Dear Mr. Coll and Ms. McStravog,

On behalf of the Catholic Health Association of the United States (CHA), I want to thank the United States Conference of Catholic Bishops (USCCB) Synod 2021- 2023 for the opportunity to participate in this Synodal process.

Catholic health care is a ministry of the Catholic Church continuing Jesus' mission of love and healing in the world today. As provider, employer, advocate, citizen - bringing together people of diverse faiths and backgrounds - our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit. The Catholic health care ministry has an immense impact in the U.S; serving 1 in 7 patients in the acute care setting each day. As the national leadership organization of the Catholic health ministry in the U.S., CHA has a unique vantage point to hear what is happening in the ministries and respond with resources and support for our members.

The teachings of the Second Vatican Council called all lay men and women to service in the Church, "The lay apostolate, however, is a participation in the salvifik mission of the Church itself Through their baptism and confirmation all are commissioned to that apostolate by the Lord Himself." This is evident in the ever­ growing lay leadership of the Catholic health ministries. In this opportunity, lay men and women are being formed to lead these ministries into the future.

In their day-to-day interactions with patients and residents, CHA members listen intently and respond to each persons' unique needs. As a result, our members are all-too-well acquainted with the challenges and real­ life experiences our most vulnerable populations face every day. In our continuing dialogue with our members, CHA has listened. The mission of each CHA member is to fulfill the healing mission of Jesus, healing

Through these conversations with our members, we hear that the health of our most vulnerable populations is compromised due to: racial injustice; the climate crisis; poverty; immigration status; lack of access to health care and insurance coverage; lack of a comprehensive system dedicated to elder care and discrimination based on gender and sexual orientation.

Our Catholic health care providers seek to advance the common good and fight these injustices with all the resources they can bring to bear. At the same time, they seek help in addressing concerns that impact their ability to fulfill Jesus' mission of healing. They seek to:

• Strengthen the Catholic identity of our ministries and expand opportunities for ministry formation; and
• Address complex health care ethical debates in collaborative ways that are deeply rooted in theology.

These are just some of the many ways in which Catholic health care providers are listening to the needs of their communities and demonstrating their commitment to continuing Jesus' mission of love and healing in the world today.

Health impact of racial injustice.
The health effects of racism on disparities in health outcomes and access to health care among racial, ethnic, geographic, socioeconomic, and other groups are well-documented. We know, for example, that racial and ethnic minority populations have less access to necessary health care than others. They are more likely to delay care, go without care, and suffer from poorer health and worse health outcomes.

These findings are not new. Health inequity is a persistent and lingering legacy of the systemic racism and social prejudices that have existed in our nation since its inception. It took the deaths of George Floyd, Breonna Taylor and Ahmaud Arbery, and the disproportionate impact of COVID-19 on racial and ethnic communities, to serve as a wake-up call for our nation about the need to end systemic racism. CHA and our members took the opportunity to renew our commitment to equity, justice, and the dignity of all persons. CHA's board of trustees unanimously issued a call to the ministry to pledge to Confront Racism by Achieving Health Equity and we launched our We Are Called initiative.

Through this initiative, almost 90% of CHA's membership has committed to: working to achieve equity in covid-19 testing, treatment, and vaccination; putting our own houses in order; building just and right relationships with our communities; and advocating for change at the federal, state, and local levels. CHA is supporting our members through convenings, webinars on key topics, highlighting member best practices, and developing resources.

While our members may be at different stages of the journey, all are deeply to committed to this work. They are: establishing internal structures to support the work: gathering data to clearly identify disparities; and addressing these disparities by working in relationships with community partners to achieve systemic change. Many are leaders in transformative activities, such as working at all levels of government to declare racism a public health issue and partnering with historically black medical schools to recruit, mentor, and train doctors form diverse backgrounds.

For all of us the work continues. Correcting the systemic sin of racism and its effects is not an easy task but the Catholic health ministry has made a long-term commitment to each of the four pledge pillars.

Health Impact of the climate crisis.
Over 20 years ago members approached CHA to ask that we coordinate and support member efforts to address climate change. Pope Francis' issuance of the encyclical Laudato Si: On Care for Our Common Home renewed and reenergized this commitment to environmental stewardship.

