June Medical Services LLC v. Kliebert (158 F. Supp. 3d 473, 2016)

FINDINGS OF FACT AND CONCLUSIONS OF LAW

JUDGE JOHN W. deGRAVELLES, UNITED STATES DISTRICT COURT, MIDDLE DISTRICT OF LOUISIANA

TABLE OF CONTENTS

OVERVIEW

I. Introduction

FINDINGS OF FACT

II. Background and Procedural Histo-K

III. Contentions of the Parties

IV. The Factual Issues

V. Abortion in Louisiana

A. Generally

B. The Clinics

(1) Hope

(2) Bossier

(3) Causeway

(4) Women’s Health

(5) Delta

C. The Doctors

(1) Doel

(2) Doe 2

(3) Doe 3

(4) Doe 4

(5) Doe 5

(6) Doe 6

D. Admitting Privileges

E. The Climate

VI. Act 620

A. Text of Act 620 and Related Provisions

B. Louisiana’s Policy and Past Legislation Regarding Abortion

C. Drafting of Act 620

D. Official Legislative History of Act 620

VII. The Purpose and Medical Reasonableness of Act 620

VIII. Efforts of Doctors to Comply With Act 620 and the Results of Those Efforts

A. Doe 1

B. Doe 2

C. Doe 3

D. Doe 4

E. Doe 5

F. Doe 6

G. Post-Trial Updates

IX. Effects of Act 620

A. The Effect of Act 620 on Doe 1-6

B. The Effect of Act 620 on the Clinics and Women of Louisiana

CONCLUSIONS OF LAW

X. Summary of Legal Arguments

XI. Test for Determining the Constitutionality'of Act 620

A. Rational Basis

B. Undue Burden Test — Generally

C. Undue Burden — Purpose Prong

D. Undue Burden — Effect Prong

XII. Analysis: Application of Tests

A. Rational Basis

B. Undue Burden — Purpose of Act 620

C. Undue Burden — Effect of Act 620

XIII. Conclusion

A. Motion to Reconsider Rulings on Summary Judgment and Motion in Li-mine

B. Preliminary Injunction

(1) Preliminary Injunction Standard

(2) Application of the Preliminary Injunction Standard

C. Judgment

OVERVIEW

I. Introduction

Before the Court is Plaintiffs’ Application for Temporary Restraining Order and Motion for Preliminary Injunction (“Application”), filed by five persons: June Medical Services LLC, d/b/a Hope Medical Group for Women (“Hope” or “Hope Clinic); Bossier City Medical Suite (“Bossier” or “Bossier Clinic”); Choice Inc., of Texas, d/b/a Causeway Medical Clinic (“Choice” or “Causeway”) (collectively, “Plaintiff Clinics”); including two natural persons, Doctor Doe 1 (“Doe l”) and Doctor Doe 2 (“Doe 2”) (collectively, “Plaintiff Doctors”) (collectively, “Plaintiffs”). (Doc. 5.) The Application sought to bar enforcement of Seer tion A(2)(a) of Act Number 620 (“Act” or “Act 620”), amending Louisiana Revised Statutes § 40:1299.35.2. Although Plaintiffs sought a temporary restraining order and a preliminary injunction in this single document, this Court issued the requested temporary order on August 31, 2014, and deferred ruling on their conjoined motion for a preliminary injunction (“TRO”), (Doc. 31 at 1-2), a distinction subsequently clarified by this Court’s later order, (Docs. 57, 84). This Ruling and Order (“Ruling”) now addresses this latter request (“Motion for Preliminary Injunction”). Also before the Court is Defendant’s Motion to Reconsider Rulings on Summary Judgment and Motion in Limine (“Motion for Reconsideration”), (Doc. 144), filed by Ms. Kathy Klie-bert (“Defendant,” “Kliebert,” “Secretary,” or “Secretary Kliebert”), who is being sued by Plaintiffs in her official capacity as then Secretary of Department of Health and Hospitals of the State of Louisiana (“DHH”).

The hearing on the Motion for Preliminary Injunction was held from June 22, 2015, through June 29, 2015. (Docs. 163-64, 166, 169, 174.) At the hearing, the Court received evidence in the form of live witness testimony, exhibits, stipulations, and designated deposition testimony agreed by Plaintiffs and Defendant (collectively, “Parties”) to be received in lieu of certain witness’ live testimony. Plaintiffs presented live testimony from the following witnesses:

— Doe 1;

— Doe 2;

— Doe 3;

— Ms. Kathaleen Pittman (“Pittman”), June’s administrator; and

— Kliebert; and

— Three experts, specifically:

— Doctor Christopher M. Estes (“Estes”), Chief Medical Officer of Planned Parenthood of South Florida and the Treasure Coast, (PX 92);

— Doctor Sheila Katz (“Katz”), an assistant professor at the University of Houston, (JX 91); and

— Doctor Eva Karen Pressman (“Pressman”), the Henry A. Thiede Professor and Cham of The Department of Obstetrics and Gynecology at The University of Rochester, (PX 94).

Defendant presented live testimony at trial from the following witnesses:

— Ms. Cecile Castello (“Castello”), Director of Health Standards Section (“HSS”) for DHH; and

— Three other experts, specifically:

— Doctor Robert Marier (“Marier”), Chairman of the Department of Hospital Medicine at Ochsner Medical Center in New Orleans, (DX 146);

— Doctor Tumulesh Kumar Singh So-lanky (“Solanky”), a professor and the chair of the Mathematics Department at the University of New Orleans, (DX 148); and

— Doctor Damon Thomas Cudihy (“Cudihy”), an obstetrician-gynae-cologist (“OB/GYN,” “Ob/Gyn,” “OBG,” or “O&G”) currently licensed to practice medicine in Louisiana and Texas, (DX 147).

A record of the exhibits admitted into evidence was filed. (Doc. 165.) A record of the deposition testimony designated by the Parties and offered into evidence was also docketed. (Doc. 168.) In addition, the Parties submitted proposed findings of fact and conclusions of law, (Docs. 196, 200), and responses to each other’s proposed findings and conclusions, (Docs. 201, 202).

In making the following findings of fact and conclusions of law, the Court has considered the record as a whole. The Court has observed the demeanor of witnesses and has carefully weighed their testimony and credibility in determining the facts of this case and drawing conclusions from those facts. All findings of fact contained herein that are more appropriately considered conclusions of law are to be so deemed. Likewise, any conclusions of law more appropriately considered a finding of fact shall be so classified.

After having considered the evidence, briefing, and record as a whole, for the reasons which follow, Defendant’s Motion for Reconsideration, (Doc. 144), is DENIED. The active admitting privileges requirement of Section A(2)(a) of Act 620 is found to be a violation of the substantive due process right of Louisiana women to obtain an abortion, a right guaranteed by the Fourteenth Amendment of the United States Constitution as established in Roe v. Wade, 410 U.S. 113, 93 S.Ct. 705, 35 L.Ed.2d 147 (1973) (“Roe ”), and pursuant to the test first set forth in Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 112 S.Ct. 2791, 120 L.Ed.2d 674 (1992) (“Casey”), and subsequently refined by the Fifth Circuit, see infra Part XI. Act 620 is therefore declared unconstitutional, its enforcement constitutionally barred. As such, the Motion for Preliminary Injunction is GRANTED IN PART, and any enforcement of § 40:1299.35.2 is enjoined as to Does 1 and 2, Hope, Bossier, and Causeway.

