Even as numerous Republican-governed states push for sweeping bans on abortion, there is a coinciding surge of concern in some Democratic-led states that options for reproductive health care are dwindling due to expansion of Catholic hospital networks.
These are states such as Oregon, Washington, California, New York and Connecticut, where abortion will remain legal despite the U.S. Supreme Court's recent ruling overturning Roe v. Wade.
Concerns in these blue states pertain to such services as contraception, sterilization and certain procedures for handling pregnancy emergencies. These services are widely available at secular hospitals but generally forbidden, along with abortion, at Catholic facilities under the Ethical and Religious Directives set by the U.S. Conference of Catholic Bishops.
The differing perspectives on these services can clash when a Catholic hospital system seeks to acquire or merge with a non-sectarian hospital, as is happening now in northeastern Connecticut. State officials are assessing a bid by Catholic-run Covenant Health to merge with Day Kimball Healthcare, an independent, financially struggling hospital and health care system based in the town of Putnam.
"We need to ensure that any new ownership can provide a full range of care -- including reproductive health care, family planning, gender-affirming care and end-of-life care," said Connecticut Attorney General William Tong, a Democrat.
Lois Utley, a specialist in tracking hospital mergers, said her organization, Community Catalyst, has identified more than 20 municipalities in blue or purple states where the only acute care hospitals are Catholic.
"We are definitely sliding backwards in terms of comprehensive reproductive health," Utley said. "Catholic systems are taking over many physician practices, urgent care centres, ambulatory care centres, and patients seeking contraception won't be able to get it if their physician is now part of that system."
According to the Catholic Health Association, there are 654 Catholic hospitals in the U.S., including 299 with obstetric services. The CHA says more than one in seven U.S. hospital patients are cared for in a Catholic facility.
The CHA's president, Sister Mary Haddad, said the Catholic hospitals provide a wide range of prenatal, obstetric and postnatal services while assisting in about 500,000 births annually.
"This commitment is rooted in our reverence for life, from conception to natural death," Haddad said via email. "As a result, Catholic hospitals do not offer elective abortions."
Protocols are different for dire emergencies when the mother "suffers from an urgent, life-threatening condition during pregnancy," Haddad said. "Catholic health clinicians provide all medically indicated treatment even if it poses a threat to the unborn."
This approach is now being mirrored in several states imposing bans that allow abortions only to save a mother's life. There is concern that doctors governed by such bans -- whether a state law or a Catholic directive -- may endanger a pregnant woman's health by withholding treatment as she begins to show ill effects from a pregnancy-related problem.
In California, Democratic state Sen. Scott Wiener is among those warily monitoring the proliferation of Catholic health care providers, who operate 52 hospitals in his state.
The hospitals provide "superb care to a lot of people, including low-income communities," Wiener said. But they "absolutely deny people access to reproductive health care as well as gender-affirming care (for transgender people)."
"It's the bishop, not professional standards, that are dictating who can receive what health care," Wiener said. "That is scary."
Charles Camosy, professor of medical humanities at the Creighton University School of Medicine, says critics of the mergers fail to acknowledge a major benefit of Catholic health care expansion.
"These mergers take place because Catholic institutions are willing to take on the really hard places where others have failed to make money," he said. "We should focus on what these institutions are doing in a positive way -- stepping into the breach where virtually no one else wants to go, especially in rural areas."
That argument has resonance in mostly rural northeast Connecticut, where Day Kimball serves an aging population of about 125,000.
Kyle Kramer, Day Kimball's CEO, said the 104-bed hospital has been seeking a financial partner for more than seven years and would soon face "very serious issues" if it had to continue on its own.
Regarding the proposed merger, he said, "Change is always difficult."
However, he said Day Kimball's providers would remain committed to comprehensive health care if the merger proceeds, seeking to ensure that patients are informed of all options when it comes to such matters as contraception, miscarriages and ectopic pregnancies.
As for abortions, Kramer said Day Kimball had never performed them for the sole purpose of ending a pregnancy and would continue that policy if partnering with Covenant.
Despite the assurances, some residents are concerned that the region's only hospital would become Catholic-owned. Some merger opponents protested outside the hospital last Monday.
"The public is being told if you don't take Covenant, you won't have a hospital at all," said Elizabeth Canning of Pomfret, Connecticut. "Which is, of course, frightening. So people go, 'Okay, well, we'll take them. ... It's better than nothing."'
"I've had wonderful care here. That's not my objection," Canning continued. "I don't want any religion involved in my health care."
Sue Grant Nash, a retired Day Kimball hospice social worker from Putnam, described herself as religious but said she doesn't believe people's values should be imposed on others.
"Very important articles of faith that Catholics may have, and I respect completely, shouldn't impact the quality of health care that is available to the public," she said.
There have been related developments in other states.
--In Washington, Democratic state Sen. Emily Randall plans to re-introduce a bill that would empower the attorney general to block hospital mergers and acquisitions if they jeopardize "the continued existence of accessible, affordable health care, including reproductive health care." Gov. Jay Inslee says he is in support of such a measure.
The state has already passed a bill that bars the state's religious hospitals from prohibiting health care providers from providing medically necessary care to hasten miscarriages or end nonviable pregnancies, like ectopic pregnancies. Under the new law, patients can sue a hospital if they are denied such care, and providers can also sue if they are disciplined for providing such care.
--In Oregon, the state has new authority to bar religious hospitals from acquiring or merging with another health care entity if that means access to abortion and other reproductive services would be reduced. A law that took effect March 1 requires state approval for mergers and acquisitions of sizable health care entities.
Thirty per cent of acute care beds in the state are controlled by systems that restrict access to these services, according to Katie Shriver of the Service Employees International Union, who testified in support of the bill last year.
The law also allows the state to consider end-of-life options allowed by hospitals seeking to establish a footprint or expand in Oregon, which in 1994 became the first state to legalize medical aid in dying.
--In Newport Beach, California, Hoag Memorial Hospital Presbyterian divorced itself from a large Catholic health system earlier this year. The separation from Providence Health & Services, which runs 52 hospitals across seven states, came after a years-long legal battle.
In a 2020 lawsuit, Hoag said it was a "captive affiliate" of Providence, which is headquartered more than 1,000 miles away in Washington state. Hoag was founded as a Presbyterian institution in 1952.
In 2013, Hoag joined with St. Joseph Health, a local Catholic hospital chain, aspiring to broaden access to health care in its area. In 2016, Providence Health absorbed St. Joseph along with Hoag.
Hoag's doctors questioned Providence's move to standardize treatment decisions across its hospitals and also balked at restrictions on reproductive care. In 2014 then-Attorney General Kamala Harris approved the health systems' affiliation on condition that Hoag would not be bound by Catholic health directives.
Hoag's lawsuit said its "Presbyterian beliefs, values and policies have been compromised due to restrictions within the larger Catholic system."
-- In New York, two Democratic legislators proposed a bill this year that would have required the state's health department to publish a list of health services that are unavailable at each general hospital so patients can be better informed.
The lawmakers said the legislation, which failed, was needed to address "health care deserts" where hospitals have closed or merged with religiously affiliated entities and reproductive care and other health services have been lost.
The New York Civil Liberties Union, which has raised concerns about hospitals in Schenectady and Lockport affiliating with Catholic entities, says some New York patients have had difficulty obtaining miscarriage services and birth control pills from Catholic providers.
Crary reported from New York. Associated Press reporters Rachel La Corte in Olympia, Wash.; Andrew Selsky in Salem, Ore.; Adam Beam in Sacramento, Calif.; and Deepa Bharath in L.A. contributed.
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