Planned Parenthood of Greater Ohio v. Richard Hodges
Planned Parenthood of Greater Ohio v. Richard Hodges
Opinion
*910
Ohio, like many governments, often partners with nonprofit organizations to promote policies of the State. Through one such partnership, the State distributes government funds to several organizations to address a wide range of public health issues. For many years, Planned Parenthood participated in these programs. In 2016, Ohio passed a law that bars its health department from funding organizations that "[p]erform nontherapeutic abortions." Ohio Rev. Code § 3701.034(B)(1). Two Planned Parenthood affiliates challenged the statute, claiming that it imposes an unconstitutional condition on public funding in violation of the Due Process Clause. The affiliates are correct that the Ohio law imposes a condition on the continued receipt of state funds. But that condition does not violate the Constitution because the affiliates do not have a due process right to perform abortions.
See
Planned Parenthood of Se. Pa. v. Casey
,
I.
Ohio distributes funds to organizations that participate in six government-sponsored health and education programs. The programs target sexually transmitted diseases, breast cancer and cervical cancer, teen pregnancy, infant mortality, and sexual violence.
Planned Parenthood of Greater Ohio and Planned Parenthood of Southwest Ohio manage twenty-seven health centers across the State. They have participated in these programs for several years. Both entities provide abortions at surgical centers in Bedford Heights, Columbus, and Cincinnati.
For several decades, both federal and state laws have prohibited recipients of public funds from using the money to provide abortions. The Planned Parenthood affiliates comply with these requirements.
In 2016, the Ohio legislature enacted, and Governor Kasich signed into law, House Bill 294 to "Prohibit[ ] [the] use of certain funds concerning nontherapeutic abortions." It requires the Ohio Department of Health to "ensure" that all of the funds it receives for the six programs "are not used to do any of the following: (1) Perform nontherapeutic abortions ; (2) Promote nontherapeutic abortions ; (3) Contract with any entity that performs or promotes nontherapeutic abortions ; (4) Become or continue to be an affiliate of any entity that performs or promotes nontherapeutic abortions." Ohio Rev. Code § 3701.034(B) - (G). The point of the limitation, the State maintains, is to promote childbirth over abortion, to avoid "muddl[ing]" that message by using abortion providers as the face of state healthcare programs, and to avoid entangling program funding and abortion funding. Appellant's Br. 39-41.
*911 Ohio's health department and its local counterparts notified Planned Parenthood of Greater Ohio and Planned Parenthood of Southwest Ohio that the new law would require the State to end their contracts under the programs. Both entities perform abortions, advocate for abortion, and affiliate with other entities that do the same.
Both of the affiliates, from now on referred to as Planned Parenthood in the singular, sued, claiming that the law violates the First and Fourteenth Amendments by conditioning government funding on giving up their rights to provide abortions and to advocate for them. The district court agreed and permanently enjoined the State from enforcing the law.
After a panel of this court affirmed the district court,
II.
As the district court saw it, the Ohio law imposes two unconstitutional conditions on Planned Parenthood. It denies the organization funding if it continues to perform abortions-what the court perceived to be a due process violation. And the law denies the organization funding if it continues to promote abortion-what the court perceived to be a free speech violation. To prevail, Planned Parenthood must show that both limitations-the conduct and speech requirements-violate the U.S. Constitution. Ohio may deny funding to Planned Parenthood in other words if either limitation satisfies the Constitution. Because the conduct component of the Ohio law does not impose an unconstitutional condition in violation of due process, we need not reach the free speech claim.
First a word or two about unconstitutional conditions. The United States Constitution does not contain an Unconstitutional Conditions Clause. What it does contain is a series of individual rights guarantees, most prominently those in the first eight provisions of the Bill of Rights and those in the Fourteenth Amendment. Governments generally may do what they wish with public funds, a principle that allows them to subsidize some organizations but not others and to condition receipt of public funds on compliance with certain obligations.
See
Rust v. Sullivan
,
What is the enumerated right at issue here? The guarantee of due process established by the Fourteenth Amendment. That provision, as the United States Supreme Court has come to construe it, prohibits a State from imposing an "undue burden" on a woman's access to an abortion before fetal viability.
Casey
,
These principles establish the following line between what Ohio may do and what it may not do. It may choose not to fund a private organization's health and education initiatives. Private organizations
*912
do not have a constitutional right to obtain governmental funding to support their activities. The State also may choose not to subsidize constitutionally protected activities. Just as it has no obligation to provide a platform for an individual's free speech, say a Speaker's Corner in downtown Columbus, it has no obligation to pay for a woman's abortion. Case after case establishes that a government may refuse to subsidize abortion services.
Rust
,
By contrast, the State may not condition a benefit by requiring the recipients to sacrifice their constitutional rights.
Regan v. Taxation With Representation of Wash.
,
The Ohio law falls on the permissible side of this line. Today's plaintiffs do not have a Fourteenth Amendment right to perform abortions. The Supreme Court has never identified a freestanding right to perform abortions. To the contrary, it has indicated that there is no such thing. "Whatever constitutional status the doctor-patient relation may have as a general matter," the Court has explained, "in the present context it is
derivative
of the woman's position. The doctor-patient relation does not underlie or override the two more general rights under which the abortion right is justified: the right to make family decisions and the right to physical autonomy. On its own, the doctor-patient relation here is entitled to the same solicitude it receives in other contexts."
