Amicus Curiae Brief — Mike Moyle, Speaker of the Idaho House of Representatives, et al., Petitioners v. United States

Supreme Court briefMar 27, 2024

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Nos. 23-726 & 23-727

IN THE

Supreme Court of the United States

MIKE MOYLE, SPEAKER OF THE IDAHO HOUSE OF

REPRESENTATIVES, ET AL., Petitioners,

UNITED STATES, Respondent.

STATE OF IDAHO, Petitioner,

UNITED STATES, Respondent.

On Writs of Certiorari to the United States

Court of Appeals for the Ninth Circuit

BRIEF OF AMICUS CURIAE PUBLIC CITIZEN

IN SUPPORT OF RESPONDENT

NANDAN M. JOSHI

Counsel of Record

ALLISON M. ZIEVE

SCOTT L. NELSON

PUBLIC CITIZEN

LITIGATION GROUP

1600 20th Street NW

Washington, DC 20009

(202) 588-1000

njoshi@citizen.org

March 2024

Attorneys for Amicus Curiae

TABLE OF CONTENTS

TABLE OF CONTENTS .............................................. i

TABLE OF AUTHORITIES ....................................... ii

INTEREST OF AMICUS CURIAE ............................ 1

SUMMARY OF ARGUMENT .................................... 2

ARGUMENT ............................................................... 5

EMTALA preempts state laws that restrict

hospitals from providing treatment that is

required to stabilize an emergency medical

condition. .......................................................... 5

II.

The Supremacy Clause does not exclude laws

enacted pursuant to Congress’s spending

power. ............................................................. 13

CONCLUSION.......................................................... 21

TABLE OF AUTHORITIES

Page(s)

Cases

Agency for International Development v.

Alliance for Open Society International, Inc.,

570 U.S. 205 (2013) ............................................... 17

Armstrong v. Exceptional Child Center, Inc.,

575 U.S. 320 (2015) ............................................... 14

Bennett v. Arkansas,

485 U.S. 395 (1988) ................................... 15, 16, 21

Biden v. Missouri,

595 U.S. 87 (2022) ................................................. 17

Chapman v. Houston Welfare Rights

Organization,

441 U.S. 600 (1979) ............................................... 15

Cummings v. Premier Rehab Keller, P.L.L.C.,

596 U.S. 212 (2022) ......................................... 16, 19

Davis v. Monroe County Board of Education,

526 U.S. 629 (1999) ............................................... 17

Engine Manufacterers Ass’n v. South Coast Air

Quality Management District,

541 U.S. 246 (2004) ................................................. 8

Flemming v. Nestor,

363 U.S. 603 (1960) ............................................... 15

Gibbons v. Ogden,

22 U.S. (9 Wheat.) 1 (1824) ............................. 17, 20

Golden State Transit Corp. v. City of Los

Angeles,

493 U.S. 103 (1989) ............................................... 14

iii

Haaland v. Brackeen,

599 U.S. 255 (2023) ............................................... 17

Harris v. McRae,

448 U.S. 297 (1980) ................................................. 9

Helvering v. Davis,

301 U.S. 619 (1937) ............................................... 15

Hospital Corp. of Marion City v. Talevski,

599 U.S. 166 (2023) ......................................... 17, 19

Lawrence County v. Lead-Deadwood School

District No. 40-1,

469 U.S. 256 (1985) ............................................... 16

Maine v. Thiboutot,

448 U.S. 1 (1980) ................................................... 19

Medicaid & Medicare Advantage Products

Ass’n of Puerto Rico, Inc. v. Emanuelli

Hernández,

58 F.4th 5 (1st Cir. 2023) ...................................... 19

Murphy v. NCAA,

584 U.S. 453 (2018) ..................................... 5, 11, 14

Mutual Pharmaceutical Co. v. Bartlett,

570 U.S. 472 (2013) ............................................... 18

Pennhurst State School & Hospital v.

