Sunday, November 15, 2020

June Medical Services L.L.C. v. Russo

 June Medical Services L.L.C. v. Russo, 140 S. Ct. 2103

Opinion handed down June 29, 2020

By Lucy Downing

I.          Introduction

In a five-four decision, the United States Supreme Court struck down a Louisiana law requiring physicians who provide abortions to obtain admitting privileges at a local hospital.  The Court held that the Louisiana admitting privilege requirement, facially identical to a Texas law the Court struck down four years ago in Whole Woman’s Health v. Hellerstedt, was an undue burden on abortion access.  However, the Court missed an opportunity to meaningfully address how targeted regulations of abortion providers (“TRAP laws”) like the admitting priviliges requirement at issue work in the greater context of abortion restrictions to gradually chip away at the abortion right.  Justice Breyer, joined by Justices Ginsburg, Sotomayor, and Kagan, wrote the plurality opinion.[1]

II.        Background

            In June 2014, the Louisiana Legislature passed Act 620 which requires any physician who performs abortions to hold “active admitting privileges at a hospital that is located not further than thirty miles from the location at which the abortion is performed or induced and that provides obstetrical or gynecological health care services.”[2]  To have “active admitting privileges,” a doctor must be a member in good standing of the hospital’s medical staff with the ability to admit a patient and to provide diagnostic and surgical services to such patient.[3]  Prior to Act 620’s passage, Louisiana law already required abortion providers either to possess local hospital admitting privileges or to have a transfer agreement with a physician who had such privileges.[4]  Act 620 removed that flexibility and attached liability to physicians for failing to comply, possibly leading to “fines of up to $4,000 per violation, license revocation, and civil liability.”[5]

            Several weeks before Act 620 was to take effect in September 2014, three abortion clinics and two abortion providers filed a lawsuit in the United States District Court for the Middle District of Louisiana alleging that Act 620 was unconstitutional as an undue burden on their patients’ rights to obtain abortions.[6]  The plaintiffs sought a temporary restraining order followed by a preliminary injunction to prevent the law from taking effect.[7]  The State opposed the temporary restraining order and urged the district court to hold a hearing on the preliminary injunction as soon as possible, but conceded that the physicians clearly had standing to bring suit.[8]  Instead of ruling on whether to stay Act 620’s effective date, the district court temporarily prohibited the State from enforcing the Act’s penalties and directed the plaintiff doctors to continue their efforts to obtain conforming privileges while keeping the court informed of their progress.[9]

III.       Legal Background

            In June 2015, the District Court held a six-day bench trial on the preliminary injunction.[10]  After hearing live testimony from a dozen witnesses and making extensive factual findings on the issue, the district court declared Act 620 facially unconstitutional and granted the preliminary injunction on its enforcement.[11]

            The State immediately appealed to the United States Court of Appeals for the Fifth Circuit asking for a stay of the preliminary injunction, which the court granted.[12]  The U.S. Supreme Court then granted its own stay at the plaintiffs’ request, leaving the district court’s injunction intact.[13]

            About two months later, the U.S. Supreme Court issued its decision in Whole Woman’s Health v. Hellerstedt, striking down a Texas law nearly identical to the Louisiana law at issue here.[14]  In Whole Woman’s Health, the Court held that “unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion impose an undue burden on the right and are therefore constitutionally invalid.”[15]  The Court then undertook a state-specific analysis and assessed the asserted benefits and burdens of the law as it operated in Texas.[16]  Reviewing the record in that case, the Court held that the Texas admitting privilege law did not further the State’s asserted interest in women’s health because it provided no real health benefit—abortions in Texas were extremely safe before the law’s passage, so there was no health-related issue the law attempted to cure.[17]  Futher, the law placed a substantial obstacle in the path of Texas women seeking an abortion because half of the state’s abortion clinics closed after the law went into effect.[18]  The Court then struck down the Texas law, reasoning that the obstacle, “when viewed in light of the virtual absence of any health benefit, imposed an undue burden on abortion access in violation of the Federal Constitution.”[19] 

