8th Circuit Hears Oral Arguments In Religious Challenge To Health Care Transgender Anti-Discrimination Rules

On Wednesday, the U.S. 8th Circuit Court of Appeals heard oral arguments in Religious Sisters of Mercy v. Becerra. (Audio of full oral arguments.) In the case, a North Dakota federal district court granted a number of Catholic-affiliated health care and health insurance entities, and several Catholic employers, an injunction barring enforcement against them of anti-discrimination rules that require them to provide (or provide insurance coverage for) transgender transition procedures. Aleteia has an extensive report on the oral arguments.

Religious Child Placement Agency Challenges HHS Non-Discrimination Regulations

Suit was filed yesterday against the U.S. Department of Health and Human Services in a Tennessee federal district court by a religious child welfare agency that offers residential and foster care services for abused and neglected children. The suit challenges an HHS regulation that prohibits foster care and adoption programs receiving federal funds from discriminating on the basis of religion, sex, sexual orientation, gender identity or same-sex marriage status. The regulation expands upon the statutory prohibition on discrimination in such programs on the basis of race, color or national origin. The complaint (full text) in Holston United Methodist Home for Children v. Becerra,(ED TN. filed 12/2/2021), alleges that the regulation exceeds the federal agency's authority and that it violates RFRA and various 1st Amendment rights. The complaint alleges in part:

28. It would substantially burden Holston Home’s exercise of its religious beliefs to knowingly engage in child placing activities in connection with persons that do not agree with its Christian statement of faith and beliefs....

30. It would substantially burden Holston Home’s exercise of its religious beliefs to knowingly engage in child placing activities in connection with couples who may be romantically cohabitating but not married, or who are couples of the same biological sex.

The Trump Administration had issued waivers of the rule for faith-based agencies, but those waivers were rescinded by the Biden Administration last month. (See prior posting). ADF issued a press release announcing the filing of the lawsuit.

HHS Rescinds Trump Era Religious Exemptions For Child Welfare Agencies In Three States

Yesterday, the Department of Health and Human Services announced that it is rescinding waivers of non-discrimination requirements issued during the Trump Administration to South Carolina, Texas and Michigan, along with certain child welfare agencies in those states. The waivers allowed faith-based foster care placement agencies to receive federal funds even though they select foster parents on the basis of religion. (See prior posting.) In its release yesterday, HHS summarized the background for its action:

Through these waivers, States and child welfare agencies – including States and organizations that did not make such requests - were granted exemptions from program nondiscrimination requirements in a rule that was not in effect. In taking today's actions, HHS is reestablishing its long-standing Department practice of evaluation of religious exemptions and modifications of program requirements on a case-by-case basis, as needed, and as is required by law—which was unprecedently changed in 2017 by the previous Administration. Today, HHS reaffirms its important commitment to core American values:  HHS will not condone the blanket use of religious exemptions against any person or blank checks to allow discrimination against any persons, importantly including LGBTQ+ persons in taxpayer-funded programs.

Christian Employers Group Challenges HHS And EEOC Protection for Transgender Health Care

Suit was filed this week in a North Dakota federal district court by a Christian membership ministry that serves for-profit and non-profit employers challenging two federal rules on health care coverage for gender transition surgery. At issue are (1) an EEOC interpretation of Title VII that requires employers to cover gender transition services in their health plans; and (2) An HHS non-discrimination requirement that forces religiously-affiliated healthcare providers to perform gender transition surgeries, procedures, counseling, and treatments. The complaint (full text) Christian Employers Alliance v. U.S. EEOC, (D ND, filed 10/18/21), alleges in part:

31. CEA members believe and teach that each human being bears the image and likeness of God, and that the two, distinct biological sexes of male and female are complementary and together reflect the image and nature of God.

32. CEA members believe and teach that rejection of one’s biological sex is a rejection of the image of God within that person.

The suit alleges violations of RFRA, free exercise and free speech protections. ADF issued a press release announcing the filing of the lawsuit.

