A Woman's Friend Pregnancy Resource Clinic v. Harris (153 F. Supp. 3d 1168, 2015)

ORDER

KIMBERLY J. MUELLER, UNITED STATES DISTRICT JUDGE

Crisis pregnancy centers devoted to providing alternatives to abortion and discouraging abortion, also known as CPCs, have been operating in this country for several decades at least. Recently, the practices of some CPCs have prompted several state and municipal legislative bodies to adopt regulations governing the information provided to women seeking reproductive care. The changing landscape effected by implementation of the federal Affordable Care Act also has provided a backdrop to state and local legislative action. In the last year, the California Legislature adopted a provision known as the FACT Act, AB 775, which governs all clinics providing family planning qr pregnancy-related services, including CPCs. In passing AB 775, the Legislature articulated its intent to supplement its own prior efforts to advise women of the state’s reproductive health programs. As applicable here, the new law, scheduled to take effect January 1, 2016, requires licensed facilities that meet certain criteria to provide a notice to clients regarding the availability of free or low-cost public family planning services. Three CPCs operating in this judicial district challenge AB 775 as unconstitutional, in violation of their First Amendment Free Speech and Free Exercise rights. In the pending motion for preliminary injunction they seek to block the new law’s taking effect pending full litigation of this action. Having carefully considered the parties’ briefs, the parties’ arguments at a specially set hearing, and the applicable law, the court DENIES plaintiffs’ motion for the reasons set forth below.

I. PROCEDURAL HISTORY

Plaintiffs filed this action in this court on October 10, 2015. Compl., ECF No. 1. Before the State -answered, plaintiffs amended the complaint. First Am. Compl. (FAC), ECF No. 4. The amended complaint alleges the California Reproductive Freedom,, Accountability, Comprehensive Care, and Transparency Act (the Act) is unconstitutional both on its face and as applied. FAC ¶ 4. It includes two claims: (1)the Act is unconstitutional because it violates plaintiffs’ rights to freedom of speech under the First Amendment to the United States Constitution, id. ¶¶ 44-47; and (2) the Act is unconstitutional because it violates plaintiffs’ rights to free exercise of religion under the same Amendment, id. ¶¶ 48-51. Plaintiffs request declaratory judgment that the Act is unconstitutional on its face and as applied, preliminary and permanent injunctive relief prohibiting enforcement of the Act, attorneys’ fees and costs, and all other appropriate relief.

The State answered on November 9, 2015. ECF No. 7. It denies the Act is unconstitutional, Answer ¶¶ 44-51, and it advances one affirmative defense: It asserts the action is barred because the claims are not ripe for review, id. at 9.

Plaintiffs filed this motion for a preliminary injunction • on ■ November 13, 2015, Mot. Prelim. Injunction, ECF No. 8; Mem. P. & A., ECF No. 9. At hearing, plaintiffs clarified their motion-is. based on an as-applied challenge only. The State opposed the motion on December 4, 2015, ECF No. 16, and plaintiffs replied on December 11, 2015, ECF No. 17. The court held a hearing on December 18, 2015. Kevin Snider and Matthew McReynolds appeared for plaintiffs, and Noreen Skelly and Marc LaForestier appeared on behalf of the State.

II. THE ACT

A. Text of Statute

California Assembly Bill.(AB) 775 enacts new sections of the California Health and Safety Code, comprising “the Reproductive FACT (Freedom, Accountability, Comprehensive Care, and Transparency) Act or Reproductive FACT Act.” Cal. Health & Safety Code § 123470. The Act provides in pertinent part, that a

“licensed covered facility” means a facility licensed under-Section. 1204. or. an intermittent clinic operating, under a primary care clinic, pursuant to subdivision (h) of Section 1206, whose primary purpose is providing family planning or pregnancy-related services, and that satisfies two or more of the following:

(1) The facility offers obstetric .ultrasounds, obstetric sonograms, or prenatal care to pregnant women.

(2) The facility provides, .or offers counseling about, contraception or contraceptive methods.

(3) The facility offers pregnancy testing or pregnancy diagnosis.

(4) The facility advertises or solicits patrons with offers to provide prenatal so-nography, pregnancy tests, or pregnancy options counseling.

(5) The facility offers abortion services.

(6) The facility has staff or volunteers who collect health information from clients.

Id. § 123471. A facility covered by the Act is required to disseminate a notice to clients:

(a) A licensed covered facility shall disseminate to clients on site the following notice in English and in the primary threshold languages for Medi-Cal beneficiaries as determined by the State Department of Health Care Services for the county in which the facility is located.

(1) The notice shall state:

“California has public programs that provide immediate free or low-cost access to comprehensive family planning services (including all FDA-approved methods of contraception), prenatal care, and abortion for eligible women. To determine whether you qualify, contact the county social services office at [insert the telephone number].”

(2) The information shall be disclosed in one of the following ways:

(A) A public notice posted in a conspicuous place where individuals wait that may be easily read by those seeking services from the facility. The notice shall be at least 8.5 inches by 11 inches and written in no less than 22-point type.

(B) A printed notice distributed to all clients in no less than 14-point type.[]

(C) A digital notice distributed to all clients that can be read at the time of check-in or arrival, in the same point type as other digital disclosures. A printed notice as described in subpara-graph (B) shall be available for all clients who cannot or do not wish to receive the information in a digital format.

(3)The notice may be combined with other mandated disclosures.

Id. § 123472.

The law imposes civil penalties for failure to comply with the notice requirements:

(a) Covered facilities that fail to comply with the requirements of this article are liable for a civil penalty of five hundred dollars ($500) for a first offense and one thousand dollars ($1,000) for each subsequent offense. The Attorney General, city attorney, or county counsel may bring an action to impose a civil penalty pursuant to this section after doing both of the following:

(1) Providing the covered facility with reasonable notice of noncompliance, which informs the facility that it is subject to a civil penalty if it does not correct the violation within 30 days from the date the notice is sent to the facility.

(2) Verifying that the violation was not corrected within the 30-day period described in paragraph (1).

(b) The civil penalty shall be deposited into the General Fund if the action is brought by the Attorney General. If the action is brought by a city attorney, the civil penalty shall be paid to the treasurer of the city in which the judgment is entered. If the action is brought by a county counsel, the civil penalty shall be paid to the treasurer of the county in which the judgment is entered.

Id. § 123473.

The Act exempts two types of facilities from the new regulation:

(1) A clinic directly conducted, maintained, or operated by the United States or any of its departments, officers, or agencies.

(2) A licensed primary care clinic that is enrolled as a Medi-Cal provider and a provider in the Family Planning, Access, Care, and Treatment Program.

Id. § 123471.

