This discussion explores the term “catholic” as a reference to the religious denomination and as an adjective that means comprehensive or universal. It is an insightful and thought-provoking conversation on this significant topic.
This transcript of their discussion has been edited for clarity and length.
Mike Sacopulos: My guest today is Patricia Gabow, MD, MACP. Gabow is a national healthcare leader who has spent 20 years as CEO of Denver Health. She’s also an author. Gabow’s most recent book is The Catholic Church and Its Hospitals: A Marriage Made in Heaven?.
Dr. Patricia Gabow, welcome to SoundPractice.
Patricia Gabow, MD, MACP: Well, thank you for having me. I’m delighted to be here and to talk about the book.
Sacopulos: Let’s jump in, and I’ve been excited for some time to talk to you about the book. But first maybe you could give us a little more of your background and your experience as a physician leader.
Gabow: Well, I was raised in an Italian Catholic family in rural Pennsylvania and went to medical school at the University of Pennsylvania. At that point, women weren’t going to medical school — I was one of six women in a class of 125. I became an internist and an academic nephrologist and started my career at Denver Health, which is a big public safety net institution. I spent my entire 40-year career there because it really fit with my values.
I tell everyone I’ve mentored over the years to try to find an institution that aligns with your values because then you can spend your whole career there, and that’s really what I did. I’m also a professor at the University of Colorado School of Medicine.
Sacopulos: Excellent. Well, let’s jump into the book. And again, the book is The Catholic Church and Its Hospitals: A Marriage Made in Heaven?. Why’d you write the book?
Gabow: Well, let me just add one thing to the title. There’s a question mark at the end of it because I think that is the question, is it a marriage made in heaven?
To answer your question about why I wrote the book, I’ve always liked to write and to investigate things. It is an important way to contribute to healthcare. By doing research you either find new knowledge or you reshape old knowledge — and then you share it with others. This way everybody doesn’t have to reinvent the wheel.
There were three very specific reasons I wrote this book. First, I’m a practicing Catholic. I was raised in a Catholic family and I really believe that Catholicism’s biblical roots and its theologic basis underscore how important healing is as an obligation of Catholic faith. All you have to do is look at Jesus’ ministry. It was all about healing people, spiritually and physically. It was about healing the marginalized and the excluded, the lepers, etc. This is where Catholic healthcare came from at its early beginnings.
The second reason is that, as I said, I’m a physician and I spent my whole career in an institution that tried to give the poor, the vulnerable, care similar to what the rich get in America. We achieved that, so I had a commitment to that population.
Finally, I’ve been involved in healthcare policy for decades and I think there were policy questions related to Catholic healthcare in America that needed to be addressed, raised up.
As I researched Catholic healthcare, I found that there were things that really inspired me and things that concerned me. I also found as I researched and talked to my friends and colleagues that people didn’t really know about Catholic healthcare — how vast it was or its implications — and these were people who had their finger on the pulse of healthcare.
So it seemed to me that this book needed to be written, and I thought I was the one who could write it, given my background as a Catholic, as a physician, and as a healthcare administrator.
Sacopulos: Well, it turns out you’re correct. The book is a great read. You just touched on the extent in reach of Catholic healthcare in the United States. Give me some numbers. How many hospitals, number of beds, geographic distribution? Give me a sense of just how pervasive Catholic healthcare is in the United States or in your state of Colorado.
Gabow: Well, I think you’ve asked a very important question, and even though I live in Colorado, where there are a lot of Catholic healthcare institutions, I was actually still surprised at how vast the system had become, because it started out as small hospitals built by nuns, some in urban centers, some in the wild west. Currently four out of the 10 largest healthcare systems in the country are Catholic; 46 states have at least one Catholic hospital, and in 20 states they make up more than 20% of the beds.
In Colorado, for example, 38% of the beds are in Catholic hospitals and 42% of all deliveries are in Catholic hospitals, which is an important number. It’s not just the beds, but the number of obstetric deliveries, because of the intersectionality between deliveries and reproductive care of women.
