Moyle v. United States; Idaho v. United States

Consequences:

Statue:

Notable Items:

Michael Dorf's blog post on the DIG and the Spending Clause.

Upcoming case from the Fifth Circuit Texas v. Becarra...quite similar.

Regarding the nexus of the Supremacy Clause and the Spending Clause (pages 45f of Brief for the Respondent):

• Biden v. Missouri , 595 U.S. 87, 94 (2022) (per curiam): “[H]ealthcare facilities that wish to participate in Medicare and Medicaid have always been obligated to satisfy a host of conditions that address the safe and effective provision of healthcare.”
• Coventry Health Care of Mo., Inc. v. Nevils, 581 U.S. 87, 95-99 (2017)
• Bennett v. Arkansas, 485 U.S. 395, 396 (1988) (per curiam)
• Lawrence County v. Lead-Deadwood Sch. Dist. No. 40-1, 469 U.S. 256, 257-258 (1985)
• Philpott v. Essex County Welfare Bd. , 409 U.S. 413, 417 (1973)
• Townsend v. Swank , 404 U.S. 282, 285 (1971)

Alito, in dissent, contends that the definition of an “emergency medical condition”, which includes the condition of an unborn child, overrides the explicit limitations ("in the case of a woman in labor" and "a pregnant woman who is having contractions") on treating/stabilizing an unborn child.

2023-12-04: Vox article
2024-04-09: Vox article.

Issue(s) Before the Court:

Petitioner's Claim(s):

Respondent's Claim(s):

Holding(s) and Disposition:

Material Facts:

• In 1986, Congress passed the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to provide stabilizing treatment when patients present with emergency medical conditions.
• After this Court’s decision in Dobbs v. Jackson Women's Health Organization (2022) , Idaho and other States enacted new laws restricting the performance of abortions.
• Soon before the Act was set to take effect, the United States sued Idaho, seeking to enjoin Idaho’s law “to the extent it conflicts with EMTALA.”
• A full recounting of the facts is available below

Procedural History:

• Per Barrett:
• The [district] court based its conclusion on three key assumptions:
  • (1) The Act prohibits the termination of ectopic pregnancies;
  • (2) the pregnant woman’s death must be objectively “imminent” or “certain” before a physician can perform an abortion; and
  • (3) the “necessary to prevent death” exception is only an affirmative defense.
• The Government's witnesses ... claimed that the [Idaho] Act might prohibit abortions as treatment for conditions includ- ing severe heart failure, pre-eclampsia, preterm premature rupture of the membranes (PPROM), sepsis, and placental abruption, because a physician could not know, “with certainty,” that an abortion is necessary to save the mother’s life in those circumstances.
• They also assumed that the Act only permitted abortions where death was “imminent.”
• After the District Court ruled, the Idaho Supreme Court construed the Act. That court explained that the Act “does not require objective certainty, or a particular level of immediacy, before the abortion can be ‘necessary’ to save the woman’s life.” Planned Parenthood Great Nw. v. State, 171 Idaho 374, 445, 522 P. 3d 1132, 1203 (2023).
• And “treating an ectopic pregnancy, by removing the fetus,” the court concluded, does not count as an “ ‘abortion’ ” under the Act.
• The Idaho Legislature later amended the definition of “abortion” to exclude “[t]he removal of a dead unborn child” and “[t]he removal of an ectopic or molar pregnancy.” It also changed the “life of the mother” affirmative defense into an exception from the prohibition on criminal abortions.
• The Ninth Circuit initially stayed the District Court’s injunction, 83 F. 4th 1130 (2023), but the en banc court vacated the panel’s stay, declined to stay the injunction, and scheduled oral argument on the merits.
• We granted Idaho’s and the Legislature’s applications to stay the District Court’s injunction pending appeal, treated the applications as petitions for a writ of certiorari before judgment, and granted the petitions.

