11th Circuit En Banc: Exclusion of Sex-Change Surgeries from Health Care Coverage Is Not Facially Discriminatory Under Title VII

In Lange v. Houston County, Georgia, (11 Cir., Sept. 9, 2025), the U.S. 11th Circuit Court of Appeals, sitting en banc, in an 8-5 decision, held that a county's employee health insurance plan is not facially discriminatory under Title VII by reason of its exclusion of coverage for "sex change surgery." The case generated 8 opinions spanning 108 pages. The majority opinion relied in large part on the U.S. Supreme Court's decision in United States v. Skrmetti. The majority said in part:

The Supreme Court’s reasoning in Skrmetti applies equally here. The County’s policy does not pay for a sex change operation for anyone regardless of their biological sex....

Neither the Supreme Court nor this Court has held that transgender status is separately protected under Title VII apart from sex. And Bostock did not add transgender status, as a category, to the list of classes protected by Title VII. To the contrary, the Court expressly denied that it was answering any question other than “whether an employer who fires someone simply for being . . . transgender has discharged or otherwise discriminated against that individual ‘because of such individual’s sex’” within the meaning of Title VII’s plain terms....

Although the plaintiffs’ claim in Skrmetti arose under the Equal Protection Clause, the Court expressly held that the state statute at issue did not discriminate based on transgender status under the same Title VII precedents that we must apply here....

In short, the County’s plan does not facially violate Title VII. The County’s plan draws a line between certain treatments, which it covers, and other treatments, which it does not. That line may or may not be appropriate as a matter of health care policy, but it is not facial discrimination based on protected status.

Judge Newsome filed a concurring opinion, saying in part:

I write separately simply to emphasize that I don’t take either Skrmetti or today’s en banc opinion to collapse the separate analyses that apply to claims under Title VII and the Fourteenth Amendment’s Equal Protection Clause....

Judge Rosenbaum filed an opinion concurring in the judgment

... I haven’t found a meaningful way to distinguish Houston County’s healthcare plan—which excludes from coverage certain surgeries, but only if they involve (in the words of the plan) a “sex change” (a procedure one would have only to address gender dysphoria)—from the law at issue in Skrmetti.  So Skrmetti requires me to conclude that the plan doesn’t classify by sex.   

I say this with deep regret for three reasons.  First, ...  the record compellingly reveals that Houston County precludes sex-affirming surgeries for discriminatory reasons..... Second, most respectfully, Skrmetti’s conclusion that the law there didn’t discriminate by sex or transgender status ... conflicts with decades of Title VII jurisprudence....  And third, Skrmetti’s determination that the law there didn’t discriminate by sex or transgender status ... effectively imports the reasoning of Geduldig v. Aiello ... into Title VII jurisprudence.  But Congress expressly amended Title VII to reject the holding and reasoning of Geduldig....

Judge Jill Pryor, joined by Judges Jordan, Abudu, Kidd and Wilson, filed a dissenting opinion, saying in part:

The majority opinion concludes that the County health plan’s exclusion of medical care related to a “sex change” does not discriminate based on sex or transgender status because it merely “draws a line between certain treatments, which it covers, and other treatments, which it does not.” ... This is the exact same reasoning that both Congress and the Supreme Court rejected for Title VII claims....

The Skrmetti majority’s discussion of Bostock does not bind us. No Title VII claim was before the Supreme Court. Skrmetti therefore did not and could not decide whether an employer’s insurance plan that bases coverage of medical treatments on sex or transgender status violates Title VII. Nor did Skrmetti address the use of equal protection precedent in the Title VII context in commenting on Bostock.... Although we do not take lightly Supreme Court dicta, we simply are not free to follow it in the face of binding Supreme Court authority to the contrary. After all, “[t]he Supreme Court has told us, over and over again, to follow any of its decisions that directly applies in a case, even if the reasoning of that decision appears to have been rejected in later decisions and leave to that Court ‘the prerogative of overruling its own decisions.’”...

Judge Abudu filed a dissenting opinion, saying in part:

I write separately to acknowledge the ongoing cultural war in which this Court, like courts before us, has had to participate.  Our role is to ensure that, regardless of religious, political, or other ideologies, the law applies equally to all.  The majority’s decision, unfortunately, undermines that goal and sets us up for yet another episode in our Circuit’s legal history where the majority just gets the outcome wrong, and the short- and long-term implications of its flawed decision cannot be ignored....

