Opinion ID: 2741461
Heading Depth: 4
Heading Rank: 1

Heading: The Closure of Abortion Clinics

Text: Plaintiffs presented the findings of Joseph Potter, Ph.D., who is an Associate Professor of Demography at the Harvard School of Public Health, a Professor of Sociology at the University of Texas, Austin, earned a Ph.D. from Princeton University in economics, and is the principal investigator for the Texas Policy Evaluation Project. Potter was certified by the court as an expert in demography, and testified to his expert opinions in this regard, and not 20 No. 13-51008 merely as a “sociology professor”—as the Abbott II panel characterized him. See Abbott II, 748 F.3d at 591. Potter, after conducting a survey of data available from 2011 until the present and investigating, inter alia, the current status of abortion providers’ admitting privileges, 6 concluded that the admitting-privileges provision will result in the loss of abortion clinics in six Texas counties—Bell, Cameron, Hidalgo, Lubbock, McLennen, and Tarrant— and that only seven counties in all of Texas will be left with an abortion provider. Based on Potter’s research, analysis, and calculations, he concluded that, if H.B. 2 goes into effect, at least a third of the clinics in Texas will close, and as a result, over 22,000 women annually will not be able to access abortion services. 7 6The Abbott II panel criticizes Potter’s evidence as unscientific and biased because he obtained his evidence from interested parties, including some of the named Plaintiffs. The Abbott II panel misrepresented Potter’s statement that, because he relied on information provided from abortion providers and other interested parties, “there is no science there.” Abbott II, 748 F.3d at 593. The Abbott II panel cited this testimony to suggest that Potter concedes that his evidence is unreliable, when in actuality, Potter stated, “[t]here’s no science there. It’s just evidence.” (emphasis added). Potter appears not to concede anything, but to simply acknowledge that in the field of demography, a social science, an expert’s calculations and conclusions are based on evidence obtained from affected individuals. Such methodologies are the regular and accepted practice in demographic research, and, as explained by Potter, are “consistent with the most rigorous and highest standards of demography to rely on that kind of factual information.” 7 The Abbott II panel cited one of the State’s experts, Dr. Uhlenberg’s, attestation that any remaining clinics would perform more abortions as the demand increased, purportedly casting doubt upon Potter’s conclusion that over 22,000 women would be unable to access abortion services in Texas after H.B. 2 is implemented. Uhlenberg’s declaration, however, ignores Potter’s explanation of his finding that, in addition to an increase in demand, enactment of the admitting-privileges provision would simultaneously result in a decrease in capacity among abortion facilities that manage to remain open in Texas. Potter’s declaration and testimony not only established a detailed account of the increased demand, but a corollary decrease in capacity, and a resulting inability of women to promptly access abortion treatment. Uhlenberg’s affidavit in no way renders the district court’s finding that clinics will close clearly erroneous. 21 No. 13-51008 The Plaintiffs’ other evidence corroborated Dr. Potter’s findings. For example, Dr. Paul Fine testified that his organization’s Fort Worth surgery center will have to stop providing abortion services because all of the providers who reside in Dallas will be unable to obtain admitting privileges at the Fort Worth hospital. Amy Hagstrom-Miller, the Founder and CEO of Whole Woman’s Health (“WWH”), likewise testified that, in Fort Worth, the WWH facility—which accounts for one third of the abortion providers in the Fort Worth area—will close because the facility does not employ any physicians with local admitting-privileges. Dr. Fine further testified that, in West Texas (specifically, in Lubbock County and the city of Waco), all of the current providers travel from hundreds of miles away to provide abortion services and thus will be ineligible for admitting privileges at local hospitals. Additionally, Darrel Jordan, M.D., the Chief Medical Officer of Planned Parenthood of Greater Texas (“PPGT”), attested via sworn affidavit that, if the admittingprivileges provision takes effect, three of the four clinics that PPGT owns— namely, clinics providing abortion services in Austin, Fort Worth, and Waco— will close. From this evidence, the district court plausibly found that clinics throughout Texas will close. The Abbott II panel criticized the district court for its “vague” and “imprecise” findings. Abbott II, 748 F.3d at 597. However, perfect precision is not what is required to satisfy clear error review. The district court’s finding, while not specific or detailed, is adequately supported by the record evidence, plausible in light of the evidence taken as a whole, and thus not clearly erroneous. Rivera, 505 F.3d at 360; see also Voting for America, Inc., 732 F.3d at 386. 