Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-16-55249/USCOURTS-ca9-16-55249-0/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 

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FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

NATIONAL INSTITUTE OF FAMILY

AND LIFE ADVOCATES, a Virginia

corporation, DBA NIFLA;

PREGNANCY CARE CENTER, a

California corporation, DBA

Pregnancy Care Clinic; FALLBROOK

PREGNANCY RESOURCE CENTER, a

California corporation,

Plaintiffs-Appellants,

v.

KAMALA HARRIS, in her official

capacity as Attorney General for the

State of California; THOMAS

MONTGOMERY, in his official

capacity as County Counsel for San

Diego County; MORGAN FOLEY, in

his official capacity as City Attorney

for the City of El Cajon, CA;

EDMUND G. BROWN, JR., in his

official capacity as Governor of the

State of California,

Defendants-Appellees.

No. 16-55249

D.C. No.

3:15-cv-02277-

JAH-DHB

OPINION

Appeal from the United States District Court

for the Southern District of California

John A. Houston, District Judge, Presiding

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2 NIFLA V. HARRIS

Argued and Submitted June 14, 2016

San Francisco, California

Filed October 14, 2016

Before: Dorothy W. Nelson, A. Wallace Tashima,

and John B. Owens, Circuit Judges.

Opinion by Judge D.W. Nelson

SUMMARY*

Civil Rights

The panel affirmed the district court’s denial of a motion

for a preliminary injunction sought by three religiouslyaffiliated non-profit corporations to prevent the enforcement

of the California Reproductive Freedom, Accountability,

Comprehensive Care, and Transparency Act.

The Act requires that licensed pregnancy-related clinics

disseminate a notice stating the existence of publicly-funded

family-planning services, including contraception and

abortion. The Act also requires that unlicensed clinics

disseminate a notice stating that they are not licensed by the

State of California. Appellants alleged that the Act violates

their fundamental rights, including their First Amendment

guarantees to free speech and the free exercise of religion. 

* 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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NIFLA V. HARRIS 3

As a threshold matter, the panel held that appellants’

claims were constitutionally and prudentially ripe. 

Addressing the free speech claim, the panel concluded that

the proper level of scrutiny to apply to the Act’s regulation of

licensed clinics was intermediate scrutiny, which the Act

survived. With respect to unlicensed clinics, the panel

concluded that the Act survived any level of scrutiny. 

The panel also rejected appellants’ arguments that they

were entitled to a preliminary injunction based on their free

exercise claims. The panel held that the Act is a neutral law

of general applicability, which survived rational basis review. 

The panel concluded that appellants were unable to

demonstrate a likelihood of success on the merits of their

First Amendment claims. 

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4 NIFLA V. HARRIS

COUNSEL

Matthew Bowman (argued) and David A. Cortman, Alliance

Defending Freedom, Washington, D.C.; Dean R. Broyles,

National Center for Law and Policy, Escondido, California;

Kristen K. Waggoner, Kevin H. Theriot, and Elissa M.

Graves, Alliance Defending Freedom, Scottsdale, Arizona;

Anne O’Connor, National Institute of Family and Life

Advocates, Fredericksburg, Virginia; for PlaintiffsAppellants.

Jonathan M. Eisenberg (argued), Office of the Attorney

General, Los Angeles, California, for Defendants-Appellees

Kamala Harris and Edmund G. Brown, Jr.

Thomas D. Bunton (argued), Senior Deputy; Thomas E.

Montgomery, County Counsel; Office of County Counsel,

San Diego, California; for Defendant-Appellee Thomas

Montgomery.

Carrie L. Mitchell, McDougal Love Eckis Boehmer & Foley,

La Mesa, California, for Defendant-Appellee Morgan Foley.

Deborah J. Dewart, Swansboro, North Carolina; James L.

Hirsen, Anaheim Hills, California; for Amicus Curiae Justice

and Freedom Fund.

Kristen Law Sagafi and Martin D. Quiñones, Tycko &

Zavareei LLP, Oakland, California, for Amicus Curiae

Physicians for Reproductive Health.

Priscilla Joyce Smith, Brooklyn, New York, for Amicus

Curiae Information Society Project at Yale Law School.

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NIFLA V. HARRIS 5

OPINION

D.W. NELSON, Circuit Judge:

The National Institute of Family and Life Advocates, et

al. appeal from the district court’s denial of their motion for

a preliminary injunction to prevent the enforcement of the

California Reproductive Freedom, Accountability,

Comprehensive Care, and Transparency Act (the FACT Act

or the Act). The Act requires that licensed pregnancy-related

clinics disseminate a notice stating the existence of publiclyfunded family-planning services, including contraception and

abortion. The Act also requires that unlicensed clinics

disseminate a notice stating that they are not licensed by the

State of California. Appellants allege that the Act violates

their fundamental rights, including their First Amendment

guarantees to free speech and the free exercise of religion.

We affirm the district court’s denial of Appellants’

motion for a preliminary injunction. For the free speech

claim, we conclude that the proper level of scrutiny to apply

to the Act’s regulation of licensed clinics is intermediate

scrutiny, which it survives. With respect to unlicensed

clinics, we conclude that the Act survives any level of

scrutiny. For the free exercise claim, we conclude that the

Act is a neutral law of general applicability, and that it

survives rational basis review. Appellants, therefore, are

unable to show the “most important” factor under Winter v.

Natural Resources Defense Council, Inc., 555 U.S. 7, 20

(2008): likelihood of success on the merits. Garcia v.

Google, Inc., 786 F.3d 733, 740 (9th Cir. 2015) (en banc).

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6 NIFLA V. HARRIS

BACKGROUND

I. The FACT Act

The FACT Act was created for the stated purpose of

ensuring that “[a]ll California women, regardless of income,

. . . have access to reproductive health services.” Assem. Bill

No. 775 § 1(a). It was enacted after the California

Legislature found that a great number of California women

were unaware of the existence of state-sponsored healthcare

programs. See id. at § 1 (a)–(c). These programs, which

expanded under the Patient Protection and Affordable Care

Act to include millions of California women, provide “lowincome women . . . immediate access to free or low-cost

comprehensive family planning services and pregnancyrelated care.” Id. at § 1(c); see also Assem. Comm. on

Health, Analysis of Assembly Bill No. 775. Specifically, the

Legislature found that:

Millions of California women are in need of

publicly funded family planning services,

contraception services and education, abortion

services, and prenatal care and delivery. In

2012, more than 2.6 millionCalifornia women

were in need of publicly funded family

planning services. More than 700,000

California women become pregnant every

year and one-half of these pregnancies are

unintended. In 2010, 64.3 percent of

unplanned births in California were publicly

funded. Yet, at the moment they learn that

they are pregnant, thousands of women

remain unaware of the public programs

available to provide them with contraception,

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NIFLA V. HARRIS 7

health education and counseling, family

planning, prenatal care, abortion, or delivery.

Id. at § 1(b).

The Legislature also found that the ability of California

women to receive accurate information about their

reproductive rights, and to exercise those rights, is hindered

by the existence of crisis pregnancy centers (CPCs). CPCs

“pose as full-service women’s health clinics, but aim to

discourage and prevent women from seeking abortions” in

order to fulfill their goal of “interfer[ing] with women’s

ability to be fully informed and exercise their reproductive

rights.” Assem. Comm. on Health, Analysis of Assembly

Bill No. 775 at 3. The Legislature found that CPCs, which

include unlicensed and licensed clinics, employ“intentionally

deceptive advertising and counseling practices [that] often

confuse, misinform, and even intimidatewomen from making

fully-informed, time-sensitive decisions about critical health

care.” Id. There are approximately 200 CPCs in California. 

