When Rita, a Michigan-based OB-GYN, learned that the hospital where she worked would be switching hands, she was dismayed.
The secular community hospital, Crittenton, had plans to join with Ascension Health, a prominent Catholic nonprofit hospital chain. Rita, who asked that her real name be withheld to protect her identity, knew the transition would profoundly impact her ability to do her job the way she saw fit. The OB-GYN specifically wanted to work at a place where she could practice the full scope of reproductive care, from preventing pregnancy to delivering babies. But now, with the hospital merger looming in the not-so-distant future, that possibility seemed increasingly unlikely.
Rita also understood the change in leadership meant that her patients’ medical options would be limited. That’s because Catholic hospitals follow a set of rules written by the U.S. Conference of Catholic Bishops, which often prohibit doctors from performing basic reproductive services — like contraception, sterilization, in vitro fertilization, abortion — and end-of-life care.
Although Rita knew certain services at the hospital would soon be banned, many of her patients had no idea. They also may not have known that mergers like Crittenton’s are becoming increasingly common.
As hospitals throughout the country struggle with financial woes, many have begun to merge with Catholic systems in order to stay in business. This means a growing number of patients are winding up in institutions guided by religious doctrine. Between 2001 and 2016, the number of hospitals affiliated with the Catholic Church increased by 22 percent. Today, one in six patients in the U.S. is cared for at a Catholic hospital — a troubling trend for health care providers like Rita, who worry that patients are increasingly being placed in centers that provide services based on faith rather than medical necessity.
“I do think as more places are being purchased by Catholic systems it’s going to become more of a problem,” she told ThinkProgress. “To take away the ability to provide services that people need or desire… I think it’s very upsetting both for an OB-GYN and also for a woman. Having those choices gives you the ability to participate in society.”
‘I think it’s very upsetting both for an OB-GYN and also for a woman.’
Rita found another job before the Catholic system moved in. Although she says her decision to leave Crittenton was based on other factors, she admits she probably would have sought employment elsewhere even if those reasons hadn’t come up. Before Rita departed from the hospital, though, she warned her patients about what was to come — and encouraged them to get their tubes tied before it was too late.
As Rita was advising her patients to move forward with their procedures, organizers with the American Civil Liberties Union of Michigan were trying to gin up support for a campaign opposing the Crittenton merger. In June, they arranged an event at a public library in a nearby town to talk about what the shift in leadership would mean for community members. But only six people showed up. “It was so hard for us to connect to anyone who cared,” said Merissa Kovach, a field organizer in charge of the campaign.
The struggle to engage people who could be directly impacted by Crittenton’s transition might not be entirely surprising given the demographic makeup of Rochester, which is predominantly white, conservative-leaning, and upper-middle class. But it suggests another problem that Kovach and others have been struggling to address: A widespread lack of awareness about a conflict that’s quietly brewing in the health care industry. It’s a trend that has managed to accelerate rapidly and yet evade public scrutiny. Because Catholic hospitals aren’t required to disclose their religious affiliation or talk about the limited medical services they may offer, many patients wind up in the dark — and don’t think about the hierarchies that govern their care until it’s too late.
In Rochester, for example, the two systems merged without much of a fuss. But just a few days after Ascension took over the hospital in October 2015, its official website changed ever so slightly. “Tubal ligations” were removed from the list of available services.
The role of Catholics in health care is nothing new — indeed, throughout the Middle Ages, it was the Catholic Church that created hospitals and hospices for the old and ill in an attempt to follow Jesus’ teachings about healing the sick. Many of the earliest hospitals in America were set up by Ursuline sisters and other Catholic orders dedicated to serving the poor. About 75 Catholic hospitals had been established in the U.S. by 1875.
But there has been a particular boom in the number of Catholic hospitals since the beginning of the 21st century, according to a groundbreaking 2013 report on the growth of Catholic hospitals and health systems by MergerWatch, a patients’ rights organization that tracks hospital mergers, and the American Civil Liberties Union (ACLU). In 2001, about 8.2 percent of the nation’s acute care hospitals were Catholic nonprofits. By 2011, that number had jumped to 10.1 percent. This increase coincided with notable drops in the numbers of other nonprofit hospitals and public hospitals.
