Opinion ID: 2806532
Heading Depth: 2
Heading Rank: 2

Heading: McAllen

Text: 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 46 Case: 14-50928 Document: 00513071917 Page: 47 Date Filed: 06/09/2015 No. 14-50928 W. Johannes, testified would not allow for expansion to meet the ASC construction standards. Testimony showed that four physicians 37 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 miles 38 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. 47 Case: 14-50928 Document: 00513071917 Page: 48 Date Filed: 06/09/2015 No. 14-50928 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 48 Case: 14-50928 Document: 00513071917 Page: 49 Date Filed: 06/09/2015 No. 14-50928 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. 49 Case: 14-50928 Document: 00513071917 Page: 50 Date Filed: 06/09/2015 No. 14-50928 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 50 Case: 14-50928 Document: 00513071917 Page: 51 Date Filed: 06/09/2015 No. 14-50928 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. 51 Case: 14-50928 Document: 00513071917 Page: 52 Date Filed: 06/09/2015 No. 14-50928 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.