Court Opinion

ID: 4376005
Source: CourtListenerOpinion
Date Created: 2019-03-12 16:00:22.208483+00
Date Added: 2024-06-11T12:04:15.493756
License: Public Domain

RECOMMENDED FOR FULL-TEXT PUBLICATION
                              Pursuant to Sixth Circuit I.O.P. 32.1(b)
                                     File Name: 19a0042p.06

                   UNITED STATES COURT OF APPEALS
                                  FOR THE SIXTH CIRCUIT

 PLANNED PARENTHOOD OF GREATER OHIO; PLANNED            ┐
 PARENTHOOD OF SOUTHWEST OHIO REGION,                   │
                             Plaintiffs-Appellees,      │
                                                        │
                                                         >      No. 16-4027
        v.                                              │
                                                        │
                                                        │
 RICHARD HODGES, in his official capacity as Director   │
 of the Ohio Department of Health,                      │
                                 Defendant-Appellant.   │
                                                        ┘

                         Appeal from the United States District Court
                        for the Southern District of Ohio at Cincinnati.
                    No. 1:16-cv-00539—Michael R. Barrett, District Judge.

                                   Argued: October 3, 2018

                              Decided and Filed: March 12, 2019

     Before: COLE, Chief Judge; SILER, BATCHELDER, MOORE, CLAY, GIBBONS,
       SUTTON, COOK, GRIFFIN, KETHLEDGE, WHITE, STRANCH, DONALD,
             THAPAR, BUSH, LARSEN, and NALBANDIAN, Circuit Judges.
                                  _________________

                                         COUNSEL

REARGUED EN BANC: Stephen P. Carney, OFFICE OF THE OHIO ATTORNEY
GENERAL, Columbus, Ohio, for Appellant. Alan E. Schoenfeld, WILMER CUTLER
PICKERING HALE AND DORR LLP, New York, New York, for Appellees. Hashim M.
Mooppan, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., for Federal
Amicus Curiae. ON SUPPLEMENTAL BRIEF: Stephen P. Carney, Eric E. Murphy, Hannah
C. Wilson, Zachery P. Keller, OFFICE OF THE OHIO ATTORNEY GENERAL, Columbus,
Ohio, for Appellant. Alan E. Schoenfeld, WILMER CUTLER PICKERING HALE AND
DORR LLP, New York, New York, Jennifer L. Branch, GERHARDSTEIN & BRANCH CO.
LPA, Cincinnati, Ohio, Helene T. Krasnoff, Carrie Y. Flaxman, PLANNED PARENTHOOD
FEDERATION OF AMERICA, Washington, D.C., Paul R.Q. Wolfson, Kimberly A. Parker,
WILMER CUTLER PICKERING HALE AND DORR LLP, Washington, D.C., for Appellees.
 No. 16-4027            Planned Parenthood of Greater Ohio et al. v. Hodges                Page 2

Hashim M. Mooppan, Matthew M. Collette, Lewis S. Yelin, UNITED STATES
DEPARTMENT OF JUSTICE, Washington, D.C., Aaron D. Lindstrom, OFFICE OF THE
MICHIGAN ATTORNEY GENERAL, Lansing, Michigan, Jay Alan Sekulow, AMERICAN
CENTER FOR LAW & JUSTICE, Washington, D.C., Steven H. Aden, AMERICANS UNITED
FOR LIFE, Arlington, Virginia, Laura Etlinger, OFFICE OF THE NEW YORK ATTORNEY
GENERAL, Albany, New York, T. Dietrich Hill, KELLOGG, HANSEN, TODD, FIGEL
& FREDERICK, P.L.L.C., Washington, D.C., Jyotin Hamid, DEBEVOISE & PLIMPTON LLP,
New York, New York, for Amici Curiae.

      SUTTON, J., delivered the opinion of the court in which SILER, BATCHELDER,
GIBBONS, COOK, GRIFFIN, KETHLEDGE, THAPAR, BUSH, LARSEN, and
NALBANDIAN, JJ., joined. WHITE, J. (pp. 13–35), delivered a separate dissenting opinion in
which COLE, C.J., and MOORE, CLAY, STRANCH, and DONALD, JJ., joined.
                                      _________________

                                           OPINION
                                      _________________

       SUTTON, Circuit Judge. Ohio, like many governments, often partners with nonprofit
organizations to promote policies of the State.       Through one such partnership, the State
distributes government funds to several organizations to address a wide range of public health
issues. For many years, Planned Parenthood participated in these programs. In 2016, Ohio
passed a law that bars its health department from funding organizations that “[p]erform
nontherapeutic abortions.”      Ohio Rev. Code § 3701.034(B)(1).       Two Planned Parenthood
affiliates challenged the statute, claiming that it imposes an unconstitutional condition on public
funding in violation of the Due Process Clause. The affiliates are correct that the Ohio law
imposes a condition on the continued receipt of state funds. But that condition does not violate
the Constitution because the affiliates do not have a due process right to perform abortions. See
Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 884 (1992) (plurality). We reverse the
district court’s contrary decision.

                                                I.

       Ohio distributes funds to organizations that participate in six government-sponsored
health and education programs. The programs target sexually transmitted diseases, breast cancer
and cervical cancer, teen pregnancy, infant mortality, and sexual violence.
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       Planned Parenthood of Greater Ohio and Planned Parenthood of Southwest Ohio manage
twenty-seven health centers across the State. They have participated in these programs for
several years. Both entities provide abortions at surgical centers in Bedford Heights, Columbus,
and Cincinnati.

       For several decades, both federal and state laws have prohibited recipients of public funds
from using the money to provide abortions. The Planned Parenthood affiliates comply with
these requirements.

       In 2016, the Ohio legislature enacted, and Governor Kasich signed into law, House Bill
294 to “Prohibit[] [the] use of certain funds concerning nontherapeutic abortions.” It requires the
Ohio Department of Health to “ensure” that all of the funds it receives for the six programs “are
not used to do any of the following:         (1) Perform nontherapeutic abortions; (2) Promote
nontherapeutic abortions; (3) Contract with any entity that performs or promotes nontherapeutic
abortions; (4) Become or continue to be an affiliate of any entity that performs or promotes
nontherapeutic abortions.” Ohio Rev. Code § 3701.034(B)–(G). The point of the limitation, the
State maintains, is to promote childbirth over abortion, to avoid “muddl[ing]” that message by
using abortion providers as the face of state healthcare programs, and to avoid entangling
program funding and abortion funding. Appellant’s Br. 39–41.

       Ohio’s health department and its local counterparts notified Planned Parenthood of
Greater Ohio and Planned Parenthood of Southwest Ohio that the new law would require the
State to end their contracts under the programs. Both entities perform abortions, advocate for
abortion, and affiliate with other entities that do the same.

       Both of the affiliates, from now on referred to as Planned Parenthood in the singular,
sued, claiming that the law violates the First and Fourteenth Amendments by conditioning
government funding on giving up their rights to provide abortions and to advocate for them. The
district court agreed and permanently enjoined the State from enforcing the law.

       After a panel of this court affirmed the district court, 888 F.3d 224 (2018), the full court
decided to review the appeal, 892 F.3d 1283 (2018) (mem.).
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                                                 II.

       As the district court saw it, the Ohio law imposes two unconstitutional conditions on
Planned Parenthood. It denies the organization funding if it continues to perform abortions—
what the court perceived to be a due process violation. And the law denies the organization
funding if it continues to promote abortion—what the court perceived to be a free speech
violation. To prevail, Planned Parenthood must show that both limitations—the conduct and
speech requirements—violate the U.S. Constitution.          Ohio may deny funding to Planned
Parenthood in other words if either limitation satisfies the Constitution. Because the conduct
component of the Ohio law does not impose an unconstitutional condition in violation of due
process, we need not reach the free speech claim.

       First a word or two about unconstitutional conditions. The United States Constitution
does not contain an Unconstitutional Conditions Clause. What it does contain is a series of
individual rights guarantees, most prominently those in the first eight provisions of the Bill of
Rights and those in the Fourteenth Amendment. Governments generally may do what they wish
with public funds, a principle that allows them to subsidize some organizations but not others
and to condition receipt of public funds on compliance with certain obligations. See Rust v.
Sullivan, 500 U.S. 173, 192–94 (1991). What makes a condition unconstitutional turns not on a
freestanding prohibition against restricting public funds but on a pre-existing obligation not to
violate constitutional rights. The government may not deny an individual a benefit, even one an
individual has no entitlement to, on a basis that infringes his constitutional rights. Agency for
Int’l Dev. v. All. for Open Soc’y Int’l, Inc., 570 U.S. 205, 214 (2013).            Otherwise, the
government could leverage its spending authority to limit, if not eliminate, the exercise of this or
that constitutional right. In the words of the Supreme Court, the principle “forbids burdening the
Constitution’s enumerated rights by coercively withholding benefits from those who exercise
them.” Koontz v. St. Johns River Water Mgmt. Dist., 570 U.S. 595, 606 (2013).

       What is the enumerated right at issue here? The guarantee of due process established by
the Fourteenth Amendment. That provision, as the United States Supreme Court has come to
construe it, prohibits a State from imposing an “undue burden” on a woman’s access to an
abortion before fetal viability. Casey, 505 U.S. at 877 (plurality).
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       These principles establish the following line between what Ohio may do and what it may
not do. It may choose not to fund a private organization’s health and education initiatives.
Private organizations do not have a constitutional right to obtain governmental funding to
support their activities. The State also may choose not to subsidize constitutionally protected
activities. Just as it has no obligation to provide a platform for an individual’s free speech, say a
Speaker’s Corner in downtown Columbus, it has no obligation to pay for a woman’s abortion.
Case after case establishes that a government may refuse to subsidize abortion services. Rust,
500 U.S. at 201–02; Harris v. McRae, 448 U.S. 297, 315–17 (1980); Maher v. Roe, 432 U.S.
464, 474 (1977). Both the United States and Ohio have done exactly that, whether through the
Hyde Amendment, see Pub. L. No. 115-31, §§ 613–14, 131 Stat. 135, 372 (2017), or through
Ohio Revised Code § 9.04(B).

