Court Opinion

ID: 4639817
Source: CourtListenerOpinion
Date Created: 2020-12-05 01:00:17.844802+00
Date Added: 2024-06-11T07:59:31.023144
License: Public Domain

Case: 19-40605   Document: 00515661850      Page: 1    Date Filed: 12/04/2020

                             REVISED

          United States Court of Appeals
               for the Fifth Circuit
                                                               United States Court of Appeals
                                                                        Fifth Circuit

                                                                      FILED
                                                              December 2, 2020
                             No. 19-40605                        Lyle W. Cayce
                                                                      Clerk

   Ronald S. Hines, Doctor of Veterinary Medicine,

                                                      Plaintiff—Appellant,

                                versus

   Jessica Quillivan, Doctor of Veterinary Medicine, in
   her official capacity as President of the Texas State
   Board of Veterinary Medical Examiners; Keith Pardue,
   in his official capacity as Vice President of the Texas
   State Board of Veterinary Medical Examiners; Sandra
   “Lynn” Criner, Doctor of Veterinary Medicine, in her
   official capacity as Secretary of the Texas State
   Board of Veterinary Medical Examiners; Michael
   White, Doctor of Veterinary Medicine, in his official
   capacity as a Member of the Texas State Board of
   Veterinary Medical Examiners; Samantha Mixon,
   Doctor of Veterinary Medicine, in her official
   capacity as a Member of the Texas State Board of
   Veterinary Medical Examiners; Randall Skaggs,
   Doctor of Veterinary Medicine, in his official capacity
   as a Member of the Texas State Board of Veterinary
   Medical Examiners; Carlos Chacon, in his official
   capacity as a Member of the Texas State Board of
   Veterinary Medical Examiners; Sue Allen, Licensed
   Veterinary Technician, in her official capacity as a
   Member of the Texas State Board of Veterinary
   Medical Examiners; George Antuna, in his official
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   capacity as a Member of the Texas State Board of
   Veterinary Medical Examiners,

                                                         Defendants—Appellees.

                  Appeal from the United States District Court
                      for the Southern District of Texas
                            USDC No. 1:18-CV-155

   Before Elrod, Southwick, and Haynes, Circuit Judges.
   Leslie H. Southwick, Circuit Judge:
          Does a veterinarian have a right to engage in telemedicine for a pet he
   has not physically examined? The plaintiff claims that right exists. He filed
   suit, challenging Texas’s physical-examination requirement for vets, which
   prohibits vets from offering individualized advice to pet owners unless the
   vet previously examined the animal. In 2015, we rejected the plaintiff’s
   claims under the First Amendment and Equal Protection Clause. Now, he
   claims that new precedent from the Supreme Court and this circuit dictate a
   different result. The plaintiff filed suit again in 2018, re-raising his First
   Amendment claims. He also added a new equal-protection claim based on
   Texas’s different telemedicine rules for physicians and veterinarians. The
   district court rejected the plaintiff’s arguments and granted the defendants’
   motion to dismiss.     We AFFIRM in part, REVERSE in part, and
   REMAND.

              FACTUAL AND PROCEDURAL BACKGROUND
          Dr. Ronald Hines, a licensed veterinarian in Texas, stopped practicing
   what might be called traditional veterinary medicine in 2002 due to his age
   and physical limitations. Soon thereafter, he began using his website to write

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   articles about pet health. People around the world began emailing Hines for
   advice about their own pets. Hines offered individualized advice over email
   and phone, and in 2003, he added to his website a flat fee for veterinary
   advice.
          Under Texas law, the “[p]ractice of veterinary medicine” is
   defined as:
                (A) the diagnosis, treatment, correction, change,
          manipulation, relief, or prevention of animal disease,
          deformity, defect, injury, or other physical condition, including
          the prescription or administration of a drug, biologic,
          anesthetic, apparatus, or other therapeutic or diagnostic
          substance or technique;
                (B) the representation of an ability and willingness to
          perform an act listed in Paragraph (A);
                 (C) the use of a title, a word, or letters to induce the
          belief that a person is legally authorized and qualified to
          perform an act listed in Paragraph (A); or
                  (D) the receipt of compensation for performing an act
          listed in Paragraph (A).
   TEX. OCC. CODE § 801.002(5). To practice lawfully, the veterinarian must
   have “sufficient knowledge of the animal,” which is defined as either having
   recently examined the animal or having visited the “premises on which the
   animal is kept.” § 801.351(b). “A veterinarian-client-patient relationship
   may not be established solely by telephone or electronic means.”
   § 801.351(c). Violations of these limitations are criminal offenses. § 801.504.
          In 2012, the Texas State Board of Veterinary Medical Examiners
   investigated Hines and found he had violated state law. The Board ordered
   him to cease providing veterinary advice electronically without physically
   examining the animal.

