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

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

HHS adopts the Final Rule

Plaintiff files Complaint

District court enters Preliminary Injunction

Defendants file Notice of Appeal

District court enters Order denying Defendants’ motion to stay the injunction pending appeal

Court of appeals enters Order granting Defendants’ motion to stay the injunction pending appeal

Court of appeals hears oral argument

District court enters Permanent Injunction

Defendants file second Notice of Appeal

District court enters Order clarifying judgment

District court enters Order denying Defendants’ motion to stay the injunction pending appeal

En Banc court of appeals enters Order granting Plaintiff’s motion for consolidation and initial hearing en banc

En banc court of appeals enters Order denying Defendants’ motion to stay the injunction pending appeal

District court enters Order denying Plaintiff’s motion to alter or amend the judgment

En banc court of appeals hears oral argument

En banc court of appeals issues Opinion affirming the permanent injunction

Defendants file a Petition for a Writ of Certiorari with the Supreme Court

Plaintiff files a Brief in Opposition with the Supreme Court

Defendants file a Reply Brief with the Supreme Court

Supreme Court grants certiorari petition and consolidates this case with others from the Ninth Circuit under lead docket number 20-429

Supreme Court dismisses the case

New Title X Rule takes effect