News Law and Policy

Medical Groups File Brief With Ninth Circuit Against Arizona Medication Abortion Restrictions

Jessica Mason Pieklo

The American Medical Association and the American Congress of Obstetricians and Gynecologists filed a friend of the court brief detailing how restrictions on medication abortion hurt patient safety and interfere with standards of medical care.

In preparation for upcoming oral arguments before the U.S. Court of Appeals for the Ninth Circuit in the fight over new Arizona regulations on medication abortions, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) filed a joint amicus curiae brief in support of the reproductive rights advocates challenging the regulations.

At issue in the lawsuit are regulations that require abortion providers to follow outdated Food and Drug Administration (FDA) protocol when administering medication abortions. In March, reproductive rights advocates sued to block the new restrictions, arguing they threatened to ban entirely medication abortion in the state and were unconstitutional. A lower court disagreed and ruled the regulations could go into effect April 1. Advocates immediately filed an appeal with the Ninth Circuit, which issued a temporary emergency injunction blocking the lower court order and preventing the regulations from taking effect pending a hearing on the appeal.

Arizona’s medication abortion restrictions are similar to those passed in states like Texas that, while passed under the guise of promoting patient safety, seek to severely restrict, if not ban altogether, the practice of medication abortion. The brief filed by ACOG and the AMA goes right to the heart of the “patient safety” concerns to detail the damage these kinds of abortion restrictions inflict in the community. According to the medical organizations, there is simply “no evidence” that these kinds of restrictions promote patient health and safety.

The law also jeopardizes women’s health, the organizations state, by “requiring that physicians deny women the benefit of the most current, well-researched, safe, evidence-based and proven protocols for the provision of medical abortion, and, instead, prescribe a regime that is less safe.” The result, the doctors argue, is a legislative mandate that is against the best interests of patients and forces doctors to “depart from their ethical obligation to provide the best possible care for their patients using their sound medical judgment—insisting, rather, that physicians substitute the judgment of the Arizona legislature for their own.”

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Arizona’s fight over medication abortion is the latest front where the medical community has amplified its objections to increased meddling by anti-choice lawmakers into medical practice and patient care. Last year, the American Medical Association and the American Congress of Obstetricians and Gynecologists came out against the efforts in Texas and elsewhere to dictate medical practice by forcing physicians who prescribe medication abortions to follow FDA protocol. But despite opposition from the medical community, federal and state courts have split on blocking similar restrictions. Most recently, the U.S. Court of Appeals for the Fifth Circuit upheld similar restrictions in Texas, while another federal court did the same for Ohio. However, the Oklahoma Supreme Court struck down that state’s medication abortion restriction, a decision the U.S. Supreme Court declined to overrule, while a state court in North Dakota blocked a similar law there.

A second lawsuit challenging the Arizona medication abortion restrictions is also pending in state court. That lawsuit was filed before the Ninth Circuit had issued a ruling on the federal action, but advocates note that the two cases are not dependent on one another. The state court action argues that because the regulation of doctors is a matter of state concern, the Arizona legislature violated Arizona law by unlawfully delegating to the FDA a matter of state concern. The complaint also claims that Arizona lawmakers violated their own rule-making procedures when passing the regulations, because they failed to provide for enough time for the public to comment, as required under law. The state court action seeks a declaratory judgment that the law is unconstitutional and an injunction stopping its enforcement.

The hearing before the Ninth Circuit is scheduled for 9 a.m. on May 13 in San Francisco, California.

Analysis Abortion

Legislators Have Introduced 445 Provisions to Restrict Abortion So Far This Year

Elizabeth Nash & Rachel Benson Gold

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. Of these, 35 percent (445 provisions) sought to restrict access to abortion services. By midyear, 17 states had passed 46 new abortion restrictions.

Including these new restrictions, states have adopted 334 abortion restrictions since 2010, constituting 30 percent of all abortion restrictions enacted by states since the U.S. Supreme Court decision in Roe v. Wade in 1973. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

Mid year state restrictions

 

Signs of Progress

The first half of the year ended on a high note, with the U.S. Supreme Court handing down the most significant abortion decision in a generation. The Court’s ruling in Whole Woman’s Health v. Hellerstedt struck down abortion restrictions in Texas requiring abortion facilities in the state to convert to the equivalent of ambulatory surgical centers and mandating that abortion providers have admitting privileges at a local hospital; these two restrictions had greatly diminished access to services throughout the state (see Lessons from Texas: Widespread Consequences of Assaults on Abortion Access). Five other states (Michigan, Missouri, Pennsylvania, Tennessee, and Virginia) have similar facility requirements, and the Texas decision makes it less likely that these laws would be able to withstand judicial scrutiny (see Targeted Regulation of Abortion Providers). Nineteen other states have abortion facility requirements that are less onerous than the ones in Texas; the fate of these laws in the wake of the Court’s decision remains unclear. 

