St. Luke’s Health System, Ltd. v. Raúl Labrador, Attorney General of the State of IdahoSt. Luke’s Health System, Ltd. v. Raúl Labrador, Attorney General of the State of Idaho
INTRODUCTION
By design, our national government is a government of limited powers. But when it acts within the realm of those limited power, the Supremacy Clause makes clear that the national government is supreme. The Founders correctly perceived that, for our federal system to work—for fifty states with different cultures and priorities to nonetheless come together as one nation—Congress must at times override the states’ dissonant policies. In this, the Supremacy Clause ensures that the tension between national and state government remains productive rather than destructive, that our political differences generate a stronger nation rather than dissolving the country into nothing more than a collection of states. Simply put, when state law and federal conflict, state law must yield. This case provides an example of these principles at work in our federal system.
One important area that Congress has chosen to regulate is the provision of emergency medical services. In response to “patient dumping“—a practice of transferring or turning away patients deemed undesirable—Congress passed the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that hospitals receiving Medicare funds provide stabilizing treatment to patients who arrive with emergency medical conditions. The law ensures that all Americans in their most vulnerable moments can receive emergency medical care.
EMTALA is decades old and generally uncontroversial. But in one narrow and heartbreaking circumstance, EMTALA conflicts with Idaho law. When a pregnant woman arrives in an emergency room experiencing severe complications, termination of the pregnancy is occasionally the sole treatment that can stabilize her. In the worst cases, an abortion is necessary to prevent the woman‘s death. In others, the woman‘s life is not at risk, but termination is the only way to prevent serious harms like kidney failure, stroke, infertility, and a host of other life-altering impairments.
The Court first ruled on this issue in August 2022, when the United States sought to enjoin Idaho‘s abortion ban as it pertained to these emergency abortions. This time, a hospital system subject to EMTALA has invoked the supremacy of federal law. The intervening years have only brought into focus the reality of the conflict. When Idaho‘s abortion ban went into full effect for six months in 2024, St. Luke‘s Health System was forced to airlift six pregnant patients with emergency medical conditions to neighboring states where they could receive the appropriate care. In contrast, only a single pregnant patient was airlifted in the entirety of 2023. This sad but illuminating natural experiment shows that Idaho‘s ban on emergency abortions is not compatible with hospitals’ stabilization obligations under EMTALA.
St. Luke‘s has established that it will likely succeed on the merits and that the Court should preserve the status quo while the parties litigate this matter. For the reasons explained in this decision, the Court will therefore grant St. Luke‘s motion for a preliminary injunction. During the pendency of this lawsuit, the Attorney General will be enjoined from enforcing
BACKGROUND
1. EMTALA and the Defense of Life Act
This case concerns the conflict between Idaho‘s Defense of Life Act and the federal Emergency Medical Treatment and Labor Act (EMTALA). Idaho‘s Defense of Life Act criminalizes abortion in nearly all circumstances. When a pregnant woman experiences a medical emergency, a health care provider may perform an abortion1 only when “necessary to prevent the death of the pregnant woman.”
This criminalization of emergency abortions creates a problem for hospital systems, which are mandated by EMTALA to provide stabilizing care to any patient with an “emergency medical condition.”
(A) 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—
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, - serious impairment to bodily functions, or
- serious dysfunction of any bodily organ or part;
EMTALA applies to every hospital that has an emergency department and participates in Medicare. See
2. United States v. Idaho
This Court addressed many of the issues presented here when it granted a preliminary injunction in United States v. Idaho, 623 F. Supp. 3d 1096 (D. Idaho 2022). In that case, the Court recognized that in certain situations a hospital could comply with
The State appealed. The Ninth Circuit initially stayed the injunction but vacated the stay after ordering a rehearing en banc. United States v. Idaho, 82 F.4th 1296 (9th Cir. 2023) (Mem.). Before the Ninth Circuit could rehear the case, however, the Supreme Court granted a writ of certiorari before judgment and stayed the injunction. Idaho v. United States, 144 S. Ct. 541 (2024) (Mem.). Six months later, the Supreme Court decided it had improvidently granted certiorari and vacated the stay. Moyle v. United States, 144 S. Ct. 2015, 2015 (2024) (per curiam). The case returned to the Ninth Circuit, where it remained pending until the United States filed a stipulation to dismiss the case on March 5, 2025.
3. St. Luke‘s Lawsuit
St. Luke‘s filed this lawsuit in mid-January 2025, as the transition of presidential administrations loomed. Although the United States v. Idaho injunction was in place when it filed, St. Luke‘s was concerned that the United States would dismiss
4. Findings of Fact3
St. Luke‘s operates eight of the 39 hospitals in Idaho that receive Medicare funding and provide emergency services. Idaho has around 22,000 births per year, and in recent years, St. Lukes has delivered around forty percent of those babies. Given that volume, it‘s not surprising that St. Luke‘s cares for pregnant patients who arrive at the emergency room with medical conditions that threaten their health, but not their lives. Occasionally—and devastatingly—these patients can be stabilized only through the termination of their pregnancies. See Seyb Supp. Dec. ¶¶ 5, 9-14, Dkt. 2-2. Stated more precisely, using EMTALA‘s defined terms, the record shows that some patients experience serious (but non-life-threatening) pregnancy-related complications that qualify as an “emergency medical condition” where abortion is the only treatment that will “stabilize” them. See, e.g., Seyb Supp. Dec. ¶ 5, Dkt. 2-2; Corrigan Dec. ¶ 29, US v. Idaho Dkt. 17-6. Yet under Idaho law, the woman experiencing these conditions must remain pregnant and endure these harms because her life is not itself at stake.
Examples of these types of conditions include: (1) preterm premature rupture of the membranes (PPROM), which can result in infection, sepsis, or organ failure; (2) preeclampsia, which can result in the onset of seizures and hypoxic brain injury; (3) placental abruption, which can result in uncontrollable bleeding or organ dysfunction; and (4) uterine hemorrhage, which can require a hysterectomy or result in kidney failure, requiring lifelong dialysis. Idaho physicians have submitted declarations describing specific patients who presented with such conditions.4 Some of these declarations describe patients who were treated before Idaho‘s Defense of Life Act took effect.5 Another describes
The injunction was stayed for approximately two weeks in late 2023 and for approximately six months between January and June 2024. During that brief period—when medical providers faced prosecution for performing emergency abortions—St. Luke‘s had to airlift six pregnant patients in medical crisis to other states to receive appropriate care.
Dr. Stacy Seyb succinctly explains the quandary Idaho physicians find themselves in when attempting to simultaneously comply with Idaho law and EMTALA during these situations:
Fundamentally, each of these conditions [pre-eclampsia, PPROM, placental abruption]—and many more pregnancy complications—poses serious risks to pregnant patients, and termination is very often the only treatment available to address these risks and stabilize the patient. In some cases, these conditions can and do cause death. But sometimes, a physician may conclude that although there is not a high probability of the pregnant patient‘s death, the patient may experience impairment or severe dysfunction of bodily organs, including losing her reproductive capacity, absent termination of her pregnancy. And often, it will simply not be possible for a physician to determine whether termination is necessary to prevent her death as opposed to some severe harm to the patient short of death.
