MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF REPRESENTATIVES, ET AL. v. UNITED STATES; IDAHO v. UNITED STATES
Nos. 23-726 and 23-727
SUPREME COURT OF THE UNITED STATES
June 27, 2024
603 U. S. ____ (2024)
ON WRITS OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
Per Curiam
NOTICE: This opinion is subject to formal revision before publication in the United States Reports. Readers are requested to notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, pio@supremecourt.gov, of any typographical or other formal errors.
The writs of certiorari before judgment are dismissed as improvidently granted, and the stays entered by the Court on January 5, 2024, are vacated.
It is so ordered.
KAGAN, J., concurring
JUSTICE KAGAN, with whom JUSTICE SOTOMAYOR joins, and with whom JUSTICE JACKSON joins as to Part II, concurring.
An Idaho law prohibits abortions unless necessary to prevent a pregnant woman‘s death; the law makes no exception for abortions necessary to prevent grave harms to the woman‘s health, like the loss of her fertility. Before the law could take effect, the Federal Government sued the State under the Emergency Medical Treatment and Labor Act (EMTALA). That law requires a Medicare-funded hospital to provide essential care to patients experiencing medical emergencies. The Government‘s suit contended that EMTALA preempts the Idaho abortion law in a narrow class of cases: when the state law bars a hospital from performing an abortion needed to prevent serious health harms.
The District Court, believing the Government was likely to prevail in its suit, entered a preliminary injunction. During the year that the injunction was in place, women in Idaho were able to obtain abortions in medical emergencies. Idaho meanwhile sought to get the injunction lifted. When the en banc Court of Appeals for the Ninth Circuit declined to stay the injunction, Idaho filed an emergency аpplication here. This Court stayed the injunction and granted the State‘s petition for certiorari before judgment. With that stay in effect, Idaho could enforce its abortion ban even when terminating a pregnancy was necessary to prevent grave harm to the woman. The on-the-ground impact was immediate.
I concur in the Court‘s decision today to vacate its stay and dismiss the writ of certiorari before judgment as improvidently granted. I do so because Idaho‘s arguments about EMTALA do not justify, and have never justified, either emergency relief or our early consideration of this dispute. With this Court‘s writ of certiorari dismissed, the lower courts can proceed with this litigation in the regular course. And with this Court‘s stay dissolved, the District Court‘s preliminary injunction will again take effect. That will prevent Idaho from enforcing its abortion ban when the termination of a pregnancy is needed to prevent serious harms to a woman‘s health.
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.
Federal law and Idaho law are in conflict about the treatment of pregnant women facing health emergencies. EMTALA requires a Medicare-funded hospital to offer an abortion when needed to stabilize a medical condition that seriously threatens a pregnant woman‘s life or health. See
Given that conflict, I agree with the Court‘s decision today to step back from its early intervention in this dispute. In the first stage of this suit, thе District Court considered both sides’ medical evidence and entered a preliminary injunction against Idaho‘s law on the ground of preemption. See 623 F. Supp. 3d 1096, 1103–1105, 1110, 1117 (2022). After the Idaho Supreme Court construed the law, the District Court revisited its findings, and reaffirmed its entry of the injunction. See 2023 WL 3284977, *1, *5 (May 4, 2023). In line with standard practice, that decision now can go to the Court of Appeals, and the District Court can afterward consider further evidence and arguments
II
JUSTICE 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. See post, at 4-15. That view has no basis in the statute.
EMTALA unambiguously requires that a Medicare-funded hospital provide whatever medical treatment is necessary to stabilize a health emergency—and an abortion, in rare situations, is such a treatment. The statutory obligation kicks in when an individual arrivеs at a hospital with an “emergency medical condition,” which is one involving serious jeopardy to health.
The statute‘s references to protecting an “unborn child” do not lead to a different result. Contrary to JUSTICE ALITO‘s view, none alters EMTALA‘s command when a pregnancy threatens the woman‘s life or health. Three of the four provisions JUSTICE ALITO cites concern the treatment of women in labor (including all those with healthy pregnancies). Those provisions ensure that a hospital, in considering the transfer of a woman to another fаcility, takes account of risks to not only the woman but also her “unborn child.”
Because the Idaho law conflicts with that requirement—prevents hospitals from doing what EMTALA commands—the Court is right to dissolve its stay of the District Court‘s injunction. Doing so will again give Idaho women access to all the needed medical treatments that EMTALA guarantees.
BARRETT, J., concurring
JUSTICE BARRETT, with whom THE CHIEF JUSTICE and JUSTICE KAVANAUGH join, concurring.
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. 601 U. S. ____ (2024). Because the shape of these cases has substantially shifted since we granted certiorari, I concur in the Court‘s judgment dismissing the writ as improvidently grantеd.
