IN THE UNITED STATES COURT OF APPEALS

FOR THE FIFTH CIRCUIT

No. 14-50928

WHOLE WOMAN’S HEALTH; AUSTIN WOMEN’S HEALTH CENTER; 

KILLEEN WOMEN’S HEALTH CENTER; NOVA HEALTH SYSTEMS, doing 

business as Reproductive Services; SHERWOOD C. LYNN, JR., M.D., on 

behalf of themselves and their patients; PAMELA J. RICHTER, D.O., on behalf 

of themselves and their patients; LENDOL L. DAVIS, M.D., on behalf of 

themselves and their patients, 

 Plaintiffs-Appellees – Cross-Appellants

v.

KIRK COLE, M.D., Commissioner of the Texas Department of State Health 

Services, in his Official Capacity; MARI ROBINSON, Executive Director of the 

Texas Medical Board, in her Official Capacity, 

 Defendants-Appellants – Cross-Appellees

Appeals from the United States District Court 

for the Western District of Texas

Before PRADO, ELROD, and HAYNES, Circuit Judges.

PER CURIAM:

Plaintiffs, Texas abortion providers, sued State of Texas officials (“the 

State”)1 seeking declaratory and injunctive relief against the enforcement of 

 

1 The Plaintiffs include Whole Woman’s Health; Austin Women’s Health Center; 

Killeen Women’s Health Center; Nova Health Systems d/b/a Reproductive Services; and 

Sherwood C. Lynn, Jr., M.D., Pamela J. Richter, D.O., and Lendol L. Davis, M.D., on behalf 

of themselves and their patients. The Defendants are Kirk Cole, M.D., Commissioner of the 

Texas Department of State Health Services, and Mari Robinson, Executive Director of the 

Texas Medical Board, in their official capacities.

United States Court of Appeals

Fifth Circuit

FILED

June 9, 2015

Lyle W. Cayce

Clerk

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recent amendments to Texas’s law regulating abortions. See 2013 Texas House 

Bill No. 2 (“H.B. 2”).2 Plaintiffs challenge H.B. 2’s physician admitting 

privileges requirement as applied to a McAllen and an El Paso abortion facility. 

Plaintiffs also challenge H.B. 2’s requirement that abortion facilities satisfy 

the standards set for ambulatory surgical centers facially and as applied to the 

McAllen and El Paso abortion facilities. The district court enjoined 

enforcement of both requirements “as applied to all women seeking a 

previability abortion,” and as applied to the McAllen and El Paso abortion 

facilities. Whole Woman’s Health v. Lakey, 46 F. Supp. 3d 673, 676 (W.D. Tex.

2014) (emphasis added). The State appeals the entry of declaratory and 

injunctive relief.3 Plaintiffs cross-appeal the dismissal of their additional 

equal-protection and unlawful-delegation claims.

After carefully considering the record in light of the parties’ extensive 

written and oral arguments, we AFFIRM the district court’s dismissal of the 

Plaintiffs’ equal-protection and unlawful-delegation claims, AFFIRM in part 

and MODIFY in part the district court’s injunction of the admitting privileges 

and ASC requirements as applied to McAllen, VACATE the district court’s 

injunction of the admitting privileges requirement as applied to “all women 

seeking a previability abortion,” and REVERSE the district court’s facial 

injunction of the ASC requirement, injunction of the ASC requirement in the 

context of medication abortion, and injunction of the admitting privileges and 

 

2 Act of July 12, 2013, 83rd Leg., 2d C.S., ch. 1, §§ 1–12, 2013 Tex. Sess. Law Serv. 

4795–802 (West) (codified at TEX. HEALTH & SAFETY CODE ANN. §§ 171.0031, 171.041–.048, 

171.061–.064, & amending §§ 245.010–.011; amending TEX. OCC. CODE ANN. §§ 164.052 & 

164.055).

3 As discussed more fully below, upon the State’s motion, a panel of this court partially 

stayed the district court’s judgment pending appeal. See Whole Woman’s Health v. Lakey, 

769 F.3d 285 (5th Cir. 2014). Upon Plaintiffs’ application, the Supreme Court vacated the 

stay in part. See Whole Woman’s Health v. Lakey, 135 S. Ct. 399 (2014).

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ASC requirements as applied to El Paso.

In plain terms, H.B. 2 and its provisions may be applied throughout 

Texas, except that Supreme Court precedent requires us to partially uphold 

the district court’s injunction of the ASC requirement as applied to the Whole 

Woman’s Health abortion facility in McAllen, Texas, and to uphold the district 

court’s injunction of the admitting privileges requirement as applied to Dr. 

Lynn when he is working at the McAllen facility.

I. Jurisprudential Background

So that our decision may benefit from a full understanding of the 

pertinent historical and jurisprudential context, we begin by reviewing the 

regulation of abortion and related Supreme Court cases.

A. Roe v. Wade

The Supreme Court’s modern abortion jurisprudence began in 1973 with 

the landmark case Roe v. Wade, 410 U.S. 113 (1973). As with the case before 

us, Roe dealt with a challenge to Texas’s regulation of abortion. Texas’s penal 

code made it a crime punishable by imprisonment to procure or attempt to 

procure an abortion unless medically necessary to save the life of the mother. 

Id. at 117–18 & n.1. Unlike the law presently challenged, the Texas law was 

not of recent vintage. First enacted in 1854 with few substantial modifications, 

it was a century old at the time of Roe. See id. at 116, 119. Nor was Texas’s 

law unique; a majority of the states had similar laws. See id. at 116, 118 & 

n.2.

Reviewing Texas’s statute against a backdrop of varying state 

regulations of abortion, Roe assessed the states’ interests in regulating 

abortion, acknowledging a legitimate interest in women’s health:

The State has a legitimate interest in seeing to it that abortion, 

like any other medical procedure, is performed under 

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circumstances that insure maximum safety for the patient. This 

interest obviously extends at least to the performing physician and 

his staff, to the facilities involved, to the availability of after-care, 

and to adequate provision for any complication or emergency that 

might arise.

Id. at 150. The Court likewise credited an interest in protecting potential life: 

“as long as at least potential life is involved, the State may assert interests 

beyond the protection of the pregnant woman alone.” Id. 

Most significantly, however, the Court recognized a constitutional right 

of privacy “broad enough to encompass a woman’s decision whether or not to 

terminate her pregnancy.” Id. at 153. While “[t]he Constitution does not 

explicitly mention any right of privacy,” id. at 152, the Court relied on its cases 

recognizing a right of personal privacy in other contexts, which it found to be 

rooted in the “Fourteenth Amendment’s concept of personal liberty and 

restrictions upon state action,” id. at 153. 

Considering these competing concepts, the Court “conclude[d] that the 

right of personal privacy includes the abortion decision, but that this right is 

not unqualified and must be considered against important state interests in 

regulation.” Id. at 154. It thus fashioned a constitutional framework that 

conditioned the states’ ability to regulate abortion on a fetus’s viability. It held 

that states may not proscribe abortion prior to viability—the point at which 

“the fetus then presumably has the capability of meaningful life outside the 

mother’s womb.” Id. at 163. After viability, generally at the end of the second 

trimester, states could proscribe or regulate abortion except when an abortion 

was necessary to preserve the life or health of the mother. Id. at 163–64. The 

Court drew this line because it believed the interest in potential life to be 

compelling only after viability. See id. at 163. 

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The Court drew a second line at the end of the first trimester of 

pregnancy. During the first trimester, states were precluded from interfering 

with a woman’s choice to obtain an abortion. Id. From the beginning of the 

second trimester onward, Roe held that “a State may regulate the abortion 

procedure to the extent that the regulation reasonably relates to the 

preservation and protection of maternal health.” Id. “Examples of permissible 

state regulation in this area are requirements as to the qualifications of the 

person who is to perform the abortion; as to the licensure of that person; as to 

the facility in which the procedure is to be performed, that is, whether it must 

be a hospital or may be a clinic or some other place of less-than-hospital status; 

as to the licensing of the facility; and the like.” Id. The Court drew this line 

because it believed the interest in the health of the mother became compelling 

only after the first trimester. See id. (crediting evidence “that until the end of 

the first trimester mortality in abortion may be less than mortality in normal 

childbirth”). Measured against Roe’s framework, Texas’s law proscribing 

abortion at all stages of pregnancy was held unconstitutional. Id. at 166.

B. The Supreme Court’s Review of Abortion Regulations Following Roe

In the approximately twenty-year period following Roe, it became a 

regular practice of the Supreme Court to consider the constitutionality of state 

abortion regulations. Roe was explicitly reaffirmed twice during this period, 

see Thornburgh v. Am. Coll. of Obstetricians & Gynecologists, 476 U.S. 747, 759 

(1986); Akron v. Akron Ctr. for Reprod. Health, Inc. (Akron I), 462 U.S. 416, 

420 (1983), before its framework was modified in Planned Parenthood of 

Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992). Because Roe allowed 

regulations during the second trimester that were “reasonably related to 

maternal health,” 410 U.S. at 164, the Court had to determine the 

reasonableness of various health regulations. Some health-based regulations 

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extended into the first trimester, some regulations were based on an interest 

in potential life but extended into the first or second trimester, and other 

regulations were said to be justified by interests not recognized in Roe. As the 

Supreme Court reviewed these regulations, two considerations often played a 

part in the analysis: (1) whether the regulation placed a substantial obstacle 

in the path of a woman’s choice to obtain an abortion;4 and (2) whether the 

regulation was reasonably related to a legitimate government interest.5 

Relevant here, the Supreme Court addressed various state laws 

regulating the facilities in which abortions are performed.6 In Doe v. Bolton, 

 

4 See, e.g., Thornburgh v. Am. Coll. of Obstetricians & Gynecologists, 476 U.S. 747, 

828 (1986) (O’Connor, J., dissenting); Simopoulos v. Virginia, 462 U.S. 506, 520 (1983) 

(O’Connor, J., concurring in part and concurring in the judgment); Akron v. Akron Ctr. for 

Reprod. Health, Inc. (Akron I), 462 U.S. 416, 434–35, 445 (1983), overruled in part by Planned 

Parenthood of Se. Penn. v. Casey, 505 U.S. 833 (1992); id. at 453 (O’Connor, J., dissenting);

Harris v. McRae, 448 U.S. 297, 315 (1980); Bellotti v. Baird (Bellotti II), 443 U.S. 622, 647 

(1979) (Powell, J., plurality opinion); Maher v. Roe, 432 U.S. 464, 473–74 (1977); Bellotti v. 

Baird (Bellotti I), 428 U.S. 132, 147 (1976).

5 See, e.g., Hodgson v. Minnesota, 497 U.S. 417, 436 (1990) (Stevens, J., plurality 

opinion); Thornburgh, 476 U.S. at 828 (O’Connor, J., dissenting); Simopoulos, 462 U.S. at 

519; Akron I, 462 U.S. at 453 (O’Connor, J., dissenting); McRae, 448 U.S. at 324; Doe v. 

Bolton, 410 U.S. 179, 194 (1973); see also Roe v. Wade, 410 U.S. 113, 164 (1973) (allowing 

regulations during the second trimester that were “reasonably related to maternal health”).

6 While not as pertinent to this case, the Supreme Court has addressed various other 

abortion regulations. The Court has interpreted the Constitution to permit states and the 

federal government to allocate resources so as to fund childbirth, but not fund abortion or the 

providing of information about abortion—thus encouraging childbirth over abortion. See, 

e.g., Rust v. Sullivan, 500 U.S. 173, 201–03 (1991); Webster v. Reprod. Health Servs., 492 U.S. 

490, 507–10 (1989); McRae, 448 U.S. at 318; Maher, 432 U.S. at 474. The Supreme Court 

also upheld general informed consent provisions that required a woman to certify in writing 

that she consented to an abortion. See Planned Parenthood of Cent. Mo. v. Danforth, 428 

U.S. 52, 65–67 (1976). On the other hand, the Court struck down “abortion regulations 

designed to influence the woman’s informed choice between abortion or childbirth” by 

requiring the giving of information that goes “far beyond merely describing the general 

subject matter relevant to informed consent.” Akron I, 462 U.S. at 444–45, overruled by 

Casey, 505 U.S. at 881–83; see also Thornburgh, 476 U.S. at 760, 763, overruled by Casey, 

505 U.S. at 881–83. The Court also struck down requirements that the information necessary 

for informed consent be provided by a physician twenty-four hours prior to the abortion, see 

Akron I, 462 U.S. at 448–51, overruled by Casey, 505 U.S. at 884–87, and that a woman obtain 

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410 U.S. 179 (1973), the Court considered a requirement that all abortions be 

performed “in a hospital licensed by the State Board of Health and also 

accredited by the Joint Commission on Accreditation of Hospitals” (“JCAH”). 

Id. at 184. The Court held that the requirement did not withstand 

constitutional scrutiny because it was “not based on differences that are 

reasonably related to the purposes of the Act in which it is found.” Id. at 194 

(internal quotation marks omitted). In so concluding, the Court explained that 

the JCAH standards were general hospital standards not specific to abortion 

and the state did not require that the performance of non-abortion surgeries 

be constrained to JCAH-accredited hospitals. See id. at 193. The Court further 

found the regulation unconstitutional under Roe because it applied to 

abortions performed during the first trimester. Id. at 195.

