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By JUDITH VANDEWATER

WASHINGTON, D.C. — The months and weeks leading up to the March 2010 enactment of the Affordable Care Act were fraught with hyperpartisan politics. The stakes were enormous — the legislation would usher in the biggest reset in health care finance in almost 50 years. The bill touched upon nearly every aspect of the U.S. health care system and held the potential to expand health insurance coverage to tens of millions of the nation's uninsured.

CHA President and Chief Executive Officer Sr. Carol Keehan, DC, right, used a May 8 visit to St. Peter's Square for Pope Francis' General Audience to introduce Sr. Mary Haddad, RSM, center. Sr. Carol retires June 30 after almost 14 years at CHA. Sr. Mary will succeed her in CHA's top post.
Foto © Vatican Media

Sr. Carol Keehan, DC, who retires as president and chief executive officer of CHA June 30, saw the ACA as a promising, if imperfect, vehicle to advance the Catholic health ministry's vision for health reform that leaves no one behind. Having brought the priorities of the Catholic health ministry into meetings and calls with White House and congressional officials where the central concepts of health reform were framed out, she put all her personal and political capital on the line to secure the final votes needed for the bill's passage.

Ensuring that everyone gets the quality health care all people deserve, not just the care they can afford, has been the through line connecting Sr. Carol's vocation as a Daughter of Charity and her career as a nurse, hospital executive and leader of CHA.

"The Affordable Care Act could not have been enacted had it not been for the tenacity and generosity and grace and determination of Sr. Carol Keehan," said Nancy-Ann DeParle, who was President Barack Obama's chief architect of the ACA.

President Barack Obama meets with CHA President and Chief Executive Officer Sr. Carol Keehan, DC, and other hospital executives in the Roosevelt Room of the White House March 16, 2010, five days before the House voted to approve the Affordable Care Act and a week before it became law. Lloyd Dean, who was then president of the predecessor company to Dignity Health, and Nancy-Ann DeParle, Obama's chief architect of health reform, also are shown.
Pete Souza/Courtesy of Barack Obama Presidential Library

Sr. Carol's public support for health reform infuriated ACA opponents, including some influential conservative bishops who maintained the law would expand access to abortion and birth control. Critics amped up their attempts to demonize and marginalize her after the law's narrow passage — there were no Republican votes in favor in either chamber. She got death threats in her email in-box. ACA protestors mounted the altar at St. Aloysius Church in Washington and screamed insults as she delivered a commencement address to the Gonzaga College High School Class of 2010. (She would later joke that in the spirit of the commencement ceremony, it was one of the rare speeches where she did not focus on access to health care insurance.)

Rather than strike back at her critics, Sr. Carol continued to speak publicly about the dignity and economic security that health insurance expansion under the ACA would bring to vulnerable families.

Faith seeks understanding
"I think it is her deep faith, her deep prayer life and sense of humor that got her through those rough days following the passage of the ACA," said Ron Hamel, who was CHA's senior director of ethics at the time and now is president of SSM Health's public juridic person. "She is very courageous. She will stand her ground, but she will always do it respectfully."

Sr. Patricia Talone, RSM, a former CHA vice president of mission services, added, "Her work is about the health ministry of Christ and the church. Her cause is about people who are sick or poor, so she is unafraid to act."

At every CHA gathering, and on stages from the City Club of Cleveland to the World Economic Forum in Davos, Switzerland, Sr. Carol has framed access to health care as a human right and a moral imperative.

"What Carol said is what Carol believed," said Colleen Scanlon, executive vice president and chief advocacy officer of CommonSpirit Health. Scanlon chaired CHA when the ACA passed. "Good public policy was always first and foremost to her. Because of who she is, a woman of great integrity and faith, people listened," Scanlon said.

Sr. Carol urged Catholic health executives, some of whom were dubious about health reform, not to blame the poor for financial challenges in their institutions. "I had sympathy for the CEOs struggling to make budget, to give the staff what they deserved in benefits and wages, and have the right equipment, but it was not on par with the sympathy I had for the millions and millions of people — including children — who did not have health care. I knew firsthand the suffering of parents who could not afford health care for a sick child," Sr. Carol said.

Mike Slubowski, the outgoing chair of the CHA board, said he's been inspired by Sr. Carol's "unrelenting and unflappable commitment to ministry and to advancing the human condition for all people, regardless of means, race, religion or creed."