Furthermore, because applications for “active admitting privileges” by several doctors technically remain “pending,” the Court orders Plaintiffs to provide to the Court and Defendant with a written notification of any changes in the status of these applications on a monthly basis, beginning on March 1, 2016. Should the status of any application change, the Parties are free to request any other relief that they may deem appropriate. Finally, so as to discuss any outstanding issues and schedule this case’s course, the Court will hold a telephonic status conference with counsel for all Parties on January 29, 2016, at 11:30 a.m.

FINDINGS OF FACT

II. Background and Procedural History

1. Plaintiffs are:

— Hope, a licensed abortion clinic located in Shreveport, Louisiana, suing on behalf of its physicians, staff and patients;

— Bossier, a licensed abortion clinic located in Bossier City, Louisiana, suing on behalf of its physicians, • staff, and patients;

— Choice, a licensed abortion clinic suing on behalf of its physicians, staff, and patients;

— Doe 1, a physician licensed to practice medicine in the State of Louisiana and board-certified in Family Medicine and Addiction Medicine, suing on his own behalf and that of his patients; and

— Doe 2, a physician licensed to practice medicine in the State of Louisiana and board-certified in OB/GYN, suing on his own behalf and that of his patients.

2. Kliebert, the Secretary of DHH. Pursuant to § 40:2175.6, Kliebert “has the authority to revoke or deny clinics’ licenses for violation of this or any other law.”(Doc. 109 at 5 (citing La. R.S. § 40:2175.6).)

3. On August 22, 2014, Plaintiffs filed the Complaint for- Declaratory and Injunc-tive Relief, (Doc. 1), and the Application, (Doc. 5), seeking to enjoin various defendants from enforcing Act 620’s Section (A)(2)(a). (Doc. 5-2 at 2-5.)

4. Act 620 has been codified at an amended Section 40:1299.35.2. La. R.S. § 40:1299.35.2. Section A(2)(a) requires every doctor who performs abortions in Louisiana to have “active admitting privileges” at a hospital within 30 miles of the facility where abortions are performed. Id. § 40:1299.35.2A(2)(a). While the Act contains other requirements, this provision is the only one being challenged. (Doc 5-1 at 8 n.l.) Act 620 was signed into law by the Governor of Louisiana,' the Honorable Pi-yush “Bobby” Jindal (“Jindal” or “Governor”), on June 12, 2014. (Doc. 138 at 2; see also, e.g., H.B. 388, 2014 Leg., Reg. Sess. (La. 20Í4) (signed by Governor, June 12, 2014).) Its effective date was set as September 1, 2014, (See, e.g., Doc. 5-1 at 8; Doc. 5-2 at 6.)

5. Hope, Bossier, and Choice are three of five licensed abortion clinics in Louisiana. (See, e.g., Doe. 109 at 4-5; Doc. 14 ¶ 10 at 3.) They are located in Shreveport, Bossier City, and Metairie, respectively. (Doc. 109 at 4-5; see also, e.g., Doc. 14 ¶¶ 11-13 at 3-4.) Does 1 and 2 are two of six physicians performing abortions in Louisiana. (Doc. 109 at 5; see also, e.g., Doc. 14 ¶¶ 14-15 at 4.) Doe 1 performs abortions at Hope; Doe 2 performs abortions at Bossier and Choice. (Doc. 109 at 5; see also, e.g., Doc. 14 ¶¶ 14-15 at 4.)

6. The Court issued the TRO on August 31,2014, enjoining enforcement of Act 620 “until a hearing is held for the purpose of determining whether a preliminary injunction should issue.” (Doc. 31 at 18.) Per this order, Plaintiffs were expected to continue seeking admitting privileges at the relevant hospitals. (Id. at 1-2.) Thus, the Act would be allowed to take effect, but the Plaintiffs would not be subject to its penalties and sanctions for practicing without the relevant admitting privileges during the application process. (Id. at 2, 18.) The Plaintiff Clinics were allowed to operate lawfully while the Plaintiff Doctors continued their efforts to obtain privileges. (Id.)

7. On September 19, 2014, three other plaintiffs-Women’s Health Care Center, Inc. (“Women’s Health” or “Women’s Clinic”); Delta Clinic of Baton Rouge, Inc. (“Delta”); Doctor John Doe 5 (“Doe 5”); and Doctor John Doe 6 (“Doe 6”) (collectively, “Women’s Health Plaintiffs”) — filed the Complaint for Declaratory and Injunc-tive Relief, thereby initiating a separate case, and a Motion for Preliminary Injunction'. (Docs. 1, 5, No. 3:14-cv-00597-JWD-RLB.) On that same day, these parties tendered a motion to consolidate their case with this earlier proceeding. (Doc. 2, No. 3:14-cv-00597-JWD-RLB.) By this Court’s order, these two cases were consolidated on September 24, 2014. (Doc. 8, No. 3:14-cv-00597-JWD-RLB.)

8. All the Parties agreed in briefs and orally at a status conference held on September 30, 2014, that significant discovery would need to be done to prepare for the hearing; therefore, the Court set the preliminary injunction hearing for March 30, 2015. (Doc. 45.) A Joint Proposed Scheduling Order was submitted by the Parties on October 8, 2014, (Doc. 49), and adopted as this Court’s order on October 21, 2014, (Doc. 56).

9. On November 3, 2014, following the addition of the Women’s Health Plaintiffs, this Court issued the Order Clarifying Temporary Restraining Order of August 31, 2014. (Doe. 57.) For the reasons given therein, the Court ruled: “It was and is the intention of this Court that the TRO remain in effect as to all parties before it until the end of the Preliminary Injunction Hearing.” (Id. at 6.)

10. On December 5, 2014, the Women’s Health Plaintiffs filed the Motion for Voluntary Dismissal. (Doc. 70.) With.the consent of the Parties, the Court dismissed this suit without prejudice on December 14, 2014. (Doc. 77.) In light of that dismissal, the Court on January 15, 2015, issued the Second Order Clarifying Temporary Restraining Order of August. 31, 2014. (Doc. 84.) In this order, for reasons explained therein, this Court ruled that “the TRO of August 31, 2014 (Doc. 31) remains in force until the Preliminary Injunction hearing on March 30, 2015 or as otherwise modified by this Court.” (Id. at 4.)

11. On February 16, 2015, Defendants filed the Motion for Partial Summary Judgment (“Partial MSJ”), (Doc. 87), which was opposed, (Doc. 104). On February 24, 2015, Defendants filed an Unopposed Motion to Set Oral Argument on Motion for Partial Summary Judgment (Doc. 90.) On March 3, 2015, the Court granted that motion, (Doc. 92), and oral argument was set and heard on March 19, 2015, (Docs. 128,137).

12. On May 12, 2015, the Partial MSJ was granted in part, finding that under binding Fifth Circuit jurisprudence, the admitting privileges requirement of Act 620 is rationally related to a legitimate State interest. (Doc. 138 at 125.) In all other respects, the motion was denied. (Id.)

13. Based on a stipulation reached among the Parties, the Joint Motion to Dismiss Defendant Mark Dawson was filed on March 17, 2015, (Doc. 110), and granted the same day, (Doc. 111). On March 20, 2015, the Parties conferred with the Court and agreed to a continuance of the hearing on the preliminary injunction until the week of June 22, 2015. (Doc. 129.) The Parties agreed that the TRO would remain in effect until the completion of the trial and ruling on the merits of the preliminary injunction. (Id.)