In Akron I, 462 U.S. 416, overruled in part by Casey, 505 U.S. 833, the 

Court parsed how stringently states could regulate abortion to protect a 

mother’s health at different stages of pregnancy. It explained that even during 

the first trimester, “[c]ertain regulations that have no significant impact on the 

woman’s exercise of her right may be permissible where justified by important 

state health objectives.” Id. at 430. The Court required these regulations to 

“not interfere” with the doctor-patient consultation or the woman’s choice to 

obtain an abortion. Id. During the second trimester, it allowed states to 

“regulate the abortion procedure to the extent that the regulation reasonably 

 

consent from her spouse to obtain an abortion, see Danforth, 428 U.S. at 69. Furthermore, 

the Court declared unconstitutional laws that “impose a blanket provision . . . requiring the 

consent of a parent or person in loco parentis as a condition for abortion of an unmarried 

minor . . . . [I]f the State decides to require a pregnant minor to obtain one or both parents’ 

consent to an abortion, it also must provide an alternative procedure whereby authorization 

for the abortion can be obtained.” Bellotti II, 443 U.S. at 643 (internal quotation marks 

omitted).

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relates to the preservation and protection of maternal health” and does not 

“depart from accepted medical practice.” Id. at 430–31 (internal quotation 

marks omitted). The Court applied these principles to invalidate a city 

ordinance that only allowed abortions in facilities that were part of a fullservice hospital. See id. at 432–33. The Court held the ordinance “place[d] a 

significant obstacle in the path of women seeking an abortion” in the form of 

higher costs to obtain an abortion, increased travel distances, and additional 

health risks due to increased travel. Id. at 434–35. Further, the Court found 

the health justification for the requirement undercut by “present medical 

knowledge” that abortions during the second trimester could safely be 

performed in a physician’s office. Id. at 437.

In contrast, in Simopoulos v. Virginia, 462 U.S. 506, the Supreme Court 

upheld a state requirement that all second-trimester abortions be performed 

in a state-licensed “outpatient surgical hospital.” Id. at 515. The Court 

explained that the law differed materially from that in Akron I: 

The requirements at issue [in Akron I] mandated that all secondtrimester abortions must be performed in general, acute-care 

facilities. In contrast, the Virginia statutes and regulations do not 

require that second-trimester abortions be performed exclusively 

in full-service hospitals. Under Virginia’s hospitalization 

requirement, outpatient surgical hospitals may qualify for 

licensing as “hospitals” in which second-trimester abortions 

lawfully may be performed.

Id. at 516 (citation and internal quotation marks omitted). Virginia’s law 

required outpatient surgical hospitals to meet standards in the following 

categories: (1) “organization, management, policies, procedures, and staffing”; 

(2) “construction standards,” including for “public areas, clinical areas, 

laboratory and radiology services, and general building”; and (3) “patient care 

services,” including anesthesia, laboratory, pathology, sanitation, laundry, 

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physical plant, medical records, emergency services, and evacuation planning. 

Id. at 515–16 (internal quotation marks omitted).

The Court held that Virginia’s outpatient-surgical-hospital requirement 

was “not an unreasonable means of furthering the State’s compelling interest 

in protecting the woman’s own health and safety.” Id. at 519 (citation and 

internal quotation marks omitted). The Court explained that, “[i]n view of its 

interest in protecting the health of its citizens, the State necessarily has 

considerable discretion in determining standards for the licensing of medical 

facilities.” Id. at 516. Unlike in Akron I, the Court concluded “[o]n their face, 

the Virginia regulations appear to be generally compatible with accepted 

medical standards governing outpatient second-trimester abortions.” Id. at 

517. The Court also saw “no reason to doubt that an adequately equipped clinic 

could, upon proper application, obtain an outpatient hospital license 

permitting the performance of second-trimester abortions.” Id. at 518–19.

C. Planned Parenthood of Southeastern Pennsylvania v. Casey

Nineteen years after Roe, in Planned Parenthood of Southeastern 

Pennsylvania v. Casey, 505 U.S. 833 (1992), a divided Court revisited Roe. In 

a joint opinion, Justices O’Connor, Kennedy, and Souter announced the 

judgment of the Court and delivered the opinion of the Court as to some parts. 

Id. at 843–44. Although parts of the joint opinion were a plurality not joined 

by a majority of the Court, the joint opinion is nonetheless considered the 

holding of the Court under Marks v. United States, 430 U.S. 188, 193 (1977), 

as the narrowest position supporting the judgment.7 

 

7 See Stenberg v. Carhart, 530 U.S. 914, 952 (2000) (Rehnquist, C.J., dissenting) 

(“Despite my disagreement with the opinion, under the rule laid down in [Marks], the Casey

joint opinion represents the holding of the Court in that case.”); K.P. v. LeBlanc, 729 F.3d 

427, 442 n.93 (5th Cir. 2013); see, e.g., Stenberg, 530 U.S. at 921 (majority opinion) (applying 

Casey’s joint opinion).

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The Court first reaffirmed Roe’s “essential holding” that before viability 

a woman has a constitutional right to choose to terminate her pregnancy.8 See 

505 U.S. at 870–71. The Court went on, however, to modify the jurisprudence, 

reasoning that the legitimate interests of the states as recognized in Roe were 

“given too little acknowledgment and implementation by the Court in its

subsequent cases,” which decided that “any regulation touching upon the 

abortion decision must survive strict scrutiny, to be sustained only if drawn in 

narrow terms to further a compelling state interest.” Id. at 871 (citing by 

example Akron I, 462 U.S. at 427). The Court found it “an overstatement to 

describe [the abortion right] as a right to decide whether to have an abortion 

‘without interference from the State.’” Id. at 875 (quoting Danforth, 428 U.S. 

at 61). Those cases that struck down an abortion regulation, “which in no real 

sense deprived women of the ultimate decision. . . . went too far.” Id. Thus, 

the Court concluded that, in practice, Roe’s trimester framework had not given 

proper effect to the states’ legitimate interests, which the Court found exist 

throughout pregnancy. See id. at 872–73, 875–76.

Accordingly, the Court held that a law, to infringe the right recognized 

in Roe, must do more than simply make the right more difficult to exercise. It 

must impose an undue burden on the exercise of that right:

Numerous forms of state regulation might have the incidental 

effect of increasing the cost or decreasing the availability of 

medical care, whether for abortion or any other medical procedure. 

The fact that a law which serves a valid purpose, one not designed 

to strike at the right itself, has the incidental effect of making it 

more difficult or more expensive to procure an abortion cannot be 

 

8 The Court recognized that “time has overtaken some of Roe’s factual assumptions,” 

because modern science and “advances in neonatal care have advanced viability to a point 

somewhat earlier.” Casey, 505 U.S. at 860 (comparing Roe, 410 U.S. at 160, with Webster,

492 U.S. at 515–16). 

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enough to invalidate it. Only where state regulation imposes an 

undue burden on a woman’s ability to make this decision does the 

power of the State reach into the heart of the liberty protected by 

the Due Process Clause. 

Id. at 874. “A finding of an undue burden is a shorthand for the conclusion 

that a state regulation has the purpose or effect of placing a substantial 

obstacle in the path of a woman seeking an abortion of a nonviable fetus.” Id.

at 877. The Court also indicated that if a law does not impose an undue burden 

on a woman’s right to choose an abortion, the law is constitutional so long as it 

is reasonably related to, or designed to further, a legitimate state interest:

Unless it [imposes an undue burden] on her right of choice, a state 

measure designed to persuade her to choose childbirth over 

abortion will be upheld if reasonably related to that goal. 

Regulations designed to foster the health of a woman seeking an 

abortion are valid if they do not constitute an undue burden.

Id. at 878 (emphasis added). Stated more simply, Casey held that a law 

regulating previability abortion is constitutional if: (1) it does not have the 

purpose or effect of placing a substantial obstacle in the path of a woman 

seeking an abortion of a nonviable fetus; and (2) it is reasonably related to (or 

designed to further) a legitimate state interest. See id.

Overruling precedent, the Court applied this test to uphold the state’s 

requirement that a physician provide the woman information on the risks of 

abortion, the gestational age of the child, alternatives to abortion, and 

available assistance if the woman chose to proceed to natural birth. See id. at 

881–83 (overruling Akron I, 462 U.S. at 444, and Thornburgh, 476 U.S. at 762). 

It found the requirement was “a reasonable measure to ensure an informed 

choice, one which might cause the woman to choose childbirth over abortion,” 

serving the state’s “legitimate goal of protecting the life of the unborn.” Id. at 

883. The Court concluded that “[t]his requirement cannot be considered a 

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substantial obstacle to obtaining an abortion, and, it follows, there is no undue 

burden.” Id.9

The Court separately upheld a 24-hour waiting period requirement. It 

found it reasonable to conclude that “important decisions will be more informed 

and deliberate if they follow some period of reflection,” and held that “[i]n 

theory, at least, the waiting period is a reasonable measure to implement the 

State’s interest in protecting the life of the unborn.” Id. at 885 (overruling 

Akron I, 462 U.S. at 450). The Court addressed the district court’s finding that 

the 24-hour waiting period, combined with the driving distances to abortion 

providers, would often produce delays of more than one day, and “for those 

women who have the fewest financial resources, those who must travel long 

distances, and those who have difficulty explaining their whereabouts to 

husbands, employers, or others, the 24-hour waiting period will be particularly 

burdensome.” Id. at 886 (internal quotation marks omitted). Despite 

acknowledging that “the waiting period ha[d] the effect of increasing the cost 

and risk of delay of abortions,” the Court held that the findings did not 

demonstrate an undue burden. Id. (internal quotation marks omitted). The 

Court reasoned that, although the district court found the requirement 

imposed a heavier burden on some women, “[a] particular burden is not of 

necessity a substantial obstacle. Whether a burden falls on a particular group 

is a distinct inquiry from whether it is a substantial obstacle even as to the 

women in that group.” Id. at 887.

The Supreme Court also facially invalidated Pennsylvania’s requirement 

that, prior to obtaining an abortion, a married woman state that she notified 

 

9 The Court also upheld a requirement that a physician must provide the information. 

See 505 U.S. at 884–85 (overruling Akron I, 462 U.S. at 448).

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her spouse that she planned to obtain an abortion. See id. at 887–98. In light 

of the domestic abuse that might result from some women notifying their 

spouses, the Court held that the requirement had the effect of placing a 

substantial obstacle in the path of a woman’s choice to obtain an abortion:

The spousal notification requirement is thus likely to prevent a 

significant number of women from obtaining an abortion. It does 

not merely make abortions a little more difficult or expensive to 

obtain; for many women, it will impose a substantial obstacle. We 

must not blind ourselves to the fact that the significant number of 

women who fear for their safety and the safety of their children are 

likely to be deterred from procuring an abortion as surely as if the 

Commonwealth had outlawed abortion in all cases.

Id. at 893–94. Pennsylvania argued that, even given this conclusion, the 

statute should not be facially invalidated because only 20% of women who 

obtained an abortion were married and 95% of those women voluntarily 

notified their spouses, resulting in the requirement affecting less than 1% of 

women seeking an abortion in Pennsylvania. See id. at 894. The Court rejected 

this argument and facially invalidated the requirement because “in a large 

fraction of the cases in which [it] is relevant, it [would] operate as a substantial 

obstacle to a woman’s choice to undergo an abortion.” Id. at 895.10

D. Application of Casey

Since Casey, the Court has applied the undue burden test three times. 

In Mazurek v. Armstrong, 520 U.S. 968 (1997) (per curiam), the Court reversed 

an injunction of Montana’s requirement that only physicians perform 

 

10 The Court reasoned:

The analysis does not end with the one percent of women upon whom the 

statute operates; it begins there. Legislation is measured for consistency with 

the Constitution by its impact on those whose conduct it affects. . . . The proper 

focus of constitutional inquiry is the group for whom the law is a restriction, 

not the group for whom the law is irrelevant. 

Id. at 894.

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abortions. The Court concluded that the law did not create a substantial 

obstacle to abortion. See id. at 973–74. The Court also rejected the argument 

that an invalid purpose was proven by a lack of medical evidence:

Respondents claim in this Court that the Montana law must have 

had an invalid purpose because all health evidence contradicts the 

claim that there is any health basis for the law. . . . But this line 

of argument is squarely foreclosed by Casey itself. In the course of 

upholding the physician-only requirement at issue in that case, we 

emphasized that “[o]ur cases reflect the fact that the Constitution 

gives the States broad latitude to decide that particular functions 

may be performed only by licensed professionals, even if an 

objective assessment might suggest that those same tasks could be 

performed by others.”

Id. at 973 (alteration in original) (quoting Casey, 505 U.S. at 885).

The two other post-Casey cases dealt with prohibitions on what has been 

termed partial-birth abortion, and the cases resulted in divergent conclusions. 

Stenberg v. Carhart involved a Nebraska law making it a felony to perform a 

partial-birth abortion unless necessary to save the life of the mother. 530 U.S. 

914, 921–22 (2000). The Supreme Court held that the law was facially 

unconstitutional for two reasons. First, the Court found impermissible the lack 

of a health exception to allow for the partial-birth abortion procedure if 

necessary to preserve the life or health of the mother (as opposed to an 

exception solely to save the life of the mother, which the statute did contain). 

Id. at 930. Although Nebraska argued that a health exception was 

unnecessary because other abortion procedures could be safely used, the Court 

found this argument contradicted by evidence presented in the district court. 

Id. at 931–37. The Court explained that division of medical opinion on the 

subject favored a health exception. Id. at 937. Second, the Court held the law 

unconstitutional because it had the “effect of placing a substantial obstacle in 

the path of a woman seeking an abortion of a nonviable fetus” by encompassing 

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within its statutory definition not only partial-birth abortion, but also the 

abortion procedure most commonly used during the second trimester of 

pregnancy—dilation and evacuation (“D&E”). Id. at 938 (citation and internal 

quotation marks omitted).

Gonzales v. Carhart, 550 U.S. 124 (2007), upheld as facially 

constitutional the Partial-Birth Abortion Ban Act of 2003 (“the Act”), 18 U.S.C. 

