Analysis Health Systems

Opposing Religious Coercion in Health Care: The Defeat of the Abington Hospital Merger in Pennsylvania

Annamarya Scaccia

In Pennsylvania, organizing by community members and medical professionals helped defeat a merger between a Catholic hospital and a secular hospital system, thereby ensuring that women's reproductive health care services are still offered.

When Rita Poley created the “Stop the Abington Hospital Merger” Facebook page, she had no idea what would happen next.

For the 69-year-old Elkins Park, Pa. resident, it was a way to connect with other Montgomery County community members outraged by the abruptly announced partnership between the secular Abington Health (AH) and the Catholic-affiliated Holy Redeemer (HR), both located in the metro Philadelphia area. The Facebook page, created July 3—a week after the merger was revealed—was a means to initiate debate about “the horrible situation that was now present in our community.”

That horrible situation? The creation of a new regional health system formed between Holy Redeemer and Abington Health (which encompasses its flagship hospital, Abington Memorial Health (AMH) and Lansdale Hospital in Hatfield Township, as well as two area outpatient facilities), would mean total elimination from the hospital system of abortion care, even as Abington Health still claimed to remain a secular institution. Abington Health doctors and community members claim they were not consulted about this decision—or the partnership—before it was announced.

“This is just very, very, very close to my heart, this issue,” says Poley of her passion to fight against the partnership and its implications for women’s reproductive health care. Poley, director and curator of Elkins Park’s Temple Judea Museum of Reform Congregation Keneseth Israel for the last 13 years, came of age during the fifties when “these battles were being fought. I had friends from college who had to endure back alley abortions.”

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But what began as a suggestion from her 44-year-old daughter Nomi Saunders turned into the straw that broke the camel’s back.

And all in a matter of over two weeks.

“In the 15 years we’ve been doing this, this is the fastest merger defeat we’ve ever seen,” says Sheila Reynerston, advocacy coordinator for the New York-based MergerWatch Project. “It was 20 days. That’s incredible.”

A Swift Change

On July 18, after an emergency hospital board meeting, both Abington Health and Holy Redeemer released a joint statement announcing that the merger was dead.

Together we had a bold vision that we believe would have served our community well. While we are disappointed, we believe this decision is in the best interest of both organizations.

Why the merger fell apart in the end is at this point only a matter of speculation, but Poley and others involved in the campaign against the partnership believe it had a lot—if not all—to do with the grassroots efforts in the Montgomery County community. After all, the Facebook page had 1,470 likes as of July 20, 10,000 community members were sporting “Stop the Abington Hospital Merger” pins, and a Change.org petition against the merger received more than 6,100 signatures. (Linda Millevoi, spokesperson for Abington Memorial Hospital responded to an Rewire inquiry about the end of the merger delining further comment, and did not respond to requests for further clarification as of press time).

“I had no idea what was going to happen but I knew if anything was going to happen, we had to have a way to come together,” says Poley. “Facebook really is the 21st century town square.”

Poley, who heard the news while conducting a tour at the museum, also cites her talk with Abington Memorial Hospital’s Executive Vice President and Chief Operating Officer, Meg McGoldrick, on July 13. According to Poley, when McGoldrick called her to inquire about a sit-down meeting to discuss an accommodation, in which AMH would establish an off-site facility for abortion services, Poley refused. Instead, she informed McGoldrick that everyone involved in the campaign was developing strategies that would help end the merger. “I told her…it was going to get much worse, and I think she heard me,” she asserts.

“The movement created by the community against this merger was unprecedented,” says Reynerston, who attended a meeting with campaigners, along with representatives from Catholics for Choice and American Civil Liberties Union (ACLU) the night of July 17. “There was so much good use of social media and in such a short amount of time. It was quite clear that the community was very unhappy.”

“It was an impressive show of dissent against an ill-planned proposal,” she adds.

