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Real Alternatives, Inc. v. Secretary Department of Health and Human Services

United States Court of Appeals, Third Circuit

August 4, 2017

REAL ALTERNATIVES, INC.; KEVIN I. BAGATTA, ESQ.; THOMAS A. LANG, ESQ.; CLIFFORD W. MCKEOWN, Appellants
v.
SECRETARY DEPARTMENT OF HEALTH AND HUMAN SERVICES; SECRETARY UNITED STATES DEPARTMENT OF LABOR; SECRETARY UNITED STATES DEPARTMENT OF THE TREASURY; UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES; UNITED STATES DEPARTMENT OF LABOR; UNITED STATES DEPARTMENT OF TREASURY

          Argued November 3, 2016

         On Appeal from the United States District Court for the Middle District of Pennsylvania (District Court No.: 1:15-cv-00105) District Judge: Honorable John E. Jones, III

          Matthew S. Bowman (Argued) David A. Cortman Alliance Defending Freedom Counsel for Appellants Real Alternatives, Inc.; Kevin I. Bagatta, Esq.; Thomas A. Lang, Esq.; Clifford W. McKeown.

          Kevin H. Theriot, Elissa M. Graves, Alliance Defending Freedom Randy Wenger Counsel for Appellants Real Alternatives, Inc.; Kevin I. Bagatta, Esq.; Thomas A. Lang, Esq.; Clifford W. McKeown.

          Benjamin C. Mizer, Peter J. Smith, Mark B. Stern, Alisa B. Klein, Patrick G. Nemeroff, Megan Barbero, Joshua M. Salzman (Argued) Counsel for Appellees Secretary Department of Health and Human Services; Secretary United States Department of Labor; Secretary United States Department of the Treasury; United States Department of Health and Human Services; United States Department of Labor; United States Department of Treasury.

          Richard B. Katskee Natacha Y. Lam Americans United for Separation of Church and State Seth M. Marnin David L. Barkey Anti-Defamation League Counsel for Amici Curiae Americans United for Separation of Church and State; Anti-Defamation League; Central Conference of American Rabbis; Hadassah, The Women's Zionist Organization of America, Inc.; National Council of Jewish Women; People for the American Way Foundation; Union for Reform Judaism; Women of Reform Judaism.

          Before: JORDAN, GREENAWAY, JR., and RENDELL, Circuit Judges

          OPINION

          RENDELL, CIRCUIT JUDGE:

         One of the many provisions of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), requires employer-provided health insurance plans to cover an array of preventative services, including FDA-approved contraceptives, at no cost to participating employees. Employees have the option of seeking out covered medical providers and using their services, in which case they are reimbursed, or they can choose not to use them. The particular provision that includes contraceptive coverage is commonly referred to as the "Contraceptive Mandate, " and it includes a limited exemption for houses of worship and their integrated auxiliaries. See 45 C.F.R. § 147.131(a); 77 Fed. Reg. 8, 725, 8, 726 (Feb. 15, 2012). A wider set of religious non-profit and for-profit employers may receive an accommodation whereby they opt out of providing contraceptive coverage, with the Government then arranging for their employees to receive the coverage through third parties at no cost to, and with no participation of, the objecting employers. See 45 C.F.R. § 147.131(b)-(c); 78 Fed. Reg. 39, 870, 39, 874-39, 875 (July 2, 2013); Zubik v. Burwell, 136 S.Ct. 1557, 1559 (2016).

         Two years after we upheld this opt-out accommodation in Geneva College v. Secretary United States Department of Health and Human Services, 778 F.3d 422, 427 (3d Cir. 2015), vacated and remanded sub nom. Zubik, 136 S.Ct. at 1561, we now confront the house-of-worship exemption. This appeal presents two primary questions that again derive from the purported intersection of the Contraceptive Mandate and religion: (1) whether the Contraceptive Mandate must exempt a secular anti-abortion group with no religious affiliation, and (2) whether an employee's religious beliefs are substantially burdened by the law's requirement that his or her employer's insurance plan cover contraceptives. After careful review, but without any hesitation, we answer both questions in the negative.

