<DOC>
[110th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:45290.wais]
THE LACK OF HOSPITAL EMERGENCY SURGE CAPACITY: WILL THE
ADMINISTRATION'S MEDICAID REGULATIONS MAKE IT WORSE?
=======================================================================
HEARINGS
before the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
MAY 5 AND 7, 2008
__________
Serial No. 110-95
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
http://www.house.gov/reform
U.S. GOVERNMENT PRINTING OFFICE
45-290 PDF WASHINGTON DC: 2008
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
EDOLPHUS TOWNS, New York TOM DAVIS, Virginia
PAUL E. KANJORSKI, Pennsylvania DAN BURTON, Indiana
CAROLYN B. MALONEY, New York CHRISTOPHER SHAYS, Connecticut
ELIJAH E. CUMMINGS, Maryland JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts TODD RUSSELL PLATTS, Pennsylvania
WM. LACY CLAY, Missouri CHRIS CANNON, Utah
DIANE E. WATSON, California JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts MICHAEL R. TURNER, Ohio
BRIAN HIGGINS, New York DARRELL E. ISSA, California
JOHN A. YARMUTH, Kentucky KENNY MARCHANT, Texas
BRUCE L. BRALEY, Iowa LYNN A. WESTMORELAND, Georgia
ELEANOR HOLMES NORTON, District of PATRICK T. McHENRY, North Carolina
Columbia VIRGINIA FOXX, North Carolina
BETTY McCOLLUM, Minnesota BRIAN P. BILBRAY, California
JIM COOPER, Tennessee BILL SALI, Idaho
CHRIS VAN HOLLEN, Maryland JIM JORDAN, Ohio
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
------ ------
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
Lawrence Halloran, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on:
May 5, 2008.................................................. 1
May 7, 2008.................................................. 175
Statement of:
Chertoff, Michael, Secretary of Homeland Security............ 205
Hoffman, Bruce, Ph.D., professor, Edmund A. Walsh School of
Foreign Service, Security Studies Program, Georgetown
University; Jay Wayne Meredith, M.D., professor and
chairman, Department of General Surgery, Wake Forest
University Baptist Medical Center; Colleen Conway-Welch,
Ph.D., dean, Vanderbilt School of Nursing; Roger Lewis,
M.D., Ph.D., Department of Emergency Medicine, Harbor-UCLA
Medical Center; and Lisa Kaplowitz, M.D., deputy commission
for emergency preparedness and response, Virginia
Department of Health....................................... 19
Conway-Welch, Colleen, Ph.D.............................. 50
Hoffman, Bruce, Ph.D..................................... 19
Kaplowitz, Lisa, M.D..................................... 80
Lewis, Roger, M.D., Ph.D................................. 64
Meredith, Jay Wayne, M.D................................. 41
Leavitt, Michael O., Secretary of Health and Human Services.. 184
Letters, statements, etc., submitted for the record by:
Chertoff, Michael, Secretary of Homeland Security, prepared
statement of............................................... 207
Conway-Welch, Colleen, Ph.D., dean, Vanderbilt School of
Nursing, prepared statement of............................. 53
Davis, Hon. Tom, a Representative in Congress from the State
of Virginia:
Wall Street Journal article.............................. 218
Prepared statement of.................................... 182
Hoffman, Bruce, Ph.D., professor, Edmund A. Walsh School of
Foreign Service, Security Studies Program, Georgetown
University, prepared statement of.......................... 22
Issa, Hon. Darrell E., a Representative in Congress from the
State of California, various documents from the Governor of
Virginia................................................... 132
Kaplowitz, Lisa, M.D., deputy commission for emergency
preparedness and response, Virginia Department of Health,
prepared statement of...................................... 83
Leavitt, Michael O., Secretary of Health and Human Services,
prepared statement of...................................... 187
Lewis, Roger, M.D., Ph.D., Department of Emergency Medicine,
Harbor-UCLA Medical Center, prepared statement of.......... 66
McCullum, Hon. Betty, a Representative in Congress from the
State of Minnesota, various prepared statements............ 231
Meredith, Jay Wayne, M.D., professor and chairman, Department
of General Surgery, Wake Forest University Baptist Medical
Center, prepared statement of.............................. 44
Sali, Hon. Bill, a Representative in Congress from the State
of Idaho, letter dated May 12, 2008........................ 238
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut:
Articles published in the Society for Academic Emergency
Medicine............................................... 97
Prepared statement of.................................... 14
Waxman, Chairman Henry A., a Representative in Congress from
the State of California, prepared statements of........... 4, 177
THE LACK OF HOSPITAL EMERGENCY SURGE CAPACITY: WILL THE
ADMINISTRATION'S MEDICAID REGULATIONS MAKE IT WORSE? DAY ONE
----------
MONDAY, MAY 5, 2008
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 10 a.m., in room
2154, Rayburn House Office Building, Hon. Henry A. Waxman
(chairman of the committee) presiding.
Present: Representatives Waxman, Watson, Norton, Shays,
Issa, and Bilbray.
Staff present: Phil Barnett, staff director and chief
counsel; Karen Lightfoot, communications director and senior
policy advisor; Andy Schneider, chief health counsel; Sarah
Despres, senior health counsel; Steve Cha, professional staff
member; Earley Green, chief clerk; Carren Audhman and Ella
Hoffman, press assistants; Leneal Scott, information systems
manager; Kerry Gutknecht and William Ragland, staff assistants;
Larry Halloran, minority staff director; Jennifer Safavian,
minority chief counsel for oversight and investigations;
Christopher Bright, Jill Schmaltz, Benjamin Chance, and Todd
Greenwood, minority professional staff members; John Cuaderes,
minority senior investigator and policy advisor; and Ali Ahmad,
minority deputy press secretary.
Chairman Waxman. The meeting of the committee will please
come to order. Today we're holding the first of 2 days of
hearings on the impact of the administration's Medicaid
regulations on hospital emergency surge capacity and the
ability of hospital emergency rooms to respond to a sudden
influx of casualties from a terrorist attack.
The committee held a hearing in June 2007 on the Nation's
emergency care crisis. We heard from emergency care physicians
that America's emergency departments are already operating over
capacity. We were warned that if the Nation does not address
the chronic overcrowding of emergency rooms their ability to
respond to a public health disaster or terrorist attack will be
severely jeopardized.
The Department of Health and Human Services was represented
at that hearing, but despite the warnings the Department has
issued three Medicaid regulations that will reduce Federal
funds to public and teaching hospitals by tens of billions of
dollars over the next 5 years. The committee held a hearing on
these and other Medicaid regulations in November 2007. An
emergency room physician told us that if these regulations are
allowed to go into effect, the Nation's emergency rooms will
take a devastating financial hit.
The two hearings that we will be holding this week will
focus on the impact of these Medicaid regulations on our
capacity to respond to the most likely terrorist attack, one
using bombs or other conventional explosives.
Today we will be hearing from an independent expert on
terrorism, an emergency room physician, a trauma surgeon, a
nurse with expertise in emergency preparedness, and a State
official responsible for planning for disasters like a
terrorist attack.
On Wednesday, we'll hear testimony from the two Federal
officials with lead responsibility for Homeland Security and
for Medicaid, the Secretary of Homeland Security, Michael
Chertoff, and the Secretary of Health and Human Services,
Michael Leavitt.
In preparation for this hearing the committee majority
staff conducted a survey of emergency room capacity in five
cities considered at greatest risk of a terrific attack,
Washington, DC, New York, Los Angeles, Chicago and Houston, as
well as Denver and Minneapolis, where the nominating
conventions will be held later this year. The survey took place
on Tuesday, March 25th at 4:30 p.m. Thirty-four Level 1 trauma
centers participated in the survey.
