Series: Sex and Gender ProPublica's Nina Martin reporting on American systems and institutions — from schools to hospitals to prisons — that fail or mistreat people on the basis of their gender or sexuality.

Oct. 17: This story has been corrected.

Over the past few years, Washington state’s liberal voters have been on quite a roll. Same-sex marriage? Approved. Assisted suicide? Check. Legalized pot? That too. Strong abortion protections? Those have been in place for decades.

Now, though, the state finds itself in the middle of a trend that hardly anyone there ever saw coming: a wave of mergers and alliances between Catholic hospital chains and secular, taxpayer-supported community hospitals. By the end of this year, the ACLU estimates, nearly half of Washington’s hospital beds could be under Catholic influence or outright control.

Many of the deals have been reached in near secrecy, with minimal scrutiny by regulators. Virtually all involve providers in Western Washington, which voted heavily for same-sex marriage last November and the Death with Dignity Act in 2008. The cultural divide between the region’s residents (Seattle recently edged out San Francisco as the area with the largest proportion of gay couples) and the Catholic Church (whose local archbishop led the effort against marriage equality and is overseeing a Vatican crackdown on independent-minded American nuns) couldn’t be wider. And yet more and more hospitals there — sustained by taxpayers, funded by Medicare, Medicaid, and other government subsidies — could be bound by church restrictions on birth control, sterilization and abortion, fertility treatments, genetic testing, and assisted suicide.

In affected communities, the news is not going over well.

“It’s the perfect storm here,” said Kathy Reim, president of Skagit PFLAG (Parents, Families and Friends of Lesbians and Gays) north of Seattle, where four area hospitals have been in merger talks this year. “We are the only state that has all these rights and privileges available to our citizens. Yet many of our hospital beds are being managed by a system that, for the most part, cannot and will not honor these rights and laws.”

Meanwhile, the deals just keep coming. Earlier this month, hospital commissioners approved a letter of intent between Skagit Valley Hospital and PeaceHealth, a Catholic enterprise that runs nine medical centers and dozens of clinics in three states. The week before, Franciscan Health System (which already has six hospitals in the region) said it would affiliate with an acute-care facility in the sprawling suburbs south of Seattle. In mid- September, UW Medicine, which includes the University of Washington’s teaching centers, signed a “strategic collaboration” with PeaceHealth to provide advanced specialized in-patient care.

In all, Washington has seen at least 10 completed or proposed Catholic-secular affiliations in the past three years, more than anywhere else in the country, says Sheila Reynertson of MergerWatch, a New York-based nonprofit group that tracks hospital consolidations. Three of the state’s five largest health-care systems are Catholic.

Catholic providers have actually been an integral part of Washington state’s health-care infrastructure since the late 1800s, when nuns from the East Coast and Europe braved rain and worse to minister to loggers and miners in remote outposts around the region. A century later, those historical ties — and their relative robustness — have made them attractive partners for community hospitals for whom the choice is: affiliate or get crushed.

“It’s harder than ever before for independent health-care organizations to thrive without alliances,” said PeaceHealth spokesman Tim Strickland. One of the main reasons: health-care reform. “It’s happening all over the country, with all kinds of providers,” he said. “We don’t perceive this trend as a Catholic scenario so much as a health-care scenario.” (Indeed, the consulting firm Booz & Company predicts that a fifth of the nation’s 5,000 hospitals could merge over the next few years.)

In some places — including big swaths of Western Washington — Catholic providers are becoming the only source of health care for an entire region. (Approximately 8 percent of what the federal government calls “sole community hospitals” are Catholic.)

The dilemma is that Catholic hospitals — there are 630 or so in the United States, representing 15 percent of all admissions every year — are not independent entities. They are bound by a 43-page document called the Ethical and Religious Directives for Catholic Health Care Services, which have been around in some form since 1921 and were last revised by the U.S. Conference of Catholic Bishops in 2009.

The 72 directives explicitly ban abortion and sterilization. They restrict other types of care as well, including emergency contraception for rape victims (“It is not permissible... to initiate or to recommend treatments [for sexual assault] that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum”), in vitro fertilization and artificial insemination (“contrary to the covenant of marriage, the unity of the spouses, and the dignity proper to parents and the child”), surrogate pregnancy, and anything that remotely resembles assisted suicide (the bishops’ preferred term is “euthanasia”).

Then there’s this:

5. Catholic health care services must adopt these Directives as policy, require adherence to them within the institution as a condition for medical privileges and employment, and provide appropriate instruction regarding the Directives for administration, medical and nursing staff, and other personnel.

Over the years, the ERDs have had their greatest impact on women and people too sick or poor to look around for another provider. Some states (including Washington) have laws requiring emergency birth control, but there have been numerous reports of Catholic-affiliated doctors and nurses who were prevented from treating female patients — including pregnant women with serious complications — in accordance with best medical practices and the patients’ own wishes. In a study last year by researchers at the University of Chicago, 52 percent of OB/GYNs affiliated with Catholic providers reported having conflicts over religious policies dictating medical care.

But the ERDs are guidelines, not hard-and-fast rules. Depending on the local bishop, Catholic providers have a certain amount of leeway in how they interpret them. In Washington state, religious hospitals have been more willing than in some other places to negotiate and accommodate their partners’ concerns — an attitude Reynertson and others call “Catholic lite.”

