Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-19-35386/USCOURTS-ca9-19-35386-3/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

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; U.S.

DEPARTMENT OF HEALTH &

HUMAN SERVICES,

Defendants-Appellants.

No. 19-15979

D.C. No.

3:19-cv-01195-EMC

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2 STATE OF CALIFORNIA V. AZAR

Appeal from the United States District Court

for the Northern District of California

Edward M. Chen, District Judge, Presiding

STATE OF OREGON; STATE OF

NEW 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; 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,

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

C.N.M.,

Plaintiffs-Appellees,

v.

ALEX M. AZAR II; U.S.

DEPARTMENT OF HEALTH &

HUMAN SERVICES; DIANE

FOLEY; OFFICE OF POPULATION

AFFAIRS,

Defendants-Appellants.

Appeal from the United States District Court

for the District of Oregon

Michael J. McShane, District Judge, Presiding

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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;

U.S. DEPARTMENT OF HEALTH &

HUMAN SERVICES; DIANE

FOLEY, M.D., 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

OPINION

Appeal from the United States District Court

for the Eastern District of Washington

Stanley Allen Bastian, District Judge, Presiding

Argued and Submitted En Banc September 23, 2019

San Francisco, California

Filed February 24, 2020

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STATE OF CALIFORNIA V. AZAR 5

Before: Sidney R. Thomas, Chief Judge, and Edward

Leavy, Kim McLane Wardlaw, William A. Fletcher,

Richard A. Paez, Jay S. Bybee, Consuelo M. Callahan,

Milan D. Smith, Jr., Sandra S. Ikuta, Eric D. Miller

and Kenneth K. Lee, Circuit Judges.

Opinion by Judge Ikuta;

Dissent by Judge Paez

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6 STATE OF CALIFORNIA V. AZAR

SUMMARY*

Title X of the Public Health Service Act

The en banc court vacated preliminary injunctions entered

by three district courts in three states against the U.S.

Department of Health and Human Services’s (“HHS”)

enforcement of a 2019 rule, promulgated by HHS under

Title X of the Public Health Service Act, concerning grants

to support voluntary family projects, and prohibition of funds

being used in programs where abortion is a method of family

planning.

Section 1008 of Title X prohibits grant funds from

“be[ing] used in programs where abortion is a method of

family planning.” Regulations issued in 1988, and upheld by

the Supreme Court in 1991, completely prohibited the use of

Title X funds in projects where clients received counseling or

referrals for abortion as a method of family planning. Rust v.

Sullivan, 500 U.S. 173, 177-79 (1991). Regulations issued in

2000 were more permissive. In March 2019, HHS

promulgated the 2019 rule, which was similar to the

regulations adopted in 1988 and upheld by Rust. Plaintiffs,

including several states and private Title X grantees, brought

various suits challenging the 2019 Final Rule.

The en banc court first considered plaintiffs’ argument

that the 2019 Final Rule was facially invalid because two

intervening congressional enactments altered the legal

landscape so that Rust’s holdings were no longer valid. The

* 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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STATE OF CALIFORNIA V. AZAR 7

court held that plaintiffs failed to provide evidence that

Congress intended to alter Rust’s conclusion that the 1988

Rule was a permissible interpretation of Title X and § 1008.

The en banc court held that the 2019 Final Rule was not

contrary to the 1996 appropriations rider, which was enacted

to ensure no federal funds were used to support abortion

services. Specifically, the panel held that because HHS can

reasonably interpret “nondirective pregnancy counseling” as

not including referrals, plaintiffs failed at the first step of their

arguments, that “pregnancy counseling” must be deemed to

include referrals. Plaintiffs also failed at the second step of

their argument that the term “nondirective” meant the

presentation of all options on an equal basis. The court held

that HHS reasonably interpreted “nondirective” to refer to the

neutral manner in which counseling was provided rather than

to the scope of topics that must be covered in counseling. The

court rejected plaintiffs’ and the dissent’s argument that the

Final Rule was directive because it required referrals for

medically necessary prenatal health care. The court also held

that requiring referrals for medically necessary prenatal

health care but not for nontherapeutic abortions did not make

pregnancy counseling directive. Nor was the Final Rule

directive because it allowed referrals for adoption. Finally,

the court held that the Final Rule’s restrictions on referral

lists did not render pregnancy counseling directive because a

referral list did not present information in a way that

encouraged or promoted a specific option.

The en banc court held that the 2019 Final Rule was

consistent with § 1554 of the Affordable Care Act (“ACA”). 

The court held that the ACA did not address the

implementation of Congress’s choice not to subsidize certain

activities. The Final Rule placed no substantive barrier on

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8 STATE OF CALIFORNIA V. AZAR

individuals’ ability to obtain appropriate medical care or on

doctors’ ability to communicate with clients or engage in

activity when not acting within a Title X project, and

therefore the Final Rule did not implicate § 1554.

The en banc court concluded that the Final Rule was not

contrary to the appropriations rider, § 1554 of the ACA, or

Title X. The court held that plaintiffs’ claims based on these

provisions would not succeed, and plaintiffs, accordingly, did

not demonstrate a likelihood of success on the merits based

on these grounds.

The en banc court next turned to plaintiffs’ arguments that

the 2019 Final Rule was arbitrary and capricious under the

Administrative Procedure Act. First, plaintiffs argued that

HHS’s promulgation of the physical and financial separation

requirement in 42 C.F.R. § 59.15 was arbitrary and

capricious. The court held that HHS examined the relevant

considerations and provided a reasoned analysis for adopting

this provision. In light of HHS’s reasoned explanation of its

decisions and its consideration of the comments raised, the

court rejected plaintiffs’ arguments that HHS failed to base its

decision on evidence, failed to consider potential harms in its

cost-benefit analysis, failed to explain its reasons for

departing from the 2000 Rule’s provisions, and failed to

consider the reliance interest of providers who have incurred

costs relying on HHS’s previous regulation. Second,

plaintiffs argued that HHS’s cost-benefit analysis of the 2019

Final Rule was arbitrary and capricious. The court held that

HHS reasonably concluded that the harms flowing froma gap

in care would not develop, and on this record, the court would

not second-guess HHS’s consideration of the risks and

benefits of its action. Third, plaintiffs asserted that the

referral restrictions were arbitrary and capricious. Because

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STATE OF CALIFORNIA V. AZAR 9

HHS’s decisionmaking path could reasonably be determined,

the court rejected plaintiffs’ claims that the counseling and

referral restrictions were arbitrary and capricious. Fourth, the

court rejected plaintiffs’ arguments that HHS’s technical

determination of which medical professionals could provide

pregnancy counseling was arbitrary and capricious. Finally,

the court rejected plaintiffs’ argument that HHS was arbitrary

and capricious in reestablishing the language of the 1988

Rule’s requirement that all family planning methods and

services be “acceptable and effective,” instead of retaining

the 2000 Rule’s revision requiring that such methods and

services also be “medically approved.” The court held that

HHS adequately explained its reasons for reestablishing the

1988 Rule, and sufficiently addressed comments that its

decision to omit the phrase “medically approved” would

promote political ideology over science, lead to negative

health consequences for clients, and undermined

recommendations from other agencies.

The en banc court held that plaintiffs would not prevail on

the merits of their legal claims, and they were not entitled to

the extraordinary remedy of a preliminary injunction. 

Accordingly,the court vacated the district courts’ preliminary

injunction orders, and remanded for further proceedings. The

government’s motion for a stay pending appeal was denied as

moot.

Judge Paez, joined by Chief Judge Thomas, and Judges

Wardlaw and W. Fletcher, dissented. Judge Paez would hold

that the 2019 Final Rule breached Congress’ limitations on

the scope of HHS’s authority, and he would uphold the

district courts’ preliminary injunctions enjoining enforcement

of the Rule. Among other things, the Final Rule gags health

care providers from fully counseling women about their

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10 STATE OF CALIFORNIA V. AZAR

options while pregnant and requires them to steer women

toward childbirth, and requires providers to physically and

financially separate any abortion services they provide from

all other health care services they deliver. Judge Paez

concluded that the majority sanctions the agency’s gross

overreach and puts its own policy preferences before the law.

COUNSEL

Hashim M. Mooppan (argued), Deputy Assistant Attorney

General; Britton Lucas (argued), Senior Counsel; Michael S.

Raab, Katherine Allen, and Jaynie Lilley, Appellate Staff; 

Joseph H. Hunt, Assistant Attorney General; Civil Division,

United States Department of Justice, Washington, D.C.; for

Defendants-Appellants Alex M. Azar II, U.S. Department of

Health & Human Services, Diane Foley, and Office of

Population Affairs.

Benjamin N. Gutman (argued), Solicitor General; Jona J.

Maukonen, Senior Assistant Attorney General; Ellen F.

Rosenblum, Attorney General; Office of the Attorney

General, Salem, Oregon; Letitia James, Attorney General;

Barbara D. Underwood, Solicitor General; Anisha S.

Dasgupta, Deputy Solicitor General; Judith N. Vale, Senior

Assistant Solicitor General; Office of the Attorney General,

New York, New York; for Plaintiffs-Appellees Oregon, New

York, Colorado, Connecticut, Delaware, District of

Columbia, Hawaii, Illinois, Maryland, Massachusetts,

Michigan, Minnesota, Nevada, New Jersey, New Mexico,

North Carolina, Pennsylvania, Rhode Island, Vermont,

Virginia, and Wisconsin.

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STATE OF CALIFORNIA V. AZAR 11

Ruth E. Harlow (argued), Fiona Kaye, Anjali Dalal, Elizabeth

Deutsch, and Brigitte Amiri, American Civil Liberties Union

Foundation, New York, New York; Emily Chiang, American

Civil Liberties Union Foundation of Washington, Seattle,

Washington; Joe Shaeffer, MacDonald Hoague & Bayless,

Seattle,Washington; for Plaintiffs-AppelleesNational Family

Planning and Reproductive Health Association; Feminist

Women’s Health Center; Deborah Oyer, M.D.; and Teresa

Gall.

Xavier Becerra, Attorney General; Edward C. DuMont,

Solicitor General; Kathleen Boergers, Supervising Deputy

Attorney General; Joshua Patashnik, Deputy Solicitor

General; Anna Rich, Brenda Ayon Verduzco, and Ketakee

Kane, Deputy Attorneys General; California Department of

Justice,SanFrancisco,California; for Plaintiff-Appellee State

of California.

Michelle S .Ybarra, Justina Sessions, Sophie Hood, and Sarah

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

California, for Plaintiffs-Appellees Essential Access Health,

Inc., and Melissa Marshall, M.D.

Alan E. Schoenfeld, Wilmer Cutler Pickering Hale and Dorr

LLP, New York, New York; Paul R.Q. Wolfson, Kimberly A.

Parker, Albinas J. Prizgintas, and Joshua M. Koppel, Wilmer

Cutler Pickering Hale and Dorr LLPP, Washington, D.C.;

Jeremy D. Sacks, Per A. Ramfjord, and Kennon Scott, Stoel

Rives LLP, Portland, Oregon; Brian D. Vandenberg, Leonard

A. Nelson, and Erin G. Sutton, American Medical

Association; Helene T. Krasnoff, and Carrie Y. Flaxman,

Planned Parenthood of America Inc., Washington, D.C.;

Mark Bonanno, General Counsel, Oregon Medical

Association, Portland, Oregon; for Plaintiffs-Appellees

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12 STATE OF CALIFORNIA V. AZAR

AmericanMedical Association; OregonMedical Association;

Planned Parenthood Federation of America, Inc.; Planned

Parenthood of Southwestern Oregon; Planned Parenthood

Columbia Willamette; Thomas N. Ewing, M.D.; and Michele

P. Megregian, C.N.M.

Robert W. Ferguson, Attorney General; Noah G. Purcell,

Solicitor General; Jeffrey T. Sprung, Kristin Beneski, and

Paul M. Crisalli, Assistant Attorneys General; Office of the

AttorneyGeneral,Seattle,Washington; for Plaintiff-Appellee

State of Washington.

Dave Yost, Attorney General; Benjamin M. Flowers, State

Solicitor; Stephen P. Carney and Jason D. Manion, Deputy

Solicitors; Office of the Attorney General, Columbus, Ohio;

Steve Marshall, Alabama Attorney General; Leslie Rutledge,

Arkansas Attorney General; Curtis T. Hill, Jr., Indiana

Attorney General; Jeff Landry, Louisiana Attorney General;

Eric S. Schmitt, Missouri Attorney General; Doug Peterson,

Nebraska Attorney General; Mike Hunter, Oklahoma

Attorney General; Alan Wilson, South Carolina Attorney

General; Jason Ravnsborg, South Dakota Attorney General;

Herbert H. Slatery III, Tennessee Attorney General; Ken

Paxton, Texas Attorney General; and Sean Reyes, Utah

Attorney General; for Amici Curiae Ohio and 12 Other

States.

Catherine Glenn Foster, Steven H. Aden, and Rachel N.

Morrison, Washington, D.C., as and for Amicus Curiae

Americans United for Life.

Jay Alan Sekulow and Stuart J. Roth, Washington, D.C., as

and for Amicus Curiae American Center for Law & Justice.

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STATE OF CALIFORNIA V. AZAR 13

Sarah E. Pitlyk and Adam S. Hochschild, Thomas More

Society, Chicago, Illinois, for Amicus Curiae Susan B.

Anthony List.

James E. Hough, Morrison & Foerster LLP, New York, New

York; Andre Fontana, Morrison & Foerster LLP, San

Francisco, California; Shannon Minter, Julianna Gonen, Amy

Whelan, and Julie Wilensky, National Center for Lesbian

Rights, San Francisco, California; for Amici Curiae National

Center for Lesbian Rights, Equality Federation, Family

Equality Council, GLMA: Health Professionals Advancing

LGBTQ Equality, The HIV Medicine Association, The

National Center for Transgender Equality, The National

LGBTQ Task Force, The Sexuality Information and

Education Council ofthe UnitedStates (SIECUS), The LGBT

Movement Advancement Project, Lambda Legal Defense and

Education Fund,Inc., GLBTQLegal Advocates & Defenders,

The Human Rights Campaign, Transgender Law Center, and

Bay Area Lawyers for Individual Freedom.

Martha Jane Perkins, National Health Law Program,

Carrboro, North Carolina, for Amici Curiae The National

Health Law Program, Advocates for Youth, American

Medical Student Association, American Society for

Reproductive Medicine,CommunityCatalyst, The Endocrine

Society, Families USA, HIV Medicine Association, In Our

Own Voice: National Black Women’s Reproductive Justice

Agenda, Juvenile Law Center, The LeadershipConference on

Civil and Human Rights, National Council ofJewish Women,

NARAL Pro-Choice America, National Abortion Federation,

National Immigration Law Center, National Institute for

Reproductive Health, National Latina Institute for

Reproductive Health, National Partnership for Women &

Families, National Women’s Health Network, National

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14 STATE OF CALIFORNIA V. AZAR

Women’s Law Center, Northwest Health Law Advocates,

Positive Women’s Network—USA, Power to Decide, Union

for ReformJudaism,Central Conference of American Rabbis,

Women of Reform Judaism, Men of Reform Judaism, Unite

for Reproductive & Gender Equity, Whitman- Walker Health,

WomenHeart, and YWCA USA.

Richard L. Revesz, Madison Condon, Bethany A. Davis Noll,

and Jason Schwartz, New York, New York, as and for

Amicus Curiae Institute for Policy Integrity at New York

University School of Law.

Zachary W. Carter, Corporation Counsel; Richard Dearing,

Claude S. Platton, Jamison Davies, Melanie C.T. Ash, and

Kevin Osowski, Of Counsel; Law Department, New York,

New York; Andre M. Davis, City Solicitor, Baltimore,

Maryland; Zach Klein, City Attorney, Columbus, Ohio;

Dennis J. Herrera, City Attorney, City Attorney’s Office, San

Francisco, California; James R. Williams, County Counsel,

County of Santa Clara, San Jose, California; Anthony P.

Condotti, City Attorney, Santa Cruz, California; Mark A.

Flessner,Corporation Counsel; Benna Ruth Solomon,Deputy

Corporation Counsel; Department of Law, Chicago, Illinois;

Michael N. Feuer, City Attorney, Los Angeles, California;

Mary C. Wickham, County Counsel,LosAngeles,California;

Philippa M. Guthrie,CorporationCounsel,LegalDepartment,

Bloomington, Indiana; Barbara J. Parker, City Attorney,

Oakland, California; Ronald C. Lewis, City Attorney; Judith

L. Ramsey, Chief, General Litigation Section; Collyn Peddie,

Senior Assistant City Attorney, Houston, Texas; Peter S.

Holmes, City Attorney, Seattle, Washington; for Amici

Curiae City of New York, New York City Health and

Hospitals, and 12 Local Governments.

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STATE OF CALIFORNIA V. AZAR 15

Bina G. Patel and David D. Doak, Quinn Emanuel Urguhart

& Sullivan LLP, San Francisco, California; Valerie Roddy,

Quinn Emanuel Urguhart & Sullivan LLP, Los Angeles,

California; for Amicus Curiae National Center for Youth

Law.

Lisa H. Bebchick, Ropes & Gray LLP, New York, New

York; Thomas N. Bulleit and Douglas Hallward-Griemeier,

Ropes & Gray LLP, Washington, D.C.; Daniel W. Richards,

Ropes & Gray LLP, East Palo Alto, California; Haley Eagon,

Ropes & Gray LLP, Boston, Massachusetts; Nadia Dahab,

Stoll Berne, Portland, Oregon; Taylor Washburn, Lane

Powell PC, Seattle, Washington; for Amici Curiae American

College of Obstetricians and Gynecologists, American

Academy of Pediatrics, American Academy of Family

Physicians, American College of Physicians, California

Medical Association, Society for Adolescent Health and

Medicine, and Society for Maternal-Fetal Medicine.

Theane Evangelis, Lauren M. Blas, and Virginia L. Smith,

Gibson Dunn & Crutcher LLP, Los Angeles, California, for

Amicus Curiae California Women’s Law Center.

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16 STATE OF CALIFORNIA V. AZAR

OPINION

IKUTA, Circuit Judge:

Title X of the Public Health Service Act gives the

Department of Health and Human Services (HHS) authority

to make grants to support “voluntary family planning

projects” for the purpose of offering “a broad range of

acceptable and effective family planning methods and

services.” 42 U.S.C. § 300(a).1 Section 1008 of Title X

prohibits grant funds from “be[ing] used in programs where

abortion is a method of family planning.” Id. § 300a-6.

Since 1970, when Title X was first enacted, HHS has

provided competing interpretations of this prohibition. 

Regulations issued in 1988, and upheld by the Supreme Court

in 1991, completely prohibited the use of Title X funds in

projects where clients received counseling or referrals for

abortion as a method of family planning. Rust v. Sullivan,

500 U.S. 173, 177–79 (1991). Regulations issued in 2000

were more permissive.

In March 2019, HHS promulgated regulations that are

similar to those adopted by HHS in 1988 and upheld by Rust. 

But the 2019 rule is less restrictive in at least one important

respect: a counselor providing nondirective pregnancy

counseling “may discuss abortion” so long as “the counselor

neither refers for, nor encourages, abortion.” 42 C.F.R.

§ 59.14(e)(5). There is no “gag” on abortion counseling. See

id.

1 Congress did not design the Title X grant program to provide

healthcare services beyond “family planning methods and services.” 

42 U.S.C. § 300(a); cf. Dissent at 81.

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STATE OF CALIFORNIA V. AZAR 17

Plaintiffs, including several states and private Title X

grantees, brought various suits challenging the 2019 rule, and

three district courts in three states entered preliminary

injunctions against HHS’s enforcement of the rule. In light

of Supreme Court approval of the 1988 regulations and our

broad deference to agencies’ interpretations of the statutes

they are charged with implementing, plaintiffs’ legal

challenges to the 2019 rule fail. Accordingly, we vacate the

injunctions entered by the district courts and remand for

further proceedings consistent with this opinion.

I

In 1970, Congress enacted Title X of the Public Health

Service Act to give HHS authority to make grants to Title X

projects that provide specified family planning services.2

Family Planning Services and Population Research Act, Pub.

L. No. 91-572, 84 Stat. 1504, 1508 (1970); 42 U.S.C. § 300a4(c). The Act gives HHS broad authority to promulgate

regulations to administer the grant program, as well as to

impose conditions on the grants that HHS “may determine to

be appropriate to assure that such grants will be effectively

utilized for the purposes for which made.” § 1006(a)–(b), 84

Stat. at 1507; 42 U.S.C. § 300a-4(a)–(b).

Congress placed only two limitations on HHS’s

discretion. First, an individual’s acceptance of family

planning services has to be “voluntary” and not “a

prerequisite to eligibility for or receipt of any other service or

assistance from, or to participation in, any other program of

2 Although Title X and its implementing regulations use both the

terms “program” and “project,” for consistency we refer to a program

using Title X funds to provide services to clients as a “Title X project.”

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18 STATE OF CALIFORNIA V. AZAR

the entity or individual that provided such service or

information.” § 1007, 84 Stat. at 1508; 42 U.S.C. § 300a-5. 

Second, § 1008 of Title X provides:

None of the funds appropriated under this

subchapter shall be used in programs where

abortion is a method of family planning.

§ 1008, 84 Stat. at 1508; 42 U.S.C. § 300a-6.

Section 1008, which has never been amended, “was

intended to ensure that Title X funds would ‘be used only to

support preventive family planning services, population

research, infertility services, and other related medical,

informational, and educational activities.’” Rust, 500 U.S.

at 178–79 (quoting H.R. Conf. Rep. No. 91-1667, at 8

(1970)); see also New York v. Sullivan, 889 F.2d 401, 407 (2d

Cir. 1989), aff’d sub nom. Rust v. Sullivan, 500 U.S. 173

(1991) (noting a legislator’s statement that “[w]ith the

‘prohibition of abortion’ amendment—title X, section

1008—the [House] committee members clearly intend that

abortion is not to be encouraged or promoted in any way

through this legislation”) (statement of Rep. Dingell). As

Rust concluded, in enacting § 1008, Congress made a

constitutionally permissible “value judgment favoring

childbirth over abortion.” 500 U.S. at 192 (quoting Maher v.