Id.

Because “pregnancydecisions are time sensitive, and care

early in pregnancy is important,” the Legislature found that

the most effective way to ensure that women are able to

receive access to family planning services, and accurate

information about such services, was to require licensed

pregnancy-related clinics unable to enroll patients in statesponsored programs to state the existence of these services. 

Assem. Bill No. 775 § 1(c)–(d).

Thus, as required under the Act, all licensed covered

facilities must disseminate a notice (the Licensed Notice)

stating, “California has public programs that provide

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8 NIFLA V. HARRIS

immediate free or low-cost access to comprehensive family

planning services (including all FDA-approved methods of

contraception), prenatal care, and abortion for eligible

women. To determine whether you qualify, contact the

county social services office at [insert the telephone

number].” Cal. Health & Safety Code § 123472(a)(1). The

Act defines a licensed covered facility as “a facility licensed

under Section 1204 or an intermittent clinic operating under

a primary care clinic pursuant to subdivision (h) of Section

1206, whose primary purpose is providing family planning or

pregnancy-related services,” and that also satisfies two or

more of the following criteria:

(1) The facility offers obstetric ultrasounds,

obstetric sonograms, or prenatal care to

pregnant women. (2) The facility provides, or

offers counseling about, contraception or

contraceptive methods. (3) The facility offers

pregnancy testing or pregnancy diagnosis.

(4) The facility advertises or solicits patrons

with offers to provide prenatal sonography,

pregnancy tests, or pregnancy options

counseling. (5) The facility offers abortion

services. (6) The facility has staff or

volunteers who collect health information

from clients.

Id. § 123471. The Act requires that the Licensed Notice be

disclosed by licensed facilities in one of three possible

manners:

(A) A public notice posted in a conspicuous

place where individuals wait that may be

easily read by those seeking services from the

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NIFLA V. HARRIS 9

facility. The notice shall be at least 8.5 inches

by 11 inches and written in no less than 22-

point type. (B) A printed notice distributed to

all clients in no less than 14-point type. (C) A

digital notice distributed to all clients that can

be read at the time of check-in or arrival, in

the same point type as other digital

disclosures.

Id. § 123472(a)(2).

The Act also covers unlicensed facilities. An unlicensed

clinic is “a facility that is not licensed by the State of

California and does not have a licensed medical provider on

staff or under contract who provides or directly supervises the

provision of all of the services, whose primary purpose is

providing pregnancy-related services” and that also satisfies

two of the following criteria:

(1) The facility offers obstetric

ultrasounds, obstetric sonograms, or prenatal

care to pregnant women. (2) The facility

offers pregnancy testing or pregnancy

diagnosis. (3) The facility advertises or

solicits patrons with offers to provide prenatal

sonography, pregnancy tests, or pregnancy

options counseling. (4) The facility has staff

or volunteers who collect health information

from clients.

Id. § 123471(b). Unlicensed clinics must disseminate a

notice (the Unlicensed Notice) stating, “This facility is not

licensed as a medical facility by the State of California and

has no licensed medical provider who provides or directly

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10 NIFLA V. HARRIS

supervises the provision of services.” Id. § 123472(b)(1). 

The Unlicensed Notice must be “disseminate[d] to clients on

site and in any print and digital advertising materials

including Internet Web sites.” Id. § 123472(b). Information

in advertising material must be “clear and conspicuous,” and

the onsite notice must be “at least 8.5 inches by 11 inches and

written in no less than 48-point type, and . . . posted

conspicuously in the entrance of the facility and at least one

additional area where clients wait to receive services.” Id.

§ 123472(b)(2)–(3).

All violators of the Act “are liable for a civil penalty of

five hundred dollars . . . for a first offense and one thousand

dollars . . . for each subsequent offense.” Id. § 123473(a).

II. Procedural History

Appellants are three religiously-affiliated non-profit

corporations.1 The National Institute of Family and Life

Advocates (NIFLA) is a national organization composed of

numerous pregnancy centers, 111 of which are located in

California. Seventy-three of the centers are licensed by the

State of California, and thirty-eight provide non-medical

services. Pregnancy Care Clinic is a licensed clinic that

provides medical services such as ultrasounds, medical

referrals, and education on family planning. Its staff includes

two doctors of obstetrics and gynecology, one radiologist, one

anesthesiologist, one certified midwife, one nurse

practitioner, ten nurses, and two registered diagnostic medical

1

In addition to this appeal, this panel also heard argument in related

cases A Woman’s Friend Pregnancy Resource Clinic v. Harris, No. 15-

17517, __ F. App’x __ (9th Cir. 2016), and Livingwell Medical Clinic,

Inc. v. Harris, No. 15-17497, __ F. App’x __ (9th Cir. 2016).

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NIFLA V. HARRIS 11

sonographers. Fallbrook Pregnancy Center is an unlicensed

clinic. It offers services such as free pregnancy tests that

patients can take themselves, educational programs, and

medical referrals. Fallbrook employs several nurses at its

facility, and also contracts with a licensed medical provider

for referrals for ultrasounds, which are provided in a separate

mobile facility nearby. Prenatal sonographs are also offered

by a contractor in a separate facility nearby.

Appellants are strongly opposed to abortion. None

provide abortions or referrals for abortions. NIFLA’s mission

is to “empower the choice for life,” and Pregnancy Care

Clinic “provides its services to women in unplanned

pregnancies pursuant to its pro-life viewpoint, desiring to

empower the women it serves to choose life for their child,

rather than abortion.” Fallbrook believes “that human life is

a gift of God that should not be destroyed by abortion.”

On October 13, 2015, Appellants brought suit against

California Attorney General Kamala Harris (the AG),

California Governor Edmund G. Brown, Jr., County Counsel

for San Diego County Thomas Montgomery, and City

Attorney of El Cajon Morgan Foley2in the Southern District

of California. Appellants alleged that the FACT Act violates

their First Amendment free speech and free exercise rights.3

2 The district court’s finding that the City Attorney of El Cajon is not

a proper defendant was harmless error. The Act grants the City Attorney

the power to enforce the Act. See Cal. Health & Safety Code § 123473. 

The City Attorney, therefore, is a proper defendant.

3 Appellants’ claims for relief are (1) Violation of the free speech

clause of the First Amendment of the United States Constitution;

(2) Violation of the due process clause of the Fourteenth Amendment of

the United States Constitution (alleged by unlicensed clinics);

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12 NIFLA V. HARRIS

Appellants brought a motion for a preliminary injunction to

enjoin enforcement of the Act prior to the full litigation of the

action.

The district court denied Appellants’ motion for a

preliminary injunction. The court found that Appellants were

unable to show a likelihood of success on their free speech

claim. With respect to the Licensed Notice, the court held

that the Act either regulated professional conduct subject to

rational basis review, or professional speech subject to

intermediate scrutiny, and the Act survived both levels of

review. The court also held that the Act did not constitute

viewpoint discrimination. With respect to the Unlicensed

Notice, the court held that it withstood any level of scrutiny. 