14. On April 1, 2015, oral argument was heard on motions in limine filed by the Parties. (Docs. 136, 151.) In the ruling issued that same day, the Court denied Plaintiffs’ Motion in Limine to Preclude Expert Testimony of Dr. Tumulesh So-lanky, (Doc. 96), and Defendant’s Motion to Exclude Expert Testimony of Sheila Katz, Ph.D„ (Doc. 99). (Doc. 136.) Plaintiffs’ Motion in Limine to Preclude Expert Testimony of Dr. McMillan, (Doc. 97), was denied as moot. (Doc. 136.) Because of their connection to the Partial MSJ, Defendant’s Motion in Limine to Exclude Irrelevant Evidence (“Defendant’s Motion in Limine”), (Doc. 95), and Plaintiffs’ Motion in Limine to Preclude Evidence of DHH Deficiency Reports and Related Evidence, (Doc. 98), were taken under advisement. (Doc. 136.) These two motions were ultimately denied. (Docs. 139,140.)

15. On June 11, 2015, Defendant filed the Motion to Reconsider Rulings on Summary Judgment and Motion in Limine. (Doc. 144.) Plaintiffs submitted their response in opposition on June 16, 2015. (Doc, 150.) Because this was submitted for consideration only six days before trial, the motion was taken under advisement and deferred to trial.

16. Trial on the Motion for Preliminary Injunction began on June 22, 2015, and ended on June 29, 2015. (Docs. 163, 164, 166-69,174). The Redacted Transcript of the trial was later docketed. (Docs. 190-95.)

III. Contentions of the Parties

. 17. In broad terms, Plaintiffs contend that Act 620 is facially unconstitutional first, because the Act places an undue burden on the right of Louisiana women seeking an abortion by placing substantial obstacles in their path, (See, e.g., Doc. 202 at 46-53); second, because the purpose of the Act is to create those obstacles, (See, e.g., id. at 53-58) and third, because Act 620 does not further a valid state interest, (See, e.g., id. at 58-65).

18. Plaintiffs argue that a preliminary injunction should issue enjoining the enforcement of Act 620 because Plaintiffs are likely to succeed at trial, (Doc. 196 at 67-85); absent an injunction, irreparable harm will occur, (Id. at 85-86); the balance of hardships weighs in Plaintiffs’ favor, (Id. at 86-87); and finally, granting the preliminary injunction will not adversely affect the public interest, (Id.).

19. Defendant counters broadly that Act 620 places no substantial burden on a woman’s right to seek an abortion in Louisiana, (See, e.g., Doc. 200 at 59-66), and that the Act serves a valid purpose, (See, e.g., id. at 66-74). Further, Defendant argues that this Court has already ruled that Act 620 serves a valid state interest and has a rational basis. (See, e.g., id. at 6-7.)

20. Defendant argues that Plaintiffs have failed to carry their burden that they are likely to succeed at trial and further, urge that no irreparable harm will occur by allowing the enforcement of Act 620. (See, e.g., id. at 88-90.)

21. Finally, Defendant contends that the balance of hardships weighs in her favor and that the enforcement of Act 620 will not adversely affect the public interest. (Id.)

IV. The Factual Issues

22. Four main issues of fact were tried at the June hearing:

(A) What is the purpose of Act 620?

(B) Is Act 620 medically necessary and reasonable?

(C) How, if at all, will the implementation of Act 620 affect the physicians and clinics who perform abortions in the state of Louisiana?

(D) How, if at all, will the implementation of Act 620 affect the ability of Louisiana women to obtain an abortion?

23. Whether these factual issues and their resolution are relevant under the applicable legal standard, and whether they play a role in this Court’s ruling, is discussed in the Conclusions of Law section. See infra Parts XI-XII.

V. Abortion in Louisiana

A. Generally

24. According to DHH, approximately 10,000 women obtain abortions in Louisiana annually. (DX 148 ¶ 11.)

25. Nationally, approximately 42% of women who have abortions fall below the federal poverty level, and another 27% fall below 200% of that level. (JX 124 at 480; Doc. 191 at 190-91.) That number is likely significantly higher for Louisiana women seeking abortions. (Id.) The expert and lay testimony on this issue are consistent. (See, e.g., Doc. 190 at 34 (Testimony of Pittman) (testifying that 70% to 90% of patients at Hope are below the federal poverty level).)

26. Under Louisiana law, a patient must receive state-mandated counseling and an ultrasound at least 24 hours before an abortion. (JX 109 ¶ 18; JX 116 ¶ 11; JX 117 ¶ 8.)

27. Due to this notification and waiting period, patients who wish to obtain an abortion must make two trips to the clinic: the first to receive the ultrasound and state-mandated counseling, and the second to obtain the sought abortion. (JX 109 ¶ 19.)

B. The Clinics

28. There are currently five women’s reproductive health clinics in Louisiana that provide abortion services. (E.g., Doc. 109 at 4; JX 109 ¶ 13.)

(1) Hope

29. Hope is a women’s reproductive health clinic located in Shreveport, Louisiana, that has been operating since 1980 and offers abortion services. (Doc. 109 at 4; see also Doc. 14 ¶ 11 at 5.) Hope is a licensed abortion clinic suing on its own behalf and on behalf of its physicians, staff and patients. (Doc. 14 ¶ 11 at 5; Doc. 190 at 14.)

30. Hope provides medication abortions through eight weeks and surgical abortions through 16 weeks, six days LMP. (Doc. 190 at 35, 119, 132.) Hope employs two doctors who perform abortions, Does 1 and 3. (Id. at 21.) Doe 1 performs approximately 71% of the abortions provided by Hope, and Doe 3 performs the remaining 29%. (Doc. 190 at 21; JX 116 ¶ 5.)

31. 69% of Hope’s patients are Louisiana residents, but the remainder travel from outside the state to Hope. (JX, 116 ¶ 10; Doc. 190 at 19, 34.)

(2) Bossier

32. Bossier is a women’s reproductive health clinic that has been operating in Bossier City since 1980 and provides first and second trimester abortions. (Doc. 109 at 4; Doc. 14 ¶ 12.) Bossier is a licensed abortion clinic and a plaintiff suing on its own behalf and on behalf of its physicians, staff, and patients. (Doc. 14 ¶ 12.)

33. Bossier provides medication abortions through eight weeks and surgical abortions through the state’s legal limit of 21 weeks, six days, LMP. (Doc. 191 at 22-23, 55-56; JX 117 ¶ 4.)

34. Bossier employs one doctor, Doe 2, who performs first and second trimester surgical procedures.as well as medication abortions. (Doc, 191 at 21; JX 117 ¶ 5.) Doe 2 is the only doctor in Louisiana who performs abortions after 16 weeks, six days LMP, (JX 187 ¶ 4; Doc. 191 at 21-22.)

35. Bossier’s patients are primarily from Louisiana, but also travel to tfie clinic from surrounding states. (Doc. 191 at 20.)'

(3)Causeway

36. Causeway is a women’s reproductive health- clinic located in Metairie, Louisiana, and has provided abortion and reproductive health services since 1999. (Doc. 109 at 2-5; Doc. 14 ¶ 13.) Causeway is a licensed abortion clinic suing on its own behalf and that of its physicians, staff, and patients. (Doc. 14 ¶ 14).

37. Causeway offers surgical abortions through 21 weeks, six days LMP, and does" not offer medication abortions. (JX 117 ¶ 4.)

