The State of Mental Health Care in Post-Katrina New Orleans

• Author: Heather D'Antonio.
• Pages: 661-689

I would like to thank Professor Michael Malinowski for his guidance as I prepared this Comment. I would also like to thank my family and friends for their unconditional love and support.

"Laws that are ambiguous prevent agencies from acting rapidly and decisively in an emergency."¹

Page 661

I Introduction

Hurricane Katrina devastated every aspect of life in New Orleans-notably, health care. While all fields of health care remain in crisis more than two years after the storm, particularly startling is the crippled state of mental health care in New Orleans. The problem with recovery of the mental health care system in New Orleans presents itself in three prongs: (1) the surge of mental illness resulting from the devastation; (2) the delay in acquiring health insurance following the storm; and (3) the general breakdown of the New Orleans mental health care infrastructure. In addition to the listed hurdles, any attempt to remedy the problem has been marked by incongruity among the state, federal, and local Page 662 governments and entities. Before and after Katrina, this incongruity manifested itself in an overwhelming bureaucracy in Louisiana's health care system and has created a culture of reactivity and shortsightedness in all areas of health care, including mental health care.

This problem demonstrates the need to streamline the administration of mental health care in a manner that can address all possible issues concerning mental health, rather than force disjointed agencies to manage with a fragmented set of statutes and regulations. In discussing the need for such a comprehensive, direct law, a medical scholar stated, "Laws that are ambiguous prevent agencies from acting rapidly and decisively in an emergency."² The Louisiana Health Emergency Powers Act (LHEPA),³ which has adapted provisions of the Model State Emergency Health Powers Act (MSEHPA),⁴ seems like a plausible prototype for such a project, as it addresses response to medical emergencies. However, the LHEPA and the MSEHPA primarily focus on health emergencies resulting from biological terrorism, which is not the concern of this Comment.⁵ Instead, Louisiana and New Orleans are faced with a different type of terror-a mental health pandemic. However, the LHEPA, with the supplementation of various existing statutes and regulations, and the continued supplementation of the MSEHPA, can be tailored to address the current and future mental health care needs of the state.

This Comment will address the state of mental health care in New Orleans before and after Katrina, with an emphasis on weaknesses exacerbated by the storm. Part II of the Comment addresses the overall state of health care before Katrina, focusing Page 663 on the deficiencies in mental health care. The remainder of the Comment illustrates specific issues in mental health care that have arisen since the storm.

Part III discusses the rise in psychological illness since the storm demonstrating the urgency for resolution of the problem. Part IV addresses the difficulties in acquiring insurance immediately following the storm and how these difficulties contributed to the failing mental health of the New Orleans area population. Part V describes the current failing condition of the mental health infrastructure, with a comment on how Governor Bobby Jindal plans to address the problem. Each section includes background information specific to the issue; an explication of any federal, state, or local response to the issue after the storm; and an analysis of the strengths and weaknesses of the law affecting the issue. Part VI proposes consolidating the law of mental health care in order to more efficiently administer care. Specifically, Part VI proposes streamlining a statutory response to mental health care emergencies within the provisions of the LHEPA in a manner that directly addresses the flaws that were exposed in the response to Katrina. Finally, Part VII provides concluding thoughts on the magnitude of this problem as well as general recommendations.

II Background: Health Care in Louisiana and New Orleans Before Hurricane Katrina

Hurricane Katrina amplified the flaws of an already failing health care system.⁶ In 2004, the year before the storm, Louisiana ranked fiftieth overall in the United Health Foundation's assessment of the adequacy of state health care systems.⁷ One of the factors that led to this ranking was the extremely low rate of insurance coverage among Louisiana citizens,⁸ which left about 20% of the population uninsured.⁹ Medicare coverage apparently accomplished little in ameliorating insurance problems; in 2003, Louisiana was last in the national rankings for overall Medicare quality, even though the state ranked first in overall Medicare Page 664 expenditure per capita.¹⁰ Governor Kathleen Blanco recognized the lack of health insurance as the "core" of Louisiana's health care problems.¹¹

