A Resource Guide and Report of the
Health Care and Homeland Security Conference, July 17-18, 2007
Health care reform is again being seriously discussed. Rapidly
rising costs, problems with access to care, and questions about
quality of care have made this a major issue. At the same time, the
post-9/11 and post-Hurricane Katrina world has focused significant
attention on improving our medical preparedness and disaster
response planning. However, discussions on one issue usually do not
consider the other. Homeland security clearly has many areas that
involve health care, from the public health infrastructure to
health-related industrial capacity. And, of course, the homeland
security community relies on the health care community to respond
to any disaster involving illness or injury. Health care reform
will be a massive undertaking involving standard information
systems, health promotion and prevention as well as acute
care, access for all with an expanded emergency capacity, and the
ability to "surge" hospital care. All of health care reform has
homeland security implications, but emergency capability and
response, hospital capacity, and public health are especially
significant for both. Recognizing this, The Heritage Foundation,
supported by the McCormick Tribune Foundation, convened leading
health care and homeland security experts to discuss the precarious
relationship between the two areas. This report, prepared with the
assistance of Martin, Blanck & Associates, is the result of
that conference and includes policy recommendations and
At the crossroads of health care delivery (and reform) and
homeland security emergency preparedness lies the disaster. Whether
the disaster is chemical, biological, nuclear, radiological or
explosive, man-made or natural, the event will trigger immediate
response in the affected population. The first reaction of those in
need of medical attention will be to flood the local emergency care
system. Our emergency response system relies on first
responders (fire, police, ambulance) to treat those in need of
care and transport them to first receivers (emergency
departments, community hospitals, trauma centers, urgent care
9/11 and Hurricane Katrina were overwhelming regional
disasters--one terrorist and one natural--that affected the entire
country in their scope, difficulties of response, lack of
communication, lack of preparedness, and oftentimes, lack of
leadership. These will surely not be the last major disasters
America will face.
What have we learned? Are we prepared for the next crisis of
We have learned about a number of things that can go wrong in
disaster response--fragmentation of responsibility, logistics
problems, and poor communication channels, to name but a few. The
establishment of the Department of Homeland Security (DHS) was
the most significant response to 9/11, and the failure of the
federal response to Hurricane Katrina four years later highlighted
the weaknesses of the relatively new federal agency.
A look at the current state of readiness of the health care and
emergency medical systems shows strains on capacity, budgetary
constraints, and low priority given to emergency response
readiness. Any surge in demand could quickly overwhelm resources.
Emergency medical services received only 4 percent of the $3.38
billion distributed by the DHS for emergency preparation in 2002
and 2003. The average hospital received less than $10,000--not
enough to equip a single critical care room. To make matters worse,
trends in the health care sector foretell even greater constraints
in the future.
Emergency planning often focuses on the first response--speed
and coordination in the first days of the crisis. Practice drills
are short and intense. It is easy to overlook the sustained impact
of the real event. An effective plan must also deal with the later
surges and continuing aftermath. When supply chains are disrupted,
additional people will require care as they run out of medicines,
for example. And the effectiveness of care providers can be
diminished by failures of communications networks, computer
systems, banking systems, transport systems and competing needs of
Nearly two years have passed, yet only one of New Orleans' seven
general hospitals is back to pre-Katrina capacity. Four remain
closed. Hospital beds are down by two-thirds. The city's trauma
center reopened in February 2007. After tourism and retail, the
city's largest private employment sector had been health care. Now,
the health care sector's current diminished state is
considered a key factor blocking post-Katrina economic revival.
Meanwhile, despite pledges of assistance and encouragement from the
Secretary of the U.S. Department of Health and Human Services
(HHS), Louisiana officials have yet to embark on a significant
improvement of their health care system.
Disaster preparedness cannot focus solely on preventing
terrorist acts. We know that at some point another disaster,
man-made or natural, will come our way. An essential component of
national response is the capability to respond quickly and
effectively to that next crisis. For that to happen, we need to
move now to strengthen the capacity and resilience of our
health care delivery services, involving everything from detecting
contagious disease outbreaks through organizing the public
Strategic solutions are needed that can garner broad political
support. Disincentives and inhibitors in our current systems
must be addressed.
The good news is that many of the efforts envisioned to address
overall problems in the health care system will also benefit
emergency response preparedness and other elements of homeland
security. These will likely take time to bring to fruition. In the
interim, we need incremental and tactical solutions to provide
immediate improvements and lay the groundwork for achieving
The Current State of First
For a variety of reasons, first receivers today are ill-prepared
to treat a sudden surge in disaster victims. We will examine issues
facing the emergency departments, the hospitals and other health
care facilities, and the medical practitioners who comprise the
first receiver community.
a. The Emergency Department Crisis
At present, our emergency rooms are at the breaking point for
capacity and delivery of care. The Institute of Medicine's
Future of Emergency Care report series of 2006 cites the
- Demand for emergency care has risen sharply--visits grew by 26
percent between 1993 and 2003.
- Over the same period the number of emergency departments (ED)
declined by 425 nationwide.
