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Who's Caring? 

For years, the city's uninsured and working poor have turned to Charity Hospital. Recent budget cuts leave patients wondering who will see them now.

The Charity Hospital clinic is packed, and a line of patients is beginning to spill out into the hallway. Yet in the middle of the crowded waiting room, 55-year-old Mabel Cook sits patiently, her hands resting on the big black purse in her lap. She arrived here at 9 a.m., more than four hours ago, but the nurse will be calling her name any minute. Or so she predicts. "I know Charity in and out," she says with a firm nod, noting that she was brought here to be born and has been coming back ever since.

For the past two decades, patients with minor ailments have come to rely on this walk-in clinic, known simply as "W-16" for its room number in the hospital's west wing. During the past year alone, 40,000 patients came through this clinic, often lining up outside its doors just as the sun was rising. That's because W-16 is first-come, first-served.

W-16 medical director Dr. Khalil Imsais has worked here for 24 years. Most often, he sees patients with upper-respiratory infections, urinary-tract infections, strains, sprains, pelvic infections and allergies. He also gives lots of immunizations and urine tests for HIV and sexually transmitted diseases.

It's also common for patients to arrive at W-16 with discharge papers from local private hospitals, says Dr. Myra Kleinpeter, who oversees outpatient clinics and also sees patients at W-16 a few days a week. Federal law requires that patients -- uninsured or not -- cannot be denied treatment if they arrive at an emergency room needing immediate care. But once that emergency care is provided, she says, the uninsured patients usually end up back at "Big Charity" -- New Orleans' Charity Hospital.

Each morning at W-16, the first 100 or so patients would routinely take a seat in the waiting room's rows of light-green chairs. The rest lean against the walls or hunch over in the hospital's big old wooden wheelchairs.

Then at 6 p.m. Friday, Oct. 3, there was no one. W-16 was closed. It was part of a last-minute effort to slash $40 million from the budgets for Charity and University hospitals. Also eliminated in the cuts were a busy diabetes clinic and one-third of the surgical suites for the two hospitals, which are formally combined into one entity known as the Medical Center of Louisiana at New Orleans (MCLNO).

"Our funding has always had its ups and downs," says Imsais. "But this is the worst time ever, in the history of Charity Hospital."

Some of Imsais' patients can be absorbed into the city's already-busy public and sliding-scale clinics. But hospital officials predict that the remainder -- more than 2,000 additional patients each month -- will end up in the already-overburdened emergency rooms at Charity and University.

It's not hard to imagine that scene, says MCLNO chief executive officer Dwayne Thomas. "The E.R. will back up," he says, "and in some cases, the waits will be staggering." Four-hour waits are expected to double and triple. Day-long waits may not be unusual. And costs will escalate, because emergency-room costs are much higher than those for primary-care clinics.

"We're going backward two steps," says Imsais. The conditions he would see in W-16 were often not serious. But they might become more threatening if a patient delayed treatment. Skin infections that would have required only a topical cream and an antibiotic at W-16 might now require hospitalization. An early diabetes diagnosis might turn into a week-long hospital stay. And with the current change in the weather, W-16 was about to begin its peak season -- lots of flu, respiratory distress, pneumonia.

Over the years, from her seat in the waiting room, Mabel Cook has seen it all. "Minor things may start out minor but they can turn major," she warns. "This is going to be bad."

Cook stops talking and looks up -- there's a nurse at the door looking at some paperwork. "Mabel Cook?" she says, looking around the waiting room. Cook smiles sweetly, grabs her purse in her hand, and walks back to see her doctor.

Late last month, the final cuts had been announced, and the clinic had posted signs announcing that Oct. 3 would be its last day. But the patients in W-16 were still in disbelief. "So the state is going to just cut this off? They're wrong for that," says Joyce Smith, a trim 49-year-old waiting at W-16 for a six-month routine checkup for breast cancer that's in remission. She had private insurance and saw private doctors until she was laid off last month, she says.