Another factor that can be attributed to the suspension was the overwhelming number of letters of discontent—most of which Poley posted to the Facebook page—that swamped the inboxes of the Abington Health administration. One such letter, sent July 3 by eight local Rabbis to Abington Health President and Chief Executive Officer Laurence M. Merlis wrote of the merger:

While we respect Catholic teachings that regard a fetus as a potential life, and understand that a Catholic hospital would refuse to provide abortion services, we are deeply concerned that this decision imposes a Catholic religious worldview on the entire community…In making the decision to no longer provide abortions at AMH, you are in effect saying that one religious tradition’s teachings should take precedence over all others. Should AMH commit to this path and refuse to perform abortion services, it would seriously undermine its status as a community hospital in any meaningful sense of the term. 

“As a Rabbi, I don’t look at this as a political issue, I look at this as a moral issue,” says Rabbi Lawrence R. Sernovitz of Old York Road Temple-Beth Am in Abington, one of the letter’s signers. “The moral issue is [that] women should have the right to have the services that they need in their own community… To take away the rights of women for a financial decision is not appropriate if you are serving the greater community.”

The Doctors Didn’t Buy It

But it wasn’t just the local clergy or citizens that were dismayed by this secular-religious partnership and subsequent elimination of abortion services. Over 200 AMH-affiliated doctors, including residents of AMH’s Obstetrics and Gynecology Department, met July 11 and unanimously opposed the planned merger, says Dr. Sherry Blumenthal, a 22-year Abington Health OB/GYN physician, Womencare Obstetrics and Gynecology P.C. partner, and chair of the Pennsylvania section of American Congress of Obstetricians & Gynecologists (ACOG).

Dr. Blumenthal was on vacation during the meeting but attended by phone (she notes in a July 19 follow up email that she was away during most of the campaigning but was still actively involved). She also authored a letter dated June 29 speaking out against the merger, and was one of the most outspoken of the Abington Health physicians. In her letter to Merlis, she wrote:

It is apparent that this was not a medical decision, but a financial one. Abington Memorial Hospital, by agreeing to certain religious concessions in its merger with Holy Redeemer Hospital, is showing disrespect for the medical rights of women, their autonomy to choose when to have children, and how many children to have.

“The concept of the merger itself is not a problem for the physicians or the community in the sense that most [doctors] understand that health care systems are greatly challenged in terms of finances, and this will become worse in the future,” she says. “The problem with this merger is the compromising the secular nature of Abington Hospital with the Catholic theology.”

According to July 24 post on the Stop the Abington Hospital Merger Facebook page, a letter from Abington Health has been emailed to a number of merger distracters further explaining the choice to call off the partnership. The letter, which was attributed to both Merlis and AMH Board of Trustees Chair Robert M. Infarinato, states:

While the affiliation made sense from many perspectives, we were unable to resolve a number of difficult issues, including clinical differences related to reproductive health…

We are grateful for the long-standing support of our community, and we respect and value the views and opinions of those who care deeply about our organization, including members of our medical staff, our patients, our employees, our volunteers, our donors and so many other members of our community.

As noted above, however, community members say they had no knowledge of the partnership before its announcement, directly contradicting the claim by Abington Health that the company “respects” the opinions of those its employs and serves. Second, Dr. Blumenthal notes that AMH’s OB/GYN department, as well as most of Abington Health’s 1,400-plus doctors, were left out of consultations about the medical impact of the potential merger. According to the physician, Dr. Joel Polin, chair of the OB/GYN department, was the only one informed of the decision originally, yet was denied the opportunity to voice his concerns at a board meeting scheduled to vote on the matter. Abington Memorial spokeswoman Millevoi, however, believes that there is a “misperception” on whether the announcement on the proposed merger indicated it was a “done deal.”

“What the boards agreed to was the signing of the letter of intent, which was in fact, never actually signed,” she wrote in an email.

