Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-19-15974/USCOURTS-ca9-19-15974-0/pdf.json

Nature of Suit Code: 899
Nature of Suit: Other Statutes - Administrative Procedure Act/Review or Appeal of Agency Decision
Cause of Action: 

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FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

STATE OF CALIFORNIA, by 

and through Attorney General 

Xavier Becerra,

Plaintiff-Appellee,

v.

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.

No. 19-15974

D.C. No.

3:19-cv-01184-EMC

 

 

 

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2 STATE OF CALIFORNIA V. AZAR

ESSENTIAL ACCESS HEALTH,

INC.; MELISSA MARSHALL,

M.D.,

Plaintiffs-Appellees,

v.

ALEX M. AZAR II, Secretary 

of U.S. Department of Health 

and Human Services; UNITED 

STATES DEPARTMENT OF 

HEALTH AND HUMAN 

SERVICES,

Defendants-Appellants.

No. 19-15979

D.C. No.

3:19-cv-01195-EMC

STATE OF OREGON; STATE OF 

NEW YORK; STATE OF 

COLORADO; STATE OF

CONNECTICUT; STATE OF 

DELAWARE; DISTRICT OF 

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 

No. 19-35386

D.C. Nos.

6:19-cv-00317-MC

6:19-cv-00318-MC

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STATE OF CALIFORNIA V. AZAR 3

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; UNITED 

STATES DEPARTMENT OF 

HEALTH AND HUMAN 

SERVICES; DIANE FOLEY;

OFFICE OF POPULATION 

AFFAIRS,

Defendants-Appellants.

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4 STATE OF CALIFORNIA V. AZAR

STATE OF WASHINGTON;

NATIONAL FAMILY PLANNING 

AND REPRODUCTIVE HEALTH 

ASSOCIATION; FEMINIST 

WOMEN'S 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; UNITED 

STATES DEPARTMENT OF 

HEALTH AND HUMAN 

SERVICES; DIANE FOLEY,

MD, in her official capacity 

as Deputy Assistant 

Secretary for Population 

Affairs; OFFICE OF 

POPULATION AFFAIRS,

Defendants-Appellants.

No. 19-35394

D.C. Nos.

1:19-cv-03040-SAB

1:19-cv-03045-SAB

ORDER ON MOTIONS 

FOR STAY PENDING 

APPEAL

Filed June 20, 2019

Before: Edward Leavy, Consuelo M. Callahan,

and Carlos T. Bea, Circuit Judges.

Per Curiam Order

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STATE OF CALIFORNIA V. AZAR 5

SUMMARY*

Civil Rights

The panel granted the United States Department of 

Health and Human Services’ motion for a stay pending 

appeal of three preliminary injunction orders issued by 

district courts in three states which enjoined from going into 

effect the 2019 revised regulations to Title X of the Public 

Health Service Act, pertaining to pre-pregnancy family 

planning services.

In 1970, Congress enacted Title X to create a limited 

grant program for certain types of pre-pregnancy family 

planning services. Section 1008 of Title X provides that 

none on the funds appropriated under the subchapter shall be 

used in programs where abortion is a method of family 

planning. In 1988, the Department of Health and Human 

Service promulgated regulations forbidding Title X grantees 

from providing counseling or referrals for, or otherwise 

encouraging, promoting, or advocating abortion as a method 

of family planning. Several years later, the Department 

suspended the 1988 regulations and promulgated new Title 

X regulations, which re-interpreted § 1008 as requiring, 

among other things, that Title X grantees provide 

“nondirective” abortion counseling and abortion referrals 

upon request. In 2019, the Department once again revised 

its Title X regulations, promulgating regulatory language 

(the “Final Rule”) that substantially reverted back to the 

1988 regulations. A group of state governments and existing 

 * This summary constitutes no part of the opinion of the court. It 

has been prepared by court staff for the convenience of the reader.

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6 STATE OF CALIFORNIA V. AZAR

Title X grantees challenged the Final Rule in federal court in 

three states (California, Washington and Oregon), and 

sought preliminary injunctive relief. The district courts in 

all three states granted plaintiffs’ preliminary injunction 

motions on nearly identical grounds. The Department 

appealed and sought to stay the injunctions pending a 

decision of the merits of its appeals.

