UNITED STATES OF AMERICA, Plaintiff, v. THE STATE OF IDAHO, Defendant.
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF IDAHO
August 24, 2022
INTRODUCTION
Pregnant women in Idaho routinely arrive at emergency rooms experiencing severe complications. The patient might be spiking a fever, experiencing uterine cramping and chills, contractions, shortness of breath, or significant vaginal bleeding. The ER physician may diagnose her with, among other possibilities, traumatic placental abruption, preeclampsia, or a preterm premature rupture of the membranes. In those situations, the physician may be called upon to make complex, difficult decisions in a fast-moving, chaotic environment. She may conclude that the only way to prevent serious harm to the patient or save her life is to terminate the pregnancy—a devastating result for the doctor and the patient.
So the job is difficult enough as it is. But once
Granted, the Idaho statute offers the physician the cold comfort of a narrow affirmative defense to avoid conviction. But only if she convincеs a jury that, in her good faith medical judgment, performing the abortion was “necessary to prevent the death of the pregnant woman” can she possibly avoid conviction. Even then, there is no certainty a jury will acquit. And the physician cannot enjoy the benefit of this affirmative defense if she performed the
Back to the pregnant patient in the emergency department. The doctor believes her EMTALA obligations require her to offer that abortion right now. But she also knows that all abortions are banned in Idaho. She thus finds herself on the horns of a dilemma. Which law should she violate?
Fortunately, the drafters of our Constitution had the wisdom to provide a clear answer in Article VI, Paragraph 2 of the Constitution—the Supremacy Clause. At its core, the Supremacy Clause says state law must yield to federal law when it is impossible to comply with both. And that is all this case is about. It is not about the bygone constitutional right to an abortion. This Court is not grappling with that larger, more profound question. Rаther, the Court is called upon to address a far more modest issue—whether Idaho‘s criminal abortion statute conflicts with a small but important corner of federal legislation. It does.
As such, the United States has shown it will likely succeed on the merits. Given that—and for the reasons discussed in more detail below—the Court has determined it should preserve the status quo while the parties litigate this matter. The Court will therefore grant the United States’ motion. During the pendency of this lawsuit, the State of Idaho will be enjoined from enforcing
BACKGROUND
A. The Emergency Medical Treatment and Labor Act
Congress enacted EMTALA in 1986 with the overarching purpose of ensuring that all patients receive adequate emergency medical care—regardless of the patient‘s ability to pay and regardless of whether the patient qualifies for Medicare. See Arrington v. Wong, 237 F.3d 1066, 1073-74 (9th Cir. 2001) (citation omitted). Under that Act, when a patient arrives at an emergency department and requests treatment, the hospital must provide an appropriate screening examination “to determine whether or not an emergency condition” exists.
(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—
- (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; . . .
EMTALA applies to every hospital that has an emergency department and participates in Medicare. See
B. Idaho‘s Criminal Abortion Law2
that “[e]very person who performs or attempts to perform an abortion . . . commits the crime of criminal abortion.”
Criminal abortion is a felony punishable by at least two, and up to five, years’ imprisonment.
The statute provides two affirmative defenses. As relevant here, an accused physician may avoid conviction by proving, by a preponderance of the evidence, that:
(1) The physician determined, in his good faith medical judgment and based on the facts known to the physician at the time, that the abortion was necessary to prevent the death of the pregnant woman; and
(2) The physician performed or attempted to perform the abortion in the manner that, in his good faith medical judgment and based on the facts known to the physician at the time, provided the best opportunity for the unborn child to survive, unless, in his good faith medical judgment, termination of the pregnancy in that manner would have posed a greater risk of the death of the pregnant woman.
C. Facts
Idaho has roughly 22,000 births per year. Not surprisingly then, some patients will experience serious, pregnancy-related complications thаt qualify as an “emergency medical condition” under EMTALA. See generally Fleisher Dec. ¶ 12, Dkt. 17-3; Corrigan Dec. ¶¶ 9-30, Dkt. 17-6; Cooper Dec. ¶¶ 6-12, Dkt. 17-7; Seyb Dec. ¶¶ 4-13, Dkt. 17-8.