         Appellant Real Alternatives urges that, pursuant to the Equal Protection Clause of the Fifth Amendment, if a religious organization may be exempted from the Contraceptive Mandate, then non-religious entities with an identical stance on contraceptives must be exempted as well. Real Alternatives additionally challenges the Contraceptive Mandate and the criteria for the exemption as not only arbitrary and capricious under the Administrative Procedures Act but also contrary to federal law.

         The other appellants, three employees of Real Alternatives, bring individual challenges to the Contraceptive Mandate. They argue that the Contraceptive Mandate violates the Church Amendment, 42 U.S.C. § 300a-7(d). They also argue that maintaining a health insurance plan that covers contraceptives through their employer violates their religious rights under the Religious Freedom Restoration Act, 42 U.S.C. §§ 2000bb to 2000bb-4 ("RFRA").

         The District Court denied Appellants' motion for summary judgment in its entirety and granted the Government's cross-motion for summary judgment in its entirety. Because we agree with the District Court's rulings on all of the issues raised, we will affirm.

         I. BACKGROUND

         A. Statutory and Regulatory Framework

         1. The Affordable Care Act and the Contraceptive Mandate

         In 2010, Congress passed the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) (collectively, the "ACA"). The ACA requires non-grandfathered group health plans and insurance providers to cover four categories of preventative health services, without cost-sharing, as provided for in guidelines supported by the Health Resources and Services Administration ("HRSA"), an arm of the Department of Health and Human Services ("HHS").[1] One of these four categories is "preventative care and screenings" for women.

         HHS requested assistance from the Institute of Medicine ("IOM"), a non-profit division of the National Academy of Sciences, to develop guidelines on the specific preventative services for women to be covered under the ACA (none existed at the time the ACA was passed). The IOM recommended that HRSA endorse a list of services that included "[FDA]-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity." Institute of Medicine, Clinical Preventative Services for Women: Closing the Gaps 10 (2011). Examples of FDA-approved contraceptive methods are diaphragms, oral contraceptives, intrauterine devices, and emergency contraceptives. Id. at 105-06. HRSA adopted the IOM's guidelines in full. Health Resources & Service Administration, Women's Preventative Service Guidelines, available at https://www.hrsa.gov/womensguidelines/ (last visited Jan. 27, 2017). In doing so, HRSA required every group health plan and health insurance plan to include coverage for these preventative care services to employees working at non- exempt employers (the "Contraceptive Mandate"). It did not require anything from the employee.

         2. Exemption to the Contraceptive Mandate

         At the same time as HRSA adopted IOM's recommended guidelines, an exemption from the Contraceptive Mandate for certain religious employers was proposed as an interim final regulation (the "Exemption"). 76 Fed. Reg. 46, 621 (Aug. 3, 2011). Commenters to the proposed guidelines had suggested that requiring religious employers to sponsor group health plans that provide contraceptive services could impinge on those employers' religious freedom. Id. at 46, 623. In light of those comments, HHS and the Departments of Labor and Treasury (collectively, the "Departments"), the agencies named in Real Alternatives's underlying lawsuit, authorized HRSA to exempt certain religious employers from the Contraceptive Mandate. The Departments specified that they sought "to provide for a religious accommodation that respects the unique relationship between a house of worship and its employees in ministerial positions" and that "[s]uch an accommodation would be consistent with the policies of States that require contraceptive services coverage, the majority of which simultaneously provide for a religious accommodation."[2] Id.