The majority reaches its conclusion without acknowledging the elephant in the room—transgender rights have come to the forefront of debate in recent years, shining a necessary light on areas of society still rife with discrimination....

... [L]ike the early work of eliminating explicit sex- and gender based distinctions in the law, we only are tasked with reading Houston County’s healthcare exclusions to decide whether they, on their face, treat Deputy Lange worse because she is transgender, i.e., that her sex was the “but-for cause” of Houston County’s decision to deny her medical coverage.  The healthcare exclusions do just that.... 

Judge Wilson, joined by Judges Abudu and Kidd, filed a dissenting opinion, saying in part:

... Because the majority manipulates Bostock’s but-for test to obfuscate the discrimination apparent on the face of the plan, I dissent.... 

Georgia Recorder reports on the decision.

Members of Healthcare Sharing Ministry Have Standing to Challenge Insurance Regulator

In Gospel Light Mennonite Church Medical Aid Plan v. New Mexico Office of the Superintendent of Insurance, (D NM, Aug. 25, 2025), a New Mexico federal district court held that two members of a healthcare sharing ministry that was barred from operating in New Mexico by insurance regulatory authorities have standing to challenge on free exercise grounds the regulator's order that ended the ministry's operation in the state. The ministry itself was originally also a party to the lawsuit, but it was dismissed because it was challenging the action in state court.

In refusing to dismiss at this stage for lack of standing, the court said in part:

... OSI acknowledges that Plaintiffs believe “they have a biblical obligation to help their fellow man when in need which is accomplished by sharing each other’s medical expenses.”...  Further, Plaintiffs present evidence—unrebutted by OSI— showing that OSI’s final order directing Gospel Light’s to cease operations tangibly interfered with their religious beliefs and practices. While Smith and Renteria admitted that they continue to pay into Gospel Light’s sharing ministry, they also testified that OSI’s final order prevented them from participating in other aspects of the program, including the ability to share in organized prayer networks which connected them to other Gospel Light members.... Importantly, Renteria stated that OSI’s actions caused her to switch her family to a different healthcare sharing ministry....

... OSI’s final order impacted Plaintiffs’ ability to fully participate in Gospel Light’s sharing ministry. That participation is a distinct part of Plaintiffs’ religious belief structure....

Plaintiffs’ statements raise a plausible inference that they share a concrete and particularized injury: the inability to utilize Gospel Light’s health sharing ministry to its full extent due to OSI’s final order. Because the scope of those injuries remains in dispute, summary judgment is inappropriate at this stage....

Supreme Court Upholds Appointment of Task Force That Recommended Insurance Coverage for Anti-HIV Drugs

In Kennedy v. Braidwood Management, Inc., (Sup. Ct., June 27, 2025), the U.S. Supreme Court in a 6-3 decision held that the method of appointing members of the U. S. Preventive Services Task Force does not violate the Constitution's Appointments Clause. The majority opinion was written by Justice Kavanaugh. Underlying the controversy were the religious objections of plaintiffs to the Task Force's mandate requiring insurance coverage for pre-exposure drugs that prevent the transmission of HIV. Plaintiffs contended that this coverage makes them complicit in facilitating homosexual behavior, drug use and sexual activity outside of marriage. As set out in a footnote by the majority: 

Braidwood also brought a claim under the Religious Freedom Restoration Act of 1993.... It prevailed on that claim and secured an injunction against enforcement of the specific requirement that it cover certain HIV-prevention medications without cost sharing. The Government did not appeal that aspect of the District Court’s judgment, and this Court’s decision will not affect the injunction premised on Braidwood’s RFRA claim.

Justice Thomas, joined by Justices Alito and Gorsuch, filed a dissenting opinion. AJMC reports on the decision.

Supreme Court GVR's Battle Over Health Insurance Abortion Coverage

In Roman Catholic Diocese v. Harris, (Sup. Ct., June 16, 2025), the U.S. Supreme Court granted certiorari, vacated the judgment of New York's highest court and remanded the case for further consideration in light of the Supreme Court's recent decision in Catholic Charities Bureau, Inc. v. Wisconsin Labor & Industry Review Commission. At issue in the case that was gvr'd today was whether the "religious employer" exemption to the state's requirement that health insurance policies cover medically necessary abortion services is too narrow.  The exemption is only available to entities whose purpose is to inculcate religious values and that primarily employ and serve persons who share their religious tenets. (See prior posting.)