B. Legislative History and Purpose

Federal health care policy provides a backdrop to the state law at issue here. In 2010, Congress passed the federal Patient Protection and Affordable Care Act (ACA), a law which made millions of Californians, 53 percent of them women, newly eligible for Medi-Cal. Hearing on AB 775 Before the Assembly Comm. on Health, 2015-2016 Sess. 2 (Cal. 2015), ECF No. 11-2 (Pls.’ Ex. 2). The ACA allowed California to establish or expand several programs that provide reproductive health care and counseling to low-income women. AB-775 § 1.

In California, more than 700,000 women become pregnant every year. AB 775 § 1. Of those pregnancies, approximately one-half are unintended. Id. In 2010, 64.3 percent of unplanned births in California were publicly funded. Id. By 2012, more than 2.6 million California women were in need of publicly funded family planning services. Id. At the moment they learn they are pregnant, thousands of women remain unaware of the California programs available that provide them with contraception, health education and counseling, family planning, prenatal care, abortion, or delivery. Id.

In order to ensure California residents can make their personal reproductive health care decisions in an informed manner, the California Legislature passed the Act. As noted above, the Act requires licensed clinics that give family planning or pregnancy-relafed. services to provide a notice to consumers regarding their reproductive rights and the availability of such services in California. Id. But the state Legislature identified a need to supplement its own efforts to advise women of the state’s reproductive health programs, particularly because pregnancy decisions are time sensitive. AB 775 § 1. The Act was seen as the “most effective way” to ensure women quickly obtain the information and services needed to make and implement timely reproductive decisions. Id.

Assemblyman David Chiu first introduced the Act' on February 25, 2015, with the goal of providing “technical, non-substantive changes” to a law that prohibited a person from “selling, offering for sale, giving away, distributing, or otherwise furnishing materials intended to determine the presence of pregnancy, unless that person has obtained a certificate of acceptability from the State Department of Public Health declaring that the materials have been approved as to efficacy and safety by the department.” Assemb. Chiu Intro. AB 775, 2015-2016 session, 99 (Cal. 2015).

On March 26, 2015, Chiu’s bill was amended to include text more similar to the statutory language ultimately adopted. See Assemb. Chiu First Amend. AB 775, 2015-2016 session, 98 (Cal. 2015) (“Assemb. First Amend.”). Specifically, the amendment included provisions requiring a licensed covered facility to disseminate a notice to all clients stating that “every pregnant woman has a right to decide whether to have a child or to obtain abortion care.” Id.

Oh April 8, 2015, the bill was again amended, removing the language added in the March 26 amendment. See Assemb. Chiu Second Amend. AB 775, 2015-2016 session, 97 (Cal. 2015) (“Assemb. Second Amend.”),' In its place, a provision was added to state the following:

California has public programs that provide immediate free or low-cost access to comprehensive family planning services, prenatal care, and abortion, for eligible women.

Id.

By incorporating this language, the Legislature sought to address & concern regarding crisis pregnancy centers (“CPCs”), facilities used by many’ pregnant women throughout California. Id. CPCs, which may be, licensed or unlicensed, provide a wide array of resources related to reproductive health. Id. at 7. Many CPCs, however, do not offer services other than what they describe as “pro-life” pregnancy options, so they do not make abortion referrals or procedures. Hearing on A.B. 775 Before the Senate Comm. on Health, 2015-2016 Sess. 6 (Cal. 2015), ECF No. 11-6 (Pls.’ Ex. 6). This is because CPCs are commonly affiliated'with organizations that do not believe women should have abortions. Pls.’ Ex. 2 at 7. Many CPCs are Christian belief-based organizations. Pls.’ Ex. 6 at 6.

As perceived by the Legislature, these beliefs lead CPCs to interfere with a woman’s ability to be fully informed and exercise her reproductive rights, primarily by posing as full-service women’s health clinics but discouraging women from seeking abortions. Id. To prevent women from accessing abortion resources, some CPCs use “intentionally deceptive advertising and counseling practices [which] often confuse, misinform, and.. .intimidate women from making fully-informed, time-sensitive decisions about critical healthcare.” Id.

Assemblyman Chiu and Assemblywoman Autumn Burke, the co-authors of AB 775, based their findings in part on a 2015 report by the National Abortion Rights Action League (NARAL), a vocal pro-choice organization. Pis.’ Ex. 2 at 2. For the report, NARAL sent several researchers- into CPCs to receive the counseling offered. Id. Many of the researchers reported being provided with inaccurate information regarding the risks of abortion, including being told that many women commit suicide after having an abortion and that abortions can cause breast cancer. Id.

On April 25, 2015, the Assembly Judiciary Committee held a hearing on the bill. Hearing on A.B. 775 Before the Assembly Comm. on Judiciary, 2015-2016 Sess. 1 (Cal. 2015), ECF No. 11-3 (Pls.’ Ex. 3). The committee considered whether the Act as proposed would regulate all pregnancy centers or just CPCs. Id. Legislators took account of a 2010 report issuing from the University of California, Hastings College of Law regarding CPC practices and potential legislative, options for regulating them. Pls.’ Ex. 2 at 5-6. The options identified in the report ranged from creating new regulations to leveraging existing regulations aimed specifically at medical services. Id. Cognizant of the potential for First Amendment challenges, legislators decided to regulate all pregnancy centers, including but not limited to CPCs. Id.

After two additional amendments, eliminating a reference to a right to privacy in the findings and substituting the language appearing in the law enacted, the Assembly passed AB 775 on May 26, 2015 by a vote of 49 to 26. Assemb. Unoff. Ballot AB 775, 2015-2016 Sess. (Cal. 2015). The Senate adopted the bill later in the year on September 3, 2015 by a vote of 24 to 14. Sen. Unoff. Ballot. AB 775, 2015-2016 Sess. (Cal 2015). The bill was forwarded to the Governor on September 16, 2015, who signed it into law on October 9, 2015. Id.; see Complete Bill History of AB 775.

Attorney General Kamala Harris was a primary co-sponsor, along with NARAL and Support Black Women for Wellness. Hearing on A.B. 775 Before the Senate Comm. on Rules, 2015-2016 Sess. 6 (Cal. 2015) (Pls.’ Ex. 7). Supporters included-the California Religious Coalition for Reproductive Choice, the California Immigrant Policy Center, and California- Latinas for Reproductive Justice. Id. Organizations in opposition to AB 775 included the Alliance for Defending Freedom, the Alternatives Pregnancy Center, the California Catholic Conference, and the California Right to Life Committee. Id.

III., THE PARTIES

A. A Woman’s Friend Pregnancy Resources Clinic (A Woman’s Friend)

A Woman’s Friend is a tax-exempt, nonprofit religious corporation established under section 501(c)(3) of the Internal Revenue Code and located in Marysville, California. Dodds Decl. ¶ 2, ECF No. 10-1; FAC ¶ 9. It is licensed under California Health and Safety Code section 1204. FAC ¶ 9. It offers all of its services free of charge. Dodds Decl. ¶ 28. It was organized “for the express purpose of providing alternatives to abortion for women experiencing unplanned pregnancies.” Id. ¶ 2. Its bylaws provide more specifically that its purpose “is to help a pregnant woman in crisis to understand [and] work through alternatives so’ she can make an informed decision about the outcome of her pregnancy.” Id. ¶ 3. “In addition, A Woman’s Friend seeks to provide counsel and practical help to all parties experiencing a crisis produced by an unplanned pregnancy.” Id. “A Woman’s Friend finds abortion an unacceptable alternative.” Id.