Rationale

Majority Opinion (xxx)

• EMTALA requires hospitals to provide abortions that Idaho’s law prohibits. When that is so, Idaho’s law is preempted.
• The Court’s ruling today follows from those premises.
• Idaho has never suggested that its law would allow an abortion in those circumstances [PPROM, pre-clampsia]. (stating that although the threat of death need not be “imminen[t],” only that threat can justify an abortion);
• ... that understanding of EMTALA is not “likely to succeed on the merits,” and so cannot support a stay of the injunction.
• A full description of the rationale is available below

Barrett Concurrance (Roberts, Kavanaugh)

• We granted certiorari before judgment in these cases to decide whether the Emergency Medical Treatment and Labor Act (EMTALA) preempts a provision of Idaho law that prohibits abortions except when necessary to save the life of the mother.
• Because the shape of these cases has substantially shifted [see Barrett Concurrence Part II for shifts] since we granted certiorari, I concur in the Court’s judgment dismissing the writ as improvidently granted.
• I See Procedural History
• II
• [stay of injunction and certiorari before judgement] were premised on the belief that Idaho would suffer irreparable harm under the injunction and that these cases were ready for the Court’s immediate determination.
• I am now convinced that these cases are no longer appropriate for early resolution.
• The parties dispute whether EMTALA requires hospitals to provide abortions—or any other treatment forbidden by state law—as necessary stabilizing care. They also disagree about whether EMTALA, as a statute enacted under Congress’s spending power and that operates on private parties, can preempt state law (an issue aired for the first time in this Court).
• As Idaho understood it, the Government’s theory would allow physicians to perform abortions whenever necessary to avoid “ ‘serious jeopardy’ ” to the mother’s mental health.
• Idaho projected that emergency rooms would function as “federal abortion enclaves governed not by state law, but by physician judgment, as enforced by the United States’s mandate to perform abortions on demand.”
• At the merits stage, however, the United States disclaimed these interpretations of EMTALA. First, it emphatically disavowed the notion that an abortion is ever required as stabilizing treatment for mental health conditions.
• Second, the United States clarified that federal conscience protections, for both hospitals and individual physicians, apply in the EMTALA context.
• Narrowing happened from the other direction too. The United States identified PPROM, placental abruption, preeclampsia, and eclampsia as conditions for which EMTALA requires an emergency abortion to be available. (The same conditions that the Government’s witnesses identified—before Idaho’s law changed.)
• But in this Court, petitioners represent that the Act permits physicians to treat each of these conditions with emergency abortions, even if the threat to the woman’s life is not imminent. [emphasis added] [not clear from oral argument...Idaho hedged and was called out on it by Barrett.] [Compare opinion of the court]
• A grant of certiorari before judgment presumes that further proceedings below are unnecessary to the Court’s resolution of the question presented. That was a miscalculation in these cases, because the parties’ positions are still evolving. [emphasis added]
• On top of that, petitioners have raised a difficult and consequential argument, which they did not discuss in their stay applications, about whether Congress, in reliance on the Spending Clause, can obligate recipients of federal funds to violate state criminal law.
• For these reasons, a “deviation from normal appellate practice” in these cases has proved to be unwise.
• Having dismissed the writ, I also agree that we should vacate the stay.
• Contrary to Idaho’s concerns at the stay stage, the Government’s interpretation of EMTALA does not purport to transform emergency rooms into “federal abortion enclaves governed not by state law, but by physician judgment, as enforced by the United States’s mandate to perform abortions on demand.”
• Thus, even with the preliminary injunction in place, Idaho’s ability to enforce its law remains almost entirely intact.

