In Little Sisters of the Poor v. Pennsylvania, decided July 8, 2020, the Supreme Court ruled 7-2 that federal agencies had the legal authority to exempt religious and moral objectors from the Affordable Care Act’s contraceptive coverage mandate. Justice Clarence Thomas wrote the majority opinion, holding that the ACA gave the Health Resources and Services Administration wide discretion over preventive care guidelines for women, including the power to write exceptions into them. The case pitted a Catholic order of nuns who care for the elderly poor against Pennsylvania and New Jersey, which argued the exemptions would strip contraceptive coverage from tens of thousands of women.
How the Case Reached the Supreme Court
The dispute went back nearly a decade. When federal agencies first implemented the ACA’s preventive care provisions, they required most employer health plans to cover contraceptives at no cost. Houses of worship received an outright exemption. Religiously affiliated nonprofits like the Little Sisters had to use an accommodation process instead: they would notify their insurer or the government of their objection, and a third-party administrator would arrange coverage separately.
That accommodation itself became a flashpoint. The Little Sisters argued that even filing the opt-out paperwork made them complicit in providing contraception, which violated their religious beliefs. In 2014, the Court decided Burwell v. Hobby Lobby Stores, Inc., holding that closely held for-profit corporations could claim religious exemptions from the mandate under the Religious Freedom Restoration Act. Two years later, Zubik v. Burwell gathered a batch of nonprofit cases, including one from the Little Sisters. Rather than resolve the merits, the Court vacated the lower rulings and sent the cases back with instructions to find a compromise. No compromise materialized.
The 2017 and 2018 Exemption Rules
In October 2017, the Departments of Health and Human Services, Labor, and the Treasury issued interim final rules that dramatically expanded who could opt out. The rules created two categories: a religious exemption for any employer with sincerely held religious objections, and a moral exemption for employers with sincerely held moral convictions against contraception. Final versions followed in November 2018.
The scope stretched well past traditional religious organizations. Any nongovernmental employer, including publicly traded for-profit companies, could claim the religious exemption. Nonprofit and closely held for-profit organizations could also qualify under the separate moral exemption. The government estimated the religious exemption might affect between 70,500 and 126,400 women of childbearing age.
Pennsylvania and New Jersey sued, arguing the agencies exceeded their regulatory authority, violated the Administrative Procedure Act, and would push women into state-funded programs. A federal district court in Philadelphia issued a nationwide injunction blocking the rules, and the Third Circuit affirmed. The Supreme Court took the case.
The Statutory Authority Ruling
The central legal question was whether the ACA authorized the exemptions at all. The answer turned on 42 U.S.C. ยง 300gg-13(a)(4), which says health plans must cover preventive care for women “as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.” Pennsylvania and New Jersey read that as a coverage command with no room for exceptions. The majority read it as a delegation.
Justice Thomas emphasized that the phrase “as provided for” gave HRSA sweeping authority to define what preventive care applicable plans must include. Because the statute delegated the job of writing the guidelines rather than spelling out what they had to contain, the same grant of authority that let HRSA require contraceptive coverage also let it identify exceptions. Congress had said nothing about exemptions one way or the other, and the Court found no evidence lawmakers intended to bar them.
Under this reading, the contraceptive mandate was never a direct congressional command. It was an agency decision made under broad delegated authority, and the agency could adjust that decision. The Court reversed the Third Circuit.
The Role of RFRA
The agencies had also pointed to the Religious Freedom Restoration Act as justification for the exemptions. RFRA bars the federal government from substantially burdening a person’s religious exercise unless doing so is the least restrictive way to advance a compelling government interest. Pennsylvania and New Jersey argued the agencies should have looked only at the ACA when writing the rules.
The majority disagreed. Because the mandate was federal law subject to RFRA, the Court found it appropriate for the agencies to consider whether the mandate might violate religious liberty protections when crafting the regulations. The majority stopped short of saying RFRA actually required the exemptions, but it validated the agencies’ choice to account for potential religious burdens during rulemaking rather than waiting for another lawsuit. Hobby Lobby had already established that the mandate could violate RFRA as applied to certain employers, and the agencies were, in effect, trying to head off the same conflict on a broader scale.
The Procedural Challenge
Pennsylvania and New Jersey also argued the agencies had violated the APA by issuing the 2017 rules as interim final rules that took effect immediately, skipping the notice-and-comment step. The Court found this objection fell short. After issuing the interim rules, the agencies opened a 60-day comment period, addressed the feedback received, and published final rules in November 2018 that did not take effect until January 2019. Those steps satisfied the APA.
The Concurring Opinions
Seven justices agreed the exemptions should survive, but they did not all agree on why.
Justice Kagan, joined by Justice Breyer, concurred in the judgment. She would have upheld the agencies’ statutory authority under Chevron deference, finding the ACA’s language ambiguous enough to deserve respect for the agencies’ reading. But Kagan flagged a problem the majority did not address: whether the exemptions were arbitrary and capricious under the APA, a separate standard that asks whether an agency made a reasoned decision. The lower courts had resolved the case on statutory authority grounds and never reached this question. Kagan wrote that the exemptions gave “every appearance of coming up short” on reasoned decision-making and signaled that the states could press the argument on remand.
Justice Alito, joined by Justice Gorsuch, went the other direction. Where the majority said agencies were permitted to consider RFRA, Alito argued RFRA compelled the exemptions. In his view, the mandate substantially burdened the Little Sisters’ religious exercise, the government had not shown it was using the least restrictive means available, and therefore RFRA required an exemption for any employer with similar objections.
Justice Ginsburg’s Dissent
Justice Ginsburg, joined by Justice Sotomayor, dissented sharply. She would have affirmed the Third Circuit and kept the nationwide injunction in place. Her core objection was practical: the exemptions contained no backup mechanism to ensure affected women could still obtain contraceptive coverage. Under the old accommodation framework, a third-party administrator would step in. Under the new rules, women were simply left without coverage.
Ginsburg cited the government’s own estimate that between 70,500 and 126,400 women would immediately lose access to no-cost contraceptive services. The suggestion that women could turn to existing publicly funded programs, she said, ignored that those programs served primarily low-income populations and were not designed to absorb tens of thousands of newly uninsured women. She also challenged the scope of the exemptions. The original religious exemption applied only to houses of worship. The new rules extended it to any nongovernmental employer, including large for-profit corporations, which Ginsburg argued was inconsistent with both the ACA and with RFRA itself.
What Happened After the Ruling
The decision reversed the Third Circuit and sent the case back for further proceedings, but as Kagan’s concurrence had anticipated, the arbitrary-and-capricious question remained open. On remand, the district court in Pennsylvania again blocked the rules on that alternative ground, issuing a nationwide order. According to the Department of Labor, the 2017 and 2018 exemption rules are currently not in effect due to subsequent court orders.
The Biden administration later proposed new rules that would remove the moral exemption while retaining a narrower religious exemption and creating an independent pathway for affected employees to obtain contraceptive coverage directly from a willing provider at no cost. For the Little Sisters of the Poor, the case remains part of a legal saga that has stretched across multiple administrations, multiple Supreme Court appearances, and more than a decade of litigation over where religious liberty ends and healthcare access begins.