Cover Story

Critical Condition

by Nathan Stubbs

After hurricanes Katrina and Rita, the state has an even higher percentage of residents living without health insurance and less money to help cover them. The looming crisis could force Louisiana to rethink public health care.

In more than 20 years as a clinical psychiatrist and adjunct professor with Minnesota's Mayo Clinic, Donald McAlpine has seen all types of mental ailments. But he wasn't sure what to expect when he came to Lafayette to assist with medical relief following Hurricane Katrina.

"All of the patients' problems have just been exacerbated [by the storm]," he says on a recent day at the Parish Health Unit on Willow Street. "I had a schizophrenic patient who was off her meds. I saw a fella whose Zoloft got washed off with the hurricane, and he had been without medical records. I talked to the next patient, and he said his hospital is gone. Problems were being treated, and then the hurricane intercedes. Now people are cut off from their health care ' they're either living two hours away, or their clinic has been destroyed."

Most of the patients that McAlpine first treated came to the clinic due to physical illness. They were then referred back to him for depression, sleep deprivation or other mental conditions.

Evacuees in areas like Acadiana and Baton Rouge have brought with them a whole new set of medical challenges for the area. Thousands of evacuees in need of their doctors, medications and medical records don't have their usual options. Many were already uninsured or on Medicaid and relied on the state's charity hospital system ' a system now facing a financial crisis. Thousands of other evacuees are now unemployed, without their previous employer-sponsored insurance and struggling to afford health care. The federal government hasn't approved financing medical care for evacuees beyond initial emergency rescue operations, though several bills are still pending in Congress.

And the state government, faced with a growing deficit estimated to eclipse $1 billion, is preparing to cut some 115,000 residents from Medicaid benefits. All told, the state could be facing nearly a 40 percent spike in its uninsured population.

Dr. Kip Schumacher, CEO of the Lafayette-based Schumacher Group, which provides medical staffing to approximately 20 facilities in the state, says the full effects of the hurricanes haven't been felt in the health care industry.

"This put us in a position," he says, "where I don't think the state can possibly end up providing the kind of services that they need to provide for its population under the circumstances. Not only are a lot of people out of work now and on Medicaid, but there's no way that the state can end up paying the kind of dollars that are necessary to run the program unless we dramatically cut enrollment. Which means that in the state that had one of the highest infant mortalities and the state that had probably the poorest health care in the country, we're going to have even less dollars now to cover more patients with."

Despite the dire forecast, a growing number of reform-minded physicians and lawmakers say this situation could finally force Louisiana to rethink the way it provides public health care. "Obviously the storm verified the weaknesses in our health care system," says Michael Oler, a Lake Charles family practitioner who has studied the state's public health system for the Calcasieu Parish Medical Society. "We need to take this crisis and evolve toward a futuristic system that can handle these kind of problems and our day-to-day management of care. There's some very progressive thinkers in Louisiana, and the state is ripe for transformation and for reform."

The majority of uninsured and low-income patients in Louisiana get care from the state's charity hospital system, which is run by LSU and largely staffed with its medical school faculty, residents and students.

Set up by former Gov. Huey Long in the 1930s, the charity hospital system serves as a safety net provider for indigent patients. It also provides a medical training program for thousands of physicians, using medical trainers and residents as a means of offering low-cost, high-quality care to residents. In recent years, however, the system has been plagued by budget woes, and the medical community has frequently complained of inequities in the system.

Now the state's two biggest charity hospitals, New Orleans' Big Charity and University Hospital, are closed and deemed beyond repair due to damage from Hurricane Katrina. As a result, a growing number of uninsured patients are flooding into both public and private hospitals in south Louisiana and creating a strain on facilities in Baton Rouge and Lafayette.

With the drastically changed landscape, the state's public health care system is bound for changes. LSU has already announced its intentions to rebuild its charity hospitals under a new model that would feature two new state-of-the-art facilities in both Baton Rouge and New Orleans, at a cost of about $1.5 billion. (LSU is also requesting $500,000 to help keep its other charity hospitals like UMC afloat.) The proposed new medical centers would be smaller than the 600-bed Big Charity, and include satellite clinics in hopes of getting more patients access to primary and preventive care.

