State Insurance Regulators Target Trinity Health-Care Sharing Ministry

NPR reported earlier this week on enforcement actions by insurance regulators in Texas, Colorado, Washington and New Hampshire against Aliera and its affiliate Trinity HealthShare for violating rules relating to health-care sharing ministries. These plans for sharing health care costs of members are significantly cheaper than standard health insurance policies. Most of the Christian affiliated ministries will not cover abortion services, and offer prayer hotlines for members. The October 30 press release from the New Hampshire Insurance Department announcing its enforcement action states in part:

Trinity represents itself as a health care sharing ministry, which would be exempt from state insurance regulation. A legal health care sharing ministry is a nonprofit organization in existence since December 31, 1999, whose members share a common set of ethical or religious beliefs and share medical expenses among members. [Trinity was not formed until 2018 and did not show it is faith based and limited its membership to those with common beliefs.]

The Department’s Consumer Services Division received dozens of complaints and concerns from consumers. Some people believed they were buying health insurance and did not know they had joined a health care sharing ministry. Many people discovered this when their claims were denied because their medical conditions were considered pre-existing under the plan, or were not covered because they were deemed inappropriate for a “Christian lifestyle.” 

[Thanks to Scott Mange for the lead.]

Court Sets Aside New Health Care Conscience Rules

In City and County of San Francisco v. Azar, (ND CA, Nov. 19, 2019), a California federal district court set aside rules adopted earlier this year by the Department of Health and Human Services to give additional protection to conscience rights of health care providers. The court said in part:

With the minor exceptions noted below, the new rule is purely an interpretive rule, not a legislative rule. An agency, of course, must interpret a statute under its care. But an interpretation, even if cast in the form of a regulation, is nothing more than that — an interpretation. The statute itself is what has the force of law, not the interpretation. No interpretation can add or subtract from the actual scope of the statute itself. If the agency misconstrues a statute, then the statute controls, not the interpretation.....

... Congress tried to strike a balance between two competing considerations. One consideration was recognition that, due to religious or ethical beliefs, some doctors, nurses, and hospitals, among others, wanted no part in the performing of abortions and sterilizations, among other medical procedures, and Congress wanted to protect them from discrimination for their refusal to perform them. The countervailing consideration was recognition of the need to preserve the effective delivery of health care to Americans, including to those seeking, for example, abortions and sterilizations. Every doctor or nurse, for example, who bowed out of a procedure for religious or ethical reasons became one more doctor or nurse whose shifts had to be covered by someone else, a burden on the healthcare system. Congress struck a balance between these two opposing considerations.

In reading the rule in question, the Court sees a persistent and pronounced redefinition of statutory terms that significantly expands the scope of protected conscientious objections. As laudable as that sounds, however, it would come at a cost — a burden on the effective delivery of health care to Americans in derogation of the actual balance struck by Congress.

California's Attorney General issued a press release commenting on the decision.  KPIX5 reports on the decision.

Court Invalidates HHS Conscience Rules

In State of New York v. U.S. Department of Health and Human Services, (SD NY, Nov. 6, 2019), a New York federal district court vacated a 2019 rule promulgated by HHS which, as summarized by the court:

purports to interpret and provide for the implementation of more than 30 statutory provisions that recognize the right of an individual or entity to abstain from participation in medical procedures, programs, services, or research activities on account of a religious or moral objection. [See prior posting].

The court summarized the conclusions it reached in its 147-page opinion:

With respect to the Church, Coats-Snowe, and Weldon Amendments, HHS was never delegated and did not have substantive rule-making authority.....

 With respect to all Conscience Provisions, HSS was never delegated and did not have authority to promulgate a Rule authorizing, as a penalty available to the agency for a recipient’s non-compliance, the termination of all of the recipient’s HHS funds....

With respect to all Conscience Provisions, the Rule is contrary to law... insofar as (1) in its application to the employment context, it conflicts with Title VII of the Civil Rights Act of 1964 ... to prescribe a framework governing the circumstances under which an employer must accommodate an employee’s religion-based objections; and (2) in its application to emergencies, it conflicts with the 1986 Emergency Medical Treatment and Labor Act....

