Whether poor women should be subject to the morals of the Vatican was the question put forth on a recent crisp fall morning in Manhattan, as New York City lurched forward with its rollover into mandatory managed care for 1.2 million Medicaid beneficiaries, two-thirds of whom are women. Pro-choice advocates and reporters gathered at City Hall on October 27 to give testimony in support of a bill to protect women on Medicaid from being auto-assigned (if the beneficiary doesn't choose a plan within a given time frame) into plans that don't directly provide contraception and family-planning services. Unfortunately the bill--opposed by the mayor as well as by Fidelis, a major Catholic HMO that wouldn't be able to comply with its provisions--is unlikely to pass.

When advocates talk of the merger crisis, they often remark on the dangerous blurring of the line between church and state. Yet groups such as the California Women's Law Center and New York's Center for Reproductive Law and Policy have not found such constitutional arguments very effective. Although there have been gains in the courts in some states--as in the recent New Mexico Supreme Court decision that medically necessary abortions for Medicaid recipients must be covered because of the state's Equal Rights Amendment--there is no legal precedent for protesting denial of access on the basis of the US Constitution. "Look, the law is not on our side," says Frances Kissling, president of Catholics for a Free Choice. "No hospital--Catholic or non-Catholic--is required to perform an abortion, and most of them don't. They're not required to provide contraception or reproductive healthcare. The only thing a hospital has to do is treat a patient who comes in through the door in a life-threatening situation."

Leaving aside for a moment that denial of reproductive care can have catastrophic consequences, what if a woman's situation is life-or-death, in conventional terms? When Elliot Hospital in Manchester, New Hampshire, went Catholic in May 1998, Dr. Wayne Goldner was refused permission to perform an emergency abortion to a patient after her water broke at fourteen weeks. She was forced to ride eighty miles in a taxi to Hanover to have the procedure. Goldner, who has spoken out on the issue and for whom abortion is a small fraction of his practice, has had his house picketed and lost his teaching position, and there was a bomb threat at his young daughter's school. And last September Michelle Lee, a 26-year-old awaiting a heart transplant, was denied an emergency abortion in Louisiana, amid disagreement over whether she faced the 50 percent chance of death required for the procedure by state law. The Louisiana State University hospital that turned her down is not Catholic but has a conservative religious culture. "At a lot of hospitals," says Maureen Britell of the National Abortion Federation, "whether they're Catholic or not, the board of directors has a strong link to a Catholic or religious organization."

Catholics for a Free Choice has been tracking the mergers for years and has perhaps the most comprehensive analysis of how activists should respond. The CFFC approach is pragmatic: Mergers are a trend that will continue. Therefore, people concerned about women's healthcare should either try to block the mergers or make sure that access to abortion and contraception is mandated in the deal structure. Services are preserved when the community and the doctors stand firm, Kissling says. A CFFC report also cites ways in which doctors and administrators have worked the system by creatively interpreting the Church's Directives. Strategies include setting aside an area of the facility for reproductive health services or having a "virtual merger"--"a close collaboration that does not merge assets or establish one governing body."

CFFC's approach takes into account an often overlooked nuance of the merger issue, which is that there can be a flip side to glorifying procreation: At some Catholic hospitals, a woman having a baby is treated like the Virgin herself. Staffers at Elizabeth Seton stress that they want the center to be aligned with St. Vincent's, emphasizing its thoughtful, pro-mother care. "This is a besieged profession," adds Pat Burkhardt, the former clinical director of Elizabeth Seton, now director of New York University's Nurse-Midwifery Program, "and St. Vincent's is consciously pro-midwife," whereas many secular hospitals are not. She believes that pro-choicers in Catholic institutions simply become adept at working the system. "There are hospitals out there that quietly make referrals," says Burkhardt. "You don't want to get the news out because that would get them shut down, but, you know, Catholic women have for years chosen to ignore the Pope and the Catholic hierarchy's stance on birth control."

There is still the question of why, in at least half the Catholic/non-Catholic mergers, the secular hospitals roll over so quickly, observes Catholics for a Free Choice's Kissling, who opened the first abortion clinic in New York's Westchester County nearly thirty years ago. "I would expect the Catholic hospital to get its values, as bad as they are, visible in the merged institution," she says. "But where is the non-Catholic hospital in standing up for women's rights?"

Bring up women's rights, and many defenders of the hospitals in question respond with a blank stare. It isn't about sexism, they say, it's about cost. Reproductive care is just too expensive.

Obviously that's not the right question--we are talking about access to basic health services--but for the sake of argument, are contraception, tubal ligation, vasectomy and abortion profitable? Like any medical treatment, in and of themselves, they're not. But according to a 1997 study by Planned Parenthood of New York City, the money saved in terms of prevention is enormous. Among the findings are that for every 1,000 members who receive contraception, the managed-care organization will save $1.2 million annually for pregnancy-related care averted. A 15 percent increase in the number of oral contraceptive users in a health plan would produce enough savings in pregnancy costs alone to provide oral contraceptives for all users in the plan. Birth control pills and exams cost between $285 and $804 per patient per year, while the average cost of delivering an unintended pregnancy is $3,200.

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