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          In 2013, Hines filed suit against the Board members in the United
   States District Court for the Southern District of Texas. He argued that
   Texas’s physical-examination requirement violated his First Amendment,
   equal-protection, and substantive-due-process rights. The defendants filed a
   Rule 12(b)(6) motion to dismiss, which the district court granted in part.
   Hines v. Alldredge, No. 1:13-CV-56, 2014 WL 11320417, at *8 (S.D. Tex. Feb.
   11, 2014). On appeal, though, this court held that all of Hines’s claims failed
   to state a claim. Hines v. Alldredge (Hines I), 783 F.3d 197 (5th Cir. 2015).
          Some things have changed since our 2015 opinion. In 2017, Texas
   revised statutes applicable to medical doctors, but not veterinarians, and
   allowed them to engage in some forms of telemedicine. The law removed
   Section 111.004(5), which had required face-to-face consultations to establish
   a physician–patient relationship before engaging in any telemedical services.
   Act of May 29, 2017, 85th Leg., R.S., ch. 205, § 2, 2017 Tex. Gen. Laws 379,
   380. The bill also added a new section to define what a practitioner–patient
   relationship looks like in the context of telemedicine. Id. (codified at Tex.
   Occ. Code § 111.005).
          Then, in 2018, the United States Supreme Court decided National
   Institute of Family & Life Advocates v. Becerra (NIFLA), 138 S. Ct. 2361 (2018).
   That case dealt with a California law requiring licensed and unlicensed crisis
   pregnancy centers to notify women about California’s low-cost services,
   including abortions.     Id. at 2368.       The Ninth Circuit upheld these
   requirements as regulations of “professional speech.” Id. at 2371. The
   Supreme Court reversed, holding the notice requirements were
   unconstitutional. Id. at 2370.
          Hines filed the present suit on October 2, 2018, in the United States
   District Court for the Southern District of Texas. Based on the change in
   Texas’s telemedicine law, Hines brought a new equal-protection claim.
   Reading NIFLA as abrogating the professional-speech doctrine, Hines also

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   asserts his First Amendment claims anew. The defendants moved for
   dismissal on December 14, and the district court granted the motion on June
   11, 2019. Hines timely filed a notice of appeal.

                                     DISCUSSION
          We review the district court’s dismissal under Rule 12(b)(6) de novo.
   Cuvillier v. Taylor, 503 F.3d 397, 401 (5th Cir. 2007). “To survive a motion
   to dismiss, a complaint must contain sufficient factual matter, accepted as
   true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal,
   556 U.S. 662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544,
   570 (2007)). This case involves two independent issues, one under the First
   Amendment and the other under the Equal Protection Clause of the
   Fourteenth Amendment. We analyze them separately.
   I.     First Amendment
          Hines admits that unless NIFLA abrogated Hines I, his claims are
   foreclosed. The parties ask the court to apply the “mode of analysis” test to
   determine whether NIFLA abrogated Hines I. Stokes v. S.W. Airlines, 887
   F.3d 199, 204 (5th Cir. 2018). They disagree on how that test should be
   applied here.
          Under the rule of orderliness, “one panel may not overrule [a prior]
   decision, right or wrong” unless there is an intervening change of authority.
   Soc’y of Separationists, Inc. v. Herman, 939 F.2d 1207, 1211 (5th Cir. 1991).
   “[W]hen the Supreme Court expressly or implicitly overrules one of our
   precedents, we have the authority and obligation to declare and implement
   this change in the law.” Stokes, 887 F.3d at 204 (emphasis added) (quotation
   marks omitted). One example of such overruling is “when the Supreme
   Court disavows the mode of analysis on which our precedent relied.” Id. Put
   another way, “Fifth Circuit precedent is implicitly overruled if a subsequent

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   Supreme Court opinion establishes a rule of law inconsistent with that
   precedent.” Gahagan v. U.S. Citizenship & Immigr. Servs., 911 F.3d 298, 302
   (5th Cir. 2018) (quotation marks omitted). However, “an intervening
   change in the law must be unequivocal, not a mere ‘hint’ of how the
   [Supreme] Court might rule in the future.” United States v. Alcantar, 733
   F.3d 143, 146 (5th Cir. 2013). “[M]ere illumination of a case is insufficient”
   to abrogate our circuit precedent. United States v. Petras, 879 F.3d 155, 164
   (5th Cir. 2018). Relatedly, “the determination whether a given precedent
   has been abrogated is itself a determination subject to the rule of
   orderliness.” Stokes, 887 F.3d at 205.
          After oral argument, another panel of this court issued its opinion in
   Vizaline, L.L.C. v. Tracy, 949 F.3d 927 (5th Cir. 2020). Hines asserts in a
   Rule 28(j) letter that Vizaline resolved whether NIFLA abrogated Hines I.
   The defendants respond that Vizaline abrogated Hines I only to the extent it
   relied on the professional-speech doctrine, but it left the incidental-burden
   doctrine untouched. Id. at 930, 934.
          Vizaline addressed a challenge to Mississippi’s licensing of surveyors.
   Id. at 928. The court stated that NIFLA “disavowed the notion that
   occupational-licensing regulations are exempt from First Amendment
   scrutiny.” Id. The Vizaline court then stated in a footnote: “Our decision in
   Hines v. Alldredge, 783 F.3d 197, 202 (5th Cir. 2015), adopted the professional
   speech doctrine. As explained below, Hines’ reasoning does not survive
   NIFLA.” Id. at 928 n.1. The district court in Vizaline had viewed the
   surveyor regulations as restricting conduct rather than speech, and only
   incidentally infringing on speech, so the district court said claims about the
   regulations were not entitled to any First Amendment scrutiny. Id. at 933.
   The Vizaline court disagreed, holding that general licensing regulations are
   not automatically immune from First Amendment scrutiny. Id. at 934. Thus,

