Moyle v. United States

Issues

Does the federal government have authority under the Emergency Medical Treatment and Labor Act, which requires hospitals to provide stabilizing care to patients, to preempt Idaho’s Defense of Life Act by requiring Idaho to perform abortions under certain circumstances?

Oral argument:

April 24, 2024

Court below:

United States Court of Appeals for the Ninth Circuit

This case asks the Supreme Court to interpret whether the Emergency Medical Treatment and Labor Act (“EMTALA”), which requires hospitals to provide stabilizing care to patients, can preempt state abortion regulations. Idaho’s Defense of Life Act prohibits hospitals from performing abortion unless it is necessary to protect the pregnant mother from death. EMTALA states that it preempts any state law which directly conflicts with its requirements, which includes providing stabilizing care to patients. Idaho and its House speaker Mike Moyle argue that EMTALA cannot preempt Idaho state law because preemption would violate state sovereignty where there is no conflict between the two laws. The United States counters that EMTALA imposes a broader standard than Idaho law, and the executive and legislature can preempt state law under EMTALA via the Supremacy Clause. The outcome of this case has important implications for abortion rights, separation of powers, and sovereignty of states.

Questions as Framed for the Court by the Parties

Whether the Supreme Court should stay the order by the U.S. District Court for the District of Idaho enjoining the enforcement of Idaho’s Defense of Life Act, which prohibits abortions unless necessary to save the life of the mother, on the ground that the Emergency Medical Treatment and Labor Act preempts it.

Facts

Idaho’s 2022 Defense of Life Act, enacted in the wake of Dobbs v. Jackson Women’s Health Organization, criminalizes the performance of abortions. ID ST § 18-622. In addition to exceptions for rape, incest, and to save the life of the fetus, the original statute provided an affirmative defense for doctors when, after a “good faith medical judgment…based on the facts known to the physician at the time, [the doctor decided] that the abortion was necessary to prevent the death of the pregnant woman.” Id. The statute was later amended to make this defense an explicit exception. Brief for Petitioner, Mike Moyle at 8-9.

Congress enacted the Emergency Medical Treatment and Labor Act (“EMTALA”) in 1986 to ensure that, in medical emergencies, patients in federally funded hospitals would receive “stabilizing care…necessary to assure, within reasonable medical probability…no material deterioration of [their] condition. United States v. Idaho at 1102. Specifically, the statute notes three “stages” of care, where a patient is (1) screened to determine if an “emergency condition” exists, (2) provided with “stabilizing” care “within the staff and facilities available at the hospital,” or (3) transferred to another facility without deterioration of their condition. 42 U.S.C. § 1395dd(e). The statute defines an “emergency condition” to include when the absence of medical treatment “could reasonably be expected” to (1) place “the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,” (2) cause “serious impairment to bodily functions,” or (3) cause “serious dysfunction” of an organ or body part. Id.

The United States sued in the United States District Court for the District of Idaho to prevent enforcement of Idaho’s statute, arguing it unlawfully preempted EMTALA and citing the Supremacy Clause, which states federal law is the “supreme law of the land.” United States v. Idaho, at Id. at 1108. The United States also asked the court for a preliminary injunction to bar enforcement of the law while the case was being decided. Id. at 1105, 1117. The court reasoned through the four permanent injunction factors: the likelihood of success on the merits, likelihood of irreparable harm without the injunction, balance of equities between parties and public interest. Id. at 1105-6.

Analyzing whether the United States was likely to succeed on the merits, the court turned to two different doctrines: (1) impossibility preemption, where one cannot fulfill the obligations of both the state and federal law, and (2) obstacle preemption, where one can fulfill both obligations, but state law serves as an obstacle to Congress’s purpose. The court also reasoned that the Supremacy Clause triggered a presumption of irreparable harm, and that the statute’s potential medical consequences tipped the balance of equities towards the federal government and better served the public interest. Id. at 1115-16. The government cited testimony from doctors arguing that the penalties the law imposes would prevent them from providing needed medical care. Id. at 1116. The trial court identified several pregnancy complications that, in its opinion, could result in an “emergency condition” requiring an abortion. Id. at 1104-05.