Ten states in addition to Texas had adopted hospital admitting privileges requirements. The day after handing down the Texas decision, the Court declined to review lower court decisions that have kept such requirements in Mississippi and Wisconsin from going into effect, and Alabama Gov. Robert Bentley (R) announced that he would not enforce the state’s law. As a result of separate litigation, enforcement of admitting privileges requirements in Kansas, Louisiana, and Oklahoma is currently blocked. That leaves admitting privileges in effect in Missouri, North Dakota, Tennessee and Utah; as with facility requirements, the Texas decision will clearly make it harder for these laws to survive if challenged.

More broadly, the Court’s decision clarified the legal standard for evaluating abortion restrictions. In its 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Court had said that abortion restrictions could not impose an undue burden on a woman seeking to terminate her pregnancy. In Whole Woman’s Health, the Court stressed the importance of using evidence to evaluate the extent to which an abortion restriction imposes a burden on women, and made clear that a restriction’s burdens cannot outweigh its benefits, an analysis that will give the Texas decision a reach well beyond the specific restrictions at issue in the case.

As important as the Whole Woman’s Health decision is and will be going forward, it is far from the only good news so far this year. Legislators in 19 states introduced a bevy of measures aimed at expanding insurance coverage for contraceptive services. In 13 of these states, the proposed measures seek to bolster the existing federal contraceptive coverage requirement by, for example, requiring coverage of all U.S. Food and Drug Administration approved methods and banning the use of techniques such as medical management and prior authorization, through which insurers may limit coverage. But some proposals go further and plow new ground by mandating coverage of sterilization (generally for both men and women), allowing a woman to obtain an extended supply of her contraceptive method (generally up to 12 months), and/or requiring that insurance cover over-the-counter contraceptive methods. By July 1, both Maryland and Vermont had enacted comprehensive measures, and similar legislation was pending before Illinois Gov. Bruce Rauner (R). And, in early July, Hawaii Gov. David Ige (D) signed a measure into law allowing women to obtain a year’s supply of their contraceptive method.

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But the Assault Continues

Even as these positive developments unfolded, the long-standing assault on sexual and reproductive health and rights continued apace. Much of this attention focused on the release a year ago of a string of deceptively edited videos designed to discredit Planned Parenthood. The campaign these videos spawned initially focused on defunding Planned Parenthood and has grown into an effort to defund family planning providers more broadly, especially those who have any connection to abortion services. Since last July, 24 states have moved to restrict eligibility for funding in several ways:

  • Seventeen states have moved to limit family planning providers’ eligibility for reimbursement under Medicaid, the program that accounts for about three-fourths of all public dollars spent on family planning. In some cases, states have tried to exclude Planned Parenthood entirely from such funding. These attacks have come via both administrative and legislative means. For instance, the Florida legislature included a defunding provision in an omnibus abortion bill passed in March. As the controversy grew, the Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid, sent a letter to state officials reiterating that federal law prohibits them from discriminating against family planning providers because they either offer abortion services or are affiliated with an abortion provider (see CMS Provides New Clarity For Family Planning Under Medicaid). Most of these state attempts have been blocked through legal challenges. However, a funding ban went into effect in Mississippi on July 1, and similar measures are awaiting implementation in three other states.
  • Fourteen states have moved to restrict family planning funds controlled by the state, with laws enacted in four states. The law in Kansas limits funding to publicly run programs, while the law in Louisiana bars funding to providers who are associated with abortion services. A law enacted in Wisconsin directs the state to apply for federal Title X funding and specifies that if this funding is obtained, it may not be distributed to family planning providers affiliated with abortion services. (In 2015, New Hampshire moved to deny Title X funds to Planned Parenthood affiliates; the state reversed the decision in 2016.) Finally, the budget adopted in Michigan reenacts a provision that bars the allocation of family planning funds to organizations associated with abortion. Notably, however, Virginia Gov. Terry McAuliffe (D) vetoed a similar measure.
  • Ten states have attempted to bar family planning providers’ eligibility for related funding, including monies for sexually transmitted infection testing and treatment, prevention of interpersonal violence, and prevention of breast and cervical cancer. In three of these states, the bans are the result of legislative action; in Utah, the ban resulted from action by the governor. Such a ban is in effect in North Carolina; the Louisiana measure is set to go into effect in August. Implementation of bans in Ohio and Utah has been blocked as a result of legal action.