Seyb Supp. Dec. ¶ 5, Dkt. 2-2.
ANALYSIS
1. Motion to Dismiss
Before considering the merits of St. Luke‘s Motion for Preliminary Injunction, the Court must make a threshold determination of justiciability. The Attorney General raises three issues here: (1) lack of Article III standing, (2) prudential unripeness, and (3) sovereign immunity. The Attorney General also argues that St. Luke‘s lacks an equitable cause of action under EMTALA. The Court concludes that each of these challenges fails.
A. Standing
The doctrine of standing stems from the principle that the federal judiciary has authority to decide only “actual cases or controversies.” Simon v. Eastern Ky. Welfare Rights Org., 426 U.S. 26, 37 (1976). The party invoking federal jurisdiction has the burden of establishing the three elements of standing: “(1) an ‘injury in fact,’ (2) a sufficient ‘causal connection between the injury and the conduct complained of,’ and (3) a ‘likelihood’ that the injury ‘will be redressed by a favorable decision.‘” Susan B. Anthony List v. Driehaus, 573 U.S. 149, 157-58 (2014) (quoting Lujan v. Defenders of Wildlife, 504 U.S. 555, 560 (1992)). The present dispute centers on the injury-in-fact requirement for a pre-enforcement plaintiff. The Attorney General also contends that he is an improper defendant for the injunction as it pertains to professional licensure penalties and that St. Luke‘s lacks third-party standing to sue on behalf of its providers.
i. Injury in Fact
St. Luke‘s brings a pre-enforcement challenge to Idaho‘s prohibition of emergency abortions. A pre-enforcement plaintiff has, by definition, not yet experienced direct harm from the enforcement of the challenged statute. Peace Ranch LLC v. Bonta, 93 F.4th 482, 487 (9th Cir. 2024). Nonetheless, the injury-in-fact requirement does not mean that a plaintiff must suffer “an actual arrest, prosecution, or other enforcement action.” Driehaus, 573 U.S. at 158. The possibility of enforcement can in itself constitute an injury, creating a dilemma for plaintiffs described variously as being forced to choose between “the rock and the hard place, the Scylla and the Charybdis, and the choice to comply or bet the farm.” Peace Ranch, 93 F.4th at 487 (quotations and alterations omitted). Thus, a plaintiff can allege an injury in fact when the circumstances “render the threatened enforcement sufficiently imminent.” Driehaus, 573 U.S. at 159.
The Ninth Circuit utilizes a three-part test, adopted from Susan B. Anthony List v. Driehaus, for pre-enforcement standing. First, the plaintiff must allege “an intention to engage in a course of conduct arguably affected with a constitutional interest.” Peace Ranch, 93 F.4th at 487 (quoting Driehaus, 573 U.S. at 161). Second, “[t]he intended future conduct must be ‘arguably proscribed by the challenged statute.‘” Id. (quoting Driehaus, 573 U.S. at 162) (alterations omitted). Third, “the threat of future enforcement must be ‘substantial.‘” Id. (quoting Driehaus, 573 U.S. at 164). St. Luke‘s challenge to Idaho‘s ban of emergency abortion meets each of these requirements.
First, the conduct at issue is “arguably affected with a constitutional interest” by the Supremacy Clause. St. Luke‘s alleges that Attorney General intends to prosecute emergency-room physicians for complying with their obligations under EMTALA to provide stabilizing treatment to pregnant patients. To the extent that Section 18-622 conflicts with EMTALA—an issue taken up below on the merits—the state law is preempted due to the Supremacy Clause. And because St. Luke‘s compliance with EMTALA in these circumstances implicates the Supremacy Clause, that conduct carries a constitutional interest.
The role of the Supremacy Clause here warrants some further explanation. It is true that “the Supremacy Clause is not the ‘source of any federal rights,’ and certainly does not create a cause of action.” Armstrong v. Exceptional Child Ctr., Inc., 575 U.S. 320, 324-25 (2015) (quoting Golden State Transit Corp. v. Los Angeles, 493 U.S. 103, 107 (1989)). But the present issue is whether the Supremacy Clause renders St. Luke‘s
In short, the Supremacy Clause does not create a constitutional right, but it does “affect[] with a constitutional interest” St. Luke‘s efforts to comply with EMTALA. This is because the Supremacy Clause resolves a constitutional tension between the medical treatment which St. Luke‘s must provide its pregnant patients under federal law and that which it can legally provide under state law. For purposes of standing, this is enough.
Second, St. Luke‘s intended conduct—the termination of pregnancies as stabilizing treatment during medical emergencies—is “arguably proscribed by” Section 18-622. The Court will take up this statutory conflict further when discussing the merits of the preliminary injunction, but the Attorney General does not dispute that St. Luke‘s meets this requirement.
Third, there is a substantial threat of enforcement. The United States’ dismissal of United States v. Idaho has dissolved that injunction, meaning that St. Luke‘s will be immediately subject to the full penalties of Section 18-622 in the absence of action here. And, contrary to the Attorney General‘s arguments, the United States’ decision to dismiss its complaint did not end the threat of injury to St. Luke‘s. Although the United States may, like any party, change its interpretation of the relevant law, it cannot unilaterally alter the meaning of a statute enacted by Congress. See Wyeth v. Levine, 555 U.S. 555, 565 (2009) (“The purpose of Congress is the ultimate touchstone in every pre-emption case.“). St. Luke‘s would still face the possibility of lawsuits by private litigants harmed by violations of EMTALA—a risk highlighted by the airlifts of six pregnant patients during the six-month stay. And of course, the United States could easily change its position on EMTALA again. The discretion inherent in the executive‘s law enforcement authority underscores St. Luke‘s vulnerability in the absence of an injunction.
Even if the United States had not dismissed the case, a preliminary injunction in a third party‘s lawsuit does not end the threat to others who intend to engage in the proscribed conduct. A preliminary injunction is a form of provisional relief designed only “to balance the equities as the litigation moves forward.” Trump v. Int‘l Refugee Assistance Project, 582 U.S. 571, 580 (2017) (per curiam). Due to the temporary nature of the remedy, the Supreme Court has held that a preliminary injunction does not alleviate the threat of injury and therefore does not deprive a plaintiff of standing. Nielsen v. Preap, 586 U.S. 392, 403 (2019) (“Unless
Accordingly, St. Luke‘s has established pre-enforcement standing to challenge
ii. Licensure Penalties
The Court now turns to a more limited question of standing: whether the Attorney General is the correct defendant for an injunction against Section 18-622‘s licensure penalties. The Attorney General argues that this aspect of the injunction cannot run against him because he does not enforce the professional boards’ rules and laws. This objection overlooks the fact that licensing penalties for violating the abortion ban are available only after a criminal conviction—indeed, such a conviction appears to be a mandatory trigger. See
To satisfy standing requirements, an alleged injury must be “fairly traceable” to the challenged criminal statute and “likely to be redressed by a favorable decision.” Matsumoto v. Labrador, 122 F.4th 787, 799 (9th Cir. 2024) (citing Lujan, 504 U.S. at 560). “An injury is fairly traceable to a challenged action as long as the links in the proffered chain of causation are not hypothetical or tenuous and remain plausible.” Id. (quoting Ass‘n of Irritated Residents v. EPA, 10 F.4th 937, 943 (9th Cir. 2021)). The Attorney General‘s direct causal role in effecting the licensure penalties easily meets this requirement. As a result, he is an appropriate defendant for this aspect of the injunction.