I
In 2022, the Department of Health and Human Services issued guidance to “remind hospitals of their existing obligation to comply with EMTALA.” Centers for Medicare & Medicaid Services, Reinforcement of EMTALA Obligations Specific to Patients Who Are Pregnant or Are Experiencing Pregnancy Loss, Note, p. 1 (July 11, 2022) (rev. Aug. 25, 2022) (italics deleted). The guidance tells physicians that if they believe that “abortion is the stabilizing treatment necessary to resolve” a pregnant woman‘s emergency medical condition, they “must provide that treatment.” Id., at 1 (italics and emphasis deleted). Any contrary state law, the guidance continues, is “preempted.” Ibid. (italics and emphasis deleted).
Idaho‘s Defense of Life Act criminalizes the performance of most abortions.
After holding an evidentiary hearing, the District Court identified a conflict and granted a preliminary injunction. 623 F. Supp. 3d 1096 (Idaho 2022). The 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 tо prevent death” exception is only an affirmative defense. Id., at 1109-1114. The Government‘s witnesses, whose testimony the court credited, made similar assumptions. Id., at 1104-1105. They claimed that the Act might prohibit abortions as treatment for conditions including 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. See, e.g., 1 App. 30–38. They also assumed that the Act only permitted abortions where death was “imminent.” See, e.g., 2 id., at 608.
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. Ibid.
Without holding a new evidentiary hearing, the District Court denied Idaho‘s motion for reconsideration. 2023 WL 3284977 (May 4, 2023). 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.”
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, аnd 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. 601 U. S. ____ (2024).
II
Before the Ninth Circuit had the opportunity to review the District Court‘s preliminary injunction, this Court stayed the injunction and granted certiorari before judgment. Both decisions 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. Since then, briefing and oral argument have “shed more light on this case than in the nature of things was afforded at the time” the Court considered petitioners’ emergency applications. Belcher v. Stengel, 429 U. S. 118, 119 (1976) (per curiam) (dismissed as improvidently granted). 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). In my judgment, it would be imprudent to
In its stay apрlication, Idaho argued that the Government‘s interpretation of EMTALA would render Idaho‘s Act virtually unenforceable. 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. Stay Reply Brief in No. 23A470, p. 6. On that broad reading, 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.” Ibid. (citation omitted). Idaho also warned that the Government‘s interpretation would “threate[n] religious healthcare providers” by forcing doctors and hospitals to perform abortions regardless of conscience objections. Id., at 15. Both of these points were relevant to the Court‘s assessment of the irreparable harm that Idaho would suffer from the preliminary injunction, Nken v. Holder, 556 U. S. 418, 434 (2009), as well as the need for “immediate determination in this Court,” Supreme Court Rule 11.
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. Brief for United States 26, n. 5; Tr. of Oral Arg. 76-78. That is an important concession: If restricted to conditions posing serious jeopardy to a woman‘s physical health, the Government‘s reading of EMTALA does not gut Idaho‘s Act.* Second, the United States clarified that federal conscience protections, for both hospitals and individual physicians, apply in the EMTALA сontext. Tr. of Oral Arg. 87-89. That is another critical point: It alleviates Idaho‘s concern that the Government‘s interpretation of EMTALA would strip healthcare providers of conscience protections.
Narrowing happened from the other direction too. The United States identified PPROM, placental abruption, pre-eclampsia, 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. Reply Brief in No. 23–726, pp. 21–22; Reply Brief in No. 23–727, pp. 8–9;
Tr. of Oral Arg. 23. The same is true for the conditions identified by the Government‘s witnesses (severe heart failure and sepsis). Reply Brief in No. 23–727, pp. 8–9.
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. The United States has clarified that EMTALA‘s reach is far more modest than it appeared when we granted certiorari and a stay.
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. Brief for Petitioners in No. 23-726, pp. 48–51; Reply Brief in No. 23–727, pp. 3-4; see also Brief for Prolife Center at the University of St. Thomas as Amicus Curiae. The District Court did not address this issue below—nor did the Ninth Circuit, which we bypassed. We should not jump ahead of the lower courts, particularly on an issue of such importance. Cutter v. Wilkinson, 544 U. S. 709, 718, n. 7 (2005) (“[W]e are a court of review, not of first view“); New York v. Uplinger, 467 U. S. 246, 251 (1984) (Stevens, J., concurring) (dismissing as improvidently granted where “constitutional questions” would otherwise be considered “premature[ly]“). The lower courts should address the Spending Clause issue in the first instance.
For these reasons, a “deviation from normal appellate practice” in these cases has proved to be unwise. Supreme Court Rule 11. I therefore agree that we should dismiss the writ of certiorari as improvidently granted and permit proceedings to run their course in the courts below.
Having dismissed the writ, I also agree that we should vacate the stay. As the party seeking emergency relief from this Court, Idaho bore the burden of showing that it would be “irreparably injured” if the preliminary injunction remained in effect. Nken, 556 U. S., at 434. The Court‘s grant of a stay reflected, among other things, its determination that Idaho had satisfied that burden. Now, based on the parties’ representations, it aрpears that the injunction will not stop Idaho from enforcing its law in the vast majority of circumstances.
