With Catholic health systems expanding, stricter rules could have implications for reproductive and maternity care across the country
The 2011 merger of the two remaining hospitals in Troy, N.Y., had many potential benefits —and one huge hurdle.
Samaritan was secular, committed to providing the widest possible spectrum of reproductive and maternity care to its Albany-area patients. St. Mary's was Catholic, limiting or banning many reproductive options— and any merger partner had to abide by the same rules.
It took several years of negotiations among three different health systems, much back-and-forth with women's advocates, and the sign-off of the local bishop. But in the end, the parties struck a deal that all of them could live with. The centerpiece was the brand-new Burdett Care Center, housed on Samaritan's second floor.
To all appearances, Burdett was a typical maternity ward. But in reality, it was a separately incorporated hospital-within-a-hospital, secular and thus free from the Catholic restrictions that Samaritan had agreed to follow. Burdett could provide birth control and perform tubal ligations; if a woman was having a miscarriage or ectopic pregnancy, doctors could treat her according to generally accepted standards of care.
Complicated? Yes. Cumbersome? Very. Still, as a compromise to preserve access to care in Troy, "it's worked very well," said Lois Uttley of the nonprofit group MergerWatch, which helped broker the arrangement.
Soon, though, compromises between Catholic health systems and their non-Catholic partners may be rarer and harder to achieve — and that could have profound implications for women's access to reproductive services in hundreds of communities across the U.S.
The U.S. Conference of Catholic Bishops is meeting in Baltimore this week, and members are considering whether to begin the process of revising — and likely tightening — its directives governing health care mergers and partnerships. The goal, according to a USCCB press release, would be to incorporate Vatican principles ensuring that Catholic institutions do not “cooperate immorally with the unacceptable procedures conducted in other health care entities with which they may be connected” or “cause scandal” as a result of such collaborations.
The USCCB — whose members oversee Catholic health care systems in their individual dioceses — didn't respond to a request for an interview about what the new directives might say or how the revision process might proceed. A spokesman for the Catholic Health Association of the United States, whose members control 1 in 6 hospital beds around the country, also declined to comment.
But women's groups and consumer advocates are worried. Stricter rules, they say, would probably doom workarounds like the Burdett center — and could affect everything from employment contracts for doctors and nurses at Catholic facilities to deals with third-party suppliers such as testing labs.
"The scope of Catholic health care in this country is big," said Sara Hutchinson Ratcliffe, domestic program director for Catholics for Choice in Washington, D.C. "The restrictions on reproductive healthcare that [the bishops] already place on Catholic health systems are far-reaching and growing. Any changes the bishops make to further limit [care] ...
should be very concerning to everyone."
The move to revise the rules, last updated in 2001, comes against a backdrop of unprecedented growth in Catholic health care over the past decade, especially since the passage of Obamacare. According to a report last year by MergerWatch and the American Civil Liberties Union, the number of Catholic-sponsored hospitals jumped 16 percent from 2001 to 2011, even as the overall number of hospitals dropped by 6 percent and the number of secular community hospitals plunged by 31 percent. Catholic hospital systems now make up four of the five largest nonprofit health-care networks in the U.S., Hutchinson Ratcliffe said.
Meanwhile, the reach of Catholic health care is expanding in new and ever more complex ways, thanks to an explosion in networks —such as integrated delivery systems and accountable care organizations — in which regional providers come together to coordinate all the care for the local population. Catholic health systems have even begun purchasing insurance companies. These kinds of deals have created "a brave new world for Catholic health care," Uttley said, increasing the potential for conflict between religious values and secular standards of medical care. "The question for the bishops," she added, "is how are they going to respond to these changing dynamics."
Under longstanding USCCB policy, when Catholic and secular health organizations merge or affiliate, the non-Catholic one must agree to "respect church teaching and discipline."
Those teachings — along with the guidelines on mergers and partnerships —are laid out in a document called the Ethical and Religious Directives for Catholic Health Care Services, which governs every Catholic hospital, clinic, nursing home, and health-care business in the country. The 72 directives ban elective abortion, sterilization, and birth control. They also restrict fertility treatments, genetic testing, and end-of-life options.
In some instances, the ERDs have been interpreted to limit crisis care for women suffering miscarriages or ectopic pregnancies, emergency contraception for sexual assault, and even the ability of doctors and nurses to discuss treatment options or make referrals. The impact of the directives is felt especially in communities —often in rural areas — served by just one hospital. In Bartlesville, Okla., for example, the only medical center in town tried to force all OB/GYNs with admitting privileges to stop prescribing birth control to female patients. (The hospital later backed down.)
Yet many patients have no idea that the ERDs exist or that their hospital or clinic has begun partnering with a Catholic facility. "It's a huge problem in terms of getting care or even getting information about your care," said Louise Melling, the deputy legal director for the ACLU, which is suing the bishops conference over a botched miscarriage treatment at a Catholic hospital in Michigan.
In Washington, which has seen more religious-secular partnerships than any other state in recent years, Seattle's archbishop tried to force a Catholic hospital with the only lab in the area to cease running tests for Planned Parenthood. Catholic health systems also have pressured doctors with admitting privileges to stop helping terminally ill patients who want to make use of the state's "death with dignity" law. This past summer, the ACLU stepped in to stop a deal involving Washington State University and a Catholic system that would have made a planned teaching clinic in Spokane subject to the ERDs (the clinic will be secular).
"We are the canary in the coal mine when it comes to religious oversight of health care," said Monica Harrington, a board member of the Center for Reproductive Rights and former senior policy analyst for the Bill and Melinda Gates Foundation in Seattle.
The bishops' proposal to review the merger and partnership rules was triggered by a memo this past February from the Vatican's Congregation for the Doctrine of the Faith. If USCCB members vote this week to go along with the Vatican proposal, the conference's Committee on Doctrine will draft a revision to the directives that will be voted on at a later meeting.
Barbra Mann Wall, a nursing professor and historian of medicine at the University of Pennsylvania, has written several books about Catholic health care. She says that Pope Francis' apparent openness on issues such as divorce and greater acceptance of gays and lesbians probably does not extend to the questions that the Vatican office and the bishops are grappling with. "These are basic issues of Catholic doctrine ... I don't think [Francis is] going to be more liberal on this."
Nor does Wall think the USCCB — which has been leading pitched battles to limit contraceptive coverage under Obamacare and weaken abortion rights in the states — is going to adopt more flexible rules on how Catholic health systems should deal with those issues. The Supreme Court's decision last June in the Hobby Lobby case has left the bishops "more emboldened," Wall said. "This is a time when I really think the church is going to move to get the things that they want."
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