Supreme Court to Hear Case on Idaho Abortion Law
In a significant legal battle, the Supreme Court is set to hear arguments on the interplay between Idaho's near-total ban on abortion and a federal law mandating Medicare-participating hospitals to provide emergency abortion care. This case comes less than two years after the Court's decision to overturn Roe v. Wade, returning abortion policy to the states.
Idaho's law, which criminalizes most abortions except in cases where the mother's life is at risk, has been challenged by the Biden administration. The administration contends that the state law contradicts the federal Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to provide necessary stabilizing treatment, including emergency abortion care.
Following a lawsuit filed by the Biden administration, a federal district court in Idaho ruled in favor of allowing physicians to perform abortions in specific emergency situations, citing the supremacy of federal law over state regulations.
"The pregnant patient, laying on a gurney in an emergency room facing the terrifying prospect of a pregnancy complication that may claim her life," U.S. District Judge B. Lynn Winmill emphasized in an August 2022 order imposing a preliminary injunction.
Despite a three-judge panel of the U.S. Court of Appeals for the 9th Circuit allowing the law to be enforced during ongoing litigation, the full 9th Circuit, upon reviewing the panel's ruling, reinstated the district court's order in October.
Early in January, the Supreme Court announced it would determine if EMTALA preempts state laws that restrict most abortions, while permitting Idaho to uphold its ban in specific emergency medical situations until a decision is reached, anticipated by the end of June.
In his ruling allowing abortions in limited medical emergencies to safeguard the health of the mother from "serious jeopardy" or "serious impairment," Winmill cautioned against doctors feeling constrained by a law that prevents them from offering necessary medical care to protect a pregnant woman's health.
As Idaho's ban remains in effect, doctors in the state have indicated that Winmill's concerns have materialized.
"Being in such a challenging position as a healthcare provider is truly difficult," expressed Dr. Lauren Miller, a specialist in maternal fetal medicine who practiced in Boise for five years. "The consequences of acting too quickly could lead to legal repercussions, while acting too late could result in severe harm to the patient."
Miller made the decision to leave Idaho last year and relocate with her family to Colorado. She felt that the pressure of balancing the fear of prosecution with providing necessary medical care for her patients was overwhelming.
"The ripple effects of not being able to instinctively provide the best care are significant," she explained. "It's crucial to understand that being compelled to engage in unethical practices goes against the core principles of medical ethics. It forces you to withhold appropriate care in order to comply with the law and avoid criminal charges."
Joining forces with three other OB-GYNs, Miller endorsed a legal brief in support of the Biden administration's stance on the issue. The group of doctors argued that Idaho's interpretation of EMTALA would create a conflicting situation between the law and medical ethics.
"Feeling constrained by my state's laws, which limit my ability to provide care in line with my oath, faith beliefs, physician beliefs, and evidence-based medicine, is a moral injury," expressed Dr. Nikki Zite, an OB-GYN practicing in Tennessee, who joined Miller in the case.
Working at the University of Tennessee Medical Center, Zite is the sole complex family OB-GYN in east Tennessee. Similar to Idaho, Tennessee restricts abortions at all stages of pregnancy, with exceptions for molar and ectopic pregnancies. The law permits doctors to use their "reasonable medical judgment" to terminate a pregnancy to prevent the mother's death or serious risk of "substantial and irreversible" harm to the pregnant woman.
Zite highlighted that even with the exception, doctors are still at risk. If Idaho succeeds, it could pave the way for more stringent abortion bans in other states, allowing terminations solely to prevent the mother's death, resulting in a fragmented emergency care system.
"The fear of medical malpractice has always been present," she added. "But never have we had to worry about committing a felony while caring for patients."
The debate on EMTALA
Idaho is among the 14 states that prohibit abortion with some exceptions, as per the Guttmacher Institute, a research organization advocating for abortion rights. Additionally, seven states forbid abortion within the first 18 weeks of pregnancy.
A coalition of 22 states, many with strict abortion regulations, are supporting Idaho in a legal battle against the Biden administration, contending that state laws safeguarding the rights of the unborn should not be invalidated.
Meghan Boone, a reproductive rights expert and law professor at Wake Forest University, explained that states still have the authority to uphold their abortion restrictions.
"The potential conflict between what EMTALA mandates and Idaho's criminalization stance on abortion is quite limited. It doesn't encompass all abortion cases," Boone stated. "EMTALA doesn't completely override a state law that prohibits or criminalizes abortion. The issue arises in cases where abortion care falls between the requirements for emergency stabilization and the state's defined boundary, which is the immediate risk to the pregnant individual's life."
Boone added, "The conflicts at the core of the case lie within these parameters."
EMTALA, established in 1986 to combat the practice of "patient dumping" by hospitals, set a national standard of care for Medicare-participating hospitals. The law mandates that these hospitals must provide stabilizing treatment to any patient facing a life-threatening emergency condition.
The Biden Administration's Argument on Pregnancy Termination and Emergency Care
The Biden administration argues that in some cases, stabilizing care involves terminating the pregnancy. Still, the instances where EMTALA and the Idaho abortion ban are at odds are rare.
If a condition arises later in pregnancy and the fetus can be delivered, there is no conflict between federal and state law, according to Solicitor General Elizabeth Prelogar's court filing. However, conflicts arise when a pregnant woman is suffering from an emergency medical condition that, without ending the pregnancy, poses a serious threat to her health, though not her life.
"Delaying care until the woman's condition deteriorates and the doctor can say that termination is necessary to prevent her death, as Idaho law requires, stacks tragedy upon tragedy with little additional likelihood of fetal survival," Prelogar wrote.
