Transcripts For CSPAN2 Supreme 20240627 : vimarsana.com

The fair argument in case 23726 borilla versus the state in the consolidating case. Mr. Turner. Thankr. Chief justice and may it pleas court but when congress amended the medicare 1986 to put them pull on the centurys own speak up if it had bee responsible for licensing doctors and setting practice indeed paula works precisely because states regulate theice of medicine and nothing nothing in an paula requires doctors to ignore the scope of their license and offecal treatments that viola state law. Three statutory provisions make this clear. First sec390 by the medicare act opening provision prevents the federal gover from controlling the practice of medicine. Thats a state regulation per second subdivision f i and presumption against they preemption of state medical replacement in the stabilization is limited to be able to do ich depends on the scope o the Hospital Steps medical license for illegal treatments are not ava treatments. Add in the courts on presumption against preemption of state regulations and combine that with the need for clear and unambiguous spending clause conditions and administrations reading becomes wholly untenable nable. Administrations misre also any limiting principle. If er doctors can perform whatever treatment they determine is appropriate doctors n ignore not only abortion laws that state regulationzero. He is an informed conse presumption against preemption on head diverts it es leaves Emergency Rooms underlay am surprising that no cos endorsed such an expansive view of and paula and everyone understand licensing laws limit medical practice. Thats why and nurse and available to perform openheart surgery no matter thed, no matter her knowledge the answer doesnt change just because we areking about abortion. The should reject the administrations unlimited reading of shifty shellshock. Normally when we have a preemption case theres some relationship between the parties. If the state being regulat the federal government under emtais the state engaged in some sort of qualified contractual relationship . Yes your honor this case the staten idaho for example has no state hospitals that participate Emergency Rooms and emtala so in this case the emtala or hospitals and doctors. They thinkre questions g at the armstrong issue and we think that is a significant quesut it wasnt part of theion presented and we think the indiana amicus brief raises significant questions and deal that argumentell is one of directict andted here emtala and we dont think its hard at all. Your honor going to that direct conflict i think you considered press limitation within the statute of availability. And before we do that just step back and get your understanding of the statute . You made some representation to how you see it working so let me tell you what i think and then you tell me whether you agree disagree or otherwise. I there to things that are plain, plain on the face of the statute. One is that emtala is about the provision of stabilizing care people who are experiencing emergency medical conditions. Thats one thing i think the statute i doing and i also think that its operating to lace the prerogatives of hospitals were states or omever with respect to that fairly narrow slice of the health care universe. This idea rgency med services is like one very minor or small part of the Overall Health Care Provision of health care. What that means is he stabilizing care in emergvide for people who cant pay for it for example, emtala says no im sorry anyone whos experie in eme condition or a stabilizing treatment to people experiencing only certain ki of emergency conditionala says heres a list oftions you haveo provide an ilizing care for those people. Similar if the says its our job t govern all of health care in our state and we say ertain kinds of health care can be given to people who are experiencinency medical conditions we dont want emtala says no we are directing is a matter of federal law when condition we have to do whatever and its capacity tolize up is that your understanding of the statute . We believe that emtala doesnt post the federal stabilization requirement that the question here is what is the content of that stabilization requirement and for that you have to okay w state law. I think we just said is important because many can see emtala imposes a stabilization requiremen it is the statute, the f government interfering if you will in the States Health care choices. Emtala is on its face the statute says its not all the states way. Federal work where messier and requirementso stabilize emergency patients and you agree with that . Just as kagan the purpose was narrowed to bridge this gap that d. Santa lets tf the table the state and its health cares the federal government has the federal government has plenty to say about it in the statute. Youre right now theres a the stabilization requirement of and as fi understood in ur opening remarks you say well if this is left to the states if im just looking at the statute, the statute tells you what the content of the stabilizationrement is. Its to provide such medical treatment as may be necessary to ensure within reason probability that material deterioration of the condition is likely to occur. Its the person who didet care. So it tells you very clearly its an objective standard and s basically a standardhat clearly has reference to accepted medical practice not to think heres the c of happens the standardou have to stabilize and what does that mean . Means to provide t treatment necessary to assure within reasonable medical probability that no material deterioration occurs. Would respond in two ways the first the ive standard they set forth in that understanding is contrary to that view. They say its a subjective standard and whatever treatment of doctor determines since thats not true. I think you can argue about this yourself but as i under the solicitor generals brief and we will see what the solicitor general says that the solicitor general says its not up to every individual. This is a standard thats accepted medical standards of care. The more fundamental point is the definition of stabilizing ca operati position prohibition iscitly qualified by that which is within the staff and facilities available. Thats quite right. S within the staff and facilities available at the hospital and if you just look at clear that thats theencely to what the state law involved. The staff and facilities available if you dont hav medical care then i guess youe cant provide the medical care. If you dont have facilities available to provide the medical care tu cant provide the dical care care in the tranad to take place for the good of the patient. The availability here, its the of availability of staff and facilities. Do you have the right doctors and you have enough doctors and the right facilities or is it better for the patient to transfer them to the hospital of you are exactly right do you have the right doctors and how do you have that answer except. Thats the initial point that i was trying to make which is at the federal mandate is to e stabilizing care for emergency conditions regardless of any other directive that the has that would prevent that care from being provided. Thats the work of the statute. Justice thats not the conclusion in the state operationsl which they are from page 36 of the brief it defines what makes a staff person availaber the atute. Does it say they arent available in the state law doesnt allow this pro . That they are available to the extent they are operating with that in tpe of their medical license and thats our argument they want to now draw far m normal. We agree thats the component andhes illegal avaabity component here. The problem we are having right now is that yo putting preemption on its head. The whole purpose of preemption is to say that if the state passes a lt violates federal law the stateno longer effective. So there is no sta licensing law ould permit you and permit the state to say dont treat diabetics with insulin. Treat them only with pills and a doctor looks at the juve ic and says without insulin they are goingt seriously ill. The likelihood and i dontnow what that means under idaho law and well get to that shortly, because i dont know we believe this is a better treatment. Federal law would ou cant do that. Medically it have to be accepted in shakir to require the treatm diabetics with insulin for the medically accepted obligation of doctors and women with certain conditions that may not r in death but more than likely will result in very serious medical cons including blindness for sd for others the loss of organs. For some to blood strokes. Idaho is sayings the doctor and say in good faith thats persons death as likely as opposedo s illness they cant perform the aborti so i dont know your argument about state licensing law because this is what this law does. Tells states you are licensing laws cant take out objective medical conditions that could save a person fm serious injury or dea i i think they are two crucial responses to your point. Let me begin preemption point. 1595 are telling hhs the federal government and court sug you cant unless theres a direct conflict if objective medical care requires you to potential serious medicalith the compons and abortion is the only thing that says you have to do it. E doctor has determined not that theres aerious med condition but that the person will die. Thats a huge difference council. Weee there is daylight between how the administration is reading emtala with idahos act permits. We agree theres a controversy here but what im saying. No, n theres more than than a controversy because what you emtala is not preemptive force is not just idaho, at half the saving condition forrtions when it threatens a womans life for what you were saying is that no state in the nation and theres some right now that dont even have that as an exception to their antion laws. What you areaying is there is no federal law on the that prohibits state from saying even if the women will die you cant perform an abortion. I know of no shat does not include a lifesaving exceptio since save debating it and if i find one your theory of this case leads to that conclusion. Her point is emtala doesnt address could i hear your answer . The administratioliance on a standard like is Clinical Evidence for some National Norm i think thats very fraught because it really is saying it nt address what the stabilizing treatment required if you go outside the that are floating out there that might change daytoday and that boils down to a question between conflict between what a cog says and what idaho law says. Actually can i just clarify because im not sure he understands flex lookingt is from a broader perspective it seems to me that emt says you must provide whatever treatment you have the capacity tong staff and to provide to stabilize patients who are experiencing emergen medical cons. Idaho law says you cannot provide that treatment unless doing so necessaprevent a patients death