One relatively straightforward example is a patient who presents at an emergency
In addition to ectopic pregnancies, there are many other complications that may arise during pregnancy—all of which may place the patient‘s health in serious jeopardy or threaten bodily functions. Despite the risks such conditions present, it is not always possible for a physician to know whether treatment for any particular condition, at any particular moment in time, is “necessary to prevent the death” of the pregnant patient, which is the prerequisite to their relying on the affirmative defense offered by the criminal abortion statute. See Fleisher Dec. ¶¶ 13-21, Dkt. 17-3. Some examples include the following scenarios:
- A patient arrives at an emergency room with nausea and shortness of breath, leading to a diagnosis of preeclampsia. Preeclampsia can quickly progress to eclampsia, with the onset of seizures.
- A woman arrives at an emergency room with an infection after the amniotic sac surrounding the fetus has ruptured. That condition can progress into sepsis, at which point the patient‘s organs may fail.
- A patient arrives at the hospital with chest pain or shortness of breath, which leads the physician to discover elevated blood pressure or a blood clot.
- A patient arrives at the emergency room with vaginal bleeding caused by a placental abruption. Placental abruption is when the placenta partly or completely separates from the inner wall of the uterus. It can lead to catastrophic or uncontrollable bleeding. If the bleeding is uncontrollable, the patient may go into shock, which could result in organ dysfunction such as kidney failure, and even cardiac arrest.
Id. ¶¶ 15-22.
Idaho physicians have submitted declarations describing specific patients who have presented with these types of complications and have required abortions.3 Each
The impact of Idaho‘s criminal abortion statute on the emergency care
dictated by EMTALA is substantial. The United States has submitted declarations from four physicians practicing in Idaho who say that if
More broadly, Dr. Corrigan says that “while the State‘s physician declarations speak in terms of absolutes,” in her view, “medicine does not work that way in most cases. Death may be a possible or even probable outcome, but different outcomes or conditions may also be probable. That is why doctors frequently refuse to answer the question, ‘What are my chances?‘” Id. ¶ 9.
Dr. Corrigan also points out that if
Compliance with the EMTALA standards is significant to this state‘s health care system. In Idaho, there are thirty-nine hospitals that receive Medicare funding and provide emergency services. Wright Dec. ¶ 8, Dkt. 17-9. Between 2018 and 2020, these hospitals’ emergency departments received approximately $74 million in federal Medicare funding, which was conditioned on compliance with EMTALA. Shadle Dec. ¶ 6, Dkt. 17-10.
LEGAL STANDARD
The United States asks for a preliminary injunction to enjoin Idaho from enforcing its criminal abortion law to the extent it conflicts with EMTALA-mandated care. “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, the United States must establish that: (1) it is likely to succeed on the merits; (2) it is likely to suffer irreparable harm in the absence of
“A district court has considerable discretion in granting injunctive relief and in tailoring its injunctive relief.” United States v. AMC Entm‘t, Inc., 549 F.3d 760, 768 (9th Cir. 2008). Generally, a court must ensure that the relief is “tailored to eliminate only the specific harm alleged” and not “overbroad.” E. & J. Gallo Winery v. Gallo Cattle Co., 967 F.2d 1280, 1297 (9th Cir. 1992). “[I]njunctive relief should be no more burdensome to the defendant than necessary to provide complete relief to the plaintiffs.” Califano v. Yamasaki, 442 U.S. 682, 702 (1979). And in the context of enjoining a state statute subjected to an as-applied challenge, the Supreme Court has said, “Generally speaking, when confronting a constitutional flaw in a statute, we try to limit the solution to the problem. We . . . enjoin only the unconstitutional applications of a statute while leaving other applications in force.” Ayotte v. Planned Parenthood of N. New England, 546 U.S. 320, 328-29 (2006).
