As Louisiana’s doctors, hospitals and clinics brace to care for thousands of newly insured patients under an expanded Medicaid program, New Orleans may have a distinct advantage when it comes to navigating the paper trail.
If that proves true, the city has the response to Hurricane Katrina to thank.
In the weird way disaster spawns innovation, New Orleans’ shattered health care system came to rely on federally financed grant programs to cover the health costs of its working poor. Those programs turned out to be guinea pigs for expanding Medicaid.
The most prominent, the Greater New Orleans Community Health Connection, or GNOCHC, will be absorbed into the larger Medicaid program when it starts July 1.
More than 65,000 patients in Orleans, Jefferson, St. Bernard and Plaquemines parishes are enrolled in GNOCHC to help cope with their often myriad medical problems. It targets not only the neediest, but also partly patches that lingering coverage gap between present-day Medicaid and private insurance.
Put in place in the 1960s, Medicaid is intended to help pay for care among poor families, children, the elderly, pregnant women and people with disabilities. Medicare, on the other hand, covers health care for anyone over 65, people under 65 with certain disabilities, and anyone with advanced kidney failure.
The GNOCHC expands on Medicaid, providing no-cost health insurance to people living slightly above the federal poverty line in Orleans, Jefferson, Plaquemines and St. Bernard parishes. The program, however, is not an all-purpose emollient. It has glaring blind spots, shortcomings the Medicaid expansion means to polish away, its supporters say.
“With Medicaid (expansion), there won’t be (as) many barriers,” said Megan McStravick, a social worker and case manager for the New Orleans Musicians Clinic.
To trace the history of GNOCHC, start on Aug. 28, 2005, the day before the storm.
Medical care for the poor in New Orleans before Katrina meant traveling to Tulane Avenue and often waiting for hours in the receiving rooms of Charity Hospital. It had been that way a long time. At least 80 years. Entire generations were born, treated and died within that hulking Art Deco shell.
But that model had fundamental problems, one of the greatest being a physical limit on access to health care, said Michael Griffin, president and CEO of the Daughters of Charity, which runs a network of health clinics around New Orleans.
“If you were low-income and you didn’t have coverage, and so you may have (while traveling to Charity) on St. Claude, passed doctors’ offices, 10 different doctors’ offices, getting downtown because those doctors’ offices didn’t take you because you didn’t have insurance,” he said. “You weren’t on Medicare. You couldn’t qualify for Medicaid, and then you end up spending half the day in the ER waiting to be seen because the federal law says everyone should have access to the emergency room.”
Katrina hit on a Monday. Levees and canal walls failed. The city flooded. Charity was deemed irredeemable and closed for good.
As New Orleans rebuilt in fits and starts, so did its health care system. To fill the chasm in care created by Charity’s demise, clinics, urgent care centers, private practices and other hospitals tried to pick up the slack. In 2007, Congress approved a $100 million “primary care access stabilization grant” meant to shore up the fragmented medical field for the next three years.
That first grant also gave a subtle first thrust to shifting New Orleans’ patients away from using hospitals as a last resort and toward using clinics and primary care instead to prevent debilitating and chronic diseases.
As that stabilization grant ran its course, Louisiana health policy advocates — Griffin included — testified on Capitol Hill in 2010 for its continuance. Out of those discussions with Congress came the GNOCHC.
It was a cooperative effort. McStravick said that “instead of working against one another for grant money and to keep our specialists,” the advocates decided to work together for what became a shared pot of money that provided continuing resources.
GNOCHC covers access to primary care providers, some specialty care and lab work, but it came up short by not covering hospitalization, screenings and medications, among other large-ticket medical items and procedures.
But there were challenges from the start. Federal officials sought to save money by not paying for crucial aspects of health care coverage such as hospitalizations, screenings for chronic illnesses and medications. That meant that even if patients were found to be suffering from a chronic illness in the ER, there was no money to pay for the medications that made them feel better.
“It wasn’t going to cover everything because the money just was not there,” Griffin said. “It was up to the providers that participated on how to get pharmacy (access) to the patient population because that wasn’t a covered service. Because it was very expensive.”
The Medicaid expansion will close many of those gaps when it begins July 1. But that still means recipients will have to navigate the bureaucracy. Clinics such as those run by Daughters of Charity will have Medicaid specialists embedded in their ranks. The state Department of Health and Hospitals plans to put more in hospital emergency rooms.
Medicaid expansion will also not provide an all-access path to health care. Because it is run by managed care plans rather than a fee-for-service model, health care providers and insurance companies are likely to butt heads over what treatments are acceptable to cover.
GNOCHC beneficiaries will be automatically enrolled in Medicaid, but only if they have a working address. The state has been sending out letters that require a response from a patient to avoid being scrubbed from the rolls.
That worries advocates who work with homeless population in Louisiana and New Orleans in particular.
“People who are homeless are among our most vulnerable citizens and statistically have a greater need for medical and psychiatric services,” said Gwynne Mashon, an attorney with Southeast Louisiana Legal Services, which provides free legal assistance to the poor. “We would hate to see them left behind during Medicaid expansion.”