Transcripts For CSPAN3 Supreme 20240703

Two hours. Chief Justice Roberts we will hear argument this morning in case 23726, moyle versus united ates, and the consolidated case. Mr. Turner. Mr. Turner thank you,r. Hief justice, and may it please the court when congssmended the medicare act in 1986, it put emtala on a nties Old Foundation of state law. States have always bee responsible for licensing doctors and setting the scope of their professional practice. Indeed, emtala wksrecisely because states regulate the practice of medicine. And nothing in emtala requires doctors to ignore the scope of their license and offer medical treatments that violate state law. Three statutory provisions make th car. First, section 1395, the medicare acts opening provision, forbids theedal government from controlling the practice of medicine. Thats the role of state reguti. Second, subdivision f in emtala codifs statutory presumption against preemption of staical regulations. And, third, emtalas stabilization provision is mid to available treatments, which depends on the scope o the hospital staffs medical license. Illegal treatments are not trtmts. Add in thicots own presumption against preemption of state regulations, combine that wh e need for clear and unambiguous spending clause conditions, and the mistrations reading becomes wholly untenable. ThE Administrationmieading also lacks any limiting principle. If er doctors caorm whatever treatment they determine aropriate, then doctors can ignore not only ste ortion laws but also state regulations on opioid use and informed consent requirements. That turns the presumption against preemption oithead and leaves Emergency Rooms unregulated under state law. Its surprising that no court has endorsed such an expansive vi of emtala, and until dobbs, nor had hhs. Everyone understandsha licensing lawsim medical practice. Thatwhy a nurse isnt available to perform openheart surgery, no matter the need, no matter her knowledge. The answer doesnt an just because were talking about abortion. The court should reject thE Administrations unlimited reading of emtala and reverse e District Courts judgment. Justice thomas the normally, when we have a preemptse, theres some relationship between the parties. T state being regulated by the federal government under tala, or is the state in engaged in some sort of quasicontractual relationship . Mr. Turner yes, your honor. In this case, the state, idaho, for example, has no state hoits that participate in with the Emergency Rooms in emtala. D so, in this case, there isnt even a quasiratnship. The parties being regulated by emtala here are hospaland doctors. And i think uruestion is getting at the armstrong issue, and wehi that is a significant question. Wnt part of the question presented. We think the indiana amicus brief raises significant questions and deals with that argument wl. But the question pseed here is one of direct conflict between idahos law anemla, and on that question, we dont think its hard at all. And, your honors, going to tha direct conflict, i think, if you consider the express limitation within the statute of availabili Justice Jackson well, before we do that, can i just step back and get your understanding of the statute . You made some representations as to how you s it working. And so let me tell you what i think, and then you can tell me otherwise. U agree, disagree, or i think that there are two things that are plain, pretty plain, on the the face of this statute. One is that emtala is about the provision of stabilizing care for peop w are experiencing emergey dical conditions. Thats one thing i think the statute is doing. D i also think that it is operating to displace the prerogatives of hoits or states or whomever with respect to that fairlyw slice of the healthcare universe. This idea of emergency medical servic ilike one very minor part or small part of of th sort of overall healthcare ovision of healthcare. So what that means is th wn a hospital wantso ly provide stabilizinca in emergencies for people who can pay for it, for example, emtala says, no, im sorry, you have to sta anyone whos experiencing an emgency medical condition, or when a hospital wants to provide stabilizing treatments to people who are experiennly certain kinds of emergency conditions, emtala says, no, herethlist of conditions and you have to provide stabg care for those people. Mirly, if a state says, look, its our job to govern all of healthcare in our state and we say that only certain kinds of healthcare can be to people who are experiencing emergency medicaitions, we dont want whatever treatment, we want only certain kinds of treatment, emtala says, no, we are directing that as a matter of federal law, when someone presents with an emergency coition, they have to be assessed and the hospital must do whatever is in its capacity to stabilize them. Is that your understanding of thute . Mr. Turner partially, your honor. We agree that emtala does impose a del stabilization requirement, but the question here is what is the content of attabilization requirement, and for that, you have to reference state law. Justice jackson ok. Well Justice Kagan if i could just i mea ihink what you just said is important be whe you conce at emtala imposes a stabilization requirement, it is, this statute, the federal government interfering, ifou will, in a states healthcare choices. So emtala is on its face a statute that says its not all the states way. There are federal requirements here. There is a requirement to stabilize emergency patients. And you agree with that . Mr. Turner yeah, Justice Kagan, we agree that emtala emtas purpose was narrow to bridge this gap that existed in some states Justice Kagan ok. So, i mean mr. Turner and theaire to treat. Justice kagan we can just take off the table this idea th, you know, just because its a state and its healthcare, that the federal government hasotng to say about it. The federal governme h plenty to say about it in this statute. Now, youre right, now theres a question of whats the contt of this stabilization quement. And as far as i understood your opening remarks, you saywe, this is left to thstes. But, if im just looking at the statute, the statute tells you what the content of the stabiliziorequirement is. Its to provide such medil treatment as may be necessary to assure within reasonable probability that no material deterioration ofheondition is likely to occur if the person were transfeedr didnt get care. So it tells you very clearly its an objective standard. Its basically it you know, s a standard that clearly has reference to accepted medical practice, not just whatever one ctor happens to think. But its here is the content of the standard. You have to stabilize. What does that mean . It means to pridthe treatment necessary to assure within reasonable medical probability that no material deterioration occurs. Mr. Turner yeah, let me respond in two way first, the objective standard that you set forth tren that understanding is contrary to thE Administrations ew. They say it is a totally subjective sndd and whatever treatment a doctor determines is appropriate, thats justice gan i think that thats not true. I mean, i think you guys can argue rself. But, as i understandhe solicitor generals brief and well see what the solicitor general says buthe 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 well, and the more fundenl point is the definition that you quoted of stabilizing caren e operivposition provision in b 1 is also textually plitly qualified by that which is within the staff d facilities available at a hospital. So tn we come Justice Jackson yes. And thats what Justice Kagan ths quite right. Thats quite right. It says within the staff and facilities aille at the hospital. And if you just lookt at language, i mean, its absolutelyle that thats not a reference to what state law invoes the staff and facilities available. If you dont have staff available to provide the medical re, then i guess you cant provide the medical care. If you dont have the facilities available to provide the medical care, then you cant provide the medical re a transfer has to take place for the good of the patient. Mr. Tuerthis is a really important Justice Kagan but this is th the availability here, because its the availability of staff and facilities. Its, you know, do you have the right doctors . Do you have enough doctors . Do you have the right facilities . Or is it btefor the patient to transfer them to the hospital a few miles away . Mr. Turner youre exactly right. Doouave the right doctors . How do you answer that questio except by reference to state licensing laws . Justice jackson but you absolutely cant do that. I mean,s sort of the initial point that i was trying to make, which is that the federal mandate is to provide stabilcare for emergency conditions, regardless of any other directive that the state s or the hospital has that would prevent that care om being provided. Thats thats the work of the statute. Mr. Turner Justice Jackson, thats not even hhss conclusion in the state operations manual, whicth proffered on page 36 of their brief, it defines what makes a staff person available under the statute, and they say it has to stice 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 says they are available to the extent they are operating within the scope of their medical license. And ats our argument. They want to now draw it far more narrow and look only at phical availability. We agree thats a component, but eres also a legal availability component here too. Justice sotomayor el, the problem were having right now is that youre sort of putting preemption on its head. Thwhole purpose of preemption is to say that if the at passes a law that violates federal law, theta law is no longer effective. So there is no state licensing law atould permit you permit the state to say dont eat diabetics with insulin. Treat them only with pills, metformin. And a doctor looks at a juvenile diabetic and says, without insulin, they going to get seriously ill and the likelihood and i dont know what that meanunr idaho law, well get tohat shortly because, i dont know, this we believe this is a better treatment. Mr. Turner yeah. Justice sotomayor al law would say, you cant do that. Medically accepted objective medicallacpted standards of care require the treatment of diabicwith insulin. The medically accepted obligation of doctors when they have women with cert conditions that manoresult in death but more than likely will resulery serious medical conditions, 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,s opposed to serious illness, they cant perform the abortion. So i dont know your argument about state licensing law because this is what this law does. It tells states, your licensing laws cant take out objti medical conditions that could save a person from serious injury or death. Mr. Turner yeah, k there are two crucial responses to your point. Let me binith the preemption point. Subdivision f and section 1395 acally are telling hhs, the federal government, and courts just the opposite, that you dont Justice Sotomayor no, its saying you canprmpt unless theres a direct conflict. If objective medical care requires you to treat women who e who present the potential of serious medical complicatns and the abortion is the only thing that can prevent that, you have to do it. Mr. Turner no Justice Sotomayor idaho law says the doctor has to determine not thathes merely a serious medical condition but that the person will die. Mr. Turner yeah. Justice sotomayor thats a huge difference, counsel. Turner your honor, we agree that the there is daylit between how thE Administration is reading emtala anwh idahos defense of life act permits. We agree that theres a controversy here. But what im sayings at Justice Sotomayor no, no, no, nono, theres more than a controversy because whatore saying to us is, if emtala doesnt have preemptive force noju idaho, it has a saving condition for abortions when it threena womans life. Mrturner well, when the Justice Sotomayor but wha youre saying ishano state in the nation and there are some right now that dont even have that as an exceptioto their antiabortion laws. What you are saying is that there is no federal law on the book that prohibits any stat from saying, even if a woman will die, you cant perform an abortion. Mr. Turner uronor, i know of no state that does not include a lifesaving exception. But, secondly, the government Justice Sotomayor some have beenebing it at least, and if find one but your theory of this case leads to that conclusion. Mr. Turner i think our point is that emtala doesnt address that very Justice Sotomayor does your theory chief juicroberts could i could i hear your answer . Mr. Turner yeah in thE Administrations reliance on a standard like best inical evidence or some national norm, i think thats very fraught because what it really is saying is the text itself doesnt address what stabilizing eaent is required. You go outside theexto professional standards that are floating out there that might change day to day, andha really boils down to a question between a conflict between wt the acog says and what idaho law says, and thats not chief Justice Roberts thank you. Thank you, counsel. Justice jackson ay, c 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 provide whatever treatment you have the capacit aning staff and facilities, to provide to stabizeatients who are experiencing emergency medical conditions. Idaho law seems to say you cannot provide that treatment unless doing so is necessary to prevent a patients death to the extent the treatment involves abortion. Why is that t direct conflict . Yoha you must in a certain situation, thats what the federal government is saying, and you cannot if it involves abortion says idaho. Mr. Turner i think