Many Hospitals Refuse To Provide Reproductive Care, Even In States Where Abortion Remains Legal

Voter approval of ballot measures protecting abortion rights in three states on Election Day was an important first step toward addressing the Supreme Court decision in Dobbs v Jackson Women’s Health Organization. Since that ruling, at least 13 states have implemented restrictions rendering access to abortion almost nonexistent. Still more states have applied extreme limits. People seeking abortion care are being forced to travel to other states, or figure out how to obtain medication abortion through the mail (which may not be their preference). Health providers are struggling to determine what pregnancy emergency care they can provide without violating newly-enacted abortion bans. Too many are unable to overcome these hurdles to get the care they need.

This dire situation is made even worse – in all fifty states — by many hospitals’ policies of refusing to provide comprehensive reproductive and pregnancy care. Their refusals to provide patients with requested contraception and sterilizations leave patients at risk of unintended pregnancies in states where abortion is banned or restricted. But even in states where abortion remains legal, and voters have supported abortion rights ballot initiatives or rejected ballot proposals to ban abortion, reproductive care is being restricted in geographic regions dominated by hospitals with refusal policies. As a result of systemic racism, the people disproportionately affected by this situation are Black, Latinx, Native American, Asian American and other people of color, and those with low incomes. In other words, such policies stand in the way of advancing health equity.

Policies prohibiting or sharply restricting abortion exist at some public hospitals, such as those run by certain municipalities, local hospital districts, or the Indian Health Service (which is governed by the discriminatory Hyde Amendment restrictions on use of federal funding for abortions), disproportionately affecting people with low incomes. Some non-profit hospitals – including Adventist, Baptist and Evangelical Lutheran hospitals, as well as secular ones, especially in the South – also have policies prohibiting their providers from performing abortions.

But the most expansive refusal policies can be found in Catholic health systems, which now include three of the nation’s six largest private health systems and are expanding rapidly through acquisitions of physician practices, urgent care centers, retail health clinics and ambulatory surgery centers. Catholic system refusal policies reach far beyond abortion access to prohibit contraception, sterilization, infertility services, gender-affirming procedures and certain end-of-life treatment options.

Amidst A Surge Of Out-Of-State Patients

Several of the states where abortion is legal and where people are traveling for abortion care also have a significant presence of Catholic facilities. These include Washington state (where 41% of total acute care hospital beds are in Catholic facilities), Colorado (38%), Oregon (30%) and Illinois (28%), according to a 2020 Community Catalyst report. Moreover, in 52 geographic regions around the country, a Catholic hospital is the sole provider of hospital care, leaving patients with little other choice, that same report found. People seeking prompt, medically-appropriate care for pregnancy emergencies have been turned away or delayed at Catholic hospitals – the same kind of horrific situations now being experienced by people suffering miscarriages or ectopic pregnancies in states with abortion bans.

Take, for instance the story of Tamesha Means of Michigan, who in 2010 was denied appropriate care by a Catholic hospital during a miscarriage of a wanted pregnancy. According to Means, she was sent home twice while experiencing excruciating pain because the Catholic hospital would not provide the medically necessary and appropriate care to treat her pregnancy emergency. She suffered an infection as a consequence of delayed care. (Michigan, where voters just approved a ballot initiatives enshrining abortion rights, has more than 40 percent of its hospital beds in Catholic facilities.) Or Kathleen Prieskorn of New Hampshire, who had to travel 80 miles in a cab to the nearest non-Catholic hospital to complete a miscarriage because refusal policies stood in the way of her doctor providing her with appropriate care.

In Arizona, Dr. Robert Holder was prevented in 2010 from giving prompt, appropriate care to a pregnant woman who arrived at the only local hospital in the middle of a miscarriage of twins. Because the hospital had just joined a Catholic health system, Holder was forced to put his patient in an ambulance and send her 90 minutes away to the nearest non-Catholic hospital, risking infection and hemorrhaging and causing serious emotional distress. These deeply personal stories of pregnant peoples’ pain, loss, grief and suffering are tragic and heartbreaking. No one experiencing a miscarriage should have to deal with dangerous and life-threatening delays in health care.

Policy Solutions

Voters’ overwhelming approval of ballot measures to protect safe abortion access on Election Day signals an opportunity to adopt additional policies to protect people who need reproductive and pregnancy care. To protect people from the further erosion of their access to comprehensive reproductive and pregnancy care, state and federal lawmakers, as well as the executive branch, should quickly pursue the following policies.

First, enact state-level transparency laws, like the one in Washington, that require hospitals to disclose to state health agencies any refusal policies they may have, so that people can be alerted in advance and potentially seek care elsewhere. Such laws are not a perfect solution to the problem, but they do increase the visibility of refusal policies for the public and policymakers. And when they are properly publicized by state health agencies, the laws can help people find hospitals and related outpatient facilities that will provide the services they need.   

Second, ensure that hospitals treat miscarriages, ectopic pregnancies and other such emergencies promptly and appropriately, including ending the pregnancy. I welcomed recent HHS guidance to all hospitals, citing the Emergency Medical Treatment and Active Labor Act (EMTALA), which advised hospitals that they cannot refuse to provide pregnancy emergency care. Washington state has enacted its own law, the Protecting Pregnant Patients Act, which prohibits hospitals from interfering with physicians’ ability to treat pregnancy emergencies, and could serve as a model for other states.

Third, recognize that access to comprehensive reproductive and pregnancy care is a health equity issue, and hospital policies to refuse such care can disproportionately affect Black and brown people, as well as people with low incomes, women and LGBTQ+ people. Two states – New York and Oregon – have enacted laws that require scrutiny of whether proposed hospital mergers would eliminate or reduce access to services, including reproductive, pregnancy and LGBTQ+-inclusive care. 

Finally, employers should ensure their employee health insurance provider networks include enough hospitals and other health facilities that do provide a full range of reproductive and pregnancy care, so that employees are not refused needed care or forced to travel long distances.  

We cannot stand by as people are being refused critically-needed reproductive and pregnancy emergency care – either because of state abortion bans or because of hospital system refusal policies. Policymakers must take decisive action to ensure people have access to the care they need – where and when they need it. This is a critically important issue that must be high on the agenda for all of those working to achieve gender equity and health justice. 

Author’s Note

Emily Stewart served as the Vice President of Public Policy for Planned Parenthood Federation of America and Planned Parenthood Action Fund, where she led some of Planned Parenthood’s most impactful strategic initiatives and campaigns to protect and expand access to sexual and reproductive health care, including the I Stand with Planned Parenthood (ISWPP) campaign to defeat efforts to repeal the Affordable Care Act (ACA) and “defund” Planned Parenthood.

https://www.healthaffairs.org/do/10.1377/forefront.20221109.117389