What the survey found was truly alarming. The 34 hospitals
surveyed did not have sufficient ER capacity to treat a sudden
influx of victims from a terrorist bombing. The hospitals had
virtually no free intensive care unit beds to treat the most
seriously injured casualties. The hospitals did not have enough
regular inpatient beds to handle the less seriously injured
victims.
The situation in Washington, DC, and Los Angeles was
particularly dire. There was no available space in the
emergency rooms at the main trauma centers serving Washington,
DC. One emergency room was operating at over 200 percent of
capacity. More than half the patients receiving emergency care
in the hospital had been diverted to hallways and waiting rooms
for treatment.
And in Los Angeles three of the five Level 1 trauma centers
were so overcrowded that they went on diversion, which means
they closed their doors to new patients. If a terrorist attack
had occurred in Washington, DC, or Los Angeles on March 25th
when we did our survey, the consequences could have been
catastrophic. The emergency care systems were stretched to the
breaking point and had no capacity to respond to a surge of
victims.
Our investigation has also revealed what appears to be a
complete breakdown in communications between the Department of
Homeland Security and the Department of Health and Human
Services.
In October 2007, the President issued Homeland Security
Directive No. 21. The directive requires the Secretary of HHS
to identify any regulatory barriers to public health and
medical preparedness that can be eliminated by appropriate
regulatory action. It also requires the Secretary of HHS to
coordinate with the Secretary of DHS to ensure we maintain a
robust capacity to provide emergency care. Yet when the
committee requested documents reflecting an analysis of the
potential implications of the Medicaid regulations on hospital
emergency surge capacity, neither department was able to
produce a single document.
This is incomprehensible. It appears that Secretary Leavitt
signed regulations that will take hundreds and millions of
dollars away from hospital emergency rooms without once
considering the impact on national preparedness. And it appears
that Secretary Chertoff never raised a single objection.
The Department of Health and Human Services was represented
at the committee's June 2007 hearing on emergency care crisis.
The importance of adequate Federal funding for emergency and
trauma care was repeatedly stressed by the expert witnesses at
the hearing. If Secretary Leavitt approves the Medicaid
regulations without considering their impact on preparedness
and without consulting with Secretary Chertoff, that would be a
shocking and inexplicable breach of responsibilities.
The most damaging of the administration's Medicaid
regulations will go into affect on May 26th, just 3 weeks from
today. As the House voted overwhelmingly, the regulation should
be stopped until their true impacts can be understood. I don't
know whether the House legislation will pass the Senate or, if
it does, whether the bill will survive a threatened
Presidential veto. But I do know that Secretary Leavitt and
Secretary Chertoff have the power to stop these destructive
regulations from going into effect. And I intend to ask them
whether they will use their authority to protect hospital
emergency rooms.
The Federal Government has poured billions of dollars into
homeland security since the 9/11 attack. As investigations by
this committee have documented, much of this investment was
squandered on boondoggle contracts. This was evident after
Hurricane Katrina when our capacity to respond fell tragically
short.
The question we will be exploring today and on Wednesday is
whether a key component of our national response hospital
emergency rooms will be ready when the next disaster strikes.
I want to recognize Mr. Shays. He is acting as the ranking
Republican for today.
[The prepared statement of Chairman Henry A. Waxman
follows:]
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Mr. Shays. Thank you, Mr. Chairman. I appreciate, Chairman
Waxman, your calling today's hearing to review the relationship
between emergency medical surge capacity and Medicaid
reimbursement policies. The sad reality we must contend with
every day is the need to be ready for that one horrible day
when terrorism sends mass casualties to an already overburdened
medical system.
Medicaid reimbursement policies may need to change to
better support large urban emergency and trauma centers, but
those changes alone will never assure adequatesurge capacity.
We cannot afford to build and maintain idle trauma facilities
waiting for the tragic day we pray never comes when they will
be needed.
In 2004, 10 terrorist bombs exploded simultaneously on
commuter trains in Madrid, Spain, killing 177 people and
injuring more than 2000. The nearest hospital had to absorb and
care for almost 300 patients in a very short time.
In the event of a similar attack here our hospitals will be
tasked with saving the greatest number of lives while
confronting a large surge of patients and coping with the wave
of the worried well. Many will arrive suffering injuries not
typically seen in emergency departments. Medical staff will be
facing the crisis with imperfect information about the causes
and scope of the event and under severe emotional stress. To
reduce the stress and treat mass casualties effectively
decisions need to be made, resources allocated, and
communication established now, not during the unexpected but
perhaps inevitable catastrophic event.
Today's hearing is intended to focus on a single aspect of
emergency preparedness, Federal reimbursement policies and
their implications for Level 1 trauma centers in major
metropolitan areas.
I appreciate Chairman Waxman's perspective on the
administration's proposed Medicaid regulation changes and join
him in voting for a moratorium on their implementation. But I
am concerned that a narrow focus on just one component of
medical preparedness risks oversimplifying the far more complex
realities the health system will face when confronting a
catastrophic event.
Stabilizing Medicaid payment policies alone won't guarantee
readiness against bombs or epidemics any more than an annual
cost to assure people they're safe against inflation or
recession. It is a factor to be sure, but not the sole or even
the determinative element to worry about when disaster strikes.
We should not miss this opportunity to address the full
range of interrelated issues that must be woven together to
build and maintain a prepared health system. That being said,
there is no question emergency departments are overcrowded,
often are understaffed and operating with strained resources on
a day-to-day basis. Ambulances are often diverted to distant
hospitals and patients are parked in substandard areas while
waiting for an inpatient bed.
In 2006, the Institutes of Medicine [IOM], found few
financial incentives for hospitals to address emergency room
overcrowding. Admissions from emergency departments are often
the lowest priority because patients from other areas of the
hospital generate more revenue. This is not to disparage
hospitals. They operate on tight margins and must navigate
challenging, often perverse financial incentives, including
Federal reimbursement standards. Strong management, regional
cooperation and greater hospital efficiencies offer some hope
for alleviating the strain on emergency departments, but during
a catastrophic event bringing so-called surge capacity online
involves very different elements.
In a mass casualty response regional capacity is more
important than any single hospital capability. Hospitals that
normally compete with each other need to be prepared to share
information about resources and personnel. They need to agree
beforehand to cancel elective surgeries, move noncritical
patients and expand beyond the daily triage and intake rates.
Unlike daily operations, surge and emergency response
requires interoperable and backup communication systems,
interoperable and backup communication systems, altered
standards of care, unique legal liability determinations and
transportation logistics. Should regional resources or capacity
prove inadequate, State assets will be brought to bear.
Available beds and patients will need to be tracked in realtime
so resources can be efficiently and effectively matched with
urgent needs. Civilian and even military transportation systems
will have to be coordinated. If needed, Federal resources and
mobile units will be integrated into the ongoing response. All
of these levels and systems have to fall into place in a short
time during a chaotic situation.
So it is clear daily emergency department operations are at
best an indirect and imperfect predictor of emergency response
capabilities. The better approach is for local, State and the
Federal Governments to plan for mass casualty scenarios and
exercise those plans. That way specific gaps can be identified
and funding can be targeted to address disconnects and
dysfunctions in the regional response. Fluctuating per capita
Medicaid payments probably will not and often cannot be used to
fund those larger structural elements of surge capacity.
Today's hearing can be an opportunity to evaluate all the
elements of emergency medical preparedness. We value the
expertise our witnesses bring to this important discussion, and
we look forward to their testimony.
[The prepared statement of Hon. Christopher Shays follows:]
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Chairman Waxman. Thank you very much. Mr. Shays.
While the rules provide for just the chairman and the
ranking member to give opening statements, I do want to give an
opportunity for the two other Members that are with us to make
any comments they wish to make.
Ms. Watson.
