With a steady but urgent cadence, Dr. Jim Souza told reporters what would become one of the most cited talking points in a protracted legal fight over Idaho’s abortion ban: Without a court order protecting emergency room doctors from prosecution, his hospital system was sending patients to nearby states when certain pregnancy complications meant termination might be necessary.

It was April 2024. Souza said Boise-based St. Luke’s Health System had airlifted six pregnant patients in a span of four months to states where abortion was a legal treatment option in health emergencies. That happened once in all of 2023, a time when a court order kept Idaho from enforcing the ban in those cases.

Souza, the hospital system’s chief physician executive, said Idaho’s law was a looming threat to hospital workers and quality health care. St. Luke’s delivered about 41% of Idaho babies last year.

“Fear is the problem. Fear of prosecution,” Souza said at the time. “And even if it doesn’t occur, it doesn’t fix the jeopardy that is actively eroding our system of care.”

Less than a year later, St. Luke’s is the one major institution — other than advocacy groups — standing in the way of restrictions on emergency abortion care in Idaho, a state with one of the most absolute abortion bans in the country.

The Justice Department on March 5 dropped a lawsuit brought under President Joe Biden that claimed Idaho’s ban, which does not allow abortions to protect a patient’s health, violated a federal law mandating access to emergency medical care. St. Luke’s administrators, who made the same claim in their own lawsuit in January, vowed to press on. A temporary court order in the St. Luke’s case will allow emergency abortions to take place for now.

The abortion lawsuit is the latest controversial stance for a hospital system operating in a state whose political climate treats public institutions — hospitals, libraries, schools, health departments — not as the basic infrastructure of society but as ideological battlegrounds.

St. Luke’s defended its medical staff during the pandemic in 2020 and 2021, when residents objected to masks and vaccines. It took on Ammon Bundy, one of the state’s flagbearers of far-right extremism, whose followers protested against hospital employees caught up in a child welfare case involving the grandchild of one of Bundy’s friends.

St. Luke’s administrators declined to speak with States Newsroom and ProPublica for this story, citing the ongoing litigation.

Idaho Attorney General Raúl Labrador, who is defending against the abortion challenge, has accused health care providers of deliberately misconstruing the ban’s prohibitions. Labrador, whose career was built on being to the right of mainstream Republicans, also has said, without providing evidence, that the reason doctors are leaving Idaho is because they made “the vast majority of their money on abortions, or they wanted to live in a place that allowed abortions.”

The state lost 22% of its OB-GYN workforce and more than half the specialists who handle high-risk pregnancies in the 15 months after the Supreme Court abortion decision, according to a report from the Idaho Coalition for Safe Healthcare.

Odette Bolano, the former CEO of Saint Alphonsus Health System, a St. Luke’s competitor, said health care institutions have historically been reluctant to take on anything with political implications. They often stay neutral because they care for all patients regardless of politics.

But Bolano, who led the Catholic-based system for six years, said everything seems to have taken on political undertones in recent years. She said health systems now have to take difficult positions when they feel something keeps them from delivering safe care.

“The price in reputation — regardless of whatever stance you take and steps you take to safeguard patients, visitors and the community at large — could be significant. It could land you in a very bad place,” she said, “but values, integrity and ability to deliver on commitments have to take precedence.”

In a small state like Idaho, where the population just crossed 2 million, St. Luke’s is a behemoth. It has eight hospitals and ranks among the state’s largest employers, with a workforce of 18,000 and more than $4 billion in revenue.

It’s also a nonprofit and unaffiliated with any national chain or any church, despite its name.

During the COVID-19 pandemic, St. Luke’s took in a crush of critically ill patients. Some had ignored public health advice and listened to people who said vaccines were harmful — including a local pathologist who promoted COVID-19 vaccine skepticism and ineffective treatments, then won appointment to a public health board alongside Labrador.

Leading St. Luke’s through the pandemic turmoil was Chris Roth.

Roth joined the system in 2007. He led its Boise-area operations, worked as the system’s chief operating officer, then became CEO when his longtime boss retired in February 2020.

The next month, Idaho went into shelter-in-place mode with the rest of the world. Blaine County, anchored around the Sun Valley ski resort and a tiny St. Luke’s hospital, became one of the nation’s early COVID-19 hot spots.

Roth and other St. Luke’s leaders spoke out in support of public health measures while a small but loud contingent of Idahoans made a show of defying those measures: burning masks at the state Capitol, staging aggressive protests at the Boise region’s health department and showing up at the homes of that agency’s board members.

