Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 1 of 7
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`WENDY J. OLSON, Bar No. 7634
`wendy.olson@stoel.com
`ALAINA HARRINGTON, Bar No. 11879
`alaina.harrington@stoel.com
`STOEL RIVES LLP
`101 S. Capitol Boulevard, Suite 1900
`Boise, ID 83702
`Telephone: 208.389.9000
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`LINDSAY C. HARRISON*
`lharrison@jenner.com
`JESSICA RING AMUNSON*
`jamunson@jenner.com
`SOPHIA W. MONTGOMERY*
`smontgomery@jenner.com
`RUBY C. GIAQUINTO*
`rgiaquinto@jenner.com
`JENNER & BLOCK LLP
`1099 New York Avenue, NW, Suite 900
`Washington, D.C. 20001
`Telephone: 202.639.6000
`*admitted pro hac vice
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`Attorneys for Plaintiff
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`IN THE UNITED STATES DISTRICT COURT
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`FOR THE DISTRICT OF IDAHO
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`ST. LUKE’S HEALTH SYSTEM, LTD.,
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`Case No. 1:25-cv-00015-BLW
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`Plaintiff,
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`v.
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`PLAINTIFF’S SUPPLEMENTAL BRIEF
`IN SUPPORT OF MOTION FOR
`PRELIMINARY INJUNCTION
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`RAÚL LABRADOR, Attorney General of the
`State of Idaho,
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`Defendant.
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`Prompted by the Court’s questions at oral argument on March 5, St. Luke’s submits this
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`supplemental brief to supply the Court with its position as to the role of the Commerce Clause and
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`its role in the preemption analysis in this case.
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 1
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`Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 2 of 7
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`By way of background, St. Luke’s position has always been that EMTALA’s preemptive
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`force does not depend on the source of congressional power that underlies the statute. The fact that
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`Congress legislates under the Spending Clause and imposes restrictions directly on funding
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`recipients does not give state officials license to veto the federal prerogatives set out in that
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`legislation. See St. Luke’s Consolidated Response and Reply in Support of Preliminary Injunction
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`at 12, ECF No. 27 (“Consolidated Resp.”). That conclusion does not threaten the existence of
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`federalism; if it did, such problems would have manifested already, given that the Supreme Court
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`has long understood the Spending Clause to operate just like any other congressional power as it
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`relates to the Supremacy Clause, even when funds flow to parties other than a state. See United
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`States v. Butler, 297 U.S. 1, 65-66, 74 (1936); Lawrence County v. Lead-Deadwood Sch. Dist. No.
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`40-1, 469 U.S. 256, 269-70 (1985).
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`That said, even if the spending power were uniquely limited in terms of preemption, that
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`would not render EMTALA’s stabilization requirement powerless in the face of conflicting state
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`law. That is so because EMTALA could have been enacted under a different Article I power: the
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`Commerce Clause. See Consolidated Resp. at 26 n.7 (incorporating by reference arguments made
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`by the United States on remand to the Ninth Circuit).1 As St. Luke’s explained during the hearing
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`on its preliminary injunction motion and the Attorney General’s motion to dismiss, the Court need
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`not reach this argument to dispose of the Attorney General’s Spending Clause theory. But because
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`1 St. Luke’s preserved this argument by incorporating the United States’ arguments before the en
`banc Ninth Circuit, which included the lawfulness of EMTALA’s preemptive force pursuant to
`the Commerce Clause. See United States v. Idaho, No. 23-35440 (9th Cir. Oct. 15, 2024), ECF
`No. 194, at 55-56. The Attorney General, too, has incorporated the arguments made by Idaho
`before the Ninth Circuit. See Consolidated Memorandum in Support of Motion to Dismiss
`Complaint [Dkt. 1] and Opposition to Motion for Preliminary Injunction [Dkt. 2], ECF No. 25-1,
`at 29.
