Since Hurricane Katrina, the population of the greater New Orleans area has decreased, and the health care delivery system for the low-income and uninsured population in the area has begun to change from one that was largely hospital-based to a more community-based system of primary care. Since the disruption to the health care system caused by the hurricane, several federal agencies have awarded grants that facilitate access to primary care. The estimated population of the greater New Orleans area decreased from 999,349 in July 2005 to 807,032 in July 2008, a level of about 81 percent of the population before Hurricane Katrina. Most of the decrease in population was in Orleans and St. Bernard parishes. (See table 1.) Before Hurricane Katrina, most health care for the low-income and uninsured population in the greater New Orleans area was provided in emergency rooms and outpatient clinics at Charity and University hospitals, which together were known as the Medical Center of Louisiana at New Orleans (MCLNO). MCLNO is part of Louisiana State University’s (LSU) statewide system of public hospitals. About half of MCLNO’s patients were uninsured, and about one-third were covered by Medicaid. As a result of damage from Hurricane Katrina and the subsequent flooding, Charity and University hospitals were closed. In November 2006, LSU reopened University Hospital, under its new, temporary name, Interim LSU Public Hospital. Charity Hospital remained closed as of June 2009. In addition to the hospital outpatient clinics, other types of clinics provided primary care, including mental health care, for the low-income and uninsured population before Hurricane Katrina. These included health centers participating in HRSA’s Health Center Program. Under Section 330 of the Public Health Service Act, HRSA provides grants to health centers nationwide to increase access to primary care. HRSA uses a competitive process to award grants, including New Access Point grants for new grantees or for existing grantees to establish additional sites. Existing grantees may also compete for Expanded Medical Capacity grants to increase service capacity, such as by expanding operating hours, or Service Expansion grants to add or expand services, such as mental health, oral health, and pharmacy services. All health center grantees are Federally Qualified Health Centers (FQHC), which enjoy certain federal benefits such as enhanced Medicare and Medicaid payment rates. However, not all FQHCs receive Health Center Program grants, and those that do not are sometimes referred to as having an FQHC Look-Alike designation. Four health center grantees served the greater New Orleans area at the time HHS awarded the PCASG in July 2007. In 2007, Louisiana enacted the Health Care Reform Act of 2007, which directed LDHH to develop and implement a new health care delivery system for the state’s Medicaid recipients and low-income uninsured citizens. LDHH proposed short-term and long-term recommendations, which included changes to the Louisiana Children’s Health Insurance Program (LaCHIP) in 2008 to expand coverage to more children. LDHH also submitted a demonstration waiver application to CMS for its Medicaid program to expand coverage and create a coordinated system of care. In response to Hurricane Katrina, several federal agencies provided grants that assist with the restoration of primary care in the greater New Orleans area. (See fig. 1.) FEMA provided CCP funds to Louisiana for certain mental health services. ACF provided supplemental SSBG funds for primary health care services, among other things. In addition, CMS provided Professional Workforce Supply Grant funds to reduce health care provider shortages and PCASG funds to restore access to primary care. The CCP provided funds for crisis counseling services—including stress reduction and coping education, community outreach, individual and group crisis counseling, and referral for other services—to Louisiana. The state subsequently distributed $29 million of these funds in the greater New Orleans area. The CCP was designed to meet the short-term mental health needs of people affected by disasters. State officials told us that, generally, the CCP allows a person to have three to five counseling visits but does not provide for a traditional mental health diagnostic assessment and cannot be used for traditional mental health or substance abuse services. CCP grantees may, however, provide information to families and individuals about available mental health and substance abuse services. Additional assistance may be available to certain families through the Louisiana CCP’s Specialized Crisis Counseling Services. ACF administers SSBG funding to assist states in delivering social services, which generally do not include health care services. In 2006, however, Congress appropriated emergency SSBG supplemental funding that could be spent on, among other things, health care services. From this appropriation, ACF awarded more than $220 million to Louisiana. The Louisiana Department of Social Services (LDSS) served as the state-level administrator and collaborated with LDHH and the Office of the Governor to develop a spending plan that dedicated about $168 million of this amount for resuming and restoring health care services. LDHH received $101.7 million, which it