To be sure, the text of the two laws differs: Idaho‘s Act allows abortion only when “necessary to prevent the death of the pregnant woman,”
Opinion of JACKSON, J.
JUSTICE JACKSON, concurring in part and dissenting in part.
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. See
Recognizing the clear conflict between EMTALA and Idaho law, a Federal District Judge issued an injunction that had the effect of ensuring that Idaho physicians would be able to provide the abortion care EMTALA requires. Five months ago, this Court stayed that injunction. As a legal matter, this Court‘s stay meant that unless a doctor could actually say that the abortion was necessary to prevent a patient‘s death, that doctor could no longer provide abortion care that she viewed as reasonably necessary to keep a patient from losing her uterus, going into organ failure, or avoiding any number of other serious health risks. Compare
This months-long catastrophe was completely unnecessary. More to the point, it directly violated federal law, which in our system of government is supreme. See
I
This Court typically dismisses cases as improvidently granted based on “circumstances . . . which ‘were not . . . fully apprehended at the time certiorari was granted.‘” The Monrosa v. Carbon Black Export, Inc., 359 U. S. 180, 183 (1959) (some alterations in original). This procedural mechanism should be reserved for that end—not turned into a tool for the Court to use to avoid issues that it does not wish to decide.
The reasons that justified our grant of certiorari in these cases still hold true today. See this Court‘s Rule 11. 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. And, on the ground, healthcare providers “have been all but paralyzed by legal uncertainties,” placing pregnant patients at risk while they are waiting to be transferred out of State to receive the care they need. Brief for St. Luke‘s Health System as Amicus Curiae 14–15.
If anything, the need for a clear answer to the Supremacy Clause question has only
Nor has there been any change in today‘s cases that might eliminate or undermine the need for this Court‘s review. The Government continues to maintain (correctly, in my view) that EMTALA‘s plain text requires hospitals to provide certain emergency abortions when doing so is the only way to stabilize an emergency condition. Brief for United States 12-20. Idaho continues to criminalize the provision of such abortions unless doing so is necessary to prevent the patient‘s death.
II
Most importantly, as JUSTICE KAGAN observes, the conflict between the state and federal law—as they are actually being interpreted and applied on the ground—is both substantial and significant. Ante, at 4–6. It is a clash that clearly exists despite the attempt by Idaho‘s counsel to muddy the waters concerning the scope of the State‘s law.
The textual conflict is plain. EMTALA requires stabilizing treatment if a patient has an acute medical condition that is so severe “that the absence of immediate medical attention could be reasonably expected to” either result in a serious health risk, or seriously threaten bodily functions or organs.
From the beginning of this litigation, the United States has emphasized the host of emergency medical conditions that require stabilizing abortions—even when the procedure is not necessarily life saving. That list includes pre-eclampsia, preterm premature rupture of the membranes (PPROM), sepsis, and placental abruption, to name just a few examples. Having now been sued over its interference with EMTALA‘s protections for people experiencing these conditions, Idaho has shifted its position, both here and before the District
Some of my colleagues appear to view this convenient rhetorical maneuver as a material change that (also conveniently) reduces the conflict between state and federal law to the point that a ruling from this Court is no longer warranted. See ante, at 6–7 (BARRETT, J., concurring). 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 conflict between state and federal law still exists—in real life. Idaho cannot credibly maintain that its law always permits abortions in cases of PPROM or pre-eclampsia such that its mandate never conflicts with federal law. The same medical condition can present with different risks in different patients. See, e.g., Brief for Physicians for Reproductive Health as Amicus Curiae 10–11; Brief for Physicians for Human Rights as Amicus Curiae 11–19. And, often, a doctor simply does not know what the risks are or whether a patient might face death. See Tr. of Oral Arg. 103-104; 2 App. 615-617. Such a doctor, observing the different legal thresholds for action under state and federal law—not to mention the severe criminal penalties for a miscalculation—would surely be cowed into not providing abortion care that medical standards warrant and federal law requires. Do not take my word for this; it is already happening.* So it is strange, to say the least, that this Court
would shirk its duty to resolve a pressing legal issue on the basis of representations that defy medical realities.
In any event, the representations Idaho‘s counsel made during oral argument and in the State‘s briefs filed in this Court are not a definitive interpretation of Idaho law. That authority remains with the Idaho Supreme Court, which has never endorsed the State‘s position. To the contrary, the Idaho Supremе Court has emphasized that, to avoid criminal liability, a doctor must subjectively believe that an abortion is necessary to prevent death. Planned Parenthood Great Northwest v. State, 171 Idaho 374, 445-446, 522 P. 3d 1132, 1203-1204 (2023). And that is to say nothing of local prosecutors, who may not be aware of (or care about) Idaho‘s newfound interpretation of its abortion ban, and who are highly incentivized to enforce the law to the hilt. See
We cannot simply wind back the clock to how things were before the Court injected itself into this matter. Our intervention has already distorted this litigation process. We permitted Idaho‘s law to go into effect by staying the District Court‘s injunction in the first place, then allowed this matter to sit on our merits docket for five months while we considered the question presented.
courts to carry on as if none of this has happened. As the old adage goes: The Court has made this bed so now it must lie in it—by proceeding to decide the merits of the critical pre-emptiоn issue this case presents.