Jackson concurrance in part, dissent in part

• To the extent that Idaho law conflicts with EMTALA, the State’s law must give way. I join in Kagan’s statutory analysis, and I concur in the Court’s per curiam decision to lift its stay, which should not have been entered in the first place.
• I dissent in part because, in my view, the Court is wrong to dismiss these cases as improvidently granted.
• I
• The reasons that justified our grant of certiorari in these cases still hold true today.
• The importance of recognizing Congress’s judgments in EMTALA remains as imperative as ever.
• The United States is still hamstrung in its ability to enforce federal law while States pass laws that effectively nullify EMTALA’s requirements.
• If anything, the need for a clear answer to the Supremacy Clause question has only increased in the intervening months. Just three days before we granted this petition, the Fifth Circuit decided a similar case, affirming a permanent injunction that prevents the United States from enforcing EMTALA’s requirements with respect to stabilizing emergency abortions prohibited by Texas law. See Texas v. Becerra, 89 F. 4th 529, 533 (2024).
• And both Idaho and the United States still agree that Idaho law directly criminalizes emergency care that the Federal Government reads EMTALA to require.
• Idaho’s lawyers may have changed their tune about the exact types of medical care that fall in the gap between state and federal law, but the fundamentals of this dispute remain the same.
• II
• Put simply, 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.
• But, under Idaho law, a doctor cannot provide this care (required by federal law) without committing a criminal act.
• Having now been sued over its interference with EMTALA’s protections for people experiencing these conditions [pre-clampsia, PPROM, sepsis, and placental abruption, to name just a few examples], Idaho has shifted its position, ....
• But it is both legally and factually implausible to say that Idaho’s current litigating position actually mitigates the conflict between that State’s law and EMTALA.
• ... the Idaho Supreme Court has emphasized that, to avoid criminal liability, a doctor must subjectively believe that an abortion is necessary to prevent death.
• Still, some of my colleagues latch onto the bald representations of Idaho’s counsel, using them as an escape hatch that justifies our dispensing with having to issue a merits ruling in these cases.
• Idaho law prohibits what federal law requires, so to that extent, under the Supremacy Clause, Idaho’s law is pre-empted. See Mutual Pharmaceutical Co. v. Bartlett, 570 U. S. 472, 479–480 (2013
• There is simply no good reason not to resolve this conflict now.
• * * *
• Despite the clarity of the legal issue and the dire need for an answer from this Court, today six [judges] refuse to recognize the rights that EMTALA protects.
• Three Justices suggest, at least in this context, that States have free rein to nullify federal law.
• And three more decline to disagree with those dissenters on the merits.
• While this Court dawdles and the country waits, pregnant people experiencing emergency medical conditions remain in a precarious position, as their doctors are kept in the dark about what the law requires.

Alito dissent (Thomas, Gorsuch)

