Post-Hurricane Woes Expose Weakness of Nation's Health Care System, Say Speakers

Inadequate national health policy has slowed the rebuilding of the New Orleans health care system in the aftermath of Hurricane Katrina, according to economic, health care and patient advocacy experts speaking at a recent Capitol Hill round-table discussion.

That policy resulted in a "lack of federal response to shore up a shredded safety net that could have provided coverage to an injured population," said Robert Phillips, M.D., M.S.P.H., director of the Robert Graham Center in Washington, in an interview. "By doing so, the system failed to ‘stoke the health care engine’ and enable physicians to stay or return to the region."

Phillips was among three speakers at the recent Capitol Hill roundtable discussion, "Hurricane Katrina: Lessons Learned for Health Care Policy," sponsored by the Society of Primary Care Policy Fellows and University of Miami Miller School of Medicine.

"The two glaring problems with U.S. health policy that were revealed by Katrina are, first, that the safety net is burgeoning, strained, and it does not require much for it to fail and, second, that we have allowed social disparities -- gaps in income, education, community -- to become so bad that whole communities lack even the most basic capacity to care for their own or to recover," said Phillips.

Phillips' echoed comments made by his colleagues during the roundtable discussion. U.S. health policy, they said during the event, undermines the health care system as a whole and leaves Americans at risk for a national breakdown. Rebuilding health care in New Orleans requires a proactive, long-term public policy that recognizes the economics of health care and the public good that derives from investing in the health infrastructure.

Phillips used Hurricane Katrina as an analogy for the nation's overall health care system. Likening the growing number of poor, underinsured and uninsured Americans to the rising flood waters in New Orleans and comparing primary care, community health and safety net providers to levees, Phillips warned that America's health care system is at high risk for disaster, even without a disaster.

"That water level is high in many of the cities around the country," Phillips said during the discussion. "That water … is right up against the top of a very fragile system of levees that are the primary care physicians, nurses, nurse practitioners, physician assistants, community health centers around this country who form the safety net, who take care of those people and hold the water at bay. But it won’t take much to push the water over those levees all over this country, we’re very close in fact."

Sara Rosenbaum, Harold and Jane Hirsh Professor of Health Law and Policy and chair of the Department of Health Policy at the George Washington University Medical Center, School of Public Health and Health Services, agreed.

Hurricane Katrina highlighted the problems of the health care system, so "we may not even need the horror of Katrina to get the next couple of congresses to start dealing" with the crisis, she said. "Anything can push a whole region like this into a health system crisis. And we’re going to start seeing it. … If you look at the numbers, you can’t help but reach this conclusion: We’re going to see whole regions of the country where the uninsured numbers are so high that even though it doesn’t happen in one cataclysmic event, you just can’t hold a health system (together) anymore, because there’s not enough paying customers any longer to make specialization possible, to make a well-funded primary care system possible."

Still, Rosenbaum urged policy-makers not to focus only on insurance as a solution. "You can’t just insure people," she said. "You can use insurance to help push a system forward, but when you make an investment in health care for people, it has to be in the infrastructure investments needed to jumpstart the improvement, and then you come back behind with the financing" through insurance.

Federal officials and legislators had -- but chose not to use -- several options for responding to Hurricane Katrina, according to roundtable speakers.

Among them was providing time-limited Medicaid coverage to anyone who verbally attested to their income and lack of coverage, an approach used successfully in New York City for six months after the Sept. 11 terrorist attacks, but not after Hurricane Katrina, said Rosenbaum. As a result, health professionals left the region because so few patients had health insurance coverage.

"In a recovery … where literally you’re having to restore a regional health care infrastructure, … you can’t do it by covering only some people," said Rosenbaum. "Everybody has to be in, everybody has to be covered, everybody has to have a way to pay. …Everybody’s got to be able to buy into what’s going to be available because it’s very hard to attract the human and financial capital that’s needed to rebuild a region if you have only a small part of the region able to pay for the care."

Moreover, public policy should allow for a time-limited enhanced payment for services, according to Rosenbaum. With enhanced payment, physicians could repay emergency loans, retain associates and support staff, and stabilize their medical practices.

"The emergency is to keep the infrastructure that has somehow survived," said Rosenbaum. Legislators and public policy-makers declined this option, saying it would create dependency on federal financing.

"But this kind of use of overage on charges is how this health care system has built itself," said Rosenbaum. "It’s why we have graduate medical education. … It’s how we, during World War II, how the farmer’s home administration helped rural areas build a health care system. It’s such an obvious sort of turnkey engine issue, and you are just stopped dead in your tracks when the response is, 'Well, we can’t do those things anymore.'"

In addition, the region requires public capital investment that could have come from the resurrection of the Hill Burton program, according to roundtable analysts. That post-World War II program granted money to facilities for construction and operation in exchange for an agreement to provide a certain amount of free care to the indigent.

Another option: "Declare the whole state a federally qualified health center," said Rosenbaum, citing the Marshfield Clinic in Marshfield, Wis., which relies on individual practices rather than a centralized facility. Grant money flows through an intermediary "which then uses the money to help lower-income families enroll with their medical care home in their community. … If you had done that, so you pumped grant money in for uninsured patients and capital improvements and then given everybody a Medicaid card, … it would have stabilized the whole region and it could have been done probably within a year," said Rosenbaum.