         The Departments originally defined a religious employer as an employer that:

(1) has as its purpose the inculcation of religious values;
(2) primarily employs persons who share its religious tenets;
(3) primarily serves persons who share its religious tenets; and
(4) is a non-profit organization under Section 6033(a)(1) and Section 6033(a)(3)(A)(i) or (iii) of the [Internal Revenue] Code.[3]

Id. The Departments also noted that HRSA's "discretion to establish an exemption applies only to group health plans sponsored by certain religious employers and group health insurance offered in connection with such plans, " and thus "health insurance issuers in the individual health insurance market would not be covered under any such exemption." Id. at 46, 623-24 (emphasis added). The Departments formally adopted the four-part definition for exempted employers in 2012. They also created a one-year safe harbor for non-exempted, non-profit organizations with religious objections, and announced that they would develop and propose changes to the regulation that "would meet two goals-providing contraceptive coverage without cost-sharing to individuals who want it and accommodating non-exempted, non-profit organizations' religious objections to covering contraceptive services . . . ." 77 Fed. Reg. at 8, 727.

         The final rules regarding the Exemption went into effect in 2012. The Departments replaced the multifactor religious employer test with one definition, essentially the fourth prong of the previous test: "[A]n employer that is organized and operates as a nonprofit entity and is referred to in section 6033(a)(3)(A)(i) or (iii) of the [Internal Revenue] Code, " which addresses churches and their integrated auxiliaries. 78 Fed. Reg. at 39, 874. The Departments noted that this new definition "continues to respect the religious interests of houses of worship and their integrated auxiliaries in a way that does not undermine the governmental interests furthered by the contraceptive coverage requirement." Id. The Departments also stated:

Houses of worship and their integrated auxiliaries that object to contraceptive coverage on religious grounds are more likely than other employers to employ people of the same faith who share the same objection, and who would therefore be less likely than other people to use contraceptive services even if such services were covered under their plan.

Id. The Departments added that their statement about a religious employer's likelihood to hire employees who share religious beliefs opposing contraceptives was made in response to commenters concerned that the Exemption would "undermine the [G]overnment's compelling interests in promoting public health and ensuring that women have equal access to health care . . . ." 80 Fed. Reg. 41, 318, 41, 325 (July 14, 2015); see also 78 Fed. Reg. at 39, 887 ("Nor do the exemption for religious employers and the accommodations for eligible organizations undermine the [G]overnment's compelling interests.").

         In 2015, the Departments stated that the Exemption was "provided against the backdrop of the longstanding governmental recognition of a particular sphere of autonomy for houses of worship, such as the special treatment given to those organizations in the [Internal Revenue] Code." 80 Fed. Reg. at 41, 325. They continued:

This exemption . . . is consistent with their special status under longstanding tradition in our society and under federal law, and is not a mere product of the likelihood that these institutions hire coreligionists. Hiring coreligionists is not itself a determinative factor as to whether an organization should be accommodated or exempted from the contraceptive requirements.

Id.

         B. Factual Background and Procedural History

         1. Appellant Real Alternatives

         Appellant Real Alternatives is a non-profit, non-religious, anti-abortion organization. It does not hold itself out as a religious entity, is not incorporated as such, and has not adopted any religious views or positions. Its primary purpose is to provide "life-affirming alternatives to abortion services, " and it offers pregnancy and parenting support programs as well as abstinence education services to women and families throughout Pennsylvania, Michigan, and Indiana. J.A. 92-93.

         Real Alternatives avers that its views on human life are based on science, reason, and non-religious philosophical principles. Id. at 93. In addition to opposing abortion, Real Alternatives opposes the use of all contraceptives because it considers these drugs to be "morally wrong." Id. at 94.

         Real Alternatives administers its programs through networks of social service agencies, which Real Alternatives hires as subcontractors. It requires all of its subcontracting organizations to share its views and to agree not to provide or recommend contraceptives or abortion. It only hires employees who share the company's stance on contraceptives and abortion.

         Since 2008, Real Alternatives has excluded contraceptive care from the health insurance plan it offers to its employees. Real Alternatives alleges that in 2014, because of the ACA, its insurer stopped omitting contraceptive care from coverage and, as a result, a new plan was offered to employees.[4] According to Real Alternatives, were it not for the ACA, its insurance provider would be willing to revert to providing a plan that omits contraceptive coverage. Real Alternatives avers that the Contraceptive Mandate violates the Equal Protection Clause and the Administrative Procedure Act ("APA").