With respect to all Conscience Provisions, HHS acted arbitrarily and capriciously in promulgating the Rule,... because (1) HHS’s stated reasons for undertaking rulemaking are not substantiated by the record before the agency, (2) HHS did not adequately explain its change in policy, and (3) HHS failed to consider important aspects of the problem before it.

With respect to all Conscience Provisions, HHS did not observe proper rulemaking procedure in promulgating the Rule... insofar as portions of the Rule that define “discriminate or discrimination” were not a “logical outgrowth” of HHS’s notice of proposed rulemaking....

With respect to all Conscience Provisions, the Rule’s authorization ... as a penalty ... in the event of a recipient’s non-compliance of the termination of all of the recipient’s HHS funds, violated the Separation of Powers and the Spending Clause of the Constitution, U.S. Const. art. I, § 8, cl. 1.

Reuters reports on the decision.

UPDATE: A press release from the Washington state Attorney General's office reports that on Nov. 7 a federal district court in Washington also found the new conscience rules invalid.

Court Vacates Obama-Era Rule Mandating Gender Transition and Abortion Procedures

In Franciscan Alliance, Inc. v. Azar, (ND TX, Oct. 15, 2019), a Texas federal district court vacated and remanded for further consideration a rule issued by the Obama administration under the Patient Protection and Affordable Care Act that prohibits discrimination on the basis of gender identity or termination of pregnancy in health care programs that receive federal financial assistance. The court relied on reasoning in its earlier preliminary injunction decision (see prior posting) concluding that requiring health care providers to perform and provide insurance coverage for gender transitions and abortions in violation of their religious beliefs violates RFRA.  The court held that vacatur is the proper remedy for an unlawful agency rule, and so refused to also issue a nationwide permanent injunction. In the case the court had allowed the ACLU and the River City Gender Alliance to intervene to defend the Obama administration rule. Becket Law issued a press release announcing the decision.

Suit Against Catholic Hospital That Refused Transgender Procedure May Move Ahead

In Minton v. Dignity Health, (CA App., Sept. 17, 2019), a California state appellate court held that a trial court should not have dismissed a suit filed under the Unruh Civil Rights Act by transgender man whose doctor was barred by a Catholic hospital from performing a hysterectomy for treatment of his gender dysphoria.  The refusal was based on Ethical and Religious Directives for Catholic Health Care Services.  The court said in part:

[Plaintiff] alleges that the Act was violated ... when defendant cancelled the scheduled procedure at Mercy and Mercy’s president told Dr. Dawson that she would never be allowed to perform Minton’s hysterectomy at Mercy.... [T]hat refusal was not accompanied by advice that the procedure could instead be performed at a different nearby Dignity Health hospital. At that point in time ... Minton was denied full and equal access to health care treatment, a violation of the Unruh Act.

Allegedly in response to pressures brought to bear on defendant, within a relatively short period of time Ivie proposed use of the facilities at the alternative hospital. In doing so, and in making those alternate facilities available three days later, defendant undoubtedly substantially reduced the impact of the initial denial of access to its facilities and mitigated the damages to which Minton otherwise would have been entitled. However, the steps that were taken to rectify the denial in response to pressure from Minton and from the media did not undo the fact that the initial withholding of facilities was absolute, unqualified by an explanation that equivalent facilities would be provided at an alternative location.

The Recorder reports on the decision.

Medical Center's Retirement Plan Is A "Church Plan" Exempt From ERISA

In Boden v. St. Elizabeth Medical Center, Inc., (ED KY, July 25, 2019), a Kentucky federal district court held that the employee retirement plan of a Catholic-affiliated health care provider is exempt from ERISA as a "church plan."  The case was initially stayed pending the Supreme Court's 2017 decision in Advocate Health Care Network v. Stapleton. (See prior posting.)  The case then proceeded under an amended complaint.  The court here, among other things, rejected plaintiffs' contention that the Pension Plan Administrative Committee is not "organization" that "maintained" St. Elizabeth's retirement plan, as required by the statute defining a "church plan." [Thanks to Tom Rutledge for the lead.]