if the treatment involves an but why is not not at conflict . In a certain situation thats what the federal government saying and you you cannot if it involves abortion says idaho. I think the example highlights the reason why. Aurse might be available. The nurse may think she knows how to enter the fla must provision in emtala the frustrations reading would call her into action putter in the operating room and open the patient up. In idaho would say no still a complex opined that say t administrations provision is thatse can do it very suggesting federal law would not take precedence and would not she cant . Ate law that says no that is a different question and let whether the emtala law clear that it doesnt. Er is in the casre the controlled substanc, this court noted that was the provisions there rely upon and assume a medical profession being regulated by police powers. Thats the same as emtala. Emtala safor page statute to address the standards of care for every conceivable medical treatment. It definitely didnt address the care but it left it to the what congress was not going tod adevery treatment for the condition. It says you do what is needed to assure nondeterioration i guess the question is do you conceive tth respect to certain medical conditions and abortion is the standard of care . No because the staof theres a lifesaving exceptionho for certain abortions. That is the standard of care in the standard of care is necessarily set and determined by the state. Your own statute has interpreted by yourourts acknowledges that whendition gets bad enough shat the womans life is imperil that doctors are supposed to give abortions. With respect to certain raret extremely obviously important conditions a circumstances abortion is the accepted mical standard of care. Isnt that right . Yes and that was my point that there is a lifesaving exception undeidaho law. Also the accepted standard of care when r than a womans life being imperiled, the Womans Health is imperiled so s take you now all of care rare within these rare cases there a significant number ere the woman, her life is not imperiled that sheng to leads her reproductive organ and youd you lose the ability to have children in the future unless anion takes place. Thats the category of cases in which emtala says my gosh a course t abortion is necessary to ensure that no material deterioration occurs and yet idaho says sno abortions here and the result is these patients are now helicoptered ouof the state. Sinecure under the hypothetical raise is a very diffic situation in these situations and nobodys arguing that the dont raise tough medical questions that implicate deeply theol and mor questions ho like 22 other states and congress and emtala recognizes there are two patients to consider in thos circumstances. In t patients scenario its tough when you havese competing interests. That wou be a good responsive federal law did not take a position on what you characterize as a t question federal law does take aion on that question. It say you dont have to wait until the person is on tge death. If the woman is going to her reproductive organs that enough to trigger this duty on the part o the hospital to stabilize patient in the way to stabilize patients in these circumstances all doctors agree. Law does not require that doctors wait until the patient is on rge of death. Theres no mnc requirement in no medical certainty requirement. And answer the following questions and these are hypothetically if youell me whether idahos exception going back to the point that even if idaho law fully complies with federal law you pregnant woman whose early into her second trimester at 16 weeks. She felt ah of fluid leave her body. She was diagnosed. The doctors believe a medical intervention to terminate her pregnanc is needed toeduce the real medical possibility of experiencing sepsis and uncontrolled hemorrhage from t broken its a story of a row on it. She was discharged in florida because the fetus sad fetal tones in the hospital said shes not likely to die they are going to be serious med the doctors they refuse the treatment. Because they couldnt say she woe. She was and went home and the next day she b she passed out and thankfully ken to hospital. There she received an abortion before she was about to die. What you are telling is that a case in which idaho would have said is okay to have an abortion clinics com i dont lifesaving exception the document could if the good if the doctor in good faith they know im asking you ithe document says i cant say shes going to die if youre doctor says with medical certainty say shing to die but i do shes going to to death if we dont have an abortion but shes not bleeding yet so im note. The doctor doesnt need to have medical certainty. Council answer yes or no. He cany that theres likely destiny can say theres likely to be a serious medical condition. Let me go toer wet pavement and patient who goes to the er at 14 weeks and again a portion using an out of the hospital up to 27 weeks. This particularnt had to deliver her baby. The baby dies and she had a hysterectomy. He can no longer have children. You are telling me the doctor could have done the abortion r . Again it goes back to whether it. Iraq can in good faith clinical judgment thats a lot for the doctor to risk. Whendaho law changed to make the issue whether shes going to die or not or r shell have a serious medical condition theres a lot of daylight by your standards. It varies casebycase. Thats the problem. I shocked actually because i thought your own experts said these cases were covered and now youre saying they are not . Im not saying that and thats Justice Sotomayor is asking i they were covered it or not and understanding of that would be covered. Those doctors said that th were eing tical judgment they could in good faith determine lifesaving care was necessary and thats my point. Is the subject of . But some doctors might reach a contrary conclusion. If theyea the conclusion that the legislatures doctors didnt would they be prosecuted under idaho . No, no. Ifreach the conclusio that dr. Run with dr. What if th prosecutor thought differently what the prosecutor thought dont any dont think any goodfaith doctor about that inclusion . That your honors the nature of prosecutorial discretion and mayesult in a case. Is idaho put out any kind of guidance hhs guidance about was covered by the law a what is not in idaho . T regulatio. The g star here is the case which the lengthy detailed treatment under the supreme cour of this law may clear come to court made clear theres no medical certainty will cram a have to wait for the mothertobe facing death. Thank you couns what hapf a dispute arises with respect to whether or not ctor was within the confines of i law as the doctor subjeo if you buy a medical authority to . Exactly how a s elevated because its an obvious concern if individual eon for doctor and we are having a debate is that covered by your subn that nothing in idaho law prohibits complying with emtala. It begs the decision whether or not something is within or out. Same i imagine there two ways the law can be enforced. The board of me has licensing oversight over doctor in Idaho Supreme Court may clear that doctors fisma will be judge an objective standard for w reasonable doctorld do. The second way would be. What is the standard . The the doctors could medical statement which is subjective. If its a complaint again doctor that his standards dont con a particular emergencyroom and he has a particular standard . Than with Idaho Supreme Court says you may consider another dr. s question of the pretextual medical judgmt. Justice thomas. Justice alito . Well i would think that the concept of good medical judgment must take into acc some objective standards but it would leave certain amount of leeway for an individual doctor and thats how i interpreted what the state Supreme Court sa you have been present here today witery quick summaries of cases and asked to pra snap judgment about what would b appropriate in those particular cases. Honestly i think it hardly were given an opportunity to answer some of the hypothetict would you agree with me that if a medical doctor is an exper his fie were asked bang, bang, bang what would you do in the going to enumerate the doctor would save this is not how i Practice Medicine but i need know more about the individual would you agree with th absolutely and in the case aecom doesnt just kneejerk say abortion is a standard of care. Aytself says expecting management is oftentimes the appropriate standards of these are difficult questions that rn on the facthat her own ground between the doctor and assessing them with his medical judgment necessarily constrained by idaho law just like every other area of the Practice Medicine. State law can find doctor judgment in some way. Said thank you. Justice sotomayor. Theres a difference between stabilizing on who condition requiringmedical stabilization then the person who presents with a con putting idahos words where there is a, it poses great risk to the pregnant woman agree that there is risk wax there will be some women who presenous medical conditions that federal law would require to be treated will not be treateder idaho law. I disagree with that. Idaho hospitals are treating someone and they are treating ese won that abortion necessary. Thats my point just answer the poinch is they will present with a serious medical condition that doctors in good faith cant say who present death but will t potential loss of life. For potential loss of an organ or serious medical competitions for the woman. And they can perform this abortion. If that hypoth exists i dont know of a condition that is so certain to result in the f an organ and not transpire with that that conditions exist yes idaho law does say abortion is the case. Are let me stop you because all of your legal theory relies on those holding that federal law doesnt require ot preempt state law from these issues. When i asked you the question if thte defines the likelihood ofth more stringently than idaho does you would say theres no federal law that would prohibit them from doit . I w say emtala does not contain the standard. So there is no standf care. In your briefing you to the sg position here and you almost arguet their position that federal law requires stabilizing treatment and not equal treatment ofnts which was a position you took in your and i think you backed off from it here but you seem to that federal law requires some condition whether or not its provided to other patients. But i have countless briefs that say that hhsas filed 32,000 this is not an unprecedented po that hhs and countless situationsited hosta for disregarding patients who required in abortion as a stabilizing treatment. Congress discuss that topic in theffordable care act explicitly said that nothing in the afle care act shall be construed to relieve any Health Care Provider from providing emergencyces as required by state or federal law. Medical provider told us at for decades they have understood