§ 1531, which Congress drafted in response to Stenberg. See 550 U.S. at 132–

33, 141. Congress made factual findings that “[a] moral, medical, and ethical 

consensus exists that the practice of performing a partial-birth abortion . . . is 

a gruesome and inhumane procedure that is never medically necessary.” Id.

at 141 (alteration in original) (internal quotation marks omitted). 

Significantly, the Supreme Court interpreted the language of the Act to be 

more specific and precise than the language of the statute in Stenberg, such 

that it prohibited only partial-birth abortion and did not encompass the 

commonly used D&E procedure. See id. at 133, 150–56. The Act contained an 

exception if the procedure was necessary “to save the life of a mother,” which 

tracked the Nebraska exception struck down in Stenberg. Compare id. at 141, 

with Stenberg, 530 U.S. at 921–22.

 The Supreme Court applied Casey’s undue burden test, “assum[ing its] 

principles for the purpose of th[e] opinion.” 550 U.S. at 146. The Court found, 

based on Congress’s stated reasons for the Act and a “description of the 

prohibited abortion procedure,” that the purpose of the Act was to: (1) 

“express[] respect for the dignity of human life”; and (2) “protect[] the integrity 

and ethics of the medical profession.” Id. at 156–57 (internal quotation marks 

omitted). Referencing Casey, the Court held that the Act was grounded in a 

legitimate purpose because “government may use its voice and its regulatory 

authority to show its profound respect for the life within the woman.” Id. at 

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157. In explaining why Casey’s purpose prong was satisfied, the Court 

described a rational basis test: 

Where it has a rational basis to act, and it does not impose an 

undue burden, the State may use its regulatory power to bar 

certain procedures and substitute others, all in furtherance of its 

legitimate interests in regulating the medical profession in order 

to promote respect for life, including life of the unborn.

Id. at 158.

The Court then applied Casey’s “effect” prong, asking whether the Act 

had the effect of imposing an undue burden by barring partial-birth abortion 

while not including a health exception. See id. at 161–67. The Court explained 

that “the Act would be unconstitutional, under precedents we here assume to 

be controlling, if it subject[ed] [women] to significant health risks.” Id. at 161 

(alteration in original) (internal quotation marks omitted). However, the Court 

noted “documented medical disagreement whether the Act’s prohibition would 

ever impose significant health risks,” id. at 162, and held that this medical 

uncertainty foreclosed facially invalidating the act based on an undue burden:

The question becomes whether the Act can stand when this 

medical uncertainty persists. The Court’s precedents instruct that 

the Act can survive this facial attack. The Court has given state 

and federal legislatures wide discretion to pass legislation in areas 

where there is medical and scientific uncertainty.

. . . Physicians are not entitled to ignore regulations that 

direct them to use reasonable alternative procedures. The law 

need not give abortion doctors unfettered choice in the course of 

their medical practice, nor should it elevate their status above 

other physicians in the medical community. . . . 

Medical uncertainty does not foreclose the exercise of 

legislative power in the abortion context any more than it does in 

other contexts. The medical uncertainty over whether the Act’s 

prohibition creates significant health risks provides a sufficient 

basis to conclude in this facial attack that the Act does not impose 

an undue burden.

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Id. at 163–64 (citations omitted).

Accordingly, having concluded that the Act did not have the purpose or 

effect of imposing an undue burden on a woman’s right to choose an abortion 

in a large fraction of relevant cases,11 the Court upheld the Act against facial 

challenge. Id. at 167–68.

E. This Court’s Decision in Abbott II

With this history in mind, in Planned Parenthood of Greater Texas 

Surgical Health Services v. Abbott (Abbott II)—an earlier case in which we 

addressed the constitutionality of the admitting privileges requirement in 

H.B. 2—we summarized those standards that are also applicable to this case:

A trio of widely-known Supreme Court decisions provides 

the framework for ruling on the constitutionality of H.B. 2. In Roe 

v. Wade, the Court held that the Fourteenth Amendment’s concept 

of personal liberty encompasses a woman’s right to end a 

pregnancy by abortion. Roe v. Wade, 410 U.S. 113, 153 (1973). In 

Casey, the Court reaffirmed what it regarded as Roe’s “essential 

holding,” the right to abort before viability, the point at which the 

unborn life can survive outside of the womb. Casey, 505 U.S. at 

870, 878. Before viability, the State may not impose an “undue 

burden,” defined as any regulation that has the purpose or effect 

of creating a “substantial obstacle” to a woman’s choice. Id. at 874, 

878. In Gonzales, the Court added that abortion restrictions must 

also pass rational basis review. Gonzales, 550 U.S. at 158 (holding 

that the State may ban certain abortion procedures and substitute 

others provided that “it has a rational basis to act, and it does not 

impose an undue burden” (emphasis added)).

748 F.3d 583, 589–90 (5th Cir.), reh’g en banc denied, 769 F.3d 330 (5th Cir. 

2014).

 

11 The Court acknowledged without deciding the issue of whether a facial challenge 

required showing that the law is unconstitutional in all circumstances or, as described in 

Casey, only in a large fraction of the cases in which the law is relevant. See id. at 167–68.

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II. Factual and Procedural Background of this Case

Having set the stage, we now turn to the matters at issue in this case. 

In 2013, the State of Texas passed H.B. 2, which contained various provisions 

relating to abortions. H.B. 2 has four primary provisions, of which the 

Plaintiffs challenge two. The first challenged provision requires a physician 

performing an abortion to have admitting privileges at a hospital within thirty 

miles of the location where the abortion is performed (the “admitting privileges 

requirement”). See TEX. HEALTH & SAFETY CODE ANN. § 171.0031(a)(1) (West 

Supp. 2014). We addressed an earlier facial challenge to this provision in

Abbott II, 748 F.3d 583.12 The second provision requires all abortion clinics to 

comply with standards set for ambulatory surgical centers (the “ASC 

requirement”).13 See TEX. HEALTH & SAFETY CODE ANN. § 245.010(a) (West 

Supp. 2014). Clinics had until September 2014, nearly fourteen months after 

H.B. 2 was passed, to comply with the ASC requirement. Id. The Texas 

Legislature’s stated purpose for enacting these provisions was to raise the 

standard and quality of care for women seeking abortions and to protect the 

health and welfare of women seeking abortions. See Senate Comm. on Health 

& Human Servs., Bill Analysis, Tex. H.B. 2, 83d Leg., 2d C.S. 1 (2013). H.B. 2 

contains a “comprehensive and careful severability provision,” Abbott II, 748 

F.3d at 589, as do the implementing regulations. See H.B. 2 § 10(b); 25 TEX.

ADMIN. CODE § 139.9.

 

12 The admitting privileges requirement went into effect on October 31, 2013. The 

district court enjoined the provision, but we stayed the injunction on October 31, 2013, 

Planned Parenthood of Greater Tex. Surgical Health Servs. v. Abbott (Abbott I), 734 F.3d 406, 

419 (5th Cir. 2013), and thereafter vacated the injunction, see Abbott II, 748 F.3d at 605. 

13 An ambulatory surgical center is “a facility that operates primarily to provide 

surgical services to patients who do not require overnight hospital care.” TEX. HEALTH &

SAFETY CODE ANN. § 243.002(1) (West 2010).

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Adopted in December 2013, the regulations implementing the ASC 

requirement mandate that abortion facilities satisfy the standards applicable 

to ASCs in addition to any standards specifically applicable to abortion 

facilities. See 25 TEX. ADMIN. CODE § 139.40; 38 Tex. Reg. 9577 (Dec. 27, 2013). 

The regulatory standards for ASCs fall into three categories: (1) operating 

requirements, including requirements for records systems, patient rights, 

quality assurance, staffing, and cleanliness, 25 TEX. ADMIN. CODE §§ 135.4–

.17, 135.26–.27; (2) fire prevention and general safety requirements, id. 

§§ 135.41–.43; and (3) physical plant requirements, which include location, 

physical construction, electrical, plumbing, and HVAC requirements, id.

§§ 135.51–.56.

Shortly after H.B. 2 was passed, some of the same parties named in this

case14 sued the State of Texas seeking to invalidate certain provisions of H.B. 2, 

specifically, the admitting privileges requirement and the provision requiring 

compliance with the FDA protocol for what is known as “medication abortions” 

(the use of drugs to induce an abortion rather than performing a surgical 

procedure) (the “medication abortion provision”). In that case, the district 

 

14 Planned Parenthood, the largest provider of abortion services in Texas, is not a 

party to this lawsuit, although it was a named plaintiff in Abbott II. Lamar Robinson, M.D. 

was a named plaintiff in Abbott II and was originally a named plaintiff in this case. However, 

on June 3, 2014, he filed a Notice of Voluntary Dismissal because he obtained admitting 

privileges at a hospital within thirty miles of the clinic at which he provided abortions.

Otherwise, Plaintiffs largely overlap with the plaintiffs in Abbott II. Whole Woman’s 

Health, Austin Women’s Health Center, Killeen Women’s Health Center, and Dr. Richter 

were plaintiffs in Abbott II. 748 F.3d 583 Doctors Lynn and Davis were not parties in Abbott 

II, but Whole Woman’s Health and Austin Women’s Health Center, respectively, sued on 

their behalf. See Complaint, Doc. No. 1, ¶¶ 13–14, Planned Parenthood of Greater Tex. 

Surgical Health Servs. v. Abbott, No. 1:13-CV-862-LY (W.D. Tex.) (stating that clinics were 

suing “on behalf of” their “physicians”). Reproductive Services was not a plaintiff in Abbott 

II, but Dr. Richter, its medical director and sole abortion-performing physician, was a 

plaintiff. See id. ¶ 21. 

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court granted relief to the plaintiffs in part, see Planned Parenthood of Greater 

Tex. Surgical Health Servs. v. Abbott, 951 F. Supp. 2d 891, 909 (W.D. Tex. 

2013), and we first granted a stay, see Planned Parenthood of Greater Tex. 

Surgical Health Servs. v. Abbott (Abbott I), 734 F.3d 406, 419 (5th Cir. 2013), 

and later affirmed in part and reversed in part, see Abbott II, 748 F.3d at 605. 

The time for seeking certiorari from the United States Supreme Court passed, 

and no petition was filed. In that earlier challenge to H.B. 2, the Plaintiffs did 

not raise any issues regarding the ASC requirement.

Instead, they waited until April of 2014, one week after the adverse 

decision in Abbott II, to file this lawsuit challenging Texas’s requirement that 

abortion facilities satisfy the standards set for ASCs. Together with a facial 

challenge to the ASC requirement, they also challenged the admitting 

privileges requirement and the ASC requirement as applied to Whole Woman’s 

Health’s abortion facility in McAllen and Reproductive Services’ abortion 

facility in El Paso. In addition, the Plaintiffs challenged H.B. 2 on several other 

grounds, including that it denies equal protection, unlawfully delegates 

lawmaking authority, and constitutes arbitrary and unreasonable state action. 

Before trial, the district court granted the State’s motion to dismiss claims 

based on these other grounds.

After a four-day bench trial employing a highly-abbreviated format for 

the presentation of evidence, the district court enjoined enforcement of the 

admitting privileges requirement and ASC requirement “as applied to all 

women seeking a previability abortion,” and as applied to the McAllen and El 

Paso abortion facilities. Lakey, 46 F. Supp. 3d at 676, 687 (emphasis added). 

The district court also enjoined the ASC requirement as applied to medication 

abortions. Id.

At trial, the parties stipulated to the following facts. Seven ASCs in five 

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major Texas cities (Austin, Dallas, Fort Worth, Houston, and San Antonio) 

were licensed to perform abortions and would be able to continue providing 

abortions after the ASC requirement went into effect. No other facility in 

Texas licensed to perform abortions satisfied the ASC requirement, and, thus, 

these other facilities would be prohibited from performing abortions after the 

ASC requirement went into effect on September 1, 2014. The parties further 

stipulated that Planned Parenthood of South Texas planned to open an ASC 

in San Antonio in September 2014. The district court accepted these stipulated 

facts, stating that the ASC requirement would “reduce the number of licensed 

abortion-providing facilities to, at most, eight.” Id. at 681.15 The district court 

also found that Texas had over forty abortion clinics prior to H.B. 2, but the 

district court did not discuss whether some of these clinics may have closed for 

reasons unrelated to H.B. 2.16 See id. Both parties offered expert testimony at 

trial as to the increased travel distances that women would face to obtain an 

abortion due to H.B. 2. The district court credited the testimony of the 

 

15 The State points out that it did not stipulate that only eight abortion facilities would 

remain in Texas, arguing that currently licensed abortion facilities that do not comply with 

the ASC requirement might buy, build, or lease a licensed ASC. The parties stipulated that 

there were “433 licensed ambulatory surgical centers in Texas.” There was testimony at trial 

that Dr. Davis and Austin Woman’s Health Center purchased land in Austin with plans to 

open an ASC in the future and that Reproductive Services hoped to open an ASC in San 

Antonio. The fact that there are currently licensed ASCs in Texas where abortions are 

performed and that abortion providers have plans to open more attests that it is indeed 

possible for abortion providers to comply with the ASC requirement. Conversely, the 

Plaintiffs offered testimony that their efforts to lease an existing ASC failed primarily due to 

hostility to abortion. The evidence thus showed that there will be at least eight licensed ASCs 

in Texas where abortions are performed.

16 For example, we noted in Abbott I and II that abortion facilities had difficulty

recruiting physicians with admitting privileges because a large proportion of physicians 

performing abortions were over the age of 60 and had already retired or were planning to 

retire. Abbott I, 734 F.3d at 415; Abbott II, 748 F.3d at 591. In addition, we noted that some 

physicians felt deterred by the terms of their existing employment or were concerned about 

private discrimination. Abbott II, 748 F.3d at 591, 599.