You asked also more detail about geography. In 35% of the counties in the United States, the Catholic hospital is either the dominant or the high market share provider in those counties, and that’s important. A substantial percentage of women of reproductive age live in those counties. Another way to look at it is that CommonSpirit, which is the largest Catholic healthcare system, says that one in four Americans have access to healthcare in their system, which is a pretty astounding number.
If you look at the care delivered, those numbers are surprising, too. There are more than 4 million admissions to Catholic hospitals annually and 94 million outpatient visits, so Catholic hospitals are doing a lot of healthcare for Americans, and for that we have to be really grateful. But there’s another part of the story, which is that not all healthcare that people want or are entitled to is available in those facilities, and that’s another part of the story that needs to be told.
Sacopulos: Is Catholic healthcare consistent across institutions, or does it vary by dioceses and orders?
Gabow: The important point to make about this is that all of Catholic healthcare, if they want to be labeled a Catholic institution, have to operate under a set of rules that the American bishops wrote, and these are called the Ethical and Religious Directives for Catholic Healthcare Services. They’re called the ERDs for short. There are 77 of these rules, and they cover a large swath of issues, including who has to obey the rules, what’s covered, including a lot of issues around reproductive care and end-of-life care.
If you want to be considered a Catholic healthcare institution you have to comply with these 77 rules.
Sacopulos: You’ve done a tremendous amount of research. What were some of the most surprising findings to you about Catholic healthcare?
Gabow: Well, the scope of the ERDs was surprising to me. I knew that they existed and I knew that Catholic healthcare institutions had to comply with them, but I didn’t realize how broad they were.
The second really big surprise to me is sort of a core issue in this book, and that is that patients don’t know about the ERDs and they don’t know that their doctor is obliged under their employment contract to follow the ERDs, even if it’s not what the patient wants. In some circumstances maybe not even in line with standard of care.
Let me give you some numbers. You like numbers, I do too… In a survey of patients, 70% thought that there would be no difference in their care if they went to a Catholic hospital or a secular hospital; 60% of women thought they would get birth control pills or tubal ligation at a Catholic hospital; 40% thought they could get an abortion for a life-threatening pregnancy; and 27% thought they could get an abortion for a major fetal complication — and women can’t get any of those at a Catholic healthcare institution.
So that lack of information is startling when you realize this is about people’s health. So why does that exist? Why is there such a lack of knowledge? I think part of that is due to Catholic healthcare systems themselves. They are not transparent about whether they’re a Catholic hospital. A survey was done that showed 75% of these Catholic institutions didn’t say they followed the ERDs, so how would people know about this?
The third thing that really surprised me, and I have to honestly say disappointed me, was how wealthy the Catholic healthcare systems have become. In my opinion they’ve moved a very far distance from the ones started by the nuns who took vows of poverty and who begged on the street for funding to take care of the poor and the most vulnerable.
For example, their revenues are comparable to the biggest for-profit companies. Among the not-for-profits they rank among the top three in revenue. Their CEOs make millions of dollars, in some instances $10, $12 million, and in some instances over four or 500 times what a frontline worker makes. And some of these institutions are aggressive about pursuing medical debt, and some of them have large venture capital investments.
So, you know, it’s not that they’re worse than other not-for-profits or worse than for-profit hospitals or hospitals owned by private equity. It’s that they say that they’re different. Their mission statements say that they’re committed to the poor and the ERDs require that they treat their employees fairly and justly, which I would say isn’t compatible with the CEO making 400 times what a frontline worker makes.
So, I think it’s a question of mission fidelity, not that they’re worse than anybody else, but are they living up to their historical past and their mission? In fact, I have a whole chapter in the book called “Mission Fidelity” which deals with this question.
Sacopulos: Your book was heavily researched and includes more than 300 references. How did you go about your research, and did the Catholic Church participate?
