If it’s true that every cloud has a silver lining, then one thread of that surrounding Hurricane Katrina is the opportunity the disaster gave New Orleans to reinvent its health care system. Prior to the storm, the system revolved around Charity Hospital and its 70 downtown clinics. This centralized structure imposed serious limitations particularly on the ability of low income, uninsured individuals to receive primary care, both due to the limited number of clinics providing such care and their locations far from where many such individuals live. Probably not coincidentally, a large percentage of this demographic suffers from diabetes, high blood pressure and asthma, chronic conditions which can largely be avoided through regular access to primary care.
In the immediate aftermath of Hurricane Katrina, clinics sprang up organically across New Orleans, often in tents and largely run by volunteers. Eventually, a number of these locations, including ones operated by universities such as Tulane and LSU, faith based organizations and government, transitioned into more permanent structures. By October, 2005, barely a month after Hurricane Katrina struck the city, planning for a redesigned health care system had begun under the auspices of the U.S. Public Health Service. Through the winter of 2006, the Bring New Orleans Back Commission, the Louisiana Recovery Authority and its Public Healthcare Sub-Committee worked to devise a patient centered, prevention oriented, community based system supported by cutting edge health information technology that would offer access to patients regardless of their ability to pay.
During the past five years, the health providers that constitute this new system have increasingly integrated their efforts. 504HealthNet is a result of this process. Seventeen of the new community based health providers belong to the network, whose goal is to coordinate their efforts among themselves, as well as with the larger health system, to optimize results. My guide to this new model was Karen DeSalvo, M.D., the Vice Dean of Community Affairs and Health Policy at Tulane University School of Medicine, who generously took time from her busy schedule to arrange visits by me over several days to a number of participating community health centers.
My first stop was the Tulane Community Health Center at Covenant House (TUCHC), across Rampart Street from the French Quarter. TUCHC began as a first aid station in Katrina’s aftermath and now provides comprehensive primary and mental health care to 10,000 downtown New Orleans neighborhood residents. The majority of the patients are middle-aged, working poor individuals, approximately 60% African-American and 12% Latino, whose preferred first language is Spanish. Slightly more than half of patients are women. During my visit, I followed Adrian Calvin through his appointment.
Mr. Calvin, 43, suffers from diabetes. He began his visit by having his blood sugar level checked by Nurse Lakeesha Allen. From there he proceeded to Dr. Eboni Price’s office for a consultation and examination.
Mr. Calvin’s diabetes is relatively severe, affecting his ability to work. He told Dr. Price that he had been having problems with his vision and that his feet were often numb. Although he said he was trying to follow his diet and medication regime, he was having a difficult time, partly due to his inability to afford all the medications he needs. “Sometimes I just feel like giving up,” he said at one point.
Dr. Price encouraged Mr. Calvin to maintain his course of treatment and suggested that he apply for Medicaid, which, with the help of Case Manager Tawana Ewing, he did. However, for an adult in Louisiana to qualify for Medicaid, they must be a parent or disabled, having an income of less than 12% of the federal poverty level if not working, and 23% if a working parent. Mr. Calvin is not a parent, so he would only qualify if he were determined to be disabled and not working with an income less than 12% of the federal poverty level.
“I’m too young for all this,” he told me, shortly before I left for my next appointment.
From Covenant House, I headed out I-10 East and the Chef Menteur highway to the Tulane Community Health Center in New Orleans East. This center, in an almost exclusively Vietnamese language shopping center storefront, opened in August, 2008 with Tulane partnering with the local community and the Mary Queen of Vietnam Community Development Corporation. The center provides adult primary care, preventive care, including vaccinations, obstetrics and gynecology services and mental health services. It serves a population that is 65% Vietnamese and 15% Latino, with the remaining 20% consisting of predominantly African-Americans. English, Vietnamese and Spanish are spoken and the center serves all clients regardless of insurance status or ability to pay. While there, I sat in on a visit by Trung Cong Huynh.
Mr. Huynh, a construction worker, had come in because he was having some breathing difficulties, primarily due to congestion. Dr. Tuan Nguyen knows Mr. Huynh well, characterizing him as a generally healthy and robust middle-aged man. After discussing his symptoms with him, in Vietnamese, and performing a basic physical examination, Dr. Nguyen concluded that Mr. Huynh was likely suffering from allergies. He recommended an over-the-counter decongestant and sent him on his way.
Next morning I rendezvoused with a Tulane Community Health Center Mobile Clinic in the parking lot of the Winn-Dixie in Gentilly. Part of the “On the Road” program, this custom built bus, with a team including a doctor, nurse, social worker and driver/data entry technician, provides a mobile medical home for adults and children in neighborhoods still lacking permanent health care facilities. On board, I observed Patrice Brown’s appointment.
Ms. Brown, like Mr. Calvin at the Covenant House clinic, had come in for a check-up primarily related to her diabetes. In the small examining room, Dr. Chukwunomnso Dennar began by asking Ms. Brown if she was following her diet and medication regime. She replied, in a lighthearted tone, that she was trying, but that she often slipped up, adding that she felt good nonetheless. Dr. Dennar took this in, then without criticizing Ms. Brown, explained the nature of diabetes.
