In 1995, Lois Uttley was working as a reproductive rights advocate in New York when the merger of two hospitals in Troy, a city near Albany, caught her off-guard.
One was secular, the other, Catholic. The secular hospital agreed to abide by rules written by Catholic bishops banning certain procedures deemed “immoral” by the church, like abortion, contraception, in-vitro fertilization and tubal ligation.
Within weeks, Uttley started to receive calls from low income women from a nearby public housing project who said they were being denied birth control.
“Unbeknownst to us, there was an emerging threat to reproductive health access occurring within the health care delivery system,” she said.
A lawsuit filed by Uttley’s then-employer, the nonprofit Family Planning Advocates of New York State, was settled with the merger intact but she resolved not to be taken by surprise again. In 1997, Uttley founded MergerWatch, which tracks secular-Catholic hospital mergers across the United States.
While high-profile legislative restrictions to abortion in states such as Alabama, Louisiana, Georgia and Ohio have been front page news, mergers and acquisitions crafted in the boardroom have largely gone unnoticed — but can have a similar effect. And they’re most prevalent in places like California, Washington and New York, where support for abortion access is high.
It’s hard to pinpoint how many such mergers have taken place. Large hospital systems are typically the product of dozens of mergers. “It would be hard to come up with an exact count,” Uttley said.
What is clear is the Catholic Church’s role in providing health care has expanded dramatically.
While the number of secular hospitals fell between 2001 and 2016, the number of Catholic hospitals rose by 22%. Four of the top 10 largest health systems in the country are now Catholic. One in seven Americans receive healthcare from a Catholic hospital, according to the Catholic Health Association, an advocacy organization that represents the nation’s more than 600 Catholic hospitals.
Catholic hospitals have a long history in the U.S. Orders of Catholic nuns established some of the first hospitals in the country and played a central role in tending the sick as far back as the Civil War.
“It’s the gospel story of the Good Samaritan,” said Sister Mary Haddad, a Sister of Mercy and CEO of the Catholic Health Association. “These huge multi-million dollar, in some cases, billion-dollar health care systems, have evolved because of the work that was done early on.”
Changes in services vary
Both Catholic and secular hospitals have had to adjust to the changing economic realities of the U.S. health care market.
The shift toward value-based care — where hospitals are paid based on patient outcomes rather than how much health care they deliver — and declines in Medicaid and Medicare reimbursement rates have put pressure on hospitals to reduce costs. By joining forces, hospitals aim to share the cost of new equipment and staff, increase their bargaining power with insurance companies, and expand into new geographic markets.
Conscience laws allow Catholic hospitals to refuse services that are otherwise legal, but the degree to which they do that varies. In some cases, secular hospitals maintain their secular identities after the merger. In others, they may be subject to some, but not all of the Church’s rules. Doctors may no longer be allowed to perform abortions, for example, but they can prescribe contraception.
In some cases, though, the consequences for reproductive care are more dramatic. In 2012, for instance, secular Swedish Health Services of Seattle merged with the Catholic system Providence Health. When that happened, Swedish stopped providing elective abortions in all of its clinics.
In most places, being denied a service because of religious restrictions means the inconvenience of having to find a different provider. But in some situations, the result can be dangerous or even fatal.
In Bellingham, Washington, a pregnant woman reported nearly dying after providers at PeaceHealth St. Joseph’s Medical Center refused to terminate her pregnancy. A hospital spokesperson said it does not comment on individual cases but referred to its statement of common values. Overseas, a miscarrying, 17-week pregnant woman in Ireland died of sepsis after her local Catholic hospital refused to abort the fetus.
Low-income women, those in rural areas and women of color are disproportionately affected. A study by the Center for Gender & Sexuality at Columbia Law School found that pregnant women of color are more likely than their white counterparts to receive reproductive health care in a facility governed by Catholic directives.
Some communities only have a Catholic hospital. For women in such places, especially low-income women who can’t afford to travel elsewhere to obtain services, certain types of reproductive care are out of reach.
“If you’re already facing barriers related to income or language or documentation status, this just adds one more thing,” said Debra Stulberg, a medical doctor and researcher at the University of Chicago. “It’s a compounding effect that’s hard to measure.”
Catholic officials point to the lack of secular alternatives in some communities as evidence of the Church fulfilling its charitable mission.
“We’ve stayed in a lot of cities and in rural areas where there’s no money to be made,” said Father Charles Bouchard, an ethicist who works with Catholic hospitals. “We’re doing this out of our mission, because we want to be there.”
Some reproductive rights groups, including Uttley’s, have challenged such claims, saying data shows Catholic hospitals aren’t more likely to provide care to Medicaid or uninsured patients. “They were far behind public hospitals in the provision of that kind of care and only slightly ahead of for-profit hospitals,” she said.
While any merger involving a Catholic hospital must be approved by the local bishop to ensure it won’t violate Catholic principles, governments don’t always assess the potential impact of hospital mergers on people in the community who may lose access to certain types of care.
Many states have a “certificate of need” process, started in the heyday of hospital construction to ensure too many hospitals weren’t built in one place. But that decades-old system hasn’t changed to reflect the trend toward consolidation. Few states require public hearings so community members can weigh in when local hospitals merge. Many women aren’t even aware the hospital where they receive care is Catholic.
To increase transparency, the state of Washington created a law mandating hospitals publicly post their reproductive health policies. Many Catholic providers say the law is unfair.
“Who does advertise what they don’t do?,” said Sister Haddad. “You let the public know what you provide, not what you don’t provide.”
More mergers could mean more limited access
But the costs of being refused service can be high. In Michigan, a woman diagnosed with a brain tumor was denied a tubal ligation following a cesarean delivery at a Catholic hospital. After childbirth is the optimal time for women to have the procedure; otherwise, they have to schedule a second surgery elsewhere at significant additional cost. A spokesperson for the hospital pointed to Catholic rules as the reason for the denial.
A study by the National Bureau of Economic Research found that Catholic hospitals reduce per bed rates of tubal ligations by 31%.
“We can’t be diagnosing patients when they walk in the door and say, ‘We’re not going to do that for you,” said Father Bouchard about the tubal ligation restrictions. “It’s really got to be part of the physician patient relationship. We realize there’s an issue about medical quality and having people do two surgeries and we’re working on that. But I just don’t know how we could make that public.”
For advocates of reproductive access, such as Stulberg, who believes the Catholic Church is imposing its values on too many people who don’t share them, “transparency is not the end solution if people still can’t get the care that they need.”
A report by the Guttmacher Institute, a nonpartisan health think tank that supports reproductive rights, found that 98% of sexually experienced Catholic women had used birth control at some point in their lives, suggesting that even Catholic women want access to at least some services banned by the church.
As Catholic hospital systems grow bigger, the prospects of partnering will become increasingly attractive for secular hospitals. Intended or not, reproductive rights advocates say such partnerships could reduce access to abortion and other reproductive services without a single ruling from the courts.
“We haven’t changed anything,” said Sister Haddad. “This has been how we’ve delivered care from the very beginning.”