State of California v. Alex Azar, II ( 2020 )

FILED
FOR PUBLICATION
FEB 24 2020
UNITED STATES COURT OF APPEALS MOLLY C. DWYER, CLERK
U.S. COURT OF APPEALS
FOR THE NINTH CIRCUIT
STATE OF CALIFORNIA, by and No. 19-15974
through Attorney General Xavier Becerra,
D.C. No. 3:19-cv-01184-EMC
Plaintiff-Appellee,
v. OPINION
ALEX M. AZAR II, in his Official
Capacity as Secretary of the U.S.
Department of Health & Human Services;
U.S. DEPARTMENT OF HEALTH &
HUMAN SERVICES,
Defendants-Appellants.
ESSENTIAL ACCESS HEALTH, INC.; No. 19-15979
MELISSA MARSHALL, M.D.,
D.C. No. 3:19-cv-01195-EMC
Plaintiffs-Appellees,
v.
ALEX M. AZAR II, Secretary of U.S.
Department of Health and Human
Services; U.S. DEPARTMENT OF
HEALTH & HUMAN SERVICES,
Defendants-Appellants.
Appeal from the United States District Court
for the Northern District of California
Edward M. Chen, District Judge, Presiding
STATE OF OREGON; STATE OF NEW No. 19-35386
YORK; STATE OF COLORADO;
STATE OF CONNECTICUT; STATE OF D.C. Nos. 6:19-cv-00317-MC
DELAWARE; DISTRICT OF 6:19-cv-00318-MC
COLUMBIA; STATE OF HAWAII;
STATE OF ILLINOIS; STATE OF
MARYLAND; COMMONWEALTH OF
MASSACHUSETTS; STATE OF
MICHIGAN; STATE OF MINNESOTA;
STATE OF NEVADA; STATE OF NEW
JERSEY; STATE OF NEW MEXICO;
STATE OF NORTH CAROLINA;
COMMONWEALTH OF
PENNSYLVANIA; STATE OF RHODE
ISLAND; STATE OF VERMONT;
COMMONWEALTH OF VIRGINIA;
STATE OF WISCONSIN; AMERICAN
MEDICAL ASSOCIATION; OREGON
MEDICAL ASSOCIATION; PLANNED
PARENTHOOD FEDERATION OF
AMERICA, INC.; PLANNED
PARENTHOOD OF SOUTHWESTERN
OREGON; PLANNED PARENTHOOD
COLUMBIA WILLAMETTE; THOMAS
N. EWING, M.D.; MICHELE P.
MEGREGIAN, C.N.M.,
Plaintiffs-Appellees,
v.
ALEX M. AZAR II; U.S. DEPARTMENT
OF HEALTH & HUMAN SERVICES;
2
DIANE FOLEY; OFFICE OF
POPULATION AFFAIRS,
Defendants-Appellants.
Appeal from the United States District Court
for the District of Oregon
Michael J. McShane, District Judge, Presiding
STATE OF WASHINGTON; NATIONAL No. 19-35394
FAMILY PLANNING AND
REPRODUCTIVE HEALTH D.C. Nos. 1:19-cv-03040-SAB
ASSOCIATION; FEMINIST WOMEN’S 1:19-cv-03045-SAB
HEALTH CENTER; DEBORAH OYER,
M.D.; TERESA GALL,
Plaintiffs-Appellees,
v.
ALEX M. AZAR II, in his official capacity
as Secretary of the United States
Department of Health and Human
Services; U.S. DEPARTMENT OF
HEALTH & HUMAN SERVICES;
DIANE FOLEY, MD, in her official
capacity as Deputy Assistant Secretary for
Population Affairs; OFFICE OF
POPULATION AFFAIRS,
Defendants-Appellants.
Appeal from the United States District Court
for the Eastern District of Washington
3
Stanley Allen Bastian, District Judge, Presiding
Argued and Submitted September 23, 2019
San Francisco, California
Before: Sidney R. Thomas, Chief Judge, and Edward Leavy, Kim McLane
Wardlaw, William A. Fletcher, Richard A. Paez, Jay S. Bybee, Consuelo M.
Callahan, Milan D. Smith, Jr., Sandra S. Ikuta, Eric D. Miller and Kenneth K. Lee,
Circuit Judges.
Opinion by Judge Ikuta, Circuit Judge
Title X of the Public Health Service Act gives the Department of Health and
Human Services (HHS) authority to make grants to support “voluntary family
planning projects” for the purpose of offering “a broad range of acceptable and
effective family planning methods and services.” 42 U.S.C. § 300(a).1 Section
1008 of Title X prohibits grant funds from “be[ing] used in programs where
abortion is a method of family planning.” Id. § 300a-6.
Since 1970, when Title X was first enacted, HHS has provided competing
interpretations of this prohibition. Regulations issued in 1988, and upheld by the
Supreme Court in 1991, completely prohibited the use of Title X funds in projects
where clients received counseling or referrals for abortion as a method of family
1
Congress did not design the Title X grant program to provide healthcare
services beyond “family planning methods and services.” 42 U.S.C. § 300(a); cf.
Dissent at 1.
4
planning. Rust v. Sullivan, 500 U.S. 173, 177–79 (1991). Regulations issued in
2000 were more permissive.
In March 2019, HHS promulgated regulations that are similar to those
adopted by HHS in 1988 and upheld by Rust. But the 2019 rule is less restrictive
in at least one important respect: a counselor providing nondirective pregnancy
counseling “may discuss abortion” so long as “the counselor neither refers for, nor
encourages, abortion.” 42 C.F.R. § 59.14(e)(5). There is no “gag” on abortion
counseling. See id.
Plaintiffs, including several states and private Title X grantees, brought
various suits challenging the 2019 rule, and three district courts in three states
entered preliminary injunctions against HHS’s enforcement of the rule. In light of
Supreme Court approval of the 1988 regulations and our broad deference to
agencies’ interpretations of the statutes they are charged with implementing,
plaintiffs’ legal challenges to the 2019 rule fail. Accordingly, we vacate the
injunctions entered by the district courts and remand for further proceedings
consistent with this opinion.
I
In 1970, Congress enacted Title X of the Public Health Service Act to give
HHS authority to make grants to Title X projects that provide specified family
5
planning services.2 Family Planning Services and Population Research Act, Pub.
L. No. 91-572, 84 Stat. 1504, 1508 (1970); 42 U.S.C. § 300a-4(c). The Act gives
HHS broad authority to promulgate regulations to administer the grant program, as
well as to impose conditions on the grants that HHS “may determine to be
appropriate to assure that such grants will be effectively utilized for the purposes
for which made.” § 1006(a)–(b), 84 Stat. at 1507; 42 U.S.C. § 300a-4(a)–(b).
Congress placed only two limitations on HHS’s discretion. First, an
individual’s acceptance of family planning services has to be “voluntary” and not
“a prerequisite to eligibility for or receipt of any other service or assistance from,
or to participation in, any other program of the entity or individual that provided
such service or information.” § 1007, 84 Stat. at 1508; 42 U.S.C. § 300a-5.
Second, § 1008 of Title X provides:
None of the funds appropriated under this subchapter shall be used in
programs where abortion is a method of family planning.
§ 1008, 84 Stat. at 1508; 42 U.S.C. § 300a-6.
Section 1008, which has never been amended, “was intended to ensure that
Title X funds would ‘be used only to support preventive family planning services,
2
Although Title X and its implementing regulations use both the terms
“program” and “project,” for consistency we refer to a program using Title X funds
to provide services to clients as a “Title X project.”
6
population research, infertility services, and other related medical, informational,
and educational activities.’” Rust, 500 U.S. at 178–79 (quoting H.R. Conf. Rep.
No. 91-1667, at 8 (1970)); see also New York v. Sullivan, 889 F.2d 401, 407 (2d
Cir. 1989), aff’d sub nom. Rust v. Sullivan, 500 U.S. 173 (1991) (noting a
legislator’s statement that “[w]ith the ‘prohibition of abortion’ amendment—title
X, section 1008—the [House] committee members clearly intend that abortion is
not to be encouraged or promoted in any way through this legislation”) (statement
of Rep. Dingell). As Rust concluded, in enacting § 1008, Congress made a
constitutionally permissible “value judgment favoring childbirth over abortion.”
500 U.S. at 192 (quoting Maher v. Roe, 432 U.S. 464, 474 (1977)).
Although the purpose of § 1008 is clear, the Supreme Court has determined
that its language is ambiguous because it does not expressly articulate how its
prohibition applies to abortion counseling, referral, and advocacy, or how to ensure
that funds are not used “in programs where abortion is a method of family
planning.” Id. at 184. As a result of this ambiguity, HHS has provided a range of
alternative interpretations of § 1008 over the years. We provide an overview of
this history as context to our analysis of the issues raised by the government’s
appeals.
A
7
In 1971, HHS promulgated (without notice and comment) the first
regulations designed to implement Title X. Project Grants for Family Planning
Services, 36 Fed. Reg. 18,465, 18,465–66 (Sept. 15, 1971). The regulations did
not address the scope of § 1008. Instead, HHS interpreted § 1008 through opinions
from its Office of General Counsel. In the mid-1970s, HHS issued a legal opinion
prohibiting directive counseling on abortion (“encouraging or promoting”
abortion) in a Title X project, while permitting nondirective (“neutral”) counseling
on abortion. Nat’l Family Planning & Reprod. Health Ass’n v. Sullivan, 979 F.2d
227, 229 (D.C. Cir. 1992). Subsequent General Counsel opinions interpreted
§ 1008 as “prohibiting any abortion referrals beyond ‘mere referral,’ that is,
providing a list of names and addresses without in any further way assisting the
woman in obtaining an abortion.” Statutory Prohibition on Use of Appropriated
Funds Where Abortion is a Method of Family Planning, 53 Fed. Reg. 2922, 2923
(Feb. 2, 1988) (the 1988 Rule).
HHS revised its Title X regulations after notice and comment in 1980. See
Grants for Family Planning Services, 45 Fed. Reg. 37,433 (June 3, 1980). But like
the 1971 regulations, the 1980 regulations did not address the scope of § 1008.
Nat’l Family Planning, 979 F.2d at 229 (citing 45 Fed. Reg. at 37,437). Instead, in
1981, HHS issued “Program Guidelines for Project Grants for Family Planning
8
Services.” See U.S. Dep’t of Health & Human Servs., Program Guidelines for
Project Grants for Family Planning Services (1981). For the first time, these
guidelines required Title X projects to give Title X clients nondirective counseling
on and referrals for abortion upon request. Id. § 8.6. The 1981 “guidelines were
premised on a view that ‘non-directive’ counseling and referral for abortion were
not inconsistent with [§ 1008] and were justified as a matter of policy in that such
activities did not have the effect of promoting or encouraging abortion.” 53 Fed.
Reg. at 2923.
It was not until 1988 that HHS addressed the scope of § 1008 in notice-and-
comment rulemaking. See 53 Fed. Reg. at 2922. The 1988 Rule recognized that
“[f]ew issues facing our society today are more divisive than that of abortion.” Id.
Because § 1008 was intended to create “a wall of separation between Title X
programs and abortion as a method of family planning,” the 1988 Rule concluded
that Congress intended Title X to circumscribe “family planning” to include “only
activities related to facilitating or preventing pregnancy, not for terminating it.” Id.
at 2922–23. The 1988 Rule accordingly defined the term “family planning” as
including “a broad range of acceptable and effective methods and services to limit
or enhance fertility.” Id. at 2944.
9
In light of these concerns, the 1988 Rule imposed specified limits on a Title
X project. First, the project could not provide prenatal care. Id. at 2945.
Therefore, “once a client served by a Title X project is diagnosed as pregnant, she
must be referred for appropriate prenatal and/or social services by furnishing a list
of available providers that promote the welfare of mother and unborn child.” Id.
Further, a Title X project could not “provide counseling concerning the use
of abortion as a method of family planning.” Id. In the preamble to the 1988 Rule,
HHS explained that counseling “which results in abortion as a method of family
planning simply cannot be squared with the language of section 1008,” and the
1988 Rule therefore rejected the 1981 program guidelines’ requirement that Title X
projects give nondirective counseling on abortion. Id. at 2923. In barring such
nondirective counseling, HHS also relied on a General Accounting Office (GAO)
report and Office of the Inspector General (OIG) audit of Title X projects
indicating that some Title X projects were “promoting abortion” under the guise of
providing nondirective counseling. Id. at 2924.3
3
For example, the audit found that some Title X projects were providing
clients with brochures prepared by abortion clinics, providing and witnessing the
signing of consent forms required by abortion clinics, making appointments for
clients at abortion clinics, and using Title X funds to pay the administrative costs
for loans provided to clients to pay for abortions. 53 Fed. Reg. at 2924 n.7.
10
Nor could a Title X project “provide referral for abortion as a method of
family planning.” Id. at 2945. Therefore, the list of available providers given to a
pregnant client could not include “providers whose principal business is the
provision of abortions.” Id.
The 1988 Rule also required a Title X project to be organized “so that it is
physically and financially separate” from activities prohibited by § 1008 and the
regulations. Id. To meet this “program integrity” requirement, “a Title X project
must have an objective integrity and independence from prohibited activities.
Mere bookkeeping separation of Title X funds from other monies is not
sufficient.” Id.
HHS explained that its rules requiring physical and financial separation were
supported by OIG-audit and GAO-report findings that Title X projects were
arguably violating § 1008 and that the lack of separation led to confusion as to
whether federal funds were being used for abortion services. Id. Both OIG and
GAO “urged [HHS] to give more specific, formalized direction to programs about
the extent of prohibition on abortion as a method of family planning.” Id. at
2923–24.
After HHS promulgated the 1988 Rule, Title X grantees challenged the
facial validity of the regulations on the grounds that the regulations were not
11
authorized by Title X, were arbitrary and capricious under the Administrative
Procedure Act (APA), and violated the First and Fifth Amendment rights of Title X
clients and the First Amendment rights of Title X health care providers. The
Supreme Court addressed these challenges in Rust.
Rust first rejected the plaintiffs’ claim “that the regulations exceed [HHS]’s
authority under Title X and are arbitrary and capricious.” Id. at 183. Because the
language of § 1008 was “ambiguous” as to “the issues of counseling, referral,
advocacy, or program integrity,” the Court gave “substantial deference” to HHS’s
interpretation under Chevron, U.S.A., Inc. v. Natural Resources Defense Council,
Inc., 467 U.S. 837, 842–43 (1984), and concluded that “[t]he broad language of
Title X plainly allows [HHS]’s construction of the statute.” Rust, 500 U.S. at 184.
“By its own terms, § 1008 prohibits the use of Title X funds ‘in programs where
abortion is a method of family planning’” but “does not define the term ‘method of
family planning,’ nor does it enumerate what types of medical and counseling
services are entitled to Title X funding.” Id. In light of the “broad directives
provided by Congress in Title X in general and § 1008 in particular,” Rust
concluded that HHS’s “construction of the prohibition in § 1008 to require a ban
on counseling, referral, and advocacy within the Title X project” was
permissible. Id.
12
Rust likewise upheld the program integrity requirements, which mandated
separate facilities, personnel, and records. The Court concluded that the
requirements were “based on a permissible construction of the statute” and were
“not inconsistent with congressional intent.” Id. at 188. Rust noted that “if one
thing is clear from the legislative history, it is that Congress intended that Title X
funds be kept separate and distinct from abortion-related activities.” Id. at 190. As
such, Rust declined to upset HHS’s “reasoned determination that the program
integrity requirements are necessary to implement the prohibition” in § 1008. Id.
Rust also rejected the plaintiffs’ argument that the regulations were arbitrary
and capricious because “they ‘reverse a longstanding agency policy that permitted
nondirective counseling and referral for abortion’” and constitute “a sharp break
from [HHS]’s prior construction of the statute.” Id. at 186. According to the
Court, HHS’s revised interpretation was entitled to deference because “the agency,
to engage in informed rulemaking, must consider varying interpretations and the
wisdom of its policy on a continuing basis.” Id. (quoting Chevron, 467 U.S. at
863–64). HHS gave a reasoned basis for its change of interpretation, including that
the new regulations were “more in keeping with the original intent of the statute.”
Id. at 187.
13
Rust then turned to the constitutional arguments. The Court rejected the
argument that the restrictions violated the First Amendment speech rights of
grantees, their staff, and clients, holding that the regulations permissibly
implemented Congress’s decision to allocate public funds “to subsidize family
planning services which will lead to conception and childbirth, and declin[e] to
promote or encourage abortion.” Id. at 193 (internal quotation marks omitted).
“Congress’ power to allocate funds for public purposes includes an ancillary power
to ensure that those funds are properly applied to the prescribed use,” and “the
regulations are narrowly tailored to fit Congress’ intent in Title X that federal
funds not be used to ‘promote or advocate’ abortion as a ‘method of family
planning.’” Id. at 195 n.4. Doctors were “always free to make clear that advice
regarding abortion is simply beyond the scope of the [Title X] program.” Id. at
200. Rust also rejected arguments that the restrictions violated a woman’s Fifth
Amendment right to choose whether to obtain an abortion because “[the] decision
to fund childbirth but not abortion ‘places no governmental obstacle in the path of
a woman who chooses to terminate her pregnancy, but rather, by means of unequal
subsidization of abortion and other medical services, encourages alternative
activity deemed in the public interest.’” Id. at 201 (quoting Harris v. McRae, 448
U.S. 297, 315 (1980)). The regulations did not infringe the doctor-patient
14
relationship, the Court held, because the doctor and patient remained free to
discuss abortion and abortion-related services “outside the context of the Title X
project.” Id. at 203. Accordingly, Rust upheld the 1988 Rule.
Within months after Rust was decided, legislators introduced the Family
Planning Amendments Act of 1992, H.R. 3090, 102d Cong. (1991), which sought
to undo the 1988 Rule and to codify the 1981 program guidelines, see S. Rep. No.
102-86 (1991). Under the proposed legislation, every applicant for a Title X grant
had to agree to offer “nondirective counseling and referrals regarding–(i) prenatal
care and delivery; (ii) infant care, foster care, and adoption; and (iii) termination of
pregnancy.” H.R. 3090, 102d Cong. § 2 (1991); S. 323, 102d Cong. § 2 (1991);
H.R. Rep. No. 102-767, at 2 (1992). The bill failed to obtain the necessary votes.
See S. 323, 102d Cong., Roll No. 452 (Oct. 2, 1992).
After this legislative effort to overturn Rust failed, President Clinton issued a
memorandum directing HHS to suspend the 1988 Rule. See The Title X “Gag
Rule,” 58 Fed. Reg. 7455 (Jan. 22, 1993). Two weeks later (without notice or
comment) HHS issued an interim rule suspending the 1988 Rule and announcing
that the nonregulatory interpretations that existed prior to the 1988 Rule, including
those in the 1981 program guidelines, would apply. See Standards of Compliance
for Abortion-Related Services in Family Planning Service Projects, 58 Fed. Reg.
15
7462 (Feb. 5, 1993). Legislators introduced another bill, the Family Planning
Amendments Act of 1995, H.R. 833, 104th Cong. (1995), which included the same
language as the amendments proposed in 1991, and would have required
nondirective counseling on and referral for the “termination of pregnancy.” H.R.
833, 104th Cong. § 2(b)(3) (1995). As before, these efforts were unsuccessful.
