The Supreme Court has allowed the Biden administration's COVID-19 vaccination requirement for workers at Medicare- and Medicaid-participating health facilities to take effect nationwide, preserving a rule covering roughly 10.4 million health-care workers even as the justices separately blocked the administration's broader vaccine-or-test requirement for large employers.
In a 5-4 decision in Biden v. Missouri, the Court concluded that the Secretary of Health and Human Services has authority to condition participation in Medicare and Medicaid on infection-control requirements that protect patients. The Supreme Court opinion says the vaccine requirement fits within the department's longstanding responsibility to ensure that federally funded health facilities operate safely.
A split result for the administration
The health-care ruling came the same day the Court, by a 6-3 vote, blocked an Occupational Safety and Health Administration emergency standard that would have required workers at companies with 100 or more employees to be vaccinated or undergo regular testing. The OSHA rule would have covered about 84 million workers; the CMS rule is narrower and tied specifically to facilities receiving federal health-care funds.
CMS Administrator Chiquita Brooks-LaSure said in a January 13 statement that the health-care requirement will cover 10.4 million workers at approximately 76,000 facilities. CMS said the decision permits nationwide implementation in states where lower courts had blocked the rule.
A Washington Post account described the rulings as a sharp distinction between a broad workplace public-health measure and a condition linked directly to the federal government's role as purchaser and regulator of Medicare and Medicaid services.
The majority ties vaccination to patient safety
The central legal question was not whether COVID-19 vaccination works but whether Congress had authorized the relevant agencies to impose these requirements. For CMS, Chief Justice John Roberts and Justice Brett Kavanaugh joined Justices Stephen Breyer, Sonia Sotomayor and Elena Kagan in allowing the rule to proceed.
The majority reasoned that preventing transmission of dangerous infectious disease is fundamental to the provision of safe medical care. The American Hospital Association's same-day summary noted the Court's 5-4 vote on the CMS rule and the separate 6-3 vote against the OSHA standard.
Four justices dissented from the CMS ruling, arguing that the administration had not shown sufficiently clear congressional authorization for a vaccination mandate affecting millions of health workers. They also raised objections to the rulemaking process and the use of an interim final rule without ordinary notice and comment.
Hospitals now turn from litigation to compliance
Hospitals and health systems have spent weeks operating under a patchwork of injunctions. The CMS requirement originally applied broadly, but federal courts blocked enforcement in about half the states while litigation proceeded. The Supreme Court's order removes those injunctions and shifts the practical focus to compliance dates, exemptions and staffing.
American Hospital Association President Rick Pollack said in an industry statement that hospitals support vaccination but remain concerned about workforce strain at a time when Omicron is driving heavy patient volume and staff absences. The association said it would work with members to balance compliance with the need to retain sufficient staffing.
A detailed AHA special bulletin emphasized that the majority viewed infection control as a familiar CMS responsibility even though a nationwide vaccination condition goes further than measures the agency has used in the past.
The rule's reach is substantial but narrower than OSHA's
The CMS requirement applies to workers in hospitals, nursing homes, home-health agencies and many other providers participating in Medicare or Medicaid, subject to medical and religious accommodations. It is tied to the government's spending and regulatory relationship with participating facilities rather than to a general claim of workplace authority.
A contemporaneous CBS News report highlighted that distinction, noting that the Court rejected OSHA's broad workplace rule while permitting the health-care mandate because Congress had given HHS authority over conditions protecting patients in federally funded medical settings.
The health-care sector now faces an operational challenge rather than a purely legal one. AHA had already warned CMS in January 4 comments that rigid deadlines could worsen shortages in stressed hospitals and urged enforcement flexibility, particularly in states where the rule had been enjoined.
The Supreme Court's split decisions leave federal pandemic authority on two different tracks. The administration cannot use OSHA's emergency power to impose a sweeping vaccine-or-test requirement on most large employers, but it can require vaccination in facilities whose participation in Medicare and Medicaid depends on meeting federal health and safety conditions. For hospitals, nursing homes and other covered providers, that distinction now carries immediate consequences for millions of employees and the patients they serve.
