “by driving a wedge between religious organizations, like the Atlanta Archdiocese, and their equally religious charitable arms, such as Plaintiffs Catholic Charities and CENGI.” Id. Because the charitable arms do not qualify as “religious employers,” the Dioceses alleged 14 The parties disagree over whether these health plans qualify as “church plans” for purposes of ERISA. We need not decide whether the plans at issue are church plans because their ERISA status does not impact our conclusion that the accommodation does not substantially burden religious exercise. If the plans are not church plans, then our analysis as to EWTN’s self-insured plan applies, and the accommodation presents no burden on religious exercise. See infra Part III.A.2.b. If the plans are church plans, then the government lacks authority to enforce the contraceptive mandate against the plaintiffs’ TPAs, rendering the plaintiffs’ assertion that their actions trigger such coverage even weaker. See, e.g., Little Sisters of the Poor Home for the Aged v. Burwell, 794 F.3d 1151, 1188 (10th Cir.) (“The lack of enforcement authority makes any burden on plaintiffs with church plans even less substantial than the burden on plaintiffs with self-insured plans that are subject to ERISA.”), cert. granted sub nom., S. Nazarene Univ. v. Burwell, 136 S. Ct. 445, and cert. granted, 136 S. Ct. 446 (2015). 15 The non-delegation doctrine is the constitutional principle that prevents Congress from delegating its legislative authority to another body with “unfettered discretion to make whatever laws” the body sees fit. A.L.A. Schechter Poultry Corp. v. United States, 295 U.S. 495, 537-38 (1935). 21 Case: 14-12696 Date Filed: 02/18/2016 Page: 22 of 148 they must expel the charities’ employees from their health plans if the Dioceses wish to take advantage of the religious exemption. 16 The Departments filed a motion to dismiss the second amended complaint or, alternatively, for summary judgment on all counts. The plaintiffs cross-moved for summary judgment as to seven of their eight counts, which alleged that the mandate and accompanying regulations: burden religious exercise in violation of RFRA (Count One); violate the Free Exercise Clause, based on the same burden (Count Two); compel speech in violation of the Free Speech Clause (Count Three); prohibit speech in violation of the Free Speech Clause (Count Four); favor certain religious groups and entangle the government in religion in violation of the Establishment Clause (Count Five); interfere with internal church governance in violation of both the Free Exercise and Establishment Clauses (Count Six); and involve an impermissible delegation of unchecked legislative authority to the Departments (Count Seven). The district court granted summary judgment to Catholic Charities and CENGI on their RFRA claims, holding that the contraceptive mandate and accommodation substantially burden the organizations’ religious exercise and are not the least restrictive means to accomplish a compelling governmental interest. 16 We note that there is no dispute that EWTN, CENGI, and Catholic Charities qualify for the accommodation and not for the religious employer exemption. 22 Case: 14-12696 Date Filed: 02/18/2016 Page: 23 of 148 The court enjoined the Departments from enforcing the mandate or the accommodation against Catholic Charities and CENGI. In addition, the court granted the plaintiffs’ motion for summary judgment on their claim that the non- interference provision created a content-based speech restriction in violation of the First Amendment. As to the Dioceses’ RFRA claim, the court granted summary judgment to the Departments. The Dioceses had argued first that they might at some point have to pay more in premiums to help cover their plan providers’ cost of contraceptive coverage, in violation of their religious beliefs, and second that the distinction between religious employers and organizations eligible for the accommodation would force the Dioceses to remove unaffiliated Catholic schools from their insurance plans. Rejecting both arguments, the district court ruled that the first argument was merely speculative (and the outcome on which the Dioceses speculated would, in any event, be prohibited by law) and the second argument failed to assert a legitimate religious exercise. The district court granted the Departments’ summary judgment motion as to all of the plaintiffs’ remaining claims based on the First Amendment, the non-delegation doctrine, and the APA. Despite the split judgment, only the Departments appealed the district court’s decision. Because revisions to the regulations have rendered the plaintiffs’ 23 Case: 14-12696 Date Filed: 02/18/2016 Page: 24 of 148 compelled speech claim based on the non-interference provision moot, 17 the appeal in this case concerns only the district court’s grant of summary judgment to Catholic Charities and CENGI on their RFRA claim. II. STANDARD OF REVIEW “This court reviews the district court’s disposition of cross-motions for summary judgment de novo, applying the same legal standards used by the district court, viewing the evidence and all factual inferences therefrom in the light most favorable to the non-movant, and resolving all reasonable doubts about the facts in favor of the non-moving party.” Am. Bankers Ins. Group v. United States, 408 F.3d 1328 (11th Cir. 2005). Summary judgment is proper if the movant can show “that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). Where the material facts are undisputed and all that remains are questions of law, summary judgment may be granted. See Saregama India Ltd. v. Mosley, 635 F.3d 1284, 1290 (11th Cir. 2011). 17 As noted above, in 2014 the Departments removed the regulations’ requirement that organizations “must not, directly or indirectly, seek to influence the third party administrator’s decision to” provide contraceptive coverage to the objecting organization’s health plan participants and beneficiaries. 26 C.F.R. § 54.9815-2713A(b)(1)(iii) (2013); see 79 Fed. Reg. at 51095; supra note 9. 24 Case: 14-12696 Date Filed: 02/18/2016 Page: 25 of 148 III. DISCUSSION A. RFRA Claims 1. Legal Background a. RFRA RFRA provides that the federal government “shall not substantially burden a person’s exercise of religion” unless it demonstrates that the burden “is in furtherance of a compelling governmental interest” and “is the least restrictive means of furthering that compelling governmental interest.” 42 U.S.C. § 2000bb- 1(a)-(b). Congress passed RFRA in 1993 in response to the Supreme Court’s decision in Employment Division, Department of Human Resources of Oregon v. Smith, 494 U.S. 872 (1990), which held that “a law that is neutral and of general applicability need not be justified by a compelling governmental interest even if the law has the incidental effect of burdening a particular religious practice.” Church of Lukumi Babalu Aye, Inc. v. City of Hialeah, 508 U.S. 520, 531 (1993) (characterizing Smith). In Smith, the Supreme Court reasoned that “[t]o make an individual’s obligation to obey [a neutral and generally applicable] law contingent upon the law’s coincidence with his religious beliefs, except where the State’s interest is ‘compelling[,]’ . . . contradicts both constitutional tradition and common sense.” Smith, 494 U.S. at 885 (internal quotation marks and citation omitted). 25 Case: 14-12696 Date Filed: 02/18/2016 Page: 26 of 148 Congress stated that the purpose of RFRA was “to restore the compelling interest test as set forth in Sherbert v. Verner, 374 U.S. 398 (1963) and Wisconsin v. Yoder, 406 U.S. 205 (1972).” 42 U.S.C. § 2000bb(b)(1). Congress declared the strict scrutiny standard provided “a workable test for striking sensible balances between religious liberty and competing prior governmental interests.” Id. § 2000bb(a)(5). Indeed, RFRA “provide[s] even broader protection for religious liberty than was available under” Sherbert or Yoder because the government must also show that it used the least restrictive means to achieve its compelling interest. Hobby Lobby, 134 S. Ct. at 2761 n.3. b. Hobby Lobby In Hobby Lobby, the Supreme Court held that enforcing the contraceptive mandate without an accommodation against closely held for-profit corporations that objected on religious grounds to providing contraceptive coverage violated RFRA. The corporations and their owners challenged the mandate as substantially burdening their religious exercise. Id. at 2764-66. The owners of the corporations sincerely believed that life begins at conception and that it is a sin to facilitate access to contraceptive drugs or devices that could destroy an embryo. Id. It was undisputed that the mandate required the plaintiffs to provide health insurance that covered methods of contraception that could result in the destruction of an embryo. Id. at 2775. The plaintiffs asserted that the mandate left them with only two 26 Case: 14-12696 Date Filed: 02/18/2016 Page: 27 of 148 options: (1) provide coverage for contraception in violation of their religious beliefs or (2) pay significant penalties. Given these choices, the Supreme Court held that the mandate “impose[d] a substantial burden.” Id. at 2779. The government argued there was no substantial burden because the connection between what the mandate required the plaintiffs to do (provide health insurance that covered contraception) and the end that they found morally wrong (the destruction of an embryo) was too attenuated. Id. at 2777. The premise of the government’s attenuation argument was that “providing the coverage would not itself result in the destruction of an embryo; that would occur only if an employee chose to take advantage of the coverage and to use one of the four [contraceptive] methods at issue.” Id. In other words, the government asserted that the plaintiffs’ belief—that providing insurance coverage for contraception facilitated the destruction of embryos—was unreasonable. The Supreme Court rejected this argument, which would have required the Court to determine 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.” Id. at 2778. The Supreme Court cautioned that “federal courts have no business addressing” such questions of religion and moral philosophy. Id. Instead, the Supreme Court deferred to the plaintiffs’ religious belief that the coverage “is 27 Case: 14-12696 Date Filed: 02/18/2016 Page: 28 of 148 connected to the destruction of embryo in a way that is sufficient to make it immoral for them to provide the coverage.” Id. The Court then considered whether the mandate survived strict scrutiny. The majority assumed that the mandate furthered a compelling governmental interest 18 but held that it was not the least restrictive means of doing so. Id. at 2779-80. The Court pointed to the accommodation, which at the time applied only to nonprofit organizations with religious objections, as a less restrictive alternative. 