Halderman,

451 U.S. 1 (1981) ................................................... 18

Rose v. Arkansas State Police,

479 U.S. 1 (1986) ................................................... 16

Sossamon v. Texas,

563 U.S. 277 (2011) ............................................... 17

South Dakota v. Dole,

483 U.S. 203 (1987) ............................................... 20

Students for Fair Admissions, Inc. v. President

& Fellows of Harvard College,

600 U.S. 181 (2023) ............................................... 17

Utility Air Regulatory Group v. EPA,

573 U.S. 302 (2014) ............................................... 13

West Virginia v. EPA,

597 U.S. 697 (2022) ............................................... 13

Wilder v. Virginia Hospital Ass’n,

496 U.S. 498 (1990) ................................................. 7

Constitutional Provisions

U.S. Const. art. I, § 7, cl. 2........................................ 15

U.S. Const. art. I, § 8 ................................................ 15

U.S. Const. art. I, § 8, cl. 1........................................ 14

U.S. Const. art. VI, cl. 2 ...................................... 14, 15

Statutes

31 U.S.C. § 6902(a) ................................................... 16

42 U.S.C. § 1395cc(b)(2) .............................................. 1

42 U.S.C. § 1395dd(a) ............................................. 6, 7

42 U.S.C. § 1395dd(b) ............................................. 6, 7

42 U.S.C. § 1395dd(b)(1)(A) .................... 2, 5, 8, 11, 12

42 U.S.C. § 1395dd(c).................................................. 6

42 U.S.C. § 1395dd(d) ................................................. 1

42 U.S.C. § 1395dd(d)(1)(A) ........................................ 7

42 U.S.C. § 1395dd(d)(1)(B) ........................................ 7

42 U.S.C. § 1395dd(d)(2) ........................................... 12

42 U.S.C. § 1395dd(d)(2)(A) ........................................ 7

42 U.S.C. § 1395dd(d)(2)(B) ........................................ 7

42 U.S.C. § 1395dd(e)(1) ............................................. 8

42 U.S.C. § 1395dd(e)(1)(A)(i)................................... 13

42 U.S.C. § 1395dd(e)(3)(A) ........................................ 8

42 U.S.C. § 1395dd(f) ...................................... 7, 12, 13

42 U.S.C. § 1395i-3(c)(3)(E) ...................................... 12

42 U.S.C. § 1395i-5(b)(5)(A)(ii) ................................. 12

42 U.S.C. § 1395w-24(g) ........................................... 19

42 U.S.C. § 1395w-26(b)(3) ....................................... 20

42 U.S.C. § 1395w-112(g) ......................................... 19

42 U.S.C. § 1395x(aa)(5)(A) ...................................... 12

42 U.S.C. § 1396u-2(e)(1)(A)(i) ................................. 10

42 U.S.C. § 1396u-2(e)(1)(B) ..................................... 10

42 U.S.C. § 1983 .................................................... 7, 19

42 U.S.C. § 18021(a)(1)(B) ........................................ 10

42 U.S.C. § 18022 ...................................................... 10

42 U.S.C. § 18023(a)(1) ............................................. 11

42 U.S.C. § 18023(d) ................................................. 11

42 U.S.C. § 18031(d)(2) ............................................. 10

Consolidated Appropriations Act, 2023,

Pub. L. No. 117-328, div. H, tit. V, 136 Stat.

4459 (2022) ............................................................ 10

§ 506(a), 136 Stat. 4908 ........................................ 10

§ 507(a)(2), 136 Stat. 4908 .................................... 10

Idaho Code § 18-604(1)(b) ......................................... 11

Idaho Code § 18-604(1)(c) ......................................... 11

Idaho Code § 18-622(2)(a)(i) ................................. 9, 11

Regulations

42 C.F.R. pt. 482 ....................................................... 19

Other Authorities

Black’s Law Dictionary (6th ed. 1990) ....................... 9

Merriam-Webster: Dictionary, https://www.

merriam-webster.com/diction

ary/treatment#medicalDictionary .......................... 9

The American Heritage Dictionary of the

English Language (1981) ........................................ 9

INTEREST OF AMICUS CURIAE*

Public Citizen, a consumer advocacy organization

with members in all 50 states, appears before Congress, administrative agencies, and the courts on a

wide range of issues. Public Citizen is a longstanding

advocate of policies to improve access to health care,

and it supports federal initiatives to expand such access by lowering the cost of health care and removing

other barriers that prevent individuals from obtaining

needed care.

Many federal health care programs, including

Medicare and Medicaid, use federal funding to support the provision of medical services to beneficiaries.

These programs typically impose various substantive

obligations on program participants. Of relevance

here, the Emergency Medical Treatment and Labor

Act (EMTALA) requires hospitals that participate in

Medicare to screen emergency room patients and provide treatment to stabilize emergency medical

conditions, and generally prohibits hospitals from

transferring patients before they are stabilized. Hospitals that do not comply with those requirements face

termination from the Medicare program, 42 U.S.C.

§ 1395cc(b)(2), as well as liability for civil penalties

and damages, id. § 1395dd(d).

Public Citizen submits this brief because it is concerned that petitioners’ arguments, if accepted, would

weaken EMTALA’s protections and undermine a

range of other conditions on federal subsidies, thereby

impeding access to health care throughout the nation.

––––––––––––––––––––––––

* This brief was not authored in whole or part by counsel for

a party. No one other than amicus curiae made a monetary contribution to preparation or submission of the brief.

SUMMARY OF ARGUMENT

I.A. EMTALA provides that Medicare-funded

hospitals “must provide … such treatment as may be

required to stabilize” a medical condition. 42 U.S.C.

§ 1395dd(b)(1)(A). That language unambiguously

imposes a mandatory duty on hospitals—a duty that

is backed up by enforcement provisions that impose

civil penalties and damages liability on hospitals and

doctors that fail to comply with their EMTALA

obligations. EMTALA also recognizes that state law

may conflict with the statute’s federal requirements

and expressly preempts conflicting state laws. A state

law that bars a Medicare-funded hospital from

providing a particular treatment needed to stabilize a

patient, where the hospital can otherwise provide that

treatment, conflicts with EMTALA and is therefore

preempted.