In addition, Appellants could not show a likelihood of success

on the merits of their free exercise claim because, the court

held, the Act is a neutral law of general applicability which

survived rational basis review. The court then explained that

even though Appellants raised “serious questions going to the

merits,” All. for the Wild Rockies v. Cottrell, 632 F.3d 1127,

1134–35 (9th Cir. 2011), they could not demonstrate that the

other Winter factors weighed in favor of granting a

preliminary injunction.

(3) Violation of the free exercise clause of the First Amendment of the

United States Constitution; (4) Violation ofthe Coats-Snowe Amendment,

42 U.S.C. § 238N (alleged by licensed clinics); and (5) Violation of the

free speech clause of the California Constitution. Because Appellants

brought their motion for preliminary injunction only under their federal

First Amendment claims, we address only those issues in this opinion.

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NIFLA V. HARRIS 13

STANDARD OF REVIEW

We review the grant or denial of a preliminary injunction

for an abuse of discretion. Sw. Voter Registration Educ.

Project v. Shelley, 344 F.3d 914, 918 (9th Cir. 2003) (en

banc) (per curiam). We review the district court’s

interpretation of underlying law de novo. Id.

ANALYSIS

I. Appellants’ Claims are Justiciable.

As a threshold matter, we must first decide whether

Appellants’ claims are justiciable. The County Counsel of

San Diego argues that this action is not constitutionally ripe,

and even if it were ripe, that we should decline to find

jurisdiction for prudential reasons.

We reject these arguments.

A. Appellants’ Claims are Constitutionally Ripe.

“[T]he Constitution mandates that prior to our exercise of

jurisdiction there exist a constitutional ‘case or controversy,’

that the issues presented are ‘definite and concrete, not

hypothetical or abstract.’” Thomas v. Anchorage Equal

Rights Comm’n, 220 F.3d 1134, 1139 (9th Cir. 1999) (en

banc) (quoting Ry. Mail Ass’n v. Corsi, 326 U.S 88, 93

(1945)). A plaintiff must face “a realistic danger of

sustaining a direct injury as a result of the statute’s operation

or enforcement,” not an “alleged injury [that] is too

imaginary or speculative to support jurisdiction.” Id.

(internal quotation marks and citation omitted). This Court

has identified three factors to assess in deciding whether a

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14 NIFLA V. HARRIS

case is constitutionally ripe: (1) whether plaintiffs have

articulated a concrete plan to violate the statute in question;

(2) whether the prosecuting authorities have communicated

a specific warning or threat to initiate proceedings; and

(3) the history of past prosecution or enforcement of the

challenged statute. Id.

These factors allowfor plaintiffs to bring pre-enforcement

challenges to laws that they claim infringe their fundamental

rights. See id. at 1137 n.1. Indeed, we have long recognized

that “[o]ne does not have to await the consummation of

threatened injury to obtain preventive relief . . . .

[p]articularly in the First Amendment-protected speech

context[.]” Cal. Pro-Life Council, Inc. v. Getman, 328 F.3d

1088, 1094 (9th Cir. 2003) (citation omitted); see also

Virginia v. Am. Booksellers Ass’n, Inc., 484 U.S. 383, 393

(1988).

Appellants’ claims are constitutionally ripe. Before the

district court and this Court, Appellants have explicitly stated

that they will not comply with the Act, even if enforced. 

Appellants have made this pledge of disobedience although

they are aware that violators of the Act are subject to civil

penalties. Cal. Health & Safety Code § 123473(a). The AG,

moreover, has not stated that she will not enforce the Act. 

See Am. Booksellers Ass’n, 484 U.S. at 393 (“The State has

not suggested that the newly enacted law will not be

enforced, and we see no reason to assume otherwise. We

conclude that plaintiffs have alleged an actual and wellfounded fear that the law will be enforced against them.”). A

lack of enforcement history is not a compelling reason to find

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NIFLA V. HARRIS 15

Appellants’ claims unripe in this context.4 The Act did not go

into effect until January 1, 2016, approximately one month

before the district court denied the motion for a preliminary

injunction. Appellants, therefore, could not have

demonstrated a significant history of enforcement. See

Wolfon v. Brammer, 616 F.3d 1045, 1060 (9th Cir. 2010)

(affording the factor of past prosecution “little weight” when

the challenged law was new); LSO Ltd. v. Stroh, 205 F.3d

1146, 1155 (9th Cir. 2000) (“[E]nforcement history alone is

not dispositive. Courts have found standing where no one

had ever been prosecuted under the challenged provision.”).

B. Appellants’ Claims are Prudentially Ripe.

Even if a case is constitutionally ripe, we have

discretionary power to decline to exercise jurisdiction. 

Thomas, 220 F.3d at 1142. When assessing prudential

ripeness, we consider: (1) the fitness of the issues for judicial

decision and; (2) hardship to the parties if we were to

withhold jurisdiction. Id. at 1141.

4 Moreover, we note that NIFLA filed a 28(j) letter informing the

Court that, on August 16, 2016, Los Angeles City Attorney Michael Feuer

sent an enforcement letter to co-counsel for NIFLA. In the letter, the City

Attorney provided notice that The People of the State of California

planned to make an ex parte application for an order to show cause why

a preliminary injunction should not issue and a temporary restraining order

enjoining the Pregnancy Counseling Center, a member of NIFLA, from

violating the FACT Act. The City indicated it also would file a complaint

containing a single cause of action—violation of California Business &

Professions Code § 17200, et seq.—and seeking equitable relief and civil

penalties. NIFLA states this chilled the speech of the Pregnancy

Counseling Center.

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16 NIFLA V. HARRIS

This Court has stated that “[a] claim is fit for decision if

the issues raised are primarily legal, do not require further

factual development, and the challenged action is final.” 

Wolfson, 616 F.3d at 1060 (quoting U.S. W. Commc’ns v.

MFS Intelenet, Inc., 193 F.3d 1112, 1118 (9th Cir. 1999)). 

When evaluating hardship “[w]e consider whether the

‘regulation requires an immediate and significant change in

plaintiffs’ conduct of their affairs with serious penalties

attached to noncompliance.’” Stormans, Inc. v. Selecky,

586 F.3d 1109, 1126 (9th Cir. 2009) (quoting Ass’n of Am.

Med. Colls. v. United States, 217 F.3d 770, 783 (9th Cir.

2000)). “[A] litigant must show that withholding review

would result in direct and immediate hardship and would

entail more than possible financial loss.” Id. (quoting MFS

Intelenet, Inc., 193 F.3d at 1118).

We conclude that both factors favor a finding of

prudential ripeness.

This action turns on a question of law. Appellants seek to

enjoin the enforcement of the Act on the grounds that it is

unconstitutional. We require no further factual development

to address Appellants’ challenge. The district court’s order

denying the motion for a preliminary injunction was also an

appealable order. 28 U.S.C. § 1292(a)(1).

We also conclude that the parties would face immediate

and significant hardships if we were to decline to exercise

jurisdiction. Until we issue a decision, Appellants must

routinely choose between holding fast to their firmly held

beliefs about abortion, or complying with the Act. And

although the San Diego County Counsel claims that he will

suffer hardship if he is forced to defend the Act, we find more

significant the definite and direct hardship that all parties will

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NIFLA V. HARRIS 17

suffer if we were to decline to find jurisdiction. As noted,

without a decision, Appellants must continually choose

between obeying the law or following their strongly held

convictions about abortion, and the AG will have to choose

whether or not to enforce a law without the benefit of a ruling

on its constitutionality.