the nurse example reallyigights the reason why, because a nurse might be available. The nurse may be may even think she knows how to, and under the flat must provision in emtala, the administratios reading would say call her into action, put her into t operating room, and open the Justice Jackson right. And mr. Turner but that is not justice jacksoand idaho Justice Kagan well, that Justice Jackson would say no, thatstill a conflict. So, fine, lets say the lets E Administrations position is that nurse can do it. Are you suggesting that federal law would not take precedence, would not preempt a state law atays no, she cant . Mr. Turner well, whether federal law could do that is a different question than whether emtala here does do th. And i think the answer is clear that it doesnt. I mean, its like the gonzales v. Oregon, case where the controlled substances act, you know, this court noted that that was t provisions there rely upon and and assume a medical profession being regulated by state police powers. Thats the same witemla. Emtala is a fourpage statute. Congress didnt attempt to address the standards of care for every conceivable medical treatment in Justice Kagan it it definitely didnt address the standa car it did leave that to the medical community. It said, you know, the congress was not going to address every treatment for every condition, but it said you do what is needetossure nondeterioration. So i guess theueion here is, do you concede that with respect ctain medical conditions, an abortion is the standard of care . Mr. Turner no, because a standard of care under idaho well, i should say, in idaho, there is a lifesaving exception for certain abortions, and that is the staof care. And the standard of care is necessarily set and determined state Justice Kagan well, i think you have to concede th wh respect to certain medical conditions abortion t standard of care because your own statute, as interpreted by your own court acknowledges that wn condition gets bad enough such that the womans life is in peril, then the the the doctors are supposed to give abortions. Mr. Turner d Justice Kagan and the reason that thats true is that with respect to certain rarbu extremely obviously important conditions and circumstances, abortion is the accepted medical standard of care. Isnt that right . Mr. Turner yes, and tt that was my point, that there is a lifesaving exception under idaho law. Now the question here is justice ga now now the question is, is it also the accepted standard of care when, rather than the womans life being in peril, the Womans Health is in peril . So lets take you know, all of these cases are rare, but within these rare cases, theres a significant number where the mais her life is not in peril, but shes going le her reproductive organs, shes going to lose the abilitto have children in the future, unless an abortion takes place. Now thats the cago of cases in which emtalsa, my gosh, of course,hebortion is necessary to assure that no matealeterioration occurs. Anyeidaho says, sorry, no abortion here. And the result is that these patients are now helicoptered out of state. Mr. Turner yeah. Your honor, the hypothetalou raise is a very ffult situation, and these situations, i mean, nobody i arguing that they dont raise toh medical questions that implicate deeply theological and moral questions. And idaho, like 22 other states, and Even Congress in emtala recognizes that there are two patients to coid in those circumstances. And the twopatient scenario is is tough when you have these competing interests. Juickagan you know, that would be a good response if federal law did not take a position on what you chacterize as a tough question, but federal law does take a positn that question. It says that you dont have to wait until the persoisn the verge of death. T woman is going to lose her reproductive organs, ths enough to trigger this duty on the part of the hospital to stabilize the patient. And the way to stabilize patients in these circumstances, all doctors agree. Mr. Turner ano law does not require that doctors wait until a paenis on the verge of death. There is no imminency requirement. There is no medical certainty requirement. Thas Justice Sotomayor im so answer the following question, and these are hypotheticals that are true. Hold on one second, and you can tell me whether idahos exception and we still go back to the point atven if idaho law fully complies with feral law you have a pregnant women woman whis early into her second trimester at 16 weeks, goes to the er because she fe aush of fluid leave her body. She was diagnosed with pprom. The doctors believe that a medical intervention to terminate her pregnancy is need to reduce the real medical possibility of experiencing sepsis and uncontrolled hemorrhe om the broken sac. This is a story of a real woman. She was discharged in florida becae e fetus still had fetal tones and the hospital said shes not like tdie, but there are going to b serious medical complications. The doctors there refused to treat her because they couldnt say she would die. She was horrified, went home. The next day, she bled. She passed out. Thankfully taken to the spal. There, she received an abortion because she was about d. 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 abortn . 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 florida doctor said, i cant say shes going to die. Mr. Turner yeah. And, your honor, my point is that Justice Sotomayor if your doctor says, i cant, with a dical certainty, say shes going to die, but i do know shes going to bleed to death if we dont have an abortion, but shes not bleeding yet, so im not sure. Mr. Turner the doctor doesnt 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. Turner yeah. Ste sotomayor like a hysterectomy. Let me go to another one. Imagine a patient who eso the er with pprom 14 weeks. Again, abortion is the excepted. Shes up she was in and out of the hospital up to 27 weeks. This particular patient, they tried had to deliver her ba. The baby died. She had a hysterectomy, and e can no longer have children. 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 t for the doctor to risk when mr. Turner well, i think its protective Justice Sotomayor when idaho law changed to make the issue whether shes gog die or not or whether shes going to have a seriousedal condition. Theres a big daylight by your standards, correct . Mr. Turner it is very case by case. The examples, the prong Justice Sotomayor thats the problem, isnt it . Justice barrett counsel, i kind of shocked actually because i thought your own expert had said below that these kinds of cases were covered. Mr. Turner yeah. Justice barrett and youre now saying theyre not . Mr. Turner no, im not saying thats jupoint, your honor, is that Justice Barret wl, youre hedging. I mean, Justice Sotomayor is ng you would this be covered or not, and it was my understanding that the legislatures witnesses said that these would be covered. Mr. Turner yeah, and those cts said, if they were exercising their medical judgment, they could in good faith determine that lesing care was necessary. And thats my point. This is a subjective standard. Justice barret b some doctors couldnt, is some ctors might reach a contrary concluoni think is what Justice Sotomayor is asking you. Mr. Turner and and let me Justice Barrett if they reached if they reachedhe conclusion that the legislatures doordid, would they be prosecuted under idaho law . Mrtuer no. No. If they if eyeached the conclusion that the dr. Reynolds, dr. White did, that these were lifesaving justrrett what if the prosecutor thought differently . What if the prosecutor thought, well, i dont think any goodfaith doctor could draw that conclusion, igog to put on my expert . Mr. Turner and thatyo honor, is the nature of prosecutorial discretion, and it may result in a a case that reque Justice Barrett does idaho put out any kiguidance . You know, hhs puts out guidance about whats covered by the law and whats not. Does idaho . Mr. Turner there are regulations. Dapa has some regulations. But i think the heuiding star here is the planned parenthood vwaen case, which is a lengthy, detailed treatment by the ihoupreme court of this law, and it made clear, the court made clear, that there is no medical certain requirement. You do not have to wait fothe mother to be facing death. Justice jackson counsel, i dont chief Justice Roberts thank you, counsel. Is there what happens if a 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 medical authority . Exactlhois that evaluated . Because its an obvious conrn if if if you have an individual exception for a doctor, and we hing a debate about is that covered b your submission that nothing in idaho law prohibits complying with emtala, i mean, who who makes the decision whether or not somethis within or without . Mr. Turner so, i mean, i i imine there are two ways the law can be enforced or at least two. The board of medinhas licensing oversight over a doctor. And the Idaho Supreme Court made cleath that Doctors Medical judgment is not going to be judged based on an objective anrd, what a reasonable doctor would do. Thats not the standard. The second way would be if a chief Justice Roberts well, what what is the standard . Mr. Turner the doctors goodfaithal judgment, which is subjective. Chief Justice Roberts and s not subject to review by any medicad if theres a complaint against the doctor that mr. Turner yeah. Chief Justice Roberts his standards dont comply . Lets say hes the only docto at the particular emergency room, and he has his own particular standard. Mr. Turner what what the Idaho Supreme Court id is that you may consider another doctos opinion only on the question of was it a pretextual medical judgment, not a goodfaith one. Chief Justice Roberts thank you. Justice thomas . Juste alito . Justice alito well, i would think that the concept of goodfaithedal judgment must take into account some objective standards, but it would leave a certain amount of leeway for an didual doctor. That was how i interpreted what the what the atsupreme court said. Now you have been presend re today with very quick summaries of cases a aed to provide a snap judgment about what would be appropriaten ose particular cases, and, honestly, i think youve hardly been given an opportunityo swer some of the hypotheticals. But would you agree with me that if mical doctor, who is an exrt in this field, were asked bang, bang, bang, what wou y do in these partul circumstances which i am now going to enumerate, the doctor would say ai i dont this is not how i practice medicine. I needo ow a lot more about the individual case. Would you agree with that . Mr. Turner absolutely. And acog has, you know, in the case of prom, for example, acog doesnt just kneejerk stay an aborti ithe standard of care. Acog itself says that expectant magent is oftentimes the appropriate standard of care and so these are difficu questions that turn on the facts that are on the ground between the doctor as he is assessing them withimedical judgment that hes bringing to bear but is also necessarily constrained by idaho law. Just like every other area of the practice of medicine, state w confines doctor judgment in some ways. Justice alito thank you. Chief Justice Roberts Justice Sotomayor . Justice sotomayor there is a diffen between stabilizing a person who presents a serious medical condition requiring stabilatn than a person who ests with a condition, quoting idahos words,he there is a poses a great risk of death to the pregnant woman. You agree theres daylight between the two . Mr. Turner we agree, and i think this is most Justice Sotomayor and so there will be some women who present serious medical condition that the federalaw would require to be treated who will not be tread der idaho law . Mr. Turner no, i disagree with that. Idaho hospitals are treating these women. Theyre not treating these women with Justice Sotomayor stop. Mr. Turner abortions nessarily, your honor, and thats an importantoi. Justice sotomayor and thats my point. Just answer the point, which is they will present with a serious medical condition that doctors inoofaith cant say will present death but will present those doctors potential loss of an organ or serious medical complications for the woman. They cant perform those abortions . Mr. Turner yeah. Your hon, that hypothetical exists, and i dont know of a a ndion that is so certain to result in the loss of an organ but also so certain noto transpire with death. If that condition exists, yes, idaho law do say that abortions in that case arent allowed. And i think Justice Sotomayor all right. Th let me stop you there because all of your legal theories rely on us holding at federal law doesnt require cannot preempt state lawn these issues. And so, when i asked you the question if a state defines likelihood of death more stngently than idaho does, you would say theres no federal law that would prohibit them from doing that . Mr. Turner well, i say that emtala does not contain a standard of Justice Sotomayor so there is no no standard of care. In your briefing, you make the sgposition here, and you almost argue that now, tha that their position that federal law requirestalizing treatment and not equal treatment of patients, which was a positi y took in your brief, you seem to have backed off omt here, you seem to agree that federal law requires some stabilizing condition, whether or not you provide it to other patients. But i have countlessris that say that both that hhs has filed that predobbs, pre2009, this is not an unecented position, that hhs in countless situations cited hospitals for scrging patients who required an abortion as a stabilizing treatment. Core discussed that topic in the Affordable Care act and exicitly said that nothing in the Affordable Care act be