The panel first noted that the Final Rule was a reasonable 

interpretation of § 1008. The panel further stated that the 

Supreme Court’s decision in Rust v. Sullivan, 500 U.S. 173 

(1991), largely foreclosed any attempt to argue that the Final 

Rule was not a reasonable interpretation of the text of 

§ 1008. The panel rejected the district courts’ conclusions 

that two intervening laws, a Health and Human Services 

appropriations rider and an ancillary provision of the 

Affordable Care Act, Title I § 1554, rendered the Final Rule 

invalid. The panel concluded that neither law impliedly 

repealed or amended § 1008. The panel further held that 

Final Rule’s counseling and referral requirements was not in 

conflict with the appropriations rider’s nondirective 

pregnancy counseling mandate. Finally, the panel held that 

even if plaintiffs properly preserved their Affordable Care 

Act challenge, it was likely that § 1554 did not affect 

§ 1008’s prohibition on funding programs where abortion 

was a method of family planning.

The panel held that, in light of the narrow permissible 

scope of the district court’s review of the Department’s 

reasoning under the arbitrary and capricious standard, the 

Department was likely to prevail on its argument that the 

district court erred in concluding that the Final Rule’s 

enactment violated the Administrative Procedure Act. 

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STATE OF CALIFORNIA V. AZAR 7

The panel held that the remaining factors also favored a 

stay pending appeal, noting that the Department and the 

public at large are likely to suffer irreparable harm in the 

absence of a stay, which were comparatively greater than the 

harms plaintiffs were likely to suffer.

COUNSEL

Jaynie Lilley, Katherine Allen, and Michael S. Raab, 

Appellate Staff; Brinton Lucas, Senior Counsel; Hashim M. 

Mooppan, Deputy Assistant Attorney General; Joseph H. 

Hunt, Assistant Attorney General; for DefendantsAppellants.

Anna Rich, Ketakee Kane, and Brenda Ayon Verduzco, 

Deputy Attorneys General; Kathleen Boergers, Supervising 

Deputy Attorney General; Michael L. Newman, Senior 

Assistant Attorney General; Xavier Becerra, Attorney 

General; Office of the Attorney General, Oakland, 

California; for Plaintiff-Appellee State of California.

Michelle Ybarra, Sarah Salomon, Sophie Hood, and Justine 

Sessions, Keker Van Nest & Peters LLP, San Francisco, 

California, for Plaintiffs-Appellees. Essential Access 

Health, Inc. and Melissa Marshall, M.D.

Judith N. Vale, Senior Assistant Solicitor General; Barbara 

D. Underwood, Solicitor General; Letitia James, Attorney 

General; Office of the Attorney General, Albany, New York; 

Benjamin Gutman, Solicitor General; Jona J. Maukonen, 

Senior Assistant Attorney General; Ellen F. Rosenblum, 

Attorney General; Office of the Attorney General, Salem, 

Oregon; Phil Weiser, Attorney General, State of Colorado; 

William Tong, Attorney General, State of Connecticut; 

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8 STATE OF CALIFORNIA V. AZAR

Kathy Jennings, Attorney General, State of Delaware; Karl 

A. Racine, Attorney General, District of Columbia; Clare E. 

Connors, Attorney General, State of Hawaii; Kwame Raoul, 

Attorney General, State of Illinois; Brian E. Frosh, Attorney 

General, State of Maryland; Maura Healey, Attorney 

General, Commonwealth of Massachusetts; Dana Nessel, 

Attorney General, State of Michigan; Keith Ellison, 

Attorney General, State of Minnesota; Aaron Ford, Attorney 

General, State of Nevada; Gurbir Singh Grewal, Attorney 

General, State of New Jersey; Hector Balderas, Attorney 

General, State of New Mexico; Josh Stein, Attorney 

General, State of North Carolina; Josh Shapiro, Attorney 

General, Commonwealth of Pennsylvania; Peter F. Neronha, 

Attorney General, State of Rhode Island; T.J. Donovan, 

Attorney General, State of Vermont; Mark R. Herring, 

Attorney General, Commonwealth of Virginia; Josh Kaul, 

Attorney General, State of Wisconsin; for PlaintiffsAppellees State of Oregon, State of New York, State of 

Colorado, State of Connecticut, State of Delaware, District 

of 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, and State of 

Wisconsin.

Alan E. Schoenfeld, Wilmer Cutler Pickering Hale and Dorr 

LLP, New York, New York; Joshua M. Koppel, Albinas J. 

