Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania
The Supreme Court ruled that federal agencies acted within their legal authority when they issued rules broadly exempting employers with religious or moral objections from the Affordable Care Act's requirement to cover contraceptives at no cost to employees.
The decision ends years of litigation involving the Little Sisters of the Poor and other religious employers, clears the exemptions to take effect, and sends the cases back to lower courts — where a separate challenge about whether the rules were reasonably explained still awaits.
“the same capacious grant of authority that empowers HRSA to make these determinations leaves its discretion equally unchecked in other areas, including the ability to identify and create exemptions from its own Guidelines.”
The majority's core reasoning for why federal agencies had authority to create religious and moral exemptions from the contraceptive mandate.
How it got here: Pennsylvania sued over the 2017 exemption rules; the district court issued a nationwide preliminary injunction; the Third Circuit affirmed; the federal government and the Little Sisters asked the Supreme Court to step in, and the Court agreed to hear the consolidated cases.
The Case in Depth
What happened
The Affordable Care Act requires covered employers to provide women with free preventive health care, and federal agencies implemented this to include all FDA-approved contraceptives. The Little Sisters of the Poor — a congregation of Catholic nuns who operate homes for elderly people — and other religious employers objected that even a compromise "self-certification" opt-out made them complicit in providing contraception, violating their beliefs. In 2017, after years of failed compromise attempts, the federal government issued new rules exempting any employer with sincere religious or moral objections from the contraceptive requirement entirely.
The question before the Court
Did federal agencies have the legal authority to broadly exempt employers with religious or moral objections from the Affordable Care Act's requirement to provide employees with free contraceptive coverage?
The Court's answer
Yes — the Court held that the agencies had authority under the ACA to create both a religious exemption and a moral exemption from the contraceptive coverage requirement. The key ACA provision delegates to the Health Resources and Services Administration (HRSA) broad power to define women's preventive care guidelines, and the Court read that same grant of authority as empowering HRSA to create exemptions from its own guidelines. Because the statute imposed no express limits on that discretion, courts could not add restrictions Congress chose not to include.
The Court also rejected both procedural challenges to the rules. The interim final rules that preceded the final regulations satisfied the APA's notice requirements regardless of their title, and any labeling error was harmless because the states had full notice of the agencies' positions. The Third Circuit's "open-mindedness" test — which asked whether agencies kept a genuinely open mind during the post-promulgation comment period — was rejected because it has no basis in the APA, and courts cannot impose procedural demands on agencies beyond what Congress enacted.
Curious how the Court got there? See the step-by-step legal reasoning →
Why it matters
Employers with sincere religious or moral objections can now opt out of providing contraceptive coverage entirely without penalty. The government estimated that between 70,500 and 126,400 women of childbearing age would lose access to no-cost contraceptives through their employer's plan and would need to seek coverage through government programs, a family member's plan, or by paying out of pocket.
What changes now
The case is sent back to lower courts with instructions to dissolve the nationwide preliminary injunction, allowing the religious and moral exemptions to take effect. Pennsylvania and New Jersey are expected to press a remaining argument — that the rules are arbitrary and capricious under the APA — which the lower courts never reached because they found the rules lacked statutory authority. Justice Kagan's concurrence flagged that challenge as potentially strong.
What this does not decide
The Court did not decide whether RFRA independently required the religious exemption — only that the ACA permitted it and that agencies were right to consider RFRA. It did not address whether the exemptions are arbitrary and capricious; that issue returns to lower courts. No constitutional challenge to the breadth of Congress's delegation to HRSA was before the Court.
Concurrences and dissents
Concurrence — Justice Alito
Justice Alito, joined by Justice Gorsuch, agreed with the majority in full but wrote separately to go further: he would have held that RFRA affirmatively required the religious exemption, not merely permitted it. Walking through all three RFRA factors, he concluded the self-certification accommodation imposed a substantial burden on employers like the Little Sisters, the government lacks a compelling interest in providing free contraceptives to all women (given the ACA's many gaps in coverage), and the accommodation was not the least restrictive means. He would have ended the litigation entirely.
