committee will come to order it has been nearly four years since hurricane katrina devastated the new orleans region since then the area has struggled to regain its footing and slowly rebuild its neighborhoods businesses and critical services one area particularly hard hit by the storm was the region's health care infrastructure we could train a flooded the city and surrounding parishes many important hospitals and outpatient clinics were severely damaged and destroyed before the storm the low income population of the region often relied on hospital emergency rooms and mostly hospital based as its main source of primary care charity hospital which was a major public hospital and a source of many of these services particularly for the working poor and uninsured was flooded essentially destroyed it remain shuttered today because this and other critical health care facilities were destroyed many of the region's residents struggle to obtain health care after the storm those facilities that remain open particularly those willing to take the uninsured or poor had limited capacity and significant waiting times while eventually some organizations were able to open some clinics major health care delivery gaps remain for months and even years after katrina and july two thousand and seven the department of health and human services with money granted from congress to restore the gulf coast region provided a hundred million dollars grant to the state of louisiana this funding called the primary care access and stabilization grant was designed to restore the ex and expand critical primary care services to the region without regards to a patien ability to pay the grant was also intended to reduce costly reliance on emergency room use for primary care services for patients who were uninsured under insured or covered by medicaid the good news is that an impressive network of health clinics has the merge which are now providing critical health care services as of june twenty second two thousand and nine over eighty million dollars of their one hundred million federal grant had been distributed and these clinics are now collectively providing care for over one hundred sixty thousand individuals and the katrina affected region nearly half of whom are uninsured either because a region does not have a clear plan or when it will begin breaking ground on a replacement for charity hospital and because there are no clear plans on how to financially sustain these clinics part of the region's population faces and on certain future i am particularly interested in understanding what needs to be done to ensure that we preserve the critical health services these clinics are currently providing in addition it has now been more than four years since hurricane could in a destroyed charity hospital while a temporary facility is providing critical care to the region we will hear today that this interim hospital is reaching capacity four years isn't long enough for a plan for a replacement facility to sit in limbo and i look forward to hearing how and when we can expect a new hospital will be days following the storm and provided critical care to those who otherwise would have gone without and we thank you for that your story is an important one and needs to be heard i applaud your efforts and i  sure all my colleagues remain committed to helping you rebuild the new orleans region and today's hearing is one more step towards that end i will now recognize the ranking member  dallas of california for his opening statement thank you mr chairman and thank you for holding this important hearing although the devastation of hurricane katrina occurred over four years ago its affects on new orleans the new orleans region still being felt by its residents today the health care infrastructure was hit especially hard and has not fully bounce back the picture of health care in new orleans area still very bleak hospitals remain shuttered physicians are short in supply and many residents as you said nearly half are uninsured a key a key number of hospitals that serve the uninsured population prior to here hurricane katrina remain closed as a result of these closures many new orleans residents now go to outpatient clinics for care they the change this change in the cars is necessary our focus here today and in fact how to get to a healthier community with a permanent hospital remains a vexing problem that we will hear about today receiving early care and proper treatments will reduce overall cost and certainly reduce the strain on emergency rooms a primary care focus can reduce overall health care spending by eliminating emergency room costs room cost shifting unfortunately many clinics are filled to capacity in the region and as you said chairman the economic conditions in new orleans continue to prevent the river the rebounding of the robust economy that could in fact fund new hospital maintenance on a permanent basis the federal government has limited resources it is clear that we have to work together to find a way for the region to be self sustaining when possible but today we will hear that that is not possible today certainly we will also hear that a leading factor in the nationwide physician shortage is the high cost of medical liability insurance and malpractise insurance as a result of a broader health care reform is needed here in congress we need to look seriously at tort reform and bring healthcare cost that make delivery systems so expensive and inefficient down additionally as a as a chairman knows public house hospitals today have certain limited immunity from tort bills being considered in the congress here today which stripped that immunity thus raising the cost of public health and their liability insurance so i hope in addition to dealing with the devastation of hurricane katrina that lingers on in new orleans we will recognize that there is not unlimited amounts of money to pay for health unless health can be delivered in an efficient and effective fashion today we'll look at whether or not we can restore new orleans ability to have primary health care delivered in a way that is sustainable cost effective and will prevent the citizens from having either poor health or excessive trips to the emergency room as a chairman i thank you for your you're holding this hearing your back thanks very much for your statement and also your involvement in this issue over the years i would like to introduce our first panel of witnesses that will be testifying griffin president and c e o of daughters of charity services of new orleans and doc to roxanne atallah is an assistant vice president of health systems for lewsey louisiana state university and d diane rowland executive director and vice president of the hidden ridge a kaiser family foundation ladies and gentlemen it is a longstanding policy that all our witnesses us horny and so if you would stand and raise your right hand good morning mr chairman and members of the committee my name is dr karen de salvo and i'm a practicing primary care physician in new orleans i also serve as the director of the tulane university community health centers thank you for the opportunity to speak on behalf of my team and our patients and to update you on the progress of health sector recovery in new orleans the challenges ahead for sustainability of the community health network and described describes strategies that may help us sustain these gains and are now too familiar story the failure of the federal levee levees in august two thousand five resulted in the devastation of the greater new orleans community including our health sector in the face of this crisis that the community realized we had a chance not just to rebuild our city but to remake it into one worthy of our storch importance to our nation one that could be a model for others this vision extended to redesigning our health sector into one that would provide all our citizens with access to high quality affordable health care the rationale for remaking our health sector was simple for decades it had performed amongst the worst in quality cost and disparities any discussion of the ever redesigned new orleans health sector has to include consideration of the role of the public hospital the medical center of louisiana new orleans formerly known as charity hospital served as the principal source of care for hundreds of thousands of uninsured and underinsured persons in the region yet in spite of good intentions of the time of the storm the system was overwhelmed and underfunded primary care services offered limited hours that reflected the schedules of medical student trainees and other doctors rather than patients they generally did not to the same doctor on a current visit and if they missed an appointment it was a twelve month wait until the next available and most of the uninsured receive their care through emergency rooms as a result and there was also not an alternative network of community care to pick up the slack  closed because of the katrina related flooding as patients lost access to the chief source of care available to them into the vacuum created by this closure a grassroots largely volunteer effort emerged to provide care to land part of this was initially led by a handful of our medical residents who set up six urgent care stations on the streets of new orleans while the city was still under mandatory evacuation and partially flooded these trainees realized that people would need care particularly the low income and marginalized populations at tulane had cared for charity for the past hundred seventy years one of these makeshift first aid stations evolved into a permanent primary care site covenant house when the dust had settled stakeholders  to work to define a vision for a rebuilt health system the invision one founded upon community health care marked by quality and efficiency because the evidence is clear that this kind of framework leads to better health and it also leads to lower costs the public hospital needs to be part of this new model but it should not be the sole source of the primary care safety net in the spring of two thousand and seven i testified along with others about the challenges in health care coverage in post katrina new orleans we were less than two years from the disaster at that point and had much work to do to rebuild the community was unified in asking for assistance to shore up what had become our new paradigm of health care in our covering city community health the result of that hearing was the awarding of the primary care access and stabilization grant a reflection of the bipartisan support for the community based model of care tulane has used these p access to thousands by increasing capacity at our main site covenant house that once makeshift first aid station has grown into a robust comprehensive n c q i recognize patient centered medical home our team is proud to have built a program that offers primary care for a we have on site integrated mental health and resiliency programs we offer social work and legal aid services he's an electronic health record and we have active quality improvement and evidence based medicine programs are engaged in workforce training for physicians nurses social workers public health students and pharmacists all in partnership with local universities and also partner actively with community organizations and members to empower them to become physically mentally and economically healthier demand for our services been so high that was outgrown our space and will soon move to a new location in the same neighborhood our new site will be a renovated building that has been blighted since katrina and will serve as a cornerstone of economic development for that neighborhood tulane has also expanded beyond covenant house due in large part to the p c a she funding we provide high quality culturally competent care throughout the city from mobile unit school based health centers and a new primary care site in collaboration with america viet nam community development corporation in new orleans east the people we serve are mostly the working poor their employers do not offer health insurance and they are not poor enough to be eligible for medicaid others have lost their insurance recently when they have lost their jobs like a man i saw recently in new orleans east he'd been laid off and it was newly insured developed a new problem that caused him to visit the emergency room the night before he had been diagnosed with painful gout this is a genetic condition he suffers through no fault of his own and it was exacerbated by his complaints with his blood pressure medications the emergency room knew of our services sent him to us and now he integrated into our medical home and has has a medical team that will help him manage his care and he will not need to rely on emergency rooms in the future quite proud of what we have accomplished as an individual organization but perhaps more proud of the collective effort i believe our experience is a model program for other urban areas however my enthusiasm is tempered by the knowledge that in the fall of two thousand and ten the funding comes to an abrupt halt the quality network of care for a population of largely uninsured working poor will need to be scaled down dramatically perhaps as much as forty percent leaving some fifty thousand citizens or so without access to primary care and community health we will lose our gains from this investment and tens of thousands of citizens will have to revert to the old option of using expensive emergency rooms with the taxpayers ultimately be the burden of cost to line community health programs will not be immune from these cutbacks to prevent the loss of gains from this investment a set of strategies are needed and none alone are likely to be sufficient will be somewhere within the control of the community would funding for uncompensated care in much the same way hospitals are supported in the disk program we look forward to working with you in the ways in which we can vital component of the world's recovery thank you very much the witnesses because we have so many witnesses today we want to stay within thank you mr chairman and members of the committee we appreciate the opportunity to be brought together this morning to discuss the important issues involved in restoring health care services in new orleans the precut health care infrastructure was hospital very expensive and generally poor outcomes as you know many low income and uninsured people travel downtown to get their care and emergency rooms and clinics charity hospital a better system would be built on a solid foundation of primary care that would excuse me that would be located closer to people's homes and would be accessible as their health care needs arise that would provide continuity of care over the long term and it would coordinate care for people with chronic or more serious conditions who need to see specialist health services research indicates that primary care also yields better health outcomes at lower costs so building primary care and new orleans became a  priority in the wake of katrina especially for those on medicaid or the out adequate insurance my testimony today is based largely on our july two thousand and nine report funds to support primary care in the area the lion's share of the money was the one hundred million dollars grant lesser amounts of federal funds were provided through the social services block grant and the professional workforce supply grant as well more recent american recovery and reinvestment act funds for enhanced medicaid payments and additional federally qualified health centers the piece is intended to restore and expand access to primary care including mental and dental services as well as referral to specialty care and ancillary services like transportation in addition the organizations must have had the intent to be sustainable that is to be able to continue providing primary care after the grant in september two thousand and ten so far the twenty five funded health care organizations have provided more than one million health encounters over two hundred fifty thousand patients after the storm provider shortages were a major reason for disruption in health services we found that the grant organizations hire and retain physicians nurses and other providers they told us that this allowed them to increase access by cutting waiting two thousand and four and two thousand and six compared to a three percent increase in counties nationwide ten of the organizations hired both medical and mental health providers to alleviate service gaps and fifteen of eighteen we interviewed for our report on mental health services for children identified the lack of providers as a significant barrier other funds were used to renovate or relocate physical space so that providers could expand capacity through additional examination rooms and the purchase of new equipment despite the progress made organizations face challenges in establishing a full continuum of care