Full opinion text
HAYWOOD S. GILLIAM, JR., United States District Judge Pending before the Court is Plaintiffs' motion for a preliminary injunction. See Dkt. No. 174. In short, Plaintiffs seek to prevent the implementation of rules creating a religious exemption (the "Religious Exemption") and a moral exemption (the "Moral Exemption") to the contraceptive mandate contained within the Affordable Care Act ("ACA"). See id. at 1; Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 83 Fed. Reg. 57,536 (Nov. 15, 2018) ("Religious Exemption"); Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 83 Fed. Reg. 57,592 (Nov. 15, 2018) ("Moral Exemption") (collectively, "the 2019 Final Rules" or "Final Rules"). Plaintiffs are the States of California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Minnesota (by and through its Department of Human Services), New York, North Carolina, Rhode Island, Vermont, and Washington, the Commonwealth of Virginia, and the District of Columbia. Federal Defendants are Alex M. Azar, II, in his official capacity as Secretary of the Department of Health and Human Services; the Department of Health and Human Services ("HHS"); Alexander Acosta, in his official capacity as Secretary of the Department of Labor; the Department of Labor; Steven Mnuchin, in his official capacity as Secretary of the Department of the Treasury; and the Department of the Treasury. Two additional parties were previously granted the right to enter this case as permissive intervenors: Little Sisters of the Poor, Jeanne Jugan Residence ("Little Sisters") and March for Life Education and Defense Fund ("March for Life"). See Dkt. Nos. 115, 134. Little Sisters is "a religious nonprofit corporation operated by an order of Catholic nuns whose faith inspires them to spend their lives serving the sick and elderly poor." Motion to Intervene, Dkt. No. 38 at 2. March for Life is a "non-religious non-profit advocacy organization" founded in response to the Supreme Court's 1973 decision in Roe v. Wade. Motion to Intervene, Dkt. No. 87 at 3. Its stated purpose is "to oppose the destruction of human life at any stage before birth, including by abortifacient methods that may act after the union of a sperm and ovum." Id. For the reasons set out below, the motion is granted to maintain the status quo pending resolution of Plaintiffs' claims, and the enforcement of the Final Rules in the Plaintiff States is preliminarily enjoined. I. BACKGROUND Before turning to the Plaintiffs' challenge to the Final Rules, the Court begins by recounting the sequence of relevant events, beginning with the enactment of the Affordable Care Act in 2010. Although much of this background was already recounted in the Court's prior order, the Court reiterates it here for the sake of clarity. See California v. Health & Human Servs. , 281 F.Supp.3d 806 (N.D. Cal. 2017), aff'd in part, vacated in part, remanded sub nom. California v. Azar , 911 F.3d 558 (9th Cir. 2018). A. The Affordable Care Act In March 2010, Congress enacted the Affordable Care Act. The ACA included a provision known as the Women's Health Amendment, which states: A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for ... with respect to women, such additional preventive care and screenings ... as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph. 42 U.S.C. § 300gg-13(a)(4). About two years later, the Senate rejected a so-called "conscience amendment" to the Women's Health Amendment that would have allowed health plans to decline to provide coverage "contrary to" an insurer or employer's asserted "religious beliefs or moral convictions." See 158 Cong. Rec. S538-39 (Feb. 9, 2012) (text of proposed bill); id. S1162-73 (Mar. 1, 2012) (debate and vote); see also Burwell v. Hobby Lobby Stores, Inc. , 573 U.S. 682, 134 S.Ct. 2751, 2789-90, 189 L.Ed.2d 675 (2014) (Ginsburg, J., dissenting) (recognizing that rejection of the "conscience amendment" meant that "Congress left health care decisions-including the choice among contraceptive methods-in the hands of women, with the aid of their health care providers"). B. The 2010 IFR and Subsequent Regulations On July 19, 2010, under the authority of the Women's Health Amendment, several federal agencies (including HHS, the Department of Labor, and the Department of the Treasury) issued an interim final rule ("the 2010 IFR"). See 75 Fed. Reg. 41,726. It required, in part, that health plans provide "evidence-informed preventive care" to women, without cost sharing and in compliance with "comprehensive guidelines" to be provided by HHS's Health Resources and Services Administration ("HRSA"). Id. at 41,728. The agencies found they had statutory authority "to promulgate any interim final rules that they determine[d were] appropriate to carry out the" relevant statutory provisions. Id. at 41,729 -30. The agencies also determined they had good cause to forgo the general notice of proposed rulemaking required under the Administrative Procedure Act ("APA"), 5 U.S.C. § 553. Id. at 41,730. Specifically, the agencies determined that issuing such notice would be "impracticable and contrary to the public interest" because it would not allow sufficient time for health plans to be timely designed to incorporate the new requirements under the ACA, which were set to go into effect approximately two months later. Id. The agencies requested that comments be submitted by September 17, 2010, the date the IFR was scheduled to go into effect. On September 17, 2010, the agencies first promulgated regulations pursuant to the 2010 IFR. See 45 C.F.R. § 147.310(a)(1)(iv) (HHS); 29 C.F.R. § 2590.715-2713 (Department of Labor); 26 C.F.R. § 54.9815-2713 (Department of the Treasury). As relevant here, the regulations were substantively identical to the 2010 IFR, stating that HRSA was to provide "binding, comprehensive health plan coverage guidelines." C. The 2011 HRSA Guidelines From November 2010 to May 2011, a committee convened by the Institute of Medicine met in response to the charge of HHS's Office of the Assistant Secretary for Planning and Evaluation: to "convene a diverse committee of experts" related to, as relevant here, women's health issues. Inst. of Med., Clinical Preventive Services for Women: Closing the Gaps , 1, 23 (2011), https://www.nap.edu/read/13181/chapter/1. In July 2011, the committee issued a report recommending that private health insurance plans be required to cover all contraceptive methods approved by the Food and Drug Administration ("FDA"), without cost sharing. Id. at 102-10. On August 1, 2011, HRSA issued its preventive care guidelines ("2011 Guidelines"), defining preventive care coverage to include all FDA-approved contraceptive methods. See Health Res. & Servs. Admin., Women's Preventive Services Guide lines , https://www.hrsa.gov/womens-guidelines/index.html. D. The 2011 IFR and the Original Religious Exemption On August 3, 2011, the agencies issued an IFR amending the 2010 IFR. See 76 Fed. Reg. 46,621 ("the 2011 IFR"). Based on the "considerable feedback" they received regarding contraceptive coverage for women, the agencies stated that it was "appropriate that HRSA, in issuing [its 2011] Guidelines, take[ ] into account the effect on the religious beliefs of certain religious employers if coverage of contraceptive services were required." Id. at 46,623. As such, the agencies provided HRSA with the "additional