Medically Necessary but Forbidden: Reproductive Health Care in Catholic-owned Hospitals

The Affordable Care Act (ACA) has resulted in a large increase in hospital mergers and acquisitions. The figures are notable: 105 merger deals were reported in 2012 alone, an increase from 50 to 60 annually in the pre-ACA, pre-recession years of 2005–2007. Catholic hospital systems have actively participated in this merger frenzy: by 2015, four out of the top five largest healthcare systems were faith-based, with 141 mergers between Catholic and non-Catholic systems since 1997.

Mergers that affiliate a hospital with a Catholic owner, network, or system, are consequential because they reduce the set of possible medical procedures. Specifically, the U.S. Conference of Catholic Bishops' (USCCB) Ethical and Religious Directives for Catholic Health Care Services forbid sterilization procedures, contraceptives, in vitro fertilization and abortion at Catholic health care facilities.  As a result, a rise in mergers between Catholic and secular hospitals and health systems over the past decade has drawn increased attention to the directives' impact on access to reproductive health care services at such facilities.

For example, in October of this year, the ACLU sued Trinity Health (the second largest Catholic Health System that owns 86 hospitals in 21 states) for not performing abortions when medically necessary. The lay press, medical and legal journals have featured discussion about the impact of these mergers on patient care, particularly with regard to reproductive health, such as abortions and sterilizations and have drawn attention to the $45 billion in federal funding these hospital systems receive each year.

We examine the effect of changes in ownership from secular to Catholic (and vice versa) on reproductive health procedures (e.g. abortion, tubal ligation, vasectomy, DNC) that are likely to be affected by Catholic ownership and banned under the USCCB Ethical and Religious Directives. Using the American Hospital Association Annual Survey and a newly collected data source on verified ownership status over time, we observe approximately a third of all hospital mergers both to and from Catholic-affiliation that occurred nationally from 1998 until 2013. We then merge this data with the Healthcare Cost and Utilization Project (HCUP) hospital discharge data from six states.

Using this hospital-level variation in ownership status for 11,206 hospitals, we estimate a difference-in-differences model with year and hospital fixed effects. We find that Catholic hospitals reduce the prevalence of abortions by 0.0013 procedures/bed/year (0.10 percent reduction from the mean; p-value=0.023), reduce the incidence of tubal ligations by 0.11 procedures/bed/year (0.13 percent reduction from the mean; p-value=0.003), reduce vasectomies by 0.0006 procedures/bed/year (1.0 percent relative to the mean; p-value=0.020), whereas there is no statistically significant change in DNCs.

A third of all Catholic hospitals are in rural areas where they are likely the only provider and so individuals are less likely to have non-Catholic options.  This is all the more the case for low-income individuals who lack the time or resources to travel to another provider.  As a result, the imposition of a particular religion’s medical restrictions on others, without their consent, could have a substantial negative impact.