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Plaintiffs’ expert, Dr. Grossman, and found that, due to H.B. 2, “a significant 

number of the reproductive-age female population of Texas will need to travel 

considerably [farther] in order to” obtain an abortion. Id. at 681–82.

Regarding the ASC requirement, the Plaintiffs offered expert testimony

that “abortions can be safely performed in office-based settings, such as 

doctors’ offices and specialized clinics,” and that “there is no medical basis for 

requiring facilities in which abortions are performed to meet ASC standards.”17 

Despite H.B. 2’s severability clause and the fact that many of the ASC 

standards seem benign and inexpensive, see, e.g., 25 TEX. ADMIN. CODE

§ 135.52(e)(1)(F) (“A liquid or foam soap dispenser shall be located at each hand 

washing facility.”), Plaintiffs conceded at oral argument that they made no 

effort to narrow their challenge to any particular standards of the ASC 

provision of H.B. 2 or its accompanying regulations. Instead, they ask us to 

invalidate the entire ASC requirement.

In opposition, the State offered expert testimony that the sterile 

environment of an ASC was medically beneficial because surgical abortion 

involves invasive entry into the uterus, which is sterile. Accordingly, the 

State’s expert opined that abortion procedures should “be performed in an ASC 

where the higher standard of care is required so as to better protect the 

patient’s health and safety.”18 

 

17 Plaintiffs offered expert testimony that the ASC requirement’s construction 

standards were “largely aimed at maintaining a sterile operating environment,” which is not 

necessary for surgical abortion because “it entails insertion of instruments into the uterus 

through the vagina, which is naturally colonized by bacteria.” Plaintiffs also offered expert 

testimony that abortion procedures do not necessitate large operating rooms or scrub nurses 

and circulating nurses, as are required for ASCs. The Plaintiffs’ expert also explained that 

medication abortions do not involve surgery but entail the oral administration of medications; 

accordingly, the expert concluded that there is “no medical basis for requiring medical 

abortion to be provided in an ASC.”

18 The State’s expert explained that other procedures requiring entry into the uterus, 

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Like the Plaintiffs, the district court made no effort to write narrowly,

finding that the entirety of the ASC requirement was not medically necessary 

and that its burdens outweighed any benefits, including that: (1) “women will 

not obtain better care or experience more frequent positive outcomes at an 

[ASC] as compared to a previously licensed facility”; (2) “it is unlikely that the 

stated goal of the requirement—improving women’s health—will actually come 

to pass”; and (3) “the severity of the burden imposed by both requirements is 

not balanced by the weight of the interests underlying them.” Lakey, 46 F. 

Supp. 3d at 684.

Regarding the as-applied challenge to the admitting privileges

requirement, the State offered expert testimony that this requirement leads to 

greater continuity of care and “assures peer-review of abortion providers by 

requiring them to be credentialed and hold admitting privileges at a local 

hospital, thereby protecting patients from less than qualified providers.”19 

Conversely, the Plaintiffs offered testimony that abortion physicians were 

being denied admitting privileges, not because of their level of competence, but 

for various other reasons, including: outright denial of admitting privileges 

with no explanation other than that it “was not based on clinical competence,” 

 

such as dilation and curettage, are traditionally performed in an ASC or hospital settings for 

that reason. The State’s expert further explained that ASC requirements as to accountability 

and monitoring mechanisms ensure patient safety and that other requirements regarding 

follow up and continuity of care result in patients receiving a higher quality of care.

19 The State’s expert opined that the physician performing the abortion “is the most 

knowledgeable about the procedure and the patient,” whereas an emergency room “physician 

has no prior relationship with the abortion patient and is unfamiliar with her medical history 

and personal preferences.” Thus, it was the State’s expert’s opinion that the admitting 

privileges requirement would lead to greater continuity of care, increased quality of care, and 

fewer risks from complications. See also Abbott II, 748 F.3d at 595 (“Requiring abortion 

providers to have admitting privileges would also promote the continuity of care in all cases, 

reducing the risk of injury caused by miscommunication and misdiagnosis when a patient is 

transferred from one health care provider to another.”).

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and having not completed a medical residency even though the bylaws of the 

hospital did not require such. As with the ASC requirement, the district court 

ultimately found the admitting privileges requirement was not medically 

justifiable and that the burdens it imposed were not outweighed by any 

potential health benefits. See id. at 684–85.

The State appeals the entry of declaratory and injunctive relief. 

Plaintiffs cross-appeal the dismissal of their equal-protection and unlawfuldelegation claims and the district court’s failure to hold the ASC requirement 

unconstitutional as applied to future abortion providers. As part of its appeal, 

the State sought a stay of the district court’s order pending resolution of the 

appeal, and a motions panel of this court stayed in part the district court’s 

injunction. See Whole Woman’s Health v. Lakey, 769 F.3d 285, 305 (5th Cir.), 

vacated in part, 135 S. Ct. 399 (2014). In turn, the Supreme Court modified 

this court’s order pending full consideration of the appeal and maintained the 

status quo by continuing the district court’s injunction of the ASC requirement 

as well as the district court’s injunction of the admitting privileges requirement 

as applied to the McAllen and El Paso facilities. See Whole Woman’s Health v. 

Lakey, 135 S. Ct. 399 (2014).20

 

20 In its reply brief, the State argues for the first time that there is no longer an Article 

III case or controversy concerning the El Paso clinic because it has not yet reopened in light 

of the district court’s injunction and the Supreme Court continuing that injunction pending 

appeal. We conclude that this issue is not moot as the State suggests. The El Paso abortion 

facility was no longer able to provide abortions after April 2014 because its physician, Dr. 

Richter, no longer had admitting privileges at a local hospital. The Plaintiffs returned the 

facility’s license because they could not afford to pay its annual assessment fees while it was 

not generating revenue. The facility has not immediately resumed providing services 

because, during the four months that it was closed, it had to close its doors, lay off its staff, 

move its records and equipment into storage, cancel its contracts with vendors, and give up 

its lease and its license. The president of the organization that ran the facility testified that 

if it was successful in this lawsuit, it would “seek to reestablish a licensed abortion facility in 

El Paso.” Because the admitting privileges requirement arguably contributed to the closure 

of the El Paso facility and there is uncontested testimony that the facility will seek to reopen 

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III. Standard of Review

We review the district court’s factual findings for clear error, its legal 

conclusions de novo, and its ultimate decision to enjoin enforcement of H.B. 2 

for abuse of discretion. See Abbott II, 748 F.3d at 589. In so doing, we are not 

bound by the determinations of the motions panel, which considered during an 

abbreviated proceeding whether an emergency stay should be granted. See 

Lakey, 769 F.3d at 305; Abbott I, 734 F.3d at 419 (citing Mattern v. Eastman 

Kodak Co., 104 F.3d 702, 704 (5th Cir. 1997)). Further, no guidance can be 

gleaned from the Supreme Court’s vacating portions of the stay without

explanation, as we cannot discern the underlying reasoning from the oneparagraph order.

IV. Admitting Privileges Requirement – Facial Challenge

By facially invalidating the admitting privileges requirement, the 

district court granted more relief than anyone requested or briefed. See Lakey, 

46 F. Supp. 3d at 677 (“[T]he two portions of Texas Health and Safety Code, 

Sections 245.010(a) and 171.0031(a)(1), create an impermissible obstacle as 

applied to all women seeking a previability abortion.” (emphasis added)). Not 

only was it inappropriate for the district court to grant unrequested relief in a

constitutional challenge to a state law, see Jackson Women’s Health Org. v. 

Currier, 760 F.3d 448, 458 (5th Cir. 2014) (narrowing a district court’s 

apparent facial relief, which the court held “was an overly broad remedy in an 

as-applied challenge”), petition for cert. filed, S. Ct. No. 14-997 (Feb. 18, 2015), 

but in so doing, the district court also ran directly afoul of the holding and 

 

upon a favorable resolution of this case, the parties still have a concrete interest in this 

controversy such that it is not moot. See Chafin v. Chafin, 133 S. Ct. 1017, 1023 (2013) (“As 

long as the parties have a concrete interest, however small, in the outcome of the litigation, 

the case is not moot.” (internal quotation marks omitted)).

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mandate of Abbott II, 748 F.3d at 598–600, and the principle of res judicata. 

See Lakey, 769 F.3d at 293. By granting a broad injunction against the 

admitting privileges requirement “as applied to all women seeking a 

previability abortion,” the district court resurrected the facial challenge put to 

rest in Abbott II.21 However much a district court may disagree with an 

appellate court, a district court is not free to disregard the mandate or directly 

applicable holding of the appellate court. See United States v. Teel, 691 F.3d 

578, 582–83 (5th Cir. 2012) (describing the law-of-the-case doctrine and 

mandate rule). We need not spend more time on this well-settled proposition—

which plaintiffs do not dispute—and, instead, VACATE this portion of the 

district court’s order.

V. ASC Requirement – Facial Challenge

A. Res Judicata

The State of Texas argues that these Plaintiffs previously challenged

H.B. 2 in Abbott II without addressing the ASC requirement and, therefore, 

res judicata bars the current facial challenge.22 For their part, the Plaintiffs 

argue that they could not have brought a challenge sooner because they did 

not know how the statute would be implemented until the implementing 

regulations went into effect. The district court agreed with Plaintiffs and 

rejected the State’s res judicata defense at the motion to dismiss stage. It also 

concluded that challenges to the admitting privileges requirement and the ASC 

requirement represent different claims and causes of action. We reverse.

 

21 The only exception to our disallowing the facial challenge in Abbott II was that we 

did not reverse the district court’s injunction with respect to physicians whose application for 

admitting privileges was still pending at the time H.B. 2 went into effect. See Abbott II, 748 

F.3d at 605.

22 Although the State did not raise this argument in its briefing on the emergency stay 

motion, it did raise the issue in its motion to dismiss before the district court.

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Res judicata bars any claims for which: (1) the parties are identical to or 

in privity with the parties in a previous lawsuit; (2) the previous lawsuit has 

concluded with a final judgment on the merits; (3) the final judgment was 

rendered by a court of competent jurisdiction; and (4) the same claim or cause 

of action was involved in both lawsuits. Petro-Hunt, L.L.C. v. United States, 

365 F.3d 385, 395 (5th Cir. 2004). The Plaintiffs do not contest the first three 

elements of the State’s res judicata defense, but contend that the “claims” are 

different. However, res judicata bars even unfiled claims if they arise out of 

the same transaction and “could have been raised” in the prior litigation. Allen 

v. McCurry, 449 U.S. 90, 94 (1980).

Contrary to the district court’s conclusion, the present facial challenge to 

the ASC requirement and the prior facial challenge to the admitting privileges 

requirement in Abbott II arise from the same “transaction[] or series of 

connected transactions.” Petro-Hunt, 365 F.3d at 395–96 (quoting 

RESTATEMENT (SECOND) OF JUDGMENTS § 24(1) (1982)). The challenges involve 

the same parties and abortion facilities; the challenges are governed by the 

same legal standards; the provisions at issue were enacted at the same time as 

part of the same act; the provisions were motivated by a common purpose; the 

provisions are administered by the same state officials; and the challenges 

form a convenient trial unit because they rely on a common nucleus of 

operative facts. See id. at 396 (describing the relevant considerations for the 

fourth prong of the res judicata analysis).

The Plaintiffs’ assertion that they could not have previously challenged 

the ASC requirement because they did not know how it would be implemented 

until the regulations were set forth is disingenuous, particularly in this 

litigation. As Plaintiffs admitted at oral argument, they challenge H.B. 2 

broadly, with no effort whatsoever to parse out specific aspects of the ASC 

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requirement that they find onerous or otherwise infirm. H.B. 2 very clearly 

required facilities that perform abortions to meet the existing requirements for 

ASCs, which were spelled out well before the effective date of this provision 

and, more importantly, well before the date of the Abbott II lawsuit: “On and 

after September 1, 2014, the minimum standards for an abortion facility must 

be equivalent to the minimum standards adopted under Section 243.010 for 

ambulatory surgical centers.” TEX. HEALTH & SAFETY CODE ANN. § 245.010(a) 

(emphasis added). The law does not allow several bites at the same apple, even 

if from a different quadrant of the apple. See Southmark Corp. v. Coopers & 

Lybrand (In re Southmark), 163 F.3d 925, 934 (5th Cir. 1999) (“[R]es judicata[]

bars the litigation of claims that either have been litigated or should have been 

raised in an earlier suit.”); David P. Currie, Res Judicata: The Neglected 

Defense, 45 U. CHI. L. REV. 317, 325 (1978) (“[T]o allow a party to advance 

arguments in a second proceeding that he could have made in a prior 

proceeding . . . imposes unnecessary costs on both opposing parties and the 

judicial system.”). We do not suggest here that future lawsuits against this 

provision based upon specific facts arising in the future would be barred (i.e., 

as-applied challenges).23 However, given the broad nature of this litigation, 

we discern nothing material that evolved between the time H.B. 2 was passed 

and Abbott II was filed, on the one hand, and the time this lawsuit was filed,

on the other, that justified dividing the litigation.24 

 

23 Similarly, we conclude, infra, that the district court correctly ruled that res 

judicata does not bar the as-applied challenges here. 

24 Plaintiffs argue that they did not know whether existing facilities would be 

“grandfathered.” Nothing in the language of the legislation allows “grandfathering” of 

existing abortion facilities. Existing ASC facilities were already “grandfathered.” In any 

event, this argument would at most support only a challenge to the lack of “grandfathering,” 

not the broad-based challenge actually filed and the broad relief granted.