The idea of spreading health care out to more sites is in line with what many health care professionals see as a growing need to create more access and preventive care for patients. In addition, it gives patients another option in the event of a disaster where some facilities may shut down.

Oler says before the state or federal government rushes into building new multimillion-dollar hospitals, it should first consider a system that gives patients more option and control. Instead of reimbursing hospitals for taking in uninsured patients, he suggests the state set up an account for every patient that qualifies for publicly assisted health coverage. These patients could then access their accounts electronically and use them at any public or private hospital.

"The state is invested in bricks and mortar," says Oler, "like at Big Charity hospital. Now, Big Charity is down. Moss Regional is down. And there needs to be some way that the patients that need care can get the care in the private community."

Mandeville state Sen. Tom Schedler, a longstanding member and former chair of the state Senate's Health and Welfare Committee, has been pushing for a more privatized system for years. He's encountered heavy resistance at the state level.

"I think that [LSU] has been very closed-shop and parochial in their thinking, and they want to protect everything in their system," Schedler says. "They will not open up to any new concepts or ideas that incorporates anyone else. They want to keep it all inside of and controlled by LSU."

However, Schedler adds, "I do think there is a growing number of legislators, as well as the general population, that are starting to question the need to just go rebuild something exactly like we had it before."

Schedler has been a proponent of wresting control of the charity system from LSU and placing each public hospital in the hands of regional boards that could make decisions about how to dedicate resources on a more local level. A Lafayette regional task force formed to look at ways of addressing its indigent care population also strongly endorsed the initiative.

"The problem is not UMC; it's with the state," says outgoing Lafayette Parish Medical Society President Roderick Clark. "It's the system that's the problem, and until the government or the Legislature or the people of the state decide to make the charity system better, it's not going to change. Doctors in this state are a minority. We did our best, but we just ran into a wall."

Many of the reforms that have been discussed are far from radical ideas, says Schedler, and would align the state closer to the national model of public health care.

"We operate a system vastly different from anyone else in the country," he says. "It was an ingenious thing when it was done by Huey Long, but it was done prior to Medicaid and Medicare. Once Medicaid and Medicare came on stream to the American public, the need for a system similar to ours tremendously was reduced, but yet we continued on with it for decades."

"When you have federal food stamps," he continues, "They don't tell you that you can only go to A&Ps and shop. You can go to any store that accepts food stamps and pretty much all of them do. So, think about how we do health care in Louisiana. We said look if you're an indigent patient you have to go or should go here. Nobody else can play in the game."

With Medicare and Medicaid, Schedler notes that public funds have already gone into the private sector. He says he still supports public hospitals, but that they need to be scaled down, and patients should be allowed to choose where they go to receive critical operations and tests.

"There's a movement to put closure to this quickly," he says, "and get [the charity hospital system] rebuilt before anyone can study it for obvious reasons. I don't think they want it to be studied that closely, for fear of what's going to be unearthed. There's a tremendous amount of waste in the system. We're over-bedded. We're over personnel. I think we're over everything. It can be done more efficiently inside the system that we have."

Health care reform has been on the state's agenda for the past decade, though proposed changes rarely come to pass, frustrating many health care professionals. Last year, after Gov. Blanco's highly touted health care summit brought about a laundry list of reform proposals, few actual changes were implemented.

"[Gov. Blanco] promised to have a summit. She had a summit, and that's been about the extent of it," says Oler, who participated in the summit with a regional Lake Charles coalition.

"As far as I know, none of the initiatives for health care have come to any fruition," says Dr. Fayez Shameih, who served as the chairman for the group. "The process has been very slow. And now with all this mess, I don't know that they're looking at health care issues right now. They're looking at the economy. They're putting health care on the back burner. I think this is the paramount responsibility for all of us. I think if we continue to be slow to act, we're going to have more problems. Without a healthy community, you can't rebuild."

