Grace Schools v. Sylvia Mathews Burwell

In the United States Court of Appeals For the Seventh Circuit Nos. 14-1430 & 14-1431 GRACE SCHOOLS, et al., AND DIOCESE OF FORT WAYNE-SOUTH BEND, INC., et al., Plaintiffs-Appellees, v. SYLVIA MATHEWS BURWELL, et al., Defendants-Appellants. Appeals from the United States District Court for the Northern District of Indiana. Nos. 3:12-cv-00459-JD-CAN and 1:12-cv-00159-JD-RBC — Jon E. DeGuilio, Judge. ARGUED DECEMBER 3, 2014 — DECIDED SEPTEMBER 4, 2015 Before MANION, ROVNER, and HAMILTON, Circuit Judges. ROVNER, Circuit Judge. The district court entered a prelimi- nary injunction in favor of the plaintiffs, a number of religious, not-for-profit organizations, preventing the defendants from applying or enforcing the so-called “contraceptive mandate” of the Patient Protection and Affordable Care Act of 2010 (“ACA”) to the plaintiffs. See 42 U.S.C. § 300gg-13(a)(4); Pub. 2 Nos. 14-1430 & 14-1431 L. No. 111-148, 124 Stat. 119 (2010). The plaintiffs contend that the ACA’s accommodations for religious organizations impose a substantial burden on their free exercise of religion, and that the ACA and accompanying regulations are not the least restrictive means of furthering a compelling government interest, in violation of the plaintiffs’ rights under the Religious Freedom Restoration Act of 1993 (“RFRA”). See 42 U.S.C. § 2000bb et seq. The defendants, several agencies of the United States government, appeal. We conclude that ACA does not impose a substantial burden on the plaintiffs’ free exercise rights and so we reverse and remand. However, we will maintain the injunction for a period of sixty days in order to allow the district court adequate time to address additional arguments made by the parties but not addressed prior to this appeal. I. The ACA requires group health plans and third-party administrators of self-insured plans to cover preventive care for women under guidelines supported by the Health Re- sources and Services Administration (“HRSA”), a component of the Department of Health and Human Services (“HHS”). 42 U.S.C. § 300gg-13(a)(4); 45 C.F.R. § 147.130(a)(1)(iv); University of Notre Dame v. Burwell, 786 F.3d 606, 607 (7th Cir. 2015) (hereafter “Notre Dame II”); University of Notre Dame v. Sebelius, 743 F.3d 547, 548 (7th Cir. 2014), vacated by 135 S. Ct. 1528 (2015) (hereafter “Notre Dame I”). The relevant guidelines include “all Food and Drug Administration approved contra- ceptive methods, sterilization procedures, and patient educa- tion and counseling for all women with reproductive capac- ity.” 77 Fed. Reg. 8725-26. The regulations adopted by the three Nos. 14-1430 & 14-1431 3 Departments implementing this part of the ACA require coverage of, among other things, all of the contraceptive methods described in the guidelines. See 45 C.F.R. § 147.130(a)(1)(iv) (HHS); 29 C.F.R. § 2590.715-2713(a)(1)(iv) (Labor); 26 C.F.R. § 54.9815-2713(a)(1)(iv) (Treasury).1 In anticipation of objections from religious organizations to these requirements, the Departments provided an exemption from the contraception coverage provision for religious employers. 45 C.F.R. § 147.131(a). A religious employer is defined 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); 26 U.S.C. § 6033(a)(3)(A). That provision of the Internal Revenue Code, in turn, refers to “churches, their integrated auxiliaries, and conventions or associations of churches,” and “the exclusively religious activities of any religious order.” 26 U.S.C. § 6033(a)(3)(A)(i) and (iii). But the exemption did not cover religiously-affiliated non-profit corporations such as schools and hospitals that did not meet the IRS guidelines for religious employers. The Departments therefore adopted additional regulations providing accommo- dations for group health plans provided by these non-profit 1 All three of these regulations have been amended since this suit was filed. The most recent amendments, which are scheduled to take effect Sept. 14, 2015, address accommodations for closely-held for-profit corporations whose owners have religious objections to some or all of the contraceptive coverage requirements of the ACA. See Burwell v. Hobby Lobby, 134 S. Ct. 2751 (2014). Because these most recent amendments are not relevant to the issues raised here, we will be referring to the version of the regulations in effect at the time this suit was filed, unless we state otherwise. 4 Nos. 14-1430 & 14-1431 religious corporations, called “eligible organizations” in the regulations: (b) Eligible organizations. An eligible organization is an organization that satisfies all of the following requirements: (1) The organization opposes providing coverage for some or all of any contraceptive services required to be covered under § 147.130(a)(1)(iv) on account of religious objections. (2) The organization is organized and operates as a nonprofit entity. (3) The organization holds itself out as a religious organization. (4) The organization self-certifies, in a form and manner specified by the Secretary, that it satisfies the criteria in paragraphs (b)(1) through (3) of this section, and makes such self-certification 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 must be executed by a person authorized to make the certification on behalf of the organization, and must be maintained in a manner consistent with the record retention requirements under section 107 of the Employee Retirement Income Security Act of 1974. Nos. 14-1430 & 14-1431 5 45 C.F.R. § 147.131(b).2 See also 78 Fed. Reg. 39,874-75. Eligible organizations are not required “to contract, arrange, pay, or refer for contraceptive coverage” to which they have religious objections. 78 Fed. Reg. 39,874. The government developed a two-page form for eligible organiza- tions to use to comply with this accommodation, the “EBSA Form 700 – Certification.”3 The short form requires the eligible organization to supply its name, the name and title of the individual authorized to make the certification on behalf of the organization, and a mailing address and telephone number for that individual. The form also requires a signature verifying the statement, “I certify the organization is an eligible organi- zation (as described in 26 CFR 54.9815-2713A(a), 29 CFR 2590.715-2713A(a); 45 CFR 147.131(b)) that has a religious objection to providing coverage for some or all of any contra- ceptive services that would otherwise be required to be covered.” The organization must then provide a copy of the certification to the organization’s health insurance issuer or, for self-insured plans, to its third-party administrator. The insurer or administrator receiving the certification is obligated to provide (or arrange for the provision of) contraception cover- age for the health plan’s participants without cost sharing through alternate mechanisms established by the regulations. 2 This regulation will also be updated as of Sept. 14, 2015. Again, we cite to the earlier version. 3 The form can be found at http://www.dol.gov/ebsa/pdf/preventive serviceseligibleorganizationcertificationform.pdf, last visited September 3, 2015. 6 Nos. 14-1430 & 14-1431 45 C.F.R. § 147.131(c). The insurer4 may not impose a charge of any variety, either directly or indirectly, on the eligible organization for the provision of contraception services.5 The insurer must also inform plan participants that the eligible organization will not provide or fund any contraception coverage. 45 C.F.R. § 147.131(d). As we will discuss below, since the filing of this suit, these regulations have been amended to allow a second method of objecting to contracep- tive coverage, by notifying HHS directly of any religiously- based objection. The plaintiffs are various religiously-based non-profit organizations including the Diocese of Fort Wayne-South Bend, Inc. (“Diocese”); Catholic Charities of the Diocese of Fort Wayne-South Bend, Inc. (“Catholic Charities”); Saint Anne Home & Retirement Community of the Diocese of Fort Wayne- 4 From this point forward, when we use the term “insurer,” we mean to include third-party administrators in those instances where the plan is self- insured unless we state otherwise. 5 Insurers are expected to recoup the costs of contraceptive coverage from savings on pregnancy medical care as well as from other regulatory offsets. See Notre Dame II, 786 F.3d at 609–10; 78 Fed. Reg. 38977-78 (“Issuers are prohibited from charging any premium, fee, or other charge to eligible organizations or their plans, or to plan participants or beneficiaries, for making payments for contraceptive services, and must segregate the premium revenue collected from eligible organizations from the monies they use to make such payments. In making such payments, the issuer must ensure that it does not use any premiums collected from eligible organiza- tions.”). Third-party administrators may seek reimbursement of up to 110% of their costs from the government. Notre Dame II, 786 F.3d at 609; 45 C.F.R. § 156.50(d)(3). Nos. 14-1430 & 14-1431 7 South Bend, Inc. (“St. Anne Home”); Franciscan Alliance, Inc.; Specialty Physicians of Illinois LLC (“Specialty Physicians”); University of Saint Francis (“St. Francis”); Our Sunday Visitor, Inc. (“Sunday Visitor”); Biola University, Inc. (“Biola”) and Grace Schools. The plaintiffs objected below to the regulatory scheme, which they characterize as a “contraceptive services mandate,” on numerous grounds. Primarily, they asserted that the regulations force them to participate in a system that contravenes their religious beliefs in violation of the RFRA. 42 U.S.C. § 2000bb et seq.6 In particular, they are forced to contract with insurers or third-party administrators that will provide their employees (and, in some cases, their students) with coverage for contraceptives, sterilization, and abortion- inducing products, all in violation of their deeply held reli- gious beliefs. The accommodation provides them no relief, they contended below, because it causes them to trigger and facilitate the same objectionable services for their employees and students. A non-complying employer7 who does not meet 6 The plaintiffs also allege that the challenged statute and regulations violate their rights under the First Amendment and under the Administra- tive Procedures Act, 5 U.S.C. § 500 et seq. Because the district court issued the injunction after considering only the RFRA, and because neither side has briefed the other issues, we will confine our discussion to the RFRA. On remand, the plaintiffs are free to pursue their other theories for relief and, in fact, we will leave the injunction in place for a limited time in order to allow the court to consider those additional claims. 7 The disputed regulations apply equally to employers providing insurance to employees and to institutions of higher education providing student health insurance. See 45 C.F.R. § 147.131(f). Some of the plaintiffs provide (continued...) 8 Nos. 14-1430 & 14-1431 an exemption faces fines of $2000 per year per full time employee8 for not providing insurance that meets coverage requirements, 26 U.S.C. § 4980H(c), or $100 per day per employee for providing insurance that excludes the required contraceptive coverage, 26 U.S.C. § 4980D, and will face the risk of other enforcement actions. The Diocese itself is exempted from challenged require- ments under the religious employer exemption,9 and the remaining plaintiffs are subject to the accommodation for non- profit, religiously-affiliated employers. The government does not contest the sincerity of the plaintiffs’ religious objections to the required contraceptive coverage. Moreover, all of the plaintiffs consider the provision of health insurance for their employees and students to be part of their religious mission. 7 (...continued) both employee and student health coverage. 8 When calculating the number of employees for the purpose of assessing this penalty, the statute directs that thirty employees be subtracted from the total number of employees, essentially reducing the penalty by $60,000 per year for affected employers. 26 U.S.C. § 4980H(c)(2)(D)(i). 9 Although the Diocese is itself exempt, the Diocesan Health Plan insures employees of the non-exempt Catholic Charities. In order to protect Catholic Charities from having to comply with either the contraceptive mandate or the accommodation, the Diocese has forgone almost $200,000 annually in increased premiums in order to maintain its grandfathered status under the ACA. See 42 U.S.C. § 18011. Grandfathered plans are those health plans that need not comply with the coverage requirements of the ACA because they were in existence when the ACA was adopted and have not made certain changes to the terms of their plans. Nos. 14-1430 & 14-1431 9 Although the plaintiffs concede that they are not required to pay for the objectionable services, they contended in the district court that being forced to contract with insurers or third-party administrators who must then provide those services makes them a facilitator of objectionable conduct, complicit in activity that violates their core religious beliefs. The plaintiffs also asserted below that the government’s interest in providing contraceptive services is not compelling and that the means the government employed are not the least restrictive available to achieve the government’s goals. On those bases, the plaintiffs sought and received a preliminary injunction in the district court. The district court noted that the RFRA prohibits the federal government from placing substantial burdens on a person’s exercise of religion unless it can demonstrate that applying 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) and (b). The court first considered whether the contraception regulations create a substantial burden on eligible employers in light of the accommodation provided by the regulations. Citing our opinion in Korte v. Sebelius, 735 F.3d 654 (7th Cir. 2013), cert. denied, 134 S. Ct. 2903 (2014), the court noted that “the pertinent inquiry for the substantial burden test under RFRA is whether the claimant has an honest conviction that what the government is requiring or pressuring him to do conflicts with his religious beliefs and whether the governmen- tal pressure exerts a sufficiently coercive influence on the plaintiffs’ religious practice.” Grace Schools v. Sebelius, 988 F. Supp. 2d 935, 950 (N.D. Ind. 2013); Diocese of Fort Wayne- 10 Nos. 14-1430 & 14-1431 South Bend, Inc. v. Sebelius, 988 F. Supp. 2d 958, 972 (N.D. Ind. 2013). The court found that the plaintiffs sincerely believe that the accommodation compels them to facilitate and serve as a conduit for objectionable contraceptive services for their employees and students. If the plaintiffs want to provide health insurance for their students and employees as part of their religious mission (and in order to avoid the fines imposed by the ACA on employers who fail to meet coverage require- ments), the court reasoned, then they must either provide the objectionable coverage themselves or comply with the accom- modation. And the plaintiffs sincerely believe that invoking the accommodation facilitates and enables the provision of contraceptive services to their employees and students; the accommodation, in short, makes them complicit in the provi- sion of services to which they possess a religious objection. That they need not pay for the services provides no relief from their religious dilemma, the district court reasoned, because they must violate their religious beliefs by either forgoing providing health insurance to their employees and students, or they must take critical steps (i.e. comply with the accommoda- tion) to facilitate a third party’s provision of the objectionable coverage. Because failure to take either of these equally objectionable routes would result in the imposition of large financial penalties, the district court found that the plaintiffs demonstrated that the ACA imposes a substantial burden on their free exercise rights in contravention of the RFRA. The court then assumed that the government possessed a compel- ling interest in providing seamless contraceptive services to women in group health plans, but found that the accommoda- Nos. 14-1430 & 14-1431 11 tion was not the least restrictive means of accomplishing that goal. The court therefore enjoined the defendants from enforcing against the plaintiffs the requirements “to