What Is EMTALA and Why Is It Before SCOTUS?

Everything you need to know about the federal law at the center of the next big abortion case at SCOTUS.

EMTALA graphic
The Supreme Court will hear oral arguments in Idaho v. United States on April 24. Shutterstock/Austen Risvolato/Rewire News Group illustration

With anti-choice groups like Alliance Defending Freedom complaining to the Supreme Court that the Biden administration is using the Emergency Medical Treatment and Active Labor Act (EMTALA) to force God-fearing hospitals to become abortion clinics, you might want to familiarize yourself with the acronym that sounds more like an antidepressant than a federal statute. (Ask your doctor if EMTALA is right for you!) That way, when oral arguments in Idaho v. United States rolls around on April 24, you’ll be prepared.

What is EMTALA?

EMTALA is a federal law enacted in 1986 that requires Medicare-funded hospitals to provide stabilizing treatment, regardless of ability to pay, to patients who show up to the emergency room with emergency medical conditions—including when that treatment involves abortion care.

The law was enacted to address patient dumping, a practice that saw hospitals dumping indigent and uninsured patients either out onto the street or in the parking lot of another hospital so they could avoid incurring expenses they wouldn’t be able to recoup either from insurance or the patient.

EMTALA has specific requirements: Medicare-funded hospitals that have an emergency department must provide a medical screening examination to patients who show up in the emergency room to determine if the patient has an emergency medical condition. If the patient does, the hospital is required to provide stabilizing treatment. If the hospital is not capable of providing stabilizing treatment, then it must arrange a transfer to a hospital that can.

By August 2022, a couple months after the Supreme Court issued its ruling in Dobbs v. Jackson Women’s Health Organization, states had already begun enforcing state bans that were waiting in the wings to be triggered by a Roe v. Wade reversal. The Biden administration sued one of those states—Idaho—alleging that the state’s abortion ban conflicts with EMTALA, and therefore that federal law trumps Idaho law. That’s basic supremacy clause 101: When a federal law conflicts with a state law, the federal law preempts the state law. (It’s also called preemption, and you’re going to hear a lot of talk about that.)

How EMTALA works

The law has an expansive definition of “emergency medical condition” when it comes to pregnant patients that, unlike most state level bans, doesn’t require a patient to be on the verge of death before requiring stabilizing treatment.

The definition reads:

a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain). The lack of immediate medical attention could reasonably be expected to result in placing the health of the patient or (in the case of pregnancy, the unborn child) in serious jeopardy, the significant impairment to bodily functions, or serious dysfunction of any bodily organ or part.

The definition of emergency medical condition when it comes to pregnant people is particularly important because it doesn’t impose a federal standard of care—because it would be ridiculous for bureaucrats to draft medical standards of care to be followed by harried emergency room doctors dealing with multiple emergent crises simultaneously.

The statute mandates that physicians provide stabilizing treatment in accordance with their professional medical judgment. It is the states that are trying to mandate the type of care that can or cannot be performed, thereby forcing emergency room doctors to abandon patients if they need an abortion due to severe symptoms that could put their health in jeopardy.

In short, this means that federal law does not require that a pregnant person be on death’s door before EMTALA protections kick in and require stabilizing treatment in the form of abortion.

The conflict between EMTALA and Idaho law

The conflict is apparent: Idaho permits abortions when “necessary to prevent the death of the pregnant woman” but does not permit abortions when the pregnant person’s health is at risk. That directly conflicts with EMTALA, which requires that abortion be offered as stabilizing treatment when the health of the pregnant patient or their “unborn child” is in serious jeopardy.

And who is making that judgment in an emergency situation? Doctors. They work in a fast-paced environment where they have to make quick decisions about their patients’ needs without wondering whether law enforcement is going to second-guess their work months in the future after a local prosecutor decides that the abortion provided wasn’t actually to save the pregnant person and arrests the doctor who provided abortion care because their pregnant patient’s health was at risk.

Ultimately, this case is about whether the Court will order emergency room doctors to let their patients suffer until the moment of death before allowing them to perform an abortion that will stave off a serious health condition.

The law has been in effect for nearly four decades and has never posed a problem until Dobbs. A few weeks after the Dobbs ruling, in July 2022, the U.S. Department of Health and Human Services (HHS) released a guidance document to “remind hospitals of their existing obligation to comply with EMTALA” in cases where an abortion would be the best course of action to stabilize a pregnant patient who presents with an emergency medical condition or complications related to a miscarriage, emergent hypertensive disorders, or severe forms of preeclampsia.

Significantly, the guidelines further say “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 preempted..”

Additionally, HHS reiterated in a letter to health-care providers its position that physicians are required by EMTALA to provide abortion care, even in cases where state laws conflict. This, of course, infuriated states like Idaho (the petitioner in one of the cases) and Texas, which filed a separate but related lawsuit called Texas v. Becerra. (In that case, the U.S. Fifth Circuit Court of Appeals ruled in favor of Texas, granting permanent injunction against the Biden administration, ruling that the federal government cannot force emergency room doctors to perform abortions if it violates their conscience or religious beliefs. The Supreme Court’s ruling in the Idaho case will resolve the Texas case.)

The issue before the Supreme Court

The crux of the issue before the Supreme Court is whether stabilizing treatment includes abortion care. There’s a lot of daylight between a condition that “merely” jeopardizes a person’s health and a condition that threatens a person’s life. In addition, EMTALA does not exclude mental health from the universe of conditions that could seriously jeopardize a person’s overall health, whereas state bans like those in Idaho and Texas don’t care about the mental health of a person seeking an abortion.

Ultimately, this case is about whether the Court will order emergency room doctors to let their patients suffer until the moment of death before allowing them to perform an abortion that will stave off a serious health condition—and the question of who makes that determination is up in the air. Or, will the Supreme Court trust that emergency room doctors know what they are doing and that they are not, contrary to the hysterical amicus briefs filed by myriad anti-choice groups, helping as many pregnant people as they can terminate pregnancies “up until the moment of birth”?