We have granted certiorari and heard argument. We have had ample opportunity to consider the issues. The parties were well represented on both sides, and dozens of amici have weighed in. What is more, the necessary legal reasoning is straightforward, and the answer to the question presented is—or at least should be—quite clear: 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) (“[I]t has long been settled that state laws that conflict with federal laws are ‘without effect‘” (quoting Maryland v. Louisiana, 451 U. S. 725, 746 (1981))). 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 Justices refuse to recognize the rights that EMTALA protects. See ante, at 4-7 (BARRETT, J., concurring); post, at 4-11 (ALITO, J., dissenting). The majority opts, instead, to dismiss these cases. But storm clouds loom ahead. Three Justices suggest, at least in this context, that States have free rein to nullify federal law. See post, at 11-14 (ALITO, J., dissenting). And three more decline to disagree with those dissenters on the merits. See ante, at 4-7 (BARRETT, J., concurring). The latter group offers only murmurs that “petitioners have raised a difficult and consequential argument” about Congress‘s authority under the Spending Clause. Ante, at 6 (BARRETT, J., concurring). So, as of today, the Court has not adopted Idaho‘s farfetched theories—but it has not rejected them either.
Instead, the Court puts off the decision. But how long must pregnant patients wait for an answer? Until we confront the pending petition that the Government filed with us after the Fifth Circuit enabled Texas‘s flouting of EMTALA? Until these very cases return to us in a few years? Will this Court just have a do-over, rehearing and rehashing the same arguments we are considering now, just at a comparatively more convenient point in time? Or maybe we will keep punting on this issue altogether, allowing chaos to reign wherever lower courts enable States to flagrantly undercut federal law, facilitating the suffering of people in need of urgent medical treatment.
After today, there will be a few months—maybe a few years—during which doctors may no longer need to airlift pregnant patients out of Idaho. As JUSTICE KAGAN emphasizes, portions of Idaho‘s law will be preliminarily enjoined (at least for now). Ante, at 2, 4. But having not heard from this Court on the ultimate pre-emption issue, Idaho‘s doctors will still have to decide whether to provide emergency medical care in the midst of highly charged legal circumstances with no guarantee that this fragile detente over the State‘s categorical prohibitions will be maintained. Cf. ante, at 8 (BARRETT, J., concurring) (“Even with the preliminary injunction in place, Idaho‘s ability to enforce its law remains almost entirely intact“).
So, to be clear: Today‘s decision is not a victory for pregnant patients in Idaho. It is delay. While this Court dawdles and the country waits, pregnant people experiencing
JUSTICE ALITO, with whom JUSTICE THOMAS joins, and with whom JUSTICE GORSUCH joins as to Parts I and II, dissenting.
This case presents an important and unsettled question of federal statutory law: whether the
After this Court‘s decision in Dobbs v. Jackson Women‘s Health Organization, 597 U. S. 215 (2022), Idaho and other States enacted new laws restricting the performance of abortions. To protect both “maternal health and safety” and “the life of preborn children,” Planned Parenthood Great Northwest v. State, 171 Idaho 374, 438, 522 P. 3d 1132, 1196 (2023) (quoting
Shortly before Idaho‘s law took effect, President Biden instructed members of his administration to find ways to limit Dobbs‘s reach. Protecting Access to Reproductive Healthcare Services, Exec. Order No. 14076, 87 Fed. Reg. 42053 (2022). In response, Government lawyers hit upon the novel argument that, under EMTALA, all Medicare-funded hospitals—that is, the vast majority of hospitals1—must perform abortions on request when the “health” of a pregnant woman is in serious jeopardy.
The Government‘s preemption theory is plainly unsound. 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.”
even if there were some ambiguity in the statutory text, we would be obligated to resolve that ambiguity
Recognizing the flaws in the Government‘s theory and Idaho‘s “strong” likelihood of success, this Court stayed the preliminary injunction pending appeal on January 5. And, wisely or not, the Court also took the unusual step of granting certiorari before Idahо‘s appeal was heard by the Ninth Circuit. See this Court‘s Rule 11. Now the Court dismisses the writ and, what is worse, vacates the stay.
This about-face is baffling. Nothing legally relevant has occurred since January 5. And the underlying issue in this case—whether EMTALA requires hospitals to perform abortions in some circumstances—is a straightforward question of statutory interpretation. It is squarely presented by the decision below, and it has been exhaustively briefed and argued. In addition to the parties’ briefs, we received 46 amicus briefs, including briefs submitted by 44 States and the District of Columbia; briefs expressing the views of 379 Members of Congress; and briefs from prominent medical organizations. Altogether, we have more than 1,300 pages of briefing to assist us, and we heard nearly two hours of argument. Everything there is to say about the statutory interpretation question has probably been said many times over. That question is as ripe for decision as it ever will be. Apparently, the Court has simply lost the will to decide the easy but emotional and highly politicized question that the case presents. That is regrettable.