In light of Whole Woman’s Health, the Court remanded this case to the Fifth Circuit for reconsideration and the Fifth Circuit remanded to the district court for further fact-finding and a ruling on the plaintiffs’ request for a permanent injunction regarding Act 620.[20]  The district court made extensive factual findings on the Act’s purported benefits and its impact on women’s access to abortion in Louisiana.[21]  With respect to the Act’s asserted benefits, the district court found that: (1) abortion in Louisiana “has been extremely safe, with particularly low rates of serious complications”; (2) it “rarely . . . is necessary to transfer patients to a hospital”; and (3) “whether or not a patient’s treating physician has admitting privileges is not relevant to the patient’s care.”[22]  Accordingly, the district court found there was “no significant health-related problem that the new law helped to cure,” and, thus, there was “no credible evidence in the record that Act 620 would further the State’s interest in women’s health beyond that which is already insured under existing Louisiana law.”[23]

            As to the Act’s burdens on women’s access to abortion, the district court found that the approximately 10,000 women who obtain abortions in Louisiana each year are served by six doctors at five abortion clinics, and that by the time of its decision, two of those clinics had closed and one of the doctors had retired, leaving only five physicians in the entire state who perform abortions, most of whom were unable to obtain admitting privileges required by Act 620.[24]  The district court further found that the doctors’ inability to obtain privileges was “caused by Act 620 working in concert with existing laws and practices, including hospital bylaws and criteria that preclude or, at least greatly discourage, the granting of privileges to abortion provers.”[25]  Thus, enforcing the Act would “result in a drastic reduction in the number and geographic distribution of abortion providers . . .” and prevent many women seeking a safe, legal abortion in Louisiana from obtaining one.[26]  The district court added that “Act 620 does not advance Louisiana’s legitimate interest in protecting the health of women seeking abortions.  Instead, Act 620 would increase the risk of harm to women’s health by dramatically reducing the availability of safe abortion in Louisiana.”[27]  Moreover, the court found no legally significant distinction between Act 620 and the Texas law struck down in Whole Woman’s Health because Act 620 was modeled after the Texas law, functions in the same manner, and similarly imposes significant obstacles to abortion access with “no countervailing benefits.”[28]  Accordingly, the district court declared Act 620 unconstitutional and entered a permanent injunction forbidding its enforcement.[29]

            The State appealed, and the Fifth Circuit reversed the district court’s decision.[30]  The Fifth Circuit disagreed with nearly all of the district court’s findings regarding Act 620’s burdens, and it differentiated the Act from the Texas law at issue in Whole Woman’s Health concluding that the burden Act 620 imposes on abortion access is “dramatically less” than that imposed by the Texas law.[31]  In terms of the Act’s asserted benefits, the Fifth Circuit argued that, “unlike Texas, Louisiana presents some evidence of a minimal benefit,” despite the district court’s contrary finding that the law provided no real health benefit to women.[32]

            The U.S. Supreme Court then issued a stay of the Fifth Circuit’s reversal at the plaintiffs’ request and granted certiorari to address the Fifth Circuit’s decision on the merits.[33]  The Court also granted the State’s cross-petition for certiorari challenging the plaintiff’s standing to bring the action.[34]

IV.       Instant Decision

            The opinion first addressed the State’s argument that the plaintiff physicians lacked standing to bring suit on behalf of their patients.  The Court held that the State waived that argument when it conceded the physicians’ standing at the district court in order to obtain a quick decision on the merits.[35]  Further, the Court pointed out its long-standing precedent of allowing abortion providers to invoke the rights of their actual or potential patients in challenges to abortion-related regulations.[36]

            Turning to the merits, the opinion reiterated the proper standard for assessing abortion regulations: “a statute which, while furthering a valid state interest has the effect of placing a substantial obstacle in the path of a woman’s choice cannot be considered a permissible means of serving its legitimate ends.”[37]  Further, “unnecessary health regulations impose an undue burden if they have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion.”[38]  Noting that the Fifth Circuit did not take issue with the legal standard used by the district court so much as the factual findings it used in reaching its decision, the Court emphasized that “a district court’s findings of fact, whether based on oral or other evidence, must not be set aside unless clearly erroneous, and the reviewing court must give due regard to the trial court’s opportunity to judge the witnesses’ credibility.”[39]  This is a highly deferential standard, and a court of appeals may not reverse a plausible account of the evidence given the record, even if it would have weighed the evidence differently if it had been sitting as the trier of fact.[40]