If the court were to accept Idaho's argument that state abortion laws supersede EMTALA's stabilization requirement, Prelogar warned it would allow its meaning to vary from state to state, thus "thwarting Congress's promise of essential emergency care to all Americans."
"If we start to say a minimum standard of care unless state law has something to say, we don't have a uniform, national standard of care," Boone said.
Lawyers representing Idaho's Republican legislative leader have argued that EMTALA does not mandate the performance of abortions that go against Idaho law. They criticized the Biden administration's interpretation of EMTALA as an overreach of federal authority, labeling the law as a "patient-dumping statute" rather than an "abortion-access statute."
"EMTALA is not a guise for the Department of Health and Human Services to impose nationwide abortion regulations. Nowhere in EMTALA is abortion mentioned," stated Republican state lawmakers in a court filing. "Interpreting EMTALA in a way that allows HHS to override state abortion laws goes against the typical legislative process of Congress and distorts the separation of powers outlined in the Constitution."
In a separate submission by Idaho's attorney general, state attorneys contended that the Biden administration is trying to establish an abortion requirement through EMTALA, warning of potential consequences extending beyond the realm of abortion.
"This could enable the federal government to financially incentivize hospitals to violate state laws, granting emergency room physicians immunity from the state-specific standards of care that govern the treatments they are permitted to administer," wrote Attorney General Raúl Labrador. "The implications of this state law nullification are broad and not limited to abortion."
The aftermath of Roe v. Wade's reversal
Idaho's legal dispute highlights the aftermath of the Supreme Court's ruling that dismantled the constitutional right to abortion and the ensuing uncertainty faced by medical professionals as they navigate the limited exceptions outlined in state laws restricting abortion.
At Zite, in Tennessee, conversations regarding the optimal care for a pregnant patient that previously took place among fellow OB-GYNs and medical personnel now involve legal advisors. Dr. Jim Souza, chief physician executive for Boise-based St. Luke's Health System, expressed that there is now a level of "second-guessing" and "hand-wringing" about the permissibility of performing an abortion within the confines of Idaho's law.
According to Idaho's regulations, abortions are permitted when essential to save the mother's life, yet EMTALA mandates care to safeguard her health. Souza highlighted the numerous adverse health outcomes that can manifest before it becomes evident that her life is in danger.
"It presents the issue as if life and death are black and white occurrences. They certainly are not. Between life and death lies an entire spectrum known as health," he shared with CBS News.
Previously, if a pregnant mother at 17 weeks experienced a ruptured membrane and went into preterm labor, the standard procedure would have been to terminate the pregnancy, effectively eliminating the risk to her health and life.
However, now, a physician apprehensive about the legal repercussions may opt to delay if an ultrasound indicates a heartbeat, putting the patient at risk of developing an infection and subsequently septic shock.
"The mother's health hangs in the balance. If we delay too long, the mother's life will be in jeopardy," Souza emphasized.
Addressing the tension surrounding abortion care in Idaho, hospitals have resorted to sending patients to neighboring states via transport flights. This allows patients to receive the necessary care "without the worry of the physician that he or she is going to be prosecuted, lose their license and go to jail," according to Souza.
In 2023, a patient had to be transferred out of state due to the restrictions on Idaho physicians providing abortions in emergency situations. Since Idaho was granted the ability to enforce the ban in emergency circumstances, six patients facing medical emergencies have been flown out of state. Souza estimates that this number will increase to 20 by the end of 2024.
Souza emphasized that pregnancy complications are time-sensitive emergencies, and the additional delay caused by transferring patients out of state further jeopardizes their health.
Despite no instances of doctors being prosecuted for violating Idaho's abortion ban, there is a prevailing concern among healthcare workers regarding potential criminal penalties for terminating pregnancies in emergency scenarios.
"How do you reassure someone who is fearful that their concerns are unwarranted?" Souza questioned. "The only way to alleviate these fears is by providing concrete evidence that there is no basis for them. The law permits action to prevent the mother's death, but there are numerous obstacles along the way."
Physicians in Idaho Face Uncertainty Amid Abortion Restrictions
In a recent development, the district court's ruling allowing some abortions in emergency situations has provided a sense of relief for physicians in Idaho. This ruling, as mandated by EMTALA, has offered clarity for doctors when dealing with pregnant patients facing emergency medical conditions.
However, despite the ongoing legal battle at the Supreme Court, concerns remain among physicians in the state. With a Republican-controlled state legislature, there is a call for more definitive guidelines to alleviate the fear that many medical professionals are experiencing, leading some to consider leaving Idaho.
Since August 2022, Idaho has seen a significant decrease in OB-GYNs, with a reported loss of at least 22% of these specialists. The shortage of obstetrical providers has made it challenging for institutions like St. Luke's, the state's largest private employer, to fill open positions swiftly. The dwindling number of applicants, especially in obstetrics, has further exacerbated the healthcare workforce crisis in the state.
As a consequence, some hospitals have been forced to close their labor and delivery services, impacting the overall healthcare system's stability. This situation is particularly concerning as Idaho's population continues to grow, affecting access to care for various demographics, including young women and individuals over 65.
"The need for gynecologic care is crucial for women to manage reproductive health," Souza emphasized. "Physicians who are leaving obstetrical care due to the risks involved are the same ones who provide gynecological care. This issue affects not only young women but all women."
Miller pointed out that Idaho had maternity care deserts even before the ban, and she expressed concerns that the situation could worsen if the challenges in recruiting obstetrics physicians continue.
"Preserving the full spectrum of life is our goal," she added. "Creating exceptions that allow or restrict certain services overlooks the complexity of healthcare, which is not just black and white."