HHS Agrees To Delay In Implementing New Health Care Conscience Rules

The Department of Health and Human Services will delay at least until Nov.22 implementation of its newly adopted rules for conscience protection of health care providers.  The move came through an consent order submitted by the Justice Department and the San Francisco City Attorney Dennis Herrera in a lawsuit brought by Herrera challenging the new rules. (See prior posting.) The delay will allow time for the court to decide the merits of the challenge. Announcing the filing of the consent order, Herrara said in part:

The Trump administration is trying to systematically limit access to critical medical care for women, the LGBTQ community, and other vulnerable patients. We’re not going to let that happen. We will continue to stand up for what’s right. Hospitals are no place to put personal beliefs above patient care. Refusing treatment to vulnerable patients should not leave anyone with a clear conscience.

Two More Suits Challenge Expanded Religious Accommodation For Health Care Providers

Suit was filed yesterday in New York federal district court challenging rules recently adopted by the U.S. Department of Health and Human Services (see prior posting) expanding the protection of conscience rights for health care providers.  The 63-page complaint (full text) in National Family Planning and Reproductive Health Association v. Azar, (SD NY, filed 6/11/2019) alleges that:

The Final Rule encourages and authorizes discrimination by unlawfully granting a wide swath of institutions and individuals broad new rights to refuse to provide health care services and information.

The complaint elaborates:

The Rule will exacerbate existing systemic barriers by endangering Plaintiffs’ members’ ability to provide care to already underserved populations. For example:

• By requiring the absolute accommodation of an employee’s refusal to provide certain information and services, the Final Rule could at any time force Plaintiffs to reduce the availability or scope of services they provide or even eliminate them entirely, particularly in small locations that may rely on a single staff member to perform multiple job functions.
• By prohibiting Plaintiffs from even asking job applicants whether they are willing to perform basic job requirements, and because the Final Rule does not require employees who intend to refuse to so notify their employers or their patients, neither Plaintiffs nor their patients may be aware when a staff member is denying a patient access to needed care or information;
• By prohibiting those of Plaintiff NFPRHA’s members who are state and local governmental Title X grantees from requiring sub-recipients to comply with the statutory and regulatory requirements of Title X’s abortion counseling and referral, the Final Rule will systematically undermine the integrity of the Title X program, further jeopardizing the ability of Plaintiffs’ patients to access necessary health care and make voluntary, informed decisions about their reproductive health.

The ACLU issued a press release announcing the filing of the lawsuit.

Separately, Planned Parenthood filed a similar lawsuit. (Full text of complaint in Planned Parenthood Federation of America, Inc. v. Azar, (SD NY, filed 6/11/2019). Courthouse News Service reports on this lawsuit.

A similar challenge to the new Rule was filed last month by a number of states and cities. (See prior posting.)

States and Cities Sue Administration Over Expanded Health Care Conscience Rules

Yesterday 19 states, the District of Columbia as well as New York City, Chicago and Cook County, Illinois together filed suit in a New York federal district court challenging rules recently adopted by the Department of Health and Human Services (see prior posting) expanding the protection of conscience rights of health care providers. The rules were formally published in the Federal Register yesterday. The 80-page complaint (full text) in State of New York v. U.S. Department of Health and Human Services, (SD NY, filed 5/21/2019) alleges in part:

This lawsuit challenges a U.S. Department of Health and Human Services regulation that – in an unprecedented and unlawful expansion of nearly thirty federal statutory provisions – would compel the Plaintiff States and local jurisdictions to grant to individual health providers the categorical right to deny lawful and medically necessary treatment, services, and information to patients, based on the provider’s own personal views.... [I]t will undermine the Plaintiffs’ ability to administer their health care systems and deliver patient care effectively and efficiently.

[T]he Final Rule seeks to coerce the Plaintiffs to comply with the Department’s overbroad application of federal law by subjecting the Plaintiffs to ... denial of potentially all federal health care funds if the Department determines... that the Plaintiffs... have failed to comply with the Final Rule... [T]his financial exposure could amount to hundreds of billions of dollars each year.

...The Final Rule far exceeds in scope and substance the underlying federal health care statutes...; conflicts with federal statutes regarding access to health care, informed consent, the provision of emergency medical services, and religious accommodations; violates constitutional safeguards that assign the spending power to Congress and prohibit the Executive Branch from coercing states to implement preferred federal policies; and violates the Establishment Clause by imposing a categorical requirement that Plaintiffs accommodate the religious objections of their employees, whatever the cost.

