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June Medical Services LLC v. Kliebert

United States District Court, M.D. Louisiana

April 26, 2017

JUNE MEDICAL SERVICES LLC d/b/a HOPE MEDICAL GROUP FOR WOMEN, on behalf of its patients, physicians, and staff; BOSSIER CITY MEDICAL SUITE, on behalf of its patients, physicians, and staff; CHOICE, INC., OF TEXAS, d/b/a CAUSEWAY MEDICAL CLINIC, on behalf of its patients, physicians, and staff, JOHN DOE 1, M.D., AND JOHN DOE 2, M.D.
v.
KATHY KLIEBERT, in her official capacity as Secretary of the Louisiana Department of Health and Hospitals and MARK HENRY DAWSON, M.D., in his official capacity as President of the Louisiana State Board of Medical Examiners

FINDINGS OF FACTS AND CONCLUSIONS OF LAW

          JOHN W. deGRAVELLES JUDGE.

         TABLE OF CONTENTS

         OVERVIEW - 1

         I. Introduction - 1

         FINDINGS OF FACT - 11

         II. Background and Procedural History - 11

         III. Contentions of the Parties - 18

         IV. The Factual Issues - 19

         V. Abortion in Louisiana - 20

         A. Generally - 20

         B. The Clinics - 21

         (1) Hope - 21

         (2) Bossier - 21

         (3) Causeway - 22

         (4) Women's Health -23

         (5) Delta - 23

         C. The Doctors - 24

         (1) Doe 1 - 24

         (2) Doe 2 - 25

         (3) Doe 3 - 26

         (4) Doe 4 - 27

         (5) Doe 5 - 27

         (6) Doe 6 - 28

         D. Admitting Privileges in Louisiana - 28

         E. The Climate - 41

         VI. Act 620 - 46

         A. Text of Act 620 and Related Provisions - 46

         B. Louisiana's Policy and Past Legislation Regarding Abortion - 48

         C. Drafting of Act 620 - 51

         D. Official Legislative History of Act 620 - 52

         VII. The Purpose and Medical Reasonableness of Act 620 - 56

         A. Expert Testimony - 58

         B. Abortion Safety - 61

         C. Requiring Abortion Practitioners to Obtain Admitting Privileges Confers No Medical Benefit - 67

         VIII. Efforts of Doctors to Comply With Act 620 and the Results of Those Efforts - 71

         A. Doe 1 - 71

         B. Doe 2 - 75

         C. Doe 3 - 86

         D. Doe 4 - 87

         E. Doe 5 - 88

         F. Doe 6 - 90

         G. Post-Trial Updates - 92

         IX. Effects of Act 620 - 92

         A. The Effect of Act 620 on Doe 1-6 - 92

         B. The Effect of Act 620 on the Clinics and Women of Louisiana - 97

         C. The Real-World Effect of Act 620 on Louisiana Women - 101

         CONCLUSIONS OF LAW - 105

         X. Summary of Legal Arguments - 105

         XI. Test for Determining the Constitutionality of Act 620 106

         XII. Analysis - 109

         A. Act 620 Does Not Protect Women's Health -109

         B. The Burdens Imposed by Act 620 - 111

         C. The Burdens Imposed by Act 620 Vastly Outweigh its Benefits - 113

         XIII. Conclusion - 113

         OVERVIEW

         I. Introduction

         Since this Court issued a preliminary injunction in this matter, the Supreme Court has held that the Fifth Circuit's interpretation of the undue burden test was incorrect. Whole Woman's Health v. Hellerstedt, 136 S.Ct. 2292, 2309 (2016) (hereinafter “WWH”) (“The Court of Appeals' articulation of the relevant standard is incorrect.”). In its ruling, this Court's conclusions of law applied the Fifth Circuit's legal standard, which WWH reversed. Specifically, this Court initially concluded, in line with Fifth Circuit precedent, that it could not consider evidence regarding whether the Act would actually serve its purported purpose to advance women's health and safety in practice, and could not weigh the Act's burdens against its benefits. (Doc. 216 ¶¶ 178, 333-35, 346, 351--52, 364--67, 372) (citing, inter alia, Whole Woman's Health v. Cole, 790 F.3d 563, 587 n.33 (5th Cir. 2015)). Accordingly, this Court ruled it could not resolve the parties' dispute over whether the Act is medically reasonable. (Id. ¶ 178(C) & n.41.)

         In addition, this Court held the undue burden test, as applied in the Fifth Circuit, precluded consideration of evidence rel ated to the challenges women would face in obtaining abortions under the Act in their “real-world” context. (Id. ¶¶ 340-43) (citing, inter alia, Cole, 790 F.3d at 589). This Court therefore did not consider evidence regarding how the Act, when considered in the real-world context of abortion patients' poverty and transportation challenges, providers' fear of anti-abortion violence, pre-existing regulations, and other obstacles to abortion access, would impose unique burdens on Louisiana women. (Id. ¶ 344.) The Supreme Court has now clarified that these facts should be considered when evaluating whether an abortion restriction is constitutional. See WWH, 136 S.Ct. at 2302, 2312-13.

         The Supreme Court held in WWH that restrictions on access to abortion before viability must be subject to meaningful judicial scrutiny: rational basis review is simply not enough when “regulation of a constitutionally protected personal liberty” is at issue. WWH, 136 S.Ct. at 2309. Rather, under the undue burden analysis, a restriction must be shown to actually “further” its purported interest, and it is constitutional only if its benefits outweigh its burdens. See Id. at 2309- 10. Additionally, in evaluating a restriction's benefits and burdens, courts must not simply defer to a State's assertions about any purported benefits or burdens, but must consider actual evidence. See Id. at 2310-12. The Court explained its reasons for rejecting the Fifth Circuit's analysis:

The rule announced in [Planned Parenthood of Southeast Pennsylvania v. Casey, 505 U.S. 833 (1992)] . . . requires that courts consider the burdens a law imposes on abortion access together with the benefits those laws confer. And the [Court of Appeals was] wrong to equate the judicial review applicable to the regulation of a constitutionally protected personal liberty with the less strict review applicable where, for example, economic legislation is at issue. The Court of Appeals' approach simply does not match the standard that this Court laid out in Casey, which asks courts to consider whether any burden imposed on abortion access is “undue.”

