The number of abortion clinics operating in Texas has fallen from more than 40 to roughly 20 since lawmakers enacted sweeping medical-facility and physician requirements in 2013, a contraction that placed the state’s rules before the Supreme Court on Wednesday in the most consequential abortion case in nearly a quarter-century.

The justices are reviewing two provisions of House Bill 2: one requiring physicians who perform abortions to have admitting privileges at a hospital within 30 miles, and another requiring clinics to meet the building, staffing and equipment standards of ambulatory surgical centers. Providers say the rules deliver little or no medical benefit while closing clinics and forcing women to travel hundreds of miles. Texas says the requirements protect patients and fall within the state’s authority to regulate medical practice.

The argument lasted about an hour before an eight-member court, one seat vacant after the death of Justice Antonin Scalia. The Supreme Court’s recording and transcript showed the justices repeatedly pressing the parties on a central factual question: whether the clinic closures were caused by the challenged provisions and whether courts must weigh a law’s health benefits against its burdens.

Two Requirements, One Constitutional Question

The text of House Bill 2, approved during a special legislative session, requires a physician to obtain admitting privileges at a nearby hospital and directs abortion facilities to comply with standards applied to ambulatory surgical centers. The broader law also restricts abortion after 20 weeks and regulates medication abortion, but those provisions are not the focus of the case.

Texas argues that admitting privileges provide credentialing and continuity of care if complications arise, while surgical-center standards ensure appropriate space, sanitation, staffing and emergency capacity. Solicitor General Scott Keller told the justices that states receive deference when regulating health and that the challengers had not proved the rules caused every closure they identified.

The clinics answer that abortion is already a low-risk procedure and that complications requiring hospital care are uncommon. They say hospitals may deny admitting privileges for reasons unrelated to competence, including minimum-admission requirements that abortion providers cannot meet precisely because serious complications are rare. They also argue that costly construction specifications — governing matters such as corridor widths, ventilation and room size — do not improve the safety of most outpatient abortions.

A January amicus brief filed by constitutional-law scholars urged the Court to require meaningful scrutiny when a state invokes health as the reason for restricting a constitutional right. The brief argues that deference cannot be so broad that courts ignore trial findings about whether a regulation actually advances the interest asserted for it.

The Burden Is Measured in Distance and Capacity

The providers’ case depends not only on the number of clinics but on what the remaining facilities can handle. If the surgical-center requirement takes full effect, they contend, the number could fall to about 10, concentrated in major metropolitan areas. Women in West Texas and the Rio Grande Valley would face particularly long journeys, added lodging and transportation costs, time away from work, and delays that can make care more complex.

The Fifth Circuit largely upheld the provisions last June, concluding that the burdens did not meet the constitutional threshold established by Planned Parenthood v. Casey. Its 2015 opinion allowed a limited exception for one clinic but otherwise deferred substantially to Texas’s asserted health rationale.

The clinics say that approach misunderstands Casey, which bars a state from imposing an undue burden — a law whose purpose or effect places a substantial obstacle in the path of a woman seeking a pre-viability abortion. Their position is that courts must examine the relationship between a regulation’s benefits and the obstacles it creates, not merely ask whether lawmakers could imagine a health justification.

The scale of the dispute extends beyond Texas. A Congressional Research Service report prepared after the Fifth Circuit ruling noted that numerous states had adopted admitting-privileges or surgical-center requirements. The Court’s treatment of evidence and deference could therefore determine how challenges to similar laws proceed across the country.

The Justices Test the Evidence

Justice Stephen G. Breyer focused on the combination of closures and travel. Justice Elena Kagan pressed Texas on the timing of shutdowns after the admitting-privileges rule took effect. Justice Sonia Sotomayor questioned why medication abortions, which involve pills rather than surgery, would require a facility built to surgical-center specifications. Their questions suggested concern that the requirements may apply far more broadly than their medical rationale supports.

Chief Justice John G. Roberts Jr. and Justice Samuel A. Alito Jr. challenged the challengers’ proof of causation. They asked whether clinic closures might have resulted from reasons other than the law and whether the record clearly showed that existing surgical centers lack capacity to absorb patients. Keller argued that the state should not lose on the basis of assumptions about future closures and crowding.

Stephanie Toti, representing Whole Woman’s Health and other providers, said the trial record established a direct connection between the requirements and the loss of services. Solicitor General Donald B. Verrilli Jr., appearing for the United States in support of the clinics, argued that the burdens must be judged against medical benefits the trial court found negligible. The contemporaneous transcript released by the Center for Reproductive Rights captures an argument dominated less by abstract slogans than by questions about distances, caseloads, hospital policies and the probative weight of trial evidence.

Outside the Court, both sides treated the case as a national referendum on regulation. The Guardian’s report from Wednesday described the dispute as the Court’s most important abortion-rights confrontation in decades, with supporters of the law casting it as patient protection and opponents calling it a blueprint for eliminating access without formally banning abortion.

An Eight-Justice Court Raises the Stakes

Scalia’s absence changes the possible outcomes. A 4-to-4 division would affirm the Fifth Circuit’s judgment without creating a nationwide Supreme Court precedent. That would leave most of the Texas restrictions in place while allowing other federal appeals courts to reach different conclusions about similar laws. The justices could also seek a narrower resolution or order additional factual proceedings, though neither path appeared clearly dominant in Wednesday’s questioning.

Justice Anthony M. Kennedy is again positioned near the center. He joined the controlling opinion in Casey but has also voted to uphold some abortion regulations. During argument, he asked whether the law might have created an unconstitutional burden while also probing whether the lower-court record was sufficient. His questions offered no definite indication of how he will vote.

The Court’s official hearing list identifies the case as an appeal from the Fifth Circuit and places Toti and Verrilli against Keller, underscoring that the dispute is both a constitutional case and a contest over the judiciary’s handling of factual evidence.

The outcome will decide more than whether particular Texas clinics remain open. It will clarify whether a state’s stated interest in health largely ends judicial inquiry or begins a closer examination of what a regulation accomplishes and what it costs patients. With the Court evenly staffed and the evidence sharply disputed, the answer may turn on a single justice — or remain unsettled beyond Texas.