Two hours. Chief juste berts we will hear argument this morning in case 23726, moyle versus United States, and the consided case. Mr. Turner. Mr. Turner thank you, mr. Chief justice, and may it please the court when congress amended the medicare act in 1986, it put emtala on a centuries Old Foundation of state law. States have always been responsiblfolicensing doctors and setting the scope of their profeson practice. Indeed, emtala works precisely beuse states regulate the practice of medicine. And noinin emtala requires doctors to ignore the scope of their licensanoffer medical treatments that violate state la the statutory provisions make first, section 1395, the medicare acts eng provision, forbids the federal government from controlling the practice of meci. Thats the role of state regulation. Second, bdision f in emtala codifies a statutory presptn against preemption of state medical regulations. An third, emtalas stabilization provision is limited to available tremes, which depends on the scope of the hospital staffs medical license. Illegal treatments are not available treatments. Add in this courts own presumption against preemption of regulations, combine that with the need for clear a unambiguous spending clause coitions, and the administrations reinbecomes wholly untenable. The administrations misreading also lacks a liting principle. If er doctors can perform whatever treatment they determine is appropriate, then doctors can ignore not only state abortion laws but al state regulations on opioid use and informed consent requirements. That turns the presumption against preemption on its head and leaves Emergency Rooms unregulated under state law. Its unsurprising that noou has endorsed such an expansive view of emtala, and unl bbs, nor had hhs. Everyone understands that licensing laws limit medical prtice. Thats why a nurse isnt available to perform openheart surgery, no matter the need, no matter her knowledge. The answer doesnt change just because were talking about abortion. The court should reject the administtis unlimited reading of emtala and reverse the District Courtjudgment. I welcome the courts questions. Justice thomas normally, when we have a preemption case, theres some relationship between the parties. Is the state being reguledy the federal government under emtala, or is the ste engaged in some sort of quasicontractual relationship . Mr. Turn s, your honor. In this case, the state, idaho, for example, has no state hospitals that participaten with the Emergency Rooms in emtala. And so, in this casethe isnt even a quasirelationship. The parties beg gulated by emtala here are hospitals and doctors. And i think your question is ttg at the armstrong issue, and we think that is a gnificant question. It wasnt part of thqution presented. We think the indiana amicus brief raises significant questions and deals with that argument well. But the question presented here isne of direct conflict between idahos law and emtala, and on that question, we dont thk s hard at all. And, your honors, going to that direct conflict, i think, if you consider the expssimitation within the statute of availability justicson ell, before we do that, can i just step back and get your understanding of the statute . You made some representations as to how you see it working. And so let me tell you what i think, and thecan tell me whether you agree, disagree, or otherwise. So i think that therartwo things that are plain, pretty plain, on the ace of this statute. One is that emtala is about the provioof stabilizing care for people who are experiencing emergency medical conditions. Thats one thing i think the statute is doing. And i also think thaits operating to displace the prerogatives of hospitals or states or whomever with respect to that fairly narrow slice of the healthcare universe. This idea of Emergency Medical Services is like one very mino sort of overall healthcare he provision of healthce. So what that means is that when a hospital wants to only provide stabilizing care in emergencies fopele who can pay for it, r example, emtala says, no, im sorry, you have to stabilize anyone whos experiencing an emergency medical condio or when a hospital wants to provide stabilizing treatments to people who are experiencing only certain kinds of emergency conditnsemtala says, no, heres the list of conditions d u have to provide stabilizing care for those people. Look, its our job to govern all of healthcare in o ste and we say that only certain kinds of healthcare can be given to people who aeriencing emergency medical conditions, we donnt whatever treatment, we want only certain kinds of trtmt, emtala says, no, we e directing that as a matter of federal law, when someone presents with an emergency condition, they have tbe assessed and the hospital must do whatever is in its capacity to stabizehem. Is that your understanding of the statute . Mrtuer partially, your honor. Wegree that emtala does impose a federal stabilization requirement, but the question re is what is the content of that stabilization requime, and for that, you have to reference state law. Justice jackson ok. Well Justice Kagan if i could just i mean, i think what you just said is important because, when you concede that emtala imposes a stabilization requirement, it , this statute, the federal government interfering, if you will, in a states healthcare choices. So emtala is on its face a statute thatayits not all the states way. Therarfederal requirements here. There is a requirement to stabilize emergency patients. And you agree with that . Mr. Turner yeah, Justice Kagan, we agree that emtala emtalas purpose was narrow to bridge this gap that existed in some states Justice Kagan o so, i mean mr. Turner and the failure to treat. Justice kagan can just take off the table this idea that, you know, just bau its a state and its healthca, at the federal government has nothing to say about it. The federal government has plen tsay about it in this statute. No yre