Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 1 of 60
`
`UNITED STATES DISTRICT COURT
`
`FOR THE DISTRICT OF IDAHO
`
`
`ST. LUKE’S HEALTH SYSTEM,
`LTD.,
` Plaintiff,
`
` v.
`
`RAÚL LABRADOR, Attorney
`General of the State of Idaho,
`
` Defendant.
`
`
`
`
`
`
`Case No. 1:25-cv-00015-BLW
`
`MEMORANDUM DECISION
`AND ORDER
`
`
`
`
`INTRODUCTION
`
`By design, our national government is a government of limited powers. But
`
`when it acts within the realm of those limited power, the Supremacy Clause makes
`
`clear that the national government is supreme. The Founders correctly perceived
`
`that, for our federal system to work—for fifty states with different cultures and
`
`priorities to nonetheless come together as one nation—Congress must at times
`
`override the states’ dissonant policies. In this, the Supremacy Clause ensures that
`
`the tension between national and state government remains productive rather than
`
`destructive, that our political differences generate a stronger nation rather than
`
`dissolving the country into nothing more than a collection of states. Simply put,
`
`when state law and federal conflict, state law must yield. This case provides an
`
`MEMORANDUM DECISION AND ORDER - 1
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 2 of 60
`
`example of these principles at work in our federal system.
`
`One important area that Congress has chosen to regulate is the provision of
`
`emergency medical services. In response to “patient dumping”—a practice of
`
`transferring or turning away patients deemed undesirable—Congress passed the
`
`Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires
`
`that hospitals receiving Medicare funds provide stabilizing treatment to patients
`
`who arrive with emergency medical conditions. The law ensures that all Americans
`
`in their most vulnerable moments can receive emergency medical care.
`
`EMTALA is decades old and generally uncontroversial. But in one narrow
`
`and heartbreaking circumstance, EMTALA conflicts with Idaho law. When a
`
`pregnant woman arrives in an emergency room experiencing severe complications,
`
`termination of the pregnancy is occasionally the sole treatment that can stabilize
`
`her. In the worst cases, an abortion is necessary to prevent the woman’s death. In
`
`others, the woman’s life is not at risk, but termination is the only way to prevent
`
`serious harms like kidney failure, stroke, infertility, and a host of other life-altering
`
`impairments. Idaho Code § 18-622 allows abortion to save the woman’s life, but an
`
`abortion to prevent any harm short of death is a felony punishable by two to five
`
`years in prison. In these devasting but fortunately rare situations, Idaho law must
`
`yield to EMTALA’s stabilization mandate.
`
`The Court first ruled on this issue in August 2022, when the United States
`
`MEMORANDUM DECISION AND ORDER - 2
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 3 of 60
`
`sought to enjoin Idaho’s abortion ban as it pertained to these emergency abortions.
`
`This time, a hospital system subject to EMTALA has invoked the supremacy of
`
`federal law. The intervening years have only brought into focus the reality of the
`
`conflict. When Idaho’s abortion ban went into full effect for six months in 2024,
`
`St. Luke’s Health System was forced to airlift six pregnant patients with
`
`emergency medical conditions to neighboring states where they could receive the
`
`appropriate care. In contrast, only a single pregnant patient was airlifted in the
`
`entirety of 2023. This sad but illuminating natural experiment shows that Idaho’s
`
`ban on emergency abortions is not compatible with hospitals’ stabilization
`
`obligations under EMTALA.
`
`St. Luke’s has established that it will likely succeed on the merits and that
`
`the Court should preserve the status quo while the parties litigate this matter. For
`
`the reasons explained in this decision, the Court will therefore grant St. Luke’s
`
`motion for a preliminary injunction. During the pendency of this lawsuit, the
`
`Attorney General will be enjoined from enforcing Idaho Code § 18-622 to the
`
`extent that statute conflicts with EMTALA-mandated care.