provide, pay for, or otherwise facilitate access to coverage for FDA approved contraceptive methods, abortion-inducing drugs, sterilization procedures, and related patient education and counseling.” Grace Schools, 988 F. Supp. 2d at 958; Diocese of Fort-Wayne-South Bend, 988 F. Supp. 2d at 980. The government appeals. II. Several months after the district court entered the injunc- tions for the plaintiffs here, we issued our opinion in Notre Dame I, where we affirmed the denial of a motion for a prelimi- nary injunction under strikingly similar circumstances to those presented by these appeals. The government asserts that our decision in Notre Dame I controls the result here and requires that we reverse the preliminary injunctions granted by the district court. The plaintiffs argue that Notre Dame I is distin- guishable and that application of the substantial burden test from Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751 (2014), and Korte requires that we affirm the preliminary injunctions here. After this appeal was fully briefed and argued, the Supreme Court vacated and remanded our opinion in Notre Dame I “for further consideration in light of Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751 (2014).” University of Notre Dame v. Burwell, 135 S. Ct. 1528 (2015). We recently issued a new opinion addressing the effect of Hobby Lobby on Notre Dame’s appeal. See Notre Dame II, 786 F.3d at 615–19. We will begin our analysis with our original Notre Dame I opinion, which continues to apply to some of the questions raised here, 12 Nos. 14-1430 & 14-1431 before we turn to Notre Dame II. “We review the district court's findings of fact for clear error, its balancing of the factors for a preliminary injunction under the abuse of discretion standard, and its legal conclusions de novo.” United Air Lines, Inc. v. Air Line Pilots Ass’n, Int’l, 563 F.3d 257, 269 (7th Cir. 2009). To obtain a preliminary injunction, a party must establish that it is likely to succeed on the merits, that it is likely to suffer irreparable harm in the absence of preliminary relief, that the balance of equities tips in its favor, and that issuing an injunc- tion is in the public interest. Smith v. Executive Dir. of Ind. War Mem’ls Comm’n, 742 F.3d 282, 286 (7th Cir. 2014). A. In Notre Dame I, a non-profit Catholic university moved to enjoin the enforcement of the ACA’s contraception provisions against it. 743 F.3d at 551. Notre Dame provides health benefits to its employees and students. The university self-insures the employees and utilizes a third-party administrator to manage the plan. It contracts directly with an insurance provider for the student health plan. 743 F.3d at 549. The ACA requires the university, as an eligible organization, either to provide contraceptive coverage for its employees or to comply with the accommodation by opting out through the use of the EBSA Form 700 certification (“Form 700"), which we described above. 743 F.3d at 550. The relevant regulations required Notre Dame to provide the completed Form 700 to its third-party adminis- trator and to the insurer of the student plan. Notre Dame filed suit shortly before the deadline for complying with the accommodation and moved for a preliminary injunction. The district court denied the motion and Notre Dame appealed, with fewer than two weeks left to meet the deadline for Nos. 14-1430 & 14-1431 13 compliance. We denied the university’s motion for an injunc- tion pending the appeal but ordered expedited briefing. On the last day to comply with the regulations, Notre Dame signed the Form 700 and supplied it to its insurer and third-party administrator. 743 F.3d at 551. The appeal proceeded. We noted that Notre Dame’s primary objection was to the regulations surrounding the Form 700 certification. One regulation provides that: the copy of the self-certification [EBSA Form 700] provided by the eligible [to opt out] organization [Notre Dame] to a third party administrator [Meritain] (including notice of the eligible organiza- tion's refusal to administer or fund contraceptive benefits) … shall be an instrument under which the plan is operated, [and] shall be treated as a designa- tion of the third party administrator as the plan administrator under section 3(16) of ERISA for any contraceptive services required to be covered under § 2590.715–2713(a)(1)(iv) of this chapter to which the eligible organization objects on religious grounds. Notre Dame I, 743 F.3d at 552–53 (quoting 29 C.F.R. § 2510.3-16). Notre Dame interpreted that regulation as if its mailing of the Form 700 to its insurer and its third-party administrator were the cause of the provision of contraceptive services to its employees and students, in violation of its religious beliefs. We noted that was not the case. Instead, the Form 700 allows the university to opt out of the provision of objectionable services entirely and the law then places the burden of providing the 14 Nos. 14-1430 & 14-1431 services on the insurer and the third-party administrator. 743 F.3d at 553. In assessing the likelihood of Notre Dame’s success on the merits, we considered and rejected the school’s claim that filling out and mailing the Form 700 is a “substantial burden” on the university’s exercise of religion. 743 F.3d at 554. Notre Dame complained that completing the form and distributing it to the insurer and third-party administrator triggered contraceptive coverage for employees and students, making the university complicit in the provision of objectionable services and burdening the university’s religious exercise. We found that the Form 700 self-certification does not trigger, cause or otherwise enable the provision of contraceptive services: Federal law, not the religious organization's signing and mailing the form, requires health-care insurers, along with third-party administrators of self-insured health plans, to cover contraceptive services. By refusing to fill out the form Notre Dame would subject itself to penalties, but Aetna [the insurer] and Meritain [the third-party administrator] would still be required by federal law to provide the services to the university’s students and employees unless and until their contractual relation with Notre Dame terminated. Notre Dame I, 743 F.3d at 554. We also rejected Notre Dame’s argument that its insurer and third-party administrator would not have been authorized as plan fiduciaries to provide the contraceptive services until the school executed Form 700. Nos. 14-1430 & 14-1431 15 743 F.3d at 554–55. The law and the regulations (and not the Form 700) designate the insurer and third-party administrator as plan fiduciaries who are then obligated by federal law to provide the contraceptive services. 743 F.3d at 555. We also concluded that the contraception regulations do not impose a substantial burden simply because the university must contract with a third party willing to provide (at the behest of the government) the services that Notre Dame finds objectionable. Because that third party did not object to providing the services, we called any such claim speculative and not a ground for equitable relief. We emphasized, in the end, that it was not the Form 700 or anything that Notre Dame was required to do by the regulatory accommodation that caused the university’s employees and students to receive the objec- tionable coverage; rather it was federal law that authorized, indeed required, insurers and third-party administrators to provide coverage. 743 F.3d at 559. Because the true objection was not to actions that the school itself was required to take but rather to the government’s independent actions in mandat- ing contraceptive coverage, we concluded that there was no substantial burden on the university’s religious exercise. 743 F.3d at 559. B. As litigation on the ACA’s contraception requirements has progressed in other cases and other circuits, new regulations have been issued in response to interim orders from the Supreme Court. In Little Sisters of the Poor Home for the Aged, Denver, Colo. v. Sebelius, 134 S. Ct. 1022 (2014), after a district court declined to enjoin the operation of the ACA against a religious organization that did not wish to file the Form 700, 16 Nos. 14-1430 & 14-1431 the Court entered an injunction pending the appeal of that decision: If the employer applicants inform the Secretary of Health and Human Services in writing that they are non-profit organizations that hold themselves out as religious and have religious objections to providing coverage for contraceptive services, the respondents are enjoined from enforcing against the applicants the challenged provisions of the Patient Protection and Affordable Care Act and related regulations pending final disposition of the appeal by the United States Court of Appeals for the Tenth Circuit. To meet the condition for injunction pending appeal, applicants need not use the form prescribed by the Government and need not send copies to third-party administrators. The Court issues this order based on all the circumstances of the case, and this order should not be construed as an expression of the Court's views on the merits. Little Sisters, 134 S. Ct. at 1022. The order, in short, relieved the Little Sisters of their obligation to file the Form 700 so long as they directly notified the government of their objection. Subsequently, the Court entered a similar injunction in a case within our circuit. See Wheaton College v. Burwell, 134 S. Ct. 2806 (2014). After essentially repeating the language from the very short order in Little Sisters, the Court clarified: Nothing in this interim order affects the ability of the applicant's employees and students to obtain, without cost, the full range of FDA approved contra- Nos. 14-1430 & 14-1431 17 ceptives. The Government contends that the appli- cant's health insurance issuer and third-party ad- ministrator are required by federal law to provide full contraceptive coverage regardless whether the applicant completes EBSA Form 700. The applicant contends, by contrast, that the obligations of its health insurance issuer and third-party administra- tor are dependent on their receipt of notice that the applicant objects to the contraceptive coverage requirement. But the applicant has already notified the Government—without using EBSA Form 700—that it meets the requirements for exemption from the contraceptive coverage requirement on religious grounds. Nothing in this order precludes the Government from relying on this notice, to the extent it considers it necessary, to facilitate the provision of full contraceptive coverage under the Act. Wheaton College, 134 S. Ct. at 2807. As with Little Sisters, the order relieved Wheaton College of its obligation to file Form 700 as long as it notified the government directly of its objec- tion. But the government was permitted to use this direct notice to facilitate the coverage required by the ACA. And finally, after the Third Circuit reversed a temporary injunction sought by a religious employer and granted by a district court, the Court again intervened: The application for an order recalling and staying the issuance of the mandate of the Court of Appeals pending the filing and disposition of a petition for a 18 Nos. 14-1430 & 14-1431 writ of certiorari, having been submitted to Justice Alito and by him referred to the Court, the applica- tion as presented is denied. The Court furthermore orders: If the applicants ensure that the Secretary of Health and Human Services is in possession of all information necessary to verify applicants’ eligibility under 26 CFR § 54.9815-2713A(a) or 29 CFR § 2590.715-2713A(a) or 45 CFR § 147.131(b) (as appli- cable), the respondents are enjoined from enforcing against the applicants the challenged provisions of the Patient Protection and Affordable Care Act and related regulations pending final disposition of their petition for certiorari. Nothing in this interim order affects the ability of the applicants’ or their organiza- tions’ employees to obtain, without cost, the full range of FDA approved contraceptives. Nor does this order preclude the Government from relying on the information provided by the applicants, to the extent it considers it necessary, to facilitate the provision of full contraceptive coverage under the Act. See Wheaton College v. Burwell, 573 U. S. ___ (2014). This order should not be construed as an expression of the Court’s views on the merits. Ibid. Justice Sotomayor would deny the application. Zubik v. Burwell, 2015 WL 3947586 (June 29, 2015) (full text found at http://www.supremecourt.gov/search.aspx? filename=/docketfiles/14a1065.htm, last visited September 3, 2015). As a result of these interim orders from the Supreme Court, the regulations have been amended so that objectors may now notify HHS directly rather than filing the Form 700. Nos. 14-1430 & 14-1431 19 And the government may, in turn, facilitate the required contraceptive coverage based on such notice. C. We turn to our recent decisions in Notre Dame II and Wheaton College v. Burwell, 791 F.3d 792 (7th Cir. 2015). In Notre Dame II, we noted that, shortly after filing its suit and immedi- ately before the regulatory deadline, the university signed the Form 700 and sent it to the insurer of its students and the third- party administrator of its employee plan. That action left us wondering what relief Notre Dame sought. Ultimately, we determined, Notre Dame wanted us to enjoin the government from forbidding Notre Dame to bar Aetna and Meritain from providing contraceptive coverage to any of the university's students or employees. Because of its contractual relations with the two companies, which continue to provide health insurance coverage and administra- tion for medical services apart from contraception as a method of preventing pregnancy, Notre Dame claims to be complicit in the sin of contraception. It wants to dissolve that complicity by forbidding Aetna and Meritain—with both of which, to repeat, it continues to have contractual relations—to pro- vide any contraceptive coverage to Notre Dame students or staff. The result would be that the students and staff currently lacking coverage other than from Aetna or Meritain would have to fend for themselves, seeking contraceptive coverage else- where in the health insurance market. 20 Nos. 14-1430 & 14-1431 Notre Dame II, 786 F.3d at 611. The university’s primary objection to the ACA was that its contractual relationship with its insurer and third-party administrator made the school a conduit for the provision of objectionable services. According to Notre Dame, the contraception regulations imposed a substantial burden on it by forcing the university to identify and contract with a third party willing to provide objectionable contraceptive services. 786 F.3d at 611–12. We noted that, although Notre Dame is the final arbiter of its religious beliefs, only the courts may determine whether the law actually forces the university to act in a way that would violate those beliefs. 786 F.3d at 612. The record contained no evidence to support a conduit theory. Nor is it within our usual practice to enjoin non-parties such as Notre Dame’s insurer and third-party administrator. We also rejected Notre Dame’s claim that the regulation requiring employers to provide Form 700 to its insurers was the cause of the provision of contracep- tive services; rather the services are provided because federal law requires the insurers to provide them. Notre Dame II, 786 F.3d at 613–14 (“It is federal law, rather than the religious organization's signing and mailing the form, that requires health-care insurers, along with third-party administrators of self-insured health plans, to cover contraceptive services.”). Because the insurer must provide the services no matter what the employer does, we noted that “signing the form simply shifts the financial burden from the university to the govern- ment, as desired by the university.” 786 F.3d at 615. See supra note 5. We thus re-asserted the core reasoning of our earlier opinion before turning to any effect that Hobby Lobby had on the case. Nos. 14-1430 & 14-1431 21 Hobby Lobby, we noted, involved closely-held for-profit corporations whose owners objected on religious grounds to the contraceptive mandate. The Supreme Court held that the RFRA applied to nonreligious institutions owned by persons with sincerely held religious objections to the ACA’s contra- ception regulations. Hobby Lobby, 134 S. Ct. at 2776–78; Notre Dame II, 786 F.3d at 615. The Court noted that the companies’ objections could be addressed by allowing them to invoke the same accommodation that the government created for religious non-profit employers, namely signing and filing the Form 700. 