B. EMTALA defines a hospital’s duty to stabilize a

medical condition in terms of providing “treatment”

necessary to prevent deterioration of a condition that

poses a serious health risk to a patient. The ordinary

meaning of “treatment” encompasses the range of

actions or procedures used to treat a medical

condition. As the record indicates and as this Court

has long recognized, the appropriate “treatment” for

preventing deterioration of certain medical conditions

will be to terminate a pregnancy. Other federal laws

that associate abortion with the treatment of medical

conditions reinforce this conclusion.

Under EMTALA, then, a hospital has a duty to

provide treatments that it is capable of providing,

including abortion, when those treatments are

required to stabilize a patient’s emergency medical

condition—that is, to prevent a deterioration of the

medical condition that would create a serious health

risk for the individual. Under Idaho law, however, a

hospital may not lawfully provide abortions in

situations where EMTALA would require it to do so.

In those situations, EMTALA and Idaho law conflict,

and the federal law preempts the state law.

Petitioners’ argument that states may decide what

constitutes a “treatment” under EMTALA overlooks

the statute’s plain text and lacks merit. EMTALA does

not delegate the authority to interpret the meaning of

“treatment” to the states. Instead, Congress made

clear that hospitals must provide any stabilizing

treatments that they have the staff and facilities to

provide. Making that duty contingent on state law

would permit states to circumvent EMTALA’s goal of

ensuring that hospitals make stabilizing treatments

available to all individuals facing emergency situations.

II. EMTALA does not exceed Congress’s spending

power, as petitioners appear to agree. Petitioners’

argument that statutes enacted pursuant to

Congress’s constitutional exercise of its spending

power cannot preempt state law is baseless.

A. The Supremacy Clause declares “the Laws of

the United States” to be “the Supreme Law of the

Land.” Such “Laws” encompass statutes enacted

under Congress’s spending power as well as those

enacted under another enumerated power. This Court

has accordingly held that statutes enacted pursuant

to the spending power preempt state laws.

This Court has also recognized that, under the

spending power, Congress may require recipients of

federal funds to comply with substantive

requirements and may provide for the enforcement of

those requirements through means other than

termination of funding. Under the Supremacy Clause,

such requirements are also “Laws” that will have the

effect of preempting conflicting state requirements.

B. Petitioners’ contrary arguments lack merit.

Idaho contends that, notwithstanding its express

preemption provision, EMTALA does not preempt

conflicting state law and that the appropriate remedy

for EMTALA violations caused by a conflicting statelaw duty is for the Department of Health and Human

Services (HHS) to penalize hospitals. This Court has

held, however, that conflicting federal and state duties

result in preemption regardless of whether a person

can avoid liability by ceasing the regulated activity or

paying a penalty. And states should not be able to

undermine federal programs by preventing in-state

participants from accepting federal funding

conditions.

In addition, Congress is not required to obtain a

state’s consent before preempting state law pursuant

to the spending power. Such a limitation on congressional authority would give states carte blanche to

override EMTALA’s requirements, as well as to pick

and choose which requirements can be imposed under

Medicare and other federal programs. And because a

state’s refusal to consent to preemption of its laws

would not make federal requirements unenforceable

against hospitals, the result of petitioners’ theory

would be to subject hospitals to conflicting state and

federal obligations, threatening them with liability

whichever obligation they chose to follow and leaving

them with no means to resolve the conflict.

The Idaho legislature’s concern with the scope of

Congress’s authority to preempt state law pursuant to

the spending power is misplaced. This Court has

recognized that the spending power is not unlimited,

and spending conditions that transgress constitutional limits are invalid and unenforceable. Here,

however, no party has shown that EMTALA exceeds

Congress’s spending power. Accordingly, under the

Supremacy Clause, EMTALA is “the supreme Law of

the Land,” and Idaho’s conflicting state law must give

way.

ARGUMENT

EMTALA preempts state laws that restrict

hospitals from providing treatment that is

required to stabilize an emergency medical

condition.

The question presented in this case is a familiar

one: Does a federal statute preempt state law? As this

Court has recently explained, federal statutes preempt state law when “Congress enacts a law that

imposes restrictions or confers rights on private actors

[and] a state law confers rights or imposes restrictions

that conflict with the federal law.” Murphy v. NCAA,

584 U.S. 453, 477 (2018). In those circumstances, “the

federal law takes precedence and the state law is

preempted.” Id.

EMTALA is undeniably a “federal law.” Accordingly, the first step for considering preemption is to

determine whether Congress has “impose[d] restrictions or confer[red] rights on private actors,” id., and,

if so, what those restrictions and rights are. Here, both

text and context confirm that EMTALA imposes on

hospitals a duty to provide, and on emergency room

patients at participating facilities a right to obtain,

“such treatment as may be required to stabilize the

medical condition.” 42 U.S.C. § 1395dd(b)(1)(A).