LGBTQ Discrimination In Placing Unaccompanied Minor Refugees Is Challenged

Suit was filed earlier this week in federal district court for the District of Columbia challenging the Office of Refugee Resettlement's contracting with religiously-sponsored agencies (including the USCCB) that discriminate on the basis of sexual orientation in providing foster parents for unaccompanied minor refugees. The complaint (full text) in Easter v. U.S. Department of Health and Human Services, (D DC, filed 10/13/2021), alleges in part:

Some ... organizations ... provide taxpayer-funded foster placement services on the federal government’s behalf in a discriminatory manner that categorically excludes lesbian, gay, and bisexual people from participating as prospective foster parents. They contend that the organizations’ religious beliefs justify denying lesbian, gay, and bisexual people from participating equally in the government program that the agencies receive taxpayer funds to administer....

The United States Constitution constrains the government by requiring freedom without favor and equality without exception in performing its functions. And what the government cannot do directly, it may not do indirectly.

Americans United issued a press release announcing the filing of the lawsuit. 

HHS Reverses Trump Administration Rules For Family Planning Grantees

The Department of Health and Human Services yesterday revoked the Trump Administration rules that prohibit family planning clinics receiving Title X funds from making referrals for abortions and which require strict physical and financial separation between abortion services and services funded by Title X monies. The HHS 124-page rule release (full text) titled Ensuring Access to Equitable, Affordable, Client-Centered, Quality Family Planning Services reinstates pre-2019 requirements, saying in part:

In addition to readopting the requirements as they existed prior to the 2019 rule, the 2021 rule also includes several revisions that will strengthen the Title X program and ensure access to equitable, affordable, client-centered, quality family planning services for all clients, especially for low-income clients, while retaining the longstanding prohibition on directly promoting or performing abortion that follows from Section 1008’s text and subsequent appropriations enactments.

The new rules require that grantees offer the opportunity for clients to receive non-directive counseling on the range of options available-- pre-natal care and delivery; infant care, foster care or adoption; and pregnancy termination. However "objecting individuals and grantees will not be required to counsel or refer for abortions in the Title X program in accordance with applicable federal law."

The new rules become effective on Nov. 6. AP reports on the new rules. Planned Parenthood issued a press release regarding the new rules.

Supreme Court Dismisses Cert. Grants On Title X Rule As HHS Considers Repeal

As previously reported, in February the U.S. Supreme Court granted certiorari in three related cases challenging a Trump Administration rule promulgated by the Department of Health and Human Services in March 2019. Among other things, the rule imposes new restrictions on abortion referrals by health care providers receiving Title X family planning funds. It effect was to cut off millions of federal dollars to Planned Parenthood. In April, however, the Biden Administration issued a proposed rule that would reverse the Trump Administration change in policy. (See prior posting.) In light of that, and the Government's assurance that it will continue to enforce the Trump Administration rules until they are changed (except in Maryland where an injunction is in force), the Supreme Court yesterday, by a vote of 6-3, dismissed the certiorari petitions. (American Medical Association v. Becerra, Docket No. 20-429, Becerra v. Mayor and City Council of Baltimore, Docket No. 20-454, Oregon v. Becerra, Docket No. 20-539, cert. dismissed 5/17/2021) (Order List.) Justices Thomas, Alito and Gorsuch would not have dismissed the petitions. SCOTUSblog reports on the Court's action.

HHS Says Affordable Care Act Bars LGBTQ Discrimination In Health Care

The U.S. Department of Health and Human Services announced yesterday that its Office for Civil Rights will interpret the Affordable Care Act's anti-discrimination provisions as including discrimination on the basis of sexual orientation or gender identity. It said that this change from Trump Administration rules was made in light of the Supreme Court's recent Bostock decision. HHS also added that in enforcing these provisions, it will comply with the Religious Freedom Restoration Act and applicable court orders.