134 S. Ct. at 2782. The Court left open the issue of whether the accommodation that was adequate for nonreligious, for-profit corporations would be sufficient to protect the rights of religious non-profit employers. As to that issue, we examined various alternative schemes that Notre Dame proposed as possible accommodations and found each of them lacking. We also noted that the Supreme Court had created an alternative to Form 700 by allowing employers to notify the government directly of its objection to the mandate. Notre Dame II, 786 F.3d at 617–18; Wheaton College, 134 S. Ct. at 2806. We rejected Notre Dame’s objections to the Wheaton College alternative notice, citing Bowen v. Roy, 476 U.S. 693 (1986). We noted that the Roy Court rejected Roy's religious objection to the government's use of his daughter's Social Security number for its purposes. The Court held “Roy may no more prevail on his religious objection to the Government's use of a Social Security number for his daughter than he could on a sincere religious objection to the size or color of the Government's filing cabinets.” Roy, 476 U.S. at 700. Notre Dame's objection to the government designating insurers as substitutes to provide contraceptive 22 Nos. 14-1430 & 14-1431 coverage was an analogous challenge to the government's management of its affairs and, accordingly, Notre Dame had not demonstrated a substantial burden to its religious exercise. Notre Dame II, 786 F.3d at 618. In Wheaton College, we similarly rejected a religious school’s objections to the contraception regulations under the RFRA, the First Amendment and the Administrative Procedures Act. 791 F.3d at 801. The college asserted that the government was using the school’s insurance plan and putting additional terms into its contracts with insurers in order to provide the objec- tionable coverage. The college sought an injunction prohibiting the government’s effort to use Wheaton’s plans as the vehicle for making contraceptive coverage available to its employees and students. It objected to notifying its insurers or the government that it claimed a religious exemption, and also to providing the government with the names of its insurers so that the government could then implement the coverage separate from the college. We noted that the ACA and accom- panying regulations do not alter any employer’s insurance plans or contracts. 791 F.3d at 794. Nor is the college being forced to allow the use of its plan to provide objectionable services. The ACA and regulations require only that the college notify either its insurers or the government that it objects, which takes the school out of the loop. 791 F.3d at 795. As in Notre Dame II, we rejected the claim that the provision of notice to insurers or the government somehow triggers or facilitates the provision of objectionable coverage. 791 F.3d at 796. As was the case with Notre Dame, Wheaton also objected to being forced to contract with insurers which, in turn, provided objectionable services, contending that this made the college Nos. 14-1430 & 14-1431 23 complicit in the provision of those services. We saw no complicity in the operation of the law, which makes every effort to separate religious employers from the provision of any objectionable services. We again noted that courts generally do not enjoin non- parties, and Wheaton had not made its insurers parties to the suit. Wheaton also expressed a reluctance to identify its insurers to the government, instead preferring that the govern- ment discover through its own research the names of the insurers. But Wheaton made no connection between the means for identifying the insurers and its religious commitments. We also noted Wheaton’s assertion that its students and employees sign a covenant agreeing to abide by the school’s moral standards, indicating perhaps that Wheaton’s concerns about the ACA are largely academic because the employees and students are unlikely to actually use the services offered. Finally, we rejected Wheaton’s claims under the First Amend- ment, ERISA and the Administrative Procedures Act, all issues which were not argued in the instant appeal, and so we will not address them further. 791 F.3d at 797–800. Before we move on to the plaintiffs’ objections in this case, we note that the case law analyzing the contraceptive mandate is rapidly evolving. Recently, the six other circuits to consider these same issues have all come to the same conclusion as our opinions in Notre Dame and Wheaton College, namely, that the contraceptive mandate, as modified by the accommodation, does not impose a substantial burden on religious organiza- tions under the RFRA. See Catholic Health Care System v. Burwell, — F.3d —, 2015 WL 4665049, *7-*16 (2d Cir. Aug. 7, 2015) (concluding that the accommodation does not impose a 24 Nos. 14-1430 & 14-1431 substantial burden); Little Sisters of the Poor Home for the Aged v. Burwell, 794 F.3d 1151 , 2015 WL 4232096, *16 (10th Cir. 2015), petition for cert. filed, 84 USLW 3056 (U.S. July 24, 2015) (No. 15- 105) (concluding that the mandate does not impose a substan- tial burden on religious exercise under RFRA and affirming the denial of a preliminary injunction in one instance and revers- ing the grant of preliminary injunctions in two others); East Texas Baptist University v. Burwell, 793 F.3d 449, 459 (5th Cir. 2015), petition for cert. filed, 84 USLW 3050 (U.S. July 8, 2015) (No. 15-35) (holding that the ACA does not impose a substan- tial burden under the RFRA and reversing the grant of a preliminary injunction); Geneva College v. Secretary United States Department of Health & Human Servs., 778 F.3d 422, 442 (3d Cir. 2015), petition for cert. filed, 83 USLW 3894 (U.S. May 29, 2015) (Nos. 14-1418 & 14A1065), and stay denied by Zubik v. Burwell, 135 S.Ct. 2924, 2015 WL 3947586 (June 29, 2015) (reversing grant of preliminary injunction and concluding that the accommodation procedures do not impose a substantial burden on religious exercise); Priests for Life v. United States Dep’t of Health & Human Servs., 772 F.3d 229, 256 (D.C. Cir. 2014), petition for cert. filed, 83 USLW 3918 (U.S. June 9, 2015) (No. 14-1453) (affirming denial of injunctive relief and conclud- ing that the ACA’s mandate does not impose a substantial burden on religious exercise); Michigan Catholic Conference v. Burwell, 755 F.3d 372, 390 (6th Cir. 2014), cert. granted, judgment vacated and remanded, 135 S. Ct. 1914 (2015), reissued, — F.3d — 2015 WL 4979692 (6th Cir. Aug. 21, 2015) (because objectors may obtain the accommodation from the contraceptive-coverage requirement without providing, paying for, and/or facilitating access to contraception, the contracep- Nos. 14-1430 & 14-1431 25 tive-coverage requirement does not impose a substantial burden on their exercise of religion).10 No court of appeals has concluded that the contraceptive mandate imposes a substan- tial burden under the RFRA. D. After this court issued its opinion in Notre Dame II, we asked the parties to file position statements addressing the effect of that opinion on this appeal. We turn now to the parties’ position statements as well as the arguments raised in their original briefs. The government, in its original brief, contended that Notre Dame I was controlling. It argued that the plaintiffs are permitted to opt out of providing contraceptive coverage, and that the plaintiffs improperly object to require- ments imposed by the accommodation on third parties rather than on themselves. The government also asserted that it is the province of the court rather than the plaintiffs to determine whether a particular regulation or law “substantially” burdens the plaintiffs’ free exercise of religion under the RFRA. Finally, the government maintained that, even if we were to determine that the regulations impose a substantial burden on the plaintiffs under the RFRA, the government’s interest in 10 The Sixth Circuit released its opinion a few weeks prior to the issuance of Hobby Lobby, but denied rehearing en banc several months later. The Supreme Court subsequently granted the petition for certiorari, vacated the opinion and remanded for further consideration in light of Hobby Lobby. The Sixth Circuit recently reissued and reaffirmed its earlier opinion and filed a supplemental opinion addressing Hobby Lobby. The Sixth Circuit continues to hold that the ACA’s contraception provisions do not impose a substantial burden under RFRA. Michigan Catholic, 2015 WL 4979692, *6- *15. 26 Nos. 14-1430 & 14-1431 providing the coverage is compelling and the regulations are narrowly tailored to meet that interest. In its position statement, the government adds that Notre Dame II rejected all of the arguments raised by the plaintiffs here. Specifically, the government again notes that the regula- tions allow the plaintiffs to opt out of providing the mandated contraceptive services, making them effectively exempt. After objectors opt out, the government tasks third parties with providing the coverage. Moreover, the opt-out does not operate as a trigger or cause for the coverage; rather federal law imposes on third parties the obligation to provide the coverage. Nothing in the ACA or regulations makes the plaintiffs complicit or allows their contracts with insurers or third party administrators to act as conduits for the provision of contraceptive services. The government repeats that, even if the regulations impose a substantial burden on the plaintiffs’ free exercise of religion under the RFRA, the regulations serve a compelling government interest and are the least restrictive means of achieving those interests. According to the govern- ment, our opinion in Notre Dame II demonstrates that the current regulations are narrowly tailored to achieve the compelling interest, and that none of the plaintiffs’ suggested alternatives would be effective. In their opening brief, the plaintiffs argued, as they did below, that the contraception regulations impose a substantial burden on their exercise of religion. The plaintiffs asserted that they exercise their religion “by refusing to take actions in furtherance of a regulatory scheme to provide their employees with access to abortion-inducing products, contraceptives, sterilization, and related education and counseling.” Brief at Nos. 14-1430 & 14-1431 27 29. The plaintiffs maintained that submitting Form 700 renders them complicit in a grave moral wrong because the form has certain legal effects that facilitate the provision of the objection- able services. The accommodation, the plaintiffs added, requires them to amend the documents governing their health plans to provide the very coverage to which they object. The plaintiffs also objected to contracting with and paying premi- ums to insurance companies or third party administrators that are authorized to provide their employees with contraceptive coverage. Moreover, the plaintiffs pointed out that if they fail to comply with the regulations, they will face onerous fines. The plaintiffs asserted that Notre Dame I is distinguishable on the facts, and that Notre Dame I did not address the arguments of the Catholic appellees here that (1) the Diocese is being forced to forgo $200,000 annually in increased premiums in order to maintain its grandfathered status11 to avoid its plan becoming a conduit for objectionable coverage for the employ- ees of Catholic Charities that are enrolled in the Diocese’s health plan; and (2) the mandate has the additional effect of artificially dividing the Catholic Church into a “worship arm” and a “good works arm.” The plaintiffs also maintained in their opening brief that the government’s “substantial burden” analysis incorrectly focuses on the nature of the actions that the regulations require the 11 “Grandfathered plans” are plans that were in existence when the ACA was adopted and that have not made certain changes to the terms of the plans. Grandfathered plans need not comply with the ACA’s coverage requirements. See 42 U.S.C. § 18011; 26 C.F.R. § 54.9815-1251T. Certain increases in premiums could cause a plan to lose its grandfathered status and thus become subject to the ACA’s coverage requirements. 28 Nos. 14-1430 & 14-1431 plaintiffs to take rather than the pressure the government has placed on the plaintiffs to take those actions. They contended that the focus of the analysis should be on the intensity of the coercion applied by the government to act contrary to their religious beliefs. Finally, they asserted that they object to actions they themselves must take under the regulations, not to the actions of third parties. In their position statement, the plaintiffs contend that Notre Dame II is distinguishable on the facts, that it is not binding here, and that it is based on legal errors. Finally, the plaintiffs argue that the strict scrutiny analysis in Notre Dame II is both foreclosed by the government’s concession in this case and inconsistent with circuit precedent. E. We turn to the specific objections raised by the plaintiffs here. They contend that the accommodation does not operate as a true “opt-out” because it requires them to engage in numerous religiously objectionable actions. The actions to which the plaintiffs object fall under two categories: first, the mandate requires them to contract with insurance companies or third-party administrators that are authorized to provide the objectionable coverage and which will provide that coverage once the plaintiffs communicate their objections. Second, they must submit the Form 700 or notify the government directly of their objection. They sincerely believe that the required actions render them complicit in a grave moral wrong because their insurance contracts serve as conduits for the provision of the objectionable services, and the notification triggers or facilitates the provision of objectionable services. They practice their Nos. 14-1430 & 14-1431 29 religion, they assert, by refusing to take actions “in furtherance of” a scheme to provide the objectionable services. And if they decline to engage in these actions, the mandate subjects them to onerous fines. The core of the disagreement between the plaintiffs and the government lies in how we apply the substantial burden test. The plaintiffs cite our decision in Korte for the proposition that the substantial burden test under the RFRA focuses primarily on the intensity of the coercion applied by the government to act contrary to religious beliefs. Korte, 735 F.3d at 683. Citing Hobby Lobby, they also assert that the RFRA allows private religious believers to decide for themselves whether taking a particular action (such as filing the Form 700 or contracting with an insurance company) is connected to objectionable conduct in a way that is sufficient to make it immoral. Hobby Lobby, 134 S. Ct. at 2778. In Korte, we noted that “exercise of religion” means “any exercise of religion, whether or not compelled by, or central to, a system of religious belief.” 