Divine Intervention

What Price Salvation?

What would you sacrifice for financial security? Managed care restrictions, technology advancements, and increased competition have forced health care organizations to ponder that question more and more frequently. And when Catholic providers like Seton promise fiscal peace of mind and quality care, the answer at least half the time tends to be reproductive services.

The Catholic Church constitutes the nation's largest nonprofit health care provider, but huge Catholic networks like Seton are a fairly new phenomenon. Until the 1980s, Catholic health care facilities operated independently or in small groups run by religious orders. But in recent years, managed care restraints and competition pressures have driven nonprofit providers like Seton and secular health care organizations into these interfaith marriages of convenience. Health care advocates say that if communities are not vigilant, an important aspect of women's health is lost in the dealmaking -- access to family planning and abortion services. According to studies by Catholics for a Free Choice, a Washington, D.C.-based nonprofit group that supports abortion rights, there have been nearly 100 mergers or affiliations involving Catholic organizations since 1990. The increased hospital consolidation, increased Vatican interference, and more restrictions on reproductive services are leaving more women -- particularly poor women dependent on public health and the largess of nonprofit facilities -- without reproductive health choices. About half the time the arrangement has not caused any major change in reproductive care, says CFFC. But in other cases, as in Luling's, the secular facility simply rolls to what the Catholic provider -- and the Catholic Church -- demand. And the result, women's health advocates say, is a system that is allowed to ignore federal law that permits abortion as well as contraception.

"People always need to be concerned when you have a public facility following one religion's rules," says CCFC's Denise Shannon, an Austin resident who has been a senior consultant with the organization for nine years. "It's very easy to look at an entity like Seton and want to feel good about them," says Shannon. "Catholic hospitals, like Catholic schools, have an enormous halo around them. They are sacred cows."

In Central Texas, many believe that halo is well-earned. In its nearly 100 years of service in Central Texas, Seton has developed a reputation for faithfully administering to the poor as well as for wise money management. Seton inherited its mission and fiscal good sense from its parent, the Daughters of Charity National Health Systems, one of the top 10 hospital systems in the country, owned by a 300-plus-year-old, St. Louis-based order of Catholic nuns, whose financial acumen has earned them the Wall Street nickname, "the Daughters of Currency." The system earns an estimated $6 billion in annual revenue, and according to a recent Wall Street Journal article, the Daughters has built up nearly $2 billion in cash and investments, one of the largest reserves of any nonprofit hospital system in the country.

Seton's success in Central Texas has been similarly impressive. Since 1995, Seton has more than doubled its revenues. But it is another dollar figure that Seton executive vice president and CEO Patricia Hayes is more proud of: the $47.5 million that the Seton Healthcare Network spent last year for charitable care and community service. Hayes says that number demonstrates Seton's commitment to the indigent and working poor of Central Texas. In 1998, Seton provided care for more than 57,000 Central Texas residents who were unable to pay for health services, and served an additional 32,509 people through other charity services, including donations and other services. Seton also served 52,067 Medicare patients and more than 40,000 Medicaid patients.

Hayes says providing access to health care to all citizens -- not limiting it -- is the tradition Seton was built upon: "I would like to put this particular value difference as it relates to sexual and morality issues into perspective with the church's tradition of social justice," says Hayes. "I don't think we should look at a single issue and say that's all Catholics care about, because it's demonstrably not true.

"I deeply respect the desire that some have to make sure [reproductive] services are provided," Hayes continues. "But there are some who say, 'What really makes me angry is I want you to provide [these services].' I just have to say, 'Well, that's one of the places, as it relates to health care, where we have differing viewpoints.' I will always respect their point of view. What you want and need me to do is to be faithful to my values and respect yours."

Model Compromise?

Given Seton's priority on health care for the poor -- and its need to survive in Austin's competitive market -- assuming management of the Brackenridge and Children's Hospital seemed a logical step for the Catholic provider. Brack was ailing -- hospital mismanagement and changes in the industry had put it in critical condition. If the safety net of the city hospital was lost, the impact would have been severe: Scores of indigent Austin residentswould show up on Seton's doorstep, overwhelming its resources.

There was understandable community uproar when the alliance with Seton was proposed. Women's health advocates feared the loss of reproductive services; Catholic officials were queasy about allowing family planning procedures permitted at Brackenridge continuing under the auspices of a Catholic-managed facility. Women's health advocates, such as Planned Parenthood of Austin executive director Glenda Parks, Austin Bishop John McCarthy, and other community activists and church ethicists were enlisted to find a solution. Seton and the city eventually hammered out a 30-year lease agreement, stating that Brackenridge must continue all services provided at the time of signing, including reproductive services. McCarthy agreed to allow Seton to contract with a third party -- then HealthSouth -- to perform procedures banned by the church. The separation was allowed under the Catholic theological principle called "material cooperation," which essentially means sometimes what is right and what is wrong intermingle in a way that makes it difficult to avoid being involved in what is wrong. For example: Catholics continue to pay taxes to the government despite the fact tax money is used for purposes deemed by the church to be morally wrong, such as the execution of prisoners under the death penalty.