PeaceHealth, for example, “strongly respects the patient-physician relationship and decisions that are made jointly by physicians and patients in the best interests of those patients,” Strickland said. This means that it will allow its affiliates to dispense birth control and do emergency abortions to save the life of the mother, he said. Franciscan is seen as being stricter, but even so, its secular partner in the small city of Bremerton is continuing to perform tubal ligations on women immediately after they give birth — the medical standard in most hospitals for women seeking such procedures, but verboten in most Catholic ones.

But usually, it’s the non-religious partner that has to give. The most high-profile example involves Swedish Health Services, a secular hospital system that partnered last year with Providence Health & Services. Like most of the recent Washington deals, this one was a kind of workaround, crafted to protect Swedish’s autonomy, reassure its patients, and mollify its critics. “To ensure Providence remained Catholic and Swedish remained secular, the partnership was intentionally structured as an affiliation, not a merger or acquisition,” Swedish said in a statement to ProPublica, adding: “As a secular organization, Swedish is not subject” to the ERDs. Among other things, this allows it to continue providing the full range of birth control services, including tubal ligations and vasectomies.

But a few days after the partnership was announced, Swedish said it would stop doing elective abortions, which it had been offering as part of its reproductive health services for years. Instead, it gave $2 million to Planned Parenthood to open a clinic adjacent to Swedish’s main Seattle hospital.

By structuring deals as “affiliations,” “partnerships” or “collaborations,” hospitals gain another advantage: sidestepping regulators. Washington’s process for scrutinizing hospital mergers only kicks in if there’s a sale, purchase or lease of an existing hospital, but most of the recent agreements have stopped short of that line. Thus, the Swedish-Providence deal did not go through a full review, even though the combined health care system is by far the largest in the state. Nor did Franciscan’s affiliation with Harrison Medical Center, the only full-service hospital serving much of the hard-to-reach Kitsap Peninsula and nearby islands, which ACLU-Washington criticized as “a thinly veiled ... transfer of assets” tantamount to a sale. Terms like “affiliation” and “alliance” leave “a lot of room to maneuver,” said the ACLU’s state legislative director, Shankar Narayan. “Without government oversight, once the camel’s nose is in the pen, you don’t have much control of where the affiliation is going to go.”

“The legitimate concern is: What happens to this relationship later?” Reynertson said. “Is this affiliation, this engagement, going to last? When are they going to get married? Once things like IT infrastructure ... are intertwined, a full merger may become inevitable. It’s a connection that can never be undone. And of course, at that point the mergers will be approved, because look how well they’re working already.”

Robb Miller, executive director of Compassion & Choices of Washington, which helped pass the state’s assisted-suicide law, doesn’t actually think things are working all that well right now. The Death With Dignity Act isn’t mandatory for providers, and even before the wave of mergers, many secular hospitals had opted not to dispense or administer lethal medications to terminally ill patients. The Catholic partnerships have drastically shrunk the pool of providers willing or able to help dying patients end their lives. Since PeaceHealth took over the public hospital serving Clark County (in the southwestern part of the state) in 2010, Miller says, doctors, nurses and social workers have stopped referring patients for counseling to groups like his. “They went from a secular organization with reasonably good policies on death with dignity to an organization with anti-choice policies based on the ERDs.” The practical result is that many terminally ill patients “simply lose their medical options” for a peaceful death, Miller said.

Strickland acknowledges that PeaceHealth forbids both physician-assisted suicide and elective abortions at its affiliates. But he insists that this not as big a change as it sounds, since many community hospitals don’t offer those health care options anyway. “We only go into communities where we’re invited,” he said, “and we have a very strong track record of adding services, not taking them away.”

But what about the future, asks PFLAG’s Reim. She notes that PeaceHealth and other Catholic-affiliated providers are unlikely to add health care services restricted by the ERDs.

“We’re expecting another 40,000 people to move to this part of the state,” she pointed out. Some of these newcomers are likely to be gay couples and transgender people who could find themselves unable get fertility treatments or hormonal therapy in their communities. “This isn’t just about protecting the rights of the people who already here, but the rights of the people who are coming,” she said.

For Mary Kay Barbieri, co-chair of a Skagit Valley group called People for Healthcare Freedom, the other big fear is that the Catholic Church and the men who run it could suddenly decide to take a harder line in how they interpret the ERDs. Or a Catholic lite provider could be gobbled up by one with stricter views, as almost happened this year when PeaceHealth and Franciscan's parent company, Colorado-based Catholic Health Initiatives, were in talks to merge (later scuttled). “That was very worrisome,” Barbieri said.

Meanwhile, the state’s largely hands-off attitude may be ending. This summer, Gov. Jay Inslee, a Democrat, directed the Department of Health to update its hospital merger oversight process, while Democratic Attorney General Bob Ferguson issued an opinion requiring all public hospital districts that offer maternity services to also provide birth control and abortions. But how those orders will play out remains a very big question. “We will be watching closely,” Barbieri said.

Correction (10/17): An earlier version of this article said that after PeaceHealth took over the public hospital serving Clark County in 2010, it closed the hospice program. It actually did not discontinue that program.