Religious Corporation Exemption to Maryland Anti-Discrimination Law Does Not Excuse LGBT Discrimination Against Data Analyst

In Doe v. Catholic Relief Services, (D MD, April 21, 2025), a Maryland federal district court held that the religious corporation exemption from the Maryland Fair Employment Practices Act does not apply to the termination of spousal health care benefits of the same-sex spouse of a data analyst and advisor working for Catholic Relief Services. The Maryland Supreme Court had previously held that "in order for the exemption to apply, the employee’s duties must directly further the core mission(s) – religious or secular, or both – of the religious entity." Finding the exemption inapplicable here, the court said in part:

... [T]he evidence preponderantly demonstrates that Doe’s ... duties and responsibilities were sufficiently apart from effectuating CRS goals (and core mission) such that his ... job activities and responsibilities were far attenuated from, and not reasonably capable of bringing about (or preventing effectuation of), CRS goals or missions.  Doe did not directly serve the poor and vulnerable overseas, solicit or secure funding for projects, or possess authority to determine how CRS would pursue its mission through its programs.  Nor did Doe manage or supervise any employee with such responsibilities.... The evidence is that from time to time, he may have been called upon to assist those who were responsible for undertaking actions that effect CRS’s goals; yet he was always one or more steps removed from taking action that effect CRS goals or that bear such responsibility. ...

Because the court concludes that none of Doe’s five full-time positions with CRS directly furthered a CRS mission, and that each of his positions was one or more steps removed from taking the actions that effect CRS goals, the court similarly concludes that CRS has not met its burden to show that MFEPA’s religious entity exemption applies here. ...

Assuming without deciding that CRS has made the threshold showing of a burden on its free exercise rights by operation of MFEPA,.., the court concludes that CRS fails to demonstrate that MFEPA is not neutral and generally applicable in its application to CRS here.

Supreme Court Hears Arguments Today on Mandated Insurance Coverage for Anti-HIV Drugs Over Religious Objections

The U.S. Supreme Court hears oral arguments this morning in Kennedy v. Braidwood Management, Inc. Plaintiffs in the case objected on religious grounds to providing their employees the U.S. Preventive Services Task Force's mandated insurance coverage for pre-exposure drugs that prevent the transmission of HIV. Plaintiffs contended that this coverage makes them complicit in facilitating homosexual behavior, drug use and sexual activity outside of marriage. In the case, the U.S. 5th Circuit Court of Appeals held that the structure of the U.S. Preventive Services Task Force violates the Appointments Clause of the U.S. Constitution. That is the issue before the Court today. Oral arguments will be streamed here at 10:00 AM. A transcript and audio recording of the arguments will be posted later today at this web page. See prior related posting.

UPDATE: Here is a link to the transcript and audio of the oral arguments. Vox reports on the oral arguments.

9th Circuit: Church Lacks Standing to Challenge Washington's Health Insurance Coverage Requirements

In Cedar Park Assembly of God of Kirkland, Washington v. Kreidler, (9th Cir., March 6, 2025), the U.S. 9th Circuit Court of Appeals in a 2-1 decision held that a church which opposes abortion and some forms of contraception lacks standing to challenge Washington's Reproductive Parity Act which requires health insurance carriers to provide coverage for contraceptives and abortions. A second state statute allows insurance companies to offer employee plans that accommodate a church's religious objections, so long as employees can separately access coverage for such services from the insurer. However, plaintiff church has been unable to find a plan that accommodates its objections. The court said in part: 

Nothing in the challenged law prevents any insurance company ... from offering Plaintiff a health plan that excludes direct coverage for abortion services. Therefore, an insurance company’s independent business decision not to offer such a plan is not traceable to the Parity Act....

Nothing in the record suggests that Plaintiff’s alleged injury would be redressed if we struck down the Parity Act....