with referrals to specialists and they are concerned about their long term sustainability most continue to have difficulties hiring and retaining staff due to persistent problems with housing schools and the overall community infrastructure in the greater new orleans area in fact her son has designated all four parishes as a health professional shortage area for mental health a designation that none had before katrina and most of the parishes a shortage areas for primary care and dental services in addition financing poses serious challenges although medicaid billing has increased and some are able to build private insurance at more than half of the organization's most of the patient populace  population and sometimes seventy percent are uninsured this is a daunting demographic given that nearly all the funding is temporary many reported that they intended to use health center program funding to improve their sustainability but with only sixteen percent of applicants awarded grants nationwide in fiscal year two thousand and eight it's unlikely they would all be successful in obtaining a grant l t h i provided  sustainability strategy guide to help them address a possible thirty million dollar annual shortfall in revenues recipients have completed and planned actions to be sustainable but it is not clear which ones will be successful and how many patients they'll be able to serve after the funds are no longer available with less than ten months remaining quickly implementing ways to pay for the large number of uninsured patients will be necessary to prevent disruptions in these vital services and to prevent the erosion of gains made in delivering primary care through this grant thank you very much mr grant  i'm the executive director of the lower ninth ward health clinic in new orleans louisiana and i appreciate the opportunity to be here to discuss the successful partnership of government and community to deliver health care services to the citizens of the new orleans region i want to first express my appreciation for the primary care access and stabilization grant which has been a lifeline for the uninsured and underinsured residents of the greater new orleans area the grant has an able to lower ninth ward health clinic as well as other health clinics to employ medical staff and provide health care services in new orleans which has been designated as we see it as a medically underserved area it is my hope that congress will recognize the critical need for our health clinics and take action to continue this fruitful collaboration which contributed significantly significantly to the recovery of the greater new orleans region before hurricane katrina i worked as a nursing supervisor at the charity hospital and the trauma surgery ward and during that time i observed many patients that were not insured and the reason why they were there were because they  access to primary health care services and these were unnecessary hospital inflation but to understand fully what is going on you have to understand that community which was most impacted by katrina you have to understand that this population was very vulnerable and they had poor out help outcomes because there were large numbers of new orleans residents living or at the poverty level th low education levels and high literacy rates there was a high dependence on the public sector by healthcare needs there were high rates of chronic illnesses high numbers of uninsured residents and the use of the emergency room was substituted for primary health care and there wasn't an adequate emergency preparedness and on august twenty ninth two thousand and five these factors collided with the worst natural and manmade disaster in the history of the united states creating a public health crisis of enormous proportions miss patricia berryhill a registered nurse and my colleague and i decided to confront the crisis head on by opening the ward health clinic on february twenty seventh and two thousand and seven this was the humanitarian mission that we have undertaken at the lower ninth ward health clinic and it is informed by the united nations guiding principles of internally displaced people a standard of care that is supported by you u s government to ensure the recovery of people around the world who have become displaced by a disaster principle nineteen of the guiding principle calls for comprehensive medical care and special attention into the health needs of displaced persons for displaced nor lenient these health needs involve the traumatic experience of the disaster and being uprooted from home as well as the physical impacts of not having access to life sustaining medications and treatment and as time passed no one came to the lower ninth ward a community separated from the rest of the city by a waterway called industrial  and historically the lower ninth ward was the last to observe obtain any services with that knowledge we opened the lower ninth ward health clinic in order to improve medical care needed by internally displaced people returning to new orleans many of whom have a history of adequate medical attention initially the clinic was staffed by volunteer medical providers of a time when many medical professionals who lived in the city were physically displaced by the disaster it was largely through the primary care the care access and stabilization grant that we were able to access the funds to employ and stabilize the medical staff purchase medications medical equipment and supplies and contract services for laboratory tests the grant also provided us with the capacity to raise funds from other sources today the lower ninth ward health clinic is proud to report that in the ploys to part time physicians with significant medical experience to medical assistance one clinical director and one executive director we serve more than twenty two hundred patients on an ongoing basis and over five thousand patients through initial medical visits we are grateful to provide a service that has not only contributed to the medical progress and positive health comes of our patients but also to their recovery and to the recovery of new orleans while we have made incremental progress there is still much work to be done in the areas of quality and disparity reduction with the adversity of this disaster there was also an opportunity to discard any effective treatments and try new innovative therapies to improve quality of care and reduce disparities the positive health care outcomes to date have been realized a large part because of the funding of the primary care access and stabilization grant we are eternally grateful to all members of congress and command past secretary of health and human services michael leavitt for his service and his leadership as well as his insightful actions with aided the new orleans region and receiving much needed funding for health care services we are looking for great anticipation to future public private collaboration which enhance and sustain the health care status of  our region and we are at a pivotal moment in the evolution of providing excellent health care services we must not forget we have an opportunity to change the trajectory of internally displaced people we are now position to do fund nominal things to improve the health and welfare of the people of new orleans and the gulf coast region thank you thank you very much for your statement dr irwin was number fifty four on the map that you have started in one thousand nine hundred seven is a community based clinic and one of the country's oldest housing developments prior to hurricane katrina the focus was its neighborhood and our programs defined by the availability of public and private grants budgets were small services were limited after hurricane katrina through the generosity of many the clinic reopened to provide health care for returning citizens and has since become one  community's largest and most comprehensive primary care centers with the p c a s g fund st thomas has gone from two point four f t e providers to eight primary care mental health providers we now have a staff of forty five people in an annual operating budget of four point five million dollars we have a patient base of fourteen thousand patients and provide over twenty two thousand patient visits per year although we use an open access appointment model we are still not able to meet the need to train and we saw patients from three to five local last year we saw patients from two hundred fifty one zip codes in three states in addition to primary care collaboration's have been made to provide our patients with specialty care and seven major medical specialties the specialty care offered and a primary care setting provides coordinated patients in it care and a cost effective way were also a training site for medical students residents and nurse practitioners as part of the c d c sponsored national breast and cervical early detection program administered by the el issues school of public health st thomas provides early breast cancer early detection with digital mammography involved for a year for over a year after katrina we were the only uninsured women and we continue to be one of only two in the region through a unique collaboration with clinic foundation the association of black cardiologist st thomas offers interventional cardiovascular care for the prevention of heart attack stroke and sudden death for uninsured patients this cardiovascular care generally unavailable or delayed for months included in my written testimony as a copy of a cardiac tracing shows have installed fourteen of them and uninsured patients with both the defense related and the cardiologist time being donated to st thomas and i would like for you to understand that this is just this this man is just one of the many thousands of lives that have been saved by this grant and their services provided all of the special services that we have available at st thomas are offered to any of that any patient of any of the safety net clinics in new orleans community as a result of the infrastructure made possible by the primary care access and stabilization grant st thomas has become a federally qualified health center and also a level three patient centered medical home recognized by the national committee for quality assurance we were recently notified that st thomas will be honored at the american college of physicians the second largest physician group in the united states which is this year warding st thomas its rosenthal award for the original approach to the delivery of health care in a way which will increase its clinical and or economic effect of this although st thomas has become a federally qualified center the and see grant of six hundred fifty thousand dollars makes up only fourteen percent of our annual four point million dollars budget we're unable to take full advantage of the augmented after the medicaid rates since only fourteen percent of our patients have medicaid seventy two percent of our patients remain uninsured although the medic percentage of medicaid eligible patients will increase in the future we think this will take at least two years without the funds provided through the primary care access and stabilization grant it is difficult to project continued viability for st thomas although we are steadily moving towards to saying ability was seventy two percent uninsured patients we do not expect to rip's have replacement revenue to support our operations until there is expanded medicaid eligibility certainly an early consequence will be the loss of the infrastructure necessary to support the policy and procedure requirements to remain a federally qualified health center and a patient center medical home and our business plan to put three years we project that in beginning think year three we could replace the revenues lost by the primary care access and stabilization grant in the intervening two years however we cannot of identify any source of adequate support nor do we see any other safety net site in our region which would cause absorb our patien as you've heard hurricane katrina created a new population of uninsured patients when the storm took people's homes jobs and health insurance p c s g e grant is unable to us to begin the restructuring of the delivery system in our state we're optimistic about th sustainability of clinics like st thomas if we're giving another two to three years for the recovery to continue but for the present if there is no bridge funding we anticipate that our patients will find themselves in the same situation they found themselves immediately coast post katrina where the only source of primary care was the crowded emergency rooms thank you very much for the opportunity to speak with you this morning and for your continued support of our community thank you very much for your statement mr griffin the morning the chairman chairman tiles congressman gal and other distinguished members on the members of the committee on oversight and government reform i'd like to thank you for allowing me to offer testimony in this public forum and ongoing health care concerns and challenges facing new orleans region post hurricane katrina my name is michael griffin and i'm with chief executive officer of daughters of charity services of new orleans a primary health care provider organization has roots in new orleans for one hundred seventy five years with services to the poor and vulnerable the daughters of charity services in new orleans are d c s you know is sponsored by since mission is to improve their health and well being of our community and we are dedicated to providing primary in preventive health care services which addresses the needs of a total individual body mind and spirit i welcome this opportunity inform me of how the primary care access and stabilization grant program has assisted us in restoring and improving the health delivery system in new orleans and what challenges are still before us when hurricane katrina struck the city of new orleans on august twenty ninth two thousand and five it severely impaired the health care delivery system medical and other support personnel were displaced in the city lost several hospitals and numerous primary care providers d c s you know was not sheltered from the impact of hurricane katrina we lost our one and only health center health center site to flooding in the aftermath of the storm yet as our history demonstrates to d c s a low board in a sense in hills would remain steadfast and committed to reason serving the poor and vulnerable in new orleans within forty five days after the storm we opened a new health center and the in the metro area next door to the department of health have it diminished capacity of the overall health care infrastructure in new orleans severely compromised continuity of care for low income and minority populations who are attempting to remain all return to the area katrina resulted in the loss of five hospitals one of which serves the vast majority of the medically underserved and poor after the aftermath of hurricane katrina was a litmus test which challenge d c s you know to improve access to her to health care services as additional locations throughout the metropolitan area with the goal of meeting primary care needs of the community at large it was because of primary care access stabilization grant awarded by the u s department of health and human services and authorized by congress that d c s and i was able to rapidly expand from one to three primary health centers in the area today today these health centers are currently providing primary care services to the under certain populations in the carrollton area the upper as a direct result of the primary care access stabilization grant funding d c s you know has been able in this past year to provide affordable and free care to twenty twenty thousand and thirty four patients tolling sixty five thousand five hundred in one patient visits seventy two percent of those patients are uninsured let me let me repeat that seventy two percent of twenty thousand patients are uninsured fifteen percent or medicaid five percent are medicare seven percent on other insurance d c s you know has experience unanticipated growth in this last year of a forty nine percent increase in our paper patient population since last july piece the primary care access stabilization grant funding allowed us to retain and hire new doctors we are offering free pharmacy services we  encourage partners like the unity foundation and the march of dimes to help fund mobile primary care units two of which are two mobile prenatal units and the other is one that treats the homeless and to restore our seton resource center for adolescent mental health development that offers behavioral health counseling services at ten public and parochial schools let me quickly tell you this story i'll share his brief story with you and uninsured my mother who didn't have a regular physician who recently attended a health fair staffed by d c s you know mobile unit and