735 F.3d at 682; 42 U.S.C. § 2000cc–5(7)(A). A substantial burden on free exercise may arise when the government compels a religious person to perform acts undeniably at odds with fundamental tenets of that person’s religious beliefs, and also when the government places substantial pressure on a person to modify his or her behavior in a way that violates religious beliefs. Korte, 735 F.3d at 682. “Put another way, the substantial-burden inquiry evaluates the coercive effect of the governmental pressure on the adherent's religious practice and steers well clear of deciding religious questions.” Korte, 735 F.3d at 683. Relying on Korte and Hobby Lobby, the plaintiffs urge us to engage in a 30 Nos. 14-1430 & 14-1431 two-step analysis of first identifying the religious belief at issue, and second, determining whether the government has placed substantial pressure on the plaintiffs to violate that belief. The plaintiffs are correct that it is not our province to decide religious questions. Hobby Lobby, 134 S. Ct. at 2778 (the RFRA presents the question of whether the mandate imposes a substantial burden on the ability of the objecting parties to conduct business in accordance with their religious beliefs, but courts have no business addressing whether the religious belief asserted is reasonable); Notre Dame II, 786 F.3d at 612 (an objector is the final arbiter of its religious beliefs); Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096, at *19 (substantial- ity does not permit a court to scrutinize the theological merit of a plaintiff's religious beliefs); Geneva College, 778 F.3d at 436 (courts should defer to the reasonableness of a plaintiff’s religious beliefs). The plaintiffs in Hobby Lobby were closely- held, for-profit corporations that were required by the ACA to provide and pay for health insurance which included coverage of certain emergency contraceptives that they believed oper- ated as abortifacients. Similar to the plaintiffs here, they believed that providing the required coverage is connected to the destruction of an embryo in a way that is sufficient to make it immoral for them to provide the coverage. “This belief implicates a difficult and important question of religion and moral philosophy, namely, 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 commis- sion of an immoral act by another.” Hobby Lobby, 134 S. Ct at 2778. Nos. 14-1430 & 14-1431 31 So we defer to the plaintiffs’ sincerely held beliefs regard- ing questions of religion and moral philosophy. But whether the government has imposed a substantial burden on their religious exercise is a legal determination. Notre Dame II, 786 F.3d at 612; Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096, at *18; East Texas Baptist University, 793 F.3d at 456–59 & n.33; Geneva College, 778 F.3d at 436; Priests for Life, 772 F.3d at 247–49; Michigan Catholic, 755 F.3d at 385. And we are not required to defer to the plaintiffs’ beliefs about the operation of the law. Notre Dame II, 786 F.3d at 612 (although an objector is the final arbiter of its religious beliefs, it is for the courts to determine whether the law actually forces the objector to act in a way that would violate those beliefs); Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096, at *18 (courts need not accept the legal conclusion, cast as a factual allegation, that a plain- tiff’s religious exercise is substantially burdened); Geneva College, 778 F.3d at 436 (courts need not accept an objector’s characterization of a regulatory scheme on its face but may consider the nature of the action required of the objector, the connection between that action and the objector’s beliefs, and the extent to which that action interferes with or otherwise affects the objector’s exercise of religion, all without delving into the objector’s beliefs); Michigan Catholic, 755 F.3d at 385 (although a court may acknowledge that the objectors believe that the regulatory framework makes them complicit in the provision of contraception, the court will independently determine what the regulatory provisions require and whether they impose a substantial burden on the objector's exercise of religion). In this instance, and as was the case in Notre Dame I and II, the plaintiffs misapprehend the operation of federal 32 Nos. 14-1430 & 14-1431 law. As many courts have noted, contraceptive coverage under the ACA results from federal law, not from any actions required by objectors under the accommodations. Notre Dame II, 786 F.3d at 614; and 786 F.3d at 623 (Hamilton, J., concur- ring); Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096, at *16; East Texas Baptist, 793 F.3d at 459; Geneva College, 778 F.3d at 437; Michigan Catholic, 755 F.3d at 387. The first action to which the plaintiffs object is filing the Form 700. They assert that the Form 700 is far more than a simple notification or objection, that it instead (1) designates the third party administrator as plan administrator and claims administrator for contraceptive benefits; (2) serves as an instrument under which the plans are operated vis-à-vis contraceptive services; and (3) apprises the third party admin- istrator of its obligations to provide contraceptive coverage. We rejected this very argument in Notre Dame II, holding that treating the mailing of the Form 700 as the cause of the provision of contraceptive services is legally incorrect. 786 F.3d at 613. The Form 700, we noted, has the effect of throwing the entire administrative and financial burden of providing contraception on the insurer and the third party administrator. 786 F.3d at 613–14. As a result, the burden is lifted from the objector’s shoulders. 786 F.3d at 614. “It is federal law, rather than the religious organization's signing and mailing the form, that requires health-care insurers, along with third-party administrators of self-insured health plans, to cover contracep- tive services.” 786 F.3d at 614. See also Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096 at *16 & *22-24 (finding that plaintiffs do not “trigger” or otherwise cause contraceptive coverage because federal law, not the act of opting out, entitles Nos. 14-1430 & 14-1431 33 plan participants and beneficiaries to coverage); Geneva College, 778 F.3d at 437–38 (same); Michigan Catholic, 755 F.3d at 387 (same). Moreover, the regulations have been amended during this litigation, and now employers need not file the Form 700. Instead, consistent with the Supreme Court’s interim orders in Little Sisters of the Poor and Wheaton College, the plaintiffs may contact the Department of Health and Human Services directly, alerting the government that they have a religious objection to providing contraceptive coverage, and providing only the name and contact information for their insurers or third party administrators. 80 Fed. Reg. 41342-47 (July 14, 2015). The burden then falls on the government to make appropriate arrangements with the insurer or third-party administrator to provide coverage for contraceptive services. The plaintiffs object to that action as well, asserting that it also makes them complicit in the provision of coverage. But that notification does nothing more than completely remove an objector from the provision of the objectionable services. See Geneva College, 778 F.3d at 436 (“While the Supreme Court reinforced in Hobby Lobby that we should defer to the reason- ableness of the appellees' religious beliefs, this does not bar our objective evaluation of the nature of the claimed burden and the substantiality of that burden on the appellees' religious exercise.”). As we noted in our Notre Dame opinions, the plaintiffs are in the strange position of objecting not to the contraceptive mandate itself but to the accommodation that relieves them of any involvement in the implementation of the contraceptive mandate. Notre Dame I, 743 F.3d at 557–58; Notre Dame II, 786 F.3d at 621 (Hamilton, J., concurring). See also Little 34 Nos. 14-1430 & 14-1431 Sisters of the Poor Home for the Aged v. Burwell, 794 F.3d —, 2015 WL 4232096, *14-15 (10th Cir. 2015) (noting the unusual nature of a claim that attacks the government's attempt to accommo- date religious exercise by providing a means to opt out of compliance with a generally applicable law). [T]he arrangements the government makes to find substitutes for those given the benefit of a religious exemption are imposed as a matter of federal law, not as a result of the exemption itself. The party claiming the exemption is not entitled to raise a religious objection to the arrangements the govern- ment makes for a substitute. Notre Dame II, 786 F.3d at 623 (Hamilton, J., concurring). In short, requiring an employer to notify the government of its objection to the mandate is no more burdensome than the government’s use of a girl’s Social Security number in a benefits program even though her father sincerely believed that the use of the number would harm his daughter’s spirit. See Notre Dame II, 786 F.3d at 618–19 (discussing Bowen v. Roy, 476 U.S. 693 (1986)). So too with the plaintiffs here. The second action to which the plaintiffs object is contract- ing with insurers and third-party administrators who will then provide the objectionable coverage, albeit at no cost to, and without further involvement of, the plaintiffs. The plaintiffs admittedly want to provide their employees and students with health insurance; indeed they have said that it is part of their religious mission to do so. But they wish to provide health insurance without the objectionable coverage. Yet this is exactly what the accommodation allows them to do. Notre Nos. 14-1430 & 14-1431 35 Dame II, 786 F.3d at 621–22 (Hamilton, J., concurring) (once an employer files the Form 700 or notifies the government directly of its religious objection, it can avoid contracting, paying, arranging, or referring for the objectionable contraceptive care); Wheaton College, 791 F.3d at 795–96 (once the college notifies its insurer or the government of its religious objections, the college and its health plans are bypassed). As with the notification requirement, the plaintiffs believe that their contracts further the provision of objectionable services. They assert that the government is using their health plans or altering the terms of their health plans to provide contraceptive coverage. But once they have objected, the government does not use the health plans or contracts at all, much less alter any terms. See Wheaton College, 791 F.3d at 796 (“Call this ‘using’ the health plans? We call it refusing to use the health plans.”). As we noted in Wheaton College: The upshot is that the college contracts with health insurers for contraceptive coverage exclusive of coverage for emergency contraceptives, and the Department of Health and Human Services con- t r a c t s w i t h t h o s e in s u r e r s t o c o ve r emergency-contraceptive benefits. The latter con- tracts are not part of the college's health plans, and so the college is mistaken when it tells us that the government is “interfering” with the college’s contracts with its insurers. The contracts, which do not require coverage of emergency contraception, are unchanged. New contracts are created, to which the college is not a party, between the government and the insurers. 36 Nos. 14-1430 & 14-1431 Wheaton College, 791 F.3d at 796. We rejected any notion of complicity in the provision of contraceptive services arising from the mere existence of a contract to provide health insur- ance without any contraceptive coverage. 791 F.3d at 797. See also Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096 at *16 (the de minimis administrative tasks required to opt out of the mandate relieves objectors from complicity); East Texas Baptist, 793 F.3d at 461 (“Under the accommodation, the contracts are solely for services to which the plaintiffs do not object; the contracts do not provide for the insurers and third-party administrators to cover contraceptives, do not make it easier for those entities to pay for contraceptives, and do not imply endorsement of contraceptives.”). To the extent that the act of opting out causes the legal responsibility to provide contraceptive coverage to shift from the plaintiffs to their insurers or third-party administrators, this feature relieves rather than burdens their religious exercise. Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096 at *16. As our colleagues in the Tenth Circuit noted, “An opt out religious accommodation typically contemplates that a non-objector will replace the religious objector and take over any legal responsibilities.” Little Sisters of the Poor, 794 F.3d at —, 2015 WL 4232096, *16 n.21; East Texas Baptist, 793 F.3d at 461–62 (RFRA does not entitle plaintiffs to block third parties such as the government or insurers from engaging in conduct with which the plaintiffs disagree); Geneva College, 778 F.3d at 438 n.13 (the provision of contraceptive coverage is not dependent upon the objector’s contract with its insurance company); Michigan Catholic, 755 F.3d at 388 (the government's imposition of an independent obligation on a third party does Nos. 14-1430 & 14-1431 37 not impose a substantial burden on an objector’s exercise of religion). Finally, the Catholic plaintiffs here (namely, the Diocese, Catholic Charities, St. Anne Home, Franciscan Alliance, Specialty Physicians, St. Francis and Sunday Visitor) assert what they characterize as unique RFRA claims that were not presented in the Notre Dame appeal and therefore are not resolved by the Notre Dame opinions. In particular, they argue that the mandate substantially burdens the Diocese’s religious exercise by forcing it to forgo almost $200,000 annually in increased premiums to maintain its grandfathered status so that it may avoid its health plan becoming a conduit for objectionable coverage for Catholic Charities’ employees who are enrolled in its health plan. See note 11 supra. But if the Diocese were to lose its grandfathered status, it would become exempt from the ACA’s contraceptive mandate, and Catholic Charities would be able to opt out of the mandate by employ- ing the accommodation. As we just concluded, that scenario would not impose a substantial burden on the free exercise rights of either the Diocese or Catholic Charities. The Catholic plaintiffs also contend that the mandate has the effect of artificially dividing the Catholic Church into a “worship” arm (the Diocese) and a “good works” arm (the remaining Catholic plaintiffs). Again, though, groups affiliated with the Diocese may opt out of providing contraceptive coverage using the accommodation and thus continue to provide health coverage under the Diocese’s health plan. Both arms of the Church are therefore extricated from the provision of objectionable contraceptive services, albeit through different means. Moreover, any division is created not by the ACA but 38 Nos. 14-1430 & 14-1431 by the Internal Revenue Code that excepts “churches, their integrated auxiliaries, and conventions or associations of churches” from certain requirements. See 26 U.S.C. § 6033(a)(3)(A)(i). It is difficult to see how laws and regulations that grant tax advantages to churches and their integrated auxiliaries somehow impose a substantial burden on affiliates. III. The accommodation does not serve as a trigger or a conduit for the provision of contraceptive services. Notre Dame II, 786 F.3d at 612–15; Wheaton College, 791 F.3d at 795–97. It is the operation of federal law, not any actions that the plaintiffs must take, that causes the provisions of services that the plaintiffs find morally objectionable. The accommodation has the legal effect of removing from objectors any connection to the provision of contraceptive services. As we noted above, every other circuit court to consider the issue of whether the mandate imposes a substantial burden on religious exercise has come to the same conclusion. As a result, the plaintiffs are not entitled to a preliminary injunction against the enforcement of the ACA regulations. If they wish to object, they may either employ the Form 700 or they may notify the Department of Health and Human Services directly. We extend the injunc- tions here for 60 days so that the district court may consider in the first instance the additional arguments that plaintiffs raised in support of injunctive relief. We reverse the district court’s judgments and remand for proceedings consistent with this opinion. REVERSED AND REMANDED. Nos. 14‐1430 & 14‐1431  39  MANION, Circuit Judge, dissenting.  The HHS accommodation is the long and winding exten‐ sion  cord  the  government  uses  to  power  its  contraceptive  mandate.  It  winds  through  regulations  and  additions  and  revisions. The court, through a perfunctory examination, in‐ terprets  the  accommodation’s  twisted  framework  and  holds  that  it  frees  the  religious  nonprofits  from  having  to  power  the  mandate  themselves  and,  thus,  does  not  violate  the  RFRA. The  court  is  wrong: A  thorough examination  reveals  that the accommodation’s tangled mess is hiding the fact that  the extension cord gets its power from the nonprofits’ health  plans and must be plugged in before it will work. It also ex‐ poses the fact that  the government  is forcing the  nonprofits  to  plug  in  the  accommodation  themselves  by  signing  the  self‐certification or providing the alternative notice.  This dissent, as long and detailed as it is, reveals that the  accommodation  never  relieves  the  religious  nonprofits  or  their  health  plans  from  the  provision  of  contraceptive  ser‐ vices  which  burdens  their  religious  exercise.  