construed to relieve any Healthcare Provider from providing Emergency Services as required by state or federal law. Medical providers have told us th for decades they have understood both federal law and state law to require abortions as stabilizing cdions for people presenting serious medicari. Lower courts, es at least cases of lower courts saying you have tpride abortion. So this is not a postdobbs unprecedented position bth government. Mr. Turner it absolutely is. The in footnote 2, thE Administration cites to two readsheets that contain 115,000 rows of enforcement instances. ThE Administration Justice Sotomayor counsel rner has not identified a single instance Justice Sotomayor counsel, predobbs, this wasnt much oa question. But there is hhs guidae d theres at least three cases in whh was invoked. The fact that we didnt have to that hhdit have to do it much before predobbs doesnt make theirosion mr. Turner my point is more Justice Sotomayor unprecedented. Mr. Turner my point is more fundamental, your honor. Its not just that therarfew instances. There are no instances. And not just on the issue of abortion. On any instance where hhs has come in and told a hospital you have to provida eatment 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 . Justice kagan mr. Turner, practicing medicine isar but there are standards of care, arent there . Mr. Turner yes, there are. Justice kagan and o othose standards of care with respect to abortion ishain certain tragic circumstances, as you yourself, as your own states law acknowledges, where a wons life is in peril and abortion is the appropriate standard of care, isnt that ght . Mr. Turner thats right. Justice kagan and emtala goes further. It says that the appropriate standard of ca ct only be about protecting a womans life. It also has to be about protecting a Womans Health. Thats what emtala says, doesnt it . Mr. Turner no, it doesnt. It defines emergency medical condition with a broader set of triggering condition b the the key question here is what is the stabilization requirement, andhais qualified by the availability term. Justice kagan the the stabilization requirement is is written in terms of making rehat a transfer would not relt in a material deterioration as to the emergency condition. Nothing about has to be at deaths door, right . Mr. Turner i inthats right, yeah. Justice kagan and there is a standardf re with respect to that on abortions too, right . If a woman is going to lose her reproductive organs unless she has an abortion, which happens in certain tragic rcstances, a doctor is supposed to provide an abortion, isnt that right . Mr. Turner emtala doesnt contain any standard of care. I dont ow where thE Administration is drawing Justice Kagan do yoo you dispute that theres a medical standa ocare that when a woman is about to lose her reproductive organs unss she has an abortion, that that doors would not say that an abortion is the appropriate standard of care in that situation . Mr. Turner your hon, at i dispute is that theres a National Uniform standard care that requires a topdown approach in all. Idaho has set its own standard of care, and it has drawn the line oa fficult question. And its inconceivable to me to think ongress attempted to answer this very fraught complicated question in a fourpage in four pages of the u. S. Code. It did not Justice Kagan Congress Said as to any condition in the world, if an emergency paencomes in, youre supposed to provide the emernccare that will ensure that that patient does not see a material deterioration in tirealth. Mr. Turner and always within the Justice Kagan thats what Congress Said. And the abortion exceptionalism here is on the part of the state saying were going to ce that with respect to every other condition but not with respect to abortion mr. Turner abortion isnt exceptiona Justice Kagan where we will not comply with the standard of care that doctors have accepted. Mr. Turner your honor, abortion isnt exceptional. There are numerous cases where states intervene and say the anrd of care in this circumstance for this condition is x, not ioids, for example. In new jersey, a doctor cannot stabilize chronic pain with more than a fiveday supply of opioids. In pennsylvania, it can be seven. Other states, there is no limit. Their reinof emtala requires thatho limitations get wiped out and you impose a National Standard there are numerous other instances where states are coming in and saying, o state, the practice of medicine must cfo to this standard. And idaho has done that with abortion. Its done it with opioids. Its done it with marijuana use. There are countless examples, your honor. Justice kagan and your theory although the su has narrowed the reach of your ate, your theory would apply even if it hadnt . I an, it would apply to ectopic pregnancies. It would apply even ifhe were not a death exception. I mean, all of your theory would apply no matter what, really, idaho did, wouldnt it . Mr. Turner if yeah, i think the answer is emtala doesnt speak to that, but there are other background principles and limitations like rationale basis review, justicrequist, the chief justice recognized Justice Kagan but your theory of emtalishat emtala preempts none of it . That ata tomorrow could say even if death is around the corner, a state tomorrow could say even if theres an ectic pregnancy, that still thats a thats a a choe the state and emtala has nothing to say about that . Mr. Turner yeah. And that understanding is a hulene with respect to the federalism rule of states. Its the primary care providers for their citizens, not the federal government. Justice kagan it may be too humble for womens health, you know . Ok. Thank you. Chief Justice Roberts Justice Gorsuch . Justice gorsuch i just wanted to understand some of your responses or efforts to respond to some of the questions that ve heard today. As i read your briefs, you thought idahohis that in cases of molar and ectopic pregnancies,orxample, that that an abortion is acceptable. Mr. Turn rrect, your honor. Justice gorsuch and the example of someone who ist immediately going to die but may at some point in the futur tt that would be acceptable . Mr. Turner it goes back to the goodfaith medical standard, but, yes, if the doctor should 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 torr or next week or a month from now . Mr. Turner there is n imminency requirement. This whole notion of delayed care is just not consistent with the Idaho Supreme Courts reading of the statute and what the statute says. Justice gorsuch and the gd faith, as i read the Idaho Supreme Court opinion,ha that controls . Thats the end of it . Mr. Turner absolutely, it is. Justice gorsuch all rht and then what do wdoith emtalas definition of individual to include both the woman and, as the statute says, the unborn child . Mr. Turner yeah. s you know, were not saying, your honor, that emtal prohibits abortions. So, for example, in cafoia, stabilizing treatment may involve abortioncoistent with what that state law allows its doctors to perform. But thk our point with the unrn child amendment in 1989 is that it would be a very strange thing for congress to expressly amend emtala to require care for unborn children, and its not just when the chd when the mother is experiencing active labor. The definitionf mergency medical condition requires care wh t child itself has an emergency medical condition regardless of whats going on th the mother. And so it would be a strange thing for congresso ve regard for the unborn child and yet also be mandating termination of unborn children. Justice gorsuch thank you. Chief Justice Roberts Justice Kavanaugh . Justice kavanaugh i just want to focus othe actual dispute iexists now, today, between the governments view of emtala and idaho la bause idaho law has changed since the time of the District Courts injunction both with the Idaho Supreme Court and with a clarifying change by the idaho legislature. You say in your reply brief, and so t t the moyle reply brief says, that for each of the conditions identified by the solicitor general where, under their view of emtala, an oron must be available, you say in the reply brief that idaho law, in fact, allows an abortion in chf those circumstances, and you go thugthem on pages 8 and 9 of the reply brief, each of the conditions. Is there any condition that youre aware of where the solicitor general ysmtala requires that an abortion be availae an emergency circumstance where idaho law, as currently stated, does not . Mr. Turner so, certainly, the admisttion maintains that there is such conditions. The ones they identify in the afdavits Justice Kavanaugh what isou what is your view . Mr. Turner and my view is that yes and igog to reference footnote 5 from the gray brief the Mental Health condition siatn. The Administration Says thats not on t tle. Ths not a scenario where abortion is the only stabilizi care required. And im not sure where that construct of only stabilizing care comes from beus under their view, its the doctors determination atontrols, not this imposed only requirement. But be that as it may, the American Psychiatric associati and so im taking general progar up on her offer in footnote 5 that there are no professional organizations that t abortion as a standard of care. The American Psychiatric association, in a 2023 position paper, says that abortions are petive for Mental Health conditions. That sounds like a necessi t me. And i dont know how, if a woman prestst seven months pregnant in an idaho emergency omnd says, im experiencing severe depression from this pregnancy, im having suicidal idti from carrying this pregnancy forth, that that wouldnt dethE Administrations reading be the only stabilizing care. Justice kavanaugh so you think the ninth Circuit Panel, when it said every circumstance described by the administtis declarations involved lifethreatening circumstances under which idaho law would allow an abortion, is what theinth Circuit Panel said . Mr. Turner wegr with that because the conditions identified in the affidavi were all conditions that would fit under the lifesavi exception, and thats telling because, you kno tse doctors, when put under oath in an affidavit, couldnt come up with any of the rrowing circumstances. They identified other ones. But i thk at the government doesnt want to talk about, again, is the Mental Health exption here. That is i just dont know how you can read their undstding of Justice Kavanaugh well, i just trying to figure out is there really a hethan the Mental Health, which we havent had a lot of briinabout, is there any other condition identified by e licitor general where you think idaho law would not allow a physician in his or her goodfaith judgment to perform an emergency abortion . Mr. Turner not in their affidavits. They maintain nonetheless that when you compa t definition of what an emergency medical condition is, it is broader than the definition of the lifesaving exception in idaho law. And so thepresent this Justice Kavanaugh well, that what they they say, but then, when we get down to the actual conditions that are listed, the examples and justic sotomayor was going through some of those you veaid in your brief at least that each the conditions identified by the government, actually, idaho law allows an emergency abortion. Mr. Turner and i agree, and i think the injunction he also Justice Kavanaugh well, whats what does that mean for what were decidg re . Mr. Turner well, what it means for idaho Justice Kavanaugh if idaho if idaho law allows an abortion in each of the emergency circumstances that is identified by the government as emtala mandating that ibellowed . Mr. Turner ill say two things. I mean, the real practical first reonse is that idahos under an injunction that inclus incredibly broad requirement that preempts state law Justice Kavanaugh ig. I i understand that. And that may mean that there shouldnt be an injunction. I take your point on that. Whatyour second . Mr. Turner my second point, your honor, is i dont know how this court can make the dermination on whether there arany realworld conditions without first answering th statutory interpretation question of what emtalas stabilization requiremt 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 st picking up on your reply brief. Yre the one who said it in your reply brief mr. Turner ye. Justice kavanaugh that theres actually no real daylight here in terms 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 really understand why we have to address the stabilizing condition wt you say is that nobody has been able to identify a conflict. And on the Mental Health thing the sg says i just pick up to check footnote 5 idaho badly errs in asserting that cong emtala according to its terms would turn Emergency Rooms into federal abortion en by allowing pregnancy termination for Mental Health concerns. So, if thats the only space that you can identify where idaho would precludeortion and emtala would require one, and the government is saying no, thats not so, whats the conflict . Mr. Turner well, your honor, i mean, of course, we think we win whether you find no factual conflict and, therefor t injunction had to go away. Justice barrett but why . Why are you here . I mean, you know, the governnt says you say mr. Turner well, they sued us, uronor. Justice barrett well, hold on a second. Youre here because theres an injunction preudg you from enforcing your law. And if your law can fully operate beusemtala doesnt curb idahos authority to enforce its law, whats mr. Turner well, it cant under junction because the injunction says that idahos law is preempted in an incredibly broad range of circumstances to avoid Justice Barrett as as it conflicts thmtala, i thought. Mr. Turner it it it is mu bader than that. It and this was based on the proffered injunctiony