Having already taken the extraordinary step of granting certiorari before judgment in order to decide whether the Government‘s new interpretation of EMTALA is correct, we have no good reason to change course now. This is especially so because the Court‘s decision to reexamine the stay issued in January makes it necessary to reassess whether Idaho showed a likelihood of success on the merits, a question that is closely related to the question whether Idaho or the Government has correctly interpreted EMTALA. I will therefore proceed to analyze what EMTALA means.
I
A
The text of EMTALA shows clearly that it does not require hospitals to perform abortions in violation of Idaho law. To the contrary, EMTALA obligates Medicare-funded hospitals to treat, not abort, an “unborn child.”
EMTALA imposes two main obligations on covered hospitals. First, a hospital must, within its “capabilit[ies],” “screen” “any individual” arriving at the emergency room without regard to the individual‘s ability to pay.
“a medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— “(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
“(ii) serious impairment to bodily functions, or
“(iii) serious dysfunction of any bodily organ or part.”
§1395dd(e)(1)(A) (emphasis added).2
When a hospital determines that an “emergency medical condition” exists, it has two options. It may provide “treatment” within the capability of its “staff and facilities.”
At no point in its elaboration of the screening, stabilization, and transfer requirements does EMTALA mention abortion. Just the opposite is true: EMTALA requires the hospital at every stage to protect an “unborn child” from harm.
Begin with the screening provision, which requires a hospital “to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists.”
Similarly, if a hospital wants to transfer a pregnant woman to another facility, it may not do so unless, among other things, a physician certifies directly or through an intermediary that the medical benefits of transfer outweigh
any “increased risks” to the woman “and, in the case of labor, to the unborn child.”
The Government struggles mightily—but unsuccessfully—to get around this language. First, the Government argues that EMTALA‘s repeated use of the term “individual,” coupled with the
child.”9 And some references expressly mention both the “individual” and “the unborn child.”10 No use of the term “individual” supports the Government‘s interpretation.
Second, based on a provision stating that an individual may not be treated without consent,
Or, to provide an example that is more closely related to the matter at hand, the right to refuse medical treatment without consent does not entail the right to demand treatment that is prohibited by law. Cancer patients have the right to refuse treatment that their doctors recommend, but they do not have a right to obtain whatever treatment they want, such as the administration of a drug that cannot legally be used in this country. Cf.
For these reasons, the text of EMTALA conclusively shows that it does not require hospitals to perform abortions.
B
For those who find it appropriate to look beyond the statutory text, the context in which EMTALA was enacted reinforces what the text makes clear. Congress designed EMTALA to solve a particular problem—preventing private hospitals from turning away patients who are unable to pay for medical care. H. R. Rep. No. 99-241(I), pt. 1, p. 27 (1985); K. Treiger, Preventing Patient Dumping: Sharpening the COBRA‘s Fangs, 61 N. Y. U. L. Rev. 1186, 1188 (1986). And none of many briefs submitted in this suit has found any suggestion in the proceedings leading up to EMTALA‘s passage that the Act might also use the carrot of federal funds to entice hospitals to perform abortions. To the contrary, EMTALA garnered broad support in both Houses of Congress, including the
It is also telling that 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 very period when EMTALA was enacted and amended the Hyde Amendment contained only one exception: for abortions necessary to save the life of the pregnant woman. Congressional Research Service, E. Liu & W. Shen, The Hyde Amendment: An Overview 1 (2022); see §204, 99 Stat. 1119 (1986 Hyde Amendment). The Hyde Amendment thus prohibited federal funds from paying for the health-related
abortions that the Government says EMTALA mandates. It would have been strange indeed if a Congress that repeatedly sought to prevent federal funding of abortions simultaneously enacted a law that, as interpreted by the Government, requires hospitals and physicians to perform that very same procedure.
The Government‘s reading of EMTALA is doubly strange given that the President who signed that law repeatedly promised not to use federal funds to subsidize or require the provision of abortions. Less than three months before signing EMTALA, President Reagan told participants in the annual March for Life that “the resources of government are not [to be] used to promote or perform abortions.” The American Presidency Project, Remarks to Participants in the March for Life Rally (Jan. 22, 1986). The next year, he touted his administration‘s work “to restrict the use of Federal funds to perform abortions.” Id., Remarks to Participants in the March for Life Rally (Jan. 22, 1987). In another 1987 speech, he promised that his administration would “oppose any legislation that would require individuals or institutions, public or private, to finance or perform abortions.” Id., Remarks at a White House Briefing for Right to Life Activists (July 30, 1987). And his 1986 and 1987 messages to Congress repeated that promise. See id., Message to the Congress on “A Quest for Excellence” (Jan. 27, 1987); id., Message to the Congress on America‘s Agenda for the Future (Feb. 6, 1986).