Prizgintas, Kimberly A. Parker, and Paul R.Q. Wolfson, 

Wilmer Cutler Pickering Hale and Dorr LLP, Washington, 

D.C.; Kennon Scott, Per A. Ramfjord, and Jeremy D. Sacks, 

Stoel Rives LLP, Portland, Oregon; Erin G. Sutton, Leonard 

A. Nelson, and Brian D. Vandenberg, Office of General 

Counsel, American Medical Association, Chicago, Illinois; 

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STATE OF CALIFORNIA V. AZAR 9

Mark Bonnano, General Counsel, Oregon Medical 

Association, Portland, Oregon; Carri Y. Flaxman and 

Helene T. Krasnoff, Planned Parenthood Federation of 

America Inc., Washington, D.C.; for Plaintiffs-Appellees 

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.

Kristin Beneski, Paul M. Crisalli, and Jeffrey T. Sprung, 

Assistant Attorneys General; Norah G. Purcell, Solicitor 

General; Robert Ferguson, Attorney General; Office of the 

Attorney General, Seattle, Washington; for PlaintiffAppellee State of Washington

Fiona Kaye, Brigitte Amiri, Elizabeth Deutsch, Anjali Dalal, 

and Ruth E. Harlow, American Civil Liberties Union 

Foundation; Emily Chiang, American Civil Liberties Union 

Foundation of Washington; Joe Shaeffer, MacDonald 

Hoague & Bayless, Seattle, Washington; Brandon D. 

Harper, Jennifer B. Sokoler, and Nicole M. Argentieri, 

O’Melveny & Myers LLP, New York, New York; Sara 

Zdeb, O’Melveny & Myers LLP, Washington, D.C.; for 

Plaintiffs-Appellees National Family Planning and 

Reproductive Health Association, Feminist Women's Health 

Center. Deborah Oyer M.D., and Teresa Gall.

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10 STATE OF CALIFORNIA V. AZAR

ORDER

PER CURIAM:

BACKGROUND

In 1970, Congress enacted Title X of the Public Health 

Service Act (“Title X”) to create a limited grant program for 

certain types of pre-pregnancy family planning services. See

Pub. L. No. 91-572, 84 Stat. 1504 (1970). Section 1008 of 

Title X, which has remained unchanged since its enactment, 

is titled “Prohibition of Abortion,” and provides:

None of the funds appropriated under this 

subchapter shall be used in programs where 

abortion is a method of family planning.

42 U.S.C. § 300a-6.

In 1988, the Department of Health and Human Services 

(“HHS”) explained that it “interpreted [§] 1008 . . . as 

prohibiting Title X projects from in any way promoting or 

encouraging abortion as a method of family planning,” and 

“as requiring that the Title X program be ‘separate and 

distinct’ from any abortion activities of a grantee.” 53 Fed. 

Reg. at 2923. Accordingly, HHS promulgated regulations 

forbidding Title X grantees from providing counseling or 

referrals for, or otherwise encouraging, promoting, or 

advocating abortion as a method of family planning. Id.

at 2945. To prevent grantees from evading these 

restrictions, the regulations placed limitations on the list of 

medical providers that a program must offer patients as part 

of a required referral for prenatal care. See id. Such a list 

was required to exclude providers whose principal business 

is the provision of abortions, had to include providers who 

do not provide abortions, and could not weigh in favor of 

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STATE OF CALIFORNIA V. AZAR 11

providers who perform abortions. Id. at 2945. The 

regulations also required grantees to keep their Title X 

funded projects “physically and financially separate” from 

all abortion-related services that the grantee might also 

provide (the “physical-separation” requirement). Id.

In 1991, the Supreme Court upheld the 1988 regulations 

against a challenge in Rust v. Sullivan, 500 U.S. 173 (1991). 

Rust held that § 1008 of Title X was ambiguous as to 

whether grantees could counsel abortion as a family 

planning option and make referrals to abortion providers. Id.

at 184. Applying deference under Chevron, USA, Inc. v. 

Natural Resources Defense Council, Inc., 467 U.S. 837, 

842–43 (1984), the Supreme Court found that the 1988 

regulations were a permissible interpretation of § 1008. Id.

at 184–85. The Supreme Court also held that the 1988 

regulations were not arbitrary or capricious because the 

regulations were justified by “reasoned analysis,” that the 

regulations were consistent with the plain language of Title 

X, and that they did not violate the First or Fifth 

Amendments. Id. at 198–201.

Several years later (and under a new presidential 

administration), HHS suspended the 1988 regulations. 

58 Fed. Reg. 7455 (1993). HHS finally promulgated new 

Title X regulations in 2000, which re-interpreted § 1008 as 

requiring Title X grantees to provide “nondirective”1

abortion counseling and abortion referrals upon request. 

