The plaintiffs, a religious hospital and group of over 20,000 health-care professionals, launched the lawsuit against the Department of Health and Human Services in August 2016 after the federal government mandated that most health-care providers perform and provide insurance coverage for such procedures.

The district court had determined that HHS could not interpret or enforce Section 1557 of the Affordable Care Act, which prohibits health-care programs that receive federal funds from discriminating against patients on the basis of sex, to compel Franciscan Alliance to insure gender-reassignment surgeries or abortions, according to the court filing. In May 2016, HHS expanded Section 1557’s definition of sex discrimination to include discrimination on the basis of “termination of pregnancy” and “gender identity.” Secretary of HHS Xavier Becerra appealed the district court’s ruling.

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At a Thursday fundraiser, Biden compared the conservative worldview as a whole to something dictatorial.

While Becerra’s appeal was pending, the Biden administration issued a “Notice and Guidance on Gender Affirming Care,” doubling down on its reasoning, which Judge Don Willett found on Friday to be flawed, that Obamacare mandates that hospitals perform gender-reassignment surgeries and abortions.

On Friday, circuit judges Jennifer Walker Elrod, Willett, and Kurt Engelhardt affirmed the decision of the district court that granted Franciscan Alliance a permanent injunction, barring the HHS from forcing it to provide gender-reassignment surgeries or abortions against its religious beliefs.

Earlier this month, Luke Goodrich, attorney with the Becket Fund who has been working on the case since the Obama-era rule was first issued, said in a call with reporters that if the plaintiffs had lost, the Biden administration would have declared “open season” on religious hospitals that object to gender transitions.

“If we lose, that means all these tens of thousands of religious doctors and hospitals all across the country are subject to massive financial penalties,” Goodrich said.

The plaintiffs were represented by Becket, which focuses on religious-liberty litigation. The ACLU joined in supporting the Biden administration as intervenor defendants. The ACLU argued that the district court erred in blocking the Biden plan because the Franciscan Alliance did not satisfy the irreparable-harm standard, or did not demonstrate that it would suffer injury without the plan’s being blocked.

“We have recognized that the loss of freedoms guaranteed by the First Amendment, RLUIPA, and RFRA all constitute per se irreparable harm,” the federal appeals court wrote Friday.

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