Id. at 2309-10 (citations omitted). Thus, WWH makes clear that courts have a “constitutional duty” to look beyond a State's assertions for restricting access to abortion to evaluate whether the restrictions at issue will actually advance any legitimate interests. Id. at 2310.

         Further, the Supreme Court specifically affirmed the relevance of evidence related to medical reasonableness and “real-world” conditions in evaluating a law's furtherance of its purported interest and its burdens on women seeking abortion. Id. at 2301-03, 2312-13. Thus, the Court recounted with favor the finding of the District Court that “[t]he great weight of evidence demonstrates that, before the act's passage, abortion in Texas was extremely safe with particularly low rates of serious complications and virtually no deaths occurring on account of the procedure.” Id. at 2302. It affirmed that abortion “has been shown to be much safer, in terms of minor and serious complications, than many common medical procedures not subject to such intense regulation and scrutiny, ” and that the challenged laws would not decrease risks, improve outcomes, or result in better care. Id. It also relied upon the district court's findings that the “requirements erect a particularly high barrier for poor, rural, or disadvantaged women.” Id. The Court also clarified that no single factor is determinative as to whether a restriction imposes an undue burden, but rather the burdens' impact must be evaluated cumulatively, and are undue if unjustified by the law's purported benefits. Id. at 2313.

         While this Court determined that the challenged Act was unconstitutional even under the Fifth Circuit's now-rejected interpretation of the undue burden test, as a result of the WHH decision, certain facts that Defendant argued were not legally relevant are now indisputably relevant and, indeed, critical to the constitutional analysis. To summarize, under WWH, this Court must consider (a) evidence regarding whether and how the restriction furthers the legislature's purported interest, which in this case, includes the Act's medical reasonableness, and (b) evidence regarding the actual burdens the restriction places on women seeking abortions. The Court must then assess the burdens and benefits of the restriction, and weigh the former against the latter to ensure that the burden the law imposes is not “undue.” A re-evaluation of certain of the Court's conclusions of law also necessarily flows from applying the standard articulated by the Supreme Court.

         By Order dated January 26, 2016 (Doc. 216), and following a trial during which extensive evidence was submitted into the record, this Court preliminarily enjoined Defendant Rebekah Gee, in her official capacity as Secretary of the Louisiana Department of Health and Hospitals, from enforcing Section A(2)(a) of Act Number 620, amending Louisiana Revised Statutes § 40:1299.35.2.3 (“the Act” or “Act 620”), [1] against Plaintiffs June Medical Services LLC, d/b/a Hope Medical Group for Women (“Hope” or “Hope Clinic”); Bossier City Medical Suite (“Bossier” or “Bossier Clinic”); Choice Inc., of Texas, d/b/a Causeway Medical Clinic (“Choice” or “Causeway”) (collectively, “Plaintiff Clinics”); Dr. John Doe, M.D. 1 (“Doe 1”)[2] and Dr. John Doe, M.D. 2 (“Doe 2”) (collectively, “Plaintiff Doctors”) (collectively, “Plaintiffs”). (Doc. 5.) Now before the Court are the parties' contentions with regard to a permanent injunction in this matter.

         The Court requested supplemental proposed findings of fact and conclusions of law from the parties on a permanent injunction following the parties' agreement that the Court may proceed to rule on the permanent injunction - including additional findings of fact and conclusions of law required by WWH - based on the existing record (Doc. 253). The parties further agreed that no further evidence is needed, apart from short stipulations submitted jointly by the parties and accepted by the Court, (Docs. 255, 265, 271), and an affidavit of Dr. Doe 2. (Doc. 272.) Therefore, pursuant to Federal Rule of Civil Procedure 65(a), and with the consent and agreement of the parties, the Court advances to the merits of the permanent injunction, consolidating it with the hearing on the preliminary injunction. The record from the preliminary injunction trial is part of the merits trial record, together with the stipulations of the parties.

         The hearing on the Motion for Preliminary Injunction was held from June 22, 2015, through June 29, 2015. (Docs. 163-64, 166, 169, 174.) At the hearing, the Court received evidence in the form of live witness testimony, exhibits, stipulations, and designated deposition testimony agreed by Plaintiffs and Defendant (collectively, “Parties”) to be received in lieu of certain witness' live testimony. Plaintiffs presented live testimony from the following witnesses:

- Doe 1;
- Doe 2;
- Doe 3;
- Ms. Kathaleen Pittman (“Pittman”), June's administrator; and
- Kliebert; and
- Three experts, specifically:
- Doctor Christopher M. Estes (“Estes”), Chief Medical Officer of Planned Parenthood of South Florida and the Treasure Coast, (PX 92);
- Doctor Sheila Katz (“Katz”), an assistant professor at the University of Houston, (JX 91); and
- Doctor Eva Karen Pressman (“Pressman”), the Henry A. Thiede Professor and Chair of The Department of Obstetrics and Gynecology at The University of Rochester, (PX 94).

         Defendant presented live testimony at trial from the following witnesses:

- Ms. Cecile Castello (“Castello”), Director of Health Standards Section (“HSS”) for DHH; and
- Three other experts, specifically:
- Doctor Robert Marier (“Marier”), Chairman of the Department of Hospital Medicine at Ochsner Medical Center in New Orleans, (DX 146);
- Doctor Tumulesh Kumar Singh Solanky (“Solanky”), a professor and the chair of the Mathematics Department at the University of New Orleans, (DX 148); and
- Doctor Damon Thomas Cudihy (“Cudihy”), an obstetrician-gynaecologist (“OB/GYN, ” “Ob/Gyn, ” “OBG, ” or “O&G”) currently licensed to practice medicine in Louisiana and Texas, (DX 147).

