Women’s Health Watch: SCOTUS Recap

Delphine O’Rourke, CEO, 8Fold Inc., speaks with Ramona Thomas, General Counsel & Vice President of Risk and Compliance, Planned Parenthood of Orange and San Bernardino Counties, about the recent Supreme Court decisions that impact women’s health. They discuss FDA v. AHM and the use of mifepristone in medication abortions, Moyle v. United States and the conflict between Idaho’s abortion law and EMTALA, and Loper Bright Enterprises v. Raimondo and the end of Chevron deference. They also discuss the practical impacts of these decisions on health care providers and what to expect over the next few months.

AHLA will cover these issues in more depth in a webinar on August 14.

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Transcript

Speaker 1: 0:00

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This episode of A HLA speaking of health law is brought to you by A HLA members and donors like you. For more information, visit american health law.org.

Speaker 3: 0:21

Welcome to the American Health Lawyers Association, women's Health Watch. I'm Delfin O'Rourke, your host, and I'm thrilled to speak today with Ramona Thomas, who is VP and General Counsel of Planned Parenthood of Orange and San Bernardino Counties in California. Um , so this is, we had an opportunity to speak earlier in the month of June and to , um, have the luxury of trying to predict the Supreme Court decisions that we were expecting would be handed down and would have an impact on women's health, reproductive rights, and healthcare generally, because , um, you know , uh, healthcare and women's health cannot be separated. We're 50% of the population and just generally , um, the trends that we see in, in Women's Health overflow ripple into other areas. So , you know, looking at the beginning of June, we had our predictions. Some were correct, others , um, you know, others were not quite spot on . But what we could have never predicted are the events in the past, over the past week and a half , um, that our country has faced everything from an assassination attempt to President Biden , um, effectively stepping down as a , as the nominee for the Democrats. In that additional layer, we were talking about how we thought the elections were gonna impact women's health. Uh , no one was predicting obviously, either of those. And, and all of that will be an overlay. Um, and I think, unfortunately, and understandably, there's been so much activity on the election front that a lot of the Post Supreme Court wrap up that I would've expected to see has just been overshadowed. So that's why one of the many reasons we thought it would be great to regroup and have, you know, what we're gonna call an after action report. What happened in, in June with the Supreme Court, really specifically focusing on two cases, the FDA versus the Alliance for Hippocratic Medicine, which as a reminder, was the challenging, the FDA's approval of Mifa Bri Stone , one of the two drugs that is commonly used for medicated abortions, which are now the most common form of abortion in the United States. And then , um, Idaho versus , uh, Tala and the Mole case regarding , um, whether Idaho Emergency Rooms have to comply with the Department of Health and Human Services guidance and provide emergency abortions , uh, when the a woman's health is, is at issue or at risk. So, those were the two big cases that we like to focus on. And then we're gonna touch on low or bright , um, which many of you , uh, you know, is referred to as sort of , you know, reversing or overruling Chevron deference, and is going to, it's cut back sharply on the power of the federal agencies to interpret the laws that the federal agencies admitter administer. And across the board, you know, this is not just healthcare, it's across the board. They're all , all different types of industries are already deciding what are they gonna do to challenge from automotive to environmental agencies, where they're saying, wait a second. Um, how can we now have courts that are gonna rely on , um, their own interpretation of ambiguous laws and overruling basically 40 years of the Chevron doctrine? Uh , we're gonna touch on just briefly the impact in healthcare, because as we all know, healthcare is the most regulated industry in the United States. So this is going to be to significantly , uh, not just impact women's health, but again, across the board. So, with that recap , um, you know, and say , Ramona, let's, let's start out with Alliance for Hippocratic Medicine. Um, what we were expecting and what happened. Um, and I'll add to that, you know, what has maybe been communicated or, or suggested in the media, you know, Supreme Court sides with or upholds medication, abortion is really not a complete picture, an accurate picture. Um , so let's start with the FDA case.