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The first half of 2016 was also noteworthy for a raft of attempts to ban some or all abortions. These measures fell into four distinct categories:

  • By the end of June, four states enacted legislation to ban the most common method used to perform abortions during the second trimester. The Mississippi and West Virginia laws are in effect; the other two have been challenged in court. (Similar provisions enacted last year in Kansas and Oklahoma are also blocked pending legal action.)
  • South Carolina and North Dakota both enacted measures banning abortion at or beyond 20 weeks post-fertilization, which is equivalent to 22 weeks after the woman’s last menstrual period. This brings to 16 the number of states with these laws in effect (see State Policies on Later Abortions).
  • Indiana and Louisiana adopted provisions banning abortions under specific circumstances. The Louisiana law banned abortions at or after 20 weeks post-fertilization in cases of diagnosed genetic anomaly; the law is slated to go into effect on August 1. Indiana adopted a groundbreaking measure to ban abortion for purposes of race or sex selection, in cases of a genetic anomaly, or because of the fetus’ “color, national origin, or ancestry”; enforcement of the measure is blocked pending the outcome of a legal challenge.
  • Oklahoma Gov. Mary Fallin (R) vetoed a sweeping measure that would have banned all abortions except those necessary to protect the woman’s life.

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In addition, 14 states (Alaska, Arizona, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maryland, South Carolina, South Dakota, Tennessee and Utah) enacted other types of abortion restrictions during the first half of the year, including measures to impose or extend waiting periods, restrict access to medication abortion, and establish regulations on abortion clinics.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.

News Family Planning

Lawsuit Challenges Arizona’s Attempt to Defund Planned Parenthood

Nicole Knight Shine

The Republican-backed law specifically targets abortion providers, excluding any facility from Medicaid that fails "to segregate taxpayer dollars from abortions, including the use of taxpayer dollars for any overhead expenses attributable to abortions.”

Planned Parenthood and the American Civil Liberties Union (ACLU) asked a federal court to block an Arizona law defunding Planned Parenthood, arguing in a legal challenge filed Thursday that the Arizona measure is “illegal.”

The GOP-backed law, signed by Republican Gov. Doug Ducey in May, specifically targets abortion providers, excluding any facility from Medicaid that fails “to segregate taxpayer dollars from abortions, including the use of taxpayer dollars for any overhead expenses attributable to abortions.”

Federal law already bars health-care providers from using Medicaid dollars for abortion care, except in cases of rape, incest, or life endangerment.

In an 18-page complaint, the plaintiffs argue that the restriction is impermissible under Medicaid statutes, and they ask for an injunction on the law, which goes into effect August 6. Planned Parenthood said in an emailed statement that the law could slash funding for birth control, cancer screenings, and preventive care, affecting more than 2,500 Medicaid patients in the state.

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The Arizona Health Care Cost Containment System, the state Medicaid agency, did not respond to a request for comment.

Jennifer Lee, staff attorney at the ACLU, called the Arizona law “another attempt to intimidate doctors who provide abortion and to punish low-income women in particular,” in a statement announcing the lawsuit. Planned Parenthood operates 11 medical centers in the state, including three in underserved and impoverished communities with high rates of infant mortality, according to the court filing.

At least ten states, including Arizona, have attempted to strip Planned Parenthood of funding—the fallout from a string of deceptive smear videos masterminded by David Daleiden, the head of the anti-choice front group the Center for Medical Progress, who now faces a felony record-tampering charge.

“This case is about the people who rely on us for basic care every day,” said Cecile Richards, president of Planned Parenthood Federation of America, in an announcement of the Arizona suit. “We’ll continue fighting in Arizona, and anywhere else there are efforts to block our patients from the care they need.”

The Arizona law represents the state’s second attempt to defund Planned Parenthood. In 2014, the Ninth Circuit Court of Appeals affirmed a lower court decision finding a similar defunding measure, HB 2800, violated federal Medicaid law.

In April, the federal Centers for Medicare & Medicaid Services sent a letter to all 50 states saying that cutting funding to qualified providers solely because they provide abortion care violates federal law.

Independent analysis suggests gutting Planned Parenthood funding exacts a toll on health care.

2015 report from the Congressional Budget Office indicated that health-care access would suffer under Planned Parenthood funding cuts, with the potential for $650 million in additional Medicaid spending over a decade and thousands of more births.

In Texas, births surged 27 percent among low-income women who were using injectable birth control but lost access to the service when the state cut Medicaid funding to Planned Parenthood, according to a study published in the New England Journal of Medicine.