65 Fed. Reg. 41270–79. The 2000 regulations also 

 1 Under the 2000 regulations, “nondirective” counseling meant the 

provision of “factual, neutral information about any option, including 

abortion, as [medical providers] consider warranted by the 

circumstances, . . . [without] steer[ing] or direct[ing] clients toward 

selecting any option.” 65 Fed. Reg. 41270–01.

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12 STATE OF CALIFORNIA V. AZAR

eliminated the 1988 regulations’ physical-separation 

requirement. Id.

In 2019, HHS once again revised its Title X regulations, 

promulgating regulatory language (the “Final Rule”) that 

substantially reverts back to the 1988 regulations. 84 Fed. 

Reg. 7714. Under the Final Rule, Title X grantees are 

prohibited from providing referrals for, and from engaging 

in activities that otherwise encourage or promote, abortion 

as a method of family planning. Id. at 7788–90. Providers 

are required to refer pregnant women to a non-abortion prenatal care provider, and may also provide women with a list 

of other providers (which may not be composed of more 

abortion providers than non-abortion providers). See id. 

at 7789. Notably, however, the Final Rule is less restrictive 

than the 1988 regulations: it allows (but does not require) the 

neutral presentation of abortion information during 

nondirective pregnancy counseling in Title X programs. Id. 

The Final Rule also revives the 1988 regulations’ physicalseparation requirement, imposes limits on which medical 

professionals can provide pregnancy counseling, clarifies 

the previous requirement that family planning methods be 

“medically approved,” and creates a requirement that

providers encourage family participation in decisions. Id.

at 7789.

The Final Rule was scheduled to take effect on May 3, 

2019, although grantees would have until March 4, 2020, to 

comply with the physical-separation requirement. Id. 

at 7714. But a group of state governments and existing Title 

X grantees (“Plaintiffs”) challenged the Final Rule in federal 

court in three states (California, Washington, and Oregon), 

and sought preliminary injunctive relief. The district courts 

in all three states granted Plaintiffs’ preliminary injunction 

motions on nearly identical grounds. See Washington v. 

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STATE OF CALIFORNIA V. AZAR 13

Azar, 19-cv-3040, 2019 WL 1868632 (E.D. Wash. Apr. 25, 

2019); Oregon v. Azar, 19-cv-317, 2019 WL 1897475 (D. 

Oregon Apr. 29, 2019); California v. Azar, 19-cv-1184, 19-

cv-1195, 2019 WL 1877392 (N.D. Cal. Apr. 26, 2019). As 

a result of the three preliminary injunctions, the Final Rule 

has not gone into effect.

HHS appealed all three preliminary injunction orders to 

this court, and filed motions to stay the injunctions pending 

a decision on the merits of its appeals. Because the three 

motions for a stay pending appeal present nearly identical 

issues, we consider all three motions jointly.

ANALYSIS

In ruling on a stay motion, we are guided by four factors: 

“(1) whether the stay applicant has made a strong showing 

that he is likely to succeed on the merits; (2) whether the 

applicant will be irreparably injured absent a stay; 

(3) whether issuance of the stay will substantially injure the 

other parties interested in the proceeding; and (4) where the 

public interest lies.” Nken v. Holder, 556 U.S. 418, 434 

(2009) (internal quotation marks omitted). Although review 

of a district court’s grant of a preliminary injunction is for 

abuse of discretion, Southwest Voter Registration Education 

Project v. Shelley, 344 F.3d 914, 918 (9th Cir. 2003), “[a] 

district court by definition abuses its discretion when it 

makes an error of law,” Koon v. United States, 518 U.S. 81, 

100 (1996).

I.

We conclude that the Government is likely to prevail on 

its challenge to the district courts’ preliminary injunctions 

based on their findings that the Final Rule is likely invalid as 

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14 STATE OF CALIFORNIA V. AZAR

