## Facts

- Maine required certain workers in licensed healthcare facilities to be vaccinated against specified communicable diseases.
- Maine amended its vaccination law to eliminate religious and philosophical exemptions, retaining only a medical exemption certified by a medical practitioner when vaccination may be medically inadvisable.
- During the COVID-19 pandemic, Maine issued an emergency rule adding COVID-19 to the required vaccines for covered healthcare workers, again allowing only the medical exemption.
- Maine concluded that vaccination rates among healthcare workers were insufficient to prevent transmission and that alternatives (e.g., testing, prior-infection exceptions, additional PPE) would not adequately prevent outbreaks in healthcare settings.
- Plaintiffs were healthcare workers who alleged that receiving available COVID-19 vaccines would violate sincerely held religious beliefs.
- Plaintiffs sought a preliminary injunction to bar enforcement of the mandate insofar as it provided no religious exemption.

## Issues

1. Whether Maine’s healthcare-worker COVID-19 vaccination requirement, which included a medical exemption but no religious exemption, was likely non-neutral or not generally applicable under the Free Exercise Clause, triggering strict scrutiny.
2. Whether the medical-only exemption scheme likely violated Equal Protection by treating religious objectors differently from those medically exempt.
3. Whether the mandate was likely preempted by federal law under the Supremacy Clause, including federal provisions concerning emergency-use authorization and vaccine-related informed consent.
4. Whether plaintiffs satisfied the requirements for a preliminary injunction, particularly likelihood of success on the merits.

## Decision

- The First Circuit affirmed the district court’s denial of a preliminary injunction.
- Plaintiffs failed to show a likelihood of success on the merits of their Free Exercise, Equal Protection, and preemption claims.
- Because likelihood of success is the most important preliminary-injunction factor, the request for injunctive relief was properly denied.
- The mandate remained in effect during the litigation.

## Legal Principles

- A generally applicable, religion-neutral law that incidentally burdens religious exercise is not subject to strict scrutiny absent evidence of non-neutrality or lack of general applicability.
- A medical exemption narrowly tied to the government’s public-health objective can be treated as materially different from a religious exemption and does not necessarily create a regime of individualized exemptions requiring religious accommodation.
- Where a vaccination requirement is neutral and generally applicable, related Equal Protection challenges based on the same alleged religious discrimination typically receive rational-basis review and may be upheld if the classification is rationally related to legitimate public-health objectives.
- Federal law preempts state action only where Congress clearly intends to displace traditional state authority; federal emergency-use and informed-consent provisions do not, without clear statement, eliminate state power to impose vaccination conditions on categories of workers.
- In preliminary-injunction analysis, failure to show likelihood of success on the merits generally defeats the motion, especially where public-health risks weigh against injunctive relief.

## Conclusion

The First Circuit held that Maine’s healthcare-worker COVID-19 vaccination mandate, which allowed only a medically based exemption, was likely neutral and generally applicable and rationally related to protecting patients and preventing facility outbreaks, and it was not clearly preempted by federal law; therefore, plaintiffs were not entitled to a preliminary injunction.


Does 1-6 v. Mills, 16 F.4th 20 (1st Cir. 2021)