       By contrast, the State may not condition a benefit by requiring the recipients to sacrifice
their constitutional rights. Regan v. Taxation With Representation of Wash., 461 U.S. 540, 545
(1983). Just as the State may not directly order someone to stop exercising his rights, it may not
coerce him into “giving them up” by denying the benefits if he exercises those rights. Koontz,
570 U.S. at 604, 612.

       The Ohio law falls on the permissible side of this line. Today’s plaintiffs do not have a
Fourteenth Amendment right to perform abortions. The Supreme Court has never identified a
freestanding right to perform abortions. To the contrary, it has indicated that there is no such
thing. “Whatever constitutional status the doctor-patient relation may have as a general matter,”
the Court has explained, “in the present context it is derivative of the woman’s position. The
doctor-patient relation does not underlie or override the two more general rights under which the
abortion right is justified: the right to make family decisions and the right to physical autonomy.
On its own, the doctor-patient relation here is entitled to the same solicitude it receives in other
contexts.” Casey, 505 U.S. at 884 (plurality) (emphasis added).

       Any doubt about the point is confirmed by the debate at hand in Casey. The abortion
providers claimed that a Pennsylvania law, requiring them to inform their patients of the abortion
procedure’s details and alternatives at least 24 hours beforehand, violated their patients’ due
process rights and their own due process rights that arose from their relationship with the
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patients. The plurality rejected both claims. Abortion rights do not arise from the provider-
patient relationship “[o]n its own,” the Court reasoned. Id. After explaining that the law did not
unduly burden women’s rights, the plurality concluded that the law had no more constitutional
import as to the providers than if its requirements dealt with “a kidney transplant.” Id. at 883. In
the absence of a constitutional right to perform abortions, the plaintiffs have no basis to bring an
unconstitutional-conditions claim.

       At the same time, the Ohio law does not violate a woman’s right to obtain an abortion. It
does not condition a woman’s access to any of these public health programs on refusing to obtain
an abortion. It makes these programs available to every woman, whether she seeks an abortion
or not. Nor, on this record, has there been any showing that the Ohio law will limit the number
of clinics that offer abortions in the State. Cf. Whole Woman’s Health v. Hellerstedt, 136 S. Ct.
2292, 2309–18 (2016).

       A review of the Supreme Court’s decisions in the area fails to reveal a single one in
which the plaintiff obtained relief based on a restriction of unprotected activity. The dissent to
its credit concedes as much. Infra, at 26 n.8. A benefits condition becomes unconstitutional
only when it violates a recipient’s constitutional rights, as the following cases confirm. See, e.g.,
Koontz, 570 U.S. 595 (permit condition on landowner burdened his Fifth Amendment rights);
All. for Open Soc’y Int’l, 570 U.S. 205 (funding condition on aid organization burdened its First
Amendment rights); Rust, 500 U.S. 173 (funding condition on Title X grantees did not violate
their First Amendment rights); Regan, 461 U.S. 540 (tax-exemption condition on organization
did not violate its First Amendment rights); Mem’l Hosp. v. Maricopa Cty., 415 U.S. 250 (1974)
(benefits condition on nonresident indigent burdened his Fourteenth Amendment rights).

       The only other circuit in the country to squarely address this issue reached the same
conclusion. “The first step in any unconstitutional-conditions claim is to identify the nature and
scope of the constitutional right arguably imperiled,” it reasoned, and abortion clinics lack a
freestanding constitutional right to practice their trade. Planned Parenthood of Ind., Inc. v.
Comm’r of Ind. State Dep’t of Health, 699 F.3d 962, 986–88 (7th Cir. 2012). Accordingly, “[a]s
long as the difference in treatment does not unduly burden a woman’s right to obtain an abortion,
the government is free to treat abortion providers differently” than other entities. Id. at 988. In
 No. 16-4027             Planned Parenthood of Greater Ohio et al. v. Hodges               Page 7

that case, the Seventh Circuit rejected an unconstitutional-conditions challenge to an Indiana law
with a conduct component identical in every material way to this Ohio law. In dicta, the Ninth
Circuit reached a similar conclusion. “Never has it been suggested,” the court explained, “that if
there were no burden on a woman’s right to obtain an abortion, medical providers could
nonetheless assert an independent right to provide the service for pay.” Teixeira v. Cty. of
Alameda, 873 F.3d 670, 689 (9th Cir. 2017) (en banc).

        Planned Parenthood nonetheless maintains that a bevy of cases establishes that clinics do
have a due process right to perform abortions. But a review of the cases leaves the reader empty
handed. Webster v. Reproductive Health Services, 492 U.S. 490 (1989), held that physicians
have no right to use public facilities to provide abortions, all consistent with the no-required-
funding-of-abortions principle on which Ohio’s policy decision rests. After explaining that
holding, Webster speculated that it might “be different if the State barred doctors who performed
abortions in private facilities from the use of public facilities for any purpose.” Id. at 510 n.8.
Three years after Webster, however, Casey ended any speculation over whether providers have a
constitutional right to offer abortion services. It indicated they do not.

        Planned Parenthood of Central & Northern Arizona v. Arizona, 718 F.2d 938, 946 (9th
Cir. 1983), another pre-Casey case, fares no better.         It never held that providers have a
constitutional right to perform abortions and indeed had no occasion to do so because it analyzed
a broad, speech-centric claim about restrictions on a combination of abortion-related activities.
Planned Parenthood of Mid-Missouri & East Kansas, Inc. v. Dempsey, 167 F.3d 458, 461–64
(8th Cir. 1999), is to like effect.

        The Tenth Circuit, it is true, accepted the existence of a Fourteenth Amendment right to
provide abortions. Planned Parenthood Ass’n of Utah v. Herbert, 828 F.3d 1245, 1260 (10th
Cir. 2016). But it did so without meaningful analysis or authority, and most importantly it did so
in a case in which the State did not challenge the existence of the right.

        Third-party-standing cases do not fill this gap. In those cases, the Supreme Court held
that abortion providers have standing to bring due process challenges on behalf of their patients.
See, e.g., Singleton v. Wulff, 428 U.S. 106, 118 (1976) (plurality); see also Diamond v. Charles,
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476 U.S. 54, 65–66 (1986). But these decisions do not establish that the providers themselves
have due process rights. Much to the contrary. The premise of these challenges is that the
providers have no constitutional rights of their own in this setting. Why else go through the
rigmarole of granting the provider third-party standing to file the claim? The first party (the
woman) has the claim, and the third party (the provider) sometimes may bring that claim on her
behalf. Any other interpretation of the third-party doctrine, as the plaintiffs use it here, would
have this disfiguring effect: It would create a constitutional right for providers to offer abortion
services and, in doing so, move the law perilously close to requiring States to subsidize
abortions. Case law rejects both possibilities.

        Even if the Fourteenth Amendment does not grant Planned Parenthood a constitutional
right to perform abortions and even if the third-party-standing doctrine does not fill this gap, the
organization maintains that the unconstitutional-conditions doctrine defeats the law all the same.
Ohio may not directly ban access to abortion services in the State, Planned Parenthood points
out, and the unconstitutional-conditions doctrine bars a State from achieving that same goal
indirectly, here by financially incentivizing abortion providers to cease offering this service.
Yes, the doctrine would prohibit the State from requiring women to forfeit benefits if they chose
to obtain an abortion and if that limitation unduly burdened their access to abortion services.
That’s because such a state law would try to achieve indirectly what the State cannot achieve
directly with respect to the underlying constitutional right. But, no, the principle does not apply
when the State regulates entities with no such constitutional right: abortion providers. In that
setting, the clinic is like anyone else in the State, subject to all manner of regulatory incentives
and disincentives, whether in the tax code, economic development plans, or any other part of
state or local law.

        Consistent with this explanation, all of the cases cited by Planned Parenthood with
respect to this direct-indirect point involved individuals or entities who held the constitutional
right and were discouraged from exercising it. See, e.g., Elrod v. Burns, 427 U.S. 347, 360–61
(1976) (employees claimed that county fired them due to their political affiliation); Perry v.
Sindermann, 408 U.S. 593, 597–98 (1972) (professor claimed that state college refused to renew
his contract due to his protected speech); Lane v. City of LaFollette, 490 F.3d 410, 419 (6th Cir.
 No. 16-4027           Planned Parenthood of Greater Ohio et al. v. Hodges                    Page 9

2007) (employee claimed that city fired him for his political beliefs); Toledo Area AFL-CIO
Council v. Pizza, 154 F.3d 307, 321 (6th Cir. 1998) (public-employee unions claimed that
prohibition on payroll deductions for political causes discouraged their political expression).

       The direct-indirect dynamic, put another way, is not by itself what triggers the doctrine.
The doctrine applies when the government attempts to ban or undermine a benefit recipient’s
exercise of a right that the Constitution guarantees. That’s why an unconstitutional-conditions
claim won’t get far if the government could have directly ordered the outcome it wishes to
incentivize. In that case, there is no right at issue. See Rumsfeld v. Forum for Acad. &
Institutional Rights, Inc., 547 U.S. 47, 58–60 (2006) (upholding funding condition that required
universities to give military recruiters equal access to students, because the First Amendment
would allow Congress to directly impose such a requirement). Because Planned Parenthood has
no constitutional right to perform abortions, the doctrine does not apply to Ohio’s incentives to
refrain from performing them.