discretion to exempt certain religious employers from the [2011] Guidelines where contraceptive services are concerned." Id. They defined a "religious employer" as one that: (1) [h]as the inculcation of religious values as its purpose; (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 [the relevant statutory provisions, which] refer to churches, their integrated auxiliaries, and conventions or associations of churches, as well as to the exclusively religious activities of any religious order. Id. The 2011 IFR went into effect on August 1, 2011. The agencies again found that they had both statutory authority and good cause to forgo the APA's advance notice and comment requirement. Id. at 46,624. Specifically, they found that "providing for an additional opportunity for public comment [was] unnecessary, as the [2010 IFR] ... provided the public with an opportunity to comment on the implementation of the preventive services requirement in this provision, and the amendments made in [the 2011 IFR were] in fact based on such public comments." Id. The agencies also found that notice and comment would be "impractical and contrary to the public interest," because that process would result in a delay of implementation of the 2011 Guidelines. See id. The agencies further stated that they were issuing the rule as an IFR in order to provide the public with some opportunity to comment. Id. They requested comments by September 30, 2011. On February 15, 2012, after considering more than 200,000 responses, the agencies issued a final rule adopting the definition of "religious employer" set forth in the 2011 IFR. See 77 Fed. Reg. 8,725. The final rule also established a temporary safe harbor, during which the agencies plan[ned] to develop and propose changes to these final regulations 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 .... Id. at 8,727. E. The Religious Accommodation On March 21, 2012, the agencies issued an advance notice of proposed rulemaking ("ANPR") requesting comments on "alternative ways of providing contraceptive coverage without cost sharing in order to accommodate non-exempt, non-profit religious organizations with religious objections to such coverage." 77 Fed. Reg. 16,501, 16,503. They specifically sought to "require issuers to offer group health insurance coverage without contraceptive coverage to such an organization (or its plan sponsor)," while also "provid[ing] contraceptive coverage directly to the participants and beneficiaries covered under the organization's plan with no cost sharing." Id. The agencies requested comment by June 19, 2012. On February 6, 2013, after reviewing more than 200,000 comments, the agencies issued proposed rules that (1) simplified the criteria for the religious employer exemption; and (2) established an accommodation for eligible organizations with religious objections to providing contraceptive coverage. See 78 Fed. Reg. 8,456, 8,458 -59. The proposed rule defined an "eligible organization" as one that (1) "opposes providing coverage for some or all of the contraceptive services required to be covered"; (2) "is organized and operates as a nonprofit entity"; (3) "holds itself out as a religious organization"; and (4) self-certifies that it satisfies these criteria. Id. at 8,462. Comments on the proposed rule were due April 5, 2013. On July 2, 2013, after reviewing more than 400,000 comments, the agencies issued final rules simplifying the religious employer exemption and establishing the religious accommodation. 78 Fed. Reg. 39,870. With respect to the latter, the final rule retained the definition of "eligible organization" set forth in the proposed rule. Id. at 39,874. Under the accommodation, an eligible organization that met a "self-certification standard" was "not required to contract, arrange, pay, or refer for contraceptive coverage," but its "plan participants and beneficiaries ... [would] still benefit from separate payments for contraceptive services without cost sharing or other charge," as required by law. Id. The final rules were effective August 1, 2013. F. The Hobby Lobby and Wheaton College Decisions On June 30, 2014, the Supreme Court issued its opinion in Burwell v. Hobby Lobby Stores, Inc. , in which three closely-held corporations challenged the requirement that they "provide health-insurance coverage for methods of contraception that violate[d] the sincerely held religious beliefs of the companies' owners." 134 S.Ct. at 2759. The Court held that this requirement violated the Religious Freedom Restoration Act of 1993 ("RFRA"), 42 U.S.C. § 2000bb et seq. , because it was not the "least restrictive means" of serving the government's proffered compelling interest in guaranteeing cost-free access to certain methods of contraception. See Hobby Lobby , 134 S.Ct. at 2781-82. The Court pointed to the religious accommodation as support for this conclusion: "HHS itself has demonstrated that it has at its disposal an approach that is less restrictive than requiring employers to fund contraceptive methods that violate their religious beliefs.... HHS has already established an accommodation for nonprofit organizations with religious objections." Id. at 2782. The Court stated that the Hobby Lobby ruling "[did] not decide whether an approach of this type complies with RFRA for purposes of all religious claims," and said its opinion "should not be understood to hold that an insurance-coverage mandate must necessarily fall if it conflicts with an employer's religious beliefs." Id. at 2782-83. Several days later, the Court issued its opinion in Wheaton College v. Burwell , --- U.S. ----, 134 S.Ct. 2806, 189 L.Ed.2d 856 (2014). The plaintiff was a nonprofit college in Illinois that was eligible for the accommodation. Id. at 2808 (Sotomayor, J., dissenting). Wheaton College sought an injunction, however, "on the theory that its filing of a self-certification form [would] make it complicit in the provision of contraceptives by triggering the obligation for someone else to provide the services to which it objects." Id. The Court granted the application for an injunction, ordering that it was sufficient for the college to "inform[ ] the Secretary of Health and Human Services in writing that it is a nonprofit organization that holds itself out as religious and has religious objections to providing coverage for contraceptive services." Id. at 2807. In other words, the college was not required to "use the form prescribed by the [g]overnment," nor did it need to "send copies to health insurance issuers or third-party administrators." Id. The Court stated that its order "should not be construed as an expression of the Court's views on the merits." Id. G. Post- Hobby Lobby and - Wheaton Regulatory Actions Shortly thereafter, on August 27, 2014, the agencies initiated two regulatory actions. First, in light of Hobby Lobby , they issued proposed rules "amend[ing] the definition of an eligible organization [for purposes of the religious accommodation] to include a closely held for-profit entity that has a religious objection to providing coverage for some or all of the contraceptive services otherwise required to be covered." 