iii. Third-Party Standing
The final question of standing concerns St. Luke‘s ability to assert claims for its providers. The Attorney General reads the Complaint as bringing claims on behalf of individual medical providers, and he accordingly argues that St. Luke‘s must meet the elements of third-party standing. The Court disagrees. St. Luke‘s has clearly brought this claim on behalf of itself. The Complaint includes factual allegations about the medical providers because St. Luke‘s is a hospital system, and the injury it faces from the enforcement of Section 18-622 derives naturally from the conduct of the professionals who work there. St. Luke‘s own financial and ethical interests are clearly impacted if its medical providers face imprisonment and loss of licensure for complying with federal law. But this does not mean that St. Luke‘s seeks to assert the rights of its providers, and nothing in the Complaint suggests that this is the case. Because St. Luke‘s seeks to vindicate its own rights, third-party standing is a non-issue.
B. Prudential Ripeness
The Attorney General next challenges justiciability by arguing that the matter is not ripe.
After a plaintiff establishes Article III standing, a court may nonetheless decline to exercise jurisdiction because the matter is prudentially unripe. Two considerations guide this analysis: “the fitness of the issues for judicial decision and the hardship to the parties of withholding court consideration.” Tingley v. Ferguson, 47 F.4th 1055, 1070 (9th Cir. 2022) (quoting Thomas v. Anchorage Equal Rts. Comm‘n, 220 F.3d 1134, 1141 (9th Cir. 2000) (en banc)). As the Ninth Circuit recently explained, “[t]he fitness prong is met when ‘the issues raised are primarily legal, do not require further factual development, and the challenged action is final.‘” Id. (quoting Stormans, Inc. v. Selecky, 586 F.3d 1109, 1126 (9th Cir. 2009)). The hardship prong considers “whether the challenged law ‘requires an immediate and significant change in the plaintiffs’ conduct of their affairs with serious penalties attached to noncompliance.‘” Id. at 1070-71 (quoting Stormans, 586 F.3d at 1126).
Regarding the fitness prong, this case is about preemption, which is a “predominantly legal” question. Pac. Gas & Elec. Co. v. State Energy Res. Conservation & Dev. Comm‘n, 461 U.S. 190, 201 (1983). The existence of a statutory conflict between Section 18-622 and EMTALA does not, in itself, require meaningful factual development. The factual questions pertain primarily to the degree and immediacy of the injury to St. Luke‘s, and at this stage the record is sufficiently developed for the Court to proceed. By detailing the impact of Section 18-622‘s full enforcement for six months in 2023, St. Luke‘s has provided “a specific factual context for the legal issues,” such that the claims “do not leave incomplete hypotheticals or open factual questions.” Tingley, 47 F.4th at 1070 (quoting Stormans, 586 F.3d at 1126).
The Attorney General suggests that more factual development is needed because the State now claims that emergency conditions like PPROM can be treated through an abortion “even if the threat to the woman‘s life is not imminent.” Moyle, 603 U.S. at 336 (Barrett, J., concurring). Although this statement might slightly broaden the life-of-the-mother exception, it does nothing to address a pregnant woman‘s need for stabilizing treatment to stop an injury short of death.
In each of the cases described in the Seyb Declaration, an abortion did not appear necessary to prevent the woman‘s death, imminent or otherwise, and there is a callous irony in the Attorney General‘s questioning of St. Luke‘s decision to airlift these women out of state. The memorandum asks “why St. Luke‘s providers did not provide an abortion in Idaho if they determined if [sic] was necessary to save the life of the mother.” Def.‘s Consolidated Mem. at 13, Dkt. 25-1. The answer, of course, is obvious—the providers were unsure. While confident that their patient‘s health would be seriously compromised, the providers were not as certain that death would occur if no abortion was performed. And their freedom and licensure would hang in the balance as they navigated that uncertain terrain. Indeed, the entire point of the Declaration—and of this lawsuit—is that an abortion is occasionally the only possible treatment to prevent serious but non-fatal harm, such as kidney failure, stroke, infertility, and a host of other life-altering impairments. As Idaho recently acknowledged before the Ninth Circuit, Section 18-622 would criminalize an abortion necessary to prevent the amputation of a pregnant woman‘s leg.7
The issue is thus fit for a judicial decision. As far as hardship, St. Luke‘s would suffer from a delay for the reasons explained in the Court‘s above analysis of the injury-in-fact requirement. This question of harm will be taken up further below when the Court considers the merits of the injunction.
Finally, the Attorney General contends that he is immune from this lawsuit. “[A] federal court generally may not hear a suit brought by any person against a
nonconsenting State.” Allen v. Cooper, 589 U.S. 248, 254 (2020). This principle of immunity does not appear in the text of the Constitution—except for the
Nonetheless, state officials, including the Attorney General, are successfully sued all the time. See, e.g., Planned Parenthood Great Nw., 122 F.4th 825, 841-43 (9th Cir. 2024). This is because sovereign immunity does not apply when a “complaint alleges an ongoing violation of federal law and seeks relief properly characterized as prospective.” Verizon Md., Inc. v. Pub. Serv. Comm‘n of Md., 535 U.S. 635, 645 (2002). As the Supreme Court concluded when setting out this doctrine in Ex parte Young, “the use of the name of the state to enforce an unconstitutional act to the injury of complainants is a proceeding without the authority of, and one which does not affect, the state in its sovereign or governmental capacity.” 209 U.S. 123, 159 (1908). Accordingly, the Ninth Circuit more recently explained, “suits seeking prospective relief under federal law may ordinarily proceed against state officials sued in their official capacities.” Planned Parenthood Great Nw., 122 F.4th at 842.
Here, St. Luke‘s seeks injunctive relief for a threatened violation of federal law. This is enough to render sovereign immunity inapplicable. See Vickery v. Jones, 100 F.3d 1334, 1346 (7th Cir. 1996) (“[T]he Young exception permits relief against state officials only when there is an ongoing or threatened violation of federal law.” (emphasis added)). The Attorney General opines that there is no “ongoing violation” because the United States v. Idaho injunction enjoins him from the relevant enforcement of Section 18-622. This argument is, of course, no longer applicable due to the dismissal of United States v. Idaho. But even if the United States had not dismissed the case, the Attorney General reads the ongoing violation requirement far too narrowly. Pre-enforcement challenges, by definition, are brought prior to the violation, in the most literal sense. In these situations, an official‘s plan to violate federal law suffices to defeat sovereign immunity. See Armstrong, 575 U.S. at 326.
In sum, for the reasons explained above, St. Luke‘s has brought a justiciable claim against the Attorney General.