18 The majority opinion assumed without deciding that the government has a compelling interest. In separate opinions, five members of the Court appeared to go further, suggesting that a majority of the Court would agree that there is, in fact, a compelling interest. The four dissenting justices concluded that the government carried its burden in showing that the mandate “furthers compelling interests in public health and women’s well being.” Hobby Lobby, 134 S. Ct. at 2799 (Ginsburg, J., dissenting). Justice Kennedy, who joined the majority, offered a separate concurrence in which he emphasized the importance of the majority’s assumption that there is a compelling interest without explicitly stating that he agreed with that premise: “[it is] important to confirm that a premise of the Court’s opinion is its assumption that the HHS regulation here at issue furthers a legitimate and compelling interest in the health of female employees.” Id. at 2786 (Kennedy, J., concurring). He also reiterated the government’s position that the mandate “provid[ed] insurance coverage that is necessary to protect the health of female employees, coverage that is significantly more costly than for a male employee.” Id. at 2785-86. Justice Ginsburg in her dissent and other courts have treated Justice Kennedy’s concurrence as recognizing that the government has a compelling interest. See id. at 2800 n.23 (Ginsburg, J., dissenting) (writing that Justice Kennedy “recognize[d], without reservation,” the existence of a compelling interest); Univ. of Notre Dame v. Burwell, 786 F.3d 606, 624 (7th Cir. 2015) (Hamilton, J., concurring) (“Justice Kennedy’s concurring opinion made clear that he viewed the governmental interests as compelling.”); Priests for Life v. U.S. Dep’t of Health & Human Servs., 772 F.3d 229, 257 (D.C. Cir. 2014) (explaining why Justice Kennedy’s concurrence was “more affirmative” than the majority opinion in recognizing a compelling interest), cert. granted sub nom., Roman Catholic Archbishop of Wash. v. Burwell, 136 S. Ct. 444 (2015), and cert. granted, 136 S. Ct. 446 (2015). We are inclined to agree that Justice Kennedy’s concurring opinion can be read as recognizing a compelling interest. Nonetheless, even if Justice Kennedy merely assumed (but did not decide) there is a compelling interest, such that a majority of the Supreme Court has not reached that conclusion, we conclude that there is a compelling interest here. See infra Part III.B.2.c.(i). 28 Case: 14-12696 Date Filed: 02/18/2016 Page: 29 of 148 The Court explained that after an organization opts out, the plan provider (for insured plans) or TPA (for self-insured plans) must exclude contraceptive coverage from the group health plan and provide separate payments for contraceptive coverage without imposing cost sharing requirements on the organization, plan, or plan participants or beneficiaries. Id. at 2782. Although the Court declined to answer whether the accommodation complied with RFRA, it lauded the accommodation as “seek[ing] to respect the religious liberty of religious nonprofit corporations while ensuring that the employees of these entities have precisely the same access to all FDA-approved contraceptives as employees of companies whose owners have no religious objections to providing such coverage.” Id. at 2759. The Court further recognized that “[t]he effect of the HHS-created accommodation on the women employed by Hobby Lobby and the other companies involved in these cases would be precisely zero.” 19 Id. at 2760. c. Wheaton College After Hobby Lobby, the Court considered the accommodation itself in the context of an injunction sought under RFRA in Wheaton College. The Court enjoined the government from enforcing the mandate but required the plaintiff to 19 Justice Kennedy praised how the accommodation reconciled the competing priorities of ensuring that “no person may be restricted or demeaned by government in exercising his or her religion” and that the same exercise does not “unduly restrict other persons . . . in protecting their own interests, interests the law deems compelling.” Hobby Lobby, 134 S. Ct. at 2786-87 (Kennedy, J., concurring). 29 Case: 14-12696 Date Filed: 02/18/2016 Page: 30 of 148 inform HHS in writing that it had religious objections to providing coverage for contraceptive services. 134 S. Ct. at 2807. The Court explained that the government could “rely[] on this notice . . . to facilitate the provision of full contraceptive coverage.” Id. The practical effect of the Wheaton College decision was twofold: the plaintiff received an accommodation, and HHS could rely on the notification to provide contraceptive coverage to the participants and beneficiaries of the plaintiff’s plan. d. Other RFRA Challenges to the Accommodation After Hobby Lobby and Wheaton College, federal courts around the country considered RFRA challenges to the accommodation. Applying these two Supreme Court decisions, seven of the eight circuits to review these cases held that the accommodation does not violate RFRA. See Mich. Catholic Conf. & Catholic Family Servs. v. Burwell, 807 F.3d 738 (6th Cir. 2015); Catholic Health Care Sys. v. Burwell, 796 F.3d 207 (2d Cir. 2015); Little Sisters of the Poor Home for the Aged v. Burwell, 794 F.3d 1151 (10th Cir.), cert. granted sub nom., S. Nazarene Univ. v. Burwell, 136 S. Ct. 445, and cert. granted, 136 S. Ct. 446 (2015); E. Tex. Baptist Univ. v. Burwell, 793 F.3d 449 (5th Cir.), cert. granted, 136 S. Ct. 444 (2015); Univ. of Notre Dame v. Burwell (“Notre Dame II”), 786 F.3d 606 (7th Cir. 30 Case: 14-12696 Date Filed: 02/18/2016 Page: 31 of 148 2015);20 Geneva Coll. v. Sec’y U.S. Dep’t of Health & Human Servs., 778 F.3d 422 (3d Cir.), cert. granted sub nom., Zubik v. Burwell, 136 S. Ct. 444, and cert. granted, 136 S. Ct. 445 (2015); Priests for Life v. U.S. Dep’t of Health & Human Servs. (“Priests for Life I”), 772 F.3d 229 (D.C. Cir. 2014), reh’g en banc denied, (“Priests for Life II”), 808 F.3d 1 (D.C. Cir. 2015), cert. granted sub nom., Roman Catholic Archbishop of Wash. v. Burwell, 136 S. Ct. 444 (2015), and cert. granted, 136 S. Ct. 446 (2015). These circuits concluded that the accommodation does not substantially burden religious exercise. 21 The Eighth Circuit disagreed, holding that the accommodation substantially burdens religious exercise and cannot survive strict scrutiny. Sharpe Holdings, Inc. v. U.S. Dep’t of Health & Human Servs., 801 F.3d 927 (8th Cir. 2015), petition for cert. filed, 84 U.S.L.W. 3350 (U.S. Dec. 15, 2015) (No. 15-775). Recently, the Supreme Court granted certiorari in several of these cases. The seven circuits that upheld the accommodation recognized that the RFRA claim in Hobby Lobby was fundamentally different from challenges to the 20 Before Hobby Lobby was decided, the Seventh Circuit affirmed the denial of a preliminary injunction to enjoin the enforcement of the mandate and accommodation in University of Notre Dame v. Sebelius (“Notre Dame I”), 743 F.3d 547 (7th Cir. 2014). Subsequently, the Supreme Court granted certiorari, vacated the Seventh Circuit’s judgment in Notre Dame I, and remanded for consideration in light of Hobby Lobby. Univ. of Notre Dame v. Burwell, 135 S. Ct. 1528 (2015). After considering Hobby Lobby, the Seventh Circuit issued Notre Dame II again affirming the denial of a preliminary injunction. 21 Two circuits have held, in the alternative, that even assuming the accommodation imposes a substantial burden, it survives strict scrutiny under RFRA. See Notre Dame II, 786 F.3d at 616-17; Priests for Life I, 772 F.3d at 256-57. 31 Case: 14-12696 Date Filed: 02/18/2016 Page: 32 of 148 accommodation itself. In Hobby Lobby, the plaintiffs challenged the mandate— that is, the requirement that they provide contraceptive coverage—when their only options were to provide the coverage or pay significant penalties. But in the accommodation cases, the plaintiffs have challenged the regulatory scheme that allows them to opt out of the mandate without penalty. Put another way, the plaintiffs in the accommodation cases “do not challenge the general obligation under the ACA to provide contraceptive coverage. They instead challenge the process they must follow to get out of complying with that obligation.” Little Sisters of the Poor, 794 F.3d at 1160. Because they assert that “the exemption process itself imposes a substantial burden on their religious faiths,” their challenges are somewhat “paradoxical and virtually unprecedented.” Priests for Life I, 772 F.3d at 246 (internal quotation marks omitted). The circuits upholding the accommodation recognized that the question of whether there is a substantial burden involves an objective inquiry. After interpreting the ACA and its regulations, they held that the act of opting out does not trigger contraceptive coverage. See, e.g., Notre Dame II, 786 F.3d at 614 (explaining that “[i]t is federal law, rather than the religious organization’s signing and mailing the form, that requires . . . third-party administrators of self-insured health plans[] to cover contraceptive services”). Although the eligible organizations asserted that the act of opting out makes them complicit in providing 32 Case: 14-12696 Date Filed: 02/18/2016 Page: 33 of 148 coverage, these courts explained that this objection could not constitute a substantial burden because individuals “have no RFRA right to be free from the unease, or even anguish, of knowing that third parties are legally privileged or obligated to act in ways their religion abhors.” Priests for Life I, 772 F.3d at 246. In Sharpe Holdings, the Eighth Circuit reached the opposite conclusion, holding that the accommodation substantially burdened religious exercise, and enjoined the government from enforcing the accommodation. Relying on Hobby Lobby, the Eighth Circuit held that it was bound to accept the plaintiffs’ “assertion that self-certification under the accommodation process—using either Form 700 or HHS Notice—would violate their sincerely held religious beliefs.”22 Sharpe Holdings, 801 F.3d at 941. Because the plaintiffs faced a substantial penalty if they failed to seek an accommodation or provide contraceptive coverage, the Eighth Circuit concluded there was a substantial burden. Id. at 942. The Eighth Circuit then applied strict scrutiny. The court assumed that the government had a compelling interest but held that the government had failed to carry its burden to show that it lacked other means to achieve its interest without imposing a substantial burden on religion. Id. at 943. The Eighth Circuit 22 Although the Eighth Circuit deferred to the plaintiffs’ understanding of how the accommodation functioned, it agreed that the act of opting out triggered coverage. See Sharpe Holdings, 801 F.3d at 942 (TPAs have no “wholly independent obligation” to provide contraceptive coverage). 