Casey
,
Any doubt about the point is confirmed by the debate at hand in
Casey
. The abortion providers claimed that a Pennsylvania law, requiring them to inform their patients of the abortion procedure's details and alternatives at least 24 hours beforehand, violated their patients' due process rights
and
their own due process rights that arose from their relationship with the patients. The plurality rejected both claims. Abortion rights do not arise from the provider-patient relationship "[o]n its own," the Court reasoned.
At the same time, the Ohio law does not violate a woman's right to obtain an abortion. It does not condition a woman's access to any of these public health programs on refusing to obtain an abortion. It makes these programs available to every woman, whether she seeks an abortion or not. Nor, on this record, has there been any showing that the Ohio law will limit the number of clinics that offer abortions in the State.
Cf.
Whole Woman's Health v. Hellerstedt
, --- U.S. ----,
A review of the Supreme Court's decisions in the area fails to reveal a single one in which the plaintiff obtained relief based on a restriction of unprotected activity.
*913
The dissent to its credit concedes as much.
Infra
, at 926-27 n.8. A benefits condition becomes unconstitutional only when it violates a recipient's constitutional rights, as the following cases confirm.
See, e.g.
,
Koontz
,
The only other circuit in the country to squarely address this issue reached the same conclusion. "The first step in any unconstitutional-conditions claim is to identify the nature and scope of the constitutional right arguably imperiled," it reasoned, and abortion clinics lack a freestanding constitutional right to practice their trade.
Planned Parenthood of Ind., Inc. v. Comm'r of Ind. State Dep't of Health
,
Planned Parenthood nonetheless maintains that a bevy of cases establishes that clinics
do
have a due process right to perform abortions. But a review of the cases leaves the reader empty handed.
Webster v. Reproductive Health Services
,
Planned Parenthood of Central & Northern Arizona v. Arizona
,
The Tenth Circuit, it is true, accepted the existence of a Fourteenth Amendment right to provide abortions.
Planned Parenthood Ass'n of Utah v. Herbert
,
*914
Third-party-standing cases do not fill this gap. In those cases, the Supreme Court held that abortion providers have standing to bring due process challenges on behalf of their patients.
See, e.g.
,
Singleton v. Wulff
,
Even if the Fourteenth Amendment does not grant Planned Parenthood a constitutional right to perform abortions and even if the third-party-standing doctrine does not fill this gap, the organization maintains that the unconstitutional-conditions doctrine defeats the law all the same. Ohio may not directly ban access to abortion services in the State, Planned Parenthood points out, and the unconstitutional-conditions doctrine bars a State from achieving that same goal indirectly, here by financially incentivizing abortion providers to cease offering this service. Yes, the doctrine would prohibit the State from requiring women to forfeit benefits if they chose to obtain an abortion and if that limitation unduly burdened their access to abortion services. That's because such a state law would try to achieve indirectly what the State cannot achieve directly with respect to the underlying constitutional right. But, no, the principle does not apply when the State regulates entities with no such constitutional right: abortion providers. In that setting, the clinic is like anyone else in the State, subject to all manner of regulatory incentives and disincentives, whether in the tax code, economic development plans, or any other part of state or local law.
Consistent with this explanation, all of the cases cited by Planned Parenthood with respect to this direct-indirect point involved individuals or entities who held the constitutional right and were discouraged from exercising it.
See, e.g.
,
Elrod v. Burns
,
The direct-indirect dynamic, put another way, is not by itself what triggers the doctrine. The doctrine applies when the government attempts to ban or undermine a benefit recipient's exercise of a
right
that the Constitution guarantees. That's why an unconstitutional-conditions claim won't get far if the government could have directly ordered the outcome it wishes to incentivize. In that case, there is no right at issue.
See
*915
Rumsfeld v. Forum for Acad. & Institutional Rights, Inc.
,
Truth be told, general concerns about indirect efforts to accomplish what cannot be accomplished directly illustrate what is wrong with this claim. Medical centers do not have a constitutional right to offer abortions. Yet, if we granted Planned Parenthood relief today, we would be effectively saying that they do. That is not the role of the unconstitutional-conditions doctrine.
That this traditional application of the unconditional-conditions doctrine might apply in other settings, as the dissent points out, infra , at 926-27, counts as a plus, not a minus, in the constitutional equation. It shows that the principle is a neutral one. And it shows that our assessment of the case turns on the nature of the unconstitutional-conditions doctrine, not on individual preferences with respect to this constitutional right or that one. Any risk of unequal application would arise in this case only if we extend the unconstitutional-conditions doctrine for the first time to an entity (here an abortion provider) that does not have a constitutional right.
In the absence of such an extension, Planned Parenthood worries that the unconstitutional-conditions doctrine will lead to several problematic outcomes. "Imagine," the dissent suggests, "that the government barred lawyers who represent indigent defendants from eligibility for loan forgiveness programs."
The initial question in each instance is whether such a law would implicate the
regulated entity
's constitutional rights or some other prohibition. That seems likely in each setting. The first application would implicate a lawyer's free speech rights.