         A record of the exhibits admitted into evidence was filed. (Doc. 165.) A record of the deposition testimony designated by the Parties and offered into evidence was also docketed. (Doc. 168.[3]) In addition, the Parties submitted proposed findings of fact and conclusions of law, (Docs. 196, 200), and responses to each other's proposed findings and conclusions, (Docs. 201, 202). Additional stipulations of fact were submitted by the parties. (Docs. 224, 255, 265, 271.)

         In making the following findings of fact and conclusions of law, the Court has considered the record as a whole. The Court has observed the demeanor of witnesses and has carefully weighed their testimony and credibility in determining the facts of this case and drawing conclusions from those facts. All findings of fact contained herein that are more appropriately considered conclusions of law are to be so deemed.[4] Likewise, any conclusions of law more appropriately considered a finding of fact shall be so classified.[5]

         After having considered the evidence, briefing, and record as a whole, for the reasons which follow, the Court declares Act 620 unconstitutional in all of its applications, and enters a permanent injunction barring its enforcement. The active admitting privileges requirement of Section A(2)(a) of Act 620 is found to be a violation of the substantive due process right of Louisiana women to obtain an abortion, a right guaranteed by the Fourteenth Amendment of the United States Constitution as established in Roe v. Wade, 410 U.S. 113 (1973), and pursuant to the test first set forth in Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992) (“Casey”), and subsequently refined in Whole Woman's Health v. Hellerstedt, 136 S.Ct. 2292, 2319 (2016) (hereinafter “WWH”). Act 620 is therefore declared unconstitutional, and its enforcement enjoined in all of its applications.

         FINDINGS OF FACT

         II. Background and Procedural History

         1. Plaintiffs are:

- Hope, a licensed abortion clinic located in Shreveport, Louisiana, suing on behalf of its physicians, staff and patients;
- Bossier, a licensed abortion clinic located in Bossier City, Louisiana, suing on behalf of its physicians, staff, and patients;[6]
- Choice, a licensed abortion clinic suing on behalf of its physicians, staff, and patients;
- Doe 1, a physician licensed to practice medicine in the State of Louisiana and board-certified in Family Medicine and Addiction Medicine, suing on his own behalf and that of his patients; and
- Doe 2, a physician licensed to practice medicine in the State of Louisiana and board-certified in OB/GYN, suing on his own behalf and that of his patients.

         2. Dr. Rebekah Gee, (“Defendant, ” “Gee, ” or “Secretary, ”) is the Secretary of DHH.[7]Pursuant to § 40.2175.6, Gee “has the authority to revoke or deny clinics' licenses for violation of this or any other law.” (Doc. 109 at 5 (citing La. Rev. Stat. § 40:2175.6).)

         3. On August 22, 2014, Plaintiffs filed the Complaint for Declaratory and Injunctive Relief, (Doc. 1), and the Application, (Doc. 5), seeking to enjoin various defendants from enforcing Act 620's Section (A)(2)(a). (Doc. 5-2 at 2-5.)

         4. Act 620 has been codified at an amended Section 40:1299.35.2. La. R.S. § 40:1299.35.2. Section A(2)(a) requires every doctor who performs abortions in Louisiana to have “active admitting privileges” at a hospital within 30 miles of the facility where abortions are performed. Id. § 40:1299.35.2A(2)(a). While the Act contains other requirements, this provision is the only one being challenged. (Doc 5-1 at 8 n.1.) Act 620 was signed into law by the Governor of Louisiana, the Honorable Piyush “Bobby” Jindal (“Jindal” or “Governor”), on June 12, 2014. (Doc. 138 at 2; see also, e.g., H.B. 388, 2014 Leg., Reg. Sess. (La. 2014) (signed by Governor, June 12, 2014).) Its effective date was set as September 1, 2014. (See, e.g., Doc. 5-1 at 8; Doc. 5-2 at 6.) Shortly before trial, on April 20, 2015, DHH promulgated implementing regulations that include an admitting privileges requirement repeating the language of Act 620 and a penalty provision of $4, 000 per violation. La. Admin. Code tit. 48, pt. I, §§ 4401 (definition of “active admitting privileges”), 4423(B)(3)(e), available at 41 La. Reg. 685, 696 (Apr. 20. 2015). These were accompanied by a statement averring that they “will only be enforced pursuant to Order” in the present case. Id. The Order the Court issues today thus embraces these regulations as well as the Act itself.

         5. Hope is one of three remaining licensed abortion clinics in Louisiana still operating. (See, e.g., Doc. 109 ¶¶ 4-5; Doc. 14 ¶ 10 at 3.) It is located in Shreveport. Causeway was an abortion clinic in Metairie. On January 26, 2016, this Court entered a preliminary injunction that did not encompass Causeway's primary physician, Doe 4, who immediately ceased providing abortions. (Doc. 216, at 112; Doc. 255 ¶ 1.) The parties entered into a stipulation that would extend the injunction to him, which this Court so ordered on February 5, 2016. (Doc. 224.) Causeway closed permanently. (Doc. 255 ¶ 2.) It returned its license to DHH, effective February 10, 2016. (Doc. 255 ¶ 3.) Bossier was an abortion clinic in Bossier City. On or about March 30, 2017, Bossier ceased business and surrendered its license, returning it to DHH. (See Doc. 271.) Does 1 and 2 are two of five remaining physicians performing abortions in Louisiana. Doe 1 performs abortions at Hope; Doe 2 performed abortion at Bossier, and now performs abortions at Hope. (Doc. 109 ¶¶ 10-11; see also, e.g., Doc. 14 ¶¶ 14-15; Doc. 272 ¶ 3.) Doe 4 no longer offers abortion care in Louisiana. (Doc. 255 ¶ 1.)

         6. The Court issued the TRO on August 31, 2014, enjoining enforcement of Act 620 “until a hearing is held for the purpose of determining whether a preliminary injunction should issue.” (Doc. 31 at 18.) Per this order, Plaintiffs were expected to continue seeking admitting privileges at the relevant hospitals. (Id. at 1-2.) Thus, the Act would be allowed to take effect, but the Plaintiffs would not be subject to its penalties and sanctions for practicing without the relevant admitting privileges during the application process. (Id. at 2, 18.) The Plaintiff Clinics were allowed to operate lawfully while the Plaintiff Doctors continued their efforts to obtain privileges. (Id.)