This trend is accelerating among all hospital chains, too, and not just nonprofits. A recently released 2016 update found that 14.5 percent of all acute care hospitals are now Catholic-owned or affiliated (up from 11.2 percent in 2001) and that four of the nation’s 10 largest hospital systems are Catholic-sponsored. Some of the growth is the result of new Catholic hospitals opening their doors — but many were the result of secular hospitals merging with Catholic systems, bringing them under the Catholic hospitals umbrella.
But while Lois Uttley, MergerWatch’s director, believes Catholic hospitals do deliver “excellent care” in many treatment areas, she and her group are working to shine a light on a major exception. They believe Catholic hospitals prevent many women from getting the reproductive health care they need — even procedures that are medically necessary — ultimately putting them in an untenable situation once they walk through the doors of one of these religious facilities.
Once a hospital elects to merge with the Catholic system, it agrees to obey a set of directives issued by the U.S. Conference of Catholic Bishops. Called the “Ethical and Religious Directives for Catholic Health Care Services” (ERDs), these rules include instructions that Catholic care “should distinguish itself by service to and advocacy for those people whose social condition puts them at the margins of our society and makes them particularly vulnerable to discrimination: the poor; the uninsured and the underinsured; children and the unborn; single parents; the elderly; those with incurable diseases and chemical dependencies; racial minorities; immigrants and refugees.”
Although these large Catholic hospital systems operate in accordance with religious values and doctrine, they aren’t directly funded or controlled by the Catholic Church. As Uttley put it, “they are not being funded by the envelope my mother used to put in the collection basket every Sunday.”
Instead, as tax-exempt nonprofit corporations, they are funded through a combination of private insurance reimbursement, Medicare and Medicaid payments, and sometimes government grants, according to Uttley.
By bringing many hospitals together into large Catholic health systems, they can cut costs through shared administration and joint purchasing, offering protection to hospitals in rural states where isolated health care facilities often struggle. “It’s to their credit, they’ve kept these hospitals operating in very challenging times,” she said.
But the directives also include prohibitions on abortion, even when a woman’s health is at risk; assistance with surrogacy; egg and sperm donation; contraception; and temporary or permanent sterilization, with few — if any — exceptions. And the condoning of or participation in euthanasia or assisted suicide “in any way” is expressly verboten for all who work at a Catholic health care institution. MergerWatch, the ACLU, and the handful of other organizations that track this issue believe these directives often mean even procedures needed to mitigate serious health risk to the patient are unavailable at a Catholic hospital.
The groups also pointed to a troubling lack of transparency: Because Catholic hospitals often choose not to disclose which services are not offered, patients don’t always realize they operate any differently from a secular institution.
Proponents of the Catholic hospital system say the distinction should already be obvious to patients given the facilities’ religious presentation. As the attorney for one Catholic hospital in California that refuses to perform tubal ligation argued in a lawsuit earlier this year, “no one is lacking for understanding that this is a Catholic hospital, from the crucifix in the front entrance to everything about it.”
But that’s not necessarily how providers see it. Nancy, a physician who provided services at Rochester’s Crittenton before the merger and continues to do so today, said the now-Catholic hospital is presented to the public as a secular institution with no disclosure of its restrictions. “I think it is incredibly difficult to understand what limits we have available,” said Nancy, who asked that her real name be withheld because she is still practicing in the field, noting that the names of Catholic hospitals don’t always reveal their religious affiliation. “It’s not Saint Crittenton. It’s not Mary of Christ Crittenton. It’s just Crittenton.”
Ascension and Crittenton did not respond to a ThinkProgress inquiry about their practices. A spokesperson for the Catholic Health Association, which represents hundreds of Catholic hospitals and facilities nationwide, said his group “encourages transparency from Catholic hospitals regarding the services they do and do not offer.”
But Brigitte Amiri, senior staff attorney for the ACLU’s Reproductive Freedom Project, says in practice, that transparency is often absent — putting patients in potentially perilous situations when they’re in urgent need of care.