See
Legal Servs. Corp. v. Velazquez
,
This last point answers the dissent's next hypotheticals about polling-place funding and gun-shop tax breaks, *916 infra , at 926-27, as well as any others that a fertile imagination could identify, so long as the law does not violate the regulated entity's rights or another prohibition. Take the gun shop. Surely a State could deny subsidies for entities dealing with the needs of victims of gun violence to entities or stores that sold guns. In the end, so long as the subsidy program does not otherwise violate a constitutional right of the regulated entity, the State may choose to subsidize what it wishes-whether abortion services or adoption services, whether stores that sell guns or stores that don't.
That leads to Planned Parenthood's next argument. Left untouched, the Ohio law will deprive Ohio women of their constitutional right of access to abortion services without undue burden, because it will lead Planned Parenthood and perhaps other abortion providers to stop providing them. Maybe; maybe not. More to the point, the conclusion is premature and unsupported by the record. It is true that, if these two Planned Parenthood affiliates opted not to provide abortions, women seeking an abortion in Ohio would have to travel farther than they currently do to obtain an abortion. It is also true that this kind of evidence may support an undue-burden challenge by establishing a "substantial obstacle" in the way of those seeking abortions.
See
Whole Woman's Health
,
But it is premature to assess any such claim now. For one, it is not clear that the plaintiffs filed an undue-burden challenge on behalf of individual women, as opposed to an unconstitutional-conditions challenge on their own behalf. For another, the record contains more speculation than evidence about what would happen if these two Planned Parenthood affiliates stopped providing abortions. For still another, the only hard evidence on point is that Planned Parenthood does not plan to stop providing abortions, as representatives from each affiliate testified that they would sacrifice government funding to continue providing abortions. On this record, it would be unduly conjectural, and unripe to boot, to imagine what would happen if the plaintiffs changed their mind. Under our Article III authority to resolve "Cases" and "Controversies," we must limit ourselves to the seen rather than the unseen. And all that the seen shows is that the law will not create an undue burden on a woman's right to an abortion.
Planned Parenthood insists that it has no obligation to establish an undue burden because the funding condition itself is unconstitutional, making it irrelevant whether the subject of the condition gives in.
See
Koontz
, 570 U.S. at 607,
That this is a pre-enforcement action, last of all, changes nothing. Even in that setting, Planned Parenthood must show that the Ohio law, if implemented, would impose an undue burden on a woman's right to an abortion. Its vow to keep performing *917 abortions sinks any pre-enforcement action, and any speculation about what would happen if it changed its mind is just that.
For these reasons, we reverse the district court's contrary decision and remand for proceedings consistent with this opinion.
SUTTON, J., delivered the opinion of the court in which SILER, BATCHELDER, GIBBONS, COOK, GRIFFIN, KETHLEDGE, THAPAR, BUSH, LARSEN, and NALBANDIAN, JJ., joined. WHITE, J. (pp. 13-35), delivered a separate dissenting opinion in which COLE, C.J., and MOORE, CLAY, STRANCH, and DONALD, JJ., joined.
HELENE N. WHITE, Circuit Judge, dissenting.
DISSENT
The majority makes short work of Plaintiffs' arguments with three simple assertions. Because Plaintiff clinics have no independent constitutional right to perform abortions, it is impossible for Ohio to violate their due process rights by withholding benefits or imposing burdens based on their abortion activities; a woman has a due process right to obtain certain nontherapeutic abortions, but no condition violates that right unless it imposes an undue burden on that right; because Plaintiff providers have made clear that they will not accede to Ohio's funding conditions, there is no undue burden on a woman's abortion right.
The majority does not mention, much less apply, the test the Supreme Court has recently articulated governing the unconstitutional-conditions doctrine. That doctrine prohibits the government from conditioning the grant of funds under a government program if: (1) the challenged conditions would violate the Constitution if they were instead enacted as a direct regulation; and (2) the conditions affect protected conduct outside the scope of the government program.
See
Agency for Int'l Dev. v. Alliance for Open Soc'y Int'l
,
Enacted in 2016, Ohio Revised Code § 3701.034 (the Statute) requires the Ohio Department of Health (ODH) to ensure that all funds it receives through six non-abortion-related federal health programs are not used to contract with any entity that performs or promotes nontherapeutic abortions, or becomes or continues to be an affiliate of any entity that performs or promotes nontherapeutic abortions. A direct regulation barring healthcare providers from performing or promoting nontherapeutic abortions or affiliating with any entity that performs or promotes nontherapeutic abortions would violate the Constitution by imposing an undue burden on women seeking abortions and violating the healthcare providers' rights to free speech and association. The Statute thus satisfies the first element of an unconstitutional condition. The Statute also plainly conditions government funding for programs unrelated to abortion on an entity's refraining from performing or promoting abortions, or affiliating with any entity that does either. Because § 3701.034 fails both parts of the test applied in AOSI , the district court properly enjoined the law from going into effect.
*918
The majority avoids this straightforward application of the unconstitutional-conditions doctrine primarily by adopting an unprecedented rule that abortion providers-entities that are necessary to ensure a woman's right to safe abortions-cannot prevail in challenging the Statute because there is no independent constitutional right to provide abortions. For the proposition that there is "no such thing" as a right to perform abortions, the majority cites the statement in the plurality opinion in
Planned Parenthood of Southeastern Pennsylvania v. Casey
that a provider's constitutional right "is derivative of the woman's position."