Plaintiff contends, in the alternative, that an employer purchasing a no-abortion plan in Washington still “indirectly facilitates” the provision of abortion services to its employees.  Plaintiff relies on but-for reasoning.  As noted above, under the conscientious-objection statute, employees can obtain coverage for abortion services through their insurance carrier, whether or not the employer has a religious objection....  So, Plaintiff’s argument goes, employees receive coverage that they would not have but for the existence of the health plan provided by their employer, even if the employer’s plan does not itself provide that coverage.... We reject this theory as well.  The general disapproval of the actions that others might decide to take does not create standing, even when some tenuous connection may exist between the disapproving plaintiff and the offense-causing action.

Judge Callahan filed a dissenting opinion.  She agreed with plaintiff's "facilitation" argument. She added in part:

Cedar Park also has standing because the Parity Act caused Kaiser Permanente to stop providing a health plan that excludes abortion coverage and the church cannot procure a comparable replacement.

10th Circuit Upholds State Insurance Regulator's Closure of Christian Health Care Sharing Ministry

In Renteria v. New Mexico Office of the Superintendent of Insurance, (10th Cir., Feb. 27, 2025), the U.S. 10th Circuit Court of Appeals, in a 2-1 decision, upheld a trial court's refusal to preliminarily enjoin the enforcement of a New Mexico cease and desist order issued by the Office of the Superintendent of Insurance against a Mennonite church's health care sharing ministry. The ministry claimed that the order violated its free exercise rights.  The court said in part:

OSI’s enforcement action here was not because of Gospel Light’s religious beliefs, it was because they operated outside of the bounds of the NMIC [New Mexico Insurance Code] that applied to their business activities. In other words, OSI’s asserted interests were to protect New Mexico consumers by regulating the insurance industry, not to burden or regulate religious conduct. That other organizations, not entirely secular and not comparable to Gospel Light, merit partial exemptions under the NMIC does not carry the water for Plaintiffs that the NMIC treats a secular activity more favorably than a comparable religious activity. Consequently, rational-basis review applies.....

OSI sought to enforce the NMIC to protect consumers. The “regulation and licensure of insurance producers” are “important state interests,”... and OSI’s final order, which enforces the NMIC against Gospel Light, is rationally related to the regulation of health insurance. As such, the government action here satisfies rational-basis review, and Plaintiffs have not shown a substantial likelihood of success on the merits on their Free Exercise claims....

Judge Carson dissented, saying in part: 

State governments must enforce statutes in a neutral and generally applicable manner.  In this case, that means the New Mexico Office of the Superintendent of Insurance (“OSI”) cannot regulate Gospel Light Mennonite Church Medical Aid Plan (“Gospel Light”), a religious organization, more stringently than it regulates similarly situated secular organizations like labor unions and fraternal organizations.  But the district court reached the opposite conclusion when it allowed the OSI to impose statutory restrictions upon Gospel Light while exempting similarly situated secular organizations.  The majority upholds the OSI’s impermissible action.  Because the district court’s and the majority’s conclusions run contrary to established Tenth Circuit and Supreme Court precedent precluding discrimination based on religious views, I respectfully dissent.

Court Refuses to Enjoin Colorado's Reporting Requirements for Health Care Sharing Ministries

In Alliance of Health Care Sharing Ministries v. Conway, (D CO, Jan. 13, 2025), a Colorado federal district court refused to issue a preliminary injunction to prevent enforcement of Colorado's reporting requirement for health care sharing plans, most of which are religiously affiliated. The court said in part:

The Alliance has not made a showing—strong or otherwise—that it is likely to succeed on the merits of any of its claims.  First, the Alliance has not demonstrated that the Reporting Law is not neutral or generally applicable, or that it is not rationally related to a legitimate government interest.  Accordingly, the Alliance has not shown that it is likely to succeed on the merits of its free exercise claim.  Second, generally applicable administrative and recordkeeping regulations like the Reporting Law do not violate the Establishment Clause.  The Alliance is therefore unlikely to succeed on the merits of its Establishment Clause claim.  Third, the Alliance has not shown that the Reporting Law’s requirement that the Alliance’s members disclose certain third-party vendors poses any risk of chilling the Alliance’s members’ First Amendment associational rights.  Thus, the Alliance’s challenge to the Reporting Law on freedom-of-association grounds is unlikely to succeed.  Fourth and finally, the Alliance has not shown that the Reporting Law—in compelling the Alliance’s members divulge their marketing materials and to report factually accurate operations data—violates the Alliance’s members’ free speech rights.  The Alliance therefore has not shown that it is likely to succeed on the merits of its free speech claim.

