To most observers, the decision by the Beach Cities Health District to turn over the lease on a section of its medical building in Redondo Beach to the Little Company of Mary health system meant little more than a change in names.
To womens-health advocates, however, the deal that was finalized this spring carried a far deeper meaning: the sudden end of reproductive services at that facility and another blow to womens medical rights by Catholic health-care providers.
The Little Company of Mary is Catholic and, like many other Catholic health systems, follows the health-care directives issued by the Roman Catholic Church: no contraceptive devices, no birth control, no morning-after pills, no tubal ligations and, of course, no abortions.
Cutting reproductive services was just one of several changes Little Company of Mary made when it took over the lease from Tenet Healthcare Corporation and turned the Redondo Beach facility into an ambulatory health-care center. But the reproduction issue is what brought womens-health advocates including the National Health Law Program and the South Bay chapter of the National Organization of Women out in protest.
They met with members of the board of directors and staff, testified at community hearings and wrote opinion pieces for newspapers to no avail. Tenet was losing money on its lease and was eager for a savior; Little Company of Mary made an offer the Beach Cities Health District could not refuse.
Salting advocates wounds, the lease includes a provision allowing Little Company of Mary to terminate its agreement with the public-health district if sterilizations, abortions and most fertility treatments are provided anywhere else in the South Bay medical center.
"Were talking about health care," said Susan Fogel, legal director of the California Womens Law Center, which has taken on the Catholic health providers issue. "I dont believe that religious proscriptions should be able to dictate the range of health care men and women can get."
Even as Catholic medical providers and organizations argue their legal and moral rights to limit reproductive services, an increasing number of Catholic health-care systems are consolidating and buying up their secular competitors. While nonreligious systems continue to be the highest revenue generators in the industry, Catholic-run systems are gaining in market share. Modern Healthcare
magazine reports that Catholic health-care systems grew 12 percent in 1996. Meanwhile, eight of the 15 most profitable health-care systems are Catholic.
Womens-health advocates view the trend with concern. They worry that Catholic health-care systems are creating monopolies and putting the squeeze on the availability of reproductive services, especially for the poor. Moreover, as state health officials move Medi-Cal recipients into managed-care programs, they are often left with just one hospital nearby and it may be Catholic. Since 1994, the number of Catholic sole-provider hospitals has risen from 46 to 76.
While the trend that such advocates fear is real, context is important. Catholic health-care systems may be growing, but they are still not the biggest players on the health-care field. Of the 501 licensed acute-care hospitals in California, just 50 are Catholic, according to the California Association of Catholic Hospitals. The largest of all, the secular Columbia/HCA Healthcare Corp., earned $19.9 billion in net patient revenues in 1996, according to a survey last year by Modern Healthcare
magazine. The Daughters of Charity National Health System, the most profitable Catholic entity listed in the magazine survey, generated $3.6 billion in net patient revenues the same year.
"At this point, no one should be worried about us taking over health care," said Bud Lee, president of the California Association of Catholic Hospitals.
Here in Southern California, the womens-health care-advocates are now tracking a deal being discussed between Catholic Healthcare West and UniHealth, a secular, nonprofit health-care system, that would leave the religious system with eight more hospitals in the region. The California Hospital Medical Center in downtown Los Angeles and two campuses of the Northridge Hospital Medical Center are among them.
One of the fastest-growing Catholic health-care systems, Catholic Healthcare West calls its plan for the Southern California hospitals a "community model": Elective abortions would be prohibited, but most other reproductive services would remain. The
advocates grudgingly acknowledge that the Catholic Healthcare West and UniHealth deal is not as drastic as others have been, but they still fear the emerging trend and what it will mean, especially for abortion.
"I think were giving up too easily on that," said Lourdes Rivera, staff attorney with the National Health Law program, a nonprofit public-interest law firm. "We shouldnt put up our feet and say, Phew, theyre only not providing abortions."
To be sure, most elective abortions are not done by doctors in hospitals, religious or secular; Planned Parenthood in Los Angeles estimates that the lions share of abortions is done in free-standing clinics like theirs.