D. Equitable Claim
The final issue raised in the Attorney General‘s motion to dismiss is whether St. Luke‘s has a valid equitable cause of action. Equitable relief is the rule rather than the exception, and such a claim is available to St. Luke‘s here.
Although the Supreme Court in Armstrong v. Exceptional Child Center held that Congress can expressly or implicitly limit the equitable powers of federal courts, equitable relief remains “traditionally available to enforce federal law.” 575 U.S. 320, 329 (2015). The Attorney General says that Armstrong forecloses this lawsuit, but Armstrong‘s foundational holding supports the viability of St. Luke‘s equitable claim.
The Armstrong Court considered whether private parties could bring an equitable
provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan ... as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area....
The Court held that the habilitation providers could not proceed in equity because Congress had implicitly foreclosed such a claim. Before reaching that holding, however, the Court observed that it had “long held that federal courts may in some circumstances grant injunctive relief against state officers who are violating, or planning to violate federal law.” Armstrong, 575 U.S. at 326. Indeed, these types of suits aren‘t particularly novel or unusual. Id. at 336-37 (Sotomayor, J., dissenting). Still, though, “Congress may displace the equitable relief traditionally available to enforce federal law,” id. at 329, and it may do so explicitly or implicitly. Id. at 327 (“The power of federal courts of equity to enjoin executive action is subject to express and implied statutory limitations.“).
The Armstrong Court concluded that two aspects of the Medicaid Act, combined, established that Congress intended to foreclose private enforcement of § 30(A) of that Act. First, the Court observed that the sole remedy Congress provided for a state‘s failure to comply with Medicaid‘s requirement was the withholding of Medicaid funds by the Secretary of Health and Human Services. By providing only an agency remedy, Congress had evidently traded “the comparative risk of inconsistent interpretations and misincentives that can arise out of an occasional inappropriate application of the statute in a private action” for “the expertise, uniformity, widespread consultation, and resulting administrative guidance that can accompany agency decisionmaking.” Id. at 328-329.
This “sole-remedy” concern is not present here. Although EMTALA does contain a similar, fund-withholding mechanism, that is not the only remedy it provides. EMTALA also creates a private right of action for individual patients and medical facilities to obtain damages or equitable relief. See
The second aspect of the Medicaid Act that convinced the Armstrong Court that Congress intended to foreclose an equitable claim was the nature of the statute itself. The Court described the statute there as “judicially unadministrable.” Id. at 328. Justice Breyer put a finer point on it. He said that “[t]he history of ratemaking“—and that‘s what was at the heart of the dispute between the Armstrong parties—“demonstrates that administrative agencies are far better suited to this task than judges.” Id. at 333
The EMTALA provisions at issue here do not suffer from this problem. The Court is not faced with a rate-setting statute that is “judicially unadministrable.” Rather, it is called upon to perform a very familiar task—statutory interpretation, or, more specifically, deciding whether a state statute conflicts with a federal one. Cf. Moyle v. United States, 603 U.S. 324, 347 (2024) (Alito, J., dissenting) (describing the underlying issue in United States v. Idaho as “a straightforward question of statutory interpretation“). Under these circumstances, the Court concludes that Armstrong does not foreclose St. Luke‘s equitable claim.
2. Preliminary Injunction
Having decided that St. Luke‘s may proceed with its claims, the Court will turn to the injunction motion. “A preliminary injunction is ‘an extraordinary and drastic remedy, one that should not be granted unless the movant, by a clear showing, carries the burden of persuasion.‘” Fraihat v. United States Immigration & Customs Enf‘t, 16 F.4th 613, 635 (9th Cir. 2021) (citation omitted). To obtain relief, St. Luke‘s must establish that: (1) it is likely to succeed on the merits; (2) it is likely to suffer irreparable harm in the absence of preliminary relief; (3) the balance of equities tips in its favor; and (4) an injunction is in the public interest. Winter v. NRDC, 555 U.S. 7, 20 (2008).
A. Likelihood of Success on the Merits
To determine whether St. Luke‘s is likely to succeed on the merits of its claims, the Court must once again consider whether EMTALA preempts Idaho‘s Defense of Life Act in the narrow range of circumstances at issue here. The Court will first explain the general nature of the statutory conflict and EMTALA‘s preemptive power. The analysis will then turn to several specific constitutional and statutory concerns: (1) restrictions on Spending Clause legislation; (2) EMTALA‘s reference to the “unborn child,” as well as the statute‘s broader context and purpose; and (3) the absence of a national standard of care under EMTALA.8 See infra §§ 2.B.ii to iv.
i. Conflict and Preemption: Idaho‘s Defense of Life Act is Preempted In the Narrow Circumstance Where It Prohibits Stabilizing Treatment Required Under EMTLA
To decide whether Idaho‘s Defense of Life Act directly conflicts with EMTALA and is therefore preempted in the context of EMTALA-mandated care, the Court is guided by the Supremacy Clause and basic preemption principles. The Supremacy Clause provides that federal law “shall be the supreme Law of the Land.”
In EMTALA, Congress indicated its intent to displace state law
Beginning with impossibility preemption, Section 18-622 directly conflicts with EMTALA because in a narrow range of circumstances it is impossible for physicians to comply with both laws. When a pregnant woman suffering from an emergency medical condition that, absent an abortion, will threaten serious harm to her health but not cause her death, Idaho law prevents the physician from performing the very treatment EMTALA requires. This is clear from a comparison of the two laws: Idaho‘s Defense of Life Act allows abortion only when “necessary to prevent the death of the pregnant woman,”
And this isn‘t simply an academic issue. Taking just one example, if a woman comes to an emergency room with PPROM, she may not be facing death, but she does face serious risks to her health, including damage to her uterus, which may prevent her from having children in the future. Six members of the Supreme Court appear to have acknowledged that a conflict exists in this precise situation. Justice Kagan, joined by Justice Sotomayor, observed that “when a woman comes to an emergency room with PPROM, the serious risk she faces may not be of death but of damage to her uterus, preventing her from having children in the future,” and that “Idaho has never suggested that its law would allow an abortion in those circumstances.” Moyle, 603 U.S. at 328 (Kagan, J., concurring). Justice Jackson stated that “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.” Id. at 342 (Jackson, J., concurring in part and dissenting in part). Even Justice Alito‘s dissent, joined by Justice Thomas and Justice Gorsuch, acknowledged that “in PPROM cases, there may be an important conflict between what Idaho law permits and what EMTALA, as interpreted by the Government, demands“—though the dissent disputed that EMTALA can ever require hospitals to perform emergency abortions. Id. at 365 (Alito, J., dissenting).
PPROM is not the only situation where it is impossible to comply with both laws. As the Court has found, patients may present in emergency rooms with several medical conditions that place their health in serious jeopardy, or threaten their bodily functions or organs, but do not necessarily threaten their lives. To highlight a few examples, doctors have described specific patients who presented with conditions including preeclampsia with severe features, HELLP Syndrome, hypovolemic shock due to blood loss, and septic abortion. See Cooper Dec. ¶¶ 6, 8, 10, US v. Idaho Dkt.