E Administration to avoid an emergency medical condition, not in the face of an emergency dil condition. So what that means is idahos law cant even operate when a doctor determines at condition might need to be avoided that hnt yet presented itself. Thats far broader than the emergencmecal condition and stabilization requirement under emtala because the stabilization requirement under emtala is only trigwhen there has been a determination that ice barrett ok. Well, i i would like to hear the solicitogerals response to that. But let me just ask u e other thing about the Mental Health consideration because i can i can understand idahos point that aenl health exception ulbe far broader than idaho law and had the poteto expand the availability of abortion far beyond what idaho law permits. But the stabilization requirement only exi until transfer, right, until transfer is psie . So its hard for me to see how, with a mental heondition, that couldnt be stabilized before neengo transfer, right . At tint, the idaho hospital could say well, you youre stable, youre not immediating to be suicidal, well leave y ithe care of, you know, a parent or a appropriate treatment. Seek mr. Turner well, that flexible vi ostabilization is very different than the governments very rigid vieof stabilizathich is, if an emergency medical condition calls for an abortion, its got to bided right there and then if its available in this ve 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 we, the the transfer provision kicks in if a hospit iunable to stabilize a condition. D , if a patient presents at a hospital and that hospitalas the capability, the availability to stabilize the conditi, the case of Mental Health, i invite general pregato come up here and tell you that ive got it all wngnd that, you know, the mother that i described would not need to receive stabilization in that circumstance and instead would tnsferred to a Psychiatric Hospital or something and that wouldnt constitute dumping under their reading. I just dont see how that comports with evytng theyve said about the rigid view 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 doctors under state law . Rner it does. And there are federal conscice protections as well. And i think that is a key point here, your honor. ThE Administration told this court in the fdaasthat individual doctors are never required to rfm an abortion from what i could tell, but that doesnt extend to hospitals. And soinhe case of catholic hoits, and there are hundreds of them treating millions of patients every year, under the administratios reading, catholic hoits who faithfully adhere to the ethical and religious directives are now required to peabortions. Justice barrett is that because no federal conscience exemption applies . Mr. Turner i dont know why they say thats the line that eyraw between individual doctors and religious institutions because coatssnowe on its face seems to cover both. Justice barrett ok. Thank you. Chief Justice Roberts Justice Jackson . Justice jackson im really surprised to hear you say that idaho law permits everything that the federal law ruis. So i just im trying to understand that because it seems to me that if thats the case, then why couldnt Emergency Room Physicians in idaho just ignore idaho law and foll t federal standard . I mean, if if if the state is doing ect what the what the federal law says is required, if its ok by idaho, then, we set idaho aside. We do what the federal law says and we all go home. Mr. Turner well, i mean, our reading, of course, is that there is no confct and so as doctors arent having to make this choice of do i follow emtala or do follow Justice Jackson so your representation on the on behalf of idaho is that if a an ergcy room physician in aho follows emtala in terms of when an abortion is required to stabilize a patient, the be complying with idaho law such that theres going to be no prosecution and no problem . Mr. Turner yes, because they have to comply with idaho law to comply with emtala. Justice jackson no, no. Im asking you, if they i they comply with emtala, will ey necessarily have satisfied the requirements of ido w . Because thats what you seemed to say in response to Justice Kavanaugh and innse to Justice Barrett. So i just want to make clear if thas the position of the state. Mr. Turner emla the scope of emtalas stabilization reirent is necessarily determined by idaho law in ts case. So Justice Jackson no. Youre saying, if they follow idaho law, then eyill be following emtala law. Mr. Turner well, i Justice Jackson id like for you to id like for you to mr. Turner i think its both, your honor. Justice n no, its not. Id like for you to entertain the other possibility. Situation in which the United States says heres a stabilizatiosiation that the United States would say the person has to have an abortion, the physicians would say were following emtala andboion is required, i thought you said in response to Justice Kavanaug yes, idaho law would also say thats a situation inhi an abortion is allowed. If thats the case it seems to me there is no daylight, thereno conflict, as youve said, but its because idahis in full compliance with what the federal law is saying. re getting it wrong, youre saying. Not what we really mean. Hats what we mean is whenever its necessary to stabilize a patient who is experiein deterioration, as federal law requires. Mr. Turner no. I i i think i understa the point that youre making. And the best way that i can think of it, your hono ithat emtalas stabilization requiremt quires medical judgment to determine what is the appropriate abizing treatment, right . And how does aocr exercise medical judgment . Well, his trni, his experience, perhaps reference to professional standards of care that are national, but Justice Jackson how about how about mr. Turner necessarily state law standards as well. Justice jackson how about ths not just something youre sort of coming up with. I mean, as Justice Kagan said at the beginning, emtala the doctor how hes supposed to decide it ts particular circumstance with reference to the medical standards of care concerning when a patient is deteriorating in an emergency ndition situation. Justice jackson so, if thats the standard in emtala, are you representing that th is exactly what idaho is saying so that all the doctors need to do is follow emtala and theyll be fine under idaho law . Rner well, of course, were saying that idahoocrs need to comply with emtala. The question is how do doctors comply with emtala, and emtala Justice Jackson let me ask you otr question. Let me i i think i understandpoint. Youre saying idaho is actually could actually bering more and the federal law has to make them do what idaho says. Mr. Turner well, and it important that Justice Jackson yeah. Mr. Turner emtala itself, it codifies this presumioof a backdrop of state law. There are background principles here, and thats what Justice Jackson all right. Let me exphat with you for just a second. I i had thought that this case was about preemption and the entirety of our preemption jurisprudenthe notion that the federal government in certai circumstances can make policy pronouncements that differ from what the steay want or what anybody else may want, and the suprclause says that what the federal government says takes precedent. So youve been saying over and over again idaho is, you know, a state and we have healthcare policy choices and weve made ve set a standard of care in this situation. All thats true. But the question is to what extent can the federal government say no, in this situation, our standard is going to apply . Mr. Turner and juice jackson thats what the dont understand how, consistent with our preemption jurisprudence, you can be saying otherwise. Mr. Turner yeah, ian put a finer point on it. I dont think its the question is necessarily what can congress do but what did congress do here with emtala, and Justice Jackson a rht. So what did it do here . Mrtuer yeah. It started, it opened the medicare act by saying t deral government shall not control the practice of medicine. And then, in emtala itself, it says state laws are not preempted. And then, t and then, when you get to justice ckn state laws are not preempted to the extent mr. Tuof a direct Justice Jackson or are only preempted to the extent a direct conflict. And so now we are are identifying a direct conflict. So why is preemption not working there . Mr. Turner and and whether therea direct conflict based on this courts longstanding precedent includes clear statement canons that w think we win on the text. Let me be very clear. The text to us is very car its an easy question. But the governments got toom overcome a lot of other hurdles, one being Justice Jackson i hear you saying two things, that were theres not a direct conflict because ever we the federal government requires, we allow, which the aci physicians for human rights, who have loo idahos law and says it prevents a lot of things in cirmsnces in which the federal government would require them disagree with you on the facts, but, anyway, you sa no conflict because we actually doing exactly what or lowing exactly what the federal government allows. And you say no conflict because the federal government ith situation wanted the states to be able to set the staar. And i guess i dont understand how thats even conceivable, given this standard, given this ute mr. Tueryeah. Justice jackson that is coming in to displace state prerogatives. Mr. Turner and if i cant convince you on the second, let medd a third. Justice jackson yes, please. Mr. Turner and there the clear statemencan. So the spending clause condition nature of this requis ngress to speak clearly and unequivocally att is imposing a abortion mandate. It ths not here in the statute. And, secondly, this courts presumption Justice Jason but doesnt that make abortion different . I mean, ato you mean . They say provide whatever necessary to stabilize. So youre sayinthd have to say provide whatever is necessary, inclubortion . Thats the only way that is taken account of here . Mr. Turner no, what im saying is, ene when we go and look at the phrase available and what it means, the gornment thE Administration is saying, well, theyreddg is tag that says consistent with state law. And were saying no, under the clear statement canon, its a presumption against prmpon. And what the government actually what congress wldeed to do if it wanted to preempt this very traditional area of state law is to put a tag regardless of state law, and that is missing. Justckso thank you. General prelogar. Erts thank general prelogar mr. Chief justice, and m iplease the court emtalas promise is simple but profound. No one who comes to an emergency room ine of urgent treatment should be denied necessary stabizg care. This case is about how that guarantee applies to pregnt women in medical crisis. In some tragic cases, women suffer emergency complications that make continuinghe pregnancy a grave threat to their lives or tirealth. A woman whose amniotic sac has ruptured prematurely, for example, needs immediate treatmentovoid a serious risk of infection that could caadinto sepsis and the risk of hysterectomy. A woman with severe preeamia can face a high risk of kidney failure that could require lifelong dialysis in cases like es where there is no other way to stabilize the womans dical condition and prevent her from deteriorating, emtals plain text requires that she be offered pregnancy termination as the necessary treatment. And thats how this law has been understood and applied for decades. That usually poses no nfct with state law. Even states that havshply restricted access to abortion after dobbs generally allow exceptions to feard the b idaho makes termination a felony punishable by years of imprisonment unless its necessary to prevent the woman death. I think i understood my friend today to acknowlgeeveral times that there is daylight between that standard and the necessary stabilizg eatment that emtala would require. And the idaho supreme cour recognized the same thing when it specifically contrasted the necsa to prevent death exception and said it was materially narrower than ari idaho law that had a health exception that tracked emtala. The situation on the ground in idaho is showing the devastating consequences of that gap. Today,ocrs in idaho and the women in idaho are in an imssle position. If a woman comes to an emergcy room facing a grave threat to r health, but she isnt yet facing death, doctors either have to delay treatment and allow her condition to material to materially deteriorate, or theyre airlifting her out the state so she can get the Emergency Care that she needs. One Hospital System in idaho ys that right now its having to transfer pregnant wenn medical crisis out of the state about once everyth week. Thats untenable, and emtala does not countenance it. None of petitioners interpretations fit with the text, and so they have tried to kehis case be about the broader debate for access to abortion in cas unwanted pregnancy. But thats not what this case is abouatll. Idahos ban on abortion is enforceable in virtually all of its applications, but in the narrow circumstances involving grave medical emergencies, idaho caot 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 . General prelogar with respect to criminal law in particular, Justice Thomas, im t immediately thinking of relevant cases. We have a whole string cite of cases in our brief at page 46 that reflect times where the cot s recognized the preemptive force of spending clause legislation, includg situations where the funding restrictions apply to private parties, so that could include the Coventry Health case, for example. Leaddeadwood is another example of this. But im not immediately recallg w that would apply in criminal law. Of