both contrary to law and arbitrary and capricious under 

5 U.S.C. § 706(2)(A).

As a threshold matter, we note that the Final Rule is a 

reasonable interpretation of § 1008. Congress enacted 

§ 1008 to ensure that “[n]one of the funds appropriated under 

this subchapter shall be used in programs where abortion is 

a method of family planning.” 42 U.S.C. § 300a-6. If a 

program promotes, encourages, or advocates abortion as a 

method of family planning, or if the program refers patients 

to abortion providers for family planning purposes, then that 

program is logically one “where abortion is a method of 

family planning.” Accordingly, the Final Rule’s 

prohibitions on advocating, encouraging, or promoting 

abortion, as well as on referring patients for abortions, are 

reasonable and in accord with § 1008. Indeed, the Supreme 

Court has held that § 1008 “plainly allows” such a 

construction of the statute. Rust, 500 U.S. at 184 (upholding 

as a reasonable interpretation of § 1008 regulations that 

(1) prohibited abortion referrals and counseling, (2) required 

referrals for prenatal care, (3) placed restrictions on referral 

lists, (4) prohibited promoting, encouraging, or advocating 

abortion, and (5) mandated financial and physical separation 

of Title X projects from abortion-related activities). The text 

of § 1008 has not changed.

II.

Because Rust largely forecloses any attempt to argue that 

the Final Rule is not a reasonable interpretation of the text of 

§ 1008, the district courts instead relied on two purportedly 

intervening laws that they say likely render the Final Rule 

“not in accordance with law.” 5 U.S.C. § 706(2)(A). The 

first is an “appropriations rider” that Congress has included 

in every HHS appropriations act since 1996. The 2018 

version states:

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STATE OF CALIFORNIA V. AZAR 15

For carrying out the program under [T]itle X 

of the PHS Act to provide for voluntary 

family planning projects, $286,479,000: 

Provided, [t]hat 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.

132 Stat 2981, 3070–71 (2018) (emphasis added). The 

second is an ancillary provision of the Affordable Care Act 

(ACA), located within a subchapter of the law entitled 

“Miscellaneous Provisions,” which reads:

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;

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16 STATE OF CALIFORNIA V. AZAR

(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 duration of a patient’s

medical needs.

Pub. L. No. 111-148, title I, § 1554 (42 U.S.C. § 18114) 

(“§ 1554”).

These two provisions could render the Final Rule “not in 

accordance with law” only by impliedly repealing or 

amending § 1008, or by directly contravening the Final 

Rule’s regulatory provisions.

First, we conclude that neither law impliedly repealed or 

amended § 1008. See Nat’l Ass’n of Home Builders v. Defs. 

of Wildlife, 551 U.S. 644, 663 (2007) (“[E]very amendment 

of a statute effects a partial repeal to the extent that the new 

statutory command displaces earlier, inconsistent 

commands.”). “[R]epeals by implication are not favored and 

will not be presumed unless the intention of the legislature 

to repeal is clear and manifest.” Id. at 662 (internal quotation 

marks and alterations omitted); United States v. Madigan, 

300 U.S. 500, 506 (1937) (“[T]he modification by 

implication of the settled construction of an earlier and 

different section is not favored.”). Indeed, “[w]e will not 

infer a statutory repeal unless the later statute expressly 

contradict[s] the original act or unless such a construction is 

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STATE OF CALIFORNIA V. AZAR 17

absolutely necessary . . . in order that [the] words [of the 

later statute] shall have any meaning at all.” Nat’l Ass’n of 

Home Builders, 551 U.S. at 662.

Plaintiffs admit that there is no irreconcilable conflict 

between § 1008 and either the appropriations rider or § 1554 

of the ACA. E.g., California State Opposition to Motion for 

Stay at p. 14; Essential Access Opposition to Motion for Stay 

at p.14. And we discern no “clear and manifest” intent by 

Congress to amend or repeal § 1008 via either of these 

laws—indeed, neither law even refers to § 1008. The 

appropriations rider mentions abortion only to prohibit 

appropriated funds from being expended for abortions; and 

§ 1554 of the ACA does not even mention abortion.

As neither statute impliedly amended or repealed § 1008, 

the question is therefore whether the Final Rule is 

nonetheless “not in accordance with law” because its 

provisions are incompatible with the appropriations rider or 

§ 1554 of the ACA. 5 U.S.C. § 706(2)(A). We think that 

HHS is likely to succeed on its challenge to the district 

courts’ preliminary injunctions because the Final Rule is not 

contrary to either provision.

The appropriations rider conditions HHS funding on a 

requirement that no Title X funds be expended on abortion, 

and that “all pregnancy counseling shall be nondirective.” 

Pub. L. No. 115-245, div. B, tit. II, 132 Stat 2981, 3070–71 

(2018). (The plain text of the rider actually seems to 

reinforce § 1008’s restrictions on funding abortion-related 

activities.)