Leading through change
While working to bend public policy to serve the poor, Sr. Carol also was guiding the CHA membership through a time of significant change in the ministry. This included the founding religious congregations' accelerating transfer of sponsored works to lay sponsorship, governance and administration. Archbishop Joseph Augustine DiNoia, OP, adjunct secretary for the Vatican's Congregation for the Doctrine of the Faith, said he has been impressed with the effort that CHA and its members brought to the formation of lay sponsors and leaders to prepare them to fulfill this sacred trust.

"It was a massive transition in the way Catholic health care would be carried out in the U.S.; and, I would say, without exaggeration, that the role of Carol Keehan in this (preparation) was huge. Huge!" he said.

When a steady drumbeat of mergers, partnerships and affiliations among and between Catholic and other-than-Catholic parties led the United States Conference of Catholic Bishops to reexamine the theological implications of such pairings, Sr. Carol underscored that partnerships were essential to the viability of the Catholic health ministry in the marketplace.

Said Slubowski: "Sr. Carol's belief is that, first and foremost, anything that strengthens Catholic health care is a good thing."

Born on Capitol Hill
After the passage of the ACA, then-Senate Majority Leader Harry Reid, D-Nev., invited Sr. Carol and Sen. Bob Casey, D-Pa., to lunch in his private dining room. They were joined by members of Casey's and Sr. Carol's staff.

"Tell me about yourself," Reid said to Sr. Carol, "for instance, where were you born?"

"Right outside your window, senator," she replied, nodding in the direction of Providence Hospital in the Capitol Hill northeast neighborhood — a hospital she headed for 15 years before joining CHA.

Together with her older brother and younger sister, Sr. Carol grew up in southern Maryland in a family that read two to three daily newspapers — one of which she delivered as a teen. At age 21, with a nursing diploma from DePaul School of Nursing in Norfolk, Va., she entered the Daughters of Charity. By 25, she'd earned a Bachelor of Science in nursing from St. Joseph's College in Emmitsburg, Md., gained experience as an emergency room nurse and worked with pregnant women and young children.

She moved to Pensacola, Fla., to open the first Sacred Heart Children's Hospital as its head of nursing, development and advocacy. It was there she began to hone her knowledge of health care finance and develop her political chops.

Financing a children's hospital that provides care for every child, irrespective of a family's ability to pay, requires a reliance on philanthropy and state funding. Sr. Carol said she learned to advocate from physician leaders, lawyers and ethical politicians — people whom she said demonstrated integrity, competence, determination and humility in working to advance the pediatric hospital. "That's been helpful to me my whole life," she said.

She knew instinctively how to wield the moral weight of her cause to maximum impact and, when necessary, to marginalize those who put their personal agendas ahead of the common good. She acted without a whiff of sanctimony, although there was sometimes a glint of mirth in her tactics.

When she got wind that a group of Florida legislators had waited until she was on religious retreat out of state to divert money from a bill she had helped shape and champion, Sr. Carol left the Daughters of Charity retreat center in Emmitsburg, at 4 a.m., drove to D.C. and hopped a flight to Tallahassee, Fla.

The legislation would enable the state's first five neonatal intensive care units — including the Level 3 NICU she had helped set up at Sacred Heart — to offset the unreimbursed costs of providing care to sick babies. The group of legislators wanted to shift some of the money in the bill to train neonatologists. Sr. Carol looked them in the eye and told them to go elsewhere for funding.

With a wink towards Moses, editorial cartoonist Roger Schillerstrom's August 27, 2007, illustration for Modern Healthcare shows Sr. Carol carrying stone tablets down a mountain.

"I will help you with a medical education bill, but I will not let you do this," Sr. Carol told the men. "This is an end run and it's wrong." The NICU grant funding was preserved in its entirety.

People, process, culture
From Sacred Heart, Sr. Carol stairstepped to posts of increasing responsibility within the Daughters of Charity National Health System, which became a founding member of Ascension in 1999. She was vice president for nursing at Providence Hospital in D.C., and chief executive at Sacred Heart Hospital in Cumberland, Md., before returning to Providence Hospital as president and chief executive. Later she built Carroll Manor Nursing & Rehabilitation Center on the grounds of the hospital. She returned to Pensacola as chair of the Sacred Heart board of trustees before taking the top job at CHA.

In Washington, where Sr. Carol spent the bulk of her career, she reversed the failing fortunes of Providence Hospital and restored the enthusiasm of a demoralized staff. She got to know the hospital's cafeteria workers as well as the city's power brokers, once attending the State of the Union as a guest of First Lady Laura Bush. She served for a number of years on the USCCB's health care subcommittee and domestic council.