22 No. 13-51008 2. Rio Grande Valley Will be Without an Abortion Clinic The district court found that all “24 counties in the Rio Grande Valley [will] be left with no abortion provider.” Abbott, 951 F. Supp. 2d at 900. The Abbott II panel concluded that this finding of fact was clearly erroneous for two reasons. First, the panel correctly notes that there are only four, not 24, counties in the Rio Grande Valley. However, as Plaintiffs contend, this error was likely typographical and probably a result of the court’s efforts to issue an opinion before the admitting-privileges provision was set to go into effect—less than one week after the completion of trial. Such an error does not render the district court’s finding that the Rio Grande Valley will be without an abortion provider clearly erroneous, given that (as will be discussed directly below) the record adequately supports the substance of this finding—that the region will lack any abortion providers after the admitting-privileges provision goes into effect. In addition to faulting the district court for its apparent typographical error, the Abbott II panel concluded that the court’s finding that the Rio Grande Valley would be without an abortion provider was clearly erroneous because the court only accepted evidence as to one of the two clinics in the Rio Grande Valley, and that the other evidence was excluded as hearsay. Abbott II, 748 F.3d at 597. Before H.B. 2 went into effect, there were two clinics in the Rio Grande Valley that provided abortion services—the WWH’s McAllen facility, and the Reproductive Health Care and Health Services Facility (“RHCHS”). The panel reasoned that because Amy Hagstrom-Miller’s testimony regarding the RHCHS facility was excluded as hearsay, the court only heard admissible evidence as to whether the WWH facility would close, and thus it was clearly erroneous to conclude that both clinics would close. Id. 23 No. 13-51008 at 597, n.12. However, the panel overlooks the un-objected-to live testimony of Andrea Ferrigno, the Corporate Vice President of WWH, which establishes, with admissible evidence, that both of the two clinics in the Rio Grande Valley will close. Specifically, Ferrigno testified that the RHCHS Facility and the WWH’s McAllen facility will both close as a result of the admitting-privileges provision. At the time of trial, Ferrigno testified that the RHCHS Facility had already announced its impending closure, and that the WWH’s McAllen clinic would also close because none of its providers has admitting privileges, and therefore, “people won’t have access to safe legal services in the entire Rio Grande Valley.” Id. This information regarding both clinics’ closures in the Rio Grande Valley is also contained in Ferrigno’s sworn declaration, which was admitted into evidence by the district court under the residual hearsay rule, FED. R. EVID. 807. See Abbott, 951 F. Supp. 2d at 897, n.3 (“The court overrules Planned Parenthood and the State’s objections [to the use of declarations at trial because] admitting the declarations will best serve the rules of evidence and the interests of justice.”) (emphasis added). Therefore, contrary to the Abbott II panel’s conclusion, the district court’s finding that the only two clinics in the Rio Grande Valley will close is not clearly erroneous because it was supported by admissible record evidence. 3. Abortion Clinic Physicians Will be Unable to Meet Hospitals’ Varying Prerequisites to Admitting Privileges The district court’s finding that each hospital’s bylaws are unique and have a variety of prerequisites for granting admitting privileges, some of which abortion providers will be unable to meet, is supported by the record. For example, Andrea Ferrigno testified that, before granting admitting privileges, hospitals have various facial requirements, including that the physician 24 No. 13-51008 maintain a local residence, be board certified, and have a minimum number of hospital admissions and surgeries. Ferrigno testified that her current abortion providers would not qualify for many hospital admitting-privileges applications because they would not meet the hospitals’ residency requirements nor do they have the number and type of prior hospital admissions typically required. For example, some hospitals require at least 50 deliveries, five C-sections, and 25 gynecological surgical procedures during the 24-month period preceding the physician’s application. Ferrigno testified that, in the last five years, her physicians have seen approximately 50,000 abortion patients, and only eight to ten of those patients required a transfer from the clinic to a hospital. Her providers thus do not regularly admit or treat patients at hospitals and, consequently, will not meet the hospitals’ admission or surgery prerequisites