Souza, who worked as a critical care doctor and pulmonologist in addition to his leadership role at St. Luke’s, gave sobering warnings about the grave reality he saw in the hospital. In the lead-up to the 2020 holiday season, Souza went on a conservative talk radio show and urged listeners to heed public health advice.

When health care organizations including St. Luke’s announced they would require COVID-19 vaccines for employees, anti-vaccine groups set up protests outside hospitals and clinics belonging to St. Luke’s and others.

Roth described a sense of helplessness and anxiety in a 2021 interview with the Idaho Capital Sun: “We’re deeply concerned about our front-line caregivers, and they are just going through hell. Every day. And then they go out to the community, and it’s business as usual — rodeos, fairs, football games, debates in the school boards.”

He spoke of St. Luke’s doctors who faced laughter from the audience at a school board meeting when they described the scene inside hospitals. “It’s like we’re seeing the de-evolution of humanity, right in front of our eyes,” Roth said.

As the nation was starting to emerge from the pandemic in 2022, another source of anxiety arose for St. Luke’s and its hospital workers: Ammon Bundy. The flashpoint was the hospital’s role in a child protection case involving the infant grandson of one of Bundy’s friends.

After police responded to a child welfare report by the baby’s health care provider, the boy was taken to St. Luke’s, where a doctor determined he was malnourished and in need of care, according to the subsequent lawsuit by St. Luke’s and trial testimony. Bundy showed up at the hospital, demanding the baby be returned to his parents. (The baby was returned six days later. No one was charged with child abuse or neglect.)

Bundy was arrested there and later pleaded guilty to trespassing.

Bundy, a self-proclaimed defender against government tyranny, moved to Idaho from Arizona after prevailing against charges associated with the 2016 armed occupation of the Malheur National Wildlife Refuge office in eastern Oregon and a 2014 standoff over his father’s unpermitted use of federal lands for cattle grazing in Nevada.

During the pandemic, Bundy led a crowd that forced its way into the Idaho House of Representatives. He also founded the People’s Rights Network, an organizing apparatus for people with populist, anti-government and survivalist goals.

Bundy, his friend and their followers took to blogs and social media after the friend’s grandson was taken to St. Luke’s, and they coordinated protests outside the hospital, where they were joined by dozens of people, including far-right legislators.

Those protests came to a head one day when Bundy posted a now-deleted video urging people to go to the hospital and begin “making noise” because he believed the baby was about to be transferred to a foster placement and “we need to go back there and get this straightened out. … This is an emergency.”

Court records say the hospital went on lockdown and sent ambulances elsewhere for an hour as an angry, armed crowd gathered outside. Callers flooded the switchboard and sent profane and threatening emails to hospital staff and executives. Roth would later read one of the emails from a protester aloud in court. It included antisemitic and homophobic slurs and said Roth was “getting strung up along with everyone else who is complacent in the medical tyranny.”

The hospital system and some of its employees, including Roth, sued Bundy, his friend and their associated commercial operations in May 2022, alleging defamation.

The lawsuit accused them of spinning lies that harmed St. Luke’s and its employees — whose names, photos and personal information spread online via Bundy’s allies and the People’s Rights Network.

Roth, in a court filing, said he worried that parents wouldn’t bring in their children for care if they believed St. Luke’s “secretly vaccinates children and engages in child trafficking.” Citing armed protests against St. Luke’s, Roth said it was important for the health system to stand up to bullying and intimidation.

“Inaction would signal that this type of behavior is acceptable in our community,” Roth wrote. “It is not.”

The baby’s grandfather answered St. Luke’s lawsuit by repeating, without evidence, his allegations against the health system.

Bundy told States Newsroom and ProPublica in a recent interview he personally didn’t make false allegations. He called someone else’s claim that St. Luke’s conspired to kidnap children “so ridiculous.” But in a still-public Instagram post, made while the lawsuit was active, Bundy accused St. Luke’s CEO of being “an accessory to child abduction.”

Bundy decided not to participate in the defamation case against him. For more than a year, he ignored the court proceedings and didn’t show up to the trial to offer a defense.

He thought the worst-case outcome would be a $50,000 default judgment, he told ProPublica.

He was wrong.

A jury rendered a $52 million judgment. Bundy and the People’s Rights Network were responsible for about half. His co-defendant filed an appeal, and the appeal request is pending.

Although Bundy did not appeal, his tangle with St. Luke’s wasn’t over. Bundy had a history of defying legal orders. After state officials barred him from the Capitol, police arrested Bundy multiple times for violating that order. After a court sentenced him to community service, Bundy tried to say campaign events during his failed bid for governor counted as service.