The Brackenridge compromise was praised as a model of a creative solution other Catholic-secular mergers could follow. But in the years since its approval, the Brackenridge agreement has become known as an example of the sometimes tenuous ground on which even the most thoughtful compromises can stand.

The same year the Brack deal was cut, the Vatican released the encyclical Evangelium Vitae, which marked a significant escalation in papal involvement in the debate over women's reproductive rights. It wasn't long before Austin's McCarthy experienced that escalation firsthand.

McCarthy began receiving letters from the Vatican's Congregation for the Doctrine of the Faith directing him to renegotiate the Brackenridge lease agreement. "After full and careful deliberation," one 1997 letter to McCarthy states, "this Congregation directs Your Excellency to ensure that direct sterilization as well as any other contraceptive programs immediately and permanently cease at Brackenridge Hospital."

The news of the letters rattled women's health advocates around the nation who saw the Brack compromise as the best answer in a worst-case scenario. It wasn't just so-called liberal choice groups making hay of the Vatican's correspondence. The conservative religious group Concerned Catholics of Austin have sent letters to the Chronicle and other local media outlets questioning McCarthy's "ability to function as a credible shepherd of the faithful." McCarthy has been lambasted in the national Catholic weekly, The Wanderer, which has run stories with headlines that wail: "Chancery Documents Indicate Bishop Deceived Vatican," and "Bishop Ignores Vatican Order to Stop Immoral Practices," which claim the bishop has engaged in a two-year "stonewall of Vatican directives." The bishop has opted to downplay the controversy as he attempts to balance his promises to the community (and Seton's legally binding pledge to the city) to preserve existing services at Brackenridge, with the pressure from church higher-ups. McCarthy is currently on sabbatical and could not be reached for this story, but Diocese spokeswoman Helen Osman says the bishop stands firm that the Seton agreement does not violate church doctrine.

When the Vatican started to squirm -- and Seton began to consider acquiring a minimal ownership of HealthSouth -- changes to the Brackenridge agreement were sought. After about a year of exploring options, Hayes says it was decided that the city would assume responsibility for contracting with a third-party provider to perform the procedures banned by the Church. Last week the City Council approved a $286,000 contract with Caton Services Inc. to provide nurses and surgical technicians to assist physicians at the hospital in performing sterilization procedures such as tubal ligations and vasectomies. Emergency care such as rape treatment is contracted under a similar third-party arrangement. These contract employees do not provide counseling services, said Carroll; patients are informed of their optionsthrough their OB/GYN provider. To offset the cost of providing the services, the city will reduce the $5.6 million annual payment it gives Seton for indigent care at Brackenridge.

Seton and city officials say the hoopla over the Vatican letter is much ado about nothing. Reproductive services were never disrupted or even threatened, they say. "As far as we can tell with everybody we've brought in to look at it, it's right in line with Catholic teaching," says Hayes of the Brack agreement. "Now, we just made the fire wall a little higher."

David Lurie, Austin/Travis County Health and Human Services Department (HHSD) director, says the partnership with Seton is no less secure than it would be with a secular provider. "It's a long-term commitment," says Lurie. "It's stable."

Activists say they do not discount Seton's efforts in upholding its end of the lease agreement, but elsewhere women have suffered the consequence of the medical profession's blurring line between church and state.

About the same time Austin was beginning to lay the groundwork for Seton to assume management of Brackenridge, New Hampshire's Elliot Hospital was working out a merger with Catholic Medical Center. The two formed Optima Healthcare, amid hearty assurances to the public that all services would be maintained. But that wasn't to be the case. The Manchester Diocese began to make rumblings about the reproductive services offered at Elliot, threatening to withdraw from the merger if abortions continued. Eventually Optima's trustees caved and agreed to ban abortions except when "medically necessary and the fetus is not viable."

Last May, the worst-case scenario occurred. A 35-year-old woman, who had miscarried one pregnancy less than a year earlier, showed up in Elliot's emergency room after her water broke at 14 weeks. Her doctor, Wayne Goldner, concerned that the woman might develop a life-threatening infection if not treated immediately, wanted to perform an emergency abortion. But, according to the doctor, he was refused permission and threatened with sanctions if he performed the procedure before the hospital's ethics committee could review the case to determine whether the woman met its guidelines which allow abortion only when the fetus has no potential to live. Refusing to put his patient's health at further risk, Goldner made arrangements for her to be driven 80 miles to another hospital where the emergency procedure was performed.

Fortunately, there are no known instances of women being turned away from Brackenridge, nor is the Brackenridge policy like the one in place in New Hampshire.

But far too often, says Lois Uttley, director of New York-based MergerWatch, Catholic providers give up too much, resulting in incidents like the one in New Hampshire. "The result is non-Catholics being forced to adhere to rules of the Catholic Church," says Uttley.