“On the day of the announcement, our chief of staff, Dr. John J. Kelly, called and met with a variety of constituents, including physicians.  Contact with these various constituents were unable to be made until after the official announcement due to confidentiality requirements.”

Dr. Blumenthal has a different take of the overall situation. “I believe the talks were done in secret because the administration did not think that stopping abortion would be as big an issue or so controversial and they may also not have wanted to know this. They grossly miscalculated,” she wrote in the follow up email before the June 24 letter was distributed. She was on the beach with her four-year-old grandson when she heard of the cancellation, and felt “relief and affirmation.”

“Without medical input, the extent of the issue and the fears of where one prohibition might lead were trumped by financial concerns and fear of future financial constraints—the latter are real concerns. They might not have proceeded if they asked the medical staff and community first, so it is a bit of a ‘Catch-22.’”

Religion Over Health Care

According to a February 28 New York Times editorial, “Women’s Health Care at Risk,” 20 mergers between secular and Catholic-affiliated hospitals were announced over the span of three years, with more to be expected. It’s an upsurge, claims the editorial that is “threatening to deprive women in many areas of the country of ready access to important reproductive services.” In fact, notes the piece, late last year, Kentucky Governor Steve Beshear rejected a merger between secular and Catholic hospitals—University Hospital, Jewish Hospital, St. Mary’s Healthcare, and St. Joseph’s in Lexington—citing concerns about “loss of control of a public asset and restrictions on reproductive services.” 

And this was the case of Abington Health and Holy Redeemer. In addition to the elimination of abortion services, AMH physicians and the Montgomery County community feared that other reproductive health services banned under the United States Conference of Bishops’ Ethical and Religious Directives for Catholic Health Care Services would have been affected down the line. 

“Abortion is one issue, obviously the issue that matters most to the OB/GYN department, but there are other reproductive issues that are extremely important as well,” says Dr. Blumenthal. “The concern about women’s health care is obviously huge and complex.”

According to a July 12 statement emailed by Millevoi, only 48 out of the 17,575 abortions performed in the five-county Philadelphia region were provided by Abington Memorial Hospital in the 12 months ending in March. But the types of abortions performed by AMH are often not viable in an outpatient setting. Instead, notes Dr. Blumenthal, most pregnancy terminations were high risk or second trimester abortions either to save a woman’s life or due to fetal chromosomal or other fetal anomalies. And these types of procedures, she says, are safer performed in a hospital setting.

In the same statement, Abington Health claims that it would have still provided “the full range of reproductive health options…including:

  • Contraception counseling and services
  • Tubal ligations
  • Vasectomies
  • Infertility services
  • Emergency contraception for rape victims and others
  • All necessary measures to preserve the health of the mother, including those that may result in terminating a pregnancy”

But just because it’s in writing doesn’t make it true, especially since all of these services are forbidden in the Catholic directives—and that’s exactly what doctors and residents were afraid of.

Reynerston points to a case last year in Sierra Vista, Arizona to illustrate this very real possibility. According to the MergerWatch advocacy coordinator, in April 2010, the independent secular Sierra Vista Regional Health Center (SVRHC) announced that it would partner Carondelet Health Network, a Catholic health system, in a two-year trial affiliation. As part of the alliance, which required SVRHC to follow the Catholic directives, tubal ligations at the time of cesareans would no longer be performed—and SVRHC went as far as to put a full-page ad out to the community stating what services were still available, one being miscarriage management, says Reynerston. Yet, three months after the announcement, a woman who was rushed to the emergency room for miscarrying the second of her twins (she miscarried one of her two 15-week twins at home prior to the visit), was forced to be transferred to an acute care facility 80 miles away. The reason? The attending physician who determined that pregnancy termination was necessary because the remaining twin could not survive checked with administration knowing that SVRHC was now under Catholic rule, and was told treatment was not possible at the hospital.