In a motion filed Jan. 28 (full text), plaintiff seeks an injunction pending appeal.

Cert. Granted in Appointments Clause Case; Underlying Issue Is Religious Objection to Insurance Coverage Mandate

The U.S. Supreme Court yesterday granted review in Becerra v. Braidwood Management, Inc., (Docket No. 24-316, certiorari granted 1/10/2025).  (Order List). The issue before the Supreme Court set out in the petition for certiorari is whether the structure of the U.S. Preventive Services Task Force violates the Appointments Clause of the Constitution. Health insurance plans are required to cover without cost sharing various preventive services recommended by the Task Force and by two other advisory bodies. As explained in the 5th Circuit opinion being reviewed, plaintiffs object on religious grounds to providing the Task Force's mandated insurance coverage for pre-exposure drugs that prevent the transmission of HIV. Plaintiffs contend that this coverage makes them complicit in facilitating homosexual behavior, drug use and sexual activity outside of marriage. UPI reports on the Court's action.

UPDATE: on January 13, the Court denied certiorari sought by a conditional cross-petition in the case. Braidwood Management, Inc. v. Becerra, (Docket No. 24-475, certiorari denied 1/13/2025). (Order List.)

Suit Challenges Illinois Requirements for Insurance Policies to Cover Abortions

Suit was filed yesterday in an Illinois federal district court challenging on both constitutional and federal statutory grounds Illinois statutes that requires health-insurance policies to cover elective abortions on the same terms as other pregnancy-related benefits and to cover, without co-pays, abortion inducing drugs. The complaint (full text) in Students for Life of America v. Gillespie, (ND IL, filed 11/20/2024), alleges that these provisions violate free exercise rights, the right of expressive association, the federal Comstock Act, the Coates-Snow Amendment and the Weldon Amendment. Thomas More Society issued a press release announcing the filing of the lawsuit.

Organization Did Not Show That Its Anti-Abortion Views Are Religious Beliefs

In Oregon Right to Life v. Stolfi, (D OR, Sept. 30, 2024), an Oregon federal district court refused to issue a preliminary injunction against Oregon's requiring Oregon Right to Life to cover abortion and certain contraceptives in its employee health plan. The organization asserted a 1st Amendment free exercise claim.  The court said in part:

... Plaintiff is not affiliated with any religious practice or institution and does not have any religious requirement for being an employee or director.  The “specific purpose” and “personal life perspectives” that Plaintiff’s directors are required to subscribe to is free of any religious elements, requiring only that they subscribe to a belief in the importance of human life and oppose abortion, euthanasia, assisted suicide, and “life-destroying research.”  As noted, Plaintiff has over 25,000 members, who are not required to subscribe to any religious belief and are responsible for electing two members of Plaintiff’s board of directors.  Other than a fleeting reference to “Judeo-Christian ethics,” there is nothing in the articles of incorporation that would suggest any religious element in Plaintiff’s organization.   

There are many reasons why an individual or entity might oppose abortion and contraception, which range from deeply held religious conviction to the purely philosophical.  Plaintiff asserts in this litigation that its reasons, as an organization, are religious, but that assertion is not fully supported by the record.  It is not necessary for the Court, at this early stage of the case, to conclusively resolve whether Plaintiff’s beliefs are, in Plaintiff’s own scheme of things, religious.  But the Court’s review of Plaintiff’s organizational documents and requirements for membership, employment, and leadership cast doubt on whether Plaintiff’s opposition is genuinely religious in nature.  This doubt undermines Plaintiff’s showing of likely success on the merits.  

Defendant also challenges whether Plaintiff actually holds the beliefs professed in the Complaint.  As noted, a major aspect of Plaintiff’s objection the RHEA mandate is the provision of certain forms of contraception.  Plaintiff has maintained a health benefit plan through Providence Health Plans since 2015, years prior to the passage of the RHEA, and now objects that Providence Health Plans is not acceptable to them because it covers challenged forms of contraception.  The fact that Plaintiff maintained benefits through Providence Health Plans prior to the passage of the RHEA, despite its provisions concerning contraception, likewise casts doubt on Plaintiff’s claim.