The disease, he told her while diagramming its course on the examining table, is chronic and progressive. Without effective treatment, it will eventually cause blindness, loss of limbs, heart attacks and strokes, among other unpleasant developments. He emphasized that the goal of maintaining her diet and medication regime is to reach the end of her life, hopefully at a ripe old age, without suffering any of these afflictions. It was hard for me to tell how convincing he had been, but Ms. Brown did appear to be paying attention.
After the tutorial, Dr. Dennar performed a physical examination of Ms. Brown, apparently finding nothing unexpected. Her appointment ended with her, still in a jocular mood, discussing her life in general while Dr. Dennar entered information about her condition on his laptop.
My penultimate working morning in New Orleans, I went to the St. Thomas Community Health Center, just off Magazine Street a couple of miles south of the Quarter. After a short wait, I was surprised to find myself ushered into the office of Dr. Don Erwin, the President and CEO of the Center. Dr. Erwin is a tall, distinguished gentleman, old enough, I believe, to be considered a doctor of the old school. He was obviously intent on conveying to me the nature and history of St. Thomas, and its relationship with 504HealthNet.
St. Thomas Community Health Center is the successor to the St. Thomas Health Services Clinic, which was started by Sister Marion Puerzer and Sister Jane Meurschel of the Sisters of Charity along with resident leaders of the St. Thomas Housing Development, then the largest public housing complex in the United States. The St. Thomas Housing Development Resident Council and the St. Thomas Irish Channel Consortium worked together to develop a community driven, accountable, anti-racist healthcare model, including requiring health care providers at the clinic to receive special training in addressing racism and poverty. Unfortunately, Hurricane Katrina wiped out the St. Thomas Health Services Clinic, forcing it to close. With the help of a long and impressive list of benefactors, the St. Thomas Community Health Center replaced it, beginning while the destruction Katrina caused was still wet.
Dr. Erwin made it clear that although the public housing complex is now closed, the relationship between the St. Thomas neighborhood and the Health Center remains at the heart of the Health Center’s mission and purpose. He spoke protectively and with obvious affection of the people the Health Center serves. And it is the potential effect that 504HealthNet might have on this unique relationship that gives him pause.
Essentially, Dr. Erwin is concerned that the St. Thomas Health Center might lose control of its own destiny and identity by becoming part of a larger entity with its own agenda. He said that he had seen this happen too often when powerful interests had put their own priorities over those of the people they were supposedly organized to serve.
“You know, a lot of these experts think people are stupid because they’re poor. But they’re not. They’ll tell you exactly what they need if you’ll just listen to them.”
So Dr. Erwin’s priorities are clear. He will support 504HealthNet only to the extent that it supports St. Thomas and its mission. While he believes that 504HealthNet has great potential, he’s keeping his powder dry until he sees how things develop.
“It’s too early to know if it will be a success or not. Maybe in a year we’ll know.”
My last stop was the Daughters of Charity Health Center, a new facility on South Carrollton Avenue not far from Xavier University. The Daughters of Charity have been providing healthcare to New Orleanians since the early 1800’s and the Health Center, which is part of Daughters of Charity Services of New Orleans, offers primary and preventive care for infants, children, adults and seniors. During my visit, I attended a routine examination of a two month old infant, Deianka McGuffey.
Deianka was brought in by her mother, Bianca Walker, and her big sister Dernee. The first order of business was a weigh-in. Medical Assistant Maria Cuellar carried Deianka from the examining room to the scale located in the hall near the station desk, causing quite a stir as Sister Mary John Code and Medical Assistant Carman Izaguirre momentarily abandoned their posts to have a look at the infant. Gently placed on the scale by Ms. Cuellar, Deianka weighed in at seven pounds, nine ounces. Returning to the examining room, Ms. Cuellar arranged Deianka on the examining table, putting her yellow booties and knit cap on her to keep her warm until Dr. Denise Woodall-Ruff, her pediatrician, arrived.
Dr. Woodall-Ruff began by asking Ms. Walker questions about the general state of Deianka’s health, which appeared to be good. She noted that she had gained weight at a normal rate since her last visit. Dr. Woodall-Ruff then began her examination by listening to Deianka’s heart, lungs and abdomen before examining her navel to be sure that the stump of the umbilical cord was healing properly. She then turned her attention to Deianka’s head, examining her eyes, mouth, throat, and ears. Lastly, Dr. Woodall-Ruff checked the development and flexibility of Deianka’s legs, ankles and feet. On all counts, everything appeared to be in order. Deianka’s visit ended with her mother playing with her as Dr. Woodall-Ruff entered the results of her examination on her computer.
My visits to the 504HealthNet affiliated health centers convinced me that the system is, in fact, a patient centered, prevention oriented, community based system supported by cutting edge health information technology that offers access to patients regardless of their ability to pay. However, patients’ ability to pay, or lack thereof, is perhaps the fly in the unguent. Currently, the system is supported by a variety of methods, including sliding scale fees, but primarily by time limited federal grants and philanthropy. Policy reforms to realign state-based health care financing are needed to establish a solid, reliable financial basis for the system. Should these reforms be accomplished, 504HealthNet could well become the national model its organizers aspire for it to be as the Health Care Reform Bill is implemented.