New York's Attorney General issued a press release announcing the law suit.

Separately, the state of California filed a similar challenge. The complaint (full text) in State of California v. Azar. (ND CA, filed 5/21/2019) is discussed in this press release from the California Attorney General.

HHS Adopts Final Rules On Conscience Protection In Health Care; Suit Filed Challenging New Rules

The U.S. Department of Health and Human Services Office of Civil Rights has submitted for publication in the Federal Register final rules on protecting the conscience rights of health care providers. The rules, set out in a 440-page release (full text), become effective in 60 days.  The Release summarizes the new rules:

This final rule revises existing regulations to ensure vigorous enforcement of Federal conscience and anti‐discrimination laws applicable to the Department, its programs, and recipients of HHS funds, and to delegate overall enforcement and compliance responsibility to the Department’s Office for Civil Rights (“OCR”). In addition, this final rule clarifies OCR’s authority to initiate compliance reviews, conduct investigations, supervise and coordinate compliance by the Department and its components, and use enforcement tools otherwise available in existing regulations to address violations and resolve complaints.

New York Times, reporting on the new rules, says in part:

some groups said they feared the provisions were overly broad and could imperil care for patients seeking reproductive health care. They also said it could lead to discrimination against gay or transgender patients and their children, and weaken public health efforts to expand childhood vaccinations.

Yesterday, San Francisco City Attorney Dennis Herrera announced that he has filed suit to invalidate the new rules. The complaint (full text) in City and County of San Francisco v. Azar, (ND CA, filed 5/2/2019), alleges in part:

The Final Rule requires the City and County of San Francisco (“City” or “San Francisco”)—in any and all circumstances—to prioritize providers’ religious beliefs over the health and lives of women, lesbian, gay, bisexual, or transgender people, and other medically and socially vulnerable populations. If San Francisco refuses to comply, it risks losing nearly $1 billion in federal funds that support critical health care services and other vital functions.

The suit alleges that the new rules are in violation of federal statutes and various constitutional provisions including the Establishment Clause.

Suit Challenges Washington State's Required Abortion Coverage

Last week, a church in Washington state filed suit in federal district court challenging the constitutionality of Washington Senate Bill 6219 signed into law last March which requires all health care plans in the state to cover contraceptives and sterilization, and to cover abortion to the same extent as they cover maternity care.  The complaint (full text) in Cedar Park Assembly of God of Kirkland, Washington v. Kreidler, (WD WA, filed 3/8/2019), alleges in part:

52. ... [T]his law targets organizations that have religious and moral beliefs against abortion. Washington State has a history of targeting religious and moral pro-life organizations and individuals.

53. The strong statutory language, lack of any church exception, and anticipated evidence that pro-abortion groups assisted in drafting and enacting SB 6219, indicates that Washington and its officials deliberately targeted religious organizations and intentionally violated those organizations’ religious beliefs.

The suit alleges violations of the Free Exercise, Equal Protection and Establishment Clauses. ADF issued a press release announcing the filing of the lawsuit.

Churches' Challenge To Required Abortion Health Care Coverage Rejected

In Foothill Church v. Rouillard, (ED CA, March 7, 2019). a California federal district court dismissed a suit brought by three churches challenging a ruling by the California Department of Managed Health Care that requires health insurance companies to include coverage for abortion services in all health insurance policies.  Rejecting the churches' Free Exercise claim, the court held that the churches have not alleged sufficient facts to call into question the defense that the ruling is a neutral law of general applicability. It also rejected the churches' equal protection claim saying that there was no showing that the state acted with the intent to adversely affect plaintiffs' religious beliefs.

Appeals Court Vacates Invalidation of California's Assisted Suicide Law

In People ex rel Becerra v. Superior Court of Riverside County, (CA App., Nov. 27, 2018), a California state appellate court issued a writ of mandate ordering the trial court to vacate its decision striking down California's End of Life Option Act.  The Act legalizes physician-assisted suicide for the terminally ill.  The trial court had held that the Act was outside the scope of the proclamation calling the special session of the legislature that passed it.  The majority in the appellate court held that plaintiffs-- doctors and a Christian medical society-- lack standing to bring the challenge.  Judge Slough, dissenting in part, argued that the court should reach the merits of the challenge to the law and should hold that the law was constitutionally enacted.  Courthouse News Service reports on the decision.