The case, states Reynerston, was used in a complaint filed with the Arizona Attorney General delivered in November 2010 against the affiliation. In April 2011, Sierra Vista Regional Health Center discontinued the partnership (in a July 9th article in The Sierra Vista Herald, SVHRC announced they were looking to partner again to build a new multi-million dollar facility but will not consider religiously-affiliated entities).

MergerWatch Director Lois Uttley believes the problem with the type of proposed partnership between Abington Health and Holy Redeemer is that the interpretation of the Catholic directives is up to the local bishop or archbishop. In the case of Philadelphia, Archbishop Charles J. Chaput of the city’s Roman Catholic Archdiocese, formerly Denver’s prelate, is “quite conservative,” says Uttley. (According to a July 2011 interview with the National Catholic Reporter, Archbishop Chaput alluded that it was “hypocritical” for pro-choice Catholic politicians to receive communion and that “a relationship between two people of the same sex is not in line with the teachings of the church and the teachings of the Gospel, and is therefore wrong.”) She adds that MergerWatch worried he would insist the reading of the abortion ban would be “broader than Abington Hospital officials might want it to be.”

And this means that, in addition to the services Abington Health claimed would still be provided, other services such as treatment of ectopic pregnancies and miscarriages could have eventually been restricted due to Archbishop Chaput’s interpretation.

The Financial Side

In the New York Times editorial, health care system partnerships are often driven by “shifts in health care economics,” in which “some secular hospitals are struggling to survive and eager to be rescued by financially stronger institutions, which in many cases may be Catholic-affiliated.”

But for Abington Health, this is not the case. Unlike Holy Redeemer, Abington Memorial Hospital received a Fitch Rating of “A,” with an outlook of “stable.” Among the key rating drivers, which included good market position (AMH “maintains a leading market share in a competitive service area,” states Fitch), solid liquidity, and above average debt burden, there sis sustained probability. Writes Fitch:

After a drop in profitability in fiscal 2010, Abington’s operating performance improved in fiscal 2011 with a 2.1 percent operating margin mainly due to its cost reduction initiatives. This trend has been sustained through the 11 [months] ended May 31, 2012 (interim period) with a 1.9 percent operating margin.

According to Moody’s, however, Holy Redeemer has $86 million of outstanding rated debt as of December 2011, receiving a Baa2 rating and an outlook of “negative”—the same rating and outlook it received from Moody’s in December 2010, when it had $110.9 million of total rated debt. One of Holy Redeemer’s challenges, writes Moody’s, is “ongoing pressure on operating cash flow.” The Catholic health system had an 8.1 percent operating cash flow margin the 2011 fiscal year, “with challenged operating performance during the first three months” in the 2012 fiscal year. There was also a $588,000 operating deficit during the three months ending in September 2011. 

“It doesn’t make sense that Abington Hospital, being the financially stronger partner, would agree to any restrictions on its services in order to partner with Holy Redeemer,” says Uttley of the failed partnership. “Each hospital should be able to maintain its own ethical policies and current service provisions.”

As Dr. Blumenthal notes, Abington Health partnering with another hospital in the geographical area would position the system to become a stronger health care force. But she also finds it suspicious—and perplexing. “The structure of the board of the merged institution would be 50/50 [and] this makes no sense,” she says. “Why is Holy Redeemer being allowed to dictate certain conditions of the merger based on Catholic religious principles?”

Abington Health did not return a request for clarification on this issue.

And Then There Were the Residents

The other issue the unsuccessful merger presented was its effect on residency training in Abington Memorial Hospital’s OB/GYN department. According to the Accreditation Council for Graduate Medical Education’s Obstetrics and Gynecology program requirements:

No program or resident with a religious or moral objection shall be required to provide training in or to perform induced abortions. Otherwise, access to experience with induced abortion must be part of residency education. This education can be provided outside the institution. Experience with management of complications of abortion must be provided to all residents. If a residency program has a religious, moral, or legal restriction that prohibits the residents from performing abortions within the institution, the program must ensure that the residents receive satisfactory education and experience in managing the complications of abortion. Furthermore, such residency programs (1) must not impede residents in the programs who do not have religious or moral objections from receiving education and experience in performing abortions at another institution and (2) must publicize such policy to all applicants to those residency programs.

