WASHINGTON — Outside the front steps of the U.S. Supreme Court on Wednesday morning, anti-abortion groups and abortion rights advocates battled to make their stances known, each wielding signs, stickers and blaring PA systems.

Inside the court’s cool marble walls, the tension over abortion access — specifically whether Idaho can enforce its abortion ban when medical emergencies threaten pregnant patients’ health — pitted Idaho against the U.S. Department of Justice.

Attorneys for each side argued in front of the nine U.S Supreme Court justices Wednesday morning. At times, the hearing seemed tense as the court’s more liberal justices pounced on Joshua Turner, Idaho’s chief of constitutional litigation and policy. In turn, the conservative justices raised substantial questions about U.S. Solicitor General Elizabeth Prelogar’s argument.

The women on the bench seemed especially skeptical of Idaho’s argument. The first half-hour of questioning for Turner came from the four female justices, including conservative Justice Amy Coney Barrett, who questioned the point of bringing the case to the court if, as Turner argued, there is no discord between state and federal law.

But the court is heavily conservative, and that split was apparent as Prelogar stood before the justices. She faced scrutiny from Barrett as well, along with the five right-leaning men on the court. If the justices rule in line with their previous stances on abortion, Idaho could see a majority in its favor.

The case dates back to 2022, when the federal government sued the state over its abortion ban, which went into effect when the Supreme Court overturned Roe v. Wade. While Idaho’s abortion law allows an exception to prevent a pregnant patient’s death, it does not carve out an option for abortion as a means of preserving patients’ health in a medical emergency. Doctors and medical associations told the Idaho Statesman and the court that abortion is a recommended stabilizing procedure for several emergency conditions.

The court’s decision will have broad impacts outside Idaho. At least six other states have similar laws, and others are in the process of implementing more strict abortion regulations, Prelogar told the court.

Does Idaho abortion law conflict with EMTALA?

At the core of the disagreements between the federal government and Idaho is whether the Emergency Medical Treatment and Labor Act, or EMTALA, is in conflict with Idaho abortion law. The Department of Justice — and numerous medical institutions — says there is a conflict; Idaho says there isn’t.

In briefs submitted to the court ahead of the oral arguments, Idaho attorneys said EMTALA neither requires hospitals to perform procedures that violate state law, nor does it expressly mention abortion as a stabilizing treatment. Idaho officials also said attempting to enforce EMTALA over state law opens the door to unconstitutional federal intervention.

In its argument, the federal government noted that EMTALA does not mandate any specific stabilizing procedures. Instead, it leaves medical decisions up to the providers — many of whom told the Statesman they regularly see cases for which abortion is an appropriate procedure to stabilize an emergency patient and protect their health.

Turner’s opening statement asserted that EMTALA does not require doctors to break state laws to provide stabilizing emergency medical care. After just a few minutes of laying out his argument, Turner stood for questions from the justices.

Justices Ketanji Brown Jackson, Sonia Sotomayor and Elena Kagan intensely interrogated Turner’s case, at times cutting his responses short to ask further questions.

The justices asked Turner for clarification on Idaho’s understanding of EMTALA. Turner told Brown that, while he agrees EMTALA imposes a requirement for hospitals to stabilize patients, “the question is the content of the stabilizing requirement.”

Turner also quibbled over some of the language of EMTALA, which requires doctors to stabilize patients with “treatment or accommodations that are available or medically indicated.” Turner said abortion is not a treatment available to doctors holding an Idaho medical license.

Sotomayor swiftly argued against that point. She raised a hypothetical situation in which a state might attempt to limit treatment for diabetes to exclude the usual standard of care.

“No state licensing law would allow a state to say, ‘Don’t treat diabetics with insulin, treat them with pills,’” Sotomayor said.

Turner told the court that Idaho law exists alongside EMTALA. He said in all hypothetical situations of obstetrical emergency presented by the federal government in the case, Idaho law would allow doctors to perform an abortion if they do so in good faith that the procedure will save the patient’s life.

“Nobody’s arguing that these cases don’t raise tough medical questions,” Turner said. “Idaho does not require that doctors wait until (patients) are on the verge of death.”

Justice Amy Coney Barrett, one of the court’s more conservative justices, called Turner out for creating a confusing argument after he told the court exemptions are “case by case.”

“You’re hedging,” Barrett said.

Later she asked Turner where Idaho’s conflict is with EMTALA if the state claims doctors can provide abortions in the hypothetical cases the federal government laid out.

“If there’s no instance where EMTALA and Idaho law clash, then why are you here?” Barrett asked.

Justices question impact of ruling for EMTALA

Prelogar, who grew up in Idaho, argued the federal government’s case. She told the justices that EMTALA is “simple but profound.”

“This case is about how that guarantee (of emergency stabilizing care) applies to women who are pregnant,” Prelogar said.

She, too, faced a rigorous line of questioning.

Justice Clarence Thomas, a conservative voice on the court, opened questioning by raising the issue of whether a spending clause — as he referred to EMTALA — can override states’ criminal laws, setting up the main critique the justices had for the solicitor general.

EMTALA is tied to federal Medicare funding. Hospitals that accept such funding are required to comply with EMTALA.

Thomas told Prelogar he found it “odd” that the regulated body in question — hospitals — were not party to the case. Justice Samuel Alito, the court’s most staunch conservative, doubled down on Thomas’ point.

“How can you impose duties on what Idaho can and cannot criminalize?” Alito asked Prelogar.

Alito also raised the question of mental health and whether a woman experiencing a mental health crisis can receive abortion as a stabilizing treatment. Prelogar said the federal government’s stance is that termination of pregnancy does not constitute treatment for a mental health emergency.

The justices questioned Prelogar over several other aspects of EMTALA and its overlap with abortion. Chief Justice John Roberts asked Prelogar whether the federal government allows exceptions to EMTALA when a physician has a conflict of conscience with a treatment.

“You cannot force a doctor to step over a conscience objection,” Prelogar said. But she noted that, if a hospital fails to employ any doctors who will perform an abortion, the hospital could face penalties under EMTALA for not offering appropriate medical care.

When will court rule on Idaho abortion case?

The justices are expected to issue a ruling on the case in June or July. The court leans conservative, prompting some analysts to predict it will rule in Idaho’s favor.

Idaho Attorney General Raúl Labrador, who attended Wednesday’s case and sat at the front of the courtroom alongside Turner, told reporters after the hearing that he felt confident in Idaho’s argument but was unsure how the court would rule.

“I think it’s really hard to read what the court’s gonna do,” Labrador said. “It’s hard to read the tea leaves.”

He reiterated Turner’s claims that Idaho abortion law exists without conflict with EMTALA and said the Idaho Medical Association has been “trying to confuse people” about when abortion is legal.

“We have been clear on what the law means, and the Idaho Supreme Court was clear about what the law means,” Labrador said.

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