`
`BACKGROUND
`
`1. EMTALA and the Defense of Life Act
`
`This case concerns the conflict between Idaho’s Defense of Life Act and the
`
`federal Emergency Medical Treatment and Labor Act (EMTALA). Idaho’s
`
`MEMORANDUM DECISION AND ORDER - 3
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 4 of 60
`
`Defense of Life Act criminalizes abortion in nearly all circumstances. When a
`
`pregnant woman experiences a medical emergency, a health care provider may
`
`perform an abortion1 only when “necessary to prevent the death of the pregnant
`
`woman.” Idaho Code § 18-622(2)(a)(i). An abortion performed to prevent any
`
`harm short of death remains a felony punishable by two to five years in prison and
`
`the revocation of the health care provider’s professional license. Id. § 18-622(1).
`
`This criminalization of emergency abortions creates a problem for hospital
`
`systems, which are mandated by EMTALA to provide stabilizing care to any
`
`patient with an “emergency medical condition.” 42 U.S.C. § 1395dd(b).
`
`Specifically, EMTALA requires hospital emergency departments to provide “such
`
`medical treatment of the condition 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). This applies to any patient experiencing
`
`(A) a medical condition manifesting itself by acute symptoms of
`sufficient severity (including severe pain) such that the absence of
`immediate medical attention could reasonably be expected to result
`in-
`
`
`
`
`
`
` 1
`
` Idaho currently defines abortion as “the use of any means to intentionally terminate the
`clinically diagnosable pregnancy of a woman with knowledge that the termination by those
`means will, with reasonable likelihood, cause the death of the unborn child,” except for ectopic
`or molar pregnancies or the “removal of a dead unborn child.” Idaho Code § 18-604(1).
`
`
`MEMORANDUM DECISION AND ORDER - 4
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 5 of 60
`
`(i)
`
`(ii)
`
`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,
`
`serious impairment to bodily functions, or
`
`(iii)
`
`serious dysfunction of any bodily organ or part;
`
`
`
`
`Id. The hospital may transfer the patient to another facility in lieu of stabilization
`
`only when the benefits of the transfer outweigh the risks. Id. § 1395dd(c).
`
`
`
`EMTALA applies to every hospital that has an emergency department and
`
`participates in Medicare. See id. § 1395cc(a)(1)(I). For hospitals that fail to comply
`
`with the statute, EMTALA imposes civil penalties and creates a private right of
`
`action for any individual who suffers harm. Id. § 1395dd(d). Individual physicians
`
`responsible for the examination, treatment, or transfer of patients also face civil
`
`penalties.
`
`2. United States v. Idaho
`
`This Court addressed many of the issues presented here when it granted a
`
`preliminary injunction in United States v. Idaho, 623 F. Supp. 3d 1096 (D. Idaho
`
`2022). In that case, the Court recognized that in certain situations a hospital could
`
`comply with Idaho Code § 18-622 only by violating EMTALA. The Supremacy
`
`Clause of the United States Constitution resolves such conflicts by providing that
`
`federal law preempts contradictory state law. Accordingly, the Court enjoined the
`
`State of Idaho from enforcing the Defense of Life Act in the very limited
`
`MEMORANDUM DECISION AND ORDER - 5
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 6 of 60
`
`circumstances where it contradicts EMTALA’s requirements. The Court later
`
`denied the State’s motion for reconsideration following an Idaho Supreme Court
`
`decision that clarified the scope of the abortion ban.2 See United States v. Idaho,
`
`No. 1:22-cv-00329, 2023 WL 3284977 (D. Idaho May 4, 2023).
`
`The State appealed. The Ninth Circuit initially stayed the injunction but
`
`vacated the stay after ordering a rehearing en banc. United States v. Idaho, 82 F.4th
`
`1296 (9th Cir. 2023) (Mem.). Before the Ninth Circuit could rehear the case,
`
`however, the Supreme Court granted a writ of certiorari before judgment and
`
`stayed the injunction. Idaho v. United States, 144 S. Ct. 541 (2024) (Mem.). Six
`
`months later, the Supreme Court decided it had improvidently granted certiorari
`
`and vacated the stay. Moyle v. United States, 144 S. Ct. 2015, 2015 (2024) (per
`
`curiam). The case returned to the Ninth Circuit, where it remained pending until
`
`the United States filed a stipulation to dismiss the case on March 5, 2025.