38. Causeway employs two doctors who perform abortions, Does 2 and 4. (See, e,g., Doc. 168-5 at 8.) Doe 2 performs approximately 25% of the abortions provided at Causeway, and Doe 4 performs the remaining 75%. (JX 117 ¶ 5.)

(4) Women’s Health

39. Women’s Health is a women’s reproductive health care clinic located in New Orleans, Louisiana, and has provided abortion and women’s reproductive health services since 2001. (Doc. 109 at 5; JX 168 ¶ 1; JX 110 ¶ 1.)

40. Women’s Health employs two doctors who perform abortions, Does 5 and 6. (JX 110 ¶ 3; JX 168 ¶ 4.) Doe 5 performs approximately 40% of the abortions provided at Women’s Clinic, and Doe 6 performs the remaining 60%. (JX 110 ¶ 3; JX 168 ¶ 4.)

41. Women’s Health provides surgical abortions for women through 16, weeks and medication abortions through eight weeks. (Doc. 168-4 at 19.) Doe 6 provides only medication abortions. (Id, at 55.)

(5) Delta

42. Delta is a' women’s reproductive health care clinic located in Baton Rouge, and has provided abortion and women’s reproductive health services since 2001. (Doc. 109 at 5.)

43. Delta employs one doctor who performs abortions, Doe 5. ( JX 110 ¶ 35.)

44. Delta provides surgical abortions for women through 16 weeks LMP, and medication abortions through eight weeks. (Doc. 168-4 at 13-14,19.)

45. The northern part of Louisiana is served by Hope in Shreveport and by Bossier Clinic in Bossier City. (Doc. 191 at 17; Doc. 190 at 110.) The southern part of this state is served by Causeway in Metairie, Delta in Baton Rouge, and Women’s Health in New Orleans. ,(JX 110 ¶ 1; JX 114 ¶ 1; JX 109 ¶ 13.)

C. The Doctors

46. There are currently six doctors who perform all abortions in Louisiana. (Doc. 109 at 4; see also, e.g., JX 109 ¶ 14.)

(1) Doel

47. Doe 1 is a board-certified physician in Family Medicine and Addiction Medicine and is one of two clinic physicians at Hope. (Doc. 109 at 5).

48. Doe 1 has over 10 years of experience, seven of those'as'an abortion provider. (Doc. 190 at 139-40; Doc. 14 ¶ 14.) He provides medication abortions through eight weeks and surgical abortions through 13 weeks, six days LMP. (Doc. 192 at 21; Doc. 190 at 132.)

49. Doe 1 was trained to provide abortion services by Doe '3, the - medical director of the Hope Clinic, where they both work. (Doc. 192 at 140-41.)

50. Despite beginning his efforts to get admitting privileges at a nearby hospital in July 2014, (Id. at 52), Doé 1 still does not have active admitting privileges at a hospital within 30 miles of Hope Clinic. (Doc. 190 at 21.) The efforts of all six doctors to gain active admitting privileges and the results of those ■ efforts are reviewed in more detail in another section of this Ruling. See infra Part VIII.

(2) Doe 2

51. Doe 2 is a board-certified obstetrician-gynecologist and is one of two clinic physicians at Causeway and the only clinic physician at Bossier who provides abortion services. (Doc. 109 at 5.) He is the medical director of Causeway and Bossier. (Id.)

52. Doe 2 has been performing abortions since 1980. (Doc. 191 at 13-14.) Doe 2 performs medication' abortions through eight weeks and surgical abortions, up through the state’s legal limit of 21 weeks, six 'days LMP. (Doc. 191 at 22-23, 55-56; JX 187 ¶ 4.) He performs medication and surgical abortions at Bossier Clinic, but only surgical abortions at Causeway Clinic. (Id. at 21-23.) Last year, Doe 2 performed approximately 550 abortions at Bossier and 450 abortions at Causeway Clinic. (Id. at 17-18.)

53. Doe 2 performs first and second trimester surgical abortions through 21 weeks, six days LMP, and is the only one of two. physicians ■ in Louisiana to offer abortion after 16 weeks, six days LMP. (Id. at 21-22.)

54. Doe 2 has been unsuccessful in getting active admitting privileges within 30 miles of Bossier and.has been able to obtain only limited privileges, which do not meet the requirements of Act 620, within 30 miles of Causeway. (See, e.g., id.)

(3)Doe 3

55. Doe 3 is. a board-certified obstetrician-gynecologist and one of two clinic physicians at Hope. (Doc. 109 at 5.) He is also the medical director at Hope. (Id.)

56. Doe 3 has been licensed to practice medicine in Louisiana since 1976. (Doc. 190 at 109.) In addition to his abortion practice, he has an active general OB/GYN practice, where he delivers babies and routinely performs gynecological surgery including hysterectomies, laparoscopies, and dilation and curettages (“D&Cs”). (Id. at Í10.)

57. Doe 3 is the chief medical officer of Hope Clinic, where he has worked since 1981. (Doc. 190 at 108, 117, 21.) He provides medication abortions through eight weeks and surgical abortions through 16 weeks, six days LMP. (Id. at 35, 119, 132.)

58. Doe 3 performs abortions at Hope Clinic on Thursday afternoons and all day on Saturday. He sees approximately 20 to 30 abortion patients a week. (Id. at 117-18, 153.) On occasion, he will cover for Doe 1 and will see more patients in those instances. (Id.)

59. Doe 3 currently has admitting privileges at Willis-Knighton Hospital in Bossier (“WKB”) and at Christus Highland Medical Center in Bossier (“Christus”), both of which are within 30 miles of Hope Clinic. (Id. at 21-22, 120, 148-49.) Doe 3’s current privileges at Christus require him to admit approximately 50 patients per year. (Id. at 150-52; JX 59.)

60. Doe 3 has his current admitting privileges because he regularly admits patients to the hospital as part of his private OB/GYN practice, not because of his work at Hope Clinic. (Id. at 124,147.)

(4)Doe 4

61. Doe 4 is a board-certified obstetri- ' cian-gynecologist and one of two clinic physicians at Causeway. (Doc. 109 at 5.)

62. Doe 4 obtained his license to practice medicine in Maryland in 1959 and has been practicing medicine for 56 years and in Louisiana since 1965. (Doc. 168-5 at 5-6.) He served as an assistant professor or assistant instructor in obstetrics and gynecology for seventeen years at Earl K. Long Hospital. (Id. at 12.)

63. When Doe 4 maintained a full OB/ GYN practice, he had admitting privileges at four hospitals in the Baton Rouge area. (Id. at 6.) He was required to have admitting privileges to do OB/GYN surgery and, in his words, “to deliver babies.” (Id.) The existence of these privileges did not benefit his pregnancy termination patients because, to his knowledge, none of his abortion patients experienced any problem and required hospital admission. (Id. at 19-20.)

64. Doe 4 performs abortions at Causeway in Metairie. (Doc. 109 at 5; see also, e.g., Doc. 168-5 at 8.) He does not currently have and has been unable to get admitting privileges at a hospital within 30 miles of Causeway. (Doc. 191 at 18; see also, e.g., Doc. 168-5 at 16.)

(5) Doe 5

65. Doe 5 is a board certified obstetrician-gynecologist. (Doc. 109 at 5; see also Doc. 168-6 at 4-5.) He is one of two clinic physicians at Women’s Clinic and the only clinic physician at Delta Clinic. (Doc. 109 at 5; see also Doc. 168-6 at 4, 13-14, 22.)