Around this same time, Congress was debating whether to appropriate funds
for Title X projects. See 141 Cong. Rec. H8194-02, at 8249–62 (Aug. 2, 1995). In
response to concerns that Title X clinics were pressing teenagers to obtain
abortions, see id. at H8260 (Rep. Waldholtz), legislators proposed a compromise
bill that would ensure no federal funds were used to support abortion services. As
ultimately enacted, the 1996 appropriations rider provided (among other things)
“[t]hat amounts provided to [Title X] projects . . . shall not be expended for
abortions, [and] that all pregnancy counseling shall be nondirective.” Pub. L. No.
115-245, 132 Stat. 2981, 3070–71. A version of this rider has been reenacted each
year since 1996.
In the wake of the defeat of the Family Planning Amendments Acts of 1992
and 1995, HHS issued a new regulation adopting the language of the failed
legislation. See Standards of Compliance for Abortion-Related Services in Family
Planning Service Projects, 65 Fed. Reg. 41,270 (July 3, 2000) (the 2000 Rule).
16
The 2000 Rule provided that a Title X project was required to offer a pregnant
woman “neutral, factual information and nondirective counseling” on “each of the
following options: (A) Prenatal care and delivery; (B) Infant care, foster care, or
adoption; and (C) Pregnancy termination.” Id. at 41,279. Each Title X project also
had to provide referral for each option “upon request.” Id.
The 2000 Rule eliminated several of the 1988 Rule’s provisions. For
instance, the 2000 Rule dropped the 1988 Rule’s definition of “family planning”
but did not provide a replacement definition. See id. at 41,278. Instead, the 2000
Rule simply stated that a family planning project must “[p]rovide a broad range of
acceptable and effective medically approved family planning methods (including
natural family planning methods) and services (including infertility services and
services for adolescents).” Id. at 41,278–79. The 2000 Rule also eliminated the
physical and financial separation requirement. See id. at 41,276.4
While HHS’s oscillations in interpreting § 1008 were playing out, Congress
enacted various laws (referred to as federal conscience laws) prohibiting
4
In promulgating the 2000 Rule, HHS did not go as far as some commenters
urged. In rejecting comments that it should read § 1008 narrowly as prohibiting
only “the provision of, or payment for, abortions” and nothing else, HHS stated
that this was not “the better reading of the statutory language.” 65 Fed. Reg. at
41,272. HHS also acknowledged that the 1988 Rule was “a permissible
interpretation” of § 1008. Id. at 41,277.
17
discrimination against individuals and entities who objected to performing or
promoting abortion on religious or moral grounds. Beginning in 1973, Congress
enacted four statutes (collectively referred to as the Church Amendments) that
prevent the government from conditioning grant funds on assistance with abortion-
related activities, 42 U.S.C. § 300a-7(b), and prohibit grant recipients from
discriminating against individuals who refused to assist with abortion because of
their “religious beliefs or moral convictions,” id. § 300a-7(c). In 1996, Congress
enacted the Coats-Snowe Amendment to the Public Health Service Act, which
prohibits the federal government from discriminating against any health care entity
because it refuses to engage in certain abortion-related activities, including
providing referrals for abortions. Omnibus Consolidated Rescissions and
Appropriations Act of 1996, Pub. L. No. 104-134, tit. V, § 515, 110 Stat. 1321,
1321-245 (1996) (codified at 42 U.S.C. § 238n(a)). Finally, in 2004 Congress
began including a rider in health care appropriations bills to prohibit discrimination
by recipients of federal grants against health care entities that refused to make
referrals for abortion, among other things. Consolidated Appropriations Act, 2005,
18
Pub. L. No. 108-447, 118 Stat. 2890, 3163 (2004) (referred to as the Weldon
Amendment).5
In 2008, HHS concluded that the 2000 Rule’s requirement that Title X
projects must provide counseling and referrals for abortion upon request was
inconsistent with these federal conscience laws. Therefore, HHS promulgated
regulations to clarify it “would not enforce this Title X regulatory requirement on
objecting grantees or applicants.” Ensuring that Department of Health and Human
Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in
Violation of Federal Law, 73 Fed. Reg. 78,072, 78,087 (Dec. 19, 2008) (the 2008
nondiscrimination regulations). After a new administration took office, HHS
decided these regulations were “unclear and potentially overbroad in scope” and
rescinded them. Regulation for the Enforcement of Federal Health Care Provider
Conscience Protection Laws, 76 Fed. Reg. 9968, 9969 (Feb. 23, 2011).
Thus, before the 2018 rulemaking, HHS’s interpretations of § 1008 had
seesawed through multiple formulations: from permitting—then
requiring—nondirective counseling on abortion as a method of family planning (in
1971 and 1981 guidance documents); to prohibiting counseling and referrals for
5
The Weldon Amendment has been continuously enacted since 2004. See,
e.g., Department of Defense and Labor, Health and Human Services, and
Education Appropriations Act, 2019, Pub. L. 115-245, 132 Stat. 2981, 3118.
19
abortion as a method of family planning (in the 1988 Rule, upheld by the Supreme
Court in 1991); and then to once again requiring nondirective counseling and
referrals for abortion on request (in the 2000 Rule). HHS also vacillated in its
interpretation of the federal conscience laws. This uncertain history was the
backdrop for HHS’s reconsideration of this controversial area in 2018.
B
In 2018, HHS returned to the task of interpreting § 1008 and issued a notice
of proposed rulemaking “to ensure compliance with, and enhance implementation
of, the statutory requirement that none of the funds appropriated for Title X may be
used in programs where abortion is a method of family planning.” Compliance
with Statutory Program Integrity Requirements, 83 Fed. Reg. 25,502, 25,502 (June
1, 2018). After receiving over 500,000 comments reflecting a “sharp diversity of
opinion,” HHS issued a final rule in March 2019. Compliance with Statutory
Program Integrity Requirements, 84 Fed. Reg. 7714, 7723 (Mar. 9, 2019) (the
Final Rule). The Final Rule largely represents a return to the 1988 Rule that the
Supreme Court upheld in Rust.
The Final Rule’s definition of the statutory term “family planning” is
substantially similar to the 1988 Rule’s definition. It “means the voluntary process
of identifying goals and developing a plan for the number and spacing of children,”
20
including by means of “a broad range of acceptable and effective family planning
methods and services.” 84 Fed. Reg. at 7787; 42 C.F.R. § 59.2 (2019). Like the
1988 Rule, the Final Rule states that family planning services “include
preconception counseling” but not “postconception care (including obstetric or
prenatal care) or abortion as a method of family planning.” 84 Fed. Reg. at 7787;
42 C.F.R. § 59.2.
In the preamble to the Final Rule, HHS explained that it adopted this
definition of “family planning” to “address in part its concern that the requirement
for abortion referrals, as provided in the 2000 [Rule], violates or leads to violations
of section 1008’s prohibition on funding Title X projects where abortion is a
method of family planning.” 84 Fed. Reg. at 7729. HHS also explained it was
reestablishing the 1988 Rule’s requirement that family planning methods and
services be “acceptable and effective,” omitting the 2000 Rule’s requirement that
they also be “medically approved,” because the term “medically approved” lacked
clear meaning in this context and does not appear in the statute. Id. at 7740–41.
Repeating the language of Title X, see 42 U.S.C. § 300(a), the Final Rule
provides that a family planning project must “[e]ncourage family participation in
the decision to seek family planning services,” 42 C.F.R. § 59.5(a)(14). In the
preamble, HHS noted that this language was required by the Title X statute itself
21
and that Congress had enacted an appropriations rider that “specifically emphasizes
that grantees encourage family participation ‘in the decision of minors to seek
family planning services.’” 84 Fed. Reg. at 7718 (quoting Pub. L. No. 115-245,
div. B, sec. 207, 132 Stat. 2981, 3070 (2018)).
The Final Rule also sets forth requirements and limitations for post-
conception services. See 42 C.F.R. § 59.14. Under the Rule, once a client is
verified as being pregnant, the client “shall be referred to a health care provider for
medically necessary prenatal health care.” Id. § 59.14(b)(1). The regulations
explain that “[p]rovision of a referral for prenatal health care is consistent with
[Title X] because prenatal care is a medically necessary service.” Id. § 59.14(e)(1).
The Final Rule differs from the 1988 Rule with respect to pregnancy
counseling. HHS noted that the 1996 appropriations rider, as reenacted annually,
22
required “that all pregnancy counseling shall be nondirective.”6 84 Fed. Reg. at
7725 n.36, 7729. Interpreting the rider’s language as permitting such counseling,
id. at 7725, the Final Rule states that a Title X project can give a pregnant client
nondirective pregnancy counseling “when provided by physicians or advanced
practice providers.” 42 C.F.R. § 59.14(b)(1)(i).7
6
The appropriations rider for 2018 provides:
For carrying out the program under title X of the [Public Health
Service] Act to provide for voluntary family planning projects,
$286,479,000: Provided, That amounts provided to said projects
under such title shall not be expended for abortions, that all pregnancy
counseling shall be nondirective, and that such amounts shall not be
expended for any activity (including the publication or distribution of
literature) that in any way tends to promote public support or
opposition to any legislative proposal or candidate for public office.
Pub. L. No. 115-245, div. B, tit. II, 132 Stat. 2981, 3070–71 (2018).
7
The Final Rule defines “Advanced Practice Provider” as:
[A] medical professional who receives at least a graduate level degree
in the relevant medical field and maintains a license to diagnose, treat,
and counsel patients. The term Advanced Practice Provider includes
physician assistants and advanced practice registered nurses (APRN).
Examples of APRNs that are an Advanced Practice Provider include
certified nurse practitioner (CNP), clinical nurse specialist (CNS),
certified registered nurse anesthetist (CRNA), and certified
nurse-midwife (CNM).
42 C.F.R. § 59.2.
23
Unlike the 1988 Rule, the Final Rule establishes that a counselor providing
nondirective pregnancy counseling “may discuss abortion” so long as “the
counselor neither refers for, nor encourages, abortion.” Id. § 59.14(e)(5). To
ensure compliance with federal conscience laws, however, a Title X provider is not
required to discuss abortion upon request. See 84 Fed. Reg. at 7716, 7746–47. In
short, the Final Rule does not impose a “gag” on abortion counseling: a counselor
“may discuss abortion” but is not required to do so. 42 C.F.R. § 59.14(e)(5).8
8
The dissent relies heavily on its mistaken view that the Final Rule is a “Gag
Rule” that “gags health care providers from fully counseling women about their
options while pregnant.” Dissent at 1–2. The dissent conjures up a “Kafkaesque”
situation where counselors have to “walk on eggshells to avoid a potential
transgression” of the Final Rule and in response to questions about terminating a
pregnancy can merely say: “I can’t help you with that or discuss it. Here is a list
of doctors who can assist you with your pre-natal care despite the fact that you are
not seeking such care.” Dissent at 6 (citation omitted). But this “Kafkaesque”
scenario is belied by the Final Rule itself, which expressly authorizes counseling
on abortion while prohibiting referrals for abortion. Indeed, the Final Rule
provides its own example of a straightforward conversation with a client who asks
about abortion:
[When a] pregnant woman requests information on abortion and asks
the Title X project to refer her for an abortion[, then] [t]he counselor
tells her that the project does not consider abortion a method of family
planning and, therefore, does not refer for abortion. The counselor
offers her nondirective pregnancy counseling, which may discuss
abortion, but the counselor neither refers for, nor encourages,
abortion.
42 U.S.C. § 59.14(e)(5) (emphasis added). The dissent’s arguments that the Final
(continued...)
24
Although the Final Rule permits a Title X project to provide nondirective
counseling that includes information about abortion, it expressly prohibits referrals
for abortion as a method of family planning. HHS explained its understanding that
“referral for abortion as a method of family planning, and such abortion procedure
itself, are so linked that such a referral makes the Title X project or clinic a
program one where abortion is a method of family planning.” 84 Fed. Reg. at
7717. Accordingly, “[a] Title X project may not perform, promote, refer for, or
support abortion as a method of family planning, nor take any other affirmative
action to assist a patient to secure such an abortion.” 42 C.F.R. § 59.14(a).
Further, “[a] Title X project may not use the provision of any prenatal, social
service, emergency medical, or other referral, of any counseling, or of any provider
lists, as an indirect means of encouraging or promoting abortion as a method of
family planning.” Id. § 59.14(c)(1).
While referrals for abortion as a method of family planning are not allowed,
the Title X project may give a pregnant client a “list of licensed, qualified,
comprehensive primary health care providers,” which may include “providers of
8
(...continued)
Rule is a “Gag Rule” is merely a restatement of its disagreement with the Final
Rule’s interpretation of § 1008 as precluding “referral for abortion as a method of
family planning.” 84 Fed. Reg. at 7717.
25
prenatal care[], some, but not the majority, of which also provide abortion as part
of their comprehensive health care services.” Id. § 59.14(c)(2). “Neither the list
nor project staff may identify which providers on the list perform abortion.” Id.
The Title X project may also provide referrals for abortion when such a procedure
is medically necessary. 84 Fed. Reg. at 7748.
Finally, the Final Rule, like the 1988 Rule, requires that a Title X project be
organized “so that it is physically and financially separate . . . from activities that
are prohibited under section 1008 of the Public Health Service Act and §§ 59.13,
59.14, and 59.16 of these regulations.” 42 C.F.R. § 59.15. HHS explained that the
physical and financial separation requirements were necessary to avoid the risk “of
the intentional or unintentional use of Title X funds for impermissible purposes,
the co-mingling of Title X funds, the appearance and perception that Title X funds
being used in a given program may also be supporting that program’s abortion
activities, and the use of Title X funds to develop infrastructure that is used for the
abortion activities of Title X clinics.” 84 Fed. Reg. at 7764.
The effective date of the Final Rule was set for May 3, 2019, but the
compliance deadline for the physical separation requirements is March 4, 2020. Id.
at 7714.
26
C
Before the Final Rule’s effective date, several states and private Title X
grantees (collectively, plaintiffs) filed lawsuits against HHS in three different
district courts seeking preliminary injunctive relief. The lawsuits challenged the
Final Rule under the APA as arbitrary and capricious, contrary to law, and in
excess of statutory authority. 5 U.S.C. § 706(2)(A), (C).9 All three district courts
granted plaintiffs’ preliminary injunction motions on similar grounds. See
Washington v. Azar, 376 F. Supp. 3d 1119 (E.D. Wash. 2019); California v. Azar,
385 F. Supp. 3d 960 (N.D. Cal. 2019); Oregon v. Azar, 389 F. Supp. 3d 898 (D.
Or. 2019). HHS timely appealed each of the preliminary injunction orders.10
We review a district court’s grant of a preliminary injunction “for an abuse
of discretion.” Gorbach v. Reno, 219 F.3d 1087, 1091 (9th Cir. 2000) (en banc).
9
Plaintiffs also brought various constitutional claims, but the district courts
did not base their preliminary injunctions on these claims. Plaintiffs do not raise
these claims as alternative grounds for affirming the district courts’ grants of
injunctive relief, so any such argument was waived. See United States v. Gamboa-
Cardenas, 508 F.3d 491, 502 (2007).
10
HHS also moved to stay the injunctions pending a decision on the merits
of its appeals. We granted the stay motion in a published order. See California v.
Azar, 927 F.3d 1068 (9th Cir. 2019) (per curiam). Upon the vote of a majority of
nonrecused active judges, we ordered reconsideration en banc of the stay motion,
California v. Azar, 927 F.3d 1045, 1046 (9th Cir. 2019) (mem.), but we did not
vacate the stay order itself, so it remained in effect, California v. Azar, 928 F.3d
1153, 1155 (9th Cir. 2019) (mem.). The stay motion is now denied as moot.
27
But “legal issues underlying the injunction are reviewed de novo because a district
court would necessarily abuse its discretion if it based its ruling on an erroneous
view of law.” adidas Am., Inc. v. Skechers USA, Inc., 890 F.3d 747, 753 (9th Cir.
2018) (citation omitted).
II
“A plaintiff seeking a preliminary injunction must establish [1] that he is
likely to succeed on the merits, [2] that he is likely to suffer irreparable harm in the
absence of preliminary relief, [3] that the balance of equities tips in his favor, and
[4] that an injunction is in the public interest.” Winter v. Nat. Res. Def. Council,
Inc., 555 U.S. 7, 20 (2008); accord Garcia v. Google, Inc., 786 F.3d 733, 740 (9th
Cir. 2015). The first factor—likelihood of success on the merits—“is the most
important” factor. Id. If a movant fails to establish likelihood of success on the
merits, we need not consider the other factors. Id.
The Supreme Court has recognized that when an issue of law is key to
resolving a motion for injunctive relief, the reviewing court has the power “to
examine the merits of the case” and resolve the legal issue. Munaf v.Geren, 553
U.S. 674, 691 (2008) (internal quotation marks omitted) (quoting N.C. R. Co. v.
Story, 268 U.S. 288, 292 (1925)). “Adjudication of the merits is most appropriate
if the injunction rests on a question of law and it is plain that the plaintiff cannot
28
prevail.” Id.; accord Blockbuster Videos, Inc. v. City of Tempe, 141 F.3d 1295,
1297 (9th Cir. 1998). The Supreme Court reaffirmed this conclusion in Winter,
noting that it could “address the underlying merits of plaintiffs’ [legal] claims” in
the preliminary injunction appeal and proceed to a decision. 555 U.S. at 31; see
also Blockbuster Videos, 141 F.3d at 1297; Friends of the Earth v. U.S. Navy, 841
F.2d 927, 931 (9th Cir. 1988).
This approach applies in appropriate APA cases. See Beno v. Shalala, 30
F.3d 1057, 1063–64 (9th Cir. 1994). In Beno, we considered plaintiffs’ claim that
an agency’s action was “‘arbitrary and capricious’ within the meaning of the
APA.” Id. at 1063. The APA claim required only review of the administrative
record and interpretation of relevant statutes; “additional fact-finding [was] not
necessary to resolve th[e] claim.” Id. at 1064 n.11. Because “the district court’s
denial of injunctive relief rested primarily on interpretations of law, not on the
resolution of factual issues,” we reviewed de novo the district court’s legal
conclusions and addressed plaintiffs’ claims on the merits. Id. at 1063–64 (internal
quotation marks omitted). We held this was appropriate because “in APA cases, a
district court decision is generally accorded no particular deference, and is
reviewed de novo because the district court is in no better position than this court
to review the administrative record.” Id. at 1063 n.9 (internal quotation marks and
29
citations omitted). This approach is consistent with the Supreme Court’s ruling
that district courts’ “factfinding capacity” is “typically unnecessary to judicial
review of agency decisionmaking” because both the district court and the court of
appeals “are to decide, on the basis of the record the agency provides, whether the
action passes muster under the appropriate APA standard of review.” Fla. Power
& Light Co. v. Lorion, 470 U.S. 729, 744 (1985).
Here, the only significant issues raised are legal. Plaintiffs argue that the
Final Rule is invalid on its face because it conflicts with other statutes and the
agency acted in an arbitrary and capricious manner in promulgating it. An
agency’s action violates the APA when it is “in excess of statutory jurisdiction [or]
authority,” 5 U.S.C. § 706(2)(C), or when it is “not in accordance with law,” id.
§ 706(2)(A), for instance, when it violates another statute, see FCC v. NextWave
Pers. Commc’ns Inc., 537 U.S. 293, 300 (2003). The record before us is sufficient
to resolve plaintiffs’ challenges, and no additional factual development is
30
required.11 The district courts issued preliminary injunctions based on their view
that plaintiffs were likely to prevail on the merits of these legal claims, and thus the
district courts were not in any better position to decide these issues than we are.