         7. On September 19, 2014, three other plaintiffs-Women's Health Care Center, Inc. (“Women's Health” or “Women's Clinic”); Delta Clinic of Baton Rouge, Inc. (“Delta”); Doctor John Doe 5 (“Doe 5”); and Doctor John Doe 6 (“Doe 6”) (collectively, “Women's Health Plaintiffs”)-filed the Complaint for Declaratory and Injunctive Relief, thereby initiating a separate case, and a Motion for Preliminary Injunction. (Docs. 1, 5, No. 3:14-cv-00597-JWD-RLB.) On that same day, these parties tendered a motion to consolidate their case with this earlier proceeding. (Doc. 2, No. 3:14-cv-00597-JWD-RLB.) By this Court's order, these two cases were consolidated on September 24, 2014. (Doc. 8, No. 3:14-cv-00597-JWD-RLB.)

         8. All the Parties agreed in briefs and orally at a status conference held on September 30, 2014, that significant discovery would need to be done to prepare for the hearing; therefore, the Court set the preliminary injunction hearing for March 30, 2015. (Doc. 45.) A Joint Proposed Scheduling Order was submitted by the Parties on October 8, 2014, (Doc. 49), and adopted as this Court's order on October 21, 2014, (Doc. 56).

         9. On November 3, 2014, following the addition of the Women's Health Plaintiffs, this Court issued the Order Clarifying Temporary Restraining Order of August 31, 2014. (Doc. 57.) For the reasons given therein, the Court ruled: “It was and is the intention of this Court that the TRO remain in effect as to all parties before it until the end of the Preliminary Injunction Hearing.” (Id. at 6.)

         10. On December 5, 2014, the Women's Health Plaintiffs filed the Motion for Voluntary Dismissal. (Doc. 70.) With the consent of the Parties, the Court dismissed this suit without prejudice on December 14, 2014. (Doc. 77.) In light of that dismissal, the Court on January 15, 2015, issued the Second Order Clarifying Temporary Restraining Order of August 31, 2014. (Doc. 84.) In this order, for reasons explained therein, this Court ruled that “the TRO of August 31, 2014 (Doc. 31) remains in force until the Preliminary Injunction hearing on March 30, 2015 or as otherwise modified by this Court.” (Id. at 4.)

         11. On February 16, 2015, Defendants filed the Motion for Partial Summary Judgment (“Partial MSJ”), (Doc. 87), which was opposed, (Doc. 104). On February 24, 2015, Defendants filed an Unopposed Motion to Set Oral Argument on Motion for Partial Summary Judgment (Doc. 90.) On March 3, 2015, the Court granted that motion, (Doc. 92), and oral argument was set and heard on March 19, 2015, (Docs. 128, 137).

         12. On May 12, 2015, the Partial MSJ was granted in part, finding that under then-binding Fifth Circuit jurisprudence, the admitting privileges requirement of Act 620 was “rationally related” to a legitimate state interest. (Doc. 138 at 25.) In all other respects, the motion was denied. (Id.)[8]

         13. Based on a stipulation reached among the Parties, the Joint Motion to Dismiss Defendant Mark Dawson was filed on March 17, 2015, (Doc. 110), and granted the same day, (Doc. 111). On March 20, 2015, the Parties conferred with the Court and agreed to a continuance of the hearing on the preliminary injunction until the week of June 22, 2015. (Doc. 129.) The Parties agreed that the TRO would remain in effect until the completion of the trial and ruling on the merits of the preliminary injunction. (Id.)

         14. On April 1, 2015, oral argument was heard on motions in limine filed by the Parties. (Docs. 136, 151.) In the ruling issued that same day, the Court denied Plaintiffs' Motion in Limine to Preclude Expert Testimony of Dr. Tumulesh Solanky, (Doc. 96), and Defendant's Motion to Exclude Expert Testimony of Sheila Katz, Ph.D., (Doc. 99). (Doc. 136.) Plaintiffs' Motion in Limine to Preclude Expert Testimony of Dr. McMillan, (Doc. 97), was denied as moot. (Doc. 136.) Because of their connection to the Partial MSJ, Defendant's Motion in Limine to Exclude Irrelevant Evidence (“Defendant's Motion in Limine”), (Doc. 95), and Plaintiffs' Motion in Limine to Preclude Evidence of DHH Deficiency Reports and Related Evidence, (Doc. 98), were taken under advisement. (Doc. 136.) These two motions were ultimately denied. (Docs. 139, 140.)

         15. On June 11, 2015, Defendant filed the Motion to Reconsider Rulings on Summary Judgment and Motion in Limine. (Doc. 144.) Plaintiffs submitted their response in opposition on June 16, 2015. (Doc. 150.) Because this was submitted for consideration only six days before trial, the motion was taken under advisement and deferred to trial.

         16. Trial on the Motion for Preliminary Injunction began on June 22, 2015, and ended on June 29, 2015. (Docs. 163, 164, 166-69, 174). The Redacted Transcript[9] of the trial was later docketed.[10] (Docs. 190-95.) On January 26, 2016, the Court declared Act 620 facially unconstitutional and entered a preliminary injunction against enforcement of Act 620 as to the Plaintiffs - Hope, Bossier, Causeway and Does 1 and 2. (Doc. 216, at 111-112.) The parties stipulated that the injunction would also include Doe 4. (Docs. 224, 226.) The Court's judgment was entered on February 10, 2016 (Doc. 227) and Defendant filed her notice of appeal with the Fifth Circuit. (Doc. 228.) This Court denied Defendant's motions for a temporary stay and for a stay pending appeal (Doc. 229) on February 16, 2016 (Doc. 234).