“The hospital closest to you might be Catholic, you might not know it, you might not think to ask these questions until [you’re facing] an emergency situation or far along in a pregnancy,” she said.
Rachel Miller found herself in that exact situation when she was a patient at Mercy hospital in Redding, California in 2015. Miller, who was pregnant with her second child, was certain she didn’t want to have more kids: In 2013, she had an emergency C-section for her first daughter, and knew she would have to repeat the procedure for the birth of her second child. After she discussed her options with her OB-GYN, she decided a tubal ligation made the most sense — she could get it right after delivering her baby and it wouldn’t require an additional hospitalization.
Miller sent a request to Mercy for the procedure, and assumed it would be approved. Instead, she received a letter back stating Mercy would be unable to accommodate her, citing the Catholic bishops’ directives.
Miller had never heard of the directives before — in fact, she had no idea that the standard of care at Mercy would be any different than what was available at a secular hospital. “I guess if someone had asked me at the time, ‘is this a Catholic hospital?’ I would have said yes, because it’s Mercy, normally a Mercy hospital is Catholic,” she told ThinkProgress. “But I had never thought about it. And as far as Catholic hospitals in general and having ERDs, I had never thought about that either.”
Miller was sure she wanted to get her tubes tied, but after Mercy’s rejection, she found that her options were limited. Redding has only one hospital with a labor and delivery department and the nearest hospital Miller could find that took her insurance was some 160 miles away. That was out of the question — Miller knew she would have to stay at the hospital for several days, and she didn’t want to be away from her toddler for that long. Mercy — the largest hospital provider in California — was her only option, and they just wouldn’t budge.
That was especially concerning to Elizabeth Gill, an attorney at the ACLU of Northern California who later took up Miller’s case. “It’s troubling that your access to health care in such a significant degree in a state like California is dictated by the moral code that corporations subscribe to, especially given that these are entities that are largely state and federally funded,” she said.
‘It’s troubling that your access to health care… is dictated by the moral code that corporations subscribe to.’
The predicament Miller found herself in is becoming increasingly common.
For many patients, Catholic hospitals are now so ubiquitous they may be the closest or only option for care. According to MergerWatch’s most recent report, more than 40 percent of the acute care beds in Alaska, Iowa, Wisconsin, Washington, and South Dakota are in Catholic-owned or affiliated hospitals, and more than 45 Catholic hospitals in the country provide the only acute care in their geographic region. Naturally, this impacts the services available to patients. As Miller experienced, the bishops’ guidelines often prevent doctors from performing tubal ligations after patients deliver, which is the safest time for the procedure.
Moreover, as the National Women’s Law Center noted in a complaint to the Centers for Medicare and Medicaid Services, many Catholic hospitals don’t follow the medical standards of care for what’s known as “miscarriage management,” often by denying services to women experiencing pregnancy complications before viability or in the middle of a miscarriage.
Tamesha Means was 18 weeks pregnant when she showed up at a Mercy hospital in Michigan in December 2010. Her water had broken prematurely. Hospital staff examined Means, but neglected to tell her that the fetus she was carrying had virtually no chance of survival — and in fact posed a risk to her health if she continued to carry it. Means was sent home, but she returned the next day as her bleeding and cramps intensified. Again, she was instructed to go home. Means returned for a third time that night — visibly in pain and showing signs of an infection. The hospital prepared to send her home once again, but stopped when she started delivering. The baby died shortly thereafter, and the hospital staff told Means to prepare funeral arrangements.
The ACLU took on the case, arguing that the directives prevented hospital staff from informing Means of the risk of the pregnancy and directly placed her in harm’s way. “Because of the Directives, MHP did not inform Ms. Means that, due to her condition, the fetus she was carrying had virtually no chance of surviving, and continuing her pregnancy would pose a serious risk to her health,” the lawsuit claimed. As a result, “Ms. Means suffered severe, unnecessary, and foreseeable physical and emotional pain.”