11
Although the parties did not submit the full administrative record (which
includes over 500,000 public comments) to the district courts, all public comments
made during the rulemaking process are available online and were available to the
parties in raising arguments to the district court. See Compliance with Statutory
Program Integrity Requirements, regulations.gov (last visited Oct. 29, 2019),
https://www.regulations.gov/document?D=HHS-OS-2018-0008-0001; 84 Fed.
Reg. at 7722 & n.26. Indeed, the parties used selected public comments to support
their arguments in their briefs both to the district courts and to us. Despite this, the
dissent asserts that “[d]eciding the merits of [p]laintiffs’ arbitrary and capricious
claim is . . . premature” because “[w]e do not have the complete administrative
record.” Dissent at 15–16. But neither plaintiffs nor the dissent identify additional
arguments that could be made after submission of the full record, see Dissent at
15–16; at most, plaintiffs stated at oral argument (but not in their briefing) that they
might delve deeper into the approximately 500,000 public comments to provide
additional support for their existing arguments. Because HHS did not omit or
withhold material information from the administrative record, the cases on which
the dissent relies are inapposite. See Walter O. Boswell Mem’l Hosp. v. Heckler,
749 F.2d 788, 793 (D.C. Cir. 1984) (holding that review could not go forward on a
partial record where doing so “would be fundamentally unfair” because agency had
withheld significant information); Nat. Res. Def. Council, Inc. v. Train, 519 F.2d
287, 292 (D.C. Cir. 1975) (remanding to district court for further review where
agency omitted a key document that “throws light on the factors and considerations
relied upon” by the agency from the administrative record). Accordingly, we
conclude that the record before us is sufficient to resolve plaintiffs’ arguments that
aspects of the Final Rule are arbitrary and capricious. See McChesney v. FEC, 900
F.3d 578, 583 (8th Cir. 2018); 5 U.S.C. § 706 (“[T]he court shall review the whole
record or those parts of it cited by a party.”).
31
See Beno, 30 F.3d at 1063 n.9.12 We have received extensive briefing and heard
argument on the issues presented. Because we can decide, based on the record
provided, “whether the action passes muster under the appropriate APA standard of
review,” Fla. Power & Light Co., 470 U.S. at 744, we may resolve the legal issues
on their merits, Beno, 30 F.3d at 1064.
III
We first consider plaintiffs’ argument that the Final Rule is facially invalid.
Plaintiffs wisely do not press the argument that the Final Rule is an impermissible
interpretation of the text of § 1008. Rust held that “[t]he broad language of Title X
plainly allows [the 1988 Rule’s] construction of the statute,” 500 U.S. at 184, and
the Final Rule is substantially the same as the 1988 Rule with respect to the
provisions at issue here.
Rather, plaintiffs mainly argue that two intervening congressional
enactments altered the legal landscape so that Rust’s holding is no longer valid.
12
In considering plaintiffs’ claims that HHS’s action was arbitrary and
capricious, the district courts properly limited their review to the record before
them. See California, 385 F. Supp. 3d at 1000–18; Washington, 376 F. Supp. 3d at
1131; Oregon, 389 F. Supp. 3d at 914–19. While the district courts made factual
findings and predictions to support their conclusion that plaintiffs showed a
likelihood of irreparable harm, see, e.g., California, 385 F. Supp. 3d at 978–85, see
also Fed. R. Civ. P. 52(a), these findings are not relevant to the resolution of the
arbitrary and capricious challenge, see Fla. Power & Light Co., 470 U.S. at 744.
32
First, plaintiffs point to the 1996 appropriations rider enacted to ensure no federal
funds were used to support abortion services. See Pub. L. No. 115-245, div. B, tit.
II, 132 Stat. 2981, 3070–71 (2018). Second, plaintiffs rely on a section of the
Patient Protection and Affordable Care Act (ACA) that limits HHS’s ability to
promulgate regulations. See Pub. L. No. 111-148, § 1554, 124 Stat. 119, 259
(2010) (codified at 42 U.S.C. § 18114).
In considering these arguments, we are mindful that the Supreme Court’s
“interpretive decisions, in whatever way reasoned, effectively become part of the
statutory scheme.” Kimble v. Marvel Entm’t, LLC, 135 S. Ct. 2401, 2409 (2015).
Therefore, Rust’s conclusion that § 1008 could be interpreted to bar abortion
counseling, referral, and advocacy within a Title X project became a part of
Title X’s scheme, and we may not lightly infer that Congress intended to overrule
that holding in enacting the appropriations rider or § 1554 of the ACA. Because
“[t]he modification by implication of [a] settled construction of an earlier and
different section” by a later enactment “is not favored,” United States v. Madigan,
300 U.S. 500, 506 (1937), plaintiffs must provide evidence that Congress intended
to alter Rust’s conclusion that the 1988 Rule was a permissible interpretation of
Title X and § 1008. They fail to do so.
A
33
We first turn to plaintiffs’ argument that the Final Rule violates the 1996
appropriations rider. At the time HHS promulgated the Final Rule, the
appropriations rider provided that “amounts provided to [the Title X project] shall
not be expended for abortions, [and] that all pregnancy counseling shall be
nondirective.” Pub. L. No. 115-245, div. B, tit. II, 132 Stat. 2981, 3070–71 (2018).
HHS interpreted this appropriations rider as permitting Title X projects to provide
counseling on abortion, and incorporated this interpretation in the Final Rule. See
84 Fed. Reg. at 7725; 42 C.F.R. § 59.14(e)(5).
Plaintiffs’ argument about the correct interpretation of this provision
proceeds in three steps. First, according to plaintiffs, the term “pregnancy
counseling” must be interpreted as including referrals. Second, plaintiffs contend
that the term “nondirective” means the presentation of all options on an equal
basis. Third, putting these two definitions together, plaintiffs argue that the term
“nondirective pregnancy counseling” requires the provision of referrals for
abortion on the same basis as referrals for prenatal care and adoption. Because the
Final Rule requires referrals for medically necessary prenatal health care and
permits referrals for adoption but precludes referrals for abortion, see 42 C.F.R.
§ 59.14, plaintiffs contend that the Final Rule does not provide nondirective
34
pregnancy counseling, and thus violates the appropriations rider. We consider
each of these steps in turn.
1
At the first step, plaintiffs and the dissent argue that the statutory term
“pregnancy counseling” must be interpreted as including referrals.13 Congress has
not provided a definition of the term “pregnancy counseling,” or otherwise
“directly addressed the precise question at issue.” Chevron, 467 U.S. at 843. In
the face of Congressional silence, we give “substantial deference” to the
interpretations provided by HHS. Rust, 500 U.S. at 184.14
In the Final Rule, HHS provided its interpretation by treating the terms
“counseling” and “referral” as referring to distinct legal concepts. See 84 Fed.
Reg. at 7716–17. While a counselor may “provide nondirective pregnancy
counseling to pregnant Title X clients on the patient’s pregnancy options, including
abortion,” id. at 7724 (emphasis added), the Final Rule prohibits any “referral for
abortion as a method of family planning,” id. at 7717.
13
As HHS recognized, the appropriations rider amended Title X by
expressly requiring all pregnancy counseling to be nondirective. 84 Fed. Reg. at
7725, 7729. Congress “may amend substantive law in an appropriations statute, as
long as it does so clearly.” Robertson v. Seattle Audubon Soc’y, 503 U.S. 429, 440
(1992).
14
HHS is the agency authorized to promulgate regulations to implement
Title X, see 42 U.S.C. § 300a-4(a).
35
In its brief on appeal, HHS made explicit the Final Rule’s implicit
interpretation of “counseling.”15 According to HHS, under the Final Rule and as a
matter of common usage, “counseling and referrals are distinct” because
“‘[p]regnancy counseling’ involves providing information about medical options,
which is different from referring a patient to a specific doctor for a specific form of
medical care.”
HHS’s interpretation of the phrase “pregnancy counseling” as a concept that
is distinct from the term “referrals” is reasonable and consistent with common
usage. The dictionary indicates that counseling does not include referrals. The
dictionary definition of the term “counseling” is “a practice or professional service
designed to guide an individual to a better understanding of [her] problems and
15
We may defer to an interpretation made in a legal brief so long as it is not
a post hoc rationalization “advanced by an agency seeking to defend past agency
action against attack.” Auer v. Robbins, 519 U.S. 452, 462 (1997). As in Auer,
there is no reason here to think that HHS’s position is a “post hoc rationalization.”
Id. Indeed, HHS has long treated “counseling” and “referral” as distinct concepts.
The 1981 guidelines and the 2000 Rule both provided that Title X projects were
required to provide “nondirective counseling on each of the options [including
pregnancy termination], and referral upon request.” 65 Fed. Reg. at 41,279;
Program Guidelines for Project Grants for Family Planning Services, § 8.6 (1981)
(emphasis added); see also 53 Fed. Reg. at 2923 (explaining that the 1981
guidelines required providers to furnish “nondirective ‘options
couns[e]ling”—including “on pregnancy termination (abortion)”—“followed by
referral for these services if [the patient] so requests”). And the 2000 Rule treated
“non-directive counseling,” see 65 Fed. Reg. at 41,272–74, as distinct from
“[r]eferral[s] for abortion, see id. at 41,274.
36
potentialities . . . .” Counseling, Webster’s Third New International Dictionary
518 (2002); see also Counseling, The American Medical Association Encyclopedia
of Medicine 317 (1989) (defining “counseling” as “[a]dvice and psychological
support given by a health professional and usually aimed at helping a person cope
with a particular problem”). By contrast, “referral” is defined as “the process of
directing or redirecting (as a medical case, a patient) to an appropriate specialist or
agency for definitive treatment.” Referral, Webster’s Third New International
Dictionary 1908 (2002). As in Rust, “[t]he broad language of Title X,” as amended
by the 1996 appropriations rider, “plainly allows [HHS]’s construction of the
statute.” 500 U.S. at 184.
Plaintiffs’ and the dissent’s argument that the term “pregnancy counseling”
must be interpreted as including referrals is primarily based on their reading of a
separate statute enacted by Congress, the Children’s Health Act of 2000, Pub. L.
No. 106-310, 114 Stat. 1101 (2000); see Dissent at 10–11. A provision of that Act,
the “Infant Adoption Awareness” section, 42 U.S.C. § 254c-6, requires HHS to
make grants to adoption organizations “for the purpose of developing and
implementing programs to train the designated staff of eligible health centers in
providing adoption information and referrals to pregnant women on an equal basis
with all other courses of action included in nondirective counseling to pregnant
37
women.” 42 U.S.C. § 254c-6(a)(1). According to plaintiffs and the dissent, this
language shows Congress intended that referrals be “included in nondirective
counseling” and that all options, including abortion, should be presented on an
equal basis. See Dissent at 10–11.
This argument fails. The Infant Adoption Awareness section neither
provides a definition of “nondirective counseling” nor “expressly states” that
nondirective counseling “encompasses referrals.” Cf. Dissent at 7 n.4.16 Simply
put, the section does not show that referrals are a type of nondirective counseling.
Indeed, it does not impose any requirements or limitations on nondirective
pregnancy counseling at all; rather, it provides funds to adoption organizations to
enable them to offer training to the staff of health centers regarding the provision
of adoption information and referrals to clients. HHS could reasonably conclude
that this section does not indicate that it considers referrals to be a type of
counseling, as opposed to something that may occur at the same time as
counseling. 84 Fed. Reg. at 7733. Given that the Infant Adoption Awareness
section is not part of Title X, does not use language similar to that in the 1996
16
Although the dissent claims that Congress “clarified the meaning of the
term ‘nondirective’” and that Congress’s “intent is clear,” in fact, the dissent
merely offers its own interpretation of what the term means in context. Dissent at
10.
38
appropriations rider, and was enacted for a substantially different purpose, it sheds
no light on Congress’s intent in enacting the appropriations rider or on the
interpretation of its statutory language. Cf. Northcross v. Bd. of Educ. of Memphis
City Sch., 412 U.S. 427, 428 (1973) (per curiam) (providing that it is appropriate to
interpret the language of two separate statutes pari passu where two statutes use
similar language and were enacted for the same purpose).17
Plaintiffs’ and the dissent’s second argument, that industry practice requires
interpreting “counseling” as including referrals, also fails, because the sources on
17
In addition to discussing the Infant Adoption Awareness section, 42
U.S.C. § 254c-6(a)(1), both the plaintiffs and HHS point to other statutes that
reference counseling and referrals. HHS notes that Congress has frequently
referred to counseling and referrals separately, showing that the two are legally
distinct concepts. See, e.g., 42 U.S.C. § 300z-10(a) (“Grants or payments may be
made only to . . . projects which do not provide abortions or abortion counseling or
referral . . . .”); id. § 300z-3(b) (referring to “counseling and referral services”); 18
U.S.C. § 248(e)(5) (“reproductive health services” includes “counseling or referral
services relating to the human reproductive system, including services relating to
pregnancy or the termination of a pregnancy”). Plaintiffs identify other statutes
that suggest referrals can occur during the course of counseling. See, e.g., 42
U.S.C. § 300ff-33 (“post-test counseling (including referrals for care)” provided to
individuals with positive HIV/AIDS test); id. § 3020e-1(b) (referring to “pension
counseling and information programs” that “provide outreach, information,
counseling, referral, and other assistance”); 20 U.S.C. § 1161k(c)(4)(A) (requiring
college counselors to provide “referrals to and follow-up with other student
services staff”). Because these statutes do not use the same language as the
appropriations rider and were not enacted for the same purpose, they do not assist
us in interpreting Congress’s direction “that all pregnancy counseling shall be
nondirective.” See 84 Fed. Reg. at 7745.
39
which plaintiffs rely shed no light on the proper interpretation of the term
“nondirective pregnancy counseling.” Dissent at 7 n.4. Plaintiffs first point to
HHS’s guidelines in Providing Quality Family Planning Services (the QFP), which
state that during a “visit [to] a provider of family planning services,” pregnancy-
test results “should be presented to the client, followed by a discussion of options
and appropriate referrals.” U.S. Dep’t of Health & Human Servs., Providing
Quality Family Planning Services, Morbidity & Mortality Wkly. Rep., Apr. 25,
2014, at 13–14. Rather than requiring an interpretation of counseling as including
referrals, this language suggests that counseling (i.e., “discussion of options”) and
referrals are distinct. Plaintiffs also point to a letter submitted by the American
Medical Association (AMA) during the notice-and-comment period on the Final
Rule. In this letter, the AMA listed several provisions in its Code of Medical
Ethics which it claimed made it unethical for a practitioner to refrain from
providing “all appropriate referrals, including for abortion services.” But the
provisions of the code cited in the letter do not even discuss referrals, let alone
define the term; rather, they state that patients have a right “to receive information
from their physicians and to have the opportunity to discuss the benefits, risks, and
costs of appropriate treatment alternatives” and “to expect that their physicians will
provide guidance about what they consider the optimal course of action for the
40
patient based on the physician’s objective professional judgment.” These sources
do not show that the term “referrals” is included in the phrase “nondirective
pregnancy counseling.”18
Because HHS can reasonably interpret “nondirective pregnancy counseling”
as not including referrals, see 84 Fed. Reg. at 7716, plaintiffs fail at the first step of
their arguments, that “pregnancy counseling” must be deemed to include referrals.
2
Plaintiffs also fail at the second step of their argument: that the term
“nondirective” means the presentation of all options on an equal basis. Neither
Title X nor the appropriations rider defines “nondirective.” Again, because
Congress has “not directly addressed the precise question at issue,” Chevron, 467
U.S. at 843, we must give substantial deference to HHS’s interpretation. Rust, 500
U.S. at 184. In the Final Rule, HHS filled the Congressional silence by
interpreting “nondirective pregnancy counseling” to mean “the meaningful
presentation of options where the physician or advanced practice provider (APP) is
‘not suggesting or advising one option over another.’” 84 Fed. Reg. at 7716
(quoting 138 Cong. Rec. H2822-02, 2826 (statement of Rep. Lloyd)).
18
The dissent does not address these sources and merely asserts, without
explanation, that “industry understanding recognizes that counseling includes
referrals.” Dissent at 7 n.4 (citing California, 385 F. Supp. 3d at 989).
41
Under this definition, “nondirective” does not mean the presentation of all
possible medical options. Rather, “nondirective” means that options must be
provided in a neutral manner, without suggesting or advising one option over
another. Thus, a physician or APP providing nondirective counseling to a client
does not have to discuss every possible option available to that client, but must
present options in a neutral manner and refrain from encouraging the client to
select a particular option. In other words, HHS interpreted “nondirective” to refer
to the neutral manner in which counseling is provided rather than to the scope of
topics that must be covered in counseling. 84 Fed. Reg. at 7716.
This is a reasonable interpretation of “nondirective.” It is consistent with
HHS’s longstanding distinction between “nondirective” counseling that is
“neutral” and “directive” counseling that encourages or promotes abortion. Nat’l
Family Planning, 979 F.2d at 229. And it is consistent with the dictionary
definition of the term “nondirective” as a type of counseling where “the counselor
refrains from interpretive or associative comment but usually by repeating phrases
used by the client encourages [the client] to express, clarify, and restructure [the
client’s] problems.” Nondirective, Webster’s Third New International Dictionary
1536 (2002); see also 84 Fed. Reg. at 7716 (nondirective counseling involves
“clients tak[ing] an active role in processing their experiences and identifying the
42
direction of the interaction”). Because HHS’s interpretation of “nondirective” is
reasonable, we defer to that interpretation. See Chevron, 467 U.S. at 843–44; Nw.
Envtl. Advocates v. EPA, 537 F.3d 1006, 1014 (9th Cir. 2008).
We also reject plaintiffs’ and the dissent’s argument that the Final Rule is
directive because it requires referrals for medically necessary prenatal health care.
Dissent at 5. HHS could reasonably conclude that referrals for prenatal care are
nondirective, as HHS defines this term, because a referral for prenatal care does not
steer the client toward any particular option and does not discourage a client from
seeking an abortion outside of the Title X program. As HHS points out, “seeking
prenatal care is not the same as choosing the option of childbirth.” 84 Fed. Reg. at
7748. Further, HHS could reasonably conclude that providing a referral for
prenatal care is not directive because it is “medically necessary” for the health of
the client during pregnancy, id. at 7748, 7761–62, regardless of whether the client
43
later chooses an abortion outside of a Title X project.19 “Where care is medically
necessary, as prenatal care is for pregnancy, referral for that care is not directive
because the need for the care preexists the direction of the counselor, and is,
instead, the result of the woman’s pregnancy diagnosis or the diagnosis of a health
condition for which treatment is warranted.” Id. at 7748. Because prenatal care is
medically necessary for a pregnant client, see id. at 7748, 7761–62, referrals for
such care are distinguishable from referrals for abortions for the purpose of family
planning, which are not medically necessary. Indeed, the Supreme Court has long
recognized that abortion need not be treated the same as other medical procedures:
“Abortion is inherently different from other medical procedures, because no other
procedure involves the purposeful termination of a potential life.” Harris v.