- Forty percent of hospitals report ED overcrowding on a daily
- As a result, ambulances are diverted half a million times per
year from overcrowded EDs to other hospitals, thus delaying
- Sharp declines in the number of hospital beds has resulted in
frequent patient "boarding"--patients may be held in ED halls or
exam rooms for 48 hours or more until an inpatient bed becomes
- Critical specialists are not often available when
- EDs have little to no surge capacity to handle mass casualty
Too many individuals are seeking primary or preventive care from
the EDs--the National Hospital Ambulatory Care Survey classified 47
percent of all visits as emergent or non-urgent.
b. The Hospital Crisis
Throughout our nation, communities view their hospitals as a
"safety net service." Our 3,000 non-profit, 1,200 state and local
government-financed, and 770 for-profit hospitals command a degree
of steadfast loyalty and expectation that care will always be
While the emergency departments struggle with crowding, the
hospitals that house them are also at the tipping point.
Approximately 30 percent of hospitals today are operating in the
According to the American Hospital Association (AHA) the
following societal and policy changes have placed additional stress
- An increase in use of "just in time" supply practices, while
helpful in reducing day-to-day inventory costs, have left hospitals
unable to cope with a surge from a disaster.
- A change in the practice pattern of physicians, separating them
into community-based office practice and specialty-based hospital
practice, has reduced the number of general practitioners in the
ERs and hospitals.
- 47 million people are uninsured, according to the latest Census
Bureau data, and a far greater number have no regular source of
medical care, creating higher demand for hospital emergency
- An aging population experiencing increasing levels of chronic
illness requires more hospitalization.
The closure of many mental health hospitals has forced
individuals with mental health or substance abuse problems to
turn to hospitals for their care. One quarter of all people seen in
hospitals today have mental health and substance abuse
problems according to the AHA.
In the last decade, over 700 hospitals have closed nationwide.
As a result, 90 percent of Level One tertiary care hospitals are
operating at 90 percent bed capacity. Over three-quarters of
emergency physicians reported in the annual American College of
Emergency Physicians' survey that their hospital does not have the
surge capacity to respond effectively to an epidemic illness or an
act of terrorism. Hospitals also lack negative-pressure units for
isolating victims of airborne diseases, and personal
protective equipment for their staff.
c. The Medical Practitioner Crisis
The medical practitioner (physicians, nurses, physician
assistants, nurse practitioners, mental health care workers)
is under siege. Costs of liability insurance, decreasing
reimbursements, the "hassle factor" of increased red tape and
regulation, and the increasing costs of practice are driving
individuals out of the system. EDs currently have vacancies in 13
percent of their staff positions. And Community Health Centers have
over 2,500 current clinical vacancies across the country.
Today, the health care sector is facing a severe shortage of
nurses. Many nurses are approaching retirement age and the nursing
profession faces difficulties both attracting new entrants and
retaining the existing workforce. As a result, the nurse supply
remains flat. This results in serious regional shortages. For
example, the state of California has a 15 percent to 20 percent
nursing vacancy rate at hospitals today, and there are estimates
that it will reach 46 percent by 2020.
Fewer and fewer young people are entering the health care
profession just as our population needs more. The 2005 Council on
Graduate Medical Education report states that there will be a
shortage of at least 90,000 full-time physicians in the U.S. by the
year 2020. Medical schools are expected to expand enrollment by a
maximum of 7 percent, leaving a shortage of 1,700 new
physicians annually. At the same time, nursing schools cannot
attract faculty to fill the numerous open teaching positions.
With medical practitioners stretched thin, training in emergency
preparedness and disaster medicine falls to a lower priority than
meeting current patient needs. There is no medical specialty that
addresses disaster medicine. Without the medical professionals
developing such a specialty, development and dissemination of
expertise in this area will languish.
The Current State of Disaster
a. Emergency Management Services
Emergency care is highly fragmented. More than 6,000 911 call
centers are in operation, supporting 15,000 Emergency Management
Service systems with 800,000 responders handling 16 million
transport requests per year. EMS systems may be run by police
departments, fire departments, city or county governments, or
private companies. These are currently under state and local
jurisdiction, as are the standards for the training and
certification of EMS personnel.
Senior officials at DHS and HHS have communicated a national
policy that puts local EMS Chiefs, Directors, and Administrators
responsible for handling response to an incident in the first 24-72
hours with local and regional resources. While the local EMS
officials recognize this policy, they are concerned that too many
federal agencies have oversight over their activities. The local
EMS community seeks one voice and consistent funding. In addition,
local EMS personnel believe that they are not made aware of the
larger overall emergency preparedness efforts and goals,
especially at the federal level. This persistent fragmentation
leaves room for confusion and wide variability of performance.
EMS systems received only 4 percent of the $3.38 billion
distributed by DHS for emergency preparation in 2002 and 2003.
b. Public Health Departments
Public health departments are not typically thought of as
emergency responders, yet for biologic events they fulfill
this role. Public health departments are charged with early
detection, epidemiologic investigations, and the application
of large population measures (e.g., immunizations) to control
biologic outbreaks. While funding for public health departments has
increased thanks to the anthrax mailings shortly after 9/11, it is
still inadequate and a national public health system with rapid
communication and notification capability has not been fully
developed. Public health and traditional emergency management
services are not well integrated, and public health is all too
often an afterthought or left out of the planning process
c. Department of Homeland Security
The Department of Homeland Security is responsible for
coordinating the overall federal response to disasters, while the
Department of Health and Human Services oversees the national
medical response. DHS essentially supports HHS efforts.