Based on these factors, the district court granted a stay partially blocking the enforcement of Idaho’s statute, and the Ninth Circuit affirmed. United States v. Idaho at 1. Both Idaho and Idaho House Speaker Mike Moyle, who had been granted permission to intervene in the case on behalf of the Idaho State Legislature, sought the Supreme Court’s review. Brief for Petitioner, Mike Moyle, at 12, 18. The Court granted certiorari. Id. at 18.

Analysis

STATUTORY CONSTRUCTION OF EMTALA

Moyle argues that the Emergency Medical Treatment and Labor Act (“EMTALA”) does not provide a specific method to stabilize patients under its requirement for hospitals to stabilize patients if the patient is subject to an emergency condition. Brief for Petitioner, Mike Moyle at 24-25. Therefore, Moyle argues that EMTALA does not impose a national health care standard that requires doctors to perform specific treatments or sets a required standard of care. Id. at 27. Moyle argues because there is no such “abortion care” requirement in the text of the statute, Congress did not clearly intend to preempt Idaho abortion regulations. Id. at 25. Moyle argues that, unlike EMTALA, Congress has explicitly mentioned abortion in other federal laws when it expressly intended to regulate abortion. Id. at 31. Moyle also contends that Congress has generally forbade using federal funds to pay for abortions unless such abortions were life-threatening. Id. at 33-34. Moyle contends that Idaho only allows life-threatening abortions, thus there is no Congressional intent to supersede Idaho’s Defense of Life Act. See Id. at 34.

Moyle further notes that the stabilization requirement explicitly includes a duty to stabilize the unborn child as well as the mother. Id. at 26. Moyle argues that EMTALA’s language treating directly conflicting state law as an exception means that EMTALA will not generally preempt state law. Id. at 22. Moyle further maintains the requirement of a “direct” conflict carves a narrower exception than other broad preemptions. Id. at 22-23. Moyle maintains that the purpose of EMTALA is to ensure that hospitals protect uninsured patients, not to provide a baseline treatment for each condition. Id. at 22.

The United States counters that EMTALA requires hospitals to provide treatment that ensures the patient’s condition will not materially deteriorate. Brief for Respondent, United States at 12-13. The United States argues that EMTALA’s requirement of stabilizing treatment creates a federal standard to give necessary and reasonable treatment beyond treating patients equally. Id. at 28. The United States further argues that EMTALA’s requirement of stabilization includes terminating pregnancy because in certain cases terminating pregnancy is the only treatment that could save a mother’s life or prevent a substantial deterioration in health. Id. at 13. The United States contends that other laws show that Congress intends to exclude certain treatments it does through separate specific rules. Id at 40. Because Congress did not exclude abortion in EMTALA, the United States argues that abortion is included in EMTALA’s general requirement of providing stabilizing treatment. Id.

The United States contends that EMTALA’s duties are for the individual patient who seeks care, who in the case of pregnancy termination, is the pregnant woman and not the unborn child. Id. at 41. The United States argues that a direct conflict plainly means when state law and EMTALA conflict. See Id. at 20. The United States further maintains that EMTALA is not limited to equal treatment, as Congress could not have meant to allow hospitals to administer deteriorating treatment if offered to everyone. Id. at 28. The United States therefore argues EMTALA imposes a baseline duty to ensure that every patient who has an emergency receives stabilizing care, not to merely end dumping uninsured patients. Id. at 29-30.

WHETHER IDAHO LAW AND EMTALA DIRECTLY CONFLICT

Moyle argues that even if EMTALA requires a health care standard or specific treatments, there is no direct conflict between EMTALA and Idaho state law. Brief for Petitioner at 21. Moyle argues that Idaho’s Defense of Life Act, like EMTALA, allows abortion to prevent death while providing the best opportunity for the child to survive. Id. at 28. Moyle argues that the United States failed to present any condition where EMTALA would require abortion, but Idaho state law prohibits it. Id. at 29-30. The State of Idaho likewise argues that all life-threatening circumstances that the government cited were necessary to prevent the pregnant mother’s death, allowed under Idaho law. Brief for Petitioner, State of Idaho at 31. Moyle contends that the United States’ argument that Idaho’s law does not provide abortion to save the mother from material health crises is an “implicit conflict,” not a “direct conflict,” because EMTALA does not explicitly define abortion requirements. See Brief for Petitioner, Mike Moyle at 28-29.