       Truth be told, general concerns about indirect efforts to accomplish what cannot be
accomplished directly illustrate what is wrong with this claim. Medical centers do not have a
constitutional right to offer abortions. Yet, if we granted Planned Parenthood relief today, we
would be effectively saying that they do. That is not the role of the unconstitutional-conditions
doctrine.

       That this traditional application of the unconditional-conditions doctrine might apply in
other settings, as the dissent points out, infra, at 26, counts as a plus, not a minus, in the
constitutional equation. It shows that the principle is a neutral one. And it shows that our
assessment of the case turns on the nature of the unconstitutional-conditions doctrine, not on
individual preferences with respect to this constitutional right or that one. Any risk of unequal
application would arise in this case only if we extend the unconstitutional-conditions doctrine for
the first time to an entity (here an abortion provider) that does not have a constitutional right.

       In the absence of such an extension, Planned Parenthood worries that the
unconstitutional-conditions doctrine will lead to several problematic outcomes. “Imagine,” the
dissent suggests, “that the government barred lawyers who represent indigent defendants from
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eligibility for loan forgiveness programs.” Id. Or imagine, we could add, that the government
denied government construction contracts to companies that build for customers of a particular
faith or race or burdened gun shops with punitive or irrational licensing requirements. Straw
men, to be sure, but revealing all the same. None of these hypotheticals reveals a doctrinal (or
policy) gap that an extension of the unconstitutional-conditions doctrine needs to fill.

       The initial question in each instance is whether such a law would implicate the regulated
entity’s constitutional rights or some other prohibition. That seems likely in each setting. The
first application would implicate a lawyer’s free speech rights.          See Legal Servs. Corp. v.
Velazquez, 531 U.S. 533, 544 (2001). The second application would implicate the prohibition on
drawing racial and faith-based classifications in any law. Just as a State could not condition an
abortion provider’s subsidy on providing services only to individuals of a certain race or religion,
so it could not condition a construction company’s contracts on serving only non-Muslim clients
or only white clients. See Emp’t Div. v. Smith, 494 U.S. 872, 877 (1990); Brown v. Bd. of Educ.,
347 U.S. 483, 488, 495 (1954). Even aside from the question whether gun stores have Second
Amendment rights, compare Teixeira, 873 F.3d at 681–90, with id. at 698–99 (Bea, J.,
dissenting), the third application confirms that all punitive or irrational licensing requirements
run the risk of violating a store’s constitutional rights, whether the store sells guns or not. But it
is hardly punitive or irrational for a State to subsidize some activities and not others. The
unconstitutional-conditions    doctrine   no   more    elevates   non-constitutional    claims   into
constitutional ones than it insulates protected rights from protection.

       This last point answers the dissent’s next hypotheticals about polling-place funding and
gun-shop tax breaks, infra, at 26, as well as any others that a fertile imagination could identify,
so long as the law does not violate the regulated entity’s rights or another prohibition. Take the
gun shop. Surely a State could deny subsidies for entities dealing with the needs of victims of
gun violence to entities or stores that sold guns. In the end, so long as the subsidy program does
not otherwise violate a constitutional right of the regulated entity, the State may choose to
subsidize what it wishes—whether abortion services or adoption services, whether stores that sell
guns or stores that don’t.
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       That leads to Planned Parenthood’s next argument. Left untouched, the Ohio law will
deprive Ohio women of their constitutional right of access to abortion services without undue
burden, because it will lead Planned Parenthood and perhaps other abortion providers to stop
providing them. Maybe; maybe not. More to the point, the conclusion is premature and
unsupported by the record. It is true that, if these two Planned Parenthood affiliates opted not to
provide abortions, women seeking an abortion in Ohio would have to travel farther than they
currently do to obtain an abortion. It is also true that this kind of evidence may support an
undue-burden challenge by establishing a “substantial obstacle” in the way of those seeking
abortions. See Whole Woman’s Health, 136 S. Ct. at 2309–18; Women’s Med. Prof’l Corp. v.
Baird, 438 F.3d 595, 604–05 (6th Cir. 2006).

       But it is premature to assess any such claim now. For one, it is not clear that the
plaintiffs filed an undue-burden challenge on behalf of individual women, as opposed to an
unconstitutional-conditions challenge on their own behalf. For another, the record contains more
speculation than evidence about what would happen if these two Planned Parenthood affiliates
stopped providing abortions. For still another, the only hard evidence on point is that Planned
Parenthood does not plan to stop providing abortions, as representatives from each affiliate
testified that they would sacrifice government funding to continue providing abortions. On this
record, it would be unduly conjectural, and unripe to boot, to imagine what would happen if the
plaintiffs changed their mind.       Under our Article III authority to resolve “Cases” and
“Controversies,” we must limit ourselves to the seen rather than the unseen. And all that the
seen shows is that the law will not create an undue burden on a woman’s right to an abortion.

       Planned Parenthood insists that it has no obligation to establish an undue burden because
the funding condition itself is unconstitutional, making it irrelevant whether the subject of the
condition gives in. See Koontz, 570 U.S. at 607. That may be true if the subject of the funding
incentive possesses the right. But that is not true in this instance because the subject—here
providers, not women—does not possess the right. All of which takes us back to where we
started. To have an unconstitutional condition, the State must impose the condition on the
individual (or entity) with the constitutional right. If there’s no right, there’s no unconstitutional
condition. And the providers have no such constitutional right. The point of the doctrine is to
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protect the underlying right: a woman’s right of access to abortion services without an undue
burden. It is not to leverage a constitutional condition into an unconstitutional one while freeing
the provider from either asserting a valid right of its own or showing any undue burden on
anyone.

        That this is a pre-enforcement action, last of all, changes nothing. Even in that setting,
Planned Parenthood must show that the Ohio law, if implemented, would impose an undue
burden on a woman’s right to an abortion. Its vow to keep performing abortions sinks any pre-
enforcement action, and any speculation about what would happen if it changed its mind is just
that.

        For these reasons, we reverse the district court’s contrary decision and remand for
proceedings consistent with this opinion.
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                                       _________________

                                              DISSENT
                                       _________________

       HELENE N. WHITE, Circuit Judge, dissenting. The majority makes short work of
Plaintiffs’ arguments with three simple assertions. Because Plaintiff clinics have no independent
constitutional right to perform abortions, it is impossible for Ohio to violate their due process
rights by withholding benefits or imposing burdens based on their abortion activities; a woman
has a due process right to obtain certain nontherapeutic abortions, but no condition violates that
right unless it imposes an undue burden on that right; because Plaintiff providers have made
clear that they will not accede to Ohio’s funding conditions, there is no undue burden on a
woman’s abortion right.

       The majority does not mention, much less apply, the test the Supreme Court has recently
articulated governing the unconstitutional-conditions doctrine.       That doctrine prohibits the
government from conditioning the grant of funds under a government program if: (1) the
challenged conditions would violate the Constitution if they were instead enacted as a direct
regulation; and (2) the conditions affect protected conduct outside the scope of the government
program. See Agency for Int’l Dev. v. Alliance for Open Soc’y Int’l, 570 U.S. 205, 213-15
(2013) (hereafter AOSI). Because (1) the funding conditions in this case would result in an
undue burden on a woman’s right to obtain nontherapeutic abortions if imposed directly, and
(2) the six federal programs have nothing to do with Plaintiffs’ performing abortions, advocating
for abortion rights, or affiliating with organizations that engage in such activity, all on their own
“time and dime,” I respectfully dissent.

       Enacted in 2016, Ohio Revised Code § 3701.034 (the Statute) requires the Ohio
Department of Health (ODH) to ensure that all funds it receives through six non-abortion-related
federal health programs are not used to contract with any entity that performs or promotes
nontherapeutic abortions, or becomes or continues to be an affiliate of any entity that performs or
promotes nontherapeutic abortions.         A direct regulation barring healthcare providers from
performing or promoting nontherapeutic abortions or affiliating with any entity that performs or
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promotes nontherapeutic abortions would violate the Constitution by imposing an undue burden
on women seeking abortions and violating the healthcare providers’ rights to free speech and
association. The Statute thus satisfies the first element of an unconstitutional condition. The
Statute also plainly conditions government funding for programs unrelated to abortion on an
entity’s refraining from performing or promoting abortions, or affiliating with any entity that
does either. Because § 3701.034 fails both parts of the test applied in AOSI, the district court
properly enjoined the law from going into effect.

       The majority avoids this straightforward application of the unconstitutional-conditions
doctrine primarily by adopting an unprecedented rule that abortion providers—entities that are
necessary to ensure a woman’s right to safe abortions—cannot prevail in challenging the Statute
because there is no independent constitutional right to provide abortions. For the proposition
that there is “no such thing” as a right to perform abortions, the majority cites the statement in
the plurality opinion in Planned Parenthood of Southeastern Pennsylvania v. Casey that a
provider’s constitutional right “is derivative of the woman’s position.” 505 U.S. 833, 884
(1992). (Maj. Op. at 5.) The majority then assumes that a “derivative” right is no right at all.
But of course, “derivative” simply means “developed from . . . something else.” Black’s Law
Dictionary (10th ed. 2014). An abortion provider’s constitutional right may be derivative of the
patient’s right—but it is a right nonetheless.