         17. On February 24, 2016, the Fifth Circuit granted Defendant's emergency motion for a stay pending appeal, June Medical Services, L.L.C. v. Gee, 814 F.3d 319 (5th Cir. 2016), with the result that, for the first time, the admitting privileges requirement of Act 620 became enforceable, requiring doctors without active admitting privileges to stop providing abortion care, and clinics without such doctors on staff, to stop providing abortion services.

         18. On March 4, 2016, the United States Supreme Court granted Plaintiffs' emergency motion to vacate the Fifth Circuit's stay, reinstating this Court's preliminary injunction. June Med. Servs., L.L.C. v. Gee, 136 S.Ct. 1354 (2016).

         1 9 . On August 8, 2016, the parties agreed at a status conference that the Court could proceed to rule on a permanent injunction based on the existing evidentiary record and a stipulation regarding Causeway and Doe 4, following submission of supplementary proposed findings of fact and conclusions of law (Doc. 253). On August 24, 2016, the Fifth Circuit remanded Defendant's appeal “so that the district court can engage in additional fact finding required by the decision in Whole Woman's Health v. Hellerstedt.” (Doc. 254.)

         20. The Court today reaffirms its declaration that the admitting privileges requirement of Act 620 is unconstitutional on its face, and enters a permanent injunction barring enforcement of the law in all of its applications.

         III. Contentions of the Parties

         21. The Court acknowledges that the following summary of the parties' contentions reflects the parties' positions on issues of fact relating to preliminary, rather than permanent injunctive relief, and were made prior to the WWH decision. For the most part, however, the summary remains accurate. See Docs. 256 and 257-1.

         22. In broad terms, [11] Plaintiffs contend that Act 620 is facially[12] unconstitutional first, because the Act places an undue burden on the right of Louisiana women seeking an abortion by placing substantial obstacles in their path, (See, e.g., Doc. 202 at 46-53);[13] second, because the purpose of the Act is to create those obstacles, (see, e.g., id. at 53-58) and third, because Act 620 does not further a valid state interest, (see, e.g., id. at 58-65).

         23. Plaintiffs argue that a preliminary injunction should issue enjoining the enforcement of Act 620 because Plaintiffs are likely to succeed at trial, (Doc. 196 at 67-85); absent an injunction, irreparable harm will occur, (id. at 85-86); the balance of hardships weighs in Plaintiffs' favor, (id. at 86-87); and finally, granting the preliminary injunction will not adversely affect the public interest, (id.).

         24. Defendant counters broadly that Act 620 places no substantial burden on a woman's right to seek an abortion in Louisiana, (see, e.g., Doc. 200 at 59-66), and that the Act serves a valid purpose, (see, e.g., id. at 66-74). Further, Defendant argues that this Court has already ruled that Act 620 serves a valid state interest and has a rational basis. (See, e.g., Id. at 6-7.)

         25. Defendant argues that Plaintiffs have failed to carry their burden that they are likely to succeed at trial and further, urge that no irreparable harm will occur by allowing the enforcement of Act 620. (See, e.g., id. at 88-90.)

         26. Finally, Defendant contends that the balance of hardships weighs in her favor and that the enforcement of Act 620 will not adversely affect the public interest. (Id.)

         IV. The Factual Issues

         27. Four main issues of fact were tried at the June hearing:

(A) What is the purpose of Act 620?
(B) Is Act 620 medically necessary and reasonable?
(C) How, if at all, will the implementation of Act 620 affect the physicians and clinics who perform abortions in the state of Louisiana?
(D) How, if at all, will the implementation of Act 620 affect the ability of Louisiana women to obtain an abortion?

         28. Whether these factual issues and their resolution are relevant under the applicable legal standard, and whether they play a role in this Court's ruling, is discussed in the Conclusions of Law section. See infra Parts XI-XII.

         V. Abortion in Louisiana

         A. Generally

         29. According to DHH, approximately 10, 000 women obtain abortions in Louisiana annually. (DX 148 ¶ 11.)

         30. Nationally, approximately 42% of women who have abortions fall below the federal poverty level, and another 27% fall below 200% of that level. (JX 124 at 480; Doc. 191 at 190- 91.)[14] That number is likely significantly higher for Louisiana women seeking abortions. (Id.) The expert and lay testimony on this issue are consistent. (See, e.g., Doc. 190 at 34 (Testimony of Pittman) (testifying that 70% to 90% of patients at Hope are below the federal poverty level).)

         31. Under Louisiana law, a patient must receive state-mandated counseling and an ultrasound at least 24 hours before an abortion. (JX 109 ¶ 18; JX 116 ¶ 11; JX 117 ¶ 8.)

         32. Due to this notification and waiting period, patients who wish to obtain an abortion must make two trips to the clinic: the first to receive the ultrasound and state-mandated counseling, and the second to obtain the sought abortion. (JX 109 ¶ 19.)

         B. The Clinics

         33. At the time of trial, there were five women's reproductive health clinics in Louisiana that provided abortion services. (See, e..g., Doc. 109 at ¶ 3; JX 109 ¶ 13.) Since then, two of those clinics, Causeway and Bossier, have ceased operation. (Docs. 255 ¶¶ 2-3; 271.)

         (1) Hope

         34. Hope is a women's reproductive health clinic located in Shreveport, Louisiana, that has been operating since 1980 and offers abortion services. (Doc. 109 at 4; see also Doc. 14 ¶ 11 at 5.) Hope is a licensed abortion clinic suing on its own behalf and on behalf of its physicians, staff and patients. (Doc. 14 ¶ 11 at 5; Doc. 190 at 14.)

         35. Hope provides medication abortions through eight weeks and surgical abortions through 16 weeks, six days LMP.[15] (Doc. 190 at 35, 119, 132.) Hope employs two doctors who perform abortions, Does 1 and 3. (Id. at 21.) Doe 1 performs approximately 71% of the abortions provided by Hope, and Doe 3 performs the remaining 29%. (Id.; JX 116 ¶ 5.)

         36. 69% of Hope's patients are Louisiana residents, but the remainder travel from outside the state to Hope. (JX, 116 ¶ 10; Doc. 190 at 19, 34.)

