Little Sisters of the Poor v. Pennsylvania
Whether the Departments of Health and Human Services, Labor, and Treasury had the statutory authority under the Affordable Care Act to issue rules creating broad religious and moral exemptions to the ACA's requirement that employer health plans cover contraceptive services for women.
The Decision
7-2 decision · Opinion by Clarence Thomas · 2020
Majority Opinion— Clarence Thomasconcurring ↓dissent ↓
In a 7–2 decision authored by Justice Clarence Thomas, the Supreme Court reversed the Third Circuit and held that the federal agencies had the statutory authority under the ACA to issue the religious and moral exemptions to the contraceptive mandate. The Court also found that the rules satisfied the procedural requirements of the Administrative Procedure Act.
Justice Thomas's majority opinion focused on the text of the ACA itself. The statute says that employer health plans must cover preventive care and screenings 'as provided for' in guidelines supported by HRSA. The Court found this language gave HRSA exceptionally broad discretion — not just to decide what services would be included, but also to define the scope and terms of that coverage, including the power to create exemptions. The majority emphasized that Congress did not impose specific constraints on how HRSA exercised this delegated authority, and courts should not read limitations into a statute that Congress chose not to include.
The Court also pointed to the long history of the agencies exercising precisely this kind of authority. From the very beginning of the contraceptive mandate, HRSA had carved out exemptions for churches and their integrated auxiliaries. The Obama administration later expanded those exemptions to include religious nonprofits through the accommodation process. The Trump-era rules, the Court reasoned, were simply a further exercise of the same broad discretionary authority that HRSA had been wielding all along. There was nothing in the statute that limited this power to narrow exemptions.
On the procedural question, the Court found that even though the 2017 interim rules had been issued without prior notice and comment, the agencies subsequently conducted a full notice-and-comment process and issued revised final rules in 2018. The final rules before the Court were therefore procedurally proper. Accordingly, the nationwide injunction blocking the rules was reversed.
The Court did not reach the broader question of whether RFRA independently compelled the government to exempt the Little Sisters from the mandate, though Justice Thomas noted in a footnote that RFRA informed the analysis of whether the exemptions were reasonable.
Concurring Opinions
Justice Samuel Alito, joined by Justice Neil Gorsuch, wrote a concurrence arguing more forcefully that the Religious Freedom Restoration Act (RFRA) independently required the government to exempt objecting employers like the Little Sisters, and that the rules would survive any challenge on remand for being arbitrary and capricious. Justice Elena Kagan, joined by Justice Stephen Breyer, wrote a narrower concurrence agreeing the agencies had statutory authority but cautioning that the rules might still be vulnerable on remand if a court found they failed arbitrary-and-capricious review — meaning the agencies might not have adequately justified the breadth of the exemptions or considered their impact on affected women.
Dissenting Opinions
Ruth Bader Ginsburgjoined by Sonia Sotomayor
Justice Ginsburg argued that the ACA's delegation of authority to HRSA was limited to identifying which preventive services must be covered, not to deciding which employers could refuse to cover them. She contended that the broad exemptions violated the ACA's core purpose of ensuring comprehensive health coverage for women and would leave tens of thousands of women without access to contraceptive care.
- The ACA was designed to close gaps in women's preventive healthcare, and Congress would not have silently delegated the power to blow open those very gaps through sweeping employer exemptions.
- The exemptions lacked any mechanism to ensure that women who lost contraceptive coverage from their employers would obtain it from an alternative source, unlike the prior Obama-era accommodation.
- The concrete harm to women and to state healthcare budgets was real and significant, and the majority's reading of HRSA's authority was implausibly broad.
Background & Facts
The Affordable Care Act (ACA), passed in 2010, required most employer-sponsored health insurance plans to cover certain preventive health services for women without cost-sharing (like copays or deductibles). Congress did not spell out exactly which services had to be covered. Instead, it delegated that task to the Health Resources and Services Administration (HRSA), a federal agency within the Department of Health and Human Services. HRSA determined that the required preventive care included all FDA-approved contraceptive methods, which meant most employers had to include birth control coverage in their health plans.
This requirement — commonly called the 'contraceptive mandate' — immediately drew objections from religious employers who believed that some or all contraceptive methods were morally wrong. The Little Sisters of the Poor, a Catholic order of nuns who operate homes for the elderly poor, were among the most prominent objectors. Even after the Obama administration created an 'accommodation' process allowing religious nonprofits to opt out by notifying their insurer or the government, the Little Sisters argued that participating in that process still made them complicit in providing contraception, violating their sincere religious beliefs. Their earlier legal battles had reached the Supreme Court in 2016 in a related case.
In 2017 and 2018, under the Trump administration, the relevant federal agencies issued new rules creating sweeping exemptions. One rule allowed virtually any employer with sincerely held religious objections to opt out of providing contraceptive coverage entirely. A second rule did the same for employers with sincerely held moral (but not necessarily religious) objections. These rules went far beyond the Obama-era accommodation and could have affected coverage for tens of thousands of women.
The states of Pennsylvania and New Jersey sued to block the new rules, arguing the agencies had no legal authority under the ACA to create such broad exemptions, and that the rules violated the Administrative Procedure Act (APA) because they were issued without following proper rulemaking procedures. A federal district court agreed and issued a nationwide injunction blocking the rules. The Third Circuit Court of Appeals affirmed, finding the agencies likely lacked statutory authority to issue the exemptions.
The Little Sisters of the Poor intervened in the case to defend the exemptions and petitioned the Supreme Court for review. The Court agreed to hear the case to resolve the question of whether the federal agencies had the power under the ACA to grant these broad exemptions.
The Arguments
The Little Sisters argued that the ACA gave HRSA broad authority to define what preventive care services must be covered, and that this same authority necessarily included the power to create exemptions from those requirements. They also argued that the Religious Freedom Restoration Act (RFRA) independently required the government to accommodate their sincere religious objections.
- The ACA's text delegates to HRSA the authority to decide which preventive care services for women must be covered, with no limitations on how HRSA exercises that discretion — meaning exemptions are within scope.
- The Obama administration itself recognized the need for religious exemptions by creating accommodations for churches and religious nonprofits, demonstrating that the statute permits carve-outs.
- Forcing the Little Sisters to comply with the contraceptive mandate — even through the accommodation process — substantially burdens their religious exercise in violation of RFRA.
Pennsylvania argued that the ACA's delegation of authority to HRSA was limited to deciding which preventive services must be covered, not to deciding who must cover them. The states contended that creating broad exemptions effectively rewrote the statute and would cause concrete harm by shifting the cost of lost contraceptive coverage onto the states.
- The ACA's text authorizes HRSA to specify what preventive care must be covered — it does not authorize HRSA to exempt entire categories of employers from the coverage requirement.
- The broad exemptions could cause tens of thousands of women to lose contraceptive coverage, increasing unintended pregnancies and imposing real costs on state healthcare programs.
- The final rules were procedurally defective because the interim final rules issued in 2017 bypassed the notice-and-comment process required by the Administrative Procedure Act.