       And, even if the abortion right belongs only to women, it has long been understood that
“the right is inextricably bound up with” a provider’s ability to offer these services. Singleton v.
Wulff, 428 U.S. 106, 114 (1976) (plurality opinion). Further, the Supreme Court has never
suggested that a party that could prevail in challenging a direct regulation is nevertheless
powerless to challenge a law that attempts to achieve the same result by imposing a condition on
unrelated funding. The majority’s novel rule gives the government the authority to impose
almost any condition it wants on abortion providers so long as the providers continue to perform
abortions. The government acknowledged as much at oral argument. This type of assault on a
constitutional right is precisely the type of harm the unconstitutional-conditions doctrine is meant
to protect against.
 No. 16-4027               Planned Parenthood of Greater Ohio et al. v. Hodges                           Page 15

                                             I. BACKGROUND

                                      Ohio Revised Code § 3701.034

        Ohio Revised Code § 3701.034 provides:
        (A) As used in this section:
                 (1) “Affiliate” means an entity that has with another entity a legal
                 relationship created or governed by at least one written instrument that
                 demonstrates any of the following:
                          (a) Common ownership, management, or control;
                          (b) A franchise agreement;
                          (c) The granting or extension of a license or other agreement that
                          authorizes an entity to use the other entity’s brand name,
                          trademark, service mark, or other registered identification mark.
                 (2) “Violence Against Women Act” means section 1910A of section
                 40151 of the “Violent Crime Control and Law Enforcement Act of 1994,”
                 part A of Title XIX of the “Public Health and Human Services Act,” 108
                 Stat. 1920 (1994), former 42 U.S.C. 300w, 42 U.S.C. 280b-1b, as
                 amended.
                 (3) “Breast and Cervical Cancer Mortality Prevention Act” means the
                 “Breast and Cervical Cancer Mortality Prevention Act of 1990,” 104 Stat.
                 409 (1990), 42 U.S.C. 300k, as amended.
                 (4) “Infertility prevention project” means the infertility prevention project
                 operated by the United States centers for disease control and prevention.
                 (5) “Minority HIV/AIDS initiative” means the minority HIV/AIDS
                 initiative operated by the office of minority health in the United States
                 department of health and human services.
                 (6) “Personal responsibility education program” means the program
                 administered by the administration for children and families in the United
                 States department of health and human services to educate adolescents on
                 abstinence and contraception for the prevention of pregnancy and sexually
                 transmitted infections.
                 (7) “Nontherapeutic abortion” has the same meaning as in section 9.04 of
                 the Revised Code.[1]

        1Ohio    law defines “nontherapeutic abortion” as “an abortion that is performed or induced when the life of
the mother would not be endangered if the fetus were carried to term or when the pregnancy of the mother was not
the result of rape or incest reported to a law enforcement agency.” Ohio Rev. Code § 9.04(A)(1).
 No. 16-4027               Planned Parenthood of Greater Ohio et al. v. Hodges                             Page 16

                   (8) “Promote” means to advocate for, assist with, encourage, or popularize
                   through advertising or publicity.
         (B) – (G)[2] The department of health shall ensure that all funds it receives
         [through the Violence Against Women Act, Breast and Cervical Cancer Mortality
         Prevention Act, Infertility prevention project, Minority HIV/AIDS initiative,
         infant mortality reduction or infant vitality initiatives] are not used to do any of
         the following:
                   (1) Perform nontherapeutic abortions;
                   (2) Promote nontherapeutic abortions;
                   (3) Contract with any entity that performs or promotes nontherapeutic
                   abortions;
                   (4) Become or continue to be an affiliate of any entity that performs or
                   promotes nontherapeutic abortions.

                                                     Plaintiffs

         Plaintiffs Planned Parenthood of Greater Ohio (PPGOH) and Planned Parenthood
Southwest Ohio Region (PPSWO) are not-for-profit corporations organized under Ohio law.
PPGOH and PPSWO are also affiliates of Planned Parenthood Federation of America, Inc.
(PPFA), which advocates for women’s access to comprehensive reproductive healthcare,
including abortion. Plaintiffs operate twenty-seven3 health centers throughout Ohio, which are
staffed with physicians, nurse practitioners, and physician assistants, who provide well-woman
exams, testing and treatment for sexually transmitted diseases, screenings for breast and cervical
cancer and HIV, and contraception and contraceptive counseling. Three of the twenty-seven
health centers also provide abortion services. Separate from their government-funded health
services and education programs, PPGOH and PPSWO advocate for a woman’s right to safe and
lawful abortion through public awareness campaigns and public education activities.

         Consistent with federal and Ohio law, no government funds are used to pay for or
subsidize Plaintiffs’ abortion services or advocacy. It is undisputed that Plaintiffs “maintain

         2Sections  (B) through (G), which address each of the programs separately, share identical language in
subsections (1) through (4), and are condensed for brevity.
         3During  the pendency of this appeal, Plaintiffs’ counsel advised that one of the twenty-eight health centers
has closed for reasons unrelated to this case. The district court’s opinion states that Plaintiffs operate twenty-eight
health centers, which was accurate at the time.
 No. 16-4027               Planned Parenthood of Greater Ohio et al. v. Hodges                              Page 17

measures to ensure that none of the funds received from the state or federal government are used,
directly or indirectly, to subsidize the promotion of abortion or performance of abortion
services.” (R. 60, PID 2136.)

         Largely through competitive grant processes, Plaintiffs have for years received funds and
material assistance distributed by ODH and county health departments under the six federal
programs impacted by § 3701.034: the Infertility Prevention Project, Breast and Cervical Cancer
Mortality Prevention Act, Violence Against Women Act, Minority HIV/AIDS Initiative, Infant
Mortality Reduction Initiative, and Personal Responsibility Education Program (PREP).4
Throughout those years, Plaintiffs passed all state and local audits and program reviews.

         After § 3701.034 was enacted, ODH and local health departments notified Plaintiffs that
their contracts under the six federal programs would be terminated and they would not be
eligible for funding. Plaintiffs’ termination of services they currently provide under these six
programs could have dramatic public-health consequences. For example, as amicus American
Public Health Association details, Plaintiffs currently provide over 70,000 free STD tests to low-
income Ohioans annually under the STD Prevention Program. With STDs among Ohioans
continuing to rise, Plaintiffs’ non-eligibility in that program could lead to three counties being
without any qualified provider because other existing program providers do not have the capacity
to fill the gap. Section 3701.034’s bar on funds being distributed to Plaintiffs under the other
five programs would require Plaintiffs to cease providing other fundamental public-health
services to primarily low-income or at-risk populations, including HIV testing and education,
cancer screenings, and sexual-violence-prevention education.5

         4Plaintiffs’counsel advised the court by letter dated July 27, 2017, that PPGOH did not reapply for grant
funding under the PREP program when its contract expired on July 31, 2017, and that it appears that ODH will no
longer be responsible for allocating PREP funds as of August 1, 2017; thus “there is a question as to whether [this
court] need consider PREP in its analysis of Section 3701.034.” (ECF No. 57.)
         5PPGOH      is the largest provider of HIV testing and treatment in Cleveland, Akron, and Canton, and
PPSWO provides approximately 1,600 anonymous and confidential HIV tests annually. PPGOH also provided
4,400 pap smears and 3,700 breast exams in the fiscal year ending in June 2015. Approximately 75% of PPSWO’s
patients and 40% of PPGOH’s patients fall within the low-income classification. Many of these patients live in
medically underserved areas––communities classified by the U.S. Department of Health and Human Services as
having too few primary-care providers, high infant mortality and poverty rates, or large elderly populations. ODH
failed to identify alternative providers to fill most of the gaps in service that would result from excluding Plaintiffs
from funding under the six federal programs.
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                                              Procedural History

         Plaintiffs filed this action for declaratory and injunctive relief under 42 U.S.C. § 1983,
alleging that § 3701.034 violates 1) their First Amendment rights “by denying state and federal
funds” to Plaintiffs “because of––and in retaliation for––their constitutionally-protected
advocacy for abortion rights and affiliation with other organizations that also advocate for
abortion rights and/or provide abortion services”; 2) the Due Process Clause “by denying state
and federal funds” to Plaintiffs “because of––and in retaliation for––the exercise of their own
constitutionally protected right to provide abortions and their patients’ exercise of the
constitutional right to choose to have an abortion”; and 3) the Equal Protection Clause “by
singling out abortion providers and those who ‘promote’ abortions, including [Plaintiffs], for
unfavorable treatment without a constitutionally sufficient justification.” (R. 1, PID 1, 27-28.)
Plaintiffs sought to enjoin ODH from enforcing § 3701.034 or terminating Plaintiffs’ funding
under the six federal programs pursuant to the Statute.

         The district court entered a temporary restraining order on the day § 3701.034 was to take
effect. Following discovery, the district court granted Plaintiffs’ motions for judgment on the
merits and permanently enjoined ODH from enforcing § 3701.034, reasoning that § 3701.034
violates the unconstitutional-conditions doctrine by impermissibly conditioning funding from
programs unrelated to abortion based on a recipient’s refraining from exercising its First
Amendment rights to free speech or association outside the contours of the six programs, and
refraining from providing abortion services protected by the Due Process Clause.6 Planned
Parenthood of Greater Ohio v. Hodges, 201 F. Supp. 3d 898 (S.D. Ohio 2016). A unanimous
panel affirmed the district court. 888 F.3d 224 (6th Cir. 2018). The full court then voted for
rehearing en banc. 829 F.3d 1283 (6th Cir. 2018).

                                      II. STANDARD OF REVIEW

         This court reviews a challenge to the constitutionality of a statute de novo. Entm’t
Prods., Inc. v. Shelby County, 721 F.3d 729, 733 (6th Cir. 2013). In reviewing the district

        6The district court did not reach Plaintiffs’ Equal Protection claim, nor does the majority. Accordingly, the
case must be remanded for the district court to consider the Equal Protection claim.
 No. 16-4027           Planned Parenthood of Greater Ohio et al. v. Hodges                   Page 19

court’s grant of injunctive relief, the district court’s factual findings are reviewed for clear error,
its legal conclusions are reviewed de novo, and the scope of injunctive relief is reviewed for
abuse of discretion. Sec’y of Labor, U.S. Dep’t of Labor v. 3Re.com, Inc., 317 F.3d 534, 537
(6th Cir. 2003). “A party is entitled to a permanent injunction if it can establish that it suffered a
constitutional violation and will suffer continuing irreparable injury for which there is no
adequate remedy at law.” Lee v. City of Columbus, 636 F.3d 245, 249 (6th Cir. 2011) (quoting
Wedgewood L.P. I v. Twp. of Liberty, 610 F.3d 340, 349 (6th Cir. 2010)).