We therefore conclude that this action is justiciable and

turn to the merits of the case.

II. The District Court Did Not Abuse Its Discretion in

Denying the Preliminary Injunction.

When bringing a motion for a preliminary injunction, a

plaintiff must demonstrate: (1) that he is likely to succeed on

the merits of his claim; (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, 555 U.S. at 20. A

preliminary injunction can also be issued if “a plaintiff

demonstrates . . . that serious questions going to the merits

were raised and the balance of hardships tips sharply in the

plaintiff’s favor,” as well as satisfaction of the other Winter

factors. All. for the Wild Rockies, 632 F.3d at 1134–35

(citation omitted).

A. Appellants Cannot Demonstrate a Likelihood of

Success on their First Amendment Free Speech

Claims.

Appellants argue that the Act should be subject to strict

scrutiny for two main reasons. First, they argue that because

the Act compels content-based speech, strict scrutiny is

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18 NIFLA V. HARRIS

appropriate. Second, they contend that the Act engages in

viewpoint discrimination.

We disagree. Although the Act is a content-based

regulation, it does not discriminate based on viewpoint. The

fact that the Act regulates content, moreover, does not compel

us to apply strict scrutiny. And because we agree with the

Fourth Circuit that the Supreme Court’s decision in Planned

Parenthood of Se. Pa. v. Casey, 505 U.S. 833 (1992), did not

announce a rule regarding the level of scrutiny to apply in

abortion-related disclosure cases, we apply our precedent in

Pickup v. Brown, 740 F.3d 1208 (9th Cir. 2013), and rule that

the Licensed Notice regulates professional speech, subject to

intermediate scrutiny.

5 The Licensed Notice survives

intermediate scrutiny. We also conclude that the Unlicensed

Notice survives any level of scrutiny. Thus, the district court

did not err in finding that Appellants cannot show a

likelihood of success on the merits of their free speech

claims.

1. Strict Scrutiny is Inappropriate.

A regulation discriminates based on content when “on its

face,” the regulation “draws distinctions based on the

message a speaker conveys.” Reed v. Town of Gilbert, 135 S.

Ct. 2218, 2227 (2015). A regulation discriminates based on

viewpoint when it regulates speech “based on ‘the specific

5 We find unpersuasive Appellees’ argument that the Act regulates

commercial speech subject to rational basis review. See Zauderer v.

Office of Disciplinary Counsel of Supreme Court of Ohio, 471 U.S. 626,

651 (1985). Commercial speech “does no more than propose a

commercial transaction.” Coyote Pub., Inc. v. Miller, 598 F.3d 592, 604

(9th Cir. 2010) (citation omitted). The Act primarily regulates the speech

that occurs within the clinic, and thus is not commercial speech.

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NIFLA V. HARRIS 19

motivating ideology or the opinion or perspective of the

speaker.’” Id. at 2230 (quoting Rosenberger v. Rector &

Visitors of Univ. of Va., 515 U.S. 819, 829 (1995)). Thus,

viewpoint discrimination is a kind of content discrimination. 

Indeed, viewpoint discrimination is a “‘more blatant’ and

‘egregious form of content discrimination.’” Id. (quoting

Rosenberger, 515 U.S. at 829).

Because viewpoint discrimination is a subset of content

discrimination, a regulation can be content-based, but

viewpoint neutral. Such is the case with the Act.

On its face, the Act compels Appellants to disseminate the

Notices. See id. at 2228 (explaining that the “first step” in

assessing whether a law is content-based or content-neutral is

to “determine[ ] whether the law is content neutral on its

face”). The Act therefore requires Appellants engage in

speech on a particular subject matter. In so doing, the Act

“[m]andat[es] speech that a speaker would not otherwise

make” which “necessarily alters the content of the speech.” 

Riley v. Nat’l Fed’n of the Blind of N.C., Inc., 487 U.S. 781,

795 (1988). The Act, therefore, is a content-based

regulation.6

The Act, however, does not discriminate based on

viewpoint. It does not discriminate based on the particular

opinion, point of view, or ideology of a certain speaker. 

Instead, the Act applies to all licensed and unlicensed

facilities, regardless of what, if any, objections theymay have

to certain family-planning services. The Act contains two

6 We disagree with the district court’s conclusion that the Act is

content-neutral. This error, however, was harmless as it appropriately

denied the motion for a preliminary injunction.

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narrow exceptions that do not disfavor any particular

speakers. The first exemption is for clinics “directly

conducted, maintained, or operated by the United States or

any of its departments, officers, or agencies.” Cal. Health &

Safety Code § 123471(c)(1). This exemption was created in

order to avoid federal preemption. The Act’s second

exemption is for a clinic “enrolled as a Medi-Cal provider and

a provider in the Family Planning, Access, Care, and

Treatment Program.” Id. § 123472(c)(2). This exemption

was created because clinics that fall under § 123472(c)(2)

already provide all of the publicly-funded health services

outlined in the Licensed Notice.

Appellants argue that this case is similar to Sorrell v. IMS

Health Inc., 564 U.S. 552 (2011), in which the Supreme

Court held that a law restricting the sale and use of pharmacy

records discriminated based on viewpoint and was subject to

more rigorous judicial scrutiny. There, the Court looked to

the law’s legislative findings and concluded that the law’s 

“express purpose” was to burden specific speakers. Id. at

565. Appellants assert that because the California legislature

also had specific speakers in mind when enacting the Act,

that is, CPCs and clinics opposed to abortion, the Act engages

in viewpoint discrimination. Appellants emphasize,

moreover, that California has no evidence that their clinics

actually misinform women.

Sorrell, however, did not rely solely on legislative intent. 

The Court concluded that the law “on its face burden[ed]

disfavored speech by disfavored speakers,” allowing use of

the pharmacy records by all “but a narrow class of disfavored

speakers.” Id. at 564, 573. Thus, while “a statute’s stated

purpose may also be considered,” Sorrell did not turn

exclusively on the law’s motivation or purpose. Id. at 565. 

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Importantly, the law in Sorrell applied to the speakers that

were the targets of the law, while it exempted others. In

sharp contrast, as discussed, the Act applies to almost all

licensed and unlicensed speakers. Other than the two narrow

exceptions unrelated to viewpoint, the Act applies equally to

clinics that offer abortion and contraception as it does to

clinics that oppose those same services.

Appellants’ reliance on Conant v. Walters, 309 F.3d 629

(9th Cir. 2002), is also misplaced. In Conant, we affirmed an

injunction that prohibited the federal government from

possibly revoking a doctor’s license based on a federal policy

that “not merely prohibit[ed] the discussion of marijuana,”

but also “condemn[ed] expression of a particular viewpoint,

i.e., that medical marijuana would likely help a specific

patient.” Id. at 637.

Conant is distinguishable. Again, other than the two

exceptions, the Act applies to all clinics, regardless of their

stance on abortion or contraception. Next, unlike in Conant,

the Act does not favor or disfavor any particular viewpoint. 

