Sharpe Holdings, Inc. v. United States Department of Health & Human Services, 801 F.3d 927

Background

CNS International Ministries and Heartland Christian College are Missouri nonprofit religious organizations that offer self-insured group health plans and object on religious grounds to certain FDA‑approved contraceptives (Plan B, ella, copper IUDs) they believe are abortifacient.
HHS/DOL/Treasury regulations implementing the ACA require group health plans to cover preventive services per HRSA guidelines, including FDA‑approved contraceptives, subject to narrow "religious employer" and grandfathered-plan exemptions.
For nonexempt religious nonprofits, regulations created an "accommodation" allowing self-certification (EBSA Form 700) or later an HHS Notice to trigger a TPA or insurer to provide contraceptive coverage without cost‑sharing; TPAs, once notified or designated, must arrange/pay for benefits and may receive reimbursement.
CNS and HCC sued under RFRA (and raised a Free Exercise claim) arguing the mandate and the accommodation (Form 700/HHS Notice) substantially burden their sincere religious exercise by forcing them to be complicit or face severe monetary penalties under the ACA.
The district court granted a preliminary injunction enjoining enforcement of the challenged provisions against CNS and HCC; the government appealed. The Eighth Circuit affirmed the injunction.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the contraceptive mandate and accommodation substantially burden plaintiffs' religious exercise under RFRA	Completing Form 700 or HHS Notice compels conduct that makes plaintiffs complicit in providing objectionable contraceptives and exposes them to crippling penalties	The accommodation does not substantially burden plaintiffs because TPAs/insurers have independent legal obligations under the ACA to provide contraceptive coverage regardless of plaintiffs' self‑certification	Held: The filing requirement (Form 700/HHS Notice) is a substantial burden because it coerces plaintiffs, under threat of severe penalties, to perform an act they sincerely believe facilitates conduct forbidden by their religion.
Whether plaintiffs likely will succeed on the merits of their RFRA claim	The accommodation is not a true accommodation because it still forces plaintiffs to participate in a scheme they find morally objectionable; thus RFRA protections apply	The government asserts a compelling interest in women’s health and equal access and contends the accommodation is the least restrictive means to achieve those interests	Held: Plaintiffs are substantially likely to succeed; the government has not shown the accommodation is the least restrictive means, and less restrictive alternatives (e.g., simple written notice like Wheaton/Zubik orders, government provision/subsidy via exchanges) exist or have not been ruled out on this record.
Whether the district court abused its discretion in granting preliminary injunctive relief	Injunction necessary to prevent irreparable religious‑exercise harm and severe penalties	Government argued injunction improper because accommodation and mandate further compelling interests and impose no substantial burden	Held: No abuse of discretion; district court properly weighed Dataphase factors and concluded likelihood of success and irreparable harm favored injunction.
Whether courts may assess substantial burden objectively despite accepting sincerity	Plaintiffs: courts must accept sincerity and not second‑guess religious line drawing; plaintiffs’ sincere belief that notice is complicit controls	Government: courts may decide as a legal matter whether the regulation objectively imposes a substantial burden (other circuits reached that conclusion)	Held: Court accepts plaintiffs’ sincere claim that the notice/framing violates their beliefs and will not substitute its judgment on religious doctrine; that suffices to find a substantial burden here.

Key Cases Cited

Burwell v. Hobby Lobby Stores, 134 S. Ct. 2751 (assumes cost‑free contraceptive access compelling under RFRA; discusses substantial burden and least‑restrictive‑means)
Gonzales v. O Centro Espirita Beneficente Uniao do Vegetal, 546 U.S. 418 (RFRA burden‑shifting: government must show compelling interest as to particular claimant)
Thomas v. Review Bd. of Ind. Emp’t Sec. Div., 450 U.S. 707 (courts must accept sincerity of religious beliefs; not arbiters of theological correctness)
Sherbert v. Verner, 374 U.S. 398 (establishes compelling interest / least‑restrictive‑means framework adopted in RFRA)
Wisconsin v. Yoder, 406 U.S. 205 (limitations on broadly formulated governmental interests; relevant to least‑restrictive‑means analysis)
Wheaton College v. Burwell, 134 S. Ct. 2806 (Supreme Court enjoined enforcement absent written notice to HHS; cited as less onerous notice alternative)
Zubik v. Burwell, 135 S. Ct. 2924 (order granting injunctive relief pending certiorari; referenced for less restrictive notice option)