19
Plaintiffs and the dissent point to declarations from doctors and nurse
practitioners conclusorily stating that prenatal care “is not medically necessary for
someone who wishes to terminate her pregnancy.” Dissent at 8 n.5. But HHS
reasonably concluded otherwise, 84 Fed. Reg. at 7748, 7761–62, based on its
determination that “pregnancy may stress and affect extant [i.e., existing] health
conditions [of the client],” such that “primary health care may be critical to ensure
that pregnancy does not negatively impact such conditions,” id. at 7750.
The dissent’s argument that HHS did not justify the referral requirement on
the ground that prenatal care is medically necessary for the health of the client,
Dissent at 8 n.5, is refuted by the record; indeed, the sentence of the Final Rule on
which the dissent relies for this argument makes clear that prenatal care is
“important for . . . the health of the women,” 84 Fed. Reg. at 7722 (emphasis
added); see also id. at 7748, 7761–62.
44
McRae, 448 U.S. 297, 325 (1980); see also Maher, 432 U.S. at 480 (“The simple
answer to the argument” that a law imposes different requirements on abortion than
other medical procedures is that other “procedures do not involve the termination
of a potential human life.”).20 Given these distinctions, requiring referrals for
20
Given the “inherent[] differen[ces]” between abortion and other medical
procedures, McRae, 448 U.S. at 325, the dissent’s attempt to liken nontherapeutic
abortion to treatment options for prostate cancer is meritless, Dissent at 7–8.
Prostate cancer is a disease, and “chemotherapy, radiation, [and] hospice” are
treatment options. Dissent at 7–8. Pregnancy is not a disease, and a
nontherapeutic abortion is not a treatment option.
By contrast, abortion is not used as a “method of family planning” under
§ 1008 or the Final Rule when abortion is medically necessary (i.e., therapeutic).
See Abortion, elective, The American Medical Association Encyclopedia of
Medicine 57 (1989) (defining a “therapeutic abortion” as an abortion “carried out
to save the life or health of the mother”). Referrals for and counseling on
therapeutic abortions are not subject to the same restrictions as those imposed on
nontherapeutic ones; rather, in situations where “emergency care is required,” the
Final Rule requires that clients be referred “immediately to an appropriate provider
of medical services needed to address the emergency.” 42 C.F.R. § 59.14(b)(2);
see also id. § 59.14(e)(2) (requiring referral for emergency medical care upon the
discovery of an ectopic pregnancy).
45
medically necessary prenatal health care but not for nontherapeutic abortions does
not make pregnancy counseling directive.21
21
The dissent’s argument that clients who receive counseling on prenatal
care and abortion (but not referrals for abortion providers) are “coerced,”
“demeaned,” and prevented from taking “an active role in identifying the
direction” of their lives is absurd. Dissent at 8 (cleaned up). Nothing in the Final
Rule prevents clients from procuring abortions. See 42 C.F.R. § 59.14. Similarly,
the dissent’s reliance on the 2000 Rule to argue that failing to provide abortion
referrals is coercive, Dissent at 8 n.5, is misplaced because the 2000 Rule merely
suggested that a referral for “prenatal care and delivery” might be coercive if the
client has rejected that option, 65 Fed. Reg. at 41,275 (emphasis added); the 2000
Rule said nothing about whether it is coercive to require a referral for prenatal care
to safeguard the health of the client, see 84 Fed. Reg. at 7722.
The dissent’s suggestion that clients relying on Title X services cannot
locate abortion providers without a referral from a Title X counselor, Dissent at 9
n.6, is contrary to the reality—recognized in the Final Rule—that “[i]nformation
about abortion and abortion providers is widely available and easily accessible,
including on the internet,” 84 Fed. Reg. at 7746. We decline to second-guess
HHS’s determination based on plaintiffs’ unsupported declarations. See Dep’t of
Commerce v. New York, 139 S. Ct. 2551, 2571 (2019); cf. Dissent at 9 n.6. In any
event, Title X was not designed to be a source of assistance for procuring
abortions, cf. Dissent at 8–9; rather, Congress’s purpose in enacting Title X was to
“fund and, thereby, encourage preconception services, a focus that “generally
excludes payment for postconception care and services,” including abortion. 84
Fed. Reg. at 7723. Congress’s restriction on Title X projects leaves clients with “at
least the same range of choice in deciding whether to obtain” an abortion as they
would have had if Congress provided no Title X funding. Harris, 448 U.S. at 317.
As Rust recognized, “a doctor’s ability to provide, and a woman’s right to receive,
abortion-related information remains unfettered outside the context of the Title X
project.” 500 U.S. at 203. That some Title X clients “may be effectively precluded
by indigency” or other circumstances from procuring “abortion-related services” is
a product of those circumstances, “not of governmental restrictions.” Id.; cf.
Dissent at 9 n.6. Thus, the dissent, and the amici on which it relies, mistakenly
(continued...)
46
Nor is the Final Rule directive because it allows referrals for adoption. See
42 C.F.R. § 59.5(a)(1). The Infant Adoption Awareness section, 42 U.S.C. § 254c-
6(a)(1), does not require Title X projects to urge or encourage adoptions; rather, it
provides funds for training staff of eligible health centers (which may include Title
X projects) to provide adoption information and referrals on an equal basis with
other courses of action included in nondirective counseling. Based on this
legislation, HHS reasonably concluded that referrals for adoption are “appropriate
under Title X, since Congress specified that Title X clinics and providers were
eligible health centers to whom adoption related training should be offered,” 84
Fed. Reg. at 7730. Further, the language of the Infant Adoption Awareness section
suggests that Congress did not interpret the phrase “nondirective counseling” as
necessarily requiring a presentation of all options on an equal basis. To the
contrary, if Congress had defined “nondirective counseling” to require the
presentation of all options on an equal basis, it would have been unnecessary to
encourage health center staff to present information about adoption “on an equal
basis with all other courses of action” as part of nondirective counseling, because
the staff would have already been required to do so. 42 U.S.C. § 254c-6(a)(1).
21
(...continued)
fault the Final Rule for not helping clients “access[] abortion.” Dissent at 8–9.
47
Finally, the Final Rule’s restrictions on referral lists do not render pregnancy
counseling directive because a referral list does not present information in a way
that encourages or promotes a specific option—it is merely “[a] list of licensed,
qualified, comprehensive primary health care providers.” 42 C.F.R.
§ 59.14(b)(1)(ii). As Rust recognized, doctors are “free to make clear that advice
regarding abortion is simply beyond the scope of the program.” 500 U.S. at 200.22
Because HHS has reasonably interpreted the phrase “pregnancy counseling”
as not including referrals, and has interpreted the word “nondirective” to mean a
neutral presentation of options as opposed to the presentation of all possible
options, we reject plaintiffs’ argument that the term “nondirective pregnancy
counseling” requires the provision of referrals for abortion on the same basis as
referrals for prenatal care and adoption. Accordingly, the challenged provisions of
the Final Rule do not violate the 1996 appropriations rider.
22
Plaintiffs briefly argue that the Final Rule’s general prohibition on
promoting or providing support for abortion as a method of family planning, see 42
C.F.R. § 59.14(a), may “chill discussions of abortion and thus inhibit[] neutral and
unbiased counseling.” We reject this argument. If a provider promoted or
supported abortion as a method of family planning, the counseling would be
directive and therefore violate the appropriations rider. See 84 Fed. Reg. at 7747.
By contrast, the Final Rule’s prohibition on promoting or supporting abortion as a
method of family planning both reinforces the rider’s nondirective-counseling
requirement and implements § 1008’s prohibition on using Title X funds in
programs “where abortion is a method of family planning.” § 1008, 42 U.S.C.
§ 300a-6.
48
B
Plaintiffs next argue that the Final Rule is inconsistent with § 1554 of the
ACA. See § 1554, 124 Stat. at 259 (codified at 42 U.S.C. § 18114). In March
2010, Congress passed the ACA “to expand coverage in the individual health
insurance market,” King v. Burwell, 135 S. Ct. 2480, 2485 (2015), and to decrease
the cost of health care, Nat’l Fed. of Indep. Bus. v. Sebelius, 567 U.S. 519, 538
(2012). The ACA adopted “a series of interlocking reforms” primarily involving
insurance reform, including barring insurers from considering an individual’s
health when deciding whether to offer coverage, requiring individuals to maintain
health insurance coverage or face a penalty, and offering certain tax credits to
make health insurance more affordable. King, 135 S. Ct. at 2485.
While Title I of the ACA focuses on health insurance issues, Subtitle G of
that title, entitled “Miscellaneous Provisions,” does not address insurance directly.
Instead, it sets forth a series of measures aimed at protecting the interests of entities
and individuals that might be affected by the ACA’s sweeping program. Among
other things, it requires HHS to promote transparency by providing a “list of all of
the authorities provided to the Secretary under th[e] Act.” 42 U.S.C. § 18112. It
also precludes discrimination against health care providers for failing to offer
assisted suicide, see id. § 18113, ensures that individuals and entities have the
49
freedom not to participate in federal health insurance programs, see id. § 18115,
and prohibits health care programs and employers from engaging in various
discriminatory acts, see id. § 18116. Section 1554, part of Subtitle G’s
“Miscellaneous Provisions,” is titled “Access to therapies” and provides:
Notwithstanding any other provision of this Act, the Secretary of Health and
Human Services shall not promulgate any regulation that—
(1) creates any unreasonable barriers to the ability of individuals to
obtain appropriate medical care;
(2) impedes timely access to health care services;
(3) interferes with communications regarding a full range of treatment
options between the patient and the provider;
(4) restricts the ability of health care providers to provide full
disclosure of all relevant information to patients making health care
decisions;
(5) violates the principles of informed consent and the ethical
standards of health care professionals; or
(6) limits the availability of health care treatment for the full durations
of a patient’s medical needs.
§ 1554, 124 Stat. at 259; 42 U.S.C. § 18114.
Plaintiffs and the dissent contend that three provisions of the Final Rule
conflict with this provision of the ACA: the Final Rule’s restrictions on promoting
or supporting abortion as a method of family planning and making referrals for
abortion; its physical and financial separation requirement; and its requirement that
50
providers encourage family participation in family planning decisions. Dissent at
13.23
We disagree. The Supreme Court has long made a distinction between
regulations that impose burdens on health care providers and their clients and those
that merely reflect Congress’s choice not to subsidize certain activities. See Rust,
500 U.S. at 192; cf. United States v. Am. Library Ass’n, 539 U.S. 194, 211–12
(2003); Regan v. Taxation With Representation of Wash., 461 U.S. 540, 549–50
23
The government argues that plaintiffs’ ACA-based challenge is waived
because § 1554 was not raised during the notice-and-comment period, and so HHS
did not have an opportunity to provide analysis and reasoning regarding whether
the Final Rule was consistent with § 1554 or to make any conforming changes to
the Final Rule. Plaintiffs contend that many comments used terminology similar to
that used in § 1554, and the similarity in terminology was enough to give HHS
notice that the Final Rule could violate § 1554. For instance, plaintiffs claim that
commenters’ objections to the Final Rule on the grounds that it would “ban Title X
providers from giving women full information about their health care options”
gave HHS notice that the Final Rule would violate § 1554’s ban on promulgating a
regulation that “interfere[] with communications regarding a full range of
treatment.” 42 U.S.C. § 18114(3). The district courts agreed. See California, 385
F. Supp. 3d at 994–95; Oregon, 389 F. Supp. 3d at 914; Washington, 376 F. Supp.
3d at 1130. Because there is an obvious difference between arguing that a
regulation violates best medical practices and arguing that a regulation violates a
statute, we are doubtful that plaintiffs preserved their argument that the Final Rule
violated § 1554. See Koretoff v. Vilsack, 707 F.3d 394, 398 (D.C. Cir. 2013) (per
curiam) (holding that a proponent must raise a “specific argument,” as opposed to a
“general legal issue” to preserve a legal argument for review) (citing Nuclear
Energy Inst., Inc. v. Envtl. Prot. Agency, 373 F.3d 1251, 1291 (D.C. Cir. 2004)).
Nevertheless, because the Final Rule does not conflict with § 1554, we need not
address this question of waiver.
51
(1983). Under the Supreme Court’s jurisprudence, a state’s decision not to
subsidize abortion on the same basis as other procedures does not impose a burden
on women, even when indigence “may make it difficult and in some cases,
perhaps, impossible for some women to have abortions,” because the law “neither
created nor in any way affected” her indigent status. Maher, 432 U.S. at 474; see
also Webster v. Reprod. Health Servs., 492 U.S. 490, 509–10 (1989) (holding that
a state law prohibiting abortions in public hospitals was permissible because it
“leaves a pregnant woman with the same choices as if the State had chosen not to
operate any public hospitals at all”); Harris, 448 U.S. at 317 (“[T]he Hyde
Amendment [prohibiting the use of federal funds to pay for abortion services
except under specified circumstances] leaves an indigent woman with at least the
same range of choice in deciding whether to obtain a medically necessary abortion
as she would have had if Congress had chosen to subsidize no health care costs at
all.”).
Rust applied this well-established principle to the Title X context, rejecting
arguments that the 1988 Rule’s limitations on counseling and referrals for abortion
impermissibly burdened the doctor-patient relationship, interfered with a woman’s
right to make “an informed and voluntary choice by placing restrictions on the
patient-doctor dialogue,” and impeded a woman’s access to abortion services. 500
52
U.S. at 202. The Court recognized “[t]here is a basic difference between direct
state interference with a protected activity and state encouragement of an
alternative activity consonant with legislative policy.” Id. at 193 (quoting Maher,
432 U.S. at 475). A government restriction on funding certain activities “is not
denying a benefit to anyone, but is instead simply insisting that public funds be
spent for the purposes for which they were authorized.” Id. at 196. Nor do
restrictions on funding interfere with appropriate medical care. In the context of
Title X funding, restrictive regulations “leave the [Title X] grantee unfettered” in
the services it can perform outside of the Title X project, id., because the
regulations “govern solely the scope of the Title X project’s activities” and “do not
in any way restrict the activities of those persons acting as private individuals,” id.
at 198–99. Further, “the Title X program regulations do not significantly impinge
upon the doctor-patient relationship” because the doctor and patient may “pursue
abortion-related activities when they are not acting under the auspices of the Title
X project,” id. at 200, and “[a] doctor’s ability to provide, and a woman’s right to
receive, information concerning abortion and abortion-related services outside the
context of the Title X project remains unfettered,” id. at 203. The Court
distinguished the sorts of limitations imposed by the 1988 Rule from a regime “in
which the Government has placed a condition on the recipient of the subsidy rather
53
than on a particular program or service, thus effectively prohibiting the recipient
from engaging in the protected conduct outside the scope of the federally funded
program.” Id. at 197 (emphasis omitted).24
Rust’s logic applies equally to statutory and constitutional claims. If, as the
Supreme Court has concluded, a rule implementing the government’s policy
decision to encourage childbirth rather than abortion does not burden or interfere
with a client’s health care at all, see Harris, 448 U.S. at 317, then it does not matter
whether the client’s heath care rights were created by the Constitution or a statute.
The same reasoning applies here and requires us to distinguish between
§ 1554’s prohibition on direct interference with certain health care activities and
the Final Rule’s directives that ensure government funds are not spent for an
unauthorized purpose. As in Rust, the Final Rule’s restrictions on funding certain
activities do not create unreasonable barriers, impede access to health services,
restrict communications, or otherwise involve “denying a benefit to anyone.” Id. at
196. Nor, as Rust explained, do they interfere with appropriate medical care or
24
The Supreme Court has repeatedly reaffirmed Rust’s ruling that the
government may constitutionally preclude recipients of federal funds from
addressing specified subjects so long as the limitation does not interfere with a
recipient’s conduct outside the scope of the federally funded program. See Agency
for Int’l Dev. v. All. for Open Soc’y Int’l, Inc., 570 U.S. 205, 213 (2013) (citing
Rust, 500 U.S. at 195 n.4); accord Walker v. Tex. Div., Sons of Confederate
Veterans, Inc., 135 S. Ct. 2239, 2246 (2015).
54
“significantly impinge upon the doctor-patient relationship.” Id. at 200. Rather,
the Final Rule leaves a grantee “unfettered in its other activities” because it
governs solely the scope of the services funded by Title X grants, id. at 196, and
doctors and their clients remain free to exchange abortion-related information
outside the context of the Title X project, id. at 203.25 Therefore, the Final Rule’s
measures to ensure that government funds are spent for the purposes for which
they were authorized does not violate § 1554’s restrictions on direct regulation of
certain aspects of care.
The ACA itself makes clear that § 1554 is meant to prevent direct
government interference with health care, not to affect Title X funding decisions.
The most natural reading of § 1554 is that Congress intended to ensure that HHS,
in implementing the broad authority provided by the ACA, does not improperly
impose regulatory burdens on doctors and patients. Indeed, by introducing § 1554
with language focusing on the ACA—that “[n]otwithstanding any other provision
25
Plaintiffs and the California district court speculate (without any support
in the record) that the Final Rule’s referral-list restrictions will delay clients from
locating abortion providers and thus leave them worse off. See California, 385 F.
Supp. 3d at 998. This is merely another version of the argument that Congress
cannot prohibit Title X projects from assisting clients seeking abortion referrals.
But such an argument has been rejected by the Supreme Court. See Rust, 500 U.S.
at 193–94 (recognizing that restrictions of this type are permissible to ensure that
“the limits of [Title X] are observed” so that project grantees and their employees
do not “engag[e] in activities outside of the project’s scope”).
55
of this Act,” HHS may not take certain steps, 42 U.S.C. § 18114—Congress
showed its intent to ensure that certain interests of individuals and entities would
be protected notwithstanding the broad scope of the ACA, and that such
protections would supersede any other provision of the ACA “in the event of a
clash.” NLRB v. SW Gen., Inc., 137 S. Ct. 929, 939 (2017) (citations omitted).
By contrast, the ACA did not seek to alter the relationship between federally
funded grant programs and abortion in a fundamental way. See, e.g., Pub. L. No.
111-148, title X, § 10104(c)(2), 124 Stat. at 897 (codified at 42 U.S.C.
§ 18023(c)(2)). Section 10104(c)(2)(A) of the Act provides that “[n]othing in this
Act shall be construed to have any effect on Federal laws regarding (i) conscience
protection; (ii) willingness or refusal to provide abortion; and (iii) discrimination
on the basis of the willingness or refusal to provide, pay for, cover, or refer for
abortion or to provide or participate in training to provide abortion.” 42 U.S.C.
§ 18023(c)(2)(A). An Executive Order issued shortly after the ACA was passed
emphasized the ACA’s neutrality regarding abortion issues, stating that “[u]nder
the Act, longstanding Federal laws to protect conscience . . . remain intact and new
protections prohibit discrimination against health care facilities and health care
providers because of an unwillingness to provide, pay for, provide coverage of, or
refer for abortions.” Ensuring Enforcement and Implementation of Abortion
56
Restrictions in the Patient Protection and Affordable Care Act, Exec. Order No.
13,535, 75 Fed. Reg. 15,599 (Mar. 24, 2010). Nor did the ACA single out Title X
for any changes. The ACA mentions Title X only to clarify that Title X providers
may qualify as “teaching health centers” eligible for funds under a different grant
program. See Pub. L. No. 111-148, tit. V, § 5508, 124 Stat. at 669–70 (codified at
42 U.S.C. § 293l-1).
In short, the ACA did not address the implementation of Congress’s choice
not to subsidize certain activities. The Final Rule places no substantive barrier on
individuals’ ability to obtain appropriate medical care or on doctors’ ability to
57
communicate with clients or engage in activity when not acting within a Title X
project, and therefore the Final Rule does not implicate § 1554.26
In sum, the Final Rule is not contrary to the appropriations rider, § 1554 of
the ACA, or Title X. Plaintiffs’ claims based on these provisions will not succeed.