Ms. Watson. Thank you very much, Mr. Chairman the Los
Angeles County board of supervisors visited Capitol Hill last
week. And the No. 1 theme that continued to surface in my
conversations with many of the supervisors was the widening gap
between the demand for Medicare/Medicaid assistance and the
administration's new regulations that will limit the amount of
Medicaid/Medicare reimbursement to the State.
The administration estimates that the total fiscal impact
of the regulatory changes of $15 billion, but a committee
report, based on States that responded to the committee's
request for information, concludes that the change in
regulations would reduce Federal payments to States by $49.7
billion over the next 5 years. The cost to California alone is
estimated to be $10.8 billion over 5 years.
Mr. Chairman, as you well know, in the case of California
the reductions and Federal funding would destabilize an already
fragile medical care delivery service for low income residents
and the uninsured. The impact of these changes will be far
reaching and potentially catastrophic. In the last year we have
witnessed the closing of many of King/Drew's hospital medical
facilities located in Watts, CA. The emergency care facility
has been closed now for some time. The impact of this closing
is that residents from this underserved area of Los Angeles are
transported to other areas of town and the critical minutes
that are needed to administer care to save lives are now lost.
The impact of King/Drew closing has had a cascading effect
on all the other area hospitals, including those outside of the
Los Angeles area, that now must pick up the slack. I cannot
imagine what would happen in these areas in the case of a mass
catastrophic event such as a terrorist attack using
conventional explosives or a natural disaster since they are
already suffering from a lack of adequate emergency medical
care facilities.
So I look forward to the testimony from today's witnesses
who are experts in medicine and medical delivery services and
counterterrorism. Again, thank you, Mr. Chairman, for holding
this hearing.
Chairman Waxman. Thank you, Ms. Watson.
Mr. Issa.
Mr. Issa. Thank you, Mr. Chairman, for holding this
hearing.
Mr. Chairman, I'm troubled with today's hearing for one
reason. I think there's a legitimate problem, overcrowding of
our emergency rooms. That overcrowding comes from a combination
of illegal immigration, legal immigration and a pattern of
going to emergency rooms when in fact urgent care would be a
better alternative. I think it is part of a bigger problem we
particularly in California face that we have in fact a large
amount of uninsured. But they are not insured, they are insured
at the emergency room. That overcrowding needs to be dealt
with.
And I trust that on a bipartisan basis in good time we will
deal with the challenges created by illegal immigration,
individuals who either because of that or because they lack
insurance are choosing the emergency room over more effective
and efficient delivery systems.
Having said that, I particularly am concerned that a
partisan amateur survey was done in order to justify or
politicize today's hearing. It's very clear both by the ranking
member's opening statement and by the facts that we will
clearly see here today that a survey of emergency rooms done by
Democrat staff for the purpose of getting the answer they
wanted, which was of course we're overcrowded at the emergency
room, is self-serving and unfortunately short-sighted.
The number of beds that could be made available in a
hospital, the number of health care professionals, doctors,
nurses and the like that could be brought to bear within a
period of time would have been part of any effective analysis
of what the surge capacity could be, the number of patients
who, although in the hospital, could be removed to other
facilities of lesser capability to make room for severely
injured people.
Although this would not change the fact that if we had a
Madrid type occurrence, even in a city like Los Angeles, 2000
severely injured people would strain our capacity in the first
few hours. And undoubtedly, undoubtedly, just like a 200-car
pileup on the 405, we would have loss of life that we would
have not have in a lesser occurrence.
I do believe that the challenges of Medicare and Medicaid
in dealing with escalating costs, and particularly for
California the cost of reimbursement which has not been
sufficient, needs to be looked at. I hope that we can work on a
bipartisan basis to deal with these problems. I hope that
today's hearings will in fact cause us all to understand the
causes and the cures for overcrowding of our emergency rooms.
However, I must reiterate that the Federal response for
this type of emergency needs to be to pay to train and to pay
to test for these kinds of emergencies. That's the appropriate
area for the Federal Government to deal with in addition to
providing certain life saving resources such as mass
antibiotics like Cipro and of course also smallpox and other
vaccinations in case of an attack.
These are the Federal responses that were agreed to after
9/11 on a bipartisan basis, and I would trust that at a minimum
we would not allow an issue such as how much is reimbursed to
California on a day-to-day basis to get in the way of making
sure that we fully fund those items which would not and could
not be funded locally or by States.
Mr. Chairman, I look forward to today's hearing. You have a
distinguished panel that I believe can do a great deal to have
us understand the problem. With that, I yield back.
Chairman Waxman. Our witnesses today do amount to a very
distinguished panel and we're looking forward to hearing from
them. Dr. Bruce Hoffman is professor of the Edmund A. Walsh
School of Foreign Service at Georgetown University here to
discuss mass casually events involving conventional explosives
in general and suicide terrorism in particular. He will also
discuss his research on the Australian, British and Israeli
responses to these types of terrorist attacks.
Dr. Wayne Meredith is a professor and chairman of the
Department of General Surgery at Wake Forest University Baptist
Medical Center. In his role as a trauma surgeon Dr. Meredith
will discuss the clinical importance of immediate response to
trauma such as that resulting from a blast attack as well as
the importance of adequate financing to maintain a coordinated
trauma care system.
Dr. Colleen Conway-Welch is the dean of the School of
Nursing at Vanderbilt University. She'll discuss the
implications of the Medicaid regulations for hospital emergency
and trauma care capacity, including whether States or
localities will be able to hold hospitals harmless against the
loss of Federal funds that will result from the regulations.
Dr. Roger Lewis is an attending physician and professor in
the Department of Emergency Medicine at Harbor-UCLA Medical
Center. He will discuss the connections between emergency
department crowding, surge capacity and disaster preparedness.
He will also discuss the impact of the Medicaid regulations on
his hospital, which participated in the majority staff snapshot
survey.
Dr. Lisa Kaplowitz is the deputy commissioner for emergency
preparedness and response at the Virginia Department of Health.
She will present the State perspective on emergency
preparedness in response to mass casualty events, including the
lessons learned from the Virginia Tech shootings.
We're pleased to have you all here today. We welcome you to
our hearing. It's the policy of this committee that all
witnesses that testify before us do so under oath. So if you
would please rise and raise your right hands, I would
appreciate it.
[Witnesses sworn.]
Chairman Waxman. The record will indicate that each of the
witnesses answered in the affirmative. Your prepared statements
will be made part of the record in full. What we'd like to ask
you to do is to acknowledge the fact that there's a clock that
will be running, indicating 5 minutes. For the first 4 minutes
it will be green, for the last minute will be orange, and then
when the time is up it will be red. And when you see the red
light we would appreciate it if you would try to conclude your
oral presentation to us. If you need another minute or so and
it is important to get the points across, we're not going to be
so rigid about it, but this is some way of trying to keep some
time period that's fair to everybody.
Dr. Hoffman, let's start with you. There's a button on the
base of the mic, we'd like to hear what you have to say.
STATEMENTS OF BRUCE HOFFMAN, PH.D., PROFESSOR, EDMUND A. WALSH
SCHOOL OF FOREIGN SERVICE, SECURITY STUDIES PROGRAM, GEORGETOWN
UNIVERSITY; JAY WAYNE MEREDITH, M.D., PROFESSOR AND CHAIRMAN,
DEPARTMENT OF GENERAL SURGERY, WAKE FOREST UNIVERSITY BAPTIST
MEDICAL CENTER; COLLEEN CONWAY-WELCH, PH.D., DEAN, VANDERBILT
SCHOOL OF NURSING; ROGER LEWIS, M.D., PH.D., DEPARTMENT OF
EMERGENCY MEDICINE, HARBOR-UCLA MEDICAL CENTER; AND LISA
KAPLOWITZ, M.D., DEPUTY COMMISSION FOR EMERGENCY PREPAREDNESS
AND RESPONSE, VIRGINIA DEPARTMENT OF HEALTH
STATEMENT OF BRUCE HOFFMAN, PH.D.