79 Fed. Reg. 51,118, 51,121. Comments were due on October 21, 2014. Second, in light of Wheaton , the agencies issued IFRs ("the 2014 IFRs") providing "an alternative process for the sponsor of a group health plan or an institution of higher education to provide notice of its religious objection to coverage of all or a subset of contraceptive services, as an alternative to the EBSA Form 700 [i.e. , the standard] method of self-certification." 79 Fed. Reg. 51,092, 51,095. The agencies asserted they had both statutory authority and good cause to forgo the notice and comment period, stating that such a process would be "impracticable and contrary to the public interest," particularly in light of Wheaton . Id. at 51,095 -96. The IFRs were effective immediately, and comments were due October 27, 2014. After considering more than 75,000 comments on the proposed rule, the agencies issued final rules "extend[ing] the accommodation to a for-profit entity that is not publicly traded, is majority-owned by a relatively small number of individuals, and objects to providing contraceptive coverage based on its owners' religious beliefs"-i.e. , to closely-held entities. 80 Fed. Reg. 41,318, 41,324. The agencies also issued a final rule "continu[ing] to allow eligible organizations to choose between using EBSA Form 700 or the alternative process consistent with the Wheaton interim order." Id. at 41,323. H. The Zubik Opinion and Subsequent Impasse On May 16, 2016, the Supreme Court issued its opinion in Zubik v. Burwell , --- U.S. ----, 136 S.Ct. 1557, 194 L.Ed.2d 696 (2016) (per curiam). The petitioners, primarily non-profit organizations, were eligible for the religious accommodation, but challenged the requirement that they submit notice to either their insurer or the federal government as a violation of RFRA. Zubik , 136 S.Ct. at 1558. "Following oral argument, the Court requested supplemental briefing from the parties addressing 'whether contraceptive coverage could be provided to petitioners' employees, through petitioners' insurance companies, without any such notice from petitioners.' " Id. at 1558-59. After the parties stated that "such an option [was] feasible," the Court remanded to afford them "an opportunity to arrive at an approach going forward that accommodates petitioners' religious exercise while at the same time ensuring that women covered by petitioners' health plans 'receive full and equal health coverage, including contraceptive coverage. ' " Id. at 1559 (emphasis added). As in Wheaton , "[t]he Court express[ed] no view on the merits of the cases," and did not decide "whether petitioners' religious exercise has been substantially burdened, whether the [g]overnment has a compelling interest, or whether the current regulations are the least restrictive means of serving that interest." Id. at 1560. On July 22, 2016, the agencies issued a request for information ("RFI") on whether, in light of Zubik , there are alternative ways (other than those offered in current regulations) for eligible organizations that object to providing coverage for contraceptive services on religious grounds to obtain an accommodation, while still ensuring that women enrolled in the organizations' health plans have access to seamless coverage of the full range of [FDA]-approved contraceptives without cost sharing. 81 Fed. Reg. 47,741, 47,741 (July 22, 2016). Comments were due September 20, 2016. On January 9, 2017, the agencies issued a document titled "FAQs About Affordable Care Act Implementation Part 36" ("FAQs"). See Dep't of Labor, FAQs About Affordable Care Act Implementation Part 36 (Jan. 9, 2017), https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-36.pdf. The FAQs stated that, based on the 54,000 comments received in response to the July 2016 RFI, there was "no feasible approach ... at this time that would resolve the concerns of religious objectors, while still ensuring that the affected women receive full and equal health coverage, including contraceptive coverage." Id. at 4. I. The 2017 IFRs On May 4, 2017, the President issued Executive Order No. 13,798, directing the secretaries of the Departments of the Treasury, Labor, and HHS to "consider issuing amended regulations, consistent with applicable law, to address conscience-based objections to the preventive care mandate." 82 Fed. Reg. 21,675, 21,675. Subsequently, on October 6, 2017, the agencies issued the Religious Exemption IFR and the Moral Exemption IFR (collectively, "the 2017 IFRs"), which were effective immediately. The 2017 IFRs departed from the previous regulations in several important ways. 1. The Religious Exemption IFR First, with the Religious Exemption IFR, the agencies substantially broadened the scope of the religious exemption, extending it "to encompass entities, and individuals, with sincerely held religious beliefs objecting to contraceptive or sterilization coverage," and "making the accommodation process optional for eligible organizations." 82 Fed. Reg. 47,792, 47,807 -08. Such entities "will not be required to comply with a self-certification process." Id. at 47,808. Just as the IFR expanded eligibility for the exemption, it "likewise" expanded eligibility for the optional accommodation. Id. at 47,812 -13. In introducing these changes, the agencies stated they "recently exercised [their] discretion to reevaluate these exemptions and accommodations," and considered factors including: "the interests served by the existing Guidelines, regulations, and accommodation process"; the "extensive litigation"; the President's executive order; the interest in protecting the free exercise of religion under the First Amendment and RFRA; the discretion afforded under the relevant statutory provisions; and "the regulatory process and comments submitted in various requests for public comments." Id. at 47,793. The agencies advanced several arguments they claimed justified the lack of an advance notice and comment process for the Religious Exemption IFR, which became effective immediately. First, the agencies cited 26 U.S.C. § 9833, 29 U.S.C. § 1191c, and 42 U.S.C. § 300gg-92, asserting that those statutes authorized the agencies "to promulgate any interim final rules that they determine are appropriate to carry out" the relevant statutory provisions. Id. at 47,813. Second, the agencies asserted that even if the APA did apply, they had good cause to forgo notice and comment because implementing that process "would be impracticable and contrary to the public interest." Id. Third, the agencies noted that "[i]n response to several of the previous rules on this issue-including three issued as [IFRs] under the statutory authority cited above-the Departments received more than 100,000 public comments on multiple occasions," which included "extensive discussion about whether and by what extent to expand the exemption." Id. at 47,814. For all of these reasons, the agencies asserted, "it would be impracticable and contrary to the public interest to engage in full notice and comment rulemaking before putting these interim final rules into effect." Id. at 47,815. Comments were due on December 5, 2017. 2. The Moral Exemption IFR Also on October 6, 2017, the agencies issued the Moral Exemption IFR, "expand[ing] the exemption[ ] to include additional entities and persons that object based on sincerely held moral convictions." 