Mayor of Balt. v. Azar, 392 F. Supp. 3d 602

Background

Baltimore City challenged HHS’s March 4, 2019 Final Rule revising Title X regulations (effective May 3, 2019), seeking a preliminary injunction to block enforcement in Maryland.
The Final Rule reinstated (in effect) an abortion "gag" on Title X providers and imposed a strict physical/financial "separation requirement" between Title X activities and abortion-related services.
Baltimore City asserted statutory and APA claims, primarily that the Rule violates: (1) the ACA §1554 non-interference mandate; (2) Congress’ long-standing Title X appropriations requirement that pregnancy counseling be "nondirective"; and (3) Title X itself.
The City argued enforcement would force it either to (a) violate medical ethics by restricting information and referrals or (b) withdraw from Title X and lose funding for clinics serving low-income residents.
Other district courts (WA, CA, OR) had already enjoined the Rule (some nationwide); the government appealed/stayed those injunctions.
The court held that Baltimore City was likely to succeed on its statutory claims (ACA §1554 and the appropriations nondirective mandate), would suffer irreparable harm absent relief, and granted a preliminary injunction enjoining enforcement of the Final Rule in Maryland.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the Final Rule violates ACA §1554 (non-interference with patient-provider communications and informed consent)	Final Rule's gag and referral restrictions interfere with communications, restrict disclosure, and violate informed-consent principles	Section language is limited to the ACA context; Rust controls and permits similar restrictions	Court: Final Rule likely violates §1554; plaintiff likely to succeed on this claim
Whether the Final Rule violates the appropriations requirement that pregnancy counseling be "nondirective"	Requiring prenatal referrals and excluding abortion referrals coerces patients and is directive, not nondirective	Rust and Title X do not support reading appropriations language to override agency interpretations; referrals are distinct from counseling	Court: Final Rule likely violates the nondirective appropriations mandate; plaintiff likely to succeed on this claim
Whether promulgation of the Final Rule was arbitrary and capricious under the APA	Rule failed to address reliance interests, changed prior agency positions without adequate justification, and ignored evidence/comments	Agency relied on Rust and prior justifications; acted within its discretion	Court: Did not decide on this claim at preliminary stage — declined to resolve APA arbitrary-and-capricious question now
Whether preliminary relief was warranted (irreparable harm, equities, public interest)	Loss of Title X funds would irreparably harm clinics and patients; complying would force unethical medical practice; public interest favors continuity of care	Government argued nationwide injunctions already issued and any harm is speculative	Court: Baltimore City showed likely irreparable harm; equities and public interest favor injunction limited to Maryland

Key Cases Cited

Rust v. Sullivan, 500 U.S. 173 (1991) (upholding 1988 Title X restrictions under Chevron deference)
Winter v. Natural Res. Def. Council, 555 U.S. 7 (2008) (standards for preliminary injunction)
Chevron U.S.A., Inc. v. Nat. Res. Def. Council, Inc., 467 U.S. 837 (1984) (agency deference framework)
Motor Vehicle Mfrs. Ass'n v. State Farm, 463 U.S. 29 (1983) (arbitrary-and-capricious review standard)
Encino Motorcars, LLC v. Navarro, 136 S. Ct. 2117 (2016) (agency must acknowledge and justify changes from prior positions)
Casa de Maryland v. U.S. Dep't of Homeland Sec., 924 F.3d 684 (4th Cir. 2019) (noting scope of review and searching inquiry into administrative record)
State of Washington v. Azar, 376 F. Supp. 3d 1119 (E.D. Wash. 2019) (district court nationwide injunction against Final Rule)
California v. Azar, 385 F. Supp. 3d 960 (N.D. Cal. 2019) (district court injunction and analysis finding Final Rule likely unlawful)
State of Oregon v. Azar, 389 F. Supp. 3d 898 (D. Or. 2019) (district court nationwide injunction against Final Rule)
Mountain Valley Pipeline, LLC v. 6.56 Acres owned by Powell, 915 F.3d 197 (4th Cir. 2019) (discussing irreparable harm and unrecoverable government funding)