When a Hospital Becomes Catholic - Lisa C. Ikemoto

• Publication year: 1996

When a Hospital Becomes Catholicby Lisa C. Ikemoto^*

I. Introduction

Mention of this topic—the potential elimination of health services resulting from a merger or affiliation between Catholic and non-Catholic hospitals—rarely triggers discussions about "community health." It does trigger comments about abortion¹ and First Amendment Free Exercise and Establishment concerns.² Some have characterized the issues arising out of these alliances as "women's reproductive health" issues,³ but few have described the issues in terms of community health. Perhaps the phrase, "women's reproductive health," suggests why. Women's health is often understood to be reproductive health, or as the narrower issue, abortion. Unfortunately, it seems to go without saying, that women's reproductive health is generally understood to be different and separate from "health." So under patriarchal logic, it stands to reason that we fail to discuss the elimination of services—many of which are known as women's reproductive health services—as a community health problem.

It is also interesting that abortion so clearly shapes the discussion of this topic. That probably reflects the level of political controversy surrounding the legality of abortion and the Catholic Church's role in the controversy, as well as the conflation of women's health with abortion. In fact, a merger or affiliation between Catholic and non-Catholic hospitals may result in the elimination of certain end-of-life choices, counseling for persons who are Human Immune Deficiency ("HIV") positive about the use of condoms to prevent HIV transmission, clinical trials for women, vasectomies, tubal ligations, contraceptive advice and distribution, the morning-after pill for rape victims, many types of assisted procreation technologies, as well as abortion. For some, the potential impact of a Catholic/non-Catholic hospital alliance on health care choices of men transforms the issue into one of community health as opposed to women's health. Yet, why should it take direct impact on men (or the middle class, or whites, or American citizens) to gain recognition of a problem as one affecting community?

Prior mergers and affiliations show that abortion and women's reproductive health services are significantly more vulnerable to elimination than those services also offered to men. The fact that women's choices are most vulnerable shows that while we have acquired some ability to lay claim to and authority over health issues that directly affect our lives, particularly reproductive health issues, women's health is still considered to be separate from and outside of community health. Impact on women (and/or persons of color, the disabled, the poor, the elderly, the immigrant) should be sufficient to trigger concerns about community health. So, while we work to claim abortion and other reproductive health services as women's issues, we must simultaneously work to create community that includes women and other marginalized persons. We must resist moves to define community health priorities by majoritarian efficiency concerns.

The failure of this topic to trigger concerns about community health may also result from the assumption that mergers and affiliations are corporate acts. This assumption limits the way we think and talk about the issues—we accept that corporate acts have primarily fiscal implications for our lives. I have found that when the deals are being made, "community" interests in creating a fiscally viable hospital are used to justify the elimination of women's health choices. These explanations tend to run along the lines of Star Trek's Vulcan credo: "The needs of the many outweigh the needs of the few." This both segregates and diminishes women's health needs. At the same time, the needs of the many rationale obscures the interests being protected, and it privileges a fiscal efficiency discourse over one that could reveal how patriarchy, class, race, and other interests might weight the needs being balanced.

When the Catholic/non-Catholic merger or affiliation takes place in a rural area, geographical as well as socio-political distances become significant. The elimination of health care services at a hospital often has more acute effects in a rural area because no other health facilities may be located nearby. Other factors particular to rural areas—lower income levels, a larger percentage of uninsured patients, lack of public transportation, smaller social service networks, and fewer information sources—exacerbate the barriers to finding alternative facilities. Those whose health needs have been marginalized in these communities may be in different, and sometimes worse, situations than those in more populated areas. On the other hand, there are many similarities between the potential responses by, for example, African-American women with low incomes in an urban neighborhood, and white women in a rural area where the nearest hospital is negotiating an alliance with a Catholic institution. Although this article highlights the particularities of deals made in rural areas, much of the discussion also applies to deals made in urban and non-metropolitan areas.