And, even if the abortion right belongs only to women, it has long been understood that "the right is inextricably bound up with" a provider's ability to offer these services.
Singleton v. Wulff
,
I. BACKGROUND
Ohio Revised Code § 3701.034
Ohio Revised Code § 3701.034 provides:
(A) As used in this section:
(1) "Affiliate" means an entity that has with another entity a legal relationship created or governed by at least one written instrument that demonstrates any of the following:
(a) Common ownership, management, or control;
(b) A franchise agreement;
(c) The granting or extension of a license or other agreement that authorizes an entity to use the other entity's brand name, trademark, service mark, or other registered identification mark.
(2) "Violence Against Women Act" means section 1910A of section 40151 of the "Violent Crime Control and Law Enforcement Act of 1994," part A of Title XIX of the "Public Health and Human Services Act,"108 Stat. 1920 (1994), former 42 U.S.C. 300w, 42 U.S.C. 280b-1b, as amended.
(3) "Breast and Cervical Cancer Mortality Prevention Act" means the "Breast and Cervical Cancer Mortality Prevention Act of 1990,"104 Stat. 409 (1990), 42 U.S.C. 300k, as amended.
(4) "Infertility prevention project" means the infertility prevention project operated by the United States centers for disease control and prevention.
(5) "Minority HIV/AIDS initiative" means the minority HIV/AIDS initiative operated by the office of minority health in the United States department of health and human services.
(6) "Personal responsibility education program" means the program administered *919 by the administration for children and families in the United States department of health and human services to educate adolescents on abstinence and contraception for the prevention of pregnancy and sexually transmitted infections.
(7) "Nontherapeutic abortion" has the same meaning as in section 9.04 of the Revised Code. [ 1 ]
(8) "Promote" means to advocate for, assist with, encourage, or popularize through advertising or publicity.
(B) - (G) [ 2 ] The department of health shall ensure that all funds it receives [through the Violence Against Women Act, Breast and Cervical Cancer Mortality Prevention Act, Infertility prevention project, Minority HIV/AIDS initiative, infant mortality reduction or infant vitality initiatives] are not used to do any of the following:
(1) Perform nontherapeutic abortions ;
(2) Promote nontherapeutic abortions ;
(3) Contract with any entity that performs or promotes nontherapeutic abortions ;
(4) Become or continue to be an affiliate of any entity that performs or promotes nontherapeutic abortions.
Plaintiffs
Plaintiffs Planned Parenthood of Greater Ohio (PPGOH) and Planned Parenthood Southwest Ohio Region (PPSWO) are not-for-profit corporations organized under Ohio law. PPGOH and PPSWO are also affiliates of Planned Parenthood Federation of America, Inc. (PPFA), which advocates for women's access to comprehensive reproductive healthcare, including abortion. Plaintiffs operate twenty-seven 3 health centers throughout Ohio, which are staffed with physicians, nurse practitioners, and physician assistants, who provide well-woman exams, testing and treatment for sexually transmitted diseases, screenings for breast and cervical cancer and HIV, and contraception and contraceptive counseling. Three of the twenty-seven health centers also provide abortion services. Separate from their government-funded health services and education programs, PPGOH and PPSWO advocate for a woman's right to safe and lawful abortion through public awareness campaigns and public education activities.
Consistent with federal and Ohio law, no government funds are used to pay for or subsidize Plaintiffs' abortion services or advocacy. It is undisputed that Plaintiffs "maintain measures to ensure that none of the funds received from the state or federal government are used, directly or indirectly, to subsidize the promotion of abortion or performance of abortion services." (R. 60, PID 2136.)
Largely through competitive grant processes, Plaintiffs have for years received funds and material assistance distributed by ODH and county health departments under the six federal programs impacted by § 3701.034 : the Infertility Prevention Project, Breast and Cervical Cancer Mortality *920 Prevention Act, Violence Against Women Act, Minority HIV/AIDS Initiative, Infant Mortality Reduction Initiative, and Personal Responsibility Education Program (PREP). 4 Throughout those years, Plaintiffs passed all state and local audits and program reviews.
After § 3701.034 was enacted, ODH and local health departments notified Plaintiffs that their contracts under the six federal programs would be terminated and they would not be eligible for funding. Plaintiffs' termination of services they currently provide under these six programs could have dramatic public-health consequences. For example, as amicus American Public Health Association details, Plaintiffs currently provide over 70,000 free STD tests to low-income Ohioans annually under the STD Prevention Program. With STDs among Ohioans continuing to rise, Plaintiffs' non-eligibility in that program could lead to three counties being without any qualified provider because other existing program providers do not have the capacity to fill the gap. Section 3701.034 's bar on funds being distributed to Plaintiffs under the other five programs would require Plaintiffs to cease providing other fundamental public-health services to primarily low-income or at-risk populations, including HIV testing and education, cancer screenings, and sexual-violence-prevention education. 5
Procedural History
Plaintiffs filed this action for declaratory and injunctive relief under
The district court entered a temporary restraining order on the day § 3701.034 was to take effect. Following discovery, the district court granted Plaintiffs' motions for judgment on the merits and permanently
*921
enjoined ODH from enforcing § 3701.034, reasoning that § 3701.034 violates the unconstitutional-conditions doctrine by impermissibly conditioning funding from programs unrelated to abortion based on a recipient's refraining from exercising its First Amendment rights to free speech or association outside the contours of the six programs, and refraining from providing abortion services protected by the Due Process Clause.
