Naked City

Unlike a pool of tranquil holy water, the current city debate regarding the fate of reproductive services at Brackenridge is neither calm nor clear. For the moment, the fate of these services at Brackenridge -- the city's only public hospital, but managed by the Catholic Seton Healthcare Network -- lies in the controversial "hospital within a hospital" proposal announced by Mayor Kirk Watson at a press conference last week.

Using lingo familiar to the women's rights groups, city officials plan to "take back" the fifth floor of Brackenridge and convert it into a separate licensed hospital that will provide "seamless," 24-hour full-service obstetrical and gynecological services. The "hospital within a hospital" plan was provoked by the United States Conference of Catholic Bishops, which in June revised its "Ethical and Religious Directives for Catholic Health Care Services" to prohibit Catholic health-care providers such as Seton from managing hospitals providing tubal ligations, vasectomies, sterilization, and other types of reproductive services.

Since signing a 30-year lease with Seton in 1995, the city -- which owns the hospital -- has hired contractors to provide reproductive services forbidden by Catholic teaching. How the city decides to continue providing them "is not really something we're trying to talk through or be a part of," says Seton's vice-president of planning Travis Froehlich. "It's something they have to do on their own."

The city is trying to do so, albeit in a way critics charge is vague and undemocratic. On Aug. 28, the city hosted a public hearing to receive input regarding the proposed change to its 1995 lease agreement with Seton and the "hospital within a hospital" plan. In a gray conference room at the Waller Creek Building, Assistant City Manager Betty Dunkerley delivered a presentation on the city's Brackenridge proposal -- which features a licensed, state-of-the-art hospital providing ob/gyn services such as tubal ligations, birth control, family planning and counseling that covers the whole range of reproductive options, a community health center with extended hours and weekend services, and offices for city case managers.

Seton, which will have no authority over the designated area, will provide separate maternity care services on the second floor of Brackenridge. The organization has agreed to do the build-out for the hospital within a hospital and to provide up-front funding for renovation of the fifth floor, estimated at $5 million; this part of the deal already is under negotiation. The city will be expected to repay the renovation costs to Seton over the next 20 years. Meanwhile, Seton has agreed to offset the $1.7 million to $2 million annual net operating loss it will incur when the city takes back the fifth floor against the $5.6 million the city currently pays it to provide charity care. As compensation for losing the fifth floor, Seton gets a lease payment reduction; specialty clinics and offices currently residing there will move to a professional building across the street.

Though the city describes its goal as "seamless" reproductive care, some citizens at the hearing charged that the city is placing political expediency before the needs of uninsured. An audience member distributed copies of the Catholic Directives, and others openly questioned the legitimacy of a public hearing at which the only plan given full consideration was the "hospital within a hospital." While the city's presentation claimed that citizens' comments were incorporated into the Brackenridge proposal, none of the citizen speakers said the plan was what they had asked for during the city's last meeting on July 18.

Dr. Albert Gros, an obstetrician and gynecologist who cares for several patients at Brack, called the "hospital within a hospital" a "sin wing" because it offers services outlawed in the rest of the building. "A trip from the second floor to the fifth floor for a postpartum tubal constitutes a pretty big seam," he said. And members of the Ad Hoc Group on Women's Reproductive Services at Brackenridge -- which includes members of Planned Parenthood, the National Organization for Women, and other groups -- were more than one-third of the 60 people in attendance. The Ad Hoc group opposes the hospital within a hospital's separation of some maternity and reproductive services from others, and many members want the city to scrap its contract with Seton altogether.

The city says finding another provider can't be done. "When we were $38 million in the hole, nobody wanted to be our partner," says Dunkerley, who has praised Seton for its quality of indigent care.

DeAnn Friedholm, a member of the Brackenridge Hospital Oversight Council, expressed her fear that the "hospital within a hospital" will create "unintentional double standards." Appointed in May, Friedholm hopes the oversight council, which monitors access to indigent care and makes recommendations to the City Council on lease issues, can be more aggressive. Historically, the oversight council has been denied information from Seton that the city says it needs for thorough recommendations. As a private, not-for-profit entity, Seton can legally keep important documents private, which several years ago prompted one frustrated member to resign in protest.

City staff doesn't need the council's approval before it presents its plan to City Council, which can vote it up or down. The oversight council's next public meeting is scheduled for early October, but Dunkerley says the city hopes to meet with members in September, when the Brackenridge proposal includes more details. "We have yet to write a word," she says, estimating the public-process period and construction of the "hospital within a hospital" might take at least 18 months.

Language in the lease allows for adjustments should the Catholic Church revise its policies in ways that would affect Seton's management and operation of Brackenridge. This language will remain, Dunkerley says. In the current brouhaha over reproductive services, Seton hasn't breached its contract because it notified the city of the changes, met with city officials, and has agreed to let the city discuss potential solutions. Meanwhile, until the city's plan is complete, Brack has allowed tubal ligations and other reproductive services to continue.

Dunkerley was reluctant to discuss what might happen if the national Conference of Catholic Bishops again changes its directives. The potential for future crises worries Council Member Beverly Griffith, who didn't say whether she would vote for a "hospital within a hospital" plan, but remarked that no citizens have called her office to support it. On her handout of directives, Griffith highlighted lines discussing abortion in the case of rape and cases in which patients ask not to be kept alive if they become brain dead. "Those two really need to be nailed down," Griffith said. "They can't be vague."