ROME – To hear Sister Carol Keehan tell it, President Donald Trump’s proposed overhaul of the Affordable Care Act, the sweeping healthcare reform enacted during the Obama years, isn’t actually about America’s health system at all – it’s basically a massive tax cut, intended to transfer roughly $880 billion from the poor to the rich.

“This is a bill to move wealth from the lowest-income Americans to the wealthiest,” Keehan said, insisting that in the version of the proposal originally floated in the House, 14 million people would lose coverage in the first year alone, and another 10 million would become uninsured down the line.

“That’s an important thing for the people in this country to understand,” she said, calling the proposal “utterly unconscionable.”

Moreover, Keehan said, another problem with the Trump administration’s plan is what has been, at least to date, its shape-shifting nature – what analysts and experts are scrambling to react to today, she said, may not even be on the table tomorrow.

“We have no insight” into what’s happening, said Keehan, President of the Catholic Health Association.

“The administration has been, I would say, singular in not being in contact with health care providers on almost any issue,” she said.

The same point, she said, applies to one of the most contentious issues surrounding health care reform from a faith-based point of view, which are the mandates imposed by the Obama administration to provide contraception coverage. Candidate Trump vowed to eliminate those requirements, but recently the Justice Department signaled intentions to continue defending them in court.

Keehan said neither she nor anybody else in the health care world knows if the administration’s eventual aim is to junk the mandates, tweak them, or continue applying them as is, leaving things essentially in flux.

The Catholic Health Association represents the roughly 640 Catholic hospitals in America and 1,400 other health care facilities, such as nursing homes, clinics and surgery centers. On health care reform, it’s found itself at the center of Catholic controversy over the years for breaking with the U.S. bishops over opt-out provisions offered by the Obama administration from the contraception mandates, though Keehan suggested the wounds of those battles, to some extent, have healed.

Today, she said, there’s a “fairly united” position among Catholic leaders in the States, including both the bishops and the CHA, against any overhaul of Obamacare that would deny coverage to large numbers of already vulnerable people.

Keehan is in Rome this week to lead an annual “ecclesiology program,” which introduces leaders in Catholic health systems to the Vatican and its personnel, as well as other Catholic leaders. She spoke to Crux during that event, and the following are excerpts from the conversation.

Crux: Tell me about the current state of the debate. What do you think is going to happen?

Keehan: It’s very difficult to understand the current state of debate. You can have people say, “We’ve withdrawn it,” or people who say, “Well, we’ll get it done next week,” and even people who say, “It doesn’t matter what the timeline is.” All of whom, by the way, seem to be authoritatively speaking for the leadership of Congress and the White House.

The bill was done in secret…

Which is another point of your criticism, correct, that there was no consultation with heath care professionals to put this together?

Absolutely. You can’t talk about how you are going to deliver heath care without talking to the people who deliver it! And I think it was done in secret for a very good reason: because it is not a health care bill. It is not a repeal and replace.

When President-elect Trump was on “60 minutes” right before his inauguration, he said in response to a question by Leslie Stahl that there would be no gap between when Obamacare ended and his program started. There would also be coverage that was as comprehensive, and possibly even more comprehensive as well as cheaper. This is not that bill. This is not a health care bill, and that is an important thing for the people in this country to understand.

This is a bill to move wealth from the lowest income Americans to the wealthiest Americans, in the first year, while 14 million lose insurance coverage that they have just gotten. Those are children, those are the elderly! Those are working people who wait on us. Up to $15.9 billion in that one year alone will go to people who make over $1 million a year. That is utterly unconscionable.

If you read anything about Catholic social teaching, if you read what Pope Francis said about what ought to guide our decisions in health care, it is absolutely deplorable. It reminds me, if you read the Old Testament, and you read Nathan confronting King David. It is exactly the same thing!

We can’t sit quietly and say “no, no, no,” we have to be very strong, because this is a disastrous switch. It will not only hurt the very poor, who are going to lose everything, but it will make insurance policies go back to the old way where [companies] could charge what they want and essential benefits may not be covered, where lifetime limits might be taken away.