She established meaningful relationships and lasting connections. "She is very engaging and understands that change comes through people, process and culture," said Slubowski, who is president and chief operating officer of Trinity Health.

DeParle said that with Sr. Carol, relationships are personal, not transactional. "She enters the room, she radiates goodness, and you want to lift your game."

Listen and learn
Colleagues say Sr. Carol leads by listening, respecting people's expertise and giving employees a path to work to their highest capacity. Throughout her career, she's made it a practice to get to know her employees at all levels of the organization.

"There is something so human and authentic about her as a leader," Slubowski said. "People like to be around her, like to talk with her. She can take the job seriously, but not take herself seriously. People follow her because they see this is a vocation, not a job to her."

Sr. Carol, right, often traveled to visit CHA members. In this June 2016 photo she poses on a dock in Southeast Alaska with Sr. Andrea C. Nenzel, CSJP, now vice chair of the board of PeaceHealth. The women were in Alaska to attend the opening of an expansion of PeaceHealth Ketchikan Medical Center on Revillagigedo Island.

"I love the people in health care," Sr. Carol said. "It's not an effort for me to want to talk to people about the work they are doing and how they are doing it. People really do care about the work they do unless you drive the caring out of their hearts by the way you treat them, or the impossible obstacles you put in their way.

"I've been a nurse's aide, a staff nurse. You see what it means if the people in central supply get their job done, if the computer works, if the emergency generator works, you get an appreciation."

Sr. Carol's penchant for personal connection translates into relentless travel. By rough calculation, she will have logged more than 70,000 miles in the first six months of this year — the equivalent of nearly three times around the globe.

When she joined CHA almost 14 years ago, she went on a listening tour to get to know members and their priorities. "After that, I was going back to visit friends," she said. "I get energized from those visits." The visits kept her connected to members' needs and priorities.

Scanlon said Sr. Carol is a consensus builder. "Carol knows advocacy is a collaborative venture. Usually you don't have great success alone. Our voices when multiplied are the true influencer. Being able to bring others along with us and truly partner is really essential," Scanlon said.

Pro-life stance
Casey, a pro-life Democrat, got to know Sr. Carol in 2009. He said Sr. Carol and CHA's advocacy staff were a resource to him and other senators during complicated negotiations over components of the evolving health reform legislation. "Whether it was making sure the Hyde Amendment (barring the use of federal funds to pay for abortion) would continue and be in place for (insurance) exchanges or making sure we had additional provisions in place to support pregnant women," Sr. Carol and CHA staff lent expertise, he said.

Sr. Carol leaves the altar at the Basilica of the National Shrine of the Immaculate Conception in Washington, D.C., where CHA members commemorated the association's 100th anniversary with a Mass on June 7, 2015. © CHA

Casey said one faction of Democrats was trying to move health reform legislation in a pro-choice direction while a group of ACA opponents was trying to derail the legislation by claiming it expanded abortion access. Sr. Carol and CHA's efforts ensured the final bill was abortion neutral, meaning it would not expand federal funding for abortion. "She had a real commitment to her faith and making sure we didn't move the needle, so to speak, on the issue of abortion," Casey said.

Sr. Carol and CHA's Lisa Smith and Michael Rodgers called on pro-life Catholic Democrats in the House who were alarmed by the USCCB's charge that the ACA would expand access to abortion. (Smith became CHA's vice president of advocacy and public policy when Rodgers retired in January as CHA's senior vice president of public policy and advocacy.) Sr. Carol explained to the representatives how CHA's legal experts came to the opposite conclusion as the USCCB staff: there was language in the bill, an executive order and a congressional colloquy that all established congressional intent to not expand federal funding for abortion through the ACA.

"I never saw it as an act of defiance against the bishops," Sr. Carol said recently of her ACA advocacy. But some people interpreted it that way. "They had their opinion and we had ours. We have a conscience as well. We see the suffering of people without health insurance."

With patience and intentionality, Sr. Carol set out to repair the public rift with the USCCB and relations between the two groups have gradually gotten back on an even keel. In recent years, the USCCB has opposed efforts to repeal the ACA in the absence of replacement legislation that would establish viable protections for "real families who need and deserve health care." Hamel said a new pope, along with new leadership and staff turnover at the bishops' conference built a foundation for improved relations.

Critical boost
At a crucial moment in the run-up to the 2010 House vote on the ACA, Sr. Carol wrote a column for this newspaper recognizing "a historic opportunity to make great improvements in the lives of so many Americans."