         2. Appellants Real Alternatives Employees

         Appellants Kevin I. Bagatta, Thomas A. Lang, and Clifford W. McKeown work for Real Alternatives (the "Real Alternatives Employees"). They are, respectively, the President, Vice President of Operations, and Vice President of Administration of Real Alternatives. They are the only full-time employees of Real Alternatives, and they aver that they share the company's beliefs concerning contraceptive drugs. Each employee receives health insurance coverage through Real Alternatives, as do their wives and total of seven minor children, three of whom are female.

         The Real Alternatives Employees aver that the Contraceptive Mandate violates the Church Amendment. They also aver that the Contraceptive Mandate violates their religious rights under RFRA. Specifically, they allege that their "sincerely held religious beliefs prohibit them from using, supporting, or otherwise advocating the use of abortifacients, or participating in a health insurance plan that covers such items for themselves or their families." J.A. 123.

         3. District Court Opinion

         The District Court denied Real Alternatives's motion for summary judgment in its entirety and granted the Government's cross-motion for summary judgment in its entirety.[5] We find the District Court's analysis informative and persuasive for the most part, and we review it here.

         The District Court began by addressing Real Alternatives's equal protection claim, finding in the first instance that Real Alternatives is not similarly situated to religious employers with comparable objections to the Contraceptive Mandate because, notwithstanding those objections, they do not share the same bases for those positions-namely, religion versus a single secular position. As discussed infra, the District Court raised and distinguished two relevant federal cases, Center for Inquiry, Inc., v. Marion Circuit Court Clerk, 758 F.3d 869 (7th Cir. 2014), and March for Life v. Burwell, 128 F.Supp.3d 116 (D.D.C. 2015). The District Court also focused on the "vast history of legislative protections [that] exist[] to safeguard religious freedom, " and contrasted "[m]oral philosophies, " which it found "have been historically unable to enjoy the same privileged state." J.A. 35. The District Court continued that even if Real Alternatives were similarly situated to a house of worship, respecting religious autonomy plainly constitutes a legitimate purpose to allow the classification to stand under rational basis review. The District Court examined the Government's statements in the ACA regulations and found that it had sufficiently identified religious freedom as the purpose furthered by the Exemption. The District Court concluded its equal protection analysis by expressing concern that "[a]llowing adherence to a single moral belief . . . to be indistinguishable from religion or an entire moral creed . . . leads us down a slippery slope." Id. at 42-43. It reasoned that "finding a singular moral objection to law on par with a religious objection" could very well lead to a flood of similar objections. Id. at 44.

         Next, the District Court concluded that Real Alternatives's claim that the Contraceptive Mandate is arbitrary and capricious "fail[s] for the same reasons that [its] Fifth Amendment equal protection claim lacked merit." Id. at 49; see also id. at 48 (noting that "[t]he standard for determining whether an [APA] violation exists under the arbitrary and capricious standard is markedly similar to rational basis review"). The District Court also rejected Real Alternatives's argument that the Contraceptive Mandate violates federal law-namely, the ACA and the Weldon Amendment of the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act of 2009 (the "Weldon Amendment")-as well as the Real Alternatives Employees' claim that it violates the Church Amendment.

         Finally, the District Court rejected the Real Alternatives Employees' RFRA claim. It found that the burden at issue-maintaining an insurance plan that includes coverage for preventative services-was not substantial enough based on the Supreme Court's approach in other RFRA cases. See J.A. 62 (first citing Bowen v. Roy, 476 U.S. 693, 703 (1986) (holding that the Government could condition public benefits on the religiously prohibited act of providing a social security number without trampling on the beneficiary's free exercise rights); then citing Lyng v. Nw. Indian Cemetery Protective Ass'n, 485 U.S. 439, 449 (1988) (finding that building a road through sacred land did not violate the free exercise rights of those who believed in the land's religious significance)). The District Court concluded in the alternative that, even if the Contraceptive Mandate did impose a substantial burden, it would still satisfy RFRA because it was the least restrictive means of furthering the Government's compelling interest in a broadly applicable system of health care that advances public health and gender equality.

