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The young woman will remain in the ER until a doctor approves of her for discharge, while more patients pile up in the waiting room; the ten psych beds at the hospital are full.  The woman is uninsured, so any outpatient care or long-term medication cannot be administered. Like many people with severe mental illness, she is likely to struggle to connect with the public outpatient care that is available and without consistent outpatient treatment, she may return to West Jefferson or another emergency department by the end of the week. If this occurs, she will not be the first to be caught between the tiers of New Orleans “two-tiered” system.

This is now a commonplace scenario in the functioning New Orleans hospitals. In August, a local journalist reported that he encountered 13 psych patients waiting in the West Jefferson emergency department. This health care shortage reflects not only a demand for mental health services that exceeds the supply available, but also gaps in coordination and funding that require more than just additional beds.

In a June 2005 report, the Department of Health and Hospitals (DHH) reported that although 97% of patients served by the Office of Mental Health (OMH) receive care in the community, 60% of OMH’s funding and 72% of staff support the inpatient setting.  The state acknowledged this inpatient-heavy distribution of funds was a primary factor in the limited access to community-based services.  DHH also grimly foretold that “implications of any potential closures [of the LSU facilities] are acknowledged to be devastating to the regions served and would leave indigent patients with severely limited options. Closures could result in emergency departments becoming "bottle-necked" with patients awaiting assessment, medical clearance and placement.”

A system like the one in place before Katrina puts the responsibility for caring for the indigent population on one hospital.  Charity was the safety-net institution for the uninsured, but also for area private hospitals, allowing them to serve only the insured, paying patients.  For this reason, hospitals outside of the public system were absolved of their responsibility to develop service capacity for the most vulnerable patients.  The shortage of psych beds availability post-Katrina demonstrates how accustomed hospitals were to forwarding psych patients to Charity. 

Since late September 2005, New Orleans has been the fastest growing city in America.  The forty thousand new residents that arrived between July 2006 and January 2007 represent an increase of 17% in six months.  Nearly a year and half after the storm, four of nine acute care hospitals in Orleans Parish are operating at some level, though many services offered at those institutions before the storm are still missing.  In January 2007, University Hospital, a part of the Charity system, reopened for inpatient services and some other hospitals continue to receive patients in their emergency rooms.  With hospitals overwhelmed, it’s clear to all stakeholders that the New Orleans area will need to implement a plan that expands health care capacity soon. 

To stem the tide, private hospitals have accepted more uninsured patients since the disaster.  The Ochsner Foundation Hospital’s proportion of uninsured patients jumped from 3% to nearly 13%, but there is no planned system to allocate care and services between functioning private hospitals.  The state and federal government reserved a pool of money—$120 million—to reimburse providers for uncompensated care, but those funds were not guaranteed and hospitals were only beginning to receive funds in January 2007.  In Louisiana, the institutional DSH and OMH allocations did not follow patients to their new providers.  The result is that East Jefferson General and West Jefferson Medical Center reported losses totaling $63 million between Hurricane Katrina and the beginning of 2006.

 Local stakeholders came together through the Louisiana Health Care Redesign Collaborative, which received its federal blessing from Secretary Leavitt of the Department of Health and Human Services in July 2006.  With local resources in tatters, an effective redesign requires federal approval, oversight and funding.  The Collaborative was charged with designing and implementing a “practical blueprint for an evidence-based, quality driven health care system for Louisiana.”