The restrictions on care don’t present a burden for patients alone — working within the system can also weigh heavily on providers who are prevented from performing the full range of medical care they expected to practice as an OB-GYN. According to a 2012 national survey, more than 50 percent of OB-GYNs who work at Catholic hospitals said they’ve run into conflicts with their institutions over the directives. Dr. Didi Saint Louis, a physician in the Southeast who completed her medical residency at a Catholic hospital, is familiar with that tension herself. She remembered seeing a patient who fell extremely ill at an early stage in a nonviable pregnancy. Saint Louis was prohibited from terminating the pregnancy — even though the fetus would not survive — and ended up transferring the patient to another hospital.
“I remember our director riding in the ambulance with the patient, she went straight to the operating room, they terminated the pregnancy, and she was fine,” she recalled. “But it could have gone so many different ways. And while the Catholic hospitals strive to give the best standard of care, this is one area where I think they fall short.”
The impact of a hospital merger can be much more profound for people living in geographically isolated regions without easily accessible alternatives. According to MergerWatch, there are 46 hospitals nationally that provide the only short-term acute care for people in their region, leaving people who lack transportation and travel resources with few alternative options.
Nancy, the physician from Michigan who works with Ascension, says she’s fortunate to be in a region with more than one hospital. “I’m in an area in which my patients can commute or get to a different location, so people in more remote areas are stuck without that,” she said. “Which is a really disturbing trend.”
About 2,000 miles west of Rochester, a Catholic hospital merger brought a very different outcome. In Washington, a battle was waged over the fate of Vashon Island’s only health clinic. Vashon, a quirky island community near Seattle, is home to about 11,000 people, 45 miles of shoreline, and an unofficial mayor who was re-elected in 2015 over a goat named Bandit. It is a Democratic bastion: Mitt Romney received a mere 18.6 percent of the vote in the 2012 elections, to Barack Obama’s 77.6 percent.
In 2012, Mark Benedum, the CEO of the island’s health clinic, announced the board had decided that, due to financial struggles, the time had come “to explore the benefits of joining a larger system.” It reached an agreement to become an affiliate of Franciscan Health System, a chain of Catholic health facilities and part of the behemoth Catholic Health Initiatives.
Benedum initially claimed patients’ options would be unaffected by this union, insisting, “it’s not going to change a thing.”
Vashon’s residents weren’t so sure. A group of skeptics, calling itself Vashon HealthWatch, worried that the island’s sole clinic would now be forced to adhere to the bishops’ directives — and that their care would be limited as a result. After consulting with MergerWatch, they organized a massive town hall meeting where members of the community could question Franciscan and Highline leadership.
On April 25, 2013, weeks after the Franciscan’s purchase of the clinic was complete, about two hundred people packed the multipurpose room at one of the the island’s schools, according to Kate Hunter, who helped organized the event. It was a far cry from the sparsely attended event that took place in Michigan. And not only did people show up, but they’d read the directives and were prepared with specific questions.
Benedum and executives from Franciscan Health Services were peppered with two hours of anxious inquiries from community members about the merger’s impact on available reproductive health and end-of-life services.
Margaret Chen, a staff attorney with the ACLU of Washington Foundation, said this level of civic engagement is atypical. “The visibility of concerned citizens was large in the Vashon Island community, maybe in part because of the unique situation [of being so separated from other options].” This response, she suggested, might have been part of the reason the new ownership agreed to continue offering birth control, family planning, and contraception to patients on the island — though a company spokesperson said the directives are “consistently applied” across all of its facilities.
While the executives sought to assure residents that “nothing is going to change at the Vashon medical clinic,” Hunter wasn’t convinced. She recalled one particularly concerning exchange toward the end of the forum: “Does your contract with your doctors specify that they will follow the directives?” a resident asked. “Yes, they do,” the Franciscan representative answered. “Our employment contract does.”
John Jenkel, who is part of the Vashon-Maury Health Collaborative, a community group that works to improve emergency care options on the island, said the relationship between the new ownership and residents was scarred by that early tension. “[T]hose directives and the manner in which the Franciscans communicated with the community caused a rift that never really made for a comfortable working relationship on our small island,” he said. “The initial discussion that the Franciscans had with the community was a rocky one, and the relationship of the directives to the type of care the Franciscans would be providing was never too clear.”
