UPDATE, February 1, 2019: On Friday, Catholic Health Initiatives and Dignity Health finalized their merger. All but one of Dignity’s non-Catholic hospitals will operate under a separate system that will allow them to provide reproductive care forbidden under the Catholic directives.

California regulators laid out a series of requirements to protect reproductive health care in the state before approving the creation of the largest Catholic health system in the United States on the day before Thanksgiving.

The move puts Catholic Health Initiatives (CHI) and Dignity Health on track to merge by the end of the year into the nation’s largest nonprofit health system, CommonSpirit Health, with 140 hospitals and more than 700 care sites across 21 states, including 31 hospitals in California alone.

As a condition of its approval, the California Attorney General’s Office will require CommonSpirit to maintain current levels of reproductive health and emergency care for five years. For an additional five years, the company must inform the office if it plans to reduce such services so regulators can assess the community impact.

Reproductive and gender-affirming services are already curtailed at these facilities nationwide. CHI and some Dignity hospitals follow Catholic directives that restrict abortion, contraception, sterilization, fertility treatments, and end-of-life care. Other Dignity facilities follow a less stringent statement of common values that bans abortion, in vitro fertilization, and end-of-life care, but says nothing about sterilization and contraception.

These differences could make it hard for regulators to track a decrease in services.

“We do know that it’s an uneven playing field; these things vary hospital to hospital and often vary patient to patient,” Ruth Dawson, staff attorney at the ACLU of Southern California, told Rewire.News. The organization sued Dignity in 2015 after a hospital in Redding cited religion to deny Rebecca Chamorro’s request for a tubal ligation immediately after her cesarean section. The ACLU sued Dignity again after its hospital in Carmichael canceled transgender man Evan Minton’s hysterectomy—although Minton’s doctor had performed hysterectomies there on women.

Dignity and CHI have different records when it comes to LGBTQ equality. Two Dignity hospitals in California received marks of 95 and 100 out of 100 for their treatment of LGBTQ patients and workers in the Human Rights Campaign’s 2018 Healthcare Equality Index. The two CHI facilities in Colorado that were rated, by contrast, received ten out of 100 points. California’s approval of the merger includes a requirement for written policies to prevent discrimination against LGBTQ people—but says nothing about cases like Minton’s, where such discrimination takes place under the guise of religion.

“We would love to have seen something that was even more proactive than what we have now,” Amanda McAllister-Wallner, director of the California LGBTQ Health and Human Services Network, told Rewire.News.

Yet some reproductive health advocates hailed California for vetting the merger extensively, holding 17 public hearings across the state.

“We need to see more rigorous oversight of proposed hospital consolidation in other states to prevent the loss of care that women and families need,” said Lois Uttley, founder of MergerWatch.

The conditions of the merger include what the attorney general’s office called “the largest commitment by a system to serving Medi-Cal beneficiaries and charity care in state history.” The hospitals must offer a 100 percent discount on care to patients who make up to 250 percent of the federal poverty limit and publicize these financial assistance programs with postings in its facilities and through relationships with organizations including community clinics and houses of worship. The health system will provide $20 million over six years to support housing and other services for homeless patients.

“Creating this kind of dedicated fund to help move people into stable housing—I think it’s pretty innovative,” Jen Flory, policy advocate at the Western Center on Law and Poverty in Sacramento, told Rewire.News.

Perhaps the greatest outstanding question about the merger is how the national health-care landscape will be shaped by the sheer size and influence of CommonSpirit Health. In a 2016 press release announcing the merger, the companies said the deal would “strengthen Catholic health care.” CHI CEO Kevin Lofton added that it would “allow us to play a far more significant role in transforming health care in this country.”

CommonSpirit will have almost unparalleled political and market influence to impose its ideological restrictions both within and beyond the doors of its own hospitals. While California regulators have moved to curb this influence, the Trump administration—which has tried to expand the ability of religious objectors to discriminate against patients—is unlikely to follow suit.