Transcripts For CSPAN Supreme 20240703

Two hours. Chief Justice Roberts e ll hear argument this morning in case6, moyle versus United States, and the consolidated case. Mr. Turner. Mr. Turner thank you, mr. Chief stice, and may it please the medicare act in 1986, it put the emtala on a centuries Old Foundation of state law. States have always been responsible for licensg doctors and setting the scope of their professional pract indeed, emtala works precisely because stesegulate the practice of medicine. And nothing in emtquires doctors to ignore the scope of their license and offer dil treatments that violate state law. Three statprovisions make this clear. Firs stion 1395, the medicare acts opening provision, forbids the federal rnment from controlling the practice of medicine. Thats the role of state regulation. Second, subdivision emtala codifies a statutory presumption agait eemption of state medical regulations. And, thirdlas stabilization provision is limited to available treatments, which depends on the scope of e spital staffs medical license. Legal treatments are not available treatments. Add in this courts own presumption against preemption of state regulio, combine that with the need for clear and unambiguous spending clause conditionsthe administrations reading become whntenable. The administrations misreading also lacks any limiting principle. Whatever treatment theyrm determine is appropriate, then doctors can ignore not only state abortion laws but also state gutions on opioid use and informed consent requirements. Th turns the presumption against preemption on its head and leaves Emergency Rooms unregulated under state law. Its unsurprising that no court has endorsed such an expansive view of emtala, and until dobbs, nohhs. Everyone understands that licensing laws limit medical practice. Thats why a nurse isnt available to perform openheart surgermatter the need, no matter her knowledge. The answer doesnt change just beuse were talking about abortion. The court should reject the administrationunmited reading of emtala and reverse the District Courts judgment. I welcome the courts questions. Justice thomas the norma when we have a preemption case, theres some relationship between the parties. Is the state being regulated by the del government under emtala, or is the state in engaged in some sort of quasicontractual relationship . Mr. Turner yes, your. In this case, the state, idaho, for example, has no state hospitals that participate in with the Emergency Rooms in emla and so, in this case, there isnt even a quasirelationship. The parties being regulateby emtala here are hospitals and doctors. And i think your question is getting at tstrong issue, and we think that is a significestion. It wasnt part of the question presented. Tnk the indiana amicus brief raises significant qutions and deals with that argument well. But the question presented here is one of conflict between idahos law and emtala, and on that question, we dont think itha at all. And, your honors, going to that direflict, i think, if you within the statute oflimitation availability Justice Jackson wefore we do that, can i just step back and get your understanding of the statute . You made some representations as to how you see it working. And so let me tell you what i think, and then you can te whether you agree, disagree, or otherwise. So i think that there are two thgs that are plain, pretty plain, on the the face of one is that emtala is about the provision of stang care for people who are experiencing emergency medical conditions. Thats one thing i think the statutoing. And i also think that it is ing to displace the states or whomever with respect to that fairly narrow slice of the healthcare universe. This idea of Emergency Medical Services is like one very minor part or small part of of the sorterall healthcare provision of healthcare. So what that means is that when a hospital wants to only provide stabilizing care in emergencies for people whoay for it, for exammtala says, no, im sorry, you have to stabilize anyons experiencing an emergency medical condition, or hospital wants to provide abilizing treatments to people certain kinds of emergency conditions, emtala no, heres the list of conditions and you haveo ovide stabilizing care for those people. Similarly, if a state says, los our job to govern all of healthcare in our state and ay that only certain kinds of healthcare can be given to people who are experiencg emergency medical conditions, we dont want whatreatment, we want only certain kinds of treatment, emtys, no, we are direthat as a matter of federal law, when someone prestsith an emergency condition, they have to be as and the hospital must do whatever is in its capacity is that your understanding of the statute . Mr. Turner pay, your honor. We agree ttala does impose a federal stabilization requirement, but the question here is ats the content of that stabilization requirement, and for that, you have to reference state law. Justice jackson ok. Well stice kagan if i could just i mean, i think what you just said is important because, when you concede that emtala imposes a stabilization requirement, it is, thistate, the federal government interfering, if you llin a states healthcare choices. Emtala is on its face a statute that says its t all the states way. There are federareirements here. There is a requirement to stabilize emergency patients. And you agree with that . Mr. Tueryeah, Justice Kagan, we agree that emtala emtalas puwas narrow to bridge this gap that existed in some States Justice kagan ok. I mean mr. Turner and the failure treat. Justice kagan we can jt take off the table this idea that, you know, just because its a state and its healthcare, that theedal government has nothing to say about it. The federal government has plenty to say abt in this statute. Now, you rht, now theres a question of whats the content of thistilization requirement. And f as i understood your opening remarks, you say, well, this is left to the states. But, if im just lki at the statute, the statute tells you what the contentf e stabilization requirement is. Its to provide such medical trtmt as may be necessary to assure within reasonable probability that no mateal deterioration of the condition is likely to occur if the person were transferred or didnt get care. So it tells yove clearly its an objective standard. Its sically it you know, its a standard that clearly ha referee accepted medical praccenot just whatever one doctor happens to think. But its here is thcoent of the standard. You have to stabilize. What does that mea it means to provide the treatment necearto assure within reasonable medical probabilitth no material deterioration occurs. Rner yeah, let me respond in two ways. First, the objective sndd that you set forth there in that understanding is contry the they say it is a totally subjective standard and whatever treatment a doctor determines is appropriate, thats Justice Kagan i think that thats not true. I meani ink you guys can argue about this yourself. But, as i understand the solicitor generals brief and well see what thsocitor general says but the solicitor general says its not up to every individual doctor. This is a standard that is objective that incorporates accepted medical standards of care. Mr. Turner, and the more fundamental point is the defiti that you quoted of stabilizing care in the operative position provision in b 1 is also textually explicitly qualified by that which is within the staff and facilities available at a hospital. So then we come Justice Jackson yes. And thats what Justice Kagan thats quite right. Thats quite right. It says within the sffnd facilities available at the hospital. And if you just look at that language, i meanis absolutely clear that thats not a reference wt state law involves. Thstaff and facilities available. If you dont have sta available to provide the medical care, then i guess you can provide the medical care. If you dot have the facilities available to provide the medical care, then youat provide the medical care. A transfer has to take place for the good of thpaent. Mr. Turner this is a really important justickan but this is this the availability here, because its the availability ofta and facilities. Its, you know, do yoha the right doctors . Do you have enough doctors . Do you have the right facilities . Or is it better for the patient to transfer them to the hospital a few miles away . Mr. Turnere exactly right. Do you have the right doctors . How do you answer that question excepty ference to state licensing laws . Justice jackson but you solutely cant do that. I mean, thats sort of the initial point that i was trying to make, which is he federal mandate is to provide stabilizing care for emergency conditions, regardless of any othective that the state has or the hospital has that would prevent that care from inprovided. Thats thats the work of the statute. Mr. Turner Justice Jackson, thats not even hhss conclusion. In the state oraons manual, which they proffered on page 36 of their brief, it defines what kea staff person available under the statute, and they y it has to Justice Sotomayor counsel, i i this whole issue Justice Jackson and does it say that theyre not available if state law doesnt doesnt allow this procedure . Mr. Turner it sayth are available to the extent they are operating within the scope of their medical license. And that is our argument. They want to now draw it far more nroand look only at physical availability. We aeehats a component, but theres also a legal availability component here too. Justice sotomayor counsel, the problem were having right now is that youre sort of putting preemption on its head. The whole purpose of preemption is to say that if the state passes a law that violat federal law, the state law is no longer effective. So there is no state licensing law that would permit you permithetate to say dont treat diabetics with insulin. Trt them only with pills, metformin. And a doctor looks at a juvenile diabetic and says, who insulin, theyre going to get seriously ill and the likelihood and i dot know what that means under idaho law, well get to that shortly because, i t know, this we believe is is a better treatment. Mr. Turner yeah. Justice sotomayor federal law would say, you cant do that. Medically accepted objective medically accepted standards of care requi t treatment of diabetics with insulin. The dilly accepted lition of doctors when they have women with certain conditions that may not result in death but more anikely will result in very serious medical cond, including blindness for some, for others, the loss of organs, for some, chronic blood strokes, idaho is saying, unless the doctor can say in good faith that this persons death is likely, as opposed to serious illness, ey nt perform the abortion. So i dont know your argument about state licensin because this is what this law does. It tellstas, your licensing laws cant take out objective medical conditions that coul save a person from serious injury or death. Are two crucial responses toere your point. Let me begin with the preemption subdiv f and section 1395 actually are telling hhs, the federal government, and courts just the opposite, that you dont Justice Sotomayor no, it saying you cant preempt unless theres a direct conflict. If objective medic ce requires you to treat women who are who present the potential of serious medical complications and the abortion is the only thing that can prevent tt,ou have to do it. Mr. Turner no Justice Sotomayor idaho law says the doctor s determine not that theres merely a seoumedical condition but that the psowill die. Mr. Turner yeah. Justice sotomayor thats a huge differce, counsel. Mr. Turner your honor, we agree that the there is daylight between how the administraon is reading emtala and what idahos defense e act permits. We agree that theres a contversy here. But what im saying is that justicsomayor no, no, no, no, no, theres more than a controversy because what youre saying to us is, if emtala doesnt have preemptive force in not just idaho, it has a saving condition for abortions when it threatens a womans life. Mr. Turner well, when the Justice Sotomayor but what youre saying is that no state in the nation and there are some right now tt nt even have that as an exception to their antiabortion ws what you are saying is that there iso deral law on the book that prohibits any state om saying, even if a woman will die, you cant perform an abortion. Mr. Turner your honor, i know of no state that does not include a lifesinexception. But, secondly, the government Justice Sotomayor some have been debating it at least, and if i find one but your theory of this case leads to that conclusion. Mr. Turner i think our point is that emtala doesnadess that very Justice Sotomayor does your theory chief Justice Roberts could i ou i hear your answer . Mr. Turner yeah. In the administrations relian oa standard like best Clinical Evidence or some al norm, i think thats very fraught because what it really is saying is the text itself doesnt drs what stabilizing treatment is required. You go outside the text to professional standards that are floating o tre that might change day to day, and that reallyoi down to a question between a conflict between what the acog says and what idaho law says, and thats no chief Justice Roberts thank you. Thank yonsel. Justice jackson actually, can i just clarify . Because im not sure i understand. You know, sort of looking at this from a broader perspective, it seems to me that emtala says you must p whatever treatment you have the capacity, meaning staff and facilities, to who are experiencing emergency medical conditions idaho law seems to say you cannotrode that treatment unless doing so is necessa t prevent a patients death to the extent the treatment invve abortion. Why is that not a direct conflict . You have you must in a certain situation, thats what the federal government is saying, and you cannot if it involves abortion says idaho. Mr. Turner thk the nurse example really highlights the reason why, because a nurse