federal and state to require abortio a stipulation stabilizing condition for people facin serious medical risk. Lower courts in these cases with the lower court saying you have tode abort this is not a post jobs unprecedented position by the ment. It up so he is. Otnote to the administrations that contain 115,000 rows of enforcement incithe administration identified a single that. Counsel. Dobbs predisposes much of the question that theres hhs guidance in at lhree cas in which was invoked to the fact that hhs didnt ho do it much before. Dobbs doesnt make their po. My point is more fundamentally or other insist that their fuel incidences there arlions of incidences and not just on abortion. Any instance where hhs comes to hustle you have to provi treatment that is. Practicing medicine is hard fair stand of care, arent e . Yes, there are. Step one of the standards of care with respect toion that susan certains tragic circumstances as you yourself as your own state law acknowledges the womans life is imperiled in abortion is the important standard of c isnt that right . Thats right and apollo g further. It says the approp standard ofare can only be about protecting a womans rights right. Also have to be about protecting a womans heah d thats what emtala says doesnt . Know it doesnt d medical emergency situation with the broader point of but the stabilization of requirement is find. The stabilization requirement is written in terms of making sure that a transfer would nott in a material deterioration as to theency condition. Nothing is to be the. I think thats ri theres a standard care with respect to that on ortions too, right click of a the woman is going to los productive organs and who is she unless she has an abortion which happens in some tragic circumstances of doctor is the poorest to provide an abortion. Do you dispute theres a medical standard of care that when a woman thabout to lose her reproductive organs unless she has an abortion that doctors would not say an abortion is the appropriate care t situation. What i dispute theres a national u standard of care that requires a topdown approach to idaho has drawn the line on a difficult question and it ionceivable to me to think that congress answered thy fraught complicated question in four pages of the u. S. Code. Then Congress Said any condition in the world if an emergency tient c in you are supposed to provide Emergency Care that will e that patient does not see material deteriorin their help. Thats what Congress Said and abortion exceptionis on the part of the. If we are going to accept respect to every other condition but not with respect t abortion. It will not comply with the standard of care that doctors have accepted. Exceptional to their numerous cases where the states as the circumstance is x and not juan. Opal unit new jersey at chronic pain with more than aic five supply and in peania and other states theres no limit. Fair readi emtala requires ose limitations get like that when you post a National Stan their numerous other instances where states are coming in and saying in our state the practice of me must conform to the standard and idaho has done that with abortion opioids and marijuana use. In your theory although Supreme Court has narrowed the reach of your statute your theory would apply even if hadnt. It would apply to ectopic ncies. It apply even if there not ath exceptind to know if your theory would apply no matter what idaho did wouldnt yet . Nk the answer is emtala doesnt s to that their background principals and limitations on a rational basis. Your theory of emtal emtala preamps none of that the state tomorrow could say even if deatround t corner a staorrow could say even if theres an economic pregnancy Ectopic Pregnancy thats the choice of the state and that understanding is a humble one wspect to the federalism rule of states as the primary care providers for their citizens. You may be too humble for womens health, you know . Thank you. Ustice corsets. I just want to understan some of your responses or efforts to respond to some of as i read your briefsou thought idaho thinks in cases of ectopinancies for example that abortion is acceptable and example of someone who is immey going to die me at some point the future that goes it goes back to the goodfaith medical standard if doctor may cannot determine in g faith thatth is going to afflict that woman. Doesnt matter whether it happens tomorrow or nexteek or month for now. There is no eminence requirement that this whole notion of delayed care is not consistent with the Supreme Courts reading of the statute an the statute says. The gooh as i read the idaho supremert opinion that the end of it. Absolutely it is. What do we do with emtalas definition of the woman orhe unborn child. We are not saying youre under the emtala prohibits abortion for example in california stabilizing treatment may with what the state law allows its doctors to perform. I think her point with the unborn chi amended in 1989 as would be a strange thing for congress to expressly amend emtala to e care for unborn children is not just when the child or theothers experiencing active labor for deon of emergency medical condition es care when the d itself has emergency medical condition regardlf whats going on with the mother. This strange thing for congress to have regard for the unborn child t be mandating termination of unborn children. Justice kavanagh. I want to cus onhe actual dispute as it exists now, today emtala an ida law becauseof idaho has changed since the time of the districrts injunction both from the Idaho Supreme Court and with the legislature. By the idaho you say in your reply brief in so to the reprise each of the conditions ided by the solicitor general wear under their view of emtala and abortion must be ailable. You say in reply brief the idaho law and fact allows an abo in each of those circumstances and to go through them on page nine of the reply brief each of the conditions. Is tny condition that you are of where theitor general says emtala requires that an abortion be available in an emergency cirnce for idaho law is currentlyd does not. Maintains that there is such a what is your view . My view is that yes the Mental Health condition situation the Administration Says thats on the table and not a scenario where ab is the only stabilizing care required and im not sure wher that construct of only stabilizing care comes from because under thew at the doctors determinationhat controls not be imposed only requirement be that as it may be and im taking general prelockon her up on her options the americanchiatric association of pos papers as abortions are imperative for Mental Health conditions. That sou like a necessity to me and i dont know how present at seven mon pregnant and idaho Emergency Rooms as im experiencing severe depression from this pre. And having cdeations from carrying this pregnancy forward and not wooden under the administrations administrations rating be the only stabilizing care. See you think t Circuit Panel when it said every administrations decorationse involve cirnces in which a idaho law would allow an tion the 9th ciranel says. We agreed that because the ition agrees that the dabo while conditions under the lifesaving exception and thats telling because the doctors and put under oat an affidavit couldnt come up with any of circumstances to be identified at the ones that the government does want to talk about it for menalth exception here. I dont know how you can read their understanding im trying to figure out is there anything other than the health which we havent had a briefing about is there any other condition identified by the solicitor general where think idaho law would not allow a position in his or her goodfaith judgment to perform an emergency abortion . Not in theirffidavits. They maintain nonetheless when you compare the definition what condition is its broader than the definition. Thats why say them will make itown to the actual conditions that are listed amples and Justice Sotomayor was goiough some of those that you upset in youef at least that each of the conditions identified by the government idaho law allows emergency abortion. What does that mean for what we are deciding here . If idaho law allows an abortion in an emergency circumstance is identified that the government has emtala mandating that ite lowed . Iday two things for the real practical first responses that idaho is under an inju that includes an incredibly broad requirement that preempts. I understand that and may mean there shouldnt be an injunction night take your point on that. Whats your second . And. My second one is i dnow how the court can make the determination whether they are real conditions without answering the statutory interpretation question of what emtalaslization requirement involves but that have to be addressed and not only because. I waspicking up on y prolife your reply brief that theres no daylight here in terms of thetions so im just picking up on what you will set. Pakistan. Uess i dont understand why we have to trust the stabilizing condition if what you sa nobody has been able to identify a conflict and in the Mental Health thing idaho badly aired in asserting constr emtala would turn Emergency Rooms into abortion enclaves bowing termination for Mental Health concerns. Thats thenly state that you can identify where idaho would eclude an abortion and emtala would requirement and would require when the government is saying thats not so what is the conflict . Your honor whether you find no factual colict and therefore. But why are you here . Hold on a second. You were here because there injunction precluding you from enforcing their laws. If your law can fully operate because emtala doesnt curb idahos abilityported select the injunction says idahos la is preempted an incredibly broad range of circumstances. As a conflict of emtala. Its much broadn that and this was based on the crawford injunction by the administration to avoid emergency medical conditions. What that means idahos law nt even operate one of doctor ines that a condition might need to be avoid that hasnt yet presented itself. Thats far broader than emergency med condition and stabilizatequirement emtala because the stabilization requirement only triggers when there ha a determination. I would like to hear the solicitor generals response about but me ask you one of the tbout Mental Health consideration because i can understand idahos point that Mental Health exception would be fader than idaho law with the potential and the available day for portions availability but the ization requirement only exp until a transfer so its hard for me thow a Mental Health condition, that couldnt be stabilized before needing to transfer. Hat point the idaho hospital could say you were a staple you were not immediately going to be suicidal and believe you me care of a parent or partner who will then make appropriate tments. It t flexible view of stabilization is very different than the governments rigid view of stabilization which if an emergency medical