33 Case: 14-12696 Date Filed: 02/18/2016 Page: 34 of 148 concluded that less restrictive alternatives included the government: (1) requiring less information from eligible organizations seeking an accommodation; (2) assuming the cost of providing contraceptives through subsidies, reimbursements, tax credits, or tax deductions to employees; (3) paying for distribution of contraceptives at community health centers, public clinics, and hospitals; or (4) making contraceptive coverage available through the healthcare exchanges. Id. at 944-45. Given these alternatives, the Eighth Circuit concluded that the accommodation failed to survive strict scrutiny. 2. RFRA Analysis With this legal landscape in mind, we now consider the plaintiffs’ RFRA challenge. We hold that their challenge fails because (1) the accommodation does not substantially burden their religious exercise, and (2) in the alternative, even if there is a substantial burden, the accommodation survives strict scrutiny. a. The Plaintiffs Allege a Sincere Religious Belief. A threshold question we must ask is whether the plaintiffs’ religious beliefs on which their RFRA claims are based are sincere. See Hobby Lobby, 134 S. Ct. at 2774 n.28 (“To qualify for RFRA’s protection, an asserted belief must be ‘sincere’. . . .”). It is well established that we defer to a plaintiff’s statement of its own belief, so long as the plaintiff actually holds that belief. See id. at 2779 (“[I]t is not for [courts] to say that [the plaintiffs’] religious beliefs are mistaken or 34 Case: 14-12696 Date Filed: 02/18/2016 Page: 35 of 148 insubstantial.”); Davila v. Gladden, 777 F.3d 1198, 1204 (11th Cir.) (“[W]e look only to see whether the claimant . . . actually holds the beliefs he claims to hold.” (internal quotation marks omitted)), cert. denied sub nom., Davila v. Hayes, 136 S. Ct. 78 (2015). Each plaintiff states that its religious beliefs prevent it from paying for, providing, or facilitating the distribution of contraceptives. Each plaintiff also asserts that it cannot be complicit in the provision of contraception. The government does not contest the sincerity of these religious beliefs, nor is there any indication whatsoever in the record that the stated beliefs are insincere. We thus conclude that the plaintiffs’ religious beliefs at issue are sincere. b. The Accommodation Does Not Substantially Burden the Plaintiffs’ Religious Exercise. We now consider whether, accepting the plaintiffs’ sincere religious beliefs, the accommodation substantially burdens their religious exercise. The plaintiffs assert that the act of notifying HHS or their TPAs of their religious objection will either trigger contraceptive coverage or make them complicit in a system that provides such coverage. Due to the significance they attach to opting out, the plaintiffs contend that the accommodation itself imposes a substantial burden because it puts them to the choice of violating their sincerely held religious beliefs or paying a substantial penalty. We accept the plaintiffs’ sincere belief that triggering coverage or being complicit in coverage violates their religious beliefs 35 Case: 14-12696 Date Filed: 02/18/2016 Page: 36 of 148 and that the accommodation puts them to a choice between honoring their religious beliefs and facing significant penalties. We nonetheless conclude that the accommodation imposes no substantial burden. (i) The Substantial Burden Analysis Involves an Objective Inquiry. “[A] ‘substantial burden’ must place more than an inconvenience on religious exercise.” Midrash Sephardi, Inc. v. Town of Surfside, 366 F.3d 1214, 1227 (11th Cir. 2004). 23 A law is substantially burdensome when it places “significant pressure” on an adherent to act contrary to her religious beliefs, meaning that it “directly coerces the religious adherent to conform . . . her behavior.” Id. Thus, the government imposes a substantial burden when it places “pressure that tends to force adherents to forego religious precepts.” Id. This inquiry involves both subjective and objective dimensions. Hobby Lobby made clear that there is a subjective aspect to this inquiry: courts must accept a religious adherent’s assertion that his religious beliefs require him to take or abstain from taking a specified action. See 134 S. Ct. at 2779. But the 23 Midrash concerned the Religious Land Use and Institutionalized Persons Act (“RLUIPA”), which Congress enacted after the Supreme Court struck down RFRA as applied to the states in City of Boerne v. Flores, 521 U.S. 507 (1997). RLUIPA imposes the same requirement as RFRA—that the government refrain from substantially burdening religious exercise unless the burden is the least restrictive means of achieving a compelling government interest—on programs and activities that receive federal funding. 42 U.S.C. § 2000cc-1. We apply the same substantial burden analysis under both RLUIPA and RFRA. See generally Davila, 777 F.3d at 1204; Midrash, 366 F.3d at 1237. 36 Case: 14-12696 Date Filed: 02/18/2016 Page: 37 of 148 substantial burden analysis does not end there. We agree with our seven sister circuits that the question of substantial burden also presents “a question of law for courts to decide.” Priests for Life I, 772 F.3d at 247. The objective inquiry requires courts to consider whether the government actually “puts” the religious adherent to the “choice” of incurring a “serious” penalty or “engag[ing] in conduct that seriously violates [his] religious beliefs.” Holt v. Hobbs, 135 S. Ct. 853, 862 (2015) (second alteration in original and internal quotation marks omitted). Put another way, courts must determine what the challenged law actually requires of the plaintiff. For example, in Holt, a Muslim inmate asserted that prison grooming policy substantially burdened his religious exercise because it prohibited him from growing a beard, which his religion required. The Supreme Court explained that because the “grooming policy requires petitioner to shave his beard,” the policy “put[]” him to the choice of violating his religious beliefs or facing serious disciplinary action. Id. In Holt, as in many RFRA cases, this inquiry was straightforward because there was no dispute about what the government’s policy objectively required of the religious adherent. But when there is a dispute about what a law or governmental policy objectively requires, it is for the courts to construe the law or policy. The plaintiffs here contend that under Hobby Lobby no such objective inquiry is required. In their view, a religious adherent’s mere assertion that she is 37 Case: 14-12696 Date Filed: 02/18/2016 Page: 38 of 148 being compelled to violate her sincerely held religious belief means that the government has put her to such a choice, regardless of what the law objectively requires. 24 We disagree. In Hobby Lobby, the plaintiffs challenged the contraceptive mandate. It was undisputed that the mandate gave the plaintiffs just two options: provide contraceptive coverage or pay a substantial penalty. Although the Supreme Court engaged in no objective analysis about what the mandate required, such analysis was unnecessary because the parties agreed that the government, through the mandate, put the plaintiffs to the choice of providing contraceptive coverage or paying a hefty fine. See Hobby Lobby, 134 S. Ct. at 2777-79; see also Priests for Life II, 808 F.3d at 2 (Pillard, J.) (concurring in denial of reh’g en banc) (“The parties in Hobby Lobby did not dispute what the law required, nor its practical effects . . . .”). Here, the parties agree that the plaintiffs have at least three options: provide contraceptive coverage, pay a penalty, or use the accommodation to opt out of providing contraceptive coverage. 25 But they disagree about whether opting out 24 The Eighth Circuit similarly interpreted Hobby Lobby as requiring courts to “accept [the plaintiffs’] assertion that self-certification under the accommodation process . . . would violate their sincerely held religious beliefs.” Sharpe Holdings, 801 F.3d at 941. 25 We agree with the dissent that the plaintiffs have a fourth option, as well: to terminate their TPAs and take over the costs and responsibilities of running their self-insured plans. See Dissent at 109-10. But, the Departments contend there is no evidence of the existence of any self-insured plan without a TPA. See 78 Fed. Reg. at 39880 (“[T]he Departments continue to believe that there are no self-insured group health plans in this circumstance.”). If an eligible organization elected to become the first self-insured plan without a TPA, it would enjoy at least a 38 Case: 14-12696 Date Filed: 02/18/2016 Page: 39 of 148 puts the plaintiffs to the choice of violating their religious beliefs or paying a substantial fine. The plaintiffs contend that because an eligible organization’s TPA only becomes obligated to provide coverage when the organization opts out, by opting out they will be triggering coverage. The government argues to the contrary that plan participants and beneficiaries are entitled to contraceptive coverage under the ACA regardless of any opt out. We conclude that it is for the courts to determine objectively what the regulations require and whether the government has, in fact, put plaintiffs to the choice of violating their religious beliefs by seeking the accommodation or incurring a substantial penalty. We reject a framework that takes away from courts the responsibility to decide what action the government requires and leaves that answer entirely to the religious adherent. Such a framework improperly substitutes religious belief for legal analysis regarding the operation of federal law. Indeed, the plaintiffs have identified nothing in RFRA or case law that allows a religious adherent to dictate to the courts what the law requires. The plain language of RFRA simply does not support reducing the role of federal courts to “rubber stamps” that automatically temporary safe harbor so long as the plan notifies (1) HHS that it has no TPA and (2) plan participants and beneficiaries that the plan provides no benefits for contraceptive services. Id. We assume for purposes of this appeal that if the government forced an eligible organization to have a self-insured plan without a TPA, it would be imposing a substantial burden. Nonetheless, we conclude there is no substantial burden because eligible organizations can instead select the accommodation. 