A Woman’s Friend requires its employees, volunteers, and board members to read and sign a statement of faith. Id. ¶ 4. Among other affirmations, the statement of faith confirms the person believes “the Bible to be the inspired, the only infallible authoritative Word of God”; “that there is one God, eternally existent in three persons: Father, Son, and the Holy Spirit”; and that “salvation is received through faith in Jesus Christ as Savior and Lord and not as a result- of good works.” Id. A Woman’s Friend also incorporates prayer throughout its operations, including at the beginning of every employee’s or volunteer’s shift and in every board meeting. Id. ¶ 5. A Woman’s Friend’s “motivation for the ministry is spiritual,” and “[n]o commercial transactions take place at the clinic.” Id. ¶ 28.

A Woman’s Friend refers to those who seek its services as “clients.” See, e.g., id. ¶ 6. Clients may call or walk in to the clinic. Id. Clients are greeted by a receptionist, who usually schedules an appointment for the same day or the next business day. Id. The receptionist helps clients fill out a form to request a service and what services clients need. Id. ¶ 7. The receptionist also copies the clients’ picture ID. Id. A registered nurse, whom A Woman’s Friend refers to as a “Client Advocate,” then meets with clients in a consultation room and fills out an information sheet. Id. ¶¶ 8, 13-19. The nurse instructs clients on the administration of a pregnancy test, and the test is administered. Id. ¶ 9.

If the test is positive, the nurse estimates a client’s due date and the date her pregnancy began. Id. ¶ 10. The nurse collects statistical and medical information, including the client’s vital signs, blood type, contraceptive use, history of pregnancies, surgeries, hospitalizations, sexually transmitted infections, other illnesses, substance abuse, current medications, and other information. Id. ¶ 15. The nurse alerts the client to symptoms that indicate immediate or more comprehensive medical care is necessary, including the symptoms of ectopic pregnancy and miscarriage. Id. ¶ 10. The nurse also offers brochures, pamphlets, referrals, and a medical appointment. Id. The nurse explains the services A Woman’s Friend offers, which include pre-parenting classes and a selection of used and new children’s clothing, maternity clothing, baby furniture, and other childcare supplies, id. all of which a Woman’s Friend offers free of charge, id. ¶ 28. The nurse advises the client to obtain health insurance benefits for prenatal care. Id. ¶ 16. The nurse teaches the client about prenatal health and well-being, nutrition, and fetal development and offers to perform a limited first trimester ultrasound. Id. ¶ 17. Usually an ultrasound appointment is scheduled for a later date, although sometimes an ultrasound may be provided the same day. Id.

If the pregnancy test is negative, the nurse encourages the client to seek confirmation from a physician and offers information about sexually transmitted infections or diseases and sexual abstinence. Id. ¶ 12.

Whether the test is positive or negative, before the client leaves, the nurse informs her it is a “life-affirming faith based organization” and gives her a copy of the New Testament, two DVDs, a gospel tract, and popcorn and candy. Id. The nurse asks the client for permission to pray together and asks her to fill out a client-service questionnaire. Id.

The medical staff at A Woman’s Friend includes a medical doctor, a doctor of obstetrics and gynecology, and several registered nurses. Id. ¶ 20. Its medical director is a medical doctor licensed to practice in California. Id. ¶ 27. He reviews A Woman’s Friend’s services annually to ensure these services comply with evidence-based medical standards and provide clients with true, correct, and current information. Id. ¶ 21. A Woman’s Friend is “committed to providing its clients with accurate and complete information about both prenatal development and abortion” and “assisting women to carry to term by providing emotional support and practical assistance.” Id. ¶ 23. “It is not a practice of A Woman’s Friend to discuss birth control with clients unless the client asks a direct question.” Id. ¶ 25. “All questions regarding this and other medical information are directed to licensed medical personnel for a response.” Id. Nevertheless, A Woman’s Friend does distribute literature that states abstinence is the only sure way to avoid pregnancy and sexually transmitted infections. Id. A Woman’s Friend does not provide ongoing prenatal care or emergency services, and it advises its clients to obtain these services from a physician or local hospital. Id. ¶ 16.

Carol Dodds, the CEO of A Woman’s Friend, id. ¶ 1, has submitted a declaration to express her belief that the Act’s notice provisions are “utterly contrary to our faith and what the organization wishes to say,” id. ¶ 30. Under her understanding of the Act, if A Woman’s Friend does not display the notice, it will be fined $500 for the first offense and $1,000 for each subsequent offense. Id. She avers that these penalties “would financially jeopardize the work of the clinic.” Id. ¶ 31.

B. Crisis Pregnancy Center of Northern California (CPCNC)

CPCNC is a religious non-profit corporation established under section 501(c)(3) of the Internal Revenue Code and located in Redding, California. FAC ¶ 10. It is licensed under California Health and Safety Code section 1204. Id. It offers all of its services free of charge. Gibbs Decl. ¶ 22, ECF No. 10-2. It is an affiliate of Care Net, and has adopted Care Net’s mission statement and statement of faith. Id. ¶¶ 4-5. Care Net is a national organization whose mission states that “every human life begins at conception and is worthy of protection.” Id. ¶ 5. “Care Net envisions a culture where women and men faced with pregnancy decisions are transformed by the gospel of Jesus Christ and empowered to choose life for their unborn children and abundant life for their families.” Id. ¶ 6. Care Net’s statement of faith explains its belief that the Bible is “the inspired, the only infallible, authoritative Word of God”; that “there is one God, eternally existent in three persons; Father, Son and Holy Spirit”; and that “salvation is received through faith in Jesus Christ as Savior and Lord and not as a result of good works,” among other tenets. Id. ¶ 7. In the same vein, CPCNC- is a “religiously based organization” and exists “to help women and men in need” rather than to “engage in commercial transactions.” Id. ¶¶ 2, 22.

CPCNC refers to those who seek its services as “clients.” See, e.g., id. ¶ 9. CPCNC’s day-to-day activities “are focused on offering free services to families that are in need of assistance throughout pregnancy and through, their child’s third year.” Id. ¶ 10. It offers its clients pregnancy tests, first trimester ultrasounds, referrals, an educational program, counseling, and mentoring. Id. ¶¶ 10, 22. CPCNC also offers classes on nutrition, labor and delivery, parenting, pregnancy, community resources and referrals, and other topics. Id. It also offers information about sexually transmitted infections or diseases, and offers information about sexual abstinence if requested. Id. ¶ 23.