condit for anrtion and it have t right there and benefits ava in this limited s the stabilization continuum you are talking about i agree its built into the policy. And thats just for a transfer. Transfer provision is at the hospital is unable to ize the patients of the patient presents at a hospital in the hospital has the capability and availability to stabilize thetion and in the case of Mental Health and fight the soliceneral to come up and say i got it all wrong anmother is subscribed would not need stabilization and th circumstance w be transferred to a psyic hospital and that when they inclmping under their reading and im dont undd that the condition calls for the hospital can do s got to be done there and then. I dontnow of any conscious exemption for dounder state law. Here your honor. S a key point the administration told this court indicates that individual doctor never required to perform an abortion from what i can tell but that d extend to hospitals on the case of catholic hospitals in their hundreds of them treating millions of patients every year year and at the administrations reading catholic hospitals who adhere to the ethical and religious directives are hard to perform abortion. Ishat because the federal exemption applied . I dont know why the that. Its between individual doctors and religious institutions. On the faces seems to cover both. Thank you. Justice jackson. Surprised to hear you say that idaho law permits everything teral lower choir so im trying to understand that but it seems to me if thats the case like why couldnt emergencyroom physicians in idaho just ignore a idaho law and follow the deral standards . If the state is doinctly what the federal law says required and its okay by idaho then find. We said idaho is suddenly do with the federal losses and we all go home. The idaho law syste is no conflict so dont have to make that choice. T your representation on the half of ida that if an emergency room position in idaho follows emtala terms of when an abortion is required to stabilize a patient they will b complying with idaho law such that they will be no prosecution and no probl they have to comply with idaho lab to comply withmtala. Comply with emtala but theyey necessarily have satisfied the requirements of idaho law because that you seem to say in response to Justice Cavanagh just a so i want to make clear if thats the position of the states. The scope of emtala stabilization policy is determined by idaho law in this case. You are saying if they follow idaho la they will b followinghe emtala law. Its the same thing. Its not. Like y to entertain the other possibility but he seemed to be United States says here is thehe stabilization situation that the ited states would say a person have to have an abortion and the physicians would say are following emtala and abortio is required but i thought you said innse to justice and idaho law would also say that thetion in which an abortion is a. If thats the case then it seems to me there is no daylight and theres flict as you have said but its because idaho is in full compliance with what the federal law is saying. We are getting it wrong. s not what we mean. What we mean is whenever its cessary to stabilize a patient whos experiencing deterioration as federal law requires. I think i understand the point you are making in the best way that i can think of it your honor is that emtalas stay was issued requirement requires medical judgment to disturb to determine what is the ch treatment. Training experience reference to professional standards up there. How bout thats not justards. Something youre coming up with. This just sagan said that beginning emtala tells the doctor how he supposedo decided in this particular rcumstance with reference to the medical standards of care concerning when a patient i deteriorating in emergency condition situation. So thats the standard in emtala. Are you representing that is exactly what idaho was saying so that all the doctors need to do is follow the emtala and theyll be fineer idaho law . Of course we are saying idaho doctors to comply with emtala per the question is how do doctors comply with emtala . Ask you another question i could understanour point youre saying idaho could actually be requiring more than the federal law has two do with idaho says. Impala emtala itself codifies the presumption of the backdrop of state love for their background principals here. Let me implore you for just a sec and i thought the case was about preemption the entirety of our preemption the federal government inon that certain circumstances can make policy pronouncements that differ from we state may want or what anybody else may want andupremacy clause is when the federal government says takes precedence so youve been over and over again in idaho is a statee have Health Care Policy choices and we have made, we set the standard of care in the situation all of that is true but the question is to what extent can teral government s no in situation areards going to apply thats what the governm is saying and i dont understand how consistent with her preemptive jurisprudence you can say otherwise . I dont think question is necessarily what can congress do t what did congressith emtala . So what did they do hear . It sta by saying the federal gont should not control the practice of mexico and medicine and emtalatate laws are. State laws are not to the extent are only to the extent of a direct conflict so now we are identifying a direct conflict. Why ishing out working their . Whether theres a direct conflied on this courts longstanding precedence include longstanding canons. The text is clear to me the question thatovernment must overcome a lot ofdles. I hear you saying hings. Theres not a direct confl with everything that federal government requires we allow whic amici positions as it prevents a lot of things a circumstances in which the federal gont would require them and they disagree with you on the factsy you say no conflict because we are doing exactly or ag with the federal government allows you say no conflict because the federal govern of the situation wanttes to be able to set the standard. I guess i donerstand how thats even conceivable given the standards given the statute that is coming into displays the prerogative. Same if i cant cvince you on this but me at a third. The spending clause condition nature this rs congress to speak clearly and unequivocally that its imposing an abortion mandate. Thats not in the stute. Sena does that make abor different . What do you mean . Theyay provide whatever is necessary to stabilize and you are saying that have to provide whatever is necessary including abortion and thats the only way thats taken account of hear . T im saying when we look at the phrase available and what it mea administration is saying they are adding this tag that sonsistent with stat law. We saying under the clear government and what congress would need to do for wanted to eempt this traditional state laws to put a tag regardless of state law thats been missi. Thank you. Thank you counsel. General prelogger. Nce send mr. Chief justice and may it please the courts talas promise a simple profound know what comes emergencyroom in n urgency treatment should be denied necessary stabilizing careor this case is about about how trantee applies to pregnant women and medical crisis. In some tragic cases women emergency complications the continuing their pregnancy grave threat to their life for their help. The woman whose amniotic sac is ed prematurely for example needs ite treatment to avoid the serious risk of infection that could cascade into sepsis and the risk of hysterectomy for a woman severereeclampsia can be highrisk of kidney failu that require lifelong dialysis. In cases like these where there other way to stabile womans medical condition prevent her from deteriorating the taxequires she be offered pregnancy termination is a necessary tment and thats how this law has been understood and applr decades. That usually posesonflict by state money consisted of sharpestricted access to abortion after dobbs generally will all exceptions to safeguard the mothe healt idaho makes termination of felony with years of imprisonment. I think i understood my friend today to ballot several tim if there is daylight between a standard and the necessary stabilizing treatment that emtala would require. Recognizes same thing when it contracted the necessary exceptdit was imperial a narrower than the prior law that had Health Connection to attract emtala to the situation with idaho showing the devastating consequences of that cap today d in idaho the women of idaho are an impossible situationne comes emergencyroom with a grave threatr health that either have to delay treatment of a heart condition to detee et3 or airli her of the states as you get the Emergency Care that she needs. One hospital systemn idaho says right now to having to transfer pregnant women in medical crisis after the s once every other week. Ats untenable and emtala none of the interpret case be that the broader debhe for access to abortion cases of unwanted pregnancy. Thats not what this case is about at all. Os ban on abortion is enforceable to a the applications but in the narrow circumstances involving great medical emergencies idaho cannot criminalize the essential care that emtala requires. I welcome the courts questions. General are you aware of any other spending clause legislation that preempts criminal law . Perspective criminal on particular Justice Thomas not thinking of relevanes. We have the whole string side of cases on page 46 that they have reed the spending clause leslion including in situations where the funding restrictions ao private parties and that include t Coventry Health case for example ledwood is another example of it. M not recalling how would apply in criminal law. A course this one hasnt from those types of distinctions in the supremacy clause. Lly when we have a preemption case thats a regulated party in fault in a su they use it as an affirmative defense for example in this case you are bri an action against the state in the es not regulated. Are there other examples of these types of suits . Their numerous examples where the United States has sought to in situations where state hasts done what iydollas found here. I point to Arizona Arizona and states an example of that nine states versus washington there aber of cases where this cou government can protect its interests in this kind of preemption action and as i mentioned before the court has a that a preemption principle applies in the context of federal funding rtrictions that apply to private parties do. A quiban when the party that you areringing the Action Action against is not the reg party . Thats great because what idaho ne is directly ered with the ability of the regular parties to take these federal funds with cons attached from being able to comply with the federal law governs their behavior t this is an essential part of the bargain that the federal invest in the hospital system. What the state has