Earlier this month, the American Civil Liberties Union (ACLU) filed what at first blush seems like a very unusual lawsuit against the United States Conference of Catholic Bishops (USCCB). Her life jeopardized by the refusal of Mercy Health Partners in Muskegon, Michigan to perform or even inform her of the need for an abortion, the plaintiff Tamesha Means is instead suing the USCCB for its ethical and religious directives which require Catholic hospitals to avoid abortion or referrals, "even when doing so places a woman's health or life at risk."
But as the numbers show, Ms. Means' case is hardly unique. While much of the focus in the abortion debate has centered on the statehouses, governors' mansions and courtrooms in the reddest of red states now making a mockery of the very idea of "the health of the mother," another disturbing trend is fast making access to abortion and other reproductive services a thing of the past across large swaths of the country. In Washington, Oregon, Illinois and other strongly pro-choice states, the rapid consolidation of smaller, rural and even teaching hospitals by expanding Catholic chains is putting women's reproductive health--and sometimes their lives--at risk. Thanks to these mergers, acquisitions and strategic partnerships, decisions about contraception, abortion, sterilization and live-saving care aren't being made by patients and their doctors, but increasingly by bishops.

For over a hundred years, Catholic hospitals have been one of the cornerstones of the U.S. health system, providing care to tens of millions of Americans of all faiths, races and ethnicities. Last year, the New Republic's Jonathan Cohn explained just how big a role they play and the public support they enjoy in return:

Today, Catholic hospitals supply 15 percent of the nation's hospital beds, and Catholic hospital systems own 12 percent of the nation's community hospitals, which means, according to one popularly cited estimate, that about one in six Americans get treatment at a Catholic hospital at some point each year. We now depend upon Catholic hospitals to provide vital services--not just direct care of patients, but also the training of new doctors and assistance to the needy. In exchange, these institutions receive considerable public funding. In addition to the tax breaks to which all nonprofit institutions are entitled, Catholic hospitals also receive taxpayer dollars via public insurance programs like Medicare and Medicaid, as well as myriad federal programs that provide extra subsidies for such things as indigent care and medical research. (Older institutions also benefited from the 1946 Hill-Burton Act, which financed hospital construction for several decades.)

But increasingly, Cohn cautioned, "the dual mandates of these institutions--to heal the body and to nurture the spirit, to perform public functions but maintain private identities--are difficult to reconcile." For many communities, a Catholic facility is already the only choice. And with the accelerating trend of hospital mergers and partnerships, policies forbidding contraception, abortion and sterilization are becoming the norm at formerly public hospitals. In cities around America, the result is growing confusion for physicians and greater risk for their patients.

As the New York Times detailed a year ago, over the previous three years about 20 new partnerships combining stand-alone hospitals or smaller systems with larger, financially stronger Catholic institutions is adversely impacting the availability of common reproductive health care services. For example:

In Seattle, Swedish Health Services has offered elective abortions for decades. But the hospital agreed to stop when it joined forces this month with Providence Health & Services, one of the nation's largest Catholic systems.

And when Seton Healthcare Family in Texas, a unit of Ascension Health, began operating Austin's public Breckenridge hospital in 1995, it curbed reproductive health care services available to its patients:

In that case, Mr. [Charles] Barnett [of Ascension Health] says the system never agreed to provide services like elective abortions and sterilizations, and public officials and hospital administrators initially struggled to find a compromise. Although another system eventually offered sterilizations on a separate floor of the hospital, complete with a separate elevator, another hospital now provides those services.

Increasingly, the clashing requirements of the Catholic hospitals public mission and religious tenets are putting patients, doctors and staff at risk. In 2007, physician Ramesh Raghavan wrote in the Journal of the American Medical Association of his wife's experience. As Cohn explained the horrifying episode:

[Raghavan's wife], a woman, also pregnant with twins, whose pregnancy was failing, threatening infection that could jeopardize her ability to have future children and perhaps her life. Distraught, she and her husband decided to terminate the pregnancy--only to learn the Catholic hospital would not perform the procedure.

A few years later, New Hampshire waitress Kathleen Prieskorn went to her doctor's office after a miscarriage--her second--began while she was three months pregnant. She quickly learned that her emergency was not one for which treatment would be available from her hospital's new operators:

Physicians at the hospital, which had recently merged with a Catholic health care system, told her they could not end the miscarriage with a uterine evacuation--the standard procedure--because the fetus still had a heartbeat. She had no insurance and no way to get to another hospital, so a doctor gave her $400 and put her in a cab to the closest available hospital, about 80 miles away. "During that trip, which seemed endless, I was not only devastated but terrified," Prieskorn told Ms. "I knew that, if there were complications, I could lose my uterus--and maybe even my life."