         II. DISCUSSION

         A. Standard of Review

         We exercise plenary review over a district court's grant of summary judgment, applying the same standard that the district court should have applied.[6] Abramson v. William Paterson Coll. of N.J., 260 F.3d 265, 276 (3d Cir. 2001). A court grants summary judgment if "there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a). There are no material facts in dispute; the questions raised by the parties are matters of law, which we review de novo. Shuman ex. rel. Shertzer v. Penn Manor Sch. Dist., 422 F.3d 141, 146 (3d Cir. 2005).

         B. Equal Protection Claim[7]

         Real Alternatives challenges the constitutionality of the Exemption's scope, arguing that it violates the organization's right to equal protection under the Fifth Amendment by exempting only religious employers and not other secular entities, such as itself, that oppose the requirements set forth in the Contraceptive Mandate. Real Alternatives urges that "[t]here is no rational purpose to impose the Mandate on those who do not want the items and will not use them, " and contends that it is excluded from the Exemption "simply because [it] is a 'non-religious ethical group[]' instead of a church." Appellants' Br. at 28 (final alteration in original). If churches receive a religious exemption, the argument goes, then so too must non-religious entities.

         1. Legal Standard

         To prevail on its equal protection claim, Real Alternatives must show that the Government has treated it differently from a similarly situated party and that the Government's explanation for the differing treatment does not satisfy the relevant level of scrutiny. City of Cleburne v. Cleburne Living Ctr., 473 U.S. 432, 439-40 (1985). The parties agree, as they must, that rational basis review is the applicable standard. Thus, there must be "a rational relationship between the disparity of treatment and some legitimate governmental purpose." United States v. Pollard, 326 F.3d 397, 407 (3d Cir. 2003) (quoting Heller v. Doe, 509 U.S. 312, 320 (1993)). Rational basis review confers a "presumption of validity" on legislation, and "the plaintiff must negate every conceivable justification for the classification in order to prove that the classification is wholly irrational." Brian B. ex rel. Lois B. v. Pa. Dep't of Educ., 230 F.3d 582, 586 (3d Cir. 2000) (citing FCC v. Beach Commc'ns, 508 U.S. 307, 314-15 (1993)).

         2. Analysis

         We must first determine whether Real Alternatives is similarly situated to a religious employer, such that the Exemption must be available to the group absent a legitimate rationale. There is no question it is not.

         Real Alternatives leans on its company-mandated eschewal of contraceptives in an attempt to situate itself in lockstep with religious employers who can avail themselves of the Exemption, contending that it is in fact "more favorably" or "identically" situated to houses of worship because all of its employees by definition oppose contraceptive coverage. Appellants' Br. at 28, 30. In making this claim, Real Alternatives invokes Center for Inquiry, in which the Seventh Circuit struck down an Indiana statute that permitted religious officials to solemnize marriages but prohibited their counterparts from secular groups from doing the same. 758 F.3d at 875. There, the court reasoned that "[a]n accommodation cannot treat religions favorably when secular groups are identical with respect to the attribute selected for that accommodation." Id. at 872.

         But Real Alternatives ignores key distinctions between that case and this one. Most notably, Real Alternatives disregards the stark contrast between itself and the appellant in Center for Inquiry, a humanist group that resembles a "religion[] in everything except belief in a deity." Id. at 871. Real Alternatives is a completely different type of entity, particularly because of its structure, aim, purpose, and function in its members' lives. Indeed, Real Alternatives's credo is limited to a one-sentence mission statement that says it "exists to provide life-affirming alternatives to abortion services throughout the nation." J.A. 92. In Center for Inquiry, the humanist organization explicitly argued that "its methods and values play the same role in its members' lives as religious methods and values play in the lives of adherents." 758 F.3d at 871 (emphasis added). Real Alternatives makes no such claim, as it is solely concerned with administering programs that reflect its moral opposition to contraceptives and abortion. Thus, Center for Inquiry does not help Real Alternatives demonstrate that it is similarly situated to a religious entity.