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Although rather obliquely presented, Plaintiffs may be arguing that the 

challenge to the ASC requirement would not have been ripe at the time Abbott 

II was filed in the district court. “[T]he ripeness inquiry focuses on whether an 

injury that has not yet occurred is sufficiently likely to happen to justify 

judicial intervention.” Pearson v. Holder, 624 F.3d 682, 684 (5th Cir. 2010) 

(alteration in original) (internal quotation marks omitted). “To determine if a 

case is ripe for adjudication, a court must evaluate (1) the fitness of the issues 

for judicial decision, and (2) the hardship to the parties of withholding court 

consideration. The fitness and hardship prongs must be balanced . . . .” Texas 

v. United States, 497 F.3d 491, 498 (5th Cir. 2007) (citing Abbott Labs. v. 

Gardner, 387 U.S. 136, 149 (1967)). “A court should dismiss a case for lack of 

‘ripeness’ when the case is abstract or hypothetical. . . . A case is generally ripe 

if any remaining questions are purely legal ones; conversely, a case is not ripe 

if further factual development is required.” Orix Credit Alliance, Inc. v. Wolfe, 

212 F.3d 891, 895 (5th Cir. 2000). 

Resolution of whether the ASC requirement is facially unconstitutional 

did not need to await promulgation of regulations that simply carried out the 

unambiguous mandate of H.B. 2. Cf. Pac. Gas & Elec. Co. v. State Energy Res. 

Conservation & Dev. Comm’n, 461 U.S. 190, 201 (1983) (“The question of preemption is predominantly legal, and although it would be useful to have the 

benefit of California’s interpretation . . . , resolution of the pre-emption issue 

need not await that development.”). This is especially true because H.B. 2’s 

precise and mandatory language did not leave the Department of State Health 

Services discretion as to the standards that would apply to abortion facilities. 

Cf. Sch. Dist. of Pontiac v. Sec’y of U.S. Dep’t of Educ., 584 F.3d 253, 262 (6th 

Cir. 2009) (en banc) (reasoning that the action did not depend on decisions 

made by state authorities, who did not have the discretion to change the impact 

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of the law at issue). Instead, it is abundantly clear from H.B. 2 that all abortion 

facilities must meet the standards already promulgated for ASCs. This 

inevitable application of the ASC standards to abortion facilities supports

deciding its constitutionality prior to the promulgation of implementing 

regulations. See Pearson, 624 F.3d at 684 (“‘Where the inevitability of the 

operation of a statute against certain individuals is patent, it is irrelevant to 

the existence of a justiciable controversy that there will be a time delay before 

the disputed provisions will come into effect.’” (quoting Reg’l Rail 

Reorganization Act Cases, 419 U.S. 102, 143 (1974))); Fla. State Conference of 

NAACP v. Browning, 522 F.3d 1153, 1164 (11th Cir. 2008). Indeed, for these 

reasons, at the time of Abbott II, a facial challenge to the ASC requirement 

would not have been “abstract or hypothetical.” Orix, 212 F.3d at 895 (citation 

omitted). Importantly, Plaintiffs made no effort to parse the regulations or 

otherwise assert anything material in the district court or on appeal with 

respect to the facial challenge that was not known the day H.B. 2 passed. The 

district court’s broad-brush striking of the entire statute also reflects nothing 

that needed to await further developments following H.B. 2’s enactment. 

In addition to the fitness prong, the hardship-to-the-parties analysis 

supports the conclusion that this issue should have been resolved at the time 

of Abbott II. It would have been in the interest of the non-ASC abortion 

facilities to know at the earliest possible time whether H.B. 2 was 

unconstitutional or whether they were required to begin making modifications 

or buying or renting space to comply with the ASC requirement. See Pac. Gas 

& Elec. Co, 461 U.S. at 201–02. It would have imposed a hardship on abortion 

facilities to require them to bring this challenge only after final agency 

regulations were promulgated, forcing them to either begin compliance 

measures or risk facing only a brief period to comply if the ASC requirement 

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was ultimately upheld upon later challenge. See id. Furthermore, trying this 

facial challenge separately from the two facial challenges brought in Abbott II

imposed a hardship on the State by requiring it to defend H.B. 2 against 

constitutional challenge in a piecemeal and duplicative fashion. Accordingly, 

we conclude that the district court erred in its ruling on the res judicata defense

to this facial challenge to the ASC requirement.

B. Merits

Even if our conclusion as to res judicata is incorrect, the facial challenge 

to the ASC requirement fails on the merits as well. Thus, for the purpose of 

completeness, we address the facial challenge, assuming arguendo that res 

judicata does not bar the challenge.

1. Rational Basis

The stated purpose of H.B. 2 was to raise the standard and quality of 

care for women seeking abortions and to protect the health and welfare of 

women seeking abortions. See Senate Comm. on Health & Human Servs., Bill 

Analysis, Tex. H.B. 2, 83d Leg., 2d C.S. 1, 2 (2013). Relying on Abbott II, the 

district court concluded that both the admitting privileges and ASC 

requirements were rationally related to a legitimate state interest. We agree: 

Abbott II held that the admitting privileges requirement is supported by a 

rational basis, 748 F.3d at 593–96, and in this case, the State supported the 

medical basis for both requirements with evidence at trial. See Lakey, 769 F.3d 

at 294.25 Plaintiffs do not argue differently and, instead, focus their attack on 

 

25 See also Simopoulos, 462 U.S. at 519 (concluding that Virginia’s outpatientsurgical-hospital requirement for second trimester abortion was “not an unreasonable means 

of furthering the State’s compelling interest in ‘protecting the woman’s own health and 

safety’” (quoting Roe, 410 U.S. at 150)); Roe, 410 U.S. at 163 (“Examples of permissible state 

[health regulations] are requirements as to the qualifications of the person who is to perform 

the abortion; as to the licensure of that person; as to the facility in which the procedure is to 

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whether the challenged provision has “the purpose or effect of placing a 

substantial obstacle in the path of a woman seeking an abortion of a nonviable 

fetus.” Casey, 505 U.S. at 877.

2. Purpose Prong

Texas’s stated purpose for enacting H.B. 2 was to provide the highest 

quality of care to women seeking abortions and to protect the health and 

welfare of women seeking abortions.26 There is no question that this is a 

legitimate purpose that supports regulating physicians and the facilities in 

which they perform abortions.27 The district court found that this was not the 

real purpose of the law and instead concluded “that the ambulatory-surgicalcenter requirement was intended to close existing licensed abortion clinics.” 

Lakey, 46 F. Supp. 3d at 685.

The district court first found an impermissible purpose from the fact that 

the implementing regulations did not provide licensed abortion facilities a 

grandfathering exception to the standards applicable to ASCs, even though a 

grandfathering provision applied to existing ASCs—what it described as 

“disparate and arbitrary treatment.” Id. The State argues that the district 

court misunderstood the application of the ASC grandfathering provision 

 

be performed, that is, whether it must be a hospital or may be a clinic or some other place of 

less-than-hospital status; as to the licensing of the facility; and the like.”).

26 See Senate Comm. on Health & Human Servs., Bill Analysis, Tex. H.B. 2, 83d Leg., 

2d C.S. 1 (2013) (“H.B. 2 seeks to increase the health and safety of a woman who chooses to 

have an abortion by requiring a physician performing or inducing an abortion to have 

admitting privileges at a hospital and to provide certain information to the woman.”); id. at 

2 (“Moving abortion clinics under the guidelines for ambulatory surgical centers will provide 

Texas women choosing abortion the highest standard of health care.”).

27 See Roe, 410 U.S. at 150 (“The State has a legitimate interest in seeing to it that 

abortion, like any other medical procedure, is performed under circumstances that insure 

maximum safety for the patient. This interest obviously extends at least to the performing 

physician and his staff, to the facilities involved, to the availability of after-care, and to 

adequate provision for any complication or emergency that might arise.”).

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because it applies to all ASCs—including ASCs that currently provide 

abortions—such that they do not have to comply with new construction 

requirements as the ASC standards are modified. See 25 TEX. ADMIN. CODE

§ 135.51(a). In this regard, the State correctly points out that ASCs that 

provide abortions are treated no differently than any other ASC. See Lakey, 

769 F.3d at 294. Even assuming arguendo there is some “disparate treatment,” 

the lack of a grandfathering provision is simply evidence that the State truly 

intends that women only receive an abortion in facilities that can provide the 

highest quality of care and safety—the stated legitimate purpose of H.B. 2. 

Another consideration is that the impact of a lack of grandfathering is lessened 

by the legislature allowing nearly fourteen months for existing abortion 

facilities to comply. See TEX. HEALTH & SAFETY CODE ANN. § 245.010(a) 

(September 1, 2014, effective date).28 In addition, because there are 433 ASCs 

in Texas, the legislature logically could have inferred that abortion providers 

could easily rent space at existing ASCs. The district court’s inferences from 

the mere fact of the law itself are thus not supported.

The district court further found an impermissible purpose likely due to 

“the dearth of credible evidence supporting the proposition that abortions 

performed in ambulatory surgical centers have better patient health outcomes 

compared to clinics licensed under the previous regime.” Lakey, 46 F. Supp. 

3d at 685.29 The district court erred in its conclusion. In Mazurek, the 

 

28 Further, the Plaintiffs do not argue that it is impossible for abortion providers to 

comply with the ASC requirement, only costly and difficult.

29 The district court also inferred an impermissible purpose from the State’s attorneys 

arguing that women in El Paso would not face an undue burden because they could simply 

travel to New Mexico, a state without a requirement that abortions be performed in an ASC. 

We agree with the State that an improper legislative purpose cannot be inferred from an 

argument raised by its lawyers more than a year after H.B. 2 was enacted.

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Supreme Court rejected the argument that the law at issue “must have had an 

invalid purpose because all health evidence contradicts the claim that there is 

any health basis for the law.” 520 U.S. at 973 (internal quotation marks 

omitted). Likewise, in Gonzales, the Court explained that legislatures have 

“wide discretion to pass legislation in areas where there is medical and 

scientific uncertainty” and that medical uncertainty, as the record 

demonstrates is present here, does not lead to the conclusion that a law is 

unconstitutional. 550 U.S. at 163. 

The Plaintiffs also argue that an impermissible purpose can be inferred 

from the effect of the law—the closure of a majority of abortion facilities in 

Texas. This argument is foreclosed by Mazurek, in which the Supreme Court 

explained that courts “do not assume unconstitutional legislative intent even 

when statutes produce harmful results.” 520 U.S. at 972; see Lakey, 769 F.3d 

at 295 (citing Mazurek, 520 U.S. at 972); cf. Casey, 505 U.S. at 874 (“The fact 

that a law which serves a valid purpose, one not designed to strike at the right 

itself, has the incidental effect of making it more difficult or more expensive to 

procure an abortion cannot be enough to invalidate it.”).

Plaintiffs bore the burden of proving that H.B. 2 was enacted with an 

improper purpose. See Abbott II, 748 F.3d at 597. They failed to proffer

competent evidence contradicting the legislature’s statement of a legitimate 

purpose for H.B. 2. See Mazurek, 520 U.S. at 972 (noting that there must be 

“some evidence” of improper purpose); see also Abbott II, 748 F.3d at 597; 

Lakey, 769 F.3d at 294–95 (stating that the district court cited no record 

evidence of improper purpose). All of the evidence referred to by the district 

court is purely anecdotal and does little to impugn the State’s legitimate 

reasons for the Act. Plaintiffs failed to prove that H.B. 2 “serve[s] no purpose 

other than to make abortions more difficult.” Casey, 505 U.S. at 901.

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3. Effect Prong

Facial challenges relying on the effects of a law “impose a heavy burden 

upon the parties maintaining the suit.” Gonzales, 550 U.S. at 167 (internal 

quotation marks omitted). In the abortion context, it is unclear whether a 

facial challenge requires showing that the law is invalid in all applications (the 

general test applied in other circumstances) or only in a large fraction of the 

cases in which the law is relevant (the test applied in Casey). See id.; Abbott

II, 748 F.3d at 588–89. In both Gonzales and Abbott II, the challenged 

provisions were upheld because even the less deferential, large-fraction test 

was not satisfied. See Gonzales, 550 U.S. at 167–68; Abbott II, 748 F.3d at 600. 

Here, the district court facially invalidated both the admitting privileges and 

ASC requirements without so much as mentioning either test. Instead, it 

based its holding on a finding that the two requirements worked together, 

along with other state requirements, to “effectively reduce or eliminate 

meaningful access to safe abortion care for a significant, but ultimately 

unknowable, number of women throughout Texas.” Lakey, 46 F. Supp. 3d at 

686 (emphasis added). This analysis runs afoul of Casey, Gonzales, and Abbott 

II, which require, at a minimum, a “large fraction.” Lakey, 769 F.3d at 296 

(quoting Abbott II, 748 F.3d at 600); see also Gonzales, 550 U.S. at 167–68; 

Casey, 505 U.S. at 895.30

As support for its holding that H.B. 2’s admitting privileges and ASC 

requirements constituted an undue burden, the district court also weighed the 

 

30 Plaintiffs cite the use of the phrase “significant number” in Casey as support for the 

district court’s approach. See, e.g., 505 U.S. at 893–94 (“The spousal notification requirement 

is thus likely to prevent a significant number of women from obtaining an abortion.”). 

However, in Casey, unlike here, the Court went on to find that this significant number 

amounted to “a large fraction.” Id. at 895.

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burdens and medical efficacy of these two requirements. Lakey, 46 F. Supp. 

3d at 684 (“[T]he severity of the burden imposed by both requirements is not 

balanced by the weight of the interests underlying them.”). In so doing, the 

district court concluded that H.B. 2 would not further the State’s interests in 

maternal health and increased quality of care.31 In defense of this approach, 

Plaintiffs argue that the two requirements at issue are unconstitutional unless 

they are shown to actually further the State’s legitimate interests. We 

disagree with the Plaintiffs and the district court’s approach.

