As public hospital districts and private religious health care systems form partnerships across the region and the nation, questions about separation of church and state have naturally followed.
The short answer is that there is no clear direction as to how far a public/religious alliance can go.
“There are really no laws against who public hospital districts can contract with,” said Ben Lindekugel, director of member services for the Association of Washington Public Hospital Districts. “It’s pretty much that blunt.”
PeaceHealth St. Joseph Medical Center partnered with San Juan County Public Hospital District No. 1 in 2009 to build a new hospital in Friday Harbor. And PeaceHealth is close to finalizing a lease and operating agreement with United General Hospital in Sedro-Woolley.
Meanwhile, Skagit County’s two other hospitals, along with a neighbor in Snohomish County, are considering partnerships that may have religious affiliations. Any changes with a new alliance would depend on the deal worked out.
But the possibility that every hospital in the area could become attached to religious-based institutions has sparked hot debate and formation of a new local group, People for Healthcare Freedom. The concern is that the partnerships might come with restrictions in the services those hospitals and doctors can provide, such as access to birth control, abortion and end-of-life assistance.
A case in point is Swedish Health Services of Seattle, which partnered with Providence last year. As part of their agreement, Swedish agreed to stop offering elective abortions at its facility.
While it is no foregone conclusion that a restriction on services would occur with alliances here, there are apparently no clear rules to prevent it — even with taxpayers on the hook.
Local hospital officials say that partnering with other and larger health care systems is the best way to remain viable and healthy in an increasingly competitive — and costly — environment.
The new United General
Skagit County residents can expect the agreement PeaceHealth is making with Sedro-Woolley’s Hospital District 304 to be similar to that of San Juan’s, said Amy Cloud, spokeswoman for the Catholic nonprofit.
A final operating agreement will probably take another month or two to hammer out and is set to begin July 1, United General Hospital CEO Greg Reed said. The new name will be PeaceHealth United General Medical Center, though Public Hospital District 304 will still own the facilities.
In keeping with its Catholic identity, PeaceHealth follows church guidelines regarding certain services and procedures: It does not permit abortion except to save the life of the mother, and while it provides emergency contraception to victims of sexual assault, it requires a negative pregnancy test first, according to PeaceHealth’s website.
The system also prohibits physician-assisted suicide, which voters approved through the Death With Dignity law passed in Washington in 2008.
United General Hospital does not currently have OB/GYN services, and the hospice it co-runs with Skagit Valley Hospital does not participate in physician-assisted suicide, though its doctors do make referrals.
“Our being involved with PeaceHealth isn’t changing anything,” Reed said.
The rest of Skagit
Skagit County’s other two hospitals, Skagit Valley Hospital and Island Hospital, also are run by public districts. Last year, they formed an alliance with Cascade Valley Hospital in Arlington as a means of strengthening their position to share resources and possibly pursue a larger partner together.
Skagit Valley Hospital board commissioners and CEO Gregg Davidson have previously noted that hospitals increasingly need economies of scale, access to technology and the leverage with insurance companies that go along with a larger health care system.
The boards of the three hospitals are still exploring their options. They haven’t sent out a request for proposals yet. But they’re putting out feelers.
What they do know is they’re not for sale. The commissioners say they’re not looking for a merger, or even a lease agreement like the one between United General and PeaceHealth.
The commissioners know they want a Northwest-based, nonprofit system, said Bruce Lisser, president of the board of commissioners for Skagit Valley Hospital.
That leaves five contenders: PeaceHealth, Swedish/Providence, University of Washington/Valley Medical Center, Tacoma-based Multicare and Virginia Mason Hospital and Medical Center. Two of those, PeaceHealth and Providence, are faith-based.
They also have a set of what Lisser calls “significant criteria” for any potential partner. These include extending access to specialty services, improving clinical quality and processes, advancing the hospitals’ vision, and recruiting and keeping doctors.
“As much as we need capital, obviously, that’s not on the top of the list,” Lisser said. The other things are more important.
If the potential partner ends up being a religious system, the districts will have to negotiate over the services they offer. For example, Skagit Valley Hospital currently offers “a full range of women’s health services typically provided in a hospital setting,” said Skagit Regional Health spokeswoman Kari Ranten.
As they look for a partner, the boards plan to listen to Skagit residents’ concerns, Lisser said.
“There’s lots of things that are important to the community, and we’re a community hospital, so our decisions we make are going to have to keep that in mind,” he said. “We’re not going to say, ‘Oh and, by the way, we’ve ignored the community.’ … It’s still important to all of us to maintain local control of our hospital and our health care decisions.”
It is the fact that health care options could be limited that has some concerned.
The ACLU of Washington sent a letter to the San Juan district’s hospital commissioners, saying they were violating the religious establishment clause of the state Constitution by paying a subsidy to PeaceHealth’s restrictions on certain services.
“In sum, government cannot subsidize health care facilities that deny reproductive health services to the community based on its religious views,” wrote ACLU of Washington Executive Director Kathleen Taylor.
But it’s unclear what kind of legal support backs that statement.
“Not many constraints exist on what kind of agreement the (hospital) commissioners can enter into,” said Jeff Mero, executive director for the Association of Washington Public Hospital Districts.
