Ernest Burrell poured eight orange, translucent plastic bottles from a bag onto the floor of his Central City apartment. They clattered on the chipped, ruddy concrete. Unpronounceable labels — Spironolactone, Amlodipine, Indapamide and more — were typed in faint serif font above handwritten notes on which pills to take once a day, twice a day, three times a day.

He fished a few more vials from a purple plaid knapsack with faded images of cartoon skulls etched in the fabric. In all, a dozen drugs and vitamins doctors say he needs to handle his high blood pressure, failing heart, depression, and Stage 3 kidney disease. 

The drugs aren’t optional. Heart attacks killed his mother, his father and his brother in the middle of their lives. His older sister wears a pacemaker. At 52, Burrell has survived two attacks himself. He needs those drugs.

“They keep me living,” he said.

But he can’t afford them. Unable to work because of his health issues, he has lived on the streets, spending the bulk of the past two years under the Pontchartrain Expressway.

Burrell has applied twice to gain access to health coverage under the Medicaid program. Twice he has been denied. Now he is one of up to 375,000 people in Louisiana who could qualify for coverage when the program expands July 1.

Burrell stands to benefit from Gov. John Bel Edwards’ plan to use federal dollars to lift residents of Louisiana – and especially of New Orleans – from the ranks of the unhealthy uninsured. But he also reflects the pressure on the city’s emergency rooms – he is what the ER doctors call a “frequent flier” – which are obligated to care for everyone regardless of their ability to pay.

Medicaid expansion will benefit people like Ernest BurrellErnest Burrell, 52, takes over a dozen medications to treat his high blood pressure, depression and Stage 3 kidney disease. He’s also a former longshoreman, homeless, unable to work and a prime candidate to keep getting the medications he needs to live when Medicaid expands. Tuesday, May 24, 2016. (Photo by Ted Jackson, | The Times-Picayune)  

In a sense, expanding Medicaid is a matter of easing economic burdens for more people who can’t afford access to care while showing patients how to best connect to doctors, nurses, pharmacists, therapists and clinicians outside ERs. But in broader terms, it is about changing a culture: Teaching people not to wait until a crisis to seek help, but instead to practice long-term preventive care.

In days, Louisiana will become the 31st state — the first in the Deep South — to expand its Medicaid program to insure residents with yearly incomes below 138 percent of the federal poverty line. That’s $16,242 for a single person, $33,465 for a family of four.

A bulk of that population lives in and around New Orleans. City officials estimate 165,000 residents in the four parishes southeast of Lake Pontchartrain could be folded into the expansion.

For New Orleans, the expansion of Medicaid is the next step on a road from the safety net take-all-comers model of Charity Hospital to the Greater New Orleans Community Health Connection, a federal grant program for a patched-together network of clinics and other health care providers that began after Hurricane Katrina. 

Edwards’ signature on the Medicaid expansion signaled the end of GNOCHC as its patients, and those of a sister program for pregnant women known as Take Charge Plus, are absorbed into Medicaid.

Burrell has traveled that history. He was born at Charity. His caseworker got him into GNOCHC after his health failed gradually, then suddenly. The Medicaid expansion, however, could fill the gaps where the Community Health Connection comes up short for him.

Raised in the Irish Channel, Burrell worked the poultry boats with cargo bound for the New Orleans Cold Storage Co. He spent 17 years on Uptown’s wharves.

“Whenever we had a ship, I would work on chicken,” he said.

The pay was good enough: $14.50 an hour, and he could hustle that to $25 on weekends. Then, around 2012, two things began to happen. The cyclical nature of shift work took a bad turn, and Burrell found himself more often still standing, unchosen, outside the waterfront work office at 721 Richard St., without a job for the day. At the same time, his breathing grew more labored, and his stamina waned. He could no longer shoulder the demands of being a longshoreman.

“It got to the point where I couldn’t pay my rent no more,” he said.

He moved into the New Orleans Mission while still picking up what shifts he could. But that didn’t last.

“I had to quit because I couldn’t perform no more,” he said. “I really liked that job.”

He lost his health insurance. Then came the heart attacks. One while he was living at the mission and the next while he was at the Salvation Army, he said. 

He survived, eventually to trundle his meager belongings to a vacant patch under the expressway. 

His health continued to falter, and Burrell became a “frequent flier,” a shorthand term for the chronically ill who use emergency rooms as primary access points to medical care – and do so often.

The fear among Medicaid’s critics is that thousands of residents with new Medicaid cards will flood emergency rooms and drive costs through the roof. Frequent fliers are a particular peeve of Louisiana’s congressional Republicans and at least one candidate who wants to get there. 

“We have to start saying ‘No,’ as the law allows us to, to our friends on Medicaid who go to emergency rooms, expensive emergency rooms, to be treated for things like acne, to get a pregnancy test, to have a wart removed, to talk to someone about losing weight, to see if they need glasses,” state Treasurer John Kennedy, a Republican running for the U.S. Senate, said in a televised speech in February. “It costs five times more to treat them in an ER than it does in a private clinic.”

Kennedy’s attacks on Medicaid expansion have frustrated members of the Edwards administration who say the key is getting people insured and guiding them into preventive care.

“Kennedy has done an incredible job of convincing the public that we can just go and turn off the spigot for waste, fraud and abuse and all of a sudden get millions of dollars back in the program,” Robert Johannessen, spokesman for the Department of Health and Hospitals, said in a February interview. “It just doesn’t work that easily.”