• And if the patient is a pregnant woman, the hospital must stabilize both “the woman” and “her unborn child.” §1395dd(e)(1)(A)(i). [Definition of “emergency medical condition” defining "what", not "who", "when" or "how". Not stabilization sections §1395dd(b) and §1395dd(c)]
• ..., Government lawyers hit upon the novel argument that, under EMTALA, all Medicare-funded hospitals—that is, the vast majority of hospitals—must perform abortions on request when the “health” of a pregnant woman is in serious jeopardy.
• Far from requiring hospitals to perform abortions, EMTALA’s text unambiguously demands that Medicare-funded hospitals protect the health of both a pregnant woman and her “unborn child.” §1395dd(e)(1)(A)(i). [Definition of "what" (“emergency medical condition”) determines when stabilization treatment must be provided and to whom as detailed in sections §1395dd(b) and §1395dd(c)]
• ... we would be obligated to resolve that ambiguity in favor of the State because EMTALA was enacted under the Spending Clause, and as we have held time and again, conditions attached to the receipt of federal funds must be unambiguous. Arlington Central School Dist. Bd. of Ed. v. Murphy, 548 U. S. 291, 296 (2006); Pennhurst State School and Hospital v. Halderman, 451 U. S. 1, 17 (1981).
• And in any event, Idaho never consented to any conditions imposed by EMTALA and certainly did not surrender control of the practice of medicine and the regulation of abortions within its territory.
• Nothing legally relevant has occurred since January 5. [Compare Barrett concurrence: "... the shape of these cases has substantially shifted ...."] [Briefs and oral arguments are not "legally relevant"]
• And the underlying issue in this case—whether EMTALA requires hospitals to perform abortions in some circumstances—is a straightforward question of statutory interpretation. ... Everything there is to say about the statutory interpretation question has probably been said many times over.
• Apparently, the Court has simply lost the will to decide the easy but emotional and highly politicized question that the case presents.
• I A Text of the Statute
• EMTALA requires the hospital at every stage to protect an “unborn child” from harm. [Safety of unborn child mentioned in §1395dd(e)(1)(B)(ii) only "(B) with respect to a pregnant woman who is having contractions—(ii)that transfer may pose a threat to the health or safety of the woman or the unborn child."]
• [quote §1395dd(e)(1)(A)(i) repeatly, adding emphasis, which defines “emergency medical condition”, not the treatment required or who is to be treated. Treatment of unborn child conditioned on "in the case of labor, to the unborn child" §1395dd(c)(1)(A)(ii) and "in the case of a woman in labor, the health of the unborn child" §1395dd(c)(2)(A)]
• I B Legislative History
• Congress designed EMTALA to solve a particular problem—preventing private hospitals from turning away patients who are unable to pay for medical care.
• ... the Congress that initially enacted EMTALA in 1986 and the one that amended it in 1989 also passed appropriations riders under what is now known as the Hyde Amendment (named after Representative Hyde) to prevent federal funds from facilitating abortions, except in limited circumstances. See Harris v. McRae, 448 U. S. 297, 302 (1980). Between 1981 and 1993 ... the Hyde Amendment contained only one exception: for abortions necessary to save the life of the pregnant woman. [additional exceptions from enactment in 1977 till 1981 and additional exceptions since 1993. See Congressional Research Service In Focus document (three pages).]
• The Hyde Amendment thus prohibited federal funds from paying for the health-related abortions that the Government says EMTALA mandates.
• I C
• Desperate to find some crumb of support for its interpretation, the Government scrapes together a handful of sources that it says evidence a general understanding that EMTALA requires hospitals to perform health-related abortions prohibited by Idaho law.
• II Spending Clause Considerations
• But there is a third strike against the Government’s position: EMTALA is an exercise of Congress’s spending power. And when Congress relies on its authority to attach conditions to the receipt of federal funds, special rules apply.
• Because the enforcement of conditions attached to the receipt of federal money depends on a recipient’s knowing and voluntary consent, “the conditions must be set out ‘unambiguously.’ ” Arlington Central, 548 U. S., at 296 (quoting Pennhurst, 451 U. S., at 17).
• And recipients must be given a “legitimate choice whether to accept the federal conditions.” National Federation of Independent Business v. Sebelius, 567 U. S. 519, 578 (2012)
• First, consider the requirement that EMTALA speak unambiguously. Even if it were possible to read EMTALA as requiring abortions prohibited by Idaho law, it is beyond dispute that such a requirement is not unambiguously clear. The statute does not mention abortion, let alone expressly bind hospitals to perform abortions contrary to state law. [does not mention defibrillation. must the statute enumerate all medical procedures lest a state enact a law prohibiting a procedure?] [emphasis added]
• Second, consider the requirement that parties be given a choice before being bound by Spending Clause conditions. [emphasis added]
• The Idaho Legislature takes its argument against preemption even further. It contends that EMTALA cannot preempt the State’s abortion regulations because Idaho is not a party to the agreement between the Federal Government and the hospitals that take Medicare funds. [analogize Jim Crow laws, 14th Amendment, universities that accept federal funding.]
• [list of speculations/horrors should one disagree with Alito's understanding of preemption and acceptance of federal funding]
• The Government has not identified any decision holding that a federal law enacted under the Spending Clause preempts a state criminal law or public health regulation.
• * * *
• In sum, the Government’s new interpretation of EMTALA is refuted by the statutory text, the context in which the law was enacted, and the rules of interpretation that we apply to Spending Clause legislation.
• III Irreparable Harm
• Even if the Court is unwilling to decide the statutory interpretation question, there is no excuse for vacating the stay of the preliminary injunction.
• Why then have six Justices voted to vacate the stay? The per curiam itself provides no explanation. [concurrence in judgement, if not in reasoning]
• In separate opinions, three of the six agree with the Government’s interpre- tation of EMTALA ....
• As for the remaining three, their only explanation is that “the injunction will not stop Idaho from enforcing its law in the vast majority of circumstances” and that therefore Idaho cannot show that it will be irreparably harmed by allowing the injunction to remain in place during the pendency of the appeal.
• As I will explain, it is very likely that the preliminary injunction will lead to more abortions, including in at least some cases where the fetus is viable. Isn’t that enough to constitute irreparable harm?
• III A Conflict between Idaho and Federal Law
• I begin with the Government’s argument that “there are numerous conditions” that may afflict a pregnant woman “where a doctor’s immediate concern is not death.” In the Government’s telling, EMTALA requires hospitals to perform an abortion on demand in these circumstances. [“emergency medical condition”]
• Idaho law says otherwise. An Idaho doctor may not perform an abortion unless the doctor “determine[s], in his good faith medical judgment ... , that the abortion [is] necessary to prevent the death of the pregnant woman.” [emphasis added.] [death vs EMTALA's (i) health ... in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part ....
• Even so, Idaho’s law is focused on “death,” and a doctor must be able to say in “good faith” that he or she was acting to preserve the woman’s life, not simply her health. I
• These different considerations—health versus life—may lead to different outcomes.
• The Members of this Court are not physicians and should therefore be wary about expressing conclusions about medical issues. [proceeds to spend three pages on PPROM.]
• By requiring Idaho hospitals [that choose to accept federal funding] to strike a different balance, the preliminary injunction thwarts the will of the people of Idaho as expressed in law by their elected representatives.
• III B Mental Health
• I now turn to Idaho’s claim that the Government’s reading of EMTALA would authorize abortions for mental-health reasons.
• ... prominent medical associations that endorse abortion for mental-health reasons as an accepted standard of practice. See, e.g., American Psychiatric Association ....
• For these reasons, there is a real potential for conflict between the Idaho law and the Government’s interpretation of EMTALA, and in my judgment, the Court seriously errs by vacating the stay we issued earlier this year.
• * * *