         (2) Bossier

         37. On or about March 30, 2017, Bossier ceased business and surrendered its license, returning it to DHH. (Doc. 271.)

         38. Bossier was a women's reproductive health clinic that had been operating in Bossier City since 1980 and provided first and second trimester abortions. (Doc. 109 at 4; Doc. 14 ¶ 12.) Bossier was a licensed abortion clinic and a plaintiff suing on its own behalf and on behalf of its physicians, staff, and patients. (Doc. 14 ¶ 12.)

         39. Bossier provided medication abortions through eight weeks and surgical abortions through the state's legal limit of 21 weeks, six days LMP. (Doc. 191 at 22-23, 55-56; JX 117 ¶ 4.)

         40. Bossier employed one doctor, Doe 2, who performs first and second trimester surgical procedures as well as medication abortions. (Doc. 191 at 21; JX 117 ¶ 5.) Doe 2 is the only doctor in Louisiana who performs abortions after 16 weeks, six days LMP. (JX 187 ¶ 4; Doc. 191 at 21- 22.)[16]

         41. Bossier's patients were primarily from Louisiana, but also traveled to the clinic from surrounding states. (Doc. 191 at 20.)

         (3) Causeway

         42. Causeway was a women's reproductive health clinic located in Metairie, Louisiana, and had provided abortion and reproductive health services since 1999. (Docs. 109 ¶ 7; 14 ¶ 13.) Causeway was a licensed abortion clinic that sued on its own behalf and on behalf of its physicians, staff, and patients. (Doc. 14 at 1.)

         43. Causeway offered surgical abortions through 21 weeks, six days LMP, and did not offer medication abortions. (JX 117 ¶ 4).

         44. Causeway employed two doctors who performed abortions, Does 2 and 4. (See, e.g., Doc. 168-5 at 8.) Doe 2 performed approximately 25% of the abortions provided at Causeway, and Doe 4 performed the remaining 75%. (JX 117 ¶ 5.) Doe 4 refrained from performing any abortions at Causeway subsequent to the Court's January 26, 2016 preliminary injunction order. (Doc. 255 ¶ 1.) A joint stipulation was filed on February 1, 2016 (Doc. 224) regarding the applicability of the injunction to Doe 4 and so ordered by the Court on February 5, 2016 (Doc. 226.) Causeway returned its license to DHH, effective February 10, 2016. (Doc. 255 ¶ 3.)

         (4) Women's Health

         45. Women's Health is a women's reproductive health care clinic located in New Orleans, Louisiana, and has provided abortion and women's reproductive health services since 2001. (Doc. 109 at 5; JX 168 ¶ 1; JX 110 ¶ 1.)

         46. Women's Health employs two doctors who perform abortions, Does 5 and 6. (JX 110 ¶ 3; JX 168 ¶ 4.) Doe 5 performs approximately 40% of the abortions provided at Women's Clinic, and Doe 6 performs the remaining 60%. (JX 110 ¶ 3; JX 168 ¶ 4.)

         47. Women's Health provides surgical abortions for women through 16 weeks and medication abortions through eight weeks. (Doc. 168-4 at 19.[17]) Doe 6 provides only medication abortions. (Id. at 55.)[18]

         (5) Delta

         48. Delta is a women's reproductive health care clinic located in Baton Rouge, and has provided abortion and women's reproductive health services since 2001. (Doc. 109 at 5.)

         49. Delta employs one doctor who performs abortions, Doe 5. (JX 110 ¶ 35.)

         50. Delta provides surgical abortions for women through 16 weeks LMP, and medication abortions through eight weeks. (Doc. 168-4 at 13-14, 19.)[19]

         51. The northern part of Louisiana is now served only by Hope in Shreveport. (Docs. 191 at 17; 190 at 110; 271.) The southern part of this state is served by Delta in Baton Rouge and Women's Health in New Orleans. (JX 110 ¶ 1; JX 114 ¶ 1; JX 109 ¶ 13.)

         C. The Doctors

         52. There are currently five doctors who perform all abortions in Louisiana. (Doc. 109 ¶ 4; see also, e.g., JX 109 ¶ 14; Doc. 255 ¶ 1.)

         (1) Doe 1[20]

         53. Doe 1 is a board-certified physician in Family Medicine and Addiction Medicine and is one of two clinic physicians at Hope. (Doc. 109 at 5).

         54. Doe 1 has over 10 years of experience, seven of those as an abortion provider. (Doc. 190 at 139-40; Doc. 14 ¶ 14.) He provides medication abortions through eight weeks and surgical abortions through 13 weeks, six days LMP. (Doc. 192 at 21; Doc. 190 at 132.)

         55. Doe 1 was trained to provide abortion services by Doe 3, the medical director of the Hope Clinic, where they both work. (Doc. 192 at 140-41.)

         56. Despite beginning his efforts to get admitting privileges at a nearby hospital in July 2014, (id. at 52), Doe 1 still does not have active admitting privileges at a hospital within 30 miles of Hope Clinic. (Doc. 190 at 21.) The efforts of all six doctors to gain active admitting privileges and the results of those efforts are reviewed in more detail in another section of this Ruling. See infra Part VIII.

         (2) Doe 2

         57. Doe 2 is a board-certified obstetrician-gynecologist and had been, until February 2016, one of two clinic physicians at Causeway and the only clinic physician at Bossier who, while that clinic was in operation, provided abortion services there. (Doc. 109 at ¶ 11; Doc. 255 ¶ 3.)

         58. Since Bossier's closure, Doe 2 has entered into a working agreement with Hope to provide abortion services when Hope's primary physicians, Doe 1 and Doe 3, are unavailable to perform abortions. (Doc. 272 ¶¶ 3-4.)

         59. Doe 2 has been performing abortions since 1980. (Doc. 191 at 17:3-6.) Doe 2 performs medication abortions through eight weeks and surgical abortions up through the state's legal limit of 21 weeks, six days LMP. (Id. 21:16-22:4; JX 187 ¶ 4). He performs medication and surgical abortions at Bossier, and had performed only surgical abortions at Causeway. (Id. at 22:3-11.) In the year prior to trial, Doe 2 performed approximately 550 abortions at Bossier and 450 abortions at Causeway (Id. at 17:21-18:5).

