Senator Eliot Shapleigh - El Paso, Texas

For years it's been known as the hospital of last resort for the uninsured and indigent in Texas.

Whether they drove hundreds of miles on their own or were shuttled in vans and buses by their local governments, they have come to the University of Texas Medical Branch at Galveston from 160 of the state's 254 counties.

"People from all across the state knew they could go there and get charity care," said Karen Love, president and executive of the Harris County Health Care Alliance.

But since the public hospital was shut down after Hurricane Ike caused $710 million in damages, many communities that depended on UTMB to treat indigent patients have scrambled to find alternatives. About 25 percent of Texans do not have insurance, the highest rate in the country, according to the U.S. Census Bureau.

Now as a wounded UTMB slowly heals after 3,000 post-Ike layoffs and losing more than half of its 550-bed hospital, concerns are mounting as to what the changes will mean long-term for indigent health care in southeast Texas and the rest of the state.

"We don't really know what level of indigent care we will now be able to provide," said Dr. Ben Raimer, UTMB's vice president of community health services.

The short-term affects on indigent health care were felt almost immediately.

Nearly 80 percent of the patients treated by UTMB come from six counties: Jefferson, Galveston, Harris, Brazoria, Fort Bend and Montgomery.

"The hurricane was definitely not a glancing blow to our health care system for poor people. It was a real devastating blow," said Jefferson County Commissioner Everette Alfred.

Jefferson County, located northeast of UTMB, had been sending 600 to 800 patients each month to the hospital under its contract with the facility for indigent care services.

Now those patients are being seen in local clinics, creating waiting lists of two months or more.

Alfred said officials are also sending patients to local doctors, which are charging more than UTMB, straining the county budget.

Other rural southeast Texas counties like Liberty, Hardin, Jasper and Newton are having trouble finding local specialty care doctors — including neurologists and oncologists — to send patients to.

"It's created a nightmare for these counties that are totally dependent on UTMB. Those were the doctors we really depended on UTMB for," said Donna Burtt, director of the Liberty County Indigent Health Care program. "We are just not finding them at times. We tell patients, 'We don't have a place to send you.'"

Health care officials say hospitals and clinics in nearby Houston and the surrounding Harris County are reporting a rise in patients at emergency rooms and public clinics. Many are indigent patients who would have normally gone to UTMB.

"You cannot take down a facility of that size and not have it impact the community at large," said David Lopez, chief executive of the Harris County Hospital District, which in fiscal year 2008 had about 1 million patients visits — most for indigent care.

However, even before the hurricane, UTMB — also home to the state's oldest medical school — had been reducing the amount of indigent care offered in an effort to reduce mounting financial losses. While UTMB has a budget of about $1.5 billion, it lost $59 million last year, mostly due to its underfunded indigent health care program, Raimer said.

In fiscal year 2008, UTMB saw more than 47,000 indigent patients at a cost of $275 million. That was up from the previous year's totals of 44,013 patients and $273 million.

While demand for health care among indigent patients has grown, but UTMB has been slowing the rate of the increase.

"That decrease has been happening because we have no increase in funding to sponsor those individuals," Raimer said. "We have no way to pay for it."

While health care costs have climbed each year, state funding has not and Medicare and Medicaid do not fully reimburse UTMB for its costs, he said.

UTMB also has contracts with nearly 40 counties and hospital districts to treat indigent patients. But they pay only about one-third of the actual costs of that care.

UTMB's financial problems were exacerbated by Ike. Its hospital and clinics, which fund nearly 60 percent of the entire budget, were shut down by the hurricane and most have not fully reopened.

The long-term affects of a downsized UTMB and what level of indigent care it can provide are still unknown.

It could take up to a year to determine the actual Ike's full affect, said Dan Stultz, CEO of the Texas Hospital Association.

"The real issue is not having a comprehensive system to ensure access to health care for all Americans," said Anne Dunkelberg, associate director of the nonprofit think tank Center for Public Policy Priorities. "There are lots of things our state can do to make sure we don't have the worst uninsured rate in the country. But we need a national solution to get out of this hole that we are in."

Raimer said as UTMB determines the level of indigent care it can provide, possible scenarios include partnerships between the teaching hospital and other entities to create a broader health care network.

"I don't see for anyone's benefit where UTMB is the only provider in that," he said. "I don't see that as good service."