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   the court reversed and remanded for the proper conduct-versus-speech
   analysis. Id.
          In Stokes, we held that circuit precedent was unequivocally abrogated
   by Supreme Court precedent. 887 F.3d at 204–05. One party argued,
   though, that one of our cases after the Supreme Court’s intervening decision
   reaffirmed our earlier caselaw.       Id. at 205.      We admitted that “the
   determination whether a given precedent has been abrogated is itself a
   determination subject to the rule of orderliness.” Id. The case relied upon
   by the party, though, was unpublished, and regardless did not appear to
   reaffirm our prior rule. Id.
          Unlike in Stokes, we are presented with a precedential opinion that
   held NIFLA abrogated Hines I. As explained in Stokes, we are to follow a
   prior panel’s determination of whether a Supreme Court case abrogated one
   of our rules. Vizaline, therefore, is our guide.
          Bound by Vizaline, we are no longer bound by Hines I. That means
   Hines’ First Amendment claims may be entitled to greater judicial scrutiny
   than Hines I allowed. The court concluded that “the relevant question is
   whether” the state’s “licensing requirements regulate only speech, restrict
   speech only incidentally to their regulation of non-expressive professional
   conduct, or regulate only non-expressive conduct.” Vizaline, 949 F.3d at
   931. Vizaline declined to give an opinion “on whether the Texas regulation
   at issue in Hines would have been upheld under the proper conduct-versus-
   speech analysis.” Id. at 934 n.9. As the Vizaline court did, we reverse and
   remand for the district court to make the initial evaluation of whether
   conduct or speech is being regulated. Id. at 934.
   II.    Equal Protection
          In Hines I, we addressed a slightly different equal-protection question
   from the one before us now. Hines’ original claim was predicated on the idea

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   that the physical-examination requirement treated veterinarians engaging in
   telemedicine differently than other veterinarians. Hines, 2014 WL 11320417,
   at *5. We rejected this claim, holding:
           [T]he requirement that veterinary care be provided only after
           the veterinarian has seen the animal is, at a minimum, rational:
           it is reasonable to conclude that the quality of care will be
           higher, and the risk of misdiagnosis and improper treatment
           lower, if the veterinarian physically examines the animal in
           question before treating it.
   Hines I, 783 F.3d at 203. Hines’ new claim rests on treating medical doctors
   differently than veterinarians as to their right to engage in telemedicine. 1
           To state a claim for equal protection, “the plaintiff must prove that
   similarly situated individuals were treated differently.” Beeler v. Rounsavall,
   328 F.3d 813, 816 (5th Cir. 2003) (quoting Bryan v. City of Madison, 213 F.3d
   267, 276 (5th Cir. 2000)). Being similarly situated is key. “Because the
   clause’s protection reaches only dissimilar treatment among similar people,
   if the challenged government action does not appear to classify or distinguish
   between two or more relevant persons or groups, then the action does not
   deny equal protection of the laws.” Mahone v. Addicks Util. Dist. of Harris
   Cnty., 836 F.2d 921, 932 (5th Cir. 1988). On appeal, the State does not
   challenge the similarly situated element of the equal-protection claim, and we
   will assume without deciding that it is met. Because Hines is not a member
   of suspect class, we consider whether the “classification rationally further[s]

           1
             Texas’s law for medical doctors does not allow all forms of telemedicine. Section
   111.005 provides that a practitioner–patient relationship may exist and thus allow
   telemedicine services when there is a preexisting relationship, or the practitioner can use
   either synchronous or asynchronous audiovisual technology to interact with the patient.
   TEX. OCC. CODE § 111.005. Thus, even if Texas had the same telemedicine
   requirements for both doctors and veterinarians, Hines would not be allowed to give
   individualized advice over non-audiovisual technology like phone or email. The chasm
   between medical doctors and veterinarians, therefore, is not quite as wide as Hines
   suggests.

