Swept Away

Hundreds of thousands of displaced Gulf Coast residents are finding themselves in a health-insurance crisis. While those injured, sick, or chronically in need of health-care services are finally gaining access to emergency medical services at shelters or in the towns and cities to which they have been evacuated, their ability to continue getting needed care is made very difficult and put at risk because the United States does not have a national health insurance system.

Paying for and keeping health insurance coverage is difficult, even in the best of times. Health-insurance premiums are unaffordable for many people, especially if they are unemployed, self-employed, or if their employer does not offer coverage. People losing jobs suddenly lose insurance; those changing jobs often lose coverage if their new employer doesn't provide it. State requirements to enroll in Medicaid are often so severe that many poor or disabled can't meet them. And even those on Medicaid often find that the program's payments to doctors are so low many providers won't treat them.

Now Hurricane Katrina's displacement of hundreds of thousands of people has made health-insurance coverage even more of a crisis for people along the Gulf Coast, especially in Louisiana. Medicaid enrollees have lost their paperwork, computers are down, and people cannot prove they had coverage. Others, suddenly unemployed or those without insurance, want to apply for Medicaid in the new state in which they suddenly find themselves. But Medicaid rules are different in each state, and federal support for it differs from place to place. States are unsure which rules should apply for evacuees or who will pay for them, their home state, their new state, or the federal government.

For those displaced hurricane victims who have insurance, many are barely able to pay for food and housing, let alone manage insurance premiums. And even if they can, those in HMOs or PPOs and required to use specific doctors or hospitals will not be able to do so for some time.

Existing problems are likely to be exacerbated if more people lose coverage over the next few months because employers in Louisiana go out of business, or if evacuees find that they cannot return home to work. Many elderly people are expected to seek nursing-home care as they find that the family and friends they had relied on for help can no longer provide it.

Health-care coverage in Louisiana, one of the poorest states, was already fragile before the hurricane hit. It had the third-highest rate of uninsured in the nation, with 22 percent of all residents under 65 lacking coverage. For the poor, defined as those under 200 percent of the federal poverty line, more than one-third had no coverage.

For the rest of the poor, Medicaid helped pay for health care, at least for children. Almost 20 percent of the non-elderly in the state were enrolled in Medicaid, and most were children whose parents didn't qualify themselves. Fifteen percent were disabled. The state's Medicaid payments to doctors were so low, however, that it was hard for many enrollees to find providers willing to treat them. The rest of the state's residents had private insurance, although for many it was a strain to keep up payments.

Then the hurricane hit. Two-thirds of the state's Medicaid enrollees were in parishes hard hit by the hurricane and floods and are now scattered throughout the country. Lost in the floodwaters are any records of their Medicaid enrollment or eligibility documents. States around the country -- especially Texas, where about 200,000 victims fled -- are struggling to provide health-care services and are warning that they can't continue to do so without federal money.

When reports surfaced that the Bush administration was going to ask Texas to absorb the added costs of caring for the hurricane evacuees, Texas Governor Rick Perry hurriedly sent off a letter to Washington threatening drastic delays in caring for Louisiana Medicaid enrollees unless the federal government agreed to pick up the total tab for care. Otherwise, he said, Texas would have to access Louisiana enrollment files and enroll Texas physicians and hospitals into Louisiana's Medicaid program before giving people needed services, something that is currently virtually impossible.

The National Association of State Medicaid Directors fired off a letter to federal Medicaid officials September 2 urging them to put hurricane victims into a unique category of eligibility to allow them to immediately enroll in any state for coverage and for the state to get completely reimbursed by the federal government. The group's vice chair, Ohio Medicaid Director Barbara Edwards, warned Friday that states need quick answers to their many questions about providing Medicaid help to evacuees.

Congress and the administration have been scrambling to give answers, but thus far the Medicaid directors' association says it has not seen anything concrete. Dr. Mark McClellan, head of Centers for Medicaid and Medicare, said last week that he was working on developing one single form that all states could use to have evacuees apply for emergency Medicaid coverage, with or without documentation of their income. On Monday, Senate Majority Leader Bill Frist said that the administration would soon announce help for Texas, and Senator Kay Bailey Hutchison said that she would introduce a Medicaid reimbursement bill authorizing the federal government to pay 100 percent of Medicaid coverage for evacuees for six months. Republican and Democratic Senate Finance Committee leaders indicated that they would introduce a bill to provide federal payment for all states providing Medicaid coverage to evacuees.

At the same time, dozens of private health insurers are suspending rules -- sometimes for a month, sometimes longer -- requiring that their enrollees use certain health-care providers. They are also giving people extra months to come up with payments for their insurance policies. But how long this largesse will last is questionable; very likely it will not be as long as many of the hurricane's victims will need it.

All this would be unnecessary if we, like virtually every industrialized nation, had a national health-insurance program. Such a program -- a universal Medicare plan, for example -- could provide everyone with the same coverage, regardless of where they live (or have to live in an emergency). And it would mean that people who lost their paperwork in a flood, fire, or other catastrophe would never have to worry that their coverage would disappear with it.

Barbara T. Dreyfuss is a freelance writer based in the Washington, D.C. area.