82 Fed. Reg. 47,838, 47,849. Additionally, "consistent with [their] expansion of the exemption, [the agencies] expand[ed] eligibility for the accommodation to include organizations with sincerely held moral convictions concerning contraceptive coverage," while also making the accommodation process optional for those entities. Id. The agencies included in the IFR a section called "Congress' History of Providing Exemptions for Moral Convictions," referencing statutes and legislative history, case law, executive orders, and state analogues. See id. at 47,844 -48. The agencies justified the immediate issuance of the Moral Exemption IFR without an advance notice and comment process on grounds similar to those offered regarding the Religious Exemption IFR, stating that "[o]therwise, our regulations would simultaneously provide and deny relief to entities and individuals that are, in the [agencies'] view, similarly deserving of exemptions and accommodations consistent[ ] with similar protections in other federal laws." Id. at 47,855. Comments were due on December 5, 2017. 3. Preliminary Injunction Against the 2017 IFRs On October 6, 2017, the States of California, Delaware, Maryland, and New York, and the Commonwealth of Virginia filed a complaint, see Dkt. No. 1, which was followed by a First Amended Complaint on November 1, see Dkt. No. 24 ("FAC"). Plaintiffs alleged that the 2017 IFRs violated Sections 553 and 706 of the Administrative Procedure Act, the Establishment Clause, and the Equal Protection Clause. FAC ¶¶ 8-12, 116-37. Plaintiffs filed a motion for a preliminary injunction on November 9, 2017. See Dkt. No. 28. a. The Court's Nationwide Injunction On December 21, 2017, the Court granted Plaintiffs' motion for a preliminary injunction. See Dkt. No. 105. The Court held that Plaintiffs had "shown that, at a minimum, they are likely to succeed on their claim that Defendants violated the APA by issuing the 2017 IFRs without advance notice and comment." Id. at 17. In addition, the Court held that Plaintiffs were likely to suffer irreparable harm, that the balance of equities tipped in Plaintiffs' favor, and that the public interest favored granting an injunction. Id. Accordingly, the Court issued a nationwide preliminary injunction enjoining implementation of the 2017 IFRs. See id. at 28. The Court's order reinstated the "state of affairs" that existed prior to October 6, 2017, including the exemption and accommodation as they existed following the Zubik remand as well as any court orders enjoining the Federal Defendants from enforcing the rules against specific parties. See id. at 29. b. Intervenors Little Sisters and March for Life Enter the Case On December 29, 2017, the Court granted the Little Sisters' motion to intervene. See Dkt. No. 115. And on January 26, 2018, the Court granted March for Life's motion to intervene. See Dkt. No. 134. c. Ninth Circuit Appeal and Decision Limiting Scope of Injunction Following the Court's order granting Plaintiffs' motion for a preliminary injunction, the agencies, Little Sisters, and March for Life appealed. See Dkt. Nos. 135-38, 142-43. On December 13, 2018, the Ninth Circuit issued an opinion largely affirming this Court's prior order, but shrinking the geographic scope of the injunction to encompass only the states that were plaintiffs at that time. See California , 911 F.3d at 584. First, the court held (on an issue of first impression) that venue was proper in the Northern District of California because "common sense" dictated that "a state with multiple judicial districts 'resides' in every district within its borders." Id. at 570. Second, the court held that the States had standing to bring their procedural APA claim because the States had shown "with reasonable probability[ ] that the IFRs will first lead to women losing employer-sponsored contraceptive coverage, which will then result in economic harm to the states." Id. at 571-72. The court noted that the States had no obligation to identify a specific woman who would lose coverage, particularly given that the agencies' regulatory impact analysis estimated that between 31,700 and 120,000 women would lose contraceptive coverage, and that "state and local governments will bear additional economic costs." Id. at 571-72. Third, the court held that the Plaintiffs were likely to succeed on the merits of their APA claim because the agencies had neither good cause nor statutory authority for bypassing the usual notice and comment procedure, and that the procedural violation was likely not harmless. Id. at 578-81. Fourth, the court affirmed this Court's ruling that the Plaintiffs had established the other requirements to entitle them to injunctive relief because they were likely to suffer irreparable harm absent an injunction, and the balance of the equities and public interest tilted in favor of granting an injunction. Id. at 581-82. Fifth, the court concluded that the scope of the preliminary injunction was overbroad because an injunction applying only to the Plaintiff-States would "provide complete relief to them." Id. at 584. J. The 2019 Final Rules The 2017 IFRs included a call for comments, due by December 5, 2017. See 82 Fed. Reg. at 47,792; 82 Fed. Reg. at 47,838. Over the 60-day comment period, the agencies received over 56,000 public comments on the religious exemption rules, 83 Fed. Reg. at 57,540, and over 54,000 public comments on the moral exemption rules, 83 Fed. Reg. at 57,596. On November 15, 2018, the agencies promulgated the Religious Exemption and Moral Exemption Final Rules. See 83 Fed. Reg. 57,536 ; 83 Fed. Reg. 57,592. The 2019 Final Rules are scheduled to take effect, superseding the enjoined IFRs, on January 14, 2019. In substance, the Final Rules are nearly identical to the 2017 IFRs. See Defendants' Opposition, Dkt. No. 198 ("Federal Opp.") at 8 (noting that the "fundamental substance of the exemptions was finalized as set forth in the IFRs"); see also Supplemental Brief for the Federal Appellants at 1, California v. Azar , 911 F.3d 558 (9th Cir. 2018) (Nos. 18-15144, 18-15166, 18-15255, 2018 WL 6044850, at *1 ("The substance of the rules remains largely unchanged ... and none of the changes is material to the States' substantive claims in this case."). The Religious Exemption made "various changes ... to clarify the intended scope of the language" in "response to public comments." 83 Fed. Reg. at 57,537. Likewise, the Moral Exemption Final Rule made "various changes ... to clarify the intended scope of the language" in "response to public comments." 