If emergency treatment were required to stabilize

a patient who arrived at an emergency department at

4:00 a.m., EMTALA would override a state law

barring Medicare-funded hospitals from providing

needed emergency treatment between midnight and

7:00 a.m. If a tracheotomy were needed to stabilize a

patient in the emergency department, EMTALA

would override a state law barring Medicare-funded

hospitals from delivering that treatment. And if an

abortion is needed to stabilize a patient in the

emergency department, EMTALA overrides a state

law barring Medicare-funded hospitals from delivering that treatment.

A. Under EMTALA, “any individual” who “comes

to the emergency department” of a Medicare-funded

hospital is entitled to “an appropriate medical

screening examination … to determine whether or not

an emergency medical condition … exists.” 42 U.S.C.

§ 1395dd(a). Two subsequent actions flow from the

results of that examination. If the “hospital

determines that the individual has an emergency

medical condition,” it “must provide either—(A)

within the staff and facilities available at the hospital,

for such further medical examination and such

treatment as may be required to stabilize the medical

condition, or (B) for transfer of the individual to

another medical facility.” Id. § 1395dd(b). The

transfer option, however, cannot be exercised until the

individual has been “stabilized” unless the individual

consents to the transfer or a physician determines

that the benefits of transfer outweigh the risks. Id.

§ 1395dd(c).

The plain language of EMTALA’s substantive

provisions speaks in terms of what a Medicare-funded

hospital “must provide” to individuals who come to

emergency rooms seeking medical assistance. That

language, phrased in “mandatory” terms, “imposes a

binding obligation” on Medicare-funded hospitals to

screen individuals for emergency medical conditions

and, where such conditions are found, to provide

required treatments and appropriate transfers.

Wilder v. Va. Hosp. Ass’n, 496 U.S. 498, 512 (1990)

(holding that Medicaid’s command with regard to

payments that states “must provide” to hospitals is

enforceable under 42 U.S.C. § 1983).

Other provisions of EMTALA confirm the point.

EMTALA authorizes the federal government to obtain

civil money penalties against hospitals and physicians

that “violate[] a requirement of [EMTALA].” 42 U.S.C.

§ 1395dd(d)(1)(A), (B). It also authorizes private civil

damages actions against hospitals for a “violation of a

requirement of [EMTALA].” Id. § 1395dd(d)(2)(A), (B).

These enforcement provisions are premised on the

existence of affirmative duties imposed on hospitals

and physicians.

Moreover, because Congress recognized that a

hospital’s federal obligations may be inconsistent with

its obligations under state law, EMTALA contains an

express preemption provision. That provision specifies

that EMTALA preempts any State or local law

requirement “to the extent that the requirement

directly conflicts with a requirement of this section.”

Id. § 1395dd(f). For instance, if a state required a

hospital capable of screening and stabilizing an

individual to transfer the individual to another

medical facility before she was stable, the hospital

could not comply with the state law without violating

its EMTALA duties. See id. § 1395dd(a), (b). In that

situation, EMTALA would preempt the state law.

B.1. EMTALA’s imposition of federal duties on

Medicare-funded hospitals is not in serious dispute.

Petitioners, however, contest the scope of Medicarefunded hospitals’ duty to provide “such treatment as

may be required to stabilize [an emergency] medical

condition.” 42 U.S.C. § 1395dd(b)(1)(A). An “emergency medical condition” exists (other than for women

“having contractions”) when “the absence of

immediate medical attention could reasonably be

expected to result in—(i) placing the health of the

individual (or, with respect to a pregnant woman, the

health of the woman or her unborn child) in serious

jeopardy, (ii) serious impairment to bodily functions,

or (iii) serious dysfunction of any bodily organ or part.”

Id. § 1395dd(e)(1). In short, an emergency medical

condition occurs when a patient is facing a serious

health risk.

EMTALA also defines what it means “to stabilize”

an emergency medical condition. The hospital must

“provide such medical treatment … as may be

necessary to assure, within reasonable medical probability, that no material deterioration of the condition

is likely to result from or occur during the transfer of

the individual from a facility.” Id. § 1395dd(e)(3)(A).

Thus, if a “medical treatment” is necessary to prevent

the patient’s condition from worsening during a

transfer (including a discharge) from the hospital,

EMTALA requires the hospital to provide it to the

patient.

2. “Statutory construction must begin with the

language employed by Congress and the assumption

that the ordinary meaning of that language accurately

expresses the legislative purpose.” Engine Mfrs. Ass’n

v. S. Coast Air Quality Mgmt. Dist., 541 U.S. 246, 252

(2004). Here, Congress imposed on Medicare-funded

hospitals a duty to provide “treatment.” Although

“treatment” is not defined in the statute, its ordinary

meaning is “a therapeutic agent, therapy, or

procedure used to treat a medical condition.”

Treatment, Merriam-Webster: Dictionary, https://

www.merriam-webster.com/dictionary/treatment#me

dicalDictionary (last visited Mar. 25, 2024); Treatment, Black’s Law Dictionary (6th ed. 1990) (“[a]

broad term covering all the steps taken to effect a cure

of an injury or disease”); The American Heritage

Dictionary of the English Language 1367 (1981)

(defining “treatment” as “application of remedies with

the object of effecting a cure; therapy”).