she had a history of hypertension cholesterol and glucose issues while having her testing done the woman expressed concerns about medicare to a medical provider about her daughter complaining of not feeling well she was constantly drinking water and going to the restroom she wondered if we could just take a look a quick look at her daughter we gave the nine year old a glucose test and found that the glucose level was above three hundred which was extremely dangerous  clinician recommended that the mother immediately take her child to children's hospital for further treatment the child was in fact admitted to children's hospital where the emergency where the emergency room doctors inform their mother that any prolonged high blood sugar could have resulted in a stroke or coma or or even death i tell this story because a demonstrates the type of community outreach we are doing it daughters of charity services in new orleans to help those who do not have health surance and our band or a family physician to call when the child gets sick i thank you chairman trials for this opportunity to testify before congress and thank you for your support will thank you very much mr griffin dr townsend statement thank you mr chairman members of the committee for the opportunity to to address you today regarding the status of health care in new orleans on behalf of the louisiana state university health system in addition to my role at the health system i also have the privilege right now of serving as the interim c e o to the public hospital in new orleans when hurricane katrina forced the closure of the medical center of louisiana  orleans we did lose critical infrastructure for health care we lost five hundred fifty inpatient beds at that time we were doing twenty three thousand patient admissions a year we had one hundred twenty thousand emergency department visits but something that's not often recognized and it's really important we did more than two hundred sixty thousand outpatient clinic visits in our hospital based clinics and that included primary care as well as specialty care we had over six hundred forty medical residen and fellows from louisiana state university and tulane university training at that hospital along with thousands of other students dental nursing allied health pharmacy it was a critical area for teaching for the wheezy an a for the workforce for the future we lost all of that in katrina and when you look at that the role of that facility it wasn't simply for the new orleans region it was a state wide resource where people who were uninsured can go to get specialty care oftentimes the specialty care isn't available to these folks even if they have a medicaid card in the rest of the state we lost all of that from katrina knowing the important role that this facility played i consider these people who stayed there during the storm and reconstituted services after as really true heroes they went from constructing tents in a parking lot where they continued to provide services they moved those tents into the convention center because it didn't flood so they at least had a roof over their head then they moved those tents into a former department store in the mall adjacent to the superdome once the flooding subsided and we continue to do specialty care and primary care clinics there today because it wasn't until november of two thousand and six that the former university hospital campus was able to be transformed and  reconstituted into an inpatient facility and that was through the work and collaboration of fema and l issue as well as louisiana's office of facility planning and control today we're operating two hundred seventy five beds about half of what we had before the storm with that we're running close to eighty five percent occupancy and as you look at hospitals across the country eighty five percent occupancy is full our i c u we have thirty six beds they stay full all the time we have thirty eight inpatient acute psychiatric beds for adults they are always full we also we also provide the only level one trauma center in south louisiana serving a nine parish area we have eleven operating rooms less than half of what we had the storm one of those always has to be on standby for trauma since we're level one so we are cramming all of our operating room cases into ten operating rooms in that facility and as a well respected physician in the community someone who was there during the storm and after the storm said we really are gaining stability but we're still pretty fragile we're probably one big bus wreck away from just crippling the entire system down there so we still have a ways to go one of the really excite things that did happen was through the generous funding of congress we got the primary care access and stabilization grant so we were able to bring six community clinics up after the storm associated with the interim hospital and this was different from before the storm where everything was pretty well located on campus now these six clinics are allowing quality patient care to happen close to where people live and the quality is evidence by a actually gave us recognition status of patients that are in medical homes in those community clinics the grant funding was flexible enough that we were also able to to provide some especially care services as we look at this this funding coming to a close we recognize that our role as an academic medical center is to support these primary care clinics so we are looking at consolidating some of those clinics into the bricks and mortar rather than the temporary buildings that they're in now but we see that access to the specialty care and inpatient care is extremely important so we're trying to partner with the community clinics that are still there that will hopefully survive after the primary care grant goes away so that we can give important services to those folks we don't just treat we also educate and we've got to do both of those together so i thank you for the opportunity to address the committee today you very much dr rowland thank you mr chairman and members of the committee i'm diane rowland executive vice president the kaiser family foundation and center can katrina has helped lead the foundation efforts to document the needs and monitor the progress in new orleans through to city wide surveys of new orleans residents in two thousand and six and again in two thousand and eight we are also planning our third survey in two thousand and ten just to be able to assess how the progress has been going all of our work underscores the importance of building a strong health care system to meet the needs of all residents of new orleans as part of making new orleans again a vital and dynamic system you have heard from all of our witnesses of the fact that new orleans did not have a fully operating system even before katrina and you have heard about the devastation that  on the city and on its health care system but the devastation was so widespread that it also brought an opportunity to establish and design a better system with community based services and integrated services for the poor an uninsured instead of a system based on a hospital and disproportionate share medicaid payments to help sustain it the public returning to new orleans had many of the same problems of the public that left new orleans many were poor and uninsured and many with chronic health problems so could train additional wipe away the problems of the residents of new orleans adequate medical care rebuilding medical capacity and the charity hospital system a stablish in care in clinics in neighborhoods were high priorities of the residents that we surveyed and came in next after rebuilding the levees which as you might imagine would have been their major concern and as we look at  redesigned health care system we need to look at the major elements that need to be put in place first and foremost health care coverage provides that means for people to access health care services and the financing to support a health care system for children in new orleans there is a success story today only eight percent of new orleans children are uninsured lower than the national average this is jill largely to the expansion of coverage through medicaid and  law chip program today in the city of new orleans over half of the children have medicaid it is their source of coverage which helps account for the lack of a large uninsured population but for adults in new orleans the story is very different louisiana among the poorest states in our nation one in four living in poverty has one of the most meager programs in terms of eligibility for adults in fact a working parent cannot qualify for the medicaid program if their income is over five thousand five hundred thirteen dollars a year or twenty five percent of the federal poverty level less than no coverage is available for childless adults and those who are in this city now we account for twenty nine percent of non elderly adults are uninsured these are the same levels of lack of insurance for adults as before katrina and these are the very individuals who are now seeking care through the community clinics they have been developed and who will need care in an ongoing manner until insurance coverage is made available attempts to improve stymied leaving these developing health systems to care for the largely uninsured adult population seventy two percent uninsured is an unsustainable level of care to be delivered in even a grant supported clinic and the good news though is that the community based system of clinics for primary care has been able to at least develop with the support of the federal grant funds it is decentralized it is in the neighborhoods where people live a forthcoming commonwealth fund study that is evaluating these clinics has found that the patient experiences show very promising results on quality on access and on efficiency for these clinics the investment in these clinics has helped to move a new model of care to the city of new orleans and appears to be bringing much needed care this judy's still substantial uninsured population but the bad news is that the future is to say inability of these clinics is in jeopardy largely due to the lack of coverage and while we all talk today about national health insurance and universal coverage as part of the health reform efforts those efforts are still not going to be phased in and thirteen or two thousand and fourteen leaving a huge gap right now for these clinics to be able to continue in order to provide them with the support they need coverage needs to be expanded many need to be able to become federally qualified health centers and there needs to be continued support for the uncompensated care that they provide to individuals who are uninsured even in the models of community health centers around the country we see that the mix of revenues that support them is grant funding from the federal government can bind with the payments for their insured patients through the medicaid program and finally a fully integrated health care system requires specialty care and ter capacity as you have just heard so reestablishing a teaching hospital with multispectral take care to back up the clinics is equally essential without improved coverage of adults combined with financial coverage for the uninsured the neighborhood primary care model will falter not in the carrot delivers but in its ability to sustain operations yet this is a critical building block for the future of new orleans health care and a critical building block as we look toward national health  reform i hope this hearing will help to shed light on the needs of these clinics in the ability to provide services to the uninsured and the low income population of new orleans thank you for this opportunity thank you very very much let me think all of you morning i think that most importantly the threat of backsliding on the progress that has been made so far in the primary care foundation is something that we would not want to see these clinics now in this primary care foundation that's been built is in an expanding mode it's in a growth mode and reverting back to a less effective system where people would have to route to seek care in an emergency room would be more expensive than would poor outcomes as you've heard in addition like emergency rooms around the country they're already at capacity so it would be very dire to lose these primary care  clinics doctor all mr chairman i know your concern is for the people of new orleans and i think what these clinics have demonstrated is that they need access to care there are severe gaps in their ability to get the care they need we know that uninsured people get less care than those with insurance and that they live sicker and die quicker so i think it's an investment not only in the clinics themselves but especially in improving the health care of the people of new orleans and many of the low income population they are suffer from multiple chronic conditions that are not readily available to emergency room care so i think you really need to have in place a good primary care network and to sustain it but thanks very much let me raise this question w down the line the lower ninth ward health clinic is moving toward sustainability by making sure that we are medical providers medicare providers and private insurance providers we came up a little bit differently because we came up post katrina truly a grassroots effort so we are putting those different place so that we can become more sustainable  st thomas is a federally qualified health center and as such we get federal funds from that as i mentioned in my testimony that the financial base is required that we have a sliding scale that we have increased our patient revenue money from funds from patient revenues from zero two years ago three years ago to estimated four hundred twenty thousand dollars this year seventy two percent uninsured population it's just very hard for us to find any kind of viable revenues that could replace this money until there is some expansion of medicaid that there will be  at the beginning year three st thomas will actually be able to replace three million dollars that we lose would lose from the primary care access and stabilization we expect to be self sufficient in your three on the business plan and we say we charge everyone there that can pay we get a sliding scale and we've asked the patients to take responsibility for helping us be viable  also are evaluating our expenses and looking at our care management model which is pretty comprehensive see how we can be more efficient and also looking at fundraising   it's forty seven billion right now they've narrowed it we're a state that taxes at a rate more than twenty five percent higher than louisiana and we've overspent we provide a lot more public health assistance in california in many areas than the louisiana does and i guess mr gao who of course is one of your representatives will probably look more specifically into a lot of what can be done and what can be delivered from the federal government but my questions are going to have to be a little more tough love not just because i'm personally a conservative but because i have an obligation to california in addition the constitution louisiana's top  tax rate is eight point four percent california's ten point four percent you have a four percent sales tax where we have an eight eight point two five percent sales tax and i know you're all health care professionals but in spite of all of this is everyone so poor in louisiana that in fact the state cannot do more for you are you going to be a permanent ward of the federal government because when i hear sustainability counting on medicaid increases  when i hear mr griffin saying well we take everyone including those who are not poor enough to qualify for medicaid then i'm extending medicaid past what we define as the poor so let me let me ask you much more  other part that i didn't hear what is your state and we'll have a second panel from your state what is your state doing to bring all the powers to bear of the state including finding funding sources for you besides simply the federal government because obviously the direct effects of the levees breaking even if we to put them all in the federal government at some point that's paid out and then we ask the question of what's going to make you as a sovereign state meeting your own obligations and dr only because i can see that you're you're you're saying how is this guy asking a doctor this question would you would you help me with this because i know that all of you look to all sources of revenue and you know you're doing a lot to to build better doctors and better better health care but i have to ask in the long run what are you doing besides coming to us and don't get me wrong mr gao is absolutely dedicated to make sure we do everything we can do but if i could ask each of you that same question it's my it's really my only question for the panel because