83 Fed. Reg. at 57,593. At least three changes in the Final Rules bear mentioning. First, the Final Rules estimate that "no more than 126,400 women of childbearing age will be affected by the expanded exemptions," which is an increase from the previous estimate of up to 120,000 women. Compare 83 Fed. Reg. at 57,551 n.26with 82 Fed. Reg. at 47,823. Second, the Final Rules increase their estimate of the expense of the exemptions to $67.3 million nationwide annually. See 83 Fed. Reg. at 57,581. Third, the Final Rules place increased emphasis on the availability of contraceptives at Title X family-planning clinics as an alternative to contraceptives provided by women's health insurers. See 83 Fed. Reg. at 57,551 ; 83 Fed. Reg. at 57,608 ; see also 83 Fed. Reg. at 25,502, 25,514 (proposed rule rendering women who lose contraceptive coverage because of religious or moral exemptions eligible for Title X services). K. Plaintiffs Challenge the Final Rules On December 18, 2018, Plaintiffs filed a Second Amended Complaint, alleging that the IFRs and Final Rules violate Section 553 of the APA, and that the Final Rules violate Section 706 of the APA, the Establishment Clause, and the Equal Protection Clause. See Dkt. No. 170 ("SAC") ¶¶ 235-60. Original Plaintiffs-the States of California, Delaware, Maryland, and New York, and the Commonwealth of Virginia-were joined by the States of Connecticut, Hawaii, Illinois, Minnesota, North Carolina, Rhode Island, Vermont, and Washington, and the District of Columbia. Id. at 13-26. On December 19, Plaintiffs filed a motion for a preliminary injunction, seeking to enjoin the implementation of the Final Rules. See Dkt. No. 174 ("Mot.") at 25. The Federal Defendants filed an opposition on January 3, 2019. See Federal Opp. That same day, both the Little Sisters, see Dkt. No. 197 ("Little Sisters Opp."), and March for Life, see Dkt. No. 199 ("March for Life Opp."), filed oppositions. The States replied on January 8. See Dkt. No. 218 ("Reply"). The Court held a hearing on January 11, after which it took the motion under submission. II. LEGAL STANDARD A preliminary injunction is a matter of equitable discretion and is "an extraordinary remedy that may only be awarded upon a clear showing that the plaintiff is entitled to such relief." Winter v. Natural Res. Def. Council, Inc. , 555 U.S. 7, 22, 129 S.Ct. 365, 172 L.Ed.2d 249 (2008). "A plaintiff seeking preliminary injunctive relief must establish that [it] is likely to succeed on the merits, that [it] is likely to suffer irreparable harm in the absence of preliminary relief, that the balance of equities tips in [its] favor, and that an injunction is in the public interest." Id. at 20, 129 S.Ct. 365. Alternatively, an injunction may issue where "the likelihood of success is such that serious questions going to the merits were raised and the balance of hardships tips sharply in [the plaintiff's] favor," provided that the plaintiff can also demonstrate the other two Winter factors. Alliance for the Wild Rockies v. Cottrell , 632 F.3d 1127, 1131-32 (9th Cir. 2011) (citation and internal quotation marks omitted). Under either standard, Plaintiffs bear the burden of making a clear showing that they are entitled to this extraordinary remedy. Earth Island Inst. v. Carlton , 626 F.3d 462, 469 (9th Cir. 2010). The most important Winter factor is likelihood of success on the merits. See Disney Enters., Inc. v. VidAngel, Inc. , 869 F.3d 848, 856 (9th Cir. 2017). III. ANALYSIS A. Venue Is Proper in the Northern District of California. Despite a clear holding from the Ninth Circuit, Federal Defendants continue to press their argument that venue is not proper in the Northern District because the State of California resides for venue purposes only in the Eastern District, "where Sacramento, the seat of state government, is located." Federal Opp. at 10. But the Ninth Circuit held that 28 U.S.C. 1391"dictates that a state with multiple judicial districts 'resides' in every district within its borders." California , 911 F.3d at 570. An "interpretation limiting residency to a single district in the state would defy common sense." Id. Given the clear precedent from the Ninth Circuit on this issue, the Court need not dwell on it: venue is proper in the Northern District. B. Plaintiffs Have Standing to Sue. The Little Sisters contend that the States lack standing to sue, see Little Sisters Opp. at 9, and the agencies "reserve the right to object" to relief for any plaintiff that has not established standing, see Federal Opp. at 10 n.4. The Court finds that Plaintiffs have established both Article III and statutory standing. 1. Plaintiffs Have Article III Standing. A plaintiff seeking relief in federal court bears the burden of establishing "the irreducible constitutional minimum" of standing. Spokeo, Inc. v. Robins , --- U.S. ----, 136 S.Ct. 1540, 1547, 194 L.Ed.2d 635 (2016) (quoting Lujan v. Defenders of Wildlife , 504 U.S. 555, 560, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992) ). First, the plaintiff must have "suffered an injury in fact." Spokeo , 136 S.Ct. at 1547. This requires "an invasion of a legally protected interest" that is concrete, particularized, and actual or imminent, rather than conjectural or hypothetical. Lujan , 504 U.S. at 560, 112 S.Ct. 2130 (internal quotation marks omitted). Second, the plaintiff's injury must be "fairly traceable to the challenged conduct of the defendant." Spokeo , 136 S.Ct. at 1547. Third, the injury must be "likely to be redressed by a favorable judicial decision." Id. (citing Lujan , 504 U.S. at 560-61, 112 S.Ct. 2130 ). "States are not normal litigants for the purposes of invoking federal jurisdiction," Massachusetts v. EPA , 549 U.S. 497, 518, 127 S.Ct. 1438, 167 L.Ed.2d 248 (2007), and are "entitled to special solicitude in [the] standing analysis," id. at 520, 127 S.Ct. 1438. For instance, states may sue to assert their "quasi-sovereign interest in the health and well-being-both physical and economic-of [their] residents in general." Alfred L. Snapp & Son, Inc. v. Puerto Rico , 458 U.S. 592, 607, 102 S.Ct. 3260, 73 L.Ed.2d 995 (1982). In that case, however, the "interest must be sufficiently concrete to create an actual controversy between the State and the defendant" such that the state is more than a nominal party. Id. at 602, 102 S.Ct. 3260. Here, the Court need not rely on the special solicitude afforded to states, or their power to litigate their quasi-sovereign interests on behalf of their citizens. Much more simply, a state may establish standing by showing a reasonably probable threat to its economic interests. See California , 911 F.3d at 573 ; see also Texas v. United States , 809 F.3d 134, 155 (5th Cir. 2015) (State of Texas had standing to mount APA challenge to Deferred Action for Parents of Americans and Lawful Permanent Residents program because Texas would "incur significant costs in issuing driver's licenses to [program] beneficiaries"), aff'd by equally divided Court , --- U.S. ----, 136 S.Ct. 2271, 2272, 195 L.Ed.2d 638 (2016). Plaintiffs have demonstrated at least two ways in which implementation of the Final Rules will damage their States' fiscs: through increased reliance on state-funded family-planning programs and through the state-borne costs of unintended pregnancies. First, Plaintiffs have shown that the Final Rules will "lead to women losing employer-sponsored contraceptive coverage, which will then result in economic harm to the states" as these women "turn to state-based programs or programs reimbursed by the state." California , 911 F.3d at 571-72. The Little Sisters take issue with the Ninth Circuit's reasoning because "the States have still failed to identify anyone who will actually be harmed by the Mandate." Little Sisters Opp. at 9. But the Ninth Circuit was clear that the States need not identify a specific woman likely to lose contraceptive coverage to establish standing. California , 911 F.3d at 572. Even if the States have not identified specific women who will be impacted by the Final Rules, Federal Defendants themselves have done much of the work to establish that Plaintiffs have standing. The Religious Exemption states that up to approximately 126,400 "women of childbearing age will be affected by the expanded exemptions." 