39 Case: 14-12696 Date Filed: 02/18/2016 Page: 40 of 148 recognize a substantial burden whenever a religious adherent asserts there is one. Catholic Health Care Sys., 796 F.3d at 218. If Congress had intended strict scrutiny to be triggered in all circumstances by a religious adherent’s claim that there is a burden, it would have said so. Instead, it required that the federal government “substantially burden” the adherent’s religious exercise. Our dissenting colleague concedes that the question of substantial burden involves an objective inquiry but asserts that the inquiry should be limited to whether the government has imposed a substantial penalty. See Dissent at 113-15. This analysis would require courts to defer to a religious adherent’s sincere belief that the government is forcing her to choose between her religious belief and paying a substantial fine, even when the religious adherent is objectively wrong about how the law operates and what action the government requires her to take. The dissent’s view is flawed because any burden (even an objectively insubstantial one) becomes a substantial burden if the penalty is heavy enough. We acknowledge that in Hobby Lobby the Supreme Court cautioned courts against dictating to religious adherents “the circumstances under which it is immoral 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.” 134 S. Ct. at 2778. In some cases, a court’s objective analysis interpreting a statute or regulation may contradict a religious adherent’s sincerely held belief about what 40 Case: 14-12696 Date Filed: 02/18/2016 Page: 41 of 148 that law requires. But such questions about what a law means are not the type of “difficult and important question of religion and moral philosophy” for which courts must defer to religious adherents. Id.; see Notre Dame II, 786 F.3d at 623 (Hamilton, J., concurring) (explaining that the interpretation of the regulations that give rise to the accommodation “is an issue not of moral philosophy but of federal law”). Deciding how the law functions is not the only objective part of the substantial burden inquiry. The Supreme Court’s free exercise cases (prior to Smith) distinguished between substantial burdens on religious exercise, which are protected, and de minimis burdens, which are not. For example, a religious adherent may not “require the Government to conduct its own internal affairs in ways that comport” with the person’s religious beliefs, even if the government action interferes with that person’s religious exercise. Bowen v. Roy, 476 U.S. 693, 699-700 (1986); see Lyng v. Nw. Indian Cemetery Protective Ass’n, 485 U.S. 439, 451 (1988) (recognizing that government’s decision to log and build roads would “have severe adverse effects” on practice of Native American religion but concluding this burden was not “heavy enough” to trigger strict scrutiny under the Free Exercise Clause). In Bowen, Native American parents challenged federal statutes requiring them to provide their daughter’s social security number to state welfare agencies as 41 Case: 14-12696 Date Filed: 02/18/2016 Page: 42 of 148 a condition of seeking benefits on the ground that it impinged upon their free exercise of religion. They sought an accommodation to keep the government from using her social security number in administering benefits, which they believed would rob their daughter of her spirit. 476 U.S. at 695-96. Even recognizing that the parents had a sincere belief that by using her social security number the government would be stealing their daughter’s spirit, the Supreme Court rejected their claim, holding that the government’s “use of a Social Security number . . . does not itself in any degree impair [the parents’] freedom to believe, express, and exerc[ise their] religion.’” Id. at 700 (internal quotation marks omitted). The Court rejected the parents’ attempt to use the Free Exercise Clause to “demand that the Government join in their chosen religious practices.” Id. at 699-700. The Court explained that “[t]he Free Exercise Clause affords an individual protection from certain forms of governmental compulsion,” yet does not extend so far to “afford an individual a right to dictate the conduct of the Government’s internal procedures.” Id. at 700. The Court acknowledged that the parents’ “religious views may not accept” the line that the Court drew “between individual and governmental conduct,” but it drew a line nonetheless. 42 Case: 14-12696 Date Filed: 02/18/2016 Page: 43 of 148 Id. at 701 n.6. Likewise, under RFRA courts must determine whether the burden on a religious adherent is, in fact, substantial. 26 As we alluded to above, the plain language of RFRA supports our conclusion that there is a distinction between a burden and a substantial burden. RFRA requires strict scrutiny only when the government “substantially burden[s] a person’s exercise of religion.” 42 U.S.C. § 2000bb-1(a). Congress chose to modify “burden” with “substantial[],”27 and we must of course interpret RFRA to give full effect to its every word. See TRW Inc. v. Andrews, 534 U.S. 19, 31 (2001) (recognizing that statutes should be construed whenever possible so that “no clause, sentence, or word shall be superfluous, void, or insignificant” (internal quotation marks omitted)). 26 We reiterate that in Hobby Lobby the Supreme Court did not grapple with this aspect of the substantial burden analysis. But it was plain that the action required of the plaintiffs in that case—paying to provide health insurance that included contraceptive coverage—imposed a substantial burden. Accordingly, the Court had no occasion to address the more difficult question presented here, where the plaintiffs’ claims of substantial burden rest on their assertion that seeking an accommodation results in another entity (the TPA) providing contraceptive coverage and thus makes them complicit in a system that achieves an end to which they have a religious objection. In other words, Hobby Lobby did not pose the issue whether courts must defer to a religious adherent’s assertion that seeking an accommodation (opting out) itself imposes a substantial burden. 27 Congress used “substantial burden” instead of “burden” in order “to clarify [that] the compelling interest required by the Religious Freedom [Restoration] Act applies only where there is a substantial burden placed on the individual free exercise of religion.” 139 Cong. Rec. S14352 (daily ed. Oct. 26, 1993) (statement of Sen. Hatch) (emphasis added). Limiting RFRA’s application to substantial burdens was intended to ensure that the government was not required “to justify every action that has some effect on religious exercise.” Id. 43 Case: 14-12696 Date Filed: 02/18/2016 Page: 44 of 148 We recognize that the distinction between burden and substantial burden is not implicated in every RFRA case. Nonetheless, there are cases brought under RFRA in which the purported burden is too slight to trigger strict scrutiny. For example, in Kaemmerling v. Lappin, an inmate challenged under RFRA the Bureau of Prison’s collection and analysis of his DNA. 553 F.3d 669, 673-74 (D.C. Cir. 2008). He claimed that the government’s sampling, collection, and analysis of his DNA violated his sincerely held religious beliefs about the proper use of DNA. The D.C. Circuit concluded there was no substantial burden. Importantly, the inmate had no religious objection to the collection of his bodily material; he challenged only how the government would subsequently use that specimen to extract his DNA information. Id. at 678-79. There was no question that the Bureau of Prisons required the inmate to submit a bodily specimen that would be used for an end to which he had a strong religious objection (that is, the collection and analysis of his DNA). But the D.C. Circuit held there was no substantial burden because the inmate “suggest[ed] no way in which these government acts pressure[d] him to modify his own behavior in any way that would violate his beliefs.” Id. at 679. Kaemmerling reinforces that a religious adherent cannot use RFRA to stop the government or third parties from taking subsequent actions to which he objects when the acts required of him impose a de minimis burden. 28 28 Our dissenting colleague worries that our framework creates a “Bizarro World” in 44 Case: 14-12696 Date Filed: 02/18/2016 Page: 45 of 148 (ii) No Substantial Burden Exists. To determine whether the accommodation objectively puts plaintiffs to the choice of violating their religious beliefs or paying a significant fine, we must understand how the accommodation functions and what it requires of these plaintiffs. The only act that the regulations require the plaintiffs to take is to seek the accommodation—that is, filling out and sending Form 700 to their TPAs or writing a letter to HHS letting it know of their objections. The plaintiffs do not contend that notifying HHS or their TPAs itself constitutes a substantial burden because of the time or effort involved. Rather, their objection is based on the significance they attribute to this act. They contend that the act of opting out triggers contraceptive coverage for plan participants and beneficiaries or makes them complicit in a system that provides contraceptive coverage. We accept that the plaintiffs truly believe that triggering contraceptive coverage or being complicit in a system providing contraceptive coverage violates their religious beliefs. But which courts determine whether the burden imposed by a law or regulation violates the adherent’s beliefs. Dissent at 117-18. The dissent overstates our position. We are not saying that courts may determine that when a prison requires a Muslim inmate to shave his beard or the government forces a Seventh-Day Adventist to work on the Sabbath, the religious adherent’s claim that the government is coercing him to forego his religious precepts is wrong. But when a dispute exists about whether the challenged governmental policy actually requires an inmate to shave his beard or a person to work on Saturday, it is for the courts to determine what the law requires. See, e.g., Sherbert, 374 U.S. at 403-04 (Supreme Court performed its own analysis to determine whether challenged policy compelled Seventh-Day Adventist to work on Saturdays). Likewise, when a religious adherent challenges an accommodation scheme as imposing a substantial burden on the religious adherent based on subsequent actions taken by the government or third parties, it is for the courts to determine whether the burden is substantial. 