The latest compromise we heard, and that got the Freedom Caucus’s endorsement of the bill, was that you don’t have to offer essential benefits. Those are the services you need most, such as chemotherapy and heart surgery. Remember that as part of a compromise, they also said that you can [eliminate those services] in every policy except the one offered to members of Congress and their staffs.

What’s the realpolitik of the situation. Is this bill going to go through?

It is very hard to know. It’s not an issue that is being decided on what’s good for healthcare. This bill is a companion to the big tax cut, and so the need here is not to fix health care but to fund the tax cut. That’s why we have said, over and over and over again, that people should look at the analysis done by the non-partisan Congressional Budget Office, which is headed by a Republican. It makes these statistics very clear. Or the Joint Committee on Taxation, which is also headed by a Republican and is nonpartisan. They make all of these points very clear.

What kind of support are you getting from other sectors of the Catholic Church in the United States on this issue?

The bishops have said that this is a very flawed bill, which should not be passed until it’s fixed. Many other organizations, some Catholic and some not, have stepped up.

Do you feel that the Catholic community is putting up a fairly united front?

On this issue, absolutely!

There was a wide expectation that with the advent of the Trump administration, the battle over the contraception mandates would be over. Yet recently the Justice Department indicated that it will continue to litigate cases challenging the mandates. Are you surprised that this issue is still around, and what do you think is going to happen? 

This administration is known for changing directions rather frequently, so I’m not that surprised. I too thought, given what he (Trump) had apparently been saying to people, in particularly the Evangelical community and folks like that, that that would be over very quickly.

He wrote a letter to the bishops in which he said, “I will make absolutely certain that religious orders like the Little Sisters of the Poor are not bullied by the federal government because of their religious beliefs.” Most people took that as a way of saying the issue was going to be off the table.

They did, but remember that early on he (Trump) put an executive order out that was a little hard to understand. It said, ‘Don’t make people do things via regulations, if you can help it, which violate their faith.’  I didn’t know what that meant.

Many of us have used the accommodation [provided under the Obama administration]. We say to the insurance company, “We will not pay for contraceptives,” and we don’t. If people go on to get contraceptive [coverage], they are led to a different website that says the CHA is not paying for this and it’s the insurance company paying for it.

What the Supreme Court did was say to the plaintiffs in the case, “Work out some kind of accommodation.” The accommodation we have right now, and that many, many Catholic organizations use, is not one they feel comfortable with …

You don’t have any special insight into what the Trump administration is eventually going to do?

We have no insight. The administration has been, I would say, singular in not being in contact with health care providers on almost any issue.

The ACLU recently filed a lawsuit in California against the Dignity Health system in a case involving a transgender person who requested an elective sterilization and was refused. Mercy San Juan indicated it could not perform the procedure, but assisted the patient in finding another facility, citing the “Ethical and Religious Directives” of the USCCB.

Do you see this as the first of what could become a wave of similar litigation around this issue?

Let me say first, we make it a policy at CHA not to comment on actual lawsuits against our members or against us. So, I won’t comment on it … However, the ACLU tends to sue us a great deal. They tend to sue a lot of people a great deal, so I don’t feel particularly put upon.

Sometimes you’re in fairly good company!


I think the real challenge for us today is to make certain that Catholic moral teaching, and Catholic social teaching, which talk about the dignity of the human being, are at the forefront of how we deal with these issues. We are doing respectful and quality care for people who want care from us irrespective of their situation.

On the other hand, there are certain things that we don’t do. I would say in this situation there is so much that we do not understand about the whole transgender situation that we have to approach it with great humility and respect, and do our best to make a prudential judgement about how the directives apply. We also should do our best to do that while always showing respect for the person involved, and a desire to be helpful.

We may not always be able to be helpful in everything a person wants, and that’s true, but it’s not at all bizarre. Many of our facilities do not perform open-heart surgery, for instance, and there are good reasons, ethical reasons why they don’t. They wouldn’t do enough of it, they wouldn’t be able to develop an expertise in it, so you can say it’s both a business and a moral choice.

You’re saying the fact that a facility does not offer a particular service is not, ipso facto, a denial of someone’s rights. It can be a choice about where they are going to deploy their resources, what they can they deliver well, and what ought to be left to others?

That’s right.