Mr. Hoffman. Thank you, Mr. Chairman, for the opportunity
to testify before this committee on this important issue. As a
counterterrorism specialist and a Ph.D., not an M.D., let me
share with the committee my impressions of the unique
challenges conventional terrorist bombings and suicide attacks
present.
This is not a place to have a wristwatch, Dr. Shmuel
``Shmulik'' Shapira observed as we looked at x-rays of suicide
bombing victims in his office in Jerusalem's Hadassah Ein Kerem
Hospital nearly 6 years ago. The presence of such foreign
objects in the bodies of his patients no longer surprised Dr.
Shapira, a pioneering figure in the field called terror
medicine. We had cases with a nail in the neck or nuts and
bolts in the thigh, a ball bearing in the skull, he recounted.
Such are the weapons of terrorists today, nuts and bolts,
screws and ball bearings or any metal shards or odd bits of
broken machinery that can be packed together with enough
homemade explosive or military ordnance and then strapped to
the body of a suicide terrorist dispatched to attack any place
people gather.
According to one estimate, the total cost of a typical
Palestinian suicide operation, for example, is about $150. Yet
for this--yet this modest sum yields a very attractive return.
On average suicide operations worldwide kill about four times
as many persons as other kinds of terrorist attacks. In Israel
the average is even higher, inflicting six times the number of
deaths and roughly 26 times the number of casualties than other
acts of terrorism.
Despite the potential array of atypical medical
contingencies that the U.S. health system could face if
confronted with mass casualty events [MCE], resulting from
terrorist attacks using conventional explosives, it is not
clear that we are sufficiently prepared. Historically the bias
and most MCE planning has been toward the worst case scenarios,
often containing weapons of mass destruction, such as chemical,
biological, radiological and nuclear weapons, on the assumption
that any other MCEs, including those where conventional
explosions are used, could simply be addressed as a lesser
included contingency.
By contrast, Israeli surgeons have found that the metal
debris and other anti-personnel matter packed around the
explosive charge causes injury to victims, victims that are
completely atypical of other emergency traumas in severity,
complexity and number.
Unlike gunshot wounds from high velocity bullets that
generally pass through the victim, for instance, these
secondary fragments remain lodged in the victim's body. Indeed,
although much is known about the ballistic characteristics of
high velocity bullets and shrapnel used in military ordnance,
very little research has yet to be done on the ballistic
properties of the improvised and anti-personnel materials used
in terrorist bombs.
The over pressure caused by the explosion is especially
damaging to the air filled organs of one's body. For this
reason the greatest risk of injury are to the lungs,
gastrointestinal tract and auditory system. The lungs are the
most sensitive organ. And ascertaining the extent of damage can
be particularly challenging given that signs of respiratory
failure may not appear until up to 24 hours after the
explosion.
And over 40 percent of victims injured by secondary
fragments from bombs suffer multiple wounds in different places
of their body. By comparison fewer than 10 percent of gunshot
victims typically are wounded in more than one place on their
body. A single victim may thus be affected in a variety of
radically different ways.
In addition, severe burn injuries may have been sustained
by victims on top of all the above trauma. Thus critical
injuries account for 25 percent of terrorist victims in Israel
overall compared with 3 percent with nonterrorism-related
injuries.
Australia's principal experiences with terrorist MCEs has
primarily been as a result of the October 2002 bombings in
Bali, Indonesia, where 91 Australian citizens were killed and
66 injured. The survivors were air lifted to Darwin where the
vast majority were treated at the Royal Darwin Hospital.
Forty-five percent of these survivors were suffering from
major trauma and all had severe burns. The large number of burn
victims presented a special challenge to the Royal Darwin
Hospital, as indeed no one hospital in the entirety of
Australia had the capacity or capabilities to manage that many
blast and burn victims. Accordingly, the Australian medical
authorities decided to move them to other hospitals across
Australia.
London's emergency preparedness and response in the event
of terrorist MCEs had been based on New York City's experience
with the 9/11 attacks. However, the suicide bombings of the
three subway cars and bus on July 7, 2005 was a significantly
different medical challenge.
In New York City on 9/11 many persons died and only a few
survived. The opposite occurred on July 7th when only a small
proportion of victims lost their lives, 52 persons tragically,
but more than 10 times that number were injured. London's long
experience with Irish terrorism, coupled with extensive
planning, drills and other exercises ensured that the city's
emergency services responded quickly and effectively in a
highly coordinated manner. But even London's well-honed
response to the MCE on July 7, 2005 was not without problems.
For example, communications between first responders with
hospitals or their control rooms were not as good as they
should have been, which resulted in uneven and inappropriate
distribution of casualties among area hospitals.
What emerges from this discussion the medical communities
emergency response and preparedness for terrorist MCEs
involving conventional explosions and suicide attacks are two
main points: First, that there are lessons we can learn from
other countries' experiences with terrorist bombings and
suicide attacks that would significantly improve and speed our
recovery should terrorists strike here. Israel, Australian,
Britain and others are highly relevant examples.
The second is that the best way to save as many lives as
possible after a terrorist bombing or suicide attack is for
physicians and other health care workers to undergo intensive
training and preparation before an attack, including staging
drills at hospitals to cope with sudden overflow of victims
with a variety of injuries from terrorist attacks.
Medical professionals and first responders must also
understand that the specific demands of responding to bombings
and suicide attacks are uniquely challenging. Death and injury
may come not only from shrapnel and projectiles, but also from
collapsed and pulverized vital organs, horrific burns, seared
lungs and internal bleeding.
It is crucial that emergency responders evaluate their
response protocols and be prepared for the unusual
circumstances created by bomb attacks. Moreover, given the
increased financial stress on our Nation's health system in
general and urban hospitals in particular, any degradation of
our existing capabilities will pose major challenges to our
Nation's readiness for attack. Indeed, the opposite is
required, a strengthening of our capabilities of hospitals and
for the emergency services that we require to effectively
respond to a terrorist MCE involving conventional bombing and
suicide attacks.
Thank you.
[The prepared statement of Mr. Hoffman follows:]
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Chairman Waxman. Thank you very much, Dr. Hoffman.
Dr. Meredith.
STATEMENT OF JAY WAYNE MEREDITH, M.D.
Dr. Meredith. Thank you, Chairman Waxman, Representative
Shays, distinguished members of the community, and guests.
Thank you for the opportunity to appear before you today to
discuss the impact of the proposed Medicaid regulations we have
on trauma centers and trauma center preparedness in our
country.
My name is Wayne Meredith. I'm the chairman of the Surgery
Department at Wake Forest University School of Medicine, and I
volunteer as the medical director of Trauma Programs at the
American College of Surgeons.
What is trauma? Trauma is a major public health problem of
which I am sure you are aware, but want to emphasize for you it
is the No. 1 killer of people under the age of 44. That means
if your children or grandchildren are going to die the reason
they are going to die is most likely going to be from an
injury. And the appropriate best way to keep that injury from
happening is to have them treated in a trauma center, to make a
trauma center available to them. That's been shown to reduce
their risk of dying from a serious 25 percent. That's better
than many other treatments that we consider standard treatment
for any other condition. It is not standard treatment across
America today because trauma center care, the systems are
disorganized, the availability of trauma centers for providing
that system are disorganized.
Trauma care is emergent, but not all emergency care is
trauma care. These are serious injuries. It requires a level of
readiness of the hospital, it requires a level of expertise of
the people to be there to make it so that they can be available
when it occurs.