The district courts held that the Final Rule’s counseling 

and referral requirements directly conflicted with the 

appropriations rider’s “nondirective” mandate. But its 

mandate is not that nondirective counseling be given in 

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18 STATE OF CALIFORNIA V. AZAR

every case. It is that such counseling as is given shall be 

nondirective. The Final Rule similarly does not require that 

any pregnancy counseling be given, only that if given, such 

counseling shall be nondirective (and may include neutrallypresented information about abortion). 84 Fed. Reg. 7716 

(“Under the [F]inal [R]ule, the Title X regulations no longer 

require pregnancy counseling, but permits the use of Title X 

funds in programs that provide pregnancy counseling, so 

long as it is nondirective.”). The Final Rule is therefore not 

in conflict with the appropriations rider’s nondirective 

pregnancy counseling mandate.

Although the Final Rule does require the provision of 

referrals to non-abortion providers, id. at 7788–90, such 

referrals do not constitute “pregnancy counseling.” First, 

providing a referral is not “counseling.” HHS has defined 

“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, 

whereas a “referral” involves linking a patient to another

provider who can give further counseling or treatment, id.

at 7748. The Final Rule treats referral and counseling as 

distinct terms, as has Congress and HHS under previous 

administrations. See, e.g., 42 U.S.C. § 300z-10; 53 Fed. 

Reg. at 2923; 2928–38 (1988); 65 Fed. Reg. 41272–75 

(2000). We therefore conclude that the Final Rule’s referral 

requirement is not contrary to the appropriations rider’s 

nondirective pregnancy counseling mandate.2

 2 But to the extent there is any ambiguity, “when reviewing an

agency’s statutory interpretation under the APA’s ‘not in accordance 

with law’ standard, . . . [we] adhere to the familiar two-step test of 

Chevron.” Nw. Envtl. Advocates v. U.S. E.P.A., 537 F.3d 1006, 1014 (9th 

Cir. 2008). Applying Chevron deference, we would conclude that 

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STATE OF CALIFORNIA V. AZAR 19

But even if referrals are included under the rubric of 

“pregnancy counseling,” it is not clear that referring a patient 

to a non-abortion doctor is necessarily “directive.” 

Nondirective counseling does not require equal treatment of 

all pregnancy options—rather, it just requires that a provider 

not affirmatively endorse one option over another. 84 Fed. 

Reg. at 7716. When Congress wants specific pregnancy 

options to be given equal treatment, it knows how to say so 

explicitly. For example, Congress has mandated that 

“adoption information and referrals” shall be provided “on 

an equal basis with all other courses of action included in 

nondirective counseling.” 42 U.S.C. § 254c-6(a)(1) 

(emphasis added). If “nondirective” already meant that all 

pregnancy options (including adoption) shall be given equal 

treatment, it would render meaningless Congress’s explicit 

instruction that adoption be treated on an equal basis with 

other pregnancy options. “[C]ourts avoid a reading that 

renders some words altogether redundant.” Scalia, Antonin, 

and Garner, Bryan A., Reading Law: The Interpretation of 

Legal Texts (2012) 176. Congress has enacted no such 

statutory provision explicitly requiring the equal treatment 

of abortion in pregnancy counseling and referrals.3

We next consider § 1554 of the ACA. As a threshold 

matter, it seems likely that any challenge to the Final Rule 

 HHS’s treatment of counseling and referral as distinct concepts is a 

reasonable interpretation of the applicable statutes.

3 But as discussed above, to the extent there is any ambiguity as to 

whether the appropriation rider’s nondirective mandate means that Title 

X grantees must be allowed to provide referrals to abortion providers on 

an equal basis with non-abortion providers, we would defer to HHS’s 

reasonable interpretation under Chevron that referral to non-abortion 

providers is consistent with the provision of nondirective pregnancy 

counseling.

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20 STATE OF CALIFORNIA V. AZAR

relying on § 1554 is waived because Plaintiffs concede that 

HHS was not put on notice of this specific challenge during 

the public comment period, such that HHS did not have an 

“opportunity to consider the issue.” Portland Gen. Elec. Co. 

v. Bonneville Power Admin., 501 F.3d 1009, 1024 (9th Cir. 

2007) (“The waiver rule protects the agency’s prerogative to 

apply its expertise, to correct its own errors, and to create a 

record for our review.”). Although some commenters stated 

that the proposed Final Rule was contrary to the ACA 

generally, and still others used generic language similar to 

that contained in § 1554, preservation of a challenge requires 

that the “specific argument” must “be raised before the 

agency, not merely the same general legal issue.” Koretoff 

v. Vilsack, 707 F.3d 394, 398 (D.C. Cir. 2013) (per curiam). 