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   a legitimate state interest.” Nordlinger v. Hahn, 505 U.S. 1, 10 (1992). When
   we apply rational basis at the failure-to-state-a-claim stage, we must treat a
   legislative classification “as valid ‘if a court is able to hypothesize a legitimate
   purpose to support the action.’” Glass v. Paxton, 900 F.3d 233, 245 (5th Cir.
   2018) (quoting Mahone, 836 F.2d at 934).
            Behind the Equal Protection Clause is the principle that government
   action should not be arbitrary. See Vill. of Willowbrook v. Olech, 528 U.S. 562,
   564 (2000). Rational-basis review is guided by the principle that we do not
   have “a license . . . to judge the wisdom, fairness, or logic of legislative
   choices.” Heller v. Doe ex rel. Doe, 509 U.S. 312, 319 (1993) (quoting FCC v.
   Beach Commc’ns, Inc., 508 U.S. 307, 313 (1993)). “When social or economic
   legislation is at issue, the Equal Protection Clause allows the States wide
   latitude, and the Constitution presumes that even improvident decisions will
   eventually be rectified by the democratic processes.” City of Cleburne v.
   Cleburne Living Ctr., 473 U.S. 432, 440 (1985) (citations omitted).
   Accordingly, “[t]he constitutional test for rationality of a legislative
   classification, whether the classes be distinguished in the text of the law or in
   its administration, is whether any rational decisionmaker could have so
   classified.” Stern v. Tarrant Cnty. Hosp. Dist., 778 F.2d 1052, 1056 (5th Cir.
   1985).
            Though rational-basis review gives broad discretion to legislatures, it
   is not unlimited. The Supreme Court says to presume legislation is valid.
   City of Cleburne, 473 U.S. at 440. We have stated that to uphold a state’s
   classification, a court need find only “a conceivable rational basis for the
   official action.” Reid v. Rolling Fork Pub. Util. Dist., 854 F.2d 751, 754 (5th
   Cir. 1988) (emphasis omitted). Notably, however, we have made clear that
   “rational” still must be actually rational, not a matter of fiction. St. Joseph
   Abbey v. Castille, 712 F.3d 215, 223 (5th Cir. 2013).

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          We examine our opinion in St. Joseph Abbey closely because it provides
   a recent and thorough explanation. There, we considered a district court’s
   order enjoining the enforcement of a Louisiana rule that granted funeral
   homes the exclusive right to sell caskets. Id. at 217. A group of monks at an
   abbey constructed and sold wooden caskets. Id. This practice violated the
   state’s rule that only a state-licensed funeral director of a state-licensed
   funeral home could sell caskets to people in the state. Id. at 218. The abbey
   sued, seeking declaratory and injunctive relief based on theories of
   substantive due process and equal protection. Id. at 220. The state argued
   that economic protection of the funeral industry was a legitimate state
   interest, but after a bench trial, the district court disagreed. Id. Applying
   rational-basis review, we affirmed. Id. at 227.
          We explained that “although rational basis review places no
   affirmative evidentiary burden on the government, plaintiffs may nonetheless
   negate a seemingly plausible basis for the law by adducing evidence of
   irrationality.” Id. at 223. We compared the state’s offered rationale to the
   setting and history of the challenged rule. Id. The state’s first articulated
   reason was economic protection of a discrete industry. Id. at 221. We held,
   though, that pure economic protectionism is not by itself a legitimate state
   interest. Id. at 222–23. A law motivated by protectionism may have a rational
   basis, but “naked economic preferences are impermissible to the extent that
   they harm consumers.” Id. at 223 (quoting Greater Hous. Small Taxicab Co.
   Owners Ass’n v. City of Hous., 660 F.3d 235, 240 (5th Cir. 2011)).
          The state had two additional reasons for the casket rule: consumer
   protection and public health and safety. Id. at 223, 226. The state argued
   that by controlling who could sell caskets, it could police deceptive sales
   tactics and thus protect consumers. Id. at 223. We held that this reasoning
   was irrational. The state did not require individuals to be buried in caskets,
   and the Federal Trade Commission found no evidence of consumer