Not all mergers have to result in a loss of service, Uttley says. In some cases, a separate corporation is created, removing the Catholic entity from any responsibility. In others, the Catholic and non-Catholic hospitals operate under separate licenses, with the hospital under the Catholic license not offering reproductive services. Sometimes a separate reproductive services facility is built on the hospital site but not in the hospital, and is operated by a non-Catholic-affiliated corporation. But, Uttley says, the community has to work to ensure that "financial terms and conditions don't sacrifice women's health service."

Planned Parentood's Glenda Parks says that while she supported the Brackenridge agreement, she could not swallow the proposal to turn the county clinic system over to Seton's care. Under the now-off-the-table proposal, family planning and reproductive services would not have been available in Seton-run clinics, forcing clinic patients who requested such services to turn elsewhere -- to clinics run by another private healthcare network, Austin Regional Clinic (ARC).

To Seton, this type of arrangement is an example of its willingness to work on compromise solutions. But it clearly would have further fragmented the county's health system. All ARC locations are in Austin, remote from rural areas. "With Brackenridge we've kept everything," said Parks. "We worked out a better situation than you'd see in most places. But we always said we'd draw the line at the clinics."

Balancing Act

The almost cavalier way some hospitals are willing to trade reproductive health care is troubling, and perhaps says as much about the overall priority the medical profession places on women's health care. After all, the inability of Catholic providers to offer an essential and legal service usually does not dissuade other health care organizations from partnering with them. The Rev. Michael Place, president and CEO of the St. Louis-based Catholic Health Association, an umbrella organization representing 1,200 Catholic health care systems and facilities, says this is because women's health advocates like CFFC and MergerWatch exaggerate the situation. In a recent letter to the Wall Street Journal, Place disputed advocates' claims that access to family planning is eliminated in Catholic-secular mergers. Health care in the 1990s is full of choices, he says; reproductive health care is just one of the many areas where providers are trying to balance market realities.

"I think that what has happened historically is that the overwhelming weight of Seton's commitment to the poor" has outweighed concerns about family planning, says Seton's Hayes. In Luling that was definitely the case: Hospital administrator Kelly says Edgar B. Davis already did not perform abortions, and he says only 15 tubal ligations were performed last year. Kelly says the procedures are available in "nearby" communities, meaning 18 miles south in Gonzales County, or 25 miles northwest in San Marcos. All in all, Kelly says, that's a small price to pay for the Luling hospital's survival.

But Hayes knows that concerns over partnerships such as Luling's are not based on numbers alone: "It's not a quantitative thing. The people who object to it object to it in principle. If one person is involved, then they object to the fact that any person would have to go to two places [for family planning]. It feels punitive to them. I respect that. ...We get into trouble saying one thing is more important than something else."

CFFC's Shannon says that Catholic providers' rules contribute to the perception of women's reproductive health as a luxury item: "Frankly, that's a very unhealthy way of looking at a whole human being."

But Catholic rules don't shoulder the blame alone. Patients who need reproductive health services, particularly low-income women, depend on the community's commitment to ensure access to reproductive health care for all women. For the most part, advocates say, the federal and state governments have not demonstrated that commitment. As an example, the Texas Family Planning Association cites its own studies showing that less than 27% of the 1.4 million low-income women in the state receive needed subsidized family planning assistance. While pregnant women may receive state and federal prenatal and delivery care through Medicaid, women who are not pregnant rarely qualify for federal assistance. In addition, the state of Texas does not fund abortions for low-income women -- a fact recently challenged last month before the state Court of Appeals. Given this lack of public commitment, is it fair to expect a private institution -- particularly one shackled with the restrictions of the Catholic Church -- to do any better?

Women's health advocates in Texas are encouraged by the support received for the Texas Campaign for Women's Health, an effort to secure $40 million annually from the Texas Department of Health to enrich low-income women's access to a laundry list of preventative care and treatment including mammography, testing, and ambulatory treatment for cervical cancer, diagnosis and treatment for sexually transmitted diseases, osteoporosis prevention, hormone replacement therapy, and birth control.

"It seems obvious to us how family planning fits in with women and children's health," said Austin Planned Parenthood's Margot Clarke at a recent League of Women Voter's forum, "but it eludes a lot of our lawmakers."

Is something a right if it's impossible to exercise it? That riddle has underscored the pro-choice debate in the Nineties, and hovers over the ongoing issue of hospital mergers. The right to abortion and the right to contraception may continue to be the law of the land, but what does that law really mean if hospitals aren't performing the objectionable procedures? An obstacle is an obstacle, advocates say. The end result is the same -- a chipping away at women's actual right to take care of, seek health measures for, and control their own bodies. In this unstable world of health care, there are a few things that seem certain: Mergers and consolidations will continue, and Seton Healthcare Network will remain a major player in Central Texas. Whether access to reproductive health care can survive amid this frenzy seems far less assured.

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