         However, Real Alternatives does bear some resemblance to the plaintiffs in March for Life, the district court decision upon which it heavily relies. There, the District Court for the District of Columbia granted summary judgment to a non-profit, secular anti-abortion group on its equal protection challenge to the Contraceptive Mandate. We cannot accept the district court's reasoning in that case. Relying almost exclusively on Center for Inquiry, the district court found that the secular group at issue was "similarly situated with regard to the precise attribute selected for accommodation"-specifically, a shared view that abortion is wrong. March for Life, 128 F.Supp.3d at 126 (emphasis omitted). But that court-and, by extension, Real Alternatives-ignored a crucial point: Unlike the corporation in Center for Inquiry, which involved a comprehensive belief system that happened not to be deity-centric, a secular anti-abortion group mirrors a single-issue interest group and not a religious organization that takes advantage of the Exemption. We agree with Judge Jones's observation regarding the disparities between the two groups: "In every other respect, they are different. Real Alternatives is an employer, a company, and not a belief system . . . and its single mission statement cannot guide believers comprehensively throughout life as a religion can." J.A. 42; cf. United States v. Seeger, 380 U.S. 163, 187 (1965) (accommodating a secular pacifist's objections to the draft because his beliefs "occup[y] the same place in his life as the belief in a traditional deity holds in the lives of" adherents to religion).

         Real Alternatives is in no way like a religious denomination or one of its nontheistic counterparts-not in structure, not in aim, not in purpose, and not in function. We do not doubt that Real Alternatives's stance on contraceptives is grounded in sincerely-held moral values, but "religion is not generally confined to one question or one moral teaching; it has a broader scope." Malnak v. Yogi, 592 F.2d 197, 209 (3d Cir. 1979) (Adams, J., concurring). We have accordingly noted three "guideposts" courts ought to use when identifying a religion:

First, a religion addresses fundamental and ultimate questions having to do with deep and imponderable matters. Second, a religion is comprehensive in nature; it consists of a belief-system as opposed to an isolated teaching. Third, a religion often can be recognized by the presence of certain formal and external signs.

Africa v. Pennsylvania, 662 F.2d 1025, 1032 (3d Cir. 1981). We thus agree with Amici Curiae that "Real Alternatives is functionally similar not to a church, but to the countless nonreligious 501(c)(3) nonprofit organizations that take morally informed positions on some discrete set of issues, " such as the NAACP and the National Organization for Marriage.[8] Amici Curiae Br. at 16.