done has said youth or operation of state learnonger permitted to comply with this fundamental stabilization requirement in this a narrow narrow quality of cas normally when it be the regulated party that the actually be asserting the preemption that you are t about . Certainly i can imagine a good party wouldt ae where every preemption defense and to say that state lawtself is to the senate prevents the party being able to comply with federal law. T aware of any precedent in this quartz coase lots of suggests its only way for the government to protect it. Thats the fact pattern in particular cases. I dont understand how your argument about preemptio here squares with the theory spending clause of congress is spending clause power. Congress can tell a state or any other entity or person look here value and if you want to accept it fine then you have to accept certai conditions. But how does congresss abilit to do that aze it to impose duties on another party that has not agr to accept this money . That there are no dutieseing imposed on idaho here. Not required to provide emergency stabilizing treatment itself. Its not duties. How do you impose instructions on what idaho can criminalize simply because hospitals in idaho have chosen to participate in medicare . I dont understd how this squares with a whole. The spending clause. It hey could squares with this courts president. Ive looked at those cases and i havent found any squared discussion on this particular issue. Im interested in the theory. Can you explain how it works in very . Isnding clause legislation is federal law passed by both houses of congress and signed by the president qualifies as low within the meaning of the supremacy cl the supremacy clauses a situation where congress has and effect of the supremacyorce clnd what if they cant do is interposes law and an obstacle to being to and. First of all is enforceable is the hospital that chooses to participate. The argument would t of the hospital is bound state law on and the state law get control it would mean that hospitals a participate in care dont thats not the argument the stamaking here. Once they hospital to accept medicare funding for not have to faceictions attached to those funds as an essential part precedent to support thats no outcome. I dont understand how that thorks. Let me move on to something else. Im going to try restate your general fear and i want you to tell me if this is right. I think your at is if woman goes to an emergencyroom and she has a condihat requires an abortion in order to eliminate quote unquote serious opardy to her quote unquote health the hospital must perform the abortion or transfer the woman to another hospital where that can be done. Is that a fair statement in your argument . What if it occurs at a point where delivering the baby is not anption. Out of the third ter is not an option to deliver the baby . Im sorry under thest trr. If youre caught supporting situation where delivery is not an option i of that circumstance way to prevent grave widths to the Womans Health or life is for the pregnancy to end amination is thenly option thats the required caregh stabilization mandate critically and many of these very same pregnancy complication means t fetus could not survive regardless. Theres not going to be any way to sustain that pregnancy. Quickly sq squarely at the question that was discussed during mr. Turners argument does the term health mean just the physical health or does it also included mental healt click in a graven mental healt gencies could never require pregnancy termination as a stabilizing care and heres that would not do anything to chemistry issue because in the Mental Healthmergency in the firstce. This is not about Mental Health in general and this is a treatment by doctors in an emergency room when it woman a n comes in with a great mental alth emergency she happened to be present being credibly unethical determine her pry she might not be in a po to give informed consent the way you treat is to address whats happening in the brain if you have a psychotic episode you administer antipsychorickwork so want a simplearcut answer to this question so that Going Forward everybody will know what position is. Govts does health mean only physil health . Does that include Mental Health . Respect with what qualifies an emergency medical condition and can includeve Mental Health emergencies may be very ear about our position could never lead to prints potencytermination that is not e accetandard of practice to treat any Mental Health emergency. Iserm serious jeopardy and e11 lips will meet immediate serious risk or risk consequences a future point suffice . Standard is defined in immediate medical treatment for theant question is in the sence of immediate medical treatmre you going to have jeopardy to your hea dysfunction of your organs for your bodily systems are shutting down . The urgency of acutecare and emergency room. It has to be immediate . Governmenttandard under the stat phrased in terms of what the consequences will occur lets focus on interaction b having some sort of urgent th crisis it takes you to an emergency room in the first place and how proximate theseppe consequences are likely to be. Are two different t whether the woman is an immediate jeopardy or whether the woman needs immed c in order to eliminate jeopardy at a later point inderstand your answer to be that the w need not be in immediate jeopardy. If she does not get care right away, jeopardy at some future point may suffice . Is focus on immediate h itself risk. It is look the possibility of a woman does not get treatment over reasonably expected topen occur as her organs cou start shutting down sheet might losetility or have other health cences focused on between the immediate for treatment which is reflective of the fact congress was narrowly focused on this emergency acute medical situation. Do the terms impai bodily funct or serious and dysfunction of anyy organ or p refer only to permanent imnt or dysfunction . Or does it also refer to temporary impairment or dysfunction . It can also refer to temporary impairment im not sure it easy to parse the two. For example a pregnant woman in distress might suffer aiver damage or kidney malfuncti do not know if thats going to permanent or not the instructioness gave his unit destabilized to guard against the very Serious Health risks. I would like to, if you could understand kind of the scope of your argument on the supremacy your mind. How it operates in putting aside this case. Could the federal government condition the receipt of funds pitals they comply with medithics rules provided for by the federal government . Dical malpractice regime, medical licensi regime suc that effectively allstate medical malpractice a state medical licensing laws to be preempted . You are imagining this i regulatory or congress has passed a statute cg a federal malpracte regime . You call it for and broadview congress authority toeck statutes what i would to assess in that situation is whether congress is acting with one ots enumerated powers. Of the spending clause. Make those judgments and attach conditions to the receipt of federal funds. It cover all hospitals in the state and effectively transforms the regulation of medicine into federal function . Court thanks it is encroaching on the states and prerogatives away sit ins consistent with our constitutional structure i dont think were in or close to that. Supported of course heiple . Federal government has authority to regulate including with respect to medical care. I dont think this any principal with exclusive governance of this by the state. The hypotheticals is the federal a function. Entirely taking over and medicare allow the federal government toce the dictate through civil monetary penalties . That is correct for. Ou can also terminate medicare agreements of a so generally the hospitals given the opportunity to come into compliance and develop a plan to make sure there will not be future violations it would obviously be an extreme sanction to terminate medicare funding but it is a possibility. Is also private right of action of the possibility o Equitable Relief as well. Yes it certainly monetary possible equity relief as well. Equitable cause of action you did not cit s to enforce. One of the roles and equity traditionally at least should not getquitable relief if and as we just discussed theres a sta here seminole tribe says you have a reticulated statute lots of remedial options you do not Equitable Relief, oughts . What some say at the outset the United States has long been recognized to h action and equity inherent actionnd equity to appeal to the courts of this nation to protect his sovereign interest. You mentioned washington and you mention arizona. But arizona was an immigration case and a washington was attempted by a staose its Workers Compensation laws on the fed government different from others. I take of thoses and equity is about proprietary we have that here . E that do i want to make sure to make clear that there are a lonine of cases stand for this principle including cases that directed directly. You want to rely on debs . I was not our brightest moment. History and tradition of this nation and recognizes entirely appropriate for the disease to seek to protectnterest in this matter and let me say its a really important issue to the United States does not press but was not passed upon. Im trying to understand wor comes from what the rietary interest here . It is your money and how it is being spent congress has given you lots of too. It also comes from the recognition under obstacl there important functions to be served by having the Medicare Program in place idaho has directly inrfered with the ability of hospitals to accept federal funds whey sent willing and make sure no matter where you to are in this country if you hav an Urgent Medical need and you go ton er you can be stabilized. Your friend on the other side said in your position would require religiously affiliated hospitals with Emergency Rooms to perform abo is he right . So my friend was w there federal conscious protections that apply to hospitals as well the key provisions are in the weldon amendment and all that depends on the Residency Program of aticular hospital. Hs said in a row making unconscious protection could never come across a hospital that a blanket oon to providing life preserving and health prese pregnancy termination care but if the hospital had that kind of objection hhs resume for mey still do not come across that hospital that would be hon hhs enforcement ability too. That apply to the entity level. Can individual doctors in the emergency room t they have a ous exempt question. Years are particularly Church Amendment principle of our position does not overwrite either side. If an individual doctor has a pregnancy termination itselfding im obligations of the entity level the hospihip plans in place to honor the individual doctors conscious objectionhile ensuring appropriate sta for Emergency Care. Theft does not mean there must