Without a Safety Net: Abandoning Louisiana's Uninsured

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The opposition to the two major programs that would ensure health care to much of the country's unhealthiest states, and how it now matters for the entire country

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Louisiana Governor Bobby Jindal [NatiHarnik/AP]

Earlier this year an uninsured patient at Lallie Kemp Medical Center, a small safety net hospital operated by LSU, suffered a subdural hematoma -- bleeding between the brain and the skull that is treatable if given prompt attention. The hospital attempted to transfer the patient to LSU's referral facility in New Orleans, but the hospital, with shrunken capacity, already had seven patients in the emergency department awaiting ICU beds. The doctor called 17 other hospitals that day, including some with neurosurgeons, operating rooms, and ICU beds available. None accepted the patient. He died that evening.

Unfortunately, examples like these are becoming easier to identify in Louisiana. The Institute of Medicine reports that 18,000 people a year die in the U.S. for lack of health insurance. When Louisiana's Health Secretary, Bruce Greenstein, was asked about the patient at Lallie Kemp in testimony before the legislature a few months ago he explained that the patient could not get care because of a shortage of neurosurgeons in Louisiana. That, of course, sounded better than the fact that it is more essentially due to the state's approach to the uninsured.

Louisiana has some serious health care challenges, with the fourth highest uninsurance rate in the country, among the highest cost and lowest quality outcomes for patients with Medicare, and among the highest rates of tobacco use, obesity, poverty, and infant mortality, to name a few. For health status and outcomes, Louisiana is among the worst in the country.

Like in other states, the health care system in Louisiana is an amalgam of private and public providers and programs loosely woven with some attempt to care for the entire population. The solutions are not simple, but in Louisiana we have perhaps the most qualified governor to address them: McKinsey consultant, Secretary of Health for Louisiana, executive director of the Bipartisan Commission on the Future of Medicare, and assistant secretary of the U.S. Department of Health and Human Services. However, instead of providing desperately needed leadership and clarity for his constituents, Bobby Jindal continues to confuse us.

Two recent reports in the New England Journal of Medicine indicate that Medicaid coverage results in better preventive care and is associated with lower mortality. Implementation of the Affordable Care Act's Medicaid expansion would provide Medicaid insurance to 456,000 Louisianans and reduce the uninsured in the state by 60 percent. Gaps in Medicaid coverage and care for the uninsured (350,000 of whom would remain after the expansion) are addressed by safety net systems which, according to the journal Health Affairs, can provide care at half the cost of providing insurance, an assessment consistent with an Urban Institute study done in Louisiana in 2007. The Louisiana State University Health Sciences Centers operate the statewide safety net system, serving over half a million people annually through which the uninsured and underinsured receive care from immunizations to neurosurgery, with outcomes on par with national norms for people with insurance.

The amount of state dollars spent on Medicaid in Louisiana is less than 9 percent of total state funds compared to the national average of over 15 percent. The average state spends twice as much on Medicaid as it does on prisons; Louisiana spends roughly the same amount. Since Jindal took office, Medicaid and Disproportionate Share Hospital spending (funding for uninsured care) in the public safety net system has decreased by nearly $200 million on an annual basis. In September he cut funding for the safety net by another $329 million, over half of the total funding for uninsured care.

Escalating health care spending in Louisiana and the U.S. is driven by the insured, not the uninsured. Jindal's spokespersons, however, have characterized care for the uninsured in the safety net system -- which has had flat spending in the last 10 years -- as "unsustainable" while proposing an ambiguous plan to shift that care to a private sector that has demonstrated cost increases that actually are unsustainable.

Adoption of the ACA's Medicaid expansion paired with a healthy safety net would provide the component pieces of a universal coverage model in Louisiana for the first time. However, Jindal has declared his opposition to the two major programs that would ensure care to the uninsured. He has made clear his intention to reject the federal Medicaid expansion and at the same time is dismantling the state's public safety net. It's a combination of blows for many of the state's citizens who are among the lowest earners in the country and are destined to go without care.

By refusing to participate in the Affordable Care Act, Jindal will deny access to 456,000 low income individuals through the Medicaid expansion. A recent analysis by the Kaiser Family Foundation put the 10 year cost at less than $1 billion for Louisiana. In fact, when that expense is offset against additional savings on state funds currently spent on the uninsured, it is probable that there would be a net financial benefit to the state.

After two years as Louisiana's Health Secretary and five years as governor, Jindal presides over a Louisiana that has one of the country's largest uninsured populations with worsening access to care. He is now chair of the Republican Governor's Association, with a message for the country. Those outside of Louisiana can start to get to know him better by examining his health care record back home.  

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Frederick P. Cerise, MD, MPH, is an associate clinical professor of medicine at Louisiana State University.

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