As a factual matter, the record supports the

conclusion that an abortion may be the “treatment”

required to “stabilize” certain medical conditions. U.S.

Br. 14–16, 19. Indeed, that principle appears to be

undisputed. Idaho law itself recognizes that an

abortion may be needed “to prevent the death of the

pregnant woman,” Idaho Code § 18-622(2)(a)(i), and

petitioners do not contest that an abortion may be

effective in preventing deterioration of certain medical

conditions that pose a serious health risk if left

untreated, Idaho Leg. Br. 12–14 (asserting that

government’s examples of medical conditions that

require termination of a pregnancy “were either lifesaving procedures or otherwise not abortions”

(cleaned up)). And this Court has long recognized that

there are “medically necessary” reasons for abortions.

See Harris v. McRae, 448 U.S. 297, 311 (1980).

Other federal laws reinforce the conclusion that an

abortion is a “treatment” for certain medical

conditions. The Hyde Amendment generally prohibits

the expenditure of appropriated funds for abortions.

See Consolidated Appropriations Act, 2023, Pub. L.

No. 117-328, div. H, tit. V, § 506(a), 136 Stat. 4459,

4908 (2022). That restriction, however, does not apply

“in the case where a woman suffers from a physical

disorder, physical injury, or physical illness, including

a life-endangering physical condition caused by or

arising from the pregnancy itself, that would, as

certified by a physician, place the woman in danger of

death unless an abortion is performed.” Id. § 507(a)(2).

Thus, federal funds can be used to pay for abortions to

treat life-threatening medical conditions precisely

because abortion may be the appropriate medical

treatment in some circumstances.

Medicaid also recognizes abortion as a treatment.

It requires participating states to have a system for

imposing sanctions on a “managed care organization”

that “fails substantially to provide medically

necessary items and services that are required … to

be provided to an enrollee.” 42 U.S.C. § 1396u2(e)(1)(A)(i). Reflecting that the plain language of that

provision would apply to failure to provide abortion

services, the statute includes an express exception

under which a managed care organization can be

sanctioned for not providing medically necessary

abortions only if it “has a contract to provide abortion

services.” Id. § 1396u-2(e)(1)(B).

The Affordable Care and Patient Protection Act

(ACA) expressly recognizes that abortions are a

possible treatment under EMTALA. The ACA

requires health insurance exchanges to “make

available qualified health plans to qualified

individuals,” id. § 18031(d)(2), and defines the

“essential health benefits” that must be offered

through such plans, id. §§ 18021(a)(1)(B), 18022. But

the ACA also gives states and plans leeway to include

or exclude coverage for abortions, id. § 18023(a)(1),

and specifically provides that the ACA does not

“relieve any health care provider from providing

emergency services” under EMTALA, id. § 18023(d).

These provisions are premised on the recognition that

abortion is a treatment for certain medical conditions

and thus is the type of service that could be covered by

an individual’s health insurance plan and the type of

treatment that may be needed to treat an emergency

medical condition.

Because abortion is a “treatment,” EMTALA

requires Medicare-funded hospitals to provide the

treatment when “required to stabilize the medical

condition,” that is, when the failure to provide the

treatment “could reasonably be expected to result” in

a serious health risk to the individual. Id.

§ 1395dd(b)(1)(A), (e)(1). Idaho law, however, “imposes restrictions that conflict with the federal law” in

certain circumstances. Murphy, 584 U.S. at 477.

Under Idaho law, a hospital may lawfully terminate a

pregnancy as a treatment for a medical condition only

in case of the “removal of a dead unborn child,” the

“removal of an ectopic or molar pregnancy,” or “to

prevent the death of the pregnant woman.” Idaho

Code §§ 18-604(1)(b), (c), 18-622(2)(a)(i). Those situations are narrower than the circumstances in which

an abortion may be required under EMTALA. Thus, if

the individual faces one of several serious but not

immediately life-threatening health risks—e.g., rupture of the amniotic sac, placental abruption, and

uterine hemorrhaging, see U.S. Br. 7, 14, 23–24—the

physician could not comply with EMTALA’s requirements without risking criminal penalties under Idaho

law. Idaho law and EMTALA thus “directly conflict[].”

42 U.S.C. § 1395dd(f).

3. Petitioners argue that this Court should not

interpret the term “treatment” in EMTALA according

to its ordinary meaning. Instead, they argue that each

state may decide what constitutes a “treatment” for

purposes of enforcing EMTALA’s requirement that

hospitals “provide … such treatment as may be

required to stabilize the medical condition.” 42 U.S.C.

§ 1395dd(b)(1)(A); see Idaho Br. 26; Idaho Leg. Br. 25.

That view cannot be reconciled with EMTALA’s text

or purpose.

First, EMTALA does not delegate to states the

authority to interpret the meaning of “treatment.”

