Two days before the GOP legislation was set for an initial vote in Congress – delayed due to last-minute wrangling and efforts to gain support – she described the bill as a disgrace, a pro-life disaster, a huge step back, catastrophic for Catholic social teaching and something that would do incredible damage.

The woman religious, who heads an organization of more than 600 hospitals and 1,400 long-term care and other health facilities in the United States, has a vested interest in the nation's health care and she also knows the ins and outs of health care legislation from working behind the scenes "forever" – as she describes it – on the Affordable Care Act.

At the time that the ACA was being drafted, some Catholic organizations opposed key elements of the measure. Once it became law, more than 40 lawsuits were filed to challenge the subsequent Department of Health and Human Service's mandate requiring that insurance plans include coverage for artificial birth control, sterilization and drugs that lead to abortions.

Sister Keehan is quick to point out that the health care legislation signed into law seven years ago is far from perfect, but she says it was an "incredible step forward."

"I do recognize the political conflict and the imperfections in the bill, but when you can make insurance that much better for people who have it and give 20 million Americans insurance, that is a huge step forward," she told Catholic News Service March 21 in her Washington office.

At a 2015 Catholic Health Association gathering in Washington, President Barack Obama thanked Sister Keehan for her steadiness, strength and "steadfast voice."

"We would not have gotten the Affordable Care Act done had it not been for her," he said.

The immediate repeal and replacement of the ACA was a key promise of President Donald Trump's campaign, but the GOP health care measure has faced opposition from both conservative and moderate Republicans. Trump told House Republicans that he will leave ACA in place and move on to tax reform if they do not support the new health care legislation.

Watching the GOP efforts to repeal and replace the ACA has been hard for Sister Keehan mainly because she and other health care leaders were not consulted in the process.

"We should never, ever throw together a bill that's going to be such a profound impact on the people of this country in this short of time and without any input from those who care for them," she said.

The work on these two health care bills couldn't have been more different, she pointed out, noting that prior to the ACA launch she felt like she "lived in committee rooms" because she was constantly meeting with committees, groups and subgroups at the White House and Congress.

With the GOP health care plan, she said there wasn't any opportunity for hospital groups or the American Medical Association to give any advice.

"We've just been dismissed," she said, noting that she attended a few small group meetings on Capitol Hill but "they were not meetings to get our input on what ought to be done with the bill but meetings to tell us what was going to be done."

"This has just been railroaded through Congress," she added.

While the U.S. bishops have applauded pro-life elements of the American Health Care Act, they also have criticized other elements and expressed concern for its impact on the disadvantaged.

In a March 17 letter to House members about the GOP measure, Bishop Frank J. Dewane of Venice, Florida, chairman of the bishops' Committee on Domestic Justice and Human Development, said the inclusion of "critical life protections" in the House health care bill is laudable, but other provisions, including those related to Medicaid and tax credits are "troubling" and "must be addressed."

He said the bill's restriction of funds to providers that promote abortion and prohibiting federal funding for abortion or the purchase of plans that provide abortion "honors a key moral requirement for our nation's health care policy." But he also criticized the absence of "any changes" from the current law regarding conscience protections against mandates to provide certain coverage or services considered morally objectionable by employers and health care providers.

"The ACA is, by no means, a perfect law," Bishop Dewane said. "The Catholic bishops of the United States registered serious objections at the time of its passage. However, in attempting to improve the deficiencies of the ACA, health care policy ought not create other unacceptable problems, particularly for those who struggle on the margins of our society."

Main provisions of the new House bill include: eliminating the mandate that most individuals have health insurance and putting in its place a new system of tax credits; expanding Health Savings Accounts; repealing Medicaid expansion and transitioning to a "per capita allotment"; and prohibiting health insurers from denying coverage or charging more money to patients based on pre-existing conditions.

Sister Keehan said she thanked Bishop Dewane for his letter to Congress and said the bishops had carefully gone through the legislation measure by measure on a number of issues. She also noted that she knows people in the pro-life community either think the new bill is strong enough or not doing enough.

As she sees it, the bill is "a pro-life disaster in the fact that when you take health care away from people, you take life."

"If you want to really, really strengthen the pro-life culture in this country, you make sure people know that their lives and the lives of their children are so valued by our country," she said, which means providing quality maternity and pediatric care and offering programs like Head Start and food stamps.

Although she said under the ACA no federal funds could be spent on abortion, a nonpartisan government agency in an assessment of the law in 2014 said abortion coverage was available in some plans. Sister Keehan also said the law included help for pregnant mothers to get drug rehabilitation, housing and maternity care, which are not included in the new bill.

"I don't find this a pro-life bill at all from every perspective," she added about the new measure.

When asked if there was a silver lining with people at least talking about the need to provide insurance for all Americans, Sister Keehan said the health care crisis for so many people doesn't give "the luxury of time."

"To be the only industrialized nation in the world that does not guarantee all its citizens health care is a disgrace," she said, adding: "We are at a real crossroads in our country's sense of its responsibility to its people."