However, at DHH, several new health care proposals have been in the works for several years, most of which are aimed at assisting more people with getting insurance. Under a new Health Insurance Flexibility Act waiver that the state has pending before the federal government, Louisiana hopes to reduce its uninsured rate by up to 5 percent.

The plan is to use some of the state's federal Medicaid funds to assist employers in providing insurance coverage. It would also give parish and regional governments the option of matching federal funds to expand public health care facilities. However, the state still lists funding current programs, such as the charity hospital system, as its first priority. How much, if any, funding will be available for new programs is unknown.

With fewer resources to cover more people, Schedler says the state may have no choice but to find more creative solutions.

"Truly the events of the past 60 days are unfortunate," he says. "But I do think that they will lend themselves to reform occurring quicker than it would ever have happened under the normal process of legislative time. That doesn't mean that there won't be some bloodshed and some gnashing of teeth, but the cuts necessary to pull us through this particular issue in some areas are going to be so devastating that it's just going to force some reform or change."

Even before hurricane Katrina, the state's health care system was under duress, largely from the effects of having such a poor, unhealthy population.

In its 2004 ratings, The United Health Foundation ranked Louisiana's population as the unhealthiest of all 50 states. According to the Kaiser Foundation, which tracks Medicaid coverage, 40 percent of the state's population either went without health insurance at all last year or relied on Medicaid, the federal and state matching program that provides health benefits for poor families, children and disabled citizens. The Kaiser Foundation noted that almost two-thirds of Louisiana's Medicaid enrollees ' more than 650,000 low-income elderly, disabled and parents with children ' lived in the parishes impacted by Hurricane Katrina.

After the hurricanes, state workers staffed shelters to help evacuees receive Medicaid assistance. The federal government has mandated all health benefit relief for hurricane victims should come through Medicaid, but many evacuees don't qualify, despite being homeless and unemployed.

"Basically, what we're seeing," says Kent Faulk, a Lafayette Medicaid program specialist, "is a lot of applications from adults who had insurance and lost their job during the hurricane, and we just don't have a program to administer to them."

According to the Department of Health and Hospitals, 8,364 new households applied to sign up for Medicaid following Hurricane Katrina. Of these, 34 percent received some form of Medicaid benefit. In the Acadiana region, 945 new households requested Medicaid, with 36 percent resulting in at least one family member qualifying.

Louisiana runs a bare bones Medicaid program that allows the state to draw a higher percentage of federal matching funds. Childless adults without disability between the ages of 19 and 64 never qualify. Those with children must be extremely poor. Many states' Medicaid programs cover entire families with incomes up to double the federal poverty level. Louisiana's Medicaid program only covers adults in families with incomes up to 13 percent of the poverty level. For a family of four, this translates to an annual income of $19,350.

The state says that it does not have the money to cover its existing Medicaid budget (which was looking at a $750 million deficit before Katrina), much less expand coverage.

Meanwhile, Congress and the Bush administration, currently engaged in planning long-term cuts to the federal Medicaid budget, have vacillated on how much they are willing and able to expand the program for evacuees.

"You've ventured into a whole brand new class of eligibles," Faulk says. "What's happening is if you approve [an expansion], you're setting a precedent for disasters in the future, and when it comes to precedents, Congress does not like to set up new programs considering the dollar amounts. Every time there's a natural disaster, this program would go into effect, and cost-wise this could cause a strain on the system."

Schumacher says it is disheartening that federal legislation aimed at providing health care aid to hurricane victims has stalled. "I feel like the feds just really abandoned us in a time when we really had a need," he says. "They just turned their back on us, quite frankly."

During a national health conference last month, DHH undersecretary Ruth Kennedy of the state's Medicaid program told the panel, "Time is of the essence. Each day that passes without us knowing and other states knowing exactly what the Medicaid relief package is going to include is adversely affecting not only our state and the evacuees but other states who are getting the evacuees. We're concerned about the continued loss of jobs and income and the economic fallout which we believe is going to be major here."

Kennedy expects the Medicaid program will absorb about a quarter of all cuts now being made in the state budget to balance its loss in tax revenue related to the hurricanes. After federal matching funds are taken into account, the program is looking to take a $1 billion hit.

