Katrina lessons going unheeded

If there were a silver lining in the black cloud of Hurricane Katrina, it could have been that lessons learned from that event would be understood and used to make improvements in the ability of our national health system to respond to natural or man-made disasters.

But now, several months after the hurricane, experts are increasingly pessimistic that we will see even modest improvements in the health system.

"Hurricane Katrina exposed a health care system incapable of withstanding the long-term impact of a major disaster," says George Washington University Department of Health Policy chairwoman Sara Rosenbaum. "Through destruction and permanent displacement, Katrina illuminated the fundamental weaknesses inherent in the national approach to health care financing, as well as the extent to which these weaknesses can threaten recovery. Yet, almost from the moment that health care emerged as a major issue, a battle rapidly ensued over the appropriate scope of the response."

Writing in the Jan. 25 Journal of the American Medical Association, Ms. Rosenbaum says Katrina did not merely lay waste to a geographic region; it also "exposed every public policy failure essential to community and population health."

The consequences of Katrina's fury for low-income populations have been particularly severe, Ms. Rosenbaum says. In the affected states, an estimated 106 federally funded community health centers with 166 service sites were destroyed, damaged, or overwhelmed by patient surges, with surrounding states experiencing up to 100,000-person patient surges. New Orleans' Charity Hospital, a principal source of health care and the only Level 1 trauma center for the entire Gulf Coast region, was left devastated and dysfunctional, furloughing nearly 2,600 employees as of November.

"To rebuild the region means rebuilding health care services," she says, "since accessible and affordable health care is essential to basic population health and safety. However, the rebuilding task faces particularly great challenges; even if capital can be found, the population is so pervasively uninsured that its ability to sustain reclaimed facilities is open to question."

Many lack employer coverage

Looking back, Ms. Rosenbaum notes that for decades people living on the Gulf Coast have had to deal with the consequences of what she calls the nation's gap-ridden approach to health care financing. She points out that in 2004, only 47% of Louisiana's nonelderly residents and 48% of Mississippi residents had employer-sponsored benefits, and the nonelderly insured population in each state stood at 21% and 20%, respectively. Only in Alabama did the proportion of the population with employer coverage exceed the national average, but privately insured residents were concentrated in the state's industrial regions and not in the coastal towns.

"Experts now estimate that displaced workers left without health insurance in Katrina's wake represent one of the largest groups ever to lose coverage in a single event in the nation's history," Ms. Rosenbaum declares.

But early assessments of displaced survivors suggested the group faces an even greater situation. A mid-September poll of survivors sheltered in Houston found 60% with annual family incomes of less than $20,000, fully half without any form of health insurance, and 40% with diabetes, hypertension, or physical disabilities. Many of the people had relied on Charity Hospital in New Orleans for their care and it was expected that dependence would be transferred to hospitals in the Houston area or wherever the evacuees eventually settle.

Ms. Rosenbaum says that while Medicaid is the most important program for addressing deficiencies in the voluntary, employer-sponsored system, it excludes most poor adults because of its historic ties to cash welfare assistance. Louisiana's Medicaid program data from October showed that more than 50% of all applicants were turned away, not because they weren't poor, but because they did not fall within one of Medicaid's traditional adult categories. Those who were eligible faced enrollment hurdles.

Coverage lost across state lines

Because Medicaid is state-based, interstate movement meant the effective loss of coverage. Relocated people must either attempt to navigate the health care system with out-of-state Medicaid cards or re-enroll in another state. Either alternative can be very difficult, Ms. Rosenbaum says, as illustrated by decades of efforts to make Medicaid more accessible to impoverished migrant farm worker families. Despite Medicaid's strengths, she says, it lacks Medicare's nationwide, uniform coverage potential and interstate portability.