45 Case: 14-12696 Date Filed: 02/18/2016 Page: 46 of 148 our objective inquiry leads us to conclude that the government has not put plaintiffs to the choice of violating their religious beliefs or facing a significant penalty. We hold there is no substantial burden. Here’s why: the ACA and HRSA guidelines are what entitle plan participants and beneficiaries to contraceptive coverage. The ACA provides that the plaintiffs’ self-insured plans “shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for . . . with respect to women, such additional preventative care and screenings . . . as provided for in” the HRSA guidelines. 42 U.S.C. § 300gg-13(a)(4). The HRSA Guidelines, in turn, “require coverage, without cost sharing, for ‘[a]ll . . . [FDA] approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.’” 77 Fed. Reg. at 8725 (alterations in original) (quoting HRSA guidelines). The plaintiffs and the dissent take a different view of the statutory and regulatory scheme, contending that an eligible organization’s act of opting out triggers the TPA’s designation as plan administrator and, without it, plan participants or beneficiaries would not receive contraceptive coverage. 29 Indeed, 29 Because the plaintiffs here have only self-insured plans, we consider only the accommodation procedures that apply to self-insured health plans. For an eligible organization with a plan insured by a third party, the accommodation imposes no new coverage obligation. The eligible organization’s act of opting out simply makes 46 Case: 14-12696 Date Filed: 02/18/2016 Page: 47 of 148 the dissent asserts that opting out requires an eligible organization’s “affirmative participation” because the act of opting out is the “linchpin on which the contraceptive mandate rests.” Dissent at 125. We disagree. The ACA and the HRSA guidelines—not the opt out—are, to borrow the dissent’s term, the “linchpins” of the contraceptive mandate because they entitle women who are plan participants and beneficiaries covered by group health insurance plans to contraceptive coverage without cost sharing. In other words, women are entitled to contraceptive coverage regardless of their employers’ action (or lack of action) with respect to seeking an accommodation. Because a woman’s entitlement to contraceptive benefits does not turn on whether her eligible organization employer chooses to comply with the law (by providing contraceptive coverage or seeking an accommodation) or pay a substantial penalty (in the form of a tax) for noncompliance, we cannot say that the act of opting out imposes a substantial burden. 30 the coverage the plan provider’s “sole responsibility rather than one shared with the group health plan itself.” Little Sisters of the Poor, 794 F.3d at 1181. 30 The dissent complains that our reading renders the act of opting out “meaningless.” Dissent at 128 (internal quotation marks omitted). The dissent misses our point. Although plan participants and beneficiaries are entitled to contraceptive coverage under federal law regardless of any opt out, notification of the opt out allows the government to identify the plan participants and beneficiaries who will not receive contraceptive coverage from a self-insured eligible organization because of that organization’s religious objection to the mandate. In other words, the act of opting out aids the government in identifying these women and making sure that they receive the contraceptive coverage to which they are legally entitled. Thus, the act of opting out 47 Case: 14-12696 Date Filed: 02/18/2016 Page: 48 of 148 We do not mean to imply that the act of opting out plays no causal role in the ultimate provision of contraceptive coverage. We acknowledge that an eligible organization’s act of notifying HHS or its TPA of its objection results in the TPA’s designation as the plan administrator and gives rise to the TPA’s obligation to provide contraceptive coverage. 31 See 29 C.F.R. § 2510.3-16(b). But we view an eligible organization’s act of opting out as, at most, an incidental cause of plan participants and beneficiaries receiving contraceptive coverage because these women are entitled to contraceptive coverage under the ACA and HRSA guidelines regardless of whether the eligible organization opts out. Accordingly, even if the act of opting out in some way leads to women receiving the contraceptive coverage to which they were entitled under federal law, the plaintiffs have failed to establish that the act of opting out substantially burdens their religious exercise. Importantly, the government does not force an eligible organization to provide contraceptive coverage, pay costs related to contraceptive coverage, notify plan participants and beneficiaries of the existence of such coverage, or even include the availability of such coverage from a separate source in information the plan provides to plan participants and beneficiaries. Instead, all has significance in the regulatory scheme, but not because it creates a woman’s entitlement to contraceptive coverage. 31 Indeed, the government has admitted that an eligible organization’s opt out results in a TPA’s designation as plan administrator and the TPA providing plan participants and beneficiaries contraceptive benefits. 48 Case: 14-12696 Date Filed: 02/18/2016 Page: 49 of 148 of these responsibilities fall upon the TPA. Rather, the only action required of the eligible organization is opting out: literally, the organization’s notification of its objection. Such an opt out requirement is “typical of religious objection accommodations that shift responsibility to non-objecting entities only after an objector declines to perform a task on religious grounds.” Little Sisters of the Poor, 794 F.3d at 1183. The plaintiffs’ challenge is in substance indistinguishable from an objection to the government’s requiring another entity to provide coverage in their stead. See Catholic Health Care Sys., 796 F.3d at 224 (characterizing an identical challenge as seeking a “blanket religious veto over the government’s interactions with others”). Put differently, the plaintiffs’ opposition to opting out is an objection to their inability to keep the TPA with which they have contracted to provide services in connection with healthcare coverage from complying with the relevant regulations. The plaintiffs point to a but-for causal relationship between their opting out and the conduct that they find religiously objectionable. But, as the Supreme Court has explained, a religious adherent cannot claim a substantial burden based on the subsequent conduct of another party. 32 See Bowen, 476 U.S. 32 The plaintiffs argue that under the accommodation they are facilitating access to contraceptives because their ongoing contractual relationship with their TPA leads the TPA to continue to provide contraceptive coverage to plan participants and beneficiaries. It is true that a TPA remains as plan administrator for purposes of contraceptive coverage only so long as the organization serves as the plan’s TPA. Nonetheless, the plaintiffs cannot show a substantial 49 Case: 14-12696 Date Filed: 02/18/2016 Page: 50 of 148 at 699-700 (“Just as the government may not insist that appellees engage in any set form of religious observance, so appellees may not demand that the Government join in their chosen religious practices by refraining from using a number to identify their daughter.”). 33 We recognize that the plaintiffs sincerely abhor and object to the subsequent acts taken by the government and their TPA, which ultimately result in the TPA providing contraceptive coverage to their plan participants and beneficiaries. We acknowledge that they “may not accept [the] distinction” that we draw here between their conduct and the downstream, separate conduct of HHS and the TPAs to provide coverage. Id. at 701 n.6. But we simply cannot say that RFRA affords the plaintiffs the right to prevent women from obtaining contraceptive coverage to which federal law entitles them based on the de minimis burden that the plaintiffs face in notifying the government that they have a religious objection. As the Seventh Circuit first articulated, an analogy to a conscientious objector to the military draft illustrates why the accommodation does not impose a burden because, as explained above, their challenge is an objection to the TPA’s subsequent conduct. 33 The dissent dismisses Bowen as distinguishable because the plaintiffs here object only to their own participation in the accommodation, not to any acts taken by the government. See Dissent at 126-27 n.32. We are not persuaded. The dissent’s position ignores that the plaintiffs object to opting out because it requires them to play a causal role (albeit, a small one) in a system in which the government requires contraceptive coverage. Put another way, their religious objection is, at its core, an objection to the government requiring the TPAs to provide coverage upon their opting out. 50 Case: 14-12696 Date Filed: 02/18/2016 Page: 51 of 148 substantial burden. See Notre Dame I, 743 F.3d at 556. A religious conscientious objector to the military draft may opt of military service based on his belief that war is immoral. The objector sincerely believes that his act of opting out triggers the drafting of another person in his place, and thus renders him complicit in the very thing to which he objects. But we would reject the assertion that the government’s subsequent act of drafting another person in his place—even though the drafting was in some sense caused by the objector’s act of opting out— transforms the act of lodging a conscientious objection into a substantial burden. See id. Likewise, we reject the plaintiffs’ assertion that opting out imposes a substantial burden because the government requires a third party to provide contraceptive coverage after an eligible organization opts out. Accordingly, we conclude that through the accommodation the government has imposed no substantial burden on the plaintiffs. We thus hold that the accommodation does not violate RFRA. c. The Accommodation Survives Strict Scrutiny. Even assuming that the accommodation imposes a substantial burden on plaintiffs’ religious exercise, RFRA allows the government to impose such a burden when it demonstrates that the burden “is in furtherance of a compelling governmental interest” and “is the least restrictive means of furthering that compelling governmental interest.” 