i see all of you as doing the right things within the structure that exist you're getting money from all revenue that you can find you're building great solutions for people who come to you and i don't i don't have any qualms quibble with that i totally see that but i'll start with doctors to solve because this is the question that california member has an obligation to ask in addition to a louisiana member who's obviously going to say we've got to do can hear me now so i better ok so when the federal levees failed and our city was destroyed we began very early to work together to think about how we would rebuild  this and education for example there's been creative thinking just like there has been in health care we did not as a community of stakeholders and health care providers think that there was going to be some math and having that would fall to make it happen  help new orleans because it's you're a state first cities are not actually directly recognized by the federal government we recognize states we're the united states of america and in a sense only states come to us and when the next panel is up i'm going to be asking that same series of tough questions what is this state doing to be equal in its support of its people to other states get the tax policy because i don't i really honestly cannot answer the question but what i was wanting to tell you is that for the past four years the community has come together a policy tables that are prats republican may be independent to think about ways that we could finance this kind of system we have developed at least three discrete plans one redesign collaborative that was a mix of public private coverage another which was a affordable health insurance plan through private coverage solely called cola and another one that was a waiver that went in about a year ago to the fed to use disproportionate share to recover  to shift the funds that money we already get but that that use it in a different way that requires federal support so all to say that we have been working incredibly hard in louisiana across party lines through two governors and have always come up with the same idea as a state this is what we want to see happen we need to figure out how to finance it at this point i can't speak on behalf of the state but there are some things that do need to happen federally to allow us to move forward state i e waivers for how we use disproportionate share money  how we might use the existing law the recovery authority money that we got for urban renewal that might require some congressional action to allow it to be for urban rebuilding anyone else that can answer just as to you know what you see your state doing because  colleague of ours a friend of mine and i want to i want this committee and all the committees to work hand in hand with your governor to enable those things but we're going to have to ask them the same tough question i'm asking you so if any of you have an answer to that narrow question of of how and it is working to meet this is just an ability requirement that you all talk about dr towns and i think what i can i obviously can't answer for the state i don't sit in that role but i think when you look at how health care is funded there are really only three pots of money and perhaps it's only two i mean there's either federal money there's state money or there's private sector money and so i think one of the things that the state is trying to do is economic development because if you have an employer who offers an insurance plan then you have access to insurance that the federal government doesn't really have to participate in nor does the state so i think that's one of the ways i mean we talked very eloquently about the other kinds of waivers and ideas for current funding not to increase it but to have more flexibility in current funding and i know we'd like to do that mr chairman i thank you for your indulgence i'm sorry we can't continue this but i assure you to thank all of you for what you do every day to address the needs of so many people and you don't have to say it i'll say it i've listened to your testimony you folks have been left behind th and you have not provided testimony yet but we've just spent a lot of time in the house addressing this issue of health care overall and just assisted show and the research shows that some forty five thousand americans die because they don't have insurance every year either research has shown that a thousand children die every year because of no insurance so the question is is that where does the tough love how far do you go with the tough love it people are dead formaldehyde in trailers where folks were living in trailers getting sick big time and this was a while back and we had this committee pushed hard to get the folks out of trailers and i just want to any of you all can comment on that i mean where is that because a lot of your work would be made even harder when they told us about the ailments that resulted from folks breathing that those fumes it was it was very quite devastating and we were very upset and we're just wondering where where is a second one person just tell me about that one who are we are living in trailers we still see patients who are exposed with now to hide and and the problem as we perceive it is there just not adequate housing for them to go to to get out of the trailers and so the eye housing is still not have jobs and so forth and so on and what i said from the beginning was a lot of people have been left behind i mean people on this panel have visited the ninth ward probably all of us and visited new orleans to see even to this day areas that have not seemingly been touched that were destroyed and i'm just wondering you know you talked about the three different areas that think that everyone is making a concerted effort to wisely use these dollars to make sure that we provide the best care for the most people in the most efficient way so i think that that's happening right now and you said something about sixty percent of the inpatient services so even in the inpatient setting we have become more efficient and cost effective and in the outpatient setting where about eighty percent of the outpatient capacity that we were before the storm we're doing about eighty percent of the visits that we were doing before the storm and then area that i'm very interested in is dental care for children the little boy and i my state who died the mit driver on medicaid but he died eleven twelve years old because the  tooth infection that would cost eighty thousand repair went to his brain and he died at twelve and i'm wondering michelle and you talked about children only eight percent children uninsured but how we handling our children with regard to dental care what's going on there well as you know from the case in maryland dental care is very limited even under the medicaid program it's a right benefit participate so that i think that is one of the areas that really has to be supplemented and helped in all the states as well as probably in louisiana but how we do it in your state that's what i want to do you know i think that dental care speaks to the broader issue of how this community of health providers working together to cover the territory so for example some adult care is provided to mobile medical units by some of the organizations in this and they have created a website with a map and a grid that will tell providers where people can go for dental care or any given day care you hospitals reopened its don't care services daughters of charity will have dental care services but we're not going to replicate that if we're just you know a couple of miles apart we're trying to be very responsible with funding but make sure that there's access to services specifically scoped our work to look at fraud waste and abuse but in the course of our work we did not see any of that ourselves and we didn't hear about that from any other organizations anyone else who might have been so based on the information that how have you seen the increase in clinics to help address the issue of that insured and whether or not the model that we should be looking at at the at the nation in order to cut down the health care costs that we are struggling trying to drive the goal the goal is to get people to go to the right place the right time for the right care because that is not only better quality but it's more cost effective and primary care is usually the best place for people to go clearly emergency rooms and hospitals are necessary part of a continuum but all things considered like the man i described in my testimony he's better suited with his high blood pressure and has got to be treated in primary care about a quarter of the cost than the emergency room and there's a fair number of people in louisiana who fall into this gap they  interesting bridge model for urban markets in particular that want to move away from hospital based funding of care of the uninsured there's a gap until there can be universal coverage but you want to make sure that you've distributed the funds so that all of your money is not in one financial and financially consolidated institution or place but we've also learned that if you pay providers for quality and value and you give us the opportunity to take care of populations instead of just paying us for volume it naturally leads to team based care and yes we do it at the interim ilish public hospital when patients arrive at the emergency room whether the care is actually emergency room appropriate or not if they're not assigned to a primary care clinic and they and particularly their uninsured then we're able to direct them to a primary care provider in one of the community clinics where they can access care and we work with them to try to make sure that they understand how to appropriately access the clinic and the emergency room when necessary  hospitals been touched in a fashion of course because we have clinics in the system but touched by the leadership of p c s g meaning very specifically going out and targeting and talking to the emergency room leadership the hospital leadership to be certain they're aware of the program we update them with flyers and information about availability and is a web site that they can go to which i think you have information on do you know community which will tell you in a zip code what's available with hours are what languages they speak with services they offer is we've been really aggressive about trying to get people directed from emergency rooms when appropriate into a medical home so that they don't continue using that other system how many more medical community based clinics do you see that in terms of the number of providers types and sizes that's a really great technical question that her site can help us with and they've been thinking about that with with some of the providers already the  ninety one access points that we have are really varied in scope and size some of them are small school base clinics or mobile units so i certainly don't want the committee to walk away thinking we have ninety one community health centers because we're not there yet and i don't know if that's the right number but it is an important planning issue we do have to decide know i think what you've heard today is that as long as about seventy two percent of the patients who have to access those community clinics remain uninsured then the sustainability of those those clinics i think it's really impossible without  an alternate funding source identified and like i said there are really essentially two pots of money there are tax dollars and there's private sector and other than other than grants and philanthropy and things like that i'm not really and system in cooperation coordination with the health care system that have helped you at all there has been discussions and work that has been done which as you as i mentioned in my presentation we actually do behavioral health in ten schools we're actively having discussions with the school system about expanding that there are also have been numerous efforts and expansion in school based health centers throughout the state as well as in the new orleans area and that's a more comprehensive provider model that has medical behavioral health and other services included in those locations and so there are i think  had a companion report in july of this year that we issued on mental health needs of children in new orleans and we noted in that report which i can provide for the record that school based health centers were an important model in who would answer what percentage of those coming into the emergency rooms exhibit mental health issues and addiction issues and to what extent do you attribute any of the p t s d obviously to the to the natural disaster and if you could address the issue of the trauma that was exhibited as a result of the hurricane and to what extent there was a lack of proper mental health services available to address the needs of us from what i understand clearly trying to get people's mental health needs met have been and demick problem and clearly the enormous crime rate in the area now you know i kind of feel like our criminal justice  substitute in a kind of a last sense for a mental health system that isn't there so i ask you to kind of comment on the lack of a mental health system and also what you see  the consequences of that today in terms of the number of people showing up with mental health issues in our health care system as a primary source of issues and whether you can reimburse for that given the exclusion that many insurers have if people come in with an accident that you can't reimburse for it if they have alcoholism if they've been drinking alcohol dollar and just as a result many insurers say they won't insure because that's a quote unquote a deliberate thing and they won't allow you to get reimbursement for if you could comment on any of those issues mr kennedy at the lower ninth ward health clinic we have seen many come in with mental health problems we had a young man who was known to us who came in and said i just want to slit my wrists we had to get him some help immediately but we just want you to know that many of the middle health problems in two thousand and six and two thousand and eight the need for mental health services was quite apparent but one of the striking things we found was in two thousand and six one year after the hurricane people reported that their mental health that is fairly good i think because so much was going on in their lives they didn't really focus on it but by the time we came back in two thousand and eight we saw a much higher contact with the health care system much more pressed ration over inability to get to bed occasions they needed and  today that fifteen percent of those in new orleans reported that they had a severe mental illness such as depression or other things so i think you're pointing out an area where the population has to be or needs and will be going back in two thousand and ten and hopefully remarkable i think improve coordination of care with the metropolitan human services district which had some problems prior to katrina as new new executive director new medical director  being coordinated so that the case manager will know that and that they can follow up on that also ways of following up when people don't get their prescriptions filled where they should so i think that they're not represented here except for me i'm on the board and it does represent a real success for for the for the promise care access and stabilization grant and i'm really happy to get a chance to help you understand that that's made a huge difference and a very dysfunctional problem that we have to your question we have any graded at almost all of the sites mental health services into primary care it's one of the benefits of this program is we can have the warm hand offered by identify the gentlewoman from california will be recognized for five minutes i want to think of our chairman for holding this most necessary hearing and i want to com all of our special guest on the panel for coming today i have been down on special delegations to new orleans and i was appalled at the promises that were made and then kept there were too many pieces of vacant property there were too many trailers with formaldehyde i'm a victim of formaldehyde too and i know how you can suffer there were two to few medical institutions catholic charities i must give them credit came in and they set up temporary facilities to serve but so many of our schools were destroyed so many of our universities were destroyed my grandmother was born in louisiana so i have a very personal personal affection for louisiana she was in a convent for eighteen years obviously she came out with so i'm very much a part of that particular state in the french quarter so i you are not to blame we felt you and we watched while you were being failed i was getting a call from the stadium about how the buses were passing up