`
`
`
`
`
` 2
`
` In August 2022, when this Court first imposed the injunction, Idaho’s abortion criminalization
`statute was even stricter than it is now. The law did not expressly exclude ectopic pregnancies,
`and the exception for the life of the mother was an affirmative defense rather than an exception
`to liability. In Planned Parenthood of the Great Northwest v. State, the Idaho Supreme Court
`determined that the termination of an ectopic pregnancy did not constitute an abortion under the
`statute and that the affirmative defense imposed a subjective rather than objective standard. 522
`P.3d 1132, 1202-04 (Idaho 2023). This Court subsequently held that neither change alleviated
`the conflict between EMTALA and Idaho Code 18-622. Since then, the Legislature has amended
`the statute to exclude ectopic pregnancies and treat a threat to the life of the mother as an
`exception to liability.
`
`MEMORANDUM DECISION AND ORDER - 6
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 7 of 60
`
`3. St. Luke’s Lawsuit
`
`St. Luke’s filed this lawsuit in mid-January 2025, as the transition of
`
`presidential administrations loomed. Although the United States v. Idaho
`
`injunction was in place when it filed, St. Luke’s was concerned that the United
`
`States would dismiss the suit. Those concerns were borne out a few weeks later:
`
`On March 4, 2025, St. Luke’s informed the Court that the United States intended to
`
`dismiss its complaint in United States v. Idaho the next day. St. Luke’s moved for
`
`an immediate TRO to avoid a gap in protections while the Court considered the
`
`merits of a preliminary injunction. After receiving expedited briefing, the Court
`
`imposed a TRO with protections identical to the United States v. Idaho injunction.
`
`The Attorney General then filed a motion to modify the TRO to apply only to St.
`
`Luke’s—rather than all hospitals and medical providers—and to narrow its
`
`substantive scope. As noted above, the Court heard oral argument on March 5,
`
`2025.
`
`4. Findings of Fact3
`
`St. Luke’s operates eight of the 39 hospitals in Idaho that receive Medicare
`
`
`
`
`
` 3
`
` These findings are relevant to the preliminary injunction motion. In considering the Rule 12(b)
`motions, the Court relied on facts alleged in the complaint. The parties did not request an
`evidentiary hearing, so the Court did not hear testimony at the hearing—just argument. The
`Court will therefore make its factual findings based on the evidence in the record here and in
`United States v. Idaho, 22-cv-329, recognizing that such findings are not final. See Univ. of
`Texas v. Camenisch, 451 U.S. 390, 395 (1981); 18B Wright, Miller, & Cooper, Federal Practice
`& Procedure § 4478.1 (3d ed.).
`
`MEMORANDUM DECISION AND ORDER - 7
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 8 of 60
`
`funding and provide emergency services. Idaho has around 22,000 births per year,
`
`and in recent years, St. Lukes has delivered around forty percent of those babies.
`
`Given that volume, it’s not surprising that St. Luke’s cares for pregnant patients
`
`who arrive at the emergency room with medical conditions that threaten their
`
`health, but not their lives. Occasionally—and devastatingly—these patients can be
`
`stabilized only through the termination of their pregnancies. See Seyb Supp. Dec.
`
`¶¶ 5, 9-14, Dkt. 2-2. Stated more precisely, using EMTALA’s defined terms, the
`
`record shows that some patients experience serious (but non-life-threatening)
`
`pregnancy-related complications that qualify as an “emergency medical condition”
`
`where abortion is the only treatment that will “stabilize” them. See, e.g., Seyb
`
`Supp. Dec. ¶ 5, Dkt. 2-2; Corrigan Dec. ¶ 29, US v. Idaho Dkt. 17-6. Yet under
`
`Idaho law, the woman experiencing these conditions must remain pregnant and
`
`endure these harms because her life is not itself at stake.
