In Biden v. Missouri, decided January 13, 2022, the Supreme Court ruled 5–4 that the Secretary of Health and Human Services acted within his statutory authority when he required staff at Medicare- and Medicaid-participating healthcare facilities to be vaccinated against COVID-19. The per curiam opinion lifted two lower-court injunctions and allowed the federal mandate to take effect for roughly 10 million healthcare workers. On the same day, in a separate ruling, the Court blocked the Biden administration’s OSHA vaccine-or-test rule for large employers.
What the CMS Rule Required
The Centers for Medicare and Medicaid Services published the interim final rule on November 5, 2021. It applied to approximately 76,000 healthcare facilities and covered an estimated 17 million healthcare workers.1National Center for Biotechnology Information. COVID-19 Vaccine Mandate for Healthcare Workers Staff at participating facilities had to be vaccinated against COVID-19 as a condition of the facility’s continued participation in the federal programs. The rule allowed exemptions for medical conditions and sincerely held religious beliefs. It did not exempt staff who teleworked full-time.
The Secretary skipped the usual notice-and-comment rulemaking process, invoking the “good cause” exception and citing the Delta variant and the approaching winter as reasons for immediate implementation.2Justia. Biden v. Missouri, 595 U.S. 87
How the Case Reached the Supreme Court
Two coalitions of states sued almost immediately. In the Eastern District of Missouri, Judge Matthew Schelp enjoined the mandate in ten states on November 29, 2021, finding the plaintiffs likely to succeed on statutory-authority, procedural, and arbitrary-and-capricious grounds.3South Dakota Attorney General. CMS Injunction, Eastern District of Missouri The next day, in the Western District of Louisiana, Judge Terry Doughty issued a broader injunction covering the remaining states not already blocked by the Missouri order.4Virginia Mercury. Vaccine Mandate for Health Care Workers Halted Nationwide by Louisiana Judge Together the two orders blocked the mandate in 24 states.
The Eighth and Fifth Circuits both denied the government’s requests to stay the injunctions. The government then filed emergency applications with the Supreme Court, which consolidated them and scheduled oral argument for January 7, 2022, alongside the challenge to the OSHA vaccine-or-test rule for large employers.5SCOTUSblog. Becerra v. Louisiana
The Majority’s Reasoning
Six days after argument, the Court granted the government’s applications and stayed both injunctions. The majority anchored its decision in 42 U.S.C. § 1395x(e)(9), which lets the Secretary impose conditions he “finds necessary in the interest of the health and safety of individuals who are furnished services” at Medicare and Medicaid facilities.6U.S. Supreme Court. Biden v. Missouri, 595 U.S. 87 The Court framed vaccination as another form of infection control, consistent with the medical principle of “first, do no harm,” and within the Secretary’s longstanding authority to regulate healthcare worker qualifications.2Justia. Biden v. Missouri, 595 U.S. 87
The majority acknowledged the mandate went further than earlier regulations but noted the Secretary had never before confronted a pandemic of this “scale and scope.”7Legal Information Institute. Biden v. Missouri The Court also rejected the argument that the rule was arbitrary and capricious, finding the Secretary had examined the data, weighed the risk of staffing shortages, and properly invoked the good cause exception given the urgency of Delta and the coming winter.2Justia. Biden v. Missouri, 595 U.S. 87
The Dissents
Justice Thomas wrote a dissent joined by Justices Alito, Gorsuch, and Barrett. He argued the government had not made a strong showing of statutory authority, calling the provisions it cited a “hodgepodge” of facility-specific rules that Congress never designed to support a nationwide vaccine mandate covering 10 million workers. Thomas invoked the principle that Congress does not hide “fundamental details of a regulatory scheme in vague or ancillary provisions” and pointed out that vaccine mandates have historically been an exercise of state police power.8Justia. Biden v. Missouri, 595 U.S. 87 – Thomas Dissent
Justice Alito filed a separate dissent joined by the same three justices. His focus was procedural. Even if the Secretary had the underlying authority, Alito wrote, he failed to follow the required notice-and-comment process, denying affected parties any “opportunity to make their views heard.” Federal law, he added, should be made by elected representatives, not “unelected administrators.”9Justia. Biden v. Missouri, 595 U.S. 87 – Alito Dissent
Why the OSHA Mandate Fell the Same Day
On January 13, 2022, the Court also decided National Federation of Independent Business v. OSHA. There, a 6–3 majority blocked the OSHA vaccine-or-test rule for employers with 100 or more employees, a rule that would have reached about 84 million workers. The Court reasoned that OSHA’s authority extended to workplace-specific hazards, not to a “universal risk” like COVID-19 that resembled everyday dangers such as crime or air pollution, and noted OSHA had never issued a comparable mandate in its 50-year history.10U.S. Supreme Court. National Federation of Independent Business v. OSHA
The split outcome turned on how specifically Congress had authorized each agency. The CMS statute expressly empowered the Secretary to set health and safety conditions on facilities receiving federal funding, and the Court found a vaccination requirement fit “neatly” within that grant. OSHA’s emergency power, by contrast, was narrower and, in the Court’s view, did not stretch to an economy-wide public health measure. The OSHA case also triggered the major questions doctrine; the per curiam opinion in Biden v. Missouri did not.11George Mason University. Major Questions Doctrine Analysis
What Happened After the Ruling
CMS set staggered compliance deadlines in early 2022, with the final date falling on March 21, 2022. Vaccination rates among nursing facility staff rose from 63% in August 2021 to 88% by March 2022, a 25-percentage-point increase.12KFF. Nursing Facility Staff Vaccinations, Boosters, and Shortages After Vaccination Deadlines Passed
Opponents had predicted mass resignations and crippling shortages. A study of more than 15,000 nursing homes published in the Journal of the American Medical Directors Association found “little evidence” the mandate materially affected staffing levels; nurse aide staffing showed modest increases after the compliance deadline, and a slight decline in licensed nurse staffing appeared in states with and without pre-existing mandates alike, suggesting broader workforce causes.13National Center for Biotechnology Information. Evidence on the Effects of the Federal COVID-19 Vaccine Mandate on Nursing Home Staffing Levels Self-reported shortages peaked at 33% of nursing facilities in January 2022 during the Omicron wave and fell to 28% by March 2022, after the deadlines passed.12KFF. Nursing Facility Staff Vaccinations, Boosters, and Shortages After Vaccination Deadlines Passed
The Biden administration announced the end of the requirement on May 1, 2023, stating that “we are now in a different phase of our response when these measures are no longer necessary.” CMS published a final rule on June 5, 2023, withdrawing the mandate effective August 4, 2023, and citing increased vaccine uptake, declining infection and death rates, and decreasing disease severity.14Federal Register. Medicare and Medicaid Programs; Policy and Regulatory Changes to the Omnibus COVID-19 Health Care Staff Vaccination Requirements Individual healthcare facilities kept the option to enforce their own vaccination policies after the federal rule ended.
Not To Be Confused With Murthy v. Missouri
A separate case carried the name Missouri v. Biden for much of its life and is often mistaken for this one. That case, later styled Murthy v. Missouri, concerned allegations that Biden administration officials pressured social media companies to suppress speech about COVID-19 and other topics. It reached the Supreme Court in 2024 on a different question, and a 6–3 majority held the plaintiffs lacked Article III standing to seek an injunction; the Court did not reach the First Amendment merits.15SCOTUSblog. Murthy v. Missouri