For decades, individuals have been guaranteed medical care in emergency departments under federal law. A new study by researchers at Tufts University and the University of Vermont analyzed violations of the Emergency Medical Treatment and Active Labor Act (EMTALA) and found states with strict, no health exception abortion bans experienced a severalfold increase since the U.S. Supreme Court overturned Roe v. Wade. The findings were published today in the JAMA Health Forum.
The researchers examined a full dataset of confirmed EMTALA violations between 2018 to 2023, capturing violations before and after the court’s Dobbs v. Jackson Women's Health Organization decision to understand its effect on federally mandated care in states where abortion is heavily restricted. They found an average quarterly increase of 1.18 obstetric-related EMTALA violations per state amongst the six study states: Texas, Idaho, Mississippi, Kentucky, Louisiana, and Oklahoma.
That figure may sound modest, but is huge from a relative perspective, says Liana Woskie, assistant professor in the Department of Community Health at Tufts and lead author of the study. “On an annual basis, that represents roughly a five- to seven-fold increase.”
And each of those violations represents a human being experiencing a pregnancy-related emergency who did not receive the screening or stabilizing care the law requires, she says. “Even a single failure at that moment can mean preventable intensive care, loss of fertility, or, in the worst cases, loss of life.”
The researchers emphasize that EMTALA violations represent an undercount of such events because of the complicated nature of even reporting them. Each data point is the result of someone—potentially a patient or medical provider—observing a problem and filing a complaint with the Centers for Medicare & Medicaid Services to investigate, which they in turn confirm.
“This uptick in violations is sort of a tip of the iceberg measure,” says co-author Jonathan Shaffer, assistant professor in the Department of Sociology at the University of Vermont. “There's so much below the surface here that the fact that we're able to detect this means that there's so much more denial of care, services, and then the health effects that come from that.”
Given the rarity of EMTALA violations, Shaffer says, the fact that they could still detect a rise makes their findings hard to dispute. “This is as conservative a bellwether I think you could devise, and I think that should give us even more confidence that this is a signal—and an important one.”
Uncovering the impact of Dobbs
Until recently, much of the reporting on the health effects of the Dobbs decision has been qualitative accounts, legal scholarship or limited to specific stories of pregnant individuals who died or suffered complications after being denied care. The EMTALA dataset was obtained by Shaffer from the Centers for Medicare &Medicaid Services using a Freedom of Information Act request and shows that high-profile cases in the news are not isolated incidents. Earlier this year a study published in JAMA showed higher than average cases of infant mortality in the 14 states with abortion bans, and an investigation in Propublica found maternal deaths from sepsis rose 50 percent in Texas.
“This is as conservative a bellwether I think you could devise, and I think that should give us even more confidence that this is a signal—and an important one.” - Jonathan Shaffer
The EMTALA dataset is unique. It detects substantiated violations of the law, not health effects from states with extreme abortion bans. The research team does not know what happened to specific patients, but the data indicates the date, type of violation, and the facility where it occurred. While obstetric violations rose in states with restrictive bans, these patterns were not observed across other categories. Altogether, it paints a picture of confusion for emergency departments in states with abortion bans without health exceptions.
“I think what those violations represent is the ambiguity that the state versus federal law represents for clinicians,” Shaffer says. “In states with the no health exception bans, basically emergency departments have to choose: do they do they follow state statute, or do they do they follow federal law?”
Their findings suggest that emergency departments are deferring to state law, likely out of fear of legal repercussions. The largest increase in EMTALA violations was found in Texas, which passed Senate Bill 8 prior to the Dobbs decision and allows any private citizen to sue healthcare providers who perform or induce an abortion in a person after six weeks of pregnancy. The analysis also observed upticks in failure to provide medical screenings to obstetric patients in emergency departments.
“A central takeaway is that hospitals in states with no-health-exception bans appear to defer to state policy over federal law,” Woskie says. “Under the Constitution’s Supremacy Clause, federal law is always meant to prevail when the two conflict. Legal scholars have raised that no-health exception abortion bans are in tension, and qualitative research describes the chilling effect on clinicians. We build on this work by providing the first quantitative evidence linking the adoption of these state bans to a clear and measurable rise in obstetric EMTALA violations in practice.”
A potential chilling effect
The research team’s analysis occurred prior to Texas House Bill 7, which goes into effect today and allows private citizens to sue out of state providers for providing abortion pills to Texans. Currently—medication abortions comprise 60 percent of abortions nationwide, and nearly all of the abortions in states with abortion bans, according to the Center for Reproductive Rights.
Woskie suspects the new law will provide a similar chilling effect on out-of-state telehealth providers who mail abortion pills to Texans, “threatening one of the last practical routes for early gestation medication abortion.”
Earlier this year, the Trump Administration rescinded guidance reaffirming the obligation under EMTALA of hospital staff to provide abortion care to patients in medical crisis. Without clear guidance from the courts, clinicians may be hesitant to perform the medical care they are federally required to give patients. An earlier paper, coauthored by Shaffer and colleagues, showed the spatial clustering of EMTALA-violating affiliated hospitals within health systems across the west, southeast, and northeast. They also found that violating hospitals most often had for-profit status, multiple ownership changes since 2016, served lower-income patients, and were concentrated in urban locations.
“EMTALA is one of the few rights to healthcare we have in America, and the Dobbs decision is in direct conflict with it when states implement abortion bans,” says Shaffer. “At the end of the day the Supreme Court is going to have another very momentous kind of decision on their hands with how they adjudicate states responsibilities to follow federal law.”