I've had the great privilege of treating well over 10,000
patients over the years who have survived and overcome
significant injuries. Just a small sampling of those patients
include such patients as Greg Thomas, who was a 40-year old
social worker riding to work. He was struck by a car and
severely injured, he was wish-boned, tearing your leg apart and
splitting your body halfway up the middle. He--he had a crushed
chest, his pelvis was broken in two, his left leg finally had
to be amputated, but he was able to survive because he got to a
trauma center immediately, he had the kind of care he required.
He now comes back to volunteer at our hospital to help with the
psychological help for other people that are being treated
there.
Josh Brown was being a good Samaritan, stopped to help
someone change a tire, was struck by a car while he was doing
that. Arrived bleeding to death in shock, and he had available
to him a team of people waiting 24/7 to be available to take
care of him and is therefore able to be discharged.
And a story I particularly like, Jason Hong was a student
at our college. He worked--he was working in his family's
convenience store in town. The convenience store was robbed. He
was shot in his thigh, striking a major artery and vein in his
thigh and was bleeding to death from that. Took him to the
trauma center immediately. We opened his leg, stanched the
bleeding which was profuse. Repaired those injuries by taking
vein from his other leg and placing it there. He survived, and,
kept his leg. Now he ultimately came back to decide he wanted
to be a doctor. He is now graduating from medical school this
May and he will be joining our residency and starting to be a
surgery resident in July of this year.
Trauma centers have to be prepared to respond on a minute's
notice for all kinds of trauma, including those of terrorist
attacks. They are the baseline of readiness, in my opinion, for
any sort of capability to be prepared for the everyday type of
terrorism that we can expect.
Are they ready? Unfortunate--and could they meet the surge
of 450 type victims that occurred at 9/11? I think the result--
the answer to that is no. We're not ready to be able to surge
at that level the way trauma centers are set up today.
Saving people--there are other studies the National
Foundation for Trauma Care, which I was the founding member of
the board, also did a study about a year and a half ago which
showed that our overall preparedness with trauma centers is
about C-minus, if you look at that, for being prepared in our
trauma centers to surge to a terrorist event.
Saving people from the brink of death, however, or from
everyday trauma, even a terrorist attack, is costly and it's
resources intensive but absolutely necessary. Our trauma care
delivery system has several requirements all of which must be
met.
Coordinated trauma system care. I talked in the very
beginning statement that got you off track, Mr. Shays,
extemporaneously talked about our lack of a coordinated system
across our country. It is a very patchwork quilt of system
currently and it needs to be organized.
The work force issues. Trauma surgeons are in great debt.
We have a tremendous lack of trauma surgeons. Over half of our
surgery--of our trauma fellowships go unfilled, we have no
nurses. We have--if you more than regionalize trauma care there
are not as many neurosurgeons in America today as there are
emergency rooms in America today. There is not one--if they
stayed in the house all the time, lived there, were chained
there, could not leave, there aren't as many neurosurgeons in
America as there are emergency rooms. Workforce shortage is
going to be something that you--that we'll be facing
dramatically going forward.
Trauma centers have to have sufficient resources to care
for all their victims and to do the cost shifting it takes to
take care of the uncompensated care and prepare for them. We
must be prepared for the trauma that we see every day. Jason
Hong gets shot in the leg on an everyday basis. We need to be
prepared for the catastrophic events, the bridge collapses that
occurred in Minnesota. We need to prepare for national
disasters whether they are Katrina level or just earthquakes or
tornados. And we need to be prepared for the major events that
could occur from terrorism, which I think are more likely to be
bombing in a cafe than they are an anthrax attack or some major
bio event, I think is much more likely. So trauma centers are
threatened by that.
The effects of the Medicaid changes will be dramatic in our
hospital. It is estimated it will cost us--let me see. Medicaid
regulations is not something--it will be $36 million from our
hospital. It currently costs about $4\1/2\ million of
infrastructure to keep the trauma center alive. And we use
about $13 million in costs in uncompensated care. Add to that
$36 million our trauma center will go under. We will not be a
part of the infrastructure for health care in our part of the
region. We serve western--all of western North Carolina.
So with that I'll truncate my remarks and thank you for
this. I just beg you to stop the Medicaid cuts and enact H.R.
5613, the Dingell-Murphy bill, fully funded the trauma systems
planning program and ensure maintenance of systems and
adequately fund H.R. 5942, the Towns-Burgess-Waxman-Blackburn
legislation, and fully fund the hospital preparedness program
and hospital partnership grants to ensure the highest level of
preparedness, funding for all hospitals and most particularly
for trauma centers. I want to thank the committee for having
these hearings and to thank you for having me participate in
them.
[The prepared statement of Dr. Meredith follows:]
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Chairman Waxman. Thank you very much, Dr. Meredith. Dr.
Welch.
STATEMENT OF COLLEEN CONWAY-WELCH, PH.D.
Dr. Conway-Welch. Good morning. My name is Colleen Conway-
Welch. I've been dean at the School of Nursing at Vanderbilt
for 24 years.
Chairman Waxman. Would you pull the mic just a little
closer? You don't have to move closer, pull the mike closer.
Dr. Conway-Welch. Thank you.
Over the last decade, however, I have taken a special
interest in the area of emergency preparedness. I am here today
to make the link between the consequences of reduced Medicaid
funding, a fragmented public health infrastructure, and a
reduced level of emergency preparedness, and to urge the
committee to recommend a moratorium on these actions until at
least March 2009.
I want to make three specific points about implementation
of the following three changes, limiting Medicaid payments to
public providers only, dropping Medicaid funding for graduate
medical education and limiting Medicaid dollars for services in
out patient settings.
If the changes anticipated for May 26th occur, it will be
virtually impossible to fix these rules legislatively in a
rushed and piecemeal manner. And DHHS will be hard pressed to
effectively respond HSPD 21, which directs the Department to
look at regulations that impact emergency preparedness.
If Medicaid dollars are reduced in these three areas, a
reduction in personnel and readiness will occur in our
hospitals and emergency departments across the country and,
even worse, it will occur in the midst of a serious and
intractable nursing and nursing faculty shortage and limit our
ability to respond to a disaster, particularly a blast or
explosive injury with serious burns.
It is also reasonable to assume that States, including
Tennessee, will not hold the providers harmless if Federal
matching funds are lost. There would be no easy way to redirect
or make up money to those who are losing it, such as the
medical schools and safety net provider hospitals. Even if the
State were able to redirect State dollars to areas eligible for
a Federal match, those funds would most likely be distributed
in Tennessee to the managed care organizations and then be part
of the overall payment structure of all of our hospitals.
I want to speak now specifically to the three changes. No.
1, limiting payment only to providers who are a unit of
government puts our rural, community, private, and 501(c)(3)
hospitals at even greater risk since they must already pick up
the slack of escalating numbers of uncompensated care and are
tied to a public health infrastructure that is increasingly
unfunded, unavailable and marginally functional. In Tennessee
this would result in only one hospital, Nashville Metro General
Hospital, being included. The TennCare Medicaid program would
lose over $200 million per year in matching funds. This would
put all of the hospitals in Tennessee, except Metro General, in
a position of cost shifting and service reductions, as well as
limiting access even further.
For example, Vanderbilt already provides more than $240
million a year in uncompensated care. While I'm discussing
Tennessee, these are issues across the country.
All disasters are local, that is true, and conventional
explosive attacks are especially local. The casualties are
immediate and nobody should expect outside help for at least 24
hours. Only a true system of local, functional, systematically
linked emergency departments and hospitals can address the
casualties of this most probable form of attack.
Proposal two, eliminating Federal support for graduate
medical education programs will result in a reduction of
medical residents in a wide variety of settings, including ERs,
trauma burn and intensive care units. They will also not have
the support of my skilled trauma nurses since these numbers
will be reduced as well.