HHS Proposes Reversal of Trump Administration Title X Family Planning Grant Rules

Yesterday the U.S. Department of Health and Human Services published a proposed rule that would reverse the Trump Administration rules on federally funded family planning services and return, with a few modifications, to the rules in effect before 2019.  As summarized by NPR News:

The [Trump Administration] rules ... forbid any provider who provides or refers patients for abortions from receiving federal funding through Title X to cover services such as contraception and STD screenings for low-income people....

The Trump administration implemented the current rules in an effort to "defund Planned Parenthood," as he had promised supporters during both his campaign and his presidency. That prompted more than 1,000 health clinics in dozens of states, including but not limited to Planned Parenthood, to leave the program.

The HHS Release (full text) titled Ensuring Access to Equitable, Affordable, Client-Centered, Quality Family Planning Services says in part:

For five decades, Title X family planning clinics have played a critical role in ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals and others.... Title X providers offered clients a broad range of effective and medically safe contraceptive methods approved by the U.S. Food and Drug Administration. Title X-funded sexually transmitted infection (STI) and human immunodeficiency virus (HIV) screening services prevented transmission and adverse health consequences....

Given the previous success of the program, the large negative public health consequences of maintaining the 2019 rules, the substantial compliance costs for grantees, and the lack of tangible benefits, the Department proposes revoking the 2019 Title X regulations. As has been clearly borne out by case law and history, the Department has the discretion to make this determination and it is in the interest of public health....

Biden Moves To Restore Funding For Family Planning Clinics; Reverses Mexico City Policy

President Biden yesterday issued Memorandum on Protecting Women’s Health at Home and Abroad (Jan. 28. 2021) (full text).  The Memorandum calls for the Secretary of Health and Human Services to consider whether to revise or repeal the Trump Administration's rules that prohibit recipients of Title X funds from referring patients to abortion providers. The rule has had a particular impact on Planned Parenthood clinics. (See prior posting.) Yesterday's Memorandum states in part:

The Title X Rule has caused the termination of Federal family planning funding for many women’s healthcare providers and puts women’s health at risk by making it harder for women to receive complete medical information.

The Memorandum also revokes the so-called "Mexico City Policy" which withholds USAID family planning funds abroad from organizations that use non-USAID funds to perform abortions, provide advice, counseling, or information on abortion, or lobby a foreign government to legalize abortion or make abortion services more easily available. The Memorandum also directs the Secretaries of State and HHS to withdraw the U.S. from the Geneva Consensus Declaration, and to resume funding to the United Nations Population Fund. CBS News has more on these developments.

HHS Adopts Amended Rules Reducing LQBTQ Anti-Discrimination Protections

The Department of Health and Human Services yesterday adopted final rules (full text of Release adopting rules) which narrow LGBTQ non-discrimination protections.  Previously, 45 CFR 75.300(c) barred discrimination on non-merit factors such as age, disability, sex, race, color, national origin, religion, gender identity, or sexual orientation in receiving benefits of HHS programs or in administering funded programs. The newly amended rule instead reads:

It is a public policy requirement of HHS that no person otherwise eligible will be excluded from participation in, denied the benefits of, or subjected to discrimination in the administration of HHS programs and services, to the extent doing so is prohibited by federal statute.

Previously 45 CFR 75.300(d) required grant recipients to treat same-sex marriages as valid. The newly amended rule instead reads:

HHS will follow all applicable Supreme Court decisions in administering its award programs.

In its 86-page release adopting the rule, HHS said that enforcing the prior rule may violate the Religious Freedom Restoration Act. ADF issued a press release announcing the adoption of the new rules. Americans United issued a press release criticizing the new rule.

US Signs Multinational Women's Health Declaration That Rejects Abortion

The U.S. Department of Health and Human Services announced that on Oct. 22, the United States co-sponsored a virtual signing ceremony for the Geneva Consensus Declaration on Promoting Women's Health and Strengthening the Family. The Declaration (full text) which calls for universal health care and supporting the role of the family was signed by 32 countries. It reads in part:

[We] Emphasize that “in no case should abortion be promoted as a method of family planning” and that “any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process”;

... Reaffirm that “the child… needs special safeguards and care… before as well as after birth”....