66. Doe 5 has been licensed to practice medicine in Louisiana since 2005. (Doc. 168-6 at 5.) He provides surgical abortions at Delta Clinic and Women’s Health through 16 weeks LMP. (Id. at 20; see also JX 110 ¶ l.)

67. Doe 5 has been successful in getting active admitting privileges within 30 miles of Women’s Health in New Orleans but has been unsuccessful in his efforts to get active admitting privileges within 30 miles of Delta in Baton Rouge. (Doc. 168-6 at 11-13; see also, e.g., JX 109 ¶¶ 33-34; JX 110 ¶¶ 15-19.)

(6) Doe 6

68. Doe 6 is a board certified obstetrician-gynecologist and one of two clinic physicians at Women’s Health. (Doc. 109 at 5; see also Doc. 168-4 at 13.)

69. Doe 6 has been practicing medicine for 48 years. (JX 109 ¶ 8.) He is currently the medical director of Women’s Clinic and Delta Clinic. (Id.) Dr. John Doe 6 provides only medication abortions and does so only at Women’s Clinic. (Id. ¶¶ 8-9.)

70. Doe 6 has been unsuccessful in his efforts to get active admitting privileges within 30 miles of Women’s. (Id. ¶¶ 23-26.)

D. Admitting Privileges in Louisiana

71. In order to perform abortions legally in Louisiana, Act 620 requires an abortion doctor to have “active admitting privileges” at a hospital within 30 miles of the facility where he or she performs abortions. La. R.S. § 40:1299.35.2A(2)(A). To have “active admitting privileges” the physician must be a “member in good standing of the medical staff’ of a hospital “with the ability to admit a patient and to provide diagnostic and surgical services to such patient ....” Id. The phrase “member in good standing of the medical staff’ is not separately defined. (Cf. Doc. 193 at 12.)

72. Thus, how a physician may obtain “medical staff’ and “active admitting” privileges from a Louisiana hospital is critical in determining the effect, if any, that Act 620 has on abortion providers and, in turn, the women that they serve.

73. The expert testimony regarding hospital admitting privileges came primarily from two experts-Pressman, Plaintiffs’ expert, (Doc. 195 at 11-96), and Marier, Defendant’s (Doc. 193 at 4-124)-and, to a lesser extent, from the other physicians, including Does 1, 2, 3, 4, 5, and 6, who testified. See supra Part I. On the issue of admitting privileges and hospital credentialing, the Court found both Pressman and Marier to be generally well qualified.

74. Additional information about the credentialing process and the specific requirements of various hospitals came from certain hospital by-laws introduced into evidence. (See, e.g., JX 46, 48, 67, 72, 76, 78-79, 81,138,140-43.)

75. Credentialing is a process that hospitals employ to determine what doctors will be allowed to perform what tasks within that hospital. (Doc. 193 at 11; see also, e.g., Doc. 195 at 23-27; Doc. 168-5 at 24.)

76. Part of this process involves the hospital’s granting or denying “admitting privileges.” (See, e.g., Doc. 193 at 20; Doc. 195 at 17, 23-25.) These privileges govern whether or not a physician is authorized to admit and treat a patient at that hospital and what care, services and treatment the physician is authorized to provide. (See, e.g., Doc. 193 at 20-21; Doc. 195 at 23, 25-26.)

77. Admitting privileges are related to but not the same as being on the “medical staff’ of a hospital. (Doc. 193 at 11; Doc. 195 at 25-26.)

78. There is no requirement that a physician have admitting privileges or be on the medical staff at a hospital in order to practice medicine. (See, e.g., Doc. 195 at 26.) Many physicians who do not have a hospital based practice, i.e. do not intend to admit and treat their patients in a hospital setting, have neither as there is no need for staff or admitting privileges under those circumstances. (See, e.g., Doc. 175 at 75; Doc. 192 at 41-42; Doc. 195 at 75.)

79. There is no state or federal statute which governs the rules for the granting or denial of hospital admitting privileges in Louisiana. Cf. Planned Parenthood of Wis., Inc. v. Van Hollen, 738 F.3d 786, 792 (7th Cir.2013) (“The criteria for granting admitting privileges are multiple, various, and unweighted.”). Rather, partly as a eon-sequence of this absence, these rules vary from hospital to hospital and are governed by each one’s distinct by-laws. (See, e.g., Doc. 193 at 12,15; Doc. 195 at 28.)

80. Specifically, there is no state or federal statute which defines or sets uniform standards for the categories of admitting privileges a hospital may grant. (Doc. 193 at 11-12.) Like other rules, these are therefore set by each hospital’s by-laws. (Id.; see also, e.g., Doc. 195 at 28; JX 81 at 1798.) To make matters more confusing, the terms used to describe those categories (e.g. “active admitting privileges”, “courtesy admitting privileges”, “clinical admitting privileges”) vary from hospital to hospital. (See, e.g., Doc. 190 at 167; Doc. 191 at 104; Doc. 193 at 11-12; Doc. 195 at 28.)

81. Similarly, terms like “medical staff’, “active staff’, “courtesy staff’, “clinical staff’ vary among hospitals. (Doc. 191 at 35; Doc. 193 at 12; Doc. 195 at 28; cf. JX 79 at 1707-12.)

82. For example, at some hospitals, an “active” staff appointment does not, alone, automatically entitle the physician to admit patients. (See, e.g., JX 46 at 185; JX 79 at 1673; JX 141 at 3259-60.)

83. Because of the varying definitions given to the categories of admitting privileges and the varying requirements for the attainment of same, whether a physician has been given “active admitting privileges’-’ or is a “member in good standing on the medical staff’ within the meaning of Act 620 entirely depends upon the specific definition, requirements and restrictions imposed by a given hospital in a given circumstance. (See, e.g., Doc. 193 at 12.)

84. Unlike some states, there is also no statute or rule in Louisiana which sets a maximum time period within which a physician’s application for admitting privileges must be acted upon. Thus, unless there is such a time limit in the hospital’s by-laws, a hospital can effectively deny a doctor’s application of privileges by never acting on it, a decision on any one doctor’s application permanently delayed without a consequence being effected or a reason being given. A definite decision stays unreached — but, with his or her request suspended, the relevant doctor’s privileges remain, as a matter of fact and law, nonexistent. In this Ruling, the Court uses the term “de facto denial” of privileges to describe this circumstance.

85. At some hospitals in Louisiana, there are suggested time- frames in which hospitals should review admitting privileges applications. (JX 72 at 1320-23; see also, e.g., JX 67 at 857-58; JX 76 at 1444-47.) However, those guidelines are not requirements, and there is no legal recourse for an applicant if the hospital fails to act on the application within the suggested time period. (See, e.g., JX 67 at 858-59; JX 72 at 1320-24; JX 109 ¶ 27.) For example, Tulane University Medical Center (“Tulane”) has an expectation, but has adopted no requirement, that applications will be processed within 150 days. (JX 78 at 1554.) If the Board of Trustees has not taken action on the application within 150 days, the applicant must repeat the verification process to ensure the information contained therein is still accurate. (Id.)

86. A hospital’s failure to act on an application by either approving or denying it may result in the hospital considering the application withdrawn. (See, e.g., Doc. 195 at 93; JX 71 at 1279.) In this additional respect, a hospital’s failure to act is, in effect, a de facto denial of the application.