         60. Doe 2 performs first and second trimester surgical abortions through 21 weeks, six days LMP, and is the only one of two physicians in Louisiana to offer abortion after 16 weeks, six days LMP. (Id. at 21-22.)[21]

         61. Doe 2 has been unsuccessful in getting active admitting privileges within 30 miles of Bossier and, prior to Causeway's closure, had been able to obtain only limited privileges, which did not meet the requirements of Act 620, within 30 miles of Causeway. (See, e.g., Doc. 191 at 24:23-29:18.)

         (3) Doe 3

         62. Doe 3 is a board-certified obstetrician-gynecologist and one of two clinic physicians at Hope. (Doc. 109 at 5.) He is also the medical director at Hope. (Id.)

         63. Doe 3 has been licensed to practice medicine in Louisiana since 1976. (Doc. 190 at 109.) In addition to his abortion practice, he has an active general OB/GYN practice, where he delivers babies and routinely performs gynecological surgery including hysterectomies, laparoscopies, and dilation and curettages (“D&Cs”). (Id. at 110.)

         64. Doe 3 is the chief medical officer of Hope Clinic, where he has worked since 1981. (Doc. 190 at 108, 117, 21.) He provides medication abortions through eight weeks and surgical abortions through 16 weeks, six days LMP. (Id. at 35, 119, 132.)

         65. Doe 3 performs abortions at Hope Clinic on Thursday afternoons and all day on Saturday. He sees approximately 20 to 30 abortion patients a week. (Id. at 117-18, 153.) On occasion, he will cover for Doe 1 and will see more patients in those instances. (Id.)

         66. Doe 3 currently has admitting privileges at Willis-Knighton Hospital in Bossier (“WKB”) and at Christus Highland Medical Center in Bossier (“Christus”), both of which are within 30 miles of Hope Clinic. (Id. at 21-22, 120, 148-49.) Doe 3's current privileges at Christus require him to admit approximately 50 patients per year. (Id. at 150-52; JX 59.)

         67. Doe 3 has his current admitting privileges because he regularly admits patients to the hospital as part of his private OB/GYN practice, not because of his work at Hope Clinic. (Id. at 124, 147.)

         (4) Doe 4

         68. Doe 4 is a board-certified obstetrician-gynecologist and had been one of two clinic physicians at Causeway. (Doc. 109 at 5, ¶ 13.)

         69. Doe 4 obtained his license to practice medicine in Maryland in 1959 and in Louisiana in 1965. (Doc. 168-5 at 5-6.) He served as an assistant professor or assistant instructor in obstetrics and gynecology for seventeen years at Earl K. Long Hospital. (Id. at 12.)

         70. When Doe 4 maintained a full OB/GYN practice, he had admitting privileges at four hospitals in the Baton Rouge area. (Doc. 168-5 at 6.) He was required to have admitting privileges to do OB/GYN surgery and, in his words, “to deliver babies.” (Id.) The existence of these privileges did not benefit his pregnancy termination patients because, to his knowledge, none of his abortion patients experienced any problem and required hospital admission. (Id. at 19-20.)

         71. Doe 4 performed abortions at Causeway in Metairie until January 2016. (Doc. 109 at 5, ¶ 13; Doc. 168-5 at 8; Doc. 255 ¶ 1.) He was not able to get admitting privileges at a hospital within 30 miles of Causeway. (Doc. 191 at 18:6-19; see also, e.g., Doc. 168-5 at 16.)

         (5) Doe 5

         72. Doe 5 is a board certified obstetrician-gynecologist. (Doc. 109 at 5; see also Doc. 168-6 at 4-5.) He is one of two clinic physicians at Women's Clinic and the only clinic physician at Delta Clinic. (Doc. 109 at 5; see also Doc. 168-6 at 4, 13-14, 22.)

         73. Doe 5 has been licensed to practice medicine in Louisiana since 2005. (Doc. 168-6 at 5.) He provides surgical abortions at Delta Clinic and Women's Health through 16 weeks LMP. (Id. at 20; see also JX 110 ¶ 1.)[22]

         74. Doe 5 has been successful in getting active admitting privileges within 30 miles of Women's Health in New Orleans but has been unsuccessful in his efforts to get active admitting privileges within 30 miles of Delta in Baton Rouge. (Doc. 168-6 at 11-13; see also, e.g., JX 109 ¶¶ 33-34; JX 110 ¶¶ 15-19.)

         (6) Doe 6

         75. Doe 6 is a board certified obstetrician-gynecologist and one of two clinic physicians at Women's Health. (Doc. 109 at 5; see also Doc. 168-4 at 13.)

         76. Doe 6 has been practicing medicine for 48 years. (JX 109 ¶ 8.) He is currently the medical director of Women's Clinic and Delta Clinic. (Id.) Doe 6 provides only medication abortions and does so only at Women's Clinic. (Id. ¶¶ 8-9.)

         77. Doe 6 has been unsuccessful in his efforts to get active admitting privileges within 30 miles of Women's. (Id. ¶¶ 23-26.)

         D. Admitting Privileges in Louisiana

         78. In order to perform abortions legally in Louisiana, Act 620 requires an abortion doctor to have “active admitting privileges” at a hospital within 30 miles of the facility where he or she performs abortions. La. R.S. § 40:1299.35.2A(2)(A). To have “active admitting privileges” the physician must be a “member in good standing of the medical staff” of a hospital “with the ability to admit a patient and to provide diagnostic and surgical services to such patient . . . .” Id. The phrase “member in good standing of the medical staff” is not separately defined. (Cf. Doc. 193 at 12.)

         79. Thus, how a physician may obtain “medical staff” and “active admitting” privileges from a Louisiana hospital is critical in determining the effect, if any, that Act 620 has on abortion providers and, in turn, the women that they serve.