83 Fed. Reg. at 57,551 n.26. At an estimated expense of $584 per year per woman impacted, this amounts to $67.3 million nationwide annually. See id. at 57,581. Further, the Final Rules explicitly rely on Title X clinics as a backstop for women who lose contraceptive coverage as a result of the Final Rules. See id. at 57,551 ; 83 Fed. Reg. at 57,608 ; see also 83 Fed. Reg. at 25,502. But Plaintiffs have shown that in many of their States, these already cash-strapped Title X clinics are operated in conjunction with state family planning services, meaning that any increase in enrollment will likely increase costs to the state. See Declaration of Kathryn Kost ("Kost Decl."), Dkt. No. 174-19 ¶ 48 ("Title X is able to serve only one-fifth of the nationwide need for publicly funded contraceptive care" and "cannot sustain additional beneficiaries as a result of the Final Rules"); Declaration of Mari Cantwell ("Cantwell Decl."), Dkt. No. 174-4 ¶ 18 (all California Title X clinics are also California Family Planning, Access, Care, and Treatment program providers); Declaration of Lauren J. Tobias ("Tobias Decl."), Dkt. No. 174-33 ¶ 5 (New York Title X clinics are same as state family planning program clinics). Or the States will be forced to shoulder the costs of the Final Rules more directly, as Federal Defendants refer women to Title X clinics funded directly by the state. See Declaration of Karen Nelson ("Nelson Decl."), Dkt. No. 174-25 ¶ 20 ($6 million of Maryland's Title X budget comes from state, $3 million from federal government). In addition, the States have submitted voluminous and detailed evidence documenting how their female residents are predicted to lose access to contraceptive coverage because of the Final Rules-and how those women likely will turn to state programs to obtain no-cost contraceptives, at significant cost to the States. See, e.g. , Cantwell Decl., Dkt. No. 174-4 ¶¶ 16-18 (Final Rules will result in more women becoming eligible for California's Family Planning, Access, Care, and Treatment program, meaning that "state dollars may be diverted to provide" contraceptive coverage); Nelson Decl., Dkt. No. 174-25 ¶ 20 ("it will be difficult for the current [State of Maryland] budget levels to accommodate the increase in women seeking [Title X services] after losing contraception coverage in their insurance plans"); Tobias Decl., Dkt. No. 174-33 ¶ 5 (exemptions in Final Rules "will result in more women receiving" New York Family Planning Program services, thus putting program at "risk [of] being overwhelmed by the increase in patients"); Declaration of Jonathan Werberg, Dkt. No. 174-36 ¶¶ 5-8 (identifying New York employers that are likely to invoke exemptions "because of their involvement in previous litigation": Hobby Lobby, with 720 New York employees; Nyack College, with 3,000 students and 1,100 employees in New York; and Charles Feinberg Center for Messianic Jewish Studies, whose parent university has 1,000 students nationwide). Of course, under the status quo, these women have a statutory entitlement to free contraceptives through their regular health insurance and thus impose no cost on the States. The States have established a causal chain linking them to harm if the Final Rules were implemented. See California , 911 F.3d at 571-72. Second, the States have shown that the Final Rules are likely to result in a decrease in the use of effective contraception, thus leading to unintended pregnancies which would impose significant costs on the States. Some of the most effective contraceptive methods are also among the most expensive. See Kost Decl. ¶¶ 15-18, 24. For example, long-acting reversible contraceptives are among the most effective methods, but may cost a woman over $1,000. See id. ¶ 25. Women who lose their entitlement to cost-free contraceptives are less likely to use an effective method, or any method at all-resulting in unintended pregnancies. See id. ¶ 27, 36-42; Declaration of Lisa M. Hollier ("Hollier Decl."), Dkt. No. 174-15 ¶ 6; Declaration of Walker A. Wilson ("Wilson Decl."), Dkt. No. 174-38 ¶ 5 (Final Rules may cause women in North Carolina to "forgo coverage and experience an unintended pregnancy"); Nelson Decl., Dkt. No. 174-25 ¶ 30 (unintended pregnancy rate of women not using contraception is 45% and loss of coverage will result in more unintended pregnancies); Declaration of Karyl T. Rattay ("Rattay Decl."), Dkt. No. 174-30 (Final Rules "will contribute to an increase in Delaware's nationally high unintended pregnancy rate as women forego needed contraception and other services"). Much of the financial burden of these unintended pregnancies will be borne by the States. See, e.g. , Rattay Decl., Dkt. No. 174-30 (in 2010, 71.3% of unplanned births in Delaware were publicly funded, costing Delaware $36 million); Declaration of Nicole Alexander-Scott ("Alexander-Scott Decl."), Dkt. No. 174-7 ¶ 3 (unintended pregnancies likely to result from Final Rules will impose costs on state of Rhode Island); Wilson Decl., Dkt. No. 174-38 ¶ 5 (unintended pregnancies likely to result from Final Rules will impose costs on State of North Carolina); Declaration of Nathan Moracco ("Moracco Decl."), Dkt. No. 174-23 ¶ 5 (State of Minnesota "may bear a financial risk when women lose contraceptive coverage" because State is obligated to pay for child delivery and newborn care for children born to low-income mothers). In sum, Plaintiffs have shown that the challenged Final Rules pose a reasonably probable threat to their economic interests because they will be forced to pay for contraceptives that are no longer provided cost-free to women as guaranteed by the Affordable Care Act, as the Ninth Circuit found with respect to the five original Plaintiff States. See California , 911 F.3d at 570. The States also have established a reasonable probability that they will suffer economic harm from the consequences of unintended pregnancies resulting from the reduced availability of contraceptives. These injuries are directly traceable to the exemptions created by the Final Rules. As the Ninth Circuit noted, under the APA, the States "will not be able to recover monetary damages." Id. at 581 (citing 5 U.S.C. § 702 (permitting "relief other than money damages") ); see also Haines v. Fed. Motor Carrier Safety Admin. , 814 F.3d 417, 426 (6th Cir. 2016) (federal courts do not have jurisdiction to adjudicate suits seeking monetary damages under the APA). Thus, granting a preliminary injunction is the only effective way to redress the potential harm to the States until the Court can fully assess the merits. The States have established the requirements of Article III standing. 2. Plaintiffs Have Statutory Standing. In addition to establishing Article III standing, a plaintiff must show that it "has a cause of action under the statute." Lexmark Int'l, Inc. v. Static Control Components, Inc. , 572 U.S. 118, 128, 134 S.Ct. 1377, 188 L.Ed.2d 392 (2014). The APA provides that a "person ... adversely affected or aggrieved by agency action within the meaning of a relevant statute, is entitled to judicial review thereof." 