Suit Challenges Idaho Invalidation of Pregnant Women's Living Wills

Suit was filed in an Idaho federal district court last week challenging the constitutionality of an Idaho statute that invalidates a woman's health care advance directive if the woman is pregnant.  The complaint (full text) in Almerico v. Denney, (D ID, filed 5/31/2018) alleges in part:

That law improperly infringes on the right to privacy in making medical decisions and subjects women of child bearing age to unequal and demeaning treatment in multiple ways. First, the law on its face eliminates the right of a woman who has been diagnosed as pregnant to have her express decisions about medical treatment, including whether to request or decline life-sustaining measures, honored by her health care providers. Second, the law renders ineffective the right of a woman who has been diagnosed as pregnant to designate her health care agent. Third, because of the law, the effectiveness of the health care directives of all women of childbearing age in Idaho is thrown into question until each woman’s pregnancy status is determined. Additionally, Defendants have exceeded the statute’s mandate by publicly stating that not only will the health care directives of women who have been diagnosed as pregnant be rendered null and void, but they will be forced to receive life-sustaining treatment for the duration of their pregnancies.

Denial of Spousal Health Benefits Because of Religious-Only Ceremony May Violate Equal Protection Clause

In Ali v. Cooper, (ND CA, Jan. 30, 2018), a California federal district court refused to dismiss an equal protection claim by an employee of the Alameda Housing Authority (AHA) after her husband's health insurance coverage was terminated.  The action was taken by the Executive Director (Cooper) and Director of Human Resources (Basta) because the couple were married in a Muslim solemnization ceremony without a civil marriage certificate. Plaintiff claims that the two defendants were motivated by religious animus in singling her out and invoking a rarely used obscure policy to deny coverage. The court said in part:

Plaintiff adequately states a claim for intentional discrimination on the basis of her religion under the Equal Protection Clause against Defendants Cooper and Basta. This claim, however, is inadequately pled against the AHA ... because Plaintiff does not allege that the official marriage-certificate policy itself was motivated by animus, but rather, that the Individual Defendants’ enforcement of the policy against her was motivated by animus....

There may be an argument that Defendant’s marriage-certificate policy might not be narrowly tailored to achieve a compelling state interest if it fails to recognize a marriage that lacks a civil certificate but is nevertheless legally valid. At this time, however, Plaintiff has not alleged that her marriage was legally-valid.... Additionally, Plaintiff has not alleged that the marriage-certificate policy burdens a sincerely held religious belief. Thus, at this time, this First Amendment theory is inadequately pled.

Report Says Women of Color Disproportionately Give Birth In Catholic Hospitals In 19 States

The Columbia Law School Public Rights/ Private Conscience Project yesterday released a new report Bearing Faith: The Limits of Catholic Health Care for Women of Color. The study focuses on racial disparities of women giving birth in Catholic hospitals governed by Ethical and Religious Directives for Catholic Health Care Services.  According to the report:

The ERDs forbid hospitals owned by or affiliated with the Catholic Church ... from providing many forms of reproductive health care, including contraception, sterilization, many infertility treatments, and abortion, even when a patient’s life or health is jeopardized by a pregnancy. Catholic hospitals represent a large and growing part of the U.S. health care system. One in six hospital beds in the country is in a hospital governed by the ERDs....

This study finds that in nineteen out of the thirty-four states/territories that we studied, women of color are more likely than white women to give birth at hospitals bound by the ERDs.

The study found that in 12 states and one territory, Catholic hospitals disproportionately served white women, two states showed little disparity, and seven states had no Catholic birth hospitals.