emergency room that can provide an abortion whether to doctors or 3yll have a conscious exemption . That circumstances it cannot override those individual ctors protection my understanding the m best actice because hospitals w to provide Emergency Care they do thing like asset d to ask doo advance that c be taken intoin account staffing decisions and ofwho i call hospitals have a lot of contingencies break or could you send there must and oncall in a hospital ofhat sort . Ondition of pursuit participation for medicare hospitals be appropriately staffed to provide Emergency Hospital has not done that does ave anyone on hand you can provide care maybe all the doctors caln sick that day there is lit no one in the everyone had a consciouse objection to the hospital not be able to provide the care there are conditions of participation that are meant to ensure there is good governanc of hospitals and organizations. Questions are the consequence of them not being able to provide the care w be what . And that circumstances and likely be out of compliance with e condition of participation that require them to be properly staffed. The question is could youce an individual d toward over conscious objection answers no. Not they must have availabler someone who can comply the procedures required will be the consequence if they didnt . Would be eventual termination of their participa medicare question. That is right at the hospital was continually disobeying the requirement to haven place sufficient personnel t run their emergency room i imagine hhs through enforcement action work witt hospital to try to bring it intpliance of leaving itself in a position it can never provide care it would terminate the medice Funding Agreement per quixotic sediment me sorry i thought you want to click clarify this colloquy but if i sd minute ago the hospital had a conscious objection and therefore did not e certain that would not render it out of compliae which is it . Let us write tospil and it would not override my question becauh a height and then i gather from the briefing there might be some situations in which i would acquire requireut the height of men would nott federal funds to be used to pay for. He said in your brief it requires oircumstances as given the federal funds do notbe cover can you give an example of that . Am i right about the hyd amendment could you give an example of that . You are right about both things it is c hospital have to provide care funding is goes again emergency medicalnt he did drug noted by medicare benef but still the hospital has to provide him a stabilizing treatment and give him that medication is no federal funding to pay for. Also applies tple who are uninsured not covered by up the whole point does notnce matter at your circumstances i doesnt matter whether you can pay or not. This is a guarantee unit stabilizing treatment. I went say i do notnk theres any inconsistency between the lines congress through and hide congress itself is recognize the statute addres in thinking of the provision of the affdae care act that was exclusively about abortion in congressaid nothing displaces hide the other f funding restrictions on abortion. Othing in daca replaces emtala to stabilize that shows twos First Congress recognized the stabilizing care can sometimes be pregnancy termination. Also showed congress recognition statute address their own distinct spher final point my friend is on drawing a line based hide either his point is even if woman is on the brink of death a goes to an emergency room and the are federal available under hyde to treat still hospitals have no obligation under emtala to provide that care. What about the colloquy is having with your friend what stabilizing treatment entails lets e a situation in which a woman iont know 10 weeks a is told if you care it have consequences for youruld health. U just need to abort before 15 weeks, something lik that for there is not in immedia she is stable which leaves the hospital. But in idaho theres no place else he can at leastil shes 15 weeks. What i the federalovernments position then . As if im underng correctly she would likely have an emergency medical condition in the first place the definition have an emergency medical con is without immediate treatment you will serious dysfunction of your your bodily function in that of situation i woman a somewhat high risk may be she has certain complications where doctors can say there is some danger of continhis pregnancy i do not think that creates the emergency medical condition that emtala is aimed at last question is for the spending clause issue it does seem odd to some of the questions are tting it does seem odd through greements for private entity in the fedovernment the private entity can get of state law. And another administration would be possibl with reliance on spending power for congress to state any hospital that tak these funds cannot perform despite state conionaltal amendment requiring abortion to bevailable, is that possible with gender reassignment surgery you canne it going back an forth through spending litigation in ways that would be unusual products congress has the power to attach conditions or does not mean i totally unlimited. Obviouslyess to be having to act pursuant to pow it would have to comply with the constitutional limits and so that law would have to be valid the spending clause itself has built and limits t like reess. Acting pursuant to an ened power for bidding gender reassignment surgery or abortion. Owed no. The spending clause itself would enough. Just to followup on not just go back to where i started could be essen regular the spending clause . Cine through the the answer i think is yes congreld prohibit gender the nation. T surgeries across they could ban abortion across the nation through the use of it spendiuse. The right question. Congress has Broad Authority of the spending cland yes if it satisfies theonditions the spending clause itself requires i t that be valid legislation the courts have many contacts recognize the spending clause ledger cancen. So the answers yes, okay. So how do we reconcile that with the snt in 1395 nothing in this subchapter allows a federal officer to exercise any control over the practice of medicine . Of the outside of congress itself is doing at that provision is inapplicable by its own terms. You dont think it informs our review and understanng of the statute in any way . In the event ofect conflict looking at emtala its th statute its clearly more specific that would control this cotself is rejected the idea there be that kind of competent thi of the vaccine case that litigants rin the same provision of the med act sec395 this court said no that cannot bear the weight or it would call into question all the conditions of participation medicare progress you agree our clear statement rule with respect to spending clause legislation with federalism or play here . I think here congress has spoken clearly with respect to is not the question. E. You think those presumptions apply . Forget about where that you can satisfy them for. The rment of clear nursing the spendin cuse legislation yes that does applies providers of always understood their obligations under emtala. General, let me ask you to respond to a couple things petitioners counsel said to ve you the opportunity to respond. He suggested or said you have not identified a circumstance i wish something that emtala requires would not allow it. I did not get chance to ask him but iook him to sort of meeting the way idaho statute erates basically allows for a doctor t wel in my view this hea threatening circumstance could eventuall lead to death and so im going to do it. To the extent doctors are still able to do that he is saying there is no preemption. S it true thelly is not an operation a diffe between the emtala and what idaho has required here . Know thats gravely mistake on three levels it is inconsistent with the actual textf the idaho law. Its inconsistith medical reality is inconsistent with whats happening o grounds this is a really important point on the text itself idaho law. Only allows termination if its necessary tont death that is textually very narrow compared to what emtala requires the category of harm to and idaho doctors have to shut thes to everything except death were under emtala youre supposed be tg about things like is she about to lose her fertility . Is her uterus to be scarred because of the bleed undergo the possibility of kidn failure . That is one critical distinction for the other critical textual distinction is the ide of necessity under idaho law you have to conclude the death will lt which is materially different. The item of Supreme Court specificecognized it. Second with reso the actual medical reality here at the far more remote possibility. So think about the health circum emtala regards against. Membrane web declarations that explain this in detail. Also the doctors explain as a woman comes in her sack as ruptured and theres no chance of fetuses going to survive at that point she does not have active signs of infection until she deteriorates will become infected. She might develop sepsis to my have dramatic conces for her future. Butt is not about that thats one example where you cannot do it. Limit and i are not getting fromhe getting airlifted out of the state to Salt Lake City and neighboring states where they are health exceptions and their laws. The doctors cannot provide the care because until they can conclude a ptor looking over their shoulder will not second guess maybe it was not really necessary to prevent thank you. You now heard an hour and a lf of argument on this case. Oneotentially very important phrase emtala has hardly been mentioned but maybe it hasnt been mentioned at all. That is emtalaseference to the womans quote unborn child. Isnt that an awed phrase to put in a statute that impos a mandate to perform abortions . Have you seen an abortion statute that uses the phrase unborn child . What does not it phrase would look at what congress is doing in 1989. Wellpublicases when work springs and conditions, their health and life a not in danger. But the fetus was in great distress the hospitals were not treating them. Dont use the phrase unborn child. Congress want to expan protection of a pregnant women they could get the same duties when they have a condition thats threatening the health and wellbeing of the unborn child that when it does not est this congress simultaneously displaced independent preexisting obligation to treat a woman who herself is facing great lifnd Health Consequences for provisions of the statute that are relevant to this issue ing the status and potentialest of an unborn chil underne of the woman goes to the hospital at the emergen medical condition that is the phrase. The hospitaust either stabilize the condition or under some circumstances the transfer the woman to another facility. We have ts emergency medical condition and that provision. Then under e1 the term emergency medical condition is defined to include a condition that places