As an example, in Tennessee the four medical schools in the
State would lose $32 million annually. These schools also serve
as the safety net providers and would be forced to reduce their
numbers of students.
Proposal three, limiting the amount and scope of Medicaid
payment for outpatient services will weaken our ER ability to
handle a surge of victims. Our large hospitals will quickly
experience automobile gridlock.
It is also absurd to think about evacuating hospitals in a
time of disaster with the high acuity level we maintain every
single day, including patients on ventilators. At Vanderbilt,
for example, the burn unit and the ICUs are already at
capacity. If disaster hits, health care providers will need to
be dispatched to community and rural clinics to help them care
for patients with serious injuries who cannot be transported or
accommodated by hospitals. As clinics, we do services and
personnel commensurate with reduced Medicaid dollars. Their
ability to avoid triage and care to patients will be
significantly impacted.
Federal disaster preparedness money that comes to Tennessee
is much appreciated. However, Federal money does not require an
outcome of increased documented operational capacity building
and it should. Tabletop exercises are marginally useful, are an
income opportunity for Beltway bandits. However, lessons
learned from one exercise are not necessarily applied to the
next.
To many health care professionals of both political parties
in the field of emergency preparedness, it appears that DHHS
and DHS do not have a mechanism to assess and monitor the
extent to which States, counties and cities have the capability
and game plan in place to respond to a disaster such as a blast
explosion and are not able to provide guidance on which to base
these plans.
There is no one place anywhere in our Nation or at any
level of government where one can go to receive reliable
information on resources; for example, how many burn beds there
are in Tennessee or how many ICU beds there are in Nevada.
There is no one-stop shop to answer it on a Federal level and
disasters are frequently not limited to one State. So regional
statistics and information are needed. For example, Tennessee
has 48 burn beds, 28 of which are at Vanderbilt and the eight
Southeast States have a total of 240, but I had to go to the
American Burn Association to get those numbers.
In summary, I am encouraging a moratorium on these Medicaid
changes, a requirement that coordination between and among
various Federal, State and local entities be enhanced to
achieve a double whammy; namely, improving emergency
preparedness response while improving the fractured public
health infrastructure. It is important to point out that
continued cuts to providers negatively impact every service a
hospital provides. Vanderbilt has historically soaked up these
reductions and looked for other sources of revenue, but that is
becoming more and more difficult.
It is logical to assume that we would have to cut such
programs as helicopter transport, HIV/AIDS programs and certain
medical and surgical specialties, including emergency
preparedness. We now support emergency preparedness in a robust
way, but we would need to limit our participation and regional
drills and internal administrative planning, as well as reduce
our commitment or eliminate stockpiling of medical supplies and
equipment that are critical.
In conclusion, please extend the moratorium until next
year. Charge DHHS and DHS to thoughtfully work together to
address the declining public health infrastructure from the
prospective of improving our emergency preparedness, and urge
that the rules be withdrawn since Congress did not direct their
propagation. A simple and immediate cut in Medicaid funding to
these three areas is not a thoughtful solution, will not work
and will have a devastating effect on our hospitals and
providers to respond in a disaster. In the final analysis if
these rules are enacted as proposed when our citizens need us
most, we will not be there.
Thank you.
[The prepared statement of Ms. Conway-Welch follows:]
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Chairman Waxman. Thank you very much, Dr. Welch.
Dr. Lewis.
STATEMENT OF ROGER LEWIS, M.D., PH.D.
Dr. Lewis. Mr. Chairman, members of the committee, thank
you for inviting me. My name is Roger Lewis. I'm a professor
and attending physician at the Department of Emergency Medicine
at Harbor-UCLA Medical Center, and I've been working as a
physician at that hospital since 1987.
Harbor-UCLA Medical Center is a publicly funded Level 1
trauma center and a teaching hospital. We're also a federally
funded disaster resource center and in that capacity work with
eight of the surrounding community hospitals to ensure disaster
preparedness and, in the event of a disaster, an effective
disaster response serving a population of approximately 2
million people. We're proud of that work and believe it is
important.
Over the last 5 or 10 years my colleagues and I at Harbor-
UCLA have witnessed an extraordinary increase in the demand for
emergency care services of all types. We have seen an
increasing volume in the number of patients who come to our
emergency department and in their degree of illness and their
need for care.
At the same time we've had a constant decrease in our
available inpatient hospital resources and this has predictably
led to a frequent occurrence of emergency department gridlock
and overcrowding. Patients wait hours to be seen, ambulances
carrying sick individuals are diverted to hospitals that are
farther away and admitted patients in the emergency may wait
hours or days for an inpatient bed.
Now I became an emergency physician because I wanted to be
the kind of doctor that could treat anybody at the time of
their greatest need. And similarly, my institution is proud of
its work as a disaster resource center because it wants to be
the kind of institution that can provide for the community as a
whole in its time of greatest need.
It never occurred to me during my training that I'd be in
the position in which patients that I knew clearly needed to be
treated in minutes instead had to wait for hours, that
ambulances carrying sick patients would be diverted to
hospitals farther away, or that we would pretend that hospitals
that have no available beds and a full emergency department
would have adequate surge capacity to respond to the most
likely type of mass casualty incidents; namely, the results of
a conventional explosive. Yet that is exact the situation in
which we find ourselves.
Now in trying to think about how to illustrate this
situation several people suggested to me that I give an
anecdote, that I tell a patient's story. And without detracting
from the important examples that have been given by the other
panel members, I would just like to comment that I don't think
any single patient's story really captures the scope and the
impact of the problem. This is the situation in which one has
to think carefully about the meaning of the statistics that are
widely available.
In fact, yesterday's anecdote, those stories about
individuals who deteriorate in the emergency department or on
the way to the hospital because their ambulance has been
diverted, are really today's norm. These events are happening
every day. Right now an ambulance in this country is diverted
from the closest hospital approximately once every minute.
There is a common misconception that emergency department
overcrowding is caused by misuse of an emergency department by
patients who have routine illnesses or could be treated in
urgent care settings. This is clearly not true. Numerous
studies done by nonpartisan investigators have shown that only
14 percent of patients in the emergency department have routine
illnesses that can be treated elsewhere. And much more
importantly, those patients use a very small fraction of the
emergency department resources and virtually never require an
inpatient bed.
Emergency department overcrowding is a direct result of
inadequate and decreasing hospital inpatient capacity. It is a
hospital problem, not an emergency department problem. There is
a direct cause and effect relationship between the hospital
resources, inpatient capacity, emergency department
overcrowding and surge capacity.
The hospital preparedness program, a federally funded
program that is intended to increase disaster preparedness, has
focused on bioterrorism and on the provision of supplies and
equipment for participating hospitals. And whereas these things
are important, they focus on one of the less probable types of
mass casualty incidents and do not in any way directly address
surge capacity.
For my hospital the proposed Medicaid rules are estimated
to result in a 9 percent decrease in the total funding for the
institution. That would have an exponential effect on the
degree of overcrowding and directly result in reductions in our
inpatient capacity. For Los Angeles County as a whole the
projected impact is $245 million. That would require a
reduction to services equal to one acute care hospital and
trauma center. We have already witnessed what happens in our
area with the closure of such a hospital.
So in summary, hospitals and emergency departments across
the United States increasingly function over capacity and prior
fiscal pressures have resulted in a reduction in the number of
inpatient beds and overcrowding. Current Federal programs
intended to enhance disaster response capability have
emphasized supplies and equipment and it largely ignored surge
capacity.
The proposed Medicaid regulations will directly result in
further reductions in hospital ED capacity and ironically
specifically target the trauma centers, teaching hospitals and
public institutions whose surge capacity we must maintain if
they are to function at the time of a disaster.