CPCNC’s staff includes four registered nurses and a registered diagnostic medical sonographer. Id. ¶ 15. Its medical director is a licensed obstetrician and medical, doctor. Id. The medical director oversees its medical procedures, reviews, approves, and signs off on ultrasounds, and accepts referrals for clients in need of prenatal and pediatric .care. Id. The medical director also regularly consults with CPCNC’s medical sonographer. Id. CPCNC’s staff includes other, non-medical personnel, but they do not provide medical advice. Id. ¶ 19. CPCNC trains its staff members over a period of six to twelve months before they begin work with clients. Id. ¶ 13. Its staff takes care-not to answer questions beyond their scope of practice and refers clients to medical doctors, the emergency room, and other local medical facilities as necessary. Id.

CPCNC is “extremely adamant” about its commitment to care and competence. Id. ¶ 20. When CPCNC’s clients are pregnant, its services are intended to provide them with information about'the options available to them, including carrying a child to term, raising the child, obtaining an adoption, or abortion. Id. CPCNC desires that each client “make an educated choice with the proper information,” based on facts and the truth and after thorough consideration of all available options. Id. ¶ 21.

Shelly Gibbs, CPCNC’s CEO, id. ¶ 1, has submitted a declaration explaining her understanding that the Act “requires that a licensed clinic like CPCNC provide a notice that girls and women may receive free or low cost abortions.” Id. ¶ 24. She understands that “the notice requires CPCNC to communicate that our clients contact the-County social services and actually provide the phone number.” Id. She believes the notice is “diametrically opposed to the religiously based mission and goals of CPCNC,” and explains that “[because the notice is to be conspicuously posted in the waiting room so that it can easily be readmit is among the first communications, if not the first communication, made to a client.” Id.

C. Alternatives Women’s Center (AWC)

AWC is a religious non-profit corporation established under section 501(c)(3) of the Internal Revenue Code and located in Escondido, California. DeArmas Decl. ¶ 2, ECF. No. 10; FAC ¶ 11. It is licensed under Health and Safety Code section 1204. FAC ¶ 11; DeArmas Decl. ¶ 7. It offers its services free of charge. DeArmas Decl. ¶¶. 18-19. It describes itself as a “Christian-based community medical clinic.” Id. ¶ 3. Its objective “is to provide to pregnant women, thé community and to others, a Biblically guided and based Christian response to pregnancy, parenting and sexuality.” Id. ¶ 4. According to its bylaws, AWC must not “support nor promote abortion as an acceptable option available to pregnancy, including pregnancy resulting from rape or incest.” Id.

“AWC is a religious ministry and is motivated by spiritual concerns.” Id. ¶ 18. It “does not act out of economic interest.” Id. AWC’s staff and volunteers sign a statement of faith as part of their application. Id. ¶ 3. This statement explains the person believes “that the Bible is the only inspired Word of God and is free from error”; that “there is one God, the creator and preserver of all things” and “He exists eternally in three persons: the Father, the Son, and the Holy Spirit, who are of one substance and equal in power and glory”; that “man can only be saved by the grace of God, thróugh faith on the basis of the work of Jesus Christ and by the agency of the Holy Spirit”; and “that human life begins at conception and is valued by God from conception onward.” Id. In short, “all Board Members, officers, employees, and volunteers must be Christians.” Id. ¶ 5;

AWC refers to those who seek its services as “patients.” See, e.g., id. ¶ 12. When a patient arrives at AWC, she receives a packet from a receptionist, who leads her to a consultation room. Id. The receptionist gets to know the patient and confirms AWC’s understanding of her expectations for the appointment. Id. A nurse then gives the patient a “Decision Guide,” and thé nurse helps the patient complete the guide if nécessary. Id. This decision guide is part of AWC’s “holistic (whole person) approach to healthcare,” which follows "a “PIESS” assessment looking to the patient’s “Physical ..., Intellectual, Emotional, psycho-Social and Spiritual” needs. Id. ¶ 12. The nurse then shows the patient where and how to complete a pregnancy test. Id. If the test is positive, the nurse records the patient’s vital signs, height, and weight, and reviews the patient’s medical history. Id. If a patient exhibits symptoms of a condition requiring further medical attention, AWC refers her to appropriate treatment. Id. AWC then offers education on the patient’s medical options using a website, and a nurse offers a same-day ultrasound. Id. At the conclusion of the appointment, AWC provides any requested educational materials, gives the patient prenatal vitamins, and requests permission to follow up with the patient to learn whether she has obtained prenatal care or an abortion and to confirm her well-being. Id.

If a patient is not pregnant, AWC offers information about reproductive health, including menstrual cycles, fertility, methods of birth control, and sexually transmitted diseases and infections. Id. ¶ 15. AWC offers referrals if - the patient requests tests for sexually transmitted'diseases and infections. Id. It recommends sexual abstinence “as the best and safest way for single women to protect their' health which includes their sexual/medical, intellectual, emotional, psycho-social and spiritual health.” Id.

AWC’s medical staff consists of medical doctors, obstetricians and gynecologists, and registered nurses. Id. ¶ 10. It has a Medical Director and Obstetrics Director. These doctors are available by phone and can consult a patient’s medical records and test results. Id. ¶ 17. Tamara DeArmas, AWC’s CEO, id. ¶ 1, submitted a declaration explaining that “AWC provides accurate evidence-based education to all their patients and does not now nor has it ever knowingly given false or inaccurate medical advice,” id. ¶ 13. AWC takes time to ensure each patient has the information she needs to make an informed choice about her pregnancy. Id.

Ms. DeArmas also explains that “[referring giris an(j women, who come through our doors, to where they can get a low cost or free abortion runs directly against the mission and goals of AWC.” Id. ¶ 20. She understands the Act’s notice requirements will force AWC “to advertise for the County regarding abortion services against our will.” Id. She finds the notice provisions particularly problematic because, as she understands them, a notice must be posted in the waiting area, and it will be the first message AWC’s patients receive. Id.

D. Defendant Harris

Defendant Harris is the Attorney General of the State of California. As noted above, she was one of AB 775’s sponsors. Pls.’ Ex. 7, at 1. Upon passage of AB 775 into law, defendant issued a statement that she was “proud to have co-sponsored the Reproductive FACT Act, which ensures that all women have equal access to comprehensive reproductive health care services, and that they have the facts they need to make informed decisions about their health and their lives.” Attorney General Kamala D. Harris Issues Statement on Governor Brown Signing Reproductive FACT Act into Law (Oct. 9, 2015). She “commendfed] Governor Brown for signing AB 775 and thank[ed] Assemblymembers David Chiu and Autumn Burke for championing this important law.”

Under section 123473(a), Defendant will have authority to enforce the Act’s notice provisions. See Cal. Health & Safety Code § 123473(a). She has introduced no evidence and has not argued she will exercise her discretion to defer civil enforcement of the Act against plaintiffs.