crs this court hasnt drawn those kinds of diinctions in recognizing the force of the supremacy claus Justice Thomas now the normally, when we have a a preemption case, its a regulated party who is involved in the suit, and they use it as airmative defense, for example, in wyeth or something. On the in this case, you are bringing an action against the state, and the states not regulated. Are there other examples of these types of suits . General prelogar sure. I anthere are numerous examples where the united stat has sought to protect s 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 it states as an example of that. Ited states versus washington. There are a number of ca where this court has recognized that the federal government can protect its interests in this kind of preemption action. And, as meioned before, the court has a long line of cases regning that that preemption principle applies in the context of federalicon that apply to private rts too. Justice thomas but even when the party that youre bringing the action ain is not a regulated party . Generaprogar thats correct, because what idaho has done here dectly interfered with the ability of the regulated parties who veaken these funds, federal funds with conditions attached, from being able to comply with the federal law that governs their behavior. And this was an essential part of the bargain that the federal goveme struck with hospitals in substantially investing in their hospit stems. And what the state has done is said you, thugour operation of state law, are no longer permitted to comply with this fundamental stilization 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 youre talking about . General prelogar certainly, i can imagine siatns, for example, where a regulated party would assert a preemption defense antoay the state law itself is preempted to the extent that it prevents that pay om being able to comply with federal law. Tm not aware of any principle or precedent in this cots case law to suggest that thats the only way f t government to protect its sovereign interes. Justice thomas that is the normal way, though . General prelogar i think that thats often the fact pattern of particular cases. Justice alito dt understand how your argument about preemption here sqre with the theory of spending clause ofongresss spending clause power. Ththry is congress can tell a state or any other entity or rson, look, heres some money or other thing of value,ndf you want to accept it, fine, then you have to accepceain conditions. But how does the congresss ability to do that authorize it to impose duties on otr party that has not agreed to accept this ne gener plogar there are no duties being imposed on idaho here. Its not required to provide emerncstabilizing treatment itself. The duties are e Justice Alito well, all right. General prelogar appedo the hospital. Justice alito not not duties. How can you impose restrictions on what idahcacriminalize simply because hospitals in idaho have chosen toarcipate in medicare . I dont understand h ts squares with the whole theory of the spending cus general prelogar well, i think that it squares with this courts long line of precedents cited at stice alito well general prelogar page 46 of our bri Justice Alito well, i ive ive looked tm. General prelogar that the court has recognized that Justice Alito ive looked at those cases. I havent found any square discussion of this particular issue. But i im interested in the theory. Can you just explain how it works in theory . General prelogar sure. So spending clause legislation is federal law. Its paedy both houses of congress. Its signed by the president. It qualifies as law within the meaninofhe supremacy clause, and Justice Alito absolutely. Absolutely. General prelogar and and so think the supremacy clause dictates the relevant principl here Justice Alito no, but what the law general prelogar that in a situation where Justice Alito i l you finish. Yes, go ahead. General prelogar in a situation where congress has ect law, it has full force and effect under thsuemacy clause, and what a state cant do is interpose itowlaw as a direct obstacle to being able to fulfill the federal ndg conditions. And thishey, Justice Alito Justice Alito no, its its a general prelogar woulme no conditions Justice Alito its a question general prelogar under medicare are enforceable. Justice alito its no. Theyre absolutely enforceable against the hospital that chooses to participate. General prelog ll, i guess the the argument then would be that if a hospil instead bound by the state law and the state law getso ntrol, it would mean that hospitals couldnpaicipate in medicare at all. And thats not the argumentha the states making here. What it wants is for its hospitals to be able to accept medicare funding but not have to face the restrictions that are attached to those funds as an sential part of the bargain. Anthere is no precedent to support that outcome. Justice alito well, i i i just dont think i don understand how how the theory works. But let me movono something else. Let im going to try t 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 emergency room and she has coition that requires an abortion in order to eliminate seoujeopardy to her health, the hospital must perform e ortion or transfer the woman to another hospital ere that can be done. Is that a fair statement of your argunt general prelogar so it includes not just serious jeopardy toer health but, obviously, also seous dysfunction of her bodily Justice Alito rht right. General prelogar organs or a serious impairment of a bodily function. Justice alito right. General prelogar and the other caveat i would make is that it would iwould require pregnancy termination only in a circumstance where thats the only possible way to stabilize her and prevent that cascade of health consequences. Justice alito does ispply at any point in pregnancy . General prog so the pregnancy complications that we ha focused on generally occur in early pregnancy, often before e int of viability. There can be complications that haen 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, what if it what if it cu at a point where delivering the baby is not an option . Youre out of the third trimester, but itrely not an option to deliver the baby. General prelogar you sa tt youre in the Justice Alito out of their trimester. General prelogar third trimester . Ste alito no. Im sorry. T 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 pve grave risk to the Womans Health or life is for the pregncto end and termination is the only option, then, ye tts the required care that emtala has throh s stabilization mandate. But, criticay,n in many of these cases Justice Alito ok. That that general prelogar the very same pregnancy complication means the fetus cant survive regardless Justice Alito i i understand that. Nel prelogar theres not going to be any way to susta that pregnancy. Justice alito let me ask you squarely the question that was discussed during mr. Tns argument. Does the term health in emtala mean just physical health, or does it also include mental al . General prelogar there can be grave nt health emergencies, but emtala could never require pregnancy rmation as the stabilizing care. Justice alito why . General prelogar and heres why. Its because that wouldnt do anything to adesthe underlying brain chemistry issue thatcausing the the Mental Health emergency in the first place. This is not about Mental Health nelly. This is about treatment by er doctors in an emergency ro. And when a woman comes in with some grave Mental Health emergency, if she has happens to be pregnant, it would be incredibly unethical to terminate her pregnancy. E might not be in a position to give any informed consent. Inea the way you treat Mental Health emergency is to address whats happening in the brain. Ifore having a psychotic episode, you administer antipsychotics. Justice alito well, i i really wt simple, clearcut answer to this question so that goinfoard everybody will know what the federal governments position is. Does health mean oy ysical health, or does it also include Mental Health . General prelogar with respect to what qualifies as a emergency medical condition, it can include grave Mental Health emergencies, but let me be very clear about our position. That could never lead to pregnancy termatn because that is not the accepted standard of practice to trt any Mental Health emergency. Justice alito does the term serious jeopardy in in e 11 i mean an immediate serious risk or may a risk of rious consequences at some future point suffice . General prelogar the standard is defined in termofhether you need immediate medical treatment. And soheelevant question is, in the absence of immediate mecatreatment, are you going to have this serious jeopardy to your health, dysfunction of your organs, will your bodily systems start shutngown, so it is pegged to the urgency of acute care in an emergency room. Justice alito so it has to be immediate . General prelogar the t relevant standard under the statute is phrased in terms of whether these consequences will occur without imdie treatment, yes. So its focused on the interaction between having some kind ournt Health Crisis that takes you to an emergency room in the first place and then hoprimate these these consequences are likely to be. Justice alo ell, there are two Different Things there, ether the person is whether the woman is in immediat jeopardy or whether the person the woman needs Immediate Care in order to eliminate jeopardy at a later point. So uerstand your answer to be that the woman need not be in immediate jeopardy, but if she doesngecare right away, jeopardy at some future point may suffice . General prelogar so the statutory standard itself is focused on iedte health risks. Its looking at the possibility that if the woman doet get treatment then and there, what will happen, what will reasonably be expected to occur is that her organs could start shutting down or she might lose her fertility or have other Serious Health consequences. It is focused on this temporal link between the immediate need r treatment, which is i think reflective of the factha congress was narrowly focused on this emergency acute medical situation. Justice alito do the tes impairment to bodily functions or seoudysfunction of any bodily organ or part refer only to permanent impairment or dysfunction . Generaprogar i think Justice Alito or do does it al rer to temporary impairment or dysfunction . General prelogar thk it can also refer to temporary impairment, but im not sure that its easy to parse the two. For example, a lot otis a pregnant woman in distress, she might start suerg liver dager kidney malfunction and you dont know ex ante wheer thats going to be permanent or no the instruction that Congress Gave in emtala is you need t stabilize to guard against those very Serious Health risks. Justice gorsuch gener,d id like to if you yeah, just understand f the scope of your argument here on the supremacy clause and how it operates in yod, putting aside the this case. Ulthe federal government condition the receipt of fds on hospitals that they comply with medical ethics rules provided for by the federal gornnt, a medical malpractice regime, and a medical licensing regime suc that effectively all state medical malpractice laws, all state medical licensing laws would be preempted . General prelogaranyoure imagining that this is regulatory action or that congress has passed a statute creating kind of a federal malpractice regime . Justice gorsuch you call it. General prelogar i mean, i think i have a broad view of congresss authority to enact statutes, and so what id want to assess in tt tuation is, you know, whether congress is acting pursuant to one of its enumerated powers. Justice gorsh pending clause. This is all spending clause. Genel elogar yeah. So so i think that very likely congress could make those kinds of judgments and attach conditions to the receipt of federal funds. And, you know, imecare, there are substantial conditions. Justice gorsuch even if it covers all hospitals in the state and effectively transforms threlation of medicine into a federal function general prelog u know, there might be a. Justice gorsuch historically . General prelogar at which this court thinks that its really encroaching on the states prerogatives in ways that a ionsistent with our constitutional sucre, but i dont think Justice Gorsuch you dont general prelogar were awhe close to that Justice Gorsuch you dont see general prelogar in this case. Juste rsuch but do you see any bounds just in principle . General prelogar i inthe bounds, you know, would have to come from this courts case law concerning federalism principles. The court has said in cases like goales versus oregon that, of course, the federal government has authority to comprehensively rela 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 you could construct hypotheticals that really Justice Gorsuch all right. Ok general prelogar seem to be the federal government entiry 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 prelogar thats corrt,es. Justice gorsuch and also, you can terminate the medicare agreements if a hospital violatesmta in your view . General prelogar yes. Generally, the hospitaisiven the opportunity to come into compliance and to devep plan to ensure that there wont be future emtala violatio. It would obviously be an extreme sanction to to terminat medicare funding, but that is a possibility. Justice gorsuch and theres also a privateig of action for emtala violations that it have the possibility of Equitable Relief as ll general prelogar yes. Certainly, monetary relief and and possibly Equitable Relief as well. Justice gorsuch in in this case, you you you brought an equitable cause of action. You didncite any statute to