Abington Health did not responde to a request for comment on how this training would have been handled if the partnership with Holy Redeemer was implemented. “Most of us came to this program because we were looking for a program that provided these types of services that would be cut off by the merger,” says Cari Brown of Easton, Pa., a second year resident in AMH’s OB/GYN department. “In this particular situation, our treating and our ability to provide these services are potentially being compromised because of a religious belief that I would estimate the majority of our residents do not or have not subscribed to.”

Brown, who along with 19 other residents released a letter on July 11 disapproving of the merger, says she only applied to AMH’s OB/GYN program because of the advanced abortion services it offers. If the merger would have grown feet, instead of being squashed over two weeks after its announcement, then that education, she says, would be severely limited.

But it’s the Victory that Matters

“Can you believe they never spoke to the doctors?” Poley asks with astonishment. “It makes you think, doesn’t it?”

“The fact that they had to do it in secrecy and announce it from the cloak of secrecy says it all,” she continues. “What were they thinking? They had to know they were going to meet up with resistance. They just had no idea of what the extent of it would be.”

And that resistance is thought to have brought the affiliation to a halt. 

Rita Poley. <em>The Jewish Exponent.</em>

Rita Poley. The Jewish Exponent.

Reynerston says the campaign against the merger possessed two key attributes in successfully bringing it down: opposition by the the surrounding community and by the medical community. “Without community support and without doctor support, proposals tend to fail and that’s exactly what happened,” she says.

When Reynerston heard the news, she just finished a call with Abington advocates and was completing a follow up email when an involved resident sent out a mass email announcing the merger’s termination. “It was really great. It was a great moment,” she says.

For Brown, now that the merger has been called off, she looks forward “to continuing to offer patients the complete range of reproductive health-care options, and supporting them through the joyful, as well as the challenging, moments that they and their families may encounter.”

“I hope our community never needs to face a situation of putting one groups’ religious doctrine ahead of evidence based medicine again.”

Rabbi Sernovitz believes that Abington Health and Holy Redeemer’s July 18 decision “speaks volumes about the power of the people to make change and to pursue social justice.” 

And Poley, exhilarated by the news, felt “happy and lucky to be living in this community where these great people came together and caused this to happen.”

But what happened in Montgomery County from July 3 to July 18 is more than about the cessation of a potentially problematic and harmful merger. It’s a striking example of how powerful and effective grassroots organizing can be when assertively tackled. 

“This campaign is going to be a great working example for other communities in the future when we no doubt have to face another [merger],” says Reynerston.

“Communities across the nation can now look to Abington, Pennsylvania for proof that it does make a difference when people stand up and speak out about a hospital merger that could have an impact on health care.”

Analysis Politics

Advocates: Bill to Address Gaps in Mental Health Care Would Do More Harm Than Good

Katie Klabusich

Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”

Despite the pushback, Murphy continues to draw on the bill’s mental health industry support; groups like the American Psychiatric Association (APA) and the National Alliance on Mental Illness (NAMI) back the bill.

Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”

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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.

All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.

Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”

For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.

“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”

“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”

Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.

Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.

“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”

Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”

The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.

In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.

Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.

“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”

Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.

LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”

In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.

“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”

Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.

“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.

While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.

“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”

The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.

In the meantime, Sen. Lamar Alexander (R-TN) has introduced the “Mental Health Reform Act of 2016” (SB 2680) which some supporters of HR 2646 are calling a companion bill. It has yet to be voted on.

Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.

Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.

“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”

Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.

“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”

Analysis Human Rights

Erika Rocha’s Suicide Brings Attention to the Dire Need for Mental Health Care in Prison

Victoria Law

Erika Rocha's was the first suicide of the year at Corona's California Institution for Women (CIW), which is currently at 130 percent capacity. CIW's suicide rate, however, is more than eight times the national rate for women behind bars.