Roe, 432 U.S. 464, 474 (1977)).

Although the purpose of § 1008 is clear, the Supreme

Court has determined that its language is ambiguous because

it does not expressly articulate how its prohibition applies to

abortion counseling, referral, and advocacy, or how to ensure

that funds are not used “in programs where abortion is a

method of family planning.” Id. at 184. As a result of this

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STATE OF CALIFORNIA V. AZAR 19

ambiguity, HHS has provided a range of alternative

interpretations of § 1008 over the years. We provide an

overview of this history as context to our analysis of the

issues raised by the government’s appeals.

A

In 1971, HHS promulgated (without notice and comment)

the first regulations designed to implement Title X. Project

Grants for Family Planning Services, 36 Fed. Reg. 18,465,

18,465–66 (Sept. 15, 1971). The regulations did not address

the scope of § 1008. Instead, HHS interpreted § 1008

through opinions from its Office of General Counsel. In the

mid-1970s, HHS issued a legal opinion prohibiting directive

counseling on abortion (“encouraging or promoting”

abortion) in a Title X project, while permitting nondirective

(“neutral”) counseling on abortion. Nat’l Family Planning &

Reprod. Health Ass’n v. Sullivan, 979 F.2d 227, 229 (D.C.

Cir. 1992). Subsequent General Counsel opinions interpreted

§ 1008 as “prohibiting any abortion referrals beyond ‘mere

referral,’ that is, providing a list of names and addresses

without in any further way assisting the woman in obtaining

an abortion.” Statutory Prohibition on Use of Appropriated

Funds Where Abortion is a Method of Family Planning,

53 Fed. Reg. 2922, 2923 (Feb. 2, 1988) (the 1988 Rule).

HHS revised its Title X regulations after notice and

comment in 1980. See Grants for Family Planning Services,

45 Fed. Reg. 37,433 (June 3, 1980). But like the 1971

regulations, the 1980 regulations did not address the scope of

§ 1008. Nat’l Family Planning, 979 F.2d at 229 (citing

45 Fed. Reg. at 37,437). Instead, in 1981, HHS issued

“Program Guidelines for Project Grants for Family Planning

Services.” See U.S. Dep’t of Health & Human Servs.,

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20 STATE OF CALIFORNIA V. AZAR

Program Guidelines for Project Grants for Family Planning

Services (1981). For the first time, these guidelines required

Title X projects to give Title X clients nondirective

counseling on and referrals for abortion upon request. Id.

§ 8.6. The 1981 “guidelines were premised on a view that

‘non-directive’ counseling and referral for abortion were not

inconsistent with [§ 1008] and were justified as a matter of

policy in that such activities did not have the effect of

promoting or encouraging abortion.” 53 Fed. Reg. at 2923.

It was not until 1988 that HHS addressed the scope of

§ 1008 in notice-and-comment rulemaking. See 53 Fed. Reg.

at 2922. The 1988 Rule recognized that “[f]ew issues facing

our society today are more divisive than that of abortion.” Id.

Because § 1008 was intended to create “a wall of separation

between Title X programs and abortion as a method of family

planning,” the 1988 Rule concluded that Congress intended

Title X to circumscribe “family planning” to include “only

activities related to facilitating or preventing pregnancy, not

for terminating it.” Id. at 2922–23. The 1988 Rule

accordingly defined the term “family planning” as including

“a broad range of acceptable and effective methods and

services to limit or enhance fertility.” Id. at 2944.

In light of these concerns, the 1988 Rule imposed

specified limits on a Title X project. First, the project could

not provide prenatal care. Id. at 2945. Therefore, “once a

client served by a Title X project is diagnosed as pregnant,

she must be referred for appropriate prenatal and/or social

services by furnishing a list of available providers that

promote the welfare of mother and unborn child.” Id.

Further, a Title X project could not “provide counseling

concerning the use of abortion as a method of family

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STATE OF CALIFORNIA V. AZAR 21

planning.” Id. In the preamble to the 1988 Rule, HHS

explained that counseling “which results in abortion as a

method of family planning simply cannot be squared with the

language of section 1008,” and the 1988 Rule therefore

rejected the 1981 program guidelines’ requirement that Title

X projects give nondirective counseling on abortion. Id.

at 2923. In barring such nondirective counseling, HHS also

relied on a General Accounting Office (GAO) report and

Office of the Inspector General (OIG) audit of Title X

projects indicating that some Title X projects were

“promoting abortion” under the guise of providing

nondirective counseling. Id. at 2924.3

Nor could a Title X project “provide referral for abortion

as a method of family planning.” Id. at 2945. Therefore, the

list of available providers given to a pregnant client could not

include “providers whose principal business is the provision

of abortions.” Id.

The 1988 Rule also required a Title X project to be

organized “so that it is physically and financially separate”

from activities prohibited by § 1008 and the regulations. Id.

To meet this “program integrity” requirement, “a Title X

project must have an objective integrity and independence

from prohibited activities. Mere bookkeeping separation of

Title X funds from other monies is not sufficient.” Id.

3 For example, the audit found that some Title X projects were

providing clients with brochures prepared by abortion clinics, providing

and witnessing the signing of consent forms required by abortion clinics,

making appointments for clients at abortion clinics, and using Title X

funds to pay the administrative costs for loans provided to clients to pay

for abortions. 53 Fed. Reg. at 2924 n.7.

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22 STATE OF CALIFORNIA V. AZAR

HHS explained that its rules requiring physical and

financial separation were supported by OIG-audit and GAOreport findings that Title X projects were arguably violating

§ 1008 and that the lack of separation led to confusion as to

whether federal funds were being used for abortion services. 

Id. Both OIG and GAO “urged [HHS] to give more specific,

formalized direction to programs about the extent of

prohibition on abortion as a method of family planning.” Id.

at 2923–24.

After HHS promulgated the 1988 Rule, Title X grantees

challenged the facial validity of the regulations on the

grounds that the regulations were not authorized by Title X,

were arbitrary and capricious under the Administrative

Procedure Act (APA), and violated the First and Fifth

Amendment rights of Title X clients and the First

Amendment rights of Title X health care providers. The

Supreme Court addressed these challenges in Rust.

Rust first rejected the plaintiffs’ claim “that the

regulations exceed [HHS]’s authority under Title X and are

arbitrary and capricious.” Id. at 183. Because the language

of § 1008 was “ambiguous” as to “the issues of counseling,

referral, advocacy, or program integrity,” the Court gave

“substantial deference” to HHS’s interpretation under

Chevron, U.S.A., Inc. v. Natural Resources Defense Council,

Inc., 467 U.S. 837, 842–43 (1984), and concluded that “[t]he

broad language of Title X plainly allows [HHS]’s

construction of the statute.” Rust, 500 U.S. at 184. “By its

own terms, § 1008 prohibits the use of Title X funds ‘in

programs where abortion is a method of family planning’”

but “does not define the term ‘method of family planning,’

nor does it enumerate what types of medical and counseling

services are entitled to Title X funding.” Id. In light of the

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STATE OF CALIFORNIA V. AZAR 23

“broad directives provided by Congress in Title X in general

and § 1008 in particular,” Rust concluded that HHS’s

“construction of the prohibition in § 1008 to require a ban on

counseling, referral, and advocacy within the Title X project”

was permissible. Id.

Rust likewise upheld the program integrity requirements,

which mandated separate facilities, personnel, and records. 

The Court concluded that the requirements were “based on a

permissible construction of the statute” and were “not

inconsistent with congressional intent.” Id. at 188. Rust

noted that “if one thing is clear from the legislative history, it

is that Congress intended that Title X funds be kept separate

and distinct from abortion-related activities.” Id. at 190. As

such, Rust declined to upset HHS’s “reasoned determination

that the program integrity requirements are necessary to

implement the prohibition” in § 1008. Id.

Rust also rejected the plaintiffs’ argument that the

regulations were arbitrary and capricious because “they

‘reverse a longstanding agency policy that permitted

nondirective counseling and referral for abortion’” and

constitute “a sharp break from [HHS]’s prior construction of

the statute.” Id. at 186. According to the Court, HHS’s

revised interpretation was entitled to deference because “the

agency, to engage in informed rulemaking, must consider

varying interpretations and the wisdom of its policy on a

continuing basis.” Id. (quoting Chevron, 467 U.S.

at 863–64). HHS gave a reasoned basis for its change of

interpretation, including that the new regulations were “more

in keeping with the original intent of the statute.” Id. at 187.

Rust then turned to the constitutional arguments. The

Court rejected the argument that the restrictions violated the

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24 STATE OF CALIFORNIA V. AZAR

First Amendment speech rights of grantees, their staff, and

clients, holding that the regulations permissibly implemented

Congress’s decision to allocate public funds “to subsidize

family planning services which will lead to conception and

childbirth, and declin[e] to promote or encourage abortion.” 

Id. at 193 (internal quotation marks omitted). “Congress’

power to allocate funds for public purposes includes an

ancillary power to ensure that those funds are properly

applied to the prescribed use,” and “the regulations are

narrowly tailored to fit Congress’ intent in Title X that federal

funds not be used to ‘promote or advocate’ abortion as a

‘method of family planning.’” Id. at 195 n.4. Doctors were

“always free to make clear that advice regarding abortion is

simply beyond the scope of the [Title X] program.” Id.

at 200. Rust also rejected arguments that the restrictions

violated a woman’s Fifth Amendment right to choose whether

to obtain an abortion because “[the] decision to fund

childbirth but not abortion ‘places no governmental obstacle

in the path of a woman who chooses to terminate her

pregnancy, but rather, by means of unequal subsidization of

abortion and other medical services, encourages alternative

activity deemed in the public interest.’” Id. at 201 (quoting

Harris v. McRae, 448 U.S. 297, 315 (1980)). The regulations

did not infringe the doctor-patient relationship, the Court

held, because the doctor and patient remained free to discuss

abortion and abortion-related services “outside the context of

the Title X project.” Id. at 203. Accordingly, Rust upheld the

1988 Rule.

Within months after Rust was decided, legislators

introduced the Family Planning Amendments Act of 1992,

H.R. 3090, 102d Cong. (1991), which sought to undo the

1988 Rule and to codify the 1981 program guidelines, see S.

Rep. No. 102-86 (1991). Under the proposed legislation,

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STATE OF CALIFORNIA V. AZAR 25

every applicant for a Title X grant had to agree to offer

“nondirective counseling and referrals regarding—(i) prenatal

care and delivery; (ii) infant care, foster care, and adoption;

and (iii) termination of pregnancy.” H.R. 3090, 102d Cong.

§ 2 (1991); S. 323, 102d Cong. § 2 (1991); H.R. Rep. No.

102-767, at 2 (1992). The bill failed to obtain the necessary

votes. See S. 323, 102d Cong., Roll No. 452 (Oct. 2, 1992).

After this legislative effort to overturn Rust failed,

President Clinton issued a memorandum directing HHS to

suspend the 1988 Rule. See The Title X “Gag Rule,” 58 Fed.

Reg. 7455 (Jan. 22, 1993). Two weeks later (without notice

or comment) HHS issued an interim rule suspending the 1988

Rule and announcing that the nonregulatory interpretations

that existed prior to the 1988 Rule, including those in the

1981 program guidelines, would apply. See Standards of

Compliance for Abortion-Related Services in Family

Planning Service Projects, 58 Fed. Reg. 7462 (Feb. 5, 1993). 

Legislators introduced another bill, the Family Planning

Amendments Act of 1995, H.R. 833, 104th Cong. (1995),

which included the same language as the amendments

proposed in 1991, and would have required nondirective

counseling on and referral for the “termination of pregnancy.” 

H.R. 833, 104th Cong. § 2(b)(3) (1995). As before, these

efforts were unsuccessful.

Around this same time, Congress was debating whether

to appropriate funds for Title X projects. See 141 Cong. Rec.

H8194-02, at 8249–62 (Aug. 2, 1995). In response to

concerns that Title X clinics were pressing teenagers to obtain

abortions, see id. at H8260 (Rep. Waldholtz), legislators

proposed a compromise bill that would ensure no federal

funds were used to support abortion services. As ultimately

enacted, the 1996 appropriations rider provided (among other

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26 STATE OF CALIFORNIA V. AZAR

things) “[t]hat amounts provided to [Title X] projects . . .

shall not be expended for abortions, [and] that all pregnancy

counseling shall be nondirective.” Pub. L. No. 115-245, 132

Stat. 2981, 3070–71. A version of this rider has been

reenacted each year since 1996.

In the wake of the defeat of the Family Planning

Amendments Acts of 1992 and 1995, HHS issued a new

regulation adopting the language of the failed legislation. See

Standards of Compliance for Abortion-Related Services in

Family Planning Service Projects, 65 Fed. Reg. 41,270 (July

3, 2000) (the 2000 Rule). The 2000 Rule provided that a

Title X project was required to offer a pregnant woman

“neutral, factual information and nondirective counseling” on

“each of the following options: (A) Prenatal care and

delivery; (B) Infant care, foster care, or adoption; and

(C) Pregnancy termination.” Id. at 41,279. Each Title X

project also had to provide referral for each option “upon

request.” Id.

The 2000 Rule eliminated several of the 1988 Rule’s

provisions. For instance, the 2000 Rule dropped the 1988

Rule’s definition of “family planning” but did not provide a

replacement definition. See id. at 41,278. Instead, the 2000

Rule simply stated that a family planning project must

“[p]rovide a broad range of acceptable and effective

medically approved family planning methods (including

natural family planning methods) and services (including

infertility services and services for adolescents).” Id.

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STATE OF CALIFORNIA V. AZAR 27

at 41,278–79. The 2000 Rule also eliminated the physical

and financial separation requirement. See id. at 41,276.4

While HHS’s oscillations in interpreting § 1008 were

playing out, Congress enacted various laws (referred to as

federal conscience laws) prohibiting discrimination against

individuals and entities who objected to performing or

promoting abortion on religious or moral grounds. Beginning

in 1973, Congress enacted four statutes (collectively referred

to as the Church Amendments) that prevent the government

from conditioning grant funds on assistance with abortionrelated activities, 42 U.S.C. § 300a-7(b), and prohibit grant

recipients from discriminating against individuals who

refused to assist with abortion because of their “religious

beliefs or moral convictions,” id. § 300a-7(c). In 1996,

Congress enacted the Coats-Snowe Amendment to the Public

Health Service Act, which prohibits the federal government

from discriminating against any health care entity because it

refuses to engage in certain abortion-related activities,

including providing referrals for abortions. Omnibus

Consolidated Rescissions and Appropriations Act of 1996,

Pub. L. No. 104-134, tit. V, § 515, 110 Stat. 1321, 1321-245

(1996) (codified at 42 U.S.C. § 238n(a)). Finally, in 2004

Congress began including a rider in health care appropriations

bills to prohibit discrimination by recipients of federal grants

against health care entities that refused to make referrals for

abortion, among other things. Consolidated Appropriations

4

In promulgating the 2000 Rule, HHS did not go as far as some

commenters urged. In rejecting comments that it should read § 1008

narrowly as prohibiting only “the provision of, or payment for, abortions”

and nothing else, HHS stated that this was not “the better reading of the

statutory language.” 65 Fed. Reg. at 41,272. HHS also acknowledged

that the 1988 Rule was “a permissible interpretation” of § 1008. Id.

at 41,277.

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28 STATE OF CALIFORNIA V. AZAR

Act, 2005, Pub. L. No. 108-447, 118 Stat. 2890, 3163 (2004)

(referred to as the Weldon Amendment).5

In 2008, HHS concluded that the 2000 Rule’s requirement

that Title X projects must provide counseling and referrals for

abortion upon request was inconsistent with these federal

conscience laws. Therefore, HHS promulgated regulations to

clarify it “would not enforce this Title X regulatory

requirement on objecting grantees or applicants.” Ensuring

that Department of Health and Human Services Funds Do

Not Support Coercive or Discriminatory Policies or Practices

in Violation of Federal Law, 73 Fed. Reg. 78,072, 78,087

(Dec. 19, 2008) (the 2008 nondiscrimination regulations). 

After a new administration took office, HHS decided these

regulations were “unclear and potentially overbroad in scope”

and rescinded them. Regulation for the Enforcement of

Federal Health Care Provider Conscience Protection Laws,

76 Fed. Reg. 9968, 9969 (Feb. 23, 2011).

Thus, before the 2018 rulemaking, HHS’s interpretations

of § 1008 had seesawed through multiple formulations: from

permitting—then requiring—nondirective counseling on

abortion as a method of family planning (in 1971 and 1981

guidance documents); to prohibiting counseling and referrals

for abortion as a method of family planning (in the 1988

Rule, upheld by the Supreme Court in 1991); and then to once

again requiring nondirective counseling and referrals for

abortion on request (in the 2000 Rule). HHS also vacillated

in its interpretation of the federal conscience laws. This

5The Weldon Amendment has been continuously enacted since 2004. 

See, e.g., Department of Defense and Labor, Health and Human Services,

and Education Appropriations Act, 2019, Pub. L. 115-245, 132 Stat. 2981,

3118.

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STATE OF CALIFORNIA V. AZAR 29

uncertain history was the backdrop forHHS’s reconsideration

of this controversial area in 2018.

B

In 2018, HHS returned to the task of interpreting § 1008

and issued a notice of proposed rulemaking “to ensure

compliance with, and enhance implementation of, the

statutory requirement that none of the funds appropriated for

Title X may be used in programs where abortion is a method

of family planning.” Compliance with Statutory Program

Integrity Requirements, 83 Fed. Reg. 25,502, 25,502 (June 1,

2018). After receiving over 500,000 comments reflecting a

“sharp diversity of opinion,” HHS issued a final rule in

March 2019. Compliance with Statutory Program Integrity

Requirements, 84 Fed. Reg. 7714, 7723 (Mar. 9, 2019) (the

Final Rule). The Final Rule largely represents a return to the

1988 Rule that the Supreme Court upheld in Rust.

The Final Rule’s definition of the statutory term “family

planning” is substantially similar to the 1988 Rule’s

definition. It “means the voluntary process of identifying

goals and developing a plan for the number and spacing of

children,” including by means of “a broad range of acceptable

and effective family planning methods and services.” 84 Fed.

Reg. at 7787; 42 C.F.R. § 59.2 (2019). Like the 1988 Rule,

the Final Rule states that family planning services “include

preconception counseling” but not “postconception care

(including obstetric or prenatal care) or abortion as a method

of family planning.” 84 Fed. Reg. at 7787; 42 C.F.R. § 59.2.

In the preamble to the Final Rule, HHS explained that it

adopted this definition of “family planning” to “address in

part its concern that the requirement for abortion referrals, as

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30 STATE OF CALIFORNIA V. AZAR

provided in the 2000 [Rule], violates or leads to violations of

section 1008’s prohibition on funding Title X projects where

abortion is a method of family planning.” 84 Fed. Reg.

at 7729. HHS also explained it was reestablishing the 1988

Rule’s requirement that family planning methods and services

be “acceptable and effective,” omitting the 2000 Rule’s

requirement that they also be “medically approved,” because

the term “medically approved” lacked clear meaning in this

context and does not appear in the statute. Id. at 7740–41.

Repeating the language of Title X, see 42 U.S.C. § 300(a),

the Final Rule provides that a family planning project must

“[e]ncourage family participation in the decision to seek

family planning services,” 42 C.F.R. § 59.5(a)(14). In the

preamble, HHS noted that this language was required by the

Title X statute itself and that Congress had enacted an

appropriations rider that “specifically emphasizes that

grantees encourage family participation ‘in the decision of

minors to seek family planning services.’” 84 Fed. Reg.

at 7718 (quoting Pub. L. No. 115-245, div. B, sec. 207, 132

Stat. 2981, 3070 (2018)).

The Final Rule also sets forth requirements and

limitations for post-conception services. See 42 C.F.R.

§ 59.14. Under the Rule, once a client is verified as being

pregnant, the client “shall be referred to a health care provider

for medically necessary prenatal health care.” Id.

§ 59.14(b)(1). The regulations explain that “[p]rovision of a

referral for prenatal health care is consistent with [Title X]

because prenatal care is a medically necessary service.” Id.

§ 59.14(e)(1).

The Final Rule differs from the 1988 Rule with respect to

pregnancy counseling. HHS noted that the 1996

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STATE OF CALIFORNIA V. AZAR 31

appropriations rider, as reenacted annually, required “that all

pregnancy counseling shall be nondirective.”6 84 Fed. Reg.

at 7725 n.36, 7729. Interpreting the rider’s language as

permitting such counseling, id. at 7725, the Final Rule states

that a Title X project can give a pregnant client nondirective

pregnancy counseling “when provided by physicians or

advanced practice providers.” 42 C.F.R. § 59.14(b)(1)(i).7

6

 The appropriations rider for 2018 provides:

For carrying out the program under title X of the

[Public Health Service] Act to provide for voluntary

family planning projects, $286,479,000: Provided,

That amounts provided to said projects under such title

shall not be expended for abortions, that all pregnancy

counseling shall be nondirective, and that such amounts

shall not be expended for any activity (including the

publication or distribution of literature) that in any way

tends to promote public support or opposition to any

legislative proposal or candidate for public office.

Pub. L. No. 115-245, div. B, tit. II, 132 Stat. 2981, 3070–71 (2018).