IV. JURISDICTION; RIPENESS

The State argues this action is unripe such that the court is without jurisdiction. Ripeness is a question of timing. See Thomas v. Anchorage Equal Rights Comm’n, 220 F.3d 1134, 1138 (9th Cir.2000) (en banc). It is a doctrine “designed to ’prevent the courts, through avoidance of premature adjudication, from entangling themselves in abstract disagreements.’” Id. (quoting Abbott Labs. v. Gardner, 387 U.S. 136, 148, 87 S.Ct. 1507, 18 L.Ed.2d 681 (1967)). It includes “both a constitutional and a prudential component.” Portman v. Cnty. of Santa Clara, 995 F.2d 898, 902 (9th Cir.1993). The court addresses each component in turn.

A. Constitutional Ripeness

Generally speaking, “the constitutional component of ripeness is synonymous with the injury-in-fact prong of the standing inquiry.” Cal. Pro-Life Council, Inc. v. Getman (Getman), 328 F.3d 1088, 1094 n. 2 (9th Cir.2003). In other words, the constitutional aspects of ripeness may often be characterized as “standing on a timeline.” Thomas, 220 F.3d at 1138. As does the doctrine of standing, ripeness “focuses on whether there is sufficient injury.” Portman, 995 F.2d at 903. A sufficient injury is an injury-in-fact; “an invasion of a legally protected interest which is (a) concrete and particularized and (b) actual or imminent, not conjectural or hypothetical.” Lujan v. Defenders of Wildlife, 504 U.S. 555, 560, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992) (citations and quotation marks omitted). “A claim is not ripe for adjudication if it rests upon contingent future events that may not occur as anticipated, or indeed may not occur at all.” Texas v. United States, 523 U.S. 296, 301, 118 S.Ct. 1257, 140 L.Ed.2d 406 (1998) (citation and quotation marks omitted).

When a plaintiff challenges a statute’s constitutionality, “neither the mere existence of a proscriptive statute nor a generalized threat of prosecution satisfies the ‘case or controversy’ requirement.” Thomas, 220 F.3d at 1139. That is, a statute’s passage does not alone make for a ripe claim. Id. Rather, the plaintiffs must face a “genuine threat of imminent prosecution.” Id. In other words, “[a] plaintiff who challenges a statute must demonstrate a realistic danger of sustaining a direct injury as a result of the statute’s operation or enforcement.” Babbitt v. United Farm Workers Nat’l Union, 442 U.S. 289, 298, 99 S.Ct. 2301, 60 L.Ed.2d 895 (1979). “To show such a ‘realistic danger,’ a plaintiff must ‘allege[ ] an intention to engage in a course of conduct arguably affected with a constitutional interest, but proscribed by a statute, and... a credible threat of prosecution thereunder.’ ” Lopez v. Candaele, 630 F.3d 775, 785 (9th Cir.2010) (quoting Babbitt, 442 U.S. at 298, 99 S.Ct. 2301) (alterations in Lopez). The Ninth Circuit has listed three factors that may aid the court’s' decision on this front: “(1) “whether the plaintiffs have articulated a concrete plan to violate the law in question,’ (2) “whether the prosecuting authorities have communicated a specific warning or threat to initiate proceedings,’ and (3) ‘the history of past prosecution or enforcement under the challenged statute.’ ” Getman, 328 F.3d at 1094 (qupting Thomas, 220 F.3d at 1139). Similar considerations inform the court’s decision when the question is expressed in terms of standing and injury in fact. See, e.g., Lopez, 630 F.3d at 786.

The Thomas court took care to clarify that this test allows pre-enforcement challenges of laws that allegedly infringe on a plaintiffs constitutional rights. 220 F.3d at 1137 n. 1. Under longstanding federal precedent, a plaintiff need not “await .the consummation of threatened injury to obtain preventive relief.” Getman, 328 F.3d at 1094; see also LSO, Ltd. v. Stroh, 205 F.3d 1146, 1155. (9th Cir.2000) (“Courts have found standing where no one had ever been prosecuted under the challenged provision.”). This is particularly true in the context of First Amendment free-speeeh eases. Getman, 328 F.3d at 1094; LSO, 205 F.3d at 1155. For example, “when the State of Virginia passed a law banning the display of certain sexually-explicit material where juveniles could examine it, the Supreme Court found that booksellers had standing to object, even though the law had not yet been enforced.” LSO, 205 F.3d at 1155 (citing Va. v. Am. Booksellers Ass’n, Inc., 484 U.S. 383, 386, 392-93, 108 S.Ct. 636, 98 L.Ed.2d 782 (1988)). To reach this decision, the Court considered that Virginia “ha[d] not suggested that the newly enacted law will not be enforced” and concluded the plaintiffs had “alleged an actual and well-founded fear that the law will be enforced against them.” Am. Booksellers, 484 U.S. at 393, 108 S.Ct. 636.

Both the Ninth Circuit’s decision in LSO and the Supreme Court’s decision in American Booksellers concerned statutes that risked the chilling of constitutionally protected speech. See Am. Booksellers, 484 U.S. at 393, 108 S.Ct. 636; LSO, 205 F.3d at 1155-56. This was also the case in Getman. See 328 F.3d at 1094-95. Here, by contrast, plaintiffs argue the Act compels rather than chills their speech; however, the court sees no reason to distinguish the eases on that basis. The Supreme Court has held that “the right of freedom of thought protected by the First Amendment against state action includes both the right to speak freely and the right to refrain from speaking at all.” Wooley v. Maynard, 430 U.S. 705, 714, 97 S.Ct. 1428, 51 L.Ed.2d 752 (1977). Moreover, the alleged injury motivating the reasoning in American Booksellers, Getman, and LSO — self-censorship—may logically be substituted in this case for the alleged injury of compelled speech; that is, just as a plaintiff may be constitutionally injured by self-censorship, a plaintiff may be injured if compelled to speak. See also Riley v. Nat. Fed. of the Blind of N.C., 487 U.S. 781, 796-97, 108 S.Ct. 2667, 101 L.Ed.2d 669 (1988) (“There is certainly some difference between compelled speech and compelled silence, but in the context of protected speech, the difference is without constitutional significance....”).

Here, the Act imposes notice requirements on “licensed covered facilities,” which, as.set forth above, are defined in three parts: (1) the facility is licensed under California Health and Safety Code section 1204; (2). the facility’s “primary purpose is providing family planning or pregnancy-related services”; and (3) two or more of the listed conditions are satisfied. Cal. Health & Safety Code § 123471(a); see also id. § 123472(a) (notice requirements). Under this definition, each of the three plaintiff organizations is a “licenséd covered facility.” Each is licensed under Health and Safety Code section 1204. FAC ¶¶ 9-11. Each plaintiffs primary purpose is the provision of pregnancy-related services. See Dodds Deck ¶ 3; Gibbs Deck ¶ 10; DeArmas Decl. ¶ 4. And each satisfies two or more of the conditions listed in section 123471(a). See Dodds Decl. ¶¶ 9-12, 15, 17 (A Woman’s Friend offers and provides obstetric ultrasounds, offers pregnancy testing, and collects health information from clients); Gibbs Decl. ¶¶ 10, 23 (CPCNC offers pregnancy tests, obstetric ultrasounds, and “offer[s] abstinence information resources if requested or as needed”); DeArmas Decl. ¶¶ 12, 15 (AWC conducts pregnancy tests, reviews patients’ medical history, conducts obstetric ultrasounds, and offers counseling and contraceptive methods).