Recently, the Office of the Chief Medical Officer within DHS was
also assigned responsibilities for planning the medical response
Within the federal organization, the challenges are
crosscutting. Since the aftermath of Katrina, the office has
undergone organization and scope changes in order to respond more
quickly to a severe disaster. On April 1, 2007, DHS announced a new
The Office of Health Affairs (OHA) was created and is led by the
Chief Medical Officer, who now has the title of Assistant Secretary
for Health Affairs and Chief Medical Officer. The Office of Health
Affairs has three main divisions each directed by a Deputy
- Weapons of Mass Destruction (WMD) and Biodefense will
lead the Department's biodefense activities, including the
Bioshield and BioWatch programs (transferring to OHA from the
Science and Technology Directorate) and the National
Biosurveillance Integration System (transferring to OHA from the
Infrastructure Protection component of DHS).
- Medical Readiness will coordinate contingency planning,
medical readiness of first responders, WMD incident management
support, and medical preparedness grant coordination.
- Component Services will provide policy, standards,
requirements, and metrics for the Department's occupational
health and safety programs and provide protective and operational
medical services within the Department.
As the Office of Health Affairs tackles its new mission, the
following challenges have been identified:
- Lack of integration and coordination at the
- The need to create a culture of preparedness both within
government and within its citizenry;
- Missing elements in the BioShield program--a comprehensive
effort to develop and make available modern, effective drugs and
vaccines to protect against attack by biological and chemical
weapons or other dangerous pathogens;
- Lack of a biological scenario among the 15 National Planning
Scenarios devised for the National Response Plan (NRP);
- The need to create curricula and training for those involved in
- Abundant preparedness fatigue;
- No certification/accreditation by hospitals or institutes for
- Reduced resources.
These issues are repeated within the policy department at DHS.
Officials within the department believe that the National Incident
Management System (NIMS)--which consists of a nationwide template
to enable federal, state, local, and tribal governments, as well as
private-sector and nongovernmental organizations, to work together
effectively and efficiently to prepare for, prevent, respond
to, and recover from catastrophic incidents--is only a
"Rolodex." The NIMS is a framework, not a solution, and
communities are failing to plan or to build in self-sufficiency,
flexibility, and coordination.
Another area in need of further review is the Target
Capabilities List that is an internal part of the National Response
Plan. The NRP establishes a comprehensive all-hazards approach to
enhance the ability of the United States to manage domestic
incidents. The plan incorporates best practices and procedures from
incident management disciplines--homeland security, emergency
management, law enforcement, firefighting, public works, public
health, responder and recovery worker health and safety, emergency
medical services, and the private sector--and integrates them into
a unified structure. It forms the basis of how the federal
government coordinates with state, local, and tribal governments
and the private sector during incidents. The Target Capabilities
List--a capabilities list planning tool used by
local-state-regional-federal agencies to prepare their communities
in the areas of public health, environmental health, triage,
fatality management, surveillance, etc.--has been developed but not
implemented. So far, only federal officials appear to be interested
in the effort; states and local officials have not embraced the
At the White House, the Office for Biodefense Policy of the
White House Homeland Security Council, which is responsible for
bio-surveillance, countermeasures, mass casualty planning, and
community preparedness, reported the following challenges:
- Limited capability for surveillance of animals (where most
disease incidents appear first) and humans;
- Limited insight into disease/threats in real time;
- No capacity for surveillance of large populations, particularly
- Lack of ability to deliver mass countermeasures in an expedited
- Lack of ability to handle mass casualty event;
- No venue to engage the local citizenry.
Progress Being Made
While the state of health care and homeland security regarding
emergency preparedness appears to be somewhat dire, planning
at all levels has shown significant progress.
a. Local Level
The National Association of Community Health Centers (NACHC) and
the National Association of Community Health Officials (NACHO)
represent Community Health Centers (CHC), which serve the most
vulnerable of the U.S. population, often in more rural communities.
By design, they serve all who seek care regardless of ability to
pay. NACHC represents 1,100 Community Health Centers in over 3,000
communities, serving 16 million patients annually. The CHCs
provide comprehensive primary and preventative health care
including health screening, immunizations, dental care,
pre-natal and neo-natal care, diabetes management, HIV prevention
and education, mental health and substance abuse counseling, as
well as health care services for migrant workers and homeless
individuals. Some 71percent of patients fall at or below the
federal poverty level in income.
Both organizations report that they are now included in the
local, regional, and state emergency preparedness planning process.
Integration has been enhanced at the local level and equipment,
protocols, laboratory capacity, and transmission of results have
all improved. Health departments nationwide are using the NIMS.
They report that most communities have plans, live exercises and
drills, mass distribution strategies, and means to integrate health
affairs with law enforcement emergency response.
Established as a "safety net" in the 1960s, CHCs help alleviate
the overcrowding of hospital emergency rooms by providing an
alternative to high-need populations for primary care. The Bush
Administration and Congress have nearly doubled annual federal
spending for CHCs since 2000 to almost $2 billion. Six years ago,
CHCs served 5 percent of the population; that has now grown to
CHCs provide additional support capabilities for local
communities facing an emergency. Eighty percent of CHCs have a
disaster plan, often developed in conjunction with the local health
department plan. CHCs also have a historical track record in
responding to past emergencies including hurricanes, wildfires, and
earthquakes. Their capabilities include:
- Increased ED surge capacity--both on and off-site,
- Mental health services for responders and others,
- Outreach to rural and hard to reach populations,
- Ability to dispatch mobile clinics,
- Telemedicine patient treatment,
- Ability to distribute medications or administer vaccines,
- Alternate care sites.
b. State Level
The National Guard has traditionally provided civilian support
to governors of states. During Hurricane Katrina, the Guard
provided 50,000 troops. Their goal in the medical arena is to
provide triage, treatment, and transportation. In the "Lessons
Learned" report after Katrina, the Guard was more fully integrated
into the NRP and specifically into the state planning process by
c. Regional Level
On July 19, 2007, at the Senate Committee on Homeland Security
and Governmental Affairs hearing, it was reported that Department
of Defense (DOD) liaison officers are stationed at all Federal
Emergency Management Agency (FEMA) district offices to better
coordinate the DOD and DHS response.
d. Federal Level
The National Response Plan and National Incident Management
System are currently being reviewed by DHS. The Secretary of
Homeland Security is conducting an interagency review to:
- Assess the effectiveness of the NRP,
- Identify improvements,
- Recommend modifications,
- Reissue the document.