In the discussion that follows, I describe the role of Catholic hospitals in health care both on a national level, and with respect to rural areas. In that section, Part II, I also sketch the relations between business and doctrine in Catholic/non-Catholic hospital alliances. In Part III, I try to expose the mechanisms that define the needs of the many and devalue the needs of the few. Among other things, I describe the Ethical and Religious Directives that shape Catholic healthcare, the justifications for trading women's health choices for the other benefits of a hospital alliance, the socio-economic factors particular to health care in rural areas, and some of the legal rules that enable the needs of the many standard of decisionmaking. Part IV represents my efforts to collect strategies and ideas that others have developed. My goal is largely to help distribute information. In the process, I hope to promote the use of means that foster community dialogue and open the negotiating process to the community. While the mechanisms I describe are legal, and therefore adversarial in nature, I look to the work of activist scholars who have developed community-constructing methods of lawyering for the principles that guide the use of these legal mechanisms.

I hope this information may prove useful to activists who are, and work on behalf of, women, poor people, and people of color. The primary intersections of subordination that affect health care in Catholic/non-Catholic hospital deals occur among these groups, and I believe that collaboration among these activists will best effect an inclusive understanding of health care needs. I speak of inclusion, and hope to simultaneously affirm that prioritizing the needs of those identified as the few over those of the many is often the most appropriate way to achieve inclusion.

II. Dollars, Deals, and Directives

Many of us are somewhat aware that Catholic health care facilities are prevalent and well established in our communities. We know of local hospitals named for patron saints or hospitals with names that contain the words "Mercy," "Charity," or "Good Samaritan." But few of us have thought about the business side of the Catholic health ministry or the links between church leaders, religious doctrine, and hospital care.⁴ In this section, I briefly lay out some facts and figures to illustrate the extent to which the Catholic health ministry has taken on responsibility for health care in the United States, particularly in rural areas. I also sketch the current impetus toward mergers and affiliations between Catholic and non-Catholic hospitals and the church-side decisionmaking structure involved in those deals.

A. Facts and Figures about the Catholic Health Care Network

The Catholic health care network delivers the largest portion of private sector health care in the United States.⁵ Sixteen percent of the national hospital admissions are in Catholic hospitals.⁶ In some areas, Catholic hospitals provide a much greater percentage of health care. For example, Catholic hospitals account for thirty-one percent of all licensed hospital beds and admissions in Illinois.⁷ Many of these facilities are concentrated in the Chicago area, where there are twenty Catholic hospitals. In a more extreme example, Sacred Heart Hospital in Lane County, Oregon supplies approximately seventy percent of the area's hospital services.⁸ In total, the Catholic health care network includes 57 multi-institutional systems, 247 health care centers,⁹ and 1556 specialized care facilities in addition to just over 600 hospitals.¹⁰

Catholic hospitals are run as private non-profit institutions.¹¹ They are tax exempt under section 501(c)(3) of the Internal Revenue Code¹² and usually enjoy state tax exempt status as well. In addition, Catholic hospitals accept Medicare and Medicaid patients. In translation, this means that Catholic hospitals are providing a significant amount of government-insured care to elderly, disabled, and low-income patients. Catholic hospitals also admit privately insured, and some indigent patients.¹³ In fact, the Catholic health ministry has expressed a strong commitment to providing care and advocacy for "the poor, the uninsured and the underinsured."¹⁴ Catholic health care facilities and organizations also support and give hands-on health care to immigrants,¹⁵ Acquired Immune Deficiency Syndrome ("AIDS") patients, the mentally ill, the disabled, and the elderly.¹⁶

Catholic hospitals are big business, as well as non-profit. A Catholics for a Free Choice¹⁷ publication reports that "in 1990, 561 Catholic short-stay hospitals generated more than $48 billion in gross patient revenue, $32 billion in net patient revenue, and $1.6 billion in net income. They also managed more than $38 billion in...