ANALYSIS
The key substantive question this Court must address is whether
A. Cause of Action
The United States has the unquestioned authority to sue. It has asked this Court, sitting in equity, to partially enjoin the enforcement of
In a somewhat related argument, the State, in its briefing, attempted to raise[] serious concerns that EMTALA‘s required stabilizing treatment, as interpreted by the United States and expressed in this litigation, is invalid as
B. Standing
To establish standing, the United States must demonstrate that it has suffered an injury in fact that is fairly traceable to Idaho‘s actions and that will likely be redressed by a favorable decision from the Court. Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-61 (1992).
Here, United States alleges at least three types of harm. First, the United States’ sovereign interests are harmed when its laws are violated. See Vt. Agency of Nat. Res. v. United States ex rel Stevens, 529 U.S. 765, 771 (2000); United States v. Arizona, 641 F.3d 339, 366 (9th Cir. 2011), rev‘d in part on other grounds, 567 U.S. 387 (2012). Second, if
From there, the standing analysis is simple. The harms the United States alleges are traceable to Idaho‘s actions in enacting and, soon, enforcing
C. Facial versus As-Applied
“As a gеneral matter, a facial challenge is a challenge to an entire legislative enactment or provision,” Hoye v. City of Oakland, 653 F.3d 835, 857 (9th Cir. 2011), and a successful facial challenge “invalidates the law itself.” Italian Colors Restaurant v. Becerra, 878 F.3d 1165, 1175 (9th Cir. 2018). An as-applied challenge, on the other hand, “challenges only one of the rules in a statute, a subset of the statute‘s applications, or the application of the statute to a specific circumstance.” Hoye, 653 F.3d at 857. Thus, “a successful as-applied challenge invalidates only the particular application of the law.” Italian Colors, 878 F.3d at 1175 (internal quotation and citation omitted).
Ultimately, though, “[t]he label is not what matters.” Doe v. Reed, 561 U.S. 186, 194 (2010) (acknowledging that plaintiffs’ claim had characteristics of both an as-applied and facial challenge). Rather, the “important” inquiry is whether the “claim and the
Here, a quick skim of the United States’ complaint reveals an as-applied challenge. In its prayer for relief, the United States asks the Court to issue a declarаtory judgment stating that ”
The State acknowledges this limiting language but nevertheless argues that the United States is bringing a facial challenge, based on the United States’ argument that there is a conflict in all instances in which both EMTALA and
The Court does not find the State‘s argument persuasive because it has failed to properly account for the staggeringly broad scope of its law, which has been accurately characterized by this Court and the Idaho Supreme Court as a “Total Abortion Ban.” See Planned Parenthood Great Nw. v. Idaho, --- P.3d ---, 2022 WL 3335696, at *1 (Idaho Aug. 12, 2022). As will be discussed more fully below,
Moreover, even if the Court were to construe the challenge as a facial one—focusing only on the subset of abortions EMTALA requires—the United States is still likely to succeed on the merits of its claim. As explained below, even within that subset there will always be a conflict between EMTALA and
D. Likelihood of Success on the Merits
With these threshold questions resolved, the Court turns to whether the United States is entitled to a preliminary injunction. The first question—whether the United States is likely to succeed on the merits—is the most important. California v. Azar, 950 F.3d 1067, 1083 (9th Cir. 2020). To resolve that question, the Court is guided by the Supremacy Clause and basic preemption principles.
1. The Supremacy Clause & Preemption
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 through an express preеmption provision, which says EMTALA preempts state law only “to the extent that the [state law] requirement directly conflicts with a requirement of this section.”
2. Impossibility Preemption
Here, it is impossible to comply with both statutes. As already discussed, when pregnant women come to a Medicare-funded hospital with an emergency medical condition, EMTALA obligates the treating physician to provide stabilizing treatment, including abortion care. But regardless of the pregnant patient‘s condition, Idaho statutory law makes that treatment a crime.
The statute‘s affirmative defense does not cure the impossibility. An affirmative defense is an excuse, not an exception. The difference is not academic. The affirmative defense admits that the physician committed a crime but asserts that the crime was justified and is therefore legally blameless. And it can only be raised after the physician has already faced indictment, arrest, pretrial detention, and trial for every abortion they perform. See generally United States v. Sisson, 399 U.S. 267, 288 (1970) (indictments need not anticipate affirmative defenses). So even though accused healthcare workers might avoid a conviction, the statute still makes it impossible to provide an abortion without also committing a crime.