                                        III. DISCUSSION

       The majority concludes that the “conduct provision” of § 3701.034 (precluding entities
that perform nontherapeutic abortions from obtaining funding under the six federal programs)
does not impose an unconstitutional condition because Plaintiffs have no due process right to
perform abortions. The majority declines to reach Plaintiffs’ First Amendment challenges to the
speech and affiliation provisions (prohibiting the allocation of program funds to any entity that
either (1) promotes nontherapeutic abortions, or (2) affiliates with any entity that performs or
promotes nontherapeutic abortions) concluding that Ohio may deny funding to Plaintiffs under
the six federal programs if any one of the provisions is valid. I address all three provisions
because each provision imposes an unconstitutional condition.

                                      A. Due Process Claim

                                                  1.

       I begin with the unconstitutional-conditions doctrine. The Supreme Court recognized this
doctrine many decades ago to ensure that the government cannot leverage its allocation of
benefits to “manipulate[]” constitutional rights “out of existence.”         Frost v. R.R. Comm’n,
271 U.S. 583, 594 (1926). Generally speaking, “the state, having power to deny a privilege
altogether, may grant it upon such conditions as it sees fit to impose.” Id. at 593. The state’s
power, however, “in that respect is not unlimited; and one of the limitations is that it may not
impose conditions which require the relinquishment of constitutional rights.” Id. at 593-94.
“Broadly stated, the rule is that the right to continue the exercise of a privilege granted by the
state cannot be made to depend upon the grantee’s submission to a condition prescribed by the
 No. 16-4027           Planned Parenthood of Greater Ohio et al. v. Hodges                 Page 20

state which is hostile to the provisions of the federal Constitution.” United States v. Chi., M., St.
P. & P.R. Co., 282 U.S. 311, 328-29 (1931). Thus, “even though a person has no ‘right’ to a
valuable governmental benefit and even though the government may deny him the benefit for
any number of reasons,” the government “may not deny a benefit to a person on a basis that
infringes his constitutionally protected interests.” Perry v. Sindermann, 408 U.S. 593, 597
(1972). This doctrine has been applied in a number of contexts where constitutional rights were
implicated, see Koontz v. St. Johns River Water Mgmt. Dist., 570 U.S. 595, 604 (2013) (“We
have said in a variety of contexts that ‘the government may not deny a benefit to a person
because he exercises a constitutional right.’” (citation omitted)), including where the government
“condition[s] benefits on a citizen’s agreement to surrender due process rights,” R.S.W.W., Inc. v.
City of Keego Harbor, 397 F.3d 427, 434 (6th Cir. 2005).

       “A predicate for any unconstitutional conditions claim is that the government could not
have constitutionally ordered the person asserting the claim to do what it attempted to pressure
that person into doing.” Koontz, 570 U.S. at 612. And, critically for this case, even when a party
“refuses to cede a constitutional right in the face of coercive pressure, the impermissible denial
of a governmental benefit is a constitutionally cognizable injury.” Id. at 607; see also AOSI, 570
U.S. at 214 (explaining that a condition need not be “actually coercive” to violate the
Constitution).

       To be sure, the unconstitutional-conditions doctrine does not render any funding
condition that may affect the exercise of constitutional rights unconstitutional. See AOSI, 570
U.S. at 214 (citing United States v. Am. Library Ass’n., Inc., 539 U.S. 194 (2003) (plurality
opinion), and Regan v. Taxation With Representation of Wash., 461 U.S. 540, 546
(1983)). Rather, “the relevant distinction” is whether the conditions “define the limits of the
government spending program” or are “outside the contours of the program itself.” Id. at 214-
15. In determining on which side of the line a condition falls, the Supreme Court distinguishes
between conditions that regulate the government-funded project and conditions that regulate the
recipient of government funds.       See Rust v. Sullivan, 500 U.S. 173, 197 (1991) (“[O]ur
‘unconstitutional conditions’ cases involve situations in which the Government has placed a
condition on the recipient of the subsidy rather than on a particular program or service, thus
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effectively prohibiting the recipient from engaging in the protected conduct outside the scope of
the federally funded program.”).

        In AOSI, the Supreme Court invalidated a statutory provision requiring organizations
receiving funds under a program designed to combat AIDS and HIV to have a policy explicitly
opposing prostitution and sex trafficking. 570 U.S. at 210, 221. The Court first noted that
“[w]ere [the Policy Requirement] enacted as a direct regulation of speech, [it] would plainly
violate the First Amendment.” Id. at 213. This did not end the inquiry, however. The Court
then asked whether the conditions “define the federal program” or “reach outside it,” id. at 217,
and explained that “[b]y demanding that funding recipients adopt—as their own—the
Government’s view on an issue of public concern, the condition by its very nature affects
‘protected conduct outside the scope of the federally funded program,’” id. at 218 (quoting Rust,
500 U.S. at 197). This was because, under the statutory condition, a funding recipient could not
“avow the belief dictated by the Policy Requirement when spending [federal program] funds, and
then turn around and assert a contrary belief, or claim neutrality, when participating in activities
on its own time and dime.” Id. at 218. Thus, “[b]y requiring recipients to profess a specific
belief, the Policy Requirement goes beyond defining the limits of the federally funded program
to defining the recipient.” Id. (citing Rust, 500 U.S. at 197).

        A     straightforward      application      of    these    principles     establishes     the    Statute’s
unconstitutionality. First, ODH could not impose the conduct provision as a direct regulation,
because to do so would mean passing a law prohibiting the performance of nontherapeutic
abortions. There is no dispute that outlawing abortions in Ohio would be an undue burden on
women’s ability to access the procedure in that state. Even if the direct regulation were limited
to Plaintiffs—a constitutionally dubious maneuver as well, see Planned Parenthood of Cent.
N.C. v. Cansler, 877 F. Supp. 2d 310, 327 (M.D.N.C. 2012)—ODH never contested Plaintiffs’
argument that a ban on their providing nontherapeutic abortions would impose an undue burden
on women seeking abortions in Ohio.7

        7Plaintiffs consistently argued that their ceasing to perform abortions would impose an undue burden on
women seeking abortion due to the reduction in abortion services available to the women of Ohio. Despite multiple
opportunities in several rounds of briefing before the district court and this court, ODH never attempted to explain
 No. 16-4027               Planned Parenthood of Greater Ohio et al. v. Hodges                            Page 22

         Second, the Supreme Court explained that permissible “conditions that define the limits
of the government spending program” are “those that specify the activities Congress wants to
subsidize.” AOSI, 570 U.S. at 214. The condition contained in the conduct provision of
§ 3701.034, however, does not “define the limits” of the six federal programs at issue because
those programs have nothing to do with abortion. Indeed, federal and Ohio law already mandate
that funds from those six programs, or any other government funds, cannot be used to subsidize
nontherapeutic abortion. Thus, there is no question that this condition “reach[es] outside” the six
federal programs and therefore constitutes an unconstitutional condition. See id. at 214-15.

         ODH disputes this conclusion, arguing that the conduct provision of § 3701.034 comports
with due process under Maher v. Roe, 432 U.S. 464 (1977), Harris v. McRae, 448 U.S. 297
(1980), and Rust, 500 U.S. 173. But these cases merely establish that the government is under no
obligation to subsidize abortion or abortion counseling by including coverage for abortion or
abortion counseling in public-benefits programs. Maher, 432 U.S. at 470-71, 474 (rejecting
challenge to regulation limiting state Medicaid benefits for first-trimester abortions to those that
are medically necessary); McRae, 448 U.S. at 322-23 (rejecting challenge to Hyde Amendment’s
limitation of Medicaid funding to those abortions necessary to save life of mother or cases of
rape or incest, while permitting funding of costs associated with childbirth); Rust, 500 U.S. at
192-94 (rejecting challenge to regulations providing that Title X family-planning funds could not
be used to fund family-planning programs where abortion is a method of family planning). That
principle is not at issue here because the six federal programs are completely divorced from
abortion or family planning.

         Rust, in fact, teaches why § 3701.034 is impermissible. Rust involved Title X, which
“provides federal funding for family-planning services.” 500 U.S. at 178. The regulations at
issue prevented recipients from using Title X funds to engage in abortion advocacy and

why Plaintiffs’ ceasing to perform abortions would not cause an undue burden, instead calling the argument
“irrelevant.” (R. 53, PID 2055.) At oral argument before the en banc court, ODH acknowledged that it never
briefed the issue but summarily argued in rebuttal that it was “pretty sure we not only do dispute that, but we’d come
out on the better side of it.” (Oct. 3, 2018, Oral Arg. 58:58-59:43.) Because a party’s claiming to be “pretty sure”
that it would dispute an issue despite never briefing that issue is insufficient to preserve the issue for appeal, ODH
forfeited the argument that Plaintiffs’ ceasing to perform abortions would not result in an undue burden. See United
States v. Universal Mgmt. Servs., Inc., 191 F.3d 750, 758 (6th Cir. 1999); Thaddeus-X v. Blatter, 175 F.3d 378, 403
n.18 (6th Cir. 1999) (en banc).
 No. 16-4027            Planned Parenthood of Greater Ohio et al. v. Hodges              Page 23

counseling. Id. at 196. Because Title X was a program meant to encourage family-planning
services leading to conception and childbirth, and thus discourage abortion, the regulations were
permissible in part because they were “designed to ensure that the limits of the federal program
are observed.” Id. at 193. In contrast, the six federal programs here have nothing to do with
family planning or abortion.