Federal, state, local, and tribal authorities, along with
private-sector and non-governmental organizations (NGO)s are
participating in the review and revision process.
Also, the Department of Health and Human Services released the
National Strategy for Pandemic Planning IV on July 18, 2007. It
outlines a number of initiatives and reports on their progress:
- In April 2007, the National Institutes of Health awarded $161
million to help expand surveillance programs.
- The Centers for Disease Control has invested $180 million to
help high-risk countries strengthen their capacity to recognize,
diagnose, and report influenza outbreaks.
- In April 2007, the Food and Drug Administration (FDA) approved
the first human H5N1 vaccine.
- In January 2007, HHS awarded $132.5 million to three vaccine
makers to develop adjuvanted vaccines against the H5N1 influenza
- In January 2007, HHS awarded $103 million to develop a new
influenza antiviral drug, peramivir, which has proven effective in
- HHS has dramatically increased its federal stockpile (surgical
mask, respirators, ventilators, etc.)
Last, on July 26, 2007, HHS issued guidance in the Federal
Register for the "Emergency Use Authorization of Medical
Products." This notice is defined as a "critical new tool for
medical and public health communities and is applicable for both
civilian and military use." The EUA allows a relevant medical
product which has not yet been approved by the FDA to be used
during an emergency.
Inhibitors to Progress
a. Spiraling Costs
Underlying the ED, hospital, and practitioner capacity crises is
the general financing problems that plague the health care sector.
The U.S. health care sector represents $2.2 trillion of the
economy--half of which is spent on Medicare and Medicaid and other
public programs and the other half on private sector spending. This
amounts to one-sixth of the entire U.S. economy. Unlike virtually
every other sector of the economy, the normal operation of
market forces, which routinely control costs, is largely absent.
Especially absent is consumer choice. Out of every $100 spent on
health care coverage, for example, only $3.50 is spent directly by
individuals and families.
The biggest challenge facing health care, then, is rising cost.
Currently, health care consumes more than 16 percent of GDP, and
the federal government's portion amounts to 8.6 percent of GDP.
That federal share is expected to grow to 20 percent of GDP by
2050. In real terms, health care sector spending is growing 2.5
percent faster than the economy. The number of those eligible for
Medicare will be doubling from 40 million people to 80 million over
the next 30 years, beginning with the first wave of the baby boom
generation in 2011. And as a demographic sector, those over 65
account for a disproportionate percentage of health care expense.
The aging of the population, the retirement of the baby boomers,
expansion of the entitlement programs (e.g., the new Medicare
Prescription Drug Program and rising Medicaid enrollment), and
lower fertility rates have led the U.S. to a point where our
healthy and growing economy cannot as easily absorb the cost of
this rapid demand for medical services as it did in the past
30 years. There is a broad consensus among health policy analysts
that Americans are facing an unsustainable growth in the cost of
health care, particularly in Medicare and Medicaid.
Cost pressures are one of the inhibitors to development of
robust emergency response approaches, but also one of the main
drivers for health care reform. Strategic solutions to constrain
health care spending, or, even more importantly, to enable
individuals and families to secure value for money, may enable more
efficient approaches to homeland security and medical emergency
b. National versus Local Risk
Pushing down planning responsibility for first response to the
local level creates a disincentive to invest. At the national
level, there is clearly substantial risk that a major disaster of
some sort will occur in the next few years. For a locality, the
risk of a disaster in that particular community is much less. It is
very difficult to justify taking money away from pressing local
needs to address an event that is highly unlikely to occur. So
while it makes sense to insist that local communities form specific
local plans, a regional or national approach to stockpiling and
positioning resources to support first response seems a wiser and
more economical approach. Rapid deployment plans would be needed.
Some of the strategic technology solutions to improve health care
will also facilitate more centralization of expertise and real-time
dissemination to remote locations. Telemedicine is an example of
c. Identification and Funding of
Federal Public Health Priorities
It is easy to forget our health care delivery system's
interdependency with public health initiatives. Certain
activities are vital to the national interest and should be
funded at the federal level. An example is surveillance of animals
and humans for emerging diseases. There should be a single federal
agency charged with identifying critical public health priorities
and educating legislators and the public on the dangers and
objectives. By funding these at the national level, resources are
assured for activities that are in the national interest and
practitioners and other health care entities can be adequately
compensated for their efforts and contributions to achieving public
d. Pay and Incentives for Health Care
Current pay and incentives for doctors, in both the public and
the private sectors, are oriented toward performing procedures
and prescribing drugs, rather than preventing illness, managing
medical conditions effectively, or achieving satisfactory health
outcomes. Financing influences delivery.
For emergency medicine, in particular, public and private
officials should look toward changing current compensation.
Compensation and measurement systems must be adapted to encourage
greater efficiency and effectiveness in the delivery of care.
