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Friday, May 31, 2019

Friday, May 31, 2019

Press, Faculty, Social Movements: Why the Opposition to the UCSF Alliance with Cathoilc Hospitals Prevailed

UCSF and UCSF Medical Center have announced that they are suspending negotiations to expand their existing relationships with four Catholic hospitals.  The reversal--highly unusual for the UC medical system--came after a public and a faculty outcry against more entanglement of the University with the private Dignity medical system that declines reproductive health services, gender-affirming surgery, and other procedures that conflict with the teachings of the Catholic Church.  This decision is a big deal: after providing some background, I'll argue that it's an example of the power of faculty effort when it stands on principle and in alignment with social movements--with help from sophisticated press coverage that higher ed too often has to do without.

Michael entitled his first draft of this post, "Does UCSF Care about Womens' and LGTBQ Health?" It was a good question, since UCSF Health's senior management seemed to be denying the restrictive reality that would be imposed on UCSF personnel operating in Dignity facilities. According to reporting by Nanette Asimov (April 26, 2019),
Dignity spokesman Chad Burns has said the Catholic hospitals require UCSF doctors to sign God-affirming agreements that prohibit medical care that violate the hospitals’ religious beliefs. He said these include the “Statement of Common Values” or the more restrictive “Ethical and Religious Directives for Catholic Health Care Services,” which characterizes certain procedures, including sterilization, as “intrinsically evil.” Depending on the hospital, prohibited care can include abortions, tubal ligations, hysterectomies, sterilizations, miscarriage care, gender surgery and contraceptive counseling.
Under the terms of the former, Dignity must deny abortions, along with in-vitro fertilization (which would disproportionately harm the gay and lesbian couples that depend on that procedure).  Under the latter, Dignity presumes that marriage is between a man and a woman, forbids the prescribing of contraception as well as abortion, and allows the morning after pill in cases of rape but not abortion (paragraph 36). 

Meanwhile, UCSF was assuring its personnel that it would not have to sign any such agreements or do anything that violated their professional ethics or secular standards of care. Asimov also reported,
UCSF spokeswoman Jennifer O’Brien said the medical center’s physicians are not required to sign those precise documents. “But they do commit to provide care consistent with those value statements as part of their credentialing and privilege application to practice in Dignity Health’s hospitals. This does not impede our physicians’ ability to prescribe contraception medications at any Dignity Health hospital, regardless of its Catholic sponsorship.”
The statement doesn't exactly make sense, reading from one sentence to the next, and is in any case flatly contradicted by the Dignity spokesperson.  The tacit deal seemed to have been that UCSF personnel could mention or even advocate procedures that they could not provide at a Dignity facility but that the patient could get elsewhere--though such counseling also contravenes Catholic directives.  UCSF seems to have carved out wiggle room in prexisiting clinical affiliations, whose complicated policies were the subject of a September 2017 Academic Senate report.

This was a long way from UCSF Health's original August 2017 announcement that it was formalizing an affiliation with Dignity.  This press release represented the new stage as a done deal that merely deepened existing affiliations between two essentially identical titans of clinical quality, one of which, Dignity, was exemplary for its charitable medical work for low-income patients.  The announcement didn't mention that Dignity restricted access to some kinds of health care or even that it was Catholic.  So the open debate in 2019 may well have forced the parties, Dignity and UCSF Health, finally to reckon with the fact that they had contradictory ideas about the alliance, which would make it unworkable in practice.

How did the debate come to the surface? Several factors came together.

First, advocates for reproductive and LGTBQ rights critiqued the UCSF plan and publicized the critique.  The ACLU of Northern California, the National Center for Lesbian Rights, and the National Health Law Program wrote a joint memorandum detailing the various ways in which the alliance would require discriminatory treatment of transgender patients, women, and people seeking palliative care, among others. The ACLU collected 6700 signatures on a petition demanding that UC reject the alliance in the name of protecting health care free of discrimination.  Word circulated about the case of Evan Minton, a transgender man, who had sued a Dignity hospital for canceling his hysterectomy after discovering that its purpose was gender affirmation.  The ACLU organized a protest for May 15th, calling on people to hold UC accountable to its values of non-discrimination, equity, and inclusion. Trans, feminist, reproductive, and other health care movements played an important role.

Second, UCSF faculty got directly involved. 1500 staff signed a petition opposing the alliance.  They also found a channel to express individual opinions en masse.  The main agent was the Faculty Association, which decided to poll its members to confirm or deny assertions of general support.  Results ran 2 to 1 against the affiliation.  When the UCSF administration declared the results unrepresentative of the overall faculty, the FA polled the entire faculty.  They got more or less exactly the same results: 2 to 1 against, with about 1/4th in favor.

The FA also collected over 300 comments.  Many were quite moving, both in favor (see #1, on experience of no restrictions in practicing at St. Marys and reciprocal influence in caring for uninsured patients from vulnerable populations); and against (#8, 48, and 64, for example).   The chair of the divisional Academic Senate favored the affiliation (see his co-authored op-ed), as apparently did much of campus Senate leadership.

