Opinion ID: 787339
Heading Depth: 2
Heading Rank: 3

Heading: Undue Burden Claim

Text: 16
17 Women have a fundamental liberty interest, protected by the due process clause of the Fourteenth Amendment, in obtaining an abortion. Casey, 505 U.S. at 845-46, 112 S.Ct. 2791. In Casey, the Supreme Court reaffirmed this central holding of Roe v. Wade, 410 U.S. 113, 93 S.Ct. 705, 35 L.Ed.2d 147 (1973). Casey, 505 U.S. at 845-46, 112 S.Ct. 2791. The Court also explained that the right to obtain an abortion is not absolute and that state interests in maternal health and protecting fetal life can, in some circumstances, justify regulations of abortion. Id. at 846, 112 S.Ct. 2791. However, a plurality of the Court abandoned both traditional equal protection scrutiny analysis and the accompanying trimester framework of Roe for determining when state regulation of abortion to promote these two important interests is justified and when it is not. Id. at 872-76, 112 S.Ct. 2791. The trimester framework and the traditional equal protection scrutiny analysis for laws impacting fundamental rights were replaced with an undue burden standard in cases where regulation of abortion is used to promote maternal health or fetal life. Id. at 876, 112 S.Ct. 2791. 18 This standard had been applied in inconsistent ways in prior abortion rights cases by various Supreme Court Justices. Id. (citing numerous cases). Therefore, the Casey opinion clarified the meaning of undue burden by defining it as 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, 112 S.Ct. 2791. In its summary of the essential holdings of the case, Casey made clear that the undue burden standard applies to health regulations: 19 As with any medical procedure, the State may enact regulations to further the health or safety of a woman seeking an abortion. Unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion impose an undue burden on the right. 20 Id. at 878, 112 S.Ct. 2791. But because Casey largely dealt with a law aimed at promoting fetal life, its application of the undue burden standard is often not extendable in obvious ways to the context of a law purporting to promote maternal health. See, e.g., A Woman's Choice-East Side Women's Clinic v. Newman, 305 F.3d 684 (7th Cir.2002) (majority and dissenting opinions representing very different views of the role of the record); Greenville Women's Clinic v. Bryant, 222 F.3d 157 (4th Cir.2000) (majority and dissenting opinions representing very different views of the standard in assessing a licensure scheme similar to the one challenged here). 21 In the context of a law purporting to promote fetal life, whatever obstacles that law places in the way of women seeking abortions logically serve the interest the law purports to promote — fetal life — because they will prevent some women from obtaining abortions. By contrast, in the context of a law purporting to promote maternal health, a law that is poorly drafted or which is a pretext for anti-abortion regulation can both place obstacles in the way of women seeking abortions and fail to serve the purported interest very closely, or at all. Indeed, in his concurring opinion in Casey, Justice Stevens indicated that a burden need not be onerous to be undue, if it is not supported by a legitimate state interest. 505 U.S. at 920-21, 112 S.Ct. 2791 (Stevens, J., concurring in part and dissenting in part). Moreover, where Casey did entertain the possibility that the Pennsylvania law at issue promoted maternal health, it took care to verify that the law could be reasonably understood to promote, in some legitimate fashion, the interest in maternal mental health: 22 To the extent Akron I and Thornburgh [ v. American College of Obstetricians and Gynecologists , 476 U.S. 747, 106 S.Ct. 2169, 90 L.Ed.2d 779 (1986)] find a constitutional violation when the government requires, as it does here, the giving of truthful, nonmisleading information about the nature of the procedure, the attendant health risks and those of childbirth, and the probable gestational age of the fetus, those cases go too far, are inconsistent with Roe's acknowledgment of an important interest in potential life, and are overruled.... It cannot be questioned that psychological well-being is a facet of health.... In attempting to ensure that a woman apprehend the full consequences of her decision, the State furthers the legitimate purpose of reducing the risk that a woman may elect an abortion, only to discover later, with devastating psychological consequences, that her decision was not fully informed. If the information the State requires to be made available to the woman is truthful and not misleading, the requirement may be permissible. 