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Mayor and City Council of Baltimore v. Azar (Maryland)

D. Md. No. 1:19-cv-01103 / 4th Cir. Nos. 19-01614, 20-01215 / Sup. Ct. No. 20-429, 20-454

This case challenged a Final Rule adopted by the U.S. Department of Health and Human Services (HHS) during the Trump-Pence administration that imposed restrictions on organizations receiving grants pursuant to Title X of the Public Health Services Act (Title X), 42 U.S.C. §§ 300 -300a-6.

Established in 1970, Title X is a federal grant program dedicated to providing individuals with comprehensive family planning and related preventive health services.  These services include birth control; wellness exams; cervical and breast cancer screenings; and testing and treatment for sexually transmitted infections (STIs).  Title X benefits low-income people; the uninsured; and communities that have historically faced barriers to healthcare access.  More than four million U.S. residents rely on Title X-funded healthcare providers for affordable birth control and preventive health services.

The restrictions imposed by the Final Rule included a “gag rule” that prohibited recipients of Title X funds from providing their patients with referrals for abortion care; and “separation requirements” mandating that recipients of Title X funds be “physically and financially separate” from any person or entity who provides, refers for, or advocates for abortion care, including by maintaining separate facilities, personnel, medical records, workstations, signage, and public identities.  The Final Rule threatened to harm the intended beneficiaries of Title X by limiting the number of healthcare providers willing and able to serve them, and preventing them from obtaining accurate information about where to obtain safe abortion care.

The City of Baltimore challenged the Final Rule to prevent these harms from impacting its residents.  The Baltimore City Health Department, founded in 1793, is the oldest continuously operating health department in the United States.  It operates a network of health centers that serve over 7,500 Title X clients annually.

On February 14, 2020, the district court issued a permanent injunction blocking the federal government from enforcing the Final Rule in Maryland.  The full court of appeals affirmed that ruling. 

In addition to Baltimore’s case, seven other cases challenged the Final Rule:

  • American Medical Association v. Azar, D. Or. No. 6:19-cv-00318 / 9th Cir. No. 35386 / Sup. Ct. No. 20-429 
  • California v. Azar, N.D. Cal. No. 3:19-cv-01184 / 9th Cir. No. 19-15974 / Sup. Ct. No. 20-539 
  • Essential Access Health, Inc. v. Azar, 3:19-cv-01195 / 9th Cir. No. 19-15979 / Sup. Ct. No. 20-429  
  • Family Planning Association of Maine v. U.S. Department of Health and Human Services, D. Me. No. 1:19-cv-00100 / 1st Cir. No. 20-1781 
  • National Family Planning and Reproductive Health Association v. Azar, E.D. Wash. No. 1:19-cv-03045 / 9th Cir. No. 19-35394 / Sup. Ct. No. 20-429 
  • Oregon v. Azar, D. Or. No. 6:19-cv-00317 / 9th Cir. No. 19-35386 / Sup. Ct. No. 20-539  
  • Washington v. Azar, E.D. Wash. No. 1:19-cv-03040 9th Cir. No. 19-35394 

Baltimore’s case is the only one that produced a permanent injunction.

On February 22, 2021, the Supreme Court granted HHS’s petition to review the Baltimore case and consolidated it for oral argument with the Ninth Circuit cases listed above.  But after the Biden-Harris administration announced its intention to repeal the Final Rule, the Supreme Court dismissed the case.

On November 8, 2021, a new Title X rule took effect, which explicitly repealed the prior rule.


Mayor and City Council of Baltimore


Secretary of the United States Department of Health and Human Services, in his official capacity; United States Department of Health and Human Services; Deputy Assistant Secretary for the Office of Population Affairs, in her official capacity; Office of Population Affairs


Baltimore City Law Department; Arnold & Porter Kaye Scholer LLP; Yale Law School Reproductive Rights and Justice Project

Timeline and Key Documents:

May 17, 2021

Supreme Court Dismisses the Case

February 22, 2021

Supreme Court Grants Certiorari Petition and Consolidates this Case with Others from the Ninth Circuit Under Lead Docket Number 20-429

May 7, 2020

En Banc Court of Appeals Hears Oral Argument

September 18, 2019

Court of Appeals Hears Oral Argument

May 4, 2019

HHS Adopts the Final Rule

April 12, 2019