Congress knew how to reference state law in

EMTALA, see 42 U.S.C. § 1395dd(d)(2), as well as in

Medicare generally, see, e.g., id. §§ 1395i-3(c)(3)(E),

1395i-5(b)(5)(A)(ii), 1395x(aa)(5)(A), but did not do so

in imposing duties on hospitals. Moreover, Congress

imposed only one condition on hospitals’ duty to

provide a required “treatment”—that such treatment

be “within the staff and facilities available at the

hospital.” Id. § 1395dd(b)(1)(A). In other words,

although EMTALA does not require a hospital to be

capable of providing every possible treatment to an

individual, if the hospital is capable of providing a

particular treatment, it must do so. State law that

contradicts EMTALA’s instruction is preempted.

Second, making the duty to provide treatment

contingent on state law would permit states to

circumvent EMTALA’s goal of providing all emergency room patients with access to needed stabilizing

treatment. A state seeking to reduce emergency room

costs, for instance, could provide that expensive

treatments must be used only for life-threatening

conditions, which would circumvent the hospital’s

duty under EMTALA to stabilize conditions that pose

a serious, but not life-threatening, health risk. Or a

state could require treatment variations based on a

patient’s age or medical condition. A state hostile to

drug users could preclude hospitals from treating

opioid overdose victims with naloxone. A state could

conclude that no treatment is indicated for a fetus,

effectively nullifying EMTALA’s requirement that the

health of an “unborn child” should inform treatment

options available to physicians and patients. See id.

§ 1395dd(e)(1)(A)(i). Congress did not intend to permit

states to override EMTALA’s duties in this manner; to

the contrary, it intended to preempt conflicting state

law. Id. § 1395dd(f).

Third, petitioners’ invocation of the majorquestions doctrine does not change the preemption

analysis. See Idaho Br. 21–22; Idaho Leg. Br. 38–47.

As the Court has explained, the major-questions

doctrine applies “in certain extraordinary cases,” in

which the Court is “‘reluctant to read into ambiguous

statutory text’ the delegation claimed to be lurking

there.” West Virginia v. EPA, 597 U.S. 697, 723 (2022)

(quoting Util. Air Reg. Grp. v. EPA, 573 U.S. 302, 324

(2014)). Here, the issue is not whether EMTALA has

delegated to HHS the power to require hospitals to

require medically needed treatments. The issues are

whether EMTALA’s plain text imposes that

requirement directly and, if so, whether it preempts

contrary state-law commands. Those issues do not

implicate the major questions doctrine.

II. The Supremacy Clause does not exclude laws

enacted pursuant to Congress’s spending

power.

Petitioners have not shown that the substantive

obligations that EMTALA imposes on Medicare-

funded hospitals fall outside of Congress’s power to

decide how to spend tax dollars “to provide for the …

general Welfare of the United States.” U.S. Const. art.

I, § 8, cl. 1. They argue, however, that state laws that

require Medicare-funded hospitals to violate obligations imposed by EMTALA are not preempted under

normal conflict-preemption principles. See Idaho Br.

20–21; Idaho Leg. Br. 48–51; see also Indiana Br. 14;

Prolife Center Br. 11–12. In their view, federal

statutes, such as Medicare, that Congress enacts

pursuant to its spending power lack the preemptive

force of federal statutes enacted pursuant to

Congress’s other enumerated powers. That view,

which would sweep well beyond the immediate issue

of emergency room abortions, cannot be reconciled

with the text of the Supremacy Clause or this Court’s

precedents.

A. As this Court has explained, federal statutes do

not of their own force preempt conflicting state laws.

Rather, “[p]reemption is based on the Supremacy

Clause,” Murphy, 584 U.S. at 477, which provides that

the “Constitution, and the Laws of the United States

which shall be made in Pursuance thereof … shall be

the supreme Law of the Land … any Thing in the

Constitution or Laws of any State to the Contrary

notwithstanding,” U.S. Const. art. VI, cl. 2. The

Supremacy Clause “creates a rule of decision” that

“instructs courts what to do when state and federal

law clash.” Armstrong v. Exceptional Child Ctr., Inc.,

575 U.S. 320, 324–25 (2015). Although the Supremacy

Clause “is not a source of any federal rights[,] it

secures federal rights by according them priority

whenever they come in conflict with state law.” Golden

State Transit Corp. v. City of Los Angeles, 493 U.S.

103, 107 (1989) (cleaned up).

Importantly here, “all federal rights, whether

created by treaty, by statute, or by regulation, are

‘secured’ by the Supremacy Clause.” Chapman v.

Hous. Welfare Rts. Org., 441 U.S. 600, 613 (1979).

That much is evident from the text of the Supremacy

Clause itself, which refers to the primacy of “the Laws

of the United States which shall be made in

Pursuance” of the Constitution. U.S. Const. art. VI, cl.

2. The Constitution elsewhere describes the process

that Congress must undertake for a bill to “become a

Law.” Id. art. I, § 7, cl. 2. And the Constitution’s

enumeration of the “Power[s]” that Congress may

exercise through its law-making authority lists the

spending power first of all. Id. art. I, § 8. Nothing in

the constitutional text suggests that a statute enacted

pursuant to Congress’s spending power is not one of

“the Laws of the United States” that “shall be the

supreme Law of the Land.” Id. art. VI, cl. 2.