7

 The Final Rule defines “Advanced Practice Provider” as:

[A] medical professional who receives at least a

graduate level degree in the relevant medical field and

maintains a license to diagnose, treat, and counsel

patients. The term Advanced Practice Provider

includes physician assistants and advanced practice

registered nurses (APRN). Examples of APRNs that

are an Advanced Practice Provider include certified

nurse practitioner (CNP), clinical nurse specialist

(CNS), certified registered nurse anesthetist (CRNA),

and certified nurse-midwife (CNM).

42 C.F.R. § 59.2.

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32 STATE OF CALIFORNIA V. AZAR

Unlike the 1988 Rule, the Final Rule establishes that a

counselor providing nondirective pregnancy counseling “may

discuss abortion” so long as “the counselor neither refers for,

nor encourages, abortion.” Id. § 59.14(e)(5). To ensure

compliance with federal conscience laws, however, a Title X

provider is not required to discuss abortion upon request. See

84 Fed. Reg. at 7716, 7746–47. In short, the Final Rule does

not impose a “gag” on abortion counseling: a counselor “may

discuss abortion” but is not required to do so. 42 C.F.R.

§ 59.14(e)(5).8

8 The dissent relies heavily on its mistaken view that the Final Rule

is a “Gag Rule” that “gags health care providers from fully counseling

women about their options while pregnant.” Dissent at 81. The dissent

conjures up a “Kafkaesque” situation where counselors have to “walk on

eggshells to avoid a potential transgression” of the Final Rule and in

response to questions about terminating a pregnancy can merely say: “I

can’t help you with that or discuss it. Here is a list of doctors who can

assist you with your pre-natal care despite the fact that you are not seeking

such care.” Dissent at 85–86 (citation omitted). But this “Kafkaesque”

scenario is belied by the Final Rule itself, which expressly authorizes

counseling on abortion while prohibiting referrals for abortion. Indeed,

the Final Rule provides its own example of a straightforward conversation

with a client who asks about abortion:

[When a] pregnant woman requests information on

abortion and asks the Title X project to refer her for an

abortion[, then] [t]he counselor tells her that the project

does not consider abortion a method of family planning

and, therefore, does not refer for abortion. The

counselor offers her nondirective pregnancy counseling,

which may discuss abortion, but the counselor neither

refers for, nor encourages, abortion.

42 U.S.C. § 59.14(e)(5) (emphasis added). The dissent’s arguments that

the Final Rule is a “Gag Rule” is merely a restatement of its disagreement

with the Final Rule’s interpretation of § 1008 as precluding “referral for

abortion as a method of family planning.” 84 Fed. Reg. at 7717.

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STATE OF CALIFORNIA V. AZAR 33

Although the Final Rule permits a Title X project to

provide nondirective counseling that includes information

about abortion, it expressly prohibits referrals for abortion as

a method of family planning. HHS explained its

understanding that “referral for abortion as a method of

family planning, and such abortion procedure itself, are so

linked that such a referral makes the Title X project or clinic

a program one where abortion is a method of family

planning.” 84 Fed. Reg. at 7717. Accordingly, “[a] Title X

project may not perform, promote, refer for, or support

abortion as a method of family planning, nor take any other

affirmative action to assist a patient to secure such an

abortion.” 42 C.F.R. § 59.14(a). Further, “[a] Title X project

may not use the provision of any prenatal, social service,

emergency medical, or other referral, of any counseling, or of

any provider lists, as an indirect means of encouraging or

promoting abortion as a method of family planning.” Id.

§ 59.14(c)(1).

While referrals for abortion as a method of family

planning are not allowed, the Title X project may give a

pregnant client a “list of licensed, qualified, comprehensive

primary health care providers,” which may include “providers

of prenatal care[], some, but not the majority, of which also

provide abortion as part of their comprehensive health care

services.” Id. § 59.14(c)(2). “Neither the list nor project staff

may identify which providers on the list perform abortion.” 

Id. The Title X project may also provide referrals for

abortion when such a procedure is medically necessary. 

84 Fed. Reg. at 7748.

Finally, the Final Rule, like the 1988 Rule, requires that

a Title X project be organized “so that it is physically and

financially separate . . . from activities that are prohibited

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34 STATE OF CALIFORNIA V. AZAR

under section 1008 of the Public Health Service Act and

§§ 59.13, 59.14, and 59.16 of these regulations.” 42 C.F.R.

§ 59.15. HHS explained that the physical and financial

separation requirements were necessary to avoid the risk “of

the intentional or unintentional use of Title X funds for

impermissible purposes, the co-mingling of Title X funds, the

appearance and perception that Title X funds being used in a

given program may also be supporting that program’s

abortion activities, and the use of Title X funds to develop

infrastructure that is used for the abortion activities of Title

X clinics.” 84 Fed. Reg. at 7764.

The effective date of the Final Rule was set for May 3,

2019, but the compliance deadline for the physical separation

requirements is March 4, 2020. Id. at 7714.

C

Before the Final Rule’s effective date, several states and

private Title Xgrantees (collectively, plaintiffs) filed lawsuits

against HHS in three different district courts seeking

preliminary injunctive relief. The lawsuits challenged the

Final Rule under the APA as arbitrary and capricious,

contrary to law, and in excess of statutory authority. 5 U.S.C.

§ 706(2)(A), (C).9 All three district courts granted plaintiffs’

preliminary injunction motions on similar grounds. See

Washington v. Azar, 376 F. Supp. 3d 1119 (E.D. Wash.

9 Plaintiffs also brought various constitutional claims, but the district

courts did not base their preliminary injunctions on these claims. 

Plaintiffs do not raise these claims as alternative grounds for affirming the

district courts’ grants of injunctive relief, so any such argument was

waived. See United States v. Gamboa-Cardenas, 508 F.3d 491, 502

(2007).

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STATE OF CALIFORNIA V. AZAR 35

2019); California v. Azar, 385 F. Supp. 3d 960 (N.D. Cal.

2019); Oregon v. Azar, 389 F. Supp. 3d 898 (D. Or. 2019). 

HHS timely appealed each of the preliminary injunction

orders.10

We review a district court’s grant of a preliminary

injunction “for an abuse of discretion.” Gorbach v. Reno,

219 F.3d 1087, 1091 (9th Cir. 2000) (en banc). But “legal

issues underlying the injunction are reviewed de novo

because a district court would necessarily abuse its discretion

if it based its ruling on an erroneous view of law.” adidas

Am., Inc. v. Skechers USA, Inc., 890 F.3d 747, 753 (9th Cir.

2018) (citation omitted).

II

“A plaintiff seeking a preliminary injunction must

establish [1] that he is likely to succeed on the merits, [2] that

he is likely to suffer irreparable harm in the absence of

preliminary relief, [3] that the balance of equities tips in his

favor, and [4] that an injunction is in the public interest.” 

Winter v. Nat. Res. Def. Council, Inc., 555 U.S. 7, 20 (2008);

accord Garcia v. Google, Inc., 786 F.3d 733, 740 (9th Cir.

2015). The first factor—likelihood of success on the

merits—“is the most important” factor. Id. If a movant fails

10 HHS also moved to stay the injunctions pending a decision on the

merits of its appeals. We granted the stay motion in a published order. 

See California v. Azar, 927 F.3d 1068 (9th Cir. 2019) (per curiam). Upon

the vote of a majority of nonrecused active judges, we ordered

reconsideration en banc of the stay motion, California v. Azar, 927 F.3d

1045, 1046 (9th Cir. 2019) (mem.), but we did not vacate the stay order

itself, so it remained in effect, California v. Azar, 928 F.3d 1153, 1155

(9th Cir. 2019) (mem.). The stay motion is now denied as moot.

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36 STATE OF CALIFORNIA V. AZAR

to establish likelihood of success on the merits, we need not

consider the other factors. Id.

The Supreme Court has recognized that when an issue of

law is key to resolving a motion for injunctive relief, the

reviewing court has the power “to examine the merits of the

case” and resolve the legal issue. Munaf v.Geren, 553 U.S.

674, 691 (2008) (internal quotation marks omitted) (quoting

N.C. R. Co. v. Story, 268 U.S. 288, 292 (1925)). 

“Adjudication of the merits is most appropriate if the

injunction rests on a question of law and it is plain that the

plaintiff cannot prevail.” Id.; accord Blockbuster Videos, Inc.

v. City of Tempe, 141 F.3d 1295, 1297 (9th Cir. 1998). The

Supreme Court reaffirmed this conclusion in Winter, noting

that it could “address the underlying merits of plaintiffs’

[legal] claims” in the preliminary injunction appeal and

proceed to a decision. 555 U.S. at 31; see also Blockbuster

Videos, 141 F.3d at 1297; Friends of the Earth v. U.S. Navy,

841 F.2d 927, 931 (9th Cir. 1988).

This approach applies in appropriate APA cases. See

Beno v. Shalala, 30 F.3d 1057, 1063–64 (9th Cir. 1994). In

Beno, we considered plaintiffs’ claim that an agency’s action

was “‘arbitrary and capricious’ within the meaning of the

APA.” Id. at 1063. The APA claim required only review of

the administrative record and interpretation of relevant

statutes; “additional fact-finding [was] not necessary to

resolve th[e] claim.” Id. at 1064 n.11. Because “the district

court’s denial of injunctive relief rested primarily on

interpretations of law, not on the resolution of factual issues,”

we reviewed de novo the district court’s legal conclusions

and addressed plaintiffs’ claims on the merits. Id. at 1063–64

(internal quotation marks omitted). We held this was

appropriate because “in APA cases, a district court decision

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STATE OF CALIFORNIA V. AZAR 37

is generally accorded no particular deference, and is reviewed

de novo because the district court is in no better position than

this court to review the administrative record.” Id. at 1063

n.9 (internal quotation marks and citations omitted). This

approach is consistent with the Supreme Court’s ruling that

district courts’ “factfinding capacity” is “typically

unnecessary to judicial review of agency decisionmaking”

because both the district court and the court of appeals “are

to decide, on the basis of the record the agency provides,

whether the action passes muster under the appropriate APA

standard of review.” Fla. Power & Light Co. v. Lorion,

470 U.S. 729, 744 (1985).

Here, the only significant issues raised are legal. 

Plaintiffs argue that the Final Rule is invalid on its face

because it conflicts with other statutes and the agency acted

in an arbitrary and capricious manner in promulgating it. An

agency’s action violates the APA when it is “in excess of

statutory jurisdiction [or] authority,” 5 U.S.C. § 706(2)(C), or

when it is “not in accordance with law,” id. § 706(2)(A), for

instance, when it violates another statute, see FCC v.

NextWave Pers. Commc’ns Inc., 537 U.S. 293, 300 (2003). 

The record before us is sufficient to resolve plaintiffs’

challenges, and no additional factual development is

required.11 The district courts issued preliminary injunctions

11 Although the parties did not submit the full administrative record

(which includes over 500,000 public comments) to the district courts, all

public comments made during the rulemaking process are available online

and were available to the parties in raising arguments to the district courts. 

See Compliance with Statutory Program Integrity Requirements,

regulations.gov (last visited Oct. 29, 2019), https://www.regulations.go

v/document?D=HHS-OS-2018-0008-0001; 84 Fed. Reg. at 7722 & n.26. 

Indeed, the parties used selected public comments to support their

arguments in their briefs both to the district courts and to us. Despite this,

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38 STATE OF CALIFORNIA V. AZAR

based on their view that plaintiffs were likely to prevail on

the merits of these legal claims, and thus the district courts

were not in any better position to decide these issues than we

are. See Beno, 30 F.3d at 1063 n.9.12 We have received

extensive briefing and heard argument on the issues

presented. Because we can decide, based on the record

the dissent asserts that “[d]eciding the merits of [p]laintiffs’ arbitrary and

capricious claim is . . . premature” because “[w]e do not have the

complete administrative record.” Dissent at 95–96. But neither plaintiffs

nor the dissent identify additional arguments that could be made after

submission of the full record, see Dissent at 95–96; at most, plaintiffs

stated at oral argument (but not in their briefing) that they might delve

deeper into the approximately 500,000 public comments to provide

additional support for their existing arguments. Because HHS did not

omit or withhold material information from the administrative record, the

cases on which the dissent relies are inapposite. See Walter O. Boswell

Mem’l Hosp. v. Heckler, 749 F.2d 788, 793 (D.C. Cir. 1984) (holding that

review could not go forward on a partial record where doing so “would be

fundamentally unfair” because agency had withheld significant

information); Nat. Res. Def. Council, Inc. v. Train, 519 F.2d 287, 292

(D.C. Cir. 1975) (remanding to district court for further review where

agency omitted a key document that “throws light on the factors and

considerations relied upon” by the agency fromthe administrative record). 

Accordingly, we conclude that the record before us is sufficient to resolve

plaintiffs’ arguments that aspects of the Final Rule are arbitrary and

capricious. See McChesney v. FEC, 900 F.3d 578, 583 (8th Cir. 2018); 5

U.S.C. § 706 (“[T]he court shall review the whole record or those parts of

it cited by a party.”).

12 In considering plaintiffs’ claims that HHS’s action was arbitrary

and capricious, the district courts properly limited their review to the

record before them. See California, 385 F. Supp. 3d at 1000–18;

Washington, 376 F. Supp. 3d at 1131; Oregon, 389 F. Supp. 3d at 914–19. 

While the district courts made factual findings and predictions to support

their conclusion that plaintiffs showed a likelihood of irreparable harm,

see, e.g., California, 385 F. Supp. 3d at 978–85, see also Fed. R. Civ. P.

52(a), these findings are not relevant to the resolution of the arbitrary and

capricious challenge, see Fla. Power & Light Co., 470 U.S. at 744.

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STATE OF CALIFORNIA V. AZAR 39

provided, “whether the action passes muster under the

appropriate APA standard of review,” Fla. Power & Light

Co., 470 U.S. at 744, we may resolve the legal issues on their

merits, Beno, 30 F.3d at 1064.

III

We first consider plaintiffs’ argument that the Final Rule

is facially invalid. Plaintiffs wisely do not press the argument

that the Final Rule is an impermissible interpretation of the

text of § 1008. Rust held that “[t]he broad language of

Title X plainly allows [the 1988 Rule’s] construction of the

statute,” 500 U.S. at 184, and the Final Rule is substantially

the same as the 1988 Rule with respect to the provisions at

issue here.

Rather, plaintiffs mainly argue that two intervening

congressional enactments altered the legal landscape so that

Rust’s holding is no longer valid. First, plaintiffs point to the

1996 appropriations rider enacted to ensure no federal funds

were used to support abortion services. See Pub. L. No. 115-

245, div. B, tit. II, 132 Stat. 2981, 3070–71 (2018). Second,

plaintiffs rely on a section of the Patient Protection and

Affordable Care Act (ACA) that limits HHS’s ability to

promulgate regulations. See Pub. L. No. 111-148, § 1554,

124 Stat. 119, 259 (2010) (codified at 42 U.S.C. § 18114).

In considering these arguments, we are mindful that the

Supreme Court’s “interpretive decisions, in whatever way

reasoned, effectively become part of the statutory scheme.” 

Kimble v. Marvel Entm’t, LLC, 135 S. Ct. 2401, 2409 (2015). 

Therefore, Rust’s conclusion that § 1008 could be interpreted

to bar abortion counseling, referral, and advocacy within a

Title X project became a part of Title X’s scheme, and we

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40 STATE OF CALIFORNIA V. AZAR

may not lightly infer that Congress intended to overrule that

holding in enacting the appropriations rider or § 1554 of the

ACA. Because “[t]he modification by implication of [a]

settled construction of an earlier and different section” by a

later enactment “is not favored,” United States v. Madigan,

300 U.S. 500, 506 (1937), plaintiffs must provide evidence

that Congress intended to alter Rust’s conclusion that the

1988 Rule was a permissible interpretation of Title X and

§ 1008. They fail to do so.

A

We first turn to plaintiffs’ argument that the Final Rule

violates the 1996 appropriations rider. At the time HHS

promulgated the Final Rule, the appropriations rider provided

that “amounts provided to [the Title X project] shall not be

expended for abortions, [and] that all pregnancy counseling

shall be nondirective.” Pub. L. No. 115-245, div. B, tit. II,

132 Stat. 2981, 3070–71 (2018). HHS interpreted this

appropriations rider as permitting Title X projects to provide

counseling on abortion, and incorporated this interpretation

in the Final Rule. See 84 Fed. Reg. at 7725; 42 C.F.R.

§ 59.14(e)(5).

Plaintiffs’ argument about the correct interpretation of

this provision proceeds in three steps. First, according to

plaintiffs, the term “pregnancy counseling” must be

interpreted as including referrals. Second, plaintiffs contend

that the term “nondirective” means the presentation of all

options on an equal basis. Third, putting these two

definitions together, plaintiffs argue that the term

“nondirective pregnancy counseling” requires the provision

of referrals for abortion on the same basis as referrals for

prenatal care and adoption. Because the Final Rule requires

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STATE OF CALIFORNIA V. AZAR 41

referrals for medically necessary prenatal health care and

permits referrals for adoption but precludes referrals for

abortion, see 42 C.F.R. § 59.14, plaintiffs contend that the

Final Rule does not provide nondirective pregnancy

counseling, and thus violates the appropriations rider. We

consider each of these steps in turn.

1

At the first step, plaintiffs and the dissent argue that the

statutory term “pregnancy counseling” must be interpreted as

including referrals.13 Congress has not provided a definition

of the term “pregnancy counseling,” or otherwise “directly

addressed the precise question at issue.” Chevron, 467 U.S.

at 843. In the face of Congressional silence, we give

“substantial deference” to the interpretations provided by

HHS. Rust, 500 U.S. at 184.14

In the Final Rule, HHS provided its interpretation by

treating the terms “counseling” and “referral” as referring to

distinct legal concepts. See 84 Fed. Reg. at 7716–17. While

a counselor may “provide nondirective pregnancy counseling

to pregnant Title X clients on the patient’s pregnancy options,

including abortion,” id. at 7724 (emphasis added), the Final

Rule prohibits any “referral for abortion as a method of

family planning,” id. at 7717.

13 As HHS recognized, the appropriations rider amended Title X by

expressly requiring all pregnancy counseling to be nondirective. 84 Fed.

Reg. at 7725, 7729. Congress “may amend substantive law in an

appropriations statute, as long as it does so clearly.” Robertson v. Seattle

Audubon Soc’y, 503 U.S. 429, 440 (1992).

14 HHS is the agency authorized to promulgate regulations to

implement Title X, see 42 U.S.C. § 300a-4(a).

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42 STATE OF CALIFORNIA V. AZAR

In its brief on appeal, HHS made explicit the Final Rule’s

implicit interpretation of “counseling.”15 According to HHS,

under the Final Rule and as a matter of common usage,

“counseling and referrals are distinct” because “‘[p]regnancy

counseling’ involves providing information about medical

options, which is different from referring a patient to a

specific doctor for a specific form of medical care.”

HHS’s interpretation of the phrase “pregnancy

counseling” as a concept that is distinct from the term

“referrals” is reasonable and consistent with common usage. 

The dictionary indicates that counseling does not include

referrals. The dictionary definition of the term “counseling”

is “a practice or professional service designed to guide an

individual to a better understanding of [her] problems and

potentialities . . . .” Counseling, Webster’s Third New

International Dictionary 518 (2002); see alsoCounseling,The

American Medical Association Encyclopedia of Medicine

15 We may defer to an interpretation made in a legal brief so long as

it is not a post hoc rationalization “advanced by an agency seeking to

defend past agency action against attack.” Auer v. Robbins, 519 U.S. 452,

462 (1997). As in Auer, there is no reason here to think that HHS’s

position is a “post hoc rationalization.” Id. Indeed, HHS has long treated

“counseling” and “referral” as distinct concepts. The 1981 guidelines and

the 2000 Rule both provided that Title X projects were required to provide

“nondirective counseling on each of the options [including pregnancy

termination], and referral upon request.” 65 Fed. Reg. at 41,279;

Program Guidelines for Project Grants for Family Planning Services,

§ 8.6 (1981) (emphasis added); see also 53 Fed. Reg. at 2923 (explaining

that the 1981 guidelines required providers to furnish “nondirective

‘options couns[e]ling”—including “on pregnancy termination

(abortion)”—“followed by referral for these services if [the patient] so

requests”). And the 2000 Rule treated “non-directive counseling,” see

65 Fed. Reg. at 41,272–74, as distinct from “[r]eferral[s] for abortion, see

id. at 41,274.

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STATE OF CALIFORNIA V. AZAR 43

317 (1989) (defining “counseling” as “[a]dvice and

psychological support given by a health professional and

usually aimed at helping a person cope with a particular

problem”). By contrast, “referral” is defined as “the process

of directing or redirecting (as a medical case, a patient) to an

appropriate specialist or agency for definitive treatment.” 

Referral, Webster’s Third New International Dictionary 1908

(2002). As in Rust, “[t]he broad language of Title X,” as

amended by the 1996 appropriations rider, “plainly allows

[HHS]’s construction of the statute.” 500 U.S. at 184.

Plaintiffs’ and the dissent’s argument that the term

“pregnancy counseling” must be interpreted as including

referrals is primarily based on their reading of a separate

statute enacted by Congress, the Children’s Health Act of

2000, Pub. L. No. 106-310, 114 Stat. 1101 (2000); see

Dissent at 90–91. A provision of that Act, the “Infant

Adoption Awareness” section, 42 U.S.C. § 254c-6, requires

HHS to make grants to adoption organizations “for the

purpose of developing and implementing programs to train

the designated staff of eligible health centers in providing

adoption information and referrals to pregnant women on an

equal basis with all other courses of action included in

nondirective counseling to pregnant women.” 42 U.S.C.

§ 254c-6(a)(1). According to plaintiffs and the dissent, this

language shows Congress intended that referrals be “included

in nondirective counseling” and that all options, including

abortion, should be presented on an equal basis. See Dissent

at 90–91.