         Real Alternatives overemphasizes its shared opposition to contraceptive coverage while inexplicably dismissing the Government's repeated statements that the Exemption "was provided against the backdrop of the longstanding governmental recognition of a particular sphere of autonomy for houses of worship . . . ." 80 Fed. Reg. at 41, 325. But framing the Exemption-or any religious exemption for that matter-so broadly as to encompass any employer who disagrees with any aspect of an underlying law lies in direct contradiction to the Supreme Court's refusal to broaden religion-based exemptions in similar contexts. See United States v. Lee, 455 U.S. 252, 260-61 (1982) (in a Social Security-related matter, rejecting a claim to extend a limited exemption because "[c]onfining the . . . exemption . . . provided for a narrow category which was readily identifiable, " and noting that "every person cannot be shielded from all the burdens incident to exercising every aspect of the right to practice religious beliefs"). Permitting Real Alternatives to qualify for the Exemption would similarly run afoul of this country's vast history of legislative protections that single out and safeguard religious freedom but not moral philosophy. See Corp. of the Presiding Bishop of the Church of Jesus Christ of Latter-Day Saints v. Amos, 483 U.S. 327, 338 (1987) ("Where, as here, [G]overnment acts with the proper purpose of lifting a regulation that burdens the exercise of religion, we see no reason to require that the exemption comes packaged with benefits to secular entities.");[9] Religious Land Use and Institutionalized Persons Act, 42 U.S.C. § 2000cc ("RLUIPA") (requiring religious accommodation for zoning and land use regulations); Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1003(b)(2) (exempting "church plan[s]" from retirement-plan regulations); Internal Revenue Code, 26 U.S.C. §§ 6033(a)(3)(A)(i), (iii) (carving out "churches, their integrated auxiliaries, . . . conventions or associations of churches, " and "the exclusively religious activities of any religious order" from a tax-filing requirement); Title VII of the Civil Rights Act of 1964, 42 U.S.C. § 2000e-1(a) (requiring that employers not discriminate on the basis of religion). If mere disagreement, however vehemently felt, were sufficient to bring an equal protection claim, virtually any law implicating religion would be rendered moot because the exemption would be too easy to invoke.[10] Cf. Cutter v. Wilkinson, 544 U.S. 709, 724 (2005) (acknowledging that "all manner of religious accommodations would fall" if the Court struck down one law that implicated religion because of the similarities among religious accommodation laws).

         Finally, even if Real Alternatives were deemed similarly situated to a religion, the group's challenge would still fail because of the historic principle of respect for the autonomy of genuine religions. This principle provides the legitimate purpose for the preferential treatment of religious organizations. The Exemption "provide[s] for a religious accommodation that respects the unique relationship between a house of worship and its employees in ministerial positions." 76 Fed. Reg. at 46, 623. It "was provided against the backdrop of the longstanding governmental recognition of a particular sphere of autonomy for houses of worship, " is "consistent with their special status under longstanding tradition in our society and under federal law, and is not a mere product of the likelihood that these institutions hire coreligionists." 80 Fed. Reg. at 41, 325. Real Alternatives brazenly dismisses these statements as disingenuous.[11] In doing so, it misses a crucial point about rational basis review: It is "constitutionally irrelevant whether this [legitimate] reasoning in fact underlay the legislative decision" because this Court has never insisted that a legislative body articulate its reasons for enacting a statute. U.S. R.R. Ret. Bd. v. Fritz, 449 U.S. 166, 179 (1980); see also Beach Commc'ns, 508 U.S. at 318 (applying Fritz to an administrative action). In any event, the attribute Congress selected for classification is not opposition to contraceptives; it is status as a house of worship and based on the long-established governmental desire to respect the autonomy of houses of worship regardless of their particular stance on contraceptives.

         It is beyond dispute that respecting church autonomy is a legitimate purpose-one that not only satisfies rational basis review but also is enshrined in the constitutional fabric of this country. Principles of noninterference trace back to "the text of the First Amendment itself, which gives special solicitude to the rights of religious organizations, " and recognizes their "independence from secular control or manipulation-in short, [their] power to decide for themselves, free from state interference, matters of church government as well as those of faith and doctrine." Hosanna-Tabor Evangelical Lutheran Church & Sch. v. EEOC, 132 S.Ct. 694, 704, 706 (2012) (quoting Kedroff v. Saint Nicholas Cathedral of Russian Orthodox Church in N. Am., 344 U.S. 94, 116 (1952)) (internal quotation marks omitted). Even when noninterference is not strictly required, the Government has discretion to grant certain religious accommodations subject to constitutional limitations.[12] See Cutter, 544 U.S. at 720- 22. These accommodations may be extended to houses of worship and religious denominations without applying to all nonprofit entities in order to "alleviate significant governmental interference with the ability of religious organizations to define and carry out their religious missions."[13] Amos, 483 U.S. at 335; see also Walz v. Tax Comm'n, 397 U.S. 664, 676 (1970) (upholding a property tax exemption for houses of worship); Hosanna-Tabor, 132 S.Ct. at 706 (finding a "special rule for ministers grounded in the Religion Clauses themselves").

