The Social Medicine Portal

Health Care Access in New Orleans Following Hurricane Katrina: A Case Study in the Failure of a Two Tiered Health Care System

Theorists predict that due to differential access to power and resources among subgroups in a population, disparities in health will be created or exacerbated by the introduction of new disease processes into the population or with any shock to the system. Those subgroups with better access to resources will always secure a health advantage in times of stress. Though disparities in health existed in Louisiana before the tragedy of Hurricane Katrina, this crisis and the inadequate government response clearly demonstrated this principle. Disparities in health outcomes worsened following the disaster with a disproportionate burden of morbidity, including new diagnoses such as post traumatic stress disorder, falling on disadvantaged groups. With the closure of Charity Hospital, the only access point to health care for many of the poor and uninsured in New Orleans, thousands of individuals were left without a source for care, which likely worsened these disparities. As Louisiana attempts to rebuild, there have been demands to fill the void left by Charity Hospital’s closure, but an important lesson should not be missed. Simply replacing Charity with another under-funded public hospital, and replicating a two tiered system that treats patients with private insurance differently than those dependent on charity care, misses the opportunity to replace the separate and unequal health care system of Louisiana with a more equitable one that serves all people.

While universal health care would not have completely eliminated disparities that existed before and after Hurricane Katrina, it is clear that the two tiered system of health care in New Orleans left thousands of individuals at risk. At the time of Katrina, statewide only adults with dependent children and incomes less than 20% of the federal poverty level (about $3000 per year) qualified for Medicaid. Due to such restrictive requirements for public coverage and the large number of small business employers not offering health benefits, 21% of non-elderly adults in Louisiana had no health insurance prior to Katrina. In New Orleans the number was 26%. Because Louisiana state law mandates universal access to health care, the state funds a public system to serve the poor and uninsured.  Charity Hospital, the focal point of the public system, accounted for over 80% of care for the uninsured in New Orleans, with the surrounding private hospitals caring for mostly patients with commercial insurance (only 4% of their patients were uninsured).  82% of Charity patients were economically disadvantaged and two-thirds were African-American. When Charity Hospital was severely damaged by the disaster and could not reopen, low-income and uninsured residents of Orleans parish were left with no place else to go. In fall 2006, according to a Kaiser Family Foundation study following Hurricane Katrina, 49% of residents of the Greater New Orleans area reported problems with health care coverage or access to care. 61% of former Charity users had no source of care other than the emergency room; African-Americans were more likely than whites to lack a regular source of care; and 15% of individuals with chronic health conditions such as diabetes or asthma had no health insurance coverage.  After Charity’s closure these uninsured patients with chronic disease who are most in need of continuity of care, were left to find a new source of care. With much damage to health care facilities and many physicians relocating outside of New Orleans, the already stressed health care system was not equipped to absorb such need.

In another early study of Katrina survivors, the impact of this impaired access to care is readily seen. 74% of the surveyed population reported a chronic health condition that preceded the disaster. Of this group, 21% needed to disrupt treatment because of barriers to care. Predictors of treatment disruption were age (with the non-elderly being at higher risk), social isolation, housing need, and lack of health insurance. Due to job loss, the already substantial problem of lack of insurance was compounded, and according to the US Census Bureau, the number of uninsured people increased at greater rates in Louisiana than any other state during the years immediately following Katrina. With more uninsured, and fewer sources of care for those without insurance, there was undoubtedly much avoidable suffering.

By spring 2008, three years after Katrina, with job recovery and Medicaid waivers to cover some hurricane survivors, the uninsured rate in New Orleans decreased to 22% among non-elderly adults, but disparities in health care access persisted and disparities in outcomes were already apparent. According to a follow-up Kaiser study, low income adults in New Orleans (those with incomes less than 200% of the federal poverty level or about $42000 for a family of four) were still more likely to report no regular source of care and less likely to have received preventive care than those of higher income. In the two Kaiser surveys, between 2006 and 2008, the rate of self reported fair or poor health status increased from 19% to 46% in the economically disadvantaged group. As a comparison, in 2008, only 19% of the higher income group rated their physical health as fair or poor. Rates of self defined fair or poor mental health were also significantly higher among low income adults, 25% vs. 16%, and had increased from 15% in 2006 in the economically disadvantaged group. Specifically, among former Charity patients, in 2008, 50% rated their physical health and 29% rated their mental health as poor or fair. While these numbers demonstrate significant disparities, they fail to capture the most extreme suffering, as those displaced to trailer parks and temporary shelters outside of New Orleans, reported even greater difficulty with access to care and much higher rates of physical and mental illness.

The reason for health disparities by socioeconomic status or race in New Orleans is not limited to lack of health insurance, and insurance coverage alone without a strong primary care infrastructure would not have increased access to care, however, the two tiered health system that exists in Louisiana, and all across the United States, one that treats patients differently based on ability to pay, leaves a large percentage of the population at increased risk. Our “safety net” for patients without insurance is porous, and sometimes, in the face of disaster, the inadequacy becomes painfully evident. An equitable health system would not have provided transportation for those trapped in the 9th ward as the flood waters rose, but after the disaster it may have helped diabetic former Charity patients find other sources of care and avoid interruptions in medical treatment. As New Orleans and Louisiana rebuild, local policy experts and community members will set priorities for their health care needs. However, following the injustices that were exposed and exacerbated by Katrina and the disproportionate burden of suffering that fell on the low-income, African-American population of Orleans Parish, a commitment to health equity could be symbolic for the rest of the country in how to treat all citizens with dignity. If we are going to build a healthy society in New Orleans, and across America, access to high quality affordable health care needs to be considered a right – not just charity. The uninsured and underinsured will always have second class health status until we guarantee health care for all.

posted by Aaron Fox, MD