Speaker 4: 4:20

Yeah, that's absolutely right. Delphine . Uh, you know, one of the things that has been a little bit misunderstood, I think in a lot of the coverage on the Supreme Court decision in the FDA case, was that this was effectively a win for Opry Stone . And unfortunately, it's really not that simple. It really isn't a win. It's really more just kind of a, a punt. It's a, it's a deferral on the actual merits of the case. And, you know, just like you gave a little bit of a recap, just a reminder, this was, this case was originally brought by an anti-abortion group in front of a particularly , um, historically conservative judge in Texas District Court. They challenged the approval and the rules that govern the use and prescription of miry stone , which had been in effect for, you know, miry Stone had been approved for over 20 years, has been approved for abor uh, medication, abortions for up to 10 weeks in the us and the World Health Organization actually approves it up to 12 weeks. Incredibly safe, incredibly effective drug. But essentially, these groups were challenging the ability of medical providers to prescribe and dispense the drugs, trying to assert that they , uh, these organizations and doctors , uh, who objected, were harmed because of economic or professional concerns or potential risks of increased complications. Basically, the , the case kind of turned out how we expected, we knew that the standing issue was going to be paramount, because, you know, just as everybody's aware, in order to get constitutional standing, you have to have a concrete and specific injury that is directly caused by the conduct of the other party and is redress by the court. And here, the big problem was the, the injuries that were alleged were so speculative, so attenuated. The connection between the FDA's action and the individuals who were claiming injury was so , um, so difficult to establish. There was no real causal link between the FDA's actions and the alleged injuries. The case was ultimately resolved exclusively on the grounds of standing. And so, while that's good, because that does help to , uh, you know, eliminate that particular threat to the availability and utility of Mifepristone within the US market. Uh , unfortunately, back in January , uh, the, the district court judge in front of whom this case was resting, did allow for three states to intervene on a different set of allegations. Essentially , um, ca Judge Kame allowed Kansas, Missouri, and Idaho to intervene, and they're alleging like a different group of, of harms. They're alleging that they have potentially increased healthcare costs. They have public health and safety concerns. They also allege that this is a regulatory overreach, and that this is a conflict between federal government and state's rights. So none of those particular injuries were evaluated when the Supreme Court heard the case the first go around , uh, because the injuries are so different. But I think a lot of the , uh, failures of the original injuries are going to persist with these state's allegations. A lot of attenuated, a lot of , um, uh, you know, not specified very generalized grievances. Uh, I think that, you know, the same sorts of concerns are, are likely to be raised with the state's allegations that are gonna be going forward over the course of the next year or so.

Speaker 3: 7:38

So, Ramona, and I'm, I've been thrilled to hear that we have non-lawyers who have been listening to this podcast series. And, and, you know, just, if you're not not familiar with the concept of standing, it's really, it's sort of this basic idea of if you haven't been harmed, and if this court can't, you know, solve your problem, let's say, then you shouldn't even be in court. You can't go to court to complain about somebody else's problem if it hasn't impacted you. So it's not even, you know , whether the merits of the case, it's, do you even have a right to show up in court? It's pretty foundational. So one of the things that was surprising is that, you know, cases usually get dismissed on standing way before they get to the Supreme Court. Um, and, and here it goes all the way to Supreme Court, it's dismissed on standing. So A, that that's surprising. And then b, there's some commentary that, you know, the Supreme Court in a lot of ways gave, gave the , um, plaintiffs a roadmap as to how to sort of , to get a second bite at the Apple. What are your thoughts on that?