Perhaps the most notorious case, as both the Times and the New Republic reported, involved Catholic Health West and one its hospitals in Phoenix. A 27-year old woman, 11 weeks pregnant and suffering from "right heart failure" came to St. Joseph's Hospital and Medical Center. What happened next may be a frightening omen of things to come:

Physicians concluded that, if she continued with the pregnancy, her chances of mortality were "close to 100 percent." An administrator, Sister Margaret McBride, approved an abortion, citing a church directive allowing termination when the mother's life is at risk. Afterward, however, the local bishop, Thomas Olmsted, said the abortion had not been absolutely necessary. He excommunicated the nun and severed ties with the hospital, although the nun subsequently won reinstatement when she agreed to confess her sin to a priest.

(Ironically, Catholic hospitals in Ireland will now provide the kinds of life-saving care their counterparts in the United States often will not. Following the tragic, painful and completely unnecessary death of Savita Halappanavar at University Hospital Galway, the Irish government took action to legalize life-saving health exceptions to its draconian abortion restrictions. For that step, in May Boston Cardinal Sean O'Malley boycotted the graduation speech at Jesuit Boston College by Irish Prime Minister Enda Kenny.)
The growing crisis for women's care resulting from the partnership and merger movement is leading to a backlash and some sadly creative solutions. Catholic Health Care splits its network into 25 Catholic and 15 non-Catholic facilities under the new name, Dignity Health. In Kentucky, Governor Steve Brashear blocked "a bid by Catholic Health Initiatives, another large system, to merge with a public hospital in Louisville, in part because of concern that some women would have less access to contraceptive services." Meanwhile in Rockford, Illinois, there is growing resistance to let the Sisters of the Third Order of St. Francis buy a local hospital because of "new restrictions that would require women to go elsewhere if they wanted a tubal ligation after a Caesarean section."
Unfortunately, in many regions of the country, there is nowhere else to go. As the New York Times recently explained, the M&A activity of Catholic hospital chains is even jeopardizing the availability of reproductive services in Washington, the only state with a statutory right to abortion. Even as Democratic Governor Jay Inslee was pushing a bill to require health insurers to cover elective abortions, the expansions by PeaceHealth, Providence Health Services and Franciscan Health Systems was making them much harder to obtain:

The concentration of mergers here, through happenstance and history -- Catholic nuns arrived in Washington with the first waves of settlers in the 1850s -- is particularly pronounced. If all the proposed religious and secular combinations go through, almost half of the hospital beds in the state -- the highest percentage in the nation, and up from less than a third at the beginning of last year -- would be controlled by the Catholic health systems, according to Merger Watch, a nonprofit group in New York that tracks hospitals.
Another wrinkle is that many Washingtonians are not that keen on religion to start with. A poll by Gallup conducted throughout 2012 put the state at 12th from the bottom in percentage of people who described themselves as "very religious." It is also one of only two states -- Oregon is the other -- where voters have approved a physician-assisted suicide law for terminally ill people. Centuries of Catholic teaching hold suicide as a mortal sin.

As the Seattle Times reported in May, preventing such mortal sins won't merely be the policy of financially-troubled, smaller hospitals taken in over in towns and rural areas like Walla Walla and Friday Harbor.

The latest in a long list of affiliations in Washington between secular hospitals and religious health-care systems is a shocker: UW Medicine and PeaceHealth announced Monday they had signed up to create a "strategic affiliation," with details to be spelled out by the end of September.
UW Medicine, which receives taxpayer support, includes the University of Washington and Harborview medical centers, Northwest Hospital & Medical Center, Valley Medical Center, UW Neighborhood Clinics, UW Physicians, UW School of Medicine and Airlift Northwest.

In response to the announcement, Sarah Dunne, legal director for the ACLU of Washington, declared, "We are troubled and concerned because we have yet to see the final details." Recalling last year's acquisition of Swedish Hospital, Dunne warned, "What we don't know is whether this is a Trojan horse. ... They're saying they're independent organizations, but we've seen this before, and lo and behold, once they're connected, one takes over the other."
Still, the worrying national trend is creating problems for all parties. Sister Carol Keehan, president of the Catholic Health Association of the United States, which represents the nation's roughly 600 Catholic hospitals, said of Americans' increasingly dependence on her organization's facilities, "That is a constant challenge. It's a challenge we take very seriously." But for American women, the challenge of getting reproductive care isn't just serious; it could be very dangerous. AS Jill C. Morrison, of the National Women's Law Center worried, the new restrictions mean "women simply don't know what they're getting."
If, that is, they can get it at all. As Lois Uttley, director of MergerWatch explained last year, "There are a lot of rural places that now have only a Catholic hospital." But as the news from Seattle, Houston, Austin and elsewhere suggest, that is increasingly true of both small towns and big cities. And that means that the health and lives of millions of American women will be not just at the mercy of the Republican Party and the United States Supreme Court, but the United States Council of Catholic Bishops as well.