the health of the womans unborn child in s jeopardy. N that situation the hospital must stabilize threat to the unborn child. The meaning is hospital must try to eliminate any threa the child the performing an abortion is empatheticao you go so far as to say the statute is clear in your favor. I do not know how you can say that in light of those provisionse just read to the statute does nothing to displace the woman hers an individual with an emergency medical when life is in danger his health is inanger. The hospital has to give it necessary stabilizing tre. In many of the cases you are thinking about there is n possible way to stabilizehe unborn child because fetus is suffici before viability that is inevitable the pregnancy will be less idaho would deny women treatment in that circumstance. Imposes to the hospital duty to the woman and also a duty to the child. How it is to adjudicate conflicts between those interests. It leaves that the s. It is a listf your argument today has been dedicated to the proposition of idaho law and thatery well be the case. But what you are asking to do is to const this statutet was enacted affecti the reagan administration. Send signed by president reagan to maine to have performed an abortion evenf during that is a violation of state law. Of congress had wano displace pive or permanent weight who are in danger of health that could redefine the statute so the fetus it as an individ with emergency medical condition. That iot how congress structured this they put the protectionickstand tion for the pregnant that run johor in a situation her own life and it i c the hospital has to offer her stabilizing treatment but she does n have to accept that t are tragic circumstances many women w to do whatever they can to save that pregnancy. The statute protects her and gives her that choice. The onl you try to get t of the statutory interpretation is by focusing on the term individual. In the dictionary act try to get a will which is outlined for true that dictionary act definition apply only if they not inconsistent with the statutory text . When you have the text that ching that you do not e the facts the hospital has a duty to the unborn child where that woman wants to have regnancy go to term. Indisputably protects the interests of the unborn child. It is inconsisten with the definition in the dictionary act. No, not a the due date runs the individual at the emergeedical condition. The statute makes c thats the pregnant woman of Course Congress wanted to be able to protect her and situation she suffered some kin emergency and her own her o health is not at risk but the fetus might die thats common things like a a great distress but the womanis is not at all affected. Hospitals otherwise not hav obligation to treat her and congressd to fix that. But to sug in doing so congress suggested the woman herself isot an individual that she does not deserve stabilization. That is an erroneous reading. Know it isuggesting a woman is not an individual when she doesnt deservilization. No one is saying that pickwick question be the state of idaho calare it she cannot get this stabilizing treatment even if shes to die for that is their theory of this case and the statute. And it is wrong. This lack of conflict the opposing colleague said it doesnt exist. Entioned a situation where it does. Why dont juices sink delete states tell us exactly how you define where it exists question. The daylight as i s it is a censure dimension they think doctors can only provide stabilizing care when th woman is facing death. And we think no, you can tak into account things like kidney failure at the risk of a seizure at lifelong neurologi impact space on that. They say the recent decision from the oregon court. You do not need death to be imminent or immediate i think is the word they used if i am not mistaken both the Idaho Supreme Court said in that decision as there is no particular level of evidence e no chance requirement. But what the court could not do exclusively be death. Harm toe also the inherent conce of necessity requiring some degree of eminence it is true its subjective standard under idaho the court made that c the idaho supreme c also said it isnt prosecutors are free to come innd have other medical experts secondguess s decisions by saying maybeou do not subjectively think you needed to prevent death. Because it looked, her back had ruptured she is not yet infected. Ats a kind of situation that leads ten being driven out of stateped on neighboring states by idaho and criminalizing the care of the essential care they need. Just in the few months that this has bee in place had to airlift six pregnant women to fake states whereas in the prior year they did one the entire year so if mr. Turner isight about what the state is trying to convey to hospitals about when theyll prosecuted, why is this happening . I think that the reason this is the happening isause those doctors canook at the text of the statute itself, they can look at Idaho Supreme Courts de which made clear, very, that this was a dep from prior idaho laws that track i and they can recogni that their livelihood is on line, their medical license, their a ability to Practice Medicine, their freedom if have to go to jail and one of these min men 32year sentences of subjective with their medical judgment because as a matter of medical reality for many of these conditionses, its not yet a woman at the brink of death or net to prevent her death, yet they know that t standard of care is to provide her or with term mission because she is just going to get worse and worse and worse if they w it out. And the other important point about this is that,cally in many of these cases, the pregis lost. Theres not any way to save fetus. There is no medical way to sustain theregnancy to give the fetus a chance. So in that situation what idaho is doing is waiting for women to wait and deteriorate and suffer lifelong Health Consequences with no possible apply for the fetus. I stacks tragedy upon tragedy. It c be transfer is the appropriate standard of care in idaho, but it cant be the standard the of care to force somebody onto a hecopter. And itsirely inconsistent with what cs was trying to do in the statute. Know, one of the pri motivators here was to prevent ent dumping. The idea was we dont want people to have to to go somewhere else to get their care. You g to the first emergency room in y state, and they have to treat and stabilize you. But this effectively allows states to take any particular treatment they dontant their hospitals to provide and dump those patients out of state and you can imagine what would happen if every state started to take this approach. A questio the spending clause questions t youve been asked. Accepted some of these theories, what the consequences of Something Like that be that we would have to worry about . Ihink that it would call into que any number of federal spending statutes that to if slide fun to private parties, and there bunch of them. Th the medicare system itselfch is, of course, a major federal spending program, there areds provided under title vi, under title ix, a lot funds to private parties ande insist on conditions of compliance if whe federal funding restrictions. Andhe court were to su say that cant preempt contrary state law, think it would seriouslyerfere with the ability of the federal government to get its benefit of the bargain in those spending programs. And you mentioned before this question has never been a part of t case . If thats right. Id not make these argum in the lower court. Ont understand them to have pressed thument a specifically, so think the lower courts d not address it. I thi District Court said in a footnote they briefly refer to it and its esstily waived. Thank you. Justice kavanaugh . Youve touched on whats happening on the grond thats an important consideration and answer to the question whats hap, but idaho is representing and i just want toet your answer nine conditions that have been, identified by government where impala would r that an abortion be available and abortion is available under reply brief. Nd thats in the if now, are there other conditions, youved out Mental Health, are there other conditions that you would identify, a you just saying thats notlly happening on the ground . I think thats part of your answer, but i just want to get a fuller answer on that. It certain isnt happening on the ground. These are the conditions that were worried abond i think the problem with my friends theory is that you just cant square it with the text o statute. The what with if theyre im sorry, keep going. I justed to say theyre not the ultimate authority on what the idaho law means. Thats the idaho supreme, and it has addressed issue in the planned parenthood case, and i thinkts significant that the Idaho Supreme Court expressly contr this statute with ore statutes that contain healthpreserving measures recognized this was a total departure from that. The legis wanted to focus and so i think that essentially means the Supreme Court of i has already touched on this issue, and its no wonder then these kinds of pregnancy complica where in theyre medical their medical judgment i not necessary to prevent yet, but the woman is going to suffer Serious Health consequences, their hands are tied, and they cant provide that carender the idaho law. Whats on page 899 of the reply brief 89, if it were idaho law, would there be a problem . If we had an authoritative idaho s Court Decision that s idaho law allows for termination in the circumstances where impala would require it, yes, of course, the conflict dose away. But with i cant imagine the court would say that because, of course, here thats not quite what they say, but i take your on that. Separate question, different category. I think one of the themes on the other side is that law passed in 1986 was a very important law addressing very importantblem; namely, the problem where hospitals were g away poor and uninsured patients who came in for Emergency Care, and the was that a canpen. We cant allow hospitals in this country to turn poor and uninsured peon emergencies. Their theme is that the law was not des contextually to deal with specific, with abortion or other specific kinds of care. And so they make aal argument, but i think they also make a broaderontextual argument about the whoa of what was going on in 1986. And i dont think thats reay come up too much, i want to make sure you respond to that. I appreciate havin chance to address that. At the outset,ting i dont think they care that theory with the text of the statute which says in no Uncertain Terms, heres the guarantee. If y go to an e. R. In this country, they have to stabilize you. They to give you such within reasonable medicaly probability to insure that you dont deteriorate. And congress did not provide a list of allble emergency medical conditions and all possible treatments, but i very clear that congress set a baseline National Standard of to insure that the no matter you live in this coun you cant be declined service