Moreover, even taking the affirmative defense into account, the plain language of the statutes demonstrates that EMTALA requires abortions that the affirmative defense would not cover. When an abortion is the necessary stabilizing treatment, EMTALA directs physicians to provide that care if they reasonably expect the patient‘s condition will result in serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or serious jeopardy to the patient‘s health.
(11th ed. 2019). And the Idaho Supreme Court has said that “[w]hen engaging in statutory interpretation,” it “begins with the dictionary definitions of disputed words or phrases contained in the statute.” Idaho v. Clark, 484 P.3d 187, 192 (Idaho 2021). Thus, an abortion is only justified under the statute if the treating physician can persuade the jury that she made a good faith determination that the patient would have died if the abortion had not been performed.
EMTALA is thus broader than the affirmative defense on two levels. First, it demands abortion care to prevent injuries that are more wide-ranging than death. Second, and more significantly, it calls for stabilizing treatment, which of course may include abortion care—when harm is probable, whеn the patient could “reasonably be expected” to suffer injury. In contrast, to qualify for the affirmative defense, the patient‘s death must be imminent or certain
Finally, as the Court discusses further below, when the defense is put up against the realities of medical judgments, its scope is tremendously ambiguous. Although this makes it difficult to determine whether some abortions would qualify for both the affirmative defense and be mandated by EMTALA, that question is ultimately immaterial to the Court‘s determination that it is impossible for physicians to comply with both statutes.
Seeking to skirt the conflict between federal and state law, the Legislature advances three main points. First, the Legislature submits declarations from two physicians who offer up opinions as to what
The Legislature‘s primary example of ectopic pregnancies as falling outside the statutory prohibition further reveals the fallacy of their argument: Idaho law expressly defines “pregnancy” as “having a developing fetus in the body” and commencing at fertilization.
The Legislature next says that terminations of ectopic pregnancies—or any other, similar lifesaving procedures—do not fall within the scope of the statute because such terminations are “covered” by the exemption of
Second, during oral argument, the Legislature acknowledged the “conceptual textual conflicts” between
In short, given the extraordinarily broad scope of
3. Obstacle Preemption
Moreover, even if it were theoretically possible to simultaneously comply with both laws, Idaho law “stands as an obstacle to the accomplishment and execution of the full purposes and objectives of Congress.” Crosby, 530 U.S. at 373. To be sure, the Supreme Court has cautioned that “a high threshold must be met if a state law is to be pre-empted for conflicting with the purposes of a federal Act.” Chamber of Commerce of the United States v. Whiting, 563 U.S. 582, 607 (2011) (citation and quotation omitted). Nevertheless, that threshold is met when it is plain that “Congress made ‘a considered judgment’ or ‘a deliberate choice’ to preclude state regulation” because “a federal enactment clearly struck a particular balance of interests that would be disturbed or impeded by state regulation.” In re Volkswagen “Clean Diesel” Mktg., Sales Practices, & Prods. Liab. Litig., 959 F.3d 1201, 1212 (9th Cir. 2020) (quoting Arizona, 567 U.S. at 405).
“The first steр in the obstacle preemption analysis is to establish what precisely were the purposes and objectives of Congress in enacting” the statute at issue. Chamber of Commerce v. Bonta, 13 F.4th 766, 778 (9th Cir. 2021). For nearly four decades, EMTALA has served as the bedrock for the emergency-care safety net. Congress enacted EMTALA primarily because it was “concerned that medically unstable patients are not being treated appropriately” including in “situations where treatment was simply not provided.” H.R. Rep. No. 99-241, Pt. I, at 27 (1985). Congress‘s clear purpose was to establish a bare minimum of emergency care that would be available to all people in Medicare-funded hospitals. See Arrington v. Wong, 237 F.3d 1066, 1073-74 (9th Cir. 2001).