         80. The expert testimony regarding hospital admitting privileges came primarily from two experts-Pressman, Plaintiffs' expert, (Doc. 195 at 11-96), and Marier, Defendant's (Doc. 193 at 4- 124)-and, to a lesser extent, from the other physicians, including Does 1, 2, 3, 4, 5, and 6, who testified. See supra Part I. On the issue of admitting privileges and hospital credentialing, the Court found both Pressman and Marier to be generally well qualified.

         81. Additional information about the credentialing process and the specific requirements of various hospitals came from certain hospital by-laws introduced into evidence. (See, e.g., JX 46, 48, 67, 72, 76, 78-79, 81, 138, 140-43.)

         82. Credentialing is a process that hospitals employ to determine what doctors will be allowed to perform what tasks within that hospital. (Doc. 193 at 11; see also, e.g., Doc. 195 at 23- 27; Doc. 168-5 at 24.)

         83. Part of this process involves the hospital's granting or denying “admitting privileges.” (See, e.g., Doc. 193 at 20; Doc. 195 at 17, 23-25.) These privileges govern whether or not a physician is authorized to admit and treat a patient at that hospital and what care, services and treatment the physician is authorized to provide. (See, e.g., Doc. 193 at 20-21; Doc. 195 at 23, 25- 26.)

         84. Admitting privileges are related to but not the same as being on the “medical staff” of a hospital. (Doc. 193 at 11; Doc. 195 at 25-26.)

         85. There is no requirement that a physician have admitting privileges or be on the medical staff at a hospital in order to practice medicine. (See, e.g., Doc. 195 at 26.) Many physicians who do not have a hospital based practice, i.e. do not intend to admit and treat their patients in a hospital setting, have neither as there is no need for staff or admitting privileges under those circumstances. (See, e.g., Doc. 175 at 75; Doc. 192 at 41-42; Doc. 195 at 75.)

         86. There is no state or federal statute which governs the rules for the granting or denial of hospital admitting privileges in Louisiana.[23] Cf. Planned Parenthood of Wis., Inc. v. Van Hollen, 738 F.3d 786, 792 (7th Cir. 2013) (“The criteria for granting admitting privileges are multiple, various, and unweighted.”). Rather, partly as a consequence of this absence, these rules vary from hospital to hospital and are governed by each one's distinct by-laws.[24] (See, e.g., Doc. 193 at 12, 15; Doc. 195 at 28.)

         87. Specifically, there is no state or federal statute which defines or sets uniform standards for the categories of admitting privileges a hospital may grant. (Doc. 193 at 11-12.) Like other rules, these are therefore set by each hospital's by-laws. (Id.; see also, e.g., Doc. 195 at 28; JX 81 at 1798.) To make matters more confusing, the terms used to describe those categories (e.g. “active admitting privileges”, “courtesy admitting privileges”, “clinical admitting privileges”) vary from hospital to hospital. (See, e.g., Doc. 190 at 167; Doc. 191 at 104; Doc. 193 at 11-12; Doc. 195 at 28.)

         88. Similarly, terms like “medical staff”, “active staff”, “courtesy staff”, “clinical staff” vary among hospitals. (Doc. 191 at 35; Doc. 193 at 12; Doc. 195 at 28; cf. JX 79 at 1707-12.)

         89. For example, at some hospitals, an “active” staff appointment does not, alone, automatically entitle the physician to admit patients. (See, e.g., JX 46 at 185; JX 79 at 1673; JX 141 at 3259-60.)

         90. Because of the varying definitions given to the categories of admitting privileges and the varying requirements for the attainment of same, whether a physician has been given “active admitting privileges” or is a “member in good standing on the medical staff” within the meaning of Act 620 entirely depends upon the specific definition, requirements and restrictions imposed by a given hospital in a given circumstance. (See, e.g., Doc. 193 at 12.)

         91. Unlike some states, [25] there is also no statute or rule in Louisiana which sets a maximum time period within which a physician's application for admitting privileges must be acted upon. Thus, unless there is such a time limit in the hospital's by-laws, a hospital can effectively deny a doctor's application of privileges by never acting on it, a decision on any one doctor's application permanently delayed without a consequence being effected or a reason being given. A definite decision stays unreached-but, with his or her request suspended, the relevant doctor's privileges remain, as a matter of fact and law, nonexistent. In this Ruling, the Court uses the term “de facto denial” of privileges to describe this circumstance.[26]

         92. At some hospitals in Louisiana, there are suggested time frames in which hospitals should review admitting privileges applications. (JX 72 at 1320-23; see also, e.g., JX 67 at 857- 58; JX 76 at 1444-47.) However, those guidelines are not requirements, and there is no legal recourse for an applicant if the hospital fails to act on the application within the suggested time period. (See, e.g., JX 67 at 858-59; JX 72 at 1320-24; JX 109 ¶ 27.) For example, Tulane University Medical Center (“Tulane”) has an expectation, but has adopted no requirement, that applications will be processed within 150 days. (JX 78 at 1554.) If the Board of Trustees has not taken action on the application within 150 days, the applicant must repeat the verification process to ensure the information contained therein is still accurate. (Id.)

         93. A hospital's failure to act on an application by either approving or denying it may result in the hospital considering the application withdrawn. (See, e.g., Doc. 195 at 93; JX 71 at 1279.) In this additional respect, a hospital's failure to act is, in effect, a de facto denial of the application.

         94. While a physician's competency is a factor in assessing an applicant for admitting privileges, it is only one factor that hospitals consider in whether to grant privileges. (See, e.g., Doc. 190 at 158-59; Doc. 195 at 25-26; Doc. 192 at 50-51; Doc. 168-5 at 17; Doc. 168-6 at 12; JX 110 ¶ 10; JX 168 ¶¶ 11-13, 17; PX 183.)

         95. Defendant argues: “When Louisiana hospitals decide whether to grant a physician staff membership, privileges to admit patients, or privileges to perform particular procedures, hospital by-laws indicate that they may make such determinations based on the physician's prior and current practice, and indicia of the physician's clinical ...


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