For almost 40 years, American hospitals have operated under a federal law that says they must treat and stabilize any patient experiencing a medical emergency.
But now, the Emergency Medical Treatment and Labor Act finds itself on a collision course with conservative states that want to ban abortion in nearly all cases.
The Biden administration has sued Idaho, saying that state鈥檚 abortion ban violates EMTALA because its exceptions are too narrow to allow doctors to perform abortions if needed to stabilize a patient. Texas, meanwhile, has sued the Biden administration, saying it's using EMTALA as an end-run around state abortion bans to 鈥渕andate that every hospital and emergency-room physician perform abortions.鈥�
The U.S. Supreme Court is hearing arguments about the Idaho case April 24. Its ruling is expected to impact the Texas case, as well as the future of both state-level abortion bans and national standards of emergency medicine.
鈥淣obody was thinking about EMTALA,鈥� when Roe v. Wade was overturned, said Sara Rosenbaum, a professor emerita at the Milken School of Public Health at the George Washington University.
鈥淓xcept for the handful of us who are really, really steeped in EMTALA, we knew the day would come when the states鈥� standards would come into direct conflict with EMTALA,鈥� Rosenbaum said. 鈥淲e knew we鈥檇 be in exactly the position we鈥檙e in now.鈥�
EMTALA鈥檚 Texas roots
Long before Texas was feuding with the federal government over EMTALA, the Lone Star State was actually laying the groundwork for its creation.
Before EMTALA, private hospitals often turned away patients who couldn鈥檛 pay. In addition to taking on all low-income and uninsured patients, public hospitals had to deal with the fallout when patients were improperly discharged from private facilities in the midst of medical emergencies.
Dr. Ron Anderson saw all this firsthand as CEO of Parkland Memorial Hospital, the public hospital in Dallas. In a , Anderson recounted the story of a pregnant woman who told her doctors at a private hospital that her husband had lost his insurance.
鈥淭hey pushed her legs together, started an IV, and sent her to Parkland,鈥� he said. 鈥淪he was crowning鈥攖he baby was coming any minute. She delivered in the hallway at Parkland.鈥�
Anderson also chaired the state health board, and in 1985, he pushed Texas legislators to pass the nation鈥檚 first anti-patient dumping law, requiring private hospitals to treat medical emergencies regardless of a patient鈥檚 ability to pay.
Congress followed in Texas鈥� footsteps, and the next year, EMTALA was born.
鈥淭he fact that Texas had done it helped a lot,鈥� Rosenbaum said, who represented community clinics on the border in patient-dumping cases at the time. 鈥淚t was a Republican Senate, a Democratic House, and Ronald Reagan was president 鈥� but the consensus was there.鈥�
EMTALA enshrines in law the emergency medicine ethos to treat 鈥渁nyone, anything, anytime.鈥� Hospitals with emergency rooms are required to screen anyone who shows up and determine whether they have an emergency medical condition. If so, the hospital must stabilize them before they can be transferred or discharged.
EMTALA defines an emergency medical condition as anything severe enough where not providing immediate medical attention could place the health of the patient 鈥� 鈥渙r with respect to a pregnant woman, the health of the woman or her unborn child鈥� 鈥� in serious jeopardy, or cause serious impairment to bodily functions, organs or parts.
A pregnant woman who is having contractions qualifies as having an emergency medical condition if there isn鈥檛 enough time to safely transfer her or if transferring her would threaten her or the pregnancy.
Hospitals that fail to properly screen or stabilize patients can be investigated and, in worst case scenarios, lose the ability to accept Medicare or Medicaid, effectively a death sentence for a hospital.
Although the stabilizing requirement applies if either a pregnant patient or their fetus is experiencing an emergency medical condition, Rosenbaum said the courts have not interpreted EMTALA to preclude abortion as a potentially stabilizing treatment. In fact, for EMTALA violations in the past for failing to perform medically necessary abortions to stabilize patients.
Texas v. EMTALA
After the U.S. Supreme Court overturned Roe v. Wade in 2022, the Biden administration issued to hospitals, reminding them that if a doctor believes an abortion is necessary to stabilize a patient鈥檚 emergency medical condition, 鈥渢he physician must provide that treatment.鈥�
鈥淲hen a state law prohibits abortion and does not include an exception for the life of the pregnant person 鈥� or draws the exception more narrowly than EMTALA鈥檚 emergency medical condition definition 鈥� that state law is preempted.鈥�
Texas sued the Biden administration over this guidance, saying it was an effort to 鈥渇orce hospitals and doctors to commit crimes鈥� and 鈥渢ransform every emergency room in the country into a walk-in abortion clinic.鈥�
The U.S. Department of Health and Human Services said this was a 鈥減atent misreading of the Guidance that bears no resemblance to reality.鈥�
Texas鈥� abortion ban has an exception that allows doctors to perform an abortion to save a patient鈥檚 life. So why is the state going to court over a requirement to perform medically necessary abortions?
The distinction is in the details. EMTALA and Texas鈥� abortion exceptions create a Venn diagram of emergency pregnancy care: EMTALA mandates care when there is a risk that a patient鈥檚 health could be in jeopardy. Texas鈥� law requires a 鈥渓ife-threatening鈥� condition that poses a 鈥渞isk of death鈥� before a doctor can act.
Texas鈥� law lays out the circumstances when a doctor is allowed to perform an abortion without facing potentially years in prison. EMTALA mandates when a hospital must offer stabilizing medical care, which could include abortions.