the people and wouldn't stop to pick them up i had fourteen relatives that we could not find we dispatched someone from my capital sacramento to go to patton rouge we finally saw one of the relatives hoisted up and taken to a hospital so i was very much a part of that and so i say all that to say i want to commend you for what you have done i want you to tell me now what we need to do in health care reform how we can pluck up the holes so that and this was the biggest natural and national disaster we have ever had and the world viewed it when the dikes broke and that water flowed in like would flow into a boat we were all so tearful so i know what you went through and i want you to tell us what we need to do in health care reform that will pluck up those holes in what we need to do in our system so never again will we have to go through those levels i was not one to support homeland security to come and take all the agencies because i thought famous should be separate and apart so we could move on a dime so in terms of health delivery what can we do dr thompson dr rolen all of you give us the input because we want to before the end of the year come out with a bill that will cover all americans the right way affordable sustainable accessible and with all preexisting conditions and i just really appreciate congressman kennedy who put a particular in fitz's on health care i had a family in my home whose son had a breakdown when he went back home and found out they didn't have insurance they lost everything and so i know the need for mental health services so  down the line starting with to solve all and why don't you give me the input on how we can make sure that health delivery is sustainable and what we should do well congressman thank you for remembering and recognizing all that pain we really do appreciate it i shared it with your i'm sorry sir i just went to thank you and what can we do i we've done a lot with very little and we're not asking for much i think what when by the way i'm from california the largest state in the union and the first state to be a majority of minorities so don't think that every californian feels the way i do but you know how i rhea i think what we've built is really valuable it's an investment by the taxpayers post katrina it's helping recover our city it's building jobs it's building workforce development new opportunity for people it's not just about health care to continue it the gap is you know somewhere in the neighborhood of thirty million dollars a year means that we can continue this until there are other options until finding special mechanisms to pay for the ensured aren't really needed because there are no uninsured and it would be really a shame to disassemble this investment which is really what we're facing in the fall so finding those funds it could be really as straightforward as allowing the louisiana recovery  funds they have in a more urban renewal fashion instead of just for housing we don't want to not give people housing but if we think that we have access and we can give them the fabric of community around their house health care that would be helpful and there's some other opportunities perhaps with the disproportionate share funds to redirect it from using it only for hospital based care but also for community based care thank you thank you congresswoman and i appreciate the feeling of just knowing that you care so many people showed that to us and it just means so much i'm not a policy person i'm a person who sees people on the front lines i'm at ground zero in the lower ninth ward but i could tell you what the impact should feel like ok it should feel like a person should be able to come to the clinic and not worry about whether akon pay for it or not it should feel like i can get the services that i need whether it's primary health care or specialty services and i just want to say that this is a wonderful collaboration because of the primary care access and stabilization grant we have been able to work together something that we really i don't think that we really did prior to katrina as much but we were forced to necessity  is the mother of invention and i'm telling you we definitely forged a lot of friendships invaluable friendships and relationships so that we could give the care to the people that so desperately needed it they should be the ones really to give you guidance it shouldn't come from the top down it should come from the bottom up because we have already shown that we've been very very effective and what we've been able to do and with meager resources we've given a lot of care and i have to commend all of the people who are at this table who have a commitment and who have been mission driven to bring about these great results that we've seen today and that partnership with government has been invaluable we would've been able to do it without you guys but the people who have been doing the work need to guide the work thank you thank you very much congressman congresswoman i would like to reinforce what's already been said and i think the first and foremost we'd like to maintain what we what we have accomplished and what we have we  all i think most of us at this table realize that health insurance for everyone is a much when you're when we're dealing with seventy two percent uninsured we see the ravages of that but i really like to help make sure that we understand that you know we understand california and everywhere else are having financial plight that's that's very clear what we'd like to encourage you to think about is that  with a p c a s g money you took a blank slate and you helped us build a health care delivery system that has got a good start it doesn't take massive amounts of money now to on to where we really could become sustainable and we could become permanent and we could grow because as you already heard we're coordinating mental health and primary care and ways that we have not been able to do before and so we really feel like that that we understand what does look like for us to be asking for money for just one particular part of the of the country but money you've spent has really made a difference you've really saved a lot of the lives we've really built starting with the governor secretary we've all worked together to build a better health care system i've been there for thirty your use that happened then we'll have the other two ladies split the minute thank you for the question i think one hundred percent access and once in coverage should be you asked about reform that that's hopefully where everything is going and as it relates to the p c s g grant and what has been accomplished in new orleans i do think there's been a tremendous accomplishment of changing a system from hospital to primary care and when you talk about coverage season we talk about access nationally there is there will be a need for more access to primary care you could be looking at a model that could be replicated nationally the model the vehicle for primary care development through the federal government in the past has been through federally qualified health centers most of the people sitting at this table only one of these entities qualify as a federally qualified health center so this has expanded the opportunity for through this crisis but for other entities to actually have more to the health care system and i'll echo a lot of what you've heard and that is we have the beginnings of a network of care which i think is part of the answer for health care reform in the future and the other piece that is extremely important in health care reform is going to be coverage and we don't have that piece and so i think what you're hearing is would like to see a bridge of funding whether it's flexibility in the community development block grant phones or whether it's a waiver for disproportionate share hospital funding to help support these these clinics that are an integral part of a network of care and i would just echo those comments that the coverage promised and the health care reform legislation passed by the house would of course help many of these clinics to be sustainable but the implementation date there is two thousand and thirteen maybe two thousand and fourteen depending on the senate action and you really do need to think about how to bridge us from where we are today to where we would want to have these clinics be and the people coverage in two thousand and thirteen and i think that involves both basing in better coverage for some of the low income people as well as providing for support  clinics during the bridge or transition period and recognizing that maybe one of the best steps would be to try and develop a plan for how to turn the clinics from free standing clinics into those that can participate in the qualified that health care is a human right i think that people deserve help from the federal government able to fulfill that need in the short term we must shore up the primary care access and stabilization grant funds before they run out and we must build a new public hospital that is financially sustainable attract world class providers researchers and students such a hospital provides a little competition for more profitable hospitals with a hospitals mr chairman around the periphery of the city who collectively take less than fifteen percent of the charity leaving the rest to go to public hospitals it's called cherry picking it's not profitable to provide health care to those who need it the most profit for profit health care industry goes out of their way to avoid it the result is we're constantly fighting to provide adequate publicly funded health care for the disadvantaged now if we are going to provide sustainable health care for new orleans we need to make sure the hospitals that are making big profits are pulling their weight the failure of profitable hospitals to provide adequate levels of charity care is not simply a new orleans problem in cleveland metro hospital has a steadily growing patient mix of charity care cases which presents a growing financial burden it's strange strange their budget the budget of the county of course a budget of patients and providers so i look forward to working with this committee to address the role private hospitals and clinics  bringing health care to new orleans and affected communities all over the nation i've listened read the testimony of the witnesses and i've heard comments by my colleagues i've heard one of my colleagues refer to new orleans as a ward of the federal government it's interesting mr chairman you know where this discussion occurs two days after president announce an escalation of a war we have money for war here we don't have money for health care we have money for war we don't have and wall street we don't have money for the storm hit new orleans was already in dire economic straits before the storm hit if there if there has been a hearing that p bold relief more clearly about the distorted priorities of america i'd like to know what it is other than this one you're trying to keep alive a health infrastructure to assist people and we're getting ready to spend a hundred and sixty billion dollars next year on a stupid war in afghanistan billions i read the kaiser report which spells out the statistics the great health care problems that still exist  infant mortality is still suffering if we can't see that new orleans has a healthcare infrastructure that is not adequate to meet the needs of people who are still recovering from this hurricane if we if we mean it's good that you're here to remind us but we're really our country falling apart and what's happening in new orleans is a signal condition of where america's priorities are totally follow you should not be we can't even take our own people here at home how disgraceful thank you for being here you've got supporters in the congress who understand that the fate of america is going to be linked to how we are able to take care of communities like there's a population of a possible eighty thousand people in the northeast and no hospital to address the needs of people there so the the needs are tremendous and we will continue doing the planning for the new academic medical center but i think it's important to know that we recognize that the charity model is not the model of the future it's not what we want to see going into health care reform not the best way to take care of patients so what we're building is a new academic medical center so l issue in partnership with tulane can train our residents and fellows and other health care professionals in that setting and as someone said we can attract world class physicians researchers do things there like you see in the birmingham's and the houstons where many people in new orleans go for care today we're exploiting patients for health care when we should be able to provide that at home so what we're doing is we are staying on track with the planning process we are waiting for a resolution from thema and once we get that we're going to move forward into this new model we are on track today to be in that new facility in the beginning of two thousand and fourteen and so at this point without knowing the famous number we're still on track we have not lost any time but we have an exciting project that we're hoping to move forward on thank you dr south and mr chairman i the issue with is this is an issue that we've been battling for for years now and and congressm we can have a hearing in which we can invite fema to explain their position and to see how we can try to overcome some of this impasse that we are experiencing down there in the  district but but i know that the the numbers between the state and the city there is a difference of around three hundred million dollars can you please tell the committee how important is it that we should receive the full for the ones who are million dollars to be built this is someone mentioned the price tag for the project the hospital itself is about a four hundred forty one million dollar construction but the entire complex so it includes a clinic building so that you can do outpatient particular specialty services there on campus so that one point two billion dollars price tag the state has already committed three hundred million dollars to that project and the remainder of the one point two billion will have to be financed and a new entity is being is is being created that will manage that new academic medical center so they're going to be responsible for some sort of bond issuance or some way to raise that money so the difference between raising eight hundred million dollars or four hundred million dollars is significant so so yes we are we are hopeful that through the arbitration process that is going on right now that the state will get a favorable declaration from fema and the number that the state has submitted reimbursement for us four hundred ninety two million dollars thank you but i thought that my time thank you very much let me just had it in new york and new orleans we would have had others involved as well but the point is that we felt it was just too important not to do it and because of and also to commend you on the great work they've done we want to do that as well and we think that you've done outstanding job in terms of in spite of even the difficult conditions and circumstances and i would like to yield to the gentleman from ohio congresswoman kaptur thank you mr chairman and i want to compliment you for holding this important hearing and for your leadership and i know how much you care as a health care expert yourself about what needs to be done in new orleans and louisiana and many of the coastal areas that were so damaged by katrina i was fortunate to be able to travel to new orleans and mississippi with the majority whip mr clyburn and with our speaker and others almost two years ago now i think it was and that was very very instructive and i guess i want to say to all those who traveled here today from louisiana it's really very it's a gift of the christmas season that we get to be angels who are in this side of eternity and who are working and doing god's work and i just want to compliment you for you could be doing many other things in your life and you've chosen to do this and the people of my region i know admire it and view it as very noble effort so let me compliment you for what you do in and through my remarks help to give you strength to continue to help those who need it so much my question i have a question and then a comment on this but yet in your testimony you talk about an adequate sustainability strategy to help these clinics in the future hopefully will be able to get them additional funding but we would be interested in your suggestions on sustainability and dr irwin in your testimony you say there's not funding to bridge the gap after the public clinics fund primary clinic funding and many of your patients will revert essentially to the same situation they found themselves in mediately post katrina and i think would be