This argument fails. The Infant Adoption Awareness

section neither provides a definition of “nondirective

counseling” nor “expressly states” that nondirective

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44 STATE OF CALIFORNIA V. AZAR

counseling “encompasses referrals.” Cf. Dissent at 87 n.4.16

Simply put, the section does not show that referrals are a type

of nondirective counseling. Indeed, it does not impose any

requirements or limitations on nondirective pregnancy

counseling at all; rather, it provides funds to adoption

organizations to enable them to offer training to the staff of

health centers regarding the provision of adoption

information and referrals to clients. HHS could reasonably

conclude that this section does not indicate that it considers

referrals to be a type of counseling, as opposed to something

that may occur at the same time as counseling. 84 Fed. Reg.

at 7733. Given that the Infant Adoption Awareness section

is not part of Title X, does not use language similar to that in

the 1996 appropriations rider, and was enacted for a

substantially different purpose, it sheds no light on

Congress’s intent in enacting the appropriations rider or on

the interpretation of its statutory language. Cf. Northcross v.

Bd. of Educ. of Memphis City Sch., 412 U.S. 427, 428 (1973)

(per curiam) (providing that it is appropriate to interpret the

language of two separate statutes pari passu where two

statutes use similar language and were enacted for the same

purpose).17

16 Although the dissent claims that Congress “clarified the meaning

of the term ‘nondirective’” and that Congress’s “intent is clear,” in fact,

the dissent merely offers its own interpretation of what the term means in

context. Dissent at 90.

17 In addition to discussing the Infant Adoption Awareness section,

42 U.S.C. § 254c-6(a)(1), both the plaintiffs and HHS point to other

statutes that reference counseling and referrals. HHS notes that Congress

has frequently referred to counseling and referrals separately, showing that

the two are legally distinct concepts. See, e.g., 42 U.S.C. § 300z-10(a)

(“Grants or payments may be made only to . . . projects which do not

provide abortions or abortion counseling or referral . . . .”); id. § 300z-3(b)

(referring to “counseling and referral services”); 18 U.S.C. § 248(e)(5)

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STATE OF CALIFORNIA V. AZAR 45

Plaintiffs’ and the dissent’s second argument, that

industry practice requires interpreting “counseling” as

including referrals, also fails, because the sources on which

plaintiffs rely shed no light on the proper interpretation of the

term “nondirective pregnancy counseling.” Dissent at 87 n.4. 

Plaintiffs first point to HHS’s guidelines in Providing Quality

Family Planning Services (the QFP), which state that during

a “visit [to] a provider of family planning services,”

pregnancy-test results “should be presented to the client,

followed by a discussion of options and appropriate

referrals.” U.S. Dep’t of Health & Human Servs., Providing

Quality Family Planning Services, Morbidity & Mortality

Wkly. Rep., Apr. 25, 2014, at 13–14. Rather than requiring

an interpretation of counseling as including referrals, this

language suggests that counseling (i.e., “discussion of

options”) and referrals are distinct. Plaintiffs also point to a

letter submitted by the American Medical Association

(AMA) during the notice-and-comment period on the Final

Rule. In this letter, the AMA listed several provisions in its

Code of Medical Ethics which it claimed made it unethical for

a practitioner to refrain from providing “all appropriate

(“reproductive health services” includes “counseling or referral services

relating to the human reproductive system, including services relating to

pregnancy or the termination of a pregnancy”). Plaintiffs identify other

statutes that suggest referrals can occur during the course of counseling.

See, e.g., 42 U.S.C. § 300ff-33 (“post-test counseling (including referrals

for care)” provided to individuals with positive HIV/AIDS test); id.

§ 3020e-1(b) (referring to “pension counseling and information programs”

that “provide outreach, information, counseling, referral, and other

assistance”); 20 U.S.C. § 1161k(c)(4)(A) (requiring college counselors to

provide “referrals to and follow-up with other student services staff”). 

Because these statutes do not use the same language as the appropriations

rider and were not enacted for the same purpose, they do not assist us in

interpreting Congress’s direction “that all pregnancy counseling shall be

nondirective.” See 84 Fed. Reg. at 7745.

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46 STATE OF CALIFORNIA V. AZAR

referrals, including for abortion services.” But the provisions

of the code cited in the letter do not even discuss referrals, let

alone define the term; rather, they state that patients have a

right “to receive information from their physicians and to

have the opportunity to discuss the benefits, risks, and costs

of appropriate treatment alternatives” and “to expect that their

physicians will provide guidance about what they consider

the optimal course of action for the patient based on the

physician’s objective professional judgment.” These sources

do not show that the term “referrals” is included in the phrase

“nondirective pregnancy counseling.”18

Because HHS can reasonably interpret “nondirective

pregnancy counseling” as not including referrals, see 84 Fed.

Reg. at 7716, plaintiffs fail at the first step of their arguments,

that “pregnancy counseling” must be deemed to include

referrals.

2

Plaintiffs also fail at the second step of their argument: 

that the term “nondirective” means the presentation of all

options on an equal basis. Neither Title X nor the

appropriations rider defines “nondirective.” Again, because

Congress has “not directly addressed the precise question at

issue,” Chevron, 467 U.S. at 843, we must give substantial

deference to HHS’s interpretation. Rust, 500 U.S. at 184. In

the Final Rule, HHS filled the Congressional silence by

interpreting “nondirective pregnancy counseling” to mean

18 The dissent does not address these sources and merely asserts,

without explanation, that “industry understanding recognizes that

counseling includes referrals.” Dissent at 87 n.4 (citing California, 385 F.

Supp. 3d at 989).

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STATE OF CALIFORNIA V. AZAR 47

“the meaningful presentation of options where the physician

or advanced practice provider (APP) is ‘not suggesting or

advising one option over another.’” 84 Fed. Reg. at 7716

(quoting 138 Cong. Rec. H2822-02, 2826 (statement of Rep.

Lloyd)).

Under this definition, “nondirective” does not mean the

presentation of all possible medical options. Rather,

“nondirective” means that options must be provided in a

neutral manner, without suggesting or advising one option

over another. Thus, a physician or APP providing

nondirective counseling to a client does not have to discuss

every possible option available to that client, but must present

options in a neutral manner and refrain from encouraging the

client to select a particular option. In other words, HHS

interpreted “nondirective” to refer to the neutral manner in

which counseling is provided rather than to the scope of

topics that must be covered in counseling. 84 Fed. Reg.

at 7716.

This is a reasonable interpretation of “nondirective.” It is

consistent with HHS’s longstanding distinction between

“nondirective” counseling that is “neutral” and “directive”

counseling that encourages or promotes abortion. Nat’l

Family Planning, 979 F.2d at 229. And it is consistent with

the dictionary definition of the term “nondirective” as a type

of counseling where “the counselor refrains from interpretive

or associative comment but usually by repeating phrases used

by the client encourages [the client] to express, clarify, and

restructure [the client’s] problems.” Nondirective, Webster’s

Third New International Dictionary 1536 (2002); see also

84 Fed. Reg. at 7716 (nondirective counseling involves

“clients tak[ing] an active role in processing their experiences

and identifying the direction of the interaction”). Because

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48 STATE OF CALIFORNIA V. AZAR

HHS’s interpretation of “nondirective” is reasonable, we

defer to that interpretation. See Chevron, 467 U.S. at 843–44;

Nw. Envtl. Advocates v. EPA, 537 F.3d 1006, 1014 (9th Cir.

2008).

We also reject plaintiffs’ and the dissent’s argument that

the Final Rule is directive because it requires referrals for

medically necessary prenatal health care. Dissent at 85. HHS

could reasonably conclude that referrals for prenatal care are

nondirective, as HHS defines this term, because a referral for

prenatal care does not steer the client toward any particular

option and does not discourage a client from seeking an

abortion outside of the Title X program. As HHS points out,

“seeking prenatal care is not the same as choosing the option

of childbirth.” 84 Fed. Reg. at 7748. Further, HHS could

reasonably conclude that providing a referral for prenatal care

is not directive because it is “medically necessary” for the

health of the client during pregnancy, id. at 7748, 7761–62,

regardless of whether the client later chooses an abortion

outside of a Title X project.19“Where care is medically

19 Plaintiffs and the dissent point to declarations from doctors and

nurse practitioners conclusorily stating that prenatal care “is not medically

necessary for someone who wishes to terminate her pregnancy.” Dissent

at 88 n.5. But HHS reasonably concluded otherwise, 84 Fed. Reg. at

7748, 7761–62, based on its determination that “pregnancy may stress and

affect extant [i.e., existing] health conditions [of the client],” such that

“primary health care may be critical to ensure that pregnancy does not

negatively impact such conditions,” id. at 7750.

The dissent’s argument that HHS did not justify the referral

requirement on the ground that prenatal care is medically necessary for the

health of the client, Dissent at 88 n.5, is refuted by the record; indeed, the

sentence of the Final Rule on which the dissent relies for this argument

makes clear that prenatal care is “important for . . . the health of the

women,” 84 Fed. Reg. at 7722 (emphasis added); see also id. at 7748,

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STATE OF CALIFORNIA V. AZAR 49

necessary, as prenatal care is for pregnancy, referral for that

care is not directive because the need for the care preexists

the direction of the counselor, and is, instead, the result of the

woman’s pregnancy diagnosis or the diagnosis of a health

condition for which treatment is warranted.” Id. at 7748. 

Because prenatal care is medically necessary for a pregnant

client, see id. at 7748, 7761–62, referrals for such care are

distinguishable from referrals for abortions for the purpose of

family planning, which are not medically necessary. Indeed,

the Supreme Court has long recognized that abortion need not

be treated the same as other medical procedures: “Abortion

is inherently different from other medical procedures,

because no other procedure involves the purposeful

termination of a potential life.” Harris v. McRae, 448 U.S.

297, 325 (1980); see also Maher, 432 U.S. at 480 (“The

simple answer to the argument” that a law imposes different

requirements on abortion than other medical procedures is

that other “procedures do not involve the termination of a

potential human life.”).20 Given these distinctions, requiring

7761–62.

20 Given the “inherent[] differen[ces]” between abortion and other

medical procedures, McRae, 448 U.S. at 325, the dissent’s attempt to liken

nontherapeutic abortion to treatment options for prostate cancer is

meritless, Dissent at 87. Prostate cancer is a disease, and “chemotherapy,

radiation, [and] hospice” are treatment options. Dissent at 87. Pregnancy

is not a disease, and a nontherapeutic abortion is not a treatment option.

By contrast, abortion is not used as a “method of family planning”

under § 1008 or the Final Rule when abortion is medically necessary (i.e.,

therapeutic). See Abortion, elective, The American Medical Association

Encyclopedia of Medicine 57 (1989) (defining a “therapeutic abortion” as

an abortion “carried out to save the life or health of the mother”). 

Referrals for and counseling on therapeutic abortions are not subject to the

same restrictions as those imposed on nontherapeutic ones; rather, in

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50 STATE OF CALIFORNIA V. AZAR

referrals for medically necessary prenatal health care but not

for nontherapeutic abortions does not make pregnancy

counseling directive.21

situations where “emergency care is required,” the Final Rule requires that

clients be referred “immediately to an appropriate provider of medical

services needed to address the emergency.” 42 C.F.R. § 59.14(b)(2); see

also id. § 59.14(e)(2) (requiring referral for emergency medical care upon

the discovery of an ectopic pregnancy).

21 The dissent’s argument that clients who receive counseling on

prenatal care and abortion (but not referrals for abortion providers) are

“coerced,” “demeaned,” and prevented from taking “an active role in

identifying the direction” of their lives is absurd. Dissent at 88 (cleaned

up). Nothing in the Final Rule prevents clients from procuring abortions. 

See 42 C.F.R. § 59.14. Similarly, the dissent’s reliance on the 2000 Rule

to argue that failing to provide abortion referrals is coercive, Dissent at 88

n.5, is misplaced because the 2000 Rule merely suggested that a referral

for “prenatal care and delivery” might be coercive if the client has rejected

that option, 65 Fed. Reg. at 41,275 (emphasis added); the 2000 Rule said

nothing about whether it is coercive to require a referral for prenatal care

to safeguard the health of the client, see 84 Fed. Reg. at 7722.

The dissent’s suggestion that clients relying on Title X services

cannot locate abortion providers without a referral from a Title X

counselor, Dissent at 89 n.6, is contrary to the reality—recognized in the

Final Rule—that “[i]nformation about abortion and abortion providers is

widely available and easily accessible, including on the internet,” 84 Fed.

Reg. at 7746. We decline to second-guess HHS’s determination based on

plaintiffs’ unsupported declarations. See Dep’t of Commerce v. New York,

139 S. Ct. 2551, 2571 (2019); cf. Dissent at 89 n.6. In any event, Title X

was not designed to be a source of assistance for procuring abortions, cf.

Dissent at 87–89; rather, Congress’s purpose in enacting Title X was to

“fund and, thereby, encourage preconception services, a focus that

“generally excludes payment for postconception care and services,”

including abortion. 84 Fed. Reg. at 7723. Congress’s restriction on Title

X projects leaves clients with “at least the same range of choice in

deciding whether to obtain” an abortion as they would have had if

Congress provided no Title X funding. Harris, 448 U.S. at 317. As Rust

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STATE OF CALIFORNIA V. AZAR 51

Nor is the Final Rule directive because it allows referrals

for adoption. See 42 C.F.R. § 59.5(a)(1). The Infant

Adoption Awareness section, 42 U.S.C. § 254c-6(a)(1), does

not require Title X projects to urge or encourage adoptions;

rather, it provides funds for training staff of eligible health

centers (which may include Title X projects) to provide

adoption information and referrals on an equal basis with

other courses of action included in nondirective counseling. 

Based on this legislation, HHS reasonably concluded that

referrals for adoption are “appropriate under Title X, since

Congress specified that Title X clinics and providers were

eligible health centers to whom adoption related training

should be offered,” 84 Fed. Reg. at 7730. Further, the

language of the Infant Adoption Awareness section suggests

that Congress did not interpret the phrase “nondirective

counseling” as necessarily requiring a presentation of all

options on an equal basis. To the contrary, if Congress had

defined “nondirective counseling” to require the presentation

of all options on an equal basis, it would have been

unnecessary to encourage health center staff to present

information about adoption “on an equal basis with all other

courses of action” as part of nondirective counseling, because

the staff would have already been required to do so. 

42 U.S.C. § 254c-6(a)(1).

recognized, “a doctor’s ability to provide, and a woman’s right to receive,

abortion-related information remains unfettered outside the context of the

Title X project.” 500 U.S. at 203. That some Title X clients “may be

effectively precluded by indigency” or other circumstances fromprocuring

“abortion-related services” is a product of those circumstances, “not of

governmental restrictions.” Id.; cf. Dissent at 89 n.6. Thus, the dissent,

and the amici on which it relies, mistakenly fault the Final Rule for not

helping clients “access[] abortion.” Dissent at 87–89.

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52 STATE OF CALIFORNIA V. AZAR

Finally, the Final Rule’s restrictions on referral lists do

not render pregnancy counseling directive because a referral

list does not present information in a way that encourages or

promotes a specific option—it is merely “[a] list of licensed,

qualified, comprehensive primary health care providers.” 

42 C.F.R. § 59.14(b)(1)(ii). As Rust recognized, doctors are

“free to make clear that advice regarding abortion is simply

beyond the scope of the program.” 500 U.S. at 200.22

Because HHS has reasonably interpreted the phrase

“pregnancy counseling” as not including referrals, and has

interpreted the word “nondirective” to mean a neutral

presentation of options as opposed to the presentation of all

possible options, we reject plaintiffs’ argument that the term

“nondirective pregnancy counseling” requires the provision

of referrals for abortion on the same basis as referrals for

prenatal care and adoption. Accordingly, the challenged

provisions of the Final Rule do not violate the 1996

appropriations rider.

22 Plaintiffs briefly argue that the Final Rule’s general prohibition on

promoting or providing support for abortion as a method of family

planning, see 42 C.F.R. § 59.14(a), may “chill discussions of abortion and

thus inhibit[] neutral and unbiased counseling.” We reject this argument. 

If a provider promoted or supported abortion as a method of family

planning, the counseling would be directive and therefore violate the

appropriations rider. See 84 Fed. Reg. at 7747. By contrast, the Final

Rule’s prohibition on promoting or supporting abortion as a method of

family planning both reinforces the rider’s nondirective-counseling

requirement and implements § 1008’s prohibition on using Title X funds

in programs “where abortion is a method of family planning.” § 1008,

42 U.S.C. § 300a-6.

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STATE OF CALIFORNIA V. AZAR 53

B

Plaintiffs next argue that the Final Rule is inconsistent

with § 1554 of the ACA. See § 1554, 124 Stat. at 259

(codified at 42 U.S.C. § 18114). In March 2010, Congress

passed the ACA “to expand coverage in the individual health

insurance market,” King v. Burwell, 135 S. Ct. 2480, 2485

(2015), and to decrease the cost of health care, Nat’l Fed. of

Indep. Bus. v. Sebelius, 567 U.S. 519, 538 (2012). The ACA

adopted “a series of interlocking reforms” primarily involving

insurance reform, including barring insurers fromconsidering

an individual’s health when deciding whether to offer

coverage, requiring individuals to maintain health insurance

coverage or face a penalty, and offering certain tax credits to

make health insurance more affordable. King, 135 S. Ct.

at 2485.

While Title I of the ACA focuses on health insurance

issues, Subtitle G of that title, entitled “Miscellaneous

Provisions,” does not address insurance directly. Instead, it

sets forth a series of measures aimed at protecting the

interests of entities and individuals that might be affected by

the ACA’s sweeping program. Among other things, it

requires HHS to promote transparency by providing a “list of

all of the authorities provided to the Secretary under th[e]

Act.” 42 U.S.C. § 18112. It also precludes discrimination

against health care providers for failing to offer assisted

suicide, see id. § 18113, ensures that individuals and entities

have the freedomnot to participate in federal health insurance

programs, see id. § 18115, and prohibits health care programs

and employers from engaging in various discriminatory acts,

see id. § 18116. Section 1554, part of Subtitle G’s

“Miscellaneous Provisions,” is titled “Access to therapies”

and provides:

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54 STATE OF CALIFORNIA V. AZAR

Notwithstanding any other provision of this

Act, the Secretary of Health and Human

Services shall not promulgate any regulation

that—

(1) creates any unreasonable barriers to

the ability of individuals to obtain

appropriate medical care;

(2) impedes timely access to health care

services;

(3) interferes with communications

regarding a full range of treatment options

between the patient and the provider;

(4) restricts the ability of health care

providers to provide full disclosure of all

relevant information to patients making

health care decisions;

(5) violates the principles of informed

consent and the ethical standards of health

care professionals; or

(6) limits the availability of health care

treatment for the full durations of a

patient’s medical needs.

§ 1554, 124 Stat. at 259; 42 U.S.C. § 18114.

Plaintiffs and the dissent contend that three provisions of

the Final Rule conflict with this provision of the ACA: the

Final Rule’s restrictions on promoting or supporting abortion

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STATE OF CALIFORNIA V. AZAR 55

as a method of family planning and making referrals for

abortion; its physical and financial separation requirement;

and its requirement that providers encourage family

participation in family planning decisions. Dissent at

92–93.23

We disagree. The Supreme Court has long made a

distinction between regulations that impose burdens on health

care providers and their clients and those that merely reflect

Congress’s choice not to subsidize certain activities. See

Rust, 500 U.S. at 192; cf. United States v. Am. Library Ass’n,

539 U.S. 194, 211–12 (2003); Regan v. Taxation With

23 The government argues that plaintiffs’ ACA-based challenge is

waived because § 1554 was not raised during the notice-and-comment

period, and so HHS did not have an opportunity to provide analysis and

reasoning regarding whether the Final Rule was consistent with § 1554 or

to make any conforming changes to the Final Rule. Plaintiffs contend that

many comments used terminology similar to that used in § 1554, and the

similarity in terminology was enough to give HHS notice that the Final

Rule could violate § 1554. For instance, plaintiffs claim that commenters’

objections to the Final Rule on the grounds that it would “ban Title X

providers from giving women full information about their health care

options” gave HHS notice that the Final Rule would violate § 1554’s ban

on promulgating a regulation that “interferes with communications

regarding a full range of treatment options.” 42 U.S.C. § 18114(3). The

district courts agreed. See California, 385 F. Supp. 3d at 994–95; Oregon,

389 F. Supp. 3d at 914; Washington, 376 F. Supp. 3d at 1130. Because

there is an obvious difference between arguing that a regulation violates

best medical practices and arguing that a regulation violates a statute, we

are doubtful that plaintiffs preserved their argument that the Final Rule

violated § 1554. See Koretoff v. Vilsack, 707 F.3d 394, 398 (D.C. Cir.

2013) (per curiam) (holding that a proponent must raise a “specific

argument,” as opposed to a “general legal issue” to preserve a legal

argument for review) (citing Nuclear Energy Inst., Inc. v. Envtl. Prot.

Agency, 373 F.3d 1251, 1291 (D.C. Cir. 2004)). Nevertheless, because the

Final Rule does not conflict with § 1554, we need not address this

question of waiver.

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56 STATE OF CALIFORNIA V. AZAR

Representation of Wash., 461 U.S. 540, 549–50 (1983). 

Under the Supreme Court’s jurisprudence, a state’s decision

not to subsidize abortion on the same basis as other

procedures does not impose a burden on women, even when

indigence “may make it difficult and in some cases, perhaps,

impossible for some women to have abortions,” because the

law “neither created nor in any way affected” her indigent

status. Maher, 432 U.S. at 474; see also Webster v. Reprod.

Health Servs., 492 U.S. 490, 509–10 (1989) (holding that a

state law prohibiting abortions in public hospitals was

permissible because it “leaves a pregnant woman with the

same choices as if the State had chosen not to operate any

public hospitals at all”); Harris, 448 U.S. at 317 (“[T]he

Hyde Amendment [prohibiting the use of federal funds to pay

for abortion services except under specified circumstances]

leaves an indigent woman with at least the same range of

choice in deciding whether to obtain a medically necessary

abortion as she would have had if Congress had chosen to

subsidize no health care costs at all.”).