for obtaining admitting privileges. Further, many of the abortion providers completed their licensures decades ago, when it was less common to have board certification, and therefore will not meet the board certification requirement. Likewise, Dr. Paul Fine testified that his organization’s Fort Worth surgery center will have to stop providing abortion services because all of the providers, who reside in Dallas, will be unable to obtain admitting-privileges at the Fort Worth hospital, which requires physicians to maintain a local residence. Dr. Jennifer Carnell similarly testified that, if abortion providers travel away from their county of residence to conduct abortion services—a common practice given that 87 percent of counties in the United States are without an abortion provider—then local Texas hospitals will not grant the physician privileges. For example, he testified that, in West Texas, where all of the providers travel hundreds of miles or from out of state to provide abortion 25 No. 13-51008 services, the physicians will be unable to comply with the admitting-privileges provision. The district court therefore did not clearly err when it found that the vast majority of abortion providers in Texas will be unable to obtain admitting privileges at local hospitals. 4. Finding Local Physicians with Active Admitting Privileges is Difficult and Unlikely The district court found that abortion clinics will be unlikely to find physicians with active admitting privileges because physicians’ contracts often “bar them from providing ‘moonlight’ services as abortion providers,” and physicians are concerned about the negative impact on their careers by associating with an abortion provider, either for financial reasons or negative attention from anti-abortion protestors. Abbott, 951 F. Supp. 2d. at 901. The district court directly referenced record evidence that supports this finding of fact. For example, the district court noted Amy Hagstrom-Miller’s testimony that some physicians’ contracts with hospitals “prevent[] them from working with abortion care on the side.” The evidence further demonstrated that, even when abortion care is not forbidden outright, some local hospitals are averse to associating with abortion providers. For example, Andrea Ferrigno attested that in at least three attempts to contact hospitals about obtaining admitting privileges for her physicians, the hospitals’ personnel verbally discouraged her from pursuing an application “because of hostility against abortion providers among members of the hospital’s governing board.” Furthermore, the Plaintiffs presented evidence that hostility, harassment, and violence from anti-abortion protestors towards abortion providers, clinics, and patients will deter local physicians with admitting privileges from providing services. For example, Dr. Jordan attested that in the small and “extremely socially conservative community” of Fort Worth, any 26 No. 13-51008 resident abortion provider would face “routine harassment, social and professional ostracism, and even a significant risk of violence (all of which extend to his or her family as well).” He added that, “[h]ostility to abortion also makes it impossible to hire a new doctor who lives in Fort Worth and has privileges at a local hospital.” Similarly, Angela Martinez, the Clinic Director of Planned Parenthood Women’s Health Center in Lubbock, Texas, attested that anti-abortion protestors harass the health center employees every day her clinic is open. Martinez explained that at her facility, anti-abortion protestors shout insults at us every day, take pictures of us (and take down license plate information), refer to employees by name, and have protested outside employees’ homes and posted pictures of employees online with their names. Because physicians are the biggest target of antiabortion harassment and violence . . . I am unaware of any Lubbock physician ever having performed abortions. . . .[F]or decades . . . the physicians who performed abortions [in Lubbock] have travelled . . . from another part of the state, most frequently from Dallas. Likewise, Hagstrom-Miller testified that at the WWH facilities, they regularly have protestors, have received bomb threats, and receive threatening phone calls. Further, staff are followed and sometimes the physicians are harassed when they are coming to and from work. Hagstrom-Miller also testified regarding “Operation Rescue,” an anti-abortion effort that targeted two physicians, publishing their names online, apparently to encourage attention and further harassment from anti-abortion protestors. HagstromMiller testified that physicians will be deterred by this “very regular[]” occurrence of harassment and violence committed against abortion providers. 