Speaker 4: 8:41

Yeah, I think that that's absolutely a fair concern. I think that the concept of this case going all the way up to the Supreme Court on what everyone really understood to be some fundamentally failing standing grounds, showed that the court was evaluating the case, not necessarily because this case was ready for a determination, but because they wanted to establish a framework in which they could make a decision on the merits. And that's, that's kind of concerning, because, you know, first of all, we don't wanna be wasting all of the court's time. And there's a lot of different layers, a lot of different , uh, mm-Hmm , <affirmative> , you know , organizations that were affected by this throughout the course. Anybody who does currently prescribe Miry Stone , there were months there where you didn't know what you were supposed to do tomorrow. How, how ready did we need to be to take Miry stone off the shelves? How likely was it that, you know, enforcement actions were gonna be coming down? And that instability and uncertainty persists now that the case is back at, you know, the, essentially the district court level. Um, you know, there , there's, it's hard to trust reliability on precedent. I mean, when you look at some of the cases that evaluate these sorts of generalized standing grounds, like increased healthcare costs, public health and safety concerns, regulatory overreach, you know, the concern is that the, especially the regulatory overreach component could resonate with the conservative majority that's concerned about federal power. And, you know, when we really try to focus on the Supreme Court's role in maintaining the separation of powers, it's just kinda unclear what to expect the court to , um, expand or contract within the existing jurisprudence in order to make the arguments that are going to be, you know, coming up to the court next time around work. And that's really where we're all paying attention to now, is, is what is the, you know, are they gonna dismiss the state's claims for lack of standing? Is there gonna be a third round of plaintiffs, or are those state's claims going to be able to be , um, you know, expanded or, or accepted in some way that historically might not have been acceptable?

Speaker 3: 10:41

And then precedent , we were saying this, you know, so it's, it's this erosion. We saw this in Roe V, you know , overturning of Roe v Wade with dogs , you know , uh, where, where precedent , um, played a key role saying we're not gonna be bound by it. 'cause it was , um, erroneously decided , um, Chevron, you know, same thing. And in lo or bright 40 years we've been relying on the Chevron doctrine. Oh, no. You know, we're, we're gonna review that. And it's destabilizing, it's destabilizing for patients. It's destabilizing for providers, it's destabilizing for innovation , um, because it does create more risk, or at least an appearance of risk. And, and to try to get funds into , uh, new, innovative solutions is, is chilled , uh, rightly or wrongly. I mean, I, I , I argue that you can de-risk it at least a lot of it. Um , but still it creates this, this , um, energy of we don't know what's gonna happen. Which again, first started with abortion and now , um, surgical abortion and now with Chevron has expanded to every year, every area where we have the administrative procedure act , um, you know , where , which is at play . Um , just a reminder that, you know, really Dobbs focused on , um, surgical abortions, a lot of the state statutes. And then, oops, there was this big loophole in, in ways with medication abortion, and that this is the next, you know, the next frontier. Um, IVF, we already saw that. We've saw, we've seen personhood. This is part of a, you know, just larger attempts, not surprising , um, that we are seeing , um, a pushback on, you know, as you described , federal, you know, federal reach versus state rights and a conservative legal group saying, yeah, this is a war on the administrative state. There has been this unlawful agency overreach. We've seen this over and over, and we're rebalancing. We're gonna, you know, quote from Chevron, return to the judges , um, and that it is part of this return to the states , return to the judges move away from this massive, big government complex that is, is , uh, controlling everything that we do. So a lot of sort of federalism versus state, a lot of, you know, broader questions about how our democracy is run, that, that intertwines in all of this. So when you and I were predicting, we said, yeah, we think it's probably gonna be dismissed. The alliance for Hippocratic Oath on, on Standing, or Hippocratic Medicine, excuse me, on standing, and then Idaho where I'm tall , was at stake, you know , um, you know, three states brought that , uh, brought that case. I'd love for you to go into it in greater detail. I wasn't sure, you know , um, how that could go. And, and I think it was less clear cut yet we're still left with a lot of confusion, more direction, yet still a lot of confusion and not the answers that we were hoping for. What are your thoughts on, you know, and again, right now we're gonna see that , um, providers in Idaho can provide emergency abortions, but that's temporary at best, as the case makes its way through the , uh, judicial system.