Under EMTALA, the obligation is on the hospital to ensure its patients receive the stabilizing care they are owed under federal law. If a doctor declines to provide an abortion on conscience grounds, the hospital has to find another doctor who can perform the procedure.
鈥淲e are all supposed to be protected when we go to a hospital,鈥� Rosenbaum said. 鈥淎, they've got to screen us, but B, if we become unstable in the hospital, then they've got to stabilize us before they let us go.鈥�
Almost two years under Texas鈥� near-total abortion ban has shown the fear and confusion doctors face when deciding whether it鈥檚 legally safe to terminate a pregnancy. Dozens of women have come forward with stories of being denied medical care for their pregnancy complications by doctors too scared to act.
Republican leaders, and the state of Texas in court filings, have blamed doctors for this confusion, saying the laws make it clear they can perform life-saving abortions. This lawsuit reflects Texas鈥� stance on how doctors are expected to handle edge cases where patients are facing emergency situations that have not yet reached the state鈥檚 鈥渞isk of death鈥� standard.
In August 2022, U.S. District Judge Wesley Hendrix ruled that while 鈥淭exas law already overlaps with EMTALA to a significant degree,鈥� HHS鈥檚 guidance 鈥済oes well beyond EMTALA鈥檚 text, which protects both mothers and unborn children, is silent on abortion, and preempts state law only when the two directly conflict.鈥�
Hendrix, a Trump-appointee who hears nearly all cases filed in Lubbock, also found that the guidance was unauthorized because the agency did not follow proper rulemaking procedure.
HHS appealed to the 5th U.S. Circuit Court of Appeals. At the November hearing, Department of Justice lawyer McKaye Neumeister said while Texas鈥� laws may not prohibit performing abortions in certain circumstances, EMTALA was one of the only ways the federal government could 鈥渆nsure that the hospitals are following their obligations in offering the care that鈥檚 required.鈥�
Judge Leslie Southwick at the hearing described HHS鈥檚 guidance as an effort to expand abortion access beyond life-saving care to 鈥渂roader categories of things, mental health or whatever HHS would say an abortion is required for.鈥�
The appeals court upheld Hendrix鈥檚 ruling. HHS has asked the Supreme Court to take up the case.
EMTALA v. Idaho
The future of the Texas case will likely be decided after the Supreme Court hears arguments in another EMTALA case later this month. That case focuses on Idaho鈥檚 abortion ban, which was temporarily blocked from going into effect after the DOJ sued, saying it conflicted with EMTALA.
U.S. District Judge B. Lynn Winmill, who was appointed by President Bill Clinton, wrote in his ruling that this case was 鈥渘ot about the bygone constitutional right to an abortion,鈥� but whether Idaho鈥檚 state law 鈥渃onflicts with a small but important corner of federal legislation. It does.鈥�
Winmill pointed to the Supremacy Clause of the U.S. Constitution, which 鈥渟ays state law must yield to federal law when it鈥檚 impossible to comply with both.鈥�
At first, a three-judge panel from the 9th U.S. Circuit Court of Appeals overturned Winmill鈥檚 ruling, but then the full court heard the case and agreed to leave the law on ice due to its conflict with EMTALA.
Idaho appealed to the U.S. Supreme Court, which ruled that the law should go into effect while the case proceeds.
Rosenbaum said a ruling in Idaho鈥檚 favor would amount to restricting what stabilizing treatment a hospital can offer a pregnant patient facing an emergency medical condition, effectively 鈥渆xcising鈥� certain care for certain people from the protections of EMTALA.
鈥淣ow you've opened the door to excise any disfavored condition,鈥� Rosenbaum said. 鈥淲hat if, 鈥榃e're going to prohibit our hospitals from providing emergency care unless someone鈥檚 dying from a drug overdose, because we think that by offering emergency care, we're encouraging people.鈥� Or hospitals are now barred from treating populations with HIV unless they're dying. There's no endpoint to this.鈥�
Where things stand now
Until the Supreme Court rules, the Idaho abortion ban remains in effect and, as of the 5th Circuit鈥檚 ruling in the Texas case, the Biden administration鈥檚 guidance saying EMTALA preempts state abortion bans is suspended.
The EMTALA clash is just one of many unresolved questions surrounding state abortion laws that has left doctors, hospital administrators and the patients they serve in a legal limbo.
While pregnant women go to the emergency room more often than the average person, it鈥檚 rare that the situation devolves to the point that a doctor has to perform an emergency abortion to stabilize the patient. But in high stakes, fast-moving crisis situations, doctors say it needs to be available as an option.
鈥淵ou have doctors stuck trying to navigate all of this, trying to uphold their oath to care for the patient in front of them, while also trying not to break the law and potentially lose their medical license or even face jail,鈥� Dr. Michael Belmonte, an OB/GYN and complex family planning specialist, said in a media briefing with the American College of Obstetricians and Gynecologists. 鈥淭his is not how any of us trained to practice medicine 鈥� and this situation is going to lead to terrible outcomes for our patients.鈥�
Rosenbaum worries that this uncertainty will make providers wary about treating pregnant women in general, for fear that it may devolve into an emergency situation they鈥檙e not allowed to treat.
鈥淵ou make pregnant women toxic,鈥� Rosenbaum said. 鈥淵ou鈥檙e a hospital in one of these states, and you see a pregnant woman being brought in with an emergency and before you even know what you're dealing with, everybody is in a panic. You can imagine what goes through people's minds in a state like Idaho or Texas.鈥�
This article originally appeared in at .