Holding Skagit, Island and Cascade Valley hospitals to the Catholic Church’s rules could geographically isolate patients, said Sheila Reynertson, advocacy coordinator for the New York-based MergerWatch Project, which fights religious restrictions on health care. A woman could have to travel as far as Whidbey Island or Port Townsend to get, for example, a voluntary tubal ligation.
“Hospitals are public goods, and they have a responsibility to make sure a community has access to health care services that they need, and that includes a full range of reproductive health care and that includes being able to participate in Death With Dignity,” Reynertson said. “That’s, I think, the state’s responsibility.”
Meanwhile, pending the Certificate of Need and the final operating agreement, the PeaceHealth United General partnership is all but sewn up. The small Sedro-Woolley facility will have the money, the resources and the restrictions of its new Catholic operator.
“It’s a tiny hospital,” Reynertson said, “but it’s raising some enormous, enormous questions.”
PeaceHealth St. Joseph doesn’t insert itself into decisions patients make with their doctors about birth control, said PeaceHealth’s Amy Cloud.
“We do not dictate to physicians, nor do we control (nor wish to control) the conversations they may have with patients about their options that take place within the sanctity of the physician-patient relationship,” Cloud said.
PeaceHealth doctors may prescribe contraceptives, and patients can fill those prescriptions at a PeaceHealth-operated pharmacy, she said. But emergency contraception, such as the “morning-after pill,” is given only to victims of sexual assault.
Patients can get vasectomies and tubal ligations at PeaceHealth facilities when they and their doctor deem it medically necessary, Cloud said.
A woman can get an abortion at a PeaceHealth facility only when her life is in danger or in the case of an “imminently lethal fetal anomaly,” Cloud said. This could include, for example, a woman brought to the emergency room who has an ectopic pregnancy that threatens her life.
State law says governments, including public hospital districts, cannot “deny or interfere with a woman’s right to choose or refuse” an abortion. But it also says no doctor can be required to perform one.
No such specific rules exist for public hospital districts “with respect to birth control or other family planning or reproductive health services,” Lindekugel said.
It’s common practice for a public hospital that does not offer OB/GYN services to make referrals, but the law only requires that in emergencies, Mero said.
In general, Cloud said, PeaceHealth refers patients elsewhere for services it doesn’t provide at a given facility. But with elective abortion and physician-assisted suicide, referrals are a little trickier.
Because PeaceHealth does not “condone or promote” those services, they don’t make direct referrals. What they do, Cloud said, is discuss options and refer patients to other community resources that can “continue the conversation.”
The need for such workarounds has organizations like the American Civil Liberties Union “greatly troubled,” said Sarah Dunne, legal director for the ACLU of Washington.
“Everyone wants efficient health care and less costly health care, but we want to make sure it’s not done in such a way that restricts access to care for patients,” she said.
The Ethical and Religious Directives set forth by the bishops of the Catholic Church instruct Catholic institutions not to honor an advance directive that is contrary to Catholic teaching. But that won’t be a problem at PeaceHealth United General Medical Center, Cloud said.
“PeaceHealth honors — and will continue to honor — advance directives,” Cloud said.
Skagit-area patients who want physician-assisted suicide currently can receive a prescription and some counseling from doctors at the hospice. They just can’t take the medication there. Skagit Valley Hospital currently will help transfer the patient somewhere else.
The Death With Dignity Act says no doctor is required to help patients end their own lives.
“With regard to the aid in dying statute, the law is clear, but the consequences are murky,” Mero said. “Public hospital districts have to abide by the law, but if their employees don’t want to, there’s not much they can do.”
The Catholic Church is serious about its directives, however. A Catholic hospital that strays too from the the church’s directives could face the fate of St. Charles Medical Center in Bend, Ore., which lost its sponsorship by the Catholic Diocese in 2010 because of such a disagreement between the bishop and hospital administrators.
PeaceHealth, meanwhile, is in expansion mode.
PeaceHealth and United General have applied for a Certificate of Need from the state Department of Health, which is required before the lease can go through.
The certificate review process includes a three-week public comment period that started Friday, Feb. 1.
“The comments could include concerns about the scope of services that would be offered (at the hospital) if the lease is approved,” said Assistant State Attorney General Lilia Lopez.
Meanwhile, PeaceHealth is also in talks with Denver-based Catholic Health Initiatives to create a new health system. Each party will own half, making them equal partners, Cloud said. The idea is for PeaceHealth to benefit from CHI’s resources, not to adopt its policies, she said.
“This partnership does not change PeaceHealth’s relationship with the Catholic Church, nor will it bring any changes to our policies,” Cloud said.
The new system is on track to start on the same day as PeaceHealth’s operations of United General: July 1.
A business decision
The alliance with PeaceHealth is more about staying afloat than anything else, United’s General’s Greg Reed said.
Partnering with a larger system gives United General access to resources and financial stability it might not otherwise have as a small facility in a rural public district.
Along those lines, the alliance could give United General more freedom in at least one area: charity cases. Another piece of PeaceHealth’s Catholic mission is to care for the poor and vulnerable, serving anyone who needs it, regardless of insurance coverage or ability to pay. Last year, PeaceHealth St. Joseph provided $40 million in uncompensated care.
“(It’s) driven off the bottom line,” Reed said. “Not knowing what’s going to happen five years or 10 years down the road, especially with unknowns in the landscape from the Affordable Care Act — our model may not be sustainable down the road.”