       Further, in rejecting the plaintiffs’ unconstitutional-conditions challenge to the
regulations, the Rust Court explained that the Supreme Court’s “‘unconstitutional conditions’
cases involve situations in which the Government has placed a condition on the recipient of the
subsidy rather than on a particular program or service, thus effectively prohibiting the recipient
from engaging in the protected conduct outside the scope of the federally funded program.” Id.
at 197. That is precisely what § 3701.034 does; it places conditions on Plaintiffs—the recipients
of the subsidies—that prohibit them from engaging in protected conduct outside the scope of the
six federal programs.

       Finally, it was critical in Rust that the regulations did not deny “the right to engage in
abortion-related activities” as a condition of receiving funding. Id. at 198. The regulations were
constitutional because they “govern[ed] the scope of the Title X project’s activities,” while
“leav[ing] the grantee unfettered in its other activities. The Title X grantee can continue to
perform abortions, provide abortion-related services, and engage in abortion advocacy; it simply
is required to conduct those activities through programs that are separate and independent from
the project that receives Title X funds.” Id. at 196. In contrast, § 3701.034’s whole purpose is to
fetter Plaintiffs in their other (i.e., abortion-related) activities, which are unrelated to the
government-funded programs. Similarly, in FCC v. League of Women Voters of California,
468 U.S. 364, 400 (1984), the Supreme Court struck down a law barring recipients of
government funds from engaging in editorializing because the law barred funding recipients
“from using even wholly private funds to finance its editorial activity.” But the Court noted that
such a law would have been permissible if it allowed the recipient “to establish ‘affiliate’
organizations which could then use the station’s facilities to editorialize with nonfederal funds.”
Id. Here, § 3701.034 expressly precludes funding recipients from being an affiliate of any entity
that performs or promotes nontherapeutic abortions. See also Planned Parenthood of Mid-Mo.
 No. 16-4027           Planned Parenthood of Greater Ohio et al. v. Hodges              Page 24

& E. Kan., Inc. v. Dempsey, 167 F.3d 458, 463 (8th Cir. 1999) (explaining that a law prohibiting
recipients of state family-planning funds from having independent abortion-provider affiliates
“would cross the line established in Rust, League of Women Voters, and Regan, and hence be an
unconstitutional condition”).

       In sum, none of the numerous reasons that the regulations in Rust were upheld is present
here: § 3701.034 does not define the scope of the federal programs; and it does not distinguish
between the programs and the grantee, restricting only the former, while permitting the latter to
“continue to perform abortions, provide abortion-related services, and engage in abortion
advocacy . . . through programs that are separate and independent from the project[s] that
receive[] the [six program funds].” Rust, 500 U.S. at 196.

       For all of these reasons, § 3701.034’s conduct provision is unconstitutional.

                                                  2.

       The majority avoids more than a cursory discussion of the principles underlying the
unconstitutional-conditions doctrine by finding that Plaintiffs’ purported lack of an independent
constitutional right to perform abortions is dispositive. As discussed above, the Supreme Court
label of the provider’s constitutional right as “derivative of the woman’s position,” 505 U.S. at
884, is a statement about the source of an abortion provider’s constitutional right—not a denial
that the provider has a constitutionally protected interest.

       However, even accepting that Plaintiffs have no wholly independent constitutional right
to perform abortions, but see, e.g., Planned Parenthood Ass’n of Utah v. Herbert, 828 F.3d 1245,
1258-60 (10th Cir. 2016) (noting that Planned Parenthood Association of Utah alleged, “without
serious challenge from defendants, a Fourteenth Amendment right” “to provide . . . abortion
services”); Dempsey, 167 F.3d at 464 (addressing the effect of the challenged Missouri law on
“Planned Parenthood’s constitutional right[]” to “provide abortion services”); Planned
Parenthood v. Doyle, 162 F.3d 463, 471 (7th Cir. 1998) (“The constitutional right to an abortion
carries with it the right to perform medical procedures that many people find distasteful or
worse.”); Planned Parenthood of Cent. & N. Ariz. v. Arizona, 718 F.2d 938, 944 (9th Cir. 1983)
(determining “whether the State unduly interfered with Planned Parenthood’s exercise of its right
 No. 16-4027           Planned Parenthood of Greater Ohio et al. v. Hodges               Page 25

to perform abortion and abortion-related services”), it does not follow that the Constitution is
indifferent to laws that condition the grant of unrelated public funds on the abandonment of all
abortion-related activity. Treating the lack of a personally held, independent right divorced from
a woman’s abortion right as a bar to Plaintiffs in this case has dire implications for abortion
providers in this circuit and is inconsistent with the purpose behind the unconstitutional-
conditions doctrine for at least two reasons.

       First, it is worth noting that the Supreme Court has not always couched the
unconstitutional conditions doctrine in rights-based language, referring instead to “protected
conduct,” Rust, 500 U.S. at 197, or “constitutionally protected interests,” Perry, 408 U.S. at 597.
Even if providers have no right of their own to provide abortions, surely providing women with
abortions free from undue governmental interference falls into the category of constitutionally
protected conduct.

       Second, as discussed above, and as the majority acknowledges (see Maj. Op. at 8), one of
the purposes of the unconstitutional-conditions doctrine is to prevent the government from
achieving indirectly—by conditioning unrelated funds on forgoing constitutionally protected
activity—what the government cannot achieve directly. But the majority says that is not what is
happening here because “the government could have directly ordered the outcome it wishes to
incentivize” in this case. (Maj. Op. at 9.) The majority does not explain how Ohio could directly
order the outcome it wishes to incentivize—that Ohio’s healthcare providers cease performing
abortions. And even if the direct regulation could constitutionally be limited to Plaintiffs alone,
ODH never challenged either in the district court or its briefing in this court, until en banc
argument, that barring Plaintiffs from performing abortions would place an undue burden on
women seeking abortion given the existing abortion providers in the area. There is no doubt that
if Ohio ordered either ban directly, Plaintiffs would be able to challenge that law on due process
grounds. See Whole Woman’s Health v. Hellerstedt, 136 S. Ct. 2292 (2016) (granting relief to
plaintiff abortion providers who challenged on due process grounds regulations imposed on their
services); see also Singleton, 428 U.S. at 117-18 (explaining that abortion providers may “assert
the rights of women patients as against governmental interference with the abortion decision”
because “[a] woman cannot safely secure an abortion without the aid of a physician,” “the
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constitutionally protected abortion decision is one in which the physician is intimately involved,”
and “there are several obstacles” to the woman asserting her own rights); Craig v. Boren,
429 U.S. 190, 195 (1976) (noting that service providers “have been uniformly permitted to resist
efforts at restricting their operations by acting as advocates of the rights of third parties who seek
access to their market or function”).

         Thus, there is no reason why Plaintiffs cannot prevail on an unconstitutional-conditions
claim in this case. The Supreme Court has never suggested that the government can impose a
condition on a third party to induce a result that would be unconstitutional if the condition were
imposed directly on a party whose rights are affected.8 Nor has the Supreme Court suggested
that an entity that could challenge a direct regulation could not prevail in challenging the
government’s attempt to reach the same result through a condition imposed on unrelated funding.
Consider the examples of the constitutional rights to counsel, to vote, and to bear arms. These
rights belong to the criminal defendant, the voter, and the gun owner, respectively. Imagine that
the government barred lawyers who represent indigent defendants from eligibility for loan
forgiveness programs, denied all government funding to private entities that volunteer to serve as
polling places in low-income neighborhoods, or ceased providing all existing tax breaks,
subsidies, and government benefits to any store that sells guns. By the majority’s logic, as long
as the beleaguered lawyers, polling places, and gun store owners continue to perform these
services, no one could successfully challenge the constitutionality of these laws based on the
protected rights.9

         8The    unconstitutional-conditions cases that the Supreme Court has addressed thus far have involved
plaintiffs’ challenges to conditions that impact their own, personal constitutional rights. See, e.g., Koontz, 570 U.S.
595; AOSI, 570 U.S. 205; Rust, 500 U.S. 173; Regan, 461 U.S. 540; Mem’l Hosp. v. Maricopa County, 415 U.S. 250
(1974). But the fact that the Court has only had the opportunity to consider cases where a recipient’s own
constitutional rights were at issue does not mean that its cases “confirm” that a “benefits condition becomes
unconstitutional only when it violates a recipient’s constitutional rights.” (Maj. Op. at 6 (emphasis added).) Those
cases just confirm that the Court can only decide the cases that come before it.
         9Legal Services Corp. v. Velazquez, 531 U.S. 533 (2001), is plainly distinguishable. That case involved the
government providing funds to organizations representing indigent clients in a claim against the government for
welfare benefits, but prohibiting those same organizations from challenging existing welfare laws as
unconstitutional or unlawful in those cases. Id. at 545-47. This law violated the First Amendment, the Court
explained, because “it operates to insulate current welfare laws from constitutional scrutiny and certain other legal
challenges, a condition implicating central First Amendment concerns,” and “there is no alternative channel for
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         The whole point of the unconstitutional-conditions doctrine is to prevent the government
from achieving indirectly what it cannot constitutionally achieve directly. And because Plaintiffs
could succeed on a due process challenge against the direct version of this law, they can likewise
challenge the indirect version as an unconstitutional condition.                        The majority’s position
contravenes the purpose of the unconstitutional-conditions doctrine.10

         ODH also asserts (and it appears the majority agrees) that the unconstitutional-conditions
doctrine, at most, bars unconstitutional conditions only when they actually operate to impose an
undue burden, and, the argument goes, § 3701.034 imposes no such undue burden because
Plaintiffs’ representatives testified that Plaintiffs would continue to perform abortions even if the
law goes into effect.          ODH relies on the Seventh Circuit’s divided opinion in Planned
Parenthood of Indiana, Inc. v. Commissioner of Indiana State Department of Health, 699 F.3d
962 (7th Cir. 2012) (hereafter PPI).11

