Health Care

Idaho v. United States

In Idaho v. United States, the Supreme Court considered whether EMTALA, a federal law requiring hospitals to provide stabilizing treatment to patients experiencing medical emergencies, preempts Idaho’s near-total abortion ban in situations where abortion constitutes the medically indicated stabilizing treatment.

Case Summary

Two years ago, after the Supreme Court ruled that there is no constitutional right to abortion in Dobbs v. Jackson Women’s Health Organization, Idaho enacted a near-total abortion ban. The United States sued Idaho, arguing that the state’s law is preempted, in part, by a federal law known as the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals that participate in the federal Medicare program to offer “stabilizing treatment,” including abortion, to patients who come to the hospital with an “emergency medical condition.” It asserted that in those limited but critically important situations in which abortion constitutes the necessary “stabilizing treatment” under EMTALA, but Idaho law forbids hospitals from providing it, the Idaho law must give way.

The district court agreed with the United States and preliminarily enjoined Idaho’s anti-abortion law. After the full Ninth Circuit, sitting en banc, declined to stay that injunction, Idaho and its legislature went to the Supreme Court. The Court agreed to stay the injunction temporarily, allowing Idaho’s law to go into effect, and granted certiorari to consider the case on the merits.

CAC filed an amicus brief on behalf of 258 members of Congress in support of the United States. Our brief made two main points.

First, drawing on the expertise of members of Congress, we explained how the text and history of EMTALA make clear that it mandates that hospitals offer abortion care when abortion constitutes the necessary stabilizing treatment for an individual’s “emergency medical condition.”

EMTALA’s plain text requires the provision of whatever stabilizing treatment is “necessary to assure, within reasonable medical probability” against “material deterioration of the [patient’s] condition.” Congress did not carve out abortion, or any other specific medical procedure, from EMTALA’s requirements. In fact, the one time Congress enacted statutory text expressly addressing both abortion and EMTALA together—in a section of the Affordable Care Act crafted by many amici—it did so to make clear that EMTALA authorizes rather than exempts abortion.

Our brief also urged the Court to reject several arguments advanced by Idaho and its legislature that attempted to contort the text of EMTALA.

We argued that the Court should decline to construe EMTALA based on its alleged purpose of preventing “patient-dumping.” Not only was that purposive argument misplaced in this case, given the lack of ambiguity in EMTALA’s original public meaning, but the statute’s purpose was broader than Idaho claims. EMTALA was not just designed to prevent “patient-dumping”; it also was passed to ensure that hospitals fulfil their basic emergency treatment obligations to the general public.

EMTALA also does not permit physicians to decline to provide stabilizing treatments that states have criminalized. Though the statute says that hospitals must provide only those treatments “within the staff and facilities available at the hospital,” that text simply makes clear that hospitals need only provide services that they have the staff and equipment to provide. Nowhere is there any indication—in the text or history of EMTALA—that Congress meant to exempt doctors from providing a stabilizing treatment they are fully capable of providing and have performed hundreds or even thousands of times because a state has newly imposed criminal punishment on such treatment.

We also argued that EMTALA’s reference to fetuses does not alter its requirement that hospitals provide abortion when necessary to stabilize an individual’s “emergency medical condition.”  The reference to an “unborn child” in the definition of “emergency medical condition” merely expands the scope of EMTALA’s screening and stabilization requirements to cover situations in which the “individual” faces no risk of serious health impairment (or at least, her condition has not progressed to that stage yet), but the individual’s fetus does face such a risk.  In other words, it ensures that a pregnant patient can receive stabilizing care when it is the patient’s fetus, not the patient, that faces a serious health impairment.

Second, after providing that detailed explanation of EMTALA’s scope, our brief explained why EMTALA, enacted pursuant to Congress’s spending authority, should be entitled to preemptive effect.

Crafted against the backdrop of numerous abuses of state authority under the Articles of Confederation, the Spending Clause and the Supremacy Clause are both critical provisions that enable Congress to fulfill its constitutionally mandated duties.  Under the Supremacy Clause, all of Congress’s constitutional laws constitute “the supreme Law of the Land,” and the Supreme Court has repeatedly held that the principle of federal supremacy applies to laws, like EMTALA, passed pursuant to Congress’s spending authority no less than it does to laws enacted pursuant to other enumerated powers.  That effectuates the plain text of the Supremacy Clause, which contains no carve-out for Spending Clause statutes, and is perfectly logical: once federal money is accepted, conditions attached to its receipt become just as binding on the recipient as any other federal law.

Of course, private parties have the choice whether or not to accept federal funding, and the strings attached to it, in the first place.  But it is Congress that our Constitution empowers to offer that choice.  States do not have the power to take that choice away by making it impossible for funding recipients to comply with both the terms of federal spending law and state law.  If that were the case, states could nullify federal laws without restraint—precisely what Idaho attempted to do in this case.

In June 2024, the Court issued a per curiam opinion dismissing the petitions as improvidently granted without ruling on the merits, and vacating the stay the Court had previously entered, which had allowed Idaho’s near-total abortion ban to go into effect while the case was pending.

Justice Kagan penned a concurring opinion, joined by Justices Sotomayor and Jackson, explaining why the Court never should have intervened or granted a stay of the district court’s injunction in the first place. Justice Barrett also wrote a concurrence, joined by the Chief Justice and Justice Kavanaugh, taking the position that any conflict between Idaho’s law and EMTALA had substantially narrowed since the start of the litigation, in light of representations by counsel at oral argument and an amendment of the Idaho law.

Justice Alito, joined by Justices Thomas and Gorsuch, dissented in an opinion advancing an atextual construction of EMTALA. In their view, EMTALA does not require that abortion be provided as emergency medical care. Their dissent also raised a troublingly narrow view of Congress’s preemptive power under the Spending Clause.

Finally, Justice Jackson authored a powerful opinion concurring in the Court’s decision to vacate the stay and allow emergency abortions to continue in Idaho for the time being, but dissenting from the Court’s decision not to decide the case now in the federal government’s favor. Echoing our brief’s textual analysis, she was clear: “under federal law, a hospital must provide an emergency abortion that is reasonably necessary to preserve a patient’s health within the meaning of EMTALA.” She also underscored the gravity of the Court’s refusal to protect pregnant patients and the supremacy of federal law: “Today’s decision is not a victory for preg­nant patients in Idaho. It is delay.”

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