Speaker 4: 13:50

Yeah, it's, it's really, it's funny, if you're, if you're at all kind of a legal nerd and you get into some of these Supreme Court decisions, it's amazing how many opinions we got out of a case where the actual holding was that Ari was imply granted. Uh , you know, when you look at Justice Kagan's concurring opinion and Barrett's concurring opinion in Jackson's opinion and Alitos dissent , um, you know, there was a lot of, of dicta and , and , and jurisprudence that was written , uh, that ultimately isn't necessarily binding law, but is a really good indicator for what is likely to be the heart of the matter when this case goes back up to the Supreme Court, which we expect it will as well. Um, so this was one that, you know, essentially the, the real challenge was a question of whether or not hospitals that receive Medicare funding and are subject to Tala , the Emergency Medical Treatment and Labor Act would have to provide stabilizing treatment to patients experiencing medical emergencies, including abortion services, when the state law prohibited abortions except to save the life of the mother. And so, this conflict between what is stabilizing care under EMTALA and what is prohibited care according to the state law, is another question of, you know, federalism versus state's rights and , uh, preemption and supremacy clause. And historically, we'd be looking at things like the Chevron doctrine to try to help determine what , um, you know, what the agencies who are charged with the enforcement of Tala have interpreted tala to mean. But now, as you identified with Loper Bright , it's no longer clear exactly how much the agency , uh, evaluations and their expertise, their evidence, their historic , um, data and research, how much that will weigh into the court's ultimate , uh, weighing of the issues or determination on the issues. Um, so it , that was a , that was another one where essentially we didn't see an answer on the merits. We just saw effectively a , a punt. Um, you know, if you look at the different opinions that were , uh, assigned to the case, you see that each of the justices focuses on a slightly different component of why the case was not ready for review. Um, you know, justice Kagan really wanted to talk about the immediate impact on pregnant patients, but thought that a more fully developed record would be better for a judicial review. Justice Barrett really focused more on procedural grounds and talked about the shifting legal positions that Idaho was taking. And then Justice Jackson was very pragmatic and very focused on the concept that regardless of whatever the, you know, supposed changes in the law were on its textual face. Uh, in practicality, the question still arises. What does a doctor do when a patient's not about to die, but is about to experience a very significant complication that Russ risks significant impairment of her bodily functions. Um, so there's some really interesting content in those opinions, but they're not binding. They're , they're , they're just , uh, information to help explain what happens when this case, or perhaps one of the other m uh , emergency abortion care under EMTALA cases like Texas v er or one of those cases, comes back up to the Supreme Court for review.

Speaker 3: 16:56

So what's, you know, what , why , one of the reasons I I love talking to you is that you have the depth of understanding as you said , would you say sort of a legal nerd , um, which I think is a compliment. And, and also you're, you're in the trenches and you see the impact on, on patients and on providers and, and providers are , you know , caught in the middle. Um, and, and so are so many, you know, the family members of the patients and, and, and everybody who's supporting the, the care journey. What are you te te tell us from your vantage point, what are you seeing? Because, you know, we dive into the decisions. We, you're, you're practicing physician, you're a a , a nurse, you're a whatever, you're not necessarily , um, spending the time or have the background to really dive into these constitutional debates, and you're like, I have patience to see. So what's the, what's the impact? What are you seeing already and what do you predict? Because we don't have more answers, you know , um, Dobbs was to say, let's, let's put an end to this conversation. Let's return it to the states. Let's move on. The Supreme Court shouldn't be involved, and these are two cases that have already come up to the Supreme Court. So what are you seeing , uh, boots on the ground?