important for you to state for the record what that would be finally before you answer let me just say that when i was down there as member of the agriculture committee among my other duties here i was just struck by the unmet opportunities to use additional space that's available in new orleans and i'm interested in having you submit for the record or comment here today on how the added strength of food power and nutrition in your region is being implemented with all those open swaths of land with the possibility that primary health care clinics could also become food stamp redemption sites for people who grow food in the area i can tell you the community that i represent one of the poorest areas in the country now we get over one hundred million dollars a year food stamps in the region and i had a grape if any a few years ago saying hey wait a minute we can turn these into economic development dollars if we can get the people who live in these areas to actually produce the food and turn them into food production side it's a no brainer so we're about that task and i'm just curious about these efforts perhaps being made by your sosia that could help your health clinics you comment and then if anyone wants a thing on agriculture i'd be most grateful i'd be happy to we've heard where the rubber hits the road as the on insurance problem there simply aren't revenues by definition from that population and it's a very large population in new orleans well above the national average should you pull your microphone a little i don't think i heard you properly there sorry can hear me now be an insurance problem in new orleans is much more severe than the national average and that's where the rubber hits the road in terms of sustainability by definition that population doesn't provide any revenues to the providers the uncompensated care and historically the only the the funding streams that have provided reimbursement for those people are the dish payments that we've heard about which are typically to institue institutions to hospitals unless there is a way to really redirect them through a waiver and the hearse health centers also provide funding for people who are for help health centers to take care of people who are uninsured our view is that c m s and hurst of already made a significant investment in the area to try to do this  demonstration of doing health care the right way primary care first as the most important building block of the continuum really would be a shame to have erosion in the progress that's been made so far if the funds can be made available to shore up these clinics at this point and since the grant ends in september really don't have ten months i mean it's pretty urgent now in january you know to start making sure that plans are in place because what happens if they're not is providers begin to worry about their job security you know they need they need to know that there's going to  be an infrastructure in place patients begin to become anxious about where they're going to get their care so it's important to expeditiously make a decision about whether we're going to continue this investment that has made this progress dollars this year it's going to be right around four hundred twenty thousand dollars we have a pretty detailed process where we try to help we have  representatives in the community who work as our partners explain to people that's really important for everybody to pay what they can for to help us be sustainable and so we we are dealing with the fact that  almost everybody pays at least twenty dollars but the fact is with a seventy two percent uninsured population which is why we get out of bed every morning we're we're not going to try to get private pay until  in our budget we pretty conservatively working with our c p a we really do think that by year three if we get a nudge and continue on by year three we could be pretty well sustainable really to if i could just make a comment about the nutrition to we have had as part of our quote mental health program it an issue program for community health and resilience to try to encourage healthy neighborhoods where small clinic where we don't kid ourselves about how broad our impact is but we have partnerships with one of the churches a six pack to church and we have a coffee shop that's part of our clinic that's run by a youth groups that's a church there eight weeks training to become working there after the first eight weeks when they work in a coffee shop i moved to the kitchen where they make pralines beginning to sell them on the internet  and we we have pepper sauce from a community garden that we're selling so you know it's just sort of a light a candle rather than curse the darkness but it has created really positive mindset with a lot of the youth particularly awful lot of kids who have nothing else to do and so we feel like that that this type of is well worth our expenditure we hope that it's the kind of thing that centers places where people can come not only to become empowered to get regular medical care to learn about their health but almost all of us have programs that reach out into the community and engage and empower them to build economic opportunity workforce training is don's describing to help develop community gardens to make it part of the healthier healthier foods in schools the model here is really going beyond just the idea of a clinic delivering medical care we feel an obligation to address lack of recruitment affect the quality of care for the people especially for the poor people in the oil and i'm happy to start i think for two lines part for the universities part the charity hospital system and whatever has been a really important site for workforce training for us for generations and it's the reason i came to new orleans to train the charities where i did my national health service corps pay back it's part of the fabric of how we develop new physicians nurses etc so there is the element of developing the new workforce to work in the community and to stay there to take care of the population that's important we are also there realizing that if you're going to train folks to work in community health centers or expect them to and they complete they need to have that opportunity and i think that's really important to shift that educational paradigm as well for patients especially for the those probably beginning to bulge at the seams a little bit and so we need to think about how we improve efficiencies of referrals and communication between the system so we don't overwhelm them needlessly and i would i would say that  actually some of our recruitment has been very good post katrina but it's because of the promise of a new academic medical center a promise of new labs for research so if you're going to have those kinds of if those  of the infrastructure are going to be present and are going to stay we're going to need that new academic medical medical center we need flagship hospital as far as recruitment for residents i think it becomes a little more difficult because we can't support the number of residents today we're supporting about three hundred l issue in tulane residents and fellows at the hospital because we just simply don't have the volume the six hundred forty that were there before they have to be in different places that education is not as attractive to residents and fellows so it makes it a little more difficult to recruit our medical school recruitment is still going well i'm happy to say though for for the dean of the medical school at  recruitment like i said with the promise of a new academic medical center are in a funding now is actually higher than it was before the storm but that hospital is critical and dr de salvo is right we need the clinics because that's part of the training that is very important but we have to have that flagship hospital we have to have those tertiary and even quaternary care kinds of services that you simply can't get in the outpatient setting  hospital that has academic excellence as well as clinical care is critical we also feel that that one benefit from recruitment has been the altruism of the country we've seen a lot of  people who come down who really want to help but it's very important for the people who are going to work in community clinics to train and community clinics you don't get that training in the hospital it's a different different type of practice and there are residents and students who come to town who come out to our clinics they make a difference for us they make a diff the number of patients we can see that makes a difference in the quality of services that we offer so that the higher quality that comes endeavor i think today with with the hospital that we have the public hospital that we have citizens in new orleans east who are uninsured i think we're serving them today as far as being able to serve them in the area i think it's really important to have primary care a bigger presence there and there are some conversations going on right now with the city of new orleans about the ability to use the medical office building that that was at the former methodist hospital to be able to expand primary care services that would be a natural link then into the in patient care as far as as inpatient services without the hospital in new orleans east obviously  i can't speak for to mine but i know that there are always contractual relationships that can be formed in order to have providers provide services at different hospitals because we do that today in the new orleans region with other hospitals  congress and as a human being with regard to your concern and commitment to ensure that those living in new orleans actually benefit from what our government has tried to do in the past it's unfortunate that this natural disaster was turned into a human disaster and your leadership in this committee's leadership makes us believe that we will be able to do the right thing but we have to do it now and i thank you again for inviting me to participate as chair of the congressional black caucus let me just i welcome all of you greet you and just say thank you for being here and most members of the c have been to new orleans many many many times and each time we go we want to come back we believe we're not doing enough yet and we have to do more and so this is an important step in the right direction and i hope mr chairman that in the future this committee could lead a delegation to visit new orleans once again but look specifically at the primary care care clinics and community care clinics i'm go just that request has been made to formally request that because i think it's time we come back and especially now during this health care reform debate and part of what we've been insisting on and least in the house  bill was an expansion of community clinics and so but would like to see how that would work post katrina because we think if it can work if it is working in new orleans it can work anywhere because of all of the issues that  the tough issues that you're dealing with let me ask you a couple of things about medical records a couple of occasions i visited and went to the hospitals and talked to some of the  personnel and was concerned they were concerned like many of us and i know you are about the medical records and how you retrieve medical information from people who are coming back and do you have medical records in terms of the computerization the technology necessary for retaining now medical records or how how it did all of that happened with regard to those who lost their homes and had to leave and are now coming electronic medical records doors of care services in new orleans we are have a paperless system for the most part and it's backed up our of town so that there is no jeopardy of that has been a true evolution and something that is that has worked very well i just like to thank you for all of your from the congressional black caucus for all of the opportunity from the loss of our paper record was to rebuild it better and we we've done that i think we've felt as a group of community providers that we wanted to move toward the paperless system we think it's got better safety parameters it's more accessible for providers it's after hours calls that we take on patients we have the information at our fingertips to help make decisions to let them decide whether the emergency rooms right place or the clinic it's also really help advance our programs in quality and quality improvement and us to share information to think about how we're going to treat chronic disease like diabetes better but i've got to ask you though and for those who lost everything and i say this as the daughter of an eighty five year old mother who walks around with a briefcase with  little notes and medical records where she lives you know they still aren't computerized and there's no technology so to remember for a person who left during the storm came back lost everything how do reconstruct a wreck i mean i can't remember everything that every medication that my mother takes or every diagnosis or you know how did every how did you do that and how do people put it all back together again you know it's a lesson learned from this tragedy really because we didn't have a lot of that information and so we did not want to go back to that situation if it were to ever happen again and we think for disaster in every day it makes sense to have the information available not just to providers by the way that the step we're not at yet is the portal for patients because really they own that information and should be able to see at any time that they that they need to have access to it but what it was going to be and it was honestly that we had we had records in the charity system that  system some of those the dictator reports and labs were available some of the hospitals had their inpatient electronic systems and so we pieced it together painstakingly with folks and it does take quite a long time when you're getting  or more distant find out what happened to them in their lives and make sure it's not lost again yeah and what medications for example understanding the health disparities in the african american community you know diabetes hypertension lung cancer breast i mean edited you want talk about one of one of the advantages that we had was that the collaboration through an h cap grant there was a path partners that many of these folks belong to including us and we had developed a retrieval system for electronic information and that piece of information that history was available electronically even after the storm in addition to that the pharmacy the pharmacies across the nation if you had to use a retail pharmacy you could retrieve that information of prescriptions and then for our patients most of them don't have a pharmacy benefit so we access patient assistance programs and they get free medications but there is an electronic system within the safety net that keeps track of what medications they've received and so that that's important information we were able to reconstitute that information very  remember earlier right after the storm access and medications and getting people back on their meds at the right time and what have you was a difficult task are the rates now leveled off in new orleans are they going up go and do we need to look at new orleans and see what we need to do and do it better or how how's how are things going medicines we have always had a really high diagnosis rate in new orleans i actually i'm not sure what that is today my guess is that perhaps because the populations down the rates may not be as high as they were because we have diagnosed so many so many of those people but there are still people who are not in care and we're still we're still trying to get those people to the appropriate level of care and this is one place where we've made such great strides that you can really it's on the front of our minds we know it's a major problem for the population and quite frankly the community is very conscious of it of the things that we get requested as a health center to go do screenings on it's hiv more than diabetes now thank you very much enemy  thank you the panel for being here and we really appreciate you know you coming and sharing with us because we see it as being very very important and of course we want you to know that you do have a lot of support on this side and we just hope to be able to move some of these things a lot quicker but you again you're coming here has been extremely beneficial also i'd like to just say that i also have a letter that is addressed to both and blackman and parish as well which are just east of the city and still recovering he has been a leader on recovery particularly in the areas restoring and building the reg but in the meantime you have to vote around here if not to talk about you so we now move to our second panel well all the witnesses come forward all the witnesses come forward pl let me just indicate before we start i we see all of