Washington — The Supreme Court on Wednesday appeared divided in a case pitting Idaho's near-total ban on abortion against a federal law that requires hospitals to provide stabilizing care to patients experiencing medical emergencies.
The dispute between the Biden administration and Idaho officials in the case known as Moyle v. United States was the second the justices heard in the span of a month that followed the Supreme Court's decision less than two years ago overturning Roe v. Wade. The outcome of the case could determine whether the Biden administration can require hospitals in states with stringent abortion laws to offer pregnancy terminations in emergency situations.
The court fight involves the Emergency Medical Treatment and Labor Act, or EMTALA, which requires hospitals that participate in Medicare to stabilize patients facing an emergency medical condition.
The Biden administration argues that in some cases, that treatment will be abortion care, and in July 2022 — following Roe's reversal — it told hospitals accepting Medicare funds that physicians must offer abortions in certain medical emergencies. If a state law prohibits the procedure, or includes an exception that is more narrow than what EMTALA provides, it is overridden by the federal law, the Centers for Medicare and Medicaid Services said.
But Idaho officials, and opponents of abortion rights, say EMTALA is silent on whether stabilizing care includes abortions and it cannot displace a state's own restrictions on the procedure.
Under Idaho's law, which took effect after Roe's reversal, abortions are only allowed when necessary "to prevent the death of the pregnant women," or in cases of rape or incest. Physicians who perform abortions in violation of the measure may be charged with a felony and face up to five years in prison.
During the arguments, Justice Sonia Sotomayor asked Joshua Turner, the lawyer arguing for Idaho, about women who present a serious medical condition that under federal law would be treated with an abortion, but in Idaho would not. She suggested a hypothetical situation under which a woman presents with a serious medical condition that a doctor can't say would result in death, but could result in potential loss of an organ or serious loss of function.
If that hypothetical exists, Turner replied, Idaho law says that abortion in that case is not allowed.
But Turner argued that Idaho did not come into conflict with federal law in cases where a pregnant woman's condition might be serious, but not imminently fatal. He said that under Idaho law, doctors must merely be acting in "good faith" when determining that a woman might need an emergency abortion.
When asked to identify where EMTALA's stabilization requirement did conflict with Idaho law, Turner raised mental health, suggesting that a pregnant woman could come in and say that a mental health issue demanded the termination of her pregnancy.
But Solicitor General Elizabeth Prelogar later told the court that a pregnant woman suffering from a mental health emergency would never be treated with an abortion "because that is not the accepted standard of practice." She would be stabilized and transferred under EMTALA, Prelogar said.
The Biden administration sued Idaho in August 2022, arguing its law is preempted by EMTALA. A federal district court in Idaho sided with the federal government and allowed physicians to perform abortions in certain emergency situations.
A three-judge panel of the U.S. Court of Appeals for the 9th Circuit then allowed the law to be fully enforced while litigation continued. But the full 9th Circuit, which reviewed the panel's ruling, reinstated the district court's order in October.
The Supreme Court in early January said it would decide whether EMTALA overrides state laws that prohibit most abortions, but allowed Idaho to continue enforcing its ban in certain emergency medical situations until it issues a decision, expected by the end of June.
The fight over EMTALA
EMTALA was enacted in 1986 to address concerns that hospitals were engaging in "patient dumping" by discharging or transferring patients who did not have insurance. The law created a national minimum care standard for hospitals participating in Medicare by requiring them to offer stabilizing treatment to any patient with an emergency condition that threatens their life or health.
The Biden administration argues the Health and Human Services Department, Congress and health care providers have long recognized that EMTALA requires hospitals to offer abortions when necessary to save the mother's life or prevent serious harm to her health.
While stabilizing care sometimes involves terminating the pregnancy, instances where EMTALA and the Idaho abortion ban are at odds are rare, Prelogar told the Supreme Court in a filing.
If a condition arises later in pregnancy and the fetus can be delivered, there is no conflict between the federal and state laws, she wrote. But it does arise when a pregnant woman is suffering from an emergency medical condition that, absent ending the pregnancy, threatens serious harm to her health, but not her life, Prelogar continued. In those circumstances, EMTALA overrides the Idaho ban, she said.