Not surprisingly, then, in several cases, this Court

has held that federal statutes enacted pursuant to the

spending power preempt conflicting state laws. For

instance, Social Security retirement benefits are an

exercise of Congress’s spending power. See Flemming

v. Nestor, 363 U.S. 603, 610–11 (1960) (explaining that

Social Security was “enacted pursuant to Congress’

power to ‘spend money in aid of the “general

welfare,”’” (quoting Helvering v. Davis, 301 U.S. 619,

640 (1937)). In Bennett v. Arkansas, 485 U.S. 395

(1988) (per curiam), this Court held that the Social

Security Act’s bar on attaching Social Security

benefits through legal process preempted an Arkansas

law to seize the Social Security benefits of prisoners to

“defray the cost of maintaining its prison system.” Id.

at 396–97. The Court declined to read an “implied

exception” into the Social Security Act to avoid the

“clear inconsistency” between the Social Security Act

and Arkansas law. Id. at 397. Instead, the Court

explained that there was “a ‘conflict’ under the

Supremacy Clause—a conflict that the State cannot

win.” Id. (citing Rose v. Ark. State Police, 479 U.S. 1, 4

(1986) (per curiam) (holding that state law that offset

state benefits based on amount of federal supplemental benefits was “repugnant to the Supremacy

Clause” because it “authorize[d] the precise conduct

that Congress sought to prohibit”)).

Likewise, in Lawrence County v. Lead-Deadwood

School District No. 40-1, 469 U.S. 256 (1985), the

Court held that a state may not “regulate the

distribution of funds that units of local government in

that State receive from the Federal Government in

lieu of taxes,” id. at 257–58, because Congress had

provided that local units “may use the payment for

any governmental purpose,” id. at 258 (quoting 31

U.S.C. § 6902(a)). The Court rejected the argument

that denying states the authority to direct how

localities use the funds would raise federalism

concerns, concluding that “pursuant to its powers

under the Spending Clause, Congress may impose

conditions on the receipt of federal funds, absent some

independent constitutional bar.” Id. at 269–70.

That EMTALA imposes substantive obligations

only on hospitals that agree to accept Medicare

funding does not affect the preemption analysis.

“Congress has broad power under the Spending

Clause of the Constitution to set the terms on which it

disburses federal funds.” Cummings v. Premier Rehab

Keller, P.L.L.C., 596 U.S. 212, 216 (2022). Such terms

often include the imposition of substantive obligations

on entities that accept federal funds, such as the duty

to refrain from discriminating against, or failing to

accommodate, a protected class of beneficiaries. See

id.; see also Students for Fair Admissions, Inc. v.

President & Fellows of Harvard Coll., 600 U.S. 181,

198 n.2 (2023); Sossamon v. Texas, 563 U.S. 277, 281

(2011); Davis v. Monroe Cnty. Bd. of Educ., 526 U.S.

629, 632–33 (1999). And “healthcare facilities that

wish to participate in Medicare and Medicaid have

always been obligated to satisfy a host of conditions

that address the safe and effective provision of

healthcare.” Biden v. Missouri, 595 U.S. 87, 94 (2022).

As the Court held last term in Health & Hospital Corp.

of Marion City v. Talevski, 599 U.S. 166 (2023),

substantive obligations imposed pursuant to the

spending power are “laws” that may be enforced

through the imposition of civil liability, as well as

through the termination of funding. Id. at 183–84.

To be sure, obligations enacted pursuant to the

spending power, like obligations imposed through

Congress’s other enumerated powers, may be invalid

if they violate the recipient’s constitutional rights,

notwithstanding the recipient’s ability to avoid the

condition by declining the funds. See, e.g., Agency for

Int’l Dev. v. All. for Open Soc’y Int’l, Inc., 570 U.S. 205,

214 (2013) (holding that spending condition violated

recipient’s First Amendment rights). But “[i]n every

such case” where the spending condition is “made in

pursuance of the constitution,” “the act of Congress …

is supreme; and the law of the State … must yield to

it.” Gibbons v. Ogden, 22 U.S. (9 Wheat.) 1, 211 (1824);

see also Haaland v. Brackeen, 599 U.S. 255, 287 (2023)

(“[W]hen Congress enacts a valid statute pursuant to

its Article I powers, state law is naturally preempted

to the extent of any conflict with a federal statute.”

(internal quotation marks omitted)).

B. Petitioners’ arguments that federal spending

statutes do not have preemptive effect lack merit. To

begin, Idaho argues that because hospitals have “the

option of ceasing to act” under EMTALA by declining

to participate in Medicare, the appropriate remedy for

any EMTALA violation “is to seek penalties against

hospitals who accept funds but fail to comply with its

requirements,” not to enforce EMTALA by requiring

hospitals to provide emergency treatment that state

law prohibits. Idaho Br. 21 (citing Mut. Pharm. Co. v.