87. While a physician’s competency is a factor in assessing an applicant for admitting privileges, it is only one factor that hospitals consider in whether to grant privileges. (See, e.g., Doc. 190 at 158-59; Doc. 195 at 25-26; Doc. 192 at 50-51; Doc. 168-5 at 17; Doc. 168-6 at 12; JX 110 ¶ 10; JX 168 ¶¶ 11-13,17; PX 183.)

88. Defendant argues: “When Louisiana hospitals decide whether to grant a physician staff membership, privileges to admit patients, or privileges to perform particular procedures, hospital by-laws indicate that they may make such determinations based on the physician’s prior and current practice, and indicia of the physician’s clinical competence.” (Doc. 200 ¶ 114 at 38 (citing to JX 2873; JX 1838; JX 1542-43; JX 852-53).)

89. The Court finds that this is only partly true because both by virtue of bylaws and how privileges applications are handled in actual practice, hospitals may deny privileges or decline to consider an application for privileges for myriad reasons unrelated to competency. Examples include the physician’s expected usage of the hospital and intent to admit and treat patients there, the number of patients the physician has treated in the hospital in the recent past, the needs of the hospital, the mission of the hospital, or the business model of the hospital. Furthermore, hospitals may grant privileges only to physicians employed by and on the staff of the hospital. And university-affiliated hospitals may grant privileges only to faculty members, These possible variances in causes and justification for any particular denial are attested to by this case’s evidentiary submissions and testimony. (See, e.g., Doc. 195 at 25-26; Doc. 190 at 123, 168-70; Doc. 193 at 82-83; JX 109 ¶¶ 27-28; JX 110 ¶ 10; JX 168 ¶¶ 11-13, 17; Doc. 168-5 at 6, 23.)

90. An apparently benign example of such a non-competency based, business driven reason for denying privileges is the denial of Doe l’s application to the Minden Medical Center (“Minden”). (JX 50 at 318; Doc. 192 at 50-51.) In declining his application for staff membership and clinical privileges, Minden’s Medical Staff Coordinator wrote to Doe 1: “Since we do not have a need for a satellite primary care physician at this time, I am returning your application and check.” (JX 50 at 318; see also JX 72 at 1323.)

91. When they had full OB/GYN practices delivering babies and performing gynecological surgery, Does 2, 4, and 6 had no problem obtaining and maintaining admitting privileges at a number of hospitals. (See, e.g., Doc. 168-5 at 6-8; JX 109 ¶ 30.) However, under Act 620, for reasons unrelated to competency, they are now unable to secure active admitting privileges. (See, e.g., Doc. 191 at 24-26; Doc. 168-5 at 16-17; JX 109 ¶¶ 23, 30, 31-34.)

92. Another example of a non-competency based application criteria is that some hospitals require the physician seeking privileges to live and/or practice within a certain distance of the hospital. (JX 83 at 1865; JX 139-a at 2925; JX 79 at 1679-83.) Does 2 and 5 travel significant distances from their respective homes to provide abortion services and would not be able to meet this priteria for hospitals within 30 miles of some or all of the clinics where they provide abortions. (Doc. 191 at 20-21; Doc. 168-6 at 4, 11-13; JX 109 ¶¶ 31-36.)

93. Defendant argues that “[t]here is no evidence suggesting that, in making the determinations about staff membership or privileges, Louisiana hospitals discriminate against physicians based on whether they provide elective abortions.” (Doc. 200 ¶ 115 at 38 (citing Marier’s testimony, as it appears on Doc. 193 at 83-86).) In his testimony, however, Marier only acknowledged that he personally knew of no hospitals which refused to extend privileges to a doctor “simply because he or she performs an abortion.” (Doc. 193 at 83-85.) Regardless, to the extent Marier’s testimony can be so construed, the Court finds his testimony on this point to be not credible and contradicted by an abundance of evidence introduced at the hearing demonstrating that hospitals can and do deny privileges for reasons directly related to a physician’s status as an abortion provider. (See, e.g., Doc. 168-6 at 12; Doc. 190 at 53; JX 109 ¶¶ 28, 30, 39.)

94.For instance, Doe 1 contacted the director of the Family Medicine Department at University Health Hospital in Shreveport (“University” or “University Health”) where he had done his residency in family medicine. Dr. Doe 1 was initially told that he would be offered a job as a faculty member teaching sports medicine which would “take care of the admitting privileges thing.” (Doc. 192 at 45.) Doe 1 was told that the application forms for admitting privileges would be forwarded to him. (Id.)

95. When Doe 1 did not get the application forms and inquired, he was told by the director of the department that he would not be offered a position because “there was some objection from certain staff about [Dpe 1] coming to work there because of where [he] work[ed], at Hope Medical.” (Id. at 45-46.)

96. This same essential response was also given to Doe 2 when he attempted to upgrade his courtesy privileges at University Health. (Doc. 191 at 24-26.)

97. There is no Louisiana statute which prohibits a Louisiana hospital or those individuals charged with credentialing responsibilities from declining an application for admitting privileges based on the applicant’s status as an abortion provider.

98. Section 40:1299.32 provides: “No hospital, clinic or other facility or institution of any kind shall be held civilly or criminally liable, discriminated against, or in any way prejudiced or damaged because of any refusal to permit or accommodate the performance of any abortion in said facility or under its auspices.” La. , R.S. § 40:1299.32.

99. The Court was surprised that Defendant’s credentialing expert, Marier, was unaware of this provision, but Marier agreed that, by virtue of this provision, “a hospital, if it chooses to, may discriminate against any abortion provider with no consequence under Louisiana law.” (Doc. 193 at 84.)

100. Section 40:1299.33(0 states: “No hospital, clinic, or other medical or health facility, whether public or private, shall ever be denied government assistance or be otherwise discriminated against or otherwise be pressured in any way for refusing to permit facilities, staff or employees to be used in any way for the purpose of performing any • abortion.” La. R.S. § 40:1299.33(C).

101. While Doe 2 ultimately received limited privileges at Tulane, the negotiations that led to these- privileges being granted clearly demonstrate that Doe 2’s status as an abortion provider was a central issue-in the decision making process over whether to grant him privileges and the limitations those privileges would have. (See JX161-81; see infra Part VIII.)

102. There are ways in which the hospital staffs and/or the general public’s hostility to abortion and abortion providers can be injected into the credentialing process. For instance, many applications for privileges require references from at least two physicians who recently have observed the applying physician as to applicant’s medical skill and “character.” (JX 143 at 3357; JX 79 at 1680-81; JX 83 at 1873; JX 143 at 3351.) For example, Minden prefers that an applicant’s peer recommendations come from physicians already on staff at that hospital. (JX 72 at 1300.) Although competent, an abortion provider can face difficulty in getting the required staff references because of staff opposition to abortion. (See, e.g,, Doc. 168-6 at 12; Doc. 190 at 53; JX 109 ¶[¶28, 30,39.)

103. Other hospitals’ admitting privileges applications require the applying physician to identify another physician on staff who will “cover” his or-her patients if the applying physician is unavailable, frequently called a “covering physician.” (JX 78 at 1539; JX 79 at 1677; JX 138 at 2855; JX 83 at 1866.) As summarized below, the evidence shows that opposition to abortion can present a major, if not insurmountable hurdlé, for an applicant getting the requited covering physician.