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 2
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`Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 3 of 7
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`the Court inquired about this issue during the argument on March 5, St. Luke’s offers this briefing
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`to assist the Court in its decision.
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`ARGUMENT
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`I.
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`Spending Clause Limitations Do Not Apply when the Condition on Spending
`Could Be Enacted Directly.
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`In Nevada v. Skinner, 884 F.2d 445, 449 (9th Cir. 1989), the Ninth Circuit held that “if
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`Congress has the authority under an enumerated power (other than the Spending Power) to compel
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`the States through direct regulation to change its practices, then it may also achieve that result
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`through the more gentle commands of the Spending Power[.]” In that case, the court confronted
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`an argument that the Federal Aid Highway Act, by conditioning highway funds on states’ adoption
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`of a 55-mph speed limit, imposed coercive conditions attendant to an exercise of the spending
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`power. The court sidestepped whether the anti-coercion principle limits federal spending authority.
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`Id. at 447-48. That principle was “simply inapplicable” because Congress could have imposed the
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`lower speed limit in question through an exercise of its power to regulate commerce. Id. at 449.
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`The Ninth Circuit in Skinner explained that the “central debate of the Spending Power cases
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`has always been whether Congress may exercise authority beyond the strict limitations imposed
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`by the other enumerated powers specified in the Constitution.” Id. As such, it had gone
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`unquestioned that “the federal government [could] act, under the Spending Power, within the ambit
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`of those other enumerated powers.” Id.; see also Fullilove v. Klutznick, 448 U.S. 448, 475 (1980)
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`(opinion of Burger, C.J.) (“The reach of the Spending Power, within its sphere, is at least as broad
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`as the regulatory powers of Congress. If, pursuant to its regulatory powers, Congress could have
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`achieved the objectives of the . . . program, then it may do so under the Spending Power.”). Simply
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`put, Skinner holds that where another federal power could just as easily effectuate a spending
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`condition as a matter of direct regulation, courts need not ask whether limits specific to the
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 3
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`Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 4 of 7
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`spending power—which exist to rein in the spending authority where it reaches beyond other
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`federal powers—are satisfied. See Skinner, 884 F.2d at 449 (“[I]f Congress has the authority under
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`the Commerce Clause to order a state directly to comply with a particular standard . . . , we see no
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`reason why Congress should be prohibited from reaching that same result indirectly by
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`withholding funds if the state fails to comply with that standard.”).
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`Under Skinner, it is irrelevant whether Congress described EMTALA as a spending statute,
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`a commerce regulation, or neither. “Congress is not required to identify the precise source of its
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`authority when it enacts legislation. It is the duty of Congress to promulgate legislation, and it is
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`the function of the courts to determine whether Congress has acted within the bounds of federal
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`power.” Id. at 449 n.8; see also NFIB v. Sebelius, 567 U.S. 519, 570 (2012) (“The question of the
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`constitutionality of action taken by Congress does not depend on recitals of the power which it
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`undertakes to exercise.” (cleaned up)).
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`Applied here, Skinner compels the conclusion that, because EMTALA could have been
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`enacted under the Commerce Clause (as explained below), the voluntary and knowing
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`requirements for conditions on spending legislation are of no moment in determining whether
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`EMTALA validly preempts Idaho law.
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`II. EMTALA is a Valid Congressional Regulation of Commerce.
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`Congress undoubtedly has authority under the Commerce Clause to enact EMTALA’s
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`stabilization requirement. The Medicare program regulates a complex national healthcare market
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`in which individuals, providers, hospital systems, medical schools, insurers, and other actors are
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`engaged in “existing commercial activity.” NFIB v. Sebelius, 567 U.S. 519, 552 (2012). Congress
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`routinely regulates that commercial activity under the Commerce Clause, including to preempt
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`contrary state law. See, e.g., 42 U.S.C. § 1320d-7(a) (HIPAA); 49 U.S.C. § 41713(b)(1) (Airline
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`Deregulation Act of 1978 addressing, e.g., air-ambulance services); 18 U.S.C. § 1347(a)(1)
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 4
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`Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 5 of 7
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`(making it a crime to “defraud any health care benefit program”); United States v. Bird, 124 F.3d
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`667, 677-78 (5th Cir. 1997) (upholding the Freedom of Access to Clinic Entrances Act under the
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`Commerce Clause).