As “licensed covered facilities,” all three plaintiffs are subject to the notice requirements of Health & Safety Code section 123472(a). Should the law be upheld, they will face two choices: comply with the Act’s notice.provisions come January 1, 2016 or not. Should plaintiffs elect to comply with the notice provisions, they argue they will be compelled to make a statement contrary to both their religious beliefs and the purposes of their formation. Should they elect not to comply, they risk an enforcement action and may face civil penalties of five hundred dollars for a first offense and one thousand dollars for each later offense. See Cal. Health & Safety Code § 123472(a) (notice requirements); id. § 123473(a) (civil penalty provisions)... The Act is not yet effective, but the State has not suggested it will decline to enforce it. Indeed it argues that should enforcement of the Act be enjoined, the State would be unable to prevent harm to “the millions of California women who ‘are in need of publicly funded family planning services, contraception services and education, abortion services, and prenatal care and delivery,’ but are unaware of the public programs available to provide them with those vital services.” Opp’n at 19 (quoting AB 775 § 1(b)).

Two of the three Getman factors weigh in favor of the claims’ ripeness. One, the plaintiffs have articulated a concrete plan to violate the Act in question. The court disagrees with the State that plaintiffs have not expressly professed their intent to disobey with the Act’s notice provisions. The plaintiffs’ declarations leave no doubt they believe displaying or distributing the notices would conflict with their religious beliefs and the purposes of their organizations. See, e.g., Dodds Decl. ¶¶ 29-31; Gibbs Decl. ¶ 24; DeArmas Decl. ¶ 20; see also LSO, 205 F.3d at 1156 (“We are not persuaded by the [defendants’] contention that [the plaintiff] was required to plead that a particular. 1 .licensee-had in fact refused to lease - premises to. [it] _”). Two, the State has in effect communicated its intent to enforce the Act. See Getman, 328 F.3d at 1094. The court recognizes that the state has not, strictly speaking, “communicated a specific warning or threat to initiate proceedings,” id. and has not given notice as required by section 123473(a)(1), but in light of applicable Supreme Court authority, this shortfall does not yet deprive the court of jurisdiction. See, e.g., Am. Booksellers, 484 U.S. at 393, 108 S.Ct. 636 (“The State has not suggested that the newly enacted law will not be enforced, and we see no reason to assume otherwise. We conclude that plaintiffs have alleged an actual and well-founded fear that the law will be enforced against them.”). The State has not disavowed plans to enforce the Act. See LSO, 205 F.3d at 1155. Defendant Harris’s recent co-sponsorship of the Act, her future role in its enforcement and the absence of any suggestion she will not enforce the Act also show the case is ripe. See Bland v. Fessler, 88 F.3d 729, 737 (9th Cir.1996).

The court finds that although plaintiffs cannot at this time possibly show a history of prosecution or enforcement prior to the Act’s taking effect, this action is constitutionally ripe. See, e.g., LSO, 205 F.3d at 1155 (“[E]nforcement history alone is not dispositive. Courts have found standing where no one had ever been prosecuted under the challenged provision.”). This is not a case of uncertainties, hypothetical, or contingencies. The parties do not dispute the Act applies to plaintiffs’ organizations. The Act requires the provision of a specific notice, which the plaintiffs argue violates specific tenets of their religious beliefs and specific provisions of their charters or bylaws. The Act foresees only one consequence of noncompliance: a fine. The Act was signed recently and will go into effect on January 1, 2016. The State has made no effort to advise the court or plaintiffs it intends not to enforce it against them. Plaintiffs’ alleged impending injuries suffice to ensure constitutional ripeness.

B. Prudential Ripeness

The prudential component of ripeness “focuses on whether there is an adequate record upon which to base effective review.” Portman, 995 F.2d at 902-03. The decision is discretionary. Thomas, 220 F.3d at 1142. The court must “evaluate both [1] the fitness of the issues for judicial decision and [2] the hardship to the parties of withholding court consideration.” Texas v. United States, 523 U.S. at 300, 118 S.Ct. 1257; Thomas, 220 F.3d at 1141 (9th Cir.2000).

1. Fitness for Judicial Decision

The Supreme Court arid Ninth Circuit have recognized the difficulty of deciding constitutional questions without the necessary factual context. See, e.g., W.E.B. DuBois Clubs of Am. v. Clark, 389 U.S. 309, 312, 88 S.Ct. 450, 19 L.Ed.2d 546 (1967) (per curiam); Thomas, 220 F.3d at 1141; Am.-Arab Anti-Discrimination Comm. v. Thornburgh, 970 F.2d 501, 510 (9th Cir.1991).

For example, in W.E.B. Du Bois Clubs, the Attorney General requested a hearing and order that the plaintiffs must register as a “communist-front organization.” 389 U.S. at 310, 88 S.Ct. 450. In response, the plaintiffs challenged the statute that granted the Attorney General authority to make this request. Id. The statute in question provided that before the government could punish the plaintiffs for failure to register, the “Subversive Activities Control Board,” an administrative agency, was required to find that the plaintiffs in fact operated a communist-front organization and issue an order to that effect. Id. at 311, 88 S.Ct. 450. And before such an order could issue, the statute required a full, public evidentiary hearing in which the plaintiffs could be represented by counsel, present evidence, and conduct cross-examination. Id. The plaintiffs challenged the registration requirement and sought to enjoin any hearing as unconstitutional. Id. But the Supreme Court found the action premature because “important and difficult constitutional issues would be decided devoid of factual context” and because it was unclear whether the plaintiffs were covered by the statute. Id. at 312, 88 S.Ct. 450.

Similarly, in Americavr-Arab Anti-Discrimination Committee, the U.S. Immigration and Naturalization Service (INS) detained the plaintiffs, who were non-immigrant aliens, because they were members of the Popular Front for the Liberation of Palestine (PFLP). 970 F.2d at 504-05. The government alleged the PFLP advocated and taught the “international and governmental doctrines of world communism,” which meant the detainees would be deported. Id. at 505. Citing W.E.B. DuBois Clubs, the Ninth Circuit found the case was not ripe. Id. at 510-12. It was unclear to the court whether the detainees were actually members of the PFLP and what actions had allegedly brought them within the parameters of the statute in question. Id. at 510-11. In addition, the statute had never been interpreted by any court. Id. at 511. Neither had the INS offered an interpretation. Id.