`
`Examples of these types of conditions include: (1) preterm premature
`
`rupture of the membranes (PPROM), which can result in infection, sepsis, or organ
`
`failure; (2) preeclampsia, which can result in the onset of seizures and hypoxic
`
`brain injury; (3) placental abruption, which can result in uncontrollable bleeding or
`
`organ dysfunction; and (4) uterine hemorrhage, which can require a hysterectomy
`
`or result in kidney failure, requiring lifelong dialysis. Idaho physicians have
`
`submitted declarations describing specific patients who presented with such
`
`MEMORANDUM DECISION AND ORDER - 8
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 9 of 60
`
`conditions.4 Some of these declarations describe patients who were treated before
`
`Idaho’s Defense of Life Act took effect.5 Another describes patients treated during
`
`the few months when this Court’s injunction was stayed. See Seyb Supp. Dec. ¶¶ 9-
`
`17, Dkt. 2-2.
`
`The injunction was stayed for approximately two weeks in late 2023 and for
`
`approximately six months between January and June 2024. During that brief
`
`period—when medical providers faced prosecution for performing emergency
`
`abortions—St. Luke’s had to airlift six pregnant patients in medical crisis to other
`
`states to receive appropriate care. Id. ¶¶ 8-15. In 2023, by contrast, only a single
`
`patient was airlifted the entire year. Id. ¶ 7. Five of the six women airlifted to other
`
`facilities presented with PPROM, and a sixth presented with pre-eclampsia. In each
`
`
`
`
`
` 4
`
` Many of the referenced declarations are on file in United States v. Idaho, No. 22-cv-329. In lieu
`of refiling these already-submitted declarations, St. Luke’s asked the Court to consider the record
`in United States v. Idaho in resolving this motion. See Mtn. Mem., Dkt. 2-1, at 12 n.3. The Court
`will grant that request.
`
` 5
`
` See Corrigan Dec. ¶¶ 8-30, US v. Idaho Dkt. 17-6 (describing three patients who required
`abortions after experiencing, respectively, (1) severe infection due to premature rupture of the
`membranes; (2) placental abruption which other medications and blood products failed to
`mitigate; and (3) preeclampsia with pleural effusions and high blood pressure); Cooper Dec.
`¶¶ 6-12, US v. Idaho Dkt. 17-7 (describing three patients who required abortions after
`experiencing, respectively, (1) preeclampsia with severe features, (2) HELLP syndrome, and (3)
`lab abnormalities consistent with a diagnosis of HELLP syndrome); Seyb Dec. ¶¶ 7-13, US v.
`Idaho Dkt. 17-8 (describing three patients who required abortions after experiencing,
`respectively, (1) a septic abortion, (2) preeclampsia with severe features, and (3) heavy vaginal
`bleeding); see also Fleisher Dec. ¶¶ 12-21, US v. Idaho Dkt. 17-3; Seyb Dec. ¶¶ 4-13, US v.
`Idaho Dkt. 17-8.
`
`
`MEMORANDUM DECISION AND ORDER - 9
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 10 of 60
`
`case, continuing the pregnancy likely would have resulted in serious and
`
`permanent physical harm. Id. ¶¶ 8-14. But because physicians could not conclude
`
`in good faith that abortion was necessary to prevent the women’s death, St. Luke’s
`
`could not provide stabilizing medical treatment.6
`
`Dr. Stacy Seyb succinctly explains the quandary Idaho physicians find
`
`themselves in when attempting to simultaneously comply with Idaho law and
`
`EMTALA during these situations:
`
`Fundamentally, each of these conditions [pre-eclampsia, PPROM,
`placential abruption]—and many more pregnancy complications—
`poses serious risks to pregnant patients, and termination is very often
`the only treatment available to address these risks and stabilize the
`patient. In some cases, these conditions can and do cause death. But
`sometimes, a physician may conclude that although there is not a high
`probability of the pregnant patient’s death, the patient may experience
`impairment or severe dysfunction of bodily organs, including losing
`her reproductive capacity, absent termination of her pregnancy. And
`often, it will simply not be possible for a physician to determine
`whether termination is necessary to prevent her death as opposed to
`some severe harm to the patient short of death.