6
Planned Parenthood of Greater Ohio v. Hodges
,
II. STANDARD OF REVIEW
This court reviews a challenge to the constitutionality of a statute de novo.
Entm't Prods., Inc. v. Shelby County
,
III. DISCUSSION
The majority concludes that the "conduct provision" of § 3701.034 (precluding entities that perform nontherapeutic abortions from obtaining funding under the six federal programs) does not impose an unconstitutional condition because Plaintiffs have no due process right to perform abortions. The majority declines to reach Plaintiffs' First Amendment challenges to the speech and affiliation provisions (prohibiting the allocation of program funds to any entity that either (1) promotes nontherapeutic abortions, or (2) affiliates with any entity that performs or promotes nontherapeutic abortions ) concluding that Ohio may deny funding to Plaintiffs under the six federal programs if any one of the provisions is valid. I address all three provisions because each provision imposes an unconstitutional condition.
A. Due Process Claim
1.
I begin with the unconstitutional-conditions doctrine. The Supreme Court recognized this doctrine many decades ago to ensure that the government cannot leverage its allocation of benefits to "manipulate[ ]" constitutional rights "out of existence."
Frost v. R.R. Comm'n
,
"A predicate for any unconstitutional conditions claim is that the government could not have constitutionally ordered the person asserting the claim to do what it attempted to pressure that person into doing."
Koontz
, 570 U.S. at 612,
To be sure, the unconstitutional-conditions doctrine does not render any funding condition that may affect the exercise of constitutional rights unconstitutional.
See
AOSI
, 570 U.S. at 214,
In
AOSI
, the Supreme Court invalidated a statutory provision requiring organizations receiving funds under a program designed to combat AIDS and HIV to have a policy explicitly opposing prostitution and sex trafficking. 570 U.S. at 210, 221,
A straightforward application of these principles establishes the Statute's unconstitutionality. First, ODH could not impose the conduct provision as a direct regulation, because to do so would mean passing a law prohibiting the performance of nontherapeutic abortions. There is no dispute that outlawing abortions in Ohio would be an undue burden on women's ability to access the procedure in that state. Even if the direct regulation were limited to Plaintiffs-a constitutionally dubious maneuver as well,
see
Planned Parenthood of Cent. N.C. v. Cansler
,
Second, the Supreme Court explained that permissible "conditions that define the limits of the government spending program" are "those that specify the activities Congress wants to subsidize."
AOSI
, 570 U.S. at 214,
ODH disputes this conclusion, arguing that the conduct provision of § 3701.034 comports with due process under
Maher v. Roe
,
Rust
, in fact, teaches why § 3701.034 is impermissible.
Rust
involved Title X, which "provides federal funding for family-planning services."
Further, in rejecting the plaintiffs' unconstitutional-conditions challenge to the regulations, the
Rust
Court explained that the Supreme Court's " 'unconstitutional conditions' cases involve situations in which the Government has placed a condition on the
recipient
of the subsidy rather than on a particular program or service, thus effectively prohibiting the recipient from engaging in the protected conduct outside the scope of the federally funded program."
Finally, it was critical in
Rust
that the regulations did not deny "the right to engage in abortion-related activities" as a condition of receiving funding.
In sum, none of the numerous reasons that the regulations in
Rust
were upheld is present here: § 3701.034 does not define the scope of the federal programs; and it does not distinguish between the programs and the grantee, restricting only the former, while permitting the latter to "continue to perform abortions, provide abortion-related services, and engage in abortion advocacy ... through programs that are separate and independent from the project[s] that receive[ ] the [six program funds]."
Rust
,
For all of these reasons, § 3701.034 's conduct provision is unconstitutional.
2.
The majority avoids more than a cursory discussion of the principles underlying the unconstitutional-conditions doctrine by finding that Plaintiffs' purported lack of an independent constitutional right to perform abortions is dispositive. As discussed above, the Supreme Court label of the provider's constitutional right as "derivative of the woman's position,"
However, even accepting that Plaintiffs have no wholly independent constitutional right to perform abortions,
but see, e.g.
,
Planned Parenthood Ass'n of Utah v. Herbert
,
First, it is worth noting that the Supreme Court has not always couched the unconstitutional conditions doctrine in rights-based language, referring instead to "protected conduct,"
Rust
,
Second, as discussed above, and as the majority acknowledges ( see Maj. Op. at 914), one of the purposes of the unconstitutional-conditions doctrine is to prevent the government from achieving indirectly-by conditioning unrelated funds on forgoing constitutionally protected activity-what the government cannot achieve directly.
*926
But the majority says that is not what is happening here because "the government could have directly ordered the outcome it wishes to incentivize" in this case. (Maj. Op. at 914.) The majority does not explain how Ohio could directly order the outcome it wishes to incentivize-that Ohio's healthcare providers cease performing abortions. And even if the direct regulation could constitutionally be limited to Plaintiffs alone, ODH never challenged either in the district court or its briefing in this court, until en banc argument, that barring Plaintiffs from performing abortions would place an undue burden on women seeking abortion given the existing abortion providers in the area. There is no doubt that if Ohio ordered either ban directly, Plaintiffs would be able to challenge that law on due process grounds.
