[StBernard] Health care debate takes new directions on campaign trail

[Westley Annis]

Health care debate takes new directions on campaign trail
Posted by Jan Moller, Capital bureau September 29, 2007 9:26PM
Categories: Breaking News
BATON ROUGE -- The health-care debate in the state Legislature used to boil
down to a basic question: How can we balance the budget? 

That was before Hurricane Katrina wiped out large chunks of the hospital
infrastructure in New Orleans and gave rise to multiple blue-ribbon
proposals for how to restructure a delivery system that many view as
outmoded and inefficient. 


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"The discussion was, 'Where do you make your cuts in Medicaid?' " said Dr.
Fred Cerise, who headed the state Department of Health and Hospitals under
Gov. Kathleen Blanco until this month, when he took a job overseeing the
Louisiana State University health-care system. "It's less of a focus on
money right now and more of, 'What's the appropriate delivery system and the
way to provide access?' " 

As Louisiana prepares to elect a new governor, the changes started under
Blanco remain incomplete, and the much-discussed effort to build a
replacement for Charity Hospital in New Orleans is still in its infancy. And
even though the state's budget shortfalls have been replaced by record
surpluses, Louisiana languishes at or near the bottom of almost every
national health-care indicator. 


>From obesity and cancer rates to infant mortality and overreliance on

emergency rooms, Louisiana seemingly has nowhere to go but up. 

Into this breach steps four major gubernatorial candidates: Democrats Walter
Boasso and Foster Campbell, independent John Georges and Republican Bobby
Jindal. While they agree on the need to build a new teaching hospital in New
Orleans, they differ on the scope of the facility and the best way to care
for the 41 percent of Louisiana residents who are either uninsured or rely
on the Medicaid program to pay for their care. 

Meanwhile, the budget crunches that have bedeviled previous administrations
figure to return, if not next year then certainly before the next governor's
four-year term is finished. Health-care costs continue to rise faster than
the public's ability to pay for it, and there is widespread agreement that
Louisiana cannot cover the uninsured without incurring substantial new
costs. 

Coverage plans differ 

"The surest way to make (improvements) happen is to provide coverage for an
uninsured person," said David Hood, who was Health and Hospitals secretary
under Gov. Mike Foster and is now a senior researcher at the nonpartisan
Public Affairs Research Council of Louisiana. "Once you give that person an
insurance card or a Medicaid card, they're going to seek out care that's
more convenient, that they believe is better." 

Critics, however, say that covering more people won't produce a healthier
population unless the state makes fundamental changes to the way it provides
health care. They point to Louisiana's experience in the federal Medicare
program -- which works like private insurance -- where the state spends more
per recipient than any other state and has the worst quality results. 

While all four major candidates favor a stronger emphasis on preventive and
primary care, they differ markedly on how to achieve it. Nowhere is the
difference more stark than in the candidates' ideas for the financing and
governance of the Charity Hospital System, Louisiana's network of 10
state-owned hospital that provides most of the care for Louisiana's 700,000
or so uninsured. 

Most of the care in the Charity System is financed by $1 billion in state
and federal "disproportionate share" Medicaid dollars that go to the
uninsured, a financing stream that's long been eyed by reformers and private
health-care interests. 

Blanco's plan involved spreading some of the money to HMO-like "medical
home" networks of neighborhood clinics and specialists for the uninsured,
while expanding the Medicaid program to cover low-income parents of minor
children. 

Three of the four major candidates want to tap at least some of the money in
the Charity System to buy private coverage for the uninsured, or to help
private and nonprofit hospitals defray some of the costs they incur for
treating the indigent. 

It's an idea that has strong backing from the state's private hospitals,
insurers and business groups and was the cornerstone of an overhaul plan
proposed last year by the Bush administration. A modified version of the
Bush plan -- put together by private hospitals and insurers and focused on
the New Orleans area -- is due to be released soon. 

Of the major candidates, only Campbell says that money should stay within
the state hospitals, arguing that any diversion of cash from the Charity
System would "tear a hole in the safety net." As he does on a range of
issues, Campbell uses questions about health-care policy as an occasion to
plug his signature issue: a 6 percent tax on oil and gas processing that
would replace the state income tax and leave the state with money to pay for
a host of new priorities. 

The biggest problem with Louisiana's health-care system isn't the model of
care, but a lack of financing, Campbell said, adding that he would work to
provide a new pool of indigent-care money for private hospitals and clinics.


Subsidizing care 

Supporters of pouring indigent-care dollars into insurance products argue
that fewer people would need safety-net care as more people get covered,
while costs would gradually stabilize as fewer people rely on emergency
rooms for routine care. 