Full Recounting of Facts

• In 1986, Congress passed the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to provide stabilizing treatment when patients present with emergency medical conditions.
• After this Court’s decision in Dobbs v. Jackson Women's Health Organization (2022) , Idaho and other States enacted new laws restricting the performance of abortions.
• Soon before the Act was set to take effect, the United States sued Idaho, seeking to enjoin Idaho’s law “to the extent it conflicts with EMTALA.”
• After holding an evidentiary hearing, the District Court identified a conflict and granted a preliminary injunction. 623 F. Supp. 3d 1096 (Idaho 2022).
• After the District Court ruled, the Idaho Supreme Court construed the Act. That court explained that the Act “does not require objective certainty, or a particular level of immediacy, before the abortion can be ‘necessary’ to save the woman’s life.” Planned Parenthood Great Nw. v. State, 171 Idaho 374, 445, 522 P. 3d 1132, 1203 (2023)
• Without holding a new evidentiary hearing, the District Court denied Idaho’s motion for reconsideration.
• The Idaho Legislature later amended the definition of “abortion” to exclude “[t]he removal of a dead unborn child” and “[t]he removal of an ectopic or molar pregnancy.” §18–604(1)(b), (c).
• It also changed the “life of the mother” affirmative defense into an exception from the prohibition on criminal abortions. §18– 622(2).
• The Ninth Circuit initially stayed the District Court’s injunction, 83 F. 4th 1130 (2023), but the en banc court vacated the panel’s stay, declined to stay the injunction, and scheduled oral argument on the merits, 82 F. 4th 1296 (2023).
• We granted Idaho’s and the Legislature’s applications to stay the District Court’s injunction pending appeal, treated the applications as petitions for a writ of certiorari before judgment, and granted the petitions.
• A list of the material facts is available above

Majority Full Argument

• See Material Facts
• See Procedural History
• I
• EMTALA requires hospitals to provide abortions that Idaho’s law prohibits. When that is so, Idaho’s law is preempted.
• The Court’s ruling today follows from those premises.
• ... the gap between them [EMTALA and Idaho law] are cases in which continuing a pregnancy does not put a woman’s life in danger, but still places her at risk of grave health consequences, including loss of fertility. In that situation, federal law requires a hospital to offer an abortion, whereas Idaho law prohibits that emergency care.
• Idaho has never suggested that its law would allow an abortion in those circumstances [PPROM, pre-clampsia]. (stating that although the threat of death need not be “imminen[t],” only that threat can justify an abortion);
• ... Idaho have had to airlift medically fragile women to other States to receive abortions needed to prevent serious harms to their health. Those transfers measure the difference between the life-threatening conditions Idaho will allow hospitals to treat and the health-threatening conditions it will not, despite EMTALA’s command. [emphasis added] [Compare Barrett concurrence.]
• ... that understanding of EMTALA is not “likely to succeed on the merits,” and so cannot support a stay of the injunction.
• II
• Alito ’s dissenting opinion requires a brief response.
• His primary argument is that although EMTALA generally obligates hospitals to provide emergency medical care, it never demands that they offer an abortion—no matter how much that procedure is needed to prevent grave physical harm, or even death.
• That view has no basis in the statute.
• What it [ EMTALA ] instead requires is the treatment that is medically appropriate to stabilize the patient.
• And from that fact, a statutory obligation arises. It does not matter that EMTALA “does not mention abortion.” Neither, as just noted, does EMTALA mention any other treatment.
• Neither, as just noted, does EMTALA mention any other treatment.
• ... [ EMTALA ] specifies [fourth item of four] that a hospital must treat a condition that “plac[es] the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.” §1395dd(e)(1)(A)(i).
• The parenthetical there, added in an amendment to EMTALA, ensures that a woman with no health risks of her own can demand emergency-room treatment if her fetus is in peril.
• The core of the rationale is available above