Supreme Court Review Sought for NY Health Insurance Abortion Coverage Mandate

 A petition for certiorari (full text) was filed yesterday with the U.S. Supreme Court in Roman Catholic Diocese of Albany v. Harris, (Sup. Ct., filed 9/18/24). In the case New York's highest appellate court rejected a claim that the "religious employer" exemption to the state's requirement that health insurance policies cover medically necessary abortion services is too narrow.  The exemption is only available to entities whose purpose is to inculcate religious values and that primarily employ and serve persons who share their religious tenets. Plaintiffs, which are religiously affiliated entities, contend that their free exercise rights are infringed because they do not meet the criteria for the exemption. (See prior posting.) Becket Fund issued a press release announcing the filing of the petition for review.

Arizona Governor Vetoes Bill That Would Have Required Equal Insurance Coverage and Access for Gender Detransitioning

On June 18, Arizona Governor Katie Hobbs vetoed (full text of veto letter) vetoed Senate Bill 1151 (full text) that would have required health insurers that cover gender transition procedures to also provide coverage for gender detransition procedures. It would also have required physicians and hospitals that provide gender transition procedures to provide or pay for gender detransition procedures. It also would have required insurance companies to report data to the state (without identifying information on patients) on detransition claims. Governor Hobbs in her veto letter said that the bill is unnecessary and would create privacy risks for patients. Catholic News Agency reported on the Governor's veto, quoting many who disapproved of her action.

New York's Top Court Says That Religious Employer Exemption from Abortion Coverage Mandate Is Not Too Narrow

In Roman Catholic Diocese of Albany v Vullo, (NY Ct. App., May 21, 2024), New York's highest appellate court rejected a claim that the "religious employer" exemption to the state's requirement that health insurance policies cover medically necessary abortion services is too narrow.  The exemption is available only to an employer that meets 4 criteria-- it is a non-profit organization whose purpose is the inculcation of religious values and it primarily employs and serves persons who share the entity's religious tenets. Plaintiffs, which are religiously affiliated entities, contend that their free exercise rights are infringed because they do not meet the criteria for the exemption, The court said in part:

... [B]oth the regulation itself and the criteria delineating a "religious employer" for the purposes of the exemption are generally applicable and do not violate the Free Exercise Clause. Neither the existence of the exemption in the regulation nor the defined criteria allow for "individualized exemptions" that are standardless and discretionary, nor do they allow for comparable secular conduct while discriminating against religious conduct.

Reuters reports on the decision.

11th Circuit: Excluding Sex Change Surgery from Health Plan Violates Title VII

 In Lange v. Houston County, Georgia, (11th Cir., May 13, 2024), the U.S. 11th Circuit Court of Appeals in a 2-1 decision held that an employer violated Title VII's ban on sex discrimination in employment when its employee health insurance plan excluded coverage for sex change surgery. The majority said in part:

The Exclusion is a blanket denial of coverage for gender-affirming surgery.  Health Plan participants who are transgender are the only participants who would seek gender-affirming surgery.  Because transgender persons are the only plan participants who qualify for gender-affirming surgery, the plan denies health care coverage based on transgender status....

 By drawing a line between gender-affirming surgery and other operations, the plan intentionally carves out an exclusion based on one’s transgender status.  Lange’s sex is inextricably tied to the denial of coverage for gender-affirming surgery.

Judge Brasher dissenting said in part:

... [T] the employer-provided health insurance plan here does not deny coverage to anyone because he or she is transgender. The alleged problem with this plan is that it excludes coverage for sex change surgeries, not that it denies coverage to transgender people. On the face of this policy, it doesn’t treat anyone differently based on sex, gender nonconformity, or transgender status....

... [T]he majority’s reasoning effectively eliminates “disparate impact” as a separate theory of liability. For various reasons, Lange is proceeding here under a disparate treatment theory, which is why the claim requires a showing of discriminatory intent. But we have developed an entire body of law—disparate impact—to address claims about certain facially nondiscriminatory employment policies that harm members of a protected class.... That body of law requires, among other things, an evaluation of an employer’s legitimate business reasons for adopting the policy.....