might be available. The nurse may be may even think she knows how to, and undethflat must provision in emtala, the administrations reading woulcall her into action, put her into the operating room, and op patient up. And e jackson right. Mr. Turner but that is not Justice Jackson and idaho Justice Kagan well, that Justice Jackson uld say no, thats still a conflict. Ne, lets say the lets say the administrations position is that nurse can do it. Are you suggesting that federal would not preempt a state law, that says no, she cant . Turner well, whether felaw could do that is a different question than whet emtala here does do that. And i think the answclear that it doesnt. I mean, its like the gonzales v. Oregon, case the controlled substances act, you know, this coted that that was the provisions there rely upon and anassume a medical profession being regulated by statce powers. Thats the same with emtala. Congress didnt attempt tout address the standards of care for every conceivable medical treatment in Justice Kagan it it definitely didnt address the standards of care. It did leave that to the medical community. It sd,ou know, the congress was not going to adess every treatment for every condition, but it idou do what is needed to assure nondeterioration. So i guess the question here is, do you concede that with respect to certain medical conditions, an abortion is the standard of care . Mr. Turner no, because a standard of care under idaho well, i should say, ho, there is a lifesaving exception for certain abortis,nd that is the standard of care. And the standard of care is necessarily set and determined by state justice ga well, i think you have to concede that with respect to certain medical conditions abortion is the andard of care because your own statute, as inrpted by your own courts, acknowledges that when a condition gets bad enough such that the womans li iin peril, then the the the doctors are suppose to give abortions. Mr. Turner and Justice Kagan and the reason that thattr is that with respect to certain rare but extremely obviously important coitns and circumstances, abortion is the accepted medic standard of care. Isnt that right . Mr. Turner yes, and that at was my point, that there is a lifesaving exception under idaho law. Now the question here is Justice Kagan now now the question is, is it also the accepted sndd of care when, ratherhathe womans life being in peril, the womans heal iin peril . So lets take you knowal of these cases are rare,ut within these rarcas, theres a significt mber where the woman is her life is not in peril, but shes going to lose hereoductive organs, shes going to lose the ability to vehildren in the future, unless an abortion takes pla. Now thats the category of cases in which emtala says, my gosh, of course, the abortion is necessary to assure that no material deterioration occurs. And yet idaho says, sorry, no abortion here. And the result is that tse patients are now helicoptered out of state. Mr. Turner yeah. Your honor, the the hypothetical you raise is a very difficult situation, and these situations, i mean, nobody is arguat they dont raise tough medical questions that plate deeply theological and moral questions. And idaho, like 22 other state and Even Congress in emtala recognizes that there o patients to consider in those circumstances. And the twopatient scenario is is tough when you have competing interests. Justice kagan you know, that would be a good response if federal law did not take a position on what you characterize as a tough question, but federal w es take a position on that question. It says that y dt have to wait until the person is on the verge of death. If the woman is going to lose her reproductive organs, thats enough to triggeth duty on the part of the hospital to stabilize the patient. And the way to stabilize patients in these circumstances, all doctors agree. Not require that doctors waits until a patient is on the verge of death. There is no imminc requirement. There is no medical certainty requirement. Thats Justice Sotomayor im sorry, answer the followingion, and these are hypotheticals that are true. Hold on one second, and you ca tell me whether idahos ption and we still go back to the point that even if idaho law fully compesith federal law you have a pregnant women woman who is early into her second trimeste at 16 weeks, goes to t e because she felt a gush of fluid leave her body. She was diagnosed with pprom. The doctors believe that a medical intervention to terminate her pregnancy is needed to reduce the real mecal possibility of experiencing sepsis and uncontrolled hemorrhage from the oken sac. This is a story of a real woman. She was discrg in florida because the fetus still had fetal tos d the hospital said shes not likely to die, but there are going to be seous medical complications. The doctors there refused treat her because they couldnt say she would die. She was horrified, wt me. The next day, shbl. She passed out. Thankfullyak to the hospital. There, she received an abortio because she was about to die. Mr. Turner yeah. Justice sotomayor what you are telling us, is that a case in which idaho, the day before, would have said its ok to have an abortion . Mr. Turner under idahos lifesaving exception, a doctor could in good faith if the doctor could in goodfaith medical judgment determine Justice Sotomayor no. Im asking you. The floriddoor said, i cant say shes going to die. Mr. Turner yeah. And, your honor, my point is that justice sotomayoyour doorays, i cant, with a medical certainty, say she going to die, but i do know shes going bed to death if we dont have an abortion, but shes t eeding yet, so im not sure. Need to have medical certainty. Justice sotomayor counsel, answer yes or no. He doesnt have he doesnt cannot say that theres likely death. He can say there is likely to be a very serious medical condition mr. Tueryeah. Justice sotomayor like a stectomy. Let me go to another one. Imagine a patient who goes to e er with pprom 14 weeks. Again, abortion is the eepd. Shes up she was in and out of the hospital upo weeks. This particular patient, they tried o deliver her baby. E by died. She had a hysterectomy, and she can no longer have cldn. All right . Youre telling me the doctor there couldnt have done the abortion earlier . Mr. Turner again, it goes back to whether a doctor can in goodfaith medical judgment make Justice Sotomayor thats a lot for the doctor to risk when mr. Turner well, i think its protti stice sotomayor when idaho law changed to make the ise whether shes going to die or not or whether shegoing to have a serious medical condition. Theres a big daylight by your standards, correct . Turner it is very case by case. The examples, the prong Justice Sotomayor thats the problem, isnt . Justice barrett counsel, im kind of shocked actulyecause i thought your own expert had said below that these ki cases were covered. Mr. Turner yeah. Justice barrett and youre now saying theyre not . Mr. Turner no, im not saying that. Thats just my point, your honor, is that Justice Barrett well, youre hedgg. I mean, Justice Sotomayor is asking you would this be covered or not, and it was my understanding that the legislatures witnesses said that these would be cove mr. Turner yeah, and those doctors said, if they were exercising their medical ju, they could in good faith determine that lifesaving re was necessary. And thats my point. This is a subjective standard. Justice barrett but some doctors couldnt, is some doctors might reach a contrary conclusion, i think is what Justice Sotomayor is asking you. Mr. Turner and and let me Justice Barrett if they reached if they reached the lusion that the legislatures doctors did, would they be osuted under idaho law . No. Turner no. If they if they reached the conclusion that the dr. Reynolds, dr. White did, that these wereaving Justice Barrett what if the prosecutor thought differently . What if the prosecutor thought, well, i dont think any goodfaith dcould draw that conclusion, im going to put on my expert . Mr. Turner and that, your honor, is the natu o prosecutorial discretion, and it may result in a a case that require justice barrets idaho put out any kind of guidance . You know, hhs puts out guidance about whats covered by the law and whats not. Does idaho mrturner there are regulations. Da some regulations. But i think the the guiding star here is the plann parenthood v. Wasden case, which is a lengthy, deil treatment by the Idaho Supreme Court of this law, and it made clear, the court ma car, that there is no medical certainty requirement. You do not have to wait for the mother to be fdeat Justice Jackson counsel, i dont juste roberts thank you, counsel. Is there what happens dispute arises with respect to whether or not the doctor was within the confines of idaho law or wasnt . Is the doctor subjected to review by a meauthority . Exactly how is that evaluated . Because its an obvious concern. If if you have an individual exception for a doctor, and were having a debate about is that covered by yourubssion that nothing in idaho law prohibits complying with emtala, i mean, who who makethe decision whether or not somethings within or withou mr. Turner so, i mean, i i imagine there are two ways the law can be enforced or at least two. The board of medicine has licensing oversight over a doctor. And the ido preme court made clear that that Doctors Medical judgment is not going to be judged bedn an objective standard, what a reasonable doctor would do. Thats not the standard. The second way would b chief Justice Roberts well, what what is the standard . Mr. Turner the ds goodfaith medical judgment, which sjective. Chief Justice Roberts and its not subject iew by any medical board if theres a complaint against the doctor that mr. Turner yeah. Chief Justice Roberts his standards dont comp lets say hes the only doctor at the particular emergency room, and he has his own particular standard. Mr. Turner what what the Idaho Supreme Court has said is that you may consider another doctors opinion only on the estion of was it a pretextual medical judgment, not a goodfaith one. Chief Justice Roberts thank you. Ste thomas . Justice alito . Justice alito well, i would think that the conptf goodfaith medical judgment must take into accot me objective standards, but it would leave a certain ou of leeway for an individual doctor. That was how i interpret wt the what the state Supreme Court said now you have been presented here dawith very quick summaries of cases and asked to provide a sn jgment about what would be appropriate in those particular cases, and, hontl i think youve hdlbeen given an opportunity to answer some of the hypothetical but would you agree with me that if a medical doctor, who is an expert in this field, were asked bang, bang, bang, what would you do in these particular circumstances which i am now going to enumeratethdoctor would say wait, i dont this is not how i practice medicine. I need to know a lot more about the individual case. Would you agree with that . Mr. Turner absolutely. And acog has, you knowhe case of prom, for example, acog doesnt ju kejerk stay an abortion is the standard of care. Acog itsys that expectant management is oftentimes the appropriate standard of care. And so these are difficult questions that turn onheacts that are on the ground between the doctor as hesessing them with his medical judgment that hes bringing to bear but is also arily constrained by idaho law. Just like every other area o the ce of medicine, state law confines doctor judgment in some ways. Justice alito thank you. Chief Justice Roberts justice Justice Sotomayor there is a difference between stabilizing a person who presents a serious medical condiorequiring stabilization than a person who presents with a condition, quoting idahos words, where there is a a great risk of to the pregnant woman. You agree theres daylight between the two . Mr. Turner we agree, and think this is most Justice Sotomayor and so there will be some women who present serious medical condition that the federal law would require to be treated who will not be treated under idaho law . Mr. no, i disagree with that. Idaho hospitals are treati these women. Theyreotreating these women with Justice Sotomayor stop. Mr. Tuer abortions necessarily, your honor, and thats an important point. Justice sotomayo a thats my point. They will present with a serious medical condition that doctors in good faith cant say will present death but will present potential loss of life. Those doctors potential ls of an organ or serious medical complications for the woman. They canrform those abortions . Mr. Turner yeah your honor, if that hypothetical exists, and i dont know of a a condition that is so certain to res the loss of an organ but also so certain not to transpire with death. If that condition exists idaho law does say that abortioninhat case arent allowed. And i think Justice Sotomayor all right. That let me stop you there because all of your legal theories rely on us holding that feralaw doesnt require cannot preempt state law on these issues. D so, when i asked you the question if a ste fines likelihood of death more stringently than idaho does, you would say theres no federal law that would prohibit them from doing that . Mr. Turner well, i would say that emtala does not contain a standard of Justice Sotomayor sthere is no no standard of care. In your briengyou make the sgs position here, and you almost argue that now, that atheir position that federal law requires stabilizing treatment and not equal treatment of pies, which was a position you took in your brief, you seem to have backed off from it here, you seem to agree that federal law requires some stabilizing condition, whet not you provide it to ottients. But i have countless briefs that say that both that hhha filed that predobbs, pre2009, this is not an unprecedented position, that hhs cntless situations cited hospitals for discharging patients whored an abortion as a stabilizing treatment. Congress discussed that topic in the Affordable Care act and explicitly said that nothing in the