The Attorney General nevertheless insists there is no conflict between the two laws. See, e.g., Mar. 5. Tr., Dkt. 40 at 33 (“Your Honor, there is no conflict between EMTALA and the Idaho Defense of Life Act.“). During oral argument, he contended that the six airlifts described above demonstrate that EMTALA does not require abortion as a stabilizing treatment. Essentially, he argues that an emergency termination is never necessary in these situations because a woman suffering from conditions such as PPROM, preeclampsia, or placental abruption, but who is not facing death, can always be stabilized for transfer. He says the fact that the six airlifts occurred necessarily “prove[s] that abortion was not necessary to provide the stabilizing care.” Id. at 34.
The first problem with this argument is that the declarations on file clearly set out situations where abortion is the necessary stabilizing treatment—direct evidence of a nonspeculative conflict.9 See, e.g., Corrigan Dec. ¶ 29, US v. Idaho Dkt. 17-6 (describing a patient with preeclampsia with severe features, where “[t]he only medically accepted standard of care” in her case “was to terminate the pregnancy through evacuation of the uterus“). To highlight one example, Dr. Seyb describes a patient, ultimately airlifted to a neighboring state, who came to the emergency room experiencing PPROM while 20 weeks pregnant. Her pregnancy was pre-viability, and the infection threatened to damage her kidneys and render her infertile. See Seyb Supp. Dec. ¶ 9. This easily meets EMTALA‘s definition of an emergency medical condition. The treating physician determined “that, without termination, the patient‘s kidneys could stop functioning,” meaning that an abortion was the appropriate stabilizing care within the meaning of EMTALA. But the physician could not “say that termination was necessary to prevent death“—imminent or otherwise. Id. ¶ 9. The Court therefore rejects the Attorney General‘s assertion that “there is no medical situation in which it‘s necessary to do an abortion as the stabilizing care.” Mar. 5, 2025 Tr., Dkt. 40, at 34.
The second problem with the Attorney General‘s argument is that the mere fact
The term “to stabilize” means, with respect to an emergency medical condition described in paragraph (1)(A), to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of an individual from a facility . . . .
Of course, airlifting patients also puts patients at risk due to significant delays in care while arranging medical transport out of state. And those delays could create a situation where the patient is no longer stable enough that the benefits of transfer outweigh the risks, again leaving St. Luke‘s medical providers to wait until termination is necessary to prevent the patient‘s death—even while knowing that the wait could have severe health consequences, including damage to the patient‘s future reproductive health. As a result, St. Luke‘s physicians described a constant fear that patients would present in an emergency room who were not stable enough to transfer, yet the medically indicated stabilizing care—termination—could not be provided because it was not yet needed to prevent the patient‘s death.
Compl. ¶ 53, Dkt. 1 (emphasis added).
Consistent with this allegation, Dr. Seyb‘s declaration discusses the risk-benefit analysis that attended the airlifts. See Supp. Seyb Dec. ¶ 17, Dkt. 2-2. In other words, it appears that each of those six patients was experiencing an emergency medical condition, but the benefits of transfer outweighed the risks. See id. ¶ 8 (indicating that the six patients had to be airlifted because St. Luke‘s was “unable to provide the full range of stabilizing care necessary to preserve the patient‘s health“). This tracks with Dr. Seyb‘s description of the six airlifted patients, where he states that each patient was experiencing an emergency medical condition: “In these instances, each patient was experiencing an emergency medical condition that placed her health in serious jeopardy, risked serious impairment to her bodily functions, or risked serious dysfunction to bodily organs or parts. The treating physicians—either one of my colleagues or I—would have offered and/or recommended termination as a treatment option, consistent with the standard of care, but believed we could not do so consistent with § 18-622.” Seyb Supp. Dec. ¶ 15, Dkt. 2-2 (emphasis added). The Attorney General‘s argument that an abortion is never the necessary stabilizing care under EMTALA is thus contradicted by the record.
Another problem with the Attorney General‘s argument that there is no practical conflict between EMTALA and the Defense of Life Act is that he is attempting to impose the rigidities of criminal law onto the fluid nature of delivering emergency medical care. Although the Idaho Supreme Court has said that a pregnant woman‘s death need not be “imminent” to
The Attorney General‘s suggestion that St. Luke‘s should simply transfer pregnant emergency-room patients also stands antithetical to EMTALA‘s key purpose. The Attorney General—along with several Supreme Court justices—have emphasized the fact that Congress enacted EMTALA in response to “patient dumping.” D.‘s Resp. to Pl.‘s Suppl. Brief at 5, Dkt. 47; D.‘s Consol. Mem. at 28, Dkt. 25-1; Moyle, 603 U.S. at 352 (Alito, J., dissenting). Before EMTALA, hospitals would often turn away or transfer patients “deemed troublesome or undesirable.” Makenzie Doubek & Scott J. Schweikart, Why Should Physicians Care About What Law Says About Turfing and Dumping Patients?, 25 AMA Journal of Ethics 892 (2023). When EMTALA passed, these “undesirable” patients were the indigent. Today, they are pregnant women. Although Congress could not have foreseen this dimension of patient dumping—women transferred to other facilities not because they are poor but because the emergency service they need has been criminalized—EMTALA‘s requirements are deliberately broad. Patients cannot be transferred to another facility until they have received stabilizing treatment, regardless of whether they can pay and regardless of what form that care must take.
In sum, the Court reaches the same conclusion it reached before, in United States v. Idaho. That is, in a narrow range of cases, it is impossible to simultaneously comply with EMTALA and
Neither the Idaho legislature‘s amendment to § 18-622 nor the Idaho Supreme Court‘s decision Planned Parenthood of the Great Nw. v. State, 522 P.3d 1132, 1202-04 (Idaho 2023), changes this conclusion. The 2023 amendments to
Finally, the fact that the Idaho Supreme Court adopted a subjective, good-faith medical judgment standard for the life-of-the-mother exception does not cure the uncertainty regarding what Idaho‘s Defense of Life Act allows medical professionals to do. See Seyb Supp. Dec. ¶ 19, Dkt. 2-2. Even in that situation, the state‘s prosecutors may call “other medical experts” to opine on “whether the abortion was, in their expert opinion, medically necessary” as a way of calling into question the doctor‘s good faith. This aspect of Idaho‘s law was explored during the following exchange between Justice Barrett and counsel for Idaho:
Justice Barrett: What if the prosecutor thought differently? What if the prosecutor thought, well, I don‘t think any good-faith doctor could draw that conclusion, I‘m going to put on my expert?
Idaho‘s Counsel: ...that, Your Honor, is the nature of prosecutorial discretion, and it may result in ... a case ....
Transcript, at 29:3-11 (emphasis added). Thus, notwithstanding the Idaho Supreme Court‘s adoption of a subjective, good-faith standard,
ii. The Spending Clause
That Congress enacted EMTALA pursuant to its spending power does not change the above analysis. The Attorney General raises the novel constitutional argument—also asserted on appeal in United States v. Idaho—that the Supremacy Clause does not always apply to Spending Clause legislation. The Court rejects this inversion of the principles of federalism.
