Opinion ID: 2806532
Heading Depth: 1
Heading Rank: 3

Heading: ASC Requirement – Facial Challenge

Text: 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. 22Although 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. 26 Case: 14-50928 Document: 00513071917 Page: 27 Date Filed: 06/09/2015 No. 14-50928 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 27 Case: 14-50928 Document: 00513071917 Page: 28 Date Filed: 06/09/2015 No. 14-50928 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. 28 Case: 14-50928 Document: 00513071917 Page: 29 Date Filed: 06/09/2015 No. 14-50928 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 29 Case: 14-50928 Document: 00513071917 Page: 30 Date Filed: 06/09/2015 No. 14-50928 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 30 Case: 14-50928 Document: 00513071917 Page: 31 Date Filed: 06/09/2015 No. 14-50928 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.
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.
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 31 Case: 14-50928 Document: 00513071917 Page: 32 Date Filed: 06/09/2015 No. 14-50928 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.
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.”). 32 Case: 14-50928 Document: 00513071917 Page: 33 Date Filed: 06/09/2015 No. 14-50928 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 28Further, 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. 33 Case: 14-50928 Document: 00513071917 Page: 34 Date Filed: 06/09/2015 No. 14-50928 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. 34 Case: 14-50928 Document: 00513071917 Page: 35 Date Filed: 06/09/2015 No. 14-50928
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. 35 Case: 14-50928 Document: 00513071917 Page: 36 Date Filed: 06/09/2015 No. 14-50928 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 . . . .”). 36 Case: 14-50928 Document: 00513071917 Page: 37 Date Filed: 06/09/2015 No. 14-50928 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. 1351008) (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. 37 Case: 14-50928 Document: 00513071917 Page: 38 Date Filed: 06/09/2015 No. 14-50928 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. 38 Case: 14-50928 Document: 00513071917 Page: 39 Date Filed: 06/09/2015 No. 14-50928 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 39 Case: 14-50928 Document: 00513071917 Page: 40 Date Filed: 06/09/2015 No. 14-50928 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 40 Case: 14-50928 Document: 00513071917 Page: 41 Date Filed: 06/09/2015 No. 14-50928 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 34Dr. 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. 41 Case: 14-50928 Document: 00513071917 Page: 42 Date Filed: 06/09/2015 No. 14-50928 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.” 42 Case: 14-50928 Document: 00513071917 Page: 43 Date Filed: 06/09/2015 No. 14-50928 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.