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`EMTALA, in particular, permissibly regulates commercial activity by creating a minimum
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`federal standard for the provision of emergency healthcare services—services that are then billed
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`and paid for, whether by the federal government, national insurers, private parties, or other sources
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`of funding. Moreover, “[i]t long has been settled that Congress’ authority under the Commerce
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`Clause extends to intrastate economic activities that affect interstate commerce.” Garcia v. San
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`Antonio Metro. Transit Auth., 469 U.S. 528, 537 (1985). EMTALA does just that. The terms
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`under which hospitals provide emergency healthcare, which is an economic activity, affect
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`interstate commerce by affecting the provision of healthcare in other states.
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`That is particularly true in this case. As this Court has already found, absent an injunction,
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`“the capacity of hospitals in neighboring states that do not prohibit physicians from providing
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`EMTALA-mandated care (Washington and Oregon, for example)” would be “pressured as patients
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`may choose to cross state lines to get the emergency care they are entitled to receive under federal
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`law.” United States v. Idaho, 623 F. Supp. 3d 1096, 1116 (D. Idaho 2022). Indeed, the interstate
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`effects of medical providers’ inability to simultaneously comply with both EMTALA and § 18-
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`622 were made clear when St. Luke’s had to airlift six patients out of state during the time when
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`this Court’s injunction was stayed. See Supp. Decl. of Stacy T. Seyb ¶¶ 8-15, ECF No. 2-2.
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`CONCLUSION
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`The Attorney General’s arguments about the limits of Congress’s Spending Clause
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`authority are wrong, but in any event, Congress’s authority to enact EMTALA under the
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`Commerce Clause resolves any doubt that EMTALA is supreme federal law.
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 5
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`Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 6 of 7
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`Dated: March 10, 2025
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`Respectfully submitted,
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` Wendy J. Olson
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`/s/ Wendy J. Olson
`Wendy J. Olson, Bar No. 7634
`Alaina Harrington, Bar No. 11879
`Stoel Rives LLP
`101 S. Capitol Blvd.
`Suite 1900
`Boise, ID 83702
`(208) 387-4291
`wendy.olson@stoel.com
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`Lindsay C. Harrison*
`Jessica Ring Amunson*
`Sophia W. Montgomery*
`Ruby C. Giaquinto*
`Jenner & Block LLP
`1099 New York Ave NW, Suite 900
`Washington, D.C. 20001
`(202) 639-6000
`lharrison@jenner.com
`*admitted pro hac vice
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`Attorneys for Plaintiff
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 6
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`Case 1:25-cv-00015-BLW Document 45 Filed 03/12/25 Page 7 of 7
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`I hereby certify that on March 10, 2025, the foregoing was electronically filed with the
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`CERTIFICATE OF SERVICE
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`Clerk of the Court using the CM/ECF system, which sent a notice of electronic filing to the
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`following persons:
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`Brian V. Church
`brian.church@ag.idaho.gov
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`David J. Meyers
`david.myers@ag.idaho.gov
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`Attorneys for Attorney General Labrador
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`Chad Golder
`cgolder@aha.org
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`Stephen Lee Adams
`sadams@gfidaholaw.com
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`Attorneys for Amici American Hospital
`Association, America’s Essential Hospitals,
`and the American Association of Medical
`Colleges
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` /s/ Wendy J. Olson
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`PLAINTIFF’S SUPPLEMENTAL BRIEF IN SUPPORT OF MOTION FOR PRELIMINARY
`INJUNCTION - 7
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