Hunter stopped going to the Vashon clinic. “I just feel so strongly that no one’s religious beliefs should interfere with my health care and I had no confidence that that would not be the case at the clinic anymore,” she said. Instead, she travels to a secular nonprofit facility in Seattle, via ferry and bus — a 60- to 90-minute trip each way.
When ThinkProgress reached out to Franciscan for comment, spokesperson Scott Thompson said that “none of the practice’s women’s reproductive services changed at the clinic after Highline’s affiliation with CHI Franciscan Health.” However, he added that the Vashon Island clinic would be closing in August. The company attributed the decision to the cost of operating the clinic and the fact that visits had declined from about 1,000 a month when they took it over to between 750 and 850 a month today.
Kate Hunter laments that with the closing, “there will be no health care clinic on Vashon Island. We’re back to ground zero.”
The bishops’ directives were last updated in 2009 and, according to observers, are due to be revised again in the near future. Reproductive rights advocates say a revision could loosen restrictions on how hospitals that become Catholic through mergers may deal with reproductive decisions — or could put the kibosh on the limited flexibility that Catholic chains have shown in places like Vashon Island.
Sara Hutchinson Ratcliffe, domestic program director for Catholics for Choice, fears it will be the latter. “I think the upcoming regulations are going to close those avenues for alternative provision for those health care services, to make the partnership agreements even more strict on who must/must not do this or that,” she said. “I think it will make it worse.”
MergerWatch’s Lois Uttley is a bit more optimistic. “We hope that they will be realistic about the fact that, in this day and age, Catholic hospitals are serving everyone in the community, not just Catholics. And they are employing doctors and staff that come from a wide background of religious affiliation,” she said. “We hope there will be a recognition that all hospitals, including Catholic ones, are licensed to serve the whole community.”
The press office for the U.S. Conference of Catholic Bishops did not respond to a ThinkProgress inquiry about their timetable for an update. But when and if the directives are updated, they could make a huge difference in terms of whether doctors at hospitals that merge with Catholic hospital systems will still be able to provide a full range of services for their patients.
‘We hope there will be a recognition that all hospitals, including Catholic ones, are licensed to serve the whole community.’
In the meantime, several approaches have been contemplated for how to address the topic.
The Center for Inquiry, which advocates for a secular society, thinks that the Medicare and Medicaid funding Catholic hospitals receive could be used as leverage to force Catholic hospitals to provide a full range of reproductive health and end-of-life care. Michael De Dora, who heads the Center’s Office of Public Policy, explained that while he does not believe all individual doctors should be forced to engage in all health care services, all hospitals should. “The responsibility should be with the hospital in any case [if] they’re receiving public funds,” he said. “That is the ideal.”
The ACLU’s Brigitte Amiri noted that some — though not many — states have considered legislation that would shield doctors from punishment, should they choose to provide services forbidden under the directives. After non-discrimination laws and same-sex marriage equality were enacted, several Catholic Charities organizations shelved adoption services rather than serve same-sex couples.
Thus far, the ACLU has concentrated its efforts on the judicial system, threatening and bringing lawsuits under the federal Emergency Medical Treatment and Active Labor Act and state medical laws. Two suits were dismissed at the trial court level, though both are being appealed, and others are still working their way through the courts. In April, for the first time, the 41,000 doctors of the California Medical Association announced they would join an ACLU of Northern California case against a Catholic hospital system that bars its doctors from performing tubal ligation.
Since these and other attempts to force Catholic hospitals to provide services have not yet been met with much success, some activists have focused on making the rules more transparent.
Washington state enacted a requirement that hospitals generally disclose what services they refuse to provide to the state government — which would become public record — but MergerWatch’s advocacy coordinator, Christine Khaikin, observed even that “leaves a lot of room for interpretation to the hospital system,” and few hospitals have reported much of anything.