Gabow: Well, I guess it would be helpful to start out by saying I am an academic person. I started out as an academic nephrologist. I’ve always done research. I’ve written over 170 papers and book chapters. So I started this like I would any research project, which is going to the published literature and looking at what was there.
But for this book I did something that I don’t usually do for an academic article, which is go to the lay press and articles and magazines and newspapers and investigative reporting, because that offered other information that you wouldn’t find in standard scholarly publications.
And, no, the Catholic Church wasn’t involved in this study, except that the United States Conference of Catholic Bishops, which published the ERDs, did give me permission to use the ERDs extensively in the text. So, in that sense I had their blessing to use the information.
Sacopulos: What are the top two or three things healthcare leaders should understand about Catholic healthcare?
Gabow: You know, if you really want to change something, I’ve always thought it’s not enough to say what the problem is. You have to provide solutions. The last book chapter has about 30 suggestions about who should act and what those leaders should actually do.
Let me talk about a few of the recommendations: Pretty audaciously I start out with a list for the pope. Now it would be totally inappropriate for me to tell the pope what to do. As a Catholic woman, I would not step into that. But what I did was create a list of questions.
There are things that should be discussed with more people than just the representation of all male American bishops. And there are some things that, you know, no one is going to change in the church and have it still be Catholic. They’re not going to okay abortion. They’re not going to say medical aid in dying is okay.
But I do ask the pope to think about questions such as, “Should contraception be a matter of a couple’s individual conscience?” At the time that the pope made the opinion that contraception could not be used unless it was natural family planning, there were theologians who disagreed strongly with that. On topics where there has been theological discussion, can we continue that theological discussion?
Unlike simple questions for the pope, I have definite suggestions on what I believe the bishops should do and the government should do. Also, what professional societies should do. Chief among what I think the bishops need to do is require transparency. They don’t have to do things that are against their conscience, but I believe they have an obligation to make sure that patients have informed decision making, and they can’t have that if there’s no transparency.
I also think that the bishops should embrace the first section of the ERDs, which is how they distinguish themselves as Catholic institutions in care of the poor, the vulnerable, the immigrants, and the refugees. They need to have an open door. They should set salary caps. They should demand that employees get fair pay. There is a list of things, but those are among the most important.
And some of those spill over into government. You probably know that there’s a federal law now that you have to have price transparency at an institution, and that’s important, but that’s about a patient’s finances. I say the government needs to guarantee care transparency, because that’s a matter of life and death and health and wellbeing.
If you want financial transparency, you surely should want care transparency. I think that’s a government responsibility. And Colorado last year passed a law about that called the Patient’s Right to Know Act, which they’re in the process of implementing. The state of Washington has that, too. But I think this is a responsibility for the federal government.
I also think it’s a responsibility for insurance companies because many patients, as you I’m sure know and probably do yourself, pick their provider based on what’s in-network, but people don’t know that an in-network hospital may have prohibitions on care they want. I think that insurers have an obligation to be transparent about that as well, and none of that exists.
Given my background at a safety-net institution, I’m particularly concerned about transparency for Medicaid patients. These are among some of the most vulnerable patients. Medicaid pays for 43% of all deliveries in America, and it’s the second largest provider of reproductive care. So Medicaid patients believe they have access to certain services, but if they go to a Catholic hospital, they don’t.
I think it’s imperative that government figures out a way to make sure that Medicaid patients know where they’re going for their care, what they’re going to get, and that they have access to everything they’re entitled to under Medicaid rules. That’s important to me.
A second area that we haven’t touched on but I think is a responsibility of government and to a lesser extent the bishops, is the issue of tax exemption of not-for-profits and community benefit. This isn’t an issue just for Catholic hospitals, this is for all not-for-profit hospitals. A study was done that shows that the tax benefit for not-for-profits is a whopping $28 billion a year. And their community benefit across all not-for-profit hospitals is about $16 billion. That’s a pretty big gap, and governments could do a lot with that money to cover people who are uninsured.