Boasso, who had little to say on health-care policy during his single term
in the Senate, pledged to "strengthen" the Charity System, but also would
plow part of its financing stream into private insurance. A policy paper
issued by his campaign does not spell out how much money he would commit to
such a program and expresses support for the "medical home" concept advanced
by Blanco. 

Boasso's plan is similar to the Bush approach, which would have used most of
the indigent-care dollars in the Charity System to buy private coverage for
319,000 low-income uninsured people. The Bush plan was not pursued by state
officials, who complained that it was unaffordable and would leave hundreds
of thousands of people without insurance or a medical safety net. 

Jindal, who served as health secretary under Gov. Mike Foster and as a
federal health policymaker under President Bush, offers a plan that also
dovetails with Bush's emphasis on using tax dollars and other incentives to
subsidize private coverage. 

Jindal said his approach would essentially split the difference between
Blanco's approach and the Bush administration. He said he would steer money
from the Charity System into Medicaid "waiver" programs, where state and
federal tax dollars would be mixed with financial contributions from
companies and their workers to provide insurance for the working poor. 

But, he said he would continue to leave substantial dollars in the public
system for the uninsured. 

Georges said he would shuffle some dollars from the Charity System to the
private and nonprofit hospitals that have seen a sharp uptick in uninsured
patients since the storms. Unlike Boasso and Jindal, however, Georges does
not explicitly call for using that money to buy insurance. 

Teaching hospital needed 

The candidates also differ in subtle ways on the proposed New Orleans
teaching hospital, a $1.2 billion, 484-bed downtown edifice that would serve
as the main hub for medical students and post-graduate residents from
Louisiana State University and Tulane University. 

All four candidates said a new hospital is needed and expressed support for
the collaboration with the U.S. Department of Veterans Affairs. But while
Campbell supports the cost and configuration that's been proposed by a state
consultant, Jindal and Boasso questioned the size of the facility, and
indicated they might push for a smaller, less expensive facility. 

Georges did not venture an opinion on how big a hospital should be built.
But like the others, he said a key to the success of the hospital would be
its ability to attract paying patients with private insurance as well as
those who don't have insurance. 

The candidates also differ on how they would handle the smaller regional
hospitals in the LSU-run Charity System, including those that have little or
no role in doctor training. Jindal and Georges favor turning over more
control to regional authorities, bringing Louisiana more in line with the
other 49 states. 

Jindal's plan would guarantee each area of the state a level of
indigent-care financing but give local officials more power to decide how
and where that money should be spent. 

Campbell said he favors the current statewide approach by which LSU and the
Legislature provide a budget for each of the state hospitals. 

LaCHIP program works 

One of the few exceptions to Louisiana's poor health-care performance is the
LaCHIP program for children of low-income working parents. Outreach efforts
by the Blanco administration have brought more than 100,000 children onto
the public insurance rolls, and Louisiana is tied for 10th nationally in the
percentage of eligible children who are signed up for the program. 

The Legislature this year voted to expand the program to cover children in
families that earn up to three times the federal poverty rate, or about
$62,000 a year for a family of four. But new rules issued last month by the
Bush administration forced the state to scale back, and the current plan is
to expand eligibility to 250 percent of poverty. 

All four major candidates support the program, and said they would continue
the state's effort to beef up enrollment and cover children in
higher-earning families. 

The LaCHIP expansion is a particularly touchy issue for Jindal, who recently
voted against a bill to expand the scope of the program and skipped a vote
on the matter last week. While Jindal supports the state's effort to expand
eligibility to 300 percent, he wants to change how the program is
administered. LaCHIP is run by the state, but Jindal would give private
insurers an opportunity to compete for that business. 

Incremental approach 

In the New Orleans area, the next governor will likely be asked to consider
the "RightCare" plan, which is the name of the proposal being advanced by
the Coalition of Leaders for Louisiana Healthcare, a group that was formed
in February after federal-state negotiations on an overhaul broke down. 

According to a draft, the "RightCare" plan, which is due to be released this
week, aims to provide coverage for up to 80,000 low-income uninsured
residents using money that now flows largely to the LSU system. Numerous
business groups and private hospitals back the plan. 

People enrolled in the plan, which would cost an estimated $135 million to
$210 million a year, would have a choice of "medical homes" where their care
would be coordinated by a primary care physician. 

John Matessino, president of the Louisiana Hospital System who helped
develop the plan, said the problem with the previous post-Katrina overhaul
plans was that they tried to do too much, too soon. 

"We have always said that any of these changes need to be done
incrementally," Matessino said. "To try to do everything in one fell swoop
is not going to work." 

Jan Moller can be reached at jmoller at timespicayune.com or (225) 342-5207.