Indeed, contrasting this case with the Fourth Circuit’s recent

decision in Stuart v. Camnitz, 774 F.3d 238 (4th Cir. 2014),

confirms that the Act does not engage in viewpoint

discrimination. In Stuart, the Fourth Circuit held that a

statute that required doctors to perform an ultrasound, display

the sonogram, and describe the fetus to women seeking

abortions violated the physicians’ First Amendment rights. 

774 F.3d at 255–56. In so doing, the Fourth Circuit

concluded that the law compelled speech that “convey[ed] a

particular opinion,” which was, “to convince women seeking

abortions to change their minds or reassess their decisions.” 

Id. at 246. Here, however, the Act does not convey any

opinion. The Licensed Notice and the Unlicensed Notice do

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not imply or suggest any preference regarding familyplanning services. Instead, the Licensed Notice merely states

the existence of publicly-funded family-planning services,

and the Unlicensed Notice only states that the particular clinic

in which it is distributed is not licensed.

We conclude that the Act is content-based, but does not

discriminate based on viewpoint.

i. Even Though the Act Engages in ContentBased Discrimination, Strict Scrutiny is

Inappropriate.

In arguing that content-based regulations are always

subject to strict scrutiny, Appellants cite the Supreme Court’s

recent decision in Reed. In Reed, the Supreme Court held

that a town’s regulation of the manner in which outdoor signs

were displayed was content-based and unable to satisfy strict

scrutiny. 135 S. Ct. at 2227, 2231. In reaching this

conclusion, the Court expressly stated that “[c]ontent-based

laws . . . are presumptively unconstitutional and may be

justified only if the government proves that they are narrowly

tailored to serve compelling state interests.” Id. at 2226.

Reed, however, does not require us to apply strict scrutiny

in this case. Since Reed, we have recognized that not all

content-based regulations merit strict scrutiny. See United

States v. Swisher, 811 F.3d 299, 311–13 (9th Cir. 2016) (en

banc) (discussing Reed and noting examples that illustrate

that “[e]ven if a challenged restriction is content-based, it is

not necessarily subject to strict scrutiny”).

Further, the Supreme Court has recognized a state’s right

to regulate physicians’ speech concerning abortion. In Casey,

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the Supreme Court considered Pennsyvania’s requirement

that a physician provide abortion-related information to his or

her patient, writing:

All that is left of petitioners’ argument is an

asserted First Amendment right of a physician

not to provide information about the risks of

abortion, and childbirth, in a manner

mandated by the State. To be sure, the

physician’s First Amendment rights not to

speak are implicated . . . but only as part of

the practice of medicine, subject to

reasonable licensing and regulation by t h e

State . . . We see no constitutional infirmity

in the requirement that the physician provide

the information mandated by the State here.

505 U.S. at 884 (citations omitted) (emphasis added). Over

a decade later, in Gonzales v. Carhart, the Court wrote that

“the State has a significant role to play in regulating the

medical profession.” 550 U.S. 124, 157 (2007).

In interpreting these cases, courts have not applied strict

scrutiny in abortion-related disclosure cases, even when the

regulation is content-based. See Stuart, 774 F.3d at 248–49

(applying intermediate scrutiny); Tex. Med. Providers

Performing Abortion Servs. v. Lakey, 667 F.3d 570, 576 (5th

Cir. 2012) (applying a reasonableness test); Planned

Parenthood Minn., N.D., S.D. v. Rounds, 530 F.3d 724,

734–35 (8th Cir. 2008) (applying a reasonableness test).

Thus, Appellants’ argument that the Act, a content-based

regulation, must be subject to strict scrutiny is unpersuasive. 

We have recognized that not all content-based regulations are

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subject to strict scrutiny, and courts have routinely applied a

lower level of scrutiny when states have compelled speech

concerning abortion-related disclosures.

ii. Casey Did Not Announce a Rule Regarding

the Level of Scrutiny to Apply to Abortionrelated Disclosure Cases.

Although courts are in agreement that strict scrutiny is

inappropriate in abortion-related disclosure cases, there is

currently a circuit split regarding the appropriate level of

scrutiny to apply. In interpreting Casey and Gonzales, and in

particular the above quoted excerpt from Casey, the Fifth and

Eighth Circuits have applied a “reasonableness” test when

determining whether an abortion-related disclosure law

violated physicians’ First Amendment rights. In Lakey, the

Fifth Circuit held that the appropriate level of scrutiny for

abortion-related disclosures was “the antithesis of strict

scrutiny,” upholding a law requiring doctors to show pregnant

women sonograms of their fetuses and make audible the

fetuses’ heartbeats. 667 F.3d at 575. The Lakey court

interpreted Casey and Gonzales to mean that such laws were

permissible as they “are part of the state’s reasonable

regulation of medical practice.” Id. at 576. Similarly, in

construing Casey and Gonzales, the Eighth Circuit upheld a

law regulating informed consent to abortion, concluding that

a state “can use its regulatory authority to require a physician

to provide truthful, non-misleading information” to patients

in the context of abortion-related disclosures. Rounds,

530 F.3d at 734–35.

TheFourth Circuit, however, disagreed that Casey created

an entirely new standard to apply in abortion-related

disclosure cases. In Stuart, the Fourth Circuit concluded that

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“[t]he single paragraph in Casey does not assert that

physicians forfeit their First Amendment rights in the

procedures surrounding abortions, nor does it announce the

proper level of scrutiny to be applied to abortion regulations

that compel speech[.]” 774 F.3d at 249. The court also noted

that Gonzales did not shed light on the First Amendment

standard post-Casey, since Gonzales was not a First

Amendment case. Id. Thus, the court assessed a law

requiring doctors to perform an ultrasound, sonogram, and

describe the fetus to pregnant patients under a professional

speech framework. Id. at 247–48, 252, 256. The court

concluded that intermediate scrutiny was the appropriate

standard and that the law failed this level of scrutiny. Id. 

Applying intermediate scrutiny, the court explained, was

“consistent with Supreme Court precedent and appropriately

recognizes the intersection . . . of regulation of speech and

regulation of the medical profession in the context of an

abortion procedure.” Id. at 249.

We agree with the Fourth Circuit that Casey did not

establish a level of scrutiny to apply in abortion-related

disclosure cases. Casey’s short discussion of a physician’s

First Amendment rights in the context of abortion means only

what it says—that there was no violation of the physicians’

First Amendment rights given the particular facts of Casey. 

See 505 U.S. at 884 (“We see no constitutional infirmity in

the requirement that the physician provide the information

mandated by the State here.” (emphasis added)). We need

not “read too much,” Stuart, 774 F.3d at 249, into Casey’s

statement that physicians are “subject to reasonable licensing

and regulation by the State.” 505 U.S. at 884. Casey did not

announce an entirely new rule with this limited statement. 

See Stuart, 774 F.3d at 249 (“That particularized finding [in

Casey] hardly announces a guiding standard of scrutiny for

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use in every subsequent compelled speech case involving

abortion.”). Nor did it render inapplicable other frameworks

for assessing free speech claims when the speech at issue

concerns abortion. Instead, what Casey did was merely

confirm what we have always known, which is that

professionals are subject to reasonable licensing by the state. 