See
Whole Woman's Health v. Hellerstedt
, --- U.S. ----,
Thus, there is no reason why Plaintiffs cannot prevail on an unconstitutional-conditions claim in this case. The Supreme Court has never suggested that the government can impose a condition on a third party to induce a result that would be unconstitutional if the condition were imposed directly on a party whose rights are affected. 8 Nor has the Supreme Court suggested that an entity that could challenge a direct regulation could not prevail in challenging the government's attempt to reach the same result through a condition imposed on unrelated funding. Consider the examples of the constitutional rights to counsel, to vote, and to bear arms. These rights belong to the criminal defendant, the voter, and the gun owner, respectively. Imagine that the government barred lawyers who represent indigent defendants from eligibility for loan forgiveness programs, denied all government funding to private entities that volunteer to serve as polling places in low-income neighborhoods, or ceased providing all existing tax breaks, subsidies, and government benefits to any store that sells guns. By the majority's logic, as long as the beleaguered lawyers, polling places, and gun store owners continue to perform these services, no one could successfully challenge the constitutionality *927 of these laws based on the protected rights. 9
The whole point of the unconstitutional-conditions doctrine is to prevent the government from achieving indirectly what it cannot constitutionally achieve directly. And because Plaintiffs could succeed on a due process challenge against the direct version of this law, they can likewise challenge the indirect version as an unconstitutional condition. The majority's position contravenes the purpose of the unconstitutional-conditions doctrine. 10
ODH also asserts (and it appears the majority agrees) that the unconstitutional-conditions doctrine, at most, bars unconstitutional conditions only when they actually operate to impose an undue burden, and, the argument goes, § 3701.034 imposes no such undue burden because Plaintiffs' representatives testified that Plaintiffs would continue to perform abortions even if the law goes into effect. ODH relies on the Seventh Circuit's divided opinion in
Planned Parenthood of Indiana, Inc. v. Commissioner of Indiana State Department of Health
,
There, PPI, a Medicaid provider that performs abortions, one of its doctors, and two low-income patients who used its services, brought suit under
[T]he government need not be neutral between abortion providers and other medical providers, and this principle is particularly well-established in the context of governmental decisions regarding the use of public funds. As long as the difference in treatment does not unduly burden a woman's right to obtain an abortion, the government is free to treat abortion providers differently.
Applying these principles here, the unconstitutional-conditions claim is not likely to succeed. Planned Parenthood does not argue that the loss of its block-grant funding imposes an undue burden-directly or indirectly-on a woman's right to obtain an abortion. If ... the government's refusal to subsidize abortion does not unduly burden a woman's *928 right to obtain an abortion, then Indiana's ban on public funding of abortion providers-even for unrelated services-cannot indirectly burden a woman's right to obtain an abortion.
PPI
,
The Seventh Circuit's analysis avoids the unconstitutional-conditions argument by looking at the effect on a woman's right to obtain an abortion if the provider does not submit to the condition and continues providing abortions. That is not the appropriate analysis. In
AOSI
, for example, the Supreme Court did not hold that the organizations' First Amendment rights were not violated because they could simply decline the funding and continue to have whatever policy they wanted about prostitution and sex trafficking. Rather, the Court determined that the condition,
if imposed directly
, would violate the Constitution. Thus, forcing the organizations to have a policy opposing prostitution and sex trafficking to obtain the relevant funding violated the First Amendment, just as forcing Plaintiffs here to refrain from performing abortions to obtain unrelated funding would violate the Due Process Clause. This is because the unconstitutional-conditions doctrine prohibits the imposition of the
condition itself
and does not require the party to actually submit to the condition to prevail.
AOSI
, 570 U.S. at 214,
The
PPI
majority also failed to recognize
Rust
's distinction between conditions placed on the government
program
and those imposed on the
recipient
. And although in summarizing
Rust
the
PPI
majority seems to recognize that
Rust
treated the unconstitutional-conditions argument as separate from the undue-burden analysis,
14
the
PPI
majority engaged in no substantive
*929
discussion of
Rust
's treatment of the separate unconstitutional-conditions claim.
See
The unstated conclusion holding the
PPI
majority's opinion together is that because the government need not subsidize abortion and need not be neutral between abortion providers and other medical providers, particularly with respect to government funds, the government could directly prohibit providers from performing abortions. Of course, this is not the case. The cited cases
15
establish that the government can prohibit PPI or other abortion providers from using program funds to perform or advocate for abortion. But nowhere does
Rust
or any other case suggest that the government can condition the receipt of unrelated funds on a recipient's abandoning all activities that facilitate a woman's right to obtain an abortion, or that advocate for such a right, and any affiliation with any entity that does either. Courts considering similar issues post-
AOSI
have not followed the Seventh Circuit's (or the majority's) analysis.
See, e.g.