Thank you very much, Mr. Chairman.
[The prepared statement of Dr. Lewis follows:]
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Chairman Waxman. Thank you very much, Dr. Lewis.
Dr. Kaplowitz.
STATEMENT OF LISA KAPLOWITZ, M.D.
Dr. Kaplowitz. Good morning Mr. Chairman, members of the
committee. I'm Lisa Kaplowitz. I'm deputy commissioner for
emergency preparedness and response for Virginia Department of
Health. In that role, I'm responsible for both the public
health and health care response to any emergency. And we take a
very all-hazards approach to emergencies in Virginia.
Virginia is large and diverse and has been impacted by any
number of emergencies since 9/11. Certainly we were impacted by
the Pentagon, which is located within Arlington County, but we
have experienced the anthrax attack, sniper episode, Virginia
Tech and multiple weather emergencies.
A few lessons from 9/11. First of all, this truly was a
mass fatality event, not really a mass casualty event. But we
certainly have learned that one key to response is coordination
of all the health care facilities in the area, cross borders in
the national capital region; that's Virginia, Washington, DC,
and Maryland. And we all need to work together, both in the NCR
and throughout the Commonwealth. We knew we needed a much
improved communication system among health care facilities and
with public health communications really was inadequate during
9/11. We had no back-up communications present. We needed a
mass fatality plan, and we needed to include mental health
planning in all emergency planning.
The Congress allocated funds for both public health and
health care preparedness as a result of 9/11 and anthrax. I
won't spend a lot of time on the public health preparedness--
I'm responsible for that--except to mention that we have
coordinated our public health and health care response. They
work very closely together.
In terms of our health care system preparedness, the key to
our success has been partnership with the hospital association
which contracts with hospitals throughout the Commonwealth, and
we got buy-in from the hospitals very quickly. We also do
regional planning. We have three hospital planning regions, a
hospital coordinator and a regional coordinating center for
each of our regions.
The funding from ASPR has been very, very valuable. It's
enabled us to purchase redundant communication systems for
hospitals, to develop a statewide Web based tracking system. We
can now track beds in a realtime basis throughout the
Commonwealth during any emergency. We've purchased supplies and
equipment often done on a regional or statewide basis. This has
included portable facilities that are located in four regions
of the Commonwealth and can be moved all around. We've
purchased ventilators that are the same ventilators statewide
that are being used in hospitals so people know how to use
them. We've purchased over 300 ventilators for use in a surge.
We've purchased antivirals and antibiotic medication located in
hospitals. And we've developed a volunteer management system.
Before I move on to trauma and burn care systems, I do want
to say that the ASPR funds are very valuable but are only a
fraction of hospital funding for emergency response. The trauma
system in Virginia was established in 1980. We now have five
Level 1 trauma centers, three Level 2 and five Level 3 centers
in the Commonwealth. We have three burn centers, for a total of
37 burn beds within the Commonwealth.
Our general assembly did a study in 2004 documenting a
large amount of unreimbursed trauma care. In 2003, it amounted
to over $44 million, and I know it's vastly greater than that 5
years later. As a result of this study, the general assembly
did create a trauma fund which helps with our reimbursed care
but, again, only provides a fraction of unreimbursed care. It's
based on fees for reinstatement of driver's license and DUI
violations.
I do want to talk a little bit about lessons learned from
Virginia Tech. Nobody expected to have a shooting event, a mass
shooting event in rural Virginia, such as occurred a year ago.
What many people don't realize is that, because of the winds
and the snow, none of the injured could be transported to a
Level 1 trauma center or even a Level 2 trauma center. The
three closest hospitals, two were Level 3 trauma centers; one
was not a designated trauma center. We had planned for this,
recognizing that all facilities need the capability of handling
trauma care. And we're very proud of the fact that none of the
injured transported to hospitals from Norris Hall died. That's
due to our coordination of EMS, as well as hospitals, public
health and our regional coordinating center. So some of our
lessons learned from Virginia Tech concerning mass trauma
include the need for coordination of all parts of public health
in the health care system.
Cross training is key. This has been mentioned already. In
a mass casualty event, all facilities need to be able to handle
trauma care. That not only involves supplies but training of
staff in all facilities. We have purchased supplies for all
facilities in the Commonwealth to handle a certain level of
trauma and burn care. We know that burn care will be key here,
and we want all facilities to be able to handle that. And we
need a real time patient tracking system which didn't exist,
and we're working very closely on that now so that patients can
be tracked from the time EMS picks them up until the time
they're in the hospital and, unfortunately, for our chief
medical examiner as well. We're very fortunate to have a very
strong Medical Examiner's Office because this was a crime scene
and had to be handled as a crime scene, and they handled it
very well.
We need to recognize that at any mass casualty event, there
will be fatalities. So, in terms of trauma surge planning in
Virginia, we've focused on a number of different aspects here:
Again, as I mentioned, purchase of key supplies and medications
for burn and trauma care in all facilities, and this has been
very basic, looking at basic supplies to be stockpiled.
Training of physicians and staff in all hospitals to
provide basic trauma and burn care, because we don't know where
trauma is going to occur, and we'll need the help of all our
facilities.
Training of EMS and hospital staff on appropriate triage.
Unfortunately, during a mass casualty event, we won't have the
luxury of transporting people to solely our trauma centers. But
we're very dependent on these centers to have the expertise
that they can then use to train others.
And we need mass fatality planning as a component of mass
casualty planning.
I was asked to make a few comments about our recent
tornadoes. We were fortunate; nobody died as a result of those
tornadoes, and there were only three serious injuries. But I
will say that there was excellent communication among the
hospitals in the area. Once again, this was a very rural area.
They communicated well. We called on our medical reserve corps
to help. Our public health folks were available immediately and
are working in the area now. So our planning has really paid
off there.
A few comments in summary. Hospital and health system
emergency preparedness can be achieved only through close
collaboration and regional planning efforts for public health
and health care. There must be a system prepared to respond,
especially for mass casualty and fatality events. Preparedness
is tested not only through exercises but through actual events.
We do an after-action report for every single event and take
our lessons learned to modify our plans. A coordinated trauma
system is essential, but we have to have a well thought out
trauma and health care surge plan to effectively respond to
large-scale events. Trauma care provided only through
designated trauma centers will not be adequate, but we need
those centers as resources to train others.
We desperately need continued Federal funding for public
health and health care preparedness. Our CDC and ASPR funds
have been very valuable, but I need to point out that it's only
a fraction of the moneys used for preparedness. It's a
relatively small amount in the Commonwealth. It doesn't even
come close to covering, for example, unreimbursed care, and
it's not for operational funding. But it has been very
valuable, and I plead with you not to have further cuts in
either CDC or ASPR funding. Thank you again for the opportunity
to share Virginia's plans, challenges and accomplishments, and
I'll be glad to answer questions.
[The prepared statement of Dr. Kaplowitz follows:]
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Chairman Waxman. Thank you very much. We're going to
proceed with questions. Ten minutes will be controlled by the
majority; 10 minutes controlled by the minority; and then we'll
go right to the 5-minute rule.
But before I even begin questions, let me just get for the
record something that I'm not sure I fully understand. Dr.
Kaplowitz, what is a Level 1 trauma center? What is a Level 2
trauma center? What is an emergency room? How do these all fit
in as you plan for emergency preparedness?
Dr. Kaplowitz. Well, actually, many people on the panel are
better able to discuss the differences of Level 1, 2 and 3.
Level 1 trauma centers require expertise to be present within
the fatality all the time, to be able to handle any level of
trauma. Level 2 and Level 3, some of that expertise can be
outside the facility but available very quickly. So, again,
Level 1 trauma centers have tremendous costs just to maintain
that ability to provide trauma care. And that's a big part of
what costs a great deal to maintain trauma centers. It's not
only the care per se, but the infrastructure as well as a
quality improvement plan, which we have a very good one in
Virginia.