See, e.g., Dent v. West Virginia, 129 U.S. 114, 122 (1889)

(examining a law regulating the medical profession and

writing that “[t]he power of the state to provide for the

general welfare of its people authorizes it to prescribe all such

regulations as in its judgment will secure or tend to secure

them against the consequences of ignorance and incapacity,

as well as of deception and fraud”).

We also agree with the Fourth Circuit that Gonzales did

not clearly speak to the level of scrutiny to apply to

physician’s First Amendment rights. See Stuart, 774 F.3d at

249 (“The fact that a regulation does not impose an undue

burden on a woman under the due process clause does not

answer the question of whether it imposes an impermissible

burden on the physician under the First Amendment.”).

We rule that strict scrutiny is inappropriate, and that

Casey did not announce a level of scrutiny to apply in

abortion-related disclosure cases.

2. The Licensed Notice Is Professional Speech

Subject to Intermediate Scrutiny.

In Pickup, we assessed the level of scrutiny to apply to

Senate Bill 1172, a California law that banned mental health

therapists from conducting on minor patients anypractice that

purported to change a patient’s sexual orientation. 740 F.3d

at 1221. We explained that the level of protection to apply to

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specific instances of professional speech or conduct is best

understood as along a continuum. At one end is a

professional’s right to engage in a “public dialogue, [where]

First Amendment protection is at its greatest.” Id. at 1227. 

There, “[professionals] are constitutionally equivalent to

soapbox orators and pamphleteers, and their speech receives

robust protection[.]” Id. at 1227–28. On the other end lies

professional conduct, where the speech at issue is, for

example, a form of treatment. Id. at 1229. When regulating

conduct, “the state’s power is great, even though such

regulation may have an incidental effect on speech.” Id.

Because the law in Pickup involved the regulation of a

specific type of therapy, we held that it regulated professional

conduct subject to rational basis review. Id. at 1231.

Pickup also delineated professional speech that falls in the

middle of the continuum. At the midpoint, “the First

Amendment tolerates a substantial amount of speech

regulation within the professional-client relationship that it

would not tolerate outside of it” because “[w]hen

professionals, by means of their state-issued licenses, form

relationships with clients, the purpose of those relationships

is to advance the welfare of the clients, rather than to

contribute to public debate.” Id. at 1228. Pickup, however,

never discussed the level of scrutiny appropriate for speech

that fell at the midpoint.

We conclude that the Licensed Notice regulates speech

that falls at the midpoint of the Pickup continuum, and that

intermediate scrutiny should apply.

To begin, the Licensed Notice regulates professional

speech. Underlying the Pickup opinion is the principle that

professional speech is speech that occurs between

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professionals and their clients in the context of their

professional relationship. In other words, speech can be

appropriately characterized as professional when it occurs

within the confines of a professional’s practice. See King v.

Governor of N.J., 767 F.3d 216, 232 (3d Cir. 2014) (“[W]e

conclude that a licensed professional does not enjoy the full

protection of the First Amendment when speaking as part of

the practice of her profession.” (emphasis added)). The idea

that the speech that occurs between a professional and a client

is distinct from other types of speech stems from the belief

that professionals, “through their education and training, have

access to a corpus of specialized knowledge that their clients

usually do not” and that clients put “their health or their

livelihood in the hands of those who utilize knowledge and

methods with which [they] ordinarily have little or no

familiarity.” Id.; see also Lowe v. SEC, 472 U.S. 181, 232

(1985) (White, J., concurring) (“One who takes the affairs of

a client personally in hand and purports to exercise judgment

on behalf of the client in the light of the client’s individual

needs and circumstances is properly viewed as engaging in

the practice of a profession.”). This is why states have the

power to regulate professions, see, e.g., Barsky v. Bd. of

Regents of Univ. of N.Y., 347 U.S. 442, 449 (1954) (“The

state’s discretion . . . extends naturally to the regulation of all

professions concerned with health.”), as well as the power to

regulate the speech that occurs within the practice of the

profession.

Licensed clinics engage in speech that occurs squarely

within the confines of their professional practice. For

example, Pregnancy Care Clinic provides medical services

such as ultrasounds, clinical services such as medical

referrals, and non-medical services such as peer counseling

and education. Thus, a regular client of Pregnancy Care

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NIFLA V. HARRIS 29

could easily use many of their services throughout the stages

of her pregnancy, such as receiving educational information

about best health practices when pregnant, relying upon

Pregnancy Care for regular check-ups, or using Pregnancy

Care as a resource for counseling. In all these instances, the

client and Pregnancy Care engage in speech that is part of

Pregnancy Care’s professional practice of offering familyplanning services. There is no question that Pregnancy

Care’s clients go to the clinic precisely because of the

professional services it offers, and that they reasonably rely

upon the clinic for its knowledge and skill. Because licensed

clinics offer medical and clinical services in a professional

context, the speech within their walls related to their

professional services is professional speech.

The professional nature of their speech does not change

even if Appellants decide to have staff members disseminate

the Licensed Notice in the clinics’ waiting rooms, instead of

by doctors or nurses in the examining room. Here, the

professional nature of the licensed clinics’ relationship with

their clients extends beyond the examining room. All the

speech related to the clinics’ professional services that occurs

within the clinics’ walls, including within in the waiting

room, is part of the clinics’ professional practice. 

Furthermore, the Licensed Notice contains information

regarding the professional services offered by the clinics, and

thus would constitute professional speech regardless of where

within the clinic it was disseminated.

We now turn to the correct level of scrutiny to apply to

the Licensed Notice and conclude that under our precedent in

Pickup, intermediate scrutiny applies. Licensed Clinics are

not engaging in a public dialogue when treating their clients,

and they are not “constitutionally equivalent to soapbox

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orators and pamphleteers.” Pickup, 740 F.3d at 1227. Thus,

it would be inappropriate to apply strict scrutiny. And, unlike

in Pickup, the Licensed Notice does not regulate therapy,

treatment, medication, or any other type of conduct. Instead,

the Licensed Notice regulates the clinics’ speech in the

context of medical treatment, counseling, or advertising.

7

Because the speech here falls at the midpoint of the

Pickup continuum, it is not afforded the “greatest” First

Amendment protection, nor the least. Id. It follows,

therefore, that speech in the middle of the Pickup continuum

should be subject to intermediate scrutiny. See Stuart,

774 F.3d at 249 (applying intermediate scrutiny when

physicians challenged an abortion-related disclosure law they

claimed violated their First Amendment rights); King,

767 F.3d at 237 (applying intermediate scrutiny when

therapists challenged a law prohibiting therapy that purported

to change patients’ sexual-orientation, which it had

determined was professional “speech” rather than “conduct”). 

Applying intermediate scrutiny is consistent with the

principle that “within the confines of a professional

relationship, First Amendment protection of a professional’s

speech is somewhat diminished,” Pickup, 740 F.3d at 1228,

but that professionals also do not “simply abandon their First

Amendment rights when they commence practicing a

profession.” Stuart, 774 F.3d at 247.

Appellants cite In Re Primus, 436 U.S. 412 (1978), to

argue that strict scrutiny should apply to professional speech

when the professional services at issue are offered free of

7 We disagree with the district court’s conclusion that the Act

regulates conduct. The district court’s error, however, was harmless as it

appropriately denied the motion for a preliminary injunction.