Speaker 4: 18:15

So I think, you know, obviously providers, like you said, physicians aren't lawyers, they're not trying to be lawyers. They're trying to provide patient care. They're not trying to interpret the ever-changing legal landscape that applies to the , the circumstances in which they're providing that care. So I think in the, in various states that have the most restrictive abortion bans, regardless of whether or not there's an injunction in place, regardless of whether or not the Supreme Court has declined to make a decision on the merits, there is always going to be at least some chilling effect on the decision making and the actual medical actions that are being taken by the providers , uh, you know, who are in those emergency rooms. Um, you know, I think one of the things that was particularly impactful to me about , uh, justice Jackson's , uh, concurrence and or her opinion was, you know, she really talked a lot about what the experience of the providers were, and some of the amicus briefs that talked about examples in Idaho where doctors lack of certainty prevented them from providing me medically necessary abortions. It wasn't that they knew that the law was in effect, it's that they didn't know, they didn't know what they were allowed to do. They didn't know what decisions they made or, or choices. They, they, they made were going to be second guessed by another provider, by a regulator, by a law enforcement officer. They didn't know what that, you know, what was going to drive that , um, that critical evaluation of the care that they chose to provide. And so you saw patients being airlifted out of the state of Ohio, or I'm sorry, out the state of Idaho , uh, into other states where they could receive the care that they needed to receive. And, you know, that's the, maybe the one good, or the one best thing that came out of that Supreme Court decision was that it lifted the , um, the stay on the preliminary injunction. So essentially, you know, Idaho has the full abortion ban in then in the district court. The district court entered a preliminary junction stopping that ban from being able to go into effect. But then when the Supreme Court granted ti , they stayed the injunction. So essentially the ban was able to go back into effect. And what, you know, one of the really impressive, or , you know, impactful , um, parts of the oral argument in the case was discussion of the fact that the state's largest provider of emergency services had to airlift pregnant women out of Idaho roughly every , every other week during the time that the stay was in place, as opposed to once in all of the prior year when the injunction was in place. So the injunctions in place, again, women in Idaho are temporarily safe again. Um, they have the ability to get these, these , um, abortions when they need them, but that, that uncertainty, that lack of clarity, that concern is always gonna be there. And then you're gonna find physicians who are or are not willing to take the risk to provide the care that they believe needs to be provided in the best interests of the patient. And that's just such a challenging situation to find yourself in as a provider, as a lawyer who's advising providers. It, it is such a , or as a hospital system that has to worry about what the overall risk to the system might be, whether that's, you know, public relations or legal or regulatory or medical malpractice. Um, if the provider makes the wrong decision, it just creates so much complexity. You know, in the access states, the states that have enshrined or codified , uh, protections for abortion services, there's less of a concern about this. You do still have it sometimes in cases where, for example, faith-based organizations or other emergency departments that have , um, really high rates of conscious objections might not be providing , um, even medically emergent abortions. But the, the real risk, the real concern, the real stress is still happening in the states that have really restrictive abortion bans in place.

Speaker 3: 22:15

And , you know, when you look back, and you and I we're , we're both in-house with different health systems, just malpractice, how that was always a gray cloud or, you know, hanging over providers, and now we think, wow, malpractice compared to everything else , um, seems a lot more , um, predictable than , than , than the implications here. Um, you know, whether it is a, a failure to treat , uh, whether it is , uh, additional liability, criminal liability when the states where the statutes provide for criminal liability , um, it's just layering on the risk. And we're seeing just more generally, there was a shortage of obs, a shortage of GYNs, a shortage of ED docs , um, across the country, particularly acute in some of our healthcare deserts. And it's only exacerbated, we've already seen statistics from , um, you know , fellowship applications. You percent already being an OB was a tough lifestyle before, very high , um, high medical malpractice insurance, high risk , um, and, and, you know, young physicians saying, I don't wanna do this. Why would I go in this environment where I am fearful? And we hear this over and over, fearful to provide care, and that's going to impact, you know, all of us, it , your , your primary care physician's doing more, it's gonna put strain, additional strain on the, on the entire system. You know, and that leads me to just more general conversation. This view that, you know, this is just impacts abortion. No , it doesn't quote just impact abortion. Um, there are downstream, there are ripple effects when it comes to privacy billing. I'm just thinking about how are you gonna BI bill for that helicopter airlifting out, you know? So if any of this does impact the work that you're doing, whether you're investing in healthcare or whether your provider or ancillary or SaaS platform to really think comprehensively about the impact on your business, it could be very positive impact and say, wow, this is great. We're, you know, we're a medicated abortion pro provider and we haven't been, you know, there isn't a national ban at this point to really think through, if you're anywhere in , in healthcare, what are the implications? What are the implications on my, on my employees of this uncertainty? How much certainty can we get knowing what we have? Um, so quickly on Chevron, again, and Chevron could be a, a, you know, part se seven part series in and of itself. And in a way, one of the, when I quote sort of benefits of Chevron is just , is that because it doesn't just , um, impact women's health and reproductive health, it's going to get broader attention. Um, so if you could just share , um, you know, and again , uh, we're , this is just playing out, but your thoughts on , um, what it's told us, what it hasn't told us, you know, we're also left with a lot of uncertainty. What's reasonable , um, you know, what is ambiguous? My concern is around, you know , the FDA we already saw with FDA versus , uh, Alliance for Hippocratic Medicine that the FDA is a target. Where do , where does it end?