Congress chose to use “federal sanctions” to ensure that emergency screening and treatment was available for “all individuals for whom care is sought.” H.R. Rep. No. 99-241, Pt. III, at 4-5 (1985). But Congress was mindful that overly severe sanctions might lead “some hospitals, particularly those located in rural or poor areas, [to] decide to close their emergency rooms entirely rather than risk the . . . penalties that might еnsue.” Id. at 6. Notably, Congress took care to avoid sanctions that would “result in a decrease in available emergency care, rather than an increase in such care, which appears to have been the major goal of [EMTALA].” Id.
a. Idaho Code § 18-622 Deters Abortions
It goes without saying that all criminal laws have some deterrent effect. But the structure of Idaho‘s criminal abortion law—specifically that it provides for an affirmative defense rather than an exception—compounds the deterrent effect and increases the obstacle it poses to achieving the goals of EMTALA.
For one, the process of enduring criminal prosecution and licensing authоrity sanctions has a deterrent effect, regardless of the outcome. As Dr. Corrigan aptly explained, “[h]aving to defend against such a case would be incredibly burdensome, stressful, costly.” Corrigan Dec. ¶ 10, Dkt. 17-6. By criminalizing all abortions, Idaho guarantees that physicians will have to accept this hardship every time they perform an abortion. The result is reluctance to perform abortions in any circumstances.
The uncertain scope of the affirmative defense intensifies that result. Providers who might be willing to depend on the affirmative defense do not have the clarity to do so because of the statute‘s ambiguous language and the complex realities of medical judgments.
Consider what a defendant-physician needs to prove to avail herself of the affirmative defense. The core of the affirmative defense at issue requires the defendant-physician to show she determined “the abortion was necessary to prevent the death of the pregnant woman.”
Applying the standard to another medical context shows its ambiguity. Say a sovereign adopted a law that allowed oncologists to provide cancer treatment “only when necessary to prevent death.” Under that standard, oncologists would likely feel comfortable providing care to a patient with a stage four terminal cancer diagnosis. But what about a patient with stage one cancer? On the one hand, treatment may be lawful because the patient has a condition that, left untreated, will eventually, almost certainly cause death. On the other hand, the patient is not in danger of dying soon, so perhaps the oncologist needs to withhold treatment until the cancer progresses to the point where treatment is more obviously necessary to prevent death.
Idaho physicians treating pregnant women face this precise dilemma. As Dr. Cooper puts it, “For those patients who are clearly suffering from a severe pregnancy related illness and for which there is a clear indicated treatment, but death is not imminent, it is unclear whether I should provide the appropriate treatment because the circumstances may not justify the affirmative defense.” See Cooper Supp. Dec. ¶ 2, Dkt. 86-5. In other words, when, precisely, does the “necessary-to-prevent-death” language apply? Healthcare providers can seldom know the imminency of death because medicine rarely works in absolutes. Corrigan Supp. Dec. ¶ 9, Dkt. 86-3. Instead, physicians treat patients whose medical risks “exist along a continuum” without bright lines to specify “when exactly a condition becomes ‘life-threatening’ or ‘necessary to prevent the death’ of
But the affirmative defense is only available to physicians once they make that often “medically impossible” determination that “death [i]s the guaranteed outcome.” Corrigan Supp. Dec. ¶ 8; see also ACEP et al Amicus Br., Dkt. 62 at 6 (describing the affirmative defense as “a legislatively imagined but medically nonexistent line“); Fleisher Dec. ¶ 12, Dkt. 17-3 (“[I]n some cases where the patient‘s health is unambiguously threatened, it may be less clear whether there is also a certainty of death without stabilizing treatment—and a physician may not ever be able to confirm whether death would result absent immediate treatment.“).
In short, against the backdrop of these uncertain, medically complex situations, the affirmative defense is an empty promise—it does not provide any clarity. The upshot of this uncertainty is that even those providers willing to risk prosecution if they were confident in the availability of the affirmative defense will be deterred from providing emergency abortion care under EMTALA, where the availability of the defense is so uncertain.