While lack of insurance may be at the root of the problem, the outward manifestation of Louisiana's health care problems has been a culture of reactive medicine that developed throughout Louisiana, creating a dependence on inpatient and emergency car1e2, rather than less expensive outpatient and preventive care.¹²Particularly, there has been a dependence on the State's Charity Hospital System, especially for the mentally ill.¹³ However, in the years before the storm, the efficiency of the Charity System fell under scrutiny.¹⁴ First, the majority of patients who sought care in the charity hospitals often had no insurance, rather than just insufficient insurance.¹⁵ As a result, the charity hospitals regularly received no reimbursement for the expensive emergency care that they provided from resources such as Medicare and Medicaid.¹⁶ As Louisiana has been ranked among the highest in the nation in emergency room visits, dependence on this emergency care created a serious financial problem.¹⁷ The dilapidated state of the Charity Hospital System in New Orleans and the threats of removing; its status as a level I trauma center evidenced this under-funding.¹⁸ In an effort to improve the management of the hospitals, the legislature transferred the authority of the Charity Hospital System from the State to the Louisiana State University (LSU) System in 1997.¹⁹ Page 665

While there is a remedy to this funding problem, in reality it only contributes to the culture of reactive health care in Louisiana by perpetuating dependence on charity hospitals. The system is called "disproportionate share hospital" funding (DSH) and is Louisiana's means of paying for the health care of its uninsured.²⁰Under this mechanism, for every thirty cents that the state invests in facilities like Charity Hospital New Orleans, the federal government will "match" the dollar. Accordingly, for every three dollars that the state invests, the federal government will invest seven. The benefits of this program are potentially great, as about $1.5 billion was allocated for Louisiana DSH funding in 2007. However, Frederick Cerise, Secretary of the Louisiana Department of Health and Hospitals (DHH), expressed his concerns about the program to United States Congress. He critiqued the program for only allowing DSH contributions for hospitals and not providing for preventive, clinic-based services. So, this DSH mechanism fosters the more expensive hospital-based care and therefore the culture of reaction rather than prevention.²¹

In the months before Katrina, problems specific to mental healthcare in Louisiana were also coming to the forefront. On July 1, 2005, about two months before the storm, Governor Blanco convened a panel to discuss improving Louisiana health care. On the topic of mental health, the panel noted that "nearly 900,000 Louisianans-about one person in five-suffer from a mental disorder, but there is no coherent state-run system for treating them."²² Specifically, several agencies had been charged with the administration of mental health care, yet no clear division of responsibilities existed among them. Furthermore, the agencies did not communicate with each other in the provision of mental health care.²³ Perhaps this unclear delegation of authority can be blamed for a cut to mental health care funding one month before the storm. When the DHH noticed an increase in the number of mentally ill patients being treated at state facilities, it attributed the patient increase to a lack of oversight. More specifically, the department blamed the increase on failure to note patient improvement and to encourage releases, the supposed result of insufficient and Page 666 infrequent patient evaluations. For this reason, the Department cut funding to the facilities.²⁴

III The rise in mental illness since hurricane Katrina

Since Hurricane Katrina, the incidence of psychological illness has increased. Just after the storm, it was estimated that Hurricane Katrina "[would] cause a 30 to 40 percent increase in the number of Louisianans needing mental health treatment . . . ,"²⁵ and it was "estimated [that] 380,000 Louisianans [would] develop post-traumatic stress disorder." These predictions have proved to be an underestimation. A recent study by the Department of Psychology at the University of New Orleans has concluded that cases of mental illness have actually doubled since the storm.²⁶

There are several factors contributing to this effect. Because of evacuation and prolonged relocation, many mentally ill patients did not have access to their physicians or their medication for an extended period of time²⁷ and were separated from their needed social...