26
The plaintiffs raise several other arguments that the Final Rule violates
Title X, but they do not merit much discussion. First, Washington argues that the
Final Rule violates § 1008’s requirement that “acceptance by any individual of
family planning services . . . shall be voluntary” because the Final Rule requires
doctors to provide referrals for prenatal care regardless whether a client asks for
abortion information. We disagree. The Final Rule preserves the requirement that
“[a]cceptance of services must be solely on a voluntary basis,” 42 C.F.R.
§ 59.5(a)(2), and nothing in the Final Rule makes acceptance of family planning
services a “prerequisite to eligibility for or receipt of any other service or
assistance from, or to participation in, any other program.” 42 U.S.C. § 300a-5.
Second, some plaintiffs argue, and the Washington district court held, 376 F.
Supp. 3d at 1130, that the central purpose of Title X is “to equalize access to
comprehensive, evidence-based, and voluntary family planning” and that the Final
Rule is inconsistent with this purpose. We disagree. The Supreme Court
determined that provisions substantially identical with those in the Final Rule were
consistent with Title X. Rust, 500 U.S. at 178–79.
Finally, Washington argues in passing that 42 C.F.R. § 59.18 is invalid
because it allows Title X funds to be used “to offer family planing methods and
services” but not “to build infrastructure for purposes prohibited with these funds,
such as support for the abortion business of a Title X grantee or subrecipient.” 42
C.F.R. § 59.18(a) (emphasis added). According to Washington, this provision
“limits the use of Title X funds for core functions” and therefore violates a
provision of Title X authorizing the use of funds “to assist in the establishment and
operation of voluntary family planning projects,” § 1001; 42 U.S.C. § 300. This
argument is meritless, because § 59.18 merely harmonizes § 1001 with § 1008’s
prohibition on the use of Title X funds “in programs where abortion is a method of
family planning.” § 1008; 42 U.S.C. § 300a-6.
58
Accordingly, plaintiffs have not demonstrated likelihood of success on the merits
based on these grounds. See Winter, 555 U.S. at 20.
IV
We now turn to plaintiffs’ arguments that the Final Rule is arbitrary and
capricious under the APA.27 The APA requires a reviewing court to “hold
unlawful and set aside agency action, findings, and conclusions found to be . . .
arbitrary [or] capricious.” 5 U.S.C. § 706(2)(A). Our review under this directive is
narrow and deferential. Dep’t of Commerce v. New York, 139 S. Ct. 2551, 2569
(2019). We “must uphold a rule if the agency has examined the relevant
considerations and articulated a satisfactory explanation for its action, including a
rational connection between the facts found and the choice made.” FERC v. Elec.
Power Supply Ass’n, 136 S. Ct. 760, 782 (2016) (cleaned up). “Th[is] requirement
is satisfied when the agency’s explanation is clear enough that its path may
reasonably be discerned,” Encino Motorcars, LLC v. Navarro, 136 S. Ct. 2117,
2125 (2016) (internal quotation marks omitted), even where an agency’s decision
27
While the district court in Oregon found only “serious questions going to
the merits of [the] claims that the Final Rule is arbitrary and capricious,” 389 F.
Supp. 3d at 903, the California district court went further and concluded that the
promulgation of the Final Rule was, in fact, arbitrary and capricious, 385 F. Supp.
3d at 1000. Rather than review these determinations separately, we consolidate our
analysis given that the Final Rule is not arbitrary and capricious as a matter of law.
59
is “of less than ideal clarity,” FCC v. Fox Television Stations, Inc., 556 U.S. 502,
513 (2009).
We defer to the agency’s expertise in interpreting the record and to “the
agency’s predictive judgment” on relevant questions. Id. at 521; see also Trout
Unlimited v. Lohn, 559 F.3d 946, 959 (9th Cir. 2009). “It is well established that
an agency’s predictive judgments about areas that are within the agency’s field of
discretion and expertise are entitled to particularly deferential review, so long as
they are reasonable.” BNSF Ry. Co. v. Surface Transp. Bd., 526 F.3d 770, 781
(D.C. Cir. 2008) (quoting Wis. Pub. Power, Inc. v. FERC, 493 F.3d 239, 260 (D.C.
Cir. 2007)). Agency predictions of how regulated parties will respond to its
regulations do not require “complete factual support in the record” and
“necessarily involve[] deductions based on the expert knowledge of the agency.”
FCC v. Nat’l Citizens Comm. for Broad., 436 U.S. 775, 814 (1978) (internal
quotation marks omitted).28
28
The district courts relied on the predictions and opinions of experts
provided by plaintiffs. See, e.g., California, 385 F. Supp. 3d at 1015–19; Oregon,
389 F. Supp. 3d at 918; Washington, 376 F. Supp. 3d at 1131. But it is not our job
to weigh evidence or pick the more persuasive opinions and predictions. Rather,
the agency has discretion to rely on its own expertise “even if, as an original
matter, a court might find contrary views more persuasive.” Lands Council v.
McNair, 629 F.3d 1070, 1074 (9th Cir. 2010) (internal quotations marks omitted).
60
We also defer to the agency’s expertise in identifying the appropriate course
of action. With respect to the agency’s final decision, we cannot “ask whether a
regulatory decision is the best one possible or even whether it is better than the
alternatives.” Elec. Power Supply Ass’n, 136 S. Ct. at 782. Nor may we
“substitute our judgment for that of the [agency].” Dep’t of Commerce, 139 S. Ct.
at 2569. We are also prohibited from “second-guessing the [agency]’s weighing of
risks and benefits and penalizing [it] for departing from the . . . inferences and
assumptions” of others. Id. at 2571.
Nor do we give heightened review to agency action that “changes prior
policy.” Fox, 556 U.S. at 514. The APA “makes no distinction . . . between initial
agency action and subsequent agency action undoing or revising that action.” Id.
at 514–15. Initial agency determinations are “not instantly carved in stone.”
Chevron, 467 U.S. at 863. Of course, the “requirement that an agency provide
reasoned explanation for its action would ordinarily demand that [the agency]
display awareness that it is changing position” and “that there are good reasons for
the new policy.” Fox, 556 U.S. at 515. For example, an agency may not “depart
from a prior policy sub silentio or simply disregard rules that are still on the
books.” Id. Likewise, “[i]t would be arbitrary or capricious to ignore,” where
applicable, that “its new policy rests upon factual findings that contradict those
61
which underlay its prior policy,” or that “its prior policy has engendered serious
reliance interests that must be taken into account.” Id. But under our narrow
review, an agency “need not demonstrate to a court’s satisfaction that the reasons
for the new policy are better than the reasons for the old one; it suffices that the
new policy is permissible under the statute, that there are good reasons for it, and
that the agency believes it to be better, which the conscious change of course
adequately indicates.” Id. In sum, we “must confine ourselves to ensuring that
[the agency] remained within the bounds of reasoned decisionmaking.” Dep’t of
Commerce, 139 S. Ct. at 2569 (internal quotation marks omitted).
Plaintiffs argue that several aspects of the Final Rule are arbitrary and
capricious: (1) the physical and financial separation requirement; (2) HHS’s
overall cost-benefit analysis; (3) the counseling and referral restrictions; (4) the
requirement that pregnancy counseling be provided only by medical doctors or
advanced practice providers; and (5) the requirement that family planning options
be “acceptable and effective,” rather than also “medically approved.” We consider
these arguments in turn.
A
Plaintiffs first argue that HHS’s promulgation of the physical and financial
separation requirement in 42 C.F.R. § 59.15 was arbitrary and capricious because
62
HHS failed to substantiate an adequate need for the requirement and ignored the
predictions of some commenters that the requirement would have a significant
adverse impact on the Title X network and client health.
We disagree. HHS examined the relevant considerations and provided a
reasoned analysis for adopting this provision. See Elec. Power Supply Ass’n, 136
S. Ct. at 782. It stated its primary reason for reestablishing the requirement was
that physical separation would more effectively implement § 1008. 84 Fed. Reg. at
7764. While the financial separation required by the 2000 Rule was a necessary
component of § 1008’s implementation, HHS explained, physical separation was
equally required given Congress’s mandate that Title X funds not support
programs in any location “‘where’ abortion is offered as a method of family
planning.” Id. at 7765 (emphasis added). HHS also expressly adopted the 1988
Rule’s rationale for physical and financial separation upheld in Rust, id., and gave
ample additional reasons supporting this conclusion.
First, HHS pointed to the public confusion caused when physical separation
was lacking. Id. According to HHS, the performance of abortion services and
Title X-funded services in the same location engendered confusion and rendered it
“often difficult for patients, or the public, to know when or where Title X services
end and non-Title X services involving abortion begin.” Id. at 7764. This
63
confusion was evidenced by comments HHS had received on the Final Rule;
according to HHS, many commenters seemed wholly unaware of the fact that
Title X explicitly excludes funding for projects where abortion is a method of
family planning. Id. at 7729. HHS could reasonably conclude that the physical
separation requirements could help minimize the appearance that the government is
funding abortion as a method of family planning. See Brief of Amici Curiae Ohio
and 12 Other States in Support of Defendants-Appellants and Reversal at 16–19,
California v. Azar, Nos. 19-15974 & 19-15979 (9th Cir. June 7, 2009)
(emphasizing the importance to many citizens of putting “a greater distance
between public funding and abortion-performing entities,” and noting that at least
18 states have enacted laws designed to avoid even the appearance that state
healthcare funds are being used to support entities involved in abortion services.).
Second, HHS concluded that performing all services in the same facility
“create[s] a risk of the intentional or unintentional use of Title X funds for
impermissible purposes, the co-mingling of Title X funds, . . . and the use of
Title X funds to develop infrastructure that is used for the abortion activities of
Title X clinics.” 84 Fed. Reg. at 7764. This risk is not speculative. As HHS
explained, economies of scale and shared overhead achieved through collocation of
a Title X clinic and an abortion-providing clinic effectively support the provision
64
of abortion. See id. at 7766. HHS relied in part on recent studies that show
abortions are increasingly being performed at facilities that had historically
focused on providing contraceptive and family planning services (the typical
profile of facilities that receive Title X funds), which supports the inference that a
growing number of Title X recipients may perform abortions at facilities that also
offer Title X-funded services. Id. at 7765.
In reaching its conclusion, HHS responded to commenters’ concerns in
detail. HHS first noted the concern that requiring physical and financial separation
“would increase the cost for doing business.” Id. at 7766. HHS explained that
such comments confirmed its concern that Title X funds were directly or indirectly
supporting abortion as a method of family planning. Id. “Money is fungible,”
Holder v. Humanitarian Law Project, 561 U.S. 1, 31 (2010), and HHS reasonably
concluded that “flexibility in the use of Title X funds under the 2000 [Rule]”
allowed grantees to use Title X funds to “build infrastructure that can be used for
[prohibited] purposes . . . such as support for the abortion business of a Title X
grantee,” 84 Fed. Reg. at 7773, 7774.
Next, with respect to those Title X projects that would need to make changes
to comply with the separation requirements, HHS predicted that the costs of
compliance would not be as significant as some commenters predicted. Id. at 7781
65
(noting such commenters “did not provide sufficient data to estimate these
[predicted] effects across the Title X program”). HHS discounted the predictions,
which relied on “assumptions that [providers] would have to build new facilities in
order to comply with the requirements.” Id. Rather, HHS predicted that most
entities would likely choose lower cost methods of compliance. Id. For example,
“Title X providers which operate multiple physically separated facilities and
perform abortions may shift their abortion services, and potentially other services
not financed by Title X, to distinct facilities, a change which likely entails only
minor costs.” Id. HHS explained that the Final Rule permitted “case-by-case
determinations on whether physical separation is sufficiently achieved to take the
unique circumstances of each program into consideration,” and that “[p]roject
officers are available to help grantees successfully implement the Title X program”
and to come up with “a workable plan” for compliance. Id. at 7766.
Finally, HHS addressed the “contention of some commenters that the
physical and financial separation requirements will destabilize the network of
Title X providers,” upset the reliance interests of providers who have incurred
costs relying on HHS’s previous regulations, and “exacerbate health inequalities or
harm patient care.” Id. HHS disagreed with the commenters’ predictions that the
separation requirements would result in a significant departure of Title X providers
66
from the program, explaining that the Final Rule “continues to allow organizations
to receive Title X funds even if they also provide abortion as a method of family
planning, as long as they comply with” the separation requirements. Id. HHS
further noted that a Congressional Research Service report estimated that only 10
percent of clinics that receive Title X funding offer abortion as a method of family
planning. Id. at 7781. And while some Title X providers “may share resources
with unaffiliated entities that offer abortion as a method of family planning,” HHS
estimated that only around 20 percent of all Title X service sites had “their Title X
services and abortion services . . . currently collocated” such that they would be
materially impacted by the separation requirements. Id. Accordingly, HHS
concluded that the separation requirements would have only “minimal effect on the
majority of current Title X providers.” Id.
At the same time, HHS predicted that providers who were willing to comply
with the new requirements would expand their services and that other provisions of
the Final Rule would encourage new “individuals and institutions to participate in
the Title X program.” Id. at 7766. For example, HHS expected “that honoring
statutory protections of conscience in Title X may increase the number of providers
in the program,” because providers or entities would now “know they will be
protected from discrimination on the basis of conscience with respect to counseling
67
on, or referring for, abortion.” Id. at 7780. HHS cited a poll by the Christian
Medical Association showing that faith-based medical professionals would limit
the scope of their practice without conscience protections; HHS reasoned the Final
Rule’s prohibition on abortion referral and removal of the 2000 Rule’s abortion
counseling requirement would allow such professionals to enter the Title X
program. Id. at 7780 n.138.29 And while HHS acknowledged that it “cannot
calculate or anticipate future turnover in grantees,” under HHS’s “best estimates,”
it did “not anticipate that there will be a decrease in the overall number of facilities
29
HHS’s inferences regarding the data’s implication for Title X applications
is within HHS’s core area of expertise and therefore entitled to deference. See
Trout Unlimited, 559 F.3d at 959; BNSF Ry. Co., 526 F.3d at 781. The dissent’s de
novo evaluation of the study is not entitled to such deference. See Dissent at
24–25.
68
offering services, since it anticipates other, new entities will apply for funds, or
seek to participate as subrecipients, as a result of the final rule.” Id. at 7782.30
Plaintiffs, in effect, argue that HHS’s determination was arbitrary and
capricious because the agency relied on its own predictions and rejected those
submitted by commenters opposing the Final Rule. We reject this argument
because HHS’s predictive judgments about the Final Rule’s effect on the
availability of Title X services are entitled to deference. See Trout Unlimited, 559
F.3d at 959. Here, the predictions concern matters squarely within HHS’s “field of
discretion and expertise.” BNSF Ry. Co., 526 F.3d at 781 (quoting Wis. Pub.
Power, 493 F.3d at 260). As the agency tasked with implementing the grant
program, HHS is in the best position to anticipate the behavior of grantees and
prospective grantees. HHS reasonably considered the evidence before it, where
30
In supporting its argument that HHS’s cost-benefit analysis is arbitrary
and capricious, the dissent looks outside the record to argue that some grantees,
such as Planned Parenthood, have voluntarily terminated their participation in Title
X. See Dissent at 22 & n.15. Of course, such post hoc, extra-record evidence
cannot be a basis for determining whether HHS’s promulgation of the Final Rule
was arbitrary and capricious. In any event, the dissent’s extra-record observation is
misleading: HHS has issued supplemental grant awards to other Title X recipients
that, in HHS’s estimation, “will enable grantees to come close to—if not [in excess
of]—prior Title X patient coverage,” Press Release, Dep’t Health & Human Servs.,
HHS Issues Supplemental Grant Awards to Title X Recipients (Sept. 30, 2019),
https://www.hhs.gov/about/news/2019/09/30/hhs-issues-supplemental-grant-award
s-to-title-x-recipients.html.
69
“complete factual support” for any prediction was “not possible or required,” Nat’l
Citizens Comm. for Broad., 436 U.S. at 814, such that its decision “remained
‘within the bounds of reasoned decisionmaking,’” Dep’t of Commerce, 139 S. Ct.
at 2569 (quoting Baltimore Gas & Elec. Co. v. Nat. Res. Def. Council, Inc., 462
U.S. 87, 105 (1983)). Although the commenters opposing the Final Rule provided
numerous expert declarations elaborating their gloomy assumptions about the
future behavior and activities of current and future Title X grantees, at bottom such
future-looking “pessimistic” predictions and assumptions are “simply evidence for
the [agency] to consider,” Dep’t of Commerce, 139 S. Ct. at 2571, and are not
entitled to controlling weight.31 HHS need not produce “some special justification
for drawing [its] own inferences and adopting [its] own assumptions.” Id.
31
Department of Commerce held that it was not arbitrary and capricious for
the Secretary of Commerce to decline to rely on the conclusions of the
“technocratic” experts in the Census Bureau. 139 S. Ct. at 2571. So too here:
HHS may reasonably decide not to rely on the opinions of outside commenters,
even where they claim expertise. The dissent insinuates that reliance on
Department of Commerce is misplaced because “the Court struck down the
Secretary of Commerce’s attempt to reinstate the citizenship question on the
census.” Dissent at 23 n.15. But the Court “d[id] not hold that the agency decision
. . . was substantively invalid”; it merely affirmed the district court’s decision to
remand to the agency due to a perceived “mismatch between the decision the
Secretary made and the rationale provided.” Dep’t of Commerce, 139 S. Ct. at
2575–76. Here, there is no “disconnect between the decision [HHS] made and the
explanation given,” id. at 2575, so the grounds on which Department of Commerce
ultimately affirmed the decision to remand are irrelevant.
70
Although plaintiffs and the dissent have reached a different conclusion, we
consider only whether the agency examined the relevant considerations and laid a
reasonably discernable path.
In light of HHS’s reasoned explanation of its decisions and its consideration
of the comments raised, we reject plaintiffs’ arguments that HHS failed to base its
decision on evidence, failed to consider potential harms in its cost-benefit analysis,
failed to explain its reasons for departing from the 2000 Rule’s provisions, and
failed to consider the reliance interest of providers who have incurred costs relying
on HHS’s previous regulation. The Final Rule’s separation requirements are not
arbitrary and capricious.
B
Plaintiffs and the dissent make a similar argument that HHS’s cost-benefit
analysis of the Final Rule was arbitrary and capricious. Dissent at 21–28. They
argue that HHS ignored the commenters who predicted the Final Rule would cause
an exodus of Title X providers and have a deleterious effect on client care, and
instead relied on its own predictions about the Final Rule’s benefits.