divided into two service categories. First, LDHH designated $80 million specifically for mental health care, including substance abuse and developmental disability services, to meet the emerging mental health crisis. Second, LDHH designated $21.7 million for primary care, which could include mental health care, to restore and resume services to meet the health care needs of people affected by the hurricanes. The primary care funds were intended to target the southernmost parishes and regions that had experienced a devastating blow to their primary care infrastructure. Each local parish could develop a proposal for restoring services its population needed and for responding to the challenges it faced in rebuilding its basic health care system. LDSS awarded the remaining health care services funds directly to LSU Health Sciences Center and Tulane University Health Sciences Center. Louisiana has until September 30, 2009, to spend these funds, which are distributed as reimbursements after services are delivered. LDHH distributed the mental health funds to various offices in the department and to the state’s four regional human services districts, which then contracted with various individuals and organizations to provide some of the services. A state official told us that the mental health funds were available statewide in part because many people from the greater New Orleans area who needed mental health services following the hurricanes were dispersed throughout the state. The $50 million Professional Workforce Supply Grant was awarded by the Secretary of HHS in March 2007. The purpose of the grant was to reduce shortages in the professional health care workforce following Hurricane Katrina, and CMS gave Louisiana flexibility to design its program within broad federal guidelines. LDHH, which administers the grant, used the funds to create and fund the Greater New Orleans Health Service Corps, which recruits individual health care providers for health care organizations by offering incentive payments to the individuals. Incentive amounts are based on an individual’s medical specialty and range from $10,000 to $110,000. To be eligible, a health care provider must, among other things, agree to serve Medicare, Medicaid, and uninsured patients; have a sliding fee scale; and provide services in a federally designated health professional shortage area (HPSA). Health care providers are also expected to enter into an agreement with LaCHIP to provide services to children enrolled in that program, if appropriate. Financial incentive payments can be given to health care providers who remain in their qualifying job or to newly hired health care providers; individuals may receive only one financial incentive payment. In July 2007, CMS awarded the PCASG to LDHH, which selected LPHI as the local partner responsible for administering the grant program. The PCASG was established by HHS under the authority of the Deficit Reduction Act of 2005, which allowed HHS to allocate funds to restore access to health care in communities affected by Hurricane Katrina, and to provide funds for other services, such as those provided by Medicaid and the State Children’s Health Insurance Program. The greater New Orleans area was targeted to receive PCASG funds because of the unique impact Hurricane Katrina and its resulting floods had on the area. LDHH and LPHI determined that 25 organizations met the PCASG requirements that CMS established, and they were all awarded funding. The 25 organizations varied in size and other characteristics. For example, some recipients are affiliated with an institution such as a university or state or local government, and some are grantees of HRSA’s Health Center Program. (For more information on the characteristics of the PCASG fund recipients, see app. II.). In addition to primary care services—medical, mental health, and dental care services—PCASG fund recipients could use grant funds to provide specialty care, such as cardiology and podiatry services, and ancillary services, including supporting services such as translation, health education, transportation, and outreach. After being awarded PCASG funding, outpatient provider organizations had to meet several CMS requirements, including creating referral relationships with local specialists and hospitals, establishing a quality assurance or improvement program, and providing a long-term sustainability plan. LPHI is responsible for distributing funds to PCASG fund recipients, including an initial disbursement and five supplemental disbursements. These are lump sum payments and are not reimbursement for individual services provided. The 25 recipients received initial disbursements totaling $17 million. The supplemental disbursements are to be made over the grant period. CMS requires that more of the funds be disbursed during the early part of the grant period and that funding decline over the 3 years to ensure that recipients do not rely primarily on PCASG funds for their continued operation and sustainability. LDHH and CMS provide oversight of the PCASG program. LDHH oversees the work performed by LPHI, conducts site visits at PCASG fund recipients, reviews budgets for LPHI and recipients, reviews and approves payments to recipients, and determines whether to approve recipients’ requests to renovate sites.