The American Atheists, a group that advocates for a strict separation of government and religion, have circulated a piece of model state legislation called the Patient’s Right to Know Act. The organization’s national legal and public policy director Amanda Knief said it would simply require that providers “inform their patients up front of all services they’re not going to provide, according to their religious, philosophical beliefs.” This “sunshine law” would not require hospitals to provide an explanation or a referral, she added, but simply a disclosure of which services are not provided there “because we’re Catholic affiliated, or we’re Pastafarian affiliated, or we don’t believe in modern medicine.”
The bill has been introduced in Arizona, and Knief is hopeful other states will soon follow. But, she acknowledges, it may have trouble gaining momentum — some progressive groups have been reluctant to back the measure because it lacks a requirement that the hospital refer the patient to a place that performs procedures prohibited by the directives.
In some communities, MergerWatch has partnered with local advocates to utilize state hospital merger laws and galvanize public actions to force accommodations or block the mergers entirely. “Frankly, totally stopping the merger is our fallback position,” Lois Uttley explained. “What we try to do, from the outset, is make sure that community access to needed reproductive health care services is preserved in some way.” She pointed to one case in which a separately funded and staffed reproductive health care center was opened on the second floor of a newly Catholic hospital that could no longer provide all services under the directives. In another, the community got a local hospital to call off its plans to affiliate with a Catholic system.
But, like with Crittenton Hospital in Michigan, these mergers often fly under the radar. Because the hospitals themselves do not highlight that they are going to begin restricting services, MergerWatch, the ACLU, and a small number of other organizations are often the only early-warning system for communities. And, as Sara Hutchison Ratcliffe of Catholics for Choice pointed out, until more people understand what these mergers mean, it can be an uphill battle for them to galvanize community resistance.
“Awareness isn’t the only solution, but it is the first step,” she said. “Until they are aware, the likelihood of something happening is small… The first step is getting those who have the power to change it involved.”
The fate that awaits Rochester, Vashon, and the numerous other communities that have recently experienced hospital mergers is uncertain. Indeed, some may choose to go the path of resistance favored by Washington’s quirky island community, organizing themselves and arranging well-attended town hall meetings. But, as Merissa Kovach and her coworkers at the ACLU of Michigan experienced while organizing their campaign, getting that community buy-in is often an uphill battle.
“One of the biggest issues with this is that it’s just not well-known at all and nobody understands what these hospitals are doing,” Kovach said. “We’re in such a public education step with this, and it’s such an unknown issue. People don’t know why they should care.”
But why did they seem to know and care in the Washington island? At least some portion of the differences between the two community responses can likely be drawn along political lines — Vashon overwhelmingly leans left, Rochester tilts right. But what took place in the Michigan city might be the more standard course of events: A merger takes place in a community that isn’t predisposed to fight it — or isn’t even aware that it might impact the care they expect to receive — and, as was the case with Rochester, a new merger quietly goes into effect. And the cumulative impact of these mergers, critics say, is an overall reduction in available reproductive services.
So what are the alternatives to Catholic medical care? In some rural communities, there aren’t any — it’s a Catholic system or nothing at all. That’s a sobering reality for people on all sides of the debate, including reproductive health advocates. They recognize that a singular focus on the expansion of the Catholic health care system ignores the forces that often propelled them to step in in the first place. Public hospitals are struggling, and their Catholic counterparts can provide much-needed care. According to the most recent MergerWatch report, the number of public short-term acute care hospitals in the U.S. dropped an astonishing 34 percent between 2001 and 2016. The number of secular nonprofit hospitals, too, shrunk by 11 percent, while for-profit systems shot up by more than 50 percent. In rural areas, where it is harder to turn a profit, these trends have left tremendous disparities in health care access.
Catholic hospitals help fill some of that gap — but at what cost? The ACLU’s Brigitte Amiri worries that hospitals’ fealty to the directives over the standard of care means that for some, the delta between the services they seek and those that are available is becoming a gulf.
“We don’t want to take away health care services from a community that desperately needs them,” she acknowledged. “But I don’t think we can be so timid about our work that we don’t push them to provide health and lifesaving care to women.” Kiley Kroh and Tara Culp-Ressler edited this piece. Cory Herro provided research assistance. Videos by Victoria Fleischer, graphics by Dylan Petrohilos, and illustrations by Laurel Raymond.