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«At America’s Expense: The Mass Incarceration of the Elderly June 2012 MergerWatch American Civil Liberties Union 475 Riverside Drive, Suite 1600 ...»

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The Growth of Catholic Hospitals and the Threat

to Reproductive Health Care

December 2013


The Growth of Catholic Hospitals and

the Threat to Reproductive Health Care

Written by:

Lois Uttley and Sheila Reynertson of the MergerWatch Project,

and Lorraine Kenny and Louise Melling of the American Civil Liberties Union

Data Analysis by:

Patricia HasBrouck of Empire Health Advisors

At America’s Expense:

The Mass Incarceration of the Elderly June 2012 MergerWatch American Civil Liberties Union 475 Riverside Drive, Suite 1600 125 Broad Street New York, NY 10004 New York, NY 10115 www.aclu.org www.mergerwatch.org Cover image credit: Tim Gruber © 2013 ACLU Foundation © 2013 The MergerWatch Project


The ACLU thanks for their generous support of its work in this area two anonymous donors, the Arcus Foundation, The Herb Block Foundation, the Robert Sterling Clark Foundation, The George Gund Foundation, The William and Flora Hewlett Foundation, the Jessie Smith Noyes Foundation, The David and Lucile Packard Foundation, and The Scherman Foundation.

The MergerWatch Project thanks for their generous support of its work in this area the Robert Sterling Clark Foundation, The Ford Foundation, and The Educational Foundation of America.

The authors also thank for assistance with research, editing, design, and communications Becca Cadoff, Margaret Crosby, Amanda Fox, Alexa Kolbi-Molinas, Jennifer Lee, Sarah Lipton-Lubet, Daniel Mach, Brucie Rosch, Diana Scholl, Neil Shovelin, Sara Smith, Stephen Smith, and Elizabeth Wagner.

Cover photo: iStockPhoto/Sandra L. Nicol



WHY WE CARE: Catholic Restrictions and the Risk to Patient Health 2 KEY FINDINGS: The Expanding Role of Catholic-Sponsored and -Affiliated Hospitals in the Market 4 AN IN-DEPTH LOOK: The Dominance and Power of Catholic-Sponsored Health Systems 7 OUR TAX DOLLARS AT WORK: Public Funding of Catholic-Sponsored and -Affiliated Hospitals 10 DEBUNKING THE MYTH: Catholic-Sponsored and -Affiliated Hospitals and Service to the Poor 12 CASE STUDIES: The Impact of Catholic Health Care Restrictions 14 A CAUTIONARY TALE: Marketplace Dominance by Catholic-Sponsored Systems in Washington State 16 CONCLUSION AND RECOMMENDATIONS: Protecting Patients’ Rights and Ac

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Appendix B: Catholic Sole Community Hospitals in the United States, 2011 25 Appendix C: 25 Largest Health Care Systems in the United States, 2011 26

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In short, this report reveals how Catholic hospitals have left far behind their humble beginnings as facilities established by orders of nuns and brothers to serve the faithful and the poor. They have organized into large systems that behave like businesses — aggressively expanding to capture greater market share — but rely on public funding and use religious doctrine to compromise women’s health care. We make recommendations about how to ensure Catholic restrictions do not interfere with patients’ rights and protect access to comprehensive reproductive health care.

–  –  –

• “Prenatal diagnosis is not permitted when undertaken with the intention of aborting an unborn child with a serious defect.”10 • “Heterologous fertilization (that is, any technique used to achieve conception by the use of gametes coming from at least one donor other than the spouses) is prohibited because it is contrary to the covenant of marriage, the unity of the spouses, and the dignity proper to parents and the child.”11

Hospital staff and physicians with admitting privileges must comply with the Directives:

• “Catholic health care services must... require adherence to [the Directives] within the institution as a condition for medical privileges and employment.”12 • “Employees of a Catholic health care institution must respect and uphold the religious mission of the institution and adhere to these Directives.”13 When non-Catholic hospitals affiliate with Catholic-sponsored hospitals or health systems, they are usually asked to adopt all or some of these religious restrictions.14 All business partnerships involving Catholic and non-Catholic hospitals are subject to approval by the local bishop.15 Miscarriage of Medicine: The Growth of Catholic Hospitals 2 and the Threat to Reproductive Health Care In the end, health care at Catholic-sponsored and -affiliated facilities is religiously restricted, even as the hospitals open their doors to people of all faiths and accept billions of taxpayer dollars. The continued growth of these facilities, with their adherence to the Directives, threatens women’s access to crucial, even lifesaving, reproductive health care.

In recent years, women seeking care at such hospitals have encountered a variety of

obstacles, including the following:

• Denials of medically appropriate care for miscarriages, when ending a doomed pregnancy promptly would prevent the woman from becoming infected and risking her future fertility.

Two such instances are detailed in the case studies section of this report, and additional examples were documented in an article published in the American Journal of Public Health;16

• Refusals to allow tubal ligations at the time of a cesarean-section delivery, even when a woman’s physician has warned that any future pregnancies could risk her health or life;17

• Refusals to treat ectopic pregnancies promptly or with the requisite standard of care.18 As more hospitals are governed by Catholic doctrine, we expect to see more women denied appropriate care.

–  –  –

• In 2011 Catholic-sponsored or -affiliated hospitals provided far less charity care proportionately than public hospitals and no more than other religiously affiliated hospitals.

(See Table 4 on page 12.)

• Catholic-sponsored or -affiliated hospitals provided the lowest proportional level of service to Medicaid patients of any type of hospital, as measured by the percentage of gross patient revenues that came from Medicaid in 2011. (See Table 5 on page 13.)

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O ne of the most significant findings of our analysis was the growth in size of Catholicsponsored health systems. Indeed, 10 of the 25 top health systems in the United States are Catholic. (See Table 3 on page 8.) In other words, these Catholic health systems are increasingly big business, with great power in local, regional, and national markets. They are also increasingly poised to influence health care policy.

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In 2011, Ascension Health was the third largest health system in the country and the largest non-profit health system. Between 2001 and 2011, Ascension’s roster of acute-care hospitals grew from 36 to 69, boosting the number of beds from 8,345 to 13,706. The system’s Medicare gross revenues nearly quintupled during that decade, going from $2.8 billion in 2001 to $14 billion in 2011.

Ascension continues to grow. In just the past two years, the health care giant has picked up three additional Catholic-sponsored health systems with a combined $5.4 billion in annual revenue.27 Today, Ascension has a presence in every region of the country with 93 acute-care hospitals in 23 states28 — including the 69 acute-care hospitals reviewed for this report — and more than 122,000 employees.29 Ascension has also diversified its portfolio over the past decade to include for-profit ventures.

It has a successful health care venture fund that now has assets of $550 million,30 and it has formed a joint venture with a private equity firm focused on Catholic hospital acquisitions.31 It is what Modern Healthcare called — even in 2007 — “a financial and commercial powerhouse.”32

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Ascension’s size and economic clout enhances its ability to influence national health care policy in line with its Catholic mission. For example, Ascension advocated that religiously affiliated health care institutions be exempted from having to comply with the Affordable Care Act’s rule that employers include coverage for contraception in their health plans.36 While hospitals and health systems like Ascension did not get the precise relief they sought, the U.S. Department of Health and Human Services granted them an accommodation, requiring a third-party, not the employer, to arrange and pay for the contraception coverage for their employees.37


In 2011, Catholic Health Initiatives (CHI) was the country’s fifth largest health system and second largest non-profit health system. Between 2001 and 2011, the number of CHI hospitals grew from 50 to 64 and its Medicare gross patient revenues ballooned from $2.7 billion to $12.2 billion.

