Angela Valavanis had already had one bad encounter with the Catholic health care system when St. Francis Hospital, the hospital in Evanston, Ill., where she delivered her second baby, refused to allow her OB/GYN to tie her tubes because of Catholic restrictions on the procedure. When she went to her doctor’s office for a check-up after the birth and asked about going back on the Pill, since she hadn’t gotten the sterilization she wanted, she got another shock: “My doctor told me that she couldn’t prescribe birth control because she had sold her practice to a Catholic health system,” said Angela. “My mouth dropped open. I was so confused to hear those words coming out of the mouth of an OB/GYN.”
An OB/GYN who can’t prescribe birth control? It’s not some bad joke. It could be a reality if your doctor’s practice is purchased by a Catholic health system that then imposes the Ethical & Religious Directives for Catholic Health Care Services, a set of rules created by the U.S. Bishop’s Conference that prohibits doctors from doing everything from prescribing the Pill to performing sterilizations or abortions.
And Angela’s experience may be just the tip of the iceberg. Driven by health-care economics and incentives in the Affordable Care Act, health systems, which are a collection of hospitals and ancillary services, are acquiring physician practices at an unprecedented rate. The percentage of doctors who were employees of health systems increased from 20 percent to 26 percent between 2012 and 2013 alone; more than 40 percent of primary care doctors like OB/GYNs are now employed by health systems directly, and experts don’t see the trend slowing.
And with Catholic hospital systems accounting for eight of the 10 of the largest nonprofit health systems in the U.S., these hospitals are poised to become major owners of doctors' offices, which could severely impede access to contraceptives if doctors are forced to follow the Directives. “The more we see these Catholic systems buying up these practices, the more we are going to see what Angela saw,” predicted Lorie Chaiten, director of the Illinois ACLU’s Reproductive Rights Project, who notes that such refusals are legal under Illinois’ Health Care Right of Conscience Act.
“Angela went to the same provider for 15 years and all of the sudden she couldn’t get birth control. This could have a huge impact on women,” Chaiten said.
Last year, Ascension Health system, a Catholic system, and the largest nonprofit health system in the country, attracted national attention when it reportedly told doctors at an Oklahoma hospital that they couldn’t prescribe birth control. Ascension quickly backed down, deciding that it would “tolerate,” but not “approve, condone or permit,” the prescription of contraception by physician employees.
Now it appears that the largest system in Illinois, Presence Health, is also prohibiting doctors from providing contraceptives. Presence was created by the merger of two smaller Catholic systems, Resurrection Health Care, which was the system that bought Angela’s doctor’s practice, and Provena Health. Today, Presence Health owns 11 hospitals and dozens of doctor’s offices.
These health systems are merging, and gobbling up doctors’ practices, because of incentives in the ACA for systems to coordinate care across the range of services that patients need, from doctor’s visits to in-patient hospital procedures, and because of health care economics, that make it prohibitively expensive for doctors to maintain solo practices.
Asked directly whether its doctors in Evanston and elsewhere in Illinois were prevented from providing contraception, Presence said in a statement, “We abide by the Ethical & Religious Directives, and there are certain services which we do not provide. It is our expectation that all physicians associated with Presence Saint Francis Hospital share with their patients the options that are available in accessing the care they seek.”
But telling women about their options isn’t a solution when they are denied access to contraception, says Chaiten. “Even if they tell you what your options are, you have to have a second appointment with another doctor to get birth control. This seems inconsistent with whole idea of OB/GYN practice.”
Not only do women have to face the inconvenience of making—and paying—for another doctor’s appointment to get one of the most basic gynecological services, but there’s also a bigger problem: “The more we stigmatize and silo reproductive health care, the more it seems like it’s OK to treat it as not basic health care,” says Chaiten.
In fact, when Angela went back to her doctor after giving birth in mid-2013, the doctor indicated to Angela that she would provide her with a prescription for birth control if Angela would just make up a non-contraceptive reason, like severe menstrual bleeding or bad acne. But Angela refused to lie.
“I felt so betrayed that a doctor would essentially sell out her patients by selling her practice to an entity that won’t allow her to provide the same level of care. I haven’t been back to her,” she says.
But for some women, changing doctors may not be an option. Health insurers are becoming increasingly restrictive about which hospitals and doctors a patient is allowed to use and may charge a steep penalty for going out of the network of preferred providers. Smaller towns and rural areas may not have a large selection of OB/GYNs. The ACLU is backing a measure in the Illinois Legislature that would require health systems to tell patients beforehand what services they don’t provide and where they can get them. Chaiten also encourages women who have been denied reproductive health services for religious reason to report it to the ACLU, which is tracking this trend.
Ironically, Angela’s experience with her OB/GYN wasn’t her last run-in with Catholic health care. After she was refused a tubal ligation and a prescription for birth control, Angela’s husband decided to get a vasectomy. His doctor, who was also part of the Catholic system, said his practice couldn’t do the procedure or make a referral. “The whole situation is so unbelievable to me. I had no idea these limitations occurred,” she says. “When I tell my friends about it, they say it’s medieval. We have to worry that if they keep buying up all these practices, it will get harder and harder to find someone who can prescribe birth control.”
Patricia Miller is the author of “Good Catholics: The Battle Over Abortion in the Catholic Church.” Her work on politics, sex and religion has appeared in the Atlantic, the Nation, Huffington Post, RH Reality Check and Ms. Magazine.