Like plaintiffs’ challenge to the physical and financial separation
requirements, the challenge to HHS’s cost-benefit analysis fails. HHS considered
and addressed “the concern expressed by some commenters regarding the effect of
71
this rule on quality and accessibility of Title X services,” and explained its reasons
for relying on its own predictions regarding the likely behavior of current and
future Title X grantees. 84 Fed. Reg. at 7780. HHS likewise rejected the
“extremely high cost estimates” for compliance with the separation requirements,
reasoning that providers would tend to seek out lower cost options, such as shifting
abortion services to distinct facilities rather than constructing new ones. Id. at
7781–82.32 HHS was not required to accept the commenters’ “pessimistic” cost
predictions, Dep’t of Commerce, 139 S. Ct. at 2571, and the agency adequately
explained why it did not expect grantees to participate in a mass rejection of
32
The dissent asserts that HHS “calculated [the] costs of compliance with
the physical separation requirement in a ‘mystifying’ way.” Dissent at 22 n.16
(quoting California, 385 F. Supp. 3d at 1008). But there is nothing “mystifying”
about HHS’s cost estimates. HHS estimated that between 10 and 30 percent of all
Title X projects would need to be evaluated to determine compliance with the
physical separation requirements. 84 Fed. Reg. at 7781. It then predicted that such
evaluations would determine that between 10 to 20 percent of the evaluated sites
do not comply with the physical separation requirements. Id. “At each of these
service sites, [HHS] estimates that an average of between $20,000 and $40,000,
with a central estimate of $30,000, would be incurred to come into compliance
with physical separation requirements in the first year following publication of a
final rule in this rulemaking.” Id. at 7781–82. HHS then added together the costs
of conducting the evaluations and bringing non-compliant facilities into
compliance, and concluded its estimates “would imply costs of $36.08 million in
the first year following publication of a final rule.” Id. at 7782. Based solely on
statements made by plaintiffs’ lawyers during oral argument, the dissent speculates
that HHS’s cost estimates were too optimistic. Dissent at 22 n.16. But we need
not favor plaintiffs’ pessimistic cost estimates over those provided by HHS. See
Dep’t of Commerce, 139 S. Ct. at 2571.
72
Title X funds, see 84 Fed. Reg. at 7766. In light of HHS’s conclusion that an
ample number of Title X projects would continue to provide family planning
services, HHS reasonably concluded that the harms flowing from a gap in care
would not develop. See id. at 7775, 7782. We give substantial deference to such
predictive judgments within the scope of HHS’s expertise. Trout Unlimited, 559
F.3d at 959. On this record, we will not second-guess HHS’s consideration of the
risks and benefits of its action. See Dep’t of Commerce, 139 S. Ct. at 2571.
C
Plaintiffs next assert that the referral restrictions are arbitrary and capricious.
They first argue that HHS failed to justify the need for this provision adequately.
We disagree. HHS stated it was reestablishing the 1988 Rule for referrals because
it concluded that the 2000 Rule was inconsistent with § 1008. Under HHS’s
interpretation of § 1008, “in most instances when a referral is provided for
abortion, that referral necessarily treats abortion as a method of family planning.”
84 Fed. Reg. at 7717. Further, HHS concluded that the 2000 Rule’s requirement
that Title X projects provide abortion referrals and nondirective counseling on
abortion was inconsistent with federal conscience laws. Id. at 7716. HHS
referenced its 2008 nondiscrimination regulations, which had reached the same
conclusion. Id. (quoting 73 Fed. Reg. at 78,087). HHS also explained that
73
eliminating the 2000 Rule’s counseling and referral requirements would “reduce
the regulatory burden [on HHS] associated with monitoring and regulating Title X
providers for compliance,” id. at 7719, “add clarity to extant conscience
protections, [and make] it easier for entities to participate who may have felt
unable to do so in the past,” id. at 7778. In sum, HHS engaged in “reasoned
decisionmaking.” Dep’t of Commerce, 139 S. Ct. at 2569.33
Plaintiffs next argue that HHS did not justify the need for the counseling and
referral restrictions because non-objecting health care staff could provide
counseling and referrals for abortion without violating the federal conscience laws.
Therefore, plaintiffs urge, HHS’s reliance on federal conscience laws as
justification was arbitrary and capricious. We reject this argument, because it
amounts to little more than the claim that HHS should have adopted plaintiffs’
preferred regulatory approach. But HHS acted well within its authority in deciding
how best to avoid conflict with the federal conscience laws. We do not “ask
whether a regulatory decision is the best one possible or even whether it is better
33
The plaintiffs’ argument that the referral restrictions are arbitrary and
capricious because they conflict with guidelines in the QFP is meritless, because
these guidelines were based on the 2000 Rule, and are superseded by the Final
Rule. See Dep’t Health & Human Servs., Announcement of Availability of Funds
for Title X Family Planning Services Grants, at 14–15 (2019).
74
than the alternatives.” Elec. Power Supply Ass’n, 136 S. Ct. at 782. Rather, we
defer to the agency’s reasoned conclusion.
Plaintiffs also argue that HHS failed to consider claims by some commenters
that the restrictions would require “providers to violate their ethical obligations to
stay in the program” because they require “providers to withhold information about
abortion (including referral) that the patient needs,” and to provide “a biased and
misleading list of primary health care providers.”34 But HHS specifically
34
The dissent repeatedly echoes the plaintiffs’ claims that the Final Rule
contradicts or violates medical ethics because it limits Title X projects from
encouraging and supporting abortion and from referring clients to abortion
providers. See Dissent at 12–13, 19–20 & n.13. Despite the dissent’s and
plaintiffs’ ethical claims, neither cites an opinion from the AMA’s Code of
Medical Ethics directly addressing abortion. See, e.g., Dissent at 20 n.13. Rather,
the dissent and plaintiffs cite more general guidance regarding a physician’s
obligation to inform the patient regarding “treatment alternatives” for medical
conditions; because a nontherapeutic abortion is not a “treatment” option for a
medical condition but rather a procedure for terminating a healthy pregnancy, such
guidance does not directly relate to this issue.
It is not surprising that medical ethical rules are not as absolute as the dissent
claims; as noted in Roe v. Wade, the AMA’s views of medical ethics and abortion
changed from a condemnation of the “unwarrantable destruction of human life” to
the conclusion that abortions could properly be performed in some circumstances.
410 U.S. 113, 142 (1973). Despite greater public acceptance of abortion today, the
issue raise controversial ethical questions, as demonstrated by (among other things)
the continued enactment of federal conscience laws and public comments urging
HHS to protect physicians’ ability to decline to counsel on or refer for abortion.
See 84 Fed. Reg. at 7746–47; see also Brief of Amici Curiae Ohio, supra at 16
(many citizens “believe that permitting abortion providers or advocates to
(continued...)
75
addressed those concerns. It stated that the counseling and referral restrictions
would not result in ethical violations because the Final Rule permitted providers to
give “nondirective pregnancy counseling to pregnant Title X clients on the
patient’s pregnancy options, including abortion.” 84 Fed. Reg. at 7724.35 HHS
reasoned that the Final Rule allows physicians “to discuss the risks and side effects
of each option, [including abortion,] so long as this counsel in no way promotes or
refers for abortion as a method of family planning.” Id. A client may “ask
questions and . . . have those questions answered by a medical professional.” Id.
HHS also noted that where care is medically necessary, referral for that care is
required, notwithstanding the Final Rule’s other requirements. Id. Consistent with
Rust, HHS concluded that “it is not necessary for women’s health that the federal
government use the Title X program to fund abortion referrals, directive abortion
counseling, or give to women who seek abortion the names of abortion providers.”
34
(...continued)
participate in providing a government-funded service implies a public imprimatur
on abortion—an imprimatur that citizens legitimately seek to withhold”).
35
The dissent argues that in reaching this conclusion, HHS contradicted its
prior conclusion in the 2000 Rule as to “what medical ethics demand.” Dissent at
19. But HHS did not provide an opinion on this issue when it overruled its prior
1988 Rule; it merely referenced the views of commenters, without adopting those
views as its own. See 65 Fed. Reg. at 41,273. Thus, the dissent’s argument that
HHS “changed its position on what medical ethics demand” is meritless.
76
Id. at 7746.36 These statements show HHS examined the relevant considerations
arising from commenters citing medical ethics and rationally articulated an
explanation for its conclusion. See Elec. Power Supply Ass’n, 136 S. Ct. at 782.
Because HHS’s decisionmaking path “may reasonably be discerned,” Dep’t
of Commerce, 139 S. Ct. at 2578, we reject plaintiffs’ claims that the counseling
and referral restrictions are arbitrary and capricious.
D
We next consider plaintiffs’ claim that the Final Rule’s requirement that all
pregnancy counseling be provided by medical doctors or advanced practice
providers is arbitrary and capricious. Plaintiffs argue that because HHS defined
the term “advanced practice providers” too narrowly, and did not have a reasoned
36
Rust rejected ethical arguments similar to those raised here. See 500 U.S.
at 213–14 (Blackmun, J. dissenting) (arguing that “the ethical responsibilities of
the medical profession demand” that a physician be free to inform patients about
abortion). According to the Court, “the Title X program regulations do not
significantly impinge upon the doctor-patient relationship” because, among other
reasons, “the doctor-patient relationship established by the Title X program [is not]
sufficiently all encompassing so as to justify an expectation on the part of the
patient of comprehensive medical advice,” and “a doctor’s silence with regard to
abortion cannot reasonably be thought to mislead a client into thinking that the
doctor does not consider abortion an appropriate option for her,” given that “[t]he
program does not provide post conception medical care.” Id. at 200. And under
the Final Rule, as under the 1988 Rule, “[t]he doctor is always free to make clear
that advice regarding abortion is simply beyond the scope of the program.” Id.
77
basis for drawing the line at which medical professionals may provide pregnancy
counseling, the provision is arbitrary and capricious.
We disagree. HHS explained that, in its judgment, “medical professionals
who receive at least a graduate level degree in the relevant medical field and
maintain a federal or State-level certification and licensure to diagnose, treat, and
counsel patients . . . are qualified, due to their advanced education, licensing, and
certification to diagnose and treat patients while advancing medical education and
clinical research.” 84 Fed. Reg. at 7728.37 We have no basis to conclude that this
line-drawing determination, an inherently discretionary task, “is so implausible”
that a difference with plaintiffs’ views “could not be ascribed to a difference in
view or the product of agency expertise.” Motor Vehicle Mfrs. Ass’n of U.S., Inc.
v. State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43 (1983). Accordingly, we reject
plaintiffs’ arguments that HHS’s technical determination of which medical
professionals may provide pregnancy counseling is arbitrary and capricious.
E
37
Although the dissent asserts that this requirement will “reduce the number
of people who can provide pregnancy counseling and . . . require significant
changes in Title X providers’ staffing,” Dissent at 23, HHS’s definition covers a
wide range of licensed medical professionals that HHS reasonably deemed
qualified to provide health care advice, including physician assistants, certified
nurse practitioners, clinical nurse specialists, certified registered nurse anesthetist,
and certified nurse-midwifes, see 42 C.F.R. § 59.2.
78
Finally, we reject plaintiffs’ argument that HHS was arbitrary and capricious
in reestablishing the language of the 1988 Rule’s requirement that all family
planning methods and services be “acceptable and effective,” instead of retaining
the 2000 Rule’s revision requiring that such methods and services also be
“medically approved.” 84 Fed. Reg. at 7732.
HHS adequately explained its reasons for reestablishing the 1988 Rule.
HHS explained that the change was intended to “ensure that the regulatory
language is consistent with the statutory language,” id. at 7740, which requires
Title X projects to “offer a broad range of acceptable and effective family
planning methods and services,” 42 U.S.C. § 300(a). HHS also explained that the
meaning of “medically approved” was unclear. 84 Fed. Reg. at 7741. “For
example, would approval by one medical doctor suffice, or would some larger
number need to approve, and if so, how many; would certain medical
organizations, or governmental organizations, or both, need to approve, and if so,
which ones; would a certain level of medical consensus need to exist concerning a
particular method or service, and if so, how would the Department measure that
consensus; and when doctors and medical organizations disagree either about a
family planning method or service, how would that requirement apply?” Id. at
7732.
79
HHS also explained its rejection of the comment suggesting the phrase
“medically approved” means “FDA approved.” HHS stated that “[s]ome family
planning methods cannot be medically approved by . . . the [FDA], because they do
not fall within its jurisdiction,” and provided examples, such as fertility-awareness
based methods of family planning. Id. at 7741 & n.69. In HHS’s judgment, “[t]his
did not mean that such methods of family planning are unacceptable or ineffective
in the view of medical sources.” Id. at 7741. Accordingly, HHS determined that
“[t]he statutory language of ‘acceptable and effective family methods or services,’
without the phrase ‘medically approved[,]’ provides sufficient guidance to Title X
projects in considering the types of family planning methods and services that they
provide.” Id.
HHS likewise sufficiently addressed comments that its decision to omit the
phrase “medically approved” would promote political ideology over science, lead
to negative health consequences for clients, and undermine recommendations from
other agencies. See id. at 7740–41. We defer to HHS’s reasonable conclusion that
Title X’s statutory requirement that family planning methods and services must be
“acceptable and effective” sufficiently prohibits Title X projects from engaging in
health fraud or quackery. Id. at 7741.
80
Because HHS “examined the relevant considerations and articulated a
satisfactory explanation for its action,” Elec. Power Supply Ass’n, 136 S. Ct. at 782
(cleaned up), we reject plaintiffs’ argument that this change was arbitrary and
capricious.
In sum, we hold that the Final Rule is not arbitrary and capricious.
***
Because plaintiffs’ claims will not succeed given our resolution of the
underlying legal questions, we end our analysis here. See Munaf, 553 U.S. at 691;
Garcia, 786 F.3d at 740. We hold that the Final Rule is a reasonable interpretation
of § 1008, it does not conflict with the 1996 appropriations rider or other aspects of
Title X, and its implementation of the limits on what Title X funds can support
does not implicate the restrictions found in § 1554 of the ACA. Moreover, the
Final Rule is not arbitrary and capricious because HHS properly examined the
relevant considerations and gave reasonable explanations. See Elec. Power Supply
Ass’n, 136 S. Ct. at 782. Plaintiffs will not prevail on the merits of their legal
claims, so they are not entitled to the “extraordinary remedy” of a preliminary
injunction. See Winter, 555 U.S. at 22. Accordingly, the district courts’
preliminary injunction orders are vacated and the cases are remanded for further
81
proceedings consistent with this opinion. The government’s motion for a stay
pending appeal is denied as moot.
VACATED AND REMANDED.38
38
Costs on appeal shall be taxed against plaintiffs.
82
FILED
State of California v. Azar, No. 19-15974+ FEB 24 2020
MOLLY C. DWYER, CLERK
PAEZ, Circuit Judge, joined by THOMAS, Chief Judge, WARDLAW and U.S. COURT OF APPEALS
FLETCHER, Circuit Judges, dissenting:
Millions of Americans depend on Title X for their health care, including
lifesaving breast and cervical cancer screenings, HIV testing, and infertility and
contraceptive services. Congress created the Title X program in 1970 to ensure
that family planning services would be “readily available to all persons desiring
such services,” Pub. L. No. 91-572 § 2, 84 Stat. 1504 (1970), and entrusted the
United States Department of Health and Human Services (“HHS”) with the
responsibility of disbursing Title X funds to health care providers serving low-
income Americans.
Since then, Congress has twice circumscribed HHS’s authority in
administering the Title X program. First, Congress directed that the health care
providers who receive Title X funds inform pregnant patients of their options
without advocating one choice over another. Second, Congress barred HHS from
promulgating regulations that burden patients’ access to health care, interfere with
communications between patients and their health care providers, or delay patients’
access to care.
In 2019, HHS promulgated the regulations at issue in this litigation (“the
Rule”). See Compliance with Statutory Program Integrity Requirements, 84 Fed.
1
Reg. 7714 (Mar. 4, 2019). Among other things, the Rule gags health care
providers from fully counseling women about their options while pregnant and
requires them to steer women toward childbirth (the “Gag Rule”). It also requires
providers to physically and financially separate any abortion services they provide
(through non-Title X funding sources) from all other health care services they
deliver (the “Separation Requirement”).
Three separate district courts in well-reasoned opinions recognized that the
Rule breaches Congress’s limitations on the scope of HHS’s authority and enjoined
enforcement of the Rule.1 In vacating the district courts’ preliminary injunctions,
the majority sanctions the agency’s gross overreach and puts its own policy
preferences before the law. Women 2 and their families will suffer for it. I strongly
dissent.
***
1
See Oregon v. Azar (Oregon), 389 F. Supp. 3d 898 (D. Or. 2019); State of
California v. Azar (California), 385 F. Supp. 3d 960 (N.D. Cal. 2019); Washington
v. Azar (Washington), 376 F. Supp. 3d 1119 (E.D. Wash. 2019).
2
While the Rule disproportionately impacts women, people of all genders rely on
Title X services, can become pregnant, and will suffer the consequences of the
Rule. See, e.g., Cal. Code Regs., tit. 2, § 11035(g) (defining individuals eligible
for pregnancy accommodation as including “transgender employee[s] who [are]
disabled by pregnancy”); Jessica A. Clarke, They Them, and Theirs, 132 Harv. L.
Rev. 894, 954 (2019) (“People of all gender identities can be pregnant[.]”); see
also Juno Obedin-Maliver & Harvey J. Makadon, Transgender Men and
Pregnancy, 9 Obstetric Med., 4, 5 (2016).
2
The majority would return us to an older world, one in which a government
bureaucrat could restrict a medical professional from informing a patient of the full
range of health care options available to her. Fortunately, Congress has ensured
such federal intrusion is no longer the law of the land.
The majority heavily relies, mistakenly, on Rust v. Sullivan and Harris v.
McRae, decisions that held the Constitution confers no affirmative entitlement to
state subsidization of abortion. Maj. Op. 11–15, 46 n.21, 51–55; Rust, 500 U.S.
173, 201 (1991); McRae, 448 U.S. 297, 318 (1980); see also Webster v.
Reproductive Health Services, 492 U.S. 490, 509 (1989); Maher v. Roe, 432 U.S.
464, 474 (1977). “Whether freedom of choice that is constitutionally protected
warrants federal subsidization,” the Court reasoned in McRae, “is a question for
Congress to answer, not a matter of constitutional entitlement.” 448 U.S. at 318.
It is constitutionally permissible to “leave[] an indigent woman with at least the
same range of choice in deciding whether to obtain a medically necessary abortion
as she would have had if Congress had chosen to subsidize no health care costs at
all.” Id. at 317. In other words, Congress can choose to disburse its funds
however it likes. I do not take issue with that principle.
The problem for the majority’s position is that Congress has in fact chosen
to disburse public funds differently since the days of Rust. Perhaps recognizing
that medical ethics and gender norms have evolved, Congress in 1996 and again in
3
2010 enacted statutory protections that exceed the constitutional floor set decades
ago. In 1996 (and every year since) Congress clarified that its decision not to
subsidize abortion does not prohibit pregnancy counseling on the range of
women’s options; to the contrary, Congress explicitly required that “all pregnancy
counseling shall be nondirective.” Omnibus Consolidated Rescissions and
Appropriations Act of 1996, Pub. L. No. 104-134, 110 Stat. 1321 (1996) (“the
nondirective mandate”). And, in 2010, Congress prohibited HHS from
promulgating regulations that frustrate patients’ ability to access health care. 42
U.S.C. § 18114.
The majority disregards twenty years of progress, insistent on hauling the
paternalism of the past into the present. Because Congress has clarified the scope
of HHS’s authority, the Rust line of cases has little bearing on the matter before us.
Our only task is to determine whether HHS has exceeded the authority Congress
granted it. And as the district courts concluded, it has.