The column, posted on the CHA website, heartened a White House that was then about 20 votes shy of a win in the House. (The Senate already had passed the bill.)

Sr. Carol's support turned the tide, DeParle said. "This was someone people trusted as a leader saying it was time to stand up. It just gave me and the president so much of a lift and so much heart to know we weren't the only ones standing there. As a result of her having the courage … there was this organic thing that happened. We saw other hospital associations step up."

NETWORK, a Catholic social justice lobby, sent an open letter to Congress signed by 50 leaders of congregations and communities of women religious. "This is the REAL pro-life stance, and we as Catholics are all for it," the authors said of ACA provisions that would protect people with preexisting conditions from being denied insurance and would substantially expand health care access for pregnant women and children.

"It almost brought me to tears," DeParle said of the letter.

Guarding a treasure
Earlier this year, as Sr. Carol began winding down her tenure at CHA, she spoke at a meeting of health care sponsors and a meeting of system mission executives. At both events, she acknowledged challenges facing the Catholic health ministry including the possibility that a federal appeals court will vacate the ACA, ongoing threats to Medicaid and Medicare funding, the perils of "skinny" health insurance plans that are thin on coverage, and the pressure from new competitors seeking to channel money from profitable services away from health systems that rely on that money to fund essential, but unprofitable service lines.

She asked this question at the end of her comments at each of the meetings: "Do you believe the best days of Catholic health care are ahead of us or behind us?"

And how would she answer that question?

"We need to have stronger, more empowered mission leaders. And the people in sponsorship, governance and executive management need to model mission," she said. "We need to make sure that people value the Catholic part of Catholic health care. I think we need to make that resurgence happen. We must make this happen. We need people to say we are guarding a treasure."

Sr. Carol brought nursing values into health care administration policy

This circa 1970 photo shows Sr. Carol and Dr. Reed Bell at Sacred Heart Children's Hospital in Pensacola, Fla., where she was the supervisor over nursing, advocacy and philanthropy and he was medical director.

Right out of the gate, an 18-year-old Carol Keehan knew she'd made the right decision by enrolling in nursing school. "I was totally and completely hooked on nursing and health care," she said. "Sometimes you just know this is it. This fits. This works. I have loved nursing ever since."

With her nursing diploma in hand, she joined the Daughters of Charity, a congregation that is committed to bettering the lot of the poor. One of her earliest nursing jobs was in the emergency room and it was a great fit for the energetic, extroverted young nurse. "I liked the fact that you spend all your time nursing," she said of the ER. "You are there at critical moments in people's lives."

She earned a bachelor's degree in nursing and became the first supervisor of the Sacred Heart Children's Hospital in Pensacola, Fla. She connected with patients and their families just as she had when nursing at the bedside.

She tells the story of a patient who pegged her as a soft touch. The child had been hospitalized multiple times for complications of diabetes and she knew Sr. Carol.

Sr. Carol with a patient.

Once the girl was admitted in the middle of the night; she was asleep when Sr. Carol made morning rounds. When the unit manager came to check on the girl, the child told her, "If Sr. Carol knew I was here, she would want me to have a doll." The unit manager came back with a doll.

Sr. Carol's heart for the poor and her vantage point as a nurse administrator fueled ideas about how the hospital could do more to provide services to families on the health care margins. But, Sr. Carol said, her ideas frequently got shut down by those who controlled the hospital's spending.

"They would start to use all the jargon of health care finance: nice but not reasonable, nice but not affordable." To defend her proposals and get to yes, Sr. Carol took accounting and statistics courses and she went on to earn a master's degree in health care finance.

"I never wanted to do finance," she said. "It doesn't appeal to me, but what does appeal is making it possible to give people the care they need in a setting that enhances their human dignity, and to be in control of that."

Michael Rodgers, CHA's former senior vice president of public policy and advocacy, said nursing has given Sr. Carol a window into the issues underlying health care disparities. "Along the way, she saw very practically the kinds of things that needed to improve in our health system," he said. "It wasn't like she was some outsider, she saw it firsthand."

Today, Sr. Carol is a member of the prestigious National Academy of Medicine (formerly the Institute of Medicine). She holds 11 honorary doctorates and the Pro Ecclesia et Pontiface Cross, a decoration of honor for distinguished service to the Vatican. But it's her nursing credential that defines her.

"I want to be a nurse," she said. "I'm proud to be a nurse. It's important to me to be able to say I still have a license."

— JUDITH VANDEWATER