Is it appropriate that Catholic health care institutions want to be full participants in the U.S. health care system, while retaining the right not to provide contraception—a part of health care that nearly all sexually active adults use?

The U.S. Conference of Catholic Bishops say yes, in a recent statement calling for the rescission of the “contraceptive mandate” provision in the Patient Protection and Affordable Care Act. And in this recent piece at First Things, Christopher T. Haley likewise warns that the religious exemption is too narrow to accommodate faithful Catholic health care. The Patient Protection and Affordable Care Act, he says, would create a “Catholic ghetto.”

Currently, Catholic health care institutions are indispensable in the United States, comprising 20% of U.S. hospitals. Those hospitals, in turn, receive large amounts of public funding. Catholic hospitals are so well-integrated, in fact, that they’ve merged with non-Catholic health care systems… to the point that it can take some sorting out to distinguish a Catholic hospital from a secular one. On the face of it, the fact that we’re even having this conversation—about a religious prohibition which only a tiny percentage of adults in the U.S. adhere to—should be a sign that Catholic health care is a big player, yes?

Well, it turns out there’s quite the backstory there. Haley’s use of the phrase “Catholic ghetto” is not cheap hyperbole, if you consider the history of Catholics in the United States. The US Catholic hospital system grew up in the eighteenth, nineteenth, and twentieth centuries; largely under the care of women’s religious orders, and largely to serve the poor. (Read about a few of the women who helped build Catholic health care.) The surrounding cultural landscape could be profoundly, hatefully anti-Catholic. Catholics found their rituals the subject of ridicule. They were suspected of being un-American, loyal to the Pope, incapable of liberty. At times Catholics were prevented from holding public office. In the mid-nineteenth century, while the number of Catholic hospitals was growing, the Know Nothing party organized around shared fears that Catholic immigrants from Ireland and Germany were overwhelming the country and acting against white Protestant interests.

So the fear of a Catholic ghetto must be understood in light of a real history of Catholics being marginalized during the very time that their health care institutions were taking root. However, the landscape of Catholic health care has changed. Catholic hospital systems are well established and fully integrated into healthcare delivery in the U.S. In fact, the Catholic Church manages a full 1/5 of all U.S. hospitals, according to The Revealer. Those hospitals are 50% funded by public funds. These Catholic hospitals are increasingly overseen not by women religious, but by laypeople trained in hospital administration.

Indeed, the very success of the Catholic health care system, and the degree to which it has been fully integrated into the wider US health care system, has itself stirred a worry about a loss of authentic Catholic identity in Catholic hospitals. And what’s one thing that has come to be seen in some quarters as especially emblematic of authentic Catholic identity? Say it with me, class: No artificial contraception! Most Protestant church bodies in the United States have come to approve of contraception under some circumstances. The Roman Catholic Church has not. I mean, not officially. If you are inclined to think of the Catholic Church as the church which has stayed faithful while other schismatic sects have veered from the truth, that will likely strike you as significant.

Some of the guardians of Catholic identity think it would be a great idea for the patients to sort this out in advance, and simply not go to Catholic hospitals if they can’t stomach Catholic teaching. (Perhaps those patients just haven’t heard the marvelous news that pregnancy is not a disease!) When a friend of mine posted the link Haley’s piece on Facebook, within a few comments someone asked the question: What’s to stop someone from just choosing a different hospital, if they have such a problem with the kind of care that a Catholic hospital can provide?

The question was sincere, but good grief, the phrase “having it both ways” comes to mind. What’s to stop a hypothetical patient from picking the option they like best, from among several convenient locations near their home? Well, gosh, where to begin? Possibly their employer health coverage? The place where they live? The fact that sometimes – such as in emergency situations — you can’t exercise consumer choice? (Obviously I’m talking more broadly than contraception here, but I think it’s important to remember that the needs of a critically ill patient have been known to conflict with a healthcare provider’s principles.)

With all due respect, putting the onus on the patient, as if patients enjoy such a range of choice in their healthcare providers, seems at least as unrealistic a prospect as convincing nearly all sexually-active adults in the U.S. that they shouldn’t use contraception. No, this problem will be something for Catholic institutions themselves to sort out. Catholic hospitals may have to negotiate a new compromise between integration into a wider system where it’s possible to do a lot of good; and sincere fidelity to a healthcare practice that very few of their constituents believe, adhere to, or think is good for them. Indeed, such negotiations have already been taking place locally, when hospital mergers press the issue. With the Affordable Care Act mandating coverage of contraception, it’s playing out nationally.

But that’s rather different from ghettoization, isn’t it? You’re put into a ghetto under compulsion. If you uncompromisingly believe something that almost nobody else believes, that’s not ghettoization, it’s just the reality of holding a tiny minority opinion. Michael Peroutka didn’t miss out on the presidency because his supporters were ghettoized. He lost because a whole lot of people wanted someone else to be president instead of Peroutka. And having a minority opinion can be, you know, fine! I’ve been told I hold many such opinions myself. But it’s a little bit disingenuous to then say, “What’s this? My uncompromising belief in something almost nobody else believes or comprehends, has somehow resulted in my being met with widespread disagreement or incomprehension! Whoever could have seen that coming? Please rectify this immediately, kthx.”