Climate change represents one of the most significant threats to human health in the 21st century- from extreme heat to severe weather, from air pollution to increasing allergens in the air, from poor water quality to poor water supplies. These changes disproportionately impact people living in poverty. Funding targeted for recovery from climate change may come at the expense of funding efforts to bring people out of poverty. Healthcare organizations need to direct money to improving operational resilience so they can continue to serve communities during extreme weather events.

CHA continues to help its members with their environmental stewardship efforts and partners with health care environmental advocacy groups like Healthcare Without Harm and Practice Greenhealth.

CHA is also working with the Dicastery for Promoting Integral Human Development to raise awareness of and enrollment in the Laudato Si' Action Platform (LSAP) within the U.S. Catholic health ministry. CHA is also part of the Catholic Climate Covenant which is coordinating the U.S. Catholic community's environmental advocacy and participation in LSAP.

CHA will continue to support and strengthen the Catholic voice which can be effective in neutralizing political polarization on climate change and support its members and partners to raise awareness of this issue. By focusing on the health impacts of climate change, particularly on the most vulnerable, and its root causes, the Catholic community can hopefully bring people with different political viewpoints together to take action.

Health impact of poverty.
Catholic health care providers see the devastating, compounding impact that poverty has on individual and community health each day. More than 37 million America people live in poverty, impacting minorities disproportionately. These individuals are at an increased risk for mental illness, have higher mortality rates and lower life expectancy. They also lack health insurance, forcing them to pay out of pocket or rely on charity to cover the cost of health care services.

Following in the footsteps of the religious founders of our organizations, Catholic health care providers work to reduce the impacts of poverty on a person's health and to address the long-term impacts of poverty on community well-being. Collectively, Catholic hospitals have developed an approach to community benefit programming that has become the national standard and provided over $11 billion annually in community benefit spending. By conducting formalized community needs assessments, we target our efforts where they are most needed. Our efforts include:

• Spending on charitable care, community health, community social services programs, education and on unreimbursed Medicaid expenses for low-income individuals;
• Partnering with our communities and developing initiatives to address the social determinants of health; and
• Amplifying our efforts by advocating for policies to: expand access to health care coverage; promote collaboration between social service and health care providers; strengthen federal economic and social safety net programs; address housing affordability; and promote policies to address smoking, climate change, and gun violence.

We will continue to partner to build healthy housing; ; create outreach programs for poor and vulnerable populations ; promote awareness about child poverty ; build affordable housing ; build outreach programs; promote individual empowerment and develop ethical and advocacy outreach efforts to ensure the poor are prioritized in COVID-19 vaccination programs.

Health impact of immigration status.
Access to affordable health care in the United States is directly related to immigration status. Undocumented immigrants lack options for accessing health services and usually pay out-of-pocket for care, which is prohibitively expensive. Even documented immigrants face barriers to care due to limited English proficiency, socio-economic status and fear of interacting with government entities.

CHA members are fully committed to providing care to all immigrants regardless of their status or ability to pay, and often serve as trusted points of care. Our members provide a variety of services including specialty clinics, preventive care services, other-than-English language services, community health services and health care program enrollment assistance to immigrants and their families throughout the nation. As an integral part of their ministries, CHA members are fully engaged in advocacy and public policy efforts to bring immigrants of all status into the U.S. health care system. Any health care system that excludes persons because of immigration status is both immoral and unworkable.

CHA has successfully advocated for many policies to assist immigrants in accessing health coverage, including successfully changing recent government regulations that would restrict immigrants' access to the Medicaid program and coverage under the Affordable Care Act and expanding coverage to undocumented immigrant children and pregnant women through the Medicaid and Children's Health Insurance Programs. CHA continues to advocate policies that would expand health care coverage as well as provide for overall, comprehensive immigration reform to provide a pathway to citizenship for millions of undocumented immigrants.

While CHA participates in broad immigration coalition groups including working with Catholic partners, even collective efforts are stymied by a pervasive anti-immigrant sentiment in the nation (even among many Catholics) that makes legislative and administrative efforts to assist immigrants difficult if not impossible to achieve. CHA and our Catholic coalition partners agree that a sustained and vigorous campaign within the American Church to highlight Catholic social teaching around immigration and migration issues is absolutely necessary to future success.