Section  I  ex‐ plains  how  the  court,  as  many  others  have  before  it,  uses  a  caricature of the HHS accommodation to avoid accepting the  nonprofits’ sincerely held religious belief as required by the  Supreme  Court  in  Burwell  v.  Hobby  Lobby  Stores,  Inc.,  134  S.  Ct. 2751 (2014). Section II shows that the nonprofits correctly  understand the accommodation’s operation, so that the court  must  accept  their  sincerely  held  religious  belief  and  hold  that  the  accommodation  imposes  a  substantial  burden  on  their  religious  exercise.  Section  III  demonstrates  that  the  government  has  utterly  failed  to  prove  that  the  HHS  ac‐ 40  Nos. 14‐1430 & 14‐1431  commodation  furthers  a  compelling  governmental  interest:  The  government  has  failed  to  establish  any  of  the  causal  links  necessary  to  prove  that  increasing  the  availability  of  contraceptive  services  will  improve  the  health  of  women  generally,  let  alone  that  of  the  nonprofits’  employees.  Fur‐ thermore, the government’s stated interest is overbroad, un‐ derinclusive,  and  marginal  at  best.  Section  IV  demonstrates  that,  even  if  the  government  had  a  compelling  interest,  the  accommodation  is  not  the  least  restrictive  means.  For  these  reasons,  Section  V  concludes  that  the  HHS  accommodation  violates  RFRA,  which  means  the  nonprofits  have  a  signifi‐ cant likelihood of success on the merits of their claim and the  district  court’s  preliminary  injunction  should  be  affirmed.  For the many reasons that follow, I dissent.  I.  The court refuses to apply RFRA.  RFRA  prevents  the  government  from  substantially  bur‐ dening a person’s religious exercise unless the burden on the  person is the least restrictive means of furthering a compel‐ ling  governmental  interest.  42  U.S.C.  §  2000bb‐1.  The  Su‐ preme  Court  has  made  it  abundantly  clear  that  courts  are  wholly  incompetent  to  decide  whether  a  governmental  ac‐ tion  burdens  a  person’s  religious  exercise.  Rather,  courts  must accept a person’s sincere belief that it is a burden. Hob‐ by Lobby, 134 S. Ct. at 2778–79. Courts determine whether the  burden is substantial, but they do so by examining the level  of  coercion  applied  to  compel  compliance,  not  what  is  re‐ quired by that compliance and to what extent it violates the  person’s  religion.  Id.  at  2779;  Korte  v.  Sebelius,  735  F.3d  654,  683 (7th Cir. 2013). Thus, the proper analysis is to determine  Nos. 14‐1430 & 14‐1431  41  first, that the nonprofits have a sincere belief that compliance  with  the  law  would  violate  their  religion,  and  second,  that  the  pressure  applied  by  the  government  to  coerce  compli‐ ance with the law is substantial. The outcome of a thorough  and  proper  analysis  is  ultimately  simple  and  straightfor‐ ward: As  in  Hobby  Lobby,  the  government  concedes  the  sin‐ cerely  held  religious  belief  and  the  fines  imposed  for  non‐ compliance are “enormous.” Hobby Lobby, 134 S. Ct. at 2779.  So,  following  Hobby  Lobby,  the  accommodation  imposes  a  substantial  burden.  That  the  government  labels  it  an  ac‐ commodation makes no difference to the burden it imposes  on the nonprofits. The analysis remains the same.  The court does not apply these straightforward steps be‐ cause it balks at the idea that we must accept a person’s as‐ sertion that a law burdens their religion. The court fears that  such a rule will allow a person to escape any number of reg‐ ulations, including this brave new world of free and univer‐ sal contraceptives, unless the government can meet the strict  scrutiny  test  laid  down  by  RFRA.1  This  was  the  same  con‐ cern  that  prompted  the  Supreme  Court’s  decision  to  limit  free exercise protections in Employment Div., Dept. of Human  Resources  of  Ore.  v.  Smith,  494  U.S.  872  (1990).  Hobby  Lobby,  134  S.  Ct.  at  2761–62.  Nevertheless,  when  it  enacted  RFRA,  Congress  meant  to  restore  exactly  the  level  of  protection  to  religious exercise that now so concerns the court. Id. at 2761–                                                   1  What  goes  unsaid  by  this  critique  is  the  conclusion  that  the  non‐ profits’  religious  beliefs  are  less  deserving  of  protection  than  the  gov‐ ernment’s scheme to marginally increase the availability of contraceptive  services for certain employees.  42  Nos. 14‐1430 & 14‐1431  62;  Korte,  735  F.3d  at  671–72.  So,  foreclosed  by  the  Supreme  Court, the court rules as it and many others have before: The  court  rejects  the  nonprofits’  sincere  belief  that  compliance  with the HHS accommodation is prohibited by their religion  by holding that the nonprofits misunderstand the manner in  which  the  accommodation  operates.  Then,  acting  as  an  ex‐ pert  theologian,  the  court  holds  that  the  accommodation’s  operation  as  understood  by  the  court  is  not  a  substantial  burden  to  the  nonprofits’  religious  exercise.  Ante,  at  38;  see  also  Wheaton  Coll.  v.  Burwell,  791  F.3d  792  (7th  Cir.  2015);  Univ.  of  Notre  Dame  v.  Burwell,  786  F.3d  606  (7th  Cir.  2015)  (Notre Dame  II);  Michigan  Catholic  Conference  v.  Burwell,  2015  WL  4979692  (6th  Cir. Aug.  21,  2015);  Little Sisters  of  the  Poor  Home for the Aged v. Burwell, 794 F.3d 1151 (10th Cir. Jul. 14,  2015); East Texas Baptist Univ. v. Burwell, 793 F.3d 449 (5th Cir.  Jun. 22, 2015); Geneva College v. Secretary United States Dep’t of  Health & Human Servs., 778 F.3d 422 (3d Cir. 2015); Priests for  Life  v.  United States Dep’t of Health  & Human Servs., 772  F.3d  229  (D.C.  Cir.  2014).  But  cf.  Notre  Dame  II,  786  F.3d  at  626  (Flaum,  J.,  dissenting);  Little  Sisters,  794  F.3d  1151,  2015  WL  4232096, *41 (Baldock, J., dissenting); Priests for Life v. United  States  HHS,  2015  U.S.  App.  LEXIS  8326,  *16  (D.C.  Cir.  May  20, 2015) (en banc denied) (Brown, J. and Kavanaugh, J., dis‐ senting);  Eternal  Word  Television  Network,  Inc.  v.  Sec’y,  U.S.  Dep’t of Health & Human Servs., 756 F.3d 1339, 1340 (11th Cir.  2014) (Pryor, J., concurring).  The court does this by improperly judging the nonprofits’  religious beliefs and ignoring the penalties used for compli‐ ance. Had the nonprofits said that they sincerely believe that  the HHS accommodation violates their religion and left it at  Nos. 14‐1430 & 14‐1431  43  that,  perhaps  the  injunction  would  remain  in  place  because  there would be nothing for the court to attack. But since the  nonprofits  said  that  they  sincerely  believe  that  the  accom‐ modation  violates  their  religion  because  the  accommodation  makes them complicit in the provision  of  contraceptive  ser‐ vices,  the  court  has  attacked  their  claim  that  the  law makes  them complicit. The court is right that  it is  “not required to  defer to the plaintiffs’ beliefs about the operation of the law.”  Ante,  at  31.  Nevertheless,  it  is  the  nonprofits  that  are  right  about the operation of the law, not the court.  II.  The  accommodation  imposes  a  substantial  burden  on  the nonprofits’ religious exercise.  The court denies that the self‐certification and alternative  notice  process  trigger  the  provision  of  contraceptive  cover‐ age.  According  to  the  court,  it  is  federal  law,  not  the  self‐ certification  form  or  alternative  notice,  which  results  in  the  contraceptive  coverage. The  court  says that  self‐certification  throws the burden of contraceptive coverage on to the non‐ profits’  health  insurance  issuers  (insurers)  and  third  party  administrators (TPAs). Ante, at 32. But how does this lift the  burden off the nonprofits when the accommodation imposes  the  “free”  contraceptive  coverage  requirement  only  on  the  insurers and TPAs that the nonprofits have hired? In spite of  that  imposition,  the  court  also  denies  that  the  accommoda‐ tion uses the nonprofits’ health plans to provide the contra‐ ceptive  coverage.  Instead,  it  says  that  the  government  con‐ tracts with the insurers and TPAs to provide the coverage to  only the beneficiaries on the nonprofits’ health plans. Ante, at  35.  But,  given  that  connection  with  the  nonprofits’  health  44  Nos. 14‐1430 & 14‐1431  plans,  how  can  the  provision  of  coverage  be  completely  in‐ dependent of those same plans?   The court can only make such sweeping claims by ignor‐ ing  the  true  operation  of  the  accommodation  and  the  legal  consequences  the  government  has  attached  to  the  self‐ certification and alternative notice. The court may think that  the nonprofits “throw” their burden onto their insurers and  TPAs,  but  it  ignores  who  is  forced  to  do  the  throwing  and  who  ultimately  carries  the  burden  once  thrown.  A  close  ex‐ amination  of  the  manner  in  which  the  regulations  actually  operate reveals that the government’s promise of accommo‐ dation  is  illusory.  The  nonprofits’  claim  that  the  HHS  ac‐ commodation makes them complicit in the provision of con‐ traceptive coverage becomes obvious.  A.  The  self‐certification  form  and  alternative  notice  trigger the coverage of contraceptive services.  The court holds that the self‐certification and alternative  notice are simply signs that the nonprofits have opted out of  providing contraceptive coverage, and once the sign is made  known the law obliges the nonprofits’ insurers and TPAs to  provide  the  unwanted  coverage.  Ante,  at  32–33.  In  reality,  once  the  nonprofits  formally  object,  they  are  opted  in.  The  self‐certification  and  alternative  notice  do  more  than  give  notice of the nonprofits’ objections. And they are much more  than  de  minimis  paperwork  necessary  to  effectuate  the  non‐ profits’ objection. They create the insurers’ and TPAs’ obliga‐ Nos. 14‐1430 & 14‐1431  45  tion  to provide  the  contraceptive coverage.2 For a  nonprofit  with  a  self‐insured  plan,  the  effect  of  the  self‐certification  and  alternative  notice  is  abundantly  clear:  the  government  makes  them  legal  instruments  under  which  the  nonprofit’s  health  plan  is  operated.  This  then  allows  the  regulations  to  treat them as legal designations of the TPA as plan adminis‐ trator and claims administrator for coverage of contraceptive  services under the nonprofit’s health plan.3 Only a nonprofit  can designate its plan administrator.4 The government’s abil‐ ity to define how a plan administrator is designated does not  give it the power to designate who will be a plan administra‐                                                   2 45 C.F.R. § 147.131(c)(2)(i) (“A group health insurance issuer that re‐ ceives a copy of the self‐certification or notification … must … [p]rovide sepa‐ rate  payments  for  any  contraceptive  services  for  plan  participants  and  beneficiaries for so long as they remain enrolled in the plan.” (emphasis  added));  29  C.F.R.  §  2590.715–2713A(c)(2)(i)  (identical  requirement  for  TPAs); 78 Fed. Reg. 39878 (listing among the key elements of the accom‐ modation the need for eligible organizations with insured group health  plans  to  self‐certify  and  that  it  is  the  “issuer  that  receives  a  self‐ certification”  that  must  comply  with  the  accommodation’s  require‐ ments); 78 Fed. Reg. 39880 (“A third party administrator that receives a  copy  of  the  self‐certification  …  must  provide  or  arrange  separate  pay‐ ments for contraceptive services … .”).  3  78  Fed.  Reg.  39879  (“The  self‐certification  …  will  be  treated  as  a  designation of the third party administrator(s) as plan administrator and  claims administrator for contraceptive benefits pursuant to section 3(16)  of ERISA.”); 29 C.F.R. § 2510.3–16 (defining the term plan administrator  to  include  the  regulatory  treatment  of  the  self‐certification  and  alterna‐ tive notice as acts of designation and declaring that each “shall be an in‐ strument under which the plan is operated”).  4 29 U.S.C. § 1102(a)(2).  46  Nos. 14‐1430 & 14‐1431  tor.5 For the TPA to have the necessary authority to provide  coverage  for  contraceptive  services,  the  nonprofit  must  desig‐ nate the TPA as a plan administrator.6 Such an act would ob‐ viously  violate  the  nonprofit’s  religion.  So  the  government  has  loaded  the  self‐certification  and  alternative  notice  with  the legal significance of designating the TPA. It is not the op‐ eration  of  law.  It  is  the  acts  of  self‐certification  and  alterna‐ tive notice that designate the TPA and facilitate the provision  of the unwanted contraception coverage. Without possession  of  the  self‐certification or alternative notice, the TPA cannot  receive  reimbursement  for  the  provision  of  contraceptives.7  In  sum,  the  government  can  only  require  the  nonprofits’  TPAs  to  cover  contraceptive  services  if  the  nonprofits  give  the government the legal authority to do so. The government  has hidden that legal authority in self‐certification and alter‐ native notice.  For insurers the situation is not as clear, but it is not the  less  burdensome.  The  law  requires  insurers  to  include  con‐ traceptive coverage in every health plan they offer.8 (Insurers  will not, however, provide something for which they are not                                                    5 29 U.S.C. § 1002(16)(A).  6  78  Fed.  Reg.  39880  (“The  third  party  administrator  serving  as  the  plan administrator for contraceptive benefits ensures that there is a party  with  legal  authority  to  arrange  for  payments  for  contraceptive  services  and  administer  claims  in  accordance  with  ERISA’s  protections  for  plan  participants and beneficiaries.”).  7 See infra note 18.  8 45 C.F.R. § 147.131(a)(1).  Nos. 14‐1430 & 14‐1431  47  paid.9) The  self‐certification  and  alternative  notice  permit  an  insurer to offer a health plan that appears not to include con‐ traceptive coverage. But this is on the condition that  the in‐ surer  still  provides  the  coverage  itself  in  the  form  of  direct  payments.10 The assertion that it is the operation of law that  designates  an  objecting  nonprofit’s  insurer  as  the  replace‐ ment  is  misleading.  It  ignores  the  fact  that  but  for  the  non‐ profit’s  hiring  of  the  insurer,  and  the  nonprofit’s  continuing  contractual  relationship  with  it,  the  government  (or  the  op‐ eration  of  law)  would  not  make  any  designation.  Without  the objection  and designation  by the  nonprofits,  the  insurer  is  not  required  to  act  at  all,  despite  the  court’s  claim  to  the  contrary. The government has turned the act of objecting into  the act of designating and it cannot escape the consequences  of that conflation by calling it an act of law.  This  is  not  like  the  case  of  a  conscientious  objector  who  objects  and  the  government  finds  a  replacement.  Under  the  regulations,  the  government  does  not  find  the  replacement,  the nonprofit does. The designation does not take place un‐ less the nonprofit either delivers the self‐certification form to  its  insurer  or  TPA,  or  uses  the  alternative  notice  to  inform  the government who its insurer or TPA is and which health  plan  is  at  issue.  By  insisting  that  the  nonprofit  deliver  the  form  or  supply  the  plan  information  for  the  government’s  use,  the  government  uses  the  objecting  nonprofit  to  do  its                                                    9 See infra note 21.  10 See supra note 2.  48  Nos. 14‐1430 & 14‐1431  dirty work. The government has not provided an exit—it of‐ fers a revolving door with only one opening.11  Furthermore,  this  is  not  like  the  case  of  a  conscientious  objector who refuses to object and goes to jail, and the gov‐ ernment still finds a replacement. If the nonprofits refuse to  self‐certify or provide the alternative notice and instead pay  the huge fines, their insurers and TPAs will not automatical‐ ly  provide  the  contraception  coverage.  To  comply  with  the  law, the insurers would refuse to sell plans without the cov‐ erage, while the TPA would refuse to provide their services.  