 In Abbott II, the district court similarly held that the admitting 

privileges requirement “does nothing to further” the State’s interest in 

maternal health, although it performed this analysis as part of the rational 

basis inquiry. Planned Parenthood of Greater Tex. Surgical Health Servs. v. 

Abbott, 951 F. Supp. 2d 891, 900 (W.D. Tex. 2013). In Abbott II, we held that 

the inquiry was “wrong on several grounds” and explained that “the 

fundamental question is whether Planned Parenthood has met its burden to 

prove that the admitting privileges regulation imposes an undue burden on a 

woman’s ability to choose an abortion.” 748 F.3d at 590. Abbott II thus 

disavowed the inquiry employed by the district court:

It is not the courts’ duty to second guess legislative factfinding, 

improve on, or cleanse the legislative process by allowing 

relitigation of the facts that led to the passage of a law. Under 

rational basis review, courts must presume that the law in 

question is valid and sustain it so long as the law is rationally 

related to a legitimate state interest. As the Supreme Court has 

 

31 See Lakey, 46 F. Supp. 3d at 684 (“[W]omen will not obtain better care or experience 

more frequent positive outcomes at an [ASC] as compared to a previously licensed facility.”); 

id. (“[I]t is unlikely that the stated goal of the [ASC] requirement—improving women’s 

health—will actually come to pass.”); id. (“The court finds no particularized health risks 

arising from abortions performed in nonambulatory-surgical-center clinics which 

countenance the imposition of the [ASC] requirement . . . .”).

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often stressed, the rational basis test seeks only to determine 

whether any conceivable rationale exists for an enactment. 

Because the determination does not lend itself to an evidentiary 

inquiry in court, the state is not required to prove that the objective 

of the law would be fulfilled.

748 F.3d at 594 (citations and internal quotation marks omitted).32 In 

addition, in Gonzales, in the course of applying the effect portion of the undueburden inquiry, the Court made clear that medical uncertainty underlying a 

statute is for resolution by legislatures, not the courts. See 550 U.S. at 163 

(“The Court has given state and federal legislatures wide discretion to pass 

legislation in areas where there is medical and scientific uncertainty.”); id. at 

164 (“Medical uncertainty does not foreclose the exercise of legislative power 

in the abortion context any more than it does in other contexts.”); id. at 166

(“Considerations of marginal safety, including the balance of risks, are within 

the legislative competence when the regulation is rational and in pursuit of 

legitimate ends.”). Thus, we conclude that the district court erred by 

substituting its own judgment for that of the legislature, albeit this time in the 

name of the undue burden inquiry. See Lakey, 769 F.3d at 297 (“Under our 

precedent, we have no authority by which to turn rational basis into strict 

 

32 As they did in Abbott II, Plaintiffs again argue that Akron I and Barnes require 

the more demanding approach employed by the district court. Compare Pls.’ Br. 35–38 

(citing, inter alia, Akron I, 462 U.S. at 430–31, and Barnes v. Mississippi, 992 F.2d 1335, 1339 

(5th Cir. 1993)), with Brief of Plaintiffs-Appellees at 15–17, Abbott II, 748 F.3d 583 (No. 13-

51008) (same). As we explained in Abbott II, Casey overruled major portions of Akron I and 

replaced Akron’s strict scrutiny test with the undue burden analysis. See 748 F.3d at 590 

(citing Casey, 505 U.S. at 871). In Barnes, we described Casey as holding that “the 

constitutionality of an abortion regulation . . . turns on an examination of the importance of 

the state’s interests in the regulation and the severity of the burden that regulation imposes 

on a woman’s right to seek an abortion.” 992 F.2d at 1339 (emphasis added). Barnes 

nevertheless examined the state’s interest without considering the extent to which the 

challenged law furthered that interest and without conducting a balancing test. See id. at 

1339–40; Lakey, 769 F.3d at 298.

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scrutiny under the guise of the undue burden inquiry.”).33

Turning to the direct application of the large fraction test to the facts of 

this case, the parties’ arguments focused on the number of women who faced 

increased travel distances due to the closure of abortion facilities. In 

particular, the arguments centered around those women who would face travel 

distances (one-way) of over 150 miles in light of Abbott II’s holding that “an 

increase of travel of less than 150 miles for some women is not an undue burden 

under Casey.” 748 F.3d at 598. The district court credited the testimony of the 

Plaintiffs’ expert, Dr. Grossman, and found that: (1) after the admitting 

privileges requirement went into effect, approximately 400,000 women of 

reproductive age would face travel distances of more than 150 miles; and (2) 

once both the admitting privileges and ASC requirements went into effect, 

 

33 Plaintiffs filed a Rule 28(j) letter referencing the recent district court opinion in 

Planned Parenthood of Wis., Inc. v. Van Hollen, No. 3:13-cv-465, 2015 U.S. Dist. LEXIS 35389 

(W.D. Wis. Mar. 20, 2015). This case follows the standards announced in Planned Parenthood 

of Wis., Inc. v. Van Hollen, 738 F.3d 786 (7th Cir. 2013), cert. denied, 134 S. Ct. 2841 (2014),

which requires balancing the burdens imposed by a law against its medical benefits, and 

which we distinguished in Abbott II, 748 F.3d at 596. “In our circuit, we do not balance the 

wisdom or effectiveness of a law against the burdens the law imposes.” Lakey, 769 F.3d at 

297 (citing Abbott II, 748 F.3d at 593–94); accord Women’s Med. Prof’l Corp. v. Baird, 438 

F.3d 595, 604–09 (6th Cir. 2006); Greenville Women’s Clinic v. Bryant, 222 F.3d 157, 170–72

(4th Cir. 2000); Women’s Health Center of W. Cnty., Inc. v. Webster, 871 F.2d 1377, 1380–81

(8th Cir. 1989). Even if some balancing were appropriate, we are unsure that the Seventh 

Circuit’s balancing test—pursuant to which even a slight or de minimis burden could be 

“undue”—is faithful to Casey, which requires a substantial obstacle. See Planned Parenthood 

of Wis. v. Doyle, 162 F.3d 463, 478 (7th Cir. 1998) (Manion, J., dissenting) (“To fail the undue 

burden test, the alternatives to the [outlawed procedure] must . . . present a substantial 

obstacle to a woman obtaining an abortion . . . [but] [t]here is no suggestion in the court’s 

opinion that the risks are more than “de minimis.”); see also Casey, 505 U.S. at 926 

(Blackmun, J., dissenting in part) (“Our precedents and the joint opinion’s principles require 

us to subject all non-de-minimis abortion regulations to strict scrutiny.”); cf. Goss v. Lopez, 

419 U.S. 565, 576 (1975) (noting that procedural due process analysis only applies when a 

deprivation is more than de minimis). In any event, and although we do not reach the issue 

here, we note that applying any balancing test would be difficult on this record because 

plaintiffs have not introduced evidence from which we could discern the number or fraction 

of reproductive-age women who would be burdened, unduly or otherwise.

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approximately 900,000 women of reproductive age would face travel distances 

of more than 150 miles. See Lakey, 46 F. Supp. 3d at 681–82.

Although Dr. Grossman and the district court did not mention 

percentages or fractions, using the district court’s finding that there were 

approximately 5.4 million women of reproductive age in Texas, see id. at 681,

the following percentages and fractions are derived: (1) 7.4% or 1/13 of women 

of reproductive age faced travel distances of 150 miles or more after the 

admitting privileges requirement went into effect; and (2) 16.7% or 1/6 of 

women of reproductive age would face travel distances of 150 miles or more 

after both requirements went into effect.

The motions panel majority found that these numbers did not satisfy the 

large fraction test:

Even assuming, arguendo, that 150 miles is the relevant cut-off, 

this is nowhere near a “large fraction.” See Abbott II, 748 F.3d at 

600. As discussed above, the Casey plurality, in using the “large 

fraction” nomenclature, departed from the general standard for 

facial challenges. The general standard for facial challenges 

allows courts to facially invalidate a statute only if “no possible 

application of the challenged law would be constitutional.” Abbott 

II, 748 F.3d at 588. In other words, the law must be 

unconstitutional in 100% of its applications. We decline to 

interpret Casey as changing the threshold for facial challenges 

from 100% to 17%.

769 F.3d at 298; see also Abbott II, 748 F.3d at 598 (holding that 10% did not 

amount to a large fraction). We agree and adopt this reasoning.

In defense of the district court’s judgment, the Plaintiffs hardly argue 

that these numbers amount to a large fraction. Instead, they try to shift the 

discussion to making the denominator not all women of reproductive age in 

Texas, but “the population of women for whom the law imposes a meaningful 

burden.” They fail to specify what that number would be or how it might be 

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derived. In addition, the Plaintiffs’ approach would appear to “make the large 

fraction test merely a tautology, always resulting in a large fraction. The 

denominator would be women that Plaintiffs claim are unduly burdened by the 

statute, and the numerator would be the same.” Lakey, 769 F.3d at 299. In 

Casey, the Court explained that the denominator was the group of women to 

whom the law was “relevant” or a “restriction.” 505 U.S. at 894–95. Because 

H.B. 2 applies to all abortion providers and facilities in Texas, and the 

Plaintiffs argued that abortion clinics all across the state would likely be 

required to close, we used all women of reproductive age or women who might 

seek an abortion as the denominator in Lakey, Abbott II, and Abbott I. See

Lakey, 769 F.3d at 299 (“Here, the ambulatory surgical center requirement 

applies to every abortion clinic in the State, limiting the options for all women 

in Texas who seek an abortion. The appropriate denominator thus includes all 

women affected by these limited options.”); Abbott II, 748 F.3d at 598, 600; 

Abbott I, 734 F.3d at 414. Plaintiff’s new denominator is inconsistent with our 

binding decision in Abbott II.

In reaching its conclusion that H.B. 2’s requirements imposed an undue 

burden on a significant number of women, the district court also found that 

travel distances combined with the following practical concerns to create a de 

facto barrier to abortion for some women: “lack of availability of child care, 

unreliability of transportation, unavailability of appointments at abortion 

facilities, unavailability of time off from work, immigration status and inability 

to pass border checkpoints, poverty level, the time and expense involved in 

traveling long distances, and other, inarticulable psychological obstacles.” 

Lakey, 46 F. Supp. 3d at 683. On this point, we agree with the motions panel 

majority: “We do not doubt that women in poverty face greater difficulties. 

However, to sustain a facial challenge, the Supreme Court and this circuit 

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require Plaintiffs to establish that the law itself imposes an undue burden on 

at least a large fraction of women. Plaintiffs have not done so here.” Lakey, 

769 F.3d at 299; see Abbott I, 734 F.3d at 415 (holding that “obstacle[s]” that 

are “unrelated to the hospital-admitting-privileges requirement” are irrelevant 

to the undue-burden inquiry in a facial challenge); cf. McRae, 448 U.S. at 316 

(“The financial constraints that restrict an indigent woman’s ability to enjoy 

the full range of constitutionally protected freedom of choice are the product 

not of governmental restrictions on access to abortions, but rather of her 

indigency.”); Maher, 432 U.S. at 474 (reasoning that “[t]he indigency that may 

make it difficult—and in some cases, perhaps, impossible—for some women to 

have abortions is neither created nor in any way affected by the” state’s 

regulation). Moreover, even accepting the district court’s finding on this point, 

it is not clear from the record what fraction of women face an undue burden 

due to this combination of practical concerns and the effects of H.B. 2. Cf.

Casey, 505 U.S. at 887 (noting, based on similar factual findings, that “[a] 

particular burden is not of necessity a substantial obstacle”).

Finally, in reaching its holding, the district court also accepted the 

finding of Dr. Grossman that the ASCs providing abortions in Texas “will not 

be able to go from providing approximately 14,000 abortions annually, as they 

currently are, to providing the 60,000 to 70,000 abortions that are done each 

year in Texas once all of the non-ASC clinics are forced to close.” As the 

motions panel majority observed, Dr. Grossman’s opinion “is ipse dixit and the 

record lacks any actual evidence regarding the current or future capacity of the 

eight clinics.” Lakey, 769 F.3d at 300.34 Further, as the motions panel majority 

 

34 Dr. Grossman based his opinion on a chain of unsupported inferences. See Lakey, 

769 F.3d at 300. First, he found that in cities with both ASC and non-ASC abortion facilities, 

some non-ASC facilities provided more abortions while some ASCs provided fewer abortions. 

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recognized, there does not appear to be any evidence in the record that the 

current ASCs are operating at full capacity or that they cannot increase 

capacity. See id. Thus, the district court’s determination on this point is 

unsupported by evidence and, therefore, is clearly erroneous. See id.

Because the Plaintiffs failed to prove that the ASC requirement imposes 

an undue burden on a large fraction of women for whom it is relevant, we 

conclude that the district court erred in striking down the ASC requirement as 

a whole as facially invalid. See Gonzales, 550 U.S. at 167–68; Abbott II, 748 

F.3d at 588–89, 598–600.35

C. ASC Requirement and the Provision of Medication Abortion

In addition to challenging the ASC requirement as facially 

unconstitutional, Plaintiffs challenged the ASC requirement as 

 

From the increased amount of abortions at some of the non-ASC facilities, Dr. Grossman 

concluded that there was an increased demand for abortions in that city. Conversely, Dr. 

Grossman found the decrease in the amount of abortions at some ASCs to be “likely indicative 

of their inability to increase capacity in the face of growing demand.” Dr. Grossman 

ultimately concluded that this purported inability to increase capacity at ASCs “may be a 

result of the admitting privileges requirement.”

