One of the newest battlefields in the abortion debate is a decades-old federal law called the Emergency Medical Treatment and Labor Act, known by doctors and health policymakers as EMTALA.
The issue involves whether the law requires hospital emergency rooms to provide abortions in urgent circumstances, including when a woman’s health is threatened by continuing her pregnancy. But, as with many abortion-related arguments, this one could have broader implications. Some legal experts say it could potentially determine how restrictive state abortion laws are allowed to be and whether states can prevent emergency rooms from providing other types of medical care, such as gender-affirming treatments.
The Biden administration is in the middle of legal battles over the law with the states of Texas and Idaho. The Supreme Court has agreed to hear the Idaho case.
What does the law do?
Enacted by Congress in 1986, EMTALA (pronounced em-TAHL-uh) requires hospitals across the country to guarantee all patients a standard of emergency care, regardless of whether they have insurance or can pay. The law, which was passed to address concerns that hospitals were failing to screen, treat or correctly transfer patients, applies to any hospital that receives Medicare funding and has an emergency department — most hospitals in the United States.
Specifically, the law says that if a patient goes to an emergency room with an “emergency medical condition,” hospitals must either provide treatment to stabilize the patient or transfer the patient to a medical facility that can. Hospitals that violate the law can face consequences including fines and exclusion from further Medicare funding.
What does that have to do with abortion?
The law does not mention abortion or name specific treatments for any emergency medical condition. It requires only that hospitals use accepted medical approaches for each patient. But soon after the Supreme Court overturned the national right to abortion in June 2022, the Biden administration issued a memorandum saying that EMTALA applies in cases where abortion is necessary to stabilize a patient.
“If a physician believes that a pregnant patient presenting at an emergency department is experiencing an emergency medical condition as defined by EMTALA, and that abortion is the stabilizing treatment necessary to resolve that condition, the physician must provide that treatment,” the memorandum said. “When a state law prohibits abortion and does not include an exception for the life of the pregnant person — or draws the exception more narrowly than EMTALA’s emergency medical condition definition — that state law is pre-empted.”
The attorneys general of Idaho and Texas have said their states’ abortion bans do not violate EMTALA, which they say requires that emergency departments stabilize both a pregnant woman and an “unborn child.”
“The federal government has been wrong from Day 1,” Idaho’s attorney general, Raúl Labrador, said in a statement about the Supreme Court’s decision to hear the case involving his state. “Federal law does not pre-empt Idaho’s Defense of Life Act. In fact, EMTALA and Idaho’s law share the same goal: to save the lives of all women and their unborn children.”
Has EMTALA been enforced in cases where patients needed abortions?
Last year, in the first case since Roe v. Wade was overturned, the federal government told a hospital in Missouri and another in Kansas that they had not provided “necessary stabilizing care” required by EMTALA when they denied an abortion to Mylissa Farmer, whose water broke at 17 weeks’ gestation, less than halfway through the pregnancy. At each hospital, doctors told Ms. Farmer that the fetus would not survive because she had lost her amniotic fluid and that if her pregnancy wasn’t aborted, she could develop a severe infection and even lose her uterus. But because the fetus still had cardiac activity, the doctors would not abort the pregnancy.
Ms. Farmer ended up traveling to Illinois for an abortion. The National Women’s Law Center filed complaints against the two hospitals with the Centers for Medicare and Medicaid Services, known as C.M.S. The agency found the hospitals in “violation of the EMTALA protections that were designed to protect patients like her” and sought plans of correction from them.
In September, the Center for Reproductive Rights filed an EMTALA complaint on behalf of an Oklahoma woman, Jaci Statton, who was denied an abortion for a condition called a partial molar pregnancy, in which a fetus is highly unlikely to survive and the mother’s health can be threatened.
After investigating the case, however, C.M.S. issued a letter saying it “did not confirm a violation” of EMTALA. While the agency did not give a reason, medical records Ms. Statton provided to The New York Times suggest that her experience at an Oklahoma health system may not have fit the exact pattern of an EMTALA violation.
In the records, one hospital in the system indicated that its emergency department had stabilized her and transferred her to another of the system’s hospitals, where she was admitted for a day and treated by a maternal-fetal medicine doctor. The doctor wrote that while prospects for the fetus were dire and Ms. Statton was experiencing bleeding and nausea, Oklahoma law would allow an abortion only if there was “an immediate threat to the life of the mother.”
The doctor added, “therefore, we are unable to offer a termination” and noted that “termination can be pursued in a different state where the procedure is legal.” Ms. Statton then traveled 180 miles to have an abortion at a clinic in Kansas.
What are the lawsuits in Texas and Idaho about?
Texas sued the federal Department of Health and Human Services in July 2022, arguing that the agency’s memorandum about EMTALA would “force abortions” in hospitals in the state, violating the state’s ban. A federal district court ruled for Texas. The Biden administration appealed. In January 2024, the U.S. Court of Appeals for the Fifth Circuit upheld the district court ruling, making it impossible, for now, for the federal government to enforce EMTALA in Texas when doctors deem that women need emergency abortions.
The Idaho case before the Supreme Court was initiated by the Biden administration. The Justice Department filed suit in August 2022 claiming that the state’s abortion ban violated EMTALA because it makes exceptions only for abortions “necessary to prevent the death of the pregnant woman” but not to address threats to a woman’s health.
“Even in dire situations that might qualify for the Idaho law’s limited ‘necessary to prevent the death of the pregnant woman’ affirmative defense,” the federal government’s lawsuit said, “some providers could withhold care based on a well-founded fear of criminal prosecution.”
Soon after the suit was filed, a federal district judge issued a preliminary injunction partly blocking the state’s ban. Last fall, a three-judge panel of the U.S. Court of Appeals for the Ninth Circuit, in San Francisco, put the lower court ruling on hold and reinstated the abortion ban, saying that the Idaho Supreme Court had interpreted the ban to give doctors more flexibility in deciding when abortions are needed to save women’s lives. But in December, an 11-member panel of the appeals court temporarily blocked the law pending an appeal.
Idaho asked the Supreme Court to step in, and the high court reinstated the abortion ban and said it would hear arguments in the case in April.
Abbie VanSickle contributed reporting.
Pam Belluck
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