Health impact of lack of access to health care and insurance coverage.
Numerous studies have shown that having health insurance is associated with improved access to health services and health outcomes. Because uninsured patients do not receive the right care in the right place, they are up to four times as likely as insured patients to require avoidable hospitalizations and emergency care. Additionally, uninsured adults were more likely to be in medical debt and are more likely to delay medical care due to costs. Today, more than 31 million people in the US are uninsured. This group is disproportionally community of color, non-citizens, and those residing in states that have not expanded Medicaid.

CHA and our members believe that health care is a basic human right and are committed to creating a more just and equitable health care system that ensures health care for everyone.

For decades, CHA and its members have advocated for access, coverage and affordability in health care and insurance coverage for everyone. Our members have long championed the expansion of Medicaid in their states, while ensuring that patients avail Affordable Care Act (ACA) benefits like access to the health insurance exchanges that include government subsidies. They have also advocated for the health care rights of the elderly and children by promoting Medicare and the Children's Health Insurance Program (CHIP).

While significant progress has been made toward expanding access to coverage and improving the
quality of care in our delivery system, far too many are still uninsured or have coverage and care that does
not fully meet their needs.

Moving forward, CHA and its members will continue to prioritize advocacy to protect the gains made by the ACA (including the enhanced subsidies made by the American Rescue Plan Act), expand Medicaid in non­ expansion states that disenfranchise millions of individuals and families and strengthen existing programs that serve our most vulnerable - seniors, the poor, children, undocumented immigrants, rural communities and low-income mothers and babies (Medicare, Medicaid and CHIP).

Health impact of lack of a comprehensive system dedicated to caring for the elderly.
CHA and its members believe that only by developing a comprehensive, compassionate and sustainable strategy can health care best serve the elderly. CHA has taken a three-pronged approach to addressing a comprehensive system dedicated to caring for the elderly.

1. The Catholic health ministry has been a leader in building an Age-Friendly Health System that uses evidence-based approaches to giving excellent care to older persons. It prioritizes the role of mobility, appropriate medications, attention to mentation (delirium and dementia) and what matters to older persons.
2. Inspired by the Vatican's February 2021 release of, "Old Age: Our Future. The Elderly After the Pandemic," CHA worked with Catholic Charities USA and the Community of Sant Egidio to examine opportunities for improving Church's response to caring for the elderly. CHA and our partners are developing tools to share experiences and strategies among health, social service, parish and volunteer ministries to help older people remain in their homes and get the care they need and want.
   
3. CHA undertook an initiative to understand the challenges and opportunities facing the Catholic­ sponsored long-term care (LTC) organizations and explore options to help continue the mission of Catholic long-term care. The CHA board is developing a plan to address these issues facing LTC facilities that existed long before the COVID pandemic and were exacerbated by it -- declining daily census in skilled nursing facilities, staffing shortages, low reimbursement rates, burdensome regulatory requirements, poor public perception, and quality issues. At the same time, Catholic independent and system-owned nursing homes are increasingly owned by for-profit and private equity companies.
   

Health impact of discrimination based on gender and sexual orientation.
Catholic health care providers are seeing an increasing number of Lesbian, Gay, Bi-sexual, Transgender (LGBT+) adults and children seeking care, both for transition services and for health care unrelated to gender identity. This is causing confusion among providers about what they can and cannot do for these patients. We also know that many patients avoid Catholic hospitals altogether for fear they will be mistreated. This is particularly problematic in smaller communities where a Catholic hospital is the sole provider.

In an attempt to address provider confusion and patient reluctance, CHA is currently promoting the discussion of sexuality and gender in health care. We are trying to establish informal collaborative relationships with hospitals and providers who specialize in transgender care. We are introducing "SOGI" (Sexual Orientation and Gender Identity) training for associates so our providers can provide respectful, quality care.