42 U.S.C. § 2000bb-1(b). Because the 51 Case: 14-12696 Date Filed: 02/18/2016 Page: 52 of 148 government has carried its burden of showing that the accommodation is the least restrictive means of furthering its compelling interests, we hold in the alternative that the accommodation survives strict scrutiny under RFRA. (i) Compelling Interests Justify the Accommodation. In applying RFRA’s strict scrutiny test, we must first determine whether the accommodation is “in furtherance of a compelling governmental interest.” Id. Because the mandate and accommodation require the provision of cost-free contraceptive coverage with little to no administrative burden on women, these regulations further compelling government interests in avoiding the adverse public health consequences of unintended pregnancies and in assuring women the equal benefit of preventative care by requiring coverage for their distinctive health needs. 34 See Priests for Life I, 772 F.3d at 258-59. 34 As we explained above, the majority in Hobby Lobby assumed without deciding that there was a compelling governmental interest. There is, however, an argument that five justices concluded there was a compelling interest. See supra note 18. But even if Justice Kennedy’s concurring opinion in Hobby Lobby did not recognize a compelling governmental interest, we would hold that the compelling interest test is satisfied here. We acknowledge that the majority opinion in Hobby Lobby criticized the government’s purported interests in “promoting public health and gender equality” as “broadly framed.” 134 S. Ct. at 2779 (internal quotation marks omitted). But we agree with the D.C. Circuit that the government has now provided a more focused analysis “by explaining how those larger interests inform and are specifically implicated in its decision to support women’s unhindered access to contraceptive coverage.” Priests for Life I, 772 F.3d at 259. 52 Case: 14-12696 Date Filed: 02/18/2016 Page: 53 of 148 (a) The Government’s Interests in Reducing the Rate of Unintended Pregnancies Are Compelling. We begin our analysis with the facts: unintended or poorly spaced pregnancies have a host of negative impacts on women and children. See supra Part I.A. Women who experience unintended pregnancies are often unaware of their condition in the early stages of their pregnancy, which leads them to delay prenatal care and cessation of behaviors such as smoking or alcohol consumption. 78 Fed. Reg. at 39872. Babies born as a result of unintended pregnancies are at a greater risk of premature birth and low birth weight. Id. Short interpregnancy intervals also result in a greater risk of prematurity and low birth weight. Id. Contraceptive use can alleviate these public health problems. 35 “[G]reater use of contraception within the population produces lower unintended pregnancy and abortion rates nationally.” IOM Report at 105. During debate over the ACA, Congress was informed that “[i]n America today, too many women are delaying or skipping preventive care because of the costs of copays and limited access.” 155 Cong. Rec. S12027 (Dec. 1, 2009) (statement of Sen. Gillibrand). The IOM Report also found that “cost-sharing 35 Many contraceptives also carry significant positive health side effects. “[T]he non- contraceptive benefits of hormonal contraception include treatment of menstrual disorders, acne or hirsutism, and pelvic pain. Long-term use of oral contraceptives has been shown to reduce a woman’s risk of endometrial cancer, as well as protect against pelvic inflammatory disease and some benign breast diseases.” IOM Report at 107 (internal citations omitted). 53 Case: 14-12696 Date Filed: 02/18/2016 Page: 54 of 148 requirements, such as deductibles and copayments, can pose barriers to care and result in reduced use of preventive and primary care services, particularly for low- income populations.” IOM Report at 109. The Women’s Health Amendment, which added to the ACA the requirement that group and individual health plans provide women with coverage for preventative care and screenings, aimed to increase women’s use of preventive care by removing administrative and financial barriers. See 155 Cong. Rec. S12027 (statement of Sen. Shaheen) (“Too often, women forgo their health care needs because they are not affordable. We know cost plays a greater role in preventing women from accessing health care than it does men. In 2007, more than half of all women reported problems accessing needed health care because of costs.”); see also Priests for Life I, 772 F.3d at 260 (explaining that Congress and the Executive branch determined with the ACA and its regulations that “serving the government’s compelling public health interests depends on overcoming the human behavioral tendencies of denial and delay documented in the legislative and regulatory record”). Moreover, the Women’s Health Amendment, which added the contraceptive mandate to the ACA’s minimum coverage requirements, specifically addressed the need to provide preventive care to women to rectify past gender discrimination in health insurance. As the Departments noted, “the statute acknowledges that both existing health coverage and existing preventive services recommendations often 54 Case: 14-12696 Date Filed: 02/18/2016 Page: 55 of 148 did not adequately serve the unique health needs of women. This disparity placed women in the workforce at a disadvantage compared to their male coworkers.” 36 78 Fed. Reg. at 39873; see also 155 Cong. Rec. S12027 (statement of Sen. Gillibrand) (“The prevention section of the bill before us must be amended so coverage of preventive services takes into account the unique health care needs of women throughout their lifespan.”). Indeed, before the ACA, “women of childbearing age spent 68 percent more on out-of-pocket health care costs than men.” 78 Fed. Reg. at 39887. The Departments explained that this “disproportionate” financial burden “prevented women from achieving health outcomes on an equal basis with men.” Id. The Departments intended the contraceptive coverage requirement to “help[] to equalize the provision of preventative health care services to women and, as a result, help[] women contribute to society to the same degree as men.” Id. As the Departments explained, “[r]esearch shows that access to contraception improves the social and economic status of women.” Id. at 39873; see generally Claudia Goldin & Lawrence F. Katz, The Power of the Pill: Oral Contraceptives & Women’s Career & Marriage Decisions, 110 J. of Pol. Econ. 731 (2002). 36 See also 155 Cong. Rec. S11987 (statement of Sen. Mikulski) (“Women are often faced with the punitive practices of insurance companies. No. 1 is gender discrimination. Women often pay more and get less. For many insurance companies, simply being a woman is a preexisting condition. . . . We pay more because of our gender, anywhere from 2 percent to over 100 percent.”). 55 Case: 14-12696 Date Filed: 02/18/2016 Page: 56 of 148 Based on this evidence, we conclude that the government’s interests in the public health of women and children, as well as in assuring women equal preventative care, are compelling. (b) The Mandate and Accommodation Further These Compelling Interests. The mandate and accommodation achieve the government’s goals by making contraceptives affordable and otherwise accessible to women. As explained above, federal law generally guarantees women contraceptive coverage without cost sharing. See 42 U.S.C. § 300gg-13(a)(4); 77 Fed. Reg. at 8725 (discussing HRSA guidelines). Importantly, under the mandate and accommodation, women covered by group health insurance plans generally are required to take no additional action to obtain this contraceptive coverage. This is because the coverage is delivered “through the existing employer-based system of health coverage.” 78 Fed. Reg. at 39888. Thus, under the mandate, women need not complete extra paperwork or sign up for an additional program because the contraceptive coverage is delivered with the health insurance they already have through their employers. This is true even when an employer opts out of providing contraceptive coverage by seeking an accommodation. Although objecting employers are not obligated to provide or pay for contraceptives, the women covered by their plans seamlessly receive contraceptive coverage from the plans’ TPAs. This system was 56 Case: 14-12696 Date Filed: 02/18/2016 Page: 57 of 148 carefully designed to make contraceptive coverage accessible by not requiring women to research plans that offer contraceptive coverage, purchase separate contraceptive coverage, or even sign up with a different entity or program. See id. As the Supreme Court acknowledged in Hobby Lobby, the Departments designed the accommodation so that it has “precisely zero” impact on female plan participants and beneficiaries. 134 S. Ct. at 2760; see also id. at 2759 (explaining the accommodation “ensur[es] that the employees of [eligible organizations] have precisely the same access to all FDA-approved contraceptives as employees of companies whose owners have no religious objections to providing such coverage”). 37 Providing women with such seamless coverage should result in a lower unintended pregnancy rate. Medical evidence reflects a causal relationship between the accessibility of contraceptives and the unintended pregnancy rate: “progress in reducing the rate of unintended pregnancy would be possible by making contraceptives more available, accessible, and acceptable.” IOM Report at 104 (internal quotation marks omitted); see also id. at 109 (“[C]ost-sharing requirements, such as deductibles and copayments, can pose barriers to care and result in reduced use of preventative and primary care services, particularly for 37 We acknowledge that the Supreme Court in Hobby Lobby expressly declined to decide whether the accommodation violated RFRA. Nonetheless, our analysis is consistent with the Court’s dicta. 57 Case: 14-12696 Date Filed: 02/18/2016 Page: 58 of 148 low-income populations.”); Dianne Greene Foster, et al., Number of Oral Contraceptive Pill Packages Dispensed & Subsequent Unintended Pregnancies, Obstetrics & Gynecology, March 2011, at 566 (concluding that when receipt of oral contraceptives was made more convenient by dispensing them annually rather than quarterly the unintended pregnancy rate dropped by 30% and the abortion rate dropped by 46%). 