Richard Nelson, 52, has never been to W-16 before today. But late last month, he was laid off from his job in a local hotel kitchen and his health insurance was cut the very same day. It's a situation, he believes, that's familiar to many hospitality workers. "With 9/11 and just the nature of the business, we're always getting laid off," he says. He could have chosen to extend his health insurance, but the $400 a month is a sum he can scarcely afford.

Last week, the U.S. Census Bureau released new data showing that more than one in seven Americans are now uninsured. And in many ways, the W-16 waiting room reflects who is uninsured in America today. There are the uninsured elderly who are not yet eligible for Medicare, and the uninsured young people, ages 19-29, who are no longer covered on their parents' insurance but don't yet have any of their own. Historically, Charity's waiting rooms have been filled by the city's working poor, many of whom have never had health insurance but who make too much money to qualify for Medicaid. In Louisiana, two parents with two children cannot make more than $260 per month.

But today, lifelong Charity patients are increasingly likely to find themselves sitting in the waiting room next to someone who used to have insurance on the job but is now without either. The Kaiser Commission on Medicaid and Uninsured has released a number of studies finding that fewer employers are offering coverage and that the coverage they're offering is more expensive, putting it out of the reach of many workers.

Locals who are newly uninsured seem to be making their way in big numbers to Charity and University. "The volume of patients is seriously up," says Carolyn Nogess, who started working at the hospital in 1966 and is now an account specialist in the admit department.

In Louisiana last year, the LSU-charity hospital system cared for most of the state's uninsured. The hospitals' budgets reflect that. At Charity-University, out of every dollar spent last year, 58 cents went toward care for the uninsured. Nationwide, public hospitals like Charity spent an average of 25 cents from each dollar for the uninsured, according to the National Association of Public Hospitals and Health Systems. That's still high compared to most hospitals -- public and private combined -- whose spending on the uninsured in 2000 came out to an average of 6 cents on the dollar.

Federal money that compensates for uncompensated care has been on the decline, even as the numbers of uninsured have been on the rise. Charity and University hospitals received $286 million for uninsured care in 2002 but will receive only $196 million for that purpose for 2004. That leaves city funding, which most other "safety-net hospitals" receive. Charity and University do not.

Most states also fund their safety-net hospitals. But most other state budgets this year did not contain big budget cuts for those hospitals, says Melanie Nathanson, a Tulane University graduate who works as a Senior Health Policy Analyst at the Washington, D.C.-based Center on Budget and Policy Priorities. Last month, the Kaiser Family Foundation released a 50-state survey of health care spending cuts. Nathanson cites the study, noting that doctors and dentists have taken a big hit in the state budgets while hospitals haven't. "What's happening at Charity is not typical," she says.

For their part, many W-16 patients believe that Louisiana could have done better by them. "The state is just giving us a bag of rocks," says Carol Ben, 60. She's been waiting for more than two hours with her 20-year-old granddaughter, Lucreshia Ben, whose jaw is swollen from an infected tooth. "God knows I don't wish anything bad would happen to our governor," says Carol Ben. "But I wish that he could sit here in this chair. You sit and sit and sit."

Ben and others in W-16 have closely followed the news reports about the Charity Hospital budget cuts. Most of them cite early reports on the issue, which had noted -- correctly -- that private hospitals would not be taking the same level of cuts as the state's charity-hospital system. "There was money meant for the charity hospitals," says one woman. "Where did it go?"

The answer to that is "very complicated," says David Hood, secretary for the state's Department of Health and Hospitals. But, he says, the Legislature knew that its budget meant big cuts for the state's 10 charity hospitals and for Louisiana State University, which oversees the hospitals. "At the end of the legislative session when the state received its additional federal money," says Hood, "the Louisiana Legislature could have chosen to make the LSU-charity system whole. They chose not to do that."

