How Catholic Healthcare Mergers Affect What Care is Offered 

Examining the complex interplay of healthcare, religion, and patient rights in the wake of Catholic health system mergers.

By Chaya Tong

Seventy miles from Tucson, Arizona, a woman was rushed to the emergency room at Sierra Vista Regional Health Center. The woman was 15 weeks pregnant with twins and had already miscarried one of the babies. The obstetrician on call told her and her husband that the second twin was unlikely to survive. As he later put it in an affidavit, “The patient was suffering an inevitable miscarriage.” At high risk for extreme hemorrhaging and infection, the woman needed an emergency abortion. As soon as possible.  

But Sierra Vista had recently merged with a Catholic Hospital System, Carondelet Health Network, which prohibited abortion because the procedure went against the church’s teachings. Because the fetus had a heartbeat, the hospital required the physician to send the patient to a different hospital for the procedure. The nearest one was in Tucson. The policy cost the patient three hours – a delay her doctor said could easily have been fatal. She was lucky to escape with her life.  

Scenes like this – which took place in 2010 and was described in Mother Jones three years later – are playing out across the country. As Catholic healthcare systems merge with standard healthcare, patients are losing options for care that do not coincide with the Church’s philosophy. To be clear, the increase in Catholic healthcare systems has been driven mainly by finances – hospital mergers mean fewer competitors. As a result of this trend, however, certain types of care have been restricted or eliminated. These include gender-affirming care, euthanasia, and multiple kinds of reproductive care including elective sterilization, IVF, contraception, and, of course, abortion.  

The real world impacts

In the decade since Sierra Vista’s trial merger, numerous hospitals, especially those in rural areas, have collapsed under financial burdens and been replaced by large Catholic hospital networks. These new Catholic hospitals have provided an option for care in underserved areas, but they also leave patients with a critical choice: a hospital affiliated with the church or no hospital at all.  

Currently, one out of every six hospital patients in the United States are being treated in a Catholic-owned hospital. In states like Alaska, Iowa, Washington, Wisconsin, and South Dakota, two out of every five patients are in a Catholic hospital. Four out of the ten largest healthcare systems in the United States are Catholic and in the last two decades, Catholic short-term acute care hospitals grew by 28 percent while their non-Catholic counterparts decreased by 14 percent. 

The Catholic Church has provided healthcare services for as long as the Church has been in existence. During the smallpox epidemic in 165-180 AD, Christians nursed the sick in Mesopotamia. The first Catholic hospital in the United States, Charity Hospital, opened its doors in New Orleans in 1727. Many of the early hospitals were opened by nuns as part of the Catholic mission to take care of the poor and the sick. Nuns in Hawaii worked with Father Damien de Veuster, who was later named a Saint by the Catholic Church, to take care of lepers at a settlement on the island of Molokai in 1873.  

All Catholic-run healthcare facilities follow the framework and guidelines laid out in the Ethical and Religious Directives for Health Care Services, ERDs, written by the United States Council of Catholic Bishops. The directives detail everything from behavior standards for staff to Catholic teachings about a person’s dignity. Catholic organizations that do not comply with the ERDs risk being ex-communicated and jeopardize the tax-exempt status they enjoy because of their association with the church.

Dr. Maryam Guiahi, an OB/GYN and chief medical officer at Planned Parenthood California Central Coast, completed her residency at a Catholic hospital in Illinois. In her program, she said, the ERDs were selectively implemented, notwithstanding the official policy, which was strict. “It was very hard for me to be in an OB/GYN residency program at a Catholic hospital,” said Dr. Guiahi. A lot of her later research in Catholic hospitals and their residency programs came out of the experience she had there. “Some of that experience is that there were some things we could do and there were some things we definitely couldn’t do,” the doctor explained. “But if you actually look at what the rulebook says, you’re not supposed to do anything.”  