,
Planned Parenthood of Sw. & Cent. Fla. v. Philip
,
*930
I agree with the majority that "[t]he point of the [unconstitutional-conditions] doctrine is to protect the underlying right: a woman's right of access to abortion services without an undue burden." (Maj. Op. at 916.) But the majority creates a loophole that enables states to circumvent the unconstitutional-conditions doctrine: the government
cannot
leverage its funding to carve away at constitutional rights by passing laws that target the individual who holds the right, but it
can
leverage funding to achieve that same result so long as it manages to find a proxy to target instead. The majority's reasoning contorts a doctrine that aims to prevent the government from manipulating rights out of existence,
Frost
,
At bottom, ODH's position and the majority's opinion open the door for the government to impose almost any condition 17 it wants on abortion providers so long as the abortion providers resist the coercion and continue to perform abortions. At oral argument, the United States, arguing in favor of ODH's position, acknowledged that ODH's position would authorize the government to pass a law prohibiting all doctors who perform abortions from providing any other medical services. (Oral Arg. at 33:10-35:30.) This is because as long as enough doctors continue to perform abortions, there would be no undue burden on a woman's right to obtain one. ( Id. ) And under the majority's reasoning, the doctors could not challenge the law as an unconstitutional condition because they have no due process right to provide abortions. Other hypotheticals are imaginable, which before today would have seemed absurd. Using this reasoning, the government can do almost anything it wants to penalize abortion providers so long as they resist the coercion and continue to perform abortions. ( Id. )
This result is especially striking in juxtaposition with the Supreme Court's abortion jurisprudence over the last three decades, which reveals that virtually every attempt to ban or undermine a woman's abortion right since
Roe v. Wade
has operated by targeting providers, not women.
See, e.g.
,
Whole Woman's Health
, --- U.S. ----,
Because the unconstitutional-conditions doctrine does not allow the government to penalize a party indispensable to the exercise of a constitutional right so long as the party refuses to cry uncle and submit to the condition, the conduct provision is unconstitutional.
B. First Amendment Claims
The majority does not reach Plaintiffs' patently meritorious First Amendment claims, reasoning that because the conduct provision does not impose an unconstitutional burden, ODH may deny funding under the Statute without regard to whether the Statute violates Plaintiffs' First Amendment rights. But Plaintiffs' First Amendment claims are not mooted by the purported constitutionality of the conduct provision, and a decision on the First Amendment claims is not rendered advisory by the majority's decision on the conduct provision. If the First Amendment challenge is successful, Plaintiffs could form affiliate entities to take over their abortion-related activities ( see Pls.' Br. on Reh'g at 18-19), and still receive funds under the six federal programs. In any event, because the conduct provision is unconstitutional, I address Plaintiffs' First Amendment claims as well.
Plaintiffs assert two claims under the First Amendment, addressing both § 3701.034 's speech provision-which prohibits the allocation of program funds to any entity that
promotes
nontherapeutic abortions-and its affiliation provision-which prohibits the allocation of program funds to any entity that
affiliates with
any entity that performs or promotes nontherapeutic abortions. It is undisputed that a funding condition can result in an unconstitutional burden on First Amendment rights.
See AOSI
, 570 U.S. at 218,
Plaintiffs' First Amendment claim is not vulnerable to attack under either of the rationales the majority appears to adopt in analyzing the due process claim. Plaintiffs are asserting their own First Amendment rights and need not show that a restriction amounts to an undue burden on a woman's right to obtain an abortion to prevail on a claim under the First Amendment. Nor does ODH dispute that it would be unconstitutional to legislate a direct ban on promoting nontherapeutic abortions or affiliating with entities that perform or promote nontherapeutic abortions.
Instead, relying on
Planned Parenthood Ass'n of Hidalgo County Texas, Inc. v. Suehs
,
In
Suehs
, the Texas legislature had created the "Women's Health Program (WHP)," designed to "expand access to preventative health and family planning services for women."
Texas's restriction on promoting elective abortions directly regulates the content of the WHP as a state program. The policy expressed in the WHP is for public funds to subsidize non-abortion family planning speech to the exclusion of abortion speech. § 1.19(b), 2011 Tex. Gen. Laws at 335. Texas's authority to promote that policy would be meaningless if it were forced to enlist organizations as health care providers and message-bearers that were also abortion advocates. The authority of Texas to disfavor abortion within its own subsidized program is not violative of the First Amendment right, as interpreted by Rust v. Sullivan. Consequently, Texas's choice to disfavor abortion does not unconstitutionally penalize the appellees' speech.
Suehs
,
I agree with the district court that this out-of-circuit precedent is distinguishable and inapposite.
Suehs
is virtually indistinguishable from
Rust
because, as the Fifth Circuit observed, Texas's restriction "directly regulates the content of the WHP as a state program."
Further, although Ohio, like Texas, may, consistent with the First Amendment, ensure that its message favoring childbirth over abortion is not garbled, this case plainly involves no state "message" related to or regarding abortion; § 3701.034 affects programs that have nothing to do with abortion or family planning, and seeks to impose restrictions on recipients' speech outside of those six government programs.
As the Supreme Court made clear in
AOSI
, the government may not prevent a recipient of government funding from expressing its own views "when participating in activities on its own time and dime." 570 U.S. at 218,
Finally, by conditioning participation in the six federal programs on refraining from being an affiliate of any entity that promotes or performs nontherapeutic abortions, the Statute effects a separate First Amendment violation of Plaintiffs' right to free association.