But the FA persisted, which is important in itself; generated empirical evidence, which is equally important as a check on spin; and gathered a large set of individual comments, which allows personal experience and care to be expressed in a way that helps collective thinking, and that serves as a displaced form of democratic deliberation.  The faculty, so often inexpressive on university policy, were brought on line.

On the systemwide level, Academic Council chair Robert May opposed the affiliation on principle.  Although he sees the business logic, he told some of us in April, the alliance would compromise the fundamental values of the university, not unlike the McCarthy-era loyalty oath of 1949.  We can debate what UC's fundamental values really are, but May articulated a support for absolutely equal access to health care regardless of any aspect of personal identity, one that allowed for no splitting the difference between UCSF and Dignity.  I think it made a difference to see a faculty member in May's position stating quite clearly what the university is for, and standing up for that.

Third, press coverage rendered the alliance as a public concern. In addition to Asimov's reporting, Michael Hiltzik wrote a pair of columns in April (here and here) describing how the details were not public, the Regents were confused, the defenses were not convincing, and the ethics were disastrous.  The first column said early on:
Dignity’s adherence to Catholic Church directives affecting medical care, including a near-total ban on abortion, is hopelessly at odds with the values of a public institution such as UCSF. What’s worse, UCSF, by implicitly accepting Dignity’s model discriminating against women and LGBTQ patients, would empower that model’s expansion.
and built up from there.  For the LA Times's business columnist --and author of a history of UC science--to deliver to UC a set of cogent criticisms helped stop the train that has always already left the station so that people could think again about where the train was going.

There are at least two issues to keep analyzing and pushing, given the possibility that UCSF and Dignity will come back later with a restructured deal.  The first is now widely discussed--how to develop fundamentally egalitarian health care in our Handmaid moment of coordinated assaults on Roe v. Wade, and more muted but pervasive opposition to transgender rights. UCSF's position was the kind of moderation that has made reproductive healthcare vulnerable (see Rebecca Traister on Democrat triangulation with abortion).

The second is the UC medical center business model.  UCSF argued that it needed Dignity to solve a capacity crisis.  But why does it have one after it spent 10 years building a whole second campus at Mission Bay? We've commented before on the planning problems there.  After all that building, where are the beds to handle projected growth? Were too many new buildings devoted to targeted projects of interest to donors?  I don't know the answers to these questions, but somebody should answer them.  It seems like something has gone very wrong with planning when two entire UCSFs, one brand-new, can't handle the clinical load.  

There is also another possibility, which is that UCSF doesn't have a capacity crisis, but a monopoly crisis.  There isn't actually an overall shortage of hospital beds in the Bay Area (Dignity has many empty ones), but only a shortage of beds controlled by UCSF.  This raises the thorny question of whether the UC medical enterprise is financially viable without a quasi-monopoly share of the local market that, among other things, would make it easier to raise prices on patients.  The question should be of burning interest to the UC system, since the US health care system is in a state of turbulent uncertainty and UC it is on the hook for its medical center losses.

But for the moment, we should see the suspended Dignity deal as a real success for faculty-staff engagement in tandem with social movements and an intellectually active press.

ADDENDUM, JUNE 1ST (from Ed Yelin, Professor of Medicine, UCSF)

Re: the UCSF capacity issue: the Mission Bay hospital provides different services than the Parnassus one, by design.  Mission Bay covers oncology, Ob/Gyn,  and pediatrics while Parnassus does the rest.  That may make sense from a faculty perspective, so a pediatrician doesn’t have to schlep across the city to see patients in two places, but it means any errors of prediction in demand bump up against the lack of flexibility and lack of redundancy.  If the Ob wards are full at Mission Bay, Parnassus can’t help.

Another issue is that they may have overbuilt lab space (this gets to the issue of who among the donors gets to have their names on buildings) and under-built clinical capacity at Mission Bay.  Just guessing based on rumors about the lab and clinical buildings.  The predictions about how much lab space would be supported by indirect cost returns from NIH grants were probably off when the Mission Bay campus was planned; they were projecting increases in real value based on the Clinton years.  The rest is history, even though from some perspectives NIH has fared better than much of the Federal government. Better to say things got bad at a slower pace!

Oh, one last thing, about the Faculty Association role.  Like to take credit for some part in this movement, but we were late to the game.  We may be more than the straw, but definitively weren’t the anvil that broke the camel’s back.  Maybe a mid-weight rider on the camel.  Faculty in Ob/Gyn and reproductive health were ahead on this.  Glad that we contributed a lot at the end.  As to the survey: we made the call to extend it to the entire faculty to head off the accusation about not being fully representative rather than reacting ex post facto to the administration’s claim about that.

ADDENDUM 2, JUNE 7

Here is a link to the Interim Report of the Academic Senate Task Force on Non-Discrimination in Health Care. It recommends what has happened, which is the suspension of the affiliation pending an reconciliation of fundamental principles, which is unlikely to say the least.

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