On April 14, 2016, one day before her parole hearing, Erika Rocha committed suicide. The 35-year-old had spent 21 years behind bars. But what should have been a day of hope for Rocha, her family, and her friends instead became a day of mourning.

Rocha’s was the first suicide of the year to rock Corona’s California Institution for Women (CIW), which is currently at 130 percent capacity. CIW’s suicide rate, however, is more than eight times the national rate for women behind bars. The prison had four suicides and 16 attempts in 2014. In 2015, it had two suicides and 35 attempts. And in the first two months of 2016, CIW had four additional suicide attempts.

These numbers, advocates say, display the consequences of the lack of mental health resources for women in prison, some of whom have been behind bars for decades.

The need for comprehensive mental health care has long plagued California prisons. In 1990, advocates filed Coleman vs. Wilson, a class-action civil rights lawsuit alleging unconstitutional medical care by the California Department of Corrections and Rehabilitation (CDCR). In 1995, a U.S. District Court ruled in Coleman that mental health-care access in the state prisons violated the Eighth Amendment prohibition against cruel and unusual punishment; the following year, it appointed a special master to review California’s prisons and to monitor mental health care. That special master is still monitoring CDCR’s mental health care.

In 2013, Lindsay Hayes, a suicide prevention expert, audited all of the state’s prisons for their suicide prevention plans. In 2015, he re-audited 18 of those prisons. In the report he released in January 2016, he noted that, while some prisons had made progress on the issue, “CIW continued to be a problematic institution that exhibited numerous poor practices in the area of suicide prevention.” These poor practices, Hayes wrote, included low completion of suicide risk evaluations, inadequate treatment planning, low compliance rates for annual suicide prevention training, and multiple suicides during the calendar year.

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“This Seemed To Be the Only Way”

No one will ever know what pushed Rocha over the edge. But others at CIW say that those who need mental health treatment there, both before and after their suicides, face a lack of preventive treatment, including counseling, and almost no follow-up.

Amber, who asked to be referred to by a pseudonym, noted that the prison lacks available mental health programming. She had already spent 14 years at another prison when she was transferred to CIW. There, she found that nearly every self-help and support group had a long waiting list.

In addition, mental health treatment was sparse. “I would only see mental health [staff] every 90 days, and that was only about five minutes,” she recalled in an interview with Rewire. “As time went on and I became more and more frustrated by the lack of anything to take my mind off my emptiness, I got more lonely and hopeless.” She stopped talking to her friends, stopped eating, lost interest in her appearance, and began losing weight. No one noticed these red flags. She told mental health staff that she wanted to stop taking medication. No one, she said, questioned her decision.

In July 2014, Amber and her friend Mindy (also a pseudonym) decided to end their lives together. Once they made their decision, Amber remembered feeling a sense of relief: “I was happy. I knew my misery and pain were ending. … This seemed to be the only way.” The two slit their throats, losing consciousness. But someone found them, alerted staff and they were transported to the hospital. How they were treated next, they said, didn’t make them feel any more hopeful about life.

After being released from the hospital, both women were placed in a mental health crisis bed, commonly referred to as “suicide watch” among people in prison. Amber described suicide watch as a place “where they strip you naked and put a hard gown on you, basically a life jacket. They give you a blanket made of the same material and have a bright light on with a nurse watching and recording [on paper] your every move. … You are not allowed anything for the first week. Then you can ‘earn’ a book. And maybe a muumuu gown if you are calm and cooperative. You aren’t even allowed a roll of toilet paper. When you need to use the toilet [in your cell], they hand you a tiny bit and watch you use it.”

Mindy spent 11 days in suicide watch; Amber was there for two weeks. Both were then placed in the prison’s specialty care unit, where they were able to have human interactions and access to group programming, which Amber described as 14 hours a week of coloring, watching movies, singing karaoke, and walking.