Around the same time, President Reagan‘s HHS Secretary testified before Congress that “the Administration steadfastly opposes [the] creation of [a] program which would encourage, promote or finаnce the performance of abortions.” Statement of the Hon. Margaret M. Heckler, in Budget Reconciliation: Hearings before the Senate Committee on Finance, 99th Cong., 1st Sess., pt. 1, p. 273 (1985). It beggars belief that President Reagan would have happily signed EMTALA into law if it did what he “steadfastly oppose[d].” Ibid.
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. None of these sources stands for that proposition.
The Government also seizes upon a provision in the Affordable Care Act stating that “[n]othing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Fed-
eral law, including . . . EMTALA.”
II
As the previous Part shows, EMTALA‘s text and context decisively refute the Government‘s interpretation. 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.
Spending Clause legislation operates “much in the nature of a contract: in return for federal funds, the [recipients] agree to comply with federally imposed conditions.” Pennhurst, 451 U. S., at 17. These conditions do not bind unless and until they are accepted, and private parties “can opt out of spending programs” at will, “completely nullifying whatever force the spending conditions once had.” Health and Hospital Corporation of Marion Cty. v. Talevski, 599 U. S. 166, 201 (2023) (THOMAS, J., dissenting); accord, Townsend v. Swank, 404 U. S. 282, 292 (1971) (Burger, C. J., concurring in result) (“[A]herence to [Spending
Clause] provisions . . . is in no way mandatory“). “[T]he ‘legitimacy of
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) (opinion of ROBERTS, C. J.); accord, Steward Machine Co. v. Davis, 301 U. S. 548, 590 (1937). The Government‘s interpretation founders at both points.
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.
The need for clear statutory language is especially important in this suit because the Government‘s interpretation would intrude on an area traditionally left to state control, namely, the practice of medicine. We typically expect Congress to “‘make its intention “clear and manifest” if it intends to pre-empt the historic powers of the States.‘” Gregory v. Ashcroft, 501 U. S. 452, 461 (1991) (quoting Rice v. Santa Fe Elevator Corp., 331 U. S. 218, 230 (1947)); see also Gonzales v. Oregon, 546 U. S. 243, 274 (2006) (“[T]he background principles of our federal system also belie the notion that Congress would use such an obscure grant of authority to regulate areas traditionally supervised by the States’ police power“).
Second, consider the requirement that parties be given a choice before being bound by Spending Clause conditions. The Government‘s interpretation purports to limit Idaho‘s choices about what conduct to criminalize. But Idaho never “agree[d]” to be bound by EMTALA,14 Cummings, 596 U. S., at 219, let alоne to surrender its historic power to regulate the practice of medicine or the performance of abortions within its borders.
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. See Brief for Petitioners in No. 23-726, pp. 50-51. As it explains, States cannot be bound by terms that they never accepted, so it is hard to see how a third party‘s agreement with the Federal Government can deprive a State of the ability to enforce its criminal laws. Accord, Talevski, 599 U. S., at 212 (THOMAS, J., dissenting) (“[E]ven those who held the broadest conception of the spending power recognized that it was only a power to spend, not a
The potential implications of permitting preemption here are far-reaching. Under the Government‘s view, Congress could apparently pay doctors to perform not only emergency abortions but also third-trimester elective abortions or eugenic abortions. It could condition Medicare funds on hospitals’ offering assisted suicide even in the vast majority of States that ban the practice. It could authorize the practice of medicine by any doctor who accepts Medicare payments
even if he or she does not meet the State‘s licensing requirements.
While the Government is not troubled by the potential consequences of its preemption argument, Congress was sensitive to state prerogatives. The Medicare Act, in which EMTALA is situated, disclaims any construction that would “authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided” in a particular State.
In response to the Legislature‘s argument, the Government claims that a handful of our cases have held that Spending Clause statutes can preempt the laws of non-consenting States, but those cases do not begin to settle the question at hand. Two are entirely inapposite.15 And the remaining cases simply upheld the Federal Government‘s ability to prevent the use of federal money for purposes
other than those intended by Congress.16 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.
For present purposes, it is not necessary to decide whether the Legislature‘s theory is correct. At a minimum, however, it prоvides yet another reason to be wary about interpreting EMTALA to displace the core powers of a non-consenting State without unmistakable clarity regarding the meaning of the federal law.
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In sum, the Government‘s new interpretation of EMTALA is refuted by the statutory text, the context in which the law was
apply to Spending Clause measures or how Idaho can be bound by conditions to which it has never agreed. JUSTICE JACKSON‘s opinion adds nothing to JUSTICE KAGAN‘s legal analysis, but she reads my opinion to suggest “that States have free rein to nullify federal law.” Ante, at 7 (opinion concurring in part and dissenting in part). Anyone who reads my opinion can see that it makes no such suggestion but simply explains what the federal law in question means.
III
Even if the Court is unwilling to decide the statutory interpretation question, there is no excuse for vacating the stay of the preliminary injunction. In order to obtain that injunction, the Government was required to make a strong showing that it was likely to prevail on the merits. See Munaf v. Geren, 553 U. S. 674, 690 (2008). And as I have explained, its argument was almost certain to lose. That in itself is sufficient to preclude continuation of the preliminary injunction.