The signatories agreed to work together to:

Improve and secure access to health and development gains for women, including sexual and reproductive health, which must always promote optimal health, the highest attainable standard of health, without including abortion;

Reaffirm that there is no international right to abortion, nor any international obligation on the part of States to finance or facilitate abortion, consistent with the long-standing international consensus that each nation has the sovereign right to implement programs and activities consistent with their laws and policies...

The primary co-sponsors of the Declaration are Brazil, Egypt, Hungary, Indonesia, Uganda and the United States. The signatories are mostly nations from Africa, the Middle East and Eastern Europe. 

[Thanks to Scott Mange for the lead.]

Court Enjoins Two Portions of Trump Administration's New Health Care Anti-Discrimination Rules

 In Whitman-Walker Clinic, Inc. v. U.S. Department of Health and Human Services, (D DC, Sept. 2, 2020), the D.C. federal district court, in a 101-page opinion, issued a nationwide injunction barring enforcement of two of the changes to health care anti-discrimination rules made by the Trump Administration earlier this year.  (See prior posting.)  The court summarized its holding:

The Court ultimately concludes that Plaintiffs have standing to level challenges to certain provisions of the 2020 Rule, but not others, and that they are likely to succeed (and will suffer irreparable harm) on two central claims: first, that the 2020 Rule arbitrarily and capriciously eliminated “sex stereotyping” from the prior Rule’s definition of “discrimination on the basis of sex”; and second, that it improperly incorporated Title IX’s exemption of certain religious organizations from the statute’s nondiscrimination mandate. 

Suit Challenges Rollback of Health Care Anti-Discrimination Rule

Suit was filed today in a New York federal district court by two transgender women of color challenging the Department of Health and Human Services' recent rule revisions that roll back health care anti-discrimination coverage for gay and transgender individuals. The complaint (full text) in Walker v. Azar, (ED NY, filed 6/26/2020), alleges in part:

2. The 2020 Rule directly contravenes the Supreme Court of the United States’ recent holding in Bostock v. Clayton Cty., Georgia ... (June 15, 2020), that discrimination “on the basis of sex” includes, without reservation, discrimination based on an individual’s gender identity, including transgender status, or sexual orientation.

3. If allowed to take effect, the 2020 Rule will directly threaten the ability of members of the LGBTQ community to access medically necessary, potentially life-saving medical and health care by removing clear prohibitions against discrimination. And even if members of the LGBTQ community are able to access such health care, the 2020 Rule puts them at grave risk of inadequate care wrought with discrimination solely on account of their identities, which the 2020 Rule makes permissible.

Human Right Campaign issued a press release announcing the filing of the lawsuit and providing additional background.

Suit Challenges Roll-Back of Health Care Protections For Transgender Individuals

Suit was filed yesterday in the D.C. federal district court challenging the Trump Administration's recent rule change that rolled back health care anti-discrimination protection for transgender individuals. The complaint (full text) in Whitman-Walker Clinic, Inc. v. U.S. Department of Health and Human Services, (D DC, filed 6/22/2020) alleges in part:

[T]he Revised Rule imports broad and sweeping exemptions for discrimination based on personal religious or moral beliefs from the identified statutes in Section 1557 [of the Patient Protection and Affordable Care Act] and other statutes, including the Religious Freedom Restoration Act ... which Section 1557 does not reference. These exemptions invite individual health care providers, health care entities, and insurers across the country to opt out of treating patients, including many transgender patients, if they believe doing so would compromise their faith....

HHS’s attempt to create new religious exemptions in Section 1557 is contrary to law and endangers patients’ health in the name of advancing the religious beliefs of those who are entrusted with caring for them—a result sharply at odds with HHS’s stated mission to “enhance and protect the health and well-being of all Americans” and to “provid[e] for effective health and human services.”

 The Hill reports on the filing of the lawsuit.