         There, PPI, a Medicaid provider that performs abortions, one of its doctors, and two low-
income patients who used its services, brought suit under 42 U.S.C. § 1983, challenging the
constitutionality of an Indiana law that prohibited state agencies from contracting with or making
grants to any entity that performs abortions. In addressing PPI’s unconstitutional-conditions
claim, the panel majority reasoned:

         [T]he government need not be neutral between abortion providers and other
         medical providers, and this principle is particularly well-established in the context
         of governmental decisions regarding the use of public funds. As long as the
         difference in treatment does not unduly burden a woman’s right to obtain an
         abortion, the government is free to treat abortion providers differently.

expression of the advocacy Congress seeks to restrict.” Id. at 546-47. No such argument could be made about a law
stripping loan forgiveness eligibility from attorneys who represent indigent defendants.
         10Nor    would affirming the district court “effectively [be] saying” that abortion providers “have a
constitutional right to offer abortions.” (Maj. Op. at 9.) It would merely be saying that states cannot strip an entity
of funding that is unrelated to abortion solely because that entity provides abortions on its “own time and dime.”
See AOSI, 570 U.S. at 218.
         11The   majority’s reliance on the Seventh Circuit “reject[ing] an unconstitutional-conditions challenge to an
Indiana law with a conduct component identical in every material way to this Ohio law” (Maj. Op. at 7) ignores that
the law at issue in PPI did not prohibit funding for any entity that promotes abortions or, more critically, any entity
that affiliates with an entity that promotes or performs abortions. See PPI, 699 F.3d at 967.
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       Applying these principles here, the unconstitutional-conditions claim is not likely
       to succeed. Planned Parenthood does not argue that the loss of its block-grant
       funding imposes an undue burden—directly or indirectly—on a woman’s right to
       obtain an abortion. If . . . the government’s refusal to subsidize abortion does not
       unduly burden a woman’s right to obtain an abortion, then Indiana’s ban on public
       funding of abortion providers—even for unrelated services—cannot indirectly
       burden a woman’s right to obtain an abortion.

PPI, 699 F.3d at 988.

       The Seventh Circuit’s analysis avoids the unconstitutional-conditions argument by
looking at the effect on a woman’s right to obtain an abortion if the provider does not submit to
the condition and continues providing abortions. That is not the appropriate analysis. In AOSI,
for example, the Supreme Court did not hold that the organizations’ First Amendment rights
were not violated because they could simply decline the funding and continue to have whatever
policy they wanted about prostitution and sex trafficking. Rather, the Court determined that the
condition, if imposed directly, would violate the Constitution. Thus, forcing the organizations to
have a policy opposing prostitution and sex trafficking to obtain the relevant funding violated the
First Amendment, just as forcing Plaintiffs here to refrain from performing abortions to obtain
unrelated funding would violate the Due Process Clause. This is because the unconstitutional-
conditions doctrine prohibits the imposition of the condition itself and does not require the party
to actually submit to the condition to prevail. AOSI, 570 U.S. at 214 (explaining that government
action need not be “actually coercive” to qualify as an unconstitutional condition); see also
Koontz, 570 U.S. at 607 (“As in other unconstitutional conditions cases in which someone
refuses to cede a constitutional right in the face of coercive pressure, the impermissible denial of
a governmental benefit is a constitutionally cognizable injury.”). 12 In contrast to the Seventh
Circuit’s holding in PPI, this court has already held that whether an entity acquiesces to the
government’s proposed condition is “irrelevant” to the condition’s constitutionality. R.S.W.W.,
397 F.3d at 436. Yet the majority perplexingly suggests that even a condition imposed directly
on women to choose between having an abortion and receiving government benefits could be
constitutional if women would choose to cease receiving government benefits. (Maj. Op. at 8
(“[T]he doctrine would prohibit the State from requiring women to forfeit benefits if they chose

       12PPI   was decided before Koontz and AOSI, which may account for its flawed analysis.
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to obtain an abortion and if that limitation unduly burdened their access to abortion
services.”).)13

         The PPI majority also failed to recognize Rust’s distinction between conditions placed on
the government program and those imposed on the recipient. And although in summarizing Rust
the PPI majority seems to recognize that Rust treated the unconstitutional-conditions argument
as separate from the undue-burden analysis,14 the PPI majority engaged in no substantive
discussion of Rust’s treatment of the separate unconstitutional-conditions claim. See 699 F.3d at
987-88. Rather, the PPI majority’s entire discussion of the unconstitutional-conditions claim
rested on the undisputed propositions that the government can constitutionally allocate funds in a
manner that favors childbirth over abortion; that there is no constitutional requirement that the
government subsidize abortion; and that denying funding for abortion does not unduly burden a
woman’s constitutional right to choose to have an abortion. The PPI majority concludes by
quoting Rumsfeld v. Forum for Academic & Institutional Rights, Inc., 547 U.S. 47, 59-60 (2006):
“It is clear that a funding condition cannot be unconstitutional if it could be constitutionally
imposed directly.” 699 F.3d at 988.

         The unstated conclusion holding the PPI majority’s opinion together is that because the
government need not subsidize abortion and need not be neutral between abortion providers and
other medical providers, particularly with respect to government funds, the government could
directly prohibit providers from performing abortions. Of course, this is not the case. The cited
cases15 establish that the government can prohibit PPI or other abortion providers from using
program funds to perform or advocate for abortion. But nowhere does Rust or any other case

         13This  suggestion would have particularly troubling implications. It seems that the majority would never
allow a facial challenge claiming that a statute imposed an unconstitutional condition on a woman’s abortion right,
because the answer to whether a statute will create an undue burden is always “[m]aybe; maybe not.” (Maj. Op. at
11.) This is antithetical to this court’s precedent, see R.S.W.W., 397 F.3d at 436, and antithetical to the purpose of
the doctrine, see, e.g., Oil States Energy Servs., LLC v. Greene’s Energy Group, LLC, 138 S. Ct. 1365, 1377 n.4
(2018) (“The doctrine prevents the Government from using conditions ‘to produce a result which it could not
command directly.’” (quoting Perry, 408 U.S. at 597)).
         14The   PPI majority stated: “Because the Title X regulations did not place an undue burden on a woman’s
right to obtain an abortion or otherwise impose an unconstitutional condition on grant recipients, the Court upheld
the regulatory scheme.” 699 F.3d at 988 (emphasis added).
        15Maher, 432 U.S. 464; Harris, 448 U.S. 297; Rust, 500 U.S. 173; and Webster v. Reprod. Health Servs.,
492 U.S. 490 (1989).
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suggest that the government can condition the receipt of unrelated funds on a recipient’s
abandoning all activities that facilitate a woman’s right to obtain an abortion, or that advocate for
such a right, and any affiliation with any entity that does either. Courts considering similar
issues post-AOSI have not followed the Seventh Circuit’s (or the majority’s) analysis. See, e.g.,
Planned Parenthood of Sw. & Cent. Fla. v. Philip, 194 F. Supp. 3d 1213, 1218-19 (N.D. Fla.
2016) (“If, as the Court said in Rust, Congress can prohibit the use of federal funds for abortion
services but cannot restrict a recipient of federal funds from separately providing abortion
services, then the Florida legislature likewise can prohibit the use of state funds for abortion
services but cannot prohibit a recipient of state funds from separately providing abortion
services.”); Cansler, 877 F. Supp. 2d at 320-21 (enjoining law that denied non-abortion-related
funding based on Planned Parenthood’s activity as an abortion-rights advocate and abortion
provider under the unconstitutional-conditions doctrine).16

         I agree with the majority that “[t]he point of the [unconstitutional-conditions] doctrine is
to protect the underlying right: a woman’s right of access to abortion services without an undue
burden.” (Maj. Op. at 11–12.) But the majority creates a loophole that enables states to
circumvent the unconstitutional-conditions doctrine: the government cannot leverage its funding
to carve away at constitutional rights by passing laws that target the individual who holds the
right, but it can leverage funding to achieve that same result so long as it manages to find a proxy
to target instead.       The majority’s reasoning contorts a doctrine that aims to prevent the
government from manipulating rights out of existence, Frost, 271 U.S. at 593-94, to permit the
State to leverage its funding to launch a thinly veiled attack on women’s rights so long as it

         16The   majority’s suggestion that Teixeira v. County of Alameda, 873 F.3d 670, 689-90 (9th Cir. 2017) (en
banc), supports its understanding of the unconstitutional-conditions doctrine is unpersuasive. Teixeira does not
expressly address the unconstitutional-conditions doctrine, but the law at issue there placed conditions on the sale of
firearms in the form of zoning restrictions. In Teixeira, the Ninth Circuit found that “the Second Amendment does
not independently protect a proprietor’s right to sell firearms,” id. at 690, and still it held that “Teixeira, as the
would-be operator of a gun store, . . . has derivative standing to assert the subsidiary right to acquire arms on behalf
of his potential customers,” id. at 678. That is exactly what Plaintiffs argue here. Moreover, the only reason the
Ninth Circuit found there was no constitutional violation in Teixeira is that, even if the store was entirely prevented
from selling guns, its customers’ Second Amendment rights would not be infringed. Id. at 679-81. In contrast,
ODH never contested below that women’s abortion rights would be violated if Plaintiffs were prevented from
performing abortions. To the extent Teixeira can be read as instructive, its reasoning supports Plaintiffs’ view of the
unconstitutional-conditions doctrine, not the majority’s.
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camouflages its unconstitutional condition in provider-focused verbiage. This strikes me as
exactly the type of maneuver the doctrine seeks to prevent.