right, now theres a question of whats the content of this stabilization requirement. And as far as i understood your opening remarks, you say, well, this is left to the states. But, if ijust looking at the statute, the statute tells you whatheontent of the stabilization requirement is. Its to provide such medical treatment as may be necessary to assure within reasab probability ato material deterioration of the condition is likely to occur if the person were transferred or didnt get care. Sot lls you very clearly its an objective standard. Its basically it you know, its a standard thaclrly has reference to accepted medical practice, not just whatever one doctor happens to thk. But ithe is the content of the standard. You have to stabilize. What ds at mean . It means to provide the trtmt necessary to assure within reasonable medical prability that no material deterioration occurs. Mr. Turner yeah, let me respond in two ways. First, thebjtive standard that you set forth there in that understandg contrary to the administrations view. They say it is a totally subjective standard and whatever treatment a doctor determines is appropriate, thats Justice Kagan i think that thats not true. I mean, i think you guys can argue about this yoursel but, as i understand the solicitor generals brief and welleehat the solicitor general says but the solicitor general says its not up to every individual doctor. This is a standard that is objective that incorporates accepted medical standards of care. Mrturner well, and the more fundamental point is the definition that you quoted of stabilizing care in the operative position provisn in b 1 is also textually explicitly qualified by at which is within the staff and facilities available at a hospital. So then we come Justice Jackson yes. And thats at Justice Kagan thats quite right. Thats quite right. It says th the staff and facilities available at the hospital. And if you just look at that langgei mean, its absolutely clear that thats t rerence to what state law involves. The staff and facilities available. If you dont ve staff available to provide the medical care, then i guess y ct provide the medical care. Ifou dont have the facilities available to provide the medical ca, en you cant provide the medical care. A transfer has to take place for thgo of the patient. Mr. Turner this is a really important Justice Kagan but this is this the availabili he, because its the availability of staff and facilities. Its, youno do you have the right doctors . Do you have enou dtors . Do you have the right faciliti . Or is it better for the patient to transfer them to the hospital a few miles away . Mrturner youre exactly right. Do you have the right docts . How do you answer that question except by reference to state licensing laws . Justice jackson b absolutely cant do that. I mean, thats sort of the initial point that i was trying to make, wch is that the federal mandate is to provide stabilizing care for emergency conditions, regardless of any other directive that the state has or the hospital s at would prevent that care from being provided. Thats thats the work of the statute. Mr. Turner ste jackson, thats not even hhss conclusion. Inhetate operations manual, which they proffered on page6 of their brief, it defines what makes a staff person available under the statut a they say it has to Justice Sotomayor counsel, i i this whole issue Justice Jackson and does it say that theyre not available if state law doesnt doesnt allow this procedure . Mr. Tuerit says they are available to the extent they are operating within t spe of their medical license. And that is our argument. They want to now draw it far more narrow and look only at physical availability. We agree thats a component, but theres also a lal availability component here too. Justice sotomayor counsel, the problem were having right now is that youre sort of putting preemption on its head. The whole purpose of pemion is to say that if the state passes a lawhaviolates federal law, the state law is no longer effective. So there is no state licensing law that would permit you permit the state to say dont treat diabetics withnsin. Treat them only with pills, metformin. And a doctor looks at a juvenile diabeticndays, without insulin, theyre going to get seriously ill and the likelihood a i dont know what that means under idaho law, wellet to that shortly becsei dont know, this we believe this is a better treatment. Mr. Turner ye. Justice sotomayor federal law would say, you cant do that. Medically accepted objective medically accepted standards of ca require the treatment of diabetics with insulin. The medically accepted obligation of doctors when they have women with certain conditions that may not result in dea b more than likely will result in very serious dil 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, as opposed to serio iness, they cant perform the abortion. So i dont know your argument about ste censing law because this is what this law does tells states, your licensing laws cant take out objective medical conditions tt could save a person from serious injury or death. Mr. Turner yeah, i think there are two crucial responses to your point let me begin with the preemption point. Subdivision f and section 1395 actually are telling hhs, the federal government, and courts just the opposite, that you dont justice sotomayo its saying you cant preempt unless theres a direct conflict. If objti medical care requires you to treat women who are who present the penal of serious medical complications and the abortions e only thing that c pvent that, you have to do it. Mr. Turner no Justice Sotomayor idaho law saysheoctor has to determine not that theres merely a serious medical condition but th the person will die. Mr. Turner yeah. Justice sotomayor thats a huge difference, counsel. Mr. Turner your hon agree that the there is daylight between how thadnistration is reading emtala and what idahofense of life act permits. We agree that theres a