Affordable Care act shall be construed to relieve any Healthcare Provider from providing emergency servess required by state feral law. Medicapriders have told us that for decades they have unrsod both federal law and ate law to require abortions as stabilizing conditions for people presenting serious medical risk. Lower courts, theres at least cases of lower crtsaying you have to provide abortion. So this is not a postdobbs unprecedented position by the government. Mr. Turner it absolutely is. The in footnote 2th administration cites to two spreadsheets that contain 115,000 rows of enforcement instances. The administration Justice Sotomayor counsel mr. Turner has not identified a single instance Justice Sotomayor unl, predobbs, this wasnt much of a question. But there is hhs guidance and eres at least three cases in which it was invoked. The cthat we didnt have to that hhs didnt have to do it much before predobbdont make their position mr. Turner my point is more Justice Sotomayor unprecedented. Mr. Turner my point is more fundamenta yr honor. Its not just that there are few instances. There are no instances. And no on the issue of abortion. On any instance where hhs s come in and told a hospital you have to provide a treatment that is contrary to state law. And this isnt just about abortion. Consider opioids. Justice sotomayor oh, now were back to that. Ok. Thank you. Chief Justice Roberts Justice Kagan . Justickan mr. Turner, practicing medicine is hard, but there are stanrdof care, arent there . Mr. Turner yes, there are. Justice kagan and one of those standards of care with respect to abortion is that in certain tragic circumstances, as you yourself, yr own states law acknlees, where a womans life is in peril and abortion is the appropriate stda of care, isnt that right . Mr. Turner ths right. Juickagan and emtala goes further. It says that the approia standard of care cant only be about protecting aoms life. It also has to be about protecting a womans health. Thats what emtala says, doesnt it . Rner no, it doesnt. It defines emergency medical ion with a broader set of triggering conditions, but the the key question here is what is the stabilization requirement, and that is qualified by the availability term. Justice kagan the the stabilization requirement is is written in terms of making sure that a transfer would not result in a material deterioration as to the emgey condition. Nothing about has to be at deaths door, righ mr. Turner i think thats right, yeah. Justice kagan and there is a standard of care with respect to that on abortions too, right . Aoman is going to lose her reproductive organs unless s has an abortion, which happens in certain tragic circumstances, a doctor is supposed to provide an abortion, isnt that right . Mr. Turner emtala doesnt contain any standard of care. I dont know where the adminiraon is drawing Justice Kagan do you do you dispute thathes a medical standard of care that when a won about to lose her reproductive organs unless she has an abortion, that that doctors would not say that an abortion is the appropriate standard of care in that situation . Mr. Turner your honor, what i dispute is thaes a National Uniform standard of care that requires a tdn approach in all states. Idaho has set its own standard e, and it has drawn the line on a difficult question. D s inconceivable to me to think that congress attempted to answer this very fraught complicated question in a fope in four pages of the u. S. Code. It did not stice kagan Congress Said as to any condition in the rl if an emergency patient comes in, youre suppod provide the Emergency Care that will ensure that that patient does not see a mari deterioration in their health. Mr. Turner d ways within the justice kan hats what Congress Said. And the abortion exceptionalism here is on the part of the state saying were going to accept that with respect to every oer ndition but not with respect to abortion. Rner abortion isnt exceptional. Justice kagan where we will not comply with the standard of care that doctors have accepted. Mr. Turner your, abortion isnt exceptional. There are meus cases where statesntvene and say the standard of care in this rcstance for this condition is x, not y. Opioids, for example. In new jersey, a doctor cannot stabilize chronic pain with more than a fiveday supply o opioids. In pennsylvania, it cabe seven. In other states, there is no limit. Their reading of emtala requires that those limitations get wiped t and you impose a National Standard. There are numerous other instances where states are coming in and saying, in our ate, the practice of medicine must conform to this standard. Aho has done that with abortion. Its done it with opioi. Its done it with marijuana use. There are countless examples, your honor. Justice kagan and your theory although the Supreme Court has naow the reach of your statute, your theory would apply even if it hadnt . I mean, it would apply to ectopic pregnancies. It would apply even if there were not a death exception i mean, all of your theory would apply no matter whatrely, idaho did, wouldnt it . Mr. Turner if yeah, i think the sw is emtala doesnt speak to that, but there are other background principles and limitations like ratioasis review, justice rehnquist, the chief justice recognized Justice Kagan butoutheory of emtala is that emtala preempts none oft . That a state tomorrow could say even if death is around the corner, a attomorrow could say even if theres an ectopic prnay, that still thats a thats a a choice of the say about that . A has nothing to mr. Turner yeah. And that understanding is a humble one with respect to the federalism ruloftates. Its the primary care providers for their citizens, not the federal government. Humble for womens health, you know . Ok. Thank you. Chief Justice Roberts Justice Gorsuch . Justice gorsuch i just wanted to understanso of your responses or efforts to respond to se the questions that weve heard today. As i read your briefs, y thought idaho thinks that in cases of molar and ectopic pregnancies, for example, that that an abortion is acceptable. Mr. Turner correct, your honor. Justice rsh and the example of someone who isnt immediately gointoie but may at some point in the future, that that would be acceptable . Mr. Turner it goes back to the faith medical standard, but, yes, if the doctor shld determine cannot determine in good faith that death is going to afflict that woman, then no Justice Gorsuch so it doesnt matter whether it happens tomorrow or next week or a month from now . Mr. Turner there is no imminency requirem this whole notion of delayed care is just not consistent with the Idaho Supreme Courts reading of the statute and what the atute says. Justice gorsuch and the good it as i read the Idaho Supreme Court opinion, that th controls . Thats the end of it . Mr. Turner absolutely, i Justice Gorsuch all right. And then what do we do with emtalas definition of individual to includbo the woman and, as e atute says, the unborn child . Mr. Turner. Its you know, were not saying, your honor, that emtala prohitabortions. So, for example, in california, stabilizing treatment y with what that state law allows its doctors to perrm but i think our point with the unborn child amendment in 1989 is that it would be a very rae thing for congress to expressly amend emtala t require care for unbn children, and s not just when the child when the mother is exriencing active labor. The definition of emergency medical ion requires care when the child itself has an emergency medical condition ress of whats going on with the mother. And iwould be a strange thing for congress to have for the unborn child and yet also be mandating termination of unborn children. Justice gorsuch thank y. Chief Justice Roberts Justice Kavanaugh . Justice kavanaugh i just want to focus on the actual dispute as it exists now, today, between the governments view of emtala and idaho law, because idaho law has changed since the time of the district crs injunction both with the Idaho Supreme Court and with a clarifying ge by the idaho legislature. You say in your reply brief, and so too the the moyle reply f says, that for each of the conditions identifd the solicitor gewhere, under their vi oemtala, an abortion must be available, you say in the reply brief that idaho law, in fact, lo an abortion in each of those circumstances, and you go through them on pages 8 and 9 of the reply brief, each of the conditions. Is there a cdition that youre aware of where e solicitor general says emtala requires that an abortion be available in an emergency circstce where idaho law, as currently stated, does not . Mr. Turner , rtainly, the administration maintains that there is such conditions. The eshey identify in the affidavits Justice Kavanaugh what is your what is your vi . Mr. Turner and my view isha reference footnote 5 from the gray brief the mealealth condition situation. The administti says thats not on the table. Thats not a scenario where abortion is the only stabilizing care ruid. Anim not sure where that construct of only stabilizg care comes from because, under their view,s the doctors determination that controls, not this ios only requirement. But be that as it may, the American Psychiatric association and so im taki geral prelogar up on her offer in footnote 5 that there are no profsial organizations that set abortion as a standard of care. The American Psychiatric association, in a 2023 position paper, says that abortions are imperative for Mental Health nditions. That sounds like a necessity to me. And i dont know how, if a woman presents at seven months pregnantn idaho emergency room and says, im experiencing severe depression from this egnancy, im having Suicidal Ideation from carrying this nancy forth, that that wouldnt under the administrations ading be the only stabilizing care. Justice kavanaugh so you think the ninth Circuit Panel, when said every circumstance described by the administrations declarations inlved lifethreatening circumstances under which idaho law would allow an abortion, is what the ninth Circuit Panel said . Mr. Turner we agree with that because e nditions identified in the affidavits we a conditions that would fit under the lifesaving exception, and thats lling because, you know, these doctors, when put under oath in an affidavit, couldnt come up with any of these harrowing circumstances. They identified ones. But i think what the government doesnt want to talk about, again, ithMental Health exception here. That is i just dont owow you can read their understanding Justice Kavanaugh well, im just trying to figure t there really a other than the mental heah,hich we havent had a lot of briefing about, is there anotr condition identified by the solicitor general where yothk idaho law would now a physician in his or her goodfaith judgment to perform an emergency abortion . Mr. Turner not in their affidavits. They maintain nonethesthat when you compare the definition of what an emergency medical condition is, it is broader than the definition of the lifesaving exception in idaho law. And so they present this Justice Kavanaugh well, thats what thehey say, but then, whene t down to the actual conditions that are listed, th examples and Justice Sotomayor was going throh me of those you have said in your brief at least that each of the conditions identified by the government, actually, idaho law allows an emergency abortion. Mr. Turner and i agree, and i think the injunction here is al Justice Kavanaugh well, whats what does that me f what were deciding here . Mr. Turner well, wh imeans for idaho Justice Kavanaugh if ido if idaho law allows an abortion in each of the emergency circumstances that is identified by the government as emtala mandating that it be allowed . Mr. Turnell say two things. I meanthreal practical First Response is that idahos unde an injunction that includes an incredibly broad requirement that preempts state law Justice Kavanaugh right. I i understan. And that may mean that there shouldnt be an injunction. I take your point on that. Whats your second . Mr. Turner my second point, your honor, iont know how this court can make the determination on whether there are any realworld conditions without first answering the sty interpretation question of what emtalas stabilization requirement actually requires. That has to be addressed, and it has to be addressed not only because thats for the direct Justice Kavanaugh well, i was just picking up on your reply brief. Youre the one who said it in your reply brief mr. Turner yeah. Justicnaugh that theres actually no no real daylight herinerms of the conditions. So im just picking up on what you all you all said. Mr. Turner yeah. I understand, your honor. Justice kavanaugh thank you. Chief Justice Roberts Justice Barrett . Justice barrett i guess i dont understand why we have to address the stabg condition if what you say is that nobody has been able to identify a ct. And on the Mental Health thing, the sg says i just picked it up to check footnote 5 daho badly errs in asserting that construing emtala according to its terms would turn Emergency Rooms into f abortion enclaves by allowing pregnancy termination for Mental Health concerns. Sohats the only space that you can identify where and emtala would require one,ion and the government is saying no, thats not so, whats the conflict . Mr. Turner well, uronor, i mean, of course, we think we win whether you nd no factual conflict and, therefore, the injunction had to go away. Justice barrett but why . Why e u here . I mean, you know, the government mr. Turner well, they sued us, your honor. Jubarrett well, hold on a second. Youreerbecause theres an injunction precluding you from enforcing your law. And if your law lly operate because emtala doesnt curb idahoauthority to enforce its law, whats mr. Turner ll, it cant under the injunction because the injunction says that idahos law isreempted in an incredibly broad range of circumstances avoid stice barrett as as it conflicts with emtala, i thought. Mr. Turner it it it is much broader than that. It and isas based on the