New Orleans transforms access to health care, but major concerns remain

NEW ORLEANS — Standing on Gravier Street, near where the Interstate 10 overpass divides downtown from the Mid-City district, residents can see the past and future of New Orleans’ health care.

Charity Hospital, the city’s iconic Art Deco teaching facility, closed since Hurricane Katrina hit, stands to the south, its limestone exterior decaying and streaked with brown. A few blocks to the northwest on the other side of the highway stands the newly opened University Medical Center (UMC), Charity’s long-awaited replacement, with an enormous emerging footprint across the city, its modern glass and steel exterior gleaming in the sun.

After the basement of Charity Hospital flooded after the levee breaks, hospital operators declared it unfit for service — a decision that unleashed citywide controversy for years and tore the fabric of the city’s health care system for the poorest residents.

Facing a lack of clinics willing to treat Medicaid patients or the uninsured, New Orleans’ poor for decades used Charity’s emergency room as a one-stop shop for care. Big Charity, as it was affectionately known, accounted for nearly 90 percent of all uncompensated outpatient care in the city. Three-quarters of its patients were black, and 85 percent earned less than $20,000 a year.

“You would look forward to going to Charity,” Mid-City resident Paulette Clay said at a new senior center not far from UMC. “It was like a big happy family.”

But even as many speak wistfully of the compassionate care and camaraderie at old Big Charity, most recognize that the hospital was hugely overburdened and in need of repair. “Don’t get me wrong,” added Clay, “it’s time for a change.” Now she has learned how to navigate a network of specialist clinics around the city through her primary doctor and was eager to sign up her friend Carol Bell for a free Medicare transportation program to take her to appointments.

In the public health community, the demise of Charity required immediate triage for the city’s health care system in the weeks and months after Katrina. But it cleared a path to long-awaited systemic overhaul.

“The big tragedy of the closing of Charity Hospital also provided an opportunity,” said Clayton Williams, the executive director of Partnership for Access to Healthcare (PATH), a health equity program administered by the Louisiana Public Health Institute (LPHI). “During that time, there was an opportunity to really get in there with a new approach.”

The goal, said Williams and others in the field, was to decentralize care for the indigent, with a shift to smaller neighborhood clinics focused on preventive and primary care.

“Folks for years had talked about developing community clinics,” said LPHI CEO Joseph Kimbrell. “But there was never anything that developed it where you had sufficient numbers of them and the resources to do that development.” He added that while it shouldn’t have been necessary to close Charity in order to decentralize care, “it wouldn’t have happened without the influx of [post-Katrina] resources.” 

The government money that flowed in after the storm, including a $100 million federal grant in 2007, spurred a new network of local clinics focused on primary care for the uninsured. Many of these new clinics have come in under the Federally Qualified Healthcare Center (FQHC), a grant program that offers enhanced Medicaid payouts and requires sites to offer comprehensive medical services in underserved communities.

In 2004 there were just seven FQHC sites in the greater New Orleans area. By 2010, that number had nearly doubled, and today there are about 45 FQHC sites. Including non-FQHC sites, there are about 60 community clinics serving over 140,000 patients, according to 504HealthNet, a community clinic and medical provider association.

The proliferation of neighborhood-based primary care clinics has been touted as a success for the city. “Access has gotten much better, from a primary care standpoint,” said Michael Griffin, the president and CEO of Daughters of Charity Services of New Orleans, a faith-based community clinic organization unrelated to Charity Hospital.

Over the last 10 years, Daughters of Charity has grown from one site in New Orleans to nine primary and pediatric clinics in the area.

While primary care options for the poor have greatly improved over the last decade, health disparities have been slower to equalize. A 2013 report by the New Orleans Health Department cited a staggering 25-year difference in average life expectancy for the healthiest and least healthy ZIP codes in the city.

The 70112 area — which encompasses UMC and is predominantly poor and black — had an average life expectancy of 55. In contrast, residents in the wealthier and mostly white 70124 ZIP code near Lake Pontchartrain had a life expectancy of 80, above the U.S. average.

Black adults in New Orleans are almost twice as likely as white adults to be uninsured and, as of 2010, twice as likely to die of diabetes. The city and the state are struggling with an HIV/AIDS epidemic. New Orleans, along with Baton Rouge, routinely rank among the top three cities nationally for infection rates. In New Orleans, black men are twice as likely as whites to have HIV, and black women are an astounding 10 times as likely as white women to be infected.

Overall, Louisiana is one of the least healthy states in the nation, ranked 48th by the United Health Foundation, and Orleans Parish has consistently placed in the bottom half of the state's rankings of health outcomes. 

“We are in a much better condition, but we are not to our goal yet, by any means,” said Jonathan Chapman, the executive director of the Louisiana Primary Care Association, which represents community clinics across the state. The existing system for low-income and uninsured, he said, “is not adequate to serve everyone every day.”

Several areas in New Orleans are federally designated as having a shortage of health care professionals, in part because not enough doctors accept Medicaid, he added. “It can still be a six or eight week wait until you are able to get in, and a lot of these folks don’t have that luxury of time,” he said. “That’s when they show up in the ER again.”

Susan Todd, the executive director of 504HealthNet, said the focus should move from building facilities toward increasing community awareness and improving health outcomes.

“To be honest, I don't know that we need another brick and mortar site,” she said. “It’s just not financially sustainable to have a clinic in every neighborhood.” Instead, the key is “making sure people know when and where to go for care.” Improving transportation options is another issue, she said, as well as expanding certain services, like bilingual social workers.

While primary care options for underserved communities have made definitive progress, it’s unclear if patients are still unsatisfied or just unaware of available options. A 2015 survey by the Kaiser Family Foundation and NPR found that 64 percent of New Orleanians still say there are not enough medical services for the poor and uninsured.

The health care community, at least, is optimistic. “Access has gotten much better,” said Griffin. “The change in the actual clinical quality and outcomes will come over time.”

New Orleans’ post-Katrina health care system was largely built with federal money and is dependent on public funding in a state with a $1.6 billion deficit. As recovery funding has dried up, clinics have had to find new sources to continue operations.

“That’s been pretty tough,” Griffin said of losing Katrina funds. “We have some major challenges … but we charge our patients, and we are constantly looking at grants to provide care.” The organization is expanding and broke ground for a facility just a few weeks ago.

Daughters of Charity, recently named one of 61 national quality leaders nationwide, has had unusual success in bridging the gulf between paying patients and the uninsured. But the broader issue is the large number of uninsured, which stands at about 17 percent of New Orleans’ population.

While Jindal has refused to expand Medicaid in Louisiana, New Orleans has been largely shielded from the Medicaid gap suffered by the rest of the state, thanks to the Greater New Orleans Community Healthcare Connection, a city-specific waiver program that sprang out of the disaster. However, federal funding for the program depends on a state contribution, which was nearly struck from the 2014 and 2015 budgets.

UMC’s operating company, LCMC Health, has said it will cost about $525 million to operate every year, including state funding. Its business model is banking on attracting paying patients from the Gulf region and beyond.

Gregory Feirn, the CEO of LCMC, is confident of the hospital’s long-term financial sustainability. “It will be a destination center, and that’s what will make it successful” he said at the dedication ceremony. “It’s a new era of health care, but health care for all.”

James Jefferson, a minister who went to UMC to be treated for cardiac issues, agreed.

“They were really nice,” he said, beneath a 32-foot dangling glass sculpture of New Orleans that is a marquis piece of the UMC’s art collection. “I was surprised.”