See
*933
Runyon v. McCrary
,
IV. ENTRY OF PERMANENT INJUNCTION
ODH conceded that it "agrees that if this Court finds the Conduct and Speech Provisions both unconstitutional," the permanent injunction factors are met. (Reply Br. at 29.)
V. CONCLUSION
For the reasons stated, the district court correctly granted Plaintiffs' motions for judgment on the merits and for a permanent injunction. Its decision should be affirmed.
Ohio law defines "nontherapeutic abortion" as "an abortion that is performed or induced when the life of the mother would not be endangered if the fetus were carried to term or when the pregnancy of the mother was not the result of rape or incest reported to a law enforcement agency." Ohio Rev. Code § 9.04(A)(1).
Sections (B) through (G), which address each of the programs separately, share identical language in subsections (1) through (4), and are condensed for brevity.
During the pendency of this appeal, Plaintiffs' counsel advised that one of the twenty-eight health centers has closed for reasons unrelated to this case. The district court's opinion states that Plaintiffs operate twenty-eight health centers, which was accurate at the time.
Plaintiffs' counsel advised the court by letter dated July 27, 2017, that PPGOH did not reapply for grant funding under the PREP program when its contract expired on July 31, 2017, and that it appears that ODH will no longer be responsible for allocating PREP funds as of August 1, 2017; thus "there is a question as to whether [this court] need consider PREP in its analysis of Section 3701.034." (ECF No. 57.)
PPGOH is the largest provider of HIV testing and treatment in Cleveland, Akron, and Canton, and PPSWO provides approximately 1,600 anonymous and confidential HIV tests annually. PPGOH also provided 4,400 pap smears and 3,700 breast exams in the fiscal year ending in June 2015. Approximately 75% of PPSWO's patients and 40% of PPGOH's patients fall within the low-income classification. Many of these patients live in medically underserved areas--communities classified by the U.S. Department of Health and Human Services as having too few primary-care providers, high infant mortality and poverty rates, or large elderly populations. ODH failed to identify alternative providers to fill most of the gaps in service that would result from excluding Plaintiffs from funding under the six federal programs.
The district court did not reach Plaintiffs' Equal Protection claim, nor does the majority. Accordingly, the case must be remanded for the district court to consider the Equal Protection claim.
Plaintiffs consistently argued that their ceasing to perform abortions would impose an undue burden on women seeking abortion due to the reduction in abortion services available to the women of Ohio. Despite multiple opportunities in several rounds of briefing before the district court and this court, ODH never attempted to explain why Plaintiffs' ceasing to perform abortions would not cause an undue burden, instead calling the argument "irrelevant." (R. 53, PID 2055.) At oral argument before the en banc court, ODH acknowledged that it never briefed the issue but summarily argued in rebuttal that it was "pretty sure we not only do dispute that, but we'd come out on the better side of it." (Oct. 3, 2018, Oral Arg. 58:58-59:43.) Because a party's claiming to be "pretty sure" that it would dispute an issue despite never briefing that issue is insufficient to preserve the issue for appeal, ODH forfeited the argument that Plaintiffs' ceasing to perform abortions would not result in an undue burden.
See
United States v. Universal Mgmt. Servs., Inc.
,
The unconstitutional-conditions cases that the Supreme Court has addressed thus far have involved plaintiffs' challenges to conditions that impact their own, personal constitutional rights.
See, e.g.
,
Koontz
,
Legal Services Corp. v. Velazquez
,
Nor would affirming the district court "effectively [be] saying" that abortion providers "have a constitutional right to offer abortions." (Maj. Op. at 914-15.) It would merely be saying that states cannot strip an entity of funding that is unrelated to abortion solely because that entity provides abortions on its "own time and dime."
See
AOSI
, 570 U.S. at 218,
The majority's reliance on the Seventh Circuit "reject[ing] an unconstitutional-conditions challenge to an Indiana law with a conduct component identical in every material way to this Ohio law" (Maj. Op. at 913) ignores that the law at issue in
PPI
did not prohibit funding for any entity that promotes abortions or, more critically, any entity that affiliates with an entity that promotes or performs abortions.
See
PPI
,
PPI was decided before Koontz and AOSI , which may account for its flawed analysis.
This suggestion would have particularly troubling implications. It seems that the majority would never allow a facial challenge claiming that a statute imposed an unconstitutional condition on a woman's abortion right, because the answer to whether a statute will create an undue burden is always "[m]aybe; maybe not." (Maj. Op. at 916.) This is antithetical to this court's precedent,
see
R.S.W.W.
,
The
PPI
majority stated: "Because the Title X regulations did not place an undue burden on a woman's right to obtain an abortion
or otherwise impose an unconstitutional condition on grant recipients, the Court upheld the regulatory scheme
."
Maher
,
The majority's suggestion that
Teixeira v. County of Alameda
,
Subject only to rational basis review, according to the United States.
Reference
- Full Case Name
- PLANNED PARENTHOOD OF GREATER OHIO; Planned Parenthood of Southwest Ohio Region, Plaintiffs-Appellees, v. Richard HODGES, in His Official Capacity as Director of the Ohio Department of Health, Defendant-Appellant.
- Cited By
- 19 cases
- Status
- Published