Hood is referring to $20 billion that came through the U.S. Congress in May. It was meant to help state governments, which are in the midst of the worst fiscal crisis since World War II. Louisiana received $264 million of that money, and the LSU-Charity hospital system had hoped to get $98 million from the legislature. Instead, at the end of June, they learned that they would be receiving $35.6 million.

The remaining $62.4 million? "I don't think you'll find a list of where that money went," says Hood, explaining that it was appropriated by the legislative committees, which doled it out bit by bit in hundreds of different amendments. "It's not just private hospitals," Hood says. "It is many providers in the Medicaid program including private hospitals, nursing homes, and physicians."

"You could very politely call it 'creative financing,'" says MCLNO chief executive officer Dwayne Thomas, who says that DHH is taking money off the top of funding intended for the charity system and using it to fund the state's Medicaid program.

Hood emphasizes that the Louisiana Legislature made the ultimate decision about where the money would go. "The money really doesn't go to DHH," he says. "It would probably take me days to go through all the details."

The people in red T-shirts hold their signs up for the TV cameras, whose operators walk in close and follow the short line of protesters as they march back and forth, chanting, on the Tulane Avenue sidewalk, right in front of Charity Hospital's front door. A little boy carries a sign that reads, "$264 million windfall funds everything but Charity." The most common sign reads "Save our hospital."

"Bush. No war, Keep our money at home," chant the protesters, led by a tall man on a bullhorn. Lanny Roy tells the crowd that he's representing Local 100, Service Employees International Union (SEIU) and Louisiana ACORN (Association of Community Organizations for Reform Now), for whom he's the vice president.

They take a little break and Roy puts the bullhorn down. But he's still fired up. He says that the charity hospital in Lake Charles, near his house, is so busy lately that patients have been waiting for 18 and 20 hours. "Working people are the lowest thing on the totem pole in darn near everything," says Roy, his forehead sweating from the heat. "First of all, let me say that we believe it is a slap in the face to the people of Louisiana for any public official to cut Charity Hospital. This is a shame and a scam."

This state has long depended on this system, says Roy, ever since the legendary Huey Long, who ran for governor under the slogan "Every Man a King" and expanded the state's charity hospital system during his reign. "He wanted to make sure that every man, woman and child got health care," Roy says. "He saw the need. And that need is still there."

Later governors, notably Edwin Edwards, were also outspoken supporters of Charity Hospital. Charity spokesman Jerry Romig recalls one of Edwards' childhood stories. "He and his brother boarded a Greyhound bus at Crowley, where they lived," says Romig. "Their mother put them on the bus and told the driver to let them out at Charity to get their tonsils out."

Inside Charity Hospital, a full-size painting of Huey Long still hangs in the boardroom. But Big Charity had been established a few centuries before, in 1736, after a dying French seaman named Jean Louis left money in his will to start a hospital "for the sick of the City of New Orleans." Today, it's said to be the oldest continuously operating public hospital in America.

Inside, the hospital's corridors are filled with images of others who have helped the hospital, including Sister Stanislas, the Daughter of Charity nun and nurse-administrator who worked in the hospital for more than a half-century and famously kept the motorcade of President Franklin Delano Roosevelt waiting outside the front door while she tended to a patient in the E.R. When she emerged, Roosevelt leaned forward and said, "Sister, I've heard a lot about you." She replied, "Mr. President, I've heard a lot about you, too."

Locally, Charity Hospital is famous because most of the city's most prominent officials, artists and musicians were born here and sat in the waiting rooms here. The late R&B star and self-proclaimed "Emperor of the Universe" Ernie K-Doe was born at Charity. So was Master P, Mayor Ray Nagin, Charity's CEO Dwayne Thomas, Kermit Ruffins. And Allen Toussaint, who for the hospital's 250th anniversary wrote a song called "Charity's Always There" -- "With opened doors that never close/Where you're never turned away/ 24 hours a day," he sang.