However, suicide watch is frequently full. In those cases, people are placed in an “overflow unit” in the prison’s Security Housing Unit (SHU), an isolation unit where people are locked in their cells for 23 to 24 hours each day. This kind of isolation can cause myriad mental health issues, including anxiety, panic, depression, agoraphobia, paranoia, aggression, and even neurological damage.

Krista Stone-Manista is an attorney with San Francisco-based Rosen Bien Galvan & Grunfeld, which co-litigated the Coleman case. She is also part of the team now monitoring compliance. She notes that, when a person reports feeling suicidal, she is supposed to be moved to a mental health crisis bed. But, because there aren’t enough mental health crisis beds, California prisons utilize what’s known as “alternative housing,” which might include isolation until a bed opens up. “What we’re seeing is that people are repudiating their suicidal ideation to get out of alternative housing,” she told Rewire. That means that they don’t receive counseling or any other type of mental health treatment.

But even when they are placed on suicide watch, the special master, in his 2015 review of CIW, found that “patients were discharged from the mental health crisis bed as soon as they reported they were no longer suicidal, with little effort to determine the underlying causes of their initial reports of suicidality.”

People incarcerated at CIW report that its environment has not improved in the two years since Amber and Mindy attempted to take their lives. In March 2015, Stephanie Feliz hung herself. Mindy, who was in the mental health unit at the time, said that Feliz walked in and requested services for a mental health crisis. Despite having a history of suicide attempts and self-mutilation, Mindy said staff told her that she had already been seen the day before. According to Mindy, Felix returned to her cell, where she was found dead two hours later. This treatment is not unusual, Mindy noted, writing to Rewire in a letter that she too has requested mental health services only to encounter delays and, at times, outright dismissal.

But no matter what changes the institution makes, Stone-Manista pointed out, “There’s only so much CIW can do for someone who is chronically suicidal. They’re not a hospital.”

CDCR did not respond to queries about the numbers of suicides and suicide attempts at CIW or about its suicide prevention practices.

Rocha’s Years in Prison

When Rocha was 14 years old, she and several older teens were arrested for an accidental shooting. Rocha was charged as an adult and, without a parent or guardian present, questioned by police and, according to advocates, pressured to plead guilty by the prosecutor. She did and was sentenced to 19 years to life. Rocha was initially sent to a juvenile prison, where she spent two years. At age 16, she was transferred to the adult Valley State Prison in Chowchilla. There, prison officials placed her in solitary, ostensibly for her own protection due to her age. She stayed in isolation for one year.

Windy Click is now program coordinator for the advocacy group California Coalition for Women Prisoners (CCWP). She was imprisoned at Valley State when Rocha arrived and met the girl shortly after she had turned 19. Rocha was looking for something positive to do and asked how to get to the prison library. While Click, then in her 30s, and Rocha never became close friends, each time Rocha was released from solitary, she sought the older woman out.

“She was a funny girl,” Click recalled in an interview with Rewire. “She liked to joke and be light-hearted.” One of the topics that Rocha frequently joked about was growing old in prison. “She’d say she would be an old lady in prison.”

Other times, however, the girl had a hard time coping with prison. “She would be very shaky, trembling almost,” Click recalled. “‘I can’t do this no more,’ she’d tell me.” During those times, Click said, Rocha would tell prison staff that she was afraid for her life and request to be placed in administrative segregation, a form of isolation commonly known as ad-seg, where she would be locked in a cell for 23 to 24 hours each day. Prison staff obliged and Rocha would be placed in isolation. When she returned to general population, Click remembered that the girl would seem better but “after a day or so, she’d be back to that shakiness.”

Click recalled one conversation in which she told Rocha, “This place isn’t the last place you’ll ever be.” But, she remembered, the younger woman couldn’t see the light at the end of the tunnel.