I. The Rule Violates Congress’s Nondirective Mandate
Since 1996, Congress has provided a clear limitation on Title X funding,
specifying “that all pregnancy counseling shall be nondirective.” Department of
Defense and Labor, Health and Human Services, and Education Appropriations
Act, and Continuing Appropriations Act, Pub. L. No. 115-245, 132 Stat. 2981,
3070–71 (2018) (emphasis added). The district courts separately determined that
4
the Rule conflicts with Congress’s nondirective mandate. 5 U.S.C. § 706(2)(A);
see Oregon, 389 F. Supp. 3d at 909–13; California, 385 F. Supp. 3d at 986–92;
Washington, 376 F. Supp. 3d at 1130. I agree. 3
The Rule is nothing but directive. By its very terms, it requires a doctor to
refer a pregnant patient for prenatal care, even if she does not want to continue the
pregnancy, while gagging her doctor from referring her for abortion, even if she
has requested specifically such a referral. 42 C.F.R. §§ 59.14(a), (b). The Rule
does not stop there. If a doctor provides a patient a referral list of primary health
care providers, no more than half of those providers may offer abortion services.
42 C.F.R. § 59.14(c)(2). And if the patient asks who on the list might actually
provide her an abortion? The Rule muzzles her doctor from telling her. Id. The
result is that patients are steered toward childbirth at every turn.
3
We review for abuse of discretion the district courts’ grant of the preliminary
injunctions. Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1131 (9th
Cir. 2011). “The district court’s interpretation of the underlying legal principles,
however, is subject to de novo review and a district court abuses its discretion
when it makes an error of law.” Sw. Voter Registration Educ. Project v. Shelley,
344 F.3d 914, 918 (9th Cir. 2003). Because Plaintiffs’ first two claims, namely
whether the Rule violates Congress’s nondirective mandate or the Affordable Care
Act, turn on the merits of several legal issues, I agree with the majority that we
may address the merits of those issues directly. The majority goes too far,
however, in adjudicating the merits of the third claim, namely whether the
promulgation of the Rule was arbitrary and capricious, for the reasons discussed in
Section III, infra.
5
What can a doctor even say when confronted with her patient’s questions
about abortion? The Rule bars doctors from “promot[ing] . . . or support[ing]
abortion as a method of family planning, []or tak[ing] any other affirmative action
to assist a patient” in exercising her right to abortion. 42 C.F.R. § 59.14(a); see
also 42 C.F.R. § 59.5(a)(5). Imagine a patient visits her Title X provider and asks
whether she can get an abortion at the local hospital. Would it qualify as
“promoting” abortion to answer the question? The Gag Rule makes doctors who
desire to provide their patients with accurate information “walk on eggshells to
avoid a potential transgression of the . . . Rule, whereas those describing the option
of continuing the pregnancy face no comparable risk.” California, 385 F. Supp. 3d
at 992.
The result is Kafkaesque. Oregon, 389 F. Supp. 3d at 912. As Judge
McShane of the District of Oregon observed:
The Gag Rule is remarkable in striving to make professional health
care providers deaf and dumb when counseling a client who wishes to
have a legal abortion or is even considering the possibility. The rule
handcuffs providers by restricting their responses in such situations to
providing their patient with a list of primary care physicians who can
assist with their pregnancy without identifying the ones who might
perform an abortion. Again, the response is required to be, “I can’t
help you with that or discuss it. Here is a list of doctors who can
assist you with your pre-natal care despite the fact that you are not
seeking such care. Some of the providers on this list—but in no case
more than half—may provide abortion services, but I can’t tell you
which ones might. Have a nice day.” This is madness.
Id. at 913 (footnote omitted).
6
The majority purports to see no problem here. Although HHS itself defines
“nondirective counseling” as “the meaningful presentation of options where the
[medical professional] is ‘not suggesting or advising one option over another,’” 84
Fed. Reg. at 7716 (citation omitted), the majority insists such counseling does not
require the meaningful presentation of “all” options. Maj. Op. 42. Rather, in the
majority’s tortured telling, “nondirective” requires only the “neutral” presentation
of some options.4 Maj. Op. 42.
Excluding an entire category of options is neither meaningful nor neutral. If
a man were diagnosed with prostate cancer, and his doctor concluded that
chemotherapy, radiation, or hospice were equally viable responses, each with
4
The majority sanctions HHS’s post hoc interpretation that “counseling” does not
include “referrals.” Maj. Op. 35–41. Judge Chen of the Northern District of
California readily dismissed this argument. California, 385 F. Supp. 3d at 988–91.
As Judge Chen explained, nondirective counseling encompasses referrals for three
reasons. First, Congress expressly stated so, a point HHS recognized when it
promulgated the Rule. See 42 U.S.C. § 254c-6(a)(1) (requiring HHS to make
training grants on “providing adoption information and referrals to pregnant
women on an equal basis with all other courses of action included in nondirective
counseling to pregnant women”) (emphasis added); 84 Fed. Reg. at 7733
(“Congress has expressed its intent that postconception adoption information and
referrals be included as part of any nondirective counseling in Title X projects
when it passed . . . 42 U.S.C. 254c-6[.]”) (emphasis added). Second, HHS itself
describes referrals as part of counseling throughout the Rule and has done so
across administrations. See, e.g., 84 Fed. Reg. at 7730, 7733–34; U.S. Dep’t
Health & Human Services, Program Guidelines for Project Grants for Family
Planning Services § 8.2 (1981) (“Post-examination counseling should be provided
to assure that the client . . . receives appropriate referral for additional services as
needed.”). Third, industry understanding recognizes that counseling includes
referrals. See California, 385 F. Supp. 3d at 989.
7
different consequences for his quality of life, he would be upset, to say the least, to
discover that he had been referred only for hospice care. Such a sham
“presentation” of options would in no sense be nondirective.
So too here. Indeed, HHS itself has recognized that there can be no
meaningful choice when a whole category of options is hidden from a patient: “In
nondirective counseling, abortion must not be the only option presented by
[medical professionals]; otherwise the counseling would violate . . . the
Congressional directive that all pregnancy counseling be nondirective[.]” 84 Fed.
Reg. at 7747. The Gag Rule does exactly that. For all pregnancy counseling not
involving abortion, women can take an “active” and “informed” role in their
pregnancy and family planning process; but once a woman asks for abortion
information, she can no longer be provided all the information she seeks about her
own medical care. See 84 Fed. Reg. at 7716–17. “[E]mpower[ed]” so long as she
does what the agency and the majority want; “coerc[ed]” and demeaned if she tries
to “take an active role in . . . identifying the direction” of her life’s course. 84 Fed.
Reg. at 7716; 65 Fed. Reg. at 41275.5 The consequences will be profound,
5
Indeed, in 2000, the agency concluded that “requiring a referral for prenatal care
and delivery or adoption where the client rejected those options would seem
coercive and inconsistent with the concerns underlying the ‘nondirective’
counseling requirement.” 65 Fed. Reg. at 41275 (emphasis added).
The majority attempts to salvage the prenatal care referral requirement by
claiming that prenatal care is medically necessary for all patients’ health,
8
delaying some women’s access to time-sensitive care and preventing others from
accessing abortion altogether.6
regardless of their intent to end a pregnancy. Maj. Op. 44 & n.19. That’s not true,
as the American College of Obstetricians and Gynecologists (“ACOG”) and other
professional medical associations, as well as numerous physicians and other health
care providers have attested. See, e.g., Br. of Amici Curiae Am. Coll. of
Obstetricians & Gynecologists, et al., at 14–15 (“Prenatal care is not medically
indicated when a pregnant patient plans to terminate her pregnancy—it is
recommended only when a patient plans to continue her pregnancy.”); Decl. of J.
Elisabeth Kruse, Nat’l Family Planning & Reprod. Health Ass’n Supplemental
Excerpts of Record (“SER”) at 256 (Washington) (“[O]f course, such care is not
medically necessary for someone who wishes to terminate her pregnancy.”); Decl.
of Dr. Melissa Marshall, California SER 579 (California) (“[P]renatal health care
is not medically necessary when a patient is terminating her pregnancy.”); Decl. of
Dr. Judy Zerzan-Thul, Washington SER 161 (Washington) (“[I]f a patient
determined to be pregnant elects to terminate the pregnancy, pre-natal care would
not be medically necessary.”). And, regardless, that’s not how HHS justified the
requirement. Rather, HHS required the prenatal care referral because “such care is
important” not only for women’s health but also “for healthy pregnancy and
birth.” 84 Fed. Reg. at 7722 (emphasis added).
6
As health care providers and amici make clear, the notion that “information about
abortion is readily available ‘on the internet’ betrays a complete lack of
understanding of the realities of our Title X patient population” who, “because of
language, literacy (including health literacy and electronic literacy), or economic
barriers[,]” depend on referrals from Title X providers in order to access care.
Kruse, Nat’l Family Planning & Reprod. Health Ass’n SER 262 (Washington); see
also Decl. of Dr. Sarah Prager, id. at 298–99 (“Because many Title X patients have
linguistic, educational, informational, and financial barriers to accessing
healthcare, the impediments introduced by the New Rule may prevent such
patients from accessing abortion altogether.”); Decl. of Dr. Blair Darney, Oregon
SER 41 (Oregon) (“Researchers have studied the reasons women delay entry to
care for abortion; logistics such as knowing where to go is among the reasons.”);
cf. Maj. Op. 46 n.21.
The barriers created by the Gag Rule are particularly substantial for young
people, LGBTQ people, those with limited English proficiency, and patients in
9
Congress has prohibited such a result. Contrary to the majority’s contention
that HHS is owed Chevron deference because Congress has not clarified the
meaning of the term “nondirective”, Maj. Op. 41, Congress has in fact done so.
And where Congress’s intent is clear, we “must give effect to the unambiguously
expressed intent of Congress.” Chevron, U.S.A., Inc. v. Nat. Res. Def. Council,
Inc., 467 U.S. 837, 843 (1984).
Congress has used “nondirective counseling” in only two instances: the
annual HHS Appropriations Act at issue here and section 254c-6(a)(1) of the
Public Health Service Act (“PHSA”). The latter provides that HHS shall make
training grants “providing adoption information and referrals to pregnant women
on an equal basis with all other courses of action included in nondirective
counseling to pregnant women.” 42 U.S.C. § 254c-6(a)(1) (emphasis added).
rural areas. See, e.g., Br. of Amici Curiae Nat’l Ctr. for Youth Law, et al., at 16–
17 (“Adolescents without easy access to transportation, a phone, and the Internet
might be unable to research the providers on the list they are given. They also
might not immediately comprehend that a medical professional, whom they trust,
has referred them for care that they do not need or want . . . . Particularly for
adolescents who are homeless or in foster care, navigating a maze of providers that
might or might not offer abortion services could prove impossible.”); Br. of Amici
Curiae Nat’l Ctr. for Lesbian Rights, et al., at 13; Decl. of Kathryn Kost, California
SER 156 (California). As one health care provider concluded, “The New Rule’s
coercive requirements would force me to disrespect, contradict, and patronize my
patient, and violate her trust[.]” Kruse, Nat’l Family Planning & Reprod. Health
Ass’n SER 262 (Washington).
10
In response, the majority asserts that because § 254c-6(a)(1) is not part of
Title X and was enacted for a different purpose, “it sheds no light on Congress’s
intent in enacting the appropriations rider or on the interpretation of its statutory
language.” Maj. Op. 38–39. If § 254c-b(a)(1) sheds no light, HHS certainly didn’t
think so: it relied on the PHSA definition in formulating the Rule. See 84 Fed.
Reg. at 7733 (“Congress has expressed its intent that . . . referrals be included as
part of any nondirective counseling in Title X projects when it passed the . . .
Public Health Service Act[.]”); 84 Fed. Reg. at 7745. As HHS apparently
recognized, Congress’s use of the term “nondirective counseling” should be read
consistently between the PHSA and the nondirective appropriations rider to
include providing referrals on an equal basis with all other options. See
Erlenbaugh v. United States, 409 U.S. 239, 243 (1972) (“[A] legislative body
generally uses a particular word with a consistent meaning in a given context.”);
see also Dir., Office of Workers’ Comp. Prog., Dep’t of Labor v. Newport News
Shipbldg. & Dry Dock Co., 514 U.S. 122, 130 (1995) (instructing that in
interpreting an ambiguous statutory phrase, “[i]t is particularly illuminating to
compare” two different statutes employing the “virtually identical” phrase).
Because the Gag Rule requires doctors to push patients toward one option
over another, it violates Congress’s mandate that patients receive counseling on
their pregnancy options in a nondirective manner.
11
II. The Rule Violates Section 1554 of the Affordable Care Act
In 2010, as part of the Affordable Care Act’s (“ACA”) sweeping reforms,
Congress imposed limits on the scope of HHS’s regulatory authority:
Notwithstanding any other provision of this Act, the Secretary of
Health and Human Services shall not promulgate any regulation
that—
(1) creates any unreasonable barriers to the ability of individuals to
obtain appropriate medical care;
(2) impedes timely access to health care services;
(3) interferes with communications regarding a full range of treatment
options between the patient and the provider;
(4) restricts the ability of health care providers to provide full
disclosure of all relevant information to patients making health care
decisions;
(5) violates principles of informed consent and the ethical standards of
health care professionals; or
(6) limits the availability of health care treatment for the full duration
of a patient’s medical needs.
42 U.S.C. § 18114 (“section 1554”). The three district courts separately
determined that the Rule violates section 1554 of the ACA. See Oregon, 389 F.
Supp. 3d at 914–15; California, 385 F. Supp. 3d at 992–1000; Washington, 376 F.
Supp. 3d at 1130. I agree.
First, the Gag Rule—which restricts communications between health care
providers and patients, 42 C.F.R. §§ 59.14(a)–(c)—will “obfuscate and obstruct
patients from receiving information and treatment for their pressing medical
needs.” California, 385 F. Supp. 3d at 998; see also Washington, 376 F. Supp. 3d
at 1130. In so doing, the Rule exceeds HHS’s statutory authority: it “impedes
12
timely access to health care services[,]” “interferes with communications regarding
a full range of treatment options[,]” “restricts the ability of health care providers to
provide full disclosure of all relevant information to patients making health care
decisions[,]” and “violates . . . the ethical standards of health care professionals[.]”
42 U.S.C. § 18114.
Second, the Separation Requirement—which requires Title X recipients to
physically and financially separate abortion provision from all other medical
services, through the use of separate entrances and exits as well as separate
accounting, personnel, and medical records, 42 C.F.R. § 59.15—plainly will
impinge on the ability of providers to offer care. See Oregon, 389 F. Supp. 3d at
915; Washington, 376 F. Supp. 3d at 1130. By its own terms, HHS’s Separation
Requirement creates unreasonable barriers to health care; it also frustrates “timely
access” to care, contrary to Congress’s plain directive that HHS may not do so. 42
U.S.C. § 18114.
Finally, the Rule’s requirement that doctors encourage family participation
in reproductive decisions will “force [doctors] to breach their ethical obligations”
in certain circumstances. California, 385 F. Supp. 3d at 1000; see also
Washington, 376 F. Supp. 3d at 1130. This requirement directly contravenes
Congress’s prohibition on promulgating regulations that “violate[] . . . the ethical
standards of health care professionals[.]” 42 U.S.C. § 18114.
13
Tellingly, the majority does not even attempt to argue that the Rule complies
with the ACA. Instead, it characterizes the Rule as falling conveniently outside the
scope of the limitations Congress imposed on HHS in the ACA. It relies on the
Rust and McRae line of cases for the proposition that, as a constitutional matter,
Congress need not subsidize abortion. It then asserts that the constitutional minima
identified in those cases “applies equally” to statutory claims. Maj. Op. 51–55.
The majority offers no support for this bold proposition.
How could it? Congress may, and regularly does, enact statutory
requirements and protections that exceed the constitutional floor. Aetna Life Ins.
Co. v. Lavoie, 475 U.S. 813, 828 (1986) (“The Due Process Clause demarks only
the outer boundaries . . . . Congress and the states, of course, remain free to impose
more rigorous standards[.]”); Am. Legion v. Am. Humanist Assoc., 139 S. Ct. 2067,
2094 (2019) (Kavanaugh, J., concurring) (“The constitutional floor is sturdy and
often high, but it is a floor.”). That is exactly what Congress has done here. 7 That
7
The majority’s assertion that the ACA does not impact Title X is contradicted by
the terms of the ACA. Maj. Op. 56–57. Section 1554 governs “any regulation,”
42 U.S.C. § 18114 (emphasis added). If Congress had meant to restrict its scope to
the ACA, it would have said “any regulation pursuant to this Act.” Cf. St. Paul
Fire & Marine Ins. Co. v. Barry, 438 U.S. 531, 550 (1978) (discussing the breadth
of the word “any” and concluding that if Congress intends to limit the scope of
statutory language, it will make that explicit). As Judge Chen reasoned, the clause
“[n]otwithstanding any other provision of this Act” is most naturally read to mean
that the Secretary “cannot engage in the type of rulemaking proscribed by [s]ection
1554 even if another provision . . . could be construed to permit it.” California,
14
a congressional decision not to subsidize abortion does not burden the abortion
right in the constitutional sense, see e.g., McRae, 448 U.S. at 316, has no bearing
whatsoever on whether an agency has overstepped its statutory authority. And,
here, the agency has.8
III. The Rule Is Likely Arbitrary and Capricious
Finally, I turn to Plaintiffs’ claim that the promulgation of the Rule was
arbitrary and capricious under the Administrative Procedure Act (“APA”). As an
initial matter, the majority contends that it is appropriate, on review of the district
courts’ preliminary injunctions, to adjudicate the merits of the arbitrary and
capricious claim. Maj. Op. 28–32. It is not. Unlike our consideration of
Plaintiffs’ first two claims, which required us to address the underlying legal
question to determine whether the district courts abused their discretion, review of
the arbitrary and capricious claim requires examination of the administrative
record. We do not have the complete administrative record before us, and neither
385 F. Supp. 3d at 995. In other words, “the directive of [s]ection 1554 is to be
given primacy” over other parts of the ACA.
8
The majority makes much of the fact that the Rule is purportedly “less restrictive
in at least one important respect” than the 1988 regulation upheld in Rust. Maj.
Op. 5. That is immaterial. The Rust decision predated the passage of the
nondirective mandate by half a decade and the ACA by two decades, so whether
the Rule or its 1988 predecessor violated those laws was not and could not possibly
have been before the Court.
15
did the district courts when they issued the preliminary injunctions. Deciding the
merits of Plaintiffs’ arbitrary and capricious claim is therefore premature. See
Walter O. Boswell Mem’l Hosp. v. Heckler, 749 F.2d 788, 792 (D.C. Cir. 1984)
(“If a court is to review an agency’s action fairly, it should have before it neither
more nor less information than did the agency when it made its decision.”)
(emphasis added); Nat. Res. Def. Council, Inc. v. Train, 519 F.2d 287, 291 (D.C.
Cir. 1975) (“The Administrative Procedure Act and the cases require that the
complete administrative record be placed before a reviewing court.”); see also
Univ. of Texas v. Camenisch, 451 U.S. 390, 395 (1981) (“[G]iven the haste that is
often necessary . . . a preliminary injunction is customarily granted on the basis of
procedures that are less formal and evidence that is less complete than in a trial on
the merits. A party thus is not required to prove his case in full at a preliminary-
injunction hearing[.]”).9 Indeed, “[t]o review less than the full administrative
record might allow a party to withhold evidence unfavorable to its case, and so the
APA requires review of ‘the whole record.’” Boswell Mem’l Hosp., 749 F.2d at
9
Indeed, while Defendants pursued their appeals of the preliminary injunctions,
briefing advanced to the merits in the Eastern District of Washington. There,
Defendants produced to Plaintiffs the full administrative record (two months after
the preliminary injunction issued), see Case No. 1:19-cv-03040-SAB, Dkt. No. 88
(June 24, 2019) and, with the benefit of the complete record, Plaintiffs further
developed their arbitrary and capricious claim. See Case No. 1:19-cv-03040-SAB,
Dkt. No. 121 (Nov. 20, 2019).