Rust applied this well-established principle to the Title X

context, rejecting arguments that the 1988 Rule’s limitations

on counseling and referrals for abortion impermissibly

burdened the doctor-patient relationship, interfered with a

woman’s right to make “an informed and voluntary choice by

placing restrictions on the patient-doctor dialogue,” and

impeded a woman’s access to abortion services. 500 U.S. at

202. The Court recognized “[t]here is a basic difference

between direct state interference with a protected activity and

state encouragement of an alternative activity consonant with

legislative policy.” Id. at 193 (quoting Maher, 432 U.S.

at 475). A government restriction on funding certain

activities “is not denying a benefit to anyone, but is instead

simply insisting that public funds be spent for the purposes

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STATE OF CALIFORNIA V. AZAR 57

for which they were authorized.” Id. at 196. Nor do

restrictions on funding interfere with appropriate medical

care. In the context of Title X funding, restrictive regulations

“leave the [Title X] grantee unfettered” in the services it can

perform outside of the Title X project, id., because the

regulations “govern solely the scope of the Title X project’s

activities” and “do not in any way restrict the activities of

those persons acting as private individuals,” id. at 198–99. 

Further, “the Title X program regulations do not significantly

impinge upon the doctor-patient relationship” because the

doctor and patient may “pursue abortion-related activities

when they are not acting under the auspices of the Title X

project,” id. at 200, and “[a] doctor’s ability to provide, and

a woman’s right to receive, information concerning abortion

and abortion-related services outside the context of the Title

X project remains unfettered,” id. at 203. The Court

distinguished the sorts of limitations imposed by the 1988

Rule from a regime “in which the Government has placed a

condition on the recipient of the subsidy rather than on a

particular program or service, thus effectively prohibiting the

recipient from engaging in the protected conduct outside the

scope of the federally funded program.” Id. at 197 (emphasis

omitted).24

Rust’s logic applies equally to statutory and constitutional

claims. If, as the Supreme Court has concluded, a rule

24 The Supreme Court has repeatedly reaffirmed Rust’s ruling that the

government may constitutionally preclude recipients offederal funds from

addressing specified subjects so long as the limitation does not interfere

with a recipient’s conduct outside the scope of the federally funded

program. See Agency for Int’l Dev. v. All. for Open Soc’y Int’l, Inc.,

570 U.S. 205, 213 (2013) (citing Rust, 500 U.S. at 195 n.4); accord

Walker v. Tex. Div., Sons of Confederate Veterans, Inc., 135 S. Ct. 2239,

2246 (2015).

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58 STATE OF CALIFORNIA V. AZAR

implementing the government’s policy decision to encourage

childbirth rather than abortion does not burden or interfere

with a client’s health care at all, see Harris, 448 U.S. at 317,

then it does not matter whether the client’s heath care rights

were created by the Constitution or a statute.

The same reasoning applies here and requires us to

distinguish between § 1554’s prohibition on direct

interference with certain health care activities and the Final

Rule’s directives that ensure government funds are not spent

for an unauthorized purpose. As in Rust, the Final Rule’s

restrictions on funding certain activities do not create

unreasonable barriers, impede access to health services,

restrict communications, or otherwise involve “denying a

benefit to anyone.” Id. at 196. Nor, as Rust explained, do

they interfere with appropriate medical care or “significantly

impinge upon the doctor-patient relationship.” Id. at 200. 

Rather, the Final Rule leaves a grantee “unfettered in its other

activities” because it governs solely the scope of the services

funded by Title X grants, id. at 196, and doctors and their

clients remain free to exchange abortion-related information

outside the context of the Title X project, id. at 203.25

Therefore, the Final Rule’s measures to ensure that

government funds are spent for the purposes for which they

25 Plaintiffs and the California district court speculate (without any

support in the record) that the Final Rule’s referral-list restrictions will

delay clients from locating abortion providers and thus leave them worse

off. See California, 385 F. Supp. 3d at 998. This is merely another

version of the argument that Congress cannot prohibit Title X projects

from assisting clients seeking abortion referrals. But such an argument

has been rejected by the Supreme Court. See Rust, 500 U.S. at 193–94

(recognizing that restrictions of this type are permissible to ensure that

“the limits of [Title X] are observed” so that project grantees and their

employees do not “engag[e] in activities outside of the project’s scope”).

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STATE OF CALIFORNIA V. AZAR 59

were authorized does not violate § 1554’s restrictions on

direct regulation of certain aspects of care.

The ACA itself makes clear that § 1554 is meant to

prevent direct government interference with health care, not

to affect Title X funding decisions. The most natural reading

of § 1554 is that Congress intended to ensure that HHS, in

implementing the broad authority provided by the ACA, does

not improperly impose regulatory burdens on doctors and

patients. Indeed, by introducing § 1554 with language

focusing on the ACA—that “[n]otwithstanding any other

provision of this Act,” HHS may not take certain steps,

42 U.S.C. § 18114—Congress showed its intent to ensure that

certain interests of individuals and entities would be protected

notwithstanding the broad scope of the ACA, and that such

protections would supersede any other provision of the ACA

“in the event of a clash.” NLRB v. SW Gen., Inc., 137 S. Ct.

929, 939 (2017) (citations omitted).

By contrast, the ACA did not seek to alter the relationship

between federally funded grant programs and abortion in a

fundamental way. See, e.g., Pub. L. No. 111-148, title X,

§ 10104(c)(2), 124 Stat. at 897 (codified at 42 U.S.C.

§ 18023(c)(2)). Section 10104(c)(2)(A) of the Act provides

that “[n]othing in this Act shall be construed to have any

effect on Federal laws regarding (i) conscience protection;

(ii) willingness or refusal to provide abortion; and

(iii) discrimination on the basis of the willingness or refusal

to provide, pay for, cover, or refer for abortion or to provide

or participate in training to provide abortion.” 42 U.S.C.

§ 18023(c)(2)(A). An Executive Order issued shortly after

the ACA was passed emphasized the ACA’s neutrality

regarding abortion issues, stating that “[u]nder the Act,

longstanding Federal laws to protect conscience . . . remain

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60 STATE OF CALIFORNIA V. AZAR

intact and new protections prohibit discrimination against

health care facilities and health care providers because of an

unwillingness to provide, pay for, provide coverage of, or

refer for abortions.” Ensuring Enforcement and

Implementation of Abortion Restrictions in the Patient

Protection and Affordable Care Act, Exec. Order No. 13,535,

75 Fed. Reg. 15,599 (Mar. 24, 2010). Nor did the ACA

single out Title X for any changes. The ACA mentions

Title X only to clarify that Title X providers may qualify as

“teaching health centers” eligible for funds under a different

grant program. See Pub. L. No. 111-148, tit. V, § 5508,

124 Stat. at 669–70 (codified at 42 U.S.C. § 293l-1).

In short, the ACA did not address the implementation of

Congress’s choice not to subsidize certain activities. The

Final Rule places no substantive barrier on individuals’

ability to obtain appropriate medical care or on doctors’

ability to communicate with clients or engage in activity

when not acting within a Title X project, and therefore the

Final Rule does not implicate § 1554.26

26 The plaintiffs raise several other arguments that the Final Rule

violates Title X, but they do not merit much discussion. First, Washington

argues that the Final Rule violates § 1008’s requirement that “acceptance

by any individual of family planning services . . . shall be voluntary”

because the Final Rule requires doctors to provide referrals for prenatal

care regardless whether a client asks for abortion information. We

disagree. The Final Rule preserves the requirement that “[a]cceptance of

services must be solely on a voluntary basis,” 42 C.F.R. § 59.5(a)(2), and

nothing in the Final Rule makes acceptance of family planning services a

“prerequisite to eligibility for or receipt of any other service or assistance

from, or to participation in, any other program.” 42 U.S.C. § 300a-5.

Second, some plaintiffs argue, and the Washington district court held,

376 F. Supp. 3d at 1130, that the central purpose of Title X is “to equalize

access to comprehensive, evidence-based, and voluntary family planning”

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STATE OF CALIFORNIA V. AZAR 61

In sum, the Final Rule is not contrary to the

appropriations rider, § 1554 of the ACA, or Title X. 

Plaintiffs’ claims based on these provisions will not succeed. 

Accordingly, plaintiffs have not demonstrated likelihood of

success on the merits based on these grounds. See Winter,

555 U.S. at 20.

IV

We now turn to plaintiffs’ arguments that the Final Rule

is arbitrary and capricious under the APA.27 The APA

requires a reviewing court to “hold unlawful and set aside

and that the Final Rule is inconsistent with this purpose. We disagree. 

The Supreme Court determined that provisions substantially identical with

those in the Final Rule were consistent with Title X. Rust, 500 U.S. at

178–79.

Finally, Washington argues in passing that 42 C.F.R. § 59.18 is

invalid because it allows Title X funds to be used “to offer family planing

methods and services” but not “to build infrastructure for purposes

prohibited with these funds, such as support for the abortion business of

a Title X grantee or subrecipient.” 42 C.F.R. § 59.18(a) (emphasis added). 

According to Washington, this provision “limits the use of Title X funds

for core functions” and therefore violates a provision of Title X

authorizing the use of funds “to assist in the establishment and operation

of voluntary family planning projects,” § 1001; 42 U.S.C. § 300. This

argument is meritless, because § 59.18 merely harmonizes § 1001 with

§ 1008’s prohibition on the use of Title X funds “in programs where

abortion is a method of family planning.” § 1008; 42 U.S.C. § 300a-6.

27 While the district court in Oregon found only “serious questions

going to the merits of [the] claims that the Final Rule is arbitrary and

capricious,” 389 F. Supp. 3d at 903, the California district court went

further and concluded that the promulgation of the Final Rule was, in fact,

arbitrary and capricious, 385 F. Supp. 3d at 1000. Rather than review

these determinations separately, we consolidate our analysis given that the

Final Rule is not arbitrary and capricious as a matter of law.

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62 STATE OF CALIFORNIA V. AZAR

agency action, findings, and conclusions found to be . . .

arbitrary [or] capricious.” 5 U.S.C. § 706(2)(A). Our review

under this directive is narrow and deferential. Dep’t of

Commerce v. New York, 139 S. Ct. 2551, 2569 (2019). We

“must uphold a rule if the agency has examined the relevant

considerations and articulated a satisfactory explanation for

its action, including a rational connection between the facts

found and the choice made.” FERC v. Elec. Power Supply

Ass’n, 136 S. Ct. 760, 782 (2016) (cleaned up). “Th[is]

requirement is satisfied when the agency’s explanation is

clear enough that its path may reasonably be discerned,”

Encino Motorcars, LLC v. Navarro, 136 S. Ct. 2117, 2125

(2016) (internal quotation marks omitted), even where an

agency’s decision is “of less than ideal clarity,” FCC v. Fox

Television Stations, Inc., 556 U.S. 502, 513 (2009).

We defer to the agency’s expertise in interpreting the

record and to “the agency’s predictive judgment” on relevant

questions. Id. at 521; see also Trout Unlimited v. Lohn,

559 F.3d 946, 959 (9th Cir. 2009). “It is well established that

an agency’s predictive judgments about areas that are within

the agency’s field of discretion and expertise are entitled to

particularly deferential review, so long as they are

reasonable.” BNSF Ry. Co. v. Surface Transp. Bd., 526 F.3d

770, 781 (D.C. Cir. 2008) (quoting Wis. Pub. Power, Inc. v.

FERC, 493 F.3d 239, 260 (D.C. Cir. 2007)). Agency

predictions of how regulated parties will respond to its

regulations do not require “complete factual support in the

record” and “necessarily involve[] deductions based on the

expert knowledge of the agency.” FCC v. Nat’l Citizens

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STATE OF CALIFORNIA V. AZAR 63

Comm. for Broad., 436 U.S. 775, 814 (1978) (internal

quotation marks omitted).28

We also defer to the agency’s expertise in identifying the

appropriate course of action. With respect to the agency’s

final decision, we cannot “ask whether a regulatory decision

is the best one possible or even whether it is better than the

alternatives.” Elec. Power Supply Ass’n, 136 S. Ct. at 782. 

Nor may we “substitute our judgment for that of the

[agency].” Dep’t of Commerce, 139 S. Ct. at 2569. We are

also prohibited from “second-guessing the [agency]’s

weighing of risks and benefits and penalizing [it] for

departing from the . . . inferences and assumptions” of others. 

Id. at 2571.

Nor do we give heightened review to agency action that

“changes prior policy.” Fox, 556 U.S. at 514. The APA

“makes no distinction . . . between initial agency action and

subsequent agency action undoing or revising that action.” 

Id. at 514–15. Initial agency determinations are “not instantly

carved in stone.” Chevron, 467 U.S. at 863. Of course, the

“requirement that an agency provide reasoned explanation for

its action would ordinarily demand that [the agency] display

awareness that it is changing position” and “that there are

good reasons for the new policy.” Fox, 556 U.S. at 515. For

example, an agency may not “depart from a prior policy sub

28 The district courts relied on the predictions and opinions of experts

provided by plaintiffs. See, e.g., California, 385 F. Supp. 3d at 1015–19;

Oregon, 389 F. Supp. 3d at 918; Washington, 376 F. Supp. 3d at 1131. 

But it is not our job to weigh evidence or pick the more persuasive

opinions and predictions. Rather, the agency has discretion to rely on its

own expertise “even if, as an original matter, a court might find contrary

views more persuasive.” Lands Council v. McNair, 629 F.3d 1070, 1074

(9th Cir. 2010) (internal quotations marks omitted).

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silentio or simply disregard rules that are still on the books.” 

Id. Likewise, “[i]t would be arbitrary or capricious to

ignore,” where applicable, that “its new policy rests upon

factual findings that contradict those which underlay its prior

policy,” or that “its prior policy has engendered serious

reliance interests that must be taken into account.” Id. But

under our narrow review, an agency “need not demonstrate to

a court’s satisfaction that the reasons for the new policy are

betterthan the reasons for the old one; it suffices that the new

policy is permissible under the statute, that there are good

reasons for it, and that the agency believes it to be better,

which the conscious change of course adequately indicates.” 

Id. In sum, we “must confine ourselves to ensuring that [the

agency] remained within the bounds of reasoned

decisionmaking.” Dep’t of Commerce, 139 S. Ct. at 2569

(internal quotation marks omitted).

Plaintiffs argue that several aspects of the Final Rule are

arbitrary and capricious: (1) the physical and financial

separation requirement; (2) HHS’s overall cost-benefit

analysis; (3) the counseling and referral restrictions; (4) the

requirement that pregnancy counseling be provided only by

medical doctors or advanced practice providers; and (5) the

requirement that family planning options be “acceptable and

effective,” rather than also “medically approved.” We

consider these arguments in turn.

A

Plaintiffs first argue that HHS’s promulgation of the

physical and financial separation requirement in 42 C.F.R.

§ 59.15 was arbitrary and capricious because HHS failed to

substantiate an adequate need for the requirement and ignored

the predictions of some commenters that the requirement

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STATE OF CALIFORNIA V. AZAR 65

would have a significant adverse impact on the Title X

network and client health.

We disagree. HHS examined the relevant considerations

and provided a reasoned analysis for adopting this provision. 

See Elec. Power Supply Ass’n, 136 S. Ct. at 782. It stated its

primary reason for reestablishing the requirement was that

physical separation would more effectively implement

§ 1008. 84 Fed. Reg. at 7764. While the financial separation

required by the 2000 Rule was a necessary component of

§ 1008’s implementation, HHSexplained, physical separation

was equally required given Congress’s mandate that Title X

funds not support programs in any location “‘where’ abortion

is offered as a method of family planning.” Id. at 7765

(emphasis added). HHS also expressly adopted the 1988

Rule’s rationale for physical and financial separation upheld

in Rust, id., and gave ample additional reasons supporting this

conclusion.

First, HHS pointed to the public confusion caused when

physical separation was lacking. Id. According to HHS, the

performance of abortion services and Title X-funded services

in the same location engendered confusion and rendered it

“often difficult for patients, or the public, to know when or

where Title X services end and non-Title X services

involving abortion begin.” Id. at 7764. This confusion was

evidenced by comments HHS had received on the Final Rule;

according to HHS, many commenters seemed wholly

unaware of the fact that Title X explicitly excludes funding

for projects where abortion is a method of family planning. 

Id. at 7729. HHS could reasonably conclude that the physical

separation requirements could help minimize the appearance

that the government is funding abortion as a method of family

planning. See Brief of Amici Curiae Ohio and 12 Other States

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66 STATE OF CALIFORNIA V. AZAR

in Support of Defendants-Appellants and Reversal at 16–19,

California v. Azar, Nos. 19-15974 & 19-15979 (9th Cir.

June 7, 2019) (emphasizing the importance to many citizens

of putting “a greater distance between public funding and

abortion-performing entities,” and noting that at least

18 states have enacted laws designed to avoid even the

appearance that state healthcare funds are being used to

support entities involved in abortion services).

Second, HHS concluded that performing all services in

the same facility “create[s] a risk of the intentional or

unintentional use of Title X funds for impermissible

purposes, the co-mingling of Title X funds, . . . and the use of

Title X funds to develop infrastructure that is used for the

abortion activities of Title X clinics.” 84 Fed. Reg. at 7764. 

This risk is not speculative. As HHS explained, economies

of scale and shared overhead achieved through collocation of

a Title X clinic and an abortion-providing clinic effectively

support the provision of abortion. See id. at 7766. HHS

relied in part on recent studies that show abortions are

increasingly being performed at facilities that had historically

focused on providing contraceptive and family planning

services (the typical profile of facilities that receive Title X

funds), which supports the inference that a growing number

of Title X recipients may perform abortions at facilities that

also offer Title X-funded services. Id. at 7765.

In reaching its conclusion, HHS responded to

commenters’ concerns in detail. HHS first noted the concern

that requiring physical and financial separation “would

increase the cost for doing business.” Id. at 7766. HHS

explained that such comments confirmed its concern that

Title X funds were directly or indirectly supporting abortion

as a method of family planning. Id. “Money is fungible,”

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STATE OF CALIFORNIA V. AZAR 67

Holder v. Humanitarian Law Project, 561 U.S. 1, 31 (2010),

and HHS reasonably concluded that “flexibility in the use of

Title X funds under the 2000 [Rule]” allowed grantees to use

Title X funds to “build infrastructure that can be used for

[prohibited] purposes . . . such as support for the abortion

business of a Title X grantee,” 84 Fed. Reg. at 7773, 7774.

Next, with respect to those Title X projects that would

need to make changes to comply with the separation

requirements, HHS predicted that the costs of compliance

would not be as significant as some commenters predicted. 

Id. at 7781 (noting such commenters “did not provide

sufficient data to estimate these [predicted] effects across the

Title X program”). HHS discounted the predictions, which

relied on “assumptions that [providers] would have to build

new facilities in order to comply with the requirements.” Id.

Rather, HHS predicted that most entities would likely choose

lower cost methods of compliance. Id. For example, “Title

X providers which operate multiple physically separated

facilities and perform abortions may shift their abortion

services, and potentially other services not financed by Title

X, to distinct facilities, a change which likely entails only

minor costs.” Id. HHS explained that the Final Rule

permitted “case-by-case determinations on whether physical

separation is sufficiently achieved to take the unique

circumstances of each program into consideration,” and that

“[p]roject officers are available to help grantees successfully

implement the Title X program” and to come up with “a

workable plan” for compliance. Id. at 7766.

Finally, HHS addressed the “contention of some

commenters that the physical and financial separation

requirements will destabilize the network of Title X

providers,” upset the reliance interests of providers who have

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68 STATE OF CALIFORNIA V. AZAR

incurred costs relying on HHS’s previous regulations, and

“exacerbate health inequalities or harm patient care.” Id.

HHS disagreed with the commenters’ predictions that the

separation requirements would result in a significant

departure of Title X providers from the program, explaining

that the Final Rule “continues to allow organizations to

receive Title X funds even if they also provide abortion as a

method of family planning, as long as they comply with” the

separation requirements. Id. HHS further noted that a

Congressional Research Service report estimated that only

10 percent of clinics that receive Title X funding offer

abortion as a method of family planning. Id. at 7781. And

while some Title X providers “may share resources with

unaffiliated entities that offer abortion as a method of family

planning,” HHS estimated that only around 20 percent of all

Title X service sites had “their Title X services and abortion

services . . . currently collocated” such that they would be

materially impacted by the separation requirements. Id.

Accordingly, HHS concluded that the separation

requirements would have only “minimal effect on the

majority of current Title X providers.” Id.

At the same time, HHS predicted that providers who were

willing to comply with the new requirements would expand

their services and that other provisions of the Final Rule

would encourage new “individuals and institutions to

participate in the Title X program.” Id. at 7766. For

example, HHS expected “that honoring statutory protections

of conscience in Title X may increase the number of

providers in the program,” because providers or entities

would now “know they will be protected from discrimination

on the basis of conscience with respect to counseling on, or

referring for, abortion.” Id. at 7780. HHS cited a poll by the

Christian Medical Association showing that faith-based

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STATE OF CALIFORNIA V. AZAR 69

medical professionals would limit the scope of their practice

without conscience protections; HHS reasoned the Final

Rule’s prohibition on abortion referral and removal of the

2000 Rule’s abortion counseling requirement would allow

such professionals to enter the Title X program. Id. at 7780

n.138.29 And while HHS acknowledged that it “cannot

calculate or anticipate future turnover in grantees,” under

HHS’s “best estimates,” it did “not anticipate that there will

be a decrease in the overall number of facilities offering

services, since it anticipates other, new entities will apply for

funds, or seek to participate as subrecipients, as a result of the

final rule.” Id. at 7782.30

Plaintiffs, in effect, argue that HHS’s determination was

arbitrary and capricious because the agency relied on its own

predictions and rejected those submitted by commenters

opposing the Final Rule. We reject this argument because

29 HHS’s inferences regarding the data’s implication for Title X

applications is within HHS’s core area of expertise and therefore entitled

to deference. See Trout Unlimited, 559 F.3d at 959; BNSF Ry. Co.,

526 F.3d at 781. The dissent’s de novo evaluation of the study is not

entitled to such deference. See Dissent at 103–104.