38 Because the government has demonstrated that the mandate and accommodation increase access to contraception, we conclude that the mandate and accommodation are effective ways to reduce the unintended pregnancy rate. Accordingly, they serve the government’s compelling interests of 38 The government’s evidence further shows that when contraception is easily accessible, women not only use it more often, they select more effective methods of contraception. In research studies, “when out-of-pocket costs for contraceptives were eliminated or reduced, women were more likely to rely on more effective long-acting contraceptive methods.” IOM Report at 109. These methods include intrauterine devices and contraceptive implants, which are long-lasting and have the additional advantage of not being dependent on user compliance. See Birth Control Methods Fact Sheet, Dep’t of Health & Hum. Servs., Office on Women’s Health, http://www.womenshealth.gov/publications/our-publications/fact-sheet/birth-control- methods.html (July 16, 2012) (showing that implants and intrauterine devices have a failure rate of less than 1 percent, compared to 5 percent for oral contraceptives and 11 to 16 percent for male condoms). These longer-acting contraceptive methods have been underutilized in the United States compared to other developed countries where unintended pregnancy rates are lower, Jeffrey F. Peipert, et al., Preventing Unintended Pregnancies by Providing No-Cost Contraception, Obstetrics & Gynecology, Dec. 2012, at 1291, in large part because they pose higher up-front costs that discourage use. See IOM Report at 108. Evidence shows that women’s use of long- acting contraceptive methods easily can be increased by making the methods cheaper and more readily available. In a study that provided intrauterine devices and implanted contraceptives at no cost to study participants, researchers found a significant decrease in unintended pregnancy and abortion rates in the study population. The study concluded that “[u]nintended pregnancies may be reduced by providing no-cost contraception and promoting the most effective contraceptive methods.” See Peipert, supra, at 1291. 58 Case: 14-12696 Date Filed: 02/18/2016 Page: 59 of 148 improving the health of women and children and assuring that women receive health benefits that meet their needs as well as the health care provided to men does. Of course, a compelling interest alone is insufficient to satisfy RFRA; we must also assess “the marginal interest in enforcing” the challenged law against the religious adherents in question. Hobby Lobby, 134 S. Ct. at 2779. “RFRA requires the Government to demonstrate that the compelling interest test is satisfied through application of the challenged law ‘to the person’—the particular claimant whose sincere exercise of religion is being substantially burdened.” Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal, 546 U.S. 418, 430-31 (2006) (quoting 42 U.S.C. § 2000bb-1(b)); see also Yoder, 406 U.S. at 221 (“Where fundamental claims of religious freedom are at stake, however, we cannot accept such a sweeping claim [of compelling interest]; despite its admitted validity in the generality of cases, we must searchingly examine the interests that the State seeks to promote . . . and the impediment to those objectives that would flow from recognizing the claimed . . . exemption.”). Yoder provides a good example of the application of this principle. There, the Amish plaintiffs challenged Wisconsin’s law requiring high school attendance until the age of 16. Yoder, 406 U.S. at 207-08. The government asserted that the law was justified by a general interest in the virtues of universal education. Id. at 59 Case: 14-12696 Date Filed: 02/18/2016 Page: 60 of 148 213-14. The Supreme Court was unsatisfied with this interest as it applied to the plaintiffs. “[T]he evidence adduced by the Amish . . . [was] persuasively to the effect that an additional one or two years of formal high school for Amish children in place of their long-established program of informal vocational education would do little to serve [the government’s stated] interests.” Id. at 222 (emphasis added). Similarly, the government’s argument in O Centro exemplifies an overly generalized interest. The plaintiffs, a religious sect with origins in the Amazon rainforest, challenged the Controlled Substances Act’s regulation of hoasca, a hallucinogenic tea they used in religious ceremonies. The federal government argued that it had “a compelling interest in the uniform application of the Controlled Substances Act, such that no exception to the ban on use of the hallucinogen can be made to accommodate the sect’s sincere religious practice.” O Centro, 546 U.S. at 423. The Supreme Court dismissed this slippery slope argument, which it said “could be invoked in response to any RFRA claim for an exception to a generally applicable law,” because it failed to consider the limited effect of an exception for the particular plaintiffs, and its stated need for universal application was undermined by the existence of other exceptions. Id. at 435-36. In contrast to Yoder and O Centro, here the government’s stated interests all concern the law’s application to these particular plaintiffs. The government argues that applying the accommodation procedure to the plaintiffs in these cases furthers 60 Case: 14-12696 Date Filed: 02/18/2016 Page: 61 of 148 its interests because the accommodation ensures that the plaintiffs’ female plan participants and beneficiaries—who may or may not share the same religious beliefs as their employer—have access to contraception without cost sharing or additional administrative burdens as the ACA requires. Unlike the exception made in Yoder for Amish children, whom the Supreme Court found had an adequate substitute for additional formal education to refute the government’s compelling interest, here the IOM Report’s findings of poor health outcomes related to unintended or poorly timed pregnancies apply to the plaintiffs’ female plan participants or beneficiaries and their children just as they do to the general population. Moreover, the accommodation’s requirement that the plaintiffs inform their TPAs or HHS of their religious objection is essential to achieving the government’s compelling interests. It ensures that a TPA is aware when it has an obligation to provide contraceptive coverage so that the women covered by these plans can receive coverage if they want it, without gaps in such coverage. The notification also guarantees that the Departments will be able to identify objecting organizations, like the plaintiffs, to make sure that the accommodation procedures work (that is, to independently ensure that the women covered by the plaintiffs’ plans are receiving the coverage to which they are entitled). Thus, the government’s interests are sufficiently particular to satisfy the O Centro standard. 61 Case: 14-12696 Date Filed: 02/18/2016 Page: 62 of 148 (c) The Exceptions to the Mandate and Accommodation Do Not Undermine the Government’s Compelling Interest. The plaintiffs argue that the government’s interests in providing broad contraceptive coverage cannot be compelling because the ACA provides exemptions from the mandate for other types of employers—namely, those (1) with grandfathered health plans, (2) with fewer than 50 employees, and (3) that qualify as “religious employers.” We disagree. First, the existence of grandfathered plans does not undermine the government’s compelling interest in providing contraceptive coverage because grandfathered plans are only a short-lived, transitional measure intended to ease the burden of compliance with the ACA’s sweeping reforms. 78 Fed. Reg. at 39887 n.49 (“[T]he Affordable Care Act’s grandfathering provision is only transitional in effect, and it is expected that a majority of plans will lose their grandfathered status by the end of 2013.”). To be grandfathered, a plan must continue to provide virtually the same benefits for the same percentage cost sharing as the plan had in effect on March 23, 2010. 45 C.F.R. § 147.140(g)(1)(ii). It becomes difficult to comply with these requirements over time. See, e.g., Second Am. Compl. at 23-24, No. 1:12-cv-03489, Doc. 56 (describing the Atlanta Archdiocese’s inability to afford to maintain its grandfathered plan past January 1, 2014). 62 Case: 14-12696 Date Filed: 02/18/2016 Page: 63 of 148 Research by the Kaiser Family Foundation demonstrates that the percentage of workers covered by grandfathered plans has rapidly declined: 26 percent in 2014, down from 36 percent in 2013, 48 percent in 2012, and 56 percent in 2011. Kaiser Family Found. & Health Research & Ed. Trust, Employer Health Benefits 2015 Annual Survey at 218 (Sept. 22, 2015). 39 In addition, some employees covered by grandfathered plans may in fact be receiving contraceptive benefits without cost sharing because, though not required to do so, their plans may include such a benefit. As an additional consideration, we do not wish to penalize the government for phasing in the ACA’s requirements to help businesses adjust to a new health care regulatory landscape. Cf. Heckler v. Mathews, 465 U.S. 728, 746 (1984) (“We have recognized, in a number of contexts, the legitimacy of protecting reasonable reliance on prior law even when that requires allowing an unconstitutional statute to remain in effect for a limited period of time. . . . The protection of reasonable reliance interests is . . . a legitimate governmental objective.”). Accordingly, even if the mandate and accommodation are phased in 39 We acknowledge that the Kaiser Family Foundation’s 2015 data shows that 25% of covered workers are enrolled in a grandfathered plan, which is not much less than the 26% in 2014. But the Foundation reported that many employers were confused and unsure about whether their plans remained grandfathered, suggesting that employers may have inaccurately reported that they had grandfathered plans. Kaiser Family Found., supra, at 214. 