Speaker 4: 25:45

Yeah. I mean, this is another great example of how the industry that gives rise to the lawsuit is certainly not the only industry affected by the outcome. Uh, you know , the Loper Bright was originally a case that was talking about a commerce department rule that had to do with boat operators , um, paying for monitors to make sure that they were complying with , uh, fishing limits to make sure that fish , right ,

Speaker 3: 26:11

Yeah . Maintain , yeah , it's an interesting sort of , yeah, facts that you're like, wait a second, how do we get these observers, these fisher people, and then all of a sudden it's impacting, you know, whether you're gonna have access to , um, you know, a therapeutic for for cardiac health. Yeah,

Speaker 4: 26:26

Yeah, exactly. I mean, the, the idea is that what the case ultimately challenged was whether or not the court should give any special deference to determinations as to the meaning of laws or the meaning of guidance, or the impact of guidance issued by the agency, the federal agency that is empowered to enforce a particular law. And so, historically, under Chevron deference, we knew that if the, you know, if the EPA is charged with enforcing the Clean Water Act and the EPA interprets the terms of the Clean Water Act in a particular way, the court was going to give deference to the EPAs interpretation of what the terms were because the court trusted the experts and the, the , uh, you know, policy , uh, people who were focused on, and educated in, and experienced in these highly nuanced and complicated and often scientific areas, that the courts were going to give d deference to that expertise. And essentially, what Loper does is says, no, just kidding. The court gives itself the exclusive power over every issue, no matter how detailed, no matter how sophisticated, no matter how scientifically based the court's ultimate determination is going to be , uh, based upon its own reasoning and its own evaluation of the circumstances and evidence, not the , uh, the information provided by expertise or policy , um, leadership coming from administrative agencies. And the, the big concerns in places like this is obviously in concepts like public health, in concepts like, you know, any sort of medical research, any sort of technological advancements, these are issues that can take professionals and experts lifetimes to become , um, knowledgeable and competent in their understanding and evaluation of. So to expect a court, you know, a , a general civil trial court , uh, to expect that judge or that jury to be able to, over the course of even a six month trial, develop, the level of expertise that would be comparable to the guidance that could be provided by these incredibly sophisticated and educated and focused professionals is just not realistic. It's just not, it is just not practical. Uh , and that's one of the things that, you know, justice Kagan spent some really beautiful language on in her dissent in , uh, Loper Bright was talking about how, you know, the meaning of regulatory law will now be up to judges who have never looked at it before the case began, as opposed to policy leaders who have spent their life working on it.

Speaker 3: 29:09

Hey , if you're a judge, you're a district court judge sitting , um, you know, in an area that doesn't usually get these types of cases, and all of a sudden you're gonna be ruling on genomes and you know, the latest in scientific discovery, and hopefully you're not going to trial. I mean, a lot of it's through motion practice it , you know , I , I clerked when I was a, a very young lawyer, and we had both a , in a district court in the eastern District of Pennsylvania, and we had both criminal and civil cases, and the , the docket was so backlogged, I can't even imagine , um, the impact that this is gonna have on district courts across the country, when, to your point, they're gonna be asked unless they start hiring just , uh, you know, armies of experts. And maybe that's good for the expert industry, but just to get through, you know, just to understand even the FDA itself says in sort of new areas, including women's health , um, the F-D-A-F-D-A has been great in partnering and saying, help us understand this new technology, help us understand these new solutions. Because, you know, the cutting edge groundbreaking solutions , um, you know, the FDA is catching up a lot. So it's just, it's gonna be fascinating and scary at the same time to see what the practical impact is, because it's one thing to from up above say, this is how it should be, and then what are we going to see , um, across the country and, and competing. That's another thing that we're not even gonna get into. Uh , but now you're gonna have judges across the country, and we talked about precedent before , um, looking at really, really highly, you know, scientific, highly technical , um, developments and, and trying to, to make sense of those. So , uh, a lot more to come. So Ramona sort of , oh, go ahead. Oh,

