Patient advocates in the Twin Cities are worried about access to a variety of health care services, including abortion and transgender care, and inpatient mental health treatment, if a megamerger proceeds between the Sanford and Fairview health systems.

Access was a recurring theme Tuesday night at a public meeting convened by Minnesota Attorney General Keith Ellison — the first of four scheduled to gather public input on the proposed combination.

In an interview after the meeting in St. Paul, Ellison said he understood the Sanford-Fairview merger could be concluded by the end of March. The attorney general wants his office's review of how the deal would affect health care competition, as well as charitable assets, to be completed shortly after the public meetings end on Jan. 31.

"There are a lot of important questions that were raised, ... and they're calling for answers," he said.

Several speakers expressed wariness over Fairview Health Services — a large Minnesota health care provider — being run from South Dakota by Sanford Health, with some pointing to examples of how the state has approached politically sensitive health care questions. One speaker raised the example of a former Sanford CEO who retired amid controversy after saying he didn't need to wear a mask to prevent the spread of COVID-19.

But Fairview Chief Executive James Hereford pushed back against the idea that Sanford is an outsider since the health system already runs 20 hospitals and 70 clinics in Minnesota.

"The reality is that Sanford has provided high-quality care to Minnesotans for nearly two decades," Hereford said during the meeting.

In November, Sioux Falls-based Sanford and Minneapolis-based Fairview proposed merging to create a health system with some 78,000 employees. The combined organization would be based in South Dakota and operate more than 50 hospitals, including the University of Minnesota Medical Center.

Fairview has owned the U's teaching hospital since 1997. The health system and university physicians jointly market health care services under the brand M Health Fairview.

Dr. Cresta Wedel Jones, an M Health physician who handles high-risk pregnancies, said during Tuesday's meeting that she handles cases where pregnancies do not go as expected. Her patients sometimes need abortions that can't be provided in a clinic.

Wedel Jones said those patients can safely be cared for within Fairview, but she is worried about the future with Sanford.

"I am concerned that we have not gotten a formalized commitment from the Sanford leadership that they will support access to abortion within the Fairview-Sanford system to the ability that is allowed in the state of Minnesota," Wedel Jones said.

"I am worried that if we don't have a formalized commitment, we will lose or have it chipped away ... here in this state, and that will compromise my patients' care."

For many years, Fairview has demonstrated an extensive commitment to providing world-class gender-affirming care for transgender patients, said Phil Duran, a patient advocate with St. Paul-based Rainbow Health. His group, however, has not found evidence that Sanford provides those same health care services to patients.

Fairview was founded by the Lutheran church, but now talks about its secular mission, he said. The mission and values at Sanford, by contrast, are described in "sectarian" terms.

"I am not here to criticize anybody who provides health care based on their faith," Duran said. "But as a lawyer, I know that some individuals and institutions have used religious beliefs as the basis for denying access to care, particularly for LGBTQ patients. The strongest objections tend to be providing and covering gender-affirming care — exactly the areas where Sanford's current practices leave us most concerned."

In December, Sanford said in a statement to the Star Tribune that it had "no plans to change Fairview's abortion care policies as a result of this merger." The statement noted that Sanford physicians "provide medically necessary abortion care in accordance with the applicable state and federal laws where we operate."

Hereford, the Fairview CEO, said at the meeting that the organization believes "strongly in providing evidence-based health care to all of our patients, including gender-affirming care and comprehensive reproductive health care. Protecting this access ... will not change."

Fairview was the first health system in Minnesota, Hereford said, to introduce a new type of care for mental health patients called EmPATH units. They are designed to provide better treatment and management of mental health crises than is possible in emergency rooms.

But adding the unit at Fairview Southdale Hospital in Edina followed the closure of inpatient mental health beds, said Sue Abderholden, executive director of NAMI Minnesota.

"Our main concern is their commitment, or lack of it, to provide quality mental health services in order to meet the increased needs of our state," Abderholden said at Tuesday's meeting. "The last merger that Fairview did with HealthEast resulted in decreased access to inpatient mental health services."

Jessica Rosenberg, a cardiac intensive care nurse at the U's Masonic Children's Hospital, said she has been concerned over the years to see South Dakota patients traveling hours to the Twin Cities for routine care and procedures that she believes should be available close to home.

What's more, Rosenberg said, she was troubled to read news accounts in December about South Dakota Gov. Kristi Noem terminating a state contract for a transgender advocacy group.

"Sanford receives millions of dollars from the state of South Dakota," Rosenberg said. "I am concerned that if she threatens that funding, that Minnesotans and the care that we receive will be affected by her decisions. And as a citizen of the state of Minnesota, I do not have any ability to vote and affect her decisions."

Sanford has made large investments over the years to expand and improve health care services in its merger markets, Bill Gassen, the Sanford CEO, said at Tuesday's meeting.

When Sanford took over a health system in Bemidji, it invested more than $100 million, Gassen said, to increase access to care including mental health, cardiology, orthopedics and oncology. After a merger with a Fargo health system that treats patients from the cross-border town of Moorhead, Minn., Sanford invested more than $1 billion, he said, to bring the community a level one trauma center among other improvements.

"There are many ways our combined system can do more for more people in Minnesota and build on this state's outstanding legacy of national excellence in health care," Gassen said. "When we say that patients will have access to better care, we mean it."

The University of Minnesota has voiced concerns about what the merger might mean for its medical education, research and patient care mission, since Fairview facilities in Minneapolis are central to that. On Tuesday, Gassen floated the idea that if the U opposes the merger, it could repurchase its hospital from the health system.

However, medical school dean Dr. Jakub Tolar suggested it's not that simple.

"The issue is: How does Minnesota ensure that the charitable assets of nonprofit Fairview remain devoted to the academic medical mission of the university," Tolar said during the meeting.