5 U.S.C. § 702. Courts have interpreted this provision to mean that a plaintiff must "establish (1) that there has been final agency action adversely affecting the plaintiff, and (2) that, as a result, it suffers legal wrong or that its injury falls within the zone of interests of the statutory provision the plaintiff claims was violated." Citizens for Better Forestry v. U.S. Dep't of Agric. , 341 F.3d 961, 976 (9th Cir. 2003) (internal quotation omitted). First, a final rule is, as the name suggests, a final agency action. See id. Second, Plaintiffs' alleged injury-increased costs from providing contraceptives and from the consequences of unintended pregnancies-is within the zone of interests of the Women's Health Amendment, which was enacted to ensure that women would have access to cost-free contraceptives through their health insurance. Cf. City of Sausalito v. O'Neill , 386 F.3d 1186, 1204-05 (9th Cir. 2004) (plaintiff city within zone of interests of Concessions Management Improvement Act because it "assert[ed] injury to its 'proprietary interest' "); Citizens for Better Forestry , 341 F.3d at 976 (plaintiffs had statutory standing because "trying to protect the environment" was within zone of interests of National Environmental Policy Act). Thus, Plaintiffs have established statutory standing. C. Plaintiffs Have Shown They Are Entitled to a Preliminary Injunction. Plaintiffs are entitled to a preliminary injunction as to the Final Rules. As to both rules, Plaintiffs have shown that they are likely to succeed, or at a minimum have raised serious questions going to the merits, on their claim that the Religious Exemption and the Moral Exemption are inconsistent with the Women's Health Amendment, and thus violate the APA. Plaintiffs also have shown that they are likely to suffer irreparable harm as a result of this violation, that the balance of hardships tips sharply in their favor, and that the public interest favors granting the injunction. 1. Plaintiffs are likely to succeed in, or have at a minimum raised serious questions regarding, their argument that the Religious Exemption is "not in accordance with" the ACA, and thus violates the APA. Under the APA, "agency decisions may be set aside only if 'arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law.' " Snoqualmie Indian Tribe v. FERC , 545 F.3d 1207, 1212 (9th Cir. 2008) (quoting 5 U.S.C. § 706(2)(A). Plaintiffs argue that "[t]he Rules cannot be reconciled with the text and purpose of the ACA-which seeks to promote access to women's healthcare, not limit it." Mot. at 10. The Court agrees that Plaintiffs are likely correct, or have, at a minimum, raised serious questions going to the merits of this claim. To explain why, the Court must address three contentions made by the Federal Defendants and the Intervenors: (1) the Contraceptive Mandate is not actually a "mandate" at all, but rather a policy determination wholly subject to the agencies' discretion; (2) the changes codified in the Religious Exemption were mandated by RFRA; and (3) even if the agencies were not required under RFRA to adopt the Religious Exemption, they nonetheless had discretion to do so. a. The "Contraceptive Mandate" in the Women's Health Amendment is in fact a statutory mandate. Echoing the Final Rules, the Federal Defendants initially argue that "the ACA grants HRSA, and in turn the Agencies, significant discretion to shape the content and scope of any preventive-services guidelines adopted pursuant to § 300gg-13(a)(4)." Federal Opp. at 17; see also Little Sisters Opp. at 12 ("The ACA did not mandate contraceptive coverage. Instead, Congress delegated to HRSA discretion to determine the contours of the preventive services guidelines."). Federal Defendants thus contend that this section of the statute "must be understood as a positive grant of authority for HRSA to develop the women's preventive-service guidelines and for the Agencies, as the administering Agencies of the applicable statutes, to shape that development." Federal Opp. at 18. Federal Defendants' conclusion is that Section 300gg-13(a)(4)"thus authorized HRSA to adopt guidelines for coverage that include an exemption for certain employers, and nothing in the ACA prevents HHS from supervising HRSA in the development of those guidelines." Id. The Court rejects the Federal Defendants' claim that the ACA delegated total authority to the agencies to exempt anyone they wish from the contraceptive mandate. The Federal Defendants never appear to have denied that the statutory mandate is a mandate until the issuance of the IFRs (and the ensuing litigation in this district and in the Eastern District of Pennsylvania challenging the IFRs and now the Final Rules). They cite no case in which a court has accepted this claim. To the contrary, this Court knows of no Supreme Court, court of appeal or district court decision that did not presume that the ACA requires specified categories of health insurance plans and issuers to provide contraceptive coverage at no cost to women. See, e.g., Zubik , 136 S.Ct. at 1559 ("Federal regulations require petitioners to cover certain contraceptives as part of their health plans"); Hobby Lobby , 134 S.Ct. at 2762 ; California , 911 F.3d at 566 (ACA and its regulations "require group health plans to cover contraceptive care without cost sharing"). The United States government also has admitted as much in its consistent prior representations to the Supreme Court. See Brief for Respondents at 25, Zubik , 136 S.Ct. at 1557 (2016) (Nos. 14-1418, 14-1453, 14-1505, 15-35, 15-105, 15-119, 15-191, 2015 WL 5732065 ) (recognizing "the generally applicable requirement to provide contraceptive coverage"); id. at 37-38, 2016 WL 537623 (recognizing that "[t]he Affordable Care Act itself imposes an obligation on insurers to provide contraceptive coverage, 42 U.S.C. 300gg-13"). Federal Defendants' argument that the statute's language requiring coverage "as provided" by the regulations confers unbridled discretion on the agencies to exempt anyone they see fit from providing coverage, Federal Opp. at 18-19, is inconsistent with the ACA's mandate that women's contraceptive coverage "shall" be provided by covered plans and issuers without cost sharing. The statute's use of the phrase "as provided for in comprehensive guidelines" simply cannot reasonably be read as a Congressional delegation of the plenary authority claimed by the Federal Defendants. Instead, Congress permitted HRSA, a health agency, to determine what "additional preventive care and screenings" in those guidelines must be covered with respect to women. See Catholic Health Care Sys. v. Burwell , 796 F.3d 207, 210 (2d Cir. 2015) ("The ACA does not specify what types of preventive care must be covered for female plan participants and beneficiaries. Instead, Congress left that issue to be determined via regulation by the [HRSA].") (emphasis added), vacated and remanded , --- U.S. ----, 136 S.Ct. 2450, 195 L.Ed.2d 260 (2016). Without dispute, the guidelines continue to identify contraceptive services as among those for which health plans and insurers "shall, at a minimum provide coverage ... and shall not impose any cost sharing requirements." See Health Res. & Serv. Admin., Women's Preventive Services Guidelines , https://www.hrsa.gov/womens-guidelines-2016/index.html (last updated Oct. 2017). Moreover, in 2012, "[t]he Senate voted down the so-called conscience amendment, which would have enabled any employer or insurance provider to deny coverage based on its asserted 'religious beliefs or moral convictions.' " Hobby Lobby , 134 S.Ct. at 2789 (Ginsburg, J., dissenting) (citing 158 Cong. Rec. S539 (Feb. 9, 2012) and S1162-73 (Mar. 1, 2012) ). Accordingly, the Court rejects the Federal Defendants' claim that the ACA