Flak over hospital realignment shows power of populism

The wailing and gnashing of teeth you hear from the big government “conservatives” in St. Tammany Parish presents an object lesson into the sea change of thought necessary for right-sizing Louisiana state government.

Local elected officials were disappointed to learn that part of the fallout of a decision by Congress to ratchet back excess funds given the state for Medicaid meant the eventual closing of the Southeast Louisiana Hospital in Mandeville, one of the three state-owned facilities devoted to mental health patients. This will reduce the roughly 900 state-run beds for maladies of this kind by about a quarter, although the Department of Health and Hospitals pledges it will find space for all, even though that might be hundred or more miles away.

It’s unfortunate that the closing comes when it did, but not that the closing will come. The state has planned for that day to come, following the trend of almost every of state that are removing beds and closing facilities (some have closed all of them). This merely follows a long term secular trend starting with the deinstitutionalization movement launching six decades ago that has left state-operated beds at less than a twentieth in number of what they had been.

That is a somewhat-deceptive statistic for there has been a surge in the number of private beds (including nonprofit-run) available since, although not nearly the same number reduced. And, as it turns out, Louisiana has been behind the curve in reduction of state beds but ahead of it, in per capita terms, in the presence of private beds. In both categories, public (2010 data) and private (2007 data) beds, Louisiana ranks in the top quarter of states in provision.

While the state may rank well comparatively, some argue in an absolute sense it or any other state really does not sufficiently provide enough public beds, according to a panel of leading figures who studying the area of mental health a few years back that declared that the preferred level of state beds provided per capita (adjusted to per 100,000) was 50 (Louisiana’s was 19.9). Still, when adding in private beds, the state’s number was close to 90, or there was almost a bed for every 1,000 people.

Hitting the mark with public beds then was deemed important because private beds typically were not covered by many private insurance plans in this health area. But with the emergence of Obamacare, that has changed as it will force insurers to provide more of these kinds of benefits by the end of next year. And in Louisiana, the transition in indigent health care provision, including mental, is towards Medicaid recipients purchasing private insurance with state subsidization. For both reasons, then, the distinction between public and private beds has disappeared. In other words, if the state wishes to maintain a certain level of provision and it cuts public beds, private beds can take their place.

Already, DHH has been pursuing this philosophy. For example, a few months ago, the acute psychiatric beds in the charity hospital in Lake Charles essentially were transferred to a nonprofit operator. And with there being little slack capacity at any of the three state mental hospitals and money following the patient, non-state providers are likely to expand their supply of beds, following this example.

Even in a localized sense, the reduction does not create a jarring discontinuity. Only 17 percent of the beds serve district (St. Tammany and four other parishes) patients, there are other local beds, and in neighboring District 1 (St. Tammany is part of District 9 for DHH administrative purposes) as of the spring there were about 80 beds per capita for any overflow – even after reductions in District 1 occurred in the spring.

So, Louisiana has the capacity outside of the state system to absorb a state reduction in an environment already better off in regards to provision that most states. While the transition away from state provision in this instance undesirably is rushed, in no way does it provoke a crisis.

Unless you listen to overwrought elected officials, such as Parish President Pat Brister and some state legislators. They complain about not having enough warning or input, but the state essentially was blindsided by the federal government on very short notice and it would be impractical to contact and consult every local official where DHH has a footprint and to move as quickly as possible. They moan about relatively high local suicide rates, without understanding that the parish government should take the public health lead in preventing the disease rather than abrogating to the state to treat the symptom.

But, most disturbingly, they make reference to the jobs losses that will occur by the closing. Some of these will be mitigated by local non-state providers absorbing demand, but since the vast majority of patients were statewide, many disappear. It’s rhetoric you might expect out of liberal Democrats, who buy into the populist nonsense that has held the state back that a primary function of the state is in the direct provision of jobs. It’s hard to believe this is the same Brister, who once lead the state Republican Party and served on the National Committee of the party that argues job creation is done best by the private sector, espousing this rhetoric.

Or that the state keep the hospital open with an infusion of half a million dollars from the parish. The only thing keeping it open longer than necessary will accomplish would be channeling taxpayer money to prop up jobs that don’t have to exist and elsewhere could be performed as well with fewer of the people’s resources involved. If Brister were serious about committing parish monies for efficient purposes in this area, she would focus it on things like supporting better intake and evaluation procedures for those with suspected mental problems so that those with them chronically end up with proper case management and for episodic patients to be steered to acute treatment and not end up clogging jails or non-psychiatric beds, changes that occurred in Orleans Parish after the spring reductions.

Her reaction provides another example of how deeply engrained into the political culture of Louisiana the populist persuasion is. Conservatives and Republicans are supposed to be the ones taking the lead to evolve the state away from that, but when you find examples such as this, it becomes very clear how long and difficult the process will be to accomplish getting Louisiana's public sector to a legitimate and affordable size.