HHS Adopts Final Rule Rolling Back Transgender and Abortion Protections In Health Care

The Department of Health and Human Services today adopted a final rule that rolls back health care anti-discrimination coverage in federally supported activities and programs. In 2016 by the Obama Administration expanded protections for transgender individuals and for those who had accessed abortion services. The 344-page adopting Release (full text) reversing those changes explains:

The 2016 Rule’s definition of discrimination “on the basis of sex” encompassed discrimination on the basis of gender identity (“an individual’s internal sense of gender, which may be male, female, neither, or a combination of male and female”). In line with that definition, the 2016 Rule imposed several requirements regarding medical treatment and coverage on the basis of gender identity. The same definition also encompassed discrimination on the basis of “termination of pregnancy” without incorporating the explicit abortion-neutrality language of 20 U.S.C. 1688 (which some commenters referred to as the Danforth Amendment) in Title IX, and it imposed a high burden of proof on providers to justify offering gynecological or other single-sex medical services. All of these are essentially legislative changes that the Department lacked the authority to make.

Responding to comments submitted on the Rule in its proposed form, the Release says in part:

The U.S. government has taken the position in Harris and other relevant litigation that discrimination “on the basis of sex” in Title VII and Title IX does not encompass discrimination on the basis of sexual orientation or gender identity. The Department shares that position and is permitted to issue regulations on the basis of the statutory text and its best understanding of the law and need not delay a rule based on speculation as to what the Supreme Court might say about a case dealing with related issues....

The Department does not condone the unjustified denial of needed medical care to anyone, and believes that everyone, regardless of gender identity or sexual orientation, should be treated with dignity and respect. The Department must interpret Congress’s purpose in passing the ACA by reading that statute’s plain text. The ACA sought to expand access to healthcare and healthcare coverage through some means but not others: in particular, Congress saw fit to incorporate into the ACA certain nondiscrimination protections, and not others. For example, in the unlikely event that a healthcare provider were to deny services to someone based solely on his or her political affiliation, the Department would not be able to address such denial of care under Section 1557. Under this final rule, OCR is committed to no less than full enforcement of the prohibitions on discrimination that Congress included in Section 1557, without exceeding the statutory text. Unlike other bases of discrimination, the categories of gender identity and sexual orientation (as well as political affiliation) are not set forth in those statutes.

Bloomberg Law reports on the new rule.

HHS Sued Over Non-Enforcement of LGBTQ Anti-Discrimination Rules

As previously reported, last November the U.S. Department of Health and Human Services announced actions that effectively allow agencies receiving HHS grants to refuse to serve gay, lesbian and transgender individuals and families on religious grounds. First, HHS issued a Notice of Non-Enforcement of  rules adopted in 2016 that prohibit such discrimination. HHS then issued a Notice of Proposed Rulemaking that would repromulgate the rules with narrower anti-discrimination protections. Yesterday, a lawsuit was filed in a New York federal district court challenging the legality of the Notice of Non-Enforcement.

The complaint (full text) in Family Equality v. Azar, (SD NY, filed 3/19/2020) contends that the Notice of Non-Enforcement violates the Administrative Procedure Actin three ways. It was promulgated without notice-and-comment rule making. It was based on a mistaken determination that the 2016 original non-discrimination rule did not comply with the Regulatory Flexibility
Act. HHS failed to consider alternative remedies, the costs and benefits of their decision, and the public interest.  Lambda Legal issued a press release announcing the filing of the lawsuit, saying in part:

As the coronavirus pandemic continues to spread rapidly throughout the U.S., LGBTQ individuals of all ages are left vulnerable by the Trump administration’s illegal action, which implicitly permits discrimination when providing critical services.