The State of Idaho argues that EMTALA only offers “available” treatments. Brief for Petitioner, State of Idaho at 24. Idaho maintains that abortions prohibited under Idaho law are not “available” in Idaho and therefore not a subject of conflict. Id. Idaho contends that EMTALA does not authorize the use of experimental medication prohibited in the state even if it could reasonably treat the patient, as EMTALA treats such medication as unavailable. Id. at 25-26. Idaho argues that EMTALA allows state standards to differ and does not force hospitals to provide treatments that exceed their capability under state regulations. Id. at 28-29. Consequently, Idaho argues that EMTALA’s purpose is to ensure that hospitals give the same stabilization treatment to patients that others receive in the state within the hospital’s capabilities, not to ensure a federal right to receive uniform abortion treatment. Id. at 31-32.

The United States argues that Idaho law directly conflicts with EMTALA because complying with both is impossible, and complying with Idaho law acts as an obstacle to complying with EMTALA. Brief for Respondent at 20. First, the United States points out that Idaho law requires an objective finding that terminating a pregnancy is “necessary” rather than EMTALA’s subjective judgment that the danger is reasonably likely. Id. at 22. Second, the United States asserts that EMTALA covers a broader range because it requires stabilizing treatment when there is a risk of serious harm to one’s health, not only when there might be a risk of death. Id. The United States maintains that many medical conditions are not life-threatening initially but may progress to be so. Id. at 23-24. The United States notes that Idaho’s change in its recent Defense of Life Act acknowledges these differences, as previous Idaho law allowed abortion when there was a risk of serious harm. See Id. at 22. The United States contends that the new law ignores EMTALA’s fundamental emphasis on adequate treatment when the patient’s health is threatened, not only when there is a risk of mortality. See Id. at 23-24.

The United States argues that “availability” means medical resources such as facilities and equipment. Id. at 36. The United States contends that when Congress meant to incorporate state laws, it has expressly referenced them. Id. The United States argues that EMTALA’s preemption clause grants authority to overrule state law. Id. at 36-37. The United States further asserts that EMTALA preempts state law that “directly” conflicts with it, and therefore the only laws that EMTALA does not preempt function state laws stricter than EMTALA. Id. The United States cites that federal case law has consistently interpreted EMTALA overrules state law if state law does not provide necessary stabilizing care. Id. at 38. The United States further contends that EMTALA’s core purpose is to avoid material health risks, not wait until the pregnant mother’s condition deteriorates. Id. at 24.

AUTHORITY TO SUBORDINATE STATE LAW

Moyle argues that if EMTALA entailed abortion requirements, it would entail enormous political and economic significance. Brief for Petitioner at 39-41. Therefore, Moyle contends that the United States failed to show authorization to override state law under the major questions doctrine, which requires the government to clearly show that Congress delegated authority to the government in significant economic and political matters. Id. at 38-39, 41. Moyle argues that there is no such authority because case law shows that EMTALA does not require abortion care. Id. at 43. Further, Moyle points out that the government began reading a duty of abortion care in EMTALA only after Dobbs v. Jackson Women’s Health Organization. Id. at 43. Moyle argues that permitting the Government to decide this issue disrupts the separation of powers. Id. at 44-47. Moyle argues that the government’s reading would also exceed Congress’ spending power, as although the government can broadly set conditional terms for receiving federal funds, it cannot coerce states based on that condition. Id.

The United States argues that EMTALA does not entail an extraordinary significance but is simply a measure to ensure stabilizing care. Brief for Respondent at 49. The United States further argues that the government’s interpretation of EMTALA only pertains to Idaho law and does not act as a national abortion regulation. Id. at 50. The United States further argues that Congress’ spending power allows Congress to set conditions for States receiving to funding, as it could mandate a treatment that federal funds could not pay for. Id at 45. The United States also points out that the hospitals, not the states, receive the federal funds and therefore Congress is not coercing the state. Id. at 46. The United States contends that states cannot allow hospitals to participate in federal programs but forbid them from complying with conditions that Congress set. Id. at 47.

