623 F.Supp.3d 1096
D. Idaho
2022
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Background

  • EMTALA requires Medicare-participating hospitals to provide emergency screening and stabilizing treatment for "emergency medical conditions," including pregnant patients whose conditions place their health or bodily functions in serious jeopardy.
  • Idaho Code § 18-622 (effective Aug. 25, 2022) criminalizes performing or attempting to perform any "abortion," defines "pregnancy" from fertilization, and prescribes felony penalties and licensure sanctions; it includes a narrow affirmative defense only if the physician determined the abortion was "necessary to prevent the death of the pregnant woman."
  • Many pregnancy complications that present in ERs (ectopic pregnancy, severe preeclampsia/HELLP, sepsis after membrane rupture, placental abruption, thromboembolism) qualify as EMTALA emergency conditions and commonly require terminating the pregnancy as stabilizing care.
  • The United States sued to enjoin Idaho from enforcing § 18-622 to the extent it conflicts with EMTALA, arguing state law is preempted under the Supremacy Clause because it criminalizes federally required stabilizing care.
  • The district court granted a preliminary injunction: Idaho and its agents are barred from enforcing § 18-622(2)-(3) against providers who perform abortions that EMTALA requires to avoid placing a pregnant patient’s health in serious jeopardy, serious impairment to bodily functions, or serious organ dysfunction.

Issues

Issue Plaintiff's Argument Defendant's Argument Held
Whether Idaho § 18-622 conflicts with EMTALA (preemption/impossibility) EMTALA mandates stabilizing treatment (including abortion) for ER patients; Idaho criminalizes those same procedures, making dual compliance impossible Idaho contends statutes can be harmonized; life- or health-preserving care is not an "abortion" under state law or falls under statutory exemptions Court: EMTALA and § 18-622 are in direct conflict; impossibility and obstacle preemption apply; U.S. likely to succeed on the merits
Whether the statute's affirmative defense or "accidental death/injury" exemption avoids preemption The affirmative defense is an after-the-fact excuse, narrower than EMTALA (only prevents death), and does not eliminate criminal liability or chilling effects State says the defense and prosecutorial restraint mean providers can comply with both laws in practice Court: the affirmative defense does not cure the conflict; it is legally insufficient and ambiguous, and will deter EMTALA-mandated care
Whether the United States has standing and a cause of action to seek injunctive relief U.S. asserts sovereign injury from undermined federal law, harms from frustrated Medicare/EMTALA protections, and redressability via injunction State disputed framing but did not overcome sovereign-interest and redressability showing Court: U.S. has cause of action and standing to bring this Supremacy Clause challenge
Whether preliminary injunction factors favor relief (irreparable harm, balance, public interest) Allowing Idaho law to take effect would irreparably harm patients and frustrate federal purposes; public interest favors enforcing federal law State argues interest in regulating abortion post-Dobbs and in enforcing its criminal law Court: irreparable harm, merged public-interest/balance factors, and equities favor injunction; narrow injunction granted

Key Cases Cited

  • Shaw v. Delta Air Lines, 463 U.S. 85 (U.S. 1983) (recognizing injunctive relief for claims that state regulation is preempted by federal law)
  • Armstrong v. Exceptional Child Ctr., Inc., 575 U.S. 320 (U.S. 2015) (federal law can preclude state regulation and courts may enjoin preempted statutes)
  • Winter v. NRDC, 555 U.S. 7 (U.S. 2008) (standard for preliminary injunction factors)
  • Crosby v. Nat'l Foreign Trade Council, 530 U.S. 363 (U.S. 2000) (impossibility and obstacle preemption principles)
  • Oneok, Inc. v. Learjet, Inc., 575 U.S. 373 (U.S. 2015) (preemption under Supremacy Clause)
  • Draper v. Chiapuzio, 9 F.3d 1391 (9th Cir. 1993) (EMTALA "direct conflict" preemption framing)
  • Arrington v. Wong, 237 F.3d 1066 (9th Cir. 2001) (EMTALA's purpose to secure emergency treatment regardless of ability to pay)
  • Ayotte v. Planned Parenthood of N. New England, 546 U.S. 320 (U.S. 2006) (equitable principle to narrowly tailor injunctive relief in as-applied challenges)
  • United States v. Arizona, 641 F.3d 339 (9th Cir. 2011) (government's sovereign interest and supremacy concerns in federal-state conflicts)
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