proffered injunction by the administration tavd an emergency medical condition, not in theof an emergency medical condition. So wt at means is idahos lacant even operate when a doctor determines that a condition might need tbe avoided that hasnt yet presented itself. Thats far broader than the emergency medical condition and stabilization requirement under emtala because the stabilization requirement under emtala is only triggered when there has been a termination that Justice Barrett ok. We i would like to hear the solicitor generals response to that. But let me just ask you one other thing abouMental Health consideration because i can i can understands point that a Mental Health exception would be far broader than idaho lawad the potential to expand the availability of abortion far beyondidaho law permits. But the stabilization requirement only exists up until transfer, right, until transfer is possible . So its harde to see how, that couldnt be stabilizedion, before needing to transfer, right . At that point, the idaho hospital could say well, youre yre stable, youre not immediately going to be suicidal, well leave you in the ca you know, a parent or a paner who will then seek mr. Turner well, that flexible view of stabilization is very different than the governments very rigid view of stabilization, which is, if an emergency medical condition calls for artion, its got to be provided right there and then s available in this very limited sense. And so the stabilization continuum that youre talking about, i agree, thats built into emtala because Justice Barrett the statute says until transfer is possible. Mr. Turner well, the the transfer pro kicks in if a hospital is unable to stabilize a condition. And so, if a patient presents at a hospital and that hospital has thbility, the availability to stabilize the condition, in the case of Mental Health, invite general prelogar to come up here and tell you that ive got it all wrong and that, you know, the mother that i described would t ed to receive stabilization in that circumstance and instead would be transferred to a Psychiatric Hospital or something and that wouldnt constituteumng under their reading. I just dont see ho comports with everything theyve said about the rigidiew of stabilization that if a condition calls for it and a hospital can do it, its got to be done there and then. Justice barrett does idaho have any kind of conscience exemption for dounder state law . Mr. Turner it does. And there are federal conscience prons as well. And i think that is a key poin here, your honor. The administration told this individual doctors are never required to perform an abortion from what i could tell, but that doesnt to hospitals. And so, in the case of catholic hospitals, and there are hundreds of them treating millio opatients every year, under the administrations reading, catholic hospitals who faithfully adhere to the ethical and religious directives areow required to perform abortions. Justice barrett is that because no federal conscience exemption applies . Mr. Turner i dont know why they sayhs the line that they draw between individual doctors and religious initions because coatssnowe on its face seems to cover both. Justice barrett ok. Thank you. Chief Justice Roberts Justice Jackson . Justice jackm really surprised to hear you say that idaho laits everything that the federal law requires. So i just itrying to unde that because it seems that if thats the case, then why couldnt emergeom physicians in idaho just ior standard . And follow the federal i mean, if if he state is doing exactly what the what the federal law says is required,s ok by idaho, then, fine, we set idaho aside. We do what the federal law says and we all go home. Mr. Turner well, i mean, our re of course, is that there is no conflict. And so as doctors arent having to make this choice of do i follow emtala or do i follow Justice Jackson so your representation on on behalf of idaho is that if a an Emergency Room Physician in idaho follows emtala in terms of whabortion is required to stabilize a patient, they will omplying with idaho law such that theres going to be no prosecution and no probl . Mr. Turner yes, because they have to comply with idaho lato comply with emtala. Justice jackson no, no. Im asking you, if they if thply with emtala, will they necessarily have satisfied because thats what you seemed to say in response to e Justice Barrett. Response to so i just wanto make clear if thats the position of the state. Mr. Turner emtala the scope of emtas stabilization requirement is necessarily determined by idaho law in this case. So ice jackson no. Youre saying, if theyolw idaho law, then they will be following emtala law. Mr. Turner well, i Justice Jackson id like for you to id like for you to mr. Turner i think it both, your honor. Justice jackson no, its not. Id like for you to entertain the other poity. You seem to be saying every situation in which the uni states says herea stabilization situation that the United States would say the person has to have an abortion, the physiciald say were following emtala and abortion is required, i thought you said in response to Justice Kavanaugh, yeho law would also say thats a situation in which an ab is allowed. If thats the case, then it seems to me there is no daylight, theres no conflict, as youve sai b its because idaho law is in full compliance with what the federal law is saying were getting it wrong, youre saying. This death thing, thats not what we really mean. What we mean is whenever its necessary to stabilize ant who is experiencing deterioration, as federal law requires. Mr. Turner no. I i i think i understand tht that youre making. And the best way that i can think of it, your honor, is that emtalas stabilization requirement requires medical judgo determine what is treatment, right . Tabilizing medical judgment . Ctor exercise well, his training, his experience, pereference to professional standards of care that are national, but Justice Jackson how about how about mr. Turner necessarily state Justice Jackson how about thats not just something youre sort of coming up with. I mean, as Justice Kagan sai the beginning, emtala tells the doctor how hes suppo decide it in this particular circum with reference to the medical stdas of care concerning when a patient is deterig in an emergency condition situation. Turner yeah, emtala Justice Jackson so, if ts e standard in emtala, are you representing that that is exactly what idahoying so that all the doctors need to do is follow emtala and theyll be fine under idaho law . Mr. Turner well, of course, were saying that idaho doctors necomply with emtala. Question is how do doctors comply with emtala, and emtala Justice Jackson let me ask you another question. Let me i think i understand your point. Youre sayaho is actually could actually be requiring more andederal law has to make them do what idaho says. Mr. Turner well, and its important that Justice Jackson yeah. Mr. Turner emtala itse codifies this presumption of a backdrop of state law. There are background principles here, and thats what stice jackson all right. Let me explore that with you for just a second. I i had t that this case was about preemption and that the entirety of our preemption jurisprudence is the tion that the federal government in certain circumstances can makey pronouncements thaer from what the state may want or what anybody elseant, and the supremacy clause says that what the federal government says takes ent. Ouve been saying over and over again idaho is, you kno a state and we have healthcare policy choices and weve made weve set a standard of care in this situation. L thats true. But the question is to what extent can teral government say no, in this situation, our standard is g to apply . Mr. Tuand Justice Jackson thats what t government is saying, and i dont understand how, cons with our preemption jurisprudence, you can be saying otherwise. Mr. Turner yeah, if i can put a finer point on it. I dont think its the question is neceary what can congress do but what did congress do here with emta and Justice Jackson all right. So what dio here . Mr. Turner yeah. It start opened the medicare act by saying the federal government shall not control the practice of and then, in emtala itself, it says state laws ar preempted. And then, when it and then, when you get to Justice Jackson state laws are eempted to the extent mr. Turner of a direct justckson or are only preempted to the extent of a conflict. Identifying a direct conflict. So why is preemption not working there . Mr. Turner and and whether theres a direct conflict based on this courts longstanding precedenudes clear statement canons that we think we win on the te let me be very clear. The text to us is very clear, its an easy on. But the governments got to come overcome a lot er hurdles, one being Justice Jackson i hu saying two things, that were theres not a conflict because everything we the federal ment requires, we allow, which the amici, physicians for rights, who have looked at idahos law and ys it prevents a lot of things in circumstances in which the l government would require them, they disagree with you on the facts, but, anyway, you say no conflict because welly are doing exactly what or allowing exactly what the federal government allows. D u say no conflict because the federal government in this ation wanted the states to be able to set the standards. And i guess i donderstand how thats even conceivable, given this standard, given this statute mr. Turner yeah. Justice jackson that is coming iisplace state prerogatives. Mr. Turner and if i cant convince you on the second, let me add a third. Justicjason yes, please. Mrturner and there the clear statement canon. So the spending au condition nature of this requires congress to speak clearly and unequivocally that it is imposing a abortion mandate. It thats not here in the statute. And, secondly, this courts presumption Justice Jackson but doesnt at make abortion different . I mean, what do you mean . They say provide whatever is ney to stabilize. So youre saying theyd have to say provide whatever i necessary, including abortion . Thats the only way that is taken account of here . Mr. Turner no, what im saying is, when we when we go and look at the phrase available and whatans, the government the administration is saying, well, theyre adding this tag that says consistent with state law. re saying no, under the clear statement canon, it presumption against preemption. And what the government ly do if it wanted to preempt this law is to put a tag regardless of state law, and th missing. Justice jackson thank you. Chief Justice Roberts thank you, counsel. General prelogar. General prelogar mr. Chief justice, and may it please the court emtalas promise is simple but profoun no one who com tan emergency room in need of urgent treatment should be deedecessary stabilizing care. This ce about how that guarantee applies to pregnant mein medical crisis. Inome tragic cases, women suffer emergency complicatns that make continuing their pregnancy a grave thre t their lives or their health. A woman whose amniot s has ruptured prematurely, for example, needs iedte treatment to avoid a serious risk of feion that could cascade into sepsis and the risk of hysterectomy. A woman with severe preeclampsia caface a high risk of kidney failure that could require lifelong dialysis. In cases like these, where there is no other way to stabilize the womans medical condition and prevent her from deteriorating, emtalas plain text requires that she be offered pregnancy terminatn the necessary treatment. D ats how this law has been understood and applied for decades. That usually poses no conflict wi state law. Even states that have sharply restricted access to abortion after dobbs generallalw exceptions to safeguard the but idaho makes termination a felony punishable by years of imprisonment unless it necessary to prevent the womans death. I thk understood my friend today to acknowledge several tis that there is daylight between that standard and e necessary stabilizing treatment that emtalwod require. And the Idaho Supreme Court recognized the same thing when it specificay ntrasted the necessary to prevent death exceioand said it was materially narrower than a prior idaho law that had a healt exception that tracked emtala. The situation on the ground in idaho is showing t dastating consequences of that gap. Today, doctors in idaho and the women in ihore in an impossible position. If a woman comes to an emergency ro fing a grave threat to her health, but she isnt ye facing death, doctors either have to delay treatmenan allow her condition to material to material deriorate, or theyre airlifting her out of the state so she can g t Emergency Care that she needs. One spal system in idaho says that right now its hang to transfer pregnant women in dical crisis out of the state about once every other week. Thats untenae,nd emtala does not countenance it. None of petitioners interpretations fit with the text, and sohehave tried to make this case be about the broader debate for access to abortion in cases of unwanted pregnancy. But thatnot what this case is about at all. Idahos ban on abortion is enforceae virtually all of itapications, but in the narrow circumstances involving grave medical emergencies, idaho cannot criminalize the essential care that emtala requires. I welcome the courts questions. Justice thomas general, are you aware of any other spending clause legislation that preempts criminal law . Genel elogar with respect torinal law in particular, justice thomas, im not immediately thinking of relevant cases. We have a whole string cite of cases in our brief at page 46 that refle tes where the court has recognized the prmpve force of spending clause legislation, including in situations where the funding strictions apply to private parties, so that could include the Coventry Health case, for example. Leaddeadwood is another example of this. But im not immediately recalling how that would apply in criminal law. Of course, this court hasnt drawn those kinds of