9th Circuit Upholds HHS Family Planning Grant Rules

In a 7-4 en banc decision yesterday, the U.S. 9th Circuit Court of Appeals upheld the Trump Administration's rules that apply to recipients of family planning grants under Title X. In State of California v. Azar, (9th Cir., Feb. 24, 2020),  the majority in an 82-page opinion vacated injunctions that had been entered by three district courts.  The court described the major provisions of the challenged rules:

While referrals for abortion as a method of family planning are not allowed, the Title X project may give a pregnant client a “list of licensed, qualified, comprehensive primary health care providers,” which may include “providers of prenatal care[], some, but not the majority, of which also provide abortion as part of their comprehensive health care services.” .... The Title X project may also provide referrals for abortion when such a procedure is medically necessary....

... [T]he Final Rule ... requires that a Title X project be organized “so that it is physically and financially separate . . . from activities that are prohibited under section 1008 of the Public Health Service Act..... [in order to avoid] the appearance and perception that Title X funds being used in a given program may also be supporting that program’s abortion activities.... 

The dissenters argued that the HHS rules violate Congressional mandates, saying in part:

The majority would return us to an older world, one in which a government bureaucrat could restrict a medical professional from informing a patient of the full range of health care options available to her. Fortunately, Congress has ensured such federal intrusion is no longer the law of the land.

ABC News reports on the decision.

HHS Says California Violated Federal Conscience Protections On Abortion Coverage

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights today issued a Notice of Violation (full text) to the state of California finding that the state violated federal law by making elective abortion coverage mandatory in all policies offered by insurance companies regulated by the state's Department of Managed Health Care. A Christian church and a Catholic religious order filed complaints with HHS saying that California's Mandate Letters to health care plans resulted in the religious organizations being required to offer their employees policies that cover abortions, in violation of the conscience provisions of the federal Weldon Amendment.

The Notice of Violation explains:

... [T]he only exemption California offered (to a health plan issuer) was limited to plans covering a narrow set of “religious employers” under California law. However, the Weldon Amendment protects from discrimination all plans that decline to cover abortion, without requiring any plan issuers, sponsors, or beneficiaries to have a religious character or have a religious reason for not providing or paying for such coverage.... [E]ven a categorical exemption of “religious employers,” as defined by California law, would have only been available to approximately 37% of those employer groups who, prior to the Mandate Letters, had health care coverage that limited or excluded abortion.

The Notice of Violation concludes:

If OCR does not receive sufficient assurance that California will cease requiring all health care plans, as a class, to cover abortion, or that it is willing to negotiate in good faith towards that end, OCR will forward this Notice of Violation and the evidence supporting OCR’s findings in this matter to the appropriate HHS funding components for further action under applicable grants and contracts regulations. Such referral may ultimately result in limitations on continued receipt of certain HHS funds in accordance with the Constitution and applicable Supreme Court case law. 

HHS also issued a press release explaining its action which in part quotes the Director of HHS's Office of Civil Rights:

We are putting California on notice that it must stop forcing people of good will to subsidize the taking of human life, not only because it’s the moral thing to do, but because it’s the law.

New HHS Obamacare Rule Requires Separate Bill For Abortion Services

The Department of Health and Human Services last week issued a group of rules (full text) on oversight of state Obamacare exchanges.  One portion of the new rules changes the billing requirements for health insurance policies that cover abortion services. The Affordable Care Act requires a separate payment by the policyholder for the amount of the premium that covers abortions in order to avoid public funds being used to pay for abortions.  The new rules sharpen that requirement.  As explained in the HHS Fact Sheet on the new rules, health plan issuers will now be required to:

(1) send an entirely separate monthly bill to the policy holder for only the portion of premium attributable to coverage of certain abortion services, and (2) instruct the policy holder to pay the portion of their premium attributable to coverage of certain abortion services in a separate transaction....  QHP issuers sending paper bills will be permitted to send the separate paper bill in the same mailing as the separate bill for the rest of the enrollee’s premium. QHP issuers sending bills electronically will be required to send the separate bill in a separate email or electronic communication.... However, if the policy holder fails to pay the separate bill in a separate transaction as instructed by the issuer, the issuer may not terminate the policy holder’s coverage on this basis, provided the amount due is otherwise paid.