30 In supporting its argument that HHS’s cost-benefit analysis is

arbitrary and capricious, the dissent looks outside the record to argue that

some grantees, such as Planned Parenthood, have voluntarily terminated

their participation in Title X. See Dissent at 101 & n.15. Of course, such

post hoc, extra-record evidence cannot be a basis for determining whether

HHS’s promulgation of the Final Rule was arbitrary and capricious. In

any event, the dissent’s extra-record observation is misleading: HHS has

issued supplemental grant awards to other Title X recipients that, in

HHS’s estimation, “will enable grantees to come close to—if not [in

excess of]—prior Title X patient coverage,” Press Release, Dep’t Health

& Human Servs., HHS Issues Supplemental Grant Awards to Title X

Recipients (Sept. 30, 2019), https://www.hhs.gov/about/news/2019/09/

30/hhs-issues-supplemental-grant-awards-to-title-x-recipients.html.

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70 STATE OF CALIFORNIA V. AZAR

HHS’s predictive judgments about the Final Rule’s effect on

the availability of Title X services are entitled to deference. 

See Trout Unlimited, 559 F.3d at 959. Here, the predictions

concern matters squarely within HHS’s “field of discretion

and expertise.” BNSF Ry. Co., 526 F.3d at 781 (quoting Wis.

Pub. Power, 493 F.3d at 260). As the agency tasked with

implementing the grant program, HHS is in the best position

to anticipate the behavior of grantees and prospective

grantees. HHS reasonably considered the evidence before it,

where “complete factual support” for any prediction was “not

possible or required,” Nat’l Citizens Comm. for Broad.,

436 U.S. at 814, such that its decision “remained ‘within the

bounds of reasoned decisionmaking,’” Dep’t of Commerce,

139 S. Ct. at 2569 (quoting Baltimore Gas & Elec. Co. v. Nat.

Res. Def. Council, Inc., 462 U.S. 87, 105 (1983)). Although

the commenters opposing the Final Rule provided numerous

expert declarations elaborating their gloomy assumptions

about the future behavior and activities of current and future

Title X grantees, at bottom such future-looking “pessimistic”

predictions and assumptions are “simply evidence for the

[agency] to consider,” Dep’t of Commerce, 139 S. Ct.

at 2571, and are not entitled to controlling weight.31 HHS

31 Department of Commerce held that it was not arbitrary and

capricious for the Secretary of Commerce to decline to rely on the

conclusions of the “technocratic” experts in the Census Bureau. 139 S. Ct.

at 2571. So too here: HHS may reasonably decide not to rely on the

opinions of outside commenters, even where they claim expertise. The

dissent insinuates that reliance on Department of Commerce is misplaced

because “the Court struck down the Secretary of Commerce’s attempt to

reinstate the citizenship question on the census.” Dissent at 101 n.15. But

the Court “d[id] not hold that the agency decision . . . was substantively

invalid”; it merely affirmed the district court’s decision to remand to the

agency due to a perceived “mismatch between the decision the Secretary

made and the rationale provided.” Dep’t of Commerce, 139 S. Ct. at

2575–76. Here, there is no “disconnect between the decision [HHS] made

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STATE OF CALIFORNIA V. AZAR 71

need not produce “some special justification for drawing [its]

own inferences and adopting [its] own assumptions.” Id.

Although plaintiffs and the dissent have reached a different

conclusion, we consider only whether the agency examined

the relevant considerations and laid a reasonably discernable

path.

In light of HHS’s reasoned explanation of its decisions

and its consideration of the comments raised, we reject

plaintiffs’ arguments that HHS failed to base its decision on

evidence, failed to consider potential harms in its cost-benefit

analysis, failed to explain its reasons for departing from the

2000 Rule’s provisions, and failed to consider the reliance

interest of providers who have incurred costs relying on

HHS’s previous regulation. The Final Rule’s separation

requirements are not arbitrary and capricious.

B

Plaintiffs and the dissent make a similar argument that

HHS’s cost-benefit analysis of the Final Rule was arbitrary

and capricious. Dissent at 100–106. They argue that HHS

ignored the commenters who predicted the Final Rule would

cause an exodus of Title X providers and have a deleterious

effect on client care, and instead relied on its own predictions

about the Final Rule’s benefits.

Like plaintiffs’ challenge to the physical and financial

separation requirements, the challenge to HHS’s cost-benefit

analysis fails. HHS considered and addressed “the concern

and the explanation given,” id. at 2575, so the grounds on which

Department of Commerce ultimately affirmed the decision to remand are

irrelevant.

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72 STATE OF CALIFORNIA V. AZAR

expressed by some commenters regarding the effect of this

rule on quality and accessibility of Title X services,” and

explained its reasons for relying on its own predictions

regarding the likely behavior of current and future Title X

grantees. 84 Fed. Reg. at 7780. HHS likewise rejected the

“extremely high cost estimates” for compliance with the

separation requirements, reasoning that providers would tend

to seek out lower cost options, such as shifting abortion

services to distinct facilities rather than constructing new

ones. Id. at 7781–82.32 HHS was not required to accept the

commenters’ “pessimistic” cost predictions, Dep’t of

Commerce, 139 S. Ct. at 2571, and the agency adequately

explained why it did not expect grantees to participate in a

mass rejection of Title X funds, see 84 Fed. Reg. at 7766. In

32 The dissent asserts that HHS “calculated [the] costs of compliance

with the physical separation requirement in a ‘mystifying’ way.” Dissent

at 102 n.16 (quoting California, 385 F. Supp. 3d at 1008). But there is

nothing “mystifying” about HHS’s cost estimates. HHS estimated that

between 10 and 30 percent of all Title X projects would need to be

evaluated to determine compliance with the physical separation

requirements. 84 Fed. Reg. at 7781. It then predicted that such

evaluations would determine that between 10 to 20 percent of the

evaluated sites do not comply with the physical separation requirements. 

Id. “At each of these service sites, [HHS] estimates that an average of

between $20,000 and $40,000, with a central estimate of $30,000, would

be incurred to come into compliance with physical separation

requirements in the first year following publication of a final rule in this

rulemaking.” Id. at 7781–82. HHS then added together the costs of

conducting the evaluations and bringing non-compliant facilities into

compliance, and concluded its estimates “would imply costs of $36.08

million in the first year following publication of a final rule.” Id. at 7782. 

Based solely on statements made by plaintiffs’ lawyers during oral

argument, the dissent speculates that HHS’s cost estimates were too

optimistic. Dissent at 102 n.16. But we need not favor plaintiffs’

pessimistic cost estimates over those provided by HHS. See Dep’t of

Commerce, 139 S. Ct. at 2571.

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STATE OF CALIFORNIA V. AZAR 73

light of HHS’s conclusion that an ample number of Title X

projects would continue to provide family planning services,

HHS reasonably concluded that the harms flowing froma gap

in care would not develop. See id. at 7775, 7782. We give

substantial deference to such predictive judgments within the

scope of HHS’s expertise. Trout Unlimited, 559 F.3d at 959. 

On this record, we will not second-guess HHS’s

consideration of the risks and benefits of its action. See Dep’t

of Commerce, 139 S. Ct. at 2571.

C

Plaintiffs next assert that the referral restrictions are

arbitrary and capricious. They first argue that HHS failed to

justify the need for this provision adequately. We disagree. 

HHS stated it was reestablishing the 1988 Rule for referrals

because it concluded that the 2000 Rule was inconsistent with

§ 1008. Under HHS’s interpretation of § 1008, “in most

instances when a referral is provided for abortion, that

referral necessarily treats abortion as a method of family

planning.” 84 Fed. Reg. at 7717. Further, HHS concluded

that the 2000 Rule’s requirement that Title X projects provide

abortion referrals and nondirective counseling on abortion

was inconsistent with federal conscience laws. Id. at 7716. 

HHS referenced its 2008 nondiscrimination regulations,

which had reached the same conclusion. Id. (quoting 73 Fed.

Reg. at 78,087). HHS also explained that eliminating the

2000 Rule’s counseling and referral requirements would

“reduce the regulatory burden [on HHS] associated with

monitoring and regulating Title X providers for compliance,”

id. at 7719, “add clarity to extant conscience protections, [and

make] it easier for entities to participate who may have felt

unable to do so in the past,” id. at 7778. In sum, HHS

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74 STATE OF CALIFORNIA V. AZAR

engaged in “reasoned decisionmaking.” Dep’t of Commerce,

139 S. Ct. at 2569.33

Plaintiffs next argue that HHS did not justify the need for

the counseling and referral restrictions because non-objecting

health care staff could provide counseling and referrals for

abortion without violating the federal conscience laws. 

Therefore, plaintiffs urge, HHS’s reliance on federal

conscience laws as justification was arbitrary and capricious. 

We reject this argument, because it amounts to little more

than the claim that HHS should have adopted plaintiffs’

preferred regulatory approach. But HHS acted well within its

authority in deciding how best to avoid conflict with the

federal conscience laws. We do not “ask whether a

regulatory decision is the best one possible or even whether

it is better than the alternatives.” Elec. Power Supply Ass’n,

136 S. Ct. at 782. Rather, we defer to the agency’s reasoned

conclusion.

Plaintiffs also argue that HHS failed to consider claims by

some commenters that the restrictions would require

“providers to violate their ethical obligations to stay in the

program” because they require “providers to withhold

information about abortion (including referral) that the patient

needs,” and to provide “a biased and misleading list of

33 The plaintiffs’ argument that the referral restrictions are arbitrary

and capricious because they conflict with guidelines in the QFP is

meritless, because these guidelines were based on the 2000 Rule, and are

superseded by the Final Rule. See Dep’t Health & Human Servs.,

Announcement of Availability of Funds for Title X Family Planning

Services Grants, at 14–15 (2019).

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STATE OF CALIFORNIA V. AZAR 75

primary health care providers.”34 But HHS specifically

addressed those concerns. It stated that the counseling and

referral restrictions would not result in ethical violations

because the Final Rule permitted providers to give

“nondirective pregnancy counseling to pregnant Title X

clients on the patient’s pregnancy options, including

abortion.” 84 Fed. Reg. at 7724.35 HHS reasoned that the

34 The dissent repeatedly echoes the plaintiffs’ claims that the Final

Rule contradicts or violates medical ethics because it limits Title X

projects from encouraging and supporting abortion and from referring

clients to abortion providers. See Dissent at 92–93, 98–99 & n.13. 

Despite the dissent’s and plaintiffs’ ethical claims, neither cites an opinion

from the AMA’s Code of Medical Ethics directly addressing abortion. 

See, e.g., Dissent at 99 n.13. Rather, the dissent and plaintiffs cite more

general guidance regarding a physician’s obligation to inform the patient

regarding “treatment alternatives” for medical conditions; because a

nontherapeutic abortion is not a “treatment” option for a medical condition

but rather a procedure for terminating a healthy pregnancy, such guidance

does not directly relate to this issue.

It is not surprising that medical ethical rules are not as absolute as the

dissent claims; as noted in Roe v. Wade, the AMA’s views of medical

ethics and abortion changed from a condemnation of the “unwarrantable

destruction of human life” to the conclusion that abortions could properly

be performed in some circumstances. 410 U.S. 113, 142 (1973). Despite

greater public acceptance of abortion today, the issue raises controversial

ethical questions, as demonstrated by (among other things) the continued

enactment of federal conscience laws and public comments urging HHS

to protect physicians’ ability to decline to counsel on or refer for abortion. 

See 84 Fed. Reg. at 7746–47; see also Brief of Amici Curiae Ohio, supra

at 16 (many citizens “believe that permitting abortion providers or

advocates to participate in providing a government-funded service implies

a public imprimatur on abortion—an imprimatur that citizens legitimately

seek to withhold”).

35 The dissent argues that in reaching this conclusion, HHS

contradicted its prior conclusion in the 2000 Rule as to “what medical

ethics demand.” Dissent at 99. But HHS did not provide an opinion on

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76 STATE OF CALIFORNIA V. AZAR

Final Rule allows physicians “to discuss the risks and side

effects of each option, [including abortion,] so long as this

counsel in no way promotes or refers for abortion as a method

of family planning.” Id. A client may “ask questions and . . .

have those questions answered by a medical professional.” 

Id. HHS also noted that where care is medically necessary,

referral for that care is required, notwithstanding the Final

Rule’s other requirements. Id. Consistent with Rust, HHS

concluded that “it is not necessary for women’s health that

the federal government use the Title X program to fund

abortion referrals, directive abortion counseling, or give to

women who seek abortion the names of abortion providers.” 

Id. at 7746.36 These statements show HHS examined the

relevant considerations arising from commenters citing

medical ethics and rationally articulated an explanation for its

conclusion. See Elec. Power Supply Ass’n, 136 S. Ct. at 782.

this issue when it overruled its prior 1988 Rule; it merely referenced the

views of commenters, without adopting those views as its own. See 65

Fed. Reg. at 41,273. Thus, the dissent’s argument that HHS “changed its

position on what medical ethics demand” is meritless.

36 Rust rejected ethical arguments similar to those raised here. See

500 U.S. at 213–14 (Blackmun, J. dissenting) (arguing that “the ethical

responsibilities of the medical profession demand” that a physician be free

to inform patients about abortion). According to the Court, “the Title X

program regulations do not significantly impinge upon the doctor-patient

relationship” because, among other reasons, “the doctor-patient

relationship established by the Title X program [is not] sufficiently all

encompassing so as to justify an expectation on the part of the patient of

comprehensive medical advice,” and “a doctor’s silence with regard to

abortion cannot reasonably be thought to mislead a client into thinking

that the doctor does not consider abortion an appropriate option for her,”

given that “[t]he program does not provide post conception medical care.” 

Id. at 200. And under the Final Rule, as under the 1988 Rule, “[t]he

doctor is always free to make clear that advice regarding abortion is

simply beyond the scope of the program.” Id.

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STATE OF CALIFORNIA V. AZAR 77

Because HHS’s decisionmaking path “may reasonably be

discerned,” Dep’t of Commerce, 139 S. Ct. at 2578, we reject

plaintiffs’ claims that the counseling and referral restrictions

are arbitrary and capricious.

D

We next consider plaintiffs’ claim that the Final Rule’s

requirement that all pregnancy counseling be provided by

medical doctors or advanced practice providers is arbitrary

and capricious. Plaintiffs argue that because HHS defined the

term “advanced practice providers” too narrowly, and did not

have a reasoned basis for drawing the line at which medical

professionals may provide pregnancy counseling, the

provision is arbitrary and capricious.

We disagree. HHS explained that, in its judgment,

“medical professionals who receive at least a graduate level

degree in the relevant medical field and maintain a federal or

State-level certification and licensure to diagnose, treat, and

counsel patients . . . are qualified, due to their advanced

education, licensing, and certification to diagnose and treat

patients while advancing medical education and clinical

research.” 84 Fed. Reg. at 7728.37 We have no basis to

conclude that this line-drawing determination, an inherently

discretionary task, “is so implausible” that a difference with

37 Although the dissent asserts that this requirement will “reduce the

number of people who can provide pregnancy counseling and . . . require

significant changes in Title X providers’ staffing,” Dissent at 102, HHS’s

definition covers a wide range of licensed medical professionals that HHS

reasonably deemed qualified to provide health care advice, including

physician assistants, certified nurse practitioners, clinical nurse specialists,

certified registered nurse anesthetists, and certified nurse-midwifes, see

42 C.F.R. § 59.2.

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78 STATE OF CALIFORNIA V. AZAR

plaintiffs’ views “could not be ascribed to a difference in

view or the product of agency expertise.” Motor Vehicle

Mfrs. Ass’n of U.S., Inc. v. State Farm Mut. Auto. Ins. Co.,

463 U.S. 29, 43 (1983). Accordingly, we reject plaintiffs’

arguments that HHS’s technical determination of which

medical professionals may provide pregnancy counseling is

arbitrary and capricious.

E

Finally, we reject plaintiffs’ argument that HHS was

arbitrary and capricious in reestablishing the language of the

1988 Rule’s requirement that all family planningmethods and

services be “acceptable and effective,” instead of retaining

the 2000 Rule’s revision requiring that such methods and

services also be “medically approved.” 84 Fed. Reg. at 7732.

HHS adequately explained its reasons for reestablishing

the 1988 Rule. HHS explained that the change was intended

to “ensure that the regulatory language is consistent with the

statutory language,” id. at 7740, which requires Title X

projects to “offer a broad range of acceptable and effective

family planning methods and services,” 42 U.S.C. § 300(a). 

HHS also explained that the meaning of “medically

approved” was unclear. 84 Fed. Reg. at 7741. “For example,

would approval by one medical doctor suffice, or would some

larger number need to approve, and if so, how many; would

certainmedical organizations, or governmental organizations,

or both, need to approve, and if so, which ones; would a

certain level of medical consensus need to exist concerning

a particular method or service, and if so, how would the

Department measure that consensus; and when doctors and

medical organizations disagree either about a family planning

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STATE OF CALIFORNIA V. AZAR 79

method or service, how would that requirement apply?” Id.

at 7732.

HHS also explained its rejection of the comment

suggesting the phrase “medically approved” means “FDA

approved.” HHS stated that “[s]ome family planning

methods cannot be medically approved by . . . the [FDA],

because they do not fall within its jurisdiction,” and provided

examples, such as fertility-awareness based methods of

family planning. Id. at 7741 & n.69. In HHS’s judgment,

“[t]his did not mean that such methods of family planning are

unacceptable or ineffective in the view of medical sources.” 

Id. at 7741. Accordingly, HHS determined that “[t]he

statutory language of ‘acceptable and effective family

methods or services,’ without the phrase ‘medically

approved[,]’ provides sufficient guidance to Title X projects

in considering the types of family planning methods and

services that they provide.” Id.

HHS likewise sufficiently addressed comments that its

decision to omit the phrase “medically approved” would

promote political ideology over science, lead to negative

health consequences for clients, and undermine

recommendations from other agencies. See id. at 7740–41. 

We defer to HHS’s reasonable conclusion that Title X’s

statutory requirement that family planning methods and

services must be “acceptable and effective” sufficiently

prohibits Title X projects from engaging in health fraud or

quackery. Id. at 7741.

Because HHS “examined the relevant considerations and

articulated a satisfactory explanation for its action,” Elec.

Power Supply Ass’n, 136 S. Ct. at 782 (cleaned up), we reject

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80 STATE OF CALIFORNIA V. AZAR

plaintiffs’ argument that this change was arbitrary and

capricious.

In sum, we hold that the Final Rule is not arbitrary and

capricious.

* * *

Because plaintiffs’ claims will not succeed given our

resolution of the underlying legal questions, we end our

analysis here. See Munaf, 553 U.S. at 691; Garcia, 786 F.3d

at 740. We hold that the Final Rule is a reasonable

interpretation of § 1008, it does not conflict with the 1996

appropriations rider or other aspects of Title X, and its

implementation of the limits on what Title X funds can

support does not implicate the restrictions found in § 1554 of

the ACA. Moreover, the Final Rule is not arbitrary and

capricious because HHS properly examined the relevant

considerations and gave reasonable explanations. See Elec.

Power Supply Ass’n, 136 S. Ct. at 782. Plaintiffs will not

prevail on the merits of their legal claims, so they are not

entitled to the “extraordinary remedy” of a preliminary

injunction. See Winter, 555 U.S. at 22. Accordingly, the

district courts’ preliminary injunction orders are vacated and

the cases are remanded for further proceedings consistent

with this opinion. The government’s motion for a stay

pending appeal is denied as moot.

VACATED AND REMANDED.

38

38 Costs on appeal shall be taxed against plaintiffs.

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STATE OF CALIFORNIA V. AZAR 81

PAEZ, Circuit Judge, joined by THOMAS, Chief Judge,

WARDLAW and FLETCHER, Circuit Judges, dissenting:

Millions of Americans depend on Title X for their health

care, including lifesaving breast and cervical cancer

screenings, HIV testing, and infertility and contraceptive

services. Congress created the Title X program in 1970 to

ensure that family planning services would be “readily

available to all persons desiring such services,” Pub. L. No.

91-572 § 2, 84 Stat. 1504 (1970), and entrusted the United

States Department of Health and Human Services (“HHS”)

with the responsibility of disbursing Title X funds to health

care providers serving low-income Americans.

Since then, Congress has twice circumscribed HHS’s

authority in administering the Title X program. First,

Congress directed that the health care providers who receive

Title X funds inform pregnant patients of their options

without advocating one choice over another. Second,

Congress barred HHS from promulgating regulations that

burden patients’ access to health care, interfere with

communications between patients and their health care

providers, or delay patients’ access to care.

In 2019, HHS promulgated the regulations at issue in this

litigation (“the Rule”). See Compliance with Statutory

Program Integrity Requirements, 84 Fed. Reg. 7714 (Mar. 4,

2019). Among other things, the Rule gags health care

providers from fully counseling women about their options

while pregnant and requires them to steer women toward

childbirth (the “Gag Rule”). It also requires providers to

physically and financially separate any abortion services they

provide (through non-Title X funding sources) from all other

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82 STATE OF CALIFORNIA V. AZAR

health care services they deliver (the “Separation

Requirement”).