distinctions in recognizing the force of the supremacy clause. Ste thomas now the normally, when we a preemption case, its a regulated partwhis involved in the snd they use it as an affirmative defense, for example, in wyeth or something. On the in this case, you are bringing an action against t state, and the states not regulated. Are there other examples of these types of suits . General prelogarsu. I mean, there are numerous examples where the United States has sought to protect its sovereign interests in situations where a state has done what idaho has done here and interposed a law that conflicts. So id point to arizona versus United States as an example of that. United states versus washington. There are a number of cases where this court has recog that the federal government can protect its interests ts kind of preemptionctn. And, as i mentioned before, the court has a long line of cases recognizing that that preemption princie plies in the context of federal funding restrictions that apply to private parties o. Justice thomas but even when the party that yore bringing the action against is not a regulated part general prelogar thats rrt, because what idaho has done here is directly interfered wi t ability of the regulated parties who have taken ese funds, federal funds with conditions attached, frobeg able to comply with the federal law that governs their behavior. And this was an essential part of the bargain that the federal government struck with hospitals sstantially investing in their hospital systems. And what the athas done is said you, through our operation of state law, are no longer permitted to complyitthis fundamental stabilization requirement in emtala in this narrow category of cases. Justice thomas well, normally, wouldnt it be the regulated party that would actually be asserting the preemption that yobout . Genel elogar certainly, i can imagine situations, for example, wre regulated party would assert a preptn defense and to say the state law itself is preempted to the extent thaitrevents that party from being able to comply with federal law. But im not aware of any inciple or precedent in this courts case law to suggest th thats the only way for the vement to protect its sovereign interests. Justice thomas thats e normal way, though . General prelogar i think at thats often the fact pattern of particular cases. Justice alito i dont understandowour argument about preemption here squares with the theory snding clause of congresss spending clause power. The theory is congress can tell a state or any other entity or person, look, heres some mey or other thing of value, and if you want to accept it, fine, then you have to accept certain conditions. But how does the congresss ability to do that authorize it to impose duties on another party that has n aeed to accept this money . General prelogar there are no duties being imposed on idaho here. s not required to provide emergency stabilizing treatment itself. The duties are are Justice Alito el all right. General prelogar applied to the hospital. Justice alito not not duties. Hocayou impose restrictions on what idaho can criminalize simplyecse hospitals in idaho have chosen to participate in medicare . I dont understand how this squares with theho theory of the spending clause. General prelogar lli think that it squares with this courts longinof precedents cited at Justice Alito well geral prelogar page 46 of our brief Justice Alito welli ive ive looked at them. General prelogarhat the court has recognized that juicalito ive looked at those cases. I havt found any square discussion of this particular issue. But i im interested in the theory. Can u st explain how it works in theory . General prelogar sur so spending clause legislation is federal law. Its passed by both houses of congress. Its signed by the president. It qualifies alaw within the meaning of the supremacy clause, an Justice Alito absolutely. Absolutely general prelogar and and so i think the supremacy clause dictates the relevant principle here Justice Alito o,ut what the law general prelogar that in a situation where Justice Alito ill let you fish. Yes, go ahead. General prelogar in a sitti where congress has enacted law, it has full force and effect under the supremacy clause, and at state cant do is interpose its own law as a direct obsclto being able to fulfill the federal funding conditions. And this theory, Justice Alito Justice Alito no, its its a geral prelogar would mean no conditions Justice Alito its a question general prelogar under medicare are enforceable. Justice alito its n there absolutely enforceable against the hospital that chooses to participate general prelogar well, i guess the hergument then would be that if a hospital is instead bound by t ste law and the state law gets to control, it would mean that hospitals couldnt participate in medicare atll. And thats not the argument that the statemang here. What it wants is for its hospitals to be able to acce medicare funding but not have to face the restrictions thatre attached to those funds as an essential part of the bargain. And there is no precedent to support that outcome. Justice alito well, i just dont think i dont understand how how e eory works. But let me move on to something else. Let im going to try to restate your general theory, and i want you to tell me if this is right. I think your argument is, if a woman goes to an emergcyoom and she has a condition that requiresn ortion in order to eliminate serious jeopardy to her hlt the hospital must perform the abortion or transfer the woman to another hospital where that can be done. That a fair statement of your argument . General prelogar iincludes not just serious jeopardy to her health b, viously, also serious dysfunction of her bodily Justice Alito right. Right. Nel prelogar organs or a serious impairment of a bodily function. Justice alito right. General prelogar and the other caveat i would make that it would it would require pregnctermination only in a circumstance where thats the on psible way to stabilize her and prevent that cascade o Health Consequences. Justice alito does this apply at any point in pregnancy . General prelogar so the pregnancy complications that we have focused on generally occur in early pregnancy, often before the point of viability. There n complications that happen after viability, but there, the standard of care is to deliver the baby if you need the pregnancy to end because its causing these Severe Health consequences for the mom. Justice alito well, wt it what if it occurs at a point where delivering the baby is not an option . You o of the third trimester, but its really not an option toeler the baby. General prelogar you said that you in the Justice Alito out of the first trimester. Generaprogar third trimester . Justice alito no. Isorry. Out of the first trimester. General prelogar so, if youre contemplating a situation where delivery is not an option, then i think, in that circumstance, if the only way to prevent grave risk to the ms health or life is for the pregnancy to end and terminatn the only option, then, yes, thats the required care that emtala has through its stabilization maat but, critically, in in many of the ces Justice Alito ok. That that neral prelogar the very same pregnancy complication meanshe fetus cant survive regardless. Justice it i i understand that. General prelogar theres not going to be any way to sustain that pregnancy. Justice alito let me ask you squarely the question that was discussed during mr. Turners argument. Does the term health in emtala mean just physical health, o does it also include Mental Health . General prelogar there can be grave Mental Health emergencies, buemtala could never require pregnancy termination as the stabilizing care. Justice alito hy general prelogar and heres why. Its cae that wouldnt do anything to address the underlying bra cmistry issue thats causing the the Mental Health emergency in the first place. This is t out Mental Health generally. This is about eaent by er doctors in an emergency room. And when a woman com iwith some grave Mental Health emergency, if she has happens to be pregnant, it would be incredibly unethical to terminate her pregnancy. She might not be in a position to give any informed consent. Instead, the way you treat nt Health Emergency is to address whats happening t brain. If youre having a psychotic episode, you administer antipsychotics. Justice alito well, i i really want a simple, clearcut answer to th qstion so that Going Forward everybody will know what the federal governmes position is. Does health mean only physical health, or ds also include Mental Health . General prelogar with respe to what qualifies as an emergency medical condio it can include grave Mental Health emergencies, but let me be very clear about our position. That could never lead to pregnancy termination because that is e accepted standard of practice to treat any Mental Health erncy. Justice alito does the term serious jear in in e 11 mn an immediate serious risk or may a risk of serious consequences at some future point suffice . General prelogar the stanrd is defined in terms of whether you need immediate medical treatment. And so the relevant question is, in the abscef immediate medical treatment, are you going to have this serious jeopardy to your health, dysfunction of your organs, will your bolyystems start shutting down, so it is pegged to the urgency of acute care in an ergcy room. Justice alito so it has to be immediate . General prelogar the the relevant standard under th statute is phrased in terms of whether these consequenc wl occur without immediate treatment, yes. So its focud the interaction beeehaving some kind of Urgent Health crisis that takes you to an emergency room in e rst place and then how proximate these these coequences are likely to be. Justice alito well, there are two ffent things there, whether the person is whether the woman is in immediate jeopardy or whether thpeon the woman needs immedia care in order to eliminate jeopardy at a lar int. So i understand your answer to be tt e woman need not be in imdiate jeopardy, but if she doesnt get care right away, jear at some future point may suffice . General prelogar so the statutory standard itsf focused on Immediate Health risks. Its lookinathe possibility that if the woman doesnt get treatment th a there, what will happen,hawill reasonably be expected to occur is that her organs couldta shutting down or she might lose her fertily have other serious Health Consequences. It is focused on this temporal linketen the immediate need for treatment, which is i think reflective of the fact that ngress was narrowly focused on this emergency acute medal situation. Justice alito do the terms impairment to bodilfutions or serious dysfunction of any bodily organ or part refer only to permanent iaient or dysfunction . General prelogar i think Justice Alito or do does it also refer to temporary imirnt or dysfunction . General prelogar i think it can also refer to temporary impairment, but im not su that its easy to parse e o. For example, a lot of times a pregnant woman in distress, she might start suffering liver damage or kidney malfunction and you dont know ex ante whether thatgoing to be permanent or not. The instruction th cgress gave in emtala is you need to stile to guard against those very Serious Health risks. Justice gorsuch general, id id like to if you yeah, just understand kind of the scope of your arment here on the supremacy clause a it operates in your mind, putting aside the this case. Could the federal government condition the receipt of funds onospitals that they comply with medical ethics rules provided f bthe federal government, a medical malpractice regime, and a medical licensing regime such that effectively all state medical malpractice laws, all state medical licensing laws would be preempted . General prelogar and youre imagininth this is regulatory action or that congress has passed a state creating kind of a federal malpractice regime . Justice gorsuch you call it. General prelogar i mean, i think i have a broad view of congressthority to enact statut, d so what id want to assess in that situation is, you know, whether congress is acting pursuant to one of its enumerated powers. Justice gorsuch spending clause. This is all spending clause. General prelogar yeah. So so i think that very likelyoness could make those kinds of judgments and attach conditions to the receipt of federal funds. And, you know, in medicare, there are suial conditions. Justice gorsuch even if it covers all hospitals in the state and effectively transforms the regulation of medicine into a federal function general prelogar you know, there might be a. Justice gorsuch historical . General prelogar at which this court thinks that its really encroaching on the ates prerogatives in ways that are inconsistent with our constitutional structure, but i dont think Justice Gorsuch you dont genalrelogar were anywhere close to that Justice Gorsuch you dont see general prelogar in this case. Justice gorsuch but do you see y bounds just in principle . General prelogar i think the bounds, you know, would have to come from this courts se law concerning federalism principles. The court has said in cases like gonzales versus oregon that, of course, the federal government has authitto comprehensively regulate on health and safety, including with respect to medical care. And so i dont think that theres any principle of exclusive governance of this area by the state. But, obviously, im sure y could construct hypotheticals that really justice gorsu all right. Ok. General prelogar sm to be the federal government entirely taking over a state function and maybe that would be subject to a different principle. Justice gorsuch yeah. And emtala and and medicare allow the federal government to enforce the emtala dictate through civil monetary penalties . General prelog ats correct, yes. Justice gorsuc a also, you can terminate the medicare agreemen ia hospital violates emtala in your view . Geraprelogar yes. Generally, the hospital is given the oppouny