Concurrence — Justice Kagan
Justice Kagan, joined by Justice Breyer, agreed the agencies had statutory authority to create exemptions but would reach that result through Chevron deference to the agencies' longstanding consistent interpretation, rather than by finding the text unambiguously authorizes exemptions. She wrote separately to flag a serious open question: whether the exemptions can survive 'arbitrary and capricious' review, noting the religious exemption appears overbroad because it covers employers who had no objection to the self-certification accommodation — creating a mismatch between the problem identified and the solution chosen.
Dissent — Justice Ginsburg
Justice Ginsburg, joined by Justice Sotomayor, would have affirmed the Third Circuit. In her reading, the ACA's text gave HRSA authority only to define what preventive services group health plans must cover — not to decide which employers must provide them. She also argued the self-certification accommodation did not substantially burden religious exercise because employers were only asked to certify their objection; the obligation to provide coverage then fell on insurers by operation of law. The blanket exemption harms tens of thousands of women without authorization from either the ACA or RFRA.
How the Court got there
The legal reasoning, step by step
- The Court started with the ACA's text, focusing on the phrase 'as provided for in comprehensive guidelines supported by HRSA' in the women's preventive-care provision. It read 'as provided for' as a sweeping grant to HRSA to decide both what services must be covered and how to structure exemptions — the statute sets no list of required services, no standards for what HRSA must include, and no prohibition on exemptions.
- Because Congress gave HRSA virtually unchecked discretion and chose not to limit that authority in any of the ways it used in other statutes, courts could not supply limits the text does not contain. The rule that 'absent provisions cannot be supplied by courts' applies equally to adding terms not found in the statute and to imposing limits on agency discretion that the text does not support.
- The Court declined to decide whether the Religious Freedom Restoration Act (RFRA — a law that generally bars the government from substantially burdening religious exercise without a compelling reason and the least burdensome approach) independently required the religious exemption. It held only that the agencies were entitled to consider RFRA when crafting the rules. Prior Court decisions in Hobby Lobby and Zubik had expressly directed the agencies to account for religious objections, and ignoring RFRA entirely would have exposed the agencies to charges that the rules were arbitrary and capricious for failing to consider an important aspect of the problem.
- On the first procedural challenge, the Court held that the interim final rules (IFRs) satisfied the APA's actual notice requirements — they identified the legal authority for the rules and described the subjects and issues in sufficient detail — regardless of whether the document was labeled 'notice of proposed rulemaking.' Any labeling defect was harmless because the states suffered no prejudice: they had full notice of the agencies' reasoning and positions.
- On the second procedural challenge, the Court rejected the Third Circuit's 'open-mindedness' test — the idea that agencies must demonstrate a genuinely receptive attitude during post-promulgation comment periods. Under Vermont Yankee Nuclear Power Corp. v. Natural Resources Defense Council (a 1978 decision establishing that the APA provides the ceiling on procedural requirements courts may impose), courts cannot invent additional procedural hurdles. All four of the APA's objective procedural requirements — adequate notice, opportunity to comment, a statement of basis and purpose, and publication at least 30 days before the rule takes effect — were satisfied here.
Doctrinal impact
Cases affected by this decision
Reaffirms Burwell v. Hobby Lobby Stores, Inc. (573 U.S. 682)
The Court confirmed Hobby Lobby's holding that the contraceptive mandate violates RFRA as applied to closely held companies with sincere complicity-based religious objections.
Reaffirms Vermont Yankee Nuclear Power Corp. v. Natural Resources Defense Council, Inc. (435 U.S. 519)
The Court reconfirmed Vermont Yankee's rule that courts cannot impose procedural requirements on agencies beyond what the APA mandates, rejecting the Third Circuit's open-mindedness test.