In Thomas v. Anchorage Equal Rights Commission, several landlords challenged an Alaska statute that banned discrimination on the basis of marital status, arguing the statute violated the First Amendment’s Free Exercise and Free Speech Clauses. 220 F.3d at 1137. The Ninth Circuit found the case was not ripe. Id. It summarized its holding as follows:

No prospective tenant has ever complained to the landlords, let alone filed a complaint against them. Neither the Alaska State Commission for Human Rights nor the Anchorage Equal Rights Commission has ever initiated an investigation into the landlords’ rental practices or commenced a civil enforcement action or criminal prosecution under the challenged laws. No violation of the laws is on the horizon and no enforcement action or prosecution is either threatened or imminent. Indeed, the principal enforcement agencies had never even heard of these landlords before they filed this action. Simply put, at this stage the dispute is purely hypothetical and the injury is speculative.

Id. Later on in the circuit court’s opinion, it called the record before it “remarkably thin and sketchy, consisting only of a few conclusory affidavits.” Id. at 1141.

In Thomas, the court acknowledged that some pre-enforcement actions may be ripe from a prudential point of view, especially if they concern “purely legal” issues. Id. at 1141-42; accord San Diego Cty. Gun Rights Comm. v. Reno, 98 F.3d 1121, 1132 (9th Cir.1996) (“[P]ure legal questions that require little factual development are more likely to be ripe.”). But that was not the situation in Thomas; no “concrete factual scenario” demonstrated how the laws, as applied, infringed the landlords’ constitutional rights. Id.

Here, unlike in W.E.B. DuBois Clubs, American-Arab Anti-Discrimination Committee, and Thomas, plaintiffs’ claims are concrete and clearly delineated by evidence, including their declarations, the text of the Act, and the Act’s legislative history. Plaintiffs’ declarations are detailed, specifying what they understand the Act will require of them and how the notice provisions they challenge conflict with their constituents’ religious convictions and provisions of their charters and bylaws. Moreover, the disputes here concern questions for which the record includes sufficient evidence: the scope of the protection provided by the First Amendment’s Free Exercise and Freedom of Speech Clauses given a specific notice required by California law.

The State’s arguments to the contrary are framed in only general terms. It argues the plaintiffs’ claims “appear to in-elude as-applied components” and therefore it believes adjudication of this case “depends on the facts surrounding any conceivable application of the statute.” Opp’n at 7. But the State identifies no particular difficulty or uncertainty that will arise if the case goes forward now. The court also notes other federal courts have recently adjudicated similar disputes, apparently without the sort of difficulties that arise in unripe cases. See, e.g., Evergreen Ass’n of N.Y. v. City of N.Y., 740 F.3d 233 (2d Cir.2014), cert. denied, — U.S. -, 135 S.Ct. 435, 190 L.Ed.2d 327 (2014); Greater Balt. Ctr. v. Mayor and City Council of Balt., 721 F.3d 264 (4th Cir.2013) (en banc). This case is suited for judicial decision now.

2. Hardship to the Parties Should the Court Withhold Consideration

As noted above, the prudential ripeness doctrine also countenances the court’s consideration of whether the parties will suffer a hardship if the court withholds a decision. Texas v. United States, 523 U.S. at 300-01, 118 S.Ct. 1257. This analysis “dovetails, in part, with the constitutional consideration of injury.” Thomas, 220 F.3d at 1142.

When a plaintiff challenges a statute or regulation, hardship is more likely if the statute has a direct effect on the plaintiffs day-to-day operations. See Texas v. United States, 523 U.S. at 301, 118 S.Ct. 1257. Hardship is less likely if the statute’s effect is abstract. See id. (rejecting argument that ongoing “threat to federalism” or “threat to personal freedom” could constitute hardship “unless the person’s primary conduct is affected”). The court may also consider whether the parties’ dispute may be adjudicated more concretely in a later proceeding, or if the denial of relief would foreclose later resolution. See Thomas, 220 F.3d at 1142; Am.-Arab Anti-Discrimination Comm., 970 F.2d at 511.

Here, the court is satisfied, the plaintiffs stand to suffer a hardship should the court withhold a decision. The Act impacts the plaintiffs’ day-to-day operations by requiring they either post a notice, hand out a printed notice, or provide digital notice. Starting January 1, 2016, the plaintiffs face a difficult decision: display a notice they argue violates their First Amendment rights or risk stiff civil penalties. The State has identified no specific advantage associated with delaying this litigation.

This case is ripe from both constitutional and prudential perspectives. The court' thus proceeds to the merits of plaintiffs’ motion.

V. LEGAL STANDARD

A preliminary injunction is an extraordinary remedy awarded only upon a clear showing the moving party is entitled to such relief. Winter v. Natural Res. Defense Council, Inc., 555 U.S. 7, 22, 129 S.Ct. 365, 172 L.Ed.2d 249 (2008). Federal Rule of Civil Procedure 65 provides a court may issue a preliminary injunction to preserve the relative position of the parties pending a trial on the merits. University of Texas v. Camenisch, 451 U.S. 390, 395, 101 S.Ct. 1830, 68 L.Ed.2d 175 (1981). The party seeking a preliminary injunction must show it is “likely to succeed on the merits,” “likely to suffer irreparable harm in the absence of the preliminary- relief,” “the balance of equities tips in [its] favor,” and “an injunction is in the public interest.” Winter, 555 U.S. at 20, 129 S.Ct. 365.

Alternatively, in the Ninth Circuit, if a plaintiff cannot show a likelihood of success but can show “serious questions going to the merits” with the “balance of hardships tip[ping] sharply in the plaintiff’s favor,” and can satisfy the other two Winter factors, then a preliminary injunction can also be proper. Shell Offshore, Inc. v. Greenpeace, Inc., 709 F.3d 1281, 1291 (9th Cir.2013) (quoting Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1134-35 (9th Cir.2011) (finding the “serious question” sliding scale test survived Winter)) (emphasis in Shell). Lastly, a' court need not reach the other prongs if the moving party cannot as a threshold matter demonstrate a “fair chance of success on the merits.” Pimentel v. Dreyfus, 670 F.3d 1096, 1111 (9th Cir.2012) (quoting Guzman v. Shewry, 552 F.3d 941, 948 (9th Cir.2009) (internal quotation marks omitted).

In deciding on whether to grant a preliminary injunction, the court may rely on declarations, affidavits, and exhibits, among other things, and such evidence does not need to conform to the standards of Federal Rule of Civil Procedure 56. Johnson v. Couturier, 572 F.3d 1067, 1083 (9th Cir.2009); see also Flynt Distrib. Co. v. Harvey, 734 F.2d 1389, 1394 (9th Cir.1984) (“The trial court may give even inadmissible evidence some weight, when to do so serves the purpose of preventing irreparable harm before trial”); Bracco v. Lackner, 462 F.Supp. 436, 442 n. 3 (N.D.Cal.1978) (evidence considered in ruling on preliminary injunction does not need to conform to standards for summary judgment). “The urgency necessitating the prompt determination of the preliminary injunction; the purpose of a preliminary injunction, to preserve the status quo without adjudicating the merits; and the [c]ourt’s discretion to issue or deny a preliminary injunction are all factors supporting the considerations of affidavits.” Bracco, 462 F.Supp. at 442 n. 3. The trial court has discretion to decide how much weight to give to each affiant’s statement. See Oakland Tribune, Inc. v. Chronicle Pub. Co., Inc., 762 F.2d 1374, 1377 (9th Cir.1985).