The Spending Clause empowers Congress to “lay and collect Taxes, . . . to pay the Debts and provide for the general Welfare of the United States.”
Here, Idaho has not accepted the federal funds at issue; those funds are paid to the participating hospitals, including St. Luke‘s. Since Spending Clause legislation is viewed as being “much in the nature of a contract,” this raises the problem that Idaho has not accepted the terms of this particular contract. See generally NFIB v. Sebelius, 567 U.S. 519, 576-77 (2012) (observing that the Supreme Court has “repeatedly characterized . . . Spending Clause legislation as ‘much in the nature of a contract‘“) (emphasis in original; citation omitted). As the Attorney General puts it, “[t]he United States’ contract with a private hospital cannot bind a nonconsenting state, any
But the point of requiring states to knowingly and voluntarily assent to conditions stated in Spending Clause legislation is that Congress would otherwise be unable to impose those conditions on the states. Those concerns are not present here. As the Supreme Court recognized in Gonzales v. Oregon, “[e]ven though regulation of health and safety is ‘primarily, and historically, a matter of local concern,’ there is no question that the Federal Government can set uniform national standards in these areas.” 546 U.S. 243, 271 (2006) (internal citations omitted; emphasis added). Thus, Congress may regulate the provision of emergency medical services under the Commerce Clause. Cf. Gonzales v. Raich, 545 U.S. 1, 9 (2005) (holding that the Commerce Clause empowers Congress to prohibit state-law-permitted individual marijuana cultivation for personal medical purposes); see also Dobbs v. Jackson Women‘s Health Organization, 597 U.S. 215, 337 (2022) (Kavanaugh, J.) (recognizing that when it comes to abortion, “[t]he Constitution is neutral and leaves the issue for the people and their elected representatives to resolve through the democratic process in the States or Congress . . . .“) (emphasis added).
The Court is not persuaded by the Attorney General‘s various arguments to the contrary. Among other things, the Attorney General says that although the Commerce Clause “authorizes Congress to regulate interstate commerce” it does not allow Congress “to order individuals to engage in it.” NFIB, 567 U.S. at 588. He likens the situation here to the individual mandate at issue in NFIB v. Sebelius, 567 U.S. 519 (2012). But that analogy doesn‘t hold because the relevant parties are already engaged in commerce: hospitals are already providing emergency healthcare services and pregnant patients are already arriving at those hospitals seeking emergency services.
Returning to the broader principle, then, Congress doesn‘t need Idaho‘s consent here, because it could adopt the regulation directly. That the structure of EMTALA suggests it was enacted under the Spending Clause instead of the Commerce Clause doesn‘t change that conclusion. As the Supreme Court has explained, “[t]he ‘question of the constitutionality of action taken by Congress does not depend on recitals of the power which it undertakes to exercise.‘” NFIB, 567 U.S. at 570 (citing Woods v. Cloyd W. Miller Co., 333 U.S. 138, 144 (1948)).
The Ninth Circuit confirmed this principle in Nevada v. Skinner, 884 F.2d 445 (9th Cir. 1989). There, Nevada argued that Congress had imposed coercive conditions attendant to an exercise of its spending power by conditioning receipt of highway funds on states’ adoption of a 55-mph speed limit. Id. at 446-47. The court held that the “anti-coercion principle” was “simply inapplicable” because Congress could have imposed the 55-mph speed limit though an exercise of its power to regulate commerce. Id. at 450. As the court explained, “if Congress has
the authority under the Commerce Clause to order a state directly to comply with a particular standard such as a 55-mile-per-hour speed law, we see no reason why Congress should be prohibited from reaching that same result indirectly by withholding funds if the state fails to comply with that standard.” Id. at 449. The same is true here.
This interpretation further reflects the Supreme Court‘s long-held understanding
iii. The Text, Context, and Purpose of EMTALA
The Attorney General next contends that the text, context, and purpose of EMTALA “preclude reading it as a preempting abortion mandate.” Response, Dkt. 25-1, at 23. This argument is primarily rooted in EMTALA‘s various references to protecting an “unborn child.” See
These references to the unborn child do not alter a hospital‘s core obligation to offer an abortion if that is the stabilizing treatment EMTALA guarantees. Having considered the parties’ various arguments on this point (including arguments based on the concurring and dissenting opinions in Moyle v. United States, 603 U.S. 324 (2024)), the Court is persuaded by the reasoning set forth in Justice Kagan‘s concurring opinion. See Moyle, 603 U.S. at 330-31 (Kagan, J., concurring). As Justice Kagan explains, the parenthetical reference to an “unborn child” in EMTALA‘s definition of an emergency medical condition, which “was added in an amendment to EMTALA,10 ensures that a woman with no health risks of her own can demand emergency-room treatment if her fetus is in peril. It does not displace the hospital‘s duty to a woman whose life or health is in jeopardy, and who needs an abortion to stabilize her condition. Then, the statute requires offering that treatment to the woman.” Moyle, 603 U.S. at 331 (Kagan, J., concurring) (emphasis added).
The Court is likewise unpersuaded by the Attorney General‘s argument that EMTALA‘s purpose and context are inconsistent with what he calls “a preempting abortion mandate.” The Attorney General correctly observes that a key purpose of EMTALA was to prevent “patient-dumping” by discharging or transferring critically ill patients who lacked insurance rather than providing them “the care they need.” 131 Cong. Rec. 28, 569 (1985) (Sen. Kennedy). But the statute‘s text and legislative history show that patient-dumping was not the only concern. Rather, Congress‘s concern about “‘patient dumping’ reflected its commitment to a broader principle that ‘every patient who has a bonafide emergency’ should receive stabilizing care.” Id. The statute Congress enacted plainly mandates that care.
The larger context in which EMTALA was enacted—particularly, the Hyde Amendment‘s restrictions on abortion funding—does not alter this conclusion. Congress enacted the first version of the Hyde Amendment in 1976 as a rider to an appropriations bill. The amendment restricted the use of federal funds to pay for abortion services. The language and scope of the Hyde Amendment changed over the years, but the version in effect when EMTALA was enacted and amended prohibited using federal funds to pay for abortions except when the life of the mother would be endangered if the fetus was carried to term. Given that context, the Attorney General say it is not plausible to conclude that EMTALA permits emergency abortions.
But the Hyde Amendment does not limit EMTALA‘s underlying stabilization obligation. And just because an abortion—or any other stabilizing treatment, for that matter—will not be subsidized with federal funds doesn‘t excuse participating hospitals from EMTALA‘s stabilization mandate. Indeed, much of the care EMTALA requires will not be subsidized by federal funds. The United States made this point before the Supreme Court, offering this hypothetical:
I‘ll give you an example of a Medicare patient who goes in and his emergency medical condition means he needs a particular drug that‘s not covered by his Medicare benefits. Still, the hospital has to provide him with stabilizing treatment and give him the medication, even though federal funding isn‘t going to pay for it.
And that also applies to people who are uninsured, who aren‘t covered by Medicare in the first instance. The ... whole point of EMTALA was it doesn‘t matter your circumstances, it doesn‘t matter whether you can pay or not, it doesn‘t matter the particulars of your situation, this is a guarantee. You can get the stabilizing treatment.