            With that standard in mind, the Court then carefully assessed whether the district court’s findings were sufficient to support its conclusion that Act 620 was unconstitutional.[41]  It concluded that, in light of the record, “the District Court’s significant factual findings—both as to burdens and as to benefits—have ample evidentiary support.  None is ‘clearly erroneous.’”[42]  The Court further concluded that “[t]his case is similar to, [and] nearly identical with, Whole Woman’s Health.  And the law must consequently reach a similar conclusion.  Act 620 is unconstitutional.”[43]

V.        Comment and Conclusion

            While the Court’s decision ended up striking down Louisiana’s admitting privilege requirement, its continued use of a state-specific analysis leaves the door open for states to continue strategically restricting abortion using the argument that each state is different.  TRAP laws such as the admitting privileges requirement at issue do not further a legitimate interest in women’s health.[44]  The American Medical Association, American Public Health Association, and American College of Obstetricians and Gynecologists oppose these restrictions, recognizing that they serve no legitimate purpose.[45]  Today, abortion procedures are generally quite safe, and TRAP laws ostensibly enacted under the guise of furthering women’s health do no more than subject women to more health risks by making the process of obtaining an abortion more burdensome.[46]  In practice, TRAP laws further strategic legislative goals of eroding the abortion right into nonexistence. 

While admitting privilege requirements have been struck down twice by the Court and blocked in eight states, they are currently still in effect in Missouri, North Dakota, and Utah.[47]  In Missouri, for example, the admitting privilege requirement acts as one piece of a complicated web of restrictions designed to make access to abortion more difficult.[48]  Other anti-abortion measures in Missouri include strict limits on insurance coverage of abortion, a parental consent requirement for minors, a mandate doctors counsel patients in a way that is intended to dissuade them from obtaining the procedure, a mandatory seventy-two-hour waiting period between clinic visits, and other similar restrictions.[49]  As the first state to enact an admitting privilege requirement, Missouri has proven this strategy quite effective as the state is down to one remaining abortion clinic.[50]  However, Missouri is not the only state using this tactic.[51]  While the Court saw the Louisiana law for what it really was, the opinion was limited to Louisiana and failed to meaningfully address how admitting privilege requirements fit into the framework of anti-abortion legislative strategies.  Thus, states like Missouri will likely continue legislating to incrementally strip away abortion access.



[1] While Justice Roberts filed a concurring opinion and Justices Thomas, Alito, Gorsuch, and Kavanaugh each filed dissenting opinions, this article focuses on the plurality opinion.

[2] June Medical Services L.L.C. v. Russo, 140 S.Ct. 2112 (2020).

[3] Id. at 2113 (quotations omitted).

[4] Id.

[5] Id.

[6] Id.

[7] Id.

[8] Id. at 2113­–14.

[9] Id. at 2114.

[10] Id.

[11] Id.

[12] Id.

[13] Id.

[14] Whole Woman’s Health v. Hellerstedt, 136 S.Ct. 2292 (2016).

[15] Id.

[16] Id.

[17] Id.

[18] Id.

[19] Id..

[20] June Medical Services L.L.C. v. Russo, 140 S.Ct. 2112, 2113­–14 (2020).

[21] Id. at 2114-16.

[22] Id. at 2114­–15 (quotations omitted).

[23] Id. at 2115 (quotations omitted).

[24] Id.

[25] Id. (quotations omitted).

[26] Id. at 2115–16.

[27] Id. at 2116.

[28] Id.

[29] Id.

[30] Id.

[31] Id.

[32] Id.

[33] Id. at 2117.

[34] Id.

[35] Id. at 2117–18.

[36] Id. at 2118-19.

[37] Id. (quotations omitted).

[38] Id. (quotations omitted).

[39] Id. at 2121 (quotations omitted).

[40] Id.

[41] See id. at 2122–32.

[42] Id. at 2132.

[43] Id. at 2133.

[44] See Elizabeth Nash & Megan Donovan, Admitting Privileges Are Back at the U.S. Supreme Court with Serious Implications for Abortion Access, Guttmacher Inst. (last visited Sept. 18, 2020), https://www.guttmacher.org/article/2019/10/admitting-privileges-are-back-us-supreme-court-serious-implications-abortion-access.

[45] Id.

[46] Id.

[47] Id.

[48] See A Dark Milestone for Women’s Rights: A State With No Abortion Clinics, N.Y. Times (May 28, 2019), https://www.nytimes.com/2019/05/28/opinion/missouri-abortion-clinic.html.

[49] Id.

[50] Id.

[51] See id.