63 Case: 14-12696 Date Filed: 02/18/2016 Page: 64 of 148 over time, the gradual implementation is insufficient to undermine the government’s compelling interest. Second, the ACA’s treatment of employers with 50 or fewer employees as exempt from the “employer mandate” and therefore not required to provide employees with health insurance at all, see 26 U.S.C. § 4980H(a)(c)(2)(A), does not undercut the government’s compelling interests. If, on the one hand, smaller employers do not provide insurance coverage, then their employees must purchase health plans on the health insurance exchanges or face tax penalties. See id. § 5000A(a), (b)(1). And plans purchased on the exchanges will include contraceptive coverage. See 42 U.S.C. § 300gg-13(a)(4). If, on the other hand, smaller employers choose to provide health insurance, then their plans are subject to the contraceptive mandate. See id. The employees of small businesses therefore will receive contraceptive coverage regardless of whether their employers are exempt from providing health insurance. This exemption reflects a practical recognition that small businesses have different financial realities from larger businesses. It in no way undermines the government’s interest in providing contraceptive coverage without cost sharing because small businesses’ employees end up with health plans subject to the contraceptive mandate whether the employers provide health insurance or not. 64 Case: 14-12696 Date Filed: 02/18/2016 Page: 65 of 148 Third, the exemption from the contraceptive mandate for religious employers does not weaken the government’s stated interests. Under the HRSA guidelines, the contraceptive mandate does not apply to a group health plan run by a religious employer, defined by the regulations 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). In finalizing the regulations, the Departments declined to extend the exemption to other organizations that have religious objections to the mandate because: Houses of worship and their integrated auxiliaries that object to contraceptive coverage on religious grounds are more likely than other employers to employ people of the same faith who share the same objection, and who would therefore be less likely than other people to use contraceptive services even if such services were covered under their plan. 78 Fed. Reg. at 39874. The exemption for religious employers attempts to balance the need for contraceptive coverage with our nation’s longstanding history of deferring to a house of worship’s decisions about its internal affairs. See 76 Fed. Reg. at 46623 (“[T]he Departments seek to provide for a religious accommodation that respects the unique relationship between a house of worship and its employees in ministerial positions.”); see also Hosanna-Tabor Evangelical Lutheran Church & Sch. v. EEOC, 132 S. Ct. 694, 704-06 (2012) (describing history of non- 65 Case: 14-12696 Date Filed: 02/18/2016 Page: 66 of 148 interference with internal affairs of houses of worship). The government undoubtedly has a compelling interest in respecting the values of religious employers and their employees, and pursuing that interest does not undermine the government’s equally compelling interest in improving women’s and the public’s health by making contraceptives easier to obtain. Especially with regard to sweeping legislation like the ACA, the government is often faced with competing compelling interests. Courts may allow the government to balance those interests without undermining any individual compelling interest. See Hobby Lobby, 134 S. Ct. at 2780 (“Even a compelling interest may be outweighed in some circumstances by another even weightier consideration.”). We also reject the plaintiffs’ argument that the Departments’ distinction between houses of worship (which are exempted from the mandate) and other organizations with religious affiliation (which must seek an accommodation) is illogical. Although it may not universally hold true, 40 it is a common-sense notion that a church’s employees likely share more beliefs with the church than do the employees of, for example, a school linked to that church, and therefore the employees of a church that objects to contraception are less likely to use contraceptive coverage even if it is available. See 78 Fed. Reg. at 39874. Thus, 40 EWTN in particular argues that the Departments’ distinction between houses of worship and other religious organizations is illogical and does not hold for EWTN because, like employees of “religious employers,” its employees share its religious convictions. 66 Case: 14-12696 Date Filed: 02/18/2016 Page: 67 of 148 the Departments distinguished between houses of worship and other religious groups using the readily available and well-established IRS tax status test. This test is predictable for affected organizations and easy for the Departments to implement. See United States v. Lee, 455 U.S. 252, 260-61 (1982) (noting it was reasonable for Congress to exempt self-employed Amish from Social Security taxes because the exemption for “the self-employed provided for a narrow category which was readily identifiable . . . [and] distinguishable from the generality of wage earners employed by others”). We do not think that the Departments’ decision to exempt houses of worship based on a bright-line test while accommodating other religious organizations undercuts the government’s compelling interests in enforcing the contraceptive mandate. In sum, the mandate and accommodation further the government’s compelling interests by ensuring that women have contraceptive coverage without cost sharing or additional administrative hurdles. Additionally, by requiring organizations that opt out of the mandate to identify themselves, the government ensures that these organizations’ health plan participants and beneficiaries can receive the coverage seamlessly through other channels. Although the government has attempted to accommodate religious freedom as well as the needs of businesses, it has not done so in a way that undermines its goal of ensuring access to contraception. 67 Case: 14-12696 Date Filed: 02/18/2016 Page: 68 of 148 (ii) The Mandate and Accommodation Are the Least Restrictive Means of Furthering the Government’s Compelling Interests. As a final step, we must determine whether the mandate and accommodation are “the least restrictive means of furthering” the government’s compelling interests. 42 U.S.C. § 2000bb-1(b). This test is “exceptionally demanding.” Hobby Lobby, 134 S. Ct. at 2780. The government must show “that it lacks other means of achieving its desired goal without imposing a substantial burden on the exercise of religion by the [plaintiffs].” Id. When a less restrictive alternative serves the government’s compelling interest “equally well,” the government must use that alternative. Id. at 2782; see id. at 2786 (Kennedy, J. concurring) (considering whether alternative “equally furthers the Government’s interest”). In determining whether potential alternatives to the mandate and accommodation equally further the government’s interests, we must consider both the cost to the government and the burden the alternatives impose on the affected women. See id. at 2760 (majority opinion) (“[W]e certainly do not hold or suggest that RFRA demands accommodation of a for-profit corporation’s religious beliefs no matter the impact that accommodation may have on thousands of women employed by Hobby Lobby. The effect of the HHS-created accommodation on the women employed by Hobby Lobby and the other companies involved in these cases would be precisely zero.” (emphasis added) (alteration, footnote, citation, 68 Case: 14-12696 Date Filed: 02/18/2016 Page: 69 of 148 and internal quotation marks omitted)); id. at 2760 (clarifying that the Court did not hold that “corporations have free rein to take steps that impose disadvantages on others or that require the general public to pick up the tab” (alteration and internal quotation marks omitted)). Because there are no less restrictive means available that serve the government’s interests equally well, we hold that the mandate and accommodation survive strict scrutiny under RFRA. Although the plaintiffs and the dissent suggest several potential less restrictive alternatives to the mandate and accommodation, their proposals fail to achieve the government’s interests as effectively. Indeed, their proposals impose burdens on women that would make contraceptives less accessible than they currently are. Because these proposals cannot be expected to reduce the rate of unintended pregnancies and thereby improve the health of women and children as effectively as the mandate and accommodation, they do not qualify as less restrictive alternatives under RFRA. Previously, the Supreme Court and a member of this Court suggested that a less restrictive alternative would be to allow eligible organizations to notify HHS of their opt out, instead of having to provide Form 700 to their plan providers or TPAs. See Wheaton Coll., 134 S. Ct. at 2807; Eternal Word Television Network, 756 F.3d at 1349 (William Pryor, J., concurring) (“The United States, for example, could require the Network to provide a written notification of its religious 69 Case: 14-12696 Date Filed: 02/18/2016 Page: 70 of 148 objection to the Department of Health and Human Services, instead of requiring the Network to submit Form 700—an instrument under which the health insurance plan is operated—to the third-party administrator.”). The Departments have responded to and addressed this concern by revising the accommodation procedures to allow eligible organizations notify HHS directly of their desire to opt out of the contraceptive mandate. 79 Fed. Reg. at 51094-95. With that potential alternative incorporated into the regulatory scheme, we turn to the alternatives proposed by the plaintiffs and the dissent. (a) The Plaintiffs’ Proposals The plaintiffs propose two less restrictive alternatives. First, they suggest that the government could pay directly for all contraceptive coverage, in effect a single-payer system for contraceptives only, 41 either by creating a new government program or expanding an existing one. 42 Either way Congress would need to pass legislation that would fundamentally change how the majority of American women 41 In a single-payer system, the government—as opposed to employers, health insurers, or patients—pays for healthcare services. See Notre Dame II, 786 F.3d at 615; Single-Payer, Merriam Webster Dictionary, http://www.merriam-webster.com/dictionary/single-payer (last visited Feb. 12, 2016). Although the plaintiffs never call their proposal a “single-payer” system for contraceptives, the label applies because they propose a system in which the government would be the sole payer for contraceptives and related services. It is important to note that all other health care would c [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/3178557. Public record. Not legal advice.