In  spite  of  the  huge  monetary  penalties,  the  nonprofits  would  still  be  prevented  from  providing  health  plans  for  their employees, which they have asserted is also a violation  of  their  religious  beliefs.  So  the  no‐win  substantial  burden  would hit them on both sides.  The  court  has  implied  that  requiring  the  nonprofit  to  identify  its  insurer  (or  TPA)  is  merely  the  most  efficient  means  for  the  government  to  achieve  its  objective,  Wheaton,  791 F.3d at 798, but efficiency does not excuse the substantial  burden  imposed  by  the  requirement.  Identifying  its  insurer  so  that  the  government  can  instruct  that  insurer  to  provide                                                    11  This  is  not  the  case  of  a  conscientious  objector  walking  into  the  draft  board,  voicing  his  objection,  being  excused,  and  walking  out.  For  the analogy to fit the HHS accommodation, the draft board must decide  that every objector will be replaced by the objector’s friend, and the ob‐ jector’s objection is only effective if the objector delivers written notice of  his  objection to  his  friend  or  tells  the  draft  board  who  his  friend  is  and  where  the  board  can  find  him.  Then,  the  objector  must  send  his  friend  money  so  that  that  his  friend  will  remain  his  friend  for  the  purpose  of  being his replacement.  Nos. 14‐1430 & 14‐1431  49  contraceptive coverage is just as burdensome to the nonprof‐ it  as  if  it  had  to  pick  its  own  replacement,  because  it  has  done just that by hiring its insurer and then objecting to the  coverage requirement. That the nonprofits could not object if  the  government,  on  its  own,  were  to  find  a  replacement  in‐ surer and discover to which employees it had to provide the  coverage is not relevant. Of course the nonprofits would not  have an objection to the government contracting with a third  party  to  provide  the  contraceptive  coverage  to  other  third  parties.  They  believe  the  provision  of  objectionable  contra‐ ceptives is always immoral, but they know they have no le‐ gal  means  to  stop  the  government  from  contracting  with  third  parties.  That  is  not  what  is  happening  here.  The  gov‐ ernment is using the nonprofits, their health plans, and their  contractual  relationships  with  their  insurers  and  TPAs,  to  provide the contraception coverage to which they object.  B.  The  accommodation  uses  the  nonprofits’  health  plans.  The HHS accommodation requires significantly more in‐ volvement  on  the  part  of  the  nonprofits  and  their  health  plans than the court relates. For starters, the accommodation  does not create independent policies or contracts. In fact, as  the  nonprofits  assert,  the  accommodation  relies  wholly  on  the existing contract between the nonprofits and the insurers  and TPAs to provide separate payments directly to the non‐ profits’ health plan beneficiaries.12 The accommodation must                                                    12 78  Fed.  Reg.  39874  (“[T]he  accommodations  established  under  these final regulations do not require the issuance of a separate excepted bene‐ fits individual health insurance policy covering contraceptive services … but  50  Nos. 14‐1430 & 14‐1431  use  the  existing  insurance  contracts  to  issue  payments  be‐ cause  separate  policies  would  violate  insurance  laws.13  The  separate payments are only provided so long as an employ‐ ee  is  enrolled  in  the  nonprofit’s  health  plan,  thus  requiring  the nonprofits’ health plans to determine eligibility.14 The ac‐ commodation also relies on the nonprofits’ health plans’ en‐ rollment  procedures.  The  insurers  and  TPAs  must  provide  notice of the separate payments when they provide notice of  the  other  benefits  under  the  nonprofits’  health  plans.15  The  separate payments can be limited to the same provider net‐ work  as  the  other  plan  benefits.16  The  end  result  is  that  the                                                    instead require a simpler method of providing direct payments for con‐ traceptive services.” (emphasis added)).  13 78 Fed. Reg. 39876 (“As the payments at issue derive solely from a  federal  regulatory  requirement,  not  a  health  insurance  policy,  they  do  not  implicate  issues  such  as  issuer  licensing  and  product  approval  re‐ quirements under state law … ”).  14  45  C.F.R.  §  147.131(c)(2)(i)(B)  (insurers  must  “[p]rovide  separate  payments  for  any  contraceptive  services  …  for  plan  participants  and  beneficiaries for so long as they remain enrolled in the plan.”); 29 C.F.R.  § 2590.715–2713A(c)(2)(i)(B)  (identical  regulatory  requirements  for  TPAs).  15 78 Fed. Reg. 39881 (“The notice [regarding the provision of contra‐ ceptive  services]  must  be  provided  contemporaneous  with  (to  the  extent  possible), but separate from, any application materials distributed in connec‐ tion  with  enrollment  (or  re‐enrollment)  in  coverage … .”  (emphasis  add‐ ed)).  16  78  Fed.  Reg.  39877  (“[A]n  issuer  …  may  require  that  contraceptive  services be obtained in‐network (if an issuer has a network of providers) in  order  for  plan  participants  and  beneficiaries  to  obtain  such  services  without cost sharing.” (emphasis added)).  Nos. 14‐1430 & 14‐1431  51  contraceptive  services  become  a  de  facto  benefit  under  the  nonprofits’  health  plans.17  The  government  admitted  as  much  when  it  stated  that  it  was  by  design  that  the  accom‐ modation  makes  the  provision  of  contraceptive  coverage  “seamless[]”  with  the  other  plan  benefits.  Gov’t  Supp  and  Reply  Br.,  14.  These  circumstances  sharply  conflict  with  the  court’s conclusion that the accommodation does not use the  nonprofits’ health plans and “makes every effort to separate  religious employers from the provision of any objectionable  services.” Ante,  at  23.  “[E]very  effort”  does  not  disguise  the  fact that the offensive provision is inseparably imbedded in  the nonprofits’ health plan. Id.  A  further  indication  that  the  accommodation  uses  the  nonprofits’ health plans is the fact that the only way an em‐ ployee receives coverage for contraceptive services under the  accommodation  is  to  enroll  in  the  objecting  nonprofit’s  health  plan. An  employee  cannot  reject  coverage  under  the  nonprofit’s plan and still receive coverage under the accom‐ modation.  The  coverage  under  the  accommodation  is  not  separate  from  the  coverage  under  the  nonprofit’s  health  plan.  It  is  the  employee’s  status  as  a beneficiary  of  the  non‐ profit’s health plan, not as an employee, that entitles the em‐ ployee to coverage under the accommodation. Simply being  hired  as  an  employee  is  not  enough  to  receive  coverage;  an                                                    17 78 Fed. Reg. 39880 (“[T]he self‐certification … identifies the limited  set of plan benefits (that is, contraceptive coverage) that the employer re‐ fuses to provide and that the third party administrator must therefore provide  or arrange for an issuer or another entity to provide.” (emphasis added)).  52  Nos. 14‐1430 & 14‐1431  employee must enroll in the nonprofit’s health plan. Cf. Notre  Dame II, 786 F.3d at 617.  C.  The  nonprofits  are  involved  in  the  payment  for  con‐ traceptive services.  Finally, there is the matter of payment. For TPAs, the self‐ certification  and  alternative  notice  act  as  authorizations  for  payment,  without  which  the  TPAs  cannot  receive  reim‐ bursement  from  the  government  for  payments  made  under  the accommodation.18 The government assumed that the re‐ imbursements for TPAs would not be passed on to the non‐                                                   18 Payments for contraceptive services provided by TPAs under the  HHS  accommodation  are  funded  through  an  adjustment  (i.e.,  discount)  to  the  federally‐facilitated  exchange  (FFE)  user  fee.  See  78  Fed.  Reg.  39882. The FFE user fee is paid by insurance issuers that participate in a  federal health care exchange to support the operations of the exchange.  See  78  Fed.  Reg.  15412;  45  C.F.R.  §  156.50(c).  The  amount  of  the  adjust‐ ment  is  equal  to  the  total  amount  of  the  payments  made  for  contracep‐ tive services provided by the TPA plus an allowance of at least 10 percent  for administrative costs. 45 C.F.R. § 156.50(d)(3). To receive the FFE user  fee  adjustment,  a  TPA  must  submit  to  HHS  “[a]n  attestation  that  the  payments  for  contraceptive  services  were  made  in  compliance  with  26  CFR  54.9815‐2713A(b)(2)  or  29  CFR  2590.715‐2713A(b)(2).”  45  CFR  §  156.50(d)(2)(iii)(E). Both the provisions cited by § 156.50 provide that the  TPA will provide the separate payments for contraceptive services “[i]f a  third party administrator receives a copy of the self‐certification from an  eligible  organization  or  a  notification.”  26  CFR  §  54.9815‐2713AT(b)(2)  and  29  CFR  §  2590.715‐2713A(b)(2).  Moreover,  §  156.50  requires  a  TPA  which receives an adjustment to maintain for 10 years and make availa‐ ble upon request “[a] copy of the self‐certification referenced in 26 CFR  54.9815‐2713A(a)(4) or 29 CFR 2590.715‐2713A(a)(4) for each self‐insured  plan  with  respect  to  which  an  adjustment  is  received.”  45  CFR  §  156.50(d)(7)(i).  Nos. 14‐1430 & 14‐1431  53  profits but, as more nonprofits are forced to use the accom‐ modation and more contraceptive services are provided un‐ der the accommodation, that assumption is unlikely to prove  true.19 For insurers there is ostensibly no reimbursement be‐ cause  the  government  claims  the  cost  of  contraceptive  ser‐ vices will be offset by the reduction in unintended pregnan‐ cies.20  Whether  this  claim  is  true  will  be  hard  to  determine  because the regulations allow insurers to recapture costs for  contraceptive  services  provided  under  the  accommodation  through  what  is  called  the  “risk  corridor  program.”21  The                                                    19 The government assumed that the adjustments granted under the  accommodation  for  2014  would  be  small  enough  to  have  no  impact  on  the  fee.  78  Fed.  Reg.  39882.  However,  the  FFE  user  fee  will  have  to  be  increased to cover 1) more adjustments as more nonprofits are forced to  take  advantage  of  this  accommodation,  and  2)  greater  adjustments  be‐ cause the HHS mandate incentivizes more expensive forms of contracep‐ tion. An increase in the FFE user fee will eventually be recouped through  an increase in premiums, albeit an increase across the insurance issuer’s  entire portfolio, but the nonprofits may be in that same portfolio.  20  78  Fed.  Reg.  39877  (“The  Departments  continue  to  believe,  and  have  evidence  to  support,  that,  with  respect  to  the  accommodation  for  insured  coverage  established  under  these  final  regulations,  providing  payments for contraceptive services is cost neutral for issuers.”).  21 78 Fed. Reg. 39878 (“[A]n issuer of group health insurance cover‐ age  that  makes  payments  for  contraceptive  services  under  these  final  regulations  may  treat  those  payments  as  an  adjustment  to  claims  costs  for purposes of medical loss ratio and risk corridor program calculations.  This adjustment compensates for any increase in incurred claims associ‐ ated with making payments for contraceptive services.”). The “risk cor‐ ridor  program”  is  a  complex  cost‐sharing  program  in  which  insurers  with healthier beneficiaries cover the costs of insurers which either failed  to  raise  premiums  or  could  not  raise  premiums  enough  to  cover  more  54  Nos. 14‐1430 & 14‐1431  program  is  temporary,  but  since  the  HHS  accommodation  was enacted during the program’s implementation, it will be  difficult  to  determine  how  the  accommodation’s  separate  payments affect premiums. Nevertheless, if it were true that  payments  for  contraceptive  services  are  cost‐neutral,  then  the  premiums  that  would  otherwise  go  toward  childbirths  are instead used for contraceptive services in order to reduce                                                    costly beneficiaries, including those that received separate payments for  contraceptive  services.  See  45  C.F.R.  §  153.500  et  seq.;  78  Fed.  Reg.  7235  (“Section 1342 of the Affordable Care Act directs the Secretary to estab‐ lish a temporary risk corridors program that provides for the sharing in  gains or losses resulting from inaccurate rate setting from 2014 through  2016 between the Federal government and certain participating plans.”);  see  also  78  Fed.  Reg.  72323  (“In  2014,  HHS  will  also  operationalize  the  premium  stabilization  programs  established  by  the  Affordable  Care  Act—the  risk  adjustment,  reinsurance,  and  risk  corridors  programs— which  are  intended  to  mitigate  the  impact  of  possible  adverse  selection  and  stabilize  the  price  of  health  insurance  in  the  individual  and  small  group markets.”). The program is supposed to pay for itself, but the reg‐ ulations allow the government to use appropriated funds to cover insur‐ er loses. See 79 Fed. Reg. 30260 (“In the unlikely event of a shortfall for  the  2015  program  year,  HHS  recognizes  that  the  Affordable  Care  Act  requires  the  Secretary  to  make  full  payments  to  issuers.  In  that  event,  HHS  will  use  other  sources  of  funding  for  the  risk  corridors  payments,  subject to the availability of appropriations.”). Perhaps this is why insur‐ ers  do  not  object  to  the  HHS  accommodation.  Insurers  know  that  the  federal government will ultimately bear the burden of covering the costs  for  contraceptive  services  they  are  unable  to  recoup.  The  risk  corridor  program has been criticized as a health insurer bailout program. See No‐ am  N.  Levey,  Critics  call  Obama  funding  plan  for  health  insurer  losses  a  ‘bailout’,  L.A.  TIMES,  May  21,  2014,  http://www.latimes.com/nation/la‐ na‐insurance‐bailout‐20140521‐story.html (last visited Sept. 3, 2015).  Nos. 14‐1430 & 14‐1431  55  childbirths  because  the  nonprofits’  premiums  are  the  only  source of funding. This is also an objectionable outcome.  D.  The  proper  substantial  burden  analysis:  the  court  must accept the nonprofits’ sincere belief that the accommo‐ dation  violates  their  religion  because  the  nonprofits  under‐ stand its operation.  The HHS accommodation is a purposely complicated act  of  bureaucratic  legalese  and  accounting  tricks  that  enables  the  government  to  claim  that  the  objecting  nonprofits  have  nothing  to  do  with  the  provision  of  contraceptive  services.  Yet, as shown in much detail above, the accommodation in‐ fects the nonprofits’ health plans with an offensive provision  that  eradicates  their  purpose,  which  is  the  exercise  of  the  nonprofits’  religion.  It  is  the  nonprofits  which  understand  the operation of the HHS accommodation, not the court, and  we must accept their sincere belief that it violates their reli‐ gion. The accommodation imposes a substantial burden be‐ cause  the  nonprofits  have  a  sincere  belief  that  compliance  with the law violates their religion and the penalties applied  by the government to coerce compliance are enormous.  III. The accommodation does not further a compelling gov‐ ernmental interest.  The government must grant the nonprofits an exemption  from the accommodation unless “it demonstrates that appli‐ cation  of  the  burden  to  the  person—(1)  is  in  furtherance  of  a  compelling governmental interest; and (2) is the least restric‐ tive  means  of  furthering  that  compelling  governmental  in‐ terest.”  42  U.S.C.  §  2000bb‐1  (emphasis  added).  “This  re‐ quires us to look beyond broadly formulated interests and to  56  Nos. 14‐1430 & 14‐1431  scrutinize the asserted harm of granting specific exemptions  to particular religious claimants—in other words, to look to  the marginal interest in enforcing the contraceptive mandate  in these cases.” Hobby Lobby, 134 S. Ct. at 2779 (internal quo‐ tation and alteration marks omitted). “RFRA creates a broad  statutory  right  to  case‐specific  exemptions  from  laws  that  substantially burden religious exercise even if the law is neu‐ tral and generally applicable, unless the government can sat‐ isfy  the  compelling‐interest  test.”  