OBSTETRIC-RELATED EMTALA VIOLATIONS POST-DOBBS: A DIFFERENCE-IN-DIFFERENCES ANALYSIS

Abstract

Objectives

EMTALA mandates that hospitals receiving Medicare funding provide stabilizing treatment, which includes abortion. But many states have abortion bans that lack, or only broadly articulate, exceptions related to a pregnant person’s health, leading to significant legal debate. We therefore sought to evaluate the impact of Dobbs v Jackson Women’s Health Organization on obstetric-related violations.

Methods

We used a nationwide sample of federal EMTALA violations (excluding Rhode Island, Delaware, and Hawaii) from 2017 to the end of 2023. We ran a two-way fixed effects difference-in-differences model comparing “conflict” states, ie, those whose state policy had no health exception in the post-Dobbs period (n=6) to non-conflict states. We examined obstetric-related violations as a share of all EMTALA filings as the primary dependent variable and used the 2022 Dobbs ruling as our intervention, employing state and month fixed-effects to account for unobservable differences by location and seasonality in healthcare utilization. We tested alternate treatment groups and examined changes in emergency department utilization as sensitivity analyses.

Results

Difference-in-differences results suggested that Dobbs led to a statistically significant increase in obstetric-related EMTALA violation filings, with 10.5% (95% CI, 8.1-12.9%; p <0.001) more violations filed per month in states with no health exception (Oklahoma, Idaho, South Dakota, Arkansas, Texas, and Mississippi) than in states with a health exception in the post-policy period, from 2022 through 2023.

Conclusions

Our analysis of Freedom of Information Act-acquired data indicates that the Dobbs ruling led to an increase in obstetric-related EMTALA violations when state law conflicted with federal policy.