`
`
`Seyb Supp. Dec. ¶ 5, Dkt. 2-2.
`
`ANALYSIS
`
`1. Motion to Dismiss
`
`Before considering the merits of St. Luke’s Motion for Preliminary
`
`
`
`
`
` 6
`
` Indeed, one of the airlifted patients, diagnosed with PPROM while twenty-two weeks pregnant,
`eventually delivered twins. Suppl. Dec. of Stacy Seyb ¶ 14, Dkt. 2-2. That patient’s case—and
`her happy outcome—underscores the essential incompatibility between the absolutes of Idaho’s
`abortion ban and the ambiguities that define emergency medical treatment decisions.
`
`MEMORANDUM DECISION AND ORDER - 10
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 11 of 60
`
`Injunction, the Court must make a threshold determination of justiciability. The
`
`Attorney General raises three issues here: (1) lack of Article III standing, (2)
`
`prudential unripeness, and (3) sovereign immunity. The Attorney General also
`
`argues that St. Luke’s lacks an equitable cause of action under EMTALA. The
`
`Court concludes that each of these challenges fails.
`
`A. Standing
`
`The doctrine of standing stems from the principle that the federal judiciary
`
`has authority to decide only “actual cases or controversies.” Simon v. Eastern Ky.
`
`Welfare Rights Org., 426 U.S. 26, 37 (1976). The party invoking federal
`
`jurisdiction has the burden of establishing the three elements of standing: “(1) an
`
`‘injury in fact,’ (2) a sufficient ‘causal connection between the injury and the
`
`conduct complained of,’ and (3) a ‘likelihood’ that the injury ‘will be redressed by
`
`a favorable decision.’” Susan B. Anthony List v. Driehaus, 573 U.S. 149, 157-58
`
`(2014) (quoting Lujan v. Defenders of Wildlife, 504 U.S. 555, 560 (1992)). The
`
`present dispute centers on the injury-in-fact requirement for a pre-enforcement
`
`plaintiff. The Attorney General also contends that he is an improper defendant for
`
`the injunction as it pertains to professional licensure penalties and that St. Luke’s
`
`lacks third-party standing to sue on behalf of its providers.
`
`i. Injury in Fact
`
`St. Luke’s brings a pre-enforcement challenge to Idaho’s prohibition of
`
`MEMORANDUM DECISION AND ORDER - 11
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 12 of 60
`
`emergency abortions. A pre-enforcement plaintiff has, by definition, not yet
`
`experienced direct harm from the enforcement of the challenged statute. Peace
`
`Ranch LLC v. Bonta, 93 F.4th 482, 487 (9th Cir. 2024). Nonetheless, the injury-in-
`
`fact requirement does not mean that a plaintiff must suffer “an actual arrest,
`
`prosecution, or other enforcement action.” Driehaus, 573 U.S. at 158. The
`
`possibility of enforcement can in itself constitute an injury, creating a dilemma for
`
`plaintiffs described variously as being forced to choose between “the rock and the
`
`hard place, the Scylla and the Charybdis, and the choice to comply or bet the
`
`farm.” Peace Ranch, 93 F.4th at 487 (quotations and alterations omitted). Thus, a
`
`plaintiff can allege an injury in fact when the circumstances “render the threatened
`
`enforcement sufficiently imminent.” Driehaus, 573 U.S. at 159.
`
`The Ninth Circuit utilizes a three-part test, adopted from Susan B. Anthony
`
`List v. Driehaus, for pre-enforcement standing. First, the plaintiff must allege “an
`
`intention to engage in a course of conduct arguably affected with a constitutional
`
`interest.” Peace Ranch, 93 F.4th at 487 (quoting Driehaus, 573 U.S. at 161).
`
`Second, “[t]he intended future conduct must be ‘arguably proscribed by the
`
`challenged statute.’” Id. (quoting Driehaus, 573 U.S. at 162) (alterations omitted).