In pursuing health care reform, policymakers should give special
consideration to emergency response objectives and means of
compensating practitioners for their roles in planning, training,
and carrying out these essential activities. The medical profession
too must be directly engaged. Without a disaster health specialty
or dedicated advanced trauma centers, it is more difficult to
generate and disseminate this vital expertise across the health
e. Information and Communication
Information and communication systems are still fragmented
across the health care sector. Resolving the fragmentation
will require leadership to ensure coordination and significant
investment in both information systems and communications network
infrastructure. The development and widespread usage of an
electronic medical record, with proper regard for patient privacy
and liberty, should be a key element of health care reform
initiatives to reduce administrative costs and errors. As more
medical records and data flow across networks and are stored on
information systems or portable media, the requirements for
ensuring data recovery, privacy, and security are paramount.
Ensuring the availability of these systems in crisis scenarios will
need full consideration in the development and execution of
While progress is being made in medical emergency planning at
the local, state, regional, and federal levels, many inhibitors
remain to be addressed. Strategic solutions are needed to ensure a
robust and resilient health care sector for the decades to come.
Large, complex problems do not lend themselves to quick fixes.
Addressing health system issues often requires long-term
commitment, sustained effort, and strong leadership to achieve
success. Many of the strategic solutions will depend on generating
public and political support for these initiatives. One way to
build support and test the viability of strategic solutions is
through pilot or demonstration projects.
Incremental and tactical solutions provide quick fixes to
strengthen readiness. Immediate steps can be taken in both the
health care and homeland security sectors to resolve minor issues
under discussion while providing the foundation for the longer-term
As tactical and strategic solutions to improve health systems
are agreed on and implemented, we must ensure that they address
requirements for emergency response.
a. Strategic Solutions
While there are many actions that may be taken quickly, it is
important to focus on the overall goals and select those activities
required to move key strategies forward.
Below are six strategic solutions for the health care sector
followed by three strategic solutions for the homeland security
sector. Even though the health care solutions fall short of full
reform, taken together, these strategic solutions should
improve the nation's position of readiness for a major disaster.
Tactical solutions supporting each strategic goal are
identified by a T and their number in the listing of tactical
solutions that follows this section.
In addition, an interim strategic solution is offered to deal
with the potential catastrophic event that occurs before any of the
strategic, or many of the tactical solutions, can be fully
implemented. We need to envisage the potentially dire circumstances
of our current unprepared status.
- Healthier population
A healthier population is both an overall objective of the
nation's health care system and a means of reducing costs by
helping people avoid and control expensive treatment for advanced
diseases. Preventive medicine and public health measures can
be employed to encourage a healthier population. Obesity and
diabetes are on a trend-line to reach an epidemic status.
Ultimately, individuals are responsible for their own health, and
the task of the policymaker is to ensure that market incentives are
in place to reward healthy behavior. Moreover, legal, regulatory,
or structural barriers to the operation of these incentives should
be systematically removed. Public and private programs that offer
attractive incentives encouraging healthy consumer choices can have
substantial long-term payoff. A healthier population will reduce
both financial stress and constraints that impede surge capacity
needed to handle disasters. A healthier population is also better
able to weather disasters and other emergency conditions.
Tactical solutions that will help drive our population in a
healthier direction include targeted public health spending (T-11),
demonstration projects for community health initiatives (T-15), and
structural reform of the health care markets and the provision of
rational incentives (T-10).
- Long-term financial viability of the health benefit
Health care costs will continue to grow as a percent of GDP.
Nonetheless, policymakers can moderate, and in some cases, actually
reverse, health care costs by making significant changes in the
private health insurance markets, re-targeting and
rationalizing existing government subsidies and tax policies in the
health care system, and restructuring health care entitlements.
Demonstration programs and experimentation with a variety of
approaches can provide the data necessary to develop political
support for change.
A number of tactical solutions can be considered as ways to
improve health care financial viability. Among these are expanded
choices for individuals and families in their access to health care
coverage (T-4), wider adoption of changes in the health insurance
markets that would result in the introduction of the free market
forces of consumer choice and competition, resulting in a health
insurance market that would function more like the popular and
successful Federal Employees Health Benefits Program than the
conventional employer-based health insurance (T-7), health saving
plans (T-5), tax breaks for individuals who do not have, or cannot
get, employer-based health insurance (T-4), and better targeting of
entitlement funding, including the introduction of income-related
subsidies for persons enrolled in Medicare and a reduction of the
growing dependence on Medicaid for long-term care services (T-8).
Other tactical solutions can contribute to financial viability by
identifying areas of waste (T-2), by providing cost data to
enable more informed consumer decisions (T-9) and by piloting
alternative approaches to paying for health results (T-16 and
- Supply of nurses and physicians
The future of our health care system is also jeopardized by
personnel shortages. A number of changes are needed to encourage
young men and women to choose the medical profession.
Broadly speaking, a general reform of the health care financing
system that expands patient choice, reduces physician dependence on
third-party payment for routine medical services, and facilitates
the restoration of the traditional doctor-patient relationship
would make entry into the medical professional more desirable
than it is today. Beyond that, tactical changes include updating
federal loan and grant laws for colleges and medical schools
(T-10), incentive reforms to improve compensation in understaffed
practice areas (T-11), and funding to ensure that medical staff are
compensated for working in high priority areas for public health
- Emergency medicine expertise
Emergency medicine can be strengthened through establishment
of a formal disaster emergency medicine specialty. This is the
responsibility of the medical profession. As research and training
are focused on this topic, more effective and comprehensive
emergency medical response strategies will be developed and
the expertise can be shared across the health care community.
