For years, religiously affiliated hospitals have merged with secular health care systems, often with disruptions to services like reproductive health care. About half of health care systems in Washington are affiliated with religious organizations, which means that even with state-level and national protections for abortion, hospitals in Washington can deny or restrict reproductive health care based on religious protocols. The result is a patchwork of reproductive health policies that vary by hospital, and can leave patients confused or without care altogether.
“That’s the worst case scenario, when you show up and this care is needed, and you need it now, and you’re not able to get it in a timely manner,” says Leah Rutman, policy counsel at the American Civil Liberties Union of Washington, which has advocated for stronger regulations governing hospital mergers.
And it’s not just abortion access that’s impacted. The U.S. Conference of Catholic Bishops’ Ethical and Religious Directives, a set of theologically rooted guidelines for Catholic health care institutions, prohibit abortion entirely, but their limitations extend far beyond elective abortion, complicating a number of routine treatments and procedures. For example, if a patient has an ectopic pregnancy — a nonviable pregnancy that occurs when a fertilized egg develops outside the uterus — the directives forbid any intervention that includes an abortion. But termination, either through medication or surgery, is the only treatment for ectopic pregnancy. If left untreated, ectopic pregnancy can cause the fallopian tube to rupture, which is a life-threatening medical emergency.
The bishops’ directives also call into question the availability of services like miscarriage management, common birth control procedures like tubal ligation, care that supports and affirms patient gender identity, and medically assisted death.
Policies limiting procedures like these have become increasingly common across the state over the past decade, and often are used to justify cutting services when hospitals merge. In January 2021, when the Catholic hospital system CHI Franciscan merged with Seattle’s Virginia Mason, CEO Ketul Patel announced that the newly formed Virginia Mason Franciscan Health would no longer provide elective abortions or aid in dying across 300 care sites in Western Washington.
Yakima Valley Memorial Hospital, which ended its affiliation with Virginia Mason in 2020, still provides abortion care, according to its latest checklist filed with the Washington State Department of Health. But the hospital’s resistance to the merger with CHI Franciscan and continuation of abortion care are unusual. (In May, the Yakima Herald-Republic reported that Yakima Valley Memorial is exploring a merger with secularly controlled MultiCare.) Even Western Washington, where most of the state’s abortion providers are concentrated, has been impacted by mergers. When Swedish Health Services and the Catholic health system’s Providence Health & Services merged in 2012, Swedish, previously a secular institution, stopped most abortion care in its facilities.
While some hospitals that don’t provide abortion care will refer patients elsewhere, a referral may not be possible in an emergency. In 2013, a Washington woman almost died at PeaceHealth St. Joseph Medical Center in Bellingham after being denied treatment for an infection following a miscarriage. Cases like hers, reported by Rewire News Group and documented by the ACLU, led the state Legislature to pass the Protecting Pregnancy Act in 2021. The law allows doctors working in institutions under the Catholic Church’s purview to override ethical-religious directives in the event that a medically necessary abortion is required. “Patients were in these situations, some of them very dire, and they were having their care delayed or denied, which is unacceptable,” said the ACLU’s Rutman.
It also gives patients the right to sue hospitals if they are denied miscarriage management treatment or termination of a nonviable pregnancy in an emergency situation like an ectopic pregnancy. But so far, Rutman said, there isn’t enough data to determine what practical impact the new law has had.
Rachael Sims, a spokesperson for the state Department of Health, declined to comment on the department’s involvement in enforcing the law, but said it “would continue to comply with the provisions required of us.”
Dr. Sarah Prager, professor of obstetrics and gynecology at the University of Washington, Seattle, said dissemination of information about the new law has been poor, and not enough time had elapsed to get much insight into hospital compliance. But she said it did not address the root problem of the ethical-religious directives themselves.
“I don’t know if there will be a difference, as abortion care is functionally not available for pretty much any reason at Catholic health care centers currently, or if abortion becomes illegal,” said Prager, who is also an OB-GYN at UW Medicine and is incoming District VIII Secretary and co-chair of the abortion access and training working group with the American College of Obstetricians and Gynecologists. Historically, she added, patients requiring life-saving abortion care have been not been treated at Catholic institutions, but instead have been transferred to hospitals like the University of Washington Medical Center in Seattle, which provide comprehensive reproductive health care, including abortion.