TLDEF issued a press release announcing the decision.

Tennessee Legislature Passes Healthcare Sharing Ministries Exemption

Yesterday the Tennessee legislature took the final procedural steps needed to send HB 1163, Healthcare Sharing Ministries Freedom to Share Act (full text) to the Governor for his signature. It exempts from state insurance regulation tax-exempt plans under which members who share a common religious or ethical belief provide for the medical or financial needs of other members through their financial contributions.

State May Regulate Health Care Sharing Ministries

In Gospel Light Mennonite Church Medical Aid Plan v. New Mexico Office of the Superintendent of Insurance, (D NM, Oct. 13, 2023), a New Mexico federal district court refused to enjoin New Mexico's insurance superintendent from regulating Health Care Sharing Ministries. The court held that the state's Insurance Code is a neutral, generally applicable statute, saying in part:

Individual Plaintiffs argue that the Superintendent’s March 26, 2020, press release, --- which cautions consumers about HCSMs and stating that these plans are unauthorized insurance products—is not neutral because it “sends a signal of official disapproval” of Individual Plaintiffs’ religious beliefs.... The Court disagrees....

Applying rational basis review, the court said that it "has little difficulty concluding that state laws mandating compliance with the Insurance Code constitute a legitimate area of governmental concern."

MD Supreme Court: State Law Sex Discrimination Ban Does Not Include Sexual Orientation Discrimination

In Doe v. Catholic Relief Services, (MD Sup. Ct., Aug. 14, 2023), the Maryland Supreme Court, responding to certified questions from a federal district court, refused in interpreting state law to follow the analogous holding of the U.S. Supreme Court in its Title VII Bostick decision.  The Maryland court held that, in light of the separate prohibition on sexual orientation discrimination in state law, the ban on sex discrimination in the Maryland Fair Employment Practices Act does not also cover discrimination on the basis of sexual orientation. It went on to hold that in light of the specific ban on pay disparities based on sex or gender identity, the Maryland Equal Pay for Equal Work Act does not bar pay disparities based on sexual orientation. Finally the court held that the exemption in the Maryland Fair Employment Practices Act for "a religious corporation, association, educational institution, or society with respect to the employment of individuals of a particular religion, sexual orientation, or gender identity to perform work connected with the activities of the religious entity" covers "claims brought by employees who perform duties that directly further the core mission (or missions) of the religious entity." It is not co-extensive with the ministerial exception doctrine.

Justice Hotten, joined by Justice Eaves, filed a dissenting opinion contending that the ban on sex discrimination in both statutes includes sexual orientation discrimination. They would also read the religious institution exemption more narrowly than the majority, contending that it only applies when a nexus exists between the employer’s religious activities and the work that an employee performs.

The underlying case that led to the certified questions involved a complaint by a Program Data Analyst employed by Catholic Relief Services who was denied spousal health benefits for his same-sex spouse.

[Thanks to Arthur Spitzer for the lead.]

Conscience Clause in Health Insurance Mandate Does Not Violate Church's Free Exercise

In Cedar Park Assembly of God of Kirkland, Washington v. Kreidler, (WD WA, July 25, 2023), a Washington federal district court dismissed a free exercise challenge by a church to a Washington law requiring all health insurance plans that provide maternity coverage to also provide substantially equivalent abortion coverage. Under the law, employers with religious or moral objections to specific services do not have to purchase coverage for those services, but enrollees must still be able to access coverage for the services. The court said in part:

None of the State’s arguments seem to fully address the crux of Cedar Park’s facilitation complaint: that its employees would not have access to covered abortion services absent Cedar Park’s post-SB 6219 plan. This fact is undisputed and undoubtedly true. Because of SB 6219, Cedar Park’s employees gained coverage for abortion services under their employer-sponsored health insurance plan that they would not otherwise have. Even if the “facilitation” is somewhat minimal, SB 6219 requires Cedar Park to facilitate access to covered abortion services contrary to Cedar Park’s religious beliefs....

Because the Court concludes that SB 6219 is neutral and generally applicable, the law is valid if it is rationally related to a legitimate governmental purpose....

The Washington legislature identified multiple legitimate governmental purposes for enacting SB 6219, including promoting gender equity, promoting economic success of women, improving women’s health, and protecting privacy.