And the Legislature cannot step in and say there is no obstacle to providing EMTALA-mandated care—that these Idaho healthcare workers may comfortably forge ahead and provided emergency abortions—based on its assertion that Idaho prosecutors would not enforce the law as written.4 The Legislature supports this argument with a single declaration from a single county prosecutor, who said he “would not prosecute any health care professional based on facts like those set forth in [the United States‘] declarations, and that he “believe[s] no Idaho prosecuting attorney would do so.” Loebs Dec. ¶ 7, Dkt. 71-6. But Idaho prosecutors have a statutory duty “to prosecute all felony criminal actions.”
One prosecutor‘s promise to refrain from enforcing the law as written, therefore, offers little solace to physicians attempting to navigate their way around both EMTALA and Idaho‘s criminal abortion laws—and whose “professional license, livelihood, personal security, and freedom”
b. Deterring Abortions is an Obstacle to EMTALA
The clear and intended effect of Idaho‘s criminal abortion law is to curb abortion as a form of medical care. This extends to emergency situations, obstructing EMTALA‘s purpose. Idaho‘s choice to impose severe and sweeping sanctions that decrease the overall availability of emergency abortion care flies in the face of Congress‘s deliberate decision to do the opposite.
The primary obstacle is delayed care. Under the status quo, physicians “rely upon their medical judgement or best practices for handling pregnancy complications.” Seyb Dec. ¶ 13, Dkt. 17-8. But because of the criminal abortion statute, “providers will likely delay care for fear of criminal prosecution and loss of licensure.” Id.; see also Cooper Supp. Dec. ¶ 7, Dkt. 86-5 (“provider fear and unease is real and widespread“). The incentive to do so is obvious—delaying care so that the patient gets nearer to death and thus closer to the blurry line of the affirmative defense. Providers may also delay care to allow extra time to consult with legal experts. See, e.g., Corrigan Dec. ¶ 25, Dkt. 17-6.
Delayed care is worse care. “The goal in medicine is to effectively identify problems and treat them promptly so patients are stabilized before they develop a life-threatening emergency. The Idaho law requires doctors to do the opposite—to wait until abortion is necessary to prevent the patient‘s death. See Huntsberger Dec. ¶ 12, Dkt. 86-4. Rather than providing the stabilizing treatment that EMTALA calls for, Idaho subjects women in medical crisis to periods of “serious physical and emotional trauma” as they wait to get nearer and nearer to death. Corrigan Supp. Dec. ¶ 13, Dkt. 86-3.
The wait for care is troubling enough on its own. Even worse, delayed care worsens patient outcomes. As a result of delay, “[p]atients may experience serious complications, have negative impacts on future fertility, require additional hospital resources including blood products, and some patients may die.” Huntsberger Dec. ¶ 15, Dkt. 86-4. A recent study of maternal morbidity in Texas confirms this. When a pregnant woman with specific pregnancy complications was treated with “the standard protocol of terminating the pregnancy to preserve the pregnant patient‘s life or health,” the rate of serious maternal morbidity was 33 percent. California et al Amicus Br., Dkt. 59 at 21.5 That rate reached 57 percent, nearly doubling, when providers used “an expectant-management approach,” meaning the physician provided “observation-only care until serious infection develops or the fetus no longer has cardiac activity.” Id.
Another effect of Idaho‘s criminal abortion law is that it will likely make it more difficult to recruit OB/GYNs, who are on the front lines of providing abortion care in emergency situations. Because Idaho does not have in-state training for the specialty, all OB/GYNs must be recruited to come here. Seyb Dec. ¶ 14, Dkt. 17-8. But if these newly trained physicians “can practice in a state without these conflicts and risks, it is only natural that they would be deterred from practicing here.” Id. By extension, OB/GYNs who are already practicing here may choose to leave or to change the nature of their practice. See, e.g., Corrigan Dec. ¶ 32, Dkt. 17-6. In both cases, the end result is fewer providers performing health and life-saving abortions. This, again, is an obstacle to EMTALA because it disrupts Congress‘s careful balance to avoid overly severe sanctions that could lead to providers deciding not to provide emergency care.
In sum, cutting back on emergency abortion care quantitatively and qualitatively is a plain obstacle to EMTALA, which Congress enacted to ensure that all individuals—including pregnant women—have access to a minimum level of emergency care.