27 No. 13-51008 She recalled at least two physicians who changed their mind about working for WWH and one who quit based on anti-abortion harassment. She testified that because of this local hostility, she has been flying in two providers from out of state to be able to meet the needs of women in the local communities. The district court’s finding that abortion facilities are unlikely to be able to hire local physicians to perform abortion services is thus adequately supported by the record. 5. Additional Record Evidence of Obstacles: Loss of Capacity, Poverty, Travel Distances, and Other Factors Affecting Access to Abortion In addition to the record evidence substantiating the district court’s express findings of facts, the Plaintiffs also presented evidence that supports the district court’s legal conclusions, but which the court neglected to reference expressly. First, the evidence established that, as a consequence of the clinic closures, the remaining clinics will be unable to meet the increased demand for abortion services, resulting in substantially diminished access to abortion for women in Texas. Dr. Potter explained that, while some clinics may remain in operation because they employ one or more physicians with local admitting privileges, these remaining clinics may have a reduced capacity, as not all of their physicians on staff have the requisite privileges. While capacity is reduced, the demand upon these limited facilities will be increased, as women who would have otherwise obtained abortion services from closed facilities, now will seek services at the remaining providers. Based on the increase in demand and simultaneous reduction in capacity, Potter found that in five of the seven counties [that will still have abortion clinics after the admitting-privileges provision goes into effect], there will be a substantial increase in the projected volume of 28 No. 13-51008 services required due to closure of clinics in other counties that will no longer have a provider. Moreover, there will be a substantial reduction in the capacity to provide services in four of these five counties. . . . All told, the projected demand for abortion care statewide is 68,8889, and the expected capacity after implementation of the law is only 43,850. The implication is that 25,039 women will not be able to access abortion care in the state, even if they could travel the long distances necessary to access the nearest clinic with capacity to serve them. Eighty-nine percent of this deficit, or 22,286 abortions, is due to closures that will occur as a result of the implementation of the challenged provision. The Plaintiffs presented Potter’s specific calculations regarding the capacity and demand for each county in which there would be a substantial change. For example, in Bexar County, where there were once eight abortion providers, after the admitting-privileges provision goes into effect, only three will remain—one of which will function at an extremely limited capacity. Therefore, the providers that will remain in operation in Bexar County will be unable to meet the demand for abortion services. 8 Angela Martinez, the Clinic 8 More specifically, in Bexar County, at the time of trial, there were five clinics (three have closed since 2011 after funding cuts). Potter concluded that two would close after the law was implemented and that one would have extremely limited capacity. Potter projected the demand at 7,006 abortions per year and capacity was calculated at 4,250. Thus, the projected volume would exceed capacity by 2,750 abortions annually. In Dallas, Potter attested that two of the five clinics would close and the projected volume will “increase dramatically” by 51% to 22,598. The capacity in Dallas would then only be approximately 12,5000, barely more than half the expected demand volume. Potter concluded that the projected volume would therefore exceed capacity by 10,098 abortions per year. In El Paso, Potter found that one of two clinics would close and the projected volume would exceed capacity by approximately 2,500 abortions per year. In Harris County, three or four of the ten providers would close and the projected volume increase on remaining clinics will be approximately 16%. In Neuces County one clinic was expected to stay open, 29 No. 13-51008 Director of Planned Parenthood Women’s Health Center, corroborated this evidence in her declaration, attesting that when nearby clinics in Midland, Abilene, and San Angelo closed in recent years, their Lubbock facility has as a result been “inundated with patient calls” and are currently “scheduling patients up to a month in advance.” Similarly, Hagstrom-Miller testified that in Austin she has one physician with privileges and one without so, after the admitting-privileges provision goes into effect, her capacity to provide services at her Austin facility will decrease by 50%. An inevitable result of the reduced capacity of abortion providers in Texas is an increase in delayed services for abortion patients. Potter attested that reduction in supply and increase in demand will mean that the “delays to obtain an appointment with many providers will