Since the U.S. Supreme Court decided in January to consider a case about whether a federal law regarding emergency medical treatment supersedes an abortion ban in Idaho, air transports out of state for pregnancy complications at one of the state’s largest hospitals have increased from one in all of 2023 to six in the past four months.

St. Luke’s Chief Medical Officer Dr. Jim Souza said if that pace continues, that number could be 20 patients before the year is over.

“We have limited resources in terms of helicopters, fixed-wing transports and ambulances. If we occupy an air transport with a patient who could completely receive the totality of her care right here, safely, it’s potentially dangerous for other patients,” Souza said.

Idaho’s abortion ban went into effect in August 2022, a few months after the U.S. Supreme Court issued its Dobbs v. Jackson Women’s Health Organization decision that overturned Roe v. Wade, ending federal protection for abortion access and allowing states to regulate it instead.

That rise has prompted some Idaho physicians to advise their pregnant patients, or those trying to become pregnant, to purchase memberships with companies like Life Flight Network or Air St. Luke’s in the Boise area to avoid potentially significant costs if they need air transport in an emergency. With or without private insurance, the cost can be thousands of dollars.

“The thought of this becoming the new normal — I don’t want it to be the new normal,” said Blaine Patterson, director of the Air St. Luke’s program, which reported the recent increase in transports by air.

The court will hear oral arguments Wednesday over whether the near-total abortion ban means doctors who may need to terminate a pregnancy to stabilize a patient in a health emergency will have to continue to transfer patients out of state or risk jail time and the loss of their medical license. The U.S. Department of Justice sued Idaho in 2022 over the ban, saying it violated the Emergency Medical Treatment and Labor Act, or EMTALA, which mandates that Medicare-funded hospitals provide stabilizing care for patients who come to an emergency room regardless of their ability to pay.

In a brief submitted to the court leading up to oral arguments, the Department of Justice cited States Newsroom’s reporting from January that without EMTALA protection in place, doctors said they would have to transfer more patients out of state for abortion care rather than wait for conditions to become life-threatening.

A pregnant patient might come to the ER for a variety of reasons, including high blood pressure, bleeding, or one of the most common occurrences, when the patient’s water breaks before a fetus can live outside of the womb, even with medical intervention. It happened 54 times at St. Luke’s Boise in 2023, or about once a week — though not all of those cases occur before a fetus is viable, which is generally considered to be about 22 weeks of gestation.

After the water breaks, there is often still a fetal heartbeat, even though the fetus ultimately won’t survive without amniotic fluid. And in the meantime, infection can quickly spread throughout the body and turn septic, which is life threatening, or it can lead to hemorrhage. Without the ban in place, a doctor would likely recommend termination of the pregnancy to avoid further complications.

But with the ban, maternal-fetal medicine specialists like Dr. Stacy Seyb of Boise aren’t taking any chances by trying to wait until the law’s exception for saving the patient’s life might apply. If termination needs to be considered, he said it’s better in his judgment to send someone to a facility out of state that can freely offer termination before it’s too late. The longer an infection or other complication persists, the greater risk it poses to a patient’s health and ability to get pregnant again in the future.

“And there are times they may not even need the procedure. But we can’t predict that, and we can’t predict how quickly their status might change,” Seyb said. “I think it’s a great hardship, it’s an extra expense to our medical system, and it doesn’t make sense why something that I’ve been doing for 30 years of my career is now taboo.”

Transport has financial, emotional and potentially physical costs

In a brief filed earlier this month by the Alliance Defending Freedom, a religious conservative law firm that has argued several abortion-related cases before the U.S. Supreme Court, including the Dobbs decision, attorneys argued on behalf of Idaho that transport out of state for an emergency termination is in line with EMTALA’s requirements.

“If state law allows a doctor to provide a particular treatment, then that service is available at a hospital for EMTALA purposes. But if state law prohibits a particular treatment, then the facility cannot provide it to anyone, no matter the circumstances,” the attorneys wrote.

Typically, only one support person at most can accompany a patient during air transport. That often means other family members must drive hours away from home in this region of the country, and find a place to stay. Seattle or Portland are seven to eight hours away, while Salt Lake City is about a five-hour drive from Boise. Utah has an 18-week abortion ban with an exception to preserve a pregnant patient’s health.

“It’s tough enough losing a pregnancy, but then to go through this in a foreign land,” Seyb said. “I feel very bad for these patients.”

There are also some patients who simply go home and wait it out, he said, because they don’t have the money or resources for air transport. Those patients may end up back at the emergency room later in worse condition.

According to the National Association of Insurance Commissioners, the average cost of these flights is between $12,000 and $25,000 before insurance is applied, based on an average 52-mile distance. Salt Lake City is almost 340 miles from Boise. Depending on the patient’s insurance plan details, 20% of that cost could still fall to them to pay out of pocket.

The median cost calculated by the Centers for Medicare and Medicaid Services is even higher at $36,000 to $40,000.

Besides the emotional and financial toll, Seyb said, there are delays in care caused by first having to make the decision to transfer and decide where the patient should go, then prep the patient for transport and make the journey while hoping no complications occur en route.

The aircraft is equipped to try to handle those situations, but by definition, it is not as well-equipped as a hospital. The specialty care teams that have to ride along for those transports in case of complications are also tied up for many hours and therefore unavailable to other hospital patients who may need them.

There are also considerations around weather in a mountainous region, said Patterson. In a time-sensitive situation, if there is a severe storm or low visibility for other reasons, it will inevitably delay care further.

“If it’s below weather minimums, we aren’t going anywhere. And those apply to everybody,” Patterson said.

‘You should think about’ membership if pregnant in Idaho

Natalie Hannah, spokesperson for the Life Flight Network, said they have not seen an increase in transports for maternal complications, nor have they seen an increase in membership requests. Life Flight has a reciprocal agreement with Air St. Luke’s and many other regional medical facilities around the West, she said, so coverage would be widespread. A membership with Life Flight costs $85 for one year for a household, while Air St. Luke’s charges $60 for one year. A member is required to have private insurance to qualify.

Patterson said a membership with Air St. Luke’s will cover copays and deductibles, and while he might only have recommended it before for those who recreate outdoors in remote areas or who ride motorcycles, he now would advise people to add pregnancy to the list. Seyb agreed that it made sense as a precautionary measure.

“You should think about it,” Patterson said.