VI. LIKELIHOOD OF SUCCESS ON THE MERITS

A. Claim One: First Amendment Freedom of Speech

The court first considers plaintiffs’ likelihood of success on their free speech claim. The parties disagree about the appropriate level of scrutiny to apply to the Act. Plaintiffs contend the Act is subject to strict scrutiny because the required notice amounts to a content-based regulation. “Mandating speech that a speaker would not otherwise make necessarily alters the content of the speech.” Riley, supra, 487 U.S. at 795, 108 S.Ct. 2667. Accordingly, laws compelling speech are considered to be content-based regulations generally subject to strict scrutiny, albeit with some exceptions. Id.) see also Turner Broad. Sys. v. FCC, 512 U.S. 622, 642, 114 S.Ct. 2445, 129 L.Ed.2d 497 (1994). The State argues the court should instead adopt one of the lesser levels of scrutiny applicable to either compelled commercial speech, professional conduct, professional speech within the confines of the patient-provider relationship, or abortion-related disclosures. At hearing, the State, while maintaining its position that the speech at issue is both commercial and professional, acknowledged that of the two doctrines, professional speech is the better fit.

As discussed below, after considering the alternatives, the court finds the Act regulates professional speech within the confines of the patient-provider relationship, which is reviewed under no greater than Intermediate scrutiny. The court next finds the Act survives intermediate scrutiny for professional speech and would likely survive even strict scrutiny for fully protected speech. The court concludes plaintiffs are not likely to succeed on the merits of their free speech claim, but have raised serious questions going to the merits under the Ninth Circuit’s “serious questions” approach.

1. Commercial Speech

a) Legal Standard

Content-based regulations are subject to lesser scrutiny when they concern commercial speech. Compelled commercial speech is subject to either intermediate scrutiny, Central Hudson Gas & Elec. Corp. v. Pub. Serv. Comm’n, 447 U.S. 557, 563-66, 100 S.Ct. 2343, 65 L.Ed.2d 341 (1980), or, if the law compels disclosure-of “purely factual and uncontroversial- information,” rational basis review, Zauderer v. Office of Disciplinary Gounsel of Supreme Court of Ohio, 471 U.S. 626, 651, 105 S.Ct. 2265, 85 L.Ed.2d 652 (1985) (“[A]n advertiser’s rights are adequately protected as long as disclosure requirements are reasonably related to the State’s interest in preventing deception of consumers.”); see also Milavetz, Gallop & Milavetz, P.A. v. United States, 559 U.S. 229, 248-53, 130 S.Ct. 1324, 176 L.Ed.2d 79 (2010). The Supreme Court has articulated several justifications for its differential treatment of commercial speech: an advertiser may easily verify the truth of the information it disseminates about a specific product or service, Central Hudson Gas, 447 U.S. at 564 n. 6, 100 S.Ct. 2343; Virginia State Bd. of Pharmacy v. Virginia Citizens Consumer Council, Inc., 425 U.S. 748, 772 n. 24, 96 S.Ct. 1817, 48 L.Ed.2d 346 (1976); commercial speech may be more durable and less likely to be chilled than other types of speech due to the advertiser’s economic self-interest, Central Hudson Gas, 447 U.S. at 564 n. 6, 100 S.Ct. 2343; Virginia State Bd. of Pharmacy, 425 U.S. at 772 n. 24, 96 S.Ct. 1817; and the State has an interest in regulating the underlying commercial transaction, Edenfield v. Fane, 507 U.S. 761, 767, 113 S.Ct. 1792, 123 L.Ed.2d 543 (1993).

The Supreme Court has defined commercial speech as “expression related solely to the economic interests of the speaker and its audience,” Central Hudson Gas, 447 U.S. at 561, 100 S.Ct. 2343, and as speech that “does no more than propose a commercial transaction,” Va. State Bd. of Pharmacy, 425 U.S. at 752, 96 S.Ct. 1817; see also Bolger v. Youngs Drug Prods. Corp., 463 U.S. 60, 66, 103 S.Ct. 2875, 77 L.Ed.2d 469 (1983) (describing proposal of a commercial transaction as “the core notion of commercial speech”); Am. Acad. of Pain Mgmt. v. Joseph, 353 F.3d 1099, 1106 (9th Cir.2004) (reviewing definition of commercial speech). However, the Court has recognized the difficulty of “drawing bright lines that will clearly cabin commercial speech as a distinct category.” City of Cincinnati v. Discovery Network, Inc., 507 U.S. 410, 419, 113 S.Ct. 1505, 123 L.Ed.2d 99 (1993). Accordingly, when it is not clear whether speech is commercial, the Court in Bolger set out three factors relevant to the determination: (i) whether the speech is an advertisement, (ii) whether the speech refers to a specific product, and (iii) whether the speaker has an economic motive for the speech. 463 U.S. at 66-68, 103 S.Ct. 2875; see also Ass’n of Nat. Advertisers, Inc. v. Lungren, 44 F.3d 726, 728 (9th Cir.1994) (reviewing Bolger factors). While “[t]he combination of all these characteristics.. .provides strong support for the... conclusion that [speech is] properly characterized as commercial speech,” Bolger, 463 U.S. at 67, 103 S.Ct. 2875, it is not necessary that each of the characteristics “be present in order for speech to be commercial,” id. at 67 n. 14, 103 S.Ct. 2875. When commercial speech is “inextricably intertwined with otherwise fully protected speech,” the court applies the test for fully protected expression. Riley, 487 U.S. at 796, 108 S.Ct. 2667. “Our lodestars in deciding what level of scrutiny to apply to a compelled statement must be the nature of the speech taken as a whole and the effect of the compelled statement thereon.” Id. The court does not “parcel out the speech, applying one test to one phrase and another test to another phrase.” Id.

The context of the speech affected also plays a role in a court’s decision. For example, in Riley, the Supreme Court considered whether North Carolina had impermissibly compelled disclosures by professional fundraisers and noted “the context of a verbal solicitation”: “if the potential donor is unhappy with the disclosed percentage” of charitable contributions collected during the previous 12 months that were actually turned over to charity, “the fundraiser will not likely be given a chance to explain the figure; the disclosure will be the last words spoken as the donor closes the door or hangs up the phone.” Id. at 799-800, 108 S.Ct. 2667. Referencing Riley, the Se