BATON ROUGE, La. – Bahnsen Miller understands the challenges — and the damages — of Louisiana's budget woes firsthand. You can't ignore them if you've been in one of the state's doctor training programs, constantly at risk of calamity.
The 31-year-old internal medicine doctor ran into questions about financial stability and watched Louisiana lose top talent to its neighbors as he recruited people to train at Our Lady of the Lake Regional Medical Center in the state's capital. The general surgery program lost applicants who went out of state because of the uncertainty, he said.
"Most residents stay in the state where they train, so if we lose a student, say, to Mississippi or Alabama for residency, there's a good chance they're not going to come back to Louisiana," said Miller, one of the hospital's chief residents last year.
Louisiana's deep, persistent budget troubles are endangering the future of medical training programs. Proposed cuts to hospitals could damage the stream of new doctors for a generation, in a state that has chronic shortages of health care workers and some of the worst health care outcomes in the nation.
And just the chatter about the financial threats is already having ripple effects, with other states' doctor-training programs cherry-picking some of Louisiana's top talent.
"The dean of the School of Medicine tells me almost daily he's getting calls from students saying, 'Is this really where I need to train? Should I stay here or should I go someplace else?'" Larry Hollier, chancellor of the LSU Health Sciences Center in New Orleans, told state senators.
At Our Lady of the Lake, doctors-in-training make rounds as usual, checking patients, diagnosing ailments and selecting treatments. They ignore the question marks about their future as much as they can, trying to disregard the legislative haggling that threatens their programs.
"It does kind of make you think about where you should go, whether staying is worth it or not," said Kevin Francioni, 24, a third-year LSU medical student training there.
In the final days of their regular legislative session, Louisiana's lawmakers are grappling with a $600 million budget shortfall and trying to determine where to levy the cuts. Not only are the LSU health sciences centers in New Orleans and Shreveport threatened with direct reductions, but perhaps more critically, the safety net hospitals that care for Louisiana's poor and uninsured patients — and in which medical students train — also are on the chopping block.
At risk, according to Hollier, the New Orleans health sciences center chancellor, is nothing less than the decimation of health care in the state.
For new doctors who will spend three to seven years training in residency programs, choosing Louisiana can be a gamble.
"Some people are saying, 'Are we going to make it?'" said Carine Nzodom, 31, in her second year of a four-year psychiatry residence program at Our Lady of the Lake.
Only a few years ago, LSU ran a statewide charity hospital system that primarily took care of the poor and uninsured patients around Louisiana. That provided the bulk of training sites for medical students.
Former Gov. Bobby Jindal began privatizing that system in 2013, handing the facilities over to private managers, shuttering some hospitals and moving safety net services to other private hospitals. Our Lady of the Lake took over most of those safety net services in one such deal, and LSU's charity hospital in Baton Rouge shut down.
Few dispute the system has improved, with expanded services, shorter wait times and a broader mix of patients with which medical students train. But that comes with rising costs. Amid budget gaps, lawmakers question the spending.
Hospital managers say without enough money, they could walk away from their contracts, leaving not only patients but also the doctors who train with them in the lurch. Gov. John Bel Edwards is trying to renegotiate the deals.
If a safety net hospital deal craters and some of the training programs shut down, Louisiana could feel effects for decades.
"I think the legislative body doesn't have the appreciation of how close we are to total dismantling of the educational programs of future physicians," said Scott Wester, CEO of Our Lady of the Lake, where 192 residents train.
If Louisiana has fewer residency slots, doctors go elsewhere. Once a state loses the federally-allocated slots, other states scoop them up, making it almost impossible to recapture them.
Health and Hospitals Secretary Rebekah Gee, a medical doctor, outlined the risks to lawmakers: If the state loses some of its 1,900-plus residency positions, "we permanently lose capacity to train doctors in the state."
Eighty-one percent of Louisiana is federally designated as a health professional shortage area for primary care, according to the state health department. The state ranks in the bottom tier nationally for a list of health issues, with high rates of cancer, obesity and diabetes.
Lawmakers are crafting a budget for the financial year that begins July 1 before the legislative session ends June 6. But that won't settle the uncertainty. Edwards, a Democrat, is calling lawmakers immediately back for a special session on taxes, in hopes of raising money to stave off cuts, including those to hospitals.
Hospital leaders said they may have to ration care or rethink their deals with the state if they don't get more than the $1 billion in financing proposed.
To Miller, the budgetary decision has stark consequences.
"This isn't just about the indigent or just about training," he said. "This is about the future of health care in Louisiana."