Korte,  735  F.3d  at  671.  “In  short, RFRA operates as a kind of utility remedy for the inev‐ itable clashes between religious freedom and the realities of  the  modern  welfare  state,  which  regulates  pervasively  and  touches nearly every aspect of social and economic life.” Id.  at 673.  “Congress’s  express  decision  to  legislate  the  compelling  interest  test  indicates  that  RFRA  challenges  should  be  adju‐ dicated  in  the  same  manner  as  constitutionally  mandated  applications of the test … .” Gonzales v. O Centro Espirita Be‐ neficente Uniao  do Vegetal, 546 U.S.  418, 430  (2006).  Thus, the  government  “must  specifically  identify  an  ‘actual  problem’  in need of solving, and the curtailment of [the right] must be  actually  necessary  to  the  solution.”  Brown  v.  Entmʹt  Merchs.  Assʹn, 131 S. Ct. 2729, 2738 (2011) (citation omitted). This re‐ quires a “high degree of necessity.” Id. at 2741. The govern‐ ment must show a “direct causal link.” Id. at 2738. The gov‐ ernment’s  “predictive  judgment”  is  insufficient,  “and  be‐ cause  it  bears  the  burden  of  uncertainty,  ambiguous  proof  will  not  suffice.” Id.  at  2738–39.  (citation  omitted).  The gov‐ ernment  must  prove  that  what  it  seeks  to  regulate  actually  causes the harm it wishes to prevent; evidence of a correlation  Nos. 14‐1430 & 14‐1431  57  is insufficient. Id. at 2739. “[S]tudies [that] suffer from signif‐ icant,  admitted  flaws  in  methodology”  fail  to  provide  this  proof. Id. If the regulation is underinclusive it is a  sign that  the governmental interest is not compelling. Id. at 2740. Put  another  way,  “only  those  interests  of  the  highest  order  and  those  not  otherwise  served”  can  be  considered  compelling.  Wisconsin v. Yoder, 406 U.S. 205, 215 (1972). But, “a law can‐ not be regarded as protecting an interest of the highest order  when it  leaves  appreciable damage to that  supposedly vital  interest unprohibited.” Church of Lukumi Babalu Aye v. City of  Hialeah,  508  U.S.  520,  547  (1993)  (internal  quotation  and  al‐ teration  marks  omitted).  Finally,  the  government  does  not  have a compelling interest in “[f]illing the remaining modest  gap”  or  in  “each  marginal  percentage  point  by  which  its  goals are advanced.” Brown, 131 S. Ct. at 2741, n.9.  The  government  asserts  the  same  interest  in  furtherance  of  the  HHS  accommodation  that  it  asserts  in  furtherance  of  the  HHS  contraceptive  mandate,  namely,  the  increased  availability of contraceptive services to improve the health of  women. The government also says that it wishes to increase  the availability of contraceptive services to equalize the pro‐ vision of preventive care for women and men so that women  can  participate  in  the  workforce  and  society  on  an  “equal  playing  field  with  men.”  The  latter  interest  boils  down  to  a  concern for women’s health. The government claims that the  inequality  stems  from  the  additional  cost  of  contraception  and  that  the  additional  cost  can  deter  women  from  using  contraceptives,  thus  allowing  the  negative  health  outcomes  that  prevent  women  from  achieving  equal  economic  status.  77 Fed. Reg. 8728.  58  Nos. 14‐1430 & 14‐1431  To  justify  increasing  the  availability  of  contraception  to  improve  the  health  of  women,  the  government  relies  exclu‐ sively on the Institute of Medicine’s 2011 study, Clinical Pre‐ ventive Services for Women: Closing the Gaps (IOM Study). The  IOM  Study  is  a  235‐page  study  of  the  current  preventative  services available for women. Only eight pages of the study  deal  with  the  issue  of  contraceptive  services.  IOM  Study,  102–09.  The  study  does  not  claim  that  contraceptives  im‐ prove  women’s  health  generally,  but  that  they  prevent  cer‐ tain  negative  health  outcomes  associated  with  unintended  pregnancies. See Priests for Life, 772 F.3d at 261 (“A core rea‐ son the government sought under the ACA to expand access  to  contraception  is  that  use  of  contraceptives  reduces  unin‐ tended  pregnancies.”).  The  government’s  interest  advanced  by the accommodation, then, is best identified as increasing  the availability of contraceptive services in order to prevent  the negative health outcomes caused with unintended preg‐ nancies. When put to the test, the government’s interest fails  to prove compelling.22  A.  A  lack  of  available  contraception  and  unintended  pregnancies are not actual problems in need of solving.  The  HHS  accommodation  relies  on  a  lengthy  chain  of  causality:  1)  the  accommodation  will  make  contraceptives  more  available  by  removing  administrative  and  cost  bur‐ dens;  2)  if  contraceptives  are  more  available,  then  more                                                    22 For a comprehensive explanation of how the government’s inter‐ est thoroughly fails the compelling interest test, see generally Helen Al‐ varé,  No  Compelling  Interest:  The  “Birth  Control”  Mandate  and  Religious  Freedom, 58 VILL. L. REV. 379 (2013).  Nos. 14‐1430 & 14‐1431  59  women will use them; 3) if more women use contraceptives,  then  there  will  be  fewer  unintended  pregnancies;  and  4)  if  there  are  fewer  unintended  pregnancies,  then  there  will  be  fewer of the negative health outcomes associated with them.  The government, therefore, must prove more than the exist‐ ence  of  negative  health  outcomes.  It  must  prove  first,  that  unintended  pregnancies  cause  the  negative  outcomes;  sec‐ ond,  that  contraceptive  use  will  cause  fewer  unintended  pregnancies; and third a higher availability of contraceptives  will cause more women to use them. The IOM Study fails to  prove  these  “direct  casual  links.”  Brown,  131  S.  Ct.  at  2738.  Instead, the study shows merely a correlation.  First, the study admits that “for some outcomes [of unin‐ tended  pregnancy],  research  is  limited.”  Id.  at  103.  It  then  proceeds  to  describe the  outcomes  correlated  with  unintend‐ ed pregnancies: outcomes that “may” or “may not” happen,  are “more” or “less likely,” have been “reported,” and have  “increased odds,” or are “associated with.” IOM Study 103.  Second,  the  study  discusses  “evidence  of  [contraceptive]  method  effectiveness,”  but  does  not  prove  that  increasing  the use of even an effective contraceptive causes fewer unin‐ tended  pregnancies.  This  is  because  such  a  simple  correla‐ tion does not take into account the factors that inhibit perfect  use of contraception or the societal changes that result from  increased reliance on contraception.23 Rather than prove that                                                    23 See Alvaré, supra note 22, at 408–411 for a discussion of the “grow‐ ing  body  of  scholarship  …  indicating  that  the  persistence  or  worsening  of high rates of unintended pregnancy, abortion, and sexually transmit‐ ted  diseases,  and  also  our  nation’s  high  rates  of  nonmarital  births  (the  60  Nos. 14‐1430 & 14‐1431  greater contraceptive use causes fewer unintended pregnan‐ cies, the study only states that “evidence exists” that it does.  Id. at 105. The IOM study bases this statement on two other  studies, but they are insufficient to provide the necessary ev‐ idence.24 According  to  the  study,  “[i]t  is  thought  that  greater  use  of  long‐acting,  reversible  contraceptive  methods— including  intrauterine  devices  and  contraceptive  implants  that  require  less  action  by  the  woman  and  therefore  have  lower use failure rates—might help further reduce unintend‐ ed  pregnancy  rates.”  Id.  at  108  (emphasis  added;  citation  omitted).  Third, the study  fails to prove that  increasing the availa‐ bility  of  contraceptives  will  cause  an  increase  in  their  use,   but concludes that “[t]he elimination of cost sharing for con‐ traception  therefore  could  greatly  increase  its  use,  including  use  of  the  more  effective  and  longer‐acting  methods,  espe‐ cially  among  poor  and  low‐income  women  most  at  risk  for  unintended  pregnancy.”  IOM  Study,  109  (emphasis  added).  However,  the  conclusion  that  eliminating  cost  sharing  “could”  increase  its  use  is  based  on  two  studies,  neither  of  which concerned contraceptive services specifically. The first  concerned preventative and primary care services generally,  and the second concerned mammograms. Id. The final claim  the  study  makes  is  that  “when  out‐of‐pocket  costs  for  con‐                                                   chief  predictor  of  female  poverty),  are  the  ‘logical’  result—in  economic  and psychological terms—of the new marketplace for sex and marriage  made  possible  by  increasingly  available  contraception  (in  some  cases,  combined with available abortion).”  24 Alvaré, supra note 22, at 399‐405.  Nos. 14‐1430 & 14‐1431  61  traceptives  were  eliminated  or  reduced,  women  were  more  likely  to  rely  on  more  effective  long‐acting  contraceptive  methods.” Id. But, a review of the study underlying that con‐ clusion reveals that “[w]e cannot be certain that the changes  in procurement were solely due to the removal of cost to the  patient,  but  there  was  a  shift  toward  prescribing  the  most  effective  methods  ([intrauterine  contraceptives]  and  injecta‐ ble  contraceptives)  and  a  substantial  increase  in  prescribing  of  [emergency  contraceptive  pills].”25  So,  not  only  was  the  study  inconclusive,  it  is  ambiguous  regarding  the  IOM  Study’s  intended  purpose  because  a  substantial  increase  in  emergency contraceptive pills  would seem to follow from  a  decrease  in  regular  contraceptive  use.  On  the  whole,  the  IOM study’s lack of causality renders the government’s claim  that  it  must  increase  the  availability  of  contraceptives  noth‐ ing more than a “predictive judgment.” Brown, 131 S. Ct. at  2738.  Another reason the IOM Study fails to prove “an ‘actual  problem’  in  need  of  solving”  is  because  it  is  overbroad.  Brown, 131 S. Ct. at 2738. The study starts with the estimation  that “[i]n 2001, … 49 percent of all pregnancies in the United  States were unintended,” but the study defines an unintend‐ ed  pregnancy  as  one  that  is  “unwanted  or  mistimed  at  the  time of conception.” IOM Study, 102. This definition includes  pregnancies  that  were  unwanted  at  the  time  of  conception,  but still wanted when the mother discovered she was preg‐ nant,  and  mothers  who  intended  to  become  pregnant,  but                                                    25  Debbie  Postlethwaite,  et  al.,  A  comparison  of  contraceptive  procure‐ ment pre‐ and post‐benefit change, 76 CONTRACEPTION 360, 364 (2007).  62  Nos. 14‐1430 & 14‐1431  did  not  intend  to  become  pregnant  by  the  specific  conjugal  act that resulted in conception. The government has zero in‐ terest  in  preventing  these  pregnancies.  Under  the  study’s  overbroad  definition,  “all  sexually  active  women  with  re‐ productive  capacity  are  at  risk  for  unintended  pregnancy.”  Id. at 103. Aside from the study’s problems with its own def‐ inition,  unintended  pregnancies  are  an  extremely  difficult  thing to quantify.26    Overall,  the  IOM  Study  lacks  the  necessary  quality  and  rigor. It heavily relies on studies from biased organizations,  such  as  the  Guttmacher  Institute  and  the  journal  CONTRACEPTION,  and  offers  no  consideration  of  competing  studies.  Id.  at  102–109.  The  study’s  own  dissenting  opinion  says it best:  Readers  of  the  Report  should  be  clear  on  the  fact  that  the  recommendations  were  made  without  high  quality,  systematic  evidence  of  the  preventive  nature  of  the  services  consid‐ ered.  Put  differently,  evidence  that  use  of  the  services in question leads to lower rates of dis‐ ability  or  disease  and  increased  rates  of  well‐ being is generally absent.  The view of this dissent is that the commit‐ tee  process  for  evaluation  of  the  evidence  lacked transparency and was largely subject to  the preferences of the committee’s composition.  Troublingly,  the  process  tended  to  result  in  a                                                    26 Alvaré, supra note 22, at 396–97.  Nos. 14‐1430 & 14‐1431  63  mix  of  objective  and subjective  determinations  filtered through a lens of advocacy. An abiding  principle in the evaluation of the evidence and  the  recommendations  put  forth  as  a  conse‐ quence  should  be  transparency  and  strict  ob‐ jectivity,  but  the  committee  failed  to  demon‐ strate  these  principles  in  the  Report.  This  dis‐ sent views the evidence evaluation process as a  fatal flaw  of  the Report  particularly in  light of  the  importance  of  the  recommendations  for  public  policy  and  the  number  of  individuals,  both men and women, that will be affected.  IOM Study, 232–33.  The  study  itself  shows  that  the  lack  of  available  contra‐ ceptive services is not a problem in need of solving. Accord‐ ing to the IOM Study, “[c]ontraceptive coverage has become  standard  practice  for  most  private  insurance  and  federally  funded  insurance  programs.”  Id.  at  108.  Further,  “[s]ince  1972,  Medicaid,  the  state‐federal  program  for  certain  low‐ income  individuals,  has  required  coverage  for  family  plan‐ ning in all state programs and has exempted family planning  services  and  supplies  from  cost‐sharing  requirements.”  Id.  Finally,  [C]omprehensive coverage of contraceptive  services and supplies [is] “the current insur‐ ance industry standard,” with more than 89  percent of insurance plans covering contracep‐ tive methods in 2002. A more recent 2010 sur‐ vey of employers found that 85 percent of large  64  Nos. 14‐1430 & 14‐1431  employers and 62 of small employers offered  coverage of FDA‐approved contraceptives.  Id. at 109 (citations omitted). Not only are contraceptive ser‐ vices  already  widely  available,  but  they  are  also  already  widely used: “More than 99 percent of U.S. women aged 15  to  44  years  who  have  ever  had  sexual  intercourse  with  a  male  have  used  at  least  one  contraceptive  method.”  IOM  Study,  103  (citation  omitted).  According  to  the  Centers  for  Disease Control and Prevention, contraceptive use is “virtu‐ ally universal among women of reproductive age.”27  The  study  similarly fails  to  prove  that  there is a need  to  increase  the  availability  of  contraceptives  to  alleviate  “the  increased  risk  of  adverse  pregnancy  outcomes  for  pregnan‐ cies that are too closely spaced” or for “women with certain  chronic  medical  conditions”  who  “may  need  to  postpone  pregnancy”  and  “women  with  serious  medical  conditions”  for whom “pregnancy may be contraindicated.” IOM Study,  103. Amazingly, the study does not even pretend to demon‐ strate a causal link in these circumstances, relying instead on  the  reader  to  make  the  inference  mistakenly.  The  study  hopes the reader ignores the common sense fact that women  in these circumstances have a higher incentive to use contra‐ ceptives if that is their chosen method to prevent these out‐ comes.                                                    27 CDC, “Advance Data No. 350, Dec. 10, 2004: Use of Contraception  and  Use  of  Family  Planning  Services  in  the  United  States:  1982‐2002”,  http://www.cdc.gov/nchs/data/ad/ad350.pdf (last visited Sept. 3, 2015).  Nos. 14‐1430 & 14‐1431  65  The  study  offers  no  evidence  regarding  the  effects  that  extra  paperwork  or  other  administrative  and  logistical  ob‐ stacles would have on contraceptive availability or use. Such  a  finding  is  absolutely  necessary  for  the  government  to  as‐ sert that it has a compelling interest in using the nonprofits’  health  plans  so  that  the  coverage  for  contraceptive  services  will be “seamless.” Instead, the IOM Study’s conclusions are  limited  to  the  elimination  of  cost‐sharing  and  provide  no  reason why a government‐run option would not work equal‐ ly as well as the HHS accommodation.  