`
`Third, “the threat of future enforcement must be ‘substantial.’” Id. (quoting
`
`Driehaus, 573 U.S. at 164). St. Luke’s challenge to Idaho’s ban of emergency
`
`abortion meets each of these requirements.
`
`MEMORANDUM DECISION AND ORDER - 12
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 13 of 60
`
`First, the conduct at issue is “arguably affected with a constitutional interest”
`
`by the Supremacy Clause. St. Luke’s alleges that Attorney General intends to
`
`prosecute emergency-room physicians for complying with their obligations under
`
`EMTALA to provide stabilizing treatment to pregnant patients. To the extent that
`
`Section 18-622 conflicts with EMTALA—an issue taken up below on the merits—
`
`the state law is preempted due to the Supremacy Clause. And because St. Luke’s
`
`compliance with EMTALA in these circumstances implicates the Supremacy
`
`Clause, that conduct carries a constitutional interest.
`
`The role of the Supremacy Clause here warrants some further explanation. It
`
`is true that “the Supremacy Clause is not the ‘source of any federal rights,’ and
`
`certainly does not create a cause of action.” Armstrong v. Exceptional Child Ctr.,
`
`Inc., 575 U.S. 320, 324-25 (2015) (quoting Golden State Transit Corp. v. Los
`
`Angeles, 493 U.S. 103, 107 (1989)). But the present issue is whether the
`
`Supremacy Clause renders St. Luke’s conduct “affected with a constitutional
`
`interest”—which is a different matter entirely. This Court rejects the recent
`
`suggestion by a district court in North Dakota that the statute at issue in a pre-
`
`enforcement challenge “must ostensibly prohibit the exercise of a specific
`
`constitutional right.” See Splonskowski v. White, 714 F. Supp. 3d 1099, 1104
`
`(D.N.D. 2024). Not only is such a requirement far narrower than the test articulated
`
`in Driehaus, but it runs contrary to Ninth Circuit caselaw recognizing pre-
`
`MEMORANDUM DECISION AND ORDER - 13
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 14 of 60
`
`enforcement standing in preemption cases even when a plaintiff’s intended conduct
`
`is not directly constitutionally protected. See Valle del Sol Inc. v. Whiting, 732 F.3d
`
`1006, 1015 (9th Cir. 2013) (preemption challenge to immigration law); Cal.
`
`Trucking Ass’n v. Bonta, 996 F.3d 644, 652-53 (9th Cir. 2021) (preemption
`
`challenge to employee classification law); see also Consumer Data Industry Ass’n
`
`v. King, 678 F.3d 898, 902 (10th Cir. 2012) (plaintiffs met injury-in-fact
`
`requirement for preemption challenge to state credit reporting law).
`
`In short, the Supremacy Clause does not create a constitutional right, but it
`
`does “affect[] with a constitutional interest” St. Luke’s efforts to comply with
`
`EMTALA. This is because the Supremacy Clause resolves a constitutional tension
`
`between the medical treatment which St. Luke’s must provide its pregnant patients
`
`under federal law and that which it can legally provide under state law. For
`
`purposes of standing, this is enough.
`
`Second, St. Luke’s intended conduct—the termination of pregnancies as
`
`stabilizing treatment during medical emergencies—is “arguably proscribed by”
`
`Section 18-622. The Court will take up this statutory conflict further when
`
`discussing the merits of the preliminary injunction, but the Attorney General does
`
`not dispute that St. Luke’s meets this requirement.
`
`
`
`Third, there is a substantial threat of enforcement. The United States’
`
`dismissal of United States v. Idaho has dissolved that injunction, meaning that St.
`
`MEMORANDUM DECISION AND ORDER - 14
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 15 of 60
`
`Luke’s will be immediately subject to the full penalties of Section 18-622 in the
`
`absence of action here. And, contrary to the Attorney General’s arguments, the
`
`United States’ decision to dismiss its complaint did not end the threat of injury to
`
`St. Luke’s. Although the United States may, like any party, change its
`
`interpretation of the relevant law, it cannot unilaterally alter the meaning of a
`
`statute enacted by Congress. See Wyeth v. Levine, 555 U.S. 555, 565 (2009) (“The
`
`purpose of Congress is the ultimate touchstone in every pre-emption case.”). St.