increase, and some providers may turn patients away entirely.” (emphasis added). He attested that “[a]bortion is of course a time-sensitive procedure: having to wait a few weeks may make it impossible for women to get an abortion.” In addition to the increased demand and delay that the Plaintiffs’ established will result from the admitting-privileges provision, the evidence demonstrated that because of the various clinic closures, women in the panhandle and other parts of West Texas will have to travel vast distances to seek in-state abortions, and that a large percentage of women who seek abortion services are impoverished and will therefore be precluded from ever obtaining abortion services. Potter testified that, in the panhandle of Texas, but would have an 182% increase in volume due to the expected closures of the only two clinics in the Rio Grande Valley, and the Neuces County Clinic thus was unlikely to meet the increased demand. In Travis County, Potter found that three of the four clinics were expected to stay open, but would experience a volume increase of 26%. Potter concluded that the projected volume for Travis County would exceed capacity by 3,401 abortions per year. 30 No. 13-51008 women will have to travel 400-500 miles to access legal abortion services. He explained that “[s]ome women who would otherwise have gotten an abortion will be prevented from doing so by these burdens.” Potter also testified that the number of women across Texas who will be required to travel over one hundred miles to obtain an abortion will double, and that in “multiple counties,” the travel distance for women seeking abortions will “exceed 400 miles.” Furthermore, the evidence demonstrated that there will be no abortion clinics west of Interstate 35, requiring women in certain West Texas areas to travel between six and eight hours to access an abortion clinic. The Plaintiffs’ evidence established that nearly half of abortion patients in Texas are below the federal poverty line and therefore will be unlikely to be able to travel these long distances to access abortion services. Specifically, data from Dr. Potter’s research in Texas indicated that approximately 40% of women seeking abortion are at or below 100% of the Federal Poverty Guidelines.” Angela Martinez attested that most of Planned Parenthood Women’s Health Center’s clients in Lubbock are parents below the federal poverty line who “often have trouble obtaining use of a car and the resources to pay for gas, permission from their employer to take the necessary time off, and/or childcare.” As Potter attested, the burden of travel is higher for younger women, women of color, and low-income women, who have fewer resources to overcome the increased cost of further travel. Martinez’s experience confirms this, as she has repeatedly heard from patients that the additional distance will make it impossible for them to obtain an abortion. Martinez attested that, “[b]ased on [her] familiarity with [the clinic’s abortion] patients and their already-difficult situations, I believe that this change [in the law] would be extraordinarily difficult for almost all of our patients, and could prevent many 31 No. 13-51008 of them from obtaining an abortion at all.” Ferrigno similarly testified that that the reality is that for women in the Rio Grande Valley to travel to Corpus Christi or San Antonio for abortion services will require “a lot of arrangements and expenses.” In addition to the Plaintiffs’ evidence that the admitting-privileges provision will severely diminish women’s access to abortion services, the evidence demonstrated that the provision will be particularly burdensome on women seeking abortions who have been pregnant for sixteen weeks or longer. Prior to implementation of H.B. 2, Texas law required that an abortion performed at sixteen or more weeks after pregnancy must be conducted at an ambulatory surgical center (“ASC”). At the time of trial, there were only six providers in the state that are licensed as ASCs. Potter attested that three of these ASCs will stop providing services as a direct result of the admitting privileges law, leaving only three operating ASCs in Texas (located in Dallas, Houston, and San Antonio). Dr. Jordan likewise attested that his facility (Planned Parenthood of Greater Texas) operates the only ASC in both Austin and Fort Worth—which are two of the six total ASCs providing abortion services in the state—and both of those facilities will have to close after enactment of the law. Therefore, women throughout all of Texas will only have three locations where they can legally obtain an abortion after sixteen weeks of pregnancy. In light of this abundance of evidence supporting the district court’s findings of facts regarding the ways in which H.B. 2’s admitting-privileges provision imposes obstacles upon a woman’s right to obtain a previability abortion, the Abbott II panel erred in rejecting the district court’s findings. 32 No. 13-51008