But most of the women who end up in hospitals for abortions are emergency cases or third-trimester patients, whom clinics generally do not have the equipment or medical expertise to treat. While Catholic lobbyists contend that doctors in Catholic hospitals can and do perform abortions when a mothers life is at stake, advocates question what a Catholic hospital would consider an emergency.
And aside from the moral quandaries, the rise of Catholic hospitals establishes a new arena for concern over maintaining the separation between church and state. Womens-health-care advocates protest what they consider to be government subsidies for Catholic hospitals. Most Catholic entities, for example, are nonprofit and operate tax-free. "Catholic hospitals have government support," said Fogel. "I dont care whether a hospital is public or private. If it wants to be in the business of delivering health care, which is as vital as air and water, it ought to have to provide it in a comprehensive way. Not providing a full range of services is not comprehensive or quality."
Catholics respond that while reproductive services such as abortion are allowed by law, they conflict with the churchs directives. The weight of the law is behind the Catholic perspective in the form of a "conscience clause," legally exempting religious health-care providers from having to provide medical services that are contrary to their beliefs.
"I dont think its a secret that Catholic hospitals dont do abortions," said Carol Hogan, spokesperson for the California Catholic Conference, which lobbies on behalf of Catholic bishops. "I can go to a department store and be upset that they dont have the brand of shoes I like. But thats life. And what about my rights? My tax money goes to pay for abortions when I dont want it to."
Pro-choice advocates say Medi-Cal coverage poses another church-state snarl, especially when the sole hospital offered by a managed-care health plan is Catholic.
Hogwash, say California health officials. "Under the terms of the contract, [managed-care providers] are required to offer enough providers to guarantee access to care so beneficiaries can get the services theyre legally entitled to," said Ken August, spokesman for the California Department of Health Services.
In the case of the Catholic Healthcare West and UniHealth affiliation, women electing to have abortions will be able to go elsewhere in the Los Angeles area. But they may have to pay for the service themselves, depending on their insurance plans, and they will have to travel.
For example, women who might have gone to the California Hospital Medical Center could choose from two Planned Parenthood clinics one in East Los Angeles and the other in Hollywood.
Catholic Healthcare West is promising to refer pregnant women to other facilities for elective abortions a caveat that would be included in a final written agreement, according to a spokesperson for the religious health system. But advocates are skeptical and wonder whether women who want abortions will end up getting counseling instead.
"Under the conscience clause, they dont have to make referrals," Fogel said. "Im not saying its company policy. But there may be people working in Catholic hospitals who may not think those services should be provided and may not want to provide them."
The Catholic Conference
does not argue the point. "A family-planning counselor would ask, Have you thought this through?" Hogan said. "Have you talked with anybody about this? They would assume if she came to a Catholic hospital she may not want to have an abortion. Catholic hospitals have First Amendment rights, and having the baby is also a choice."
The opposition Catholic Healthcare West faces in Los Angeles is mild compared to the situation in San Bernardino, where the same group is buying Community Hospital of San Bernardino. Catholic Healthcare West already runs St. Bernardine Medical Center, a nearby Catholic hospital.
Following the same "community model" proposed for Los Angeles, Catholic Healthcare West would ban elective abortions at its new San Bernardino facility but continue other reproductive services.
After community meetings and negotiations, Catholic Healthcare West thought it had ironed out the kinks. Instead, the greatest opposition has come from within the facility. Some of the doctors including the entire obstetrics and gynecology department, which performs roughly 10 abortions per year, half of them elective voted against the Catholic health systems anti-abortion directive.
Their argument: A woman has the legal right to an abortion, and she should not have to go elsewhere to get the procedure done. The response from the hospitals board of directors: Too bad the deal is done.
"How about in case of rape? Birth defects? A woman who has four or five children and cant afford another one?" asked Dr. Talal Muhtaseb, chairman of the community hospitals obstetrics and gynecological department. "But the board has decided its not going to listen to us even though we are the medical providers."