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charge. We reject this argument.8In In re Primus, the

Supreme Court addressed whether a lawyer’s First

Amendment rights were violated when a state bar punished

her for writing a letter to a possible client about free legal

services available at the American Civil Liberties Union, an

organization with which she was affiliated, but offered her no

compensation. 436 U.S. at 414–15. The Supreme Court held

that the lawyer’s constitutional rights were violated, writing

that “[i]n the context of political expression and association

. . . a State must regulate with significantly greater precision.” 

Id. at 437–38. Here, however, Appellants have positioned

themselves in the marketplace as pregnancy clinics. Their

non-profit status does not change the fact that they offer

medical services in a professional context. Nor does their

non-profit status transform them into, for example, an

organization that engages in “political expression and

association.” Id.

3. The Licensed Notice Survives Intermediate

Scrutiny.

In order to survive intermediate scrutiny, “the State must

show . . . that the statute directly advances a substantial

governmental interest and that the measure is drawn to

achieve that interest.” Sorrell, 564 U.S. at 572. Intermediate

scrutiny is “demanding” but requires less than strict scrutiny. 

8 We do not think a necessary element of professional speech is for

the client to be a paying client. A lawyer who offers her services to a

client pro bono, for example, nonetheless engages in professional speech.

But see Moore-King v. Cty. of Chesterfield, 708 F.3d 560, 569 (4th Cir.

2013) (“[T]he relevant inquiry to determine whether to apply the

professional speech doctrine is whether the speaker is providing

personalized advice in a private setting to a paying client or instead

engages in public discussion and commentary.” (emphasis added)).

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Retail Digital Network, LLC v. Appelsmith, 810 F.3d 638, 648

(9th Cir. 2016). “What is required is ‘a fit that is not

necessarily perfect, but reasonable; that represents not

necessarily the single best disposition but one whose scope is

in proportion to the interest served; that employs not

necessarily the least restrictive means but . . . a means

narrowly tailored to achieve the desired objective.’” Id. at

649 (quoting Bd. of Trustees of the State Univ. of N.Y. v. Fox,

492 U.S. 469, 480 (1989)).

We conclude that the Licensed Notice satisfies

intermediate scrutiny. California has a substantial interest in

the health of its citizens, including ensuring that its citizens

have access to and adequate information about

constitutionally-protected medical services like abortion. The

California Legislature determined that a substantial number

of California citizens may not be aware of, or have access to,

medical services relevant to pregnancy. See Assem. Bill No.

775 § 1(b). This includes findings that in 2012, 2.6 million

California women were in need of publicly-funded familyplanning services, and that thousands of pregnant California

women remain unaware of the state-funded programs that

offer an array of services, such as health education and

planning, prenatal care, and abortion. Id. As we have long

recognized, “[s]tates have a compelling interest in the

practice of professions within their boundaries, and . . . as

part of their power to protect the public health, safety, and

other valid interests they have broad power to establish

standards for . . . regulating the practice of professions.” Am.

Acad. of Pain Mgmt. v. Joseph, 353 F.3d 1099, 1109 (9th Cir.

2004) (quoting Fla. Bar v. Went For It, Inc., 515 U.S. 618,

625 (1994)).

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NIFLA V. HARRIS 33

We conclude that the Licensed Notice is narrowly drawn

to achieve California’s substantial interests. The Notice

informs the reader only of the existence of publicly-funded

family-planning services. It does not contain any more

speech than necessary, nor does it encourage, suggest, or

imply that women should use those state-funded services.

The Licensed Notice is closely drawn to achieve California’s

interests in safeguarding public health and fully informing

Californians of the existence of publicly-funded medical

services. And given that many of the choices facing pregnant

women are time-sensitive, such as a woman’s right to have an

abortion before viability, Casey, 505 U.S. at 846, we find

convincing the AG’s argument that because the Licensed

Notice is disseminated directly to patients whenever they

enter a clinic, it is an effective means of informing women

about publicly-funded pregnancy services.

Appellants argue that because California could find other

ways to disseminate the information in the Licensed Notice

to the public, such as in an advertising campaign, the Act

cannot survive heightened scrutiny. The Second and Fourth

Circuits used similar reasoning to strike down provisions of

abortion-related regulations. See Evergreen Ass’n, Inc. v.

City of N.Y., 740 F.3d 233, 250 (2d Cir. 2014) (stating that

“the City can communicate this message through an

advertising campaign”);Centro Tepeyac v. Montgomery Cty.,

722 F.3d 184, 191 (4th Cir. 2013) (en banc) (stating that the

government had “several options less restrictive than

compelled speech” such as “launch[ing] a public awareness

campaign” (internal quotation marks and citation omitted)).

But Evergreen andCentro Tepeyac applied strict scrutiny,

which is much more stringent than the intermediate scrutiny

we apply today. Unlike when evaluating a law under strict

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scrutiny, under intermediate scrutiny, a law need not be the

least restrictive means possible. See Appelsmith, 810 F.3d at

649. Thus, even if it were true that the state could

disseminate this information through other means, it need not

prove that the Act is the least restrictive means possible.9

Further, unlike the portions of the regulations before the

Second and Fourth Circuits, the Licensed Notice does not use

the word “encourage,” or other language that suggests the

California Legislature’s preferences regarding prenatal care. 

See Evergreen, 740 F.3d at 250 (striking down the portion of

the regulation that required clinics to state that “the New

York City Department of Health and Mental Hygiene

encourages women who are or who may be pregnant to

consult with a licensed provider”); Centro Tepeyac, 722 F.3d

at 191 (striking the portion of the regulation that mandated

clinics to state that “the Montgomery County Health Officer

encourages women who are or may be pregnant to consult

with a licensed health care provider”).

4. The Unlicensed Notice Survives Any Level of

Review.

We now address the speech regulated by the Unlicensed

Notice. While we acknowledge that unlicensed clinics do not

offer many of the medical services available at licensed

9 We note that, given the preliminary stage of this case, it is unclear

whether California actually could have disseminated this information as

effectively in an advertising campaign, as Appellants argue. At oral

argument, the AG noted that California has advertised its publicly-funded

programs, but many women were still unaware of their existence given the

expansion of certain health programs. Oral Argument at 28:44, A

Woman’s Friend Pregnancy Resource Clinic v. Harris, No. 15-17517,

http://www.ca9.uscourts.gov/media/view_video.php?pk_vid=0000009827.

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NIFLA V. HARRIS 35

clinics, they nonetheless offer some professional services. 

Fallbrook Pregnancy Center, for example, offers educational

programs. They also give medical referrals for ultrasounds

and sonographs, which are offered nearby. Indeed, the Act

covers unlicensed clinics like Fallbrook precisely because

their “primary purpose is [to provide] pregnancy-related

services” and those services can include collecting health

information, offering prenatal care, or pregnancy tests and

diagnosis. Cal. Health & Safety Code § 123471(b).

We need not resolve the question, however, of whether

the Unlicensed Notice regulates professional speech because

it is clear to us that the Unlicensed Notice will survive even

strict scrutiny.

In order to survive strict scrutiny, a regulation must be

“narrowly tailored to serve a compelling interest.” WilliamsYulee v. Fla. Bar, 135 S. Ct. 1656, 1665 (2015).

California has a compelling interest in informing pregnant

women when they are using the medical services of a facility

that has not satisfied licensing standards set by the state. And

given the Legislature’s findings regarding the existence of

CPCs, which often present misleading information to women

about reproductive medical services, California’s interest in

presenting accurate information about the licensing status of

individual clinics is particularly compelling.