In 2018, the ERDs were updated to address collaborations between Catholic healthcare and other healthcare providers as mergers became increasingly common. The United States Council of Catholic Bishops advised hospital administrators in Catholic healthcare networks to prioritize mergers with Catholic organizations before considering non-Catholic partnerships. Before partnering with another healthcare provider, Catholic institutions are also required to ensure that the new provider’s facility and workers will not play any role in “immoral procedures.”  

Expanding influence

Catholic hospital networks have expanded because of the general rise in hospital mergers in the last few years. Hospital mergers, meant to improve finances or consolidate care, have been on the uptick following the economic recession and trends toward insurance consolidation. “One of the reasons hospitals are merging is that insurers have also been merging, and hospitals negotiate rates with insurers,” Liz Coyle, executive director of Georgia Watch, the state’s leading consumer advocacy organization, explained. “The trend has been that hospitals have more facilities. They’re larger. They’re able to negotiate more favorable rates for payment by the insurance company for services in that hospital.” Under the Obama administration, mergers also increased drastically as the government pushed for the integration of care and offered financial incentives under the 2010 Affordable Care Act.

Under the broader umbrella of healthcare mergers, Catholic healthcare systems have increasingly merged with secular healthcare providers. Lois Uttley, a healthcare access consultant who tracks hospital acquisitions, authored a report on the growth of Catholic healthcare systems. “They started doing that [merging with secular institutions] I think out of a desire to protect their Catholic mission of healthcare,” Uttley said. “But it quickly became about the financial bottom line and enabling Catholic health systems to gain market share in certain markets.” 

But these mergers, Catholic or not, are generally not a good sign for consumers. In many cases, they decimate rural areas, leaving them without a healthcare system nearby. In the case of Sierra Vista, the nearest hospital was 70 miles away. One study in North Carolina found that for rural hospitals that were financially stable and then acquired by a larger healthcare system, the risk of collapse was double that of an independent hospital. “While often these systems will say that it’s going to create efficiency, and you would think that patients might see that reflected in lower costs, we certainly have not seen health care costs go down for consumers,” Coyle said. “We believe that, like in any industry, less competition means higher prices and less choice for consumers.” 

At times, a Catholic healthcare merger may be the only lifeline an area has to retain a local hospital at all. March of Dimes, a non-profit organization supporting infant and maternal health, reported in 2022 that between 2020 and 2022, 153 counties across the country had significantly decreased access to maternity care due to fewer obstetric providers, fewer hospitals, or both. Meanwhile, another study shows that over the last two decades, the number of communities relying solely on a Catholic hospital for their healthcare has increased. In 2020, 30 percent or more of all births in ten states occurred in a Catholic hospital, 52 Catholic hospitals served as the only short-term acute hospital providers in their regions. 

“We’re seeing places close, which means people don’t have access to care and have to go further to get care,” Faith Daniel, Project Manager for the Hospital Equity and Accountability Project (HEAP) at Community Catalyst, said. “If the hospital doesn’t exist, and people don’t have access to care, then the hospital that they do end up going to is a Catholic Health System [provider where] they don’t have access to the services that they need.” 

Procedures denied

Catholic hospitals will not perform procedures forbidden by the ERDs even when health insurance would cover the cost of the procedures. As a result, patients are not receiving the benefits to which they are entitled. “The health insurance is stuck with it,” Uttley said. “If the only hospital is a Catholic one, then the health insurance has trouble getting the full range of reproductive health services for its enrollees.”  

The same goes for Medicaid, which many Catholic hospitals accept, and which ordinarily covers birth control. Dr. Guiahi gave an example of what happens when a Medicaid patient seeks birth control in a Catholic hospital setting. “You can be a Medicaid recipient, which is state public health insurance that is funded through state dollars that the Catholic hospital accepts, and that state Medicaid covers your IUD,” she said. “But because you end up in that Catholic hospital because it’s the only hospital, you don’t get to have an IUD.” 