enforce emtala. And one ofheules in equity traditionally at least is that yodt get an Equitable Relief if theres an adeque remedy at law. And as we just discussed, theres a pretty reticulated statute here. Seminole tribeay when you have a reticulated statute and lots of remedial options, you dont get Equitable Relief. Thoughts . General prelogar so let me say at the outset that the United States has long been recognized to have an action in equity, an 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 Justice Gorsuch its sovereign its pprtary interests . You mentioned washington and you mentioned general prelogar arizona versus justice gouch arizona. General prelogar united States Justice gorsuch arizona was an general prog is another example of that. Justice gorsuch Arizona Arizona was just sorry to interrupt, but arizona was an immigration case and general prelogar right. Justice gorsuch the border, and washington was an attempt by a state to impose its Worker Compensation laws on the federal government in a way different om others. I i take those points. And eqtys all about proprietary interests and things like that. Do we have that here . Geraprelogar the well, i think that the court its t i want to make sure to make clear that therere long line of cases that stand for this principle, including ceshat have addressed it directly like in re debs Justice Gorsuch oh, debs. General prelogar wyandot, so Justice Gorsuch do you really want ry on debs, general . I mean, that wat exactly our brightest moment. General prelog do think, though, that it reflects the history and adion of this nation in recognizing that its entirely appropriate for the unit states to seek to protect its interests in this manner and let me say, Justice Gorsuch justice gorchwhat do you general prelogar this is a really importa iue to the United States. It wasnt pressed below. It wasnt pass un. Justice gouc im just trying general prelogar we havent briefeitt all. Justice gorsuch im trying t general prelogar its not riictional. Justice gorsuch im ju ting to understand where it comes from. What is the proprietary interest here . General prelogar it comes from Justice Gorsuch it seems to me its its your money and how iting spent, and congress has given you lots of tools. General prelogar i think it also comes from the coition under obstacle preemption principles that there are important futis to be served by having the Medicare Program in place. And idaho has directly inteer with the ability of hospitals to accept these federal funds when they stand willing and able to comply with emtalas mandates and fulfill congresss desire here to make sure that no matter where you are in this couny,f 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 robts counsel, your friend on the other side said that your position would requi religiously affiliated hospitals with Emergency Rooms to perform abortions. Was he right . General prelarno. My friend was wrong. There are federal conscience protections that apply at the entity level to hospitals as well. The key provisions are in the weldon amendment and also atsnowe, although that depends on the Residency Program of a particular hospital. Now hhs said in a 2008 rulemaking on conscience protections that ihanever come across a hospital that had a blanket objection to providing lifepreserving and healthpreserving pregnancy teination care, but if a hospital had that kind of objeioand hhs recently informed me they still have not come across that hospital, that ulbe honored visavis hhss enforcement ability. Chief Justice Roberts you said that applies at the entity level. Can individual doctors ith emergency room do they have a conscien emption . General prelogar oh, yes. Yes. Thre protected under the Church Amendments principally. And our position is that emtala does not override either set of conscience protections. So, if ainvidual doctor has a conscience objection to providing pregnancy termination, emla itself imposes obligations at the entity ve and the hospital should have plans in place to honor the individual doctors conscience objection while ensuring appropriate staffing for emergencca. Chief Justice Roberts well, does that does that mean th thermu be somebody in the emergency room that can provide an abortion . Wh if what if there are two doctors, three doctors, and they all have a conscience exemption . General prelogar no in that circumstance, emtala could not override those individual dto conscience protections, but my understanding is that as a hospitals want to be able toause provide Emergency Care, they do things like ask doctors to articulate their objtis in advance so that that c b taken into account in making staffing decisions and whos on call. Hospitals have a lot of plans in place chief Justice Roberts are are you saying general prelogar for these kinds of contingencies. Chief Justice Roberts yeah. Are are you saying that there must be somedyvailable and on call in in a hospital of that sort . Neral prelogar the conditions of participation for medicare require hospitals to be appropriately staffetorovide emergency treatment. Now, in a situation where a hospital doesnt hasnt done that and it doesnhave anyone on hand who can provide care, you know, maybe alofhe doctors called in sick that day and theres just literally no one in the emergency room, or in ase, if everyone had a conscience objection, then the hospital would not be able to provide the care. But there are conditions of participation that are meant to enre that there is Good Governance of hospitals an organization to account chief Justice Roberts when you say general prelogar forhe situations. Chief Justice Roberts and the consequence of them not ing able to provide the care would be what . General prelogar in that circumstance, i think they would likely be ouompliance with the conditions of participation reqre them to be appropriately staffed. But, if the question is could you force an individual doctor tep in then over a conscience objection, the answer is no. And i want to be really clear about that. Chief Justice Roberts i know, buthquestion general prelogar we dont understand emtala to displace it. Chief Justice Roberts excuse me. The question is whether they must have available someone who can mp the procedures required by emtala. And what would be th consequence if they didnt . Would it be eventual termination of their participation in general prelogar thats right. So, if a hospital was continually disobeying the requirement to have in place sufficient personnel to run their emergency room, then i imagine that hhs would, through enforcement action, work with atospital to try to bring it into compliance. And if the hospitaulmately is just leaving itself in a sition where it can never provide care, then it would termine e medicare funding agreement. Justice gorsuch i thought Justice Barrett general Justice Gorsuch u st said a minute ago im sorry. Ste barrett oh, no, go ahead. Justice gorsuch i thought you i just want to clarify this colloquy. I thought you said a minute ago, though, if the hospital had conscience objection and therefore didnt provide certai care, that that wouldnt render itutf compliance. Which is it . General prelogar thats correct. Justice gorsuch ok. All right. General prelogar so the hospital could assert a conscience objection Justice Gorsuch thats all. General prelogar and emtala wod t override that. Justice barrett my question i have a question about the Hyde Amendment. So gather from the briefing that there might be some situations in which emtala would require an abortio b the Hyde Amendment wouldnt permit federal funds to be used to pay for it. D you said in your brief that emtala requires in other circumans as well stabilizing treatment to be given that fer funds dont cover. Can you give an example of that . And am rht about the Hyde Amendment . And then can y ge an example of that . Nel prelogar yes. So you are right about both things. Is common under emtala that hospitals are going to have to pride care where theres not federal funding available. And ill give you emple of a medicare patntho goes in and his emergency medical condition means he needs a particularruthats not covered by medicare benefits. Still, the hostahas to provide him with stabilizing treaenand give him that medication, even though the federal funding isnt going to pafoit. And that also applies to people who are uninsured, who ant covered by medicare in the first instance. E the whole point of emtala was it doesnt matt yr circumstances, it doesnt matter whether you can pay orotit doesnt matter the particulars of your tuion, this is a guarantee. You can get stabilizing treatment. I wanto y, though, that i dont think theres any inconsistency between the lines Congress Drew in emtala and hyde. D congress itself has recognized that these statutes address scte issues. Im thinking here of the provision in t aordable care act that was exclusively about abortion, and ther cgress said nothing in the aca displaces hyde and the other federal fundg strictions on abortion, but also, nothing in the aca displaces emtala requirement to stabilize. D that shows two things. It shows first that congress recognized that stabilizing care can sometimes be pregnancy termination. And i think it also showed congresss recognition that these stut addressed their own stct spheres. And one final point on hyde, Justice Barrett. My friend isnt drawing a line d on hyde either because his point is, even if a woman o to an emergency room and theres are federal Funds Available under hyde to treat her, still, hospitals have no obligation under emtala to provide that care. Justice barrett swh about the colloquy i was having with yourrid about what stabilizing treatment entails lets imina situation in which a woman is, i dont know, 10 weeks, and is told that if you carry this pregnancy to te, it could have, you know, consequences for your health, buyou just would need to abort before, like, say, 15 weeks, Something Like that. So theres not an immediacy, like so shes stable when she leaves the hospital, butn idaho, theres no place else that she can go at least until shes 15 weeks what is the federal governments position then . Nel prelogar i think, if im unrsnding the hypothetical correctly, that she likely wouldnt have an emergencmecal condition in the first place because the definition of hangn emergency medical condition is that, without immeat treatment, you are reasonably you willnably be expected to have serious dysfunction of your organs ious impairment of your bodily functions. And , that situation where a woman is somewhat high risk, you know, maybe she she has certain complicationwhe doctors can say theres some danger with continuing thi pregnancy, i dont think that that creates the kind of emergency medical condition that emtala is aimed at. Justice barrett k. Last question, and this is about the spending clause issue. So it does sm d and i think kind of what some of the questions are gettin it does seem odd that through a Side Agreement between a private entity and the feder government, the private entity can get out of state law, right . So, in another administration, wo be possible then in reliance on the spending power for congress to say, you know, any hospital that takes these funds cannot perform abortions or any hospital despite state larequiring a state constitutional amendment requiring abortion to be available,s at possible or, you know, with gender reassignmenturgery . I mean, you can imagine it kind of going back and forth through spdi clause litigation in ways that would be unusual. General prog yes, i think congress has broad power under the spending clae attach conditions. Now dsnt mean that its wholly unlimited. Obously, congress would be having to act pursuant to an enumerated power, it would have to cwith other constitutional limits, and so the w would have to be valid. The spending clause itas builtin limits, things like relatedness and pure notice. Justice barrett so it would have to be acting pursuant to an enumerated pern forbidding gender reassignment surgery or abortionr ose sorts of things . General prelogarohno. I just meant that it would have bvalid spending. Justice barrett the spendin clause . General prelogar the spending ause. Justice barrett the spending clause. Genel elogar itself would be enough. Justice barrett ok. Ok. General prelogar yes. So we think Justice Gorsuch yeah. So general prelogar the spending clausitlf would be engh Justice Gorsuch jt to follow up on that and going back to where i srt with could could the federal government essentially regulate the practi omedicine of the states through the spending clause, the answer, i think, is yes, congress coulpribit gender reassignment surgeries across the nation, it could ban abortion across the nation, through the use of its spending clause authority, rit . General prelogar congress does have Broad Authority under the spending clause. And, yes, if it satisfies the conditions that the spending clause theel itself requires, then i think that that would be valid legislation. Justice gorsuch how nel prelogar and the court has in many contexts regned Justice Gorsuch how do we general prelogar the spending cuslegislation preempts. So to Justice Justice gorsuc sthe the answer is yes . Ok so how do we reconcile that with the statement in 1395 at nothing in this subchapter allows a federal officer to exercise any control over the practice of medicine . General prelogar so, at the outset, i think, if Congress Self is doing it, then that provision is inapplicable by its own terms. Ths looking at the justice gorch you dont think it informs our view and understanding of the statute in any way . Geraprelogar well, i think, in the event of some kind of direct conflict, you know, okg at emtala in particular, its the later in time enacted statute, and its