While the picture in September was one of devastated state economies and community health infrastructures, long-term joblessness, deepening poverty and dislocation, and a lasting disconnect from health insurance, federal emergency legislation envisions short-term emergencies and a health care system that, even if seriously affected in the short run, remains relatively stable and capable of recovery through quick, time-limited infusions of funds, Ms, Rosenbaum explains. But federal emergency health policy is not structured to address a disaster of such magnitude that a total population is displaced and an entire health care system leveled. In that type of situation, Ms. Rosenbaum argues, aid must be long term and structured to replace or act as health insurance.

"The need for a health insurance replacement program for an entire population, over a longer time period, should hardly have been a surprise to policy-makers," she declared. "Indeed, the nation had only recently lived through just such an event and had responded with just this type of structural assistance. In the aftermath of the 2001 World Trade Center attacks, New York established a Disaster Relief Medicaid program for all low-income residents. In the four months following Sept. 11, the program reached almost 350,000 people using a highly simplified single-page application, oral attestation of need rather than extensive verification, and on-the-spot eligibility determinations and enrollment. The program was temporary, and at the end many persons reverted to their previous uninsured status. But the program was considered highly successful, especially for the estimated half of all beneficiaries who had health problems at the time of enrollment."

Philosophical debate exists

While federal policy-makers looked again to Medicaid in the wake of the Katrina disaster, Ms. Rosenbaum said the pathway to assistance was bitterly contentious, reflecting a deep philosophical divide.

"The central issue," she said, "rapidly became whether, at least in a time of disaster with massive public health implications, the nation should do what it otherwise does not, namely provide health insurance to all affected low-income persons."

Sen. Chuck Grassley (R-IA) introduced the Emergency Health Care Relief Act of 2005, modeled on the New York City effort, but it drew immediate opposition from the Bush administration, which instead came up with a plan that limited aid to five months, retained Medicaid's exclusion of more than half of all poor adults (relying instead on establishing an uncompensated care fund for use by designated states, which would be under no obligation to pay any specific physician or other health care provider), eliminated national coverage portability, and assumed continued financial contributions from affected states.

The budget reconciliation bill that was adopted and signed by the president followed the administration's approach, although with additional funding. As a result, Ms. Rosenbaum says, the agreement left uninsured persons without recourse to individual coverage and dependent on the willingness of health care institutions and health professionals to furnish uncompensated care for which they may or may not ever be paid. She also tells State Health Watch she is not sure sufficient funding was included in the measure.

"A unified national approach to coverage for low-income persons during emergencies is hardly a sweeping reform of the U.S. health care system," Ms. Rosenbaum says, "but it would appear to be an important addition to the national policy armament in times of crisis. Even as the crisis of Katrina is transformed into a slow and painful recovery, the nation already is, at least rhetorically, in preparation mode for an influenza pandemic. The time for overcoming the ideological divide over public entitlements for the low-income population in the name of public health preparedness would seem to be at hand."

Health system is 'fragile'

"The lessons from Katrina should extend well beyond disasters. Katrina clarified the fact that, at its core, the U.S. system of health care finance is as fragile as the homes swept away by the hurricane. … The notion that the world's most powerful nation would continue to lurch from disaster to disaster, jury-rigging inadequate and temporary solutions, is simply untenable. Is it really necessary to wait for the next disaster to strike before taking the modest step of establishing a fallback public health insurance system in times of national crisis?"

Ms. Rosenbaum tells SHW her analysis has struck a responsive chord with Trust for America's Health, which has been warning the nation is unprepared for a flu pandemic and urged the paper be rewritten to focus on an avian flu outbreak.

She expressed disappointment over the approach taken by the administration in the budget reconciliation bill for Medicaid, saying widespread disasters pose a problem for the whole community.

"In Louisiana, there's no critical mass to rebuild the entire system," she says. "Without financing, it's hard to rebuild the system, even for those still there who are insured. The problem is not just those in Louisiana who don't have health care. There are no hospitals, no doctors, no nurses. Even the affluent are having trouble finding health care on the Gulf Coast."

(Ms. Rosenbaum can be contacted at (202) 296-6922.)