After the Supreme Court overturned Roe v. Wade in June 2022, 14 states have imposed near-total abortion bans. (Arizona may soon join them.) While all of these states include exemptions to save the life of the mother, the language is inherently vague. The abortion bans typically allow for emergency abortions to prevent "serious risk of substantial and irreversible impairment of a major bodily function" or "serious, permanent impairment of a life-sustaining organ." But the laws do not address "expectations regarding the most common obstetric complications that can lead to late-stage pregnancy loss, such as previable premature rupture of membranes, excessive bleeding, gestational hypertension, preeclampsia, or placental abruption."

The American College of Obstetricians and Gynecologists says that it is critical that hospitals "provide guidance that permits treatment to the full extent of applicable state law and support and defend their clinicians when they provide care to patients." 

In many hospitals, that is not happening. The result is that pregnant women are showing up at emergency rooms and are not receiving the care they need. An Associated Press report last week, based on federal documents, found that "[c]omplaints that pregnant women were turned away from U.S. emergency rooms spiked in 2022 after the U.S. Supreme Court overturned Roe v. Wade." Sara Rosenbaum, a professor of health law at George Washington University, says that pregnant patients have “become radioactive to emergency departments.” 

In 2022, Amanda Zurawski experienced complications after her water broke around 18 weeks of pregnancy, but her doctor in Texas refused to induce labor even though “a miscarriage was inevitable.” Zurawski was only able to receive an abortion after she developed sepsis. Due to the infection, Zurawski “will suffer lasting effects to her fertility,” including “the permanent closure of one of her fallopian tubes and a collapsed uterus.” Zurawski is one of 20 women suing the state who “allege they were denied medical care for their complicated pregnancies as a result of the state’s abortion laws.”

In 2023, Jaci Statton “was turned away from an Oklahoma emergency room despite having a partial molar pregnancy,” which is non-viable and requires emergency medical care. “Oklahoma’s laws nearly killed me. Even though I had an extremely dangerous pregnancy and was repeatedly bleeding, I was told to wait in a hospital parking lot until I was near death in order to get the life-saving care I needed,” Statton said.

Shanae Smith-Cunningham experienced a "pre-viability preterm prelabor rupture of the membranes," a condition known as PPROM, in 2023. PPROM "can cause significant complications, including infection and hemorrhage, that can threaten the health or life of the mother, according to multiple studies." But when Smith-Cunningham went to HCA Florida Northwest Hospital in Margate, Florida, she was sent home. Her doctor, mentioning the overturning of Roe, said she "couldn’t do anything to help." Smith-Cunningham eventually miscarried and later needed to undergo surgery.

HCA Healthcare is the largest for-profit hospital chain in the country. The publicly traded company operates 168 hospitals and had over $65 billion dollars in revenue in 2023. Today, a group of HCA shareholders will attempt to pass a resolution requiring it to clarify its policy on treating pregnant patients facing medical emergencies in states that severely restrict abortion rights.

Shareholders demand action

In HCA Healthcare’s stockholder meeting today, shareholders are considering a proposal filed by the United Church Foundation, which provides “values-aligned investing” to churches and faith-based organizations. The proposal requires HCA to “issue a public report detailing any known and potential risks to the Company posed by state laws severely restricting abortions in the case of medical emergencies.” The report, to be filed before December 31, 2024, would also be expected to discuss any “strategies beyond litigation and legal compliance” that HCA is taking to “mitigate these risks.”

The proxy memo detailing the proposal, which was prepared by Rhia Ventures, a social impact organization that focuses on reproductive health, states that “about 70% of HCA Healthcare’s US-based hospitals operate in states that have adopted laws severely restricting access to abortion absent exigent circumstances that often differ from federal statutory emergency abortion exceptions.” This includes Florida and Texas, which “represent 50% of the company’s hospitals and 50% of consolidated revenues.” The memo also states that, in 2023, “over 9.3 million patients were treated in HCA emergency rooms.” 

The proposal argues that doctors in states with abortion restrictions “have been struggling with the legality of providing terminations for ectopic pregnancies, incomplete miscarriages, or other circumstances where miscarriage is inevitable, or the health or life of the pregnant woman is in danger,” putting the “physicians and the hospital at legal risk.” It also states that “abortion bans are creating impediments to physician recruitment and retention.” 