eyewitnesses in and what we would do is that we will allow you to start but we would have to have another break to go and vote i mean i really apologize but the committee thank you for the opportunity to testify today on behalf of the secretary of the department of health and human services and the administrator of the health resources and services administration we appreciate your interest and support of primary care in new orleans and welcome the opportunity to work with you to strengthen h h s and her programs in the region i appreciate the remarks of the previous panel i applaud their finances to provide access to care for the people of new orleans person also helps most vulnerable americans receive quality primary care without regard of their ability to pay person works to expand health care for millions of americans the uninsured mothers and their children those living with hiv and aids and residents of rural areas are so recognizes that people need access to primary health care and through it provide access to primary care services in the wheezy ana in july of two thousand and seven c m s awarded wheezy and the primary care access and stabilization grant it's really a grant of one hundred million dollars to assist public and not for profit clinics in the greater new orleans area to expand access to primary care including primary mental health care to all residents low income and uninsured residents the grant was designed to support the long term sustainability of primary care in new orleans the grant required sustainability plans within the grant application and capered funds over the life of a three year grant the louisiana department of health and hospitals made provisions with the louisiana public health institute to help the state and minister and oversee this grants day to day operations as we have heard from the previous panel the organizations receiving p s a's as she operates about robert's ninety one primary care and behavioral health clinic sites across the region including fixed and mobile facilities as of september two thousand and nine these clinics have served approximately two hundred fifty two thousand patients the department's pleased with the improvements and primary care access that his offer to from this grant and h h s looks forward to continuing our close partnership with the state and local health care organizations to meet the primary care needs of residents in the gulf coast person's efforts to support primary care in post katrina new orleans include support for health centers the primary care workforce and infrastructure health centers are community based and consumer driven organization that serve populations of limited access to health care these include low income population the uninsured those with limited english proficiency individuals  families families experiencing homelessness and those living in public housing these centers are designed to provide accessible dignified health services to low income families in two thousand and four prior to hurricane katrina her as a funded to this includes for existing health center grantees that received seven point one million dollars in two thousand and nine to operate eighteen sites and service thirty four thousand people the fifth health center is a new grantee that receives funding and the recovery act new orleans is additionally benefited from recovery act funding and has received thirteen awards that support new health center access points increased demand for services and capital improvement award the recovery act funding will allow these primary care providers to see an additional thirty five thousand patients at more than twenty clinics across the area over two year period two and how centers are using these funds to provide additional mental and behavioral health services which we know from our discussions today are critical to this region in addition to providing direct patient care hertha strengthens primary care by placing health care providers in communities where they are needed most the national health service corps through scholarship along with payment programs helps health professional storage areas  primary care and doctors solve who is in the previous panel is an excellent example of the national service corps alum a payment program in addition to supporting a national service corps we directly support health professions programs that provide infrastructure for training  education and this includes the southwest area health education graham we also provide resources to address what you can a patient population challenges including women and children and as of this summer we had another grants that would support care for people living with hiv and aids her supervisor ryan white care funds to the nuance aids task force and they provide comprehensive hiv care for about eight hundred people living with hiv and aids we are extremely proud of our programs and look forward to continuing to work with you mr chairman and members of the committee to provide quality primary care for all ages has invested a great deal of time and resources in this is the recovery in new orleans and there's much more work to be done and we're looking forward to collaborating with you in that effort thank you s reconvene the venue making to begin as i'd say continue but you never started thank you mr chairman it's an honor to be here today i have prepared some comments i'm going to depart a little bit from my prepared comments and sort of get to the crux of what some of our financial challenges are going forward you've heard good stories this morning about the good things that were done as a result of this grant there were other grants as well and congress and  the executive branch of the law for the state of louisiana new orleans and for that we're grateful we're also grateful for the selection of craig to be the ministre trofimov i worked with him for during the eight hurricanes that florida faced in two thousand and four two thousand and five and i don't know a more capable person in the country to lead sima i just want to get to some of the real financing challenges that we've got that that really trumps all of this because all of this will become very difficult for us to sustain if we can't solve these specific issues first our state faces the largest reduction in federal match in medicaid in the history of the medicaid program january of two thousand and eleven our federal match will decrease by eighteen percentage points from an eighty one percent match under the stimulus to sixty three percent that's an annualized loss of nine hundred million dollars per year that louisiana will either have to have to reduce from the expenditures in the program that's one sixth of our medicaid program on top of that we face a reduction in our dish program you've heard a lot about the low low eligibility the twelve percent eligibility for adults in louisiana the report of the reason for that is we have historically used this public hospital system to provide access for people that were low income you heard that nearly ninety five percent of our children have insurance coverage and we have a very low eligibility for adults that's true because we have the public system however the funding for that public system is in jeopardy right now because beginning in july we'll face what we estimate will be a up to a two hundred fifty million dollar reduction in our dish  program twenty percent reduction that begins july first so those two issues combined are more than a billion dollar reduction to our safety net programs this coming year we also are facing obviously the loss in the primary care access and stabilization grant funding there's want to tell you a story my first week on the job there was a young police officer named cola cotton who was murdered on the job she was murdered by somebody who'd been treated in our institutions and our mental health institutions in new orleans had just been released from a mental health institution we found that the mental health system in new orleans and throughout the state of louisiana has been a glock did for twenty years so the governor and i set out along with the legislature and some of them are here today to establish some major reforms in our mental health system we passed several laws one of them we refer to as nikolas law that allows for involuntary outpatient treatment for people who don't take the medications when they're determined to be at harm a risk to themselves or others we increased funding for mental health by eighty nine million dollars we implemented forensic a sort of community team just sort of community teams multi systemic therapy functional family therapy services that have never been offered in new orleans before that today are being offered and because we're doing it because we've tried to move the standard from institutional care to a community based model we're serving three times the number of people that have mental health needs i want to say there was a question earlier about what is louisiana doing let me let me tell you some of things that we're doing first of all i mentioned we've we've increased our funding for mental health by eighty nine million dollars last year even facing economic challenges that we are facing the department of health and human services just put out a press release a couple weeks ago or put out a statement a couple weeks ago saying that louisiana is one of the most officially operated medicaid programs and it has done is the model for how to retain coverage for children we went from forty fourth in the nation in child immunizations to justify a month announcing that we're now second in the nation and child immunizations pushing our overall health care rankings to forty seventh in the nation still very low but the highest we've ever had since the rankings have been done so there is forward progress being made but if we do not solve these challenges these financial challenges if this estimate problem does not get resolved the consequences will be extremely devastating for our state and many of the gains that you've seen particularly the investments that have been made by the federal government will be we think will be in peril and to be clear the reason that the federal match is dropping in medicaid is because of the very things you've done to help us it's an ironic twist in the formula the medicaid matching formula was never designed for states that had major disasters so what happens is tremendous investments are made billions of dollars of investment are made in our state economic activity occurs we have a temporary increase in our per capita income our per capita income went up forty two percent from two thousand and five the two thousand and seven but yet we still have the second highest rate of poverty in our medicaid realm it's the highest it's ever been and yet three years later because of the federal formula in law our per our match in medicaid drops as a direct correlation to the increase in the per capita income resulting from the recovery mr chairman i know my time is up i will say that this is help that only congress this is this is something that only oversight and government reform for giving the city of new orleans an opportunity to speak to and for providing the funding for primary care access and stabilization this vital funding to help support the city to reestablish a health system of care along with providing critically needed medical and mental health services to the greater new orleans area communities post hurricane katrina the causes for our historical social health disparities as a state and more specifically in new orleans are complex and far reaching and not easily counteracted when contrary to made landfall twenty eight percent of new orleans citizens live in poverty twenty five percent had never finished high school fifty percent live in a single parent home and twenty five percent had no health insurance hurricane katrina has only exists exacerbated what was already a fragile health infrastructure and medical service delivery system the current lack of access to both primary medical care mental health services for such a large portion of our parish i perhaps the strongest correlate to our repeatedly poor health outcomes the goal of the new world health department is to provide direct medical care services and help to build a sustainable and long term infrastructure along with the opportunity for collaboration and coordination and creating an equitable and accessible health care system for all residents therefore i'd like to focus on five things the lack of access to primary medical care services where citizens most in need the professional medical mental health provider shortages a profound lack of mental health services health disparities and the need for it to need support for to finish the rebuilding of the city's health infrastructure today with the population of new orleans having reached an estimated three hundred fifty thousand people close to seventy five percent i was presenting a number of the services offered by the new world health department are much less the city operates only three primary care clinics one homeless clinic one fixed in the fight and two mobile dental sites the geographic coverage is limited and one of the primary care clinics is loaded on located on the west bank and so i have the map up there kind of little dots one is located in central city and one is in the world these across a large industrial canal so i don't know if you can if you look to the right on the map where there is only a couple little but that in the far right corner that's new orleans east where our clinic is there has been a significant decrease in the number of medical mental health and dental providers seen in orleans parish according to a two thousand and seven blue cross blue shield report only twenty eight percent of their original met a professional professionals returned to practice in orleans parish last year the louisiana department of health and hospitals reported that less than twenty five percent of those provided accepted medicaid patient there has never been an adequate mental health infrastructure in new orleans and today the need for care and treatment have only increased exponentially since katrina made landfall during the last four years the availability of psychiatric beds have been dramatically reduced combined with a large number of mental health  care providers never returning which is left to citizens most in need with the most after goals in receiving care need care and treatment and beyond not being able to meet the mental health needs of our citizens it has created a cross cutting effect on families communities work sites and the bro health care delivery system from the hospital emergency rooms to the primary care physicians to the local jail facility facilities which today houses the most psychiatric beds in the parish just as behaviors and lifestyle choices are the cause of most chronic infectious diseases access to primary preventative and treatment care is what improve health outcomes and decreases disparities gaps what research is shown is that health disparities in louisiana are often found in populations which are poor minority high school dropouts low income uninsured and lack transportation the new orleans health department identified an extremely high need an underserved and understaffed site within orleans parish and responded by stabbing a clinic site with  as you can see on the map it was in new orleans east will be with the my slides in new orleans east represent approximately thirty five percent of total parish land area and fifteen percent of overall population yet four years later there is still no hospital so just going to put up my industry with a strong increasing middle upper class black population and the enemy saw pilate like all of new orleans of particular neurons these data has shown a significant population shift each month that the ne clinic has been open we have seen a fifteen percent i'm sixty five percent of our patients are uninsured our typical patient is a working mother who comes in for wic services brings in her children for pediatric services pursuits a place in healthy start parenting classes gets her pap smear and birth control and has her brother to come in for a blood pressure checked she can get all of this done at this one site neurology for a growing population that is geographically isolated the p c c funding has allowed us to provide convenient compassionate services because even with four years later they're still very limited here in the area health unit on these units we provide dental exams pro fees deep scaling amalgam bonding removable partial dentures complete dentures crowns and bridges we have an oral surgeon who can help with more difficult cases we have begun oral health education programs with the schools as well so you can see one of our bands are very excited about we are hopeful that the availability of services plus the student education will stand out so beyond the schools and the senior