Catholic health care must follow the science. Reluctancy to honor widely accepted standards of care jeopardizes medical credibility overall. Knowledge about gender dysphoria and incongruence continues to grow. At the same time, there is a movement toward a medical consensus on treatment. Gender dysphoria is a diagnosable condition that can be a symptom of permanent gender incongruence. These clinical conditions are not the same as various "gender ideologies." The distress of gender dysphoria is so severe that up to 40% of trans adolescents have attempted suicide. Younger children with gender dysphoria do not need treatment; they only need support and safety.

Catholic health care is committed to serving LGBT+ patients and their families. We must listen carefully and develop plans to accompany them through a journey of diagnosis and treatment as fully as possible.

Strengthening the Catholic identity of our ministries.
In the last 40 years, the demographics of leadership of Catholic health ministries has changed. As a result of the call of the laity at the Second Vatican Council and the decreasing numbers of men and women religious, the Catholic health care ministry is being predominately led by lay men and women. In light of this change, the question of maintaining Catholic identity emerged.

To ensure the Catholic identity of these ministries, many health care systems are using assessment processes to articulate the core elements of Catholic ministry identity and develop a process for benchmarking key objective measures. These assessments lead to recommendations and action plans to strengthen Catholic identity. Currently, CHA is working with its members to create a uniform set of core elements and benchmarking measures to ensure consistency across the Catholic health ministry.

A key element of maintaining Catholic identity is special preparation of all who serve in the ministry through ministry formation.

Our Catholic health ministry depends on leaders who can create and steward organizational cultures that incarnate Jesus' healing. These are leaders who hear and respond to a call to service - a call that comes from God and from the communities in which these leaders live and flourish. It is through ministry formation that leaders develop these necessary qualities.

Ministry formation creates experiences that invite those who serve in Catholic health care to discover connections between personal meaning and organizational purpose. These connections inspire and enable participants to articulate, integrate, and implement the distinctive elements of Catholic health ministry so that it flourishes now and into the future. Building upon lived experience, formation inspires individuals to consider their calling in a contemplative way, finding deeper meaning in their work and realizing their gifts as they grow in service to the community and one another.

Catholic health care in the United States recognizes the challenges and opportunities of serving in an increasingly secular and pluralistic world. The ministries will continue to create programs and assessments as well as dedicate positions in mission to oversee Catholic identity and ministry formation.

Addressing complex health care ethical problems.
The Catholic health care ministry bridges the areas of medicine and the health sciences, Catholic theology and ethics and the law. Our purpose of caring for all, and especially the most vulnerable among us, is rooted in our faith.

Inevitably, due to developments in science, and the changing world in which we live, ethical questions arise. These issues are both macro (in the sense that they challenge the ministry as a whole) and micro (in the sense that they are applications of principles within specific circumstances and patients). As Catholic health care ministers, we must address these issues as they arise in order to stay faithful to our mission.

In working with the members of the CHA, it is clear that ethical challenges are not just theological, medical, or legal questions. In fact, they are all three. They are multi-faceted and in order to have an authentic response, it is essential that many stakeholders are a part of the process of discussion and resolution.

In an address early in his pontificate, Pope John Paul II said in Puebla, Mexico in 1979 that "Perhaps one of the most glaring weaknesses of present-day civilization lies in an inadequate view of the human being." This is particularly true in contemporary healthcare, where persons are sometimes reduced to individual organs. Instead, we need to re-commit ourselves to understanding the whole person, in their totality.

A challenge for anyone who has tried to address complex healthcare ethical problems is to understand the many dimensions of such problems and to find ways of facilitating knowledge in theology and ethics, the health sciences and the law. Solutions which exclude healthcare professionals, members of the magisterium and theologians, or legal professionals have not been successful. In particular, it is essential to create effective models of collaboration between bishops and Catholic healthcare.

We have also been reminded in some of the most recent emerging questions that there is so much we need to learn from other professions in order to provide a fuller understanding of the issue. Listening, dialogue and reflection are necessary as we seek to bring Jesus' healing ministry to a world in need.

CHA is appreciative of this opportunity to help inform the work of this synodal process. You will be in our prayers as you continue to listen to the members of the Church as well as the movement of the Holy Spirit in this effort of renewal.

Blessings,

Sister Mary Haddad, RSM
President and CEO
Catholic Health Association of the United States

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