Beyond medical professionals creating a formal disaster medicine
specialty (T-17), policymakers can help by establishing an
institute at the National Institutes of Health for emergency
medical research (T-19), and funding physician training in
emergency medicine (T-18). There are state initiatives that are
worth examining. The Maryland Trauma Center model should be
emulated (T-16) as a strategic way of focusing and distributing
emergency medicine expertise.
- Strategic use of information systems
Information systems can improve workflow, save operational
expenses, and eliminate costly and wasteful paperwork. They
can also improve accuracy and reduce both medical and
administrative errors. Security, privacy, availability, disaster
recovery, and resiliency must be designed and built into these
Electronic medical records (T-12) are a key initiative that will
enable significant improvements in public health. Other tactical
solutions for improved emergency readiness that have a strong
dependency on information systems include: medical surveillance
systems (T-32), medical distribution systems (T-33), situational
awareness (T-34), a health professional registry (T-13), self-help
and self-diagnosis information (T-28), and communications
- Emergency regulatory relief
Laws and regulations must be modified to provide regulatory
relief to enable prompt action during emergencies. Relief from
medical liability for practitioners (T-22) and revision of
Standards of Care (T-25) during an emergency will make it both
easier and less risky for medical practitioners to provide
Leadership in crisis
DHS needs to provide more integrated training and
opportunities for local, state, and regional entities to understand
their role in a crisis. Leadership means setting priorities at the
national level and ensuring effective communications channels that
allow ideas and mandates to flow both up and down the chain.
Accountability and measurement are also required.
A key component enabling realistic plans and prioritization is the
baseline assessment (T-24). A pre-hospital focus providing
leadership to first responders (T-25) will reduce the load on
emergency rooms during disasters. DHS leadership is essential
in plans for Plug and Play surge capacity (T-20), alternative care
centers (T-21), and public education campaigns (T-26). Effective
communication (T-23) and internal coordination (T-29) are
critical both in planning for and reacting to disasters.
Coordination of grant funding (T-27) and public health funding
(T-11) can ensure that important priorities are not neglected. The
DHS Target Capabilities List (T-31) and isolation and quarantine
plans (T-30) require local adoption. Accountability is
enhanced through requiring performance metrics and standards (T-1)
and assessment rating tools (T-3).
The federal government needs to lead health diplomacy efforts
around the globe. An effective health diplomacy program can earn
global goodwill and contribute to a reduced terrorist threat over
Tactical solutions include targeting of public health funding to
include issues important globally (T-11), use of medical
surveillance systems (T-32) and medical distribution systems (T-33)
to assist other nations, and disseminating medical expertise and
research results in the disaster medicine specialty (T-17).
and education capability
DHS needs to lead the effort to educate citizens regarding the
true and accurate situation occurring around them. First responders
and the National Guard depend on first-hand accounts in order to
deploy assets and resources accurately. Often during times of
crisis, reports are greatly exaggerated or inaccurate and thus
hinder the response effort.
Real-time assessment can be aided by situational awareness efforts
(T-34), and real-time systems including medical surveillance (T-32)
and medical distribution (T-33).
- Interim strategy for severe crisis containment
Health care delivery systems are unprepared for severe
disaster or emergency events on a wide scale in the immediate
future. Strategic initiatives will take years to unfold. What if
something catastrophic happens tomorrow?
We need to have contingency plans ready to respond on a moment's
notice in the event of a dire emergency. DHS should have
access to contingency military field services (T-35).
b. Tactical Solutions
Immediate steps can be taken in both the health care and
homeland security sectors to resolve minor issues under discussion
while providing the foundation for longer-term strategic solutions.
Many of the tactical solutions address broader issues causing
stress on the health care sector. Steps to alleviate these
conditions may also strengthen disaster and emergency response
Health Care Sector
- Establish measurable performance standards for any new
congressional health care program spending. Allow for greater
transparency and efficiency in allocation of congressional monies
for health care by identifying and clarifying the mission of the
program dollars, and the performance of federal agencies in the
achievement of that mission. This will allow improved tracking
of health care programs and their performance.
- Intensify scrutiny of waste in existing federal health
programs. A more systematic identification of wasteful,
duplicative health care spending would allow these dollars to be
- Promote transparency on pricing, quality, and
performance. Federal and state officials should encourage
private-sector organizations, including consumer groups and even
medical societies, to institute Web-based evaluations of
hospitals, clinics, and other medical providers. To a large extent,
this is already happening with health insurance plans in the
Federal Employees Health Benefits Program, with plan ratings or
evaluations by organizations such as Consumers' Checkbook,
and the National Association of Retired Federal Employees ( NARFE).
Such ratings could also be posted on government sites. State and
federal officials themselves could post provider pricing for
medical services, especially for state-regulated hospitals and
other facilities that get taxpayer funds. This would allow
individuals and families to better understand the real options
available to them, as well as encourage improvement in performance
and greater competition among hospitals, especially for elective
- Dramatically expand private health insurance coverage by
giving tax breaks for individuals and families without
employer-sponsored insurance. Provide persons who do not and
cannot get health insurance through the place of work with tax
relief, enabling them to buy affordable health insurance. This
would eliminate the massive tax penalty that burdens persons trying
to buy health coverage on their own. The greater the reliance on
private health insurance, the less likely will it be for persons to
use the hospital emergency room for non-urgent medical
- Promote Health Savings Accounts (HSA). Encourage an
expansion and broader use of HSAs by persons employed by state and
local governments. This option encourages consumers to wisely spend
their out-of-pocket health care dollars while providing
catastrophic coverage. It allows persons to pay doctors
directly for routine medical services while relying upon insurance
for the coverage of larger items. This approach would not only
allow greater efficiency of service at the point of delivery, it
would also reduce the existing third-party payment pressures on
doctors and other medical professionals. Now increasingly
popular in the private sector, this option should also be available
for state and local government employees.