citizens in the future and it is right now it's feeling a significant  need clothing and over below are a few recommendations from the city of new orleans number one to increase medicaid eligibility to increase the number of individual qualify for coverage in our insured to use flexibility within eleven fifteen waiver much mr williams mr chairman thank you and members of the committee thank you for the opportunity to address this important topic today i'm employed by the louisiana public health institute a nonprofit organization that works statewide to improve health through public private partnering l t h our was chosen as the state's local partner in administering the primary care access and stabilization grant and i serve as the director of that program today my testimony will in my five minutes hopefully summarize how the granites been used over the past year two years towards the grand goals and discuss the challenges we face in maintaining the gains we've achieved the catastrophic flooding throughout new orleans region following hurricane katrina wiped out the health care safety net as you've heard about today there's a map showing the relative flood depths that you could look at in relation to the location of the clinics which is overlapping  and also if you as you've heard today the clinic representatives here today were among those who spent the first couple of years after katrina cobbling together resources and trying to get the growing healthcare needs met in the region then in  in july of zero seven we received the hundred million dollar primary care access and stabilization grant from h h s to stabilize and expand the clinics that were on the brink of failure at that time and we want to thank you and h h s very much for making that possible and making it possible under terms that allowed for the use of those funds in a flexible way so that we could be effective towards the goals of the grant we strive for a health care system with a public private network of primary care clinics as foundation to facilitate access to the right care delivered in the right place at the right time and for fundamental goals have guided our efforts to use this grant to advance towards this vision number one increase access to care on a population basis number two deliver high quality evidence based health care number three create an organized system of care and number four develop sustainable business entities access quality system this and sustainability have been our mantra twenty five public and private organ nonprofit organizations in new orleans region were eligible to participate in the grant program the first award of sixteen point seven million was distributed to the organizations within two months after the issuance of the notice a grant award supplemental awards have been made every six months since then to all twenty five entities and so far eighty million two hundred seventy five thousand dollars has been distributed the remaining grant funds will be distributed in december of this year and the grant funds will be substantially exhausted by some september thirtieth of next year however we expect a no cost extension will be approved by c m s shortly to help the grant stretch these dollars as far as possible about eighty percent of the funds have been spent on personnel and contracts for the provision of direct patient care services and the remainder on equipment supplies facility renovations and other expenses that support care delivery now summarize the status and progress made towards our priority go to increase access to care on a population basis the outstanding performance of the twenty five participating organizations in this priority go all areas led to an increase in the number of service delivery sites in the region from sixty seven pre grant to ninety three today and there's a map you've seen that shows the distribution of all those sites across the region in addition they've increased the of the delivery system by almost fifty percent in two years in terms of patient served you can look at the next exhibit which is a graph that shows the increase in patient volume by six month period since the beginning of the gr it's a dramatic dramatic growth in a system in such a short period of time in the past year they provide a primary in mental health care services to nearly one hundred seventy five thousand individuals into a total of two hundred fifty thousand since the gran in the past year forty two percent were uninsured representing about half of the uninsured in the region and twenty five percent had medicaid more importantly over forty percent of the conditions cared for in the primary care clinics are conditions that would likely require expensive emergency room care if not effectively managed in the outpatient setting known goal number two as a can which is deliver high quality evidence based health care as a condition of receiving grandsons all participating clinics met minimum quality improvement benchmark such as providing same day appointments for gin care in addition three point eight million dollars was set aside for a voluntary quality improvement incentive program in partnership with the national committee on quality assurance or an and secure way this incentive program rewards clinics that achieve standards set by and secure way in their patient centered medical home framework significantly forty of the clinics received and secured a recognition through the incentive program and this is the highest  one more minute here i'm going to skip down to goal number four on sustainable sustainability which i think is the focus of the hearing here are substantial improvements and billing practices among the participating organizations have been achieved for example eighty two percent of the primary care organizations are now billing medicaid medicare and or private insurance despite the progress has been made in this goal area we estimate the participating provider organizations would face a thirty million dollar annual operating deficit if they were to maintain their current capacity without the help of this grant or some other such source the projected deficit stems from their mission to serve people who are not covered by any insurance and hence whom the clinics receive little or no revenue over half of the participating organizations depend on grant funds for more than fifty percent of their operating expenses and several rely on grant funds for more than seventy five percent of their operating expense expenses organizations caring for the highest portions of uninsured individuals are most at risk and some of the highest volume and highest quality clinics that you've heard from today have patient populations that include upwards of seventy percent uninsured individuals this program was in vision a bridge to a more favorable policy environment and however it's clear that those conditions are still years away unless we work together now to devise and implement solutions to span the gap the progress that's been made will quickly erode and  health system recovery in new orleans area will take a giant step backwards resulting in an estimated thirty to forty percent reduction in services overall among these organizations most organizations will be forced to contract severely several likely fail altogether many people who currently rely on these clinics will go without care or end up in emergency room meanwhile if and when relief comes down the road in form of in the form of coverage expansion the expensive exercise of expanding the health care delivery system to handle the new demand will have to be repeated and wouldn't be more effective and efficient overall to keep this network intact than to let that happen and desirable result of this hearing would be that all parties involved will redouble their efforts to immediately identify and implemented a set of solutions to address these threats these could include allocation of existing unobligated and community development block grant recovery funds for this purpose granting permission for the state to use medicaid disproportionate share funds for outpatient primary care and physicians ervice is an exploration of additional sustainability and sustainable options for funding it has been an honor today to participate in the hearing and thank you for your continued support of our already they make a schedule for the school nurses at the schools and find out which has need dental services they send home a packet with all the kids in their parents fill it out and then they make a schedule they let us know that we're going to have say ten kids the next day and we usually have a schedule for the week we right now are rotating between two different schools we go to one school one week and then one school next week and then each week we get requests from other schools i mean everybody wants it because there's such a need for dental services in the city so some of the harder part is getting through the bureaucracy to make sure that we can get there get the services to them but the kids really enjoyed being able to get the services because a lot of that we've had kids who hadn't been to the dinner since the storm and we've been able to take care of them on the dental units now for the senior center the senior centers in the city have to go through the different it's four different  then coming in testifying here later you know i want you know that when he became subcommittee cheer back some years ago i was going to change the procedure because i wanted agency people to hear in terms of what was being said because i always have the agency people first and then after that we bring others in and up to the agency people would testify everybody would get up and walk out and then when the people that who had the problems of the when they testified nobody from the agency was around the hear it so i was the one who said from now on we are the people talk first and then have the agency to come in afterwards but i want you to know that your being  the agency would think about you know let's looking at sort of stablish in sort of group task force i don't like where task force but a group sort of work together to see in terms of how we might be able to move some of these efforts along i know you might not be able to make the decision sitting at the table today but can you take this back to request that we would like to  establish i guess a committee to explore ways to continue restoring health care services to the post katrina region and i think there's still a lot that needs to be done and i know you just can't right away say you know but the point is that you know if you could take that back and let us know in terms of there's any real interest in this because you know with many members of congress you know along with the representative from the area that would like to see in terms of what more we might be able to do and sometimes it's not money it's just sort of getting things coordinated and i just want to get your views on and recognize and that is not something that you can bang the table and say you do but the point is that when you take that back and think about it yes sir it has been very helpful and interesting to have spent the day listening to my colleagues talk about new orleans and access to primary health care as it is at this time and how it's changed compared to the before and after katrina workforce our colleagues and family would be very interested to hear the challenges that the city still faces in providing access to adequate mental health services and so certainly sir i will take your challenge and your charge back to the department see what we might do we have been working together build a replacement facility for the now shuttered charity hospital when will construction begin how will it be financed and is anything that the congress can do to facilitate thank you mr chairman we've taken several steps to move the process along to the extent that we can obviously the financing is a big piece of this that hasn't been resolved we're hundred ninety two million dollars under the stafford act famous last offer was one hundred fifteen one hundred fifty million up from the original offer of twenty six million or so we are in the process of acquiring the property  we we we're in that we the architects are doing the design planning phase of the project so all the things that can be done while we work out the financing piece of this is critical the other thing that we've done is that we've  completely changed the model from the old charity public hospital model we've actually looked at what happened in atlanta with with grady we looked at tampa general we looked at other shans hospital in gainesville with the university of florida we've looked at models of teaching hospitals that used to be public but have converted to the nonprofit model and that's what we've done and we entered a memorandum memorandum of understanding between tulane l s u and the state that was signed about about two or three months ago so all of those pieces have been put in place the one piece it's not places as the fema piece of this which is substantial if we do not  way the financing is supposed to work is the state committed three hundred million we had estimated the four hundred ninety two million and then the difference between that and the one point one billion one point two billion dollars was going to be financed through the debt markets if it doesn't come through with a significant amount of money if the arbitration doesn't go our way that could really imperil our ability to finance this hospital given the situation i mean we we would have to finance more than the estimated four hundred million we had started that we had planned on so irrespective of whether somebody believes we should rebuild the old hospital or build a new one it's all academic if we can't get the money from fema and so the question about what congress can do to the extent that seem a fall short to the arbitration process if it doesn't go our way certainly congress can step i believe it would be a strange coincidence if it wasn't the if this wasn't a four million dollar car about the primary care access stabilization grant that was specifically earmarked for the city of new orleans health department to address not just mental health although that's allowable expenditure of the primary care grant funds but also to address health care needs and particularly under served areas and and to provide the dental services which are up and running  they got off to a slow start spending that money but they are well underway to make good use of it at this point as far as i as i know today and we can get you know of the four million dollars which a portion of that was spent on mental health which portion of this was  us to go from where we are today we're currently we have a two hundred and seventy five million dollar deficit in our medicaid program this year into a situation next year where we face a nine hundred million dollar shortfall and then go into a period where we have to then do an expansion of medicaid it couldn't be done it was the maintenance of effort requirement under the stimulus and then in both of the house and senate bills would really put a lot of pressure on provider rates and really i think effectively make our program insolvent and so we really need a solution to this estimate problem the all of the good work that has been done community based clinics we can we can do those things but but we also have to provide state match with a decrease in federal match that we're facing we're not capable of doing that so i think  the fundamental problems here are fixing the problem acknowledging this dish audit rule and the in the quarter of a billion dollars per year impact it's going to have in our state in addition to the problem and then third the thirty million dollars probably are going to have when this grant runs out in less than a year we have three converging factors that any one of which would be devastating but all three of them are virtually impossible for the state to be able to overcome on our own and then th organization can sit down and discuss the problem and come up with some kind of solution in connection with tulane and ellis you to see how can we can address that particular need out there for a possibly hundred twenty thousand people one hundred twenty thousand people right now do not have access to to a hospital i know i live out there northeast about two years ago i had to drive my father close to forty minutes to meet with them well thank you very much yes i have missed them thank you very much and let me thank all of you for your testimony and of course you've been very very helpful and we look forward to working with you in the days and what's ahead and of course to move some of these things forward and i think that the news very difficult circumstance the conditions that you been able to do some amazing things and i want you know we really salute you for that and again thank you so much for your testimony this hearing is