controversy here. But what im saying is that Justice Sotomayor no, no, no, no, no, theres mo tn a controversy because what youre saying to us is,f tala doesnt have preemptive force in not just idaho, it has a sin condition for abortions when it threatens a womans life mr. Turner well, whenhe Justice Sotomayor but what youre saying is that no state in the nation and there are someig now that dont even have that as an exception to their anartion laws. What you are saying is that ere is no federal law on the book that prohibits any state from saying, even if a woman will die, you cant perform an abortion. Mr. Turner your honor, i know of no state that does not incle lifesaving exception. But, secondly, the government Justice Sotomayor some have been debating it at least, a if i find one but yr eory of this case leads to that conclusion. Mr. Turner i think our point is that emtala doesnt address that very Justice Sotomayor does your theo chief Justice Roberts could i could i hear your answer . Mr. Turner yeah. In the administrations reliance on a standard like best Clinical Evidence orom national norm, i think thats very fraught becsehat it really is saying is the text itself dst address what stabilizing treatment is required. You go outside the text to professional standards that are flting out there that might change day to day, and that really boils down to a question between a conflict between what the acog says and what idaho law sad thats not chief Justice Roberts thank you. Ank you, counsel. Justice jackson actually, can i just clarify . Because im not sure i understand. You know, sort of looking at this from a broader perspective, it seems to me that emtala says yomust provide whatever treatment you have the capacity, meaning staff and falies, to provide to stabilize patients who are experiencing emergency medicacoitions. Idaho law seems to say you cannot provide that treatment unless doing sisecessary to prevent a patients death to the extent the tatnt involves abortion. Why is that not a direct conflict . You have you must in a cta situation, thats what the federal government is saying, and you cannot if it involves abortion says idaho. Rner i think the nurse example really highlights the reason why, because a nurse might be available. The nurse may be may even think she knows how to, and under the flat must provision in emtala, the administrations g would say call her into action, put her into the operating omand open the patient up. Justice jackson ig. And mr. Turner but that is not Justice Jackson and idaho Justice Kagan well, that juste ckson would say no, thats still a conflict. So, fine, lets say the lets say the administrations position is that nurse can do it. Are you suggesting that federal law would not take precedence, would not preempt a state law that says no, she cant . Mr. Turner well, whether federal law could do that is a different questi tn whether emtala here does do that. And i thk e answer is clear that it doesnt. I mean, its like the gonzales v. Ogo case where the controlled substances act, you owthis court noted that that was the provisions there ly up and and assume a medical profession being regulated by state police powers. Thats the same with emtala. Emtala is a fouragstatute. Congress didnt attempt to address e andards of care for every conceivable medical treatment in Justice Kagan it it definitely didnt address the standards of care. It did leave that to the medical community. It said, you know, the congress was not gngo address every treatment for every conditn,ut it said you do what is needed to assure nondeterioration. So i guess the question here is, do you concede that with respect to certain medical condion an abortion is the standard of care . Mr. Turner no, e a standard of care under idaho well, i ou say, in idaho, there is a lifesaving exception for ceaiabortions, and that is the standard of care. And the standard of care is necessarily set and determined by state stice kagan well, i think you have to concede that with respect to cerinedical conditions abortion is the standard of care because your own stut as interpreted by your own courts, acknowledges that when a condition gets bad enough such that the womans life is in peril, then the the the doctorsreupposed to give abortions. Mr. Turner and Justice Kagan and the reason th tts true is that with respect to certain rare but extremely obviously important conditions and circumstances, abortion is the acpt medical standard of care. Isnt that right . Mr. Turner yes, and that that was my point, that there is a lifesaving exception under idaho law. Now the question here is Justice Kagan now now the question is, is it also the acpted standard of care when, rather than the womans life being in peril, the Womans Health is in peril . So lets take u know, all of these cas a rare, but with tse rare cases, theres a gnificant number where the woman is her life is t peril, but shes going to lose her reproductive organs, shes going to lose the ability to have children in the future, unless an aborti tes place. Now thats the category of cases in which emtala says, my gosh, of course, the abortion is necessary to assure that no material deterioration occur and yet idaho says, sorry,o abortion here. And the resu ithat these patients are now helicoptered out of state. Mr. Turner yeah. Your honor, the the hypothetical you raise is a very difficult situation, and situations, i mean, nobody is arguing that they dont raise tough medical questionth implicate deeply theological and moral questions. And idaho, like 22th states, and Even Congress in emtala recognizeshathere are two patients to consider in those circumstce and the twopatient scenario is is tough when you have these competing interests. Justice kagan you know, tt would be a good response if federal law dinotake a position on what you characterize as a toug question, t deral law does take a position on that question. Itaythat you dont have to wait until the person is on the verge of deat