Why then have six Justices voted to vacate the stay? The per curiam itself provides no explanation. In separate opinions, three of the six agree with the Government‘s interpretation of EMTALA, see supra, at 15, n. 17, and that at least is an explanation that would make sense if the premise (the correctness of the Government‘s interpretation) were sound. 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. Ante, at 7 (BARRETT, J., joined by ROBERTS, C. J., and KAVANAUGH, J., concurring). That justification is patently unsound. “‘[A]ny time a State is enjoined by a court from effectuating statutes enacted by representatives of its people, it suffers a form of irreparable injury.‘” Maryland v. King, 567 U. S. 1301, 1303 (2012) (ROBERTS, C. J., in chambers). And in this case, Idaho‘s injury is not abstract. 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. The State of Idaho wants to prevent that; the preliminary injunction stands in its way. Isn‘t that enough to constitute irreparable harm?
The Justices who have joined JUSTICE BARRETT‘s concurrence claim that the parties’ briefs and oral arguments seem to have narrowed the degree to which EMTALA, as interpreted by the Government, conflicts with the Idaho law, ante, at 7-8,
Idaho agreed that the Government‘s interpretation of EMTALA conflicts with state law. In particular, the State worried that “the United States’ novel theory” would “authorize emergency-room doctors to perform abortions” for mental-health reasons and would thus “turn emergency rooms into federal abortion enclaves governed not by state law but by subjective physician judgment.” Brief for Petitioner in No. 23-727, p. 30; see also Tr. of Oral Arg. 45-46.
Thus, whatever narrowing may have occurred during briefing and argument in this Court, both the Government and the State of Idaho fervently maintain that it matters whether the Idaho law is enforced. Do any Justices in the majority seriously disagree? Do any of them think that the parties, not to mention their armies of amici, are fighting about nothing? Three of the six Justices in the majority also agree that there is a conflict—and judging from their fiery rhetoric, a big one. See ante, at 1 (KAGAN, J., joined by SOTOMAYOR, J., and by JACKSON, J., as to Part II, concurring); ante, at 7 (JACKSON, J., concurring in part and dissenting in part). And they are correct to this extent: there is a real conflict.
A
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.” Tr. of Oral Arg. 103. In those cases, the Government explains, a doctor might be worried about serious risks to the woman‘s “health.” Ibid. In the Government‘s telling, EMTALA requires hospitals to perform an abortion on demand in these circumstances.
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.”
These standards do not require a doctor to be “objec-tive[ly] certai[n]” that the abortion is “necessary to save the woman‘s life.” Planned Parenthood, 171 Idaho, at 445, 522 P. 3d, at 1203 (emphasis deleted). Nor does Idaho law require that the risk of death be particularly immediate. Ibid. Indeed, the Idaho Supreme Court has explained that the law “leaves wide room for the physician‘s ‘good faith medical judgment’ on whether [an] abortion was ‘necessary.‘” Ibid.; accord, id., at 446, 522 P. 3d, at 1203 (noting that the Act “imposes a subjective standard based on the individual physician‘s good faith medical judgment“). And any latitude, it said, “operates for the benefit, not the disadvantage, of the pregnant woman.” Id., at 445-446, 522 P. 3d, at 1203-1204. Even so, Idaho‘s law is focused on “death,” and a
These different considerations—health versus life—may lead to different outcomes. For instance, consider the situation of a woman who experiences a condition that was discussed in the briefs and at argument: preterm prelabor rupture of membranes (PPROM), which occurs when a woman‘s amniotic sac breaks before the 37th week of pregnancy. 1 App. 295. The Members of this Court are not physicians and should therefore be wary about expressing conclusions about mеdical issues. But guidance provided by prominent medical institutions is sufficient to show how Idaho law and EMTALA, as interpreted by the Government, may conflict in such cases.
If a woman experiences PPROM between the 34th and 37th week of pregnancy and does not go into labor, her physician is likely to recommend that labor be induced.18 In that situation, it does not appear that the risk of conflict is high.