delegates to the agencies complete discretion to implement any exemptions they choose, including those at issue here. See Pennsylvania , 281 F.Supp.3d at 579 (rejecting government's argument that "HRSA may determine not only the services covered by the ACA, but also the manner or reach of that coverage," because "the ACA contains no statutory language allowing the Agencies to create such sweeping exemptions to the requirements to cover 'preventive services,' which, as interpreted by those same agencies, include mandatory no-cost coverage of contraceptive services"). To the extent the Federal Defendants rely on the existence of the church exemption instituted in 2013 to support their position, Federal Opp. at 18-19, the legality of that exemption is not before the Court. The Court notes, however, that the church exemption was rooted in provisions of the Internal Revenue Code that apply to churches, their integrated auxiliaries, and conventions or associations of churches, as well as to the exclusively religious activities of any religious order. See 78 Fed. Reg. at 39,874 (classifying "an employer that [was] organized and operate[d] as a nonprofit entity and [was] referred to in section 6033(a)(3)(A)(i) or (iii) of the Code [as] a religious employer for purposes of the religious employer exemption."). While a court could someday be presented with the question of whether the church exemption is uniquely required by law given the special legal status afforded to churches and their integrated auxiliaries, the existence of that exemption simply does not mean that the agencies have boundless authority to implement any other exemptions they choose. b. The Religious Exemption likely is not required by RFRA. Because the Women's Health Amendment, including the requirement to cover the preventive care and screenings identified in the guidelines, is a law of general applicability, the next question is whether RFRA requires the government to relieve qualifying entities of the obligation to comply by providing the Religious Exemption, as opposed to the accommodation provided for under the pre-IFR version of the rules currently in force. The Court finds that the Religious Exemption likely is not required by RFRA. "RFRA suspends generally applicable federal laws that 'substantially burden a person's exercise of religion' unless the laws are 'the least restrictive means of furthering a compelling governmental interest.' " Oklevueha Native Amer. Church of Hawaii v. Lynch , 828 F.3d 1012, 1015 (9th Cir. 2016) (internal quotation and citation omitted). The Ninth Circuit has held that "[u]nder RFRA, a 'substantial burden' is imposed only when individuals are forced to choose between following the tenets of their religion and receiving a governmental benefit ... or coerced to act contrary to their religious beliefs by the threat of civil or criminal sanctions ...." Navajo Nation v. United States Forest Serv. , 535 F.3d 1058, 1070 (9th Cir. 2008). The government "is not required to prove a compelling interest for its action or that its action involves the least restrictive means to achieve its purpose, unless the plaintiff first proves the government action substantially burdens his exercise of religion." Id. at 1069. The Federal Defendants and the Little Sisters argue that the current accommodation, under which eligible organizations are not required to contract, arrange, pay, or refer for contraceptive coverage, substantially burdens religious objectors' exercise of religion. Federal Opp. at 22; Little Sisters Opp. at 15 (contending that "RFRA mandates a broad religious exemption" from the contraceptive coverage requirement). Federal Defendants and the Little Sisters argue that even requiring objectors to notify the government that they are opting out of the otherwise-applicable obligation to cover contraceptive services for their female employees, students, or beneficiaries makes them complicit in the provision of products incompatible with their religious beliefs. Federal Opp. at 22 ("The accommodation, like the Mandate, imposes a substantial burden because it requires some religious objectors to 'act in a manner that they sincerely believe would make them complicit in a grave moral wrong as the price of avoiding a ruinous financial penalty.' ") (quoting Sharpe Holdings, Inc. v. Dep't of Health & Human Serv. , 801 F.3d 927, 941 (8th Cir. 2015), vacated sub nom. Dep't of Health & Human Servs. v. CNS Int'l Ministries , 84 U.S.L.W. 3626, 84 U.S.L.W. 3630, --- U.S. ----, --- S.Ct. ----, --- L.Ed.2d ----, 2016 WL 2842448, at *1 (2016) ; Little Sisters Opp. at 16 ("The Little Sisters cannot, in good conscience, provide these services on their health benefits plan or authorize others to do so for them."). While the Ninth Circuit has not considered this question, nine other courts of appeal have. Of those courts, all other than the Eighth Circuit (in the Sharpe Holdings decision on which the Federal Defendants exclusively rely) concluded that the accommodation does not impose a substantial burden on objectors' exercise of religion. This Court agrees with the eight courts that so held, and finds that Plaintiffs are likely to prevail on this argument. First, whether a burden is substantial is an objective question: a court "must assess the nature of a claimed burden on religious exercise to determine whether, as an objective legal matter, that burden is 'substantial' under RFRA." Catholic Health Care Sys. , 796 F.3d at 217. In other words, "[w]hether a law substantially burdens religious exercise under RFRA is a question of law for courts to decide, not a question of fact." Priests for Life , 772 F.3d at 247. Importantly, the Court may not, and does not here, question the "sincerity of [a party's] belief that providing, paying for, or facilitating access to contraceptive services is contrary to [its] faith," or its judgment that "participation in the accommodation violates this belief." Catholic Health Care Sys. , 796 F.3d at 217. But "[w]hether the regulation objected to imposes a substantial burden is an altogether different inquiry." Id. at 218. As several courts have noted, the Supreme Court's decision in Hobby Lobby "did not collapse the distinction between beliefs and substantial burden, such that the latter could be established simply through the sincerity of the former." Catholic Health Care Sys. , 796 F.3d at 218 ; see also Eternal Word , 818 F.3d at 1145 (noting that "nothing in RFRA or case law ... allows a religious adherent to dictate to the courts what the law requires," and explaining that "questions about what a law means are not the type of 'difficult and important questions of religion and moral philosophy' for which courts must defer to religious adherents") (citing Hobby Lobby , 134 S.Ct. at 2778 ). Both before and after the Supreme Court's decision in Wheaton College , all courts of appeal to consider the question, with the exception of the Eighth Circuit, have concluded that requiring religious objectors to notify the government of their objection to providing contraceptive coverage, so that the government can ensure that the responsible insurer or third-party administrator steps in to meet the ACA's requirements, does not impose a substantial burden on religious exercise. As the Eleventh Circuit explained post- Wheaton in Eternal Word , under the accommodation "the only action required of