Discussion

ACCESS TO HEALTHCARE

121 Members of Congress, in support of Moyle and Idaho, assert the United States’ interpretation of EMTALA’s “anti-patient dumping” policy could be unlawfully extended to limit Idaho’s abortion restriction. Brief amici curiae of 121 Members of Congress at 4, 15. They cite the legislative record to argue the intent of EMTALA, to protect mothers and their unborn children against patient dumping, would be contravened by interpreting it to condone abortions. Id. at 11. The United States Conference of Catholic Bishops, in support of Moyle and Idaho, asserts that EMTALA’s preemption of Idaho’s statute would limit access to healthcare, given religious opposition to abortion and the Catholic Church’s status as one of the largest providers of healthcare in the nation. Brief amici curiae of United States Conference of Catholic Bishops, et al. at 14, 21. It argues the federal government’s preemption arguments create a “false conflict” between EMTALA and Idaho’s statute, driving Catholic healthcare professionals away from the field, given the Biblical prohibitions on abortion. Id. at 21. It argues this would ultimately hurt low-income patients, given acceptance of Medicaid funds is conditioned on compliance with EMTALA. Id. at 22.

The U.S. Women’s Chamber of Commerce, in support of the United States, asserts Idaho’s “total abortion ban” would hinder access to healthcare and lead to “maternity deserts” where no obstetric care is available. Brief amici curiae of U.S. Women's Chamber of Commerce, et al. at 8. Citing data indicating an exodus of obstetricians from Idaho following the statute’s enactment and testimony from former Idaho obstetricians, they assert that the chilling effect Idaho’s statute has on their work only furthers this decline. Id. at 9,11. Disability Rights Advocates and Scholars, in support of the United States, argue that these chilling effects of Idaho’s statute would hinder disabled people’s access to medical care, compounding their existing marginalization issues and contravening EMTALA’s intent to protect at-risk patients. Brief amici curiae of Disability Rights Advocates and Scholars at 12-15.

STATE REGULATION OF DOCTORS

The State of Indiana joined by 21 other states, in support of Moyle and Idaho, asserts that the United States’ construction would invert the medical profession’s traditional regulatory structure, allowing EMTALA to serve as an “excuse” for state-prohibited professional conduct outside the abortion context. Brief amici curiae of States of Indiana and 21 other states at 6. They argue this would improperly impart a “national standard of care” onto state-regulated hospitals, removing the state's traditional role in regulating the conduct of doctors. Id. at 9. Additionally, they assert that applying the Supremacy Clause to EMTALA, a law founded in the Constitution’s Spending Clause, would improperly expand the scope of the Supremacy Clause to include grant requirements. Id. at 14. The Center for Constitutional Jurisprudence, in support of Moyle and Idaho, argues that this would lead to private entities which accept federal funding “waiving” state sovereignty through the application of EMTALA’s provisions, contrary to existing jurisprudence. Brief amicus curiae of Center for Constitutional Jurisprudence at 7-8. In addition to the constitutional conflicts, the Manhattan Institute, in support of Moyle and Idaho, asserts such a construction would cause conflict with other state statutes such as assisted suicide laws, as medically “killing” a patient arguably violates EMTALA’s stabilization provisions. Brief amicus curiae of Manhattan Institute at 9.

St. Luke’s Health System, in support of the United States, argues Idaho’s construction of EMTALA would impose conflicting obligations on doctors, where performing an abortion to stabilize a mother to comply with EMTALA would lead to criminal prosecution under Idaho’s statute. Brief amicus curiae of St. Luke’s Health System, Ltd. at 10. They assert that the alternative, where Idaho hospitals refuse Medicaid funding, would be financially ruinous for both hospitals and low-income patients. Id. Local Prosecutors, in support of the United States, assert that prosecutors are not properly equipped to review a doctor’s discretion over whether an abortion is necessary to “prevent death.” Brief amici curiae of Local Prosecutors and Law Enforcement Leaders at 14. They argue the justice system would be ill-equipped to review medical determinations, chilling a doctor’s decision over whether to administer potentially lifesaving care. Id. at 17. Pregnancy Justice, in support of the United States, asserts this construction would gut EMTALA by exempting abortion from necessary lifesaving care. Brief amici curiae of Pregnancy Justice, New York University School of Law Reproductive Justice Clinic, and If/When/How at 9. It argues compliance with Idaho’s statute could lead to the deterioration of a pregnant women’s health, contrary to EMTALA’s aims. Id.