`
`Luke’s would still face the possibility of lawsuits by private litigants harmed by
`
`violations of EMTALA—a risk highlighted by the airlifts of six pregnant patients
`
`during the six-month stay. And of course, the United States could easily change its
`
`position on EMTALA again. The discretion inherent in the executive’s law
`
`enforcement authority underscores St. Luke’s vulnerability in the absence of an
`
`injunction.
`
`Even if the United States had not dismissed the case, a preliminary
`
`injunction in a third party’s lawsuit does not end the threat to others who intend to
`
`engage in the proscribed conduct. A preliminary injunction is a form of provisional
`
`relief designed only “to balance the equities as the litigation moves forward.”
`
`Trump v. Int’l Refugee Assistance Project, 582 U. S. 571, 580 (2017) (per curiam).
`
`Due to the temporary nature of the remedy, the Supreme Court has held that a
`
`preliminary injunction does not alleviate the threat of injury and therefore does not
`
`MEMORANDUM DECISION AND ORDER - 15
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 16 of 60
`
`deprive a plaintiff of standing. Nielsen v. Preap, 586 U.S. 392, 403 (2019)
`
`(“Unless that preliminary injunction was made permanent and was not disturbed on
`
`appeal, these individuals faced the threat of [injury].”); see O.A. v. Trump, 404 F.
`
`Supp. 3d 109, 145-46 (D.D.C. 2019) (“Preliminary injunctive relief does not defeat
`
`Article III standing.”). Indeed, the periodic stays of the injunction in United States
`
`v. Idaho illustrate the precariousness of a third party’s reliance on another’s
`
`lawsuit.
`
`
`
`Accordingly, St. Luke’s has established pre-enforcement standing to
`
`challenge Idaho Code § 18-622 to the extent that the law conflicts with EMTALA.
`
`ii. Licensure Penalties
`
`The Court now turns to a more limited question of standing: whether the
`
`Attorney General is the correct defendant for an injunction against Section 18-
`
`622’s licensure penalties. The Attorney General argues that this aspect of the
`
`injunction cannot run against him because he does not enforce the professional
`
`boards’ rules and laws. This objection overlooks the fact that licensing penalties
`
`for violating the abortion ban are available only after a criminal conviction—
`
`indeed, such a conviction appears to be a mandatory trigger. See § 18-622(1)
`
`(stating that a health care professional’s license “shall” be suspended or revoked).
`
`To satisfy standing requirements, an alleged injury must be “fairly traceable”
`
`to the challenged criminal statute and “likely to be redressed by a favorable
`
`MEMORANDUM DECISION AND ORDER - 16
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 17 of 60
`
`decision.” Matsumoto v. Labrador, 122 F.4th 787, 799 (9th Cir. 2024) (citing
`
`Lujan, 504 U.S. at 560). “An injury is fairly traceable to a challenged action as
`
`long as the links in the proffered chain of causation are not hypothetical or tenuous
`
`and remain plausible.” Id. (quoting Ass'n of Irritated Residents v. EPA, 10 F.4th
`
`937, 943 (9th Cir. 2021)). The Attorney General’s direct causal role in effecting
`
`the licensure penalties easily meets this requirement. As a result, he is an
`
`appropriate defendant for this aspect of the injunction.