These days, the babies are born in the maternity wards at University Hospital. But people still say that they were born at Charity. The oft-heard phrase "I'm a Charity Hospital baby" is one that can still be claimed by half of the babies born in New Orleans each year. Many will head back to Charity throughout their life.

Pregnant mothers were often brought to Charity in a speeding car with a white handkerchief flapping out the window that signaled a medical emergency, says Carolyn Nogess. "It was common practice here. You got that person here quick, fast and in a hurry. And doctors knew, when they saw a car with a white hanky pull up, that someone had been shot or stabbed or that a mother was ready to deliver."

Sometimes people waved a towel or a T-shirt or a piece of sheet, but as long as it was white, the police wouldn't stop you, Nogess says. "People would move out of your way faster for that than for the ambulance," says Nogess' longtime colleague and fellow Charity Hospital baby, admit manager Mary Council-Williams. "But it went the way of the dinosaur," says Nogess.

From her office window, Nogess can see the front entrance of Charity, where a gunshot victim drove up off Tulane Avenue and onto the sidewalk a few weeks ago. "We've seen everything," she says.

On that same sidewalk, the ACORN protestors in their red shirts are still shaking their signs and chanting. Lanny Roy's voice can be heard over everyone else's, courtesy of his bullhorn. "The people. United. Will never be defeated," they yell, while patients and young doctors with stethoscopes around their necks stop to watch for a second and then walk through Charity's big front door.

Around the back of the building, the emergency department's waiting room is full and everything is quiet except for some low-volume jabber from the television. Below the TV are silver letters on the wall that read "Welcome to the Medical Center of Louisiana, where the unusual occurs and miracles happen."

Carolyn Hughes, 45, is waiting to see a doctor after getting dizzy and light-headed on a city bus yesterday. The doctors think that she might have had a light stroke.

Hughes is a Charity Hospital baby and lifelong Charity patient. She works at another local hospital, she says, but she can't afford the insurance plan it offers. So she comes to Charity. "I want to make sure I'm well before I go take care of somebody else," says Hughes.

For the people who don't believe that the charity hospitals should be fully funded, University-Charity CEO Dwayne Thomas has one request.

"If you really like your doctor, look first at your doctor's wall and see where he or she was trained," Thomas says. Because, for anyone who lives in Louisiana, there's a good chance that your doctor was trained at Charity Hospital.

The 615 medical residents at Charity and University hospitals are considered so vital that the recent budget cuts were crafted around them. "It was one of the primary considerations in our budget reductions," Thomas explains. The W-16 walk-in clinic, for instance, was one of the few areas where no residents train. "So from that aspect," he says, "that cut was an easy decision."

DHH's David Hood says that he has no idea how Charity and University decided on their specific cuts. "I have no idea why they chose operating rooms," he says. And if the process centered around residents, he asks, "Then why are we hearing so much about, 'Residents won't want to do their residency here in Louisiana; they'll want to go elsewhere.'?"

With such large-scale cuts, it's inevitable that some cuts will affect residents, says Dr. Perry Rigby, director of health care systems at the LSU Health Sciences Center. Because one-third of the surgical suites have been closed, residents will be doing one-third fewer operations. With the cuts, Charity and University operating rooms now will have to turn away more than 3,700 procedures annually.

This marked reduction in surgeries may mean the loss of one-third of the hospitals' 177 surgical residents -- around 59 residents total. "Fewer patients will be operated on," Rigby says. "And eventually, we won't be doing enough operations to satisfy the accreditation for each resident."

Surgical residents are often ambitious and sought-after. "They have a place elsewhere," Rigby says. In this highly competitive world, one negative factor can deter potential surgical residents for years to come. "So even if the money were restored soon, we might not have any chance of recruiting people for next year," Rigby says.

Thomas believes that -- from a state perspective -- the charity hospitals are often viewed in terms of their patients, not in terms of their role in academic training. "I think there is a lack of appreciation for the fact that we're part of higher education in Louisiana," he says. Yet the charity hospitals ensure a steady stream of new doctors practicing in this state, he says, because 70 percent of the trainees who come through the LSU-charity system go on to practice in Louisiana.