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   deception by third-party casket sellers. Id. at 225. Overall, the structure of
   the law revealed a “disconnect between the post hoc hypothesis of consumer
   protection and the grant of an exclusive right of sale to funeral homes.” Id.
   at 226. As for health and safety, we found the reason disconnected from
   reality. Id. The state did not require caskets to be constructed a certain way
   nor did the state require funeral directors to have special expertise about
   caskets. Id. Accordingly, there was no rational relationship “between public
   health and safety and limiting intrastate sales of caskets to funeral
   establishments.” Id.
          “A hypothetical rationale, even post hoc, cannot be fantasy.” Id. at
   223. “[G]reat deference due state economic regulation does not demand
   judicial blindness to the history of a challenged rule or the context of its
   adoption nor does it require courts to accept nonsensical explanations for
   regulation.” Id. at 226. In the end, all that was left of the state’s motivation
   was economic protectionism that actually seemed to harm consumers. See
   id. at 226–27. Despite “try[ing] as we [were] required to do, we c[ould]
   suppose” no rational basis for the challenged law. Id. at 227. We upheld the
   district court’s injunction against the state’s actions against the abbey. Id.
          We do not read St. Joseph Abbey to hold that a plaintiff alleging an
   equal-protection claim is always entitled to present evidence and make it
   beyond the motion-to-dismiss stage. Indeed, such a reading would ignore
   that a state is not required “to produce evidence to sustain the rationality of
   a statutory classification.” Heller, 509 U.S. at 320. St. Joseph Abbey dealt
   with a “purported rational basis that rose to the level of ‘fantasy.’” Glass,
   900 F.3d at 245 (quoting St. Joseph Abbey, 712 F.3d at 223). In addition, the
   court tried to conceive other potentially rational bases but could not think of
   any. St. Joseph Abbey, 712 F.3d at 227. We do not consider St. Joseph Abbey
   to have altered how we conduct rational-basis review; instead, it thoroughly
   applied that standard of review to an irrational law.

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          Turning now to the statute before us, we remind ourselves that it was
   rational for the state legislature to conclude that an in-person examination of
   an animal reduces “the risk of misdiagnosis and improper treatment.” Hines
   I, 783 F.3d at 203. Hines contends that Texas’s new telemedicine law shows
   our prior conclusion was misguided because Texas now believes expanding
   telemedical services for humans will improve overall care. To the extent
   Hines is claiming that there is a disparity between care for animals that do not
   have access to in-person veterinary care and care for animals that do, that
   claim is foreclosed by our prior opinion. We will not consider anew the
   rationality of treating veterinarians engaging in telemedicine differently than
   veterinarians practicing in person. The new issue is equal protection for the
   State’s choice to allow doctors who treat humans to engage in telemedicine
   but not doctors who treat animals.
          Hines tries to rebut a number of conceivable justifications for
   regulating telemedicine differently than televeterinary services. The State
   offers several reasons why Texas would treat veterinarians and medical
   doctors differently, citing several of the reasons conceived by the district
   court. “[H]umans ordinarily can communicate about their own symptoms
   with a doctor via electronic means, whereas animals cannot.” Additionally,
   “humans typically understand human physiology better than animal
   physiology.” Hines rejects these reasons by identifying inconsistencies such
   as the fact that some humans, like infants, are also unable to speak.
          A classification may be underinclusive or overinclusive and yet
   survive rational-basis review. Harris v. Hahn, 827 F.3d 359, 369 (5th Cir.
   2016). The Constitution does not require perfect policies to achieve a state’s
   legitimate interests. Id. “When a legislature has a choice of means, each
   rationally related to its legislative purpose, it may constitutionally choose any
   of them. Its choice of one does not render the others irrational.” Stern, 778
   F.2d at 1056. That Texas has taken a different approach for medical doctors

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   and for veterinarians is not per se irrational. Id. We find helpful our now-
   colleague’s analysis in a Texas Supreme Court opinion:
                  It is instructive to consider the U.S. Supreme Court’s
          first occupational licensing case, from 1889. In Dent v. West
          Virginia — which has never been overruled and is still cited
          approvingly — the Court upheld a physician-licensing regime,
          calling it a way to protect “the general welfare of [the] people”
          and “secure them against the consequences of ignorance and
          incapacity, as well as of deception and fraud.” But the Court
          cautioned that constitutional limits exist. Government is free
          to mandate requirements “appropriate to the calling or
          profession,” but not those that “have no relation to such
          calling or profession.” Why? Because that would “deprive
          one of his right to pursue a lawful vocation.” Restrictions must
          have a reasonable connection to the person’s fitness or
          capacity. That explains the High Court’s 1957 ruling in
          Schware v. Board of Bar Examiners, the only time the Court has
          struck down a licensing restriction under rational-basis review.
          In Schware, the Court invalidated New Mexico’s attempt to bar
          a Communist Party member from practicing law: “any
          qualification must have a rational connection with the
          applicant’s fitness or capacity to practice.”
   Patel v. Tex. Dep’t of Licensing & Regul., 469 S.W.3d 69, 110–11 (Tex. 2015)
   (Willett, J., concurring) (footnotes omitted). The key is rational connection.
          We agree with the State here that it is rational to distinguish between
   humans and animals based on the species’ differing capabilities. More to the
   point, though, the law’s differentiating between medical doctors and
   veterinarians is a logical distinction, unlike the artificial line-drawing of the
   casket rule considered in St. Joseph Abbey. Texas’s statutory requirements
   for medical doctors are found in Title 3 of the Texas Occupations Code, while
   the requirements for veterinarians are in Title 4. The occupations have
   different governing boards and rulemaking bodies. They require different
   schooling. They treat different subjects, and the treatment sometimes differs