Apr. 24, 2024 Tr., at 94:21 to 95:11.11 Put another way, EMTALA and the Hyde
The Court believes the more relevant legislative context is found in Congress‘s passage of the Affordable Care Act. In a section of that Act dealing entirely with abortion, Congress provided that the Affordable Care Act would not require insurance plans to cover abortion and prohibited the use of federal subsidies for abortions.
The Attorney General says this view of the Affordable Care Act is flawed because another provision says state abortion laws are not preempted. But that provision is limited to state laws regarding coverage, funding, and procedural requirements. It provides:
Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of (or requirement of) coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of an abortion on a minor.
iv. National Standard of Care
The Attorney General‘s next argument arises from cases holding that EMTALA does not establish a national standard of care. The logic is that because EMTALA does not establish a national standard of care, it cannot require hospitals to perform any specific medical procedure: “if state law prohibits a particular treatment, then the treatment is not available, and EMTALA does not require it.” Reply, Dkt. 29, at 9; see also Opp., Dkt. 25-1, at 23. Thus, the Attorney General says that even if terminating a pregnancy is the only treatment that will “stabilize” a patient with an “emergency medical condition” (as those terms are defined in EMTALA), and even if physicians at the hospital are capable of providing that treatment, EMTALA cannot require it. This interpretation distorts EMTALA‘s core mandate.
EMTALA does not create a private federal right of action for “medical malpractice” under “a national standard of care.” Bryant v. Adventist Health System/West, 289 F.3d 1162, 1166 (9th Cir. 2002); Eberhardt v. City of Los Angeles, 62 F.3d 1253, 1258 (9th Cir. 1995). But that
The Ninth Circuit‘s decision in Eberhardt v. City of Los Angeles, 62 F.3d 1253 (9th Cir. 1995), illustrates how federal and state laws operate in these situations. There, the plaintiff sued a hospital and physician for discharging his son in an unstable mental condition, alleging that they had violated EMTALA‘S requirement to properly screen and stabilize him. Regarding the screening requirement, the court explained that “[t]he hospital‘s failure to detect the decedent‘s alleged suicidal tendency may be actionable under state medical malpractice law, but not under EMTALA.” Id. at 1258. But the court also explained that “Congress‘s refusal to impose a national standard of care does not mean that a hospital can discharge its duty under EMTALA by not providing any screening, or by providing screening at such a minimal level that it properly cannot be said that the screening is ‘appropriate.‘” Id. (citing Baber v. Hosp. Corp. of Am., 977 F.2d 872, 879 n.7 (4th Cir. 1992)). And to determine what “appropriate” meant, the court looked to the standard articulated in EMTALA: “The touchstone is whether, as § 1395dd(a) dictates, the procedure is designed to identify an ‘emergency medical condition,’ that is manifested by ‘acute’ and ‘severe’ symptoms.” Id.
The Eberhardt court also had to decide if the hospital had violated EMTALA‘s stabilization requirement. That was an easier issue; the court decided there was no violation because the hospital hadn‘t detected an emergency medical condition in the first place. But the court nevertheless clarified that the hospital was independently obligated to satisfy EMTALA‘s stabilization requirement. And, once again, the Court noted that EMTALA‘s text would guide the inquiry:
[W]e do note that the stabilization requirement is not met by simply dispensing uniform stabilizing treatment, but rather, by providing the treatment necessary “to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result....”
42 U.S.C. § 1395dd(e)(3)(A) .
Id. at 1259 n.3 (citing In the Matter of Baby K, 16 F.3d 590, 596 (4th Cir. 1994) (holding that “the Hospital must provide that treatment necessary to prevent the material deterioration of each patient‘s emergency medical condition“)).
Under Eberhardt‘s logic, although EMTALA does not supplant state medical malpractice law, states cannot enact legislation denying patients the right to an “appropriate” screening examination. Nor can states enact legislation denying the stabilizing care EMTALA guarantees. If they do, it is state law that must give way—not federal law.
B. Likelihood of Irreparable Harm
Turning to likelihood of irreparable harm in the absence of an injunction, the Court easily finds St. Luke‘s has made this showing. Given the unique posture of
Allowing the law to go back into full effect would prevent St. Luke‘s medical providers from providing necessary care in emergency circumstances, resulting in significant and irreparable harm. And if St. Luke‘s is unable to provide this care, St. Luke‘s likely will be directly harmed, including a potential loss of Medicare funds, the possibility of private lawsuits by patients denied the stabilizing care mandated by EMTALA, and the potential loss of staff.
C. The Balance of the Equities and the Public Interest
The next question is whether the balance of equities tips in the St. Luke‘s favor and whether an injunction is in the public interest. When the government is a party, these factors merge. See Drakes Bay Oyster Co. v. Jewell, 747 F.3d 1073, 1092 (9th Cir. 2020).
Looking first to the public at large, in the most general sense, “preventing a violation of the Supremacy Clause serves the public interest.” United States v. California, 921 F.3d 865, 893-94 (9th Cir. 2019). But the equities also favor St. Luke‘s and the public in a more direct, tangible way. In the absence of an injunction, St. Luke‘s patients will be unable to access EMTALA-mandated stabilizing care, which, in turn, would likely lead to the patient-dumping EMTALA was designed to stop and which occurred when this Court‘s previous injunction was stayed.
The Attorney General says the equities and public interest favor him because Idaho should be able to exercise its powers without “unnecessary interference from federal overreach.” Opp., Dkt. 25-1, at 35. He argues the State has an interest in protecting unborn children and that “[e]ach day that the Act is enjoined undermines the public interest.” Id. He also claims that Idaho‘s Defense of Life Act is saving lives: “[i]n 2023, the first full year in which Idaho‘s [abortion] laws were in effect, pregnancy-related deaths dropped by 44.4 % compared to 2021.” Id. at 1. The Court has reservations about that reported statistic.12 But assuming its accuracy, the argument ignores the fact that there was a
It‘s also worth repeating that the injunction St. Luke‘s requests is a modest one. Even when the injunction is in place, the Attorney General will be free to enforce
D. The Scope of the Injunction
The final task is to determine the appropriate scope of the injunction. The TRO currently in effect states:
Specifically, the Attorney General, including his officers, employees, and agents, are prohibited from initiating any criminal prosecution against, attempting to suspend or revoke the professional license of, or seeking to impose any other form of liability on, any medical provider or hospital based on their performance of conduct that is defined as an “abortion” under Idaho Code § 18-604(1), but that is necessary to avoid: (i) “placing the health of” a pregnant patient “in serious jeopardy“; (ii) a “serious impairment to bodily functions” of the pregnant patient; or (iii) a “serious dysfunction of any bodily organ or part” of the pregnant patient, pursuant to
42 U.S.C. § 1395dd(e)(1)(A)(i) -(iii)
Dkt. 33, at 4. The TRO is only in effect until the Court issues this decision, so the Court is free to change its mind about the scope of the TRO. And, in any event, the Ninth Circuit has “long recognized ‘the well-established rule that a district judge always has power to modify or to overturn an interlocutory order or decision while it remains interlocutory.‘” Credit Suisse First Bos. Corp. v. Grunwald, 400 F.3d 1119, 1124 (9th Cir. 2005) (quoting Tanner Motor Livery, Ltd. v. Avis, Inc., 316 F.2d 804, 809 (9th Cir. 1963)).