10th Circuit: ERISA "Church Plan" Exemption Does Not Violate Establishment Clause

In Medina v. Catholic Health Initiatives, (10th Cir., Dec. 19, 2017), the U.S. 10th Circuit Court of Appeals held that Catholic Health Initiatives retirement plan for employees of 92 hospitals qualifies as a "church plan" under ERISA. One of the issues in the case was resolved by the Supreme Court while this appeal was pending.  Resolving the other issues, the 10th Circuit held that CHI's internal benefits committee qualifies as the statutorily required organization associated with a church that maintains a retirement plan.  The Court went on to conclude that the "church plan" exemption does not violate the Establishment Clause.  It held that the exemption meets all three prongs of the Lemon test.  Rejecting the argument that the exemption has the effect of favoring religion, the Court said in part:

Any law of general applicability that exempts religious organizations from its requirements could be said to convey a message that religion is favored. Religion is, after all, being exempted from a rule everyone else has to follow. Such an approach would mean that Congress could never exempt religious organizations from laws that might burden them—even when burdening religious organizations would itself run afoul of the Constitution. But this is common practice. A number of statutes regulate wide swathes of the American economy. And many of these statutes expressly exempt religious organizations from various requirements. 

Court Upholds California Requirement That Health Plans Cover Abortions

In Foothill Church v. Rouillard, (ED CA, Sept. 1, 2017), a California federal district court upheld against a free exercise challenge letters from the California Department of Managed Health Care requiring private health insurers to remove all limitations on or exclusions of abortion services from their health care policies.  Three churches sued arguing that this prevents them from providing their employees with health insurance that is consistent with their Christian teachings.  The court in dismissing plaintiffs' amended complaint held, however, that the Department's letters were neutral and generally applicable, and thus consistent with the free exercise clause.  Plaintiffs also alleged that the Department had granted an exception to one health care plan, allowing it to exclude coverage for abortion except in the case of rape or incest, but has not granted an exception for a policy that excludes abortion coverage in all cases. The court said, however, that plaintiffs did not allege that a plan with total exclusions had been submitted, or that an exemption for it had been rejected. WND has additional background. (See prior related posting.)

Court Enjoins Illinois Law Requiring Referrals Out For Abortions

In National Institute of Family Life Advocates v. Rauner, (ND IL, July 19, 2017), an Illinois federal district court granted a preliminary injunction to plaintiffs, a group of pro-life health care facilities and medical personnel, who object to Illinois SB 1564.  The statute, as a condition of immunity from suit for not performing conscience-infringing health care services, requires objecting personnel to refer the patient elsewhere for the services.  The court, citing other free-expression cases, concluded:

...the amended act under review in this case applies only to health care providers with conscience-based objections to certain legal treatment options such as abortion. Therefore, the court finds that plaintiffs have demonstrated a likelihood of showing that the amended act discriminates against health care providers that are of the point of view that abortion is wrong by compelling only them to speak a message that, from their viewpoint, is abhorrent.

The court issued a preliminary injunction barring enforcement of the statute

to the extent that enforcement would penalize health care facilities, health care personnel, or physicians who object to providing information about health care providers who may offer abortion or who object to describing abortion as a beneficial treatment option.

Christian Post reports on the decision.

Court Enjoins Health Care Gender Identity and Abortion Non-Discrimination Rule

Today, in a 46-page opinion, a Texas federal district court issued a nationwide preliminary injunction barring enforcement of a regulation issued by the Obama administration under the Patient Protection and Affordable Care Act that prohibits discrimination on the basis of gender identity or termination of pregnancy in health care programs that receive federal financial assistance. In Franciscan Alliance, Inc. v. Burwell, (ND TX, Dec. 31, 2016), a Texas federal district court, in a suit by eight states and three private health care providers, first held that the Department of Health and Human Services exceeded its authority in interpreting the statutory ban on "sex" discrimination to include discrimination on the basis of gender identity, stating:

Title IX and Congress’s incorporation of it in the ACA unambiguously adopted the binary definition of sex.

The court also concluded that the health care providers have shown a substantial likelihood that the challenged Rule violates the Religious Freedom Restoration Act in requiring them to perform and provide insurance coverage for gender transitions and abortions in violation of their religious beliefs. Becket Fund issued a press release announcing the decision.

Judge Reed O'Connor who handed down the decision had previously issued a nationwide injunction baring enforcement of federal guidelines interpreting Title IX as barring discrimination by schools on the basis of gender identity. (See prior posting.)