The hospitals also provide hands-on, face-to-face training for thousands of students a year. At any given time, three out of five residents and health fellows in Louisiana are being trained in this state's charity-hospital system. And almost every resident in the state will work, at some point, within that system.

"We train everybody -- doctors, nurses, pharmacists, physical therapy students," says Dr. Myra Kleinpeter, the director of outpatient clinics, who trained here herself as a Tulane University resident. The hospital offers an incredible volume of patients and range of ailments, she says. "I saw cases here that other people only read about."

CEO Dwayne Thomas believes that the legislature would like to re-configure the charity system. He agrees. "I will be the first to tell you that the charity system could be re-organized," he says. But these cuts came too quickly, he says, especially for the hospital's resident programs. "To force these sorts of budget cuts within a three-month period is like trying to stop an 18-wheeler on a dime," he says.

Mary Knapper started working at Charity Hospital in 1957, as a candy striper. She was 11 years old. She had been a sickly child, and so she'd spent a lot of time there, and it made her curious. "I was interested in the human body and what made it tick," she says.

Knapper says she knows from experience how good the doctors are. She worked at Charity, in the surgery wards, for nearly four decades before retiring after an on-the-job back injury. During hurricanes, she remembers now she worked for three days straight and how the hospital sent an ambulance for her kids so they wouldn't be home without her, and she put them to work too, sweeping and helping patients.

She worked nights, she says, but only once did she see one of the ghost nuns that Charity staffers have talked about for years. It was a young nun, she says, who came up one night and tapped her on the shoulder, told her to look around. Some thieves were shoving supplies into the freight elevator, says Knapper, and so she called security and they were caught.

Knapper also recalls seeing gunshot victims come in, near death, and then running into them later at the grocery store. "It was a feeling of great satisfaction to know that you had helped to save someone's life," she says.

If she's sick, she will never go anywhere else, she says. "It feels good," she says. "I've always had someone I can depend on."

That sentiment is common across town, says Tammi Fleming, who heads up the local program Health Care for All, which enrolls public-housing residents in Medicaid and LaCHIP, the children's health plan.

Fleming sums up what she sees. "Some people go to Charity because there's nothing else. Some people go because they prefer it."

Carolyn Nogess sees it in the admit office where she works. Some people use their private insurance so that they can get low-cost prescriptions, but when they get really sick, they want to go nowhere else but Charity Hospital.

"It's part myth and part perception," says Fleming. Partly, she says, the hospital's stellar reputation with trauma patients gives it a mythical reputation around town. But there's more to it than that, she says. "In the past, especially in the African-American and poor population, people didn't have experience with private clinics and hospitals. So if that's your only experience, it seems like the only place that can take care of people who are sick."

Knapper agrees. Many people -- especially older people like her, she says -- will always go to back to Charity, especially for big procedures. "We know from way back when how we were treated with dignity and respect at Charity Hospital. So when you got insurance, you went back."

Carolyn Nogess hears it all the time. "People who have insurance still want to be seen here," she says. "They'll say, 'My mama and my grandma came here, now I'm coming here, my kids will, too.'"

That sort of loyalty would seem great for any hospital. Except for the fact that most HMOs don't cover care at Charity Hospital. Coventry Healthcare of Louisiana is the only HMO that does, says Nogess. As a result, insured patients who come to Charity choose to pay out-of-pocket fees for that care.

Of course, all the HMOs have had patients brought here by ambulance, since Charity is the designated Level I trauma center for the region -- the only hospital that has the round-the-clock, comprehensive staff to handle difficult trauma cases. Which means that, if an ambulance arrives at the scene and finds anyone who is severely injured, that patient must be taken to Charity. "If it's a trauma, you're coming," says Nogess.