clearly more specific, so it would l. But this court itself has rejected the idea that there would be that kind of conflict. And im thinking of the cms vaccine case whereitigants relied on this exact same provision of the medicare t, section 1395, and this court id no, that cant bear the weight that those litigants cod ace on it or it would call into question all of the conditnsf participation in medicare. That our clear statement rule with respect to spending clause legislation, our clear statement rule with respect to federalism are in play here . General prelogar i think that he, ngress has spoken clearly with respect to what providers jti gorsuch oh, i i general prelogar re supposed to do. Justice gorsuch thats not the questi. Do you think those presumptions forget about whether you can satisfy them. General prelogarth requirement of clear notice under spending clause legislation, yes, i think that have always understood theirrs obligations under emtala. Juste rsuch ok. Justice jackson general, let me ask you rpond to a couple of things petitioners couns said and just give y t opportunity to respond. He suggestedr id that you havent identified a circumstance in which sothg that emtala requires idaho woult allow. And i i didnt get a chance to ask him, but i took i took him to sort of mean that the way that idahos statute operates, basically allows for a doctor to say, well, in my view, you know, this healththreatening circumstance cldventually lead tdeh, and so im going to do it. So, to the extent that doctors are ilable to do that, i guess, hes saying theres preemption. But is it true that therrely isnt in operation a difference between the two the emtala and what idaho has required here . Nel prelogar no. That is gravely mistaken on three levels. Its innstent with the actual text of the idaho law. Its inconste with medical reality. And its inconsistent with whats happening on the ground. And this is a really important point, so let me try to unpack th. On the text itself, idahos law only allows termination ifts necessary to prevent death. And that is textuallve narrow compared to what emtala requires with the category o harm to begin with. In idaho, doctors have tsh their eyes to everything except death, whereas, under emta, youre supposed to be thinking about things like, is she abou to lose her fertility . Is her uterus going to become incredibly scarred because of the bleeding . Is she about to undergo the possibility of kidney failure . So i think that that is one critical distinction. Thotr critical textual distinction is the idea of necessity. Under idaho law, you have to nclude that death will necessarily result, which is also materlldifferent, and the Idaho Supreme Court specifically rogzed it. Second, with respect to the actual medical reatyere, there are numerous conditions thate e worried about where a doctors immediate concern is nodeh. Thats a far more remote poibility. Theyre thinking about the heal ccumstances that emtala guards against. And let me give you two examples. The first is pprom, premature ruure of the membranes. We have declarations at 594 that explaith in detail and also at ja 615 to 617. What the doctors explained there this is dr. Flech and dr. Cooper is a woman comes in with pprom, her sac isupred. Theres no chance the fetus is going to be leo survive, but at that point, she doesnt have active signs of infection, and so, until she deteriorates, you ct think shes close to death. What youre woredbout is she will become infected. She might develop sepsis. She might have these dramatic consequences for her future, but is not about death. So i think that is one example where you cant do it. And then, finally, just the acalractice on the ground, women in ida tay are not getting treatment. They are gti airlifted out of the state to Salt Lake City and toeiboring states where the e health exceptions and there are laws because the doctors are facing mandatory mimum two years in prison, loss of their license, criminal prosecution. The doctors cant provide the care because until they can conclude that a prosecutor looking over their shoulder wont secondguess that maybe it wasnally 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 ha of argument on this case, and one potentially very important ra in emtala has hardly been mentioned. Maybe it hasnev been mentioned at all. And that is emtalas reference to the womans unborn child. Isnt th aodd phrase to put in a statute that imposes a mandate to perform abortions . Have youveseen an abortion statute that uses the phrase unborn child . General prelogar is not an odd phrase when you look at what congress was doing in 1989. There were wellpublicized cas where women were experiencing conditions, their own health and life were not in danger, but the fetus was in grave distress and hospitals werentrting them. So what congress did Justice Alito well, have you seen general prelogar is that it ustice alito have you seen abortion statutes that use thphse unborn child . Doesnt that tell us something general prelogar it tells us that congress wanted to expand the protection for pregnant women so that they could get the same duties to screen and stabilize when they ha a condition thats threatening the health and wellbeing ofhe unborn child. But what it doesnsuggest is that congress simultaneously displaced the independt preexistinobgation to treat a woman who herself is facing grave life and health coequences. Justice alito well, letwalk through the provisions of the statute that are relevant to this issue regarding the status and the potential inres of an unborn child. Under b 1 , if a woman goes to a hospital with an emergency medicacoition thats the phse the hospital must either stabilize the condition , under some circumstances, transfer the the womato another facility. So we have this phrase, emergency medical condition, in that provio and then, under e 1 , the term emergency medical conditionis defined to include a conditi that places the health of the womans unborn child in seriou jeopardy. So, in thasiation, the hospital must stabilize the threat to the unborn child. And it seems that thpln meaning is that the hospital must try to eliminate any immediate threat to the child, but performingn ortion is antithetical to that duty. General prelogar but, ia circumstance Justice Alito now a you you go you go so far as to say that the statute is clear in your favor. I i dont know howouan say that in light of the of those provisions that i just read to you. General prelogar the statute did nothing to displace the woman herself as an individual with an emergency medical ndion when her life is in danger, when her health is in danger. That stabilization obligation equally runs to her and makes clear that the hostahas to give her necessary stabilizing treatment. And in many of the cases youre thinking about, there is no possible way to to stabilize thunrn child because the fetus is sufficiently before viability that s inevitable that the pregnancy is going to be lost, but idahoou deny women treatment in that circumstance Justice Alito doesnt general prelogar even though is senseless. Justice alito doesnt what ive read to you show that the statute imposeonhe hospital a duty to the woman certainly and also a duty to the child . And it doesnt tell the hospital how it is to adjudicate conflicts between those interests and it leaves that to state law. Now maybe a loost of your gument today has been dedicated to the propoti that the idaho law is a bad law, and th m well be the case. But what youresking us to do is to construe this statute that was enacted back during the Reagan Administration and signed by president reagan to mean that theres an obligiounder certain circumstances to perform an abortion even if dog at is a violation of state law. Nel prelogar if congress had wanted to displace protections for pregnant women who are in danger of losing their own lives or their health, then it cod ve redefined the statute so that the fetus itself an individual with an emergency medical condition. But ths not how congress structured this. Instead, it put the protection texpand protection for the pregnant woman. Thdues still run to her. And in a situation whe h own life and health is gravely endangered, then, in that situation, emtala car. It says the hospital has to offer her stabilizing treatmt. Justice alo he the only general prelogar and she doesnt have to accept it. These are tragic circumstances and many women want to do whatever they n save that prnancy. But the statute protects her and gives her that choice. Justice alito the only way you try to get out of the statutory interpretation that i st posited is by focusing on the term individual. And you say, aha, in the dicony act, individual is defined to exclude an unborn child or a fetus. Thats the only way you can try to get out of what ive just outlin. And isnt it true that under the dictionary that dictiony act definitions apply only if they are not inconsistent wi the statutory text . And when you have a textha certainly, you wouldnt dispute the fact that the spal has a duty to the unrnhild where the woman wants to wants to have the pregnancy go to term, it indisputably protects the inres of the unborn child. So its inconsistent with the definition in the in the dictionary act. General prelogar no, noat all. The duty runs to the individual with the emergency medical condition. The statute makes clear thats the pregnant wan and, of course, congress wanted to be able to protect her in situations where shes suffering some kind ergency and her own health isnt at risk, but the fetus mit e. That includes common things like a prolsef the umbilical cord into the cervix where the fetus igrave distress, but the woman is not at all affected. Hoitals otherwise wouldnt have an obligation to treat r, and congress wanted to fix that. But to suggest that in doing so congress suggested that the woman herself isnt an individual, that she dst deserve stabilization, i think that tt an erroneous reading of this statute. Justice alito nobodys suggesting that the woman is not an individual and she et she doesnt deserve stabilization. Geraprelogar well, the Justice Alito nobodys suesng that. General prog i think the premise of the question would be that the state of idaho Justice Alito it wasnt the predicate. It wasnt general prelogar aneclare that she cannot get the stabilizing treatment even if shes about d. That is their theory of this case and this statute, and its wrong. Chief Justice Roberts Justice Sotomayor . Justice sotomayor general, this thila of conflict which your opposing counsel colleague says doesnt exist, you mentioned a situation where it. Why dont you succinct ste what you well, they admit theres daylig. Tell us exactly how you define where the daylight exists. General prelogar the daylight, as i see i ests on two dimensions. They think that doctors can only provide stabilizing care when the woman is facing death. And we think, no, you can take into account things like kidney failure, the risk of szure, and lifelong neurological impacts based on that. Justice sotoyo well, they they said the recent decision of the oregonou says you dont need death to be imminent or immediat ihink, is the word they used if im not wrong. General prelogar so what the Idaho Supreme Court said in that decision is that thereno particular level of imminency d no certain chance requirement. But what the court couldndo is turn away from the language requiring the type oha to exclusively be death. And also, the inherent concept of necessity ruing some degree of imminence, its true that its a suecve standard under idaho law, and the court made that ea but what the Idaho Supreme Court also said is prosecutors are free to come in and vether medical experts secondguess doctors decisns by saying maybe you didnt suectively think she really needed it as necessary to prevent atbecause, look, her her sac had ruptured, but she wasnt yet infected. And thats exactly the kind of situation that leads to women being driven out of state, dumped on neighboring statesy idaho, and criminalizing the care, the essential care that they need. Justice sotomayor thank you. Chief Justice Roberts Justice Kagan . Justice kagan yeah, if you could just talk a littleit about that because, as i understood it, for example, i read reny that the hospital that has the greatt ergency Room Services in idaho has just inheew months that this has been in place had to airlift six pregnant women tnehboring states, whereas, in the prior year, they didnehe entire year. So, if mr. Turner is right about what the state is trying to convey to hospitals about when theyll be prosecuted, kewhy is this happening . General prelogar i think that the reason this is happening is because those doctors can look at the texofhe statute itself, they can look at the Idaho Supreme Courts decision, whicma clear, very clear, that this was a departure from prior idaho laws tt acked emtala. And they can recognize that their livelihood is t line, their medical license, their ability to practice medicine, their freedom if they have to go to jail d rve one of these minimum twoyear sentences of imprisonment, and they simply nn provide the care, even consistent with their subjecve medical judgment, because as a matter matter of medical reality, for many tse conditions, its not yet putting a woman at the brinkf ath or necessary to prevent her death, t they know that the standard of care is to provide hewi termination because she is just going to get worse and worse and worse if they wait iou and the other important point about this, and i think it goe back to this dual stabilization idea, is that, tgilly, in many of these cases, the pregnancy lt. Theres not going to be any way to save that fetus beusa woman who has pprom at 17 weeks, there is no medical way to sustain the pregnancy to