Kennedy says that all Medicaid beneficiaries who are not mandated for coverage by the federal government are expected to be cut. This list of about 115,000 beneficiaries includes 108,000 children on the state's LACHIP program; 2,500 pregnant women between 133 and 200 percent of the poverty level; 600 people with breast and cervical cancer; 700 on the ticket to work program; and 2,500 medically needy patients.

Lafayette Parish's Health Unit in the Clifton Chenier Center is typically set up for low-cost screenings, immunizations and services for special needs children. But for the past six weeks, it has doubled as a free full-service general clinic for hurricane victims. The clinic's volunteer staff has given shots and immunizations, written prescriptions, monitored patients' blood pressures and even offered psychiatric evaluations.

The clinic was set up by the Office of Public Health and a volunteer group called "Operation Minnesota Lifeline" to help Lafayette cope with an unprecedented influx of patients into the local public health care system. Public Health Unit Director Tina Stefanski would only say that visitors to the PHU had doubled since the opening of the general practice clinic for evacuees, declining to give specific numbers.

At UMC, approximately 30 beds have now been brought back for inpatient treatment since Hurricane Katrina. UMC has long operated under capacity, having to scale down its services and capabilities over the years due to state budget cuts. The hospital is now reportedly up to about 130 inpatient beds, with a goal of reaching a maximum capacity of 165.

The hospital has regained its orthopedics and ENT services and residency programs that it had lost a few years ago, and LSU has also relocated its ophthalmology program here.

The moves are encouraging to local city-parish officials, who are scrambling to assist LSU in finding housing for the new staff because of the potential to be a long-term boon for the local health care industry.

"Lafayette really has a good chance of improving the scope and capacity of its services at UMC," says Dr. Andy Blalock, president of the Lafayette Parish Medical Society. "And what we're hoping will result from this is that UMC will have physicians and services here it's never had."

Officials at UMC did not return numerous calls for comment, but two members of the Minnesota Lifeline team who met with UMC physicians said they were told that UMC has had a 40 percent increase in its inpatient services and a doubling of outpatient services.

To ensure that UMC does not get overwhelmed, Blalock says it's critical to keep the general and preventive public health care services at the parish health unit running.

"The big issue in America right now is access to health care," he says. "They're giving people access. They're giving people health care who can't afford health care insurance and can't get into UMC."

The teams from Minnesota have made primary, preventive care for stressed evacuees a focus. They have made regular trips throughout Acadiana to clinics, shelters, and hotels to offer immunizations and check on evacuees. Over the past two months, they have given more than 17,000 immunizations and 4,500 medical evaluations. However, as of last Friday, the group wrapped up its mission, and its last team packed up and returned home to Minnesota.

Late last week, Stefanski was still negotiating with the U.S. Public Health Service to bring in more physicians to keep the clinic running. Because volunteer aid will eventually expire, Blalock is trying to negotiate with LSU to set up a permanent clinic at the site with medical residents.

"If we do this right, this could end up being a model program for the rest of the state," Blalock says. "The great limiting factor so far has been we do not have faculty enrolled to keep these residents working in a supervised manner."

Steve Jorgensen, one of the managers of Operation Minnesota Lifeline, says his group is planning on continuing to support the Office of Public Health in keeping its needs met, especially given the current strain on the system.

"UMC has done a great job to keep providing services and keep supporting the community," he says. "If our hospital was running at 100 percent and then we went to 140 percent for 60 days in a row and our outpatient clinics doubled in their volume, which happened at UMC, we'd be hurting. Somehow that group's been able to hold it together to keep providing services in a demand that would cripple most hospitals. I was impressed."

With public facilities like UMC at full capacity, both the private and non-profit hospital sectors are overflowing with patients with little ability to pay for their care ' contributing to skyrocketing health care costs. "The cost of that uninsured care is passed on," says Oler. "That's why your insurance premiums are going up. That's why your co-pays and deductibles are going up. That's why you're having harder access to specialists and getting into the emergency rooms ' because you personally are picking up the tab for the uninsured. The cost shifting is destroying the system."