Nov. 4, 2005 – Two months after vicious winds and surging waters crushed communities on the Gulf Coast, the health institutions impacted by the storm are at the center of a different calamity, fraught with waiting lists, empty prescription bottles and unpaid medical bills.
The Bush administrationâ€™s plan for addressing the health needs of hurricane survivors is to adjust the Medicaid system, the federal healthcare program for the poor. But healthcare advocacy groups say such stopgap measures fail to remedy the short-term crisis or the longstanding problems amplified by the plight of Katrinaâ€™s poorest victims.
Through a special waiver program, the Department of Health and Human Services has authorized states to provide Medicaid to Katrina survivors, based on existing eligibility guidelines that cover families, the elderly and the disabled. But these provisions leave out many poor adults, including those who have lost jobs and employer-sponsored healthcare plans due to the hurricane.
Medicaid enrollment patterns in Louisianaâ€™s hurricane-shelter population indicate that even in their native state, a large portion of people seeking assistance will be shut out of the system. A state-led outreach effort in shelters, which ended last month, found that nearly one in every five survivors who requested Medicaid was rejected during initial eligibility screenings because they did not fit Medicaid requirements.
Concerns about the cost of the Gulf Coast recovery has in fact pushed Congress toward a shrinkage, rather than expansion, of major federal programs.
Tara Lachney, a spokesperson for the Louisiana Department of Health and Hospitals, reported that of about 6,900 remaining households that progressed to the application process, nearly 60 percent were denied coverage, or had their applications shelved "in hopes that we would be able to cover them under a future program."
Those hopes are riding on legislation to expand Medicaid in Katrinaâ€™s wake. A bill introduced by Senators Charles Grassley (R-Iowa) and Max Baucus (D-Montana) would essentially grant full coverage to all affected individuals who met basic income requirements and would waive state matching fund rules, thus committing the federal government to absorbing the full cost.
But conservative lawmakers have stalled the proposal, instead pushing through a narrower plan that would relieve impacted states of matching payments but would not broaden eligibility categories.
Concerns about the cost of the Gulf Coast recovery has in fact pushed Congress toward a shrinkage, rather than expansion, of major federal programs, with proposed spending reductions for Medicaid, food stamps and subsidized child care.
"What they want to cut are low-income programs that either help these very same people, or other people very much like them," said Deborah Weinstein, executive director of the advocacy organization Coalition on Human Needs. "And that is outrageous."
Edwin Park, a health policy analyst with the progressive think tank Center on Budget and Policy Priorities, said that initially, the group had hoped Katrina would place a "highlight on poverty" in Congress and convince legislators of the need to bolster programs like Medicaid.
Several hospitals, including Big Charity Hospital, the cityâ€™s primary indigent-care facility, are now shut down indefinitely.
"But I think what weâ€™re seeing is the opposite -- that itâ€™s being used in the justification for budget cuts," he said.
As talk of reform dies down in Washington, service providers resign themselves to desperate but familiar shortages.
Anthony Iton, public-health officer for Alameda County, California â€“ which has absorbed about 1,200 Katrina evacuees, most from New Orleans â€“ sees the daily struggle to care for survivors as part of a more troubling syndrome. "Itâ€™s not the lack of a healthcare system," he said. "Itâ€™s the lack of core investments in critical social resources for everybody."
Most of the survivors who have accessed Alamedaâ€™s medical system lack private insurance, and many have chronic conditions like hypertension and diabetes. Iton said that as service providers connect survivors with local care networks, "the Katrina impact is noticeable, but itâ€™s not necessarily something thatâ€™s going to break the system, because the system is already pretty much operating on fumes, anyways."
Since local needs go unmet every day, he explained, especially among undocumented immigrants and other underserved groups, "the bottom line is, you know, weâ€™re dealing with daily Katrinas."
In terms of health quality, Louisianaâ€™s residents were sinking long before the flood. In 2004, the state ranked last in the nation in public health quality, according to the mainstream research group United Health Foundation, and ranked near the bottom in per-capita public-health spending and uninsured rates, as well as infant mortality and cancer deaths.
Among public health activists and officials, the discussion on how and what to rebuild outlines a tension between long-term sustainability and immediate needs.
The Kaiser Family Foundation conducted a survey of 680 refugees in Houston, Texas â€“ nearly all from the New Orleans area â€“ and found that of surveyed childless adults under 65 who would probably not qualify for Medicaid, about half lacked any insurance, and nearly one-quarter reported a time since the hurricane when they needed medical attention but did not receive it.
A New Prescription for Public Health
There is also fear that the public-health infrastructure will not be rebuilt fast enough to keep pace with the repopulation of the area. Several hospitals, including Big Charity Hospital, the cityâ€™s primary indigent-care facility, are now shut down indefinitely. Thousands of the cityâ€™s healthcare employees have been temporarily laid off.
"Weâ€™re still worried about the future, in terms of having enough healthcare facilities available to take care of patients," said Joseph Guarisco, an emergency-medicine specialist at one of the cityâ€™s only fully operational facilities, Ochsner Clinic Foundation Hospital. The reopening of the city, he said, has increased intakes of injuries and acute illnesses, but "thereâ€™s certainly no trauma system in place" to absorb an influx of patients.
Among public health activists and officials, the discussion on how and what to rebuild outlines a tension between long-term sustainability and immediate needs. Patrick Libbey, executive director of the National Association of County and City Health Officials, said that "free" medical care for the poor could help, but cannot substitute for a revamping of the economy to provide "a level of income that might also carry with it health benefits," as well as stronger social institutions that promote community well-being.
He cautioned against rebuilding a "dual-track system" that segregates the uninsured into free, but less sustainable, public facilities, which could "contribute to disparitiesâ€¦ in terms of quality of care, access of care between different groups."
But one unique initiative in the cityâ€™s Algiers district is trying to sow an alternative public health system that cares for underserved populations without compromising quality â€“ or principles. The Common Ground Collective Clinic, established by activists shortly after the hurricane, hopes to raise the bar for the cityâ€™s healthcare by injecting a dose of humanity into the medical bureaucracy.
"We treat people with respect," said Scott Weinstein, a volunteer nurse from Montreal who helped establish the operation. "And we treat them as neighbors. Not as clients, you know, who have to take a number."
Operating out of a converted mosque -- with technical and material support drawn from donations around the country, local health authorities and federal relief agencies -- the volunteer staff provides free health care to about 100 patients of all ages in a typical day. The clinic offers routine services like prescription refills and vaccinations, along with less conventional treatments like acupuncture and massage therapy.
Their next move will be to transition to a standard nonprofit structure with a full-time staff and, eventually, to pass control of the free clinic on to its main stakeholders: the local people it serves.
Weinstein said that Common Groundâ€™s grassroots model of care is as practical as it is radical. "Itâ€™s a vehicle for community building," he said, "for community empowerment.â€¦ Itâ€™s a building-block process, and healthcare is just one block."