104. For example, Doe 5 has applied for admitting privileges at three hospitals in the Baton Rouge area: Woman’s Hospital in April or May of 2014 and Lane Regional Medical Center and Baton Rouge General Medical Center in July of 2014. (Doc. 168-6 at 11.) Doe 5 has been unable to. find a local physician who is willing to provide coverage for him when he is not in Baton Rouge, which all three hospitals require. (JX 109 ¶¶ 32-33; JX 110; Doc. 51; Doc. 168-6 at 11-12.) Doe 3 also has had difficulty finding physicians to cover for him due to the animosity towards him as an abortion provider. (Doc. 190 at 11-13.) While Doe 2 ultimately got limited privileges at Tulane, (JX 183), the evidence therefore demonstrates that staff physicians who oppose abortion present a real obstacle, see infra, Part VIII.B.

105. Some other non-competency based admitting privileges requirements create á particular obstacle for abortion providers whose practice is not hospital based, who do not admit patients to a hospital as a part of their practice, and who do not perform surgeries at a hospital.

106. As one example, hospitals often grant admitting privileges to a physician because the physician plans to provide services in the hospital. (See, e.g., Doc. 195 at 24r-25; Doc. 193 at 66.) In general, hospital admitting privileges are not provided to physicians who never intend to provide services in a hospital. (Doc. 195 at 23-25, 27, 74-75; Doc. 193 at 66-67.)

107. Thus, in connection with the applications of Does 1 and 2 at Willis-Knighton Medical Center (“WKMC”), Willis-Knigh-ton South (‘WKS”), and Willis-Knighton Pierremont Health Center (“WKP”) in Shreveport, (JX 53,144), the Willis-Knigh-ton Health System (“Willis-Knighton”), which runs these three (as well as other) entities, has required these doctors to submit data on hospital admissions, patient management and consultations of patients in the past 12 months in a hospital. (Doc. 192 at 75-76; JX 128; JX 89 at 1950.)

108. Because their abortion practice is not hospital based, neither doctor can possibly comply with that requirement. In the case of Doe 1, since he formally responded to a hospital’s request for more information regarding his history of admitting patients during the preceding twelve months, saying he had no such information, he has never again heard from the hospital— there being neither a denial nor an approval of his application. (Doc. 192 at 75-78.) Similarly, when Doe 2 gave the hospital the only information in his possession, he received formal notice that this was insufficient and “[without that [additional] information, your application remains incomplete and cannot be processed.” (JX 89 at 1950.) Doe 2 could do nothing else, explaining, “I’m in a Catch-22 basically. I can’t provide information I don’t have.” (Doe. 191 at 79-80.)

109. Even if these Does and similar practitioners somehow got admitting privileges, it is unlikely they would be able to keep them. If over a period of two to three years, a physician has not admitted any patients to the hospital, a hospital credentialing committee is likely to understand that this physician no longer requires admitting privileges. (See, e.g., Doc. 195 at 91.) Because, by all accounts, abortion complications are rare, (See, e.g., Doc. 168-5- at 14, 16, 20-21; Doc. 193 at 81-82; Doc. 195 at 38-39), an abortion provider is unlikely to have a consistent need'to admit patients.

110. Furthermore, surgical privileges are meant for providers who plan to perform surgeries at the hospital. (Doc. 195 at 95-96.)

111. For the reasons outlined above, the Court finds that the Louisiana practice of credentialing, i.e. a hospital’s consideration of and acting (or hot acting) upon applications for admitting privileges, creates particular hardships and obstacles for abortion providers.

112. The efforts made by Does 1-6, to comply with the admitting privileges requirement of Act 620, and the result of those efforts, is reviewed in another section of this Ruling. See infra Part VIII.

E. The Climate

113. The evidence is overwhelming that in Louisiana, abortion providers, the clinics where they work and the staff of these clinics, are subjected to violence, threats of violence, harassment and danger.

114. Defendant offered no evidence to counter Plaintiffs’ evidence on this point. Rather, Defendant makes two arguments: first, some of the. Plaintiffs’ evidence on this point is hearsay, and second, the violence is “legally irrelevant” to the undue burden analysis. (Doc. 201 at 14-15.) The issue of legal relevance is addressed in the Conclusions of Law'section of this Ruling. See infra Parts XI-XII.

115. Defendant objects to the testimony and exhibits cited in, Plaintiffs’ proposed findings and conclusions (Doc. 196 ¶¶79, 84, 87, 89), as hearsay. However, almost all of this testimony was not objected to by Defendant at the time it was introduced. Moreover, in some instances, this testimony came in by way of exhibits offered jointly by the Parties or in questions asked by counsel for the Defendant.

116. ■ But even if. the objected-to evidence were excluded, there is a mountain of uncontradicted and un-objected to evidence supporting this conclusion, some of which is summarized below.

117. In addition to the harassment and violence, as was discussed briefly in the previous section and will be discussed in more detail in the section reviewing the doctors’ efforts to gain admitting privileges, the personal and/or religious feelings against abortion by the public, some members of the medical profession and hospital administrators has had a negative effect on the doctors’ efforts to gain admitting privileges. (See, e.g., Doc. 168-6 at 12; Doc. 190 at 53; Doc. 191 at 24-26; Doc. 192 at 45-46; JX 109 ¶¶ 28, 30, 39.)

118. Indeed, after reviewing Plaintiffs’ motion to allow the Plaintiff doctors to use pseudonyms as well.as their supporting affidavits, the United States Magistrate Judge concluded: “The Court is satisfied that the potential for harassment, intimidation and violence in this case, particularly recent instances of such conduct, both nationwide and in Louisiana, justifies the unusual and rare remedy of allowing the individual Plaintiffs to proceed anonymously.” (Doc. 24 at 3; see also Doc 190 at 108; Doc. 191 at 12; Doc. 192 at 6.) A similar order was signed when Does 3-6 were added as parties. (Doc. 55.)

119. Also recognizing these legitimate safety concerns, Defendant joined with Plaintiffs in a Joint Consent Motion Regarding Confidential Trial Procedures, (Doc. 158), granted on June 23, 2015, (Doc. 161). These procedures included allowing Does 1-3 to testify' from behind a screen. (Doc. 158 at 1.)

120. The security concerns even went beyond the Parties, however. A request for anonymity was made on behalf of a hospital which had granted privileges to Doe 5 and the non-party doctors who assisted in the privileges request. No objection was made by any party and the Court ordered this hospital to be called “Hospital C” and the doctor involved for that hospital,” Dr. C.” (Id.) Other doctors involved in granting the limited privileges to Doe 2 were ordered to be called “Dr. A” and “Dr. B.” m

121. In order to insure the use of the pseudonyms and protect the identities of Plaintiff doctors as well as certain non-party doctors and hospitals, the Plaintiffs and Defendant filed a joint motion to redact portions of the trial transcript, which the Court granted. (Doc. 180.) By their filings in this case, therefore, Defendant and Plaintiffs have implicitly acknowledged the charged emotions generated by this particular issue within and outside this state.

122. The evidence, in turn, leaves no question about the dangers and hostility regularly endured by Plaintiffs.

123. Each of Louisiana’s five clinics experiences frequent demonstrations by antiabortion activists. (Doc. 190 at 24, 108; Doc. 191 at 13; JX 109 ¶¶ 10-12; JX 117 ¶6; JX 112 ¶2; JX 113 ¶2; Doc. 168-6 at 25.) These demonstrations require some clinics to have additional security on site. (Doc. 190 at 23.)