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   substantially. The professions have their similarities, of course, but in our
   inquiry, there are rational reasons to believe regulations suitable for one
   profession are not constitutionally required for the other.
          One Texas appellate court considered whether the Texas Medical
   Liability and Insurance Improvement Act applied to veterinarians. Neasbitt
   v. Warren, 22 S.W.3d 107, 108 (Tex. App.—Fort Worth 2000, no pet.). The
   defendant in the negligence action, a veterinarian, sought a cost bond under
   the medical liability law, which on its face applied only to health care
   providers or physicians. Id. Observing the different statutory schemes for
   physicians and veterinarians, the court held that the liability law did not apply
   to the claim against the veterinarian. Id. at 112. The court stated, “The
   reality that physicians and veterinarians have traditionally been licensed and
   regulated by entirely separate state boards and under entirely different
   statutes provides further support for differentiating between the two
   professions.” Id. at 111. We agree with that sentiment.
          Moreover, unlike the challenged law in St. Joseph Abbey, the physical-
   examination requirement for veterinarians is not a protectionist measure
   designed to stop veterinarians from competing with medical doctors. See St.
   Joseph Abbey, 712 F.3d at 226–27. Indeed, medical services are not an
   economic substitute for veterinarian services. That means the services are
   not interchangeable. In the antitrust-law context, we could say that the two
   services are not part of the same relevant product market, competing against
   one another. Apani S.W., Inc. v. Coca-Cola Enters., Inc., 300 F.3d 620, 626
   (5th Cir. 2002).     Our takeaway is that Texas’s physical-examination
   requirement is not a “naked transfer of wealth” from veterinarians to
   medical doctors because those two professions are not in competition with
   one another to begin with. See St. Joseph Abbey, 712 F.3d at 223. The state-
   licensed funeral homes could raise prices on caskets because of the state’s
   rule disallowing the abbey from selling caskets in state. See id. at 226. By

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   contrast, physicians practicing telemedicine are not able to raise prices due
   to the regulations on veterinarians’ practice of telemedicine.
          It is not irrational for a state to change in stages its licensing laws to
   adapt to our new, technology-based economy. If the Texas legislature finds
   the recently enacted changes on telemedicine successful, it may decide to
   expand those changes to include veterinarians. It is reasonable to have a trial
   period rather than to make a hasty policy change. Though we could conceive
   no rational basis for the law challenged in St. Joseph Abbey, we can conceive
   many rational bases here. The district court properly dismissed Hines’
   equal-protection claim.
          We AFFIRM in part, REVERSE in part, and REMAND for
   further proceedings.

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   Jennifer Walker Elrod, Circuit Judge, concurring in part 1 and
   dissenting in part:
            To prevail at this stage, Dr. Hines must show only that Texas lacks a
   rational basis for prohibiting veterinarians from using telemedicine the same
   way medical doctors can. Because I believe Dr. Hines has made this showing,
   I would reverse the district court’s dismissal of Dr. Hines’s Equal Protection
   claim.
            Under Texas law, a veterinarian must either examine an animal
   directly or visit the premises on which the animal is kept before establishing
   a patient relationship. Tex. Occ. Code § 801.351(b). Only after doing one of
   those two things may a veterinarian treat an animal via virtual means.
   Medical doctors, on the other hand, may form a patient relationship entirely
   through virtual means. Dr. Hines contends that Texas’s different and more
   burdensome requirement for veterinarians practicing telemedicine compared
   to medical doctors practicing telemedicine violates the Fourteenth
   Amendment’s guarantee of equal protection of the laws.
            The Equal Protection clause forbids the Government from giving
   differential treatment to people who are similarly situated, unless the
   Government has a rational basis for doing so. See Nordlinger v. Hahn, 505
   U.S. 1, 10 (1992); Gibson v. Tex. Dep’t of Ins.—Div. of Workers’ Comp., 700
   F.3d 227, 238 (5th Cir. 2012). Here, the only question is whether, accepting
   as true all well-pleaded facts in Dr. Hines’s complaint, he has plausibly
   alleged that he has been treated differently than other similarly situated

            1
             I agree with the majority opinion that the case should be remanded to the district
   court so that the regulation at issue can be evaluated under National Institute Of Family &
   Life Advocates v. Becerra, 138 S. Ct. 2361 (2018) and Vizaline L.L.C. v. Tracy, 949 F.3d 927
   (5th Cir. 2020).

