Document ID: ./input/supremecourt_opinions/opinions/23pdf/23-726_6jgm.pdf
Page Number: 34.0

Cite as:  603 U. S. ____ (2024) 

11 

ALITO, J., dissenting 

eral law, including . . . EMTALA.” 42 U. S. C. §18023(d) (in-
ternal  quotation  marks  omitted).    Because  this  provision
was placed in a section of the Act concerning abortion, the
Government  infers  that  it  reflects  a  congressional  under-
standing  that  EMTALA  sometimes  requires  abortions. 
Brief for United States 19–20.  That inference is totally un-
warranted.  The provision in question refers to the entire
massive Affordable Care Act, not just the relatively few pro-
visions  concerning  abortion.    Compare  §18023(d),  with
§18023(c) (referring more narrowly to “this subsection”).  It 
reaffirms the duty of participating hospitals to comply with
EMTALA, but it does not expand what the text of EMTALA
requires.13    So  this  provision  cannot  support  the  Govern-
ment’s interpretation of EMTALA either. 

II 
As the previous Part shows, EMTALA’s text and context
decisively  refute  the  Government’s  interpretation.    But 
there  is  a  third  strike  against  the  Government’s  position: 
EMTALA is an exercise of Congress’s spending power.  And 
when Congress relies on its authority to attach conditions 
to the receipt of federal funds, special rules apply.

Spending Clause legislation operates “much in the nature
of  a  contract:  in  return  for  federal  funds,  the  [recipients]
agree  to  comply  with  federally  imposed  conditions.” 
Pennhurst, 451 U. S., at 17.  These conditions do not bind 
unless and until they are accepted, and private parties “can
opt out of spending programs” at will, “completely nullify-
ing  whatever  force  the  spending  conditions  once  had.” 
Health and Hospital Corporation of Marion Cty. v. Talevski, 
599 U. S. 166, 201 (2023) (THOMAS, J., dissenting); accord, 
Townsend  v.  Swank,  404  U. S.  282,  292  (1971)  (Burger,
C. J.,  concurring  in  result)  (“[A]herence  to  [Spending 

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13 Section  18023(d)  also  demands  compliance  with  state  emergency
care requirements, and laws like Idaho’s impose requirements regarding 
permissible emergency care for pregnant women.