Patients denied care at religiously affiliated hospitals have also been transferred to Cedar River Clinics, which has locations in Seattle, Tacoma and Renton,, said Mercedes Sanchez, director of development, communications and community education and outreach. But in states where abortion will be banned if Roe v. Wade is overturned, she said, “transfers to other clinics aren't an option, and there's no possibility of transferring out of the state in a timely manner. So I think this is going to become even a worse nightmare than people are currently talking about.”
The Protecting Pregnancy Act is just one relatively recent effort to rein in hospital mergers’ impact on reproductive health care. The Keep Our Care Act, which was introduced in the state Legislature earlier this year but did not make it out of committee, would have required health care systems to furnish documentation about expected impacts on reproductive health care, gender-affirming care and end-of-life care in the communities they serve before moving ahead with a proposed merger. In a hearing on the bill, state Sen. Emily Randall, D-Bremerton, who sponsored the legislation, said she was especially concerned about outsized impacts on rural communities with limited health care options. Even in her own Kitsap County district, she said, the Naval Hospital is the only secular health care provider available.
While hospital mergers remain less regulated in Washington than in states like California and Oregon, hospitals here are required to disclose what reproductive health care services they offer by completing a checklist through the state Health Department. Using this checklist, each hospital is required to clarify what treatments it provides across six categories of care, including abortion, contraception, emergency contraception services, fertility treatments, pregnancy care and other services like HIV testing and treatment. The results are publicly available for every hospital in the state, although there’s some ambiguity about when services may be available.
Swedish Medical Center, for example, do not list medication or surgical abortion as services it provides on its Health Department checklist, but does include an addendum saying that pregnancy terminations are performed in Swedish facilities “[w]hen necessary, on an emergency basis.” Similarly, CHI Franciscan hospitals do not include medication or surgical abortion or referrals for abortion among their reproductive health services, but they note some services may be provided when medically indicated.
But even offering these services on an emergency basis can be problematic for patient outcomes. “If someone is experiencing a medical emergency like an ectopic pregnancy, they cannot afford (nor would they ever think) to stop and research if the nearest hospital is religiously affiliated and therefore won't offer the most appropriate, evidence-based care,” said Prager of UW Medicine. “They are going to go to the closest hospital and may not even know they are not being offered all their options. This definitely can lead to worse health outcomes for these patients.”
Even before the rise of hospital mergers, the American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists documented a number of cases across the country in which patient outcomes were adversely impacted by providers’ refusal to participate in reproductive health care. The professional organization has been clear in advocating that reproductive health care be upheld when hospitals merge, citing concerns about physicians’ ability to care for their patients.
“Where reproductive health care services are prohibited, health care providers are put in the difficult position of having to withhold needed care until patients’ conditions deteriorate to a point at which care is permitted,” said the group in a position statement on reproductive health care restrictions, including those at religiously ffiliated institutions. “Ultimately, the health of women and quality of the patient-physician relationship suffer.”
As hospitals continue to merge, ambiguities about the availability of reproductive health care follow, and the prospect of Roe v. Wade’s reversal is already compounding this confusion. “I think one of the things people are going to be — and are already — confused about is whether abortion is still legal in Washington state if Roe is overturned,” Rutman says.
The state’s Reproductive Privacy Act ensures that even if Roe is overturned, abortion would remain legal in Washington state. But the confusion comes at a time when the state’s reproductive health care infrastructure is already strained, especially in areas where there are few clinics and high demand resulting from out-of-state patients. While 18 health centers provide abortion in and around the greater Seattle area alone, just 11 health centers operate east of the Cascades, only three of which are full-service clinics providing both onsite surgical and medication abortion in Yakima, Kennewick and Spokane.
Clinics across the state are preparing to accommodate a growing influx of patients from states like Idaho, whose residents already routinely seek abortion care in Washington. While elected officials have pushed the idea that Washington will become even more of a haven for patients seeking abortions in world without Roe v. Wade, expanding actual capacity for care beyond those five clinics on the eastern side of the state would be complex, with so many of the state’s hospital beds under religious control.
This is the result of years of hospital mergers that have weakened the state’s ability to provide adequate reproductive health care. The true extent of that weakness will soon be determined if Roe v. Wade is overturned.
This story has been updated to correct outdated information on the number of eastern Washington health centers offering either surgical or medication abortions.