There were similar problems with Plaintiffs’ evidence in Abbott II. As we noted in 

Lakey:

[A]n expert who was part of the same research team as Dr. Grossman offered 

similarly unsupported conjecture [in Abbott II] when predicting that, as a 

result of the admitting privileges requirement, approximately 22,000 women in 

Texas would be unable to obtain abortions. On cross-examination in [Lakey], 

Dr. Grossman admitted that his colleague’s earlier predictions proved to be 

inaccurate. Dr. Grossman testified in [Lakey] that there had been a decrease 

of only 9,200 abortions and that the decrease could not be wholly ascribed to 

the admitting privileges requirement. Indeed, Dr. Grossman acknowledged on 

cross-examination that in his team’s published, peer-reviewed article, the 

researchers qualified their findings by noting that they “cannot prove causality 

between the State restrictions and falling abortion rate.”

769 F.3d at 300 n.16.

35 Given our holding, we also reject the Plaintiffs’ argument on cross-appeal that the

district court erred by excepting from its facial injunction of the ASC requirement “abortion 

providers that seek to become licensed in the future.”

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unconstitutional statewide in the context of the provision of medication 

abortion (in which drugs, as opposed to surgical procedures, are used to induce 

an abortion). On this claim, the district court concluded that the ASC 

requirement was invalid “specifically as applied to the provision of medication 

abortions,” with the entirety of the district court’s analysis being that in this 

context “any medical justification for the requirement is at its absolute weakest 

in comparison with the heavy burden it imposes.” Lakey, 46 F. Supp. 3d at 

686. The State appeals this portion of the district court’s judgment, pointing 

out that the district court’s conclusion is improperly based solely on its belief 

that the law is medically unjustified. 

The Plaintiffs do not respond with any arguments on appeal in support 

of this portion of the judgment. For the same reasons that we hold the district 

court erred in facially invalidating the ASC requirement, we conclude that the 

record and district court’s opinion do not justify statewide invalidation of the 

ASC requirement in the context of medication abortions: (1) res judicata bars 

this claim, as it arises out of the same transaction as the claims in Abbott II 

and it “could have been raised” in Abbott II, Allen, 449 U.S. at 94; and (2) the 

ASC requirement in the context of medication abortion is rationally related to 

a legitimate state interest and has not been shown to have an improper 

purpose or impose an undue burden on a large fraction of women for whom it 

is relevant, Gonzales, 550 U.S. at 167–68.

VI. As-Applied Challenges

In Abbott II, we rejected the facial challenge to the admitting privileges

requirement but noted that an as-applied challenge to the Rio Grande Valley 

(which is comprised of Starr, Hidalgo, Willacy, and Cameron County, 

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hereinafter collectively, “Rio Grande Valley”)36 may be appropriate based upon 

the evidence presented in that case. See Abbott II, 748 F.3d at 589 (“Later asapplied challenges can always deal with subsequent, concrete constitutional 

issues.”). Plaintiffs have thus asserted such an as-applied challenge related to 

a facility in McAllen, as well to a facility in El Paso that was not previously 

discussed.

A. Res Judicata for As-Applied Challenges

The State makes the same res judicata arguments as to these challenges 

as it does for the facial challenge. The res judicata analysis is different, 

however, when we address the as-applied challenges because, as we suggested 

in Abbott II, the actual factual development may be different than anticipated 

in a facial challenge setting. We now know with certainty that the non-ASC 

abortion facilities have actually closed and physicians have been unable to 

obtain admitting privileges after diligent effort. Thus, the actual impact of the 

combined effect of the admitting privileges and ASC requirements on abortion 

facilities, abortion physicians, and women in Texas can be more concretely 

understood and measured. See Hernandez v. City of Lafayette, 699 F.2d 734, 

737 (5th Cir. 1983) (addressing whether the changes are “significant” and 

create “new legal conditions” (internal quotation marks omitted)). 

 Our sister circuits have confronted the issue of how the ripeness analysis 

(a subsidiary consideration in the res judicata analysis discussed above) differs 

between a facial challenge and an as-applied challenge. The Eleventh Circuit 

has explained: 

 

36 Plaintiffs’ expert, Dr. Grossman, used the term “Lower Rio Grande Valley” to 

describe the area comprising the following four counties: Starr, Hidalgo, Willacy, and 

Cameron. See also Abbott II, 748 F.3d at 597 (“The Rio Grande Valley . . . has four counties.”).

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Because the question of ripeness depends on the timing of 

the adjudication of a particular issue, it applies differently to facial 

and as-applied challenges. A facial challenge asserts that a law 

always operates unconstitutionally . . . . In the context of a facial 

challenge, a purely legal claim is presumptively ripe for judicial 

review because it does not require a developed factual record. An 

as-applied challenge, by contrast, addresses whether a statute is 

unconstitutional on the facts of a particular case or to a particular 

party. Because such a challenge asserts that a statute cannot be 

constitutionally applied in particular circumstances, it necessarily 

requires the development of a factual record for the court to 

consider.

Harris v. Mexican Specialty Foods, Inc., 564 F.3d 1301, 1308 (11th Cir. 2009) 

(citations and internal quotation marks omitted). The First Circuit has 

explained this approach as well:

[A] challenge to a rule or statute may be ripe for adjudication on 

the question of facial constitutionality and yet not be ripe for 

adjudication on the question of constitutionality as applied. See, 

e.g., Grayned v. City of Rockford, 408 U.S. 104, 121 & n.50 (1972) 

(upholding noise control ordinance but reserving decision on 

constitutionality of possible applications); Times Film Corp. v. City 

of Chicago, 365 U.S. 43 (1961) (upholding ordinance requiring 

licensing of films prior to public exhibition) and Teitel Film Corp. 

v. Cusack, 390 U.S. 139 (1968) (invalidating same ordinance as 

applied); Adler v. Board of Education, 342 U.S. 485 (1952) 

(upholding New York statutory scheme for identifying and 

removing subversive school teachers) and Keyishian v. Board of 

Regents, 385 U.S. 589 (1967) (invalidating portions of same 

statutory scheme as applied).

Kines v. Day, 754 F.2d 28, 31 (1st Cir. 1985). Other courts have concluded that 

an as-applied challenge was not ripe although a facial challenge was ripe. See

13B CHARLES A. WRIGHT ET AL., FEDERAL PRACTICE & PROCEDURE § 3532.3 (3d 

ed. 1998) (“A number of other cases in more general settings reflect similar 

distinctions between the ripeness of broad attacks on the legitimacy of any 

regulation and the nonripeness of more particular attacks on more specific 

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applications.”); see, e.g., Richmond Med. Ctr. for Women v. Herring, 570 F.3d 

165, 180 (4th Cir. 2009) (en banc); Sam & Ali, Inc. v. Ohio Dep’t of Liquor 

Control, 158 F.3d 397, 398–400 (6th Cir. 1998); Hotel Emps. & Rest. Emps. Int’l 

Union v. Nev. Gaming Comm’n, 984 F.2d 1507, 1512–13 (9th Cir. 1993). 

Although we agree with the State that some aspects of the as-applied 

challenge were extant at the time the Abbott II litigation was filed, some 

important facts occurred later, such as the actual closure of abortion facilities 

in Corpus Christi and El Paso and the physicians ultimately being denied 

admitting privileges after diligent effort. Cf. Orix, 212 F.3d at 895 (“[A] case 

is not ripe if further factual development is required.” (citation omitted)). We 

disclaimed reliance on such facts in Abbott II, 748 F.3d at 589 (“Later asapplied challenges can always deal with subsequent, concrete constitutional 

issues.”); id. at 599 n.14 (“To the extent that the State and Planned Parenthood 

rely on developments since the conclusion of the bench trial and during this 

appeal, we do not consider any arguments based on those facts . . . .”). Although 

Plaintiffs could have foreseen (and did foresee) some of these closures and

admitting privilege rejections, the State suggested that we could not know 

these matters with certainty at the time, and we deferred consideration of 

these facts to a time when they were more concretely presented. That time 

arrived, and the district court correctly held it was not precluded from 

addressing the actual facts in the as-applied context. Thus, although it is a 

close question, we conclude that the district court did not err in denying relief 

to the State on this defense as to the McAllen and El Paso as-applied 

challenges.

B. McAllen

Whole Woman’s Health operates a licensed abortion facility in McAllen 

that is not an ASC and which resides on a lot that the Plaintiffs’ expert, George 

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W. Johannes, testified would not allow for expansion to meet the ASC 

construction standards. Testimony showed that four physicians37 of Whole 

Woman’s Health unsuccessfully sought admitting privileges from hospitals 

within thirty miles of the clinic, with one of the hospitals notifying them that 

the denial of admitting privileges “was not based on clinical competence.” 

Whole Woman’s Health has been unsuccessful in recruiting physicians with 

admitting privileges to work at the McAllen facility. It contends, then, that 

the ASC and admitting privileges requirements will prevent it from providing 

abortions. The McAllen clinic ceased providing abortions on November 1, 2013. 

While women in the Rio Grande Valley could previously travel 150 miles 

or less to Corpus Christi to obtain an abortion, see Abbott II, 748 F.3d at 597–

98, the abortion facility in Corpus Christi has now closed. The State argues 

that women in the Rio Grande Valley continue to be able to obtain abortions in 

San Antonio and Houston, where the abortion facilities now nearest to them 

are located. Indeed, Plaintiffs’ expert, Dr. Grossman, concluded that fifty 

percent of the women from the Rio Grande Valley were previously obtaining 

abortions somewhere other than Corpus Christi, even before that clinic closed. 

Nonetheless, the closure of the Corpus Christi clinic means that all women in 

the Rio Grande Valley will have to travel approximately 235 miles38 to San 

Antonio or farther to obtain an abortion. In addition, the president and CEO 

of Whole Woman’s Health, Amy Hagstrom Miller, and a certified community 

health worker, Lucila Ceballos Felix, testified regarding the difficulties that 

 

37 Of those four, only Dr. Lynn is a party to the case. The other three were neither 

named as parties nor identified in the district court; their names were redacted from exhibits.

38 The record reflects that the distance between McAllen, which is located near the 

center of the Rio Grande Valley, and the center of San Antonio is approximately 235 miles. 

The distance between McAllen and the ASC-compliant clinic in San Antonio, based on the 

address information in the parties’ Joint Stipulation to Facts, is 234 miles.

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women in the Rio Grande Valley faced after the McAllen facility ceased 

performing abortions, including that the clinic saw an increase in selfattempted abortion and some women indicated they would be unable to make 

the trip from McAllen to San Antonio or Houston to obtain an abortion.39

In Abbott II, relying on Casey, we held that having to travel 150 miles 

from the Rio Grande Valley to Corpus Christi to obtain an abortion was not an 

undue burden for purposes of the facial challenge raised there and that “Casey 

counsels against striking down a statute solely because women may have to 

travel long distances to obtain abortions.” 748 F.3d at 598. Casey permitted 

even farther distances than 150 miles because it involved a 24-hour waiting 

period and women in 62 of Pennsylvania’s 67 counties were required to travel 

for one to more than three hours one way to obtain an abortion. See Lakey, 769 

F.3d at 303 (citing Abbott II, 748 F.3d at 598).40 

We recognize that any statement of “how far is too far” will involve some 

imprecision. Casey suggested that three hours (one way) was not too far.41 

 

39 While some of Hagstrom Miller’s testimony, and that of Ceballos Felix, appears to 

be hearsay (or even double hearsay in the case of the interviews by other employees of the 

clinic), the record is unclear whether the State objected on these grounds. Moreover, the 

district court relied on Hagstrom Miller’s and Ceballos Felix’s entire testimony for its findings 

that women in the Rio Grande Valley faced “practical concerns” and the State did not 

challenge these findings as clear error. We conclude that the district court’s findings are not 

clearly erroneous. See Abbott II, 748 F.3d at 589 (noting the standard); Reich v. Lancaster, 

55 F.3d 1034, 1045 (5th Cir. 1995) (“The trial judge’s unique perspective to evaluate the 

witnesses and to consider the entire context of the evidence must be respected.” (internal 

quotation marks omitted)).

40 Texas has a 24-hour waiting period, but the waiting period is reduced to 2 hours 

for women who certify that they live “100 miles or more from the nearest [licensed] abortion 

provider.” See TEX. HEALTH & SAFETY CODE ANN. § 171.012(a)(4) (West Supp. 2014).

41 Casey even suggested that doubling what amounted to a six-hour round trip was 

not an undue burden. 505 U.S. at 887 (“[T]he District Court did not conclude that the waiting 

period is [a substantial] obstacle even for the women who are most burdened by it. Hence, 

on the record before us . . . we are not convinced that the 24-hour waiting period constitutes 

an undue burden.”). The district court in Casey noted that the waiting period doubled travel 

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Abbott II held that 150 miles is not too far and concluded that Casey suggested 

that no distance, standing alone, could be too far. 748 F.3d at 598. We hold

that, in the specific context of this as-applied challenge as to the McAllen 

facility, the 235-mile distance presented, combined with the district court’s 

findings,42 are sufficient to show that H.B. 2 has the “effect of placing a 

substantial obstacle in the path of a woman seeking an abortion.” Casey, 505 

U.S. at 877. Therefore, we hold that the district court did not err in enjoining 

the ASC requirement “as applied” to the McAllen facility. However, we 

conclude that the injunction was overbroad as it fails to recognize that the 

Corpus Christi facility (or one like it) could reopen in the future. Thus, we 

modify the injunction to apply to the McAllen facility until such time as 

another licensed abortion facility becomes available to provide abortions at a 

location nearer to the Rio Grande Valley than San Antonio.

