Catholic Healthcare Delivery in America — Noble Origins to the Modern Era

Catholic healthcare occupies a large and growing footprint in American healthcare, and across the American landscape with facilities cropping up in farm country and emerging in urban centers. The vast system of Catholic healthcare we see today is actually quite surprising. In the first half of the 1800s, only 5% of Americans were Catholic and although that number grew to 13% by 1900, much of that growth was due to the arrival of mostly poor immigrants.

One powerful driving force enabled this growth of the Catholic healthcare system: the Catholic women religious — the nuns — coming from Europe, who were tirelessly and fearlessly committed to living Jesus’ example of healing all who came to him. Catholic healthcare had a humble beginning. The nuns established small hospitals in the teeming cities and the remote territories of the Wild West to serve those in need.

Today, those hospitals have evolved into multi-billion-dollar healthcare corporations comprised of hospitals, physician groups, outpatient facilities, insurance companies, and even venture capital companies. Four of the 10 largest U.S. healthcare systems, in monetary terms, are Catholic systems. In some states, more than 40% of the hospital beds are in Catholic hospitals. One of the largest Catholic systems, CommonSpirit, claims that one in four Americans have access to healthcare in its system.

Reflecting this reach, Catholic hospitals deliver large volumes of healthcare to the American people. For example, in 2020 almost 500,000 babies — 15% of all the babies born in the United States — entered the world in a Catholic hospital. Added to those numbers of deliveries are millions of clinic and emergency department visits and hospital stays.

If the magnitude of care provided by Catholic healthcare were the entire story, there would be nothing to do but offer gratitude. There would be no questions to ask, no concerns to raise. But it is not that simple.

These hospitals and the many other components of the healthcare systems owned by Catholic systems, and some with whom they are affiliated, function under the supervision of the Catholic bishops. These entities must comply with 77 rules known as the Ethical and Religious Directives for Catholic Health Care Services (ERDs). The ERDs were first published in 1948 and have been reissued multiple times, most recently in 2018.

Beyond the prohibition of abortion, neither the scope of the rules nor their implications for care are well-known to patients, to communities, or even to those with their finger on the healthcare pulse. The ERDs cover a large swath of healthcare, from commitment to social responsibility including care of the poor, to spiritual care, to the definitions of the beginning and end of life and the attendant prohibitions of some care and procedures, to relationships and mergers with other entities.

Part of the lack of knowledge about the rules that govern Catholic healthcare stems from the fact that there is little transparency about the Catholic ownership of a given hospital and a hospital’s enforcement of the ERDs, including the wide range of prohibited care. Patients believe that their care will be determined solely by standards of medical care and what the physician believes to be in their best interest. They often are unaware that the physicians who care for them in Catholic hospitals, emergency departments, and clinics must obey all the prohibitions within the ERDs.

The myriad prohibitions in care lead to the question, “What enables a group of less than 300 Catholic bishops to define the healthcare of millions of Americans, 80% of whom are not Catholic?”

This is really a two-part question. The first part of the question focuses on the power of the American bishops. The hierarchical structure of the Catholic Church establishes the bishops’ ability to oversee and direct practices of Catholic institutions, even ones they do not directly operate or fund.

The second part of the question focuses on how this power can extend beyond the members of the Catholic Church. The answer to this begins with the First Amendment of the Constitution and free exercise of religion. This freedom has been amplified by a subsequent series of so called “conscience laws” which give individual healthcare providers and healthcare organizations the right to exercise their own beliefs, even when those beliefs may not comport to those of the patients for whom they are caring.

Compliance with the rules of a single religious group in the delivery of healthcare, which is funded primarily with public dollars and advantaged by tax-exemptions, gives rise to many implications and issues for patients, for a community, and for the entire healthcare system in our pluralistic country. Therefore, this entire terrain deserves broad and meaningful exploration.

Excerpted from The Catholic Church and Its Hospitals: A Marriage Made in Heaven?, by Patricia A. Gabow, MD, MACP.