E. Likelihood of Irreparable Harm
Having concluded that that the United States is likely to succeed on the merits of its claims, the Court turns to whether the United States has shown it is likely to suffer irreparable harm in the absence of an injunction.
The United States has met that burden, as Supremacy Clause violations trigger a presumption of irreparable harm when the United States is a plaintiff. See generally United States v. Arizona, 641 F.3d 339, 366 (9th Cir. 2011), rev‘d in part on other grounds, 567 U.S. 387 (2012) (“[A]n alleged constitutional infringement will often alone constitute irreparable harm.“) (citation omitted). As one court has explained, “The United States suffers injury when its valid laws in a domain of federal authority are undermined by impermissible state regulations.” United States v. Alabama, 691 F.3d 1269, 1301 (11th Cir. 2012).
And so it is here. If Idaho‘s criminal abortion statute is allowed to go fully into effect, federal law will be significantly frustrated—as discussed in detail above. Most significantly, allowing the criminal abortion ban to take effect, without a cutout for EMTALA-rеquired care, would inject tremendous uncertainty into precisely what care is required (and permitted) for pregnant patients who present in Medicare-funded emergency rooms with emergency medical conditions. See generally United States v. South Carolina, 840 F. Supp. 2d 898, 925 (D.S.C. 2011) (finding irreparable harm where state immigration law “could create a chaotic situation in immigration enforcement“). The net result—discussed further in the next section—is that these patients could suffer irreparable injury in the absence of an injunction.
F. The Balance of Equities and the Public Interest
The next question is whether the balance of equities tips in the United
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) (citing Arizona, 641 F.3d at 366). As the Ninth Circuit has explained, “it is clear that it would not be equitable or in the public‘s interest to allow the state to violate the requirements of federal law, especially when there are no adequate remedies available. In such circumstances, the interest of preserving the Supremacy Clause is paramount.” Arizona, 641 F.3d at 366 (cleaned up, citations omitted).
Next, based on the various declarations submitted by the parties, the Court finds that allowing the Idaho law to go into effect would threaten severe, irreparable harm to pregnant patients in Idaho. Speaking of patients, although the parties and the Court have often focused mainly on the actions and competing interests of doctors, prosecutors, legislators, and governors, we should not forget the one person with the greatest stake in the outcome of this case—the pregnant patient, laying on a gurney in an emergency room facing the terrifying prospect of a pregnancy complication that may claim her life. One cannot imagine the anxiety and fear she will experience if her doctors feel hobbled by an Idaho law that does not allow them to provide the medical care necessary tо preserve her health and life. From that vantage point, the public interest clearly favors the issuance of a preliminary injunction.
In that regard—and as discussed at some length above—the United States has submitted declarations from physicians explaining that there are any number of pregnancy-related complications that require emergency care mandated by EMTALA but that are forbidden by Idaho‘s criminal abortion law. Idaho physicians have treated such complications in the past, and it is inevitable that they will be called upon to do so in the future. Not only would
Turning to the other side of the equitable balance sheet, the State of Idaho will not suffer any real harm if the Court issues the modest preliminary injunction the United States is requesting. In fact, as a practical matter, the State (and, to a much greater extent, the Legislature) argue that physicians who perform the types of emergency abortions at issue here won‘t violate Idaho law anyway; therefore, by their own reasoning, they will suffer no harm if enforcement of
ORDER
IT IS ORDERED that:
- Plaintiff‘s motion for a preliminary injunctiоn (Dkt. 17) is GRANTED.
- The Court hereby restrains and enjoins the State of Idaho, including all of its officers, employees, and agents, from enforcing
Idaho Code § 18-622(2) -(3) as applied to medical care required by the Emergency Medical Treatment and Labor Act (EMTALA),42 U.S.C. § 1395dd . Specifically, the State of Idaho, including all of its 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 (1) is defined as an “abortion” underIdaho 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 to42 U.S.C. § 1395dd(e)(1)(A)(i)-(iii) . - 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: August 24, 2022
B. Lynn Winmill
United States District Judge