This giant Catholic-sponsored health system continues to grow. In May 2013, for example, CHI completed a $2 billion acquisition of St. Luke’s Episcopal Health System in Texas,38 which included six acute-care hospitals in the Houston-metro area, as well as three emergency care centers, two medical clinics, and two diagnostic and treatment centers. Catholic health care restrictions now apply in all of these historically non-Catholic facilities.39 CHI is also now the majority sponsor of KentuckyOne Health, Kentucky’s largest health system, formed in 2012 by the merger of two local health systems, Jewish Hospital & St.

Mary’s Healthcare and St. Joseph Health System.40 The University of Louisville Hospital joined the system in early 2013 in an arrangement that “carved out” governance of its Center for Women and Infants, thus protecting it as a secular health care provider,41 but subjected the rest of the hospital and its 2,600 employees to Catholic restrictions on delivery of medical care.42 Miscarriage of Medicine: The Growth of Catholic Hospitals 8 and the Threat to Reproductive Health Care Today, because of the addition of new hospitals since 2011, CHI has 87 acute-care hospitals in 17 states, approximately 88,000 employees, and annual operating revenues of more than $10 billion.43 Like Ascension, CHI has a powerful position in the marketplace as well as the ability to influence health policy. Modern Healthcare has included CHI’s President and CEO Kevin Lofton 10 times on its list of the 100 most influential people in health care.44 CHI established an online Advocacy Action Center in 2007, “designed to make the collective voice of Catholic Health Initiatives heard in the nation’s capital... [and] to participate in key advocacy efforts by communicating with legislators.”45


Catholic Health East (CHE) and Trinity Health were two of the largest health systems in the nation in 2011. In 2013, they merged. As a combined system, CHE Trinity Health has 82 acutecare hospitals in 20 states, annual operating revenue of $13.3 billion, more than $19 billion in assets, and close to 86,000 employees, including about 4,000 physicians.46 The beginnings of this behemoth were modest. CHE was created in 1998 when three regional Catholic health systems combined with the goal of “strengthen[ing] the role and identity of the Catholic health ministry in the eastern United States.”47 By 2011, the Pennsylvania-based system had become the eighth largest health system in the nation.

Trinity Health, headquartered in Michigan, was formed in 2000 through the merger of two smaller Catholic systems. A decade later it had become the eleventh largest health system in the United States.

In an interview with Crain’s Detroit Business, Judith Persichilli, interim president and CEO of the newly merged system, touted its financial strengths and remarked that the merger announcement had prompted other hospitals, including secular ones, to express interest in joining the system.48 Persichilli indicated that CHE Trinity Health “would look to align with secular organizations if they ‘share our vision and values.’”49 Trinity Health officials said they hoped the merger would give them a more powerful, unified voice as a Catholic system.50 Trinity Health President and CEO Joseph Swedish called the mega-merger “a natural progression... so we can better serve people much more efficiently based on our Catholic tradition.”51 That would mean, of course, more hospitals that are restricted in the health care they provide.

In October 2013, CHE Trinity Health named a new high-profile president and CEO, Richard J.

Gilfillan, who had been the founding director of the federal Center for Medicare and Medicaid Innovation and the former chief executive at the highly successful Geisinger Health Plan.52 “In the midst of a transforming industry, Rick brings a national presence and comprehension to guide our ministry as we pursue new opportunities, tackle new challenges and fulfill our mission,” the chair of CHE Trinity Health’s board of directors said, in announcing the appointment.53 Miscarriage of Medicine: The Growth of Catholic Hospitals 9 and the Threat to Reproductive Health Care


Public Funding of Catholic-Sponsored and -Affiliated Hospitals E ven as Catholic hospitals impose religious restrictions on the services they provide — limiting information, referrals, and care — they receive billions of taxpayer dollars each year.

Looking at revenues from Medicare and Medicaid reimbursements, this study found that

in 2011:

• Catholic-sponsored and -affiliated hospitals billed Medicare $81 billion and Medicaid $34 billion, for a combined total of $115 billion in “gross patient revenues”; and

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