In response to the proposal, HCA argued in its proxy statement that the company has “strong risk management processes in place” and that they are “appropriate and sufficient.” The statement also argues that the “reporting called for in this proposal is neither practicable nor a good use of Company resources, given its broad scope.” HCA argues it would require them to consider "not only the current laws in each of the 20 states where we operate, but also all proposed bills and regulations."

The proxy memo prepared by Rhia Ventures, however, states that “there is no evidence of any specific measures to mitigate risk around emergency abortions in any of HCA Healthcare’s disclosures.” The proxy memo also argues that “HCA’s political participation is extensive” and includes lobbying activity and donations to state and federal politicians. The memo argues that “it would be reasonably expected that the Company’s government relations team already engages in monitoring political activity,” and therefore, “reporting on its findings should not be overly burdensome.”

In February 2023, the United Church Foundation withdrew a similar proposal that asked HCA to provide guidance on performing abortions in emergency scenarios in states with abortion restrictions. The original proposal was withdrawn after HCA released a statement in December 2022 saying that physicians at HCA Healthcare hospitals “may perform an emergency abortion that such physician (exercising his or her independent medical judgment) determines and documents as meeting an applicable federal requirement or state law exception.” But the current proposal argues that HCA’s previous statement has been insufficient.

Shelley Alpern, the Director of Corporate Engagement at Rhia Ventures, told Popular Information that they’ve “been in conversation with HCA since December of 2022,” and “we’re not getting any more than vague assurances from the company.” Alpern said, “the point that [HCA] continually make[s] is that… they rely on the judgment of their physicians in these matters… but that’s not enough.” Rhia Ventures is also preparing a similar proposal at Tenet Healthcare that will come up for a vote later this spring, according to Alpern. 

HCA's financial support for anti-abortion politicians

HCA claims it does not have the resources to concern itself with legislative activity in the states that it operates. This appears to be false. A review of campaign finance records reveals that, in several states, HCA is financially supporting the politicians who supported putting abortion bans in place. 

A Popular Information investigation found that HCA affiliates have donated thousands of dollars to anti-abortion politicians in states with abortion restrictions. In Texas, where abortions are banned without exception for rape or incest with only “narrow exemptions for the life and health of pregnant people,” the HCA Texas Good Government Fund has donated $19,000 to 24 anti-abortion legislators since 2023. This includes legislators who voted to pass Texas’ abortion ban that went into effect after Roe was overturned and legislators who have expressed support for other anti-abortion legislation.

In Tennessee, where HCA is based, a near-total ban is in place, with exceptions for if it is “necessary to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman.” Part of the ban is currently being challenged in court by “seven women who were denied abortions following pregnancy complications and two doctors,” who are arguing that the exceptions of the law are too vague. Since 2023, HCA TriStar Fund, a division of HCA that operates in Tennessee and Kentucky, has donated $92,000 to 61 anti-abortion politicians in Tennessee. This includes politicians who voted to pass an abortion ban that was triggered by the overturning of Roe and legislators who have expressed support for other anti-abortion legislation. 

In Florida, a six-week abortion ban with exceptions will go into effect on May 1, replacing the current 15-week ban, following a Florida Supreme Court ruling. The exceptions include if it is “necessary to save the pregnant woman’s life or avert a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant woman other than a psychological condition.” Since 2023, HCA divisions have donated $88,000 to 44 anti-abortion politicians in Florida, including legislators who voted for the six-week abortion ban and politicians who have expressed support for other anti-abortion legislation. This includes donations from HCA East Florida Division, HCA North Florida Division, and HCA West Florida Division. 

The Catholic conflict

HCA's Florida website promotes its hospitals for "women who have high-risk pregnancies." 

HCA owns and operates Florida Mercy Hospital in Miami. The hospital is a Catholic institution and adheres to the "Ethical and Religious Directives for Catholic Health Care Services." According to those directives, "abortion… is never permitted." It defines abortion as a "procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion." It warns that "Catholic healthcare institutions need to be concerned about the danger of scandal in any association with abortion providers." 

This directly conflicts with the guidance of the American College of Obstetricians and Gynecologists, which says hospitals in states with severe abortion restrictions should permit "treatment to the full extent of applicable state law." It also conflicts with the Emergency Medical Treatment and Labor Act (EMTALA), which requires any hospital receiving Medicare or Medicaid payments to "provide stabilizing care for any patient whose life or health is in serious jeopardy." For some patients, that necessitates terminating a pregnancy. 

The conflict between the EMTALA and Idaho's strict abortion ban, which allows abortion only to prevent the death of a pregnant woman, was the subject of a Supreme Court argument on Wednesday.