to come into compliance and to develop a plan to ensure thathe wont be future emtala violations. It wldbviously be an extreme sanction to to terminate meca funding, but that is a possibility. Justicgouch and theres also a private right of action r emtala violations that it have the possibility of Equitable Relief as well . General prelogar s. Certainly, monetary relief and and possibly Equitable Relief as well. Justice gorsuch in in this case, you you you brought an equitable causef tion. You didnt cite any statute to enforce emtala. And one of the rules in equity tradiolly at least is that you dont get an Equitable Relief if theres an adequate reme alaw. And as we just discussed, theres a pretty reticulat statute here. Seminole tribe says, when you ha a reticulated statute and lots of remedial options, you dont get Equitable Relief. Thoughts . Neral prelogar so let me say at the outset that the ute states has long been recognized to have an action in equity,n inherent action in equity to appeal to the courts of this of this nation to protect its sovereign interests. And thats been reflected in things like jtice gorsuch its sovereign its proprietary interests . You mentioned washington and you mentioned general prega arizona versus Justice Gorsuch arizona. General prelogar united States Justice gorsuc arizona was an general prelogar is another example of that. Justice gorsuch Arizona Arizona was just sorry to interrupt, but arizona was an immigration case and genel prelogar right. Justice gorsuch the rd, and washington was an attempt by a state to impose its Worker Compensation laws on the federal government in a way different from others. I i te ose points. And equity is all about propriarinterests and things like that. Do we havehahere . General prelogar the well, i think that the court its not ianto make sure to make clear that there are a long line of caseshastand for this principle, including cases that ha addressed it directly like in re debs Justice Gorsuch oh, debs. General prelogar wyandot, so Justice Gorsuch do you really want to rely on debs, general . I mean, that wasnt exactly our brightest moment. General prelogar i do think, though, att reflects the history and tradition of this nationn cognizing that its entirely appropriate for the United States to seek to protect its interests in this manner. And t say, Justice Gorsuch Justice Gorsuch what do you genalrelogar this is a really important issue to the uned states. It wasnt pressed belo it wasnt passed upon. Justice gorsuch im just trying general prelogar we havent briefed it at all. Justice gorsuch im trying to genalrelogar its not jurisdictional. Justice gorsuch im just trying tondstand where it comes fr. What is the proprietary interest here . General prelogar it comes from Justice Gorsuch it seems to me its ityour money and how its being spent, and congress has given you lots of tools. General prelogar i think it also comes from the recognition under obstacle preemption principles that there e important functions to be served by having the Medicare Program in place. And idaho has directly interfered with the ability of hospitals to accept these federal funds when they std willing and able to comply with emtalas mandates and fulll congresss desire hertoake sure that no matter whe u are in this country, if you have an Urgent Medical need and you go to an er, you can be stabilized. Justice gorsuch thank you. Justice jackson general, is there chief Justice Roberts unl, your friend on the other side said that your position would require religiously affiliated hospitals with Emergency Rooms to rfm abortions. Was he right . General prelogar no. My friend was wrong. There are federacocience protections that apply at the entity levelo spitals as well. The key provisions are in the weldon ameme and also coatssnowe, although that dendon the Residency Program of a particular hospital. Now hhs said in a 2008 making on conscience protections that it had never come across a hospital that had a blanket objection to providing lifepreserving d healthpreserving pregnancy termination care, but if a hospital h tt kind of objection and hhs recently informed me they still have not come acrs at hospital, that would be honored visavis hhs enforcement ability. Chf stice roberts you said that applies at the entity level. Can individual doctors in the emgency room do they have a conscience exemption . General prog oh, yes. Yes. Theyre protected under the Church Amendments principally. And our position is that emtala does not override either set of conscience proteio. So, if an individual doctor has a conscience objection to providing pregnancy termination, emtala itself imposes obligations at the entity level, and the hospital should ha plans in place to honor the individual doctors nscience objection while ensuring appropriate stfi for Emergency Care. Chief justice rort well, does that does that mean that there must be somebody in the emergency room that can provide an aboio what if what if there are two cts, three doctors, and they all have a conscience exemptn . General prelogar no. In that circumstance, emtala could not override tse individual doctors conscience protections, but my understanding is that as a matter of best practice, because hospitals want to be able provide Emergency Care, they do thin le ask doctors to articulate their objections in advance so that that can be taken into accountn king staffing decisions and whs on call. Hospitals have a lotf ans in place chief Justice Roberts are are you saying general prelogar for these kinds of contingeie chief Justice Roberts yeah. Arre you saying that there must be somebody available and on calin in a hospital of that sort . General prelogar the conditions of participation for medicare require hospitals to be appropriately staffed to provide emergency trtmt. Now, in a situation where a hospital doesnt hnt done that and it doesnt have anyone on hanwhcan provide care, you know, maybe all of the doctors called in sick that day and theres just literally no one in the emergency room, or in this case, if everyone had a nscience objection, then the hospital would not be able to provide the care. But there are conditions of partipion that are meant to ensure that there is Good Governance of hospitals and organization to accounhief Justice Roberts when you say general prelogar for these situations. Chief Justice Roberts and the consequence of them not being able to provide the care would be what . General prelogar in that circumstance, i inthey would likely be out of compliance with the conditions of participation that require them to be appropriately staffed. But, if the question is could you force an individual doctor to step in then over a ence objection, the answer is no. And i want to be really clear about that. Chieice roberts i know, but the question general prelogar we dont understand emtadisplace it. Chief Justice Roberts excuse me. The question is whether or not must have available someone who can comply the procedures re by emtala. And what would be the consequence if they dt . Would it be eventual termination of their participationn medicare . General prelogar thatt. So, if a hospital was continually disobenghe requirement to have in place sufficient personnel to run their emergency room, then i imagine that hhs would, through enforcemtion, work with that hospital to try to bring it into compliance. And if the hospital ultimately is jt aving itself in a position where it can never provide care, then it would terminate the medicare funding reent. Justice gorsuch i thought Justice Barrett general Justice Gorsuch you just said a minute ago im sorry. Justice barrett oh, no, go ead. Justice gorsuch i thought you i just want to clarify is colloquy. I thought you said mute ago, though, if the hospital had a conscience objection a therefore didnt provide certain care, thathawouldnt render it out of compliance. Whicist . General prelogar thats correct. Juicgorsuch ok. All right. General prelogar so the hospital could assert a conscience objection ste gorsuch thats all. General prelogar and emtala would not override that. Stice barrett my question i have a question about the de amendment. So i gather from the briefing that there might be some situations in which emta wld require an abortion, but the Hyde Amendment wouldnt permit federal funds to be us tpay for it. And you said in your brief that emtala requires in other circumstances as well stabilizg eatment to be given that federal funds dont cover. Can you give aexple of that . And am i right about the Hyde Amendment . And then can you give an example of tha general prelogar yes. Sooure right about both things. It is common under emtala that hospitals are going to have to provide care where theres no federal funding available. And ill give you an example of a medicare patient who goes in and his emergency medical condition means nds a particular drug thats not coreby medicare benefits. Still, the hospital has to provide him thtabilizing treatment and give him that medication, even though the federal fuinisnt going to pay for it. And that also pls to people who are uninsured, who arent covered by medarin the first instance. The the whole point of emtala was it doesnt matter your circumstances, idont matter whether you can pay or not, it doesnt matt t particulars of your situation, this is a guarantee. You can get stiling treatment. I want to say, though, that i dont think theres any inconsistey tween the lines Congress Drew in emtala and hyde and congress itself has cognized that these statutes address discrete issues. m thinking here of the provision in the Affordable Care act th w exclusively about abortion, and there, Congress Said nothing in the aca displaces hyde and the other federal funding restrictions on abortion, but nothing in the aca displaces emtalas requt to stabilize. And that shows two things. Hows first that congress recognized that stabilizing care can sometimes be pre termination. And i think it also showed congresss ition that these statutes addressed their own distinct spheres. And onl point on hyde, Justice Barrett. My frint drawing a line based on hyde either because his point is, even if a woman is on brink of death and she goes to an emergency room and there are federal Funds Available under hyde to treat her, still, hospitals have no obligation under emtala to provide at care. Justice barrett so what about the colloquy i was having with your friend about what stabilintreatment entails lets imagine a situation in which a woman is, i dont know, 10 weeks, and is told thatf you carry this pregnancy to term, it could have, you know, consequences for your health, but you just would need to abort before, like, say, 15 weeks, Something Like that. So theres not an immediacy, like so shes stable wn e leaves the hospital, but in ido, theres no place else that she can go at least uil shes 15 weeks. What is the federal gornnts position then . General prelogar i think, if im understanding the hypothetical correctly, that she likely wouldnhave an emergency medical condition in thfit place because the definition of having an emergency medical condition is that, without immediate treatment, you asonably you will reasonably be expected e serious dysfunction of your organs or serious impairmentur bodily functions. And so, in that situation where a woman is somewhat high risk, you knowe she she has certain complications where doctors can says some danger with continuing this egncy, i dont think that that creates the kind of emergency medical condition that emtala is aimed at. Last question, and this is about the spending clause so it does seem odd and i think kiwhat some of the questions are getting at it does seem odd that through a side agreentetween a private entity and the federal government, the privatenty can get out of state law, right . So, in a administration, would it be possible then in reliance on the spending power for congress to say, you any hospital that takes these funds cannot perform abortions or any hospital despite state law requiring a state nstitutional amendment requiring abortion available, is that possible or, you know, withenr reassignment surgery . I mean, you can imagine it kind of going bk d forth through spending clause litigation in ys that would be unusual. General prelogar yes, i think congssas broad power under the spending clause to attach conditions. Now it doesnt mean that its wholly unlimited. Obviously, congress would be having to act pursuant to an enumerated power, it would have to comply with other constituon limits, and so the law would have to be valid the spending clause itself has builtin limits, things like relatedness and pure notice. Justice barrett so it would have to be acting pursuant to an enumerated power in forbidding gender reassignmt rgery or abortion or those sorts of things . General prelogar oh, no. I just mnthat it would have to be valid spending. Justice barrett the spending clause . Geraprelogar the spending clause. Justice barrt he spending clause. General prelogar itself would be enough. Justice barrett ok. Ok. General prelogar yes. So we think Justice Gorsuch yeah. So geral prelogar the spending clause itself would be enough. Justice gorsuch so just to follow up on that and going back to where i started with could could the federal government essentially rela the practice of medicine of the states through the spending clause, e swer, i think, is yes, congress could prohibit gender reassignment surgeries across the nation, it could ban abtion across the nation, through the use of its spendin clause authority, right . General prelogar core does have Broad Authority under the spending clause. And, yes, if it satisfies the conditions that e ending clause themself itself requires, then i think that that would be videgislation. Justice gorsuch how general prelogar and the court has in many contexts recognized Justice Gorsuch how do we general prelogar t spending clause legislation preempts. So to justice usce gorsuch so the the answer is yes . Ok. So how do we reconcile that wi the statement in 1395 that thing in this subchapter