Finally,  the  IOM  Study  does  not  concern  the  employees  of  the  nonprofits  who  are  less  likely  to  use  contraception  given  their  own  religious  beliefs.  Instead,  its  conclusions  mostly  concern  the  “poor  and  low‐income  women  most  at  risk for unintended pregnancy.” Id. at 109. The study’s hope  is that the elimination of cost sharing for contraception will  induce the poor to use more effective, long‐acting methods,  such  as  IUDs,  implants,  and  sterilization.  Id.  at  108‐109.  However, “the government must establish a compelling and  specific  justification  for  burdening  these  claimants.”  Korte,  735  F.3d  at  685;  see  also  Hobby  Lobby,  134  S.  Ct.  at  2761.  The  IOM  Study  fails  to  prove  any  connection  whatsoever  with  the  nonprofits’  employees.  In  fact,  there  are  already  a  high  level of access to contraception, a higher rate of use, and an  increased use of  more effective methods  among the women  with  more  income  and  education.28  Simply  put,  the  IOM  study  fails  to  “specifically  identify  an  ‘actual  problem’  in  need  of  solving,”  and,  consequently,  the  government  has                                                    28 Avaré, supra note 22, at 426.  66  Nos. 14‐1430 & 14‐1431  failed to demonstrate a compelling interest. Brown, 131 S. Ct.  at 2738.  B.  The accommodation is underinclusive.  The HHS accommodation’s underinclusiveness is another  sign  that  the  governmental  interest  is  not  compelling.  Id.  at  2740.  The  government  “leaves  appreciable  damage  to  that  supposedly  vital  interest  unprohibited”  by  allowing  reli‐ gious  employers,  grandfathered  plans,  and  employers  with  fewer  than  50  employees  to  avoid  providing  contraceptive  coverage.  Lukumi,  508  U.S.  at  547  (internal  quotation  marks  omitted). Although  more health plans will lose their grand‐ fathered status the longer the ACA is in place, the number of  persons employed by religious employers and organizations  with  fewer  than  50  employees  will  remain  considerable  in  light  of  the  less  than  2,000  covered  employees  concerned  here.  The  accommodation  is  also  underinclusive  because  it  does not account for the other causes of the negative health  outcomes  the  IOM  Study  correlates  with  unintended  preg‐ nancies.  According  to  the  study,  “women  with  unintended  pregnancies  are more  likely  than  those  with  intended  preg‐ nancies  to  receive  later  or  no  prenatal  care,  to  smoke  and  consume  alcohol  during  pregnancy,  to  be  depressed  during  pregnancy,  and  to  experience  domestic  violence  during  pregnancy.”  IOM  Study,  103.  The  study  implies  that  unin‐ tended  pregnancies  cause  these  conditions,  but  there  could  just as well be another cause that causes not only these con‐ ditions, but the unintended pregnancy as well: poverty, lack  of education, abuse, or other causes of risk taking behaviors.  Nos. 14‐1430 & 14‐1431  67  The  HHS  accommodation  addresses  none  of  these  alterna‐ tive causes, focusing solely on unintended pregnancies. Most  notably, the study does not acknowledge the fact that preg‐ nancies resulting from failed contraceptives are also consid‐ ered unintended.  Most  damaging  to  the  government’s  asserted  interest  in  the contraceptive mandate is the fact that those women most  at  risk  for  an  unintended  pregnancy  are  “women  who  are  aged 18 to 24 years and unmarried, who have a low income,  who are not high school graduates, and who are members of  a racial  or ethnic  minority group.” IOM Study, 102 (citation  omitted).  These  women—let  alone  the  nonprofits’  employ‐ ees—are less likely to be served by the HHS accommodation,  or the ACA’s contraception mandate generally, because they  are less likely to have the type of employment that qualifies  them for the health insurance under the ACA. These women  would  not  obtain  contraceptive  services  through  the  HHS  accommodation,  but through  a number of government  pro‐ grams such as Medicaid, 42 U.S.C. § 1396 et seq. (2010), and  the Title X Family Planning Program, 42 U.S.C. § 300 (2006).  “The consequence is that [the HHS accommodation] is wild‐ ly underinclusive when judged against its asserted justifica‐ tion, which … is alone enough to defeat it.” Brown, 131 S. Ct.  at 2740.  C.  Forcing nonprofits to use the accommodation can on‐ ly provide a marginal increase in contraception.  Contraceptive  services  are  already  widely  available  and  their use is virtually universal. The HHS accommodation on‐ ly fills the “remaining modest gap” by making already prev‐ 68  Nos. 14‐1430 & 14‐1431  alent  contraceptive  services  free  for  employees  of  religious  nonprofits. Id. at 2741. This “can hardly be a compelling state  interest.”  Id.  Further,  the  “more  focused  inquiry”  of  RFRA  requires the government to demonstrate that it has a compel‐ ling  interest  in  filling  the  gap  made  by  the  less  than  2,000  employees of the nonprofits here. Hobby Lobby, 131 S. Ct. at  2779. This is even less of a compelling interest. Further still,  the accommodation fills in even less of the gap when viewed  from the perspective of unintended pregnancies. This is be‐ cause  the  accommodation  seeks  to  treat  unintended  preg‐ nancies  through  contraceptive  services,  but  contraceptives  are not always effective for a variety of reasons. Even if this  gap  could  be  decreased  by  improving  the  effectiveness  of  contraceptives, “the government does not have a compelling  interest in each marginal percentage point by which its goals  are advanced.” Brown, 131 S. Ct. at 2741, n.9.  D.  A  primary  concern  underlying  the  accommodation  is  cost.  Cost  appears  to  be  a  primary  concern  underlying  the  HHS accommodation. After all, babies are expensive. Of the  IOM  Study’s  eight‐page  discussion  of  contraceptives,  a  sig‐ nificant  portion  is  spent  on  the  cost  savings  to  be  expected  from  their  use  despite  the  study’s  acknowledgement  that  cost considerations are out of scope:  Although it is beyond the scope of the  committee’s consideration, it should be  noted that contraception is highly cost‐ effective. The direct medical cost of unin‐ tended pregnancy in the United States was  Nos. 14‐1430 & 14‐1431  69  estimated to be nearly $5 billion in 2002, with  the cost savings due to contraceptive use esti‐ mated to be $19.3 billion. … It is thought that  greater use of long‐acting, reversible contra‐ ceptive methods—including intrauterine de‐ vices and contraceptive implants that require  less action by the woman and therefore have  lower use failure rates—might help further re‐ duce unintended pregnancy rates. Cost barri‐ ers to use of the most effective contraceptive  methods are important because long‐acting,  reversible contraceptive methods and steriliza‐ tion have high up‐front costs.   IOM  Study,  107–08  (citations  omitted).  The  study’s  primary  conclusion  is  that  the  use  of  contraceptive  services— particularly  longer‐acting  methods  like  IUDs—will  greatly  increase if they are free, “especially among poor and low‐income  women.” Id. at 109 (emphasis added). The appearance is that  the  government  desires  to  use  contraceptives  that  “require  less  action  by  the  woman”  to  prevent  poor,  unmarried,  mi‐ nority women from having babies, as if babies were a costly  disease.  IOM  Study,  108.  Of  course,  this  appearance  is  less‐ ened by the fact that the government is vigorously enforcing  the HHS contraception mandate on even religious nonprofits  through the accommodation.  Because the government has failed to prove that the HHS  accommodation  furthers  a  compelling  governmental  inter‐ est, it is not allowed to burden the nonprofits’ religious exer‐ cise with the accommodation. 42 U.S.C. § 2000bb‐1. Thus, the  70  Nos. 14‐1430 & 14‐1431  government  must  grant  the  nonprofits  the  same  exemption  that it grants to religious employers. 45 C.F.R. § 147.131(a).  IV. The accommodation is not the least restrictive means.  Even  if  the  government  had  proved  that  the  HHS  ac‐ commodation was in furtherance of a compelling interest, it  would still have to grant the nonprofits’ an exemption from  the  accommodation  because  the  accommodation  is  not  the  least  restrictive  means.  42  U.S.C.  §  2000bb‐1(b)(2).  The  Su‐ preme Court in Hobby Lobby spoke of an obvious means that  would be less restrictive than the HHS accommodation:  The most straightforward way of doing this  would  be  for  the  Government  to  assume  the  cost of providing the [objectionable] contracep‐ tives at issue to any women who are unable to  obtain them under their health‐insurance poli‐ cies  due  to  their  employers’  religious  objec‐ tions. This would certainly be less restrictive of  the  plaintiffs’  religious  liberty,  and  HHS  has  not  shown  …  that  this  is  not  a  viable  alterna‐ tive.  131  S.  Ct.  at  2780.  The  government  argues  that  RFRA  does  not require the government to create entirely new programs  to  accommodate  religious  objections,  but  the  government  provides  no  authority  for  its  position.  The  Court  did  not  hold  that  it  was  so  in  Hobby  Lobby.  Id.  at  2786.  Rather,  the  Court  stated  that  Congress  understood  that  by  passing  RFRA it might cost the government extra to avoid burdening  religion.  Id.  at  2781.  Besides,  the  government  already  main‐ tains  programs,  such  as  Medicaid  and  the  Title  X  Family  Nos. 14‐1430 & 14‐1431  71  Planning Program mentioned earlier, which could be opened  up to the employees of the nonprofits.  The government also argues that a government‐run pro‐ gram is not a valid means because it would create additional  burdens  for  the  nonprofits’  employees  and  RFRA  does  not  protect  religious  exercise  that  “unduly  restrict[s]  other  per‐ sons,  such  as  employees,  in  protecting  their  own  interests,  interests the law deems compelling.” Id. at 2786–87 (Kenne‐ dy,  J.,  concurring).  This  requirement  is  not  found  in  RFRA.  What  the  government  fails  to  acknowledge  is  that  the  pur‐ pose of an inquiry into the burdens on others is to determine  whether  a  particular  religious  accommodation  violates  the  Establishment  Clause.  See  Cutter  v.  Wilkinson,  544  U.S.  709,  719–20  (2005)  (Ginsburg,  J.).  To  determine  whether  a  reli‐ gious  accommodation  under  RFRA  is  compatible  with  the  Establishment Clause “courts must take adequate account of  the  burdens  a  requested  accommodation  may  impose  on  nonbeneficiaries,  and  they  must  be  satisfied  that  the  Act’s  prescriptions are and will be administered  neutrally among  different faiths.” Id. at 712 (citation omitted). A religious ac‐ commodation’s effect on third parties must be examined be‐ cause  “[a]t  some  point,  accommodation  may  devolve  into  ‘an unlawful fostering of religion.’” Id. at 714 (quoting Corpo‐ ration of Presiding Bishop of Church of Jesus Christ of Latter‐day  Saints  v.  Amos,  483  U.S.  327,  334‐335  (1987)).  The  Supreme  Court “has long recognized that the government may … ac‐ commodate  religious  practices  …  without  violating  the  Es‐ tablishment Clause.” Id. at 713 (quoting Hobbie v. Unemploy‐ ment Appeals Comm’n of Fla., 480 U.S. 136, 144‐145 (1987)).  72  Nos. 14‐1430 & 14‐1431  Administering a government‐run program for contracep‐ tive coverage in order to relieve the nonprofits of the burden  on their religion imposed by the accommodation would not  “devolve into ‘an unlawful fostering of religion.’” Id. at 714.  A  government‐run  program  would  provide  the  contracep‐ tion coverage on a cost‐free basis. Any burden resulting from  an employee’s participation in the program would be de min‐ imis because it truly would be nothing more than additional  paperwork  (unlike  the  self‐certification  and  alternative  no‐ tice). Furthermore, such a small burden would be no differ‐ ent  than  the  burden  experienced  by  the  many  who  obtain  dental  and  vision  care  benefits  from  different  plans  and  fill  their  prescriptions  at  pharmacies  unassociated  with  their  health care providers. It would be absurd to say that such a  de  minimis  burden  even  came  close  to  the  establishment  of  religion. Finally, any burden would be within the employee’s  power  to  avoid  by  changing  employment  to  an  employer  that  provides  the  coverage.  According  to  the  government,  when  the  contraceptive  services  mandate  was  enacted,  85%  percent  of  large  employers  and  62%  percent  of  small  em‐ ployers  already  covered  contraceptives  services  under  the  health plans. Even more plans will cover contraceptives and  that coverage will be copayment‐free now that the mandate  is in force.  V.  Conclusion  This  dissent  explores  the  road  less  traveled  by.  As  de‐ tailed above, the detour exposes two serious misrepresenta‐ tions.  First,  the  so‐called  accommodation  is  nothing  but  a  mirage.  The  government  strung  together  the  complicated  Nos. 14‐1430 & 14‐1431  73  details  to  create  a  lengthy  and  twisted  extension  cord.  The  end  result  is  the  de  facto  imposition  of  a  provision  offering  “free”  birth  control  into  the  nonprofits’  necessary  health  plans. The unwanted provision is very offensive and contra‐ ry to the nonprofits’ sincerely held religious beliefs. The im‐ position does not occur if the nonprofits refuse to plug in the  extension  cord  by  refusing  to  self‐certify  or  otherwise  indi‐ cate  consent  through  the  alternative  notice.  But  this  refusal  causes  enormous,  existential  monetary  penalties.  So,  there  are substantial burdens at both ends of the accommodation.  Second, deep into the detour is the falsehood behind the  government’s claim that increasing the availability of contra‐ ceptive  services  furthers  a  “compelling  governmental  inter‐ est.”  That  label  is  needed  to  overcome  the  nonprofits’  sin‐ cerely  held  religious  beliefs  that  no  one  disputes.  But,  con‐ traceptive  services  are  already  widely  available  from  the  great majority of employers. And, for the primarily targeted  poor  and/or  unemployed  women,  whom  the  mandate  does  not affect, there are already programs like Medicaid and Ti‐ tle  X  that  offer  free  contraceptive  services. At  its  center,  the  IOM Study recognizes that babies are medically very expen‐ sive,  so  the  government  endeavors  to  reduce  “unexpected”  pregnancies  to  save  money.  In  effect,  the  government  con‐ siders pregnancy a preventable disease.  Aside  from  the  fact  that  the  government  desires  to  sub‐ stantially  burden  the  nonprofits’  religious  exercise  in  fur‐ therance  of  an  exaggerated,  misnamed,  and  misdirected  in‐ terest,  there  are,  no  doubt,  less  restrictive  means  of  further‐ ing its interest. But why even go there? The government cer‐ 74  Nos. 14‐1430 & 14‐1431  tainly  has  no  compelling  interest  in  forcing  contraceptive  coverage  into  the  nonprofits’  otherwise  wanted  and  needed  health plans when they unanimously assert they don’t want  the  coverage  and  don’t  need  it.  The  obvious  solution  for  these  plaintiffs  (and  likely  for  the  plaintiffs  involved  in  the  similar—and  similarly  expensive—litigation  in  at  least  six  other federal circuits, see supra p.42) is for the government to  extend  the  religious  employer  exemption  to  all  religious  nonprofits that object to the coverage. 45 C.F.R. § 147.131(a).  The  nonprofits  have  shown  a  likelihood  of  success  on  their claims that the HHS accommodation violates RFRA. 42  U.S.C. § 2000bb‐1. The preliminary injunction granted by the  district court should be affirmed. Korte, 735 F.3d at 666 (“Alt‐ hough  the  claim  is  statutory,  RFRA  protects  First  Amend‐ ment free‐exercise rights, and in First Amendment cases, the  likelihood of success on the merits will often be the determi‐ native factor.” (internal quotation marks omitted)).  For all these reasons, I dissent.