- Promote rational incentives for employees enrolled in
employer-based coverage. Employers should allow consumers to
choose health plans that provide financial incentives, including
reduced premiums, co-payments or deductibles for employees to
enroll in plans that provide prevention or wellness services,
including screening for blood pressure, cholesterol or diabetes, as
well as regimens that promote diet, exercise, smoking cessation,
and body mass reduction. New incentives for tests and screenings
would encourage positive changes in behavior, improve workforce
health, and thus reduce health care costs.
- Adopt statewide health insurance market reforms that would
expand coverage, guarantee portability of private health
insurance, and increase efficiency. The state health insurance
markets are highly concentrated, dominated by a few plans,
overregulated, balkanized, and dysfunctional. Not only does the
status quo obstruct efficient access to affordable coverage for
millions of Americans, it also contributes to rising costs of
uncompensated care and emergency room over-crowding. State
officials can address this problem by creating a single statewide
health insurance market for individuals and small businesses,
contracting out to private third-party administrators to enroll
individuals and families in health insurance, and encouraging
employers to switch financing from defined benefit to defined
contribution. The third-party administrators would be designated as
the employer's plan for purposes of federal tax and employment law.
This would enable individuals and families to choose the health
plans they want tax-free, to own the plans, and to keep them when
moving from job to job. This dramatic increase in the
portability of health insurance would increase access to care,
reduce the incidence of un-insurance, and thus contribute to a
reduction in current usage of hospital emergency rooms for
non-urgent care. Beyond that, of course, such a reform would
encourage intense competition among health plans for
beneficiaries, as in the Federal Employees Health Benefits program
(FEHBP), thus keeping costs under control while sharply expanding
- Restructure Medicare payment and institute income-related
subsidies for Medicare enrollees. Today, with the exception of
Medicare Part B, the Medicare payment for enrollees is the same,
regardless of income. This means that wealthy retirees living on
corporate pension plans are entitled to the same level of taxpayer
subsidy that poor retirees get. In order to make this program more
sustainable, Congress should adopt income-based, sliding-scale,
payment for all of Medicare. This will ease the pressure of
Medicare spending on other sectors of the health care
- Reform physician payment in the entitlement programs.
Medicare and Medicaid payment is flawed and outdated.
Particularly in the case of Medicaid, it is discouraging physician
participation or the acceptance of new patients. Congress should
revisit and restructure the Medicare payment system, and the states
should do the same with Medicaid. The proper course is to provide a
flat payment for medical services in Medicare, and allow physicians
to balance bill. For special areas, such as emergency medicine,
Congress should target additional funding for physicians in
emergency medicine. In tandem with a reformed health insurance
market focused on value and results, physician payment would change
as demand changed, resulting, for example, in greater demand for
physicians who provide preventive medicine.
- Provide special incentives to nurses and physicians and
other medical professionals who wish to specialize in emergency
medical care or disaster-related medicine. Congress could make
special provision for federal loans and grants for colleges and
medical schools to encourage young men and women who choose to
specialize in emergency care, or who are willing to commit to a
public service assignment based on the need for emergency medicine
skills. Similar to military service, the participants in this
program can be subject to "Reserve-like" call-up in the event of a
terrorist attack or other national emergency. The medical
Reserve would also be a resource to receive emergency training and
preparation in the event of a regional catastrophe.
- Revisit public health spending. Congress should identify
key public health goals to ensure practitioners and health care
providers are compensated for achieving clear public health
objectives.Some examples of public health initiatives that could
lower overall costs would: develop quality measures; increase and
track vaccination rates; and develop a systematic approach to
chronic disease management in the areas of heart disease, mental
health, and diabetes in publicly funded programs.
- Promote the widespread use of an Electronic Medical
Record. Americans should have a "Visa-like" portable card to
store an electronic medical record. A portable personal record will
reduce costs and make it more likely that information is readily
accessible in a disaster. Security and privacy issues would, of
course, need to be addressed as part of this initiative.
- Health Professional Registry: Federal and state
officials should maintain a registry of doctors and nurses and
medical professionals, including retirees and those who have left
the medical profession, who may be able to volunteer in the event
of a national, state, or regional emergency.
- A new federal/state partnership to provide insurance
coverage for low-income population. The federal and state
governments spend tens of billions of dollars on the uninsured,
mostly compensating hospitals and other health care facilities for
the costs of caring for those who are uninsured and unable to pay
for medical services, once again, often in hospital emergency
rooms. The federal government should offer grants or incentives to
state officials to help them expand health insurance coverage,
through the private sector, and thus reduce these uncompensated
care costs. This kind of federal-state cooperation could result in
more efficient and less costly health care for lower income
- Experiment with community health initiatives. Using a
clinical trial-like methodology to test different funding and
incentive approaches, Congress could determine what works best in
achieving community-based health goals through federally funded
community health centers. Demonstration projects could be designed
and rigorously evaluated. Results of these projects could help
inform policymakers in evaluating proposals for reform.
- Experiment with new funding strategies for the provision of
trauma care. One model is the world-class trauma operation
administered by the state of Maryland. It has developed an
efficient system to maintain available trauma center beds.