“We also must consider the proper place of H.B. 2’s comprehensive and 

careful severability provision . . . .” Abbott II, 748 F.3d at 589 (citing Leavitt v. 

Jane L., 518 U.S. 137, 138–39 (1996)). H.B. 2’s severability provision directs 

that “every provision, section, subsection, sentence, clause, phrase, or word” is 

severable and that it is the intention of the legislature that only those portions 

 

distances for some women who were more than three hours (one-way) from the nearest clinic. 

Planned Parenthood of Se. Pa. v. Casey, 744 F. Supp. 1323, 1352 (E.D. Pa. 1990), aff’d in part, 

rev’d in part, 947 F.2d 682 (3d Cir. 1991), aff’d in part, rev’d in part, 505 U.S. 833 (1992). See 

also Abbott II, 748 F.3d at 598, which cited the district court’s opinion in Casey and noted the 

distances involved.

42 See supra note 39 and accompanying text. We note that our resolution of this asapplied challenge does not depend on the testimony of Plaintiffs’ expert, Dr. Grossman (or 

any related findings by the district court), as to the percentage of women in Texas driving 

more than 150 miles or the capacity of abortion facilities to handle any changes in, or 

reallocation of, demand. As we noted earlier, Dr. Grossman’s testimony on the capacity of 

remaining ASC abortion facilities is ipse dixit, and the record lacks evidence on this subject. 

See supra note 34 and accompanying text.

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of the act or regulations that impose an undue burden be invalidated, with all 

others left in place. H.B. 2, § 10(b). The implementing regulations include 

similar language. See 25 TEX. ADMIN. CODE § 139.9. It is thus necessary to 

“sever [H.B. 2 and the implementing regulations’] problematic portions while 

leaving the remainder intact.” Ayotte v. Planned Parenthood of N. New Eng., 

546 U.S. 320, 329 (2006). The Plaintiffs have been careful to avoid identifying 

which specific portions of the ASC standards contribute to the closure of 

abortion facilities, and the district court did not sever out only the problematic 

portions. We are thus forced to perform this analysis without the benefit of 

their input.

The regulatory standards for ASCs fall into three categories: (1) 

operating requirements, 25 TEX. ADMIN. CODE §§ 135.4–.17, 135.26–.27; (2) 

requirements related to fire prevention, general safety, and handling of 

hazardous materials, id. §§ 135.41–.43; and (3) physical-plant requirements, 

id. §§ 135.51–.56. The Plaintiffs put forth expert testimony that abortion 

facilities could not meet the ASC standards because they would be required to 

modify their existing buildings to meet the physical-plant requirements, 

corresponding to §§ 135.51–.56, and the fire-prevention requirements, 

corresponding to § 135.41.43 In the same manner, the district court’s findings 

 

43 The parties stipulated that the McAllen clinic did not comply with the ASC 

requirement, but did not stipulate as to the feasibility of Whole Woman’s Health operating 

an ASC-compliant facility in the future. The parties also did not stipulate whether other 

ASC-compliant clinics might open in the Rio Grande Valley.

The parties offered conflicting expert testimony regarding whether Whole Woman’s 

Health could renovate its current facility. Plaintiffs’ expert, George W. Johannes, inspected 

several of Plaintiffs’ facilities to determine how the ASC requirement would affect their 

operations. He testified that none of Plaintiffs’ clinics, including the one in McAllen, were 

built on a large enough footprint to accommodate an ASC-compliant facility. Moreover, he 

testified that only three of the clinics had sufficient land to expand their footprints. McAllen 

was not one of those three. Johannes estimated that the cost of expanding these clinics 

ranged from $1.7 million to $2.6 million. He testified that to build a new ASC-compliant 

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with respect to the prohibitive effects of the ASC requirement focused on the 

structural modifications or new buildings that would be required by these 

standards. While the Plaintiffs also complained of the nursing requirements 

at § 135.15(a), we are not aware of any record evidence that complying with 

the nursing requirements would cause the closure of abortion facilities. The 

Plaintiffs admitted that the remaining operational requirements were 

comparable to the standards with which abortion facilities were already 

required to comply. Therefore, we conclude that the district court erred by not 

constraining its injunction to only those regulations that create an undue 

burden, namely, § 135.51–.56 (physical plant) and § 135.41 (fire prevention). 

See Lakey, 769 F.3d at 304. We modify the injunction as to McAllen to enjoin 

only the enforcement of the ASC physical-plant and fire-prevention standards, 

as described more fully below. See §§ 135.41, 135.51–.56.

With respect to the admitting privileges requirement, Whole Woman’s 

 

facility would cost $3.4 million, not including the price of land. His testimony reflects that 

Whole Woman’s Health could not expand the McAllen facility, but would have to relocate 

either by obtaining new land and constructing a $3.4 million dollar facility, or leasing an 

existing ASC-compliant facility at a different location. Hagstrom Miller similarly testified 

that Whole Woman’s Health in McAllen could not comply with the ASC requirement.

The state agreed that it would be expensive for Whole Woman’s Health to acquire or 

build an ASC-compliant facility, but nevertheless argued that doing so would be feasible. The 

State’s expert, Deborah Kitz, testified that the McAllen clinic could reduce its costs by 

running more efficiently and reducing the management fee it pays to Whole Woman’s Health, 

which she testified was significantly above the average rate. The State’s expert also 

disagreed with Plaintiffs’ expert, testifying that the McAllen facility already had sufficient 

space to renovate into an ASC-compliant facility and would not even need to relocate.

The district court determined that the Plaintiffs’ expert was more credible, finding 

that the cost of complying with the ASC requirement was upwards of $1.5 million for clinics 

that could renovate their existing facilities, and over $3 million for those that had to acquire 

land and construct a new facility. It determined that the McAllen clinic was an “[e]xisting 

clinic[], unable to meet the financial burdens imposed by the new regulatory regime, and 

w[ould] close as a result.” On appeal, the State did not challenge these findings as clear error. 

Accordingly, we accept the district court’s findings with respect to the prohibitive costs of 

upgrading or relocating the McAllen clinic.

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Health presented considerable evidence that Plaintiff Dr. Lynn and three 

unidentified physicians working at the McAllen facility were unable to obtain 

admitting privileges at local hospitals for reasons other than their competence. 

Plaintiffs also presented evidence that they were unsuccessful in recruiting 

physicians to work at the McAllen facility who had admitting privileges at a 

local hospital. Accordingly, we conclude that the district court’s injunction of 

the admitting privileges requirement as applied to the McAllen facility when 

utilizing Dr. Lynn at that specific facility should be upheld, as described more 

fully below.

To sum up, we affirm in part and modify in part the district court’s 

injunction of the admitting privileges and ASC requirements as applied to 

McAllen, as follows: (1) The State of Texas is enjoined from enforcing § 135.51–

.56 and § 135.41 of the ASC regulations against the Whole Woman’s Health 

abortion facility located at 802 South Main Street, McAllen, Texas, when that 

facility is used to provide abortions to women residing in the Rio Grande Valley

(as defined above), until such time as another licensed abortion facility 

becomes available to provide abortions at a location nearer to the Rio Grande 

Valley than San Antonio; (2) The State of Texas is enjoined from enforcing the 

admitting privileges requirement against Dr. Lynn when he provides abortions 

at the Whole Woman’s Health abortion facility located at 802 South Main 

Street, McAllen, Texas, to women residing in the Rio Grande Valley. The 

remainder of the injunction as to the McAllen facility is vacated.

C. El Paso Abortion Facility

Reproductive Services operates a licensed abortion facility in El Paso 

that is not an ASC. The physician at this facility, Dr. Richter, applied for 

admitting privileges at three hospitals but was only able to obtain temporary 

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privileges at one hospital. These privileges were later revoked.44 Reproductive 

Services has been unsuccessful in recruiting physicians with admitting 

privileges to work at the El Paso facility. After Dr. Richter’s temporary 

admitting privileges were revoked in April 2014, the El Paso facility stopped

providing abortions and eventually closed. The closest Texas abortion facility 

that will remain open is in San Antonio, over 550 miles away. There is an 

abortion facility approximately twelve miles away in Santa Teresa, New 

Mexico. Prior to H.B. 2, more than half of the women who obtained abortions 

at the Santa Teresa facility were from El Paso.

The State argues the closure of the El Paso abortion facility will not 

impose an undue burden because women in this area can travel to the Santa 

Teresa facility. The Plaintiffs contend that this argument is precluded by 

Jackson Women’s Health Organization v. Currier, 760 F.3d 448, 457–58 (5th 

Cir. 2014), petition for cert. filed, S. Ct. No. 14-997 (Feb. 18, 2015), where we 

held that a statute that would have the effect of closing the only abortion 

facility in the state could not be upheld based upon evidence of facilities in 

other states. In that case, although Mississippi’s admitting privileges

requirement for abortion physicians was shown to cause the closure of the only 

abortion clinic in the state, women could travel to abortion facilities outside 

the state. Id. at 451, 455. The State argues that Jackson is distinguishable 

 

44 Plaintiffs state that the hospital denied Dr. Richter admitting privileges because 

she was an abortion provider. As emphasized in Abbott II, Texas and federal law prohibit 

discrimination on this basis and Texas provides a private cause of action to challenge such 

discrimination. See 748 F.3d at 598 & n.13 (citing TEX. OCC. CODE ANN. §§ 103.002(b), 

103.003, and 42 U.S.C. § 300a-7(c)). This undermines the argument that the admitting 

privileges requirement is the cause of the closure of the facility since the suggestion is that 

the cause is actually unlawful discrimination for which state law provides Dr. Richter a 

remedy. However, because we conclude that the closure of the El Paso facility, whatever its 

cause, does not create an undue burden on a woman’s right to choose an abortion, we need 

not address this issue further.

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because, unlike in Mississippi, H.B. 2 will not cause the closure of all abortion 

facilities in Texas. The Plaintiffs did not respond to this argument in their 

merits briefs. The motions panel acknowledged Jackson and noted that “the 

situation in Texas is markedly different from that in Mississippi” because 

H.B. 2 would not close the last clinic in the state. Lakey, 769 F.3d at 304. 

However, the motions panel declined “to construe [Jackson’s] broad language 

so narrowly in [an] emergency stay proceeding.” Id. As discussed above, a 

motions panel proceeding is an abbreviated one; having now considered the 

matter in full, we conclude that Jackson is distinguishable.

In Jackson, we relied on State of Missouri ex rel. Gaines v. Canada, 305 

U.S. 337 (1938), an equal protection case in which the University of Missouri 

denied admission to Gaines because he was African-American and offered him 

a stipend to attend school in an adjacent state. We explained that “Gaines

simply and plainly holds that a state cannot lean on its sovereign neighbors to 

provide protection of its citizens’ federal constitutional rights.” 760 F.3d at 

457. In this case, unlike in Gaines and Jackson, the State has not completely 

shunted its responsibility onto other states. H.B. 2 does not result in the 

closure of all abortion providers in the state: at least eight ASCs will continue 

to provide abortions in Texas. See Lakey, 769 F.3d at 304 (“Given the panel’s 

reliance on Gaines, the panel may have meant to apply its limitation only to 

states where all the abortion clinics would close.”). In addition, the principle 

relied on by Jackson has little traction in this as-applied challenge because 

prior to H.B. 2, half of the patients at the Santa Teresa clinic came from El 

Paso, which is in the same cross-border metropolitan area as Santa Teresa.45 

 

45 We note that this analysis would likely be different in the context of an 

international border, and we disclaim any suggestion that the analysis here applies to a city 

across an international border from a United States city in question. 

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This demonstrates that Texas women regularly choose to have an abortion in 

New Mexico independent of the actions of the State. Given these facts 

particular and peculiar to El Paso, it would ignore reality in this as-applied 

challenge to “focus[] solely on the effects within the regulating state,” as we did 

in Jackson. 760 F.3d at 457. 

Unlike the city of Jackson, Mississippi, which is 175–200 miles from the

borders of Tennessee and Louisiana, the evidence in this case shows that El 

Paso and Santa Teresa are part of the same metropolitan area, though 

separated by a state line, and that people regularly go between the two cities 

for commerce, work, and medical care. No such situation was presented by the 

evidence or considered by the panel in Jackson. Taking the Plaintiffs’ version 

of Jackson, a clinic just over the line in Texarkana, Arkansas, would not be a 

fact that could be considered by a court in Texarkana, Texas. An injunction is 

an equitable remedy, and it would be wholly inequitable to ignore the reality 

of metropolitan areas that straddle state lines and in which people regularly 

travel back and forth in commerce. See Weinberger v. Romero-Barcelo, 456 

U.S. 305, 311–12 (1982) (explaining that “an injunction is an equitable 

remedy,” which does not “issue[] as of course or to restrain an act the injurious 

consequences of which are merely trifling” (citation and internal quotation 

marks omitted)). To the extent that Jackson can be read to so provide, it is 

dicta as that situation was simply not presented in that case. 

Therefore, although the nearest abortion facility in Texas is 550 miles 

away from El Paso, there is evidence that women in El Paso can travel the 

short distance to Santa Teresa to obtain an abortion and, indeed, the evidence 

is that many did just that before H.B. 2. Accordingly, because H.B. 2 does not 

place a substantial obstacle in path of those women seeking an abortion in the 

El Paso area, we hold that the district court erred in sustaining Plaintiffs’ as-

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applied challenge in El Paso.

VII. Plaintiffs’ Cross-Appeal

The Plaintiffs appeal the district court’s dismissal of their equal 

protection and unlawful delegation claims. For substantially the same reasons 

as the district court stated in its order dismissing these claims, we affirm the 

judgment of the district court on these claims.

Accordingly, the district court’s judgment is AFFIRMED in part, 

MODIFIED in part, VACATED in part, and REVERSED in part.

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