23 Id. at 882, 112 S.Ct. 2791 (emphasis added). 24 Thus, the undue burden standard is not triggered at all if a purported health regulation fails to rationally promote an interest in maternal health on its face, as would be the case where the state required physicians to provide false or misleading information to women seeking abortions. Plaintiffs in this case argue that the entire licensing scheme at issue does not even rationally promote an interest in maternal health, and that the statutes and regulations therefore clearly infringe the right to abortion and violate the Constitution, since the undue burden standard is not triggered. 25 Mazurek v. Armstrong, 520 U.S. 968, 117 S.Ct. 1865, 138 L.Ed.2d 162 (1997), provides an example of how laws that purport to promote health, but may in fact fail to do so, should be analyzed. The Court in Mazurek was faced with such a law but still applied the undue burden standard. Id. 520 U.S. at 973, 117 S.Ct. 1865 (`[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. ') (quoting Casey, 505 U.S. at 885, 112 S.Ct. 2791). The physician-only abortion provision at issue in Mazurek was subject to the undue burden standard, even in the face of evidence that it was objectively unnecessary, and could therefore only potentially injure maternal health by reducing the number of abortion providers. Id. Thus, Mazurek compels us to hold that where a health regulation of abortion is not facially pretextual or irrational with respect to the interest it purports to assert, it is subject to the substantial obstacle test in Casey. 26 Although plaintiffs have presented a great deal of evidence supporting the inference that the statutory and regulatory scheme will actually worsen maternal health and safety, as a facial matter, the scheme as a whole is a typical set of health and safety standards, unusual primarily because it singles out abortion clinics. Moreover, the legislative history indicates that at least one of the triggers for enacting the scheme was the death of a patient at an abortion clinic engaging in atrociously substandard practices. In the face of this clear history, plaintiffs have not presented evidence sufficient to create an issue of material fact as to whether this licensing scheme is a pretext for restricting the right to abortion. See infra note 2. Thus, their claim that the scheme infringes abortion rights must be analyzed under Casey's undue burden standard. 27
28 Casey made clear that the substantial obstacle standard for determining when a law poses an undue burden on the right to obtain an abortion is record-dependent. 505 U.S. at 901, 112 S.Ct. 2791 (While at some point increased cost could become a substantial obstacle, there is no such showing on the record before us.). 29 In Greenville Women's Clinic, the Fourth Circuit overturned a district court's finding that plaintiffs had demonstrated that a very similar regulatory scheme amounted to an 11877 undue burden on abortion rights. 222 F.3d at 159. The Fourth Circuit determined that as a matter of law, plaintiffs had not shown that the regulatory scheme at issue amounted to an undue burden on abortion rights. The dissent summarized the numerous findings of fact the district court had made after a six-day bench trial which it felt compelled the opposite result. 222 F.3d at 175-76. (Hamilton, J., dissenting). 30 We depart from the Fourth Circuit's holding in Greenville Women's Clinic to the extent it neglects that [a] significant increase in the cost of obtaining an abortion alone can constitute an undue burden on the right to have an abortion. 222 F.3d at 201 (Hamilton, J., dissenting) (citing Casey, 505 U.S. at 901, 112 S.Ct. 2791). A significant increase in the cost of abortion or the supply of abortion providers and clinics can, at some point, constitute a substantial obstacle to a significant number of women choosing an abortion. Plaintiffs in this case have raised an issue of material fact as to whether the Arizona scheme creates such an obstacle. We note that in Greenville, the district court did not grant summary judgment in favor of the state. Rather, the district court held a bench trial, facilitating findings of fact far more specific than the conclusory finding the court below made. 31 To survive a motion by the state for summary judgment on an undue burden claim, specific allegations of the dollar amount by which abortion costs will rise are not required. Rather, the usual summary judgment standards apply, and all inferences from the evidence must be made in favor of the nonmoving party. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). A grant of summary judgment to defendants is inappropriate if plaintiffs have submitted evidence sufficient to create an issue of material fact as to whether a health regulation is unnecessary and has the purpose or effect of imposing a substantial obstacle to women seeking an abortion. See, e.g., Kearney v. Standard Ins. Co., 175 F.3d 1084, 1093-94 (9th Cir. 1999) (en banc). Here, a reasonable fact-finder could find that the challenged set of statutes and regulations is unnecessary and has the effect of imposing a substantial obstacle on women seeking an abortion. 32 The district court's characterization of plaintiffs' evidence as undetermined fee increases predicted by abortion providers, but not supported by specific credible estimates is incomplete and fails to draw all inferences in favor of the plaintiffs. See Raad v. Fairbanks N. Star Borough Sch. Dist., 323 F.3d 1185, 1194 (9th Cir.2003). Plaintiffs have presented evidence and testimony that individual providers will incur tens of thousands of dollars in expenses complying with the scheme. These estimates are based on specific costs, such as purchasing a camera for an ultrasound machine, investing time in complying with the heavy administrative burdens of the law, hiring nurses where previously medical assistants were used, and paying employees overtime so that follow-up calls can be made on weekends. Plaintiffs have presented testimony that one provider may be forced to stop practicing medicine altogether, and that a Planned Parenthood clinic will see an approximately two-thirds drop in the number of its physicians. Plaintiffs have placed into evidence expert testimony concerning the fact that increased monetary cost delays and deters patients obtaining abortions, and that delay in abortion increases health risks. They have also presented evidence tending to show that abortion is a very low-risk procedure most of the time, that it entails equal or even less risk than many other procedures not similarly regulated in Arizona, and that the regulations are therefore unnecessary as a matter of public health. Therefore, a reasonable factfinder could certainly conclude, from the evidence presented, that the licensing scheme at issue is unnecessary and that, by increasing the cost of abortion and limiting the supply of abortion providers and hours during which they can provide abortions, it imposes a substantial obstacle to women seeking abortions at those practices and clinics. 33 As in any case, there must be more than a scintilla of evidence favoring the non-moving party to create an issue of material fact, Summers v. Teichert & Son, Inc., 127 F.3d 1150, 1152 (9th Cir.1997) (citing Anderson, 477 U.S. at 252, 106 S.Ct. 2505), but plaintiffs in this case have presented far more than a scintilla of such evidence. They are therefore entitled to a bench trial and specific findings of fact by the district court as to the impact these burdens will have on women seeking abortions. 34 The district court noted in its order that it would not weigh, in assessing the undue burden claim, certain of the burdens imposed on providers and patients. With respect to most of these requirements, it made sense for the district court to discount these burdens, as it had already determined that those provisions were unconstitutional and severable from the rest of the law, and would enjoin their enforcement. However, with respect to the admitting privileges requirement, the district court erred in discounting the burdens imposed by this requirement. The district court found this requirement enforceable, as do we, see infra Part VIII. We therefore direct the district court to take account of the evidence plaintiffs have submitted concerning the burdens this requirement imposes, such as the onerousness of applying for privileges, attending staff meetings, and taking one's share of emergency on-call time. 35 The district court stated that the scheme's stigmatizing of abortion practice and usurping of providers' ability to exercise medical judgment were not appropriate questions for it to consider. Whether or not these burdens are strong enough to alter the ultimate outcome in this case, there is no indication in Casey or any other case that such burdens are somehow irrelevant to the analysis of whether a law imposes a substantial obstacle to seeking an abortion. Plaintiffs presented expert testimony concerning the effects of stigmatization of abortion on the supply of abortion providers, and the district court is therefore directed, in its role as factfinder, to give these burdens their appropriate weight on remand.