give the fetus a chance. So in atituation, what idaho is doing is waiting for women to wait and deteriorate and suffer the Lifelong Health nsuences with no possible upside for the fetus. It just stacks tragedy upon tragedy. Justice kagan and it it it cant be the appropriate you know, its like its become transfer is the appropriate standard of care in idah but it cant be the right standard of care to force somebody onto a helicopter. General prelogar anis entirely inconsistent with what congress was trying to dinhe statute. You know, one of the primary motivators here was to prevent patient dumping. The idea was we dont want op 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 particular treatment they dont nt their hospitals to provide and dump those patients out of state. And you can image at would happen if every state started to take this approach. Justice kaga auestion on the spending clause questions that youve been asked. I mean, what would if you accepted some of these theories, what what would the consequences of Something Like that be that we would have to worry about . General prelogar i think that would call into question any number of federal spending statutes that provide funds to private parties, and there are a bunch of them. You know, theres the medicare system itself, which is of course a morederal spending program. There are funds oved under title , der title ix, a lot of federal statutes out there th ge funds to private parties and insist on conditio of compliance with the federal funding restrictions. And if the court were to suddenly say that cant preempt contraryta law, then i think that it would seriously interfere with the ability of the federal government to get its benefit of the bargain i those spending programs. Justice gan and you mentioned before that this question has ner been a part of this case . General prelogar thats right. They did not make these arguments in the lower court. Eyriefly referred to the spending clause, but i dont understand them to have pressed this argument specifically. And so i think that the lower courts did not address it. I think the District Court said in aooote, they briefly refer to it in a footnote of their brief, and its essentially waived. Justice kagan thank you. Chief Justice Roberts justice jusavanaugh . Justice kavanaugh youve touched on whats happening on the ground, and thats an important considerioin answer to the question of whats happening. But idaho is representing and i stant to get your answer on this that, as i count it, nine conditions that have been identified by the government where emtala wouldeqre that an abortion be available, an abortion is available under idaho law. And thats in the reply brief. Now, are there other conditions . Ove ruled out Mental Health. Are there other conditions you would identify, or are youus saying that thats not really happening on the ground . I think thats part of your answer, but i just wantoet a fuller answer on that. General prelogar it certainly it happening on the ground. These are the conditions that were worried about and i think the problem with my friends theory that idaho law would permit it is thayojust cant square it with the text of the statute. You know, the the justice vanaugh what if there were general prelogar theta of idaho Justice Kavanaugh im sorry kp ing. General prelogar well, i just wanted tsatheyre not the ultimate authority on what the idaho law an thas the Idaho Supreme Court, of course. And it has addressed this issue in the planned parenthood case. And i think its really significant that, in planned parenthood, the Idaho Supreme Court expressly contrasted this statute with other statutes that contain healthpreserving measures and recognizeth was a a total departure from that. The legislature wanted to focus exclusively and mo nrowly on a necessary to prevent death exception. So i think that that that essentially means that the supreme urof idaho has already touched on this issue, and its no wonder, then, that doctors who are facing these kinds of pregnancy complications, where in their medical judgment its not necessarily to prevent death yet, but the woman is going to suffer serusealth consequences, their hands are tied and they canprovide that care under the idaho law. Justice vaugh if the whats on page 8 and 9 of the reply brief redaho law, would there be a problem still . General prelogar iwe had an authoritative idaho supreme courdesion that said idaho law allows for termination in the circumstances eremtala would require it, yes, of course. Then theonict goes away. Justice kavanaugh well neral prelogar but i cant imagine the court would say that cause, of course, here Justice Kavanaugh thats not quite what 8 and 9 say, but i i take your point on that. Serate question, different category. I think one of the themeonhe other side is that this law passed in 19 w a very important law addressing a very important problem; nel the problem where hospitals were turning away poor and uninsud patients who came in for Emergency Care. And the idea was that cant happen. Ct allow hospitals in this country to turn away poor an insured people in an emergencies. But their theme is that the law was not desiedontextually to deal with specific with abortion or other specific kinds of car and so they make a textual argument, but i think they also ke broader contextual argument about the whole idea of what was going on in 1986. And i want to make sure i dont think thats really come up too muc i want to make sure you respond to that. Geraprelogar i appreciate having the chance to address that. So at the outset, i dont think they can square that theorwi the text of the statute, which says, in no uncertain terms, here is the fundamenta guarantee. If you have an emergency medical condition and you go to an er in this country, they have to stabilize you. They have to give you such treatment asaye necessary within reasonable medical probability to ensure that you dont teriorate. And, yes, congress did not provide a reticulated li o all possible emergency medical coitns and all possible treatments, but it was vy clear that congrs t a baseline National Standard of care to ensure that, no matter where you ven this country, u nt be declined service and the the urgent urgent needs of your medical condition adessed. And, you know, it would be no different if the state h ce out and decided to ban epinephrine. Ats the singular way to treat anaphylaxis, a severe alrg reaction. That would violate the statute, and we would be up here making the exactly samergents, because congress didnt want that. If you have anaphylaxis and you go to an er anywhere around this country, theyre going to give you epinephrine. And Congress Mandated that. And i dont see any way to try to draw lines around to exclude pregnancy complications in the very narrow but tragic circumstances where the only way to addressheomans condition and prevent material deterioration is for the pregnancy to end. Justice kavanaugh thank you. Chief Justice Roberts Justice Barrett . Justice barrett so, general, i i understand e imary difference between emtala and the idaho statute to be is health, that that idaho focuses t risk of life, but the federal government says that emtala well, emtala says that the health is am i right, its health and life . General prelogar thats thats the principal difference, but i think its also the difference between necessary to prevent death versus the Health Concerns would be reasonably expected to occur. So i think that that is a standard that builds in a little more space for doctors to ke action. Justice barrett got it. Ishe federal government aware of any state, other than idaho, atas a law that does not take health into account . General prelogar there are six other states tt ve severe abortion restrictions without a health exception. So i think that those are the primary category of states were concerned about here. Justice barrett thank you. General prelogar i should i should me clear that there are some pending judicial challenges in tho stes, and so their laws are not always enforceable or in effect right now. Justice barrett besides texas, has the federal government has the federal government brought suits similar to the one brought in idaho and tasn any of these other states . General prelogar to be clear, texas was not our Justice Barrett right ok. General prelogar affirmative litigation. They sued us. But we have not brought affirmate tigation in other states. And i think its this case has been on a cour a idahos law was particularly severe because at the point at which we sued it seemed to cover ectopic pregnancy, and the state conceded that. Now, they 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 Justice Jackson . Ice jackson general, petitioner relies pretty heavily on cletement rule principles. And i wonder whether you might comment on my thought that those principles actuallagainst them in this case. As you said, congress set a baseline National Standard of care. It has said, in no uncertain terms, that the hospital must provide stabilizing care to op experiencing emergency medical conditions. Ere was no, as youve said, you know, particular conditions or particular treatments talked about, carved out, et cetera. So if a clear statem required, wouldnt it be the requirement of exemption of exempting abortion . Justice alito has about some ofhe exemptions for unborn child. Of them wed like an exemption. Nothing ats this clear National Standard of care. I think congress was clearly requiring sbization. It wasnt exeminparticular coitions or particular types of treatment. This court has said there is no canon of duluth dona rose. When you have a provision like that, the facthayou dont have a specifieneration of one of its applications does not mean you should read in some side of me kind of implicit exception. What ihink we would need to see is a clear statement that congress meant for you to not provide abortions. I think it is important to recognize thaevy relevant actor has understoodt is way from the beginning. Then the agencys position all ong we not adopting a new position. Providers have understood it. They have always provided fesustaining and healthy stating pregnancy termination consistent with and tyler. Congress recognized it in the Affordable Care act. And i think there is any argument to be made that people understood what congress is doing thute. Thank you, counsel. Quick thank you, your honor. And tell it takes state law practice standards as they find them. As Justice Gorsuch noted, that isha section 1395 said. In the Vaccine Mandate case at was referenced, that is what the Generals Office told this court when is at 1395 does t require does not allow federal officials to dictate partila treatments for particular cases. Ats what they are trying to do hereit its it is confirmed by subdivision f. Anything that could codify this, to Justice Jacksons colloquy at the end, that is the poi. You do presume that state law continue to operate alongside impala you dont presume the opposite. It is ppted byhe operations manual. That is the Rosetta Stone of intel enforcement. It tells doctors, it tel c enforcement agents on the ground that you consider what is available byefencing what is in the scope of that doctors license. That is exactly what we are ying. It is also specifically directed it requires hospitals comply with stateaw that dec hospitals to acquire their hospitals staff. They totally lack any case history that would support the adnistrations meeting. This always was understood to be e caswi you think we would find tse 115,000 instances. A single instance where state law was overridden. And finally, the text. The text qualifies and tell us steve drew stabilization requirement. Kw they can perform open het surgery and we know debtors can draw blood. It is not just a plain mandate devoid of reference to state law. We know the word available even in common usage incorporates state law. You are just the other day that when considering wheth ts is available for homeless people, it is in a physical and legal sense. There is a physical question and a legal question. Opioids are available in the hospital. They are on the shelf, physically there. There is a legal question that comes into play there. The same with abortions. In response to the chief justice question, the general said both hospitals and doctors are exempt from and tell us suppose it tion mandate. We are relieved to hear that. I think it hhlhts the utter inconsistency of thE Administrations meetg. If the establishg quirement is done on them not to override conscious protections, d cannot be so specific and include a requirement that is in direct conflict with state those two do not drive. This court does not lately find a direct conflict. Coress must speak clearly. It has not done so here. ThE Administrations position ultimately is untethered from any limiting pncle. But i think we heard that. The is no way to limit this to abortion. There is no way to limit it to idaho. They are 22 states with an abortion law on the books this isnt going to end with idaho or the six states because all the states that have abortion regulations define the heth and the emergency does. Tion narrower than m tele this question will come up in state after state after state. It is not limited to physical health. I kn ty say there is no circumstance in which mical condition can require stabilization within abortion. Now he is just fighting with the American Psychiatric association. That is not consistent. It isnt limited tan tele. U ll point out theajor spending because implications that are at play here. We recogni this is usually concerning if the federal government can pay private actors to buy the state law. In by enumerated powers. I think they admitted that. The court does not have to answer that question by our read