amid the urgent needs o your medical condition. State had decided to banthe epinephrin singular way to treat an allergicction. Congress tonight want tha if have anaphylaxis and you go to an em r. , heir going to give you epinephrine, and congress csman a kateed that. And i dont mandated that. Excluding pregnancy in the narrowut tragic circumstances where the only way toddress the womans condition is for the pregnancy to end. Finish. Thank you. Justice barrett . General, i understand the primary if diffe between and the idaho statute to be the health,hat idaho focuses on the risk of l but the federal government says that that impala well, impala says that the health am i right . Health and life . Tha the principle the difference between necessary to prevent death versus the Health Concerns would be reasonably expected to occur. I think that a builds in a little more space for doctors to got it. N. Is the federal governm aware of any state other than idaho that has a law that does not take health into account . There are six other states that have severe abortion ctions would want a health exception, so i that those are the p category of states wererned about here. Thank you. Should make clear there are some pending judicial challenges in tho states, so their laws are not always enforceable or in effect row. Besides texas, has the federal government, has t idaho and texas in any of theses other states . To be cle, xas was not right. Y sued out, but we hav brought affirmative litigat in other states, and i think this case has been on a course k and coos law was particularly cover Ectopic Pregnancy the state conceded. That it was one of the most pressing can concerns because of that. Thank you. Justice jackson . Pretty heavily on clearrelied stt rule principles, i wonderther you might comment on my thoughthat those them in thise . Uallyut against as a you said, congress set a baseline National Standard the of care. It is said in no Uncertain Terms that the hospital must provide stabilizing care to people riencing emergency medical cons. If there was no, youve said, you know, particular condition or particular treatment talked about a, carved out, etc. So if a clear statement is require required, wouldnt it be the requirement of exempting abortion . I you know,tice alito has talked about some of the the refe to unborn child, but none of them read l an exemption that i would think a ear statement rule would require in a circumstance in which the baseline is this clear National Standard of care. Yes, i agree. I think that congress clearly was requi stabilization and made that an unqualified ma it wasnt exempting parti conditions or parti type of treatments. And, you know, this court has said theres no canon of doughnut holes. That you have a provisi dont have a specifichat you enumer of one of its applications doetean that you should read in some kind of implicit exception. So if we lking for something clear, we would need to see, i would think, the clear statement that congress meant for you not to have too provide an abortionursuant to the mandate of providing stabilizing care. Yes. And i think its impornt to recognize that every relevant actor has understood statute this way from thening. They understood congress clear mandate here. This has been the agencys position all along. We are not adopting a position. Enforcement activity and in hhs guidance and rule makings in this area. Providers have undd it, even hospitals that a dont provide elective abortions. They have also provided lifesustaining and healthsustaining pregnancy termination consistent with impala. Congress itself rzed it in the Affordable Care act, and i dont think theny reasonable argument that people misunderstood what congress was doing in the statute. Thank you. Tha, counsel. Al, mr. Turner . Thank you, your honors. em pal takes s impala are state law practice of medicine stand as it finds them. As Justice Gorsuch noted, thats what section 1395 says. And in fac the vaccine mandase that was refe, that thats what the solici Generals Office told this court whe it said that 1395 doe not require, doesot allow federal officials to dictate particular treatments for particular cases. Thats exactly what they are trying to do here with impala. Its also confirmed by subdivision that codifies a presumption against preemption. And so to Justice Jacksons colloquy at the end, that is the point. You do presume that state law cont to operate alongside impala. You dont presu opposite. Its supported by cms Operations Manual which is hs Rosetta Stone of impala enforcement. It tellsoctors, it tells cm if s enforcement a on the groundhat you consider what is available by referencing what is within scope of that doctors license. That is exactly w that we are saying. It is alsofically directed in 42cfr4889. 11 which requires hospitals to assure thatir medical staff comply with state law. Thats a federal regulation that directs hospitals to require their hospital staff toy with state law. Its also confirmed by the 115,000 enforcemetances that totally lack any theory that wouport any, any case history that would support the administrations reading. She says t has always been understood to be the case. Well, youd think tha we would find a singl example where state law wasverridden by impala, and isnt one. Finally, the text. E text qualifies impalas stabilization requirement requiremy the staff that is available. We know nurses cant perform eart surgery, and we know janitors cant draw blo its not just plain mandate void of reference to state law. And wenow the word available even in common usage incorporates state law. For example, you just the other day t when considering homeless people, it has both a sense. Al sen is a legal and whether cigarettes or hol are available to people in idaho, theres both a physical question and a legal question. Opioids are available in hospitals. They are the shelf. They are physically t but theres a legal questionhat comes into play too. It is the same with ans. In response to the chief justices question on conscience, the general said hospitals and doctors are exempt from impalas supposed abortion mandate. Were relieved to hear that, but i think that it highlights utter inconsistency o administrations reading. So if impalas stabilization requirement is general enough not to override extratextual protections like conscience protections, then i cannot be so specific and include a requirement that is in direct conflict with state law. Those two dont jibe. Thrt does not lightly find aect conflict. Congress must speak clearly. It has not done so here. The administrations position ultimately is untethered from any limiting principle. I think we heard that. Theres just n way to limit this toion. And theres no way to lim there are 22 states with abortion laws on the books. This isnt goingnd with idaho, its not going to end with the six states that the general mentioned because all of the states that have abortio regulations twine the health and the emergency exception narrower than i does. So this questions goingo come up in state after statefter state. Physical himited to i know the general says the nomstance in which a health, a Mental Health condition wouuire stabilization withbortion. But now just fighting with the erican psychiatric association. The very standard that shes setting up to say controls the impala a inquiry. Ats to not consist thats not consistent. And it isnt limitedo impala. Justice thomas, alito,ce gorsuch, you all a pointed out the major spending clause implications that are at play here. I disagree that we didnt briefhis. Pages 2021 of our opening brief we recognize that this is hugely concerning if the federal rnment can pay private actors to violate state law. Not just any state law, state criminal lawses. The implications of that are vast. It leaves the federal government unbound by numerated powers. And i think the general admitted that. The court doesnt have to answer that question on our reading, it does on theirs. Thank you, counsel. The case is submitted. Security remains tight ahead of the first president ial debate between President Biden and former President Trump in atlanta. Multiple agencies including the secret service and local Law Enforcement have coordinated with each oh to secure the perimeter around the cnn studio where that debate will take place tonight. [background sounds] [inaudible conversations] [background sounds] tonight, tune in to the cnn president ial debate simulcast live on cspan2. Watch as the two presumptive nominees, President Joe Biden and former president donald trump, face off as they try to earn your vote ahead of the general election in november. Our coverage begins at 8 p. M. Eastern with a preview of whats to come. And then at a 9 p. M. If eastern, our simulcast of the cnn president ial debate. And following the debate, stay with cspan as we take your calls and get your reaction to the first debate of the campaign season. The cnn president ial debate simulcast live tonight at nine eastern on cspan2 2, cspan now, our prix mobile video app, or online at a cspan. Org. Cspan, your unfiltered view of politics. On friday President Biden is in raleigh league, north carolina, for his First Campaign event following cnns debate. Well is hav live coverage beginning at noo eastern on sp2. And later at 3 p. M. , fme president donald trumpak his First Campaign stop at a rally in chesapeake, virginia, after the debate thats also on cspan2, cspan now, our free mobile app, or online at a cspan. Org. Cspans washington journal, a live forum involving you to discuss the hate e issues in government latest issues in government, politics and Public Policy from washington, d. C. To across the country. Coming up friday morning, were getting your reaction to tonights president ial debate between President Joe Biden and former president donald trump. Join the conversation with your phone calls, Text Messages and social media comments. Cspans washington journal live at a 7 eastern friday morning on cspan, cspan now or online at cspan. Org. American history tv, saturdays on cspan2, exploring the people and events that tell the american story. At 4 45 p. M. Eastern, a look at womens history in the federal government including the influx of women into the federal government from the Nixon Administration through the late 20th century and the substantive role played by americas first ladies. And then at 7 p. M. Eastern, watch American History tv series Historic Convention speeches featuring notable remark by president ial nominees and other political figure from the past several decades. This week, former georgia governor jimmy carter accepts his partys nomination at the 1976 Democratic National convention in new york city. And at 9 30 p. M. Eastern on the presidency, Theodore Roosevelt president ial Library Foundation ceo Edward Okeefe talks about the women who shaped Theodore Roosevelts character and political outlook. Watch American History tv saturdays on cspan2 and if find a full schedule on your Program Guide or watch online anytime at cspan. Org history