allows a federal officer to exercise any ctr over the practice of medicine . General prelogar so, at the outset, i think, if congress itself is doing it, then that provision is inapplicable by its own terms. Thats looking at the Justice Gorsuch you dont think it informs our view and understandinofhe statute in any way . General prelogar well, i think, in the event of some kind of direct cflt, you know, looking at emtala in particular, its the later in time enacted state, and its clearly more specific, so it would control. This court itself has rejected the idea that there would be that kindf nflict. And iinking of the cms vaccine case where the litigants relied on xact same provision of the medicare act, sect95, and this court said no, that cant bear the weight that those litigants could place on it or it would ll into question all of the conditions of participation in re. Justice gorsuch do you agree that our clear statement re with respect to spending clause legislation, our clear stateme rule with respect to federalism are in play here . Neral prelogar i think that here, congress has spoken y with respect to what providers Justice Gorsuch oh, i general prelogar are supposed to do. E gorsuch thats not the question. Do you think those ptions apply . Forget about whether you can satisfy them. General prelogar the requirement of cleice under spending clause legislation, yes, i that that does apply, and providers have always understood their obligations under emtala. Justice gorsuch ok. Justice n general, let me ask you to respond to a couple of things petitioners counsel said and just give you the opportunity to respond. He suggested or said that you havenidentified a circumstance in which something that emtala requires idaho wouldnt allow. And i i didnt get a chance to ask him, t took i took him to sort of mean that the way thatdas statute operates, it basically allows for a doctor say, well, in my view, you know, this healththreeng circumstance could eventually lead to death, and so im going to do it. So, to thextt that doctors are still able to do that, i guess, hes saying theres no preemp but is it true that there really it in operation a difference between the two the emtal and what idaho has requid here . General prelogar no. That is gravely mistaken on three levels. Its inconsistent with the actu tt of the idaho law. Its inconsistent with medical realy. And its inconsistent with whats happening on the gun and this is a really important point, sleme try to unpack this. On the text itself, as law only allows termination if its necessy prevent death. And that is textually very narrow compared tohaemtala requires with the category of ha tbegin with. In idaho, doctors have to shut their eyes to everhi except death, whereas, under emtala, youre supposed toe inking about things like, is she about to lose her fertility . Is her uterus gointoecome incredibly scarred because of the bleeding . Is she about to undergo the possibility of kidney failure . So i think that that is on critical distinction. The other critical textual stction is the idea of necessity. Under idaho law, you have to conclude that death will cessarily result, which is also materially different, and e Idaho Supreme Court specifically recognized it. Second, wi rpect to the there are numerous conditions that we are worried about where doctors immediate concern is not death. Thats a far more remote possibility. They tnking about the Health Circumstances that emtala guards against. And let me give you two examples. The first is pprom, premature rupture of the membranes. Have declarations at 594 that explain this in detail and also ata 615 to 617. What the doctors explainedhe this is dr. Fleischer and dr. Cooper aoman comes in with pprom, her sac is ruptured. Theres nohae the fetus is going to be able to survive, but at that point, she doesnt have active signs of infection, and so, until she deteriorates, you cant think shes close to death. What youre worried about is she will bominfected. Shmit develop sepsis. She might have these dramatic consequences for her future, but its not about death. I think that is one example where you cant do it. And then, finally, just the actual practice on the ground, women in idaho today are not getting treatment. They are getting airlifted out of tte to Salt Lake City and to neighboring states where there are health exceptions and there are laws because the docts e facing mandatory minimum two years in prison, lo of their license, criminal prosecution. The doctors cant provide the care because until they can conclude that a prosecor looking over their shoulder wont second thamaybe it wasnt really necessary to prevent death. Chief Justice Roberts thank you, counsel. Justice thomas . Justice alito . Justice alito weve now heard lets see an hour and a half of argument on this case, and one potentially very important phrase in emtala has rd been mentioned. Maybe it hasnt even been mentioned atll and that is emtalas reference to the womans nbn child. Isnt that an odd phrase to put in a statute that imposes a mandate to perfo artions . Have you ever seen an abortion stute that uses the phrase unborn child . General prelogar its not an d phrase when you look at what congress was doing i19. There were wellpublicized cases where women were experncg conditions, their own health and life were not in danger, but the fetus was in grave distress and hospitals werent treating them. What congress did Justice Alito well, have you se general prelogar is that it Justice Alito have you seen abortion statutes that use the phrase unborn child . Doesnt that tell us something . General prelogar it tells us that congress wanted to expand the protection for pregnant won that they could get the same duties to screen and stabilize when they have a condition thatthatening the health and wellbeing of the unborn child. But what it doesnt suggest is that conessimultaneously displaced the independent preexisting obligation to treat a woman who herself is facing grave life a hlth consequences. Justice alito well, lets walk through the provisions of the statute that are relevant to this issue regarding the status and the potential interests of an unborn child. Under b 1 , if a woman goes to a hospital witanemergency medical condition thats the phrase the hospital must eithertalize the condition or, under some circumstances, transfer the the woman to another facility. So we have this phrase, emergency medicalontion, in that provision. And then, under e1 the term emergency medical condition is defined to include a condition that places the healthf e womans unborn child in serious jeopardy. So, in that situation, the hospital must stabilize the threato e unborn child. And it seems that the plain meaning is that e spital must try to eliminate any imdie threat to the child, but performing an abortion is antithetalo that duty. General prelogar but, in a ciumstance Justice Alito now and you you go you go so far as to say that the statutislear in your favor. I i dont know how you can say that in light of the of those provisions that i just read to you. General prelogar the statute did nothing to displacth woman herself aindividual with an emgey medical condition when her life is in danger, when her health is in danger. That stabilization obligation equally runs to her and ke clear that the hospital has to give her necessary sbizing treatment. And in many of the cases youre thinking about, there is no possible way to to stabilize the unborn child because the fes sufficiently before viability that its inevitable that t pgnancy is going to be lost, but idaho would deny men treatment in that circumstance Justice Alito doesnt generalregar even though its senseless. Justice alito doesnt what ive re to you show that the statute imposes on the hospital a dutyo e woman certainly and also a duty to the child . And it doesnte the hospital how it is to adjudicate conflicts betweethe interests and it leaves that to state law. Now maybe a lot most of your argument today has been dedicated to the proposition at the idaho law is a bad law, and that may well be the case. But what youre asking us to do is tcotrue this statute that was enacted back during the Reagan Administration and signed by president rgan to mean that theres an obligation under certain circstces to perform an abortion even if doing that is a vlaon of state law. General prelogar if congress had wanted to displace protections for pregnant wom who are in danger of losing their own lives or their healt then it could have redefined the statute so that the fetus itself is an individual with an ergency medical condition. But thats not how congress structured this. Instea iput the protection in to expand protection for the pregnant woman. The duties still run to her. And in a situation where her own fe and health is gravely endangered, then, in tha situation, emtala is clear. It says the hoit has to offer her stabilizing treatment. Justice alito the the only general prelogar and she doesnt have to accept it. These are tragic circumstances. And many women want to do whatever they can to save that pregnancy. But the state otects her and gives her that choice. Juicalito the only way you try to get out of the statutor interpretation that i just posited is by focusi othe term individual. And you say, aha, in the dictionary act, individuals fined to exclude an unborn chd a fetus. Thats the only way you can try to get out of atve just outlined. And isnt it truth under the dictionary that dictionary act definionapply only if they are not inconsistent with the atory text . And when you have a text that, certainly, you wouldndiute the fact that the hospital has a duty to the unborn child where the woman wants to wants to have the pregnan gto term, it indisputay protects the interests of the unborn child. So its inconsistent with the definition in the in the dictionary act. General prelogar no, not at all. E ty runs to the individual with the emergency medical condition. The statute makes clear as the pregnant woman. And, of course, core wanted to be able to protect her in situations where ss suffering some kind of emergency and her own al isnt at risk, but the fetus might die. That includes mm things like a prolapse of the umbilical cord into theerx where the fetus is in grave distress, but the woman is not at all affected. Hospitals otherwise wouldnt have an obligation to treat her, and ngss wanted to fix that. But to suggest that in doing so ngss suggested that the woman herself isnt an individual, that she doesnt deserve stabilization, i think that that is an erroneous reading of this statute. Justice alito nobodys suggesting that the woman is not an individual and she doesnt she doesndeserve stabilization. General prelogar well, the Justice Alito nobodys suggesting that. General prelogar i think the premise of the question would be that the state of idaho Justice Alito it wasnt the predicate. It wasn general prelogar can declare that she cannot get the stabilizing treatment even if shes about to die. Ats their theory of this case and this statute, and its wrong. Chief Justice Roberts Justice Sotomayor . Justice sotomaeneral, this this lack of conflict which urpposing counsel colleague says doesnt exist, you mentiod situation where it does. Why dont you succinctly state what you well, they adm theres daylight. Tell us exactly how u fine where the daylight exists. General prelogar thight, as i see it, exists on two dimensions. Eyhink that doctors can only provide stabilizing care when the woman is facing death. And we think, no, you can take into account things like kne failure, the risk of a seizure, and lifelong neurological impacts based on that. Justice sotomayor well, they they said the rentecision of the oregon court says you dont need death to be imminent or immediate, i think, is the word they used if im not wrong. General prelogar so what the Idaho Supreme Court said in that decision is that theres no partul level of imminency and no certain chance quement. But what the court couldnt do is turn away from thlauage requiring the type of harm to exclusively be death. And also, the inherentonpt of necessity requiring some degree of mince, its true that its a subjective standard under ahlaw, and the court made that clear, but what the Idaho Supreme Court also said is prosecutors arfr to come in and have other medical experts secondguess doctors decisions by sayg ybe you didnt subjectively think she really needed it as necessary to prevent death because, look, her her sac had ruptured, but she wasnt yet infeed and thats exactly the kind of situation that leads to women being drivenutf state, dumped on neighboring states by idaho, and criminalinghe care, the seial care that they need. Justice somayor thank you. Chief Justice Roberts Justice Kagan . Justice kagan yeah, if you could just talk a little bit about that because, as i understood it, for example, i read recently that the hospital that has the greatest Emergency Room Services in idaho has just in the few months that this has beenn ace had to airlift six pregnant women to neighboring states, whereas, in e ior year, they did one the entire year. So, if mr. Turner is right about what the state is trying to convey to hospitals about when theyll be prosecuted, like, why is this happening . Nel prelogar i think that threason this is happening is because those doctors can look at the text of the statute itself, they can look at the idaho supremcots decision, which made clear, very clear, that ts s a departure from prior idaho laws that tracked emtala. Anthey can recognize that their livelihood is on the line, their medical license, their ability to practice dine, their freedom ifhehave to go to jail and serve one of these minimum twoyear sentences of imprisonntand they simply cannot provide the care, even consistent with their subjective medical judgment, because as a matt matter of medical reality, for many of these conditions, itnot yet putting a woman at the brink of death or nessy to prevent her death, yet they know that the standard of care is to provide her with teination because she is