On the other hand, when PPROM occurs earlier than that, the chances of conflict are greatly increased. If PPROM occurs before the 34th week and the woman‘s pregnancy continues, she may experience conditions such as an infection of the amniotic fluid, inflammation of the uterine lining, hemorrhage, or sepsis.19 However, life-threatening
complications are not inevitable, and according to the PPROM Foundation, death is “extremely rare.”20 A physician may try to delay labor by putting the woman on bed rest and administering steroids to help the baby‘s lungs grow and antibiotics to prevent infection.21
When PPROM occurs before the 24th week of pregnancy, the potential for conflict appears to be even higher. But in that situation, it may still be possible to manage the situation until the baby can be delivered,22 and there is a chance of a good outcome for both the mother and child, although studies have yielded different results.23 Thus, when PPROM occurs before
In these situations, the Defense of Life Act requires doctors to consider whether performing an abortion is necessary to prevent the woman‘s death. Because this is a “subjective” standаrd, Planned Parenthood, 171 Idaho, at 446, 522 P. 3d, at 1204, different doctors may reach different conclusions about when PPROM endangers the woman‘s life. At least some may conclude in some cases of PPROM occurring before the 34th week of pregnancy that the woman‘s life is not endangered since she may never develop a serious infection, let alone life-threatening sepsis or any other potentially fatal condition, if she receives proper treatment. See 1 App. 306-307. Rather, those doctors may believe that Idaho law requires them to try to delay delivery long enough to save the child‘s life, unless PPROM becomes sufficiently “severe” to cause “infection and serious risk of sepsis.” See, e.g., 2 id., at 547.24
According to the Government‘s experts, however, EMTALA requires a hospital to perform an abortion at the woman‘s request whenever PPROM is diagnosed, even if the woman has not yet developed an infection or any other health complications. That is because, they assert, it can
be “reasonably expected” that, in “the absence of immediate medical attention,” PPROM would “plac[e] the health” of the pregnant woman “in serious jeopardy” or cause “serious dysfunction” to her reproductive organs.
This gap between the Idaho law and the Government‘s interpretation of EMTALA matters. Idaho has always permitted abortions that are necessary to preserve the life of a pregnant woman, but it has not allowed abortions for other non-life-threatening medical conditions. Planned Parenthood, 171 Idaho, at 391-394, 522 P. 3d, at 1149-1152 (summarizing Idaho‘s historical restrictions); see also Dobbs, 597 U. S., at 302-330 (compiling other state statutes with identical exceptions). This balance reflects Idaho‘s judgment about a difficult and important moral question. See Planned Parenthood, 171 Idaho, at 437-438, 522 P. 3d, at 1195-1196. By requiring Idaho hospitals to strike a different balance, the preliminary injunction thwarts the will of the people of Idaho as expressed in law by their elected representatives.
B
I now turn to Idaho‘s claim that the Government‘s reading of EMTALA would authorize abortions for mental-health reasons. My colleagues dismiss this concern because at argument, the Solicitor General “emphatically disavowed the notion that an abortion is ever required as stabilizing treatment for mental health conditions.” Ante, at 5 (BARRETT, J., concurring). But it is hard to see how the Government could reach that conclusion. At oral argument, the Solicitor General conceded that the term “health” in EMTALA includes mental health, Tr. of Oral Arg. 77-78, and if that is so, it is not difficult to imagine a situation in which the Government‘s interpretation of EMTALA could require an abortion.
Suppose, for example, that a woman in the 10th week of gestation experiences serious depression due to her pregnancy. If she asks emergency medical professionals for treatment, her medical carе providers might conclude that her continued pregnancy could “reasonably be expected” to seriously jeopardize the woman‘s mental health.
We have seen where a rule permitting abortions to protect the psychological health of pregnant women may lead. In Roe, the Court held that a woman had the right to obtain a post-viability abortion that was deemed “necessary, in appropriate medical judgment, for the preservation of the life or health of the mother.” Roe v. Wade, 410 U. S. 113, 165 (1973). In the companion case Doe v. Bolton, 410 U. S. 179 (1973), the Court wrote that a doctor, in judging whether an abortion was needed to preserve a pregnant woman‘s health, could consider “all factors—physical, emotional, psychological, familial, and the woman‘s age—relevant to the well-being of the patient.” Id., at 192. That decision was viewed by many as essentially preventing States from restricting post-viability abortions.25 As Harvard
Law School Professor Mary Ann Glendon put it: “[W]hen Roe is read with Doe, third-trimester restrictions are effectively ruled out as well—for Roe‘s dictum that such restrictions might be permissible
The Solicitor General tried to explain why the Government‘s interpretation would not lead down this path, but her explanation is hard to understand. She said that mental-health emergencies “could never lead to pregnancy termination” because abortion “is not the accepted standard of practice to treat any mental health emergency.” Tr. of Oral Arg. 77-78; accord, Brief for United States 26, n. 5.
That assertion appears to be inconsistent with the position taken by prominent medical associations that endorse abortion for mental-health reasons as an accepted standard of practice. See, e.g., American Psychiatric Association, Position Statement on Abortion and Women‘s Reproductive Healthcare Rights (Mar. 2023) (“Freedom to act to interrupt pregnancy must be considered a mental health imperative“); American Psychological Association, Resolution Affirming and Building on APA‘s History of Support for Reproductive Rights (Feb. 2022).
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.
* * *
Today‘s decision is puzzling. Having taken the unusual step of granting certiorari before Idaho‘s appeal could be heard by the Ninth Circuit, the Court decides it does not want to tackle this case after all and thus returns the appeal to the Ninth Circuit, which will have to decide the issue that this Court now ducks. What is more, the Court vacates the stay it issued earlier this year even though the majority fails to provide any facially plausible explanation for doing so.
I cannot endorse this turn of events and therefore respectfully dissent.