- BIOETHICS FORUM ESSAY
Rebuilding Health Care in the City That Care Forgot: Notes from New Orleans
I know what it means to miss New Orleans. I recently visited this utterly fascinating place for the first time when I gave a talk at a symposium on access and equity in health care organized by Louisiana State University. For two days, I got to eavesdrop on and participate in the local conversation on how to rebuild a major city’s health care system, without replicating its well-known flaws.
Hurricane Katrina damaged or destroyed much of the city’s health care infrastructure for low-income patients, which was built around the Charity Hospital network administered by LSU. The storm also displaced physicians and other health care professionals, only some of whom have returned. Local clinicians are delivering health care through a provisional system of reopened and interim facilities, and they are in continual conversation with health policy experts about how to create a differently organized system that delivers much better results. One approach promoted by the nonprofit Louisiana Public Health Institute is the “medical home” model of neighborhood-based primary and preventive care, to compensate for the loss of Charity Hospital and to move from an institutionally dependent model of uncompensated care to one designed to help the city’s low-income residents to maintain and improve their health. These clinicians and policy analysts understandably fear that political values will trump social values. They’re aware that changing the way New Orleanians think about and use health care is its own challenge. Other challenges include persuading new medical school graduates to choose New Orleans for their residencies, and recruiting seasoned professionals to return or relocate to the city.
The symposium also provided me with a crash course in aspects of health care, health economics, and public health policy that are much discussed locally but are not always part of the national coverage of New Orleans post-Katrina. Here’s a sampling of what I learned:
Katrina was especially hard on New Orleans residents with severe psychiatric illnesses, as inpatient psychiatric care was concentrated at Charity Hospital. At present, individuals who are sick enough to be admitted must rely on the ER for basic care. Many of these individuals are now homeless and live in tent encampments; I saw one encampment when my streetcar passed under a highway bridge that sheltered the tents. Including the needs of the mentally ill in plans to improve public health and the delivery of health care means addressing NIMBY concerns: a decentralized model will bring mental health services, and consumers, into the neighborhoods. It also means confronting the fears of longtime mental health consumers, who were accustomed to receiving care through Charity and don’t yet trust that different would be better.
Another challenge for health policymakers in a city with lots of poor people in poor health: considering social values with respect to the health of a new “stranger at the door,” the undocumented workers who constitute a new immigrant community. New Orleans is being rebuilt by these workers, many of whom are from Mexico. Some workers have brought their partners and extended families, who may themselves find work in hotels and other service professions. These families’ health care needs ranged from on-the-job accidents to chronic disease treatment, to culturally sensitive prenatal and maternity care, to family medicine. Should planners assume that these new residents will have to rely on EMTALA (the federal law which prevents hospital emergency rooms from turning patients away for financial reasons), or should they anticipate their health care needs in designing and building community-based, linguistically and culturally appropriate health care services? Does the city want to encourage them to stay in the “new” New Orleans? The clinicians I met were passionately committed to providing equitable care to undocumented workers, using the languages of morality and economics as well as medicine to make their case. But they acknowledged that there was local tension around this issue, and that it was not yet clear how nonemergency health care services for undocumented residents would be funded.
These challenges, and others, are not unique to New Orleans. Overstrapped ERs in New York City and Los Angeles also serve as providers of last – and first – resort to the mentally ill who lack community-based services and to undocumented workers and uninsured citizens who are forced to receive treatment for chronic disease through services designed to treat acute problems. But New Orleans is unique in that it must think through the whole of its health care delivery system – and the values, structures, and financing needed to sustain a better, more equitable system – right now. Can other cities, other states, and the nation, manage to do this without a catalyst like Katrina?