It didn’t help that Rocha spent more than a decade without seeing her family, who lived nearly 300 miles in the Los Angeles area. Lacking a car, they could not make the trek to Central Valley. It was not until Rocha was moved to CIW, 15 minutes from their home, that they could visit. By then, Rocha’s father had died; her stepmother Linda Reza brought her three daughters as soon as Rocha was allowed to receive visits.

“She was still the same little kid that left us,” Reza remembered of that first visit in an interview with Rewire.

That was how Geraldine, Rocha’s half-sister, saw it as well: “She’s nine years older than me. But it was like I was the big sister.”

Rocha got along best with her teenage sister Freida, who was born after her incarceration and whom she met for the first time in the CIW visiting room. When the family visited, Reza remembered that Rocha and Freida would head to the visiting room’s play area and play on the swings. Reza recalled that, when Rocha received news of her upcoming hearing, she and Freida made plans to share a room at Reza’s house, clipping magazine pictures and envisioning how to decorate the room.

Colby Lenz, a volunteer legal advocate with CCWP, saw a different, more vulnerable side, one that Rocha did her best to keep from her family. “She was the most fragile and traumatized person I had ever met in prison,” Lenz recalled about their first meeting less than two years ago. It was only partway through the legal visit that Rocha began to open up. “She went back to [age] 14 or 15 and talked about her early years—how much time she had done in solitary, how they treated her.”

Under California’s SB 260, which passed in 2013 and went into effect in January 2014, Rocha became eligible for a youth parole hearing for youth sentenced as adults to long prison sentences. As part of the hearing process, she was given a psychiatric evaluation. But, said Lenz, no one explained to her why she was undergoing a psychiatric evaluation. The process brought her back to the police interrogations she had gone through at age 14 without a parent or guardian present. Frightened and retraumatized, Rocha not only waived her hearing, but also attempted to take her own life.

In 2015, Rocha learned she was scheduled for another youth parole hearing on April 15, 2016. In the weeks before, Reza recalled that Rocha was excited. The last time she called, Reza wasn’t able to answer her phone. The message Rocha left was hopeful. “Tell my sisters I know they’re going to kick my ass when I get home,” she said. “But that’s okay, I’ll take it.”

“In a Hopeless Place, Most Don’t Make It”

Since Rocha’s death, CCWP has reported that at least 22 people in CIW have been placed on suicide watch for attempting suicide or stating that they felt suicidal.

Mariposa, who asked to go by her stage name, is one of those 22 placed on suicide watch. She is the co-author of the one-woman play Mariposa and the Saint about her own time in solitary. She was also Rocha’s cellmate and fiancée. After Rocha was found hanging in their shared cell, Mariposa was immediately placed in suicide watch, where she was not allowed regular visits, phone calls, or mail. She was, however, allowed a legal visit with CCWP, but, advocates told Rewire, kept in a treatment cage the entire time.

Those inside the prison report that the lack of programs and activities contributes to the feeling of hopelessness. “People have way too much time to think and be in their heads,” wrote another woman at CIW to Rewire one month before Rocha’s death. “A lot of us are only hanging on by hope alone. In a hopeless place, most don’t make it.”

Krista Stone-Manista noted that CDCR is working on new policies and procedures to move people who need more care or longer-term care to inpatient care rather than keeping them inside the prisons, which are often inadequately staffed with mental health professionals. She also pointed to CDCR’s reduction of the use of solitary confinement, noting that studies have shown the damage to mental health and that suicides and suicide attempts often occur in segregation. In addition, she says, CDCR is working on how to respond to reports of suicidal thoughts before they become attempts or actual suicides.

All of these efforts are too late for Rocha. “When I get out, I want you to take me to the park,” Reza remembered her stepdaughter telling her and her sisters during one visit. “I want to play on the swings and the slide and run in the grass.”

Reza plans to honor that wish. “After her cremation, we’re going to have a reception in the park,” she said. “We’re going to put her on the swings.”