16
792. Accordingly, I address only Plaintiffs’ likelihood of success on the merits.
The majority should have done the same.10
Under the APA, a court “shall . . . hold unlawful and set aside agency action
. . . found to be . . . arbitrary [and] capricious.” 5 U.S.C. § 706(2)(A). An agency
action is arbitrary and capricious if “the agency has relied on factors which
Congress has not intended it to consider, entirely failed to consider an important
aspect of the problem, [or] offered an explanation for its decision that runs counter
to the evidence before the agency.” Motor Vehicle Mfrs’ Ass’n v. State Farm Mut.
Auto. Ins. Co., 463 U.S. 29, 43 (1983). “[T]he agency must examine the relevant
data and articulate a satisfactory explanation for its action including a rational
10
The cases on which the majority relies to proceed to the merits are inapt. First,
unlike the cases the majority cites, Maj. Op. 28–32, we do not have the full
administrative record before us. Cf. Beno v. Shalala, 30 F.3d 1057, 1064 n.11 (9th
Cir. 1994) (reaching the merits because “Plaintiffs’ . . . claim requires a review of
the administrative record, which is complete, and interpretation of relevant statutes;
additional fact-finding is not necessary to resolve this claim”) (emphasis added);
Blockbuster Videos, Inc. v. City of Tempe, 141 F.3d 1295, 1297 (9th Cir. 1998)
(same, because “[t]he record . . . is fully developed”); see also Fla. Power & Light
Co. v. Lorion, 470 U.S. 729, 744 (1985) (“The APA specifically contemplates
judicial review on the basis of the agency record compiled in the course of . . .
[the] agency action[.]”) (emphasis added). Nor is this a case that implicates
sensitive foreign policy concerns. Munaf v. Geren, 553 U.S. 674, 692 (2008)
(reasoning that reaching the merits was “the wisest course” because the case
“implicate[d] sensitive foreign policy issues in the context of ongoing military
operations”).
17
connection between the facts found and the choice made.” Id. (internal quotation
marks omitted).
When an agency changes its policy, the agency must provide a “reasoned
explanation for its action.” FCC v. Fox Television Stations, Inc., 556 U.S. 502,
515 (2009). The new policy need not be better than the old one, but it must be
permissible and based on “good reasons.” Id. When the reasons the agency relies
on for changing its position are “not new,” the agency fails to provide a “reasoned
explanation.” Org. Vill. of Kake v. U.S. Dep’t of Agric., 795 F.3d 956, 967 (9th
Cir. 2015) (en banc). “In explaining its changed position, an agency must also be
cognizant that longstanding policies may have engendered serious reliance
interests that must be taken into account.” Encino Motorcars, LLC v. Navarro, 136
S. Ct. 2117, 2126 (2016) (internal quotation marks omitted). Here, the Rule
replaced the regulation adopted in 2000, not the 1988 regulation addressed in Rust;
thus the 2000 Rule is the one to which we must look to assess HHS’s changed
positions. See Standards of Compliance for Abortion-Related Services in Family
Planning Services Projects, 65 Fed. Reg. 41270 (Jul. 3, 2000). Plaintiffs are likely
to prevail on their claim that the promulgation of the Rule was arbitrary and
capricious for at least two reasons. 11
11
None of the district courts needed to address Plaintiffs’ arbitrary and capricious
arguments because they had independently found Plaintiffs were likely to succeed
on their other merits arguments. Nevertheless, each district court recognized the
18
A. HHS Failed to Provide a Reasoned Justification for Its Policy Change
First, the Rule represents a dramatic shift in policy, yet HHS failed to
provide the required “reasoned explanation for its action.” Fox Television, 556
U.S. at 515. Take the Gag Rule and Separation Requirement, for example. In
2000, when it adopted regulations rescinding the 1988 version of the Gag Rule,
HHS explicitly considered Congress’s recently enacted nondirective mandate as
well as comments emphasizing that “medical ethics and good medical care . . .
requir[e] that patients receive full and complete information to enable them to
make informed decisions”; “[c]onsequently,” the agency “decided to reflect [the
nondirective requirement] . . . in the regulatory text.” 65 Fed. Reg. at 41273. By
contrast, here HHS has changed its position on what medical ethics demand
without providing a reasoned explanation for or acknowledgment of the change, as
strength of Plaintiffs’ APA challenge. California, 385 F. Supp. 3d at 1000–19
(addressing—with painstakingly detailed analysis—the shortcomings of HHS’s
justifications for the physical separation requirement, the counseling and referral
restrictions, the “physicians or advanced practice providers” requirement, and the
removal of the “medically approved” requirement, as well as HHS’s inadequate
cost-benefit analysis); Oregon, 389 F. Supp. 3d at 917–18 (noting that HHS
“nowhere squares” particular medical ethics requirements with the requirements of
the Rule and that HHS “appears to have failed to seriously consider persuasive
evidence”); Washington, 376 F. Supp. 3d at 1131 (recognizing that Plaintiffs and
amici had “presented facts and argument that the . . . Rule is arbitrary and
capricious because it reverses long-standing positions of [HHS]” without
considering relevant medical opinions and likely consequences).
19
is required by the APA. 12 See Org. Vill. of Kake, 795 F.3d at 966 (“Unexplained
inconsistency between agency actions is a reason for holding an interpretation to
be an arbitrary and capricious change.”) (internal quotation marks and citation
omitted). 13
12
That abortion remains controversial, as the majority contends, Maj. Op. 75 n.34,
does not explain why HHS may shift its understanding of medical ethics from 2000
without a reasoned explanation.
13
I also agree with Judge McShane of the District of Oregon that HHS’s “failure to
respond meaningfully to the evidence” that the Gag Rule contradicts medical ethics
“renders its decision[] arbitrary and capricious.” Oregon, 389 F. Supp. 3d at 918
(quoting Tesoro Alaska Petroleum Co. v. FERC, 234 F.3d 1286, 1294 (D.C. Cir.
2000)). A doctor and leader of the American Medical Association—the
organization that “literally wrote the book on medical ethics”—stated that the
American Medical Association’s Code of Medical Ethics prohibits withholding
information from a patient, except in emergency situations, and requires decisions
or recommendations to be based on the patient’s medical needs. Id. at 916. He
concluded that the Gag Rule “is an instruction to physicians to intentionally
mislead patients, which, if followed, is an instruction for physicians to directly
violate the Code of Medical Ethics[.]” Id. at 917.
In its cursory response, HHS merely announced that it “believes” the Rule
presents no ethical problems because patients are permitted to ask questions “and
to have those questions answered by a medical professional.” 84 Fed. Reg. at
7724. That assertion is contradicted by the plain text of the Rule, which
specifically prohibits medical professionals from answering certain questions, such
as, “who on this list is an abortion provider?” 42 C.F.R. § 59.14(c)(2). HHS’s
insistence that the Gag Rule is “nondirective” does not salvage the Rule either, as it
is both conclusory and, for the reasons explained in Section I, supra, false.
Because the Gag Rule “contradicts . . . persuasive evidence from the leading expert
on medical ethics,” and HHS has failed to present even a “plausible explanation
outlining its rationale for rejecting the evidence and reaching a different
conclusion,” Oregon, 389 F. Supp. 3d at 917 (citing State Farm Mut., 463 U.S. at
43), it is arbitrary and capricious. The majority is wrong to conclude otherwise.
20
Similarly, in 2000, HHS recognized that “Title X grantees are subject to
rigorous financial audits” and ultimately concluded that a physical separation
requirement “is not likely ever to result in an enforceable compliance policy that is
consistent with the efficient and cost-effective delivery of family planning
services.” 65 Fed. Reg. at 41275–76 (2000) (emphasis added). As justification for
its about-face in the new Rule, HHS speculated about a “risk” of Title X funds
being used for impermissible purposes.14 84 Fed. Reg. at 7765 (discussing the risk
of “potential co-mingling” without citing any evidence of co-mingled funds). A
speculative risk is not a reasoned explanation. Ariz. Cattle Growers’ Ass’n v. U.S.
Fish & Wildlife, 273 F.3d 1229, 1244 (9th Cir. 2001); see also Nat’l Fuel Gas
Supply Corp. v. FERC, 468 F.3d 831, 841 (D.C. Cir. 2006).
B. HHS’s Cost-Benefit Analysis Is Contrary to the Evidence
Second, the Rule is likely arbitrary and capricious because HHS offered an
explanation for its cost-benefit analysis that runs contrary to the evidence before
the agency. See State Farm Mut., 463 U.S. at 43. As the district courts explained,
there are at least three provisions of the Rule that will cause providers to leave the
14
To be clear: the “recent studies” that the majority notes HHS relied on do not
demonstrate any actual misuse of Title X funds. Maj. Op. 65. Rather, they reflect
facilities that comply with Title X but likely will be forced out of the program by
the Separation Requirement. 84 Fed. Reg. at 7765.
21
Title X program, leading to decreased access to Title X-funded care, which will in
turn create costs that HHS did not account for.
First, the Gag Rule. Because it “require[s] doctors to violate . . .
fundamental ethical and professional norms[,]” Oregon, 389 F. Supp. 3d at 916,
the Gag Rule will trigger providers to leave the Title X program, “drastically
reduc[ing] access to Title X services, and lead[ing] to serious disruptions in care
for Title X patients.” California, 385 F. Supp. 3d at 1008. For example, the
provider serving approximately 40% of all Title X patients—1.6 million people—
which is also the only family planning provider in ten percent of rural counties,
declared that if the Gag Rule is implemented, it will leave the Title X program in
order to maintain its ethical obligations to patients.15 Oregon, 389 F. Supp. 3d at
918; California, 385 F. Supp. 3d at 979.
15
Indeed, this exodus has come to pass. Plaintiffs informed us that all Planned
Parenthood Title X direct grantees would withdraw from Title X beginning August
19, 2019, as a result of enforcement actions by HHS, and they have done so. See
Sarah McCammon, Planned Parenthood Withdraws From Title X Program Over
Trump Abortion Rule, Nat’l Pub. Radio (Aug. 19, 2019),
https://www.npr.org/2019/08/19/752438119/planned-parenthood-out-of-title-x-
over-trump-rule. Planned Parenthood is not alone. See Nicole Acevedo, Nearly
900 Women’s Health Clinics Have Lost Federal Funding Over Gag Rule, NBC
News (Oct. 22, 2019) https://www.nbcnews.com/news/latino/nearly-900-women-s-
health-clinics-have-lost-federal-funding-n1069591; Anna North, How A Beloved
Clinic for Low-Income Women Is Fighting to Stay Alive in the Trump Era, Vox
(Nov. 22, 2019), https://www.vox.com/identities/2019/11/22/20952297/title-x-
funding-abortion-birth-control-trump.
22
Second, the Separation Requirement. Compliance with the Separation
Requirement will be so cost-prohibitive for many providers that they will have to
leave the Title X program.16 California, 385 F. Supp. 3d at 1008–11.
Third, the requirement that only “physicians or advanced practice providers”
may provide counseling. See 84 Fed. Reg. at 7727–28 (defining “advanced
practice providers”). This limitation will significantly reduce the number of people
who can provide pregnancy counseling and will require significant changes in Title
X providers’ staffing, or else devastate their capacity to serve patients. Id. at 7778
(noting that for “1.7 million Title X family planning encounters in 2016,” services
were delivered by providers who are not “physicians or advanced practice
providers”); California, 385 F. Supp. 3d at 1013 (recognizing that “65% of Title X
sites rel[ied] on trained health educators, registered nurses, and other qualified
providers (excluding physicians and advanced practice clinicians) to counsel
16
HHS also calculated costs of compliance with the physical separation
requirement in a “mystifying” way. California, 385 F. Supp. 3d at 1008. HHS’s
internal guidelines—and common sense—suggest that compliance costs for
making physically separate facilities would include expenses related to equipment,
leasing space, utilities, and personnel. Yet, HHS estimated that an average of only
$30,000 per affected Title X site would be incurred to comply with the physical
separation requirement. 84 Fed. Reg. at 7782. As Plaintiffs’ counsel indicated at
oral argument, even just hiring a single front desk staff member to staff a new
entrance to a facility would exceed that estimate, not to mention all the other costs
that would accompanying creating and maintaining such a facility. See, e.g.,
Washington SER 355–56 (Washington); California SER 396–97 (California).
23
patients in selecting contraceptive methods”) (internal quotation marks and citation
omitted).
HHS dismissed the loss of access by speculating that there would not “be a
decrease in the overall number of facilities offering [Title X] services, since [HHS]
anticipates other, new entities will apply for funds, or seek to participate as
subrecipients, as a result of the final rule.” 84 Fed. Reg. at 7782. HHS
simultaneously contradicted that very prediction, by stating, “[HHS] cannot
calculate or anticipate future turnover in grantees.” Id. (emphasis added).
Nonetheless, HHS stated, “[b]ased on [HHS’s] best estimates, it anticipates that the
net impact on those seeking services from current grantees will be zero[.]” Id.
HHS provided no explanation of how it arrived at its “best estimates.” See also
California, 385 F. Supp. 3d at 983 (“[A]t oral argument [before the district court],
when pressed for any record evidence substantiating this (highly consequential)
assertion, Defendants’ counsel could offer none.”). Nor did HHS provide any
specifics about its estimates, such as the locations or geographic distribution of any
“new” clinics, their number or size, or how long it would take them to become
operational grantees. Thus, HHS failed to offer “an explanation for its decision
that runs counter to the evidence before” it. State Farm Mut., 463 U.S. at 43.
Proceeding in this manner is the hallmark of arbitrary and capricious
administrative action.
24
The majority disagrees, citing readily distinguishable case law and a poll
that did not conclude what the majority purports it does. 17 Maj. Op. 68. The
“poll” that HHS cited is a summary showing both that a majority of “faith-based
healthcare professionals” would prefer not to violate their conscience and that a
majority of them never experienced pressure to refer a patient for a procedure to
which the professional had moral, ethical, or religious objections. 84 Fed. Reg. at
7780 n.138; Freedom2Care & The Christian Med. Ass’n, National Poll Shows
Majority Support Healthcare Conscience Rights, Conscience Law (May 3, 2011),
https://perma.cc/3AU4-ACGA. Nothing suggests that the poll asked medical
professionals about expanding into Title X. It is baffling how HHS made the leap
17
The majority relies extensively on the Supreme Court’s recent opinion, Dep’t of
Commerce v. New York, 139 S. Ct. 2551 (2019). Maj. Op. 59, 61–62, 70–77. That
case raised the issue of whether the Secretary of Commerce was required to accept
the Census Bureau’s predictions about accurate gathering of citizenship data.
Dep’t of Commerce, 139 S. Ct. at 2569. The Court held that the Secretary was not
beholden to the Bureau’s analysis because “the Census Act authorizes the
Secretary, not the Bureau, to make policy choices within the range of reasonable
options[,]” id. at 2571 (emphasis added), and there was support for the Secretary’s
decision, id. at 2569. Conversely, here, we are reviewing HHS’s own
administrative decisions in the face of contravening evidence, and there is no
support for HHS’s decisions.
Moreover, the Court struck down the Secretary of Commerce’s attempt to
reinstate the citizenship question on the census. See 139 S. Ct. at 2575–76 (“Our
review is deferential, but we are ‘not required to exhibit a naiveté from which
ordinary citizens are free.’”). Similarly, here, deference to HHS does not mean
turning a blind eye to the agency’s actions, as the majority does.
25
from the poll data—the quality and veracity of which is unclear from the summary
the agency cited—to its conclusion that there would be no decrease in facilities.
Id. And a predicate to giving deference to an agency is that the agency’s
inferences must not contradict the findings of the study. State Farm Mut., 463
U.S. at 43. That is by no means de novo review, contrary to the majority’s
contention. Maj. Op. 68 n.29.
Moreover, the cases on which the majority relies to endorse HHS’s
guesswork arose in different circumstances. Maj. Op. 68–70. When the Supreme
Court in FCC v. National Citizens Committee for Broadcasting condoned an
agency’s “forecast” for future behaviors without “complete factual support,” the
underlying agency decision was “to ‘grandfather’” existing policies into a new
rule. 436 U.S. 775, 813–14 (1978). There, the agency’s predictions concerned
maintenance of the status quo, rather than the change in policy HHS made here.
And in other cases cited by the majority, the regulations at issue “reflect[ed]
reasoned predictions about technical issues.” BNSF Ry. Co. v. Surface Transp.
Bd., 526 F.3d 770, 781 (D.C. Cir. 2008) (citation omitted); see also Trout
Unlimited v. Lohn, 559 F.3d 946, 959 (9th Cir. 2009) (noting that the record
showed that the agency relied on “scientific data, and not on mere speculation”).
HHS’s prediction here is not reasoned or based on any data or studies, and should
not be afforded deference. See Sorenson Commc’ns Inc. v. FCC, 755 F.3d 702,
26
708 (D.C. Cir. 2014) (“[T]he wisdom of agency action is rarely so self-evident that
no other explanation is required.”); McDonnell Douglas Corp. v. U.S. Dep’t of the
Air Force, 375 F.3d 1182, 1187 (D.C. Cir. 2004) (“[W]e do not defer to the
agency’s conclusory or unsupported suppositions.”).
Further, because of HHS’s sunny, and baseless, prediction that new clinics
will appear to provide services to at least 40% of the patient population served by
Title X, HHS did not address the potential health consequences of decreased
services and their corresponding costs in its cost-benefit analysis. As the Northern
District of California recognized, the decreased services could cause a 31%
increase in the nation’s unintended pregnancy rate, which would lead to “[b]illions
of dollars in public costs[.]” California, 385 F. Supp. 3d at 1016. Even if the
number of clinics were to remain the same, a changed geographic reach would
have devastating consequences. See 84 Fed. Reg. at 7782 (recognizing that
patients will have to travel further to obtain health care); California, 385 F. Supp.
3d at 1017–18 (noting that when a rural Indiana county lost a Planned Parenthood
clinic, “the county lost free HIV testing services and almost immediately
experienced one of the largest and most rapid HIV outbreaks the country has ever
seen”) (internal quotation marks omitted). An agency governed by the APA must
grapple with potential costs, and HHS—an agency with power over public health,
27
no less—failed to do so here. See State Farm Mut., 463 U.S. at 43; Nat’l Ass’n of
Home Builders v. EPA, 682 F.3d 1032, 1040 (D.C. Cir. 2012).
The majority is correct that we give agencies deference—but only insofar as
the agency “examine[s] the relevant data and articulate[s] a satisfactory
explanation for its action including a rational connection between the facts found
and the choice made.” State Farm Mut., 463 U.S. at 43 (internal quotation marks
omitted). The majority fails to hold HHS to that basic standard here.
***
In vacating the preliminary injunctions, the majority blesses an executive
agency’s disregard of the clear limits placed on it by Congress. The consequences
will be borne by the millions of women who turn to Title X-funded clinics for
lifesaving care and the very contraceptive services that have caused rates of
unintended pregnancy—and abortion—to plummet.
I strongly dissent.
28