Maryland's comprehensive model views hospital-based emergency
medical services as a "necessary public service similar to police,
ambulance and fire." Maryland developed the Emergency Medical
Services Operating Fund (EMSOF) and the Maryland Trauma Physician
Services Fund. Both programs are funded in creative ways. For
example, the Physician Services fund is supported by a $2.50 per
year surcharge to the state vehicle registration fee.
- Establish a new disaster medicine specialty. Within the
medical profession, disaster medicine/disaster health should be
formally designated as a medical specialty. Focused on a wide
variety of disaster-related health impacts, this new specialty
would fill roles in trauma centers and emergency departments.
- Physician training. The medical profession should also
establish routine emergency medical training for physicians and
other health care providers. A disaster requires the
physician/health care provider to move out of the safety of the
hospital or office setting and into a makeshift area often lacking
basic medicines, medical supplies, light, water, food, and
- Emergency medicine research. An Institute of Emergency
Medicine should be established as part of the National Institutes
of Health and dedicated to spearheading emergency medical research
efforts. This institute should work closely with the Centers for
Disease Control and Prevention to devise more comprehensive
emergency medical response strategies.
- Plug and Play Surge capacity. The U.S. Department of
Health and Human Services should create teams that can be quickly
deployed to cover surge capacity requirements in the event of a
terrorist attack or natural disaster. Members of the disaster
medicine specialty and CHC specialty areas should be considered for
these roles, as well as physicians and other medical personnel
enrolled in a registry to volunteer for service.
- Alternative care centers. Clearly, hospitals and EDs do
not have the surge capacity to respond to a medium- or large-scale
disaster. Local communities themselves must plan for the
establishment of alternative care centers to cope with a large
surge of victims needing assistance, including those who need
mental health services after the trauma of such an event.
- Provide liability and licensure requirements relief.
Policymakers must provide medical liability relief for doctors,
nurses, and other medical professionals, including volunteers,
delivering care in a crisis situation. Likewise, medical
professionals should also be granted relief from licensure
requirements during that period. Medical personnel caring for the
victims of a terrorist attack or national emergency should not have
to contend with the added worry of a malpractice suit.
Homeland Security Sector
- Communications chain. 9/11 and Katrina after-action
reports, both official and anecdotal, clearly delineated the
lack of communication from the local to regional to state to
federal level. The communications chain of command needs to be an
integral part of any community-based disaster planning
- Baseline Assessment. A baseline assessment is the
underpinning of readiness planning. To assess readiness and
set priorities for funding and action, we need to thoroughly
understand the current state of readiness. DHS needs to
aggressively and fully document the nation's baseline ability to
respond to disasters. The facts presented in the "Current State"
section of this report suggest that a comprehensive baseline will
identify many gaps in readiness.
- Focus more on pre-hospital issues. The goal should be to
focus on initiatives that limit the requirement to rush individuals
to a hospital during a disaster. Emergency medical and community
volunteer services that can identify and deliver care to the scene
should be developed as a priority. Developing these programs
could include sharing best practices and credentialing and
employing emergency assets across community and state
- Public education and public relations campaign for
citizens. The more resilient and self-reliant a community, the
better will citizens be able to withstand a disaster. Local
community programs that help build a "culture of preparedness"
among the American citizenry are essential.
- Better coordination of grant funding. Federal and state
DHS entities need to better coordinate the limited grant funding
for training, exercises, and equipment to ensure that communities'
needs are met.
- Self-help/self-diagnosis. Local communities need to
train the population on practical medical self-diagnosis and
treatment techniques. Emergency medicine expertise, including input
from CHC staff, and use of strategic information systems can
facilitate this effort.
- Internal coordination. Coordination between the National
Protection and Preparedness Division of DHS and the Office of the
Chief Medical Officer at DHS would allow for a fuller understating
of what facilities are available for use during a disaster.
- Isolation and quarantine plans. Communities should be
required to institute isolation and quarantine plans. While
communities plan for emergency response, few are considering the
necessary steps of isolation and quarantine measures as ways
to contain a pandemic.
- Implement the DHS Target Capabilities List. Much work
has been completed to define the Target Capabilities List, but
few local, regional, or state communities have implemented this
- Institute medical surveillance systems. Both active and
passive measures are needed to ensure accurate and timely data
collection and data analysis efforts. Currently, the U.S. has
limited medical surveillance systems in place with almost no
ability to perform surveillance overseas.
- Medical distribution system. The federal government
needs to step up efforts to provide for the rapid and accurate
distribution of stockpiled medicines and equipment during emergency
- Improve situational awareness among leaders and
decision-makers. Situational awareness involves the real-time
acquisition, representation, and interpretation of relevant
information to make sense of current events, anticipate future
developments, make intelligent decisions, and stay in control. Many
of the after-action reports of both 9/11 and Katrina referred to
the inability of key leaders to make the right decisions at the
right time. Clearly, involving leadership individuals in live
emergency drills and ensuring they fully understand theirscope and
authority is critical to disaster preparedness.
- DOD contingency military field facilities. As an interim
measure, DHS should be prepared to call in DOD units domestically
to deal with catastrophic health events such as smallpox, avian
flu, or other highly contagious pathogens or to help treat victims
of nuclear attacks. The military must be highly skilled at setting
up emergency military facilities in an "ad hoc" environment and
assist in delivering emergency care to individuals who are
sheltering in place. If community health facilities are totally
unprepared, this scenario is preferable to utter chaos.
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