Although the United States does not guarantee health care as a right, federal law states that hospitals cannot deny life-saving emergency care. But a new study finds that restrictive state abortion laws may be affecting the frontline of emergency care, despite federal protections — potentially blocking access to early screening and treatment for pregnancy-related emergencies.
The US Emergency Medical Care and Labor Act of 1986 (EMTALA) requires all Medicare-participating hospitals to screen every emergency department patient and provide stabilization therapy.
EMTALA was written to defer to clinical judgment: It requires hospitals to stabilize emergency conditions using the standard of care, regardless of the type of care required.”
Liana Woskie, assistant professor of community health at Tufts University and lead author of the study
“For pregnant patients, stabilization may mean terminating a pregnancy when it poses a serious threat to the patient’s health,” he continues. “When state laws limit the conditions in which clinicians feel safe to intervene, essential care can be delayed, which directly conflicts with Americans’ right to timely emergency care.”
Both before and after Roe v. Wade was overturned, US state abortion laws varied widely, Woskie notes. Some states allow abortion only to prevent the death of a pregnant patient. Other state abortion bans include a health exception that allows care when continuing the pregnancy would cause serious harm to a patient, such as severe bleeding, infection or loss of fertility.
This new analysis of federal enforcement records found that states with abortion bans that do not have a patient health exception saw what researchers say is a significant increase in pregnancy-related EMTALA violations.
These violations—which carry hefty fines for hospitals and providers and can lead to termination of a hospital’s Medicare agreement and civil lawsuits—are the result of complaints investigations filed with the U.S. Centers for Medicare & Medicaid Services (CMS).
Complaints can be submitted by anyone. But Woskie explains that they are most often filed by health care workers who witness a failure to provide proper emergency care and, less frequently, by patients or their families who say they did not receive proper treatment under the law. CMS and state officials jointly review EMTALA complaints, often relying on state inspectors to investigate. It can take weeks or even months for CMS to finally determine if there has been a breach.
For the study, which was published in the journal JAMA Health ForumWoskie and her colleagues at Tufts and the University of Vermont analyzed every EMTALA violation from 2018 through early 2023. The research used a “difference-in-differences” design, which is a statistical method used to estimate the impact of a policy or event by comparing changes over time between a group affected by the policy and a group affected by a group.
After obtaining EMTALA enforcement records through the Freedom of Information Act from CMS, the team compared those from six states with abortion bans that allowed no health exemption for the pregnant patient — Idaho, Kentucky, Louisiana, Mississippi, Oklahoma and Texas — with a control group of 34 states plus a physical exemption for mental health. The researchers also adjusted for changes in states’ emergency patient volumes.
The study found that there were an additional 1.18 pregnancy-related EMTALA violations per trimester in those states on average after the bans went into effect.
“This results in about five additional EMTALA violations per state per year,” Woskie says. “Each violation represents a hospital in formal violation of federal law. And while the cases are rare, each one reflects a confirmed instance in which a patient did not receive the emergency care they were entitled to.”
Woskie explains that the overall increase was not evenly distributed among the states. Texas—where a restrictive abortion policy went into effect earlier than the rest of the country—showed the clearest early signal of an increase in pregnancy-related EMTALA violations.
The other five states with no-exempt health policies showed a more modest upward trend after Roe v. Wade was overturned in June 2022.
Problematic uncertainty
The study cites qualitative research showing increasing reluctance among clinicians to treat general pregnancy-related emergencies under restrictive state abortion laws, as well as legal literature raising concerns that state laws violate EMTALA.
But until now there has been little empirical evidence of how conflict plays out in practice.
The study also analyzed the types of violations and reported that a significant post-ban increase in medical screening tests and general compliance reports drove the increases in pregnancy-related EMTALA violations. The authors noted that this points to potential harms very early in the emergency care-seeking process, when assessment and triage need to take place.
The findings suggest that in the face of abortion bans without health exemptions, emergency departments may behave more conservatively. “When doctors hesitate, diagnosis can be delayed, conditions can worsen, and the harms that EMTALA was designed to prevent become more likely,” says Woskie.