Catholic healthcare mergers have particularly deleterious effects on reproductive care, cutting off access to abortion and certain pregnancy prevention measures. Catholic hospitals restrict tubal ligations, for example – a procedure that blocks off the fallopian tubes and is a form of permanent birth control. Daniel describes restriction on reproductive care as “layered” – Catholic healthcare is one piece of a series of systemic blockades on abortion access. In 2022, the Supreme Court overturned Roe v. Wade, in a decision that removed the federal right to abortion. Since that decision, states have decided individually whether to allow abortion, and many state legislatures have enacted strict laws forbidding it. In Texas, for example, abortion is illegal except when it is needed to save a pregnant patient’s life or avoid “substantial impairment.” In Louisiana, providers that perform an abortion can face up to 15 years in prison.⁹ “On top of that, we have institutional issues where we have a Catholic health system that would deny access to an abortion or birth control even in a state where abortion may be legal,” Daniel said.  

Many women who seek care from a Catholic-owned hospital may not realize that their hospital will not perform certain reproductive services until it is too late. Almost all hospitals that merge retain their original, non-Catholic name. As a result, patients may not find out they are served at a Catholic institution until they are denied a desired procedure. Historically, Catholic hospitals were distinct from secular hospitals in their signage, naming, and even day-to-day operations. Nuns were a visible presence on hospital premises and crosses decorated the walls. Now, secular and Catholic care look much the same at first glance. “The interesting thing is that the newer Catholic healthcare systems are having increasingly less religious names,” Dr. Guiahi noted.  

In 2016, Franciscan Alliance, a large Catholic health system in Indiana, dropped all saints’ names from its hospitals. Common Spirit Health, one of the country’s top five health systems, and Dignity Health also sports names that patients may have difficulty identifying as Catholic. Dr. Guiahi says the names are misleading. “If you’re going to be Catholic, own it, say it across the wall, and stick with the rules,” she added.  

Women using Catholic hospitals often receive compromised reproductive healthcare if they are getting it at all, she said. Instead of offering an array of birth control options, for example, Catholic hospitals might only offer pills, one of the mildest forms of contraception. For abortions, hospitals affiliated with the church are even more stringent. “[For] a patient who has an inevitable abortion, they’re saying you’re not sick enough yet. You’re not bleeding enough yet. We can’t do your abortion yet, even though it’s a threat to life,” Dr. Guiahi said. “These are the kinds of things I saw happening in Catholic hospitals that were morally distressing as a provider.” 

The question of training

Patients at Catholic-run hospitals are not the only ones receiving compromised treatment. New doctors being trained at these facilities are, too. In a paper published in 2017 in The Journal of Graduate Medical Education, Guahi found that obstetricians and gynecologists who trained at Catholic healthcare facilities felt inadequately prepared to provide reproductive services. All doctors are required to complete a residency, or training program, at a hospital before they can start practicing. Medical students are matched with a hospital for their residency and have limited choice over which hospital they go to. This is the scenario Dr. Guiahi found herself in when she was matched to a Catholic hospital in Chicago after medical school.  

“I expected to be an expert in women’s healthcare and I didn’t know how to do tubal ligation when I graduated, nor was I competent at IUD insertions,” she said. “My research showed that when you apply religious principles to medical care, like in Catholic healthcare settings, trainees get less training, particularly in procedures which are harder to do on site.” In particular, residencies at Catholic hospitals do not prepare their trainees to perform uterine evacuation, a procedure used in abortion but also needed for treatment of unintended and abnormal pregnancies, including miscarriages.  

“Now, a disproportionate amount of OB/GYN trainees will not get that training, and so that’s a concern for women who have miscarriages in banned states that their future physicians will not know how to manage a hemorrhage during one of those cases,” Dr. Guiahi said.  

Even if Catholic healthcare mergers have allowed for a hospital in areas that would otherwise not have one, it has not resulted in increased access to care across the board. “The outcome of that is that the patient doesn’t get a tubal ligation and has an unintended pregnancy. Is that the patient’s fault or is that the healthcare system’s failure? I would argue it’s the healthcare system’s failure,” Guahi said. “We are taking a pluralistic society into the hospital and then we are allowing religious rules to dictate their care.”