124. Hope Clinic in Shreveport has been the subject of three violent attacks: once by a man wielding a sledgehammer, once by an arsonist who threw a Molotov cocktail at the clinic, and once by having a hole drilled through the wall and butyric acid poured through it. (Doc. 190 at 23; JX 116 ¶ 8.)

125. In the fall of 2014, following passage of the Act, anti-abortion activists ai> tempted to interfere with Doe 5’s admitting privileges application at Woman’s Hospital in Baton Rouge by sending threatening letters to the hospital. (JX 110 ¶ 14; JX 109 ¶ 29.) Woman’s Hospital also had to remove anti-abortion activists from its medical staff offices due to the activists’ disruptive conduct. (JX 110 ¶ 14.)

126. When Doe 5 worked as a hospital employed physician, protests outside the hospital caused the hospital administration to give him an ultimatum: quit performing abortions or resign from the hospital staff. (JX 110 II21; see also Doc. 168-6 at 23-24.) In his words, he “was therefore forced to stop working at the hospital so that ... [he] could continue providing services at Women’s Clinic and Delta Clinic.” (JX 110 ¶ 21; see also JX 109 ¶ 30.)

127. After Doe 5 recently acquired privileges at a local hospital (Hospital C), anti-abortion activists began sending threatening letters to that hospital causing him to fear that he might lose the privileges that he acquired. (JX 110 ¶ 20; see also JX 109 ¶ 39.)

128. Anti-abortion activists picketed the school of the children of a doctor formerly affiliated with Delta, after which that doctor quit. (Doc. 168-4 at 23-24.)

129. A physician quit working at Causeway after receiving harassing telephone calls at his private practice and antiabortion activists demonstrated outside the hospital where he worked. (Doc. 168-8 at 8.)

130. Doe 1 works at Hope-but he does so in fear of violence. (Doc. 192 at 78-79.)

131. Doe 2 has received threatening phone calls, has been followed into restaurants and accosted, and has been shouted at with profanity and told that he was going to hell. (Doe. 191 at 12-13.)

132. Doe 2 was forced to leave a private practice when the practice’s malpractice insurer refused to cover him if he continued to perform elective pregnancy terminations. (Id. at 16-17.)

133. Doe 3 has been threatened as a result of his work at Hope Clinic. (JX 113 ¶ 3.) Last year, anti-abortion activists from outside Louisiana left fliers on neighbors’ mailboxes calling him an abortionist and saying they wanted to convert him to Jesus. (Doc 190 at 108-09.) Local police have had to patrol his neighborhood and search his house before he entered. (JX 113 ¶ 4.)

134. These individuals also approached Doe 3’s regular medical practice patients as they tried to enter his office, requiring the building security officers to escort the activists off the premises. (Id. ¶ 3.) These individuals told Doe 3’s patients that he killed babies and that they should not see him. (Doc. 190 at 109.)

135. Doe 3 fears that, if the other Louisiana abortion providers are not able to obtain admitting privileges, he will become an even greater target for anti-abortion violence. (JX 113 ¶¶ 6-7.) He specifically testified that “all [these individuals] have to do is eliminate [him] as they have Dr. Tiller and some of the other abortion providers around the country” to eliminate abortion entirely in northern Louisiana. (Doc. 190 at 174.)

136. Doe 3 also explicitly emphasized that he is concerned that such individuals could “cause a lot of other ... problems that would affect [his] ability to perform the rest of [his] practice.” (Id. at 174-75; cf. JX 113 ¶¶ 6-7.)

137. Doe 3 has difficulty arranging coverage for his OB/GYN practice because other OB/GYN doctors in the Shreveport area refuse to cover his practice as a result of his work at Hope. (Doc. 190 at 111-13.)

138. As a result of his fears, and the demands of his private OB/GYN practice, Doe 3 has testified that if he is the last physician performing abortion in either the entire state or in the northern part of the state, he will not continue to perform abortions. (Id. at 174-76.)

139. Anti-abortion activists have picketed the homes — and neighbors’ homes— of Does 5 and 6, also distributing threatening flyers. (Doc. 168-6 at 24; JX 109 ¶ 11.)

140. Anti-abortion activists have targeted at least one physician who agreed to provide emergency care for abortion complications, even though he did not provide abortions himself. (Doc. 168-6 at 11, 24-25; JX 110 ¶ 20.)

VI. Act 620

A. Text of Act 620 and Related Provisions

141. The challenged statute is-Act 620. La. R.S. § 40:1299.35.2.

142. Act 620 amended Louisiana Revised ■ Statutes § 40:1299.35.2(a), 1299.35.2.1, and 2175.3(2) and (5). (Id.)

143. On June 12, 2014, Governor Bobby Jindal signed Act 620 into law, with an effective date of September 1, 2014. (See, e.g., Doc. 109 at 4.)

144. Act 620 provides that every physician who performs or induces an abortion shall “have active admitting privileges at a hospital that is located not further than thirty miles from the location at which the abortion is performed or induced and that provides obstetrical or gynecological health care services.” La. R.S. § 40:1299.35.2A(1).

145. The Act defines “active admitting privileges” to mean that “the physician is a member in good standing of the medical staff of a hospital that is currently licensed by the department, with the ability to admit a patient and to provide diagnostic and surgical services to such patient ....” Id. § 40:1299.35.2A(2)(a).

146. Regulations connected to the Act and promulgated after the commencement of this litigation by DHH use the same definition of “active admitting privileges.” La. Admin Code tit. 46, § 4401. These regulations note that federal litigation is pending on the issue of admitting privileges and that licensing provisions regarding admitting privileges will only be enforced pursuant to an order, judgment, stipulation, or agreement issued in this case. Id. § 4423.

147. The Act provides that any outpatient abortion facility that knowingly or negligently provides abortions through a physician who does not satisfy the Act is subject to denial, revocation, or non-renewal of its license by DHH. La. R.S. § 40:1299.35.2A(1).

148. The Act provides that a physician who fails to comply with the admitting privileges requirement can be fined $4,000 per violation. Id. § 40:1299.35.2A(2)(c).

149. In addition, discipline by the Board is made an enforcement provision in Act 620.. Id. § 40.T299.35.2.1E. The Board has the authority to take disciplinary action against any physician. Id. § 37:1261 et seq. The Board has the authority to investigate physicians for violations of law, such as Act 620. Id. § 40:1299.35.2E. By violating this law, physicians could be subjected to fines or other sanctions, including the suspension or revocation of the physician’s license to practice medicine. (Doc. 168-10 at 12, 14-15; see also Doc. 31 at 4 n.4.)

B. Louisiana’s Policy and Other Legislation Regarding Abortion

■ 150. ' The Louisiana legislature has codified a statement of opposition to legalized abortion, stating:

It is the intention of the Legislature of the State of Louisiana to regulate abortion to the extent permitted by the decisions of the United States Supreme Court. The Legislature does solemnly declare and find in reaffirmation of the longstanding policy of this State that the unborn child is a human being from, the time of conception and is, therefore, a legal person for purposes of the unborn child’s right to life and is entitled to the right to life from conception under the laws and Constitution of this State. Further the Legislature finds and declares that the longstanding policy of this State is to protect the right to life of the unborn child from conception by prohibiting abortion impermissible only because of the decisions of the United States Supreme Court and that, therefore, if those decisions of the United States Supreme Court are ever reversed or modified or the United States Constitution is amended to allow protection of the unborn then the fo