During the week leading up to Christmas, Red and I had an extended e-mail debate about a difficult topic, made
worse because one of us is passionate for it and better informed (a deadly combination) - events in Louisiana, and the complications of efforts to rebuild and redevelop the area.
And if you couldn't guess - I was the less informed, dispassionate one.
Specifically, we were discussing plans, announced around Thanksgiving, to build a massive new hospital complex in New Orleans, combining a new VA Medical Center and LSU's need for a new Medical Center into one huge project. That, in turn, would allow LSU to abandon and probably tear down Charity Hospital, one of the symbols of the devastation caused by Katrina, when floodwaters and an emergency evacuation of all patients afterward led to the hospital's closure. It has never reopened.
LSU has claimed that reopening Charity is a hopeless task - if the basement, which sustained the flood damage, could be fixed (they say it can't), they would still, they say, also need to refurbish or rehab the rest of the structure. That's an expensive, time consuming project, they say. And the City and State largely agree. Others dispute all of it - both that Charity's damages are so severe, or that refurbishing it would be so complex as to be impossible.
So... this plan to build a new hospital. And the opposition to stop it.
Oh, and by the way... the new hospital would not have Charity's explicit mission to provide care first and foremost to the city's neediest.
The aptly named Charity system was Louisiana's approach to public hospitals; now, when those hospitals have become an expensive drain on budgets, Bobby Jindal is moving to close or privatize the whole system. New Orleans is actually his simplest case, since Charity is closed; in Baton Rouge, which has seen a huge influx of poorer people - mainly refugees from New Orleans - the idea of losing a hospital serving poor populations is even more controversial and problematic.
Along with closing the hospitals, Jindal is moving to reform the Medicaid system in Louisiana, historically one of the nation's worst. Here, Jindal's experience as head of Health and Hospitals in state government may well make a difference: more than any other national GOP figure, Jindal has shown some real savvy in the proposal to move Louisiana's Medicaid system to greater availability (it reaches, right now, only a sliver, the poorest, of the actual poor in the state), by moving to Managed Care, and attempting to use incentives to improve practice and reduce costs. These are reforms that are long overdue, and have been a key element of some of the most creative reform proposals on the left.
But the hospitals proposal is a different, more problematic solution. Abandoning a system of public hospitals may make sense in the long run - care that is delivered more by clinics and other settings will reach more people and cover more needs - but there's no real alternative in existence yet, which means the likelihood would be closing hospitals... and leaving people with nothing. That's no answer. And it's why activists for the poor are up in arms.
Even worse, though, is the New Orleans proposal. Activists have been trying to derail the plan, which would raze sections of a historic neighborhood in downtown New Orleans, most recently by filing a lawsuit aimed at forcing LSU to reopen Charity, if not completely, than in some form as a provider of basic services. They are right to ask just why LSU, which claims Charity can't be reopened, will fare any better with a huge complex attached to the VA, that won't be focused on care for the neediest populations.
Like many urban centers, downtown New Orleans has a glut of hospital beds all clustered in the same place - the Charity hospial (also called "Big Charity") sits between the current VA Center and Tulane's Medical Center, itself a top rated hospital. Moving the VA and LSU's hospitals will still put all the medical centers within six blocks. As Red noted to me, that leaves many residents of New Orleans, living in outlying neighborhoods still not remotely redevolped since the hurricane, with near 25 minute commutes - by ambulance - for care. Any sensible plan would try to spread care options out, not re-centralize them.
Still, the protests to "reopen Charity" are themselves problematic; LSU is not wrong to say that Charity may not be the best way to deliver care to the indigent that they really need. LSU is trying - too slowly, and without enough thought - to build more freestanding clinics to provide a range of services and provide care in the downtown area. Actually getting them open - which can be accomplished much faster than rebuilding Charity - would be a real boon. Moreover, at a time when health care reforms are a top of mind part of the political debate, one aspect not discussed enough is that urban areas need to reduce hospital beds, generally, not expand them. A behemoth like Charity is actually, in many ways a relic, and community redevelopment should not, necessarily, be married to preserving it.
Indeed, the real mystery in all of this has less to do with the controversy around Charity, and the more central aspect of the proposal no one has challenged: why does the VA need a new Medical Center in New Orleans? The VA Medical Center was completed in the eighties. It is hailed, on their own website as a terrific facility with great services. Why knock it down and move the whole affair six blocks? The biggest problems of avalability of hospital services for the poor in the area could probably be greatly improved, simply and elegantly, by opening some VA space (they surely have it) to care for the poor who are not Veterans. That's the kind of limited vision in healthcare which is holding us back.
As I said to Red, one of the problems here is that Hospitals are, in many ways, like upscale sports stadium projects: they make great announcements, you can show architects drawings, they sound like income generators... and few ask the hard questions of why they're needed or if the land use and tax abatements they gte don't make them expensive, needless propositions in the long run. Ray Nagin, already vastly discredited, surely needs an announcement like the one he made around Thanksgiving to salvage his record from total irrelevance; Jindal, too, needs the lift of appearing to tackle the economic and urban issues of post-recovery New Orleans.
Hopefully, their half-baked plan (it's not clear that LSU can just abandon Charity, or that anything approaching the necessary funding exists), will die before it can be started... though for residents in the area, that may be cold comfort when their houses are threatened with imminent teardowns. Even more hopefully, the new year and new political structures will help even more to put the brakes on (it's hard to imagine Obama's VA pursuing this plan). But all of this is a painful reminder of how little progress has been made in New Orleans, and how much of the progress that has occurred has been made on the backs of the neediest populations, with little regard for their well being or future lives. And the anger Red has for how awful the situation is and how few people see or understand what's happening... well, she's got me there, when all I've got is faith and hope. Which is why I think she won the debate. Now we have to see who wins the war - and who gets the charity.
Good post.
Why do you say cities need fewer hospital beds?
Posted by: Redstar | January 04, 2009 at 05:09 PM