Speaker 4: 30:59

I was just gonna offer, and you know, it is important to note that Loper Bright doesn't prohibit courts from taking what the agency has said into account. And so they can still use it, but that's the point, is that they're going to basically be treating it like they'd be treating any other expert testimony. And anybody who has ever litigated, especially in the context of any sort of professional liability, can tell you that that cases come down to a battle of the experts. And oftentimes you can find an expert to say whatever it is that you want them to say. And so the, the less , um, you know , variable, the, the more tempered, the more kind of longstanding interpretations that the agencies have developed over the course of years or decades, and multiple administrations and multiple political alignments, those tend to, you know, like what is the, the Martin Luther King , uh, junior quote, the arc of the moral universe is long, but it bends towards justice. The, the similar concept with the agency interpretations is that the arc of the determination may be long, but it bends towards moderation. Whereas the expert debate that you're gonna get in litigations now is gonna be much more variable and dynamic, and is gonna be much more driven by the arguments of the day as opposed to these long story traditional histories, which is just kind of surprising to see this court , uh, refuse to acknowledge the value of that.

Speaker 3: 32:19

I love that you just quote Martin Luther King Jr. Like that off the top of your head, <laugh>. Um , that's

Speaker 4: 32:24

An easy one. That's a , that's a classic one. You gotta have that .

Speaker 3: 32:27

Yeah , I can't tell a joke and remember the punchline. Um , so, and then the other piece is, you know, why then do you have an f fda a yeah. If they're not the experts, or at least have some deference, and I appreciate it's not, you know, they can, and if, if it's only, if it's confusing, et cetera. But it just again, adds, and that's been one of our themes. It adds a con confusion. And as, as lawyers, one of the things that we like is clarity. You know, it's rule of law and whatever side you are sort of ethically, morally, politically religious, it's, as lawyers, we need more clarity to be able to advise our clients. I mean, we seek that clarity. Um, so this just adds more, more mud , um, to the overall conversation. Um, any sort of last thoughts , um, and what we , we should expect the next couple months, you know , um, in, again, this is up until now doing now in the elections, you know, we're gonna have , um, there's can't even anticipate or predict the events to come. Um, but anything that you're seeing that's coming down the pike that we, you know, we might not have our, our eyes on. I

Speaker 4: 33:31

Mean, I think you're gonna see some legislative responses by individual states that are trying to , um, prepare for, or anticipate or, or prevent the impact of some of these cases in negative ways. Uh , I think you're gonna see the development of cases steps in the, the district court level cases that have now, you know, kind of, that's where the case has gone back to in both , um, the FDA case and the Idaho versus Emtala case. Um, you know, you, you're gonna see the, the normal sort of litigation steps , uh, go forward. And it will be interesting to see in the mole that Idaho case, you know, one of Justice Barrett's big focuses in her opinion was this concept that the law in Idaho had changed so many times that now maybe we don't need to be as worried about the impact of the, the law or the injunction. Well, it'll be interesting to see how the district court takes that. Do they agree? Do they change their opinion on whether or not the injunction should remain in place, or do they maintain the injunction? Because from their perspective, there's still just as much uncertainty as there was before the Supreme Court ever got involved. So I think you're just gonna see kind of the natural sequence, and then you're gonna see legislative responses kind of late to see any new citizen-based initiatives for any ballots or anything. But obviously as we've learned over the past week, you know, no matter how close the election is, things can still get a little dicey in between now and then. So , um, expect a lot of upheaval, just like always.

Speaker 3: 34:57

Ramona, thank you is always fabulous to talk to you and thank you to A HLA for , uh, an opportunity and a platform to raise these issues and continue our organization's engagement on the most pressing issues of facing the healthcare industry.

Speaker 4: 35:14

Thank you very much.

Speaker 2: 35:23

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