The Attorney General says the TRO should be narrowed in two respects. First, he says it shouldn‘t apply to anyone other than St. Luke‘s. Second, he says the Court restrained conduct that falls outside EMTALA‘s stabilization mandate. Put differently, the Attorney General says the TRO applies to too many people and restrains too much conduct.
i. The Scope of Conduct
The Court will begin with the scope of the conduct restrained. The Attorney General says the restraining order sweeps too broadly because it allows healthcare providers
Specifically, the Attorney General, including his officers, employees, and agents, are prohibited from initiating any criminal prosecution against, attempting to suspend or revoke the professional license of, or seeking to impose any other form of liability on, any medical provider or hospital based on their performance of conduct that is defined as an “abortion” under
Idaho Code § 18-604(1) , but that isnecessary to avoid: (i) “placing the health of” a pregnant patient “in serious jeopardy“; (ii) a “serious impairment to bodily functions” of the pregnant patient; or (iii) a “serious dysfunction of any bodily organ or part” of the pregnant patient, pursuant to 42 U.S.C. § 1395dd(e)(1)(A)(i) (iii)necessary to “stabilize” a patient presenting with an “emergency medical condition” as required by EMTALA pursuant to42 U.S.C. § 1395dd(e)(1)(A) ,(3)(A) .
This revised language continues to capture the intended effect of the injunction, and the Attorney General has indicated that this revision addresses his concern regarding the “necessary to avoid” framework. See Reply, Dkt. 43, at 11. Accordingly, the Court will modify the injunction to incorporate this revision.
ii. The Universal Injunction
The next issue is whether the injunction should apply to parties not before the Court. The TRO the Court entered applied to “any medical provider or hospital,” yet St. Luke‘s is the only plaintiff before the Court. The Attorney General says such an injunction is erroneous, particularly given the Supreme Court‘s order in Labrador v. Poe ex rel. Poe, 144 S. Ct. 921 (2024), where several members of the Supreme Court questioned the value of universal injunctions. Id. at 921-28 (Gorsuch, J., concurring, joined by Thomas, J. and Alito, J.); id. at 928-34 (Kavanaugh, J., concurring, joined by Barrett, J.).
“The general rule regarding the scope of preliminary injunctive relief is that it ‘should be no more burdensome to the defendant than necessary to provide complete relief to the plaintiffs before the court.‘” Regents of the Univ. of California v. U.S. Dep‘t of Homeland Sec., 908 F.3d 476, 511 (9th Cir. 2018), rev‘d in part, vacated in part, 591 U.S. 1 (2020) (citation omitted). And “where relief can be structured on an individual basis, it must be narrowly tailored to remedy the specific harm shown.” City & County of San Francisco v. Trump, 897 F.3d 1225, 1244 (9th Cir. 2018) (quoting Bresgal v. Brock, 843 F.2d 1163, 1170-71 (9th Cir. 1987)). Nonetheless, “broad injunctions are appropriate when necessary to remedy a plaintiff‘s harm.” East Bay Sanctuary Covenant v. Garland, 994 F.3d 962, 986 (9th Cir. 2020). Similarly, “an injunction is not necessarily made over-broad by extending benefit or protection to persons other than prevailing parties in the lawsuit—even if it is not a class action—if such breadth is necessary to give prevailing parties the relief to which they are entitled.” Bresgal, 843 F.2d at 1171-72 (emphasis in original).
Granted, St. Luke‘s does not exist in vacuum, and it suggests it would not have the capacity to accept transfers from other Idaho hospital systems, which, in turn, would impact its ability to appropriately care for its patients. See Response, Dkt. 39, at 3; Seyb Supp. Dec. ¶ 24, Dkt. 2-2. In other words, St. Luke‘s says this is a systemic problem that justifies statewide relief. St. Luke‘s also says that if the injunction is narrowed to cover only St. Luke‘s, this would create “difficult administrability issues” because providers would be subject to different rules at different hospitals. Response, Dkt. 39, at 6. The problem, however, is that the Court must focus on the harm St. Luke‘s alleges to itself, and what sort of injunction would remedy that harm. And the potential additional strain on St. Luke‘s resources, as well as the stated “administrability issues,” are—relatively speaking—small and indirect harms. Thus, in keeping with the requirement that an injunction be narrowly tailored to remedy the specific harm shown, the Court will modify the restraining order. That said, the Court will not limit the injunction only to St. Luke‘s; it will include St. Luke‘s medical providers as well. Although these medical providers are not before the Court, a broader injunction is nonetheless necessary. To redress the harms St. Luke‘s alleges to itself, St. Luke‘s medical providers must have the ability to provide EMTALA-mandated stabilizing care.
iii. St. Luke‘s “Concessions”
Finally, the Attorney General says the restraining order must be modified such that it explicitly accounts for “St. Luke‘s concessions, which were in line with the concessions of the United States Solicitor General.” Motion, Dkt. 34, at 5 (citing Dkt. 2-1 at 17-18). This issue received very little attention in the briefing. The Attorney General included a single sentence in his motion, which just directed the Court to St. Luke‘s brief. The cited portion of the brief, in turn, discussed statements the Solicitor General made during oral argument in United States v. Idaho. These statements relate to mental health emergencies, post-viability abortions, conscience protections, and the fact that EMTALA requires treatment only when a medical situation is acute. The cited portion of St. Luke‘s brief states:
The United States did not make any representations before the Supreme Court that were not already true about EMTALA‘s scope. It explained that: (1) EMTALA does not require pregnancy termination as stabilizing care to treat mental health conditions, (2) EMTALA does not require abortion after viability since post-viability, the pregnancy can terminate through delivery; (3) EMTALA requires treatment only when a medical situation is acute; and (4) EMTALA does not override conscience protections. But these points were always true about EMTALA; the EMTALA this Court confronts today is unchanged and its injunction‘s scope remains correct.
Dkt. 2-1, at 17 (internal citations omitted).
The Court does not find it necessary to modify the injunction to specifically address
E. Bond Requirement
The Court will waive the bond requirement, finding that a bond under
ORDER
1. Defendant‘s Motion to Dismiss (Dkt. 25) is DENIED.
2. Plaintiff‘s Motion for a Preliminary Injunction (Dkt. 2) and Defendant‘s Motion to Modify the Universal TRO (Dkt. 34) are GRANTED IN PART and DENIED in part, in that the Court will enter the following preliminary injunction:
3. The Court orders that Attorney General Raúl Labrador—and his officers, employees, and agents—are preliminarily enjoined from enforcing
4. This preliminary injunction is effective immediately and shall remain in full force and effect through the date on which judgment is entered in this case.
DATED: March 20, 2025
B. Lynn Winmill
U.S. District Court Judge