Fleming suggests talking to Marian Jordan, who works with her at Health Care for All. They have health insurance through work, but Jordan still chose to go to Charity for a recent outpatient procedure.

Jordan, who will be 54 this month, explains that she was "born and raised in Charity," and spent lots of time there as a sickly kid, with asthma and a bad heart. She's had private insurance a few times, she says, but had some bad experiences with private hospitals. One hospital kept her waiting for hours even though she was bleeding internally, because she couldn't reach her brother, who was out of town with their insurance card.

Jordan will go to a private doctor for little things, she says. But if things get bad, she heads straight for the big white building on Tulane Avenue. "I say, 'Baby, if I were you, I'd go to Charity, because you'll find out what's going on with your body.' I don't think I can ever get better health care other than Charity. You'd have to have experienced it to understand."

Lois Joseph feels the same way. Back in the late 1960s, Joseph graduated from the Charity school of nursing and started working at the hospital not long after they took down the shingles that said "White" and "Colored."

Joseph now works at a local daycare and has health insurance. But she knows where she's headed if she's seriously ill. "I don't care how much insurance I have," Joseph says. "Day after tomorrow, if I get sick, I'll go to Charity."

When he thinks of his walks through the waiting areas at Charity Hospital, one word sticks in the mind of Dr. Elliott C. Roberts, Sr., who was director of Charity Hospital throughout the 1980s. "Patience," he says. "It's patience. Individuals who are willing to wait their turn and in many numbers."

It just comes with the territory of being a Charity Hospital patient, says Mary Council-Williams. "I remember when you'd come and bring your breakfast and your lunch," she says.

"And don't forget snacks for the kids," says Carolyn Nogess from her neighboring desk. "If you come here enough, you get a system. You come early morning and early Sundays as opposed to Mondays."

Those waits had been reduced in recent years. But the closure of W-16 is going to mean a return to the days of long, long waits -- breakfast, lunch, and maybe even dinner in the Charity waiting room, they say.

But people who need care will figure out some system, and word will get around. Go ask anyone on the streets, says Nogess. "Ask him what time to come to Charity. He knows. They just know."

You have to, she says. Because there's nowhere else to go.

click to enlarge DONN YOUNG
click to enlarge Twenty-year-old Lucreshia Ben, whose jaw is - swollen from an infected tooth, gets her blood - pressure checked. "God knows I don't wish anything - bad would happen to our governor," says - Lucreshia's grandmother Carol Ben, waiting in a - nearby room. "But I wish that he could sit here in - this chair. You sit and sit and sit." - DONN YOUNG
  • Donn Young
  • Twenty-year-old Lucreshia Ben, whose jaw is swollen from an infected tooth, gets her blood pressure checked. "God knows I don't wish anything bad would happen to our governor," says Lucreshia's grandmother Carol Ben, waiting in a nearby room. "But I wish that he could sit here in this chair. You sit and sit and sit."
click to enlarge W-16 medical director Dr. Khalil Imsais shares a - brief light moment with colleagues Olander - Holloway and Dr. Myra Kleinpeter. "Our funding has - always had its ups and downs," says Imsais. "But - this is the worst time ever, in the history of Charity - Hospital." - DONN YOUNG
  • Donn Young
  • W-16 medical director Dr. Khalil Imsais shares a brief light moment with colleagues Olander Holloway and Dr. Myra Kleinpeter. "Our funding has always had its ups and downs," says Imsais. "But this is the worst time ever, in the history of Charity Hospital."
click to enlarge Charity's corridors are filled with images of people - who have helped the hospital, including Sister - Stanislas, the Daughter of Charity nurse- - administrator who famously kept President Franklin - Delano Roosevelt waiting while she tended to a - patient in the E.R. - DONN YOUNG
  • Donn Young
  • Charity's corridors are filled with images of people who have helped the hospital, including Sister Stanislas, the Daughter of Charity nurse- administrator who famously kept President Franklin Delano Roosevelt waiting while she tended to a patient in the E.R.


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