Bartlett, 570 U.S. 472, 488 (2013)). As Idaho recognizes, however, Mutual Pharmaceutical held that “an

actor seeking to satisfy both his federal- and state-law

obligations is not required to cease acting altogether

in order to avoid liability” when federal and state law

conflict; instead, the conflicting state law is preempted. 570 U.S. at 488 (emphasis added). Adherence

to that principle is especially important when the

activity that would need to be halted is participation

in a federal program. Otherwise, any state would be

able to frustrate the implementation of any aspect of

any federal spending program with which the state

disagrees by imposing conflicting requirements or prohibitions on persons subject to the state’s jurisdiction.

Invoking the principle that Spending Clause

legislation “is much in the nature of a contract,”

Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S.

1, 17 (1981), petitioners contend that a federal

program enacted pursuant to the spending power

cannot preempt conflicting state law without the

state’s consent, see Idaho Br. 20; Idaho Leg. Br. 49–51.

But this Court has used the contract-law “analogy” to

ensure that the recipient of the funds understands the

obligations and remedies that are attached to federal

funds and “voluntarily and knowingly accepts the

terms.” Cummings, 596 U.S. at 218–20. This Court

has never suggested that the analogy can be stretched

to the point where the federal statutes that establish

a spending program are not “Laws” within the

meaning of the Supremacy Clause. As this Court

explained in holding that obligations imposed by a

spending program create federal rights enforceable

under 42 U.S.C. § 1983, “‘laws’ indeed means ‘laws.’”

Talevski, 599 U.S. at 177 (citing Maine v. Thiboutot,

448 U.S. 1, 4–6 (1980)). Thus, once the recipient of

federal funding (here, the hospital) has consented to

accept the funding conditions, federal law requires it

to comply notwithstanding any contrary state law.

Consent by the state to the choice-of-law rule imposed

by the Supremacy Clause is not required.

Indeed, if federal spending programs could not

preempt state law, states could override any of

EMTALA’s requirements related to screening,

treating, and transferring emergency room patients,

as well as other Medicare provisions. See 42 C.F.R. pt.

482 (establishing conditions for hospital participation

in Medicare). For instance, Medicare bars states from

imposing “premium taxes” on payments and

premiums paid to Medicare+Choice organizations, 42

U.S.C. § 1395w-24(g), and on prescription drug plans

and sponsors participating in Part D drug plans, id.

§ 1395w-112(g). Medicare also establishes uniform

payment structures for certain entities that

“supersede” state law. See Medicaid & Medicare

Advantage Prods. Ass’n of P.R., Inc. v. Emanuelli

Hernández, 58 F.4th 5, 9 (1st Cir. 2023) (quoting 42

U.S.C. § 1395w-26(b)(3)). Under petitioners’ theory,

these efforts to establish a uniform federal standard

for Medicare would be in question. Given the

devastating effects of petitioners’ proposed rule on

federal spending initiatives, it is not surprising that

they cannot identify any precedent to support the

principle that federally imposed obligations on private

parties depend on state consent for their efficacy.

Moreover, a consent requirement would be wholly

unworkable because it would not resolve the conflict

between federal and state law. That is because, even

assuming state consent were constitutionally required

for state law to be preempted by EMTALA, a state’s

withholding of such consent would not bar

enforcement of EMTALA requirements against

hospitals. Accordingly, the effect of a state-consent

requirement would be to leave both state and federal

laws in effect “like equal opposing powers.” Gibbons,

22 U.S. (9 Wheat.) at 210. That is precisely the situation the Supremacy Clause was designed to avoid. Id.

The Idaho legislature asks this Court to disregard

the constitutional design out of concern that Congress

may use the spending power as “an instrument of

unlimited federal power.” Idaho Leg. Br. 49. As this

Court has held, the “spending power is of course not

unlimited,” but in fact “subject to several general

restrictions.” South Dakota v. Dole, 483 U.S. 203, 207

(1987). The Court there explained that, when the state

is the recipient of federal funds, federal spending

programs must “be in pursuit of the general welfare,”

conditions on funding must be “unambiguous[],” the

conditions must be related “to the federal interest in

particular national projects or programs,” and the

conditions cannot violate “other constitutional provisions.” Id. at 207–08 (internal quotation marks omitted).

EMTALA does not transgress these limits, and

petitioners do not demonstrate that EMTALA imposes

conditions that exceed Congress’s spending power.

Without a showing that EMTALA itself is unconstitutional, there is no basis in the Supremacy Clause,

this Court’s precedent, or logic for concluding that

hospitals are simultaneously required to comply with

their obligations under EMTALA and conflicting state

laws. Accordingly, either EMTALA’s requirements or

Idaho’s abortion restrictions must give way. The

Supremacy Clause supplies the answer. See Bennett,

485 U.S. at 397 (stating that a “‘conflict’ under the

Supremacy Clause” is “a conflict that the State cannot

win”).

CONCLUSION

For the foregoing reasons and the reasons stated

in respondent’s brief, the judgment of the district

court should be affirmed.

Respectfully submitted,