We conclude that the Unlicensed Notice is narrowly

tailored to this compelling interest. By stating that the clinic

in which it is disseminated is not licensed by the State of

California, the Unlicensed Notice helps ensure that women,

who may be particularly vulnerable when they are searching

for and using family-planning clinical services, are fully

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informed that the clinic they are trusting with their well-being

is not subject to the traditional regulations that oversee those

professionals who are licensed by the state. The Unlicensed

Notice is also only one sentence long. It merely states that

the facility in which it appears is not licensed by California

and has no state-licensed medical provider. It says nothing

about the quality of service women may receive at these

clinics, and in no way implies or suggests California’s

preferences regarding unlicensed clinics.

The Second and Fourth Circuits held that regulations with

provisions similar to the Unlicensed Notice survived strict

scrutiny. In Evergreen, the Second Circuit concluded that the

portion of the regulation that required clinics to state if they

“have a licensed medical provider on staff who provides or

directly supervises the provision of all of the services”

survived strict scrutiny because it was not overly broad, and

was “the least restrictive means to ensure that a woman [was]

aware of whether or not a particular pregnancy services

center ha[d] a licensed medical provider.” 740 F.3d at

246–47 (emphasis in original). Similarly, in Centro Tepeyac,

the Fourth Circuit held that the portion of the regulation that

stated “the Center does not have a licensed medical

professional on staff,” survived strict scrutiny because it

“merely notifie[d] patients that a licensed medical

professional [was] not on staff, d[id] not require any other

specific message, and in neutral language state[d] the truth.” 

722 F.3d at 190 (internal quotation marks and citation

omitted). The surviving portions of the regulations in

Evergreen and Centro Tepeyac merely state whether or not

the clinics had licensed providers, which is exactly what the

Unlicensed Notice does.

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We therefore hold that the district court did not abuse its

discretion in finding that Appellants cannot demonstrate a

likelihood of success on their free speech claim. The

Licensed Notice regulates professional speech, subject to

intermediate scrutiny, which it survives. The Unlicensed

Notice survives any level of review.10

B. Appellants Cannot Demonstrate a Likelihood of

Success on their First Amendment Free Exercise

Claim.

Courts have long recognized that “the right of free

exercise does not relieve an individual of the obligation to

comply with a ‘valid and neutral law of general applicability

on the ground that the law proscribes (or prescribes) conduct

that his religion prescribes (or proscribes).’” Empl’t Div.,

Dep’t. of Human Res. of Or. v. Smith, 494 U.S. 872, 879

(1990) (quoting United States v. Lee, 455 U.S. 252, 263 n.3

(1982) (Stevens, J., concurring in judgment)). A neutral and

generally applicable law is subject to only rational basis

review. Stormans, Inc. v. Wiesman, 794 F.3d 1064, 1075–76

(9th Cir. 2015).

The Act is facially neutral. “A law lacks facial neutrality

if it refers to a religious practice without a secular meaning

discernable from the language or context.” Id. at 1076

(citation omitted). The Act references no religious practice

and is thus facially neutral.

10 To be clear, we do not conclude that strict scrutiny is the correct

level ofscrutiny to apply to the Unlicensed Notice. We only conclude that

it can survive strict scrutiny.

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The Act is also operationally neutral. It “prescribe[s] and

proscribe[s] the same conduct for all, regardless of

motivation.” Id. at 1077. The Act applies to all covered

facilities, and is indifferent to the basis for any objection. 

Thus, contrary to Appellants’ assertion, this case is

distinguishable from Church of Lukumi Babalu Aye, Inc. v.

City of Hialeah. There, the Supreme Court found non-neutral

a law that banned animal sacrifices for only a particular

religion while sacrifices “that [were] no more necessary or

humane in almost all other circumstances [went]

unpunished.” 508 U.S. 520, 536 (1993). But, unlike in

Lukumi, the Act applies to all licensed and unlicensed

facilities, regardless of any objection, religious or otherwise. 

The fact that Appellants’ objections are grounded in their

religious beliefs does not affect the Act’s neutrality. See

Stormans, 794 F.3d at 1077 (“The Free Exercise Clause is not

violated even if a particular group, motivated by religion,

may be more likely to engage in the proscribed conduct.”).

The Act is generally applicable. “[I]f a law pursues the

government’s interest only against conduct motivated by

religious belief but fails to include in its prohibitions

substantial, comparable secular conduct that would similarly

threaten the government’s interest, then the law is not

generally applicable.” Id. at 1079 (internal quotation marks

and citation omitted). A law is not generally applicable if it

“in a selective manner impose[s] burdens only on conduct

motivated by religious belief[.]” Lukumi, 508 U.S. at 543.

The Act has two exemptions, and neither renders the Act

not generally applicable. As noted, the Act’s first exemption

exists to avoid federal preemption, and its second exemption

is for clinics that already provide all of the publicly-funded

services outlined in the Act. See supra section II.A.1. 

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NIFLA V. HARRIS 39

Because the Act’s exemptions are “tied directly to limited,

particularized, business-related, objective criteria,” the Act is

generally applicable. Stormans, 794 F.3d at 1082.

And finally, this action is not a “hybrid-rights” case in

which a free exercise plaintiff has made out a “colorable

claim that a companion right has been violated.” San Jose

Christian Coll. v. City of Morgan Hill, 360 F.3d 1024, 1032

(9th Cir. 2004). Appellants have not shown a likelihood of

success on the merits of their free speech claim. Thus, there

is no “colorable claim” for “a companion right.” Id.

We conclude that the Act is a neutral law of general

applicability, subject to only rational basis review. See

Stormans, 794 F.3d at 1075–76. Because the Licensed Notice

survives intermediate scrutiny, and the Unlicensed Notice

survives any level of review, the Act necessarily also survives

rational basis review.11

CONCLUSION

Appellants have failed to demonstrate that the first, most

important, Winter factor favors granting their motion for a

preliminary injunction. Garcia, 786 F.3d at 740. We reject

Appellants’ arguments that they are entitled to a preliminary

11 We also find that Appellants have not raised “serious questions”

going to the merits of their claims; thus, the alternate test set forth in

Alliance for the Wild Rockies does not apply. The district court’s

conclusion that there were serious questions going to the merits was

harmless error because the district court appropriately denied the motion

for a preliminary injunction. Because Appellants cannot show a

likelihood of success on the merits or “serious questions” going to the

merits of their First Amendment claims, we need not discuss the

remaining Winter factors.

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40 NIFLA V. HARRIS

injunction based on their free speech claims. The Act is a

content-based regulation that does not discriminate based on

viewpoint. And because Casey did not announce a new rule

regarding the level of scrutiny to apply to abortion-related

disclosure cases, we apply this Court’s professional speech

framework and conclude that the Licensed Notice is subject

to intermediate scrutiny, which it survives. The Unlicensed

Notice survives any level of review.

We also reject Appellants’ arguments that they are

entitled to a preliminary injunction based on their free

exercise claims. The Act is a neutral law of general

applicability, which survives rational basis review.

Appellants, therefore, are unable to demonstrate

likelihood of success on the merits of their First Amendment

claims.

AFFIRMED.

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