Three separate district courts in well-reasoned opinions

recognized that the Rule breaches Congress’s limitations on

the scope of HHS’s authority and enjoined enforcement of the

Rule.1

In vacating the district courts’ preliminary injunctions,

the majority sanctions the agency’s gross overreach and puts

its own policy preferences before the law. Women2

and their

families will suffer for it. I strongly dissent.

***

The majority would return us to an older world, one in

which a government bureaucrat could restrict a medical

professional from informing a patient of the full range of

health care options available to her. Fortunately, Congress

has ensured such federal intrusion is no longer the law of the

land.

1

See Oregon v. Azar (Oregon), 389 F. Supp. 3d 898 (D. Or. 2019);

State of California v. Azar (California), 385 F. Supp. 3d 960 (N.D. Cal.

2019); Washington v. Azar (Washington), 376 F. Supp. 3d 1119 (E.D.

Wash. 2019). 

2 While the Rule disproportionately impacts women, people of all

genders rely on Title X services, can become pregnant, and will suffer the

consequences of the Rule. See, e.g., Cal. Code Regs., tit. 2, § 11035(g)

(defining individuals eligible for pregnancy accommodation as including

“transgender employee[s] who [are] disabled by pregnancy”); Jessica A.

Clarke, They Them, and Theirs, 132 Harv. L. Rev. 894, 954 (2019)

(“People of all gender identities can be pregnant[.]”); see also Juno

Obedin-Maliver&Harvey J. Makadon, Transgender Men and Pregnancy,

9 Obstetric Med., 4, 5 (2016).

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The majority heavily relies, mistakenly, on Rust v.

Sullivan and Harris v. McRae, decisions that held the

Constitution confers no affirmative entitlement to state

subsidization of abortion. Maj. Op. 22–24, 50 n.21, 55–59;

Rust, 500 U.S. 173, 201 (1991); McRae, 448 U.S. 297, 318

(1980); see also Webster v. Reproductive Health Services,

492 U.S. 490, 509 (1989); Maher v. Roe, 432 U.S. 464, 474

(1977). “Whether freedom of choice that is constitutionally

protected warrants federal subsidization,” the Court reasoned

in McRae, “is a question for Congress to answer, not a matter

of constitutional entitlement.” 448 U.S. at 318. It is

constitutionally permissible to “leave[] an indigent woman

with at least the same range of choice in deciding whether to

obtain a medically necessary abortion as she would have had

if Congress had chosen to subsidize no health care costs at

all.” Id. at 317. In other words, Congress can choose to

disburse its funds however it likes. I do not take issue with

that principle.

The problem for the majority’s position is that Congress

has in fact chosen to disburse public funds differently since

the days of Rust. Perhaps recognizing that medical ethics and

gender norms have evolved, Congress in 1996 and again in

2010 enacted statutory protections that exceed the

constitutional floor set decades ago. In 1996 (and every year

since) Congress clarified that its decision not to subsidize

abortion does not prohibit pregnancy counseling on the range

of women’s options; to the contrary, Congress explicitly

required that “all pregnancy counseling shall be

nondirective.” Omnibus Consolidated Rescissions and

Appropriations Act of 1996, Pub. L. No. 104-134, 110 Stat.

1321 (1996) (“the nondirective mandate”). And, in 2010,

Congress prohibited HHS frompromulgating regulations that

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84 STATE OF CALIFORNIA V. AZAR

frustrate patients’ ability to access health care. 42 U.S.C.

§ 18114.

The majority disregards twenty years of progress,

insistent on hauling the paternalism of the past into the

present. Because Congress has clarified the scope of HHS’s

authority, the Rust line of cases has little bearing on the

matter before us. Our only task is to determine whether HHS

has exceeded the authority Congress granted it. And as the

district courts concluded, it has.

I. The Rule Violates Congress’s Nondirective Mandate

Since 1996, Congress has provided a clear limitation on

Title X funding, specifying “that all pregnancy counseling

shall be nondirective.” Department of Defense and Labor,

Health and Human Services, and Education Appropriations

Act, and Continuing Appropriations Act, Pub. L. No. 115-

245, 132 Stat. 2981, 3070–71 (2018) (emphasis added). The

district courts separately determined that the Rule conflicts

with Congress’s nondirectivemandate. 5 U.S.C. § 706(2)(A);

see Oregon, 389 F. Supp. 3d at 909–13; California, 385 F.

Supp. 3d at 986–92; Washington, 376 F. Supp. 3d at 1130. I

agree.3

3 We review for abuse of discretion the district courts’ grant of the

preliminary injunctions. Alliance for the Wild Rockies v. Cottrell,

632 F.3d 1127, 1131 (9th Cir. 2011). “The district court’s interpretation

of the underlying legal principles, however, is subject to de novo review

and a district court abuses its discretion when it makes an error of law.” 

Sw. Voter Registration Educ. Project v. Shelley, 344 F.3d 914, 918 (9th

Cir. 2003). Because Plaintiffs’ first two claims, namely whether the Rule

violates Congress’s nondirective mandate or the Affordable Care Act, turn

on the merits of several legal issues, I agree with the majority that we may

address the merits of those issues directly. The majority goes too far,

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STATE OF CALIFORNIA V. AZAR 85

The Rule is nothing but directive. By its very terms, it

requires a doctor to refer a pregnant patient for prenatal care,

even if she does not want to continue the pregnancy, while

gagging her doctor fromreferring her for abortion, even if she

has requested specifically such a referral. 42 C.F.R.

§§ 59.14(a), (b). The Rule does not stop there. If a doctor

provides a patient a referral list of primary health care

providers, no more than half of those providers may offer

abortion services. 42 C.F.R. § 59.14(c)(2). And if the patient

asks who on the list might actually provide her an abortion?

The Rule muzzles her doctor from telling her. Id. The result

is that patients are steered toward childbirth at every turn.

What can a doctor even say when confronted with her

patient’s questions about abortion? The Rule bars doctors

from “promot[ing] . . . or support[ing] abortion as a method

of family planning, []or tak[ing] any other affirmative action

to assist a patient” in exercising her right to abortion. 

42 C.F.R. § 59.14(a); see also 42 C.F.R. § 59.5(a)(5). 

Imagine a patient visits her Title X provider and asks whether

she can get an abortion at the local hospital. Would it qualify

as “promoting” abortion to answer the question? The Gag

Rule makes doctors who desire to provide their patients with

accurate information “walk on eggshells to avoid a potential

transgression of the . . . Rule, whereas those describing the

option of continuing the pregnancy face no comparable risk.” 

California, 385 F. Supp. 3d at 992.

however, in adjudicating the merits of the third claim, namely whether the

promulgation of the Rule was arbitrary and capricious, for the reasons

discussed in Section III, infra.

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The result is Kafkaesque. Oregon, 389 F. Supp. 3d

at 912. As Judge McShane of the District of Oregon

observed:

The Gag Rule is remarkable in striving to

make professional health care providers deaf

and dumb when counseling a client who

wishes to have a legal abortion or is even

considering the possibility. The rule

handcuffs providers by restricting their

responses in such situations to providing their

patient with a list of primary care physicians

who can assist with their pregnancy without

identifying the ones who might perform an

abortion. Again, the response is required to

be, “I can’t help you with that or discuss it. 

Here is a list of doctors who can assist you

with your pre-natal care despite the fact that

you are not seeking such care. Some of the

providers on this list—but in no case more

than half—may provide abortion services, but

I can’t tell you which ones might. Have a

nice day.” This is madness.

Id. at 913 (footnote omitted).

The majority purports to see no problem here. Although

HHS itself defines “nondirective counseling” as “the

meaningful presentation of options where the [medical

professional] is ‘not suggesting or advising one option over

another,’” 84 Fed. Reg. at 7716 (citation omitted), the

majority insists such counseling does not require the

meaningful presentation of “all” options. Maj. Op. 47. 

Rather, in the majority’s tortured telling, “nondirective”

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STATE OF CALIFORNIA V. AZAR 87

requires only the “neutral” presentation of some options.4

Maj. Op. 47.

Excluding an entire category of options is neither

meaningful nor neutral. If a man were diagnosed with

prostate cancer, and his doctor concluded that chemotherapy,

radiation, or hospice were equally viable responses, each with

different consequences for his quality of life, he would be

upset, to say the least, to discover that he had been referred

only for hospice care. Such a sham “presentation” of options

would in no sense be nondirective.

So too here. Indeed, HHS itself has recognized that there

can be no meaningful choice when a whole category of

4 The majority sanctions HHS’s post hoc interpretation that

“counseling” does not include “referrals.” Maj. Op. 41–46. Judge Chen

of the Northern District of California readily dismissed this argument. 

California, 385 F. Supp. 3d at 988–91. As Judge Chen explained,

nondirective counseling encompasses referrals for three reasons. First,

Congress expressly stated so, a point HHS recognized when it

promulgated the Rule. See 42 U.S.C. § 254c-6(a)(1) (requiring HHS to

make training grants on “providing adoption information and referrals to

pregnant women on an equal basis with all other courses of action

included in nondirective counseling to pregnant women”) (emphasis

added); 84 Fed. Reg. at 7733 (“Congress has expressed its intent that

postconception adoption information and referrals be included as part of

any nondirective counseling in Title X projects when it passed . . .

42 U.S.C. 254c-6[.]”) (emphasis added). Second, HHS itself describes

referrals as part of counseling throughout the Rule and has done so across

administrations. See, e.g., 84 Fed. Reg. at 7730, 7733–34; U.S. Dep’t

Health & Human Services, Program Guidelines for Project Grants for

Family Planning Services § 8.2 (1981) (“Post-examination counseling

should be provided to assure that the client . . . receives appropriate

referralfor additionalservices as needed.”). Third, industry understanding

recognizes that counseling includes referrals. See California, 385 F. Supp.

3d at 989.

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88 STATE OF CALIFORNIA V. AZAR

options is hidden from a patient: “In nondirective counseling,

abortion must not be the only option presented by [medical

professionals]; otherwise the counseling would violate . . . the

Congressional directive that all pregnancy counseling be

nondirective[.]” 84 Fed. Reg. at 7747. The Gag Rule does

exactly that. For all pregnancy counseling not involving

abortion, women can take an “active” and “informed” role in

their pregnancy and family planning process; but once a

woman asks for abortion information, she can no longer be

provided all the information she seeks about her own medical

care. See 84 Fed. Reg. at 7716–17. “[E]mpower[ed]” so long

as she does what the agency and the majority want;

“coerc[ed]” and demeaned if she tries to “take an active role

in . . . identifying the direction” of her life’s course. 84 Fed.

Reg. at 7716; 65 Fed. Reg. at 41275.5 The consequences will

5

Indeed, in 2000, the agency concluded that “requiring a referral for

prenatal care and delivery or adoption where the client rejected those

options would seem coercive and inconsistent with the concerns

underlying the ‘nondirective’ counseling requirement.” 65 Fed. Reg. at

41275 (emphasis added).

The majority attempts to salvage the prenatal care referral

requirement by claiming that prenatal care is medically necessary for all

patients’ health, regardless of their intent to end a pregnancy. Maj. Op. 48

& n.19. That’s not true, as the American College of Obstetricians and

Gynecologists (“ACOG”) and other professional medical associations, as

well as numerous physicians and other health care providers have attested. 

See, e.g., Br. of Amici Curiae Am. Coll. of Obstetricians & Gynecologists,

et al., at 14–15 (“Prenatal care is not medically indicated when a pregnant

patient plans to terminate her pregnancy—it is recommended only when

a patient plans to continue her pregnancy.”); Decl. of J. Elisabeth Kruse,

Nat’l Family Planning & Reprod. Health Ass’n Supplemental Excerpts of

Record (“SER”) at 256 (Washington) (“[O]f course, such care is not

medically necessary for someone who wishes to terminate her

pregnancy.”); Decl. of Dr. Melissa Marshall, California SER 579

(California) (“[P]renatal health care is not medically necessary when a

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STATE OF CALIFORNIA V. AZAR 89

be profound, delaying some women’s access to time-sensitive

care and preventing others from accessing abortion

altogether.6

patient is terminating her pregnancy.”); Decl. of Dr. Judy Zerzan-Thul,

Washington SER 161 (Washington) (“[I]f a patient determined to be

pregnant elects to terminate the pregnancy, pre-natal care would not be

medically necessary.”). And, regardless, that’s not how HHS justified the

requirement. Rather, HHS required the prenatal care referral because

“such care is important” not only for women’s health but also “for healthy

pregnancy and birth.” 84 Fed. Reg. at 7722 (emphasis added). 

6 As health care providers and amici make clear, the notion that

“information about abortion is readily available ‘on the internet’ betrays

a complete lack of understanding of the realities of our Title X patient

population” who, “because of language, literacy (including health literacy

and electronic literacy), or economic barriers[,]” depend on referrals from

Title X providers in order to access care. Kruse, Nat’l Family Planning &

Reprod. Health Ass’n SER 262 (Washington); see also Decl. of Dr. Sarah

Prager, id. at 298–99 (“Because many Title X patients have linguistic,

educational, informational, and financial barriers to accessing healthcare,

the impediments introduced by the New Rule may prevent such patients

from accessing abortion altogether.”); Decl. of Dr. Blair Darney, Oregon

SER 41 (Oregon) (“Researchers have studied the reasons women delay

entry to care for abortion; logistics such as knowing where to go is among

the reasons.”); cf. Maj. Op. 50 n.21.

The barriers created by the Gag Rule are particularly substantial for

young people, LGBTQpeople, those with limited English proficiency, and

patients in rural areas. See, e.g., Br. of Amici Curiae Nat’l Ctr. for Youth

Law, et al., at 16–17 (“Adolescents without easy access to transportation,

a phone, and the Internet might be unable to research the providers on the

list they are given. They also might not immediately comprehend that a

medical professional, whomthey trust, has referred them for care that they

do not need or want . . . . Particularly for adolescents who are homeless or

in foster care, navigating a maze of providers that might or might not offer

abortion services could prove impossible.”); Br. of Amici Curiae Nat’l

Ctr. for Lesbian Rights, et al., at 13; Decl. of Kathryn Kost, California

SER 156 (California). As one health care provider concluded, “The New

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90 STATE OF CALIFORNIA V. AZAR

Congress has prohibited such a result. Contrary to the

majority’s contention that HHS is owed Chevron deference

because Congress has not clarified the meaning of the term

“nondirective”, Maj. Op. 46, Congress has in fact done so. 

And where Congress’s intent is clear, we “must give effect to

the unambiguously expressed intent of Congress.” Chevron,

U.S.A., Inc. v. Nat. Res. Def. Council, Inc., 467 U.S. 837, 843

(1984).

Congress has used “nondirective counseling” in only two

instances: the annual HHS Appropriations Act at issue here

and section 254c-6(a)(1) of the Public Health Service Act

(“PHSA”). The latter provides that HHS shall make training

grants “providing adoption information and referrals to

pregnant women on an equal basis with all other courses of

action included in nondirective counseling to pregnant

women.” 42 U.S.C. § 254c-6(a)(1) (emphasis added).

In response, the majority asserts that because § 254c6(a)(1) is not part of Title X and was enacted for a different

purpose, “it sheds no light on Congress’s intent in enacting

the appropriations rider or on the interpretation of its statutory

language.” Maj. Op. 44. If § 254c-b(a)(1) sheds no light,

HHS certainly didn’t think so: it relied on the PHSA

definition in formulating the Rule. See 84 Fed. Reg. at 7733

(“Congress has expressed its intent that . . . referrals be

included as part of any nondirective counseling in Title X

projects when it passed the . . . Public Health Service

Act[.]”); 84 Fed. Reg. at 7745. As HHS apparently

recognized, Congress’s use of the term “nondirective

Rule’s coercive requirements would force me to disrespect, contradict, and

patronize my patient, and violate her trust[.]” Kruse, Nat’l Family

Planning & Reprod. Health Ass’n SER 262 (Washington).

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STATE OF CALIFORNIA V. AZAR 91

counseling” should be read consistently between the PHSA

and the nondirective appropriations rider to include providing

referrals on an equal basis with all other options. See

Erlenbaugh v. United States, 409 U.S. 239, 243 (1972) (“[A]

legislative body generally uses a particular word with a

consistent meaning in a given context.”); see also Dir., Office

of Workers’ Comp. Prog., Dep’t of Labor v. Newport News

Shipbldg. & Dry Dock Co., 514 U.S. 122, 130 (1995)

(instructing that in interpreting an ambiguous statutory

phrase, “[i]t is particularly illuminating to compare” two

different statutes employing the “virtually identical” phrase).

Because the Gag Rule requires doctors to push patients

toward one option over another, it violates Congress’s

mandate that patients receive counseling on their pregnancy

options in a nondirective manner.

II. The Rule Violates Section 1554 of the Affordable Care

Act

In 2010, as part of the Affordable Care Act’s (“ACA”)

sweeping reforms, Congress imposed limits on the scope of

HHS’s regulatory authority:

Notwithstanding any other provision of this

Act, the Secretary of Health and Human

Services shall not promulgate any regulation

that—

(1) creates any unreasonable barriers to the

ability of individuals to obtain appropriate

medical care;

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(2) impedes timely access to health care

services;

(3) interferes with communications regarding

a full range of treatment options between the

patient and the provider;

(4) restricts the ability of health care providers

to provide full disclosure of all relevant

information to patients making health care

decisions;

(5) violates principles of informed consent

and the ethical standards of health care

professionals; or

(6) limits the availability of health care

treatment for the full duration of a patient’s

medical needs.

42 U.S.C. § 18114 (“section 1554”). The three district courts

separately determined that the Rule violates section 1554 of

the ACA. See Oregon, 389 F. Supp. 3d at 914–15;

California, 385 F. Supp. 3d at 992–1000; Washington, 376 F.

Supp. 3d at 1130. I agree.

First, the Gag Rule—which restricts communications

between health care providers and patients, 42 C.F.R.

§§ 59.14(a)–(c)—will “obfuscate and obstruct patients from

receiving information and treatment for their pressing

medical needs.” California, 385 F. Supp. 3d at 998; see also

Washington, 376 F. Supp. 3d at 1130. In so doing, the Rule

exceeds HHS’s statutory authority: it “impedes timely access

to health care services[,]” “interferes with communications

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STATE OF CALIFORNIA V. AZAR 93

regarding a full range of treatment options[,]” “restricts the

ability of health care providers to provide full disclosure of

all relevant information to patients making health care

decisions[,]” and “violates . . . the ethical standards of health

care professionals[.]” 42 U.S.C. § 18114.

Second, the Separation Requirement—which requires

Title X recipients to physically and financially separate

abortion provision from all other medical services, through

the use of separate entrances and exits as well as separate

accounting, personnel, and medical records, 42 C.F.R.

§ 59.15—plainly will impinge on the ability of providers to

offer care. See Oregon, 389 F. Supp. 3d at 915; Washington,

376 F. Supp. 3d at 1130. By its own terms, HHS’s Separation

Requirement creates unreasonable barriers to health care; it

also frustrates “timely access” to care, contrary to Congress’s

plain directive that HHS may not do so. 42 U.S.C. § 18114.

Finally, the Rule’s requirement that doctors encourage

family participation in reproductive decisions will “force

[doctors] to breach their ethical obligations” in certain

circumstances. California, 385 F. Supp. 3d at 1000; see also

Washington, 376 F. Supp. 3d at 1130. This requirement

directly contravenes Congress’s prohibition on promulgating

regulations that “violate[] . . . the ethical standards of health

care professionals[.]” 42 U.S.C. § 18114.

Tellingly, the majority does not even attempt to argue that

the Rule complies with the ACA. Instead, it characterizes the

Rule as falling conveniently outside the scope of the

limitations Congress imposed on HHS in the ACA. It relies

on the Rust and McRae line of cases for the proposition that,

as a constitutional matter, Congress need not subsidize

abortion. It then asserts that the constitutional minima

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94 STATE OF CALIFORNIA V. AZAR

identified in those cases “applies equally” to statutory claims. 

Maj. Op. 55–59. The majority offers no support for this bold

proposition.

How could it? Congress may, and regularly does, enact

statutory requirements and protections that exceed the

constitutional floor. Aetna Life Ins. Co. v. Lavoie, 475 U.S.

813, 828 (1986) (“The Due Process Clause demarks only the

outer boundaries . . . . Congress and the states, of course,

remain free to impose more rigorous standards[.]”); Am.

Legion v. Am. Humanist Assoc., 139 S. Ct. 2067, 2094 (2019)

(Kavanaugh, J., concurring) (“The constitutional floor is

sturdy and often high, but it is a floor.”). That is exactly what

Congress has done here.7 That a congressional decision not

to subsidize abortion does not burden the abortion right in the

constitutional sense, see e.g., McRae, 448 U.S. at 316, has no

7 The majority’s assertion that the ACA does not impact Title X is

contradicted by the terms of the ACA. Maj. Op. 59–60. Section 1554

governs “any regulation,” 42 U.S.C. § 18114 (emphasis added). If

Congress had meant to restrict its scope to the ACA, it would have said

“any regulation pursuant to this Act.” Cf. St. Paul Fire & Marine Ins. Co.

v. Barry, 438 U.S. 531, 550 (1978) (discussing the breadth of the word

“any” and concluding that if Congress intends to limit the scope of

statutory language, it will make that explicit). As Judge Chen reasoned,

the clause “[n]otwithstanding any other provision of this Act” is most

naturally read to mean that the Secretary “cannot engage in the type of

rulemaking proscribed by [s]ection 1554 even if another provision . . .

could be construed to permit it.” California, 385 F. Supp. 3d at 995. In

other words, “the directive of [s]ection 1554 is to be given primacy” over

other parts of the ACA.

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STATE OF CALIFORNIA V. AZAR 95

bearing whatsoever on whether an agency has overstepped its

statutory authority. And, here, the agency has.8

III. The Rule Is Likely Arbitrary and Capricious

Finally, I turn to Plaintiffs’ claim that the promulgation of

the Rule was arbitrary and capricious under the

Administrative Procedure Act (“APA”). As an initial matter,

the majority contends that it is appropriate, on review of the

district courts’ preliminary injunctions, to adjudicate the

merits of the arbitrary and capricious claim. Maj. Op. 35–39. 

