UC Berkeley

Catholic hospitals represent a large and growing segment of the U.S. health care system. The number of Catholic hospitals has grown by over 20% in the last two decades and now approximately one in seven U.S. hospitals is Catholic. These hospitals operate under the Ethical and Religious Directives for Catholic Health Care Services (ERDs), a set of 77 directives that emphasize the Church’s role in caring for poor and vulnerable populations, while also prohibiting certain services such as contraception, sterilization, and abortion. As Catholic health systems continue to expand, a fundamental question emerges: what are the consequences for hospital operations, access to care, and patient outcomes?This dissertation addresses that question across three empirical studies, each using rigorous quasi-experimental methods to provide causal evidence on the consequences of Catholic identity in U.S. health care. Together, the three chapters examine how religious directives shape organizational behavior--from broad hospital operations to specific reproductive health services--and who is ultimately harmed when religious and medical logics conflict.Chapter 1 examines how hospital operations change after acquisition by Catholic versus non- Catholic health systems, using a 14-year national panel and a staggered difference-in-differences design. Catholic acquisitions increase provision of some mission-oriented services (e.g., chaplaincy and charity care) and preserve obstetric care. However, cost-cutting behavior (e.g., reductions in employment and operating expenses) are similar across Catholic and non-Catholic acquisitions, suggesting financial pressures shape post-acquisition behavior regardless of religious ownership.Chapter 2 turns to reproductive healthcare, providing the first causal evidence that hospital adherence to the ERDs reduces access to postpartum contraception and increases the risk of short-interval pregnancy. Using over nine million birth hospitalizations and an instrumental variable model, I find that giving birth at an ERD-adherent hospital reduces permanent contraception by 63% and non-permanent contraception by 36% relative to non-ERD-adherent hospitals. Effects are concentrated among rural patients, for whom ERD-adherent hospitalization also increases the likelihood of a short-interval pregnancy (within 18 months) by 33%.Chapter 3 examines how Catholic hospitals manage the tension between conflicting religious and medical logics. Using a quasi-experimental analysis of over one million hospitalizations and 27 qualitative interviews, I find that hospitals rely on delayed intervention and patient transfers to manage the conflict--strategies that preserve institutional identity but result in worse patient outcomes. When patients have an urgent, pregnancy-related admission at an ERD-adherent hospital, they are 0.93 percentage points less likely to be induced for an abortion (179% relative to the mean). In addition, vulnerable populations, specifically Hispanic patients and those with complex pregnancies, are more likely to experience abortion-related complications at ERD-adherent hospitals.Taken together, this dissertation provides the first causal evidence on how religious restrictions in U.S. Catholic hospitals impact operations, access, and outcomes. The findings inform active policy debates regarding institutional conscience protections, antitrust oversight, and hospital transparency--providing evidence that religious institutional identity has significant, and unevenly distributed, consequences for patient access and health.