just going to get worse and wor a worse if they wait it out. And the other impoanpoint about this, and i think it goes back to this dual stabizion idea, is that, tragically, in many of these cases, the pregnancy is lost. Theres not gog to be any way to save that fetus because a woman who has pprom at 17 weeks, there is no medical way to sta the pregnancy to give the fetus a chance. So in that situation, what idaho is doing is waiting for women to wait and deteriorate and suffe the lifelong Health Consequences with no posslepside for the fetus. It just stacks tragedy un tragedy. Justice kagan and it it it cant be the appropriate you know, its like its become transfer is the appropriate standardf re in idaho. But it cant be t rht standard of care to force somebo oo a helicopter. General prelogar and its entirely incsient with what congress was trying to do in the statute. You know, onofhe primary motivators here was to prevent patient dumping. Thidea was we dont want people to have to go somewhere else to get their care. You go to the first emergency room in your state, and they have to treat you and stabilize you. But this effectively allows states to take any particula treatment they dont want their spitals to provide and dump those patients out of ste. And you can imagine what would happen if erstate started to take this approach. Justice kagan a question on the spending clause questions that youve been ke i mean, what would if you accepted some ofhese theories, what what would the consequences of somethinli that be that we would have to worry abt . General prelogar i think that it would call into question any number of federal spending statutes that provide fundto private parties, and the a a bunch of them. You know, theres the medicare system itself, whi iof course a major federal spending program. There are funds provided under title vi, under title ix, a lot of federal statutes out there that give funds to private parties and insist on conditions of cplnce with the federal funding restrictions. And if the court were to suddenly say that cant preempt contrary state law, then i think that it would seriously interfere with the ability of the federal government to get its benefit of the bargain in thosspding programs. Justice kagan and you mentioned before that this question has never been a part of this se general prelogar thats right. They did not make these arguments in the lower court. They briefly referred to the spending clause, but i dont understand them to he essed this argument specifically. And so i think that theow courts did not address it. I think the stct court said in a footnote, they briefly refer to it in a footnote of their brief, and its essentially waived. Justice kagan thank you. ChieJustice Roberts Justice Justice kavanaugh . Justice kavanaugh youve touched on whats happening on the ground, and thats an answer to the question of whats happening. But idaho is representing and i just want to get your answer on this that, as i count it, nine conditions that have been identified by the governnt where emtala would require that an abortion be available, an abortion is availablunr idaho law. And thathe reply brief. Now, are there other conditions . Youve ruled out Mental Health. Arthe other conditions you would identify, or are you just saying that thatnot really happening on the ground . I think thats part o answer, but i just want to get a fuller answer on that. General prelog certainly isnt happening on the ground. These are the conditions that were worried about. And i think the problem with my friends thryhat idaho law would permit it is that you just cant squa iwith the text of the statute. You owthe the Justice Kavanaugh what if there were general prelogar the state of idaho Justice Kavanah im sorry keep going. General prelogar well, i just wanted to say theyre not the ulmate authority on what the idaho law means. Thats the Idaho Supreme Court, crse. And it has addressed this issue in the planned parenthooca. And i think itreally significant that, in planned parenthood, the Idaho Supreme Court prsly contrasted this statute with other statutes that contain healthpreserving measures and recognized this was a total departure from that. The legislature wanted tfos a necessary to prevent deathon exception. So i think that that that essentially meanth the Supreme Court of idaho has already touched on this issue, and its wonder, then, that doctors who are facing these ndof pregnancy complications, where in their medical judgment its not necessarily to prevent death but the woman is going to suffer serious Health Consequencesthr hands are care under the idaho law. De that Justice Kavanaugh if the whas on page 8 and 9 of the reply brief were idaho law, would the a problem still . General prelogar so if we had an authoritavedaho Supreme Court decision that said idaho law alwsor termination in the circumstances where emtala would requiryes, of course. Then the conflict goes away. Juickavanaugh well general prelogar but i can imagine the court would say that because, of course, here Justice Kavanaugh thats not quite what 8 and 9 say, bui i take your point on that. Separate question, different category. I think one of the themes on the other side is ths law passed in 1986 was a very important w dressing a very important problem; namely, the problem where spals were turning away poor and uninsured patients who came inor Emergency Care. And the id w that cant happen. We cant allow hospitals in thi country to turn away poor and uninsured people in an emergencies. But their theme is that the law was not designed contextually to deal with specific with abortion or othespific kinds of care. And so they make a textual argumentbui think they also make a broader contextual arment about the whole idea of what was going on in 1986. And i want to make sure i dont think as really come up too much. I want to make sure yoreond to that. General prelogar i appreciate ving the chance to address that. So athoutset, i dont think they can square that theory with thte of the statute, which says, in no uncertain terms, here is the fundamental guarantee. If you have an emergencyedal condition and you go to an er in this country, they havto stabilize you. They have to give u ch treatment as may be necessary within reasonable medical probability eure that you dont deteriorate. And, yescoress did not provide a reticulated list of all possib ergency medical conditions and all possible treatments, but it was very clear that congress set a baseline National Standard of care to ensure tha nmatter where you live in this country, you cant be declined service and the the urgent urgent needofour medical condition addressed. And, you kno iwould be no different if the state had come ouandecided to ban epinephrine. Thats the singular way to ea anaphylaxis, a severe allergic acon. That would violate the statu, anwe would be up here making the exactly same arguments, because congress didnt want that. If you have anaphylaxis and you go to an er anywhe aund this country, thre going to give yoepephrine. And Congress Mandated that. And i dont see any way to try to draw lines around to exclude pregnancy complications in the circumstances where the only way to address the womans condition and prevent material deterioration is for the pregnancy to end. Justice kavanaugh thank you. Ief Justice Roberts Justice Barrett . Justice barrett so, genali i understand the primary difference bwe emtala and the idaho statute to be this health, that th iho focuses on the risk of life, but the federal government says that emtala llemtala says that the health is am i right, is health and life . General prelogar thats thats the principal difference, but i think its also t difference between necessary to prevent death versus theealth concerns would be reasonably expected to occur. So i think that that is a standard that budsn a little more space for doctors to take action. Justice barrett got it. Is the federal government aware of any state, other than idaho, that has a law that does not take health into account . Genel elogar there are six other states that have severe abortionesictions without a health exception. So tnk that those are the primary category of states were concerned about here. Justice barrett thank you. General prelogar i should i should make clear that there are me pending judicial challenges in those states, and so their laws are not always enforceable or in effect right n. Justice barrett besides texas, has the federal government hathfederal government brought suits similar to the o brought in idaho and texas in any of these oth stes . General prelogar to be clear, texas was not our jti barrett right. Ok. Generaprogar affirmative litigation. They sued us. But we have not brought affirmative litigation in other states. And i thinis this case has been on a course and idahos law was particularly severe because t point at which we sued it seemed to cover ectopic pregnancy, and the state conceded that. Noy have modified the law to exclude that, but it was one of the most pressing concerns because of that. Justice barrett thank you. Chief Justice Roberts jus jackson . Justice jackson general, petitioner relies pretvily on clear statement rule princi and i wonder whether you might coent on my thought that those principles actually cut against them in this case. As you said, congress set a baseline natioandard of care. It has said, in no uncertain terms, that the hospital must provide stabilizing care to people experiencing emergency medical conditions. There was no, as youve sai you know, particular conditions or particular treatments about, carved out, et cetera. So if a clear statement is required, wouldnit be the exempting abortion . Ption Justice Alito has talked about some of themptions for unborn child. None of them wed like an exemption. Nothing that is this clear nation sndard of care. I think congress was clearly requiring stabilization. It wasnt exempting particular conditions or particular types of treatment. Th court has said there is no canon of duluth dona rose. En you have a provision like that, the fact that you dont have specific enumeration of one of i alications does not mean you should read in some side of some kind of implicit ption. Wh i think we would need to e is a clear statement that ress meant for you to not provide abortions. I think important to recognize that every relevant actor ha understood it this way from the begni. Then the agencys position all along we not adopting a new position. Providers venderstood it. They hav always provided lifesustaining and healthy stating pregnancy termination consistent with and tyler. Congress recognized it in the Affordable Care act. And i think there isny argument to be made that people understood what congress is doing the statute. Thank you, unl. Quick thank you, your hor. And tell it takes state law practandards as they find them. As Justice Gorsuch noted, that is what section 1395 said. In the Vaccine Mandate case that referenced, that is what the Generals Office told this court when is at 1395 does not require does not allow federal officials to dictate particular treatments for particular cases. Do here with hey are trying to it is it is confirmed by subdivision f. Anything that could codify this, to Justice Jacksoncolloquy at the end, that is the point. You do presume that state law continue to operate alongside impala. You dont presume opposite. It is supported by the that is the Rosetta Stone of intel enforcement. Tells doctors, it tells cms enforcement agents on the available by referencing what is in t scope of that doctors license. That is exactly what we are saying. It is also specicay directed it requires hospitals comply with state law. That directs hospitals to acquire hospitals staff. They totally lack any case history that would support the this always was understood to be the case will you think we would find those 115,000 instances. Le instance where state law was overridden. And finally, the text. The text qualifies and tel us steve drew station requirement. We know they can perform open heart surgery and we know debtors can draw blood. It is not just a plainante devoid of reference to state law. We know the word available even inommon usage incorporates state law. You are just the other day that when considering whether this is available for homelesseoe, it iin physical and legal sense. There is a physical question and a legal question. Opioids are available in the hospital. They are on thshf, physically there. There is a legalueion that comes into play there. E me with abortions. Inesnse to the chief justice qution, the general said both hospitals and doctors are exempt from and tell us suppo it abortion mandate. We are relieved hr that. I think it highlights the utter incoisncy of the administrations meeting. If the establishing requirement is done on them not to override nscious protections, and it cannot be so specific and include a requirenthat is in direct conflict with state law. Those two do not drive. This court does not lately find a direct conflict. Congress must speak clearly. It has not done so here. The administras position ultimately is untethered from any limiting principle. But i inwe heard that. There is no way to limit this to abortion. There is no way to limit it to idaho. They are 22 states with abortion law on the books. This isnt going to end with idaho or the s states because all the steshat have abortion rions define the health and the emergency ption narrower than m tele does. This question will come up in state after state after state. It is not limitetohysical health. I know they say there is no stance in which a medical condition require stabilizatn thin abortion. Now he ist fighting with the American Psychiatric association. That is not consistent. It isnt limited to an tele. You will point the major spending becau ilications that are at play here. We recognize this is usually concerng if the federal government can pay private actors to buy the state law. Iny enumerated powers. I think they admitted that. The court does not have to answer that question by our read