It is not. Unlike our consideration of Plaintiffs’ first two

claims, which required us to address the underlying legal

question to determine whether the district courts abused their

discretion, review of the arbitrary and capricious claim

requires examination of the administrative record. We do not

have the complete administrative record before us, and

neither did the district courts when they issued the

preliminary injunctions. Deciding the merits of Plaintiffs’

arbitrary and capricious claim is therefore premature. See

Walter O. Boswell Mem’l Hosp. v. Heckler, 749 F.2d 788,

792 (D.C. Cir. 1984) (“If a court is to review an agency’s

action fairly, it should have before it neither more nor less

information than did the agency when it made its decision.”)

(emphasis added); Nat. Res. Def. Council, Inc. v. Train,

519 F.2d 287, 291 (D.C. Cir. 1975) (“The Administrative

Procedure Act and the cases require that the complete

8 The majority makes much of the fact that the Rule is purportedly

“less restrictive in at least one important respect” than the 1988 regulation

upheld in Rust. Maj. Op. 16. That is immaterial. The Rust decision

predated the passage of the nondirective mandate by half a decade and the

ACA by two decades, so whether the Rule or its 1988 predecessor violated

those laws was not and could not possibly have been before the Court. 

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96 STATE OF CALIFORNIA V. AZAR

administrative record be placed before a reviewing court.”);

see also Univ. of Texas v. Camenisch, 451 U.S. 390, 395

(1981) (“[G]iven the haste that is often necessary . . . a

preliminary injunction is customarily granted on the basis of

procedures that are less formal and evidence that is less

complete than in a trial on the merits. A party thus is not

required to prove his case in full at a preliminary-injunction

hearing[.]”).9Indeed, “[t]o review less than the full

administrative record might allow a party to withhold

evidence unfavorable to its case, and so the APA requires

review of ‘the whole record.’” Boswell Mem’l Hosp.,

749 F.2d at 792. Accordingly, I address only Plaintiffs’

likelihood of success on the merits. The majority should have

done the same.10

9

Indeed, while Defendants pursued their appeals of the preliminary

injunctions, briefing advanced to the merits in the Eastern District of

Washington. There, Defendants produced to Plaintiffs the full

administrative record (two months after the preliminary injunction issued),

see Case No. 1:19-cv-03040-SAB, Dkt. No. 88 (June 24, 2019) and, with

the benefit of the complete record, Plaintiffs further developed their

arbitrary and capricious claim. See Case No. 1:19-cv-03040-SAB, Dkt.

No. 121 (Nov. 20, 2019).

10 The cases on which the majority relies to proceed to the merits are

inapt. First, unlike the cases the majority cites, Maj. Op. 35–39, we do not

have the full administrative record before us. Cf. Beno v. Shalala, 30 F.3d

1057, 1064 n.11 (9th Cir. 1994) (reaching the merits because “Plaintiffs’

. . . claim requires a review of the administrative record, which is

complete, and interpretation of relevant statutes; additional fact-finding is

not necessary to resolve this claim”) (emphasis added); Blockbuster

Videos, Inc. v. City of Tempe, 141 F.3d 1295, 1297 (9th Cir. 1998) (same,

because “[t]he record . . . is fully developed”); see also Fla. Power &

Light Co. v. Lorion, 470 U.S. 729, 744 (1985) (“The APA specifically

contemplates judicial review on the basis of the agency record compiled

in the course of . . . [the] agency action[.]”) (emphasis added). Nor is this

a case that implicates sensitive foreign policy concerns. Munaf v. Geren,

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STATE OF CALIFORNIA V. AZAR 97

Under the APA, a court “shall . . . hold unlawful and set

aside agency action . . . found to be . . . arbitrary [and]

capricious.” 5 U.S.C. § 706(2)(A). An agency action is

arbitrary and capricious if “the agency has relied on factors

which Congress has not intended it to consider, entirely failed

to consider an important aspect of the problem, [or] offered

an explanation for its decision that runs counter to the

evidence before the agency.” Motor Vehicle Mfrs’ Ass’n v.

State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43 (1983). 

“[T]he agency must examine the relevant data and articulate

a satisfactory explanation for its action including a rational

connection between the facts found and the choice made.” Id.

(internal quotation marks omitted).

When an agency changes its policy, the agency must

provide a “reasoned explanation for its action.” FCC v. Fox

Television Stations, Inc., 556 U.S. 502, 515 (2009). The new

policy need not be better than the old one, but it must be

permissible and based on “good reasons.” Id. When the

reasons the agency relies on for changing its position are “not

new,” the agency fails to provide a “reasoned explanation.” 

Org. Vill. of Kake v. U.S. Dep’t of Agric., 795 F.3d 956, 967

(9th Cir. 2015) (en banc). “In explaining its changed

position, an agency must also be cognizant that longstanding

policies may have engendered serious reliance interests that

must be taken into account.” Encino Motorcars, LLC v.

Navarro, 136 S. Ct. 2117, 2126 (2016) (internal quotation

marks omitted). Here, the Rule replaced the regulation

adopted in 2000, not the 1988 regulation addressed in Rust;

thus the 2000 Rule is the one to which we must look to assess

553 U.S. 674, 692 (2008) (reasoning that reaching the merits was “the

wisest course” because the case “implicate[d] sensitive foreign policy

issues in the context of ongoing military operations”).

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HHS’s changed positions. See Standards of Compliance for

Abortion-Related Services in Family Planning Services

Projects, 65 Fed. Reg. 41270 (Jul. 3, 2000). Plaintiffs are

likely to prevail on their claim that the promulgation of the

Rule was arbitrary and capricious for at least two reasons.11

A. HHS Failed to Provide a Reasoned Justification for

Its Policy Change

First, the Rule represents a dramatic shift in policy, yet

HHS failed to provide the required “reasoned explanation for

its action.” Fox Television, 556 U.S. at 515. Take the Gag

Rule and Separation Requirement, for example. In 2000,

when it adopted regulations rescinding the 1988 version of

the Gag Rule, HHS explicitly considered Congress’s recently

enacted nondirective mandate as well as comments

emphasizing that “medical ethics and good medical care . . .

requir[e] that patients receive full and complete information

11 None of the district courts needed to address Plaintiffs’ arbitrary

and capricious arguments because they had independently found Plaintiffs

were likely to succeed on their other merits arguments. Nevertheless, each

district court recognized the strength of Plaintiffs’ APA challenge. 

California, 385 F. Supp. 3d at 1000–19 (addressing—with painstakingly

detailed analysis—the shortcomings of HHS’s justifications for the

physical separation requirement, the counseling and referral restrictions,

the “physicians or advanced practice providers” requirement, and the

removal of the “medically approved” requirement, as well as HHS’s

inadequate cost-benefit analysis); Oregon, 389 F. Supp. 3d at 917–18

(noting that HHS “nowhere squares” particular medical ethics

requirements with the requirements of the Rule and that HHS “appears to

have failed to seriously consider persuasive evidence”); Washington,

376 F. Supp. 3d at 1131 (recognizing that Plaintiffs and amici had

“presented facts and argument that the . . . Rule is arbitrary and capricious

because it reverses long-standing positions of[HHS]” without considering

relevant medical opinions and likely consequences).

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STATE OF CALIFORNIA V. AZAR 99

to enable them to make informed decisions”;

“[c]onsequently,” the agency “decided to reflect [the

nondirective requirement] . . . in the regulatory text.” 65 Fed.

Reg. at 41273. By contrast, here HHS has changed its

position on what medical ethics demand without providing a

reasoned explanation for or acknowledgment of the change,

as is required by the APA.12See Org. Vill. of Kake, 795 F.3d

at 966 (“Unexplained inconsistency between agency actions

is a reason for holding an interpretation to be an arbitrary and

capricious change.”) (internal quotation marks and citation

omitted).13

12 That abortion remains controversial, as the majority contends, Maj.

Op. 75 n.34, does not explain why HHS may shift its understanding of

medical ethics from 2000 without a reasoned explanation.

13 I also agree with Judge McShane of the District of Oregon that

HHS’s “failure to respond meaningfully to the evidence” that the Gag

Rule contradicts medical ethics “renders its decision[] arbitrary and

capricious.” Oregon, 389 F. Supp. 3d at 918 (quoting Tesoro Alaska

Petroleum Co. v. FERC, 234 F.3d 1286, 1294 (D.C. Cir. 2000)). A doctor

and leader of the American Medical Association—the organization that

“literally wrote the book on medical ethics”—stated that the American

Medical Association’s Code of Medical Ethics prohibits withholding

information from a patient, except in emergency situations, and requires

decisions or recommendations to be based on the patient’s medical needs. 

Id. at 916. He concluded that the Gag Rule “is an instruction to physicians

to intentionally mislead patients, which, if followed, is an instruction for

physicians to directly violate the Code of Medical Ethics[.]” Id. at 917.

In its cursory response, HHS merely announced that it “believes” the

Rule presents no ethical problems because patients are permitted to ask

questions “and to have those questions answered by a medical

professional.” 84 Fed. Reg. at 7724. That assertion is contradicted by the

plain text of the Rule, which specifically prohibits medical professionals

from answering certain questions, such as, “who on this list is an abortion

provider?” 42 C.F.R. § 59.14(c)(2). HHS’s insistence that the Gag Rule

is “nondirective” does not salvage the Rule either, as it is both conclusory

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Similarly, in 2000, HHS recognized that “Title Xgrantees

are subject to rigorous financial audits” and ultimately

concluded that a physical separation requirement “is not

likely ever to result in an enforceable compliance policy that

is consistent with the efficient and cost-effective delivery of

family planning services.” 65 Fed. Reg. at 41275–76 (2000)

(emphasis added). As justification for its about-face in the

new Rule, HHS speculated about a “risk” of Title X funds

being used for impermissible purposes.1484 Fed. Reg.

at 7765 (discussing the risk of “potential co-mingling”

without citing any evidence of co-mingled funds). A

speculative risk is not a reasoned explanation. Ariz. Cattle

Growers’ Ass’n v. U.S. Fish & Wildlife, 273 F.3d 1229, 1244

(9th Cir. 2001); see also Nat’l Fuel Gas Supply Corp. v.

FERC, 468 F.3d 831, 841 (D.C. Cir. 2006).

B. HHS’s Cost-Benefit Analysis Is Contrary to the

Evidence

Second, the Rule is likely arbitrary and capricious

because HHS offered an explanation for its cost-benefit

and, for the reasons explained in Section I, supra, false. Because the Gag

Rule “contradicts . . . persuasive evidence from the leading expert on

medical ethics,” and HHS has failed to present even a “plausible

explanation outlining its rationale for rejecting the evidence and reaching

a different conclusion,” Oregon, 389 F. Supp. 3d at 917 (citing State Farm

Mut., 463 U.S. at 43), it is arbitrary and capricious. The majority is wrong

to conclude otherwise.

14 To be clear: the “recent studies” that the majority notes HHS relied

on do not demonstrate any actual misuse of Title X funds. Maj. Op. 66. 

Rather, they reflect facilities that comply with Title X but likely will be

forced out of the program by the Separation Requirement. 84 Fed. Reg.

at 7765.

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STATE OF CALIFORNIA V. AZAR 101

analysis that runs contrary to the evidence before the agency. 

See State Farm Mut., 463 U.S. at 43. As the district courts

explained, there are at least three provisions of the Rule that

will cause providers to leave the Title X program, leading to

decreased access to Title X-funded care, which will in turn

create costs that HHS did not account for.

First, the Gag Rule. Because it “require[s] doctors to

violate . . . fundamental ethical and professional norms[,]”

Oregon, 389 F. Supp. 3d at 916, the Gag Rule will trigger

providers to leave the Title X program, “drastically

reduc[ing] access to Title X services, and lead[ing] to serious

disruptions in care for Title X patients.” California, 385 F.

Supp. 3d at 1008. For example, the provider serving

approximately 40% of all Title X patients—1.6 million

people—which is also the only family planning provider in

ten percent of rural counties, declared that if the Gag Rule is

implemented, it will leave the Title X program in order to

maintain its ethical obligations to patients.15 Oregon, 389 F.

Supp. 3d at 918; California, 385 F. Supp. 3d at 979.

15 Indeed, this exodus has come to pass. Plaintiffs informed us that

all Planned Parenthood Title X direct grantees would withdraw from Title

X beginning August 19, 2019, as a result of enforcement actions by HHS,

and they have done so. See Sarah McCammon, Planned Parenthood

Withdraws From Title X Program Over Trump Abortion Rule, Nat’l Pub.

Radio (Aug. 19, 2019), https://www.npr.org/2019/08/19/752438119/pla

nned-parenthood-out-of-title-x-over-trump-rule. Planned Parenthood is

not alone. See Nicole Acevedo, Nearly 900 Women’s Health Clinics Have

Lost Federal Funding Over Gag Rule, NBC News (Oct. 22, 2019)

https://www.nbcnews.com/news/latino/nearly-900-women-s-healthclinics-have-lost-federal-funding-n1069591; Anna North, How A Beloved

Clinic for Low-Income Women Is Fighting to Stay Alive in the Trump Era,

Vox (Nov. 22, 2019), https://www.vox.com/identities/2019/11/22/2095

2297/title-x-funding-abortion-birth-control-trump.

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Second, the Separation Requirement. Compliance with

the Separation Requirement will be so cost-prohibitive for

many providers that they will have to leave the Title X

program.

16

 California, 385 F. Supp. 3d at 1008–11.

Third, the requirement that only “physicians or advanced

practice providers” may provide counseling. See 84 Fed.

Reg. at 7727–28 (defining “advanced practice providers”). 

This limitation will significantly reduce the number of people

who can provide pregnancy counseling and will require

significant changes in Title X providers’ staffing, or else

devastate their capacity to serve patients. Id. at 7778 (noting

that for “1.7 million Title X family planning encounters in

2016,” services were delivered by providers who are not

“physicians or advanced practice providers”); California,

385 F. Supp. 3d at 1013 (recognizing that “65% of Title X

sites rel[ied] on trained health educators, registered nurses,

and other qualified providers (excluding physicians and

advanced practice clinicians) to counsel patients in selecting

contraceptive methods”) (internal quotation marks and

citation omitted).

16 HHS also calculated costs of compliance with the physical

separation requirement in a “mystifying” way. California, 385 F. Supp.

3d at 1008. HHS’s internal guidelines—and common sense—suggest that

compliance costs for making physically separate facilities would include

expenses related to equipment, leasing space, utilities, and personnel. Yet,

HHS estimated that an average of only $30,000 per affected Title X site

would be incurred to comply with the physical separation requirement. 

84 Fed. Reg. at 7782. As Plaintiffs’ counsel indicated at oral argument,

even just hiring a single front desk staff member to staff a new entrance

to a facility would exceed that estimate, not to mention all the other costs

that would accompanying creating and maintaining such a facility. See,

e.g., Washington SER 355–56 (Washington); California SER 396–97

(California).

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HHS dismissed the loss of access by speculating that

there would not “be a decrease in the overall number of

facilities offering [Title X] services, since [HHS] anticipates

other, new entities will apply for funds, or seek to participate

as subrecipients, as a result of the final rule.” 84 Fed. Reg.

at 7782. HHS simultaneously contradicted that very

prediction, by stating, “[HHS] cannot calculate or anticipate

future turnover in grantees.” Id. (emphasis added). 

Nonetheless, HHS stated, “[b]ased on [HHS’s] best estimates,

it anticipates that the net impact on those seeking services

from current grantees will be zero[.]” Id. HHS provided no

explanation of how it arrived at its “best estimates.” See also

California, 385 F. Supp. 3d at 983 (“[A]t oral argument

[before the district court], when pressed for any record

evidence substantiating this (highly consequential) assertion,

Defendants’ counsel could offer none.”). Nor did HHS

provide any specifics about its estimates, such as the

locations or geographic distribution of any “new” clinics,

their number or size, or how long it would take them to

become operational grantees. Thus, HHS failed to offer “an

explanation for its decision that runs counter to the evidence

before” it. State Farm Mut., 463 U.S. at 43. Proceeding in

this manner is the hallmark of arbitrary and capricious

administrative action.

The majority disagrees, citing readily distinguishable case

law and a poll that did not conclude what the majority

purports it does.17 Maj. Op. 68–69. The “poll” that HHS

17 The majority relies extensively on the Supreme Court’s recent

opinion, Dep’t of Commerce v. New York, 139 S. Ct. 2551 (2019). Maj.

Op. 62, 63–64, 70–77. That case raised the issue of whether the Secretary

of Commerce was required to accept the Census Bureau’s predictions

about accurate gathering of citizenship data. Dep’t of Commerce, 139 S.

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cited is a summary showing both that a majority of “faithbased healthcare professionals” would prefer not to violate

their conscience and that a majority of them never

experienced pressure to refer a patient for a procedure to

which the professional had moral, ethical, or religious

objections. 84 Fed. Reg. at 7780 n.138; Freedom2Care &

The Christian Med. Ass’n, National Poll Shows Majority

Support Healthcare Conscience Rights, Conscience Law

(May 3, 2011), https://perma.cc/3AU4-ACGA. Nothing

suggests that the poll asked medical professionals about

expanding into Title X. It is baffling how HHS made the leap

from the poll data—the quality and veracity of which is

unclear fromthe summary the agency cited—to its conclusion

that there would be no decrease in facilities. Id. And a

predicate to giving deference to an agency is that the agency’s

inferences must not contradict the findings of the study. 

State Farm Mut., 463 U.S. at 43. That is by no means de

novo review, contrary to the majority’s contention. Maj. Op.

69 n.29.

Ct. at 2569. The Court held that the Secretary was not beholden to the

Bureau’s analysis because “the Census Act authorizes the Secretary, not

the Bureau, to make policy choices within the range of reasonable

options[,]” id. at 2571 (emphasis added), and there was support for the

Secretary’s decision, id. at 2569. Conversely, here, we are reviewing

HHS’s own administrative decisions in the face of contravening evidence,

and there is no support for HHS’s decisions.

Moreover, the Court struck down the Secretary of Commerce’s

attempt to reinstate the citizenship question on the census. See 139 S. Ct.

at 2575–76 (“Our review is deferential, but we are ‘not required to exhibit

a naiveté from which ordinary citizens are free.’”). Similarly, here,

deference to HHS does not mean turning a blind eye to the agency’s

actions, as the majority does.

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STATE OF CALIFORNIA V. AZAR 105

Moreover, the cases on which the majority relies to

endorse HHS’s guesswork arose in different circumstances. 

Maj. Op. 68–71. When the Supreme Court in FCC v.

National Citizens Committee for Broadcasting condoned an

agency’s “forecast” for future behaviors without “complete

factual support,” the underlying agency decision was “to

‘grandfather’” existing policies into a new rule. 436 U.S.

775, 813–14 (1978). There, the agency’s predictions

concerned maintenance of the status quo, rather than the

change in policy HHS made here. And in other cases cited by

the majority, the regulations at issue “reflect[ed] reasoned

predictions about technical issues.” BNSF Ry. Co. v. Surface

Transp. Bd., 526 F.3d 770, 781 (D.C. Cir. 2008) (citation

omitted); see also Trout Unlimited v. Lohn, 559 F.3d 946, 959

(9th Cir. 2009) (noting that the record showed that the agency

relied on “scientific data, and not on mere speculation”). 

HHS’s prediction here is not reasoned or based on any data or

studies, and should not be afforded deference. See Sorenson

Commc’ns Inc. v. FCC, 755 F.3d 702, 708 (D.C. Cir. 2014)

(“[T]he wisdom of agency action is rarely so self-evident that

no other explanation is required.”); McDonnell Douglas

Corp. v. U.S. Dep’t of the Air Force, 375 F.3d 1182, 1187

(D.C. Cir. 2004) (“[W]e do not defer to the agency’s

conclusory or unsupported suppositions.”).

Further, because of HHS’s sunny, and baseless,prediction

that new clinics will appear to provide services to at least

40% of the patient population served by Title X, HHS did not

address the potential health consequences of decreased

services and their corresponding costs in its cost-benefit

analysis. As the Northern District of California recognized,

the decreased services could cause a 31% increase in the

nation’s unintended pregnancy rate, which would lead to

“[b]illions of dollars in public costs[.]” California, 385 F.

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Supp. 3d at 1016. Even if the number of clinics were to

remain the same, a changed geographic reach would have

devastating consequences. See 84 Fed. Reg. at 7782

(recognizing that patients will have to travel further to obtain

health care); California, 385 F. Supp. 3d at 1017–18 (noting

that when a rural Indiana county lost a Planned Parenthood

clinic, “the county lost free HIV testing services and almost

immediately experienced one of the largest and most rapid

HIV outbreaks the country has ever seen”) (internal quotation

marks omitted). An agency governed by the APA must

grapple with potential costs, and HHS—an agency with

power over public health, no less—failed to do so here. See

State Farm Mut., 463 U.S. at 43; Nat’l Ass’n of Home

Builders v. EPA, 682 F.3d 1032, 1040 (D.C. Cir. 2012).

The majority is correct that we give agencies

deference—but only insofar as the agency “examine[s] the

relevant data and articulate[s] a satisfactory explanation for

its action including a rational connection between the facts

found and the choice made.” State Farm Mut., 463 U.S. at 43

(internal quotation marks omitted). The majority fails to hold

HHS to that basic standard here.

***

In vacating the preliminary injunctions, the majority

blesses an executive agency’s disregard of the clear limits

placed on it by Congress. The consequences will be borne by

the millions of women who turn to Title X-funded clinics for

lifesaving care and the very contraceptive services that have

caused rates of unintended pregnancy—and abortion—to

plummet.

I strongly dissent.

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