"Delaying care until the woman's condition deteriorates and the doctor can say that termination is necessary to prevent her death, as Idaho law requires, stacks tragedy upon tragedy with little additional likelihood of fetal survival," Prelogar wrote.
The Biden administration has argued that the gap between what EMTALA requires and what is allowed under Idaho's law — an abortion to protect a mother's health versus an abortion to save her life — has "devastating real-world consequences."
"Many pregnancy complications do not pose a threat to the woman's life when she arrives at the emergency room — but delaying care until necessary to prevent her death could allow her condition to deteriorate, placing her at risk of acute and long-term complications," Prelogar wrote.
If Idaho prevails and the Supreme Court agrees that state abortion restrictions supersede EMTALA's stabilization requirement, Prelogar warned it would allow care under the law to vary from state-to-state, "thwarting Congress's promise of essential emergency care to all Americans."
But lawyers for Idaho's Republican legislative leader argued that EMTALA does not include a requirement for abortion care, and they accused the Biden administration of recasting the law as an abortion mandate.
"EMTALA is not [the Department of Health and Human Services'] Trojan horse for nationwide abortion rules. EMTALA nowhere mentions abortion," Republican state lawmakers said in a filing to the court. "Reading EMTALA as empowering HHS to displace state abortion laws defies the usual expectations of how Congress legislates and distorts the Constitution's separation of powers."
Led by Idaho House Speaker Mike Moyle, the GOP lawmakers claimed that the Biden administration's reading of EMTALA is an "intolerable federal power grab," and they called the law a "patient-dumping statute, not an abortion-access statute."
In a separate filing from Idaho's attorney general, state lawyers, alongside the conservative legal group Alliance Defending Freedom, claimed the Biden administration is attempting to "create a nationwide abortion mandate" in emergency rooms that participate in Medicare.
"It would allow the federal government to pay hospitals to violate state law, exempting emergency-room doctors from the state-law standards of practice that govern the treatments they are authorized to provide," Idaho Attorney General Raúl Labrador wrote. "Nothing about that nullification of state law is narrow, and it is not, and will not be, limited to abortion."
Labrador, a Republican, told CBS News chief legal correspondent Jan Crawford that Idaho's law and EMTALA do not conflict.
"There's a lot of misinformation of what the Idaho law does, and it's really important for people to understand that if the life of the mother is in jeopardy, Idaho law actually allows an abortion," he said.
Labrador accused the Biden administration of "trying to scare people into believing that women are going to die."
The landscape after Roe's reversal
Idaho is one of 14 states that outlaw abortion with some exceptions, according to the Guttmacher Institute, a pro-abortion rights research organization, while another seven outlaw abortion in the first 18 weeks of pregnancy.
Twenty-two states, many of which have the most stringent abortion laws, are siding with Idaho in the dispute, arguing that the Biden administration is attempting to invalidate state laws that protect the unborn.
No physician has been prosecuted or charged in Idaho for violating its ban. But the battle before the Supreme Court demonstrates the fallout from its decision unwinding the constitutional right to abortion and the challenges for physicians who are navigating states' narrow exceptions to their abortion bans.
Dr. Jim Souza, chief physician executive for Boise-based St. Luke's Health System, said there is now "second-guessing" and "hand-wringing" about whether an abortion can be performed within the bounds of Idaho's law.
In 2023, when Idaho physicians could provide abortions in certain emergency situations under the district court's order, one patient was transferred out of state, Souza said. But in the months since the Supreme Court has allowed Idaho to enforce its law in all circumstances, six patients with medical emergencies have been flown out of state, Souza said. He estimated that number will rise to 20 by the end of 2024.
While supporters of abortion rights are sounding the alarm about the consequences of a decision in favor of Idaho, the case has not received as much attention as a second abortion-related challenge heard by the Supreme Court last month, which involves the widely used abortion pill mifepristone.
In that case, a group of anti-abortion rights doctors and medical associations argued the Food and Drug Administration undertook a series of unlawful actions that made the drug more easier to obtain.
The Supreme Court appears poised to reject the challenge on procedural grounds. But that court fight and the dispute involving Idaho's abortion ban and EMTALA underscore the chaotic landscape for abortion access in the wake of Roe's reversal. Decisions from the high court in both of those cases are expected by the end of June.
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