       At bottom, ODH’s position and the majority’s opinion open the door for the government
to impose almost any condition17 it wants on abortion providers so long as the abortion providers
resist the coercion and continue to perform abortions. At oral argument, the United States,
arguing in favor of ODH’s position, acknowledged that ODH’s position would authorize the
government to pass a law prohibiting all doctors who perform abortions from providing any
other medical services. (Oral Arg. at 33:10-35:30.) This is because as long as enough doctors
continue to perform abortions, there would be no undue burden on a woman’s right to obtain
one. (Id.) And under the majority’s reasoning, the doctors could not challenge the law as an
unconstitutional condition because they have no due process right to provide abortions. Other
hypotheticals are imaginable, which before today would have seemed absurd.             Using this
reasoning, the government can do almost anything it wants to penalize abortion providers so long
as they resist the coercion and continue to perform abortions. (Id.)

       This result is especially striking in juxtaposition with the Supreme Court’s abortion
jurisprudence over the last three decades, which reveals that virtually every attempt to ban or
undermine a woman’s abortion right since Roe v. Wade has operated by targeting providers, not
women. See, e.g., Whole Woman’s Health, 136 S. Ct. 2292 (imposing admitting-privileges and
surgical-center requirements on providers); Stenberg v. Carhart, 530 U.S. 914 (2000)
(criminalizing providers’ performance of particular abortion procedures); Casey, 505 U.S. 833
(imposing civil penalties on providers who perform abortions without receiving signed statement
of spousal consent); Hodgson v. Minnesota, 497 U.S. 417 (1990) (criminalizing providers’
performance of abortions on minors without both parents’ consent). Those laws, each of which
was struck down as unconstitutional, reflect a basic reality that legislatures seeking to undermine
abortion rights have long understood: when a constitutional right requires a third party to
vindicate it, a restriction imposed on that indispensable third party effectively restricts the
rightholder. That is why the Constitution prohibits unduly burdening a woman’s abortion right,
even in the form of laws that directly target only the gatekeeper to a woman’s abortion right—
       17Subject   only to rational basis review, according to the United States.
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her provider. The impact of the condition is the same, because the provider is the target in name
only. In practice, the provider is merely a proxy for the woman and her constitutional rights.

       Because the unconstitutional-conditions doctrine does not allow the government to
penalize a party indispensable to the exercise of a constitutional right so long as the party refuses
to cry uncle and submit to the condition, the conduct provision is unconstitutional.

                                   B. First Amendment Claims

       The majority does not reach Plaintiffs’ patently meritorious First Amendment claims,
reasoning that because the conduct provision does not impose an unconstitutional burden, ODH
may deny funding under the Statute without regard to whether the Statute violates Plaintiffs’
First Amendment rights.      But Plaintiffs’ First Amendment claims are not mooted by the
purported constitutionality of the conduct provision, and a decision on the First Amendment
claims is not rendered advisory by the majority’s decision on the conduct provision. If the First
Amendment challenge is successful, Plaintiffs could form affiliate entities to take over their
abortion-related activities (see Pls.’ Br. on Reh’g at 18-19), and still receive funds under the six
federal programs. In any event, because the conduct provision is unconstitutional, I address
Plaintiffs’ First Amendment claims as well.

       Plaintiffs assert two claims under the First Amendment, addressing both § 3701.034’s
speech provision—which prohibits the allocation of program funds to any entity that promotes
nontherapeutic abortions—and its affiliation provision—which prohibits the allocation of
program funds to any entity that affiliates with any entity that performs or promotes
nontherapeutic abortions.      It is undisputed that a funding condition can result in an
unconstitutional burden on First Amendment rights. See AOSI, 570 U.S. at 218 (“By requiring
recipients to profess a specific belief, the Policy Requirement goes beyond defining the limits of
the federally funded program to defining the recipient.”); Rumsfeld, 547 U.S. at 59 (the First
Amendment supplies “a limit on Congress’ ability to place conditions on the receipt of funds”).

       Plaintiffs’ First Amendment claim is not vulnerable to attack under either of the
rationales the majority appears to adopt in analyzing the due process claim. Plaintiffs are
asserting their own First Amendment rights and need not show that a restriction amounts to an
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undue burden on a woman’s right to obtain an abortion to prevail on a claim under the First
Amendment. Nor does ODH dispute that it would be unconstitutional to legislate a direct ban on
promoting nontherapeutic abortions or affiliating with entities that perform or promote
nontherapeutic abortions.

       Instead, relying on Planned Parenthood Ass’n of Hidalgo County Texas, Inc. v. Suehs,
692 F.3d 343 (5th Cir. 2012), ODH argues that the Statute’s speech provision does no more than
is constitutionally permissible by seeking “to ensure that contractors who convey Ohio’s
messages do so efficiently and effectively.” (Appellant’s Br. at 52-53 (citation and internal
quotation marks omitted).) This argument is unpersuasive.

       In Suehs, the Texas legislature had created the “Women’s Health Program (WHP),”
designed to “expand access to preventative health and family planning services for women.”
692 F.3d. at 346 (internal quotation marks and citation omitted).          The Texas legislature
prohibited the Texas Health and Human Services Commission (THHSC), which administers the
WHP, from contracting with “entities that perform or promote elective abortions or are affiliates
of entities that perform or promote elective abortions.” Id. (internal quotation marks and citation
omitted). The plaintiff health-clinic operators alleged that the regulations violated their First
Amendment rights of free-speech and association, and the Fourteenth Amendment’s guarantee of
equal protection. Applying the unconstitutional-conditions doctrine, the district court determined
that the regulations likely violated these constitutionally guaranteed rights and issued a
preliminary injunction. The Fifth Circuit vacated the preliminary injunction and remanded,
explaining:

       Texas’s restriction on promoting elective abortions directly regulates the content
       of the WHP as a state program. The policy expressed in the WHP is for public
       funds to subsidize non-abortion family planning speech to the exclusion of
       abortion speech. § 1.19(b), 2011 Tex. Gen. Laws at 335. Texas’s authority to
       promote that policy would be meaningless if it were forced to enlist organizations
       as health care providers and message-bearers that were also abortion advocates.
       The authority of Texas to disfavor abortion within its own subsidized program is
       not violative of the First Amendment right, as interpreted by Rust v. Sullivan.
       Consequently, Texas’s choice to disfavor abortion does not unconstitutionally
       penalize the appellees’ speech.

Suehs, 692 F.3d at 350.
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       I agree with the district court that this out-of-circuit precedent is distinguishable and
inapposite. Suehs is virtually indistinguishable from Rust because, as the Fifth Circuit observed,
Texas’s restriction “directly regulates the content of the WHP as a state program.” Id. Here,
however, § 3701.034 does not regulate, and has no relation to, the content of the six federal
programs.

       Further, although Ohio, like Texas, may, consistent with the First Amendment, ensure
that its message favoring childbirth over abortion is not garbled, this case plainly involves no
state “message” related to or regarding abortion; § 3701.034 affects programs that have nothing
to do with abortion or family planning, and seeks to impose restrictions on recipients’ speech
outside of those six government programs.

       As the Supreme Court made clear in AOSI, the government may not prevent a recipient of
government funding from expressing its own views “when participating in activities on its own
time and dime.” 570 U.S. at 218. Because “the conditions imposed by Section 3701.034 seek to
leverage funding to regulate speech outside the contours of the six programs impacted by Section
3701.034,” the unconstitutional-conditions doctrine applies. Planned Parenthood of Greater
Ohio, 201 F. Supp. 3d at 906. Therefore, the district court correctly determined that § 3701.034
violates the First Amendment by conditioning participation in funding for these programs on a
recipient’s forgoing the exercise of its rights of free speech outside these programs. See AOSI,
570 U.S. at 218; see also Dempsey, 167 F.3d at 462 (“Legislation that simply dictates the proper
scope of government-funded programs is constitutional, while legislation that restricts protected
grantee activities outside government programs is unconstitutional . . . .”); Planned Parenthood
of Cent. & N. Ariz., 718 F.2d at 944 (although the state need not fund abortions, the state “may
not unreasonably interfere with the right of Planned Parenthood to engage in abortion or
abortion-related speech activities”).

       Finally, by conditioning participation in the six federal programs on refraining from
being an affiliate of any entity that promotes or performs nontherapeutic abortions, the Statute
effects a separate First Amendment violation of Plaintiffs’ right to free association. See Runyon
v. McCrary, 427 U.S. 160, 175 (1976) (“[T]he Court has recognized a First Amendment right to
‘engage in association for the advancement of beliefs and ideas[.]’ That right is protected
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because it promotes and may well be essential to the ‘[e]ffective advocacy of both public and
private points of view, particularly controversial ones’ that the First Amendment is designed to
foster.” (third alteration in original) (internal citation omitted) (quoting NAACP v. Alabama ex
rel. Patterson, 357 U.S. 449, 460 (1958))). Plaintiffs are affiliates of PPFA, which advocates for
women’s access to comprehensive reproductive healthcare, including abortion. Thus, even if
Plaintiffs ceased performing and promoting nontherapeutic abortions or transferred those
functions to an affiliate, the affiliation provision would still prohibit them from obtaining funds
under the six federal programs due to their status as affiliates of PPFA. See AOSI, 570 U.S. at
215 (explaining that the funding condition at issue in Regan, 461 U.S. 540, did not violate the
unconstitutional-conditions doctrine because the organization retained the ability to “return[] to a
‘dual structure’ it had used in the past”). ODH offers no argument for the constitutionality of
this provision aside from those offered to defend the speech provision. For the same reasons, the
affiliation provision also imposes an unconstitutional condition.

                       IV. ENTRY OF PERMANENT INJUNCTION

       ODH conceded that it “agrees that if this Court finds the Conduct and Speech Provisions
both unconstitutional,” the permanent injunction factors are met. (Reply Br. at 29.)

                                       V. CONCLUSION

       For the reasons stated, the district court correctly granted Plaintiffs’ motions for judgment
on the merits and for a permanent injunction. Its decision should be affirmed.