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   individuals and he has plausibly alleged that no rational basis accounts for the
   difference. In my view, Dr. Hines has done so and thus, has stated a claim.
           The district court concluded that doctors and veterinarians are
   similarly situated for the narrow purpose of analyzing the laws that concern
   telemedicine. As the district court acknowledged, doctors and veterinarians
   belong to different professions. Nevertheless, both groups provide medical
   advice to living subjects and the benefits and drawbacks of expanding access
   to medical care through telemedicine are the same for both groups.
           While the majority opinion purports to assume that doctors and
   veterinarians are similarly situated with respect to telemedicine laws, since
   this issue was not appealed, the opinion’s analysis places great weight on
   differences between the professions that go to the “similarly situated”
   element. For instance, the majority opinion notes that the occupations have
   different governing boards and rulemaking bodies and that they attend
   different types of educational institutions for their training. However, the
   district court expressly considered that “doctors and veterinarians are
   subject to different licensing boards and are considered separate professions”
   when it decided that that the “similarly situated” element was met. The
   majority opinion “assumes” this holding but then undercuts it to support the
   conclusion that Texas’s telemedicine laws pass rational basis review. I agree
   with the magistrate judge and district court that veterinarians and doctors are
   similarly situated regarding regulation of their use of telemedicine.
           I would further hold that the state has failed to demonstrate a rational
   basis for their disparate regulation, at least at this stage of litigation. 2 When
   we conduct a rational basis review, legislation is presumed valid, but a
   presumption is not a guarantee. See City of Cleburne v. Cleburne Living Ctr.,

           2
            The magistrate judge concluded that Texas lacked a rational basis, but the district
   court held that Texas did have a rational basis.

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                                     No. 19-40605

   473 U.S. 432, 440 (1985); St. Joseph Abbey v. Castille, 712 F.3d 215, 223 (5th
   Cir. 2013).    “[A]lthough rational basis review places no affirmative
   evidentiary burden on the government, plaintiffs may nonetheless negate a
   seemingly plausible basis for the law by adducing evidence of irrationality.”
   St. Joseph Abbey, 712 F.3d at 223. A “hypothetical rationale, even post hoc,
   cannot be fantasy.” Id. When a plaintiff provides a court with undisputed
   context that betrays the otherwise rational basis the state has offered, the
   state can no longer expect the court’s deference. Rational basis review is a
   level of scrutiny, not a rubber-stamping exercise. See Harris Cty. v. CarMax
   Auto Superstores Inc., 177 F.3d 306, 323 (5th Cir. 1999) (“[T]he rational basis
   test ‘is not a toothless one.’”) (quoting Mathews v. Lucas, 427 U.S. 495, 510
   (1976)).
          St. Joseph Abbey was a recent and standard application of rational basis
   review in action. In that case, an abbey of Benedictine monks who sold
   handcrafted caskets challenged the state of Louisiana’s rules that allowed
   only state-licensed funeral homes to sell caskets to people in Louisiana. St.
   Joseph Abbey, 712 F.3d at 217–18. Louisiana offered three seemingly plausible
   bases for the challenged rules: economic protection of the funeral industry,
   consumer protection for casket purchasers, and public health and safety for
   casket purchasers. As to the first rationale, our court in St. Joseph Abbey ruled
   that economic protection of a favored industry is not, on its face, a legitimate
   state interest. Id. at 222–23. As to the second and third rationales, both were
   seemingly plausible. If all rational basis review required was the offering or
   conjecture of a seemingly plausible basis, the court could have stopped there
   and dismissed the monks’ claim.
          Instead, the court considered the context that the monks put forward,
   which negated both of the state’s bases. For instance, regarding “health and
   safety,” the monks pointed out that Louisiana did not require caskets for
   burial, did not impose requirements for their construction or design, did not

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   require a casket to be sealed before burial, and did not require funeral
   directors to have any special expertise in caskets. Id. at 223–27. These facts
   fatally undermined the logic of Louisiana’s “health and safety” basis for
   permitting only funeral homes to sell caskets to in-state customers. 3
           St. Joseph Abbey does not mean, as perhaps the majority opinion fears,
   that Equal Protection claims can never be dismissed at the 12(b)(6) stage or
   that survival of a claim at the 12(b)(6) stage is equivalent to a judgment as a
   matter of law in favor of the plaintiff. In cases where the state provides a
   rational basis for the challenged law and the plaintiffs are unable to negate the
   basis, the case will be dismissed. But where the state provides only a
   theoretically plausible rationale and the plaintiff is successful in affirmatively
   undermining the logic that makes that basis rational, then the claim can
   proceed to an evidentiary stage. In that stage, the state may be able to provide
   evidence or better argumentation that rehabilitates their bases for the
   challenged law or supports new bases. If the state does so, the Equal
   Protection claim later may be dismissed before trial, even though the claim
   survived a motion to dismiss.
           In this case, like in St. Joseph Abbey, the state has offered several
   seemingly plausible bases for its differential treatment of veterinarians and

           3
              Our precedent contains many more examples of cases where state laws or
   regulations have failed rational basis review. See, e.g., Doe v. Plyler, 628 F.2d 448, 458 (5th
   Cir. 1980), aff’d 457 U.S. 202 (1982) (holding that a Texas statute that had been applied so
   as to deny free public education to children based on their undocumented status violated
   the Equal Protection clause, despite the school district’s asserted justifications); Thompson
   v. Gallagher, 489 F.2d 443, 449 (5th Cir. 1973) (holding that city ordinance requiring that
   any veteran employed by the city have an honorable discharge was not reasonably related
   to the city’s interest in maintaining the quality of its work force, in part because it subjected
   veterans to standards to which nonveterans were not subjected).