It’s time to step back and really look at tax exemption for not-for-profit healthcare. There have to be clearer guidelines about what you can use in that category. I did a study with a group at Johns Hopkins and it showed that there was huge variability across not-for-profits in terms of the amount of community benefit they get, even though they all get the same tax exemption. That’s not a level playing field, and the government needs to figure out a way to level that playing field.
The very final thing that I think needs to be done really relates to my being a physician, and I have a chapter in the book on this. It’s something that I’m quite concerned about, and that is the relationship between the oath that you take as a physician to put the patient always above your own needs, your own conscience, and your employment contract. Right now, about 70% of physicians are employed. I think it’s important to understand what’s the intersection between the requirements of your employment contract and your professed oath and your own conscience.
If you’re employed in Catholic healthcare, you must agree to follow all the ERDs, and I think that sometimes comes in conflict with your professed oath and with your own conscience. Professional societies have to get into this and say what’s the hierarchy there, what’s the intersectionality, and how should physicians navigate this terrain. I think that’s important.
Sacopulos: I agree with you and I’m interested, have the ERDs impacted physician recruitment for these Catholic healthcare systems? Because it seems to me that we’re in a time where physician recruitment is difficult for many, and this may be problematic for some folks coming into practice.
Gabow: Well, About 20% or so of American adults say they’re Catholic, so we know that not all the physicians at a Catholic hospital are Catholic. And if you look at some of the data on Catholics use of, for example, contraception, you’ll see that even people who are Catholic don’t necessarily embrace all of the pronouncements in the ERDs, so clearly there are physicians who are practicing at Catholic hospitals who don’t embrace all of these.
It’s going to affect some groups of physicians more than others. A cardiac surgeon or a neurosurgeon is probably not going to be as impacted by having to agree to follow all the ERDs as an OB/GYN doctor is, or a palliative care physician, or maybe an ICU specialist. So I don’t think it would impact recruitment across the terrain because of differences in the nature of the practices.
In a book called Bishops and Bodies, published in 2023, the author, Lori Freedman, interviewed a number of physicians. And what she found is that OB/GYN physicians often try to find workarounds so they can change a diagnosis and be able to do a tubal, for example.
You know, you talked about recruiting being a problem, and one of the problems is burnout, and we know that moral dilemmas contribute to burnout. If people are placed in morally difficult situations that they don’t agree with, that takes its toll and leads to burnout.
And whether that’s preventing you from seeing uninsured patients, or doing certain treatments for an uninsured patient, or not being able to do a tubal when you’re doing a Cesarean section and you know that should be done, this burns you out, and over time you lose people from the profession. But I haven’t seen anything that says Catholic hospitals are having more problems recruiting than anyone else, although I think you raised an interesting question. Should that be studied, particularly in relation to certain disciplines?
Sacopulos: Our time together is almost up, but I was hoping you could talk a little bit more about the role of bishops in policymaking for Catholic health systems. It seems like they’re intricately involved, but I don’t know how frequently, and maybe you could talk a little bit more about that.
Gabow: Well, the Catholic church is a very male hierarchical structure. That’s the first thing you need to know. And it starts with the pope but the bishops have responsibility for Catholic institutions, even the ones they don’t own in their areas of responsibilities, which are geographic areas called dioceses. They have a responsibility to see that if you say you’re a Catholic institution, you follow certain rules which they create.
Now, the American bishops created these ERDs decades ago, and they’ve been updated them about six times since then, so it is their work that created the ERDs for American healthcare systems, and it’s their responsibility to enforce. As we talked about earlier, bishops differ in how aggressive they will be on that, but I would say that as a group, the American bishops have been more aggressive about issues of reproductive care than they have been about the whole first set of ERDs, which is [about] care of the poor. I think that’s just where the American bishops are right now.
Sacopulos: The book is The Catholic Church and Its Hospitals: A Marriage Made in Heaven?. The author, and my guest today, is Dr. Patricia Gabow. Dr. Gabow, thank you so much for being on SoundPractice.
Gabow: Well, thank you for having me and for this wonderful conversation. I appreciate it.