Although “agencies are required to ensure that they have 

authority to issue a particular regulation,” they “have no 

obligation to anticipate every conceivable argument about 

why they might lack such statutory authority.” Id. at 398.

But even if this challenge were preserved, it seems likely 

that § 1554 does not affect § 1008’s prohibition on funding

programs where abortion is a method of family planning. 

Section 1554 prohibits “creat[ing] any unreasonable barriers 

to the ability of individuals to obtain appropriate medical 

care,” “imped[ing] timely access to health care services,” 

“interfer[ing] with communications regarding a full range of 

treatment options between the patient and the provider,” 

“restrict[ing] the ability of health care providers to provide 

full disclosure of all relevant information to patients making 

health care decisions,” “violat[ing] the principles of 

informed consent and the ethical standards of health care 

professionals,” and “limit[ing] the availability of health care 

treatment for the full duration of a patient’s medical needs.” 

42 U.S.C. § 18114. But as the Supreme Court noted in Rust, 

there is a clear distinction between affirmatively impeding 

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STATE OF CALIFORNIA V. AZAR 21

or interfering with something, and refusing to subsidize it. 

Rust, 500 U.S. at 200–01. In holding that the 1988 

regulations did not violate the Fifth Amendment, the 

Supreme Court reasoned that “[t]he Government has no 

constitutional duty to subsidize an activity merely because 

the activity is constitutionally protected,” and that the 

Government “may validly choose to fund childbirth over 

abortion and implement that judgment by the allocation of 

public funds for medical services relating to childbirth but 

not to those relating to abortion.” Id. at 201. The 

Government’s “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. (internal quotations and citations 

omitted). Indeed, the Supreme Court has recognized that 

“[t]he difficulty that a woman encounters when a Title X 

project does not provide abortion counseling or referral 

leaves her in no different position than she would have been 

if the Government had not enacted Title X.” Id. at 202. 

Rust’s reasoning is equally applicable to counter the district 

courts’ conclusions that the Final Rule is invalidated by 

§ 1554. Title X is a limited grant program focused on 

providing pre-pregnancy family planning services—it does 

not fund medical care for pregnant women. The Final Rule 

can reasonably be viewed as a choice to subsidize certain 

medical services and not others.4

 4 The preamble to § 1554 also suggests that this section was not 

intended to restrict HHS interpretations of provisions outside the ACA. 

If Congress intended § 1554 to have sweeping effects on all HHS 

regulations, even those unrelated to the ACA, it would have stated that 

§ 1554 applies “notwithstanding any other provision of law,” rather than 

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22 STATE OF CALIFORNIA V. AZAR

III.

The district courts also held that the Final Rule likely 

violates the Administrative Procedure Act (APA)’s 

prohibition on “arbitrary and capricious” regulations. 

5 U.S.C. § 706(2)(A). “‘Arbitrary and capricious’ review 

under the APA focuses on the reasonableness of an agency’s 

decision-making process.” CHW W. Bay v. Thompson, 

246 F. 3d 1218, 1223 (9th Cir. 2001) (emphasis in original). 

But “[t]he scope of review under the ‘arbitrary and 

capricious’ standard is narrow and a court is not to substitute 

its judgment for that of the agency.” Vehicle Mfrs. Ass’n of 

U.S., Inc. v. State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43 

(1983). We think that is precisely what the district courts 

did.

To find that the Final Rule’s enactment was arbitrary and 

capricious, the district courts generally ignored HHS’s 

explanations, reasoning, and predictions whenever they 

disagreed with the policy conclusions that flowed therefrom.

For example, with respect to the physical separation 

requirement, the district courts ignored HHS’s reasoning for 

its re-imposition of that requirement (which was approved 

by Rust): that physical separation would ensure that Title X 

funds are not used to subsidize abortions via co-location of 

Title X programs in abortion clinics. See 84 Fed. Reg. 

at 7763–68. HHS’s reasoning included citation to data 

suggesting “that abortions are increasingly performed at 

sites that focus primarily on contraceptive and family 

 

“[n]otwithstanding any other provision of this Act.” See, e.g., Andreiu v. 

Ashcroft, 253 F.3d 477, 482 (9th Cir. 2001) (holding that the phrase 

“notwithstanding any other provision of law” in 8 U.S.C. § 1252(f)(2) 

meant that the provision “trumps any contrary provision elsewhere in the 

law”).