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   doctors. However, Dr. Hines has offered context that belies the rationality
   of these differences. 4
           Texas provided three potential rational bases for the differential
   treatment: First, humans’ ability to communicate with their physicians
   enables them to receive better telemedical care than animals. Second, humans
   are more familiar with human physiology and can describe it to the doctor.
   Third, having higher standards for telemedicine for animals is rational
   because of the importance of preventing the spread of zoonotic disease,
   which can pass to humans.
           The magistrate judge concluded that the state’s rationales were
   irrational, and aptly explained why in his report and recommendation:
           If a pediatrician can use telemedicine to treat a three-month old
           infant—based upon medical records, the parent’s description

           4
             The majority believes the holding of Hines v. Alldredge, 783 F.3d 197, 203 (5th Cir.
   2015) (Hines I) has a preclusive effect on our rational basis review of the telemedicine
   restrictions for veterinarians. Dr. Hines challenged the restriction on Equal Protection
   grounds in his 2013 lawsuit, Hines I, on the basis that he was treated irrationally, being a
   duly licensed veterinarian but forbidden from providing veterinary advice like his
   colleagues who ran brick-and-mortar clinics. The Fifth Circuit rejected the challenge,
   concluding: “it is reasonable to conclude that the quality of care will be higher, and the risk
   of misdiagnosis and improper treatment lower, if the veterinarian physically examines the
   animal in question before treating it.” Hines I, 783 F.3d at 203.
            But the situation has since changed. When Dr. Hines brought his initial suit,
   doctors and veterinarians were treated similarly with respect to their practice of
   telemedicine. In 2017, the Texas legislature revised the statutes applicable to medical
   doctors and removed their restriction, allowing medical doctors to establish a doctor-
   patient relationship solely through electronic means. Veterinarians, however, remained
   subject to the restriction requiring an in-person visit before providing telemedical care. The
   2017 revision to statutes regulating medical doctors changes the posture of this case and
   the effect of Hines I. In short, the holding of Hines I was based on a premise that is no longer
   true: that Texas believes the risks of telemedicine without an initial in-person visit
   outweigh the potential benefits of increased access. We are not bound to again uphold the
   telemedicine restriction merely because it was upheld previously under different
   circumstances.

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                                           No. 19-40605

           of external symptoms and a visual examination of the child—
           the Court cannot adduce why a veterinarian cannot do the
           same for a dog, cat, or hamster.
   As Dr. Hines argues, “[i]t simply is not rational to allow telemedicine
   without a physical examination for babies but deny the same form of
   telemedicine for puppies on the ground that puppies cannot speak.” 5 Babies
   and other non-communicative adults were intentional beneficiaries of
   Texas’s expansion of telemedicine, not the subjects of unwitting
   overinclusion. Texas has never shown a preference for animals over humans
   that would support requiring higher standards for animals’ medical
   treatment. Cf. Strickland v. Medlen, 397 S.W.3d 184, 185 (Tex. 2013)
   (Willett, J.) (holding that dog owners could not recover non-economic
   damages for loss of companionship under Texas tort law because “[p]ets are
   property in the eyes of the law.”).
           Although the rational basis test is deferential, it does not require us to
   accept “nonsensical explanations for regulation.” St. Joseph Abbey, 712 F.3d

           5
             In my view, the magistrate judge’s reasoning is fatal to both the state’s first and
   second rationales. The district court disagreed, accepting both. The district court then
   considered in greater detail and accepted the state’s third rationale that requiring
   veterinarians to physically examine an animal before subsequently treating that animal via
   telemedicine can improve human health by suppressing zoonotic disease. However, this
   rationale simply is not based in reality, considering that the restriction on telemedicine does
   not actually require a veterinarian to inspect an animal for disease during an initial
   examination or even, in fact, require an in-person examination of each animal. A
   veterinarian can begin a veterinarian-patient relationship with an animal as long as he or
   she has visited the premises on which the animal is kept. See Tex. Occ. Code § 801.351(b).
   Furthermore, this theoretical rationale is again betrayed by the fact that medical doctors
   establishing a doctor-patient relationship are not required to physically examine their
   human subjects at all, despite the fact that human-to-human transmission of diseases poses
   a far greater risk to human health. If the state’s goal was to reduce diseases affecting
   humans, the existing telemedicine restriction on veterinarians would be a fantastical means
   of achieving it.

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   at 226. The magistrate judge correctly concluded that Texas’s explanations
   are indeed nonsensical. I therefore respectfully dissent.

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