`
`iii. Third-Party Standing
`
`The final question of standing concerns St. Luke’s ability to assert claims for
`
`its providers. The Attorney General reads the Complaint as bringing claims on
`
`behalf of individual medical providers, and he accordingly argues that St. Luke’s
`
`must meet the elements of third-party standing. The Court disagrees. St. Luke’s has
`
`clearly brought this claim on behalf of itself. The Complaint includes factual
`
`allegations about the medical providers because St. Luke’s is a hospital system,
`
`and the injury it faces from the enforcement of Section 18-622 derives naturally
`
`from the conduct of the professionals who work there. St. Luke’s own financial
`
`and ethical interests are clearly impacted if its medical providers face
`
`imprisonment and loss of licensure for complying with federal law. But this does
`
`not mean that St. Luke’s seeks to assert the rights of its providers, and nothing in
`
`the Complaint suggests that this is the case. Because St. Luke’s seeks to vindicate
`
`MEMORANDUM DECISION AND ORDER - 17
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 18 of 60
`
`its own rights, third-party standing is a non-issue.
`
`B. Prudential Ripeness
`
`The Attorney General next challenges justiciability by arguing that the
`
`matter is not ripe.
`
`After a plaintiff establishes Article III standing, a court may nonetheless
`
`decline to exercise jurisdiction because the matter is prudentially unripe. Two
`
`considerations guide this analysis: “the fitness of the issues for judicial decision
`
`and the hardship to the parties of withholding court consideration.” Tingley v.
`
`Ferguson, 47 F.4th 1055, 1070 (9th Cir. 2022) (quoting Thomas v. Anchorage
`
`Equal Rts. Comm’n, 220 F.3d 1134, 1141 (9th Cir. 2000) (en banc)). As the Ninth
`
`Circuit recently explained, “[t]he fitness prong is met when “the issues raised are
`
`primarily legal, do not require further factual development, and the challenged
`
`action is final.” Id. (quoting Stormans, Inc. v. Selecky, 586 F.3d 1109, 1126 (9th
`
`Cir. 2009)). The hardship prong considers “whether the challenged law ‘requires
`
`an immediate and significant change in the plaintiffs’ conduct of their affairs with
`
`serious penalties attached to noncompliance.’” Id. at 1070-71 (quoting Stormans,
`
`586 F.3d at 1126).
`
`Regarding the fitness prong, this case is about preemption, which is a
`
`“predominantly legal” question. Pac. Gas & Elec. Co. v. State Energy Res.
`
`Conservation & Dev. Comm’n, 461 U.S. 190, 201 (1983). The existence of a
`
`MEMORANDUM DECISION AND ORDER - 18
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 19 of 60
`
`statutory conflict between Section 18-622 and EMTALA does not, in itself, require
`
`meaningful factual development. The factual questions pertain primarily to the
`
`degree and immediacy of the injury to St. Luke’s, and at this stage the record is
`
`sufficiently developed for the Court to proceed. By detailing the impact of Section
`
`18-622’s full enforcement for six months in 2023, St. Luke’s has provided “a
`
`specific factual context for the legal issues,” such that the claims “do not leave
`
`incomplete hypotheticals or open factual questions.” Tingley, 47 F.4th at 1070
`
`(quoting Stormans, 586 F.3d at 1126).
`
`The Attorney General suggests that more factual development is needed
`
`because the State now claims that emergency conditions like PPROM can be
`
`treated through an abortion “even if the threat to the woman’s life is not
`
`imminent.” Moyle, 603 U.S. at 336 (Barrett, J., concurring). Although this
`
`statement might slightly broaden the life-of-the-mother exception, it does nothing
`
`to address a pregnant woman’s need for stabilizing treatment to stop an injury short
`
`of death.
`
`In each of the cases described in the Seyb Declaration, an abortion did not
`
`appear necessary to prevent the woman’s death, imminent or otherwise, and there
`
`is a callous irony in the Attorney General’s questioning of St. Luke’s decision to
`
`airlift these women out of state. The memorandum asks “why St. Luke’s providers
`
`did not provide an abortion in Idaho if they determined if [sic] was necessary to
`
`MEMORANDUM DECISION AND ORDER - 19
`
`
`
`
`

`

`Case 1:25-cv-00015-BLW Document 49 Filed 03/20/25 Page 20 of 60
`
`save the life of the mother.” Def.’s Consolidated Mem. at 13, Dkt. 25-1. The
`
`answ