         We reiterate, however, that Real Alternatives cannot satisfy the first prong of a successful equal protection claim. Finding all single-issue non-profit organizations to be similarly situated to houses of worship based on their adherence to a shared position on one issue would expand religious exemptions beyond what is constitutionally required. That a legitimate purpose of the highest order- respect for religious autonomy-justifies the Exemption only underscores the inevitability of our conclusion. We therefore find that Real Alternatives's equal protection claim fails as a matter of law.

         C. APA Claim

         Real Alternatives asserts two claims under the APA: (1) the Contraceptive Mandate is arbitrary and capricious because it does not serve a rational governmental purpose as applied to Real Alternatives, an organization that employs only people who oppose contraceptive coverage; and (2) it violates the Constitution and federal law. Both claims lack merit.

         1. Legal Standard

         A reviewing court may "hold unlawful and set aside agency action" that is "(A) arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law" or "(B) contrary to constitutional right, power, privilege, or immunity." 5 U.S.C. § 706(2)(A)-(B).

         We have held that the standard for determining whether an APA violation exists under the arbitrary and capricious standard is substantially similar to rational basis review:

Agency action is arbitrary and capricious if the agency offers insufficient reasons for treating similar situations differently. If [an] agency makes an exception in one case, then it must either make an exception in a similar case or point to a relevant distinction between the two cases. Review of an equal protection claim in the context of agency action is similar to that under the APA. That is, an agency's decision must be upheld if under the Equal Protection Clause, it can show a rational basis for its decision. As such, the equal protection argument can be folded into the APA argument, since no suspect class is involved and the only question is whether the . . . treatment of [appellees] was rational (i.e., not arbitrary and capricious).

Nazareth Hosp. v. Sec'y U.S. Dep't of Health & Human Servs., 747 F.3d 172, 179-80 (3d Cir. 2014) (alteration in original) (citations and internal quotation marks omitted) (emphasis added).

         2. Analysis

         Because we find that Real Alternatives's equal protection claim fails, we need not reexamine its arbitrary and capricious claim, which is subject to the same standard of review. Id.

         Real Alternatives argues that the Contraceptive Mandate also violates the APA because it infringes on two other federal laws: the ACA and the Weldon Amendment. The Real Alternatives Employees argue that the Contraceptive Mandate also violates the Church Amendment and, therefore, the APA. We disagree with these contentions and find no violations. We address each law in turn.

         a. ACA

         The ACA states that none of its provisions "shall be construed to require a qualified health plan to provide coverage of [abortion] services as part of its essential health benefits for any plan year." 42 U.S.C. § 18023(b)(1)(A)(i). Real Alternatives argues that the Contraceptive Mandate violates this provision by "requiring coverage of certain 'FDA-approved contraceptives' which act as abortifacients, in that they cause the demise of human embryos after conception and before and/or after implantation in the uterus." Appellants' Br. at 57. Real Alternatives does not cite any statutory or regulatory definition of abortion that includes contraceptives.[14]

         However, longstanding FDA regulations treat pregnancy as "the period of time from implantation until delivery, " 45 C.F.R. § 46.202(f), and categorize drugs that may prevent implantation as contraceptives rather than as abortifacients. 62 Fed. Reg. 8, 610, 8, 611 (Feb. 25, 1997) ("Emergency contraceptive pills are not effective if the woman is pregnant; they act by delaying or inhibiting ovulation, and/or altering tubal transport of sperm and/or ova (thereby inhibiting fertilization), and/or altering the endometrium (thereby inhibiting implantation)."). Further, we defer to the Government's definition because "this Court will normally accord particular deference to an agency interpretation of longstanding duration." Barnhart v. Walton, 535 U.S. 212, 220 (2002) (internal ...


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