St. Luke’s was not going to let go of its courtroom win.

When Bundy sold his property to a friend so that St. Luke’s would have no claim to it, St. Luke’s sued Bundy again — and it now owns the property.

When he continued to defy court orders, St. Luke’s sought contempt charges. While Bundy was being arraigned, the judge threatened him with arrest if, once again, he failed to show up for a trial. Bundy didn’t show, and the judge issued a $250,000 misdemeanor warrant that remains active in Ada County.

Bundy moved to Utah and, in July, filed for bankruptcy.

Within days of the bankruptcy filing, St. Luke’s was on Bundy’s heels once more. The hospital system has since persuaded the bankruptcy court to order Bundy and his wife to show up and answer questions about their finances and assets.

Bundy has called St. Luke’s actions “lawfare.” When asked for comment on his actions since the defamation suit was decided, Bundy said, among other things, “Sounds like another hit piece.”

The public positions St. Luke’s took during COVID-19 and with Bundy were a precursor to its decision to take a stand on abortion as emergency treatment.

“St. Luke’s is here because we care about the pregnant patients in our community, and we want them to receive the emergency care that is available to anyone who presents to an emergency room,” Peg Dougherty, deputy general counsel for St. Luke’s Health System, said outside Boise’s federal courthouse last week.

Idaho’s trigger abortion ban was ready to go two months after the Supreme Court struck down Roe v. Wade’s protections of abortion rights in 2022. It criminalizes the termination of a pregnancy at any stage. Penalties include prison time, and the physician’s medical license can be revoked. There are exceptions for documented rape and incest or to save a pregnant patient’s life, but not to preserve the patient’s health.

Opponents say a health exception is essential in rare cases where emergency abortion is the best treatment option, such as when a patient’s water breaks before the fetus is viable. That can quickly cause a deadly infection.

In a brief to the Supreme Court describing one such case, an abortion rights group said the doctor, whom it did not name, decided it was necessary to wait until the patient’s condition was life-threatening before feeling legally permitted to end the pregnancy. The group described the experience as “traumatic for the patient and torture for the doctor.”

The Biden Justice Department sued the state in 2022. The agency alleged Idaho’s ban conflicts with a federal law, the Emergency Medical Treatment and Labor Act, requiring any emergency room that accepts Medicare to offer stabilizing treatment to every patient who comes through the door.

A series of shifting appeals and court orders in the case left emergency abortion care in Idaho legal, then illegal, then legal again since June. Anticipating that the Trump administration would drop the Biden-era challenge, St. Luke’s sued in January, seeking a new order while the case proceeds. Senior U.S. District Judge B. Lynn Winmill granted St. Luke’s request for a temporary order on March 5, keeping emergency abortions legal while Winmill considers a longer-term injunction.

Dr. Caitlin Gustafson, president of the Idaho Coalition for Safe Healthcare and a practicing family medicine obstetrician, said it is remarkable that St. Luke’s is willing to use its power so that patients and doctors don’t feel abandoned.

“The need for EMTALA isn’t going away no matter what administration is there, and we’re still stuck,” Gustafson said.

She also suspects the lawsuit could be a bulwark against further attempts by politicians and interest groups to dictate the decisions of health care providers.

Physicians and advocates in other states are watching.

Dr. Christopher Ford, an emergency room physician in Wisconsin, has seen the effects of an abortion ban on emergency care, when abortion was effectively prohibited in Wisconsin for 15 months.

“We had patients presenting with partial surgical or medical abortions who were very apprehensive to seek care,” Ford said. “We had very young patients from age 16, up to age 41 or 42, who were essentially septic and at incredible risk of mortality and morbidity.”

He said it seems atypical for a hospital system to take on a lawsuit of this nature, and he is glad to see it.

“It’s definitely a testimony to how important this is and how other hospitals should follow suit,” he said. “Just reading it from the outside looking in, the hospitals are getting involved as a last-ditch effort as the only way to advocate for their patients sitting in front of them.”

When health systems sue, it is typically over business matters. Individual doctors and patients are the usual plaintiffs in abortion cases, along with advocacy organizations like the Center for Reproductive Rights or Planned Parenthood.

For those reasons, St. Luke’s stands out.

“I think it’s a testament to them meeting the moment,” said Melanie Folwell, executive director for Idahoans United for Women and Families, which is organizing an abortion rights ballot initiative for 2026. “We are at an inflection point, and if they don’t act, who will?”