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STATE OF CALIFORNIA V. AZAR 23

planning services—sites that could be recipients of Title X 

funds.” Id. at 7765. Similarly, the district courts ignored 

HHS’s primary reasoning for prohibiting abortion 

counseling and referrals: that such restrictions are required 

by HHS’s reasonable reading of § 1008 (again, approved by 

Rust). Id. at 7746–47. Further, the district courts ignored 

HHS’s consideration of the effects that the Final Rule would 

likely have on the number of Title X providers, and credited 

Plaintiffs’ speculation that the Final Rule would “decimate” 

the Title X provider network, rather than HHS’s 

prediction—based on evidence cited in the administrative 

record—“that honoring statutory protections of conscience 

in Title X may increase the number of providers in the 

program,” by attracting new providers who were previously 

deterred from participating in the program by the former 

requirement to provide abortion referrals. See id. at 7780. 

Such predictive judgments “are entitled to particularly 

deferential review.” Trout Unlimited v. Lohn, 559 F.3d 946, 

959 (9th Cir. 2009). With respect to the Final Rule’s 

definition of “advanced practice provider,” and its provision 

on whether family planning methods must be “medically 

approved,” HHS reasoned that these provisions would 

clarify subjects that had caused confusion in the past. 

84 Fed. Reg. at 7727–28, 32. Although the district courts 

insist that HHS failed to consider that the Final Rule requires 

providers to violate medical ethics, HHS did consider and 

respond to comments arguing just that. See id. at 7724, 

7748. HHS similarly considered the costs of compliance 

with the Final Rule. Id. at 7780.

In light of the narrow permissible scope of the district 

court’s review of HHS’s reasoning under the arbitrary and 

capricious standard, we conclude that HHS is likely to 

prevail on its argument that the district court erred in 

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24 STATE OF CALIFORNIA V. AZAR

concluding that the Final Rule’s enactment violated the 

APA.5

IV.

The remaining factors also favor a stay pending appeal. 

HHS and the public at large are likely to suffer irreparable 

harm in the absence of a stay, which are comparatively 

greater than the harms Plaintiffs are likely to suffer.

Absent a stay, HHS will be forced to allow taxpayer 

dollars to be spent in a manner that it has concluded violates 

the law, as well as the Government’s important policy 

interest (recognized by Congress in § 1008) in ensuring that 

taxpayer dollars do not go to fund or subsidize abortions. As 

the Supreme Court held in Rust, “the government may ‘make 

a value judgment favoring childbirth over abortion, and . . .

implement that judgment by the allocation of public funds,” 

and by “declining to ‘promote or encourage abortion.’” 

Rust, 500 U.S. at 193. Additionally, forcing HHS to wait 

until the conclusion of a potentially lengthy appeals process 

to implement the Final Rule will necessarily result in 

predictable administrative costs, and will beget significant 

uncertainty in the Title X program.

The harms that Plaintiffs would likely suffer if a stay is 

granted are comparatively minor. The main potential harms 

that Plaintiffs identify are based on their prediction that 

implementation of the Final Rule will cause an immediate 

 5 The district court in Washington also briefly stated that the Final 

Rule was likely invalid because it “violates the central purpose of Title 

X, which is to equalize access to comprehensive, evidence-based, and 

voluntary family planning.” Washington Preliminary Injunction Order 

at 15. But this conclusion is foreclosed by the existence of § 1008, and 

by the Supreme Court’s contrary finding in Rust.

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STATE OF CALIFORNIA V. AZAR 25

and steep decline in the number of Title X providers. But 

these potential harms obviously rely on crediting Plaintiffs’ 

predictions about the effect of implementing the Final Rule, 

over HHS’s predictions that implementation of the final rule 

will have the opposite effect. As described above, we think 

that HHS’s predictions—supported by reasoning and 

evidence in the record (84 Fed. Reg. at 7780)—is entitled to 

more deference than Plaintiffs’ contrary predictions. While 

some Title X grantees will certainly incur financial costs 

associated with complying with the Final Rule if the 

preliminary injunctions are stayed, we think that harm is 

minor relative to the harms to the Government described 

above.

V.

Because HHS and the public interest would be 

irreparably harmed absent a stay, harms to Plaintiffs from a 

stay will be comparatively minor, and HHS is likely to 

prevail in its challenge of the preliminary injunction orders 

before a merits panel of this court (which is set to hear the 

cases on an expedited basis), we conclude that a stay of the 

district courts’ preliminary injunction orders pending appeal 

is proper.

The motion for a stay pending appeal is GRANTED.

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