Medicaid in Louisiana is run through five managed care plans. The state is a pass-through for federal reimbursements. That means the plans have incentives to curb abuse to keep costs down, said Department of Health and Hospitals Secretary Rebekah Gee.

“So this issue of ‘Let’s go lasso a bunch of criminals and get their money back and that’s going to be our budget solution’ — it’s just not accurate,” she said. “It’s just a red herring. It’s politics.”

The rate of pre-expansion Medicaid visitors to New Orleans emergency rooms varies widely, from less than 20 percent at University Medical Center to as high as 75 percent at Children’s Hospital due to its focus on kids and pregnant women – prime foci of the present-day Medicaid program if they meet the proper income thresholds.

Predictions of what a larger Medicaid pool will do to those ratios depend on who is asked. New Orleans emergency department directors are braced for a rush of newly insured, low-income patients similar to the spikes seen in Oregon, California and elsewhere.

In some ways, emergency departments blame themselves for the predicament. Short wait times and all-access care bring hospitals bragging rights in competitive markets. But those offerings also encourage the patient behavior that has emergency department directors concerned about a tsunami of new Medicaid patients. 

“One of the biggest problems we may be facing as an emergency department is the culture of America, and people really enjoy sort of ‘Burger King medicine’: Drive in, grab their antibiotics and go,” said Dr. Matthew Bernard, Touro Infirmary’s emergency department director. “And so people really want quick and fast and convenient access. And I think that’s something that we are able to do well, but it doesn’t deter people from coming to us. It’s just the opposite. It probably encourages more people to try to use us.”

But Lisa Napier, the chief financial officer for Charity’s successor, University Medical Center, said she sees the shift in the state’s approach to health care for the poor as eventually reducing the appeal of ERs as a first entry point for new patients. 

“I think it may have a decreasing effect on emergency rooms,” she said. “If you don’t have insurance today, and tomorrow you have an insurance card. … I believe those patients are going to try to get care in a more appropriate setting. Managed Medicaid plans, they’re going to encourage patients to get care in non-emergency settings.”

That redirection is the administration’s goal during the program’s initial months, Gee said.

“I’ve already got a plan to work with the barbershops, beauty shops and churches around the state to re-educate people around responsible use of health care and how you do it,” said Gee, a former DHH administrator who worked as a Touro obstetrician before Edwards tapped her to join his administration.

Her plan is to embed Medicaid caseworkers in emergency departments and hospitals around the state to guide the newly insured to other access points in the health care system: clinics, primary care practices, community health centers.

“There will need to be an education,” Gee said. “Why do we want (to reach) people in the hospitals? For that very reason: ‘Hey, you came in today, next time here is where you can go.'”

Gee’s strategy marks the next step of what began with Charity’s demise: to prevent patients from using hospitals and clinics only when they are at their sickest by teaching them to take care of themselves before getting to that point. 

“It gets back to grandmother, your mom, saying back in the day an ounce of prevention is worth a pound of cure,” said Michael Griffin, executive director of Daughters of Charity, a health clinic operator and prime Medicaid provider in New Orleans. “That same old adage is still appropriate in this case.”

And with the Medicaid expansion comes greater access for sick people to reach a secondary round of care: medications and the specialists who can address their often-complicated lattice of diseases.

But that raises new concerns among health care providers.

“Do we have enough specialists out there, now that all these people will have access to primary care and specialists?” asked Gwynne Mashon, a lawyer with the Southeastern Louisiana Legal Services who is handling Burrell’s Medicaid access case.

There is worry among physicians that they can’t afford to treat Medicaid patients. They earn 62 cents on every dollar they charge. They also feel that rate will chase colleagues away from opening their practices to newly insured Medicaid patients.

The new program could test a medical field already under severe pressure from looming state budget cuts and a dearth of available practitioners. 

Several specialists and primary care physicians, however, said their moral imperative to care for those who need it trumped the poor economics staring them down. Plus, some compensation has to be better than nothing at all, which is what they get for treating uninsured patients who can’t pay their bills.

“Getting people care in an accessible, insurable environment creates a benefit individually and to the society,” said Dr. Josh Lowentritt, a private practice internist who works at several New Orleans hospitals and clinics. “We’d rather get paid (62) cents than zero.”

Economic and hospital pressures aside, Medicaid expansion presents an entirely new menu of services previously unavailable to patients living in that gap between the working class and the destitute.

“They’re not strolling in (to emergency rooms) for beauty secrets,” said Dr. Christy Valentine, who built a practice after Hurricane Katrina focused on New Orleans residents eligible for Medicaid coverage. “They want to get healthy and they now have a card. But what does that mean?”

For Burrell, it means regular access to a heart specialist, a psychologist, and desperately needed medications. While GNOCHC gave him access to talk to a primary care provider, that’s basically where it stopped.

This could be a turning point for Burrell. NAMI pays his rent on a two-room, backdoor apartment on General Taylor Street. The city-run Health Care for the Homeless acts as his primary care provider. Southeastern Louisiana Legal Services is working to get him Social Security disability benefits. And the St. Vincent de Paul Society is giving him his lifesaving prescriptions for free.

But that last and most vital lifeline can’t last forever, Burrell said. 

“I’ve got one more month of medications,” he said. If he doesn’t get into the Medicaid expansion, “I guess I got to have to try to get it some other way.”

Medicaid expands, ERs brace, Ernest Burrell prays