Emergency rooms are places where people can show up for
emergency care in any facility, whether they're a designated
trauma center or not. I will say that there are fewer and fewer
designated trauma centers in the Commonwealth because of the
cost to maintain a trauma center. It's been very, very
difficult and becoming more and more expensive, and that's been
very problematic.
Chairman Waxman. Thank you very much.
As I indicated in my opening statement, we asked the staff
to do a survey of emergency care capacity in seven U.S. cities.
At the time of the survey, none of the 34 Level 1 trauma
centers that participated had enough treatment spaces in their
emergency rooms to handle the victims of a terrorist attack
like the one that happened in Madrid in 2004. In fact, more
than half of the ERs were already operating above capacity.
That means, on an average day, patients were already being
treated in hallways, waiting rooms and administrative offices.
Dr. Meredith, should the findings in this survey be of
concerns to Americans?
Dr. Meredith. Yes, sir. I think the capacity available
today in our safety net hospitals is a problem, it is a threat.
If you think about a bottle-neck theory, the patients are
building up in the emergency departments, not because there's
so many patients coming to them who shouldn't be there but
because there's no place for them to go. The ability for our
hospitals to absorb them just in terms of numbers of beds and
numbers of doctors that take care of patients is lacking. And
that's what's causing this emergency department overflow
overloading and buildup. And the other pieces, one of the
strategies is to move patients around, but as several of the
other people on our panel have said, most of the kinds of
patients that are occupying intensive care unit beds,
ventilator beds, burn unit beds are not going to be very easily
moved. They will be very difficult to move. And to move them
from the Level 1 trauma centers and the burn units to other
facilities is probably not the best way to manage them. So it's
a problem.
Chairman Waxman. It's been over 6 years since we suffered
the attacks on 9/11. Are our emergency rooms prepared to handle
the surge of victims that could result from a terrorist attack?
Dr. Meredith. If you just--no, sir. I will just tell you
from going to trauma center to trauma center, and I've been in
a lot of them, there is very little surge capacity available in
the trauma centers in the safety net hospitals in our country
today.
Chairman Waxman. One of the striking findings of the survey
is how overcrowded emergency rooms are on a normal day. This
day, when our staff called the trauma centers and emergency
rooms in the major cities, was just an ordinary day, and they
were already over capacity. They had to treat patients in
hallways and waiting rooms. I would like to ask, is
overcrowding in emergency rooms jeopardizing the health of
patients and the ability of hospitals to provide the best care
possible?
Dr. Lewis.
Dr. Lewis. First of all, the day that survey was conducted
was a typical day, at least in Los Angeles. During that week in
the prior 4 days we had been on diversion--I'm sorry, in the
prior week, we had been on diversion for more than the
equivalent of 4 days. So that was a typical situation. It
absolutely negatively impacts the availability of the emergency
department resources and the ability of patients to receive
care for emergent medical conditions. There are delays in
treating patients with chest pains, patients with potentially
important infections and with a wide variety of illnesses and
injuries.
Chairman Waxman. Well, the ability to respond to a bombing,
such as occurred in Madrid, is called surge capacity. Surge
capacity depends on more than just the emergency room. A
hospital needs enough resources in places like the intensive
care unit and hospital beds. But in the survey by committee
staff, the problems extended beyond the emergency room. One
major problem is something called boarding. Could you tell us,
Dr. Lewis, what is boarding, and what impact does this have on
emergency room abilities to deal with a surge?
Dr. Lewis. Mr. Chairman the term boarding refers to the
holding of a patient.
Chairman Waxman. Is your mic on?
Dr. Lewis. Yes, it is. The term boarding refers to the use
of emergency department treatment spaces for the holding of
patients who are ill enough to require admission to the
hospital, whose emergency care has been completed, they have
been stabilized, and who the decision has been made to admit
them into the hospital but there is no room in the hospital to
treat that patient. Boarding has a number of important effects.
The two most important effects are a reduction in the quality
of care for that individual patient, because they are not
receiving the ICU care in a comfortable and streamlined
environment. But more importantly from my point of view and the
purpose of this hearing is it reduces the total effective
capacity of that emergency department. On a typical day in my
emergency department, for example, one-quarter or as much as a
third of the treatment spaces and the most intensive treatment
spaces may be taken up by a boarder once we get to the
afternoon hours, and that reduces the effective size of my
emergency department by that percentage.
Chairman Waxman. Well, what happened in Madrid was a
terrorist bombing, just a bombing, and not a--when I say ``just
a bombing,'' not weapons of mass destruction or anything
catastrophic other than what a terrorist attack using bombs can
produce; 89 patients needed to be hospitalized, and 20 needed
critical care. But not one of the hospitals surveyed had that
many in-patient beds or critical care beds. In fact, the
average hospital surveyed only had five intensive care unit
beds, just a fraction of the 29 critical care beds needed in
Madrid. Six hospitals had no ICU beds at all. Dr. Lewis and Dr.
Conway-Welsh, are you concerned about these findings?
Dr. Lewis. Obviously I'm concerned about the findings. One
of the comments that's made in response to data like that is
this idea that many of those patients could be rapidly moved
out of the hospital in the event of an unexpected and
catastrophic event. But, in fact, the information on intensive
care unit availability is particularly problematic because
those are patients that are too ill even to be in the normal
treatment area of the hospital. So, as was mentioned by some of
my colleagues, those patients are virtually impossible to move
out. And so those spaces if they are used are truly encumbered
and will not be available even in the setting of a mass
casualty incident.
Dr. Welsh.
Dr. Conway-Welsh. There is another issue to that as well,
and that is automobile gridlock. Many of our emergency rooms
have not been designed to handle a large influx of private
vehicles, which is what would happen. And I know, at
Vanderbilt, if we got 50 cars lined up for our ER, that's it. I
mean, they're not going anywhere. So I think that the gridlock
issue as a concern for our emergency rooms is also very real.
I think Dr. Lewis made an important point when he said that
the ER overcrowding, if you will, is actually a hospital
problem. And I believe that is absolutely correct. And we're
trying to fix something piecemeal when there's much larger
problems, of which you are well aware, that really need to be
addressed in a coordinated fashion by DHS and DHHS.
Chairman Waxman. Could you expand on that?
Dr. Conway-Welsh. Well, the role of coordination and
guidance among those two offices is, frankly, very murky. And
there is--if we recall the problems that happened with Katrina,
it was sort of a right hand not knowing what the left hand was
doing. There was, frankly, nobody to step in as a parent and
say, you will play well in the sand box, you will get this
done. And there was a lot of uproar between it's a State issue
or a Federal issue or a city issue. That simply has to be
stopped.
Chairman Waxman. It's been suggested that all of these
things are supposed to be handled at the local level. The State
ought to be able to coordinate emergency services. The
hospitals ought to be prepared for whatever needs they might
have. Some people have said that it won't really matter whether
a hospital ER is operating way above capacity or even under
diversion. If a bombing occurs and there are hundreds of
casualties need immediate care, then the hospital will simply
clear out all patients who don't have life-threatening
conditions. And if a local ER somehow can't create enough
capacity, then care will be available in neighboring hospitals,
in nearby communities or from emergency response teams deployed
by the Federal Government. I wonder, is this grounded in
reality, or is this an exercise in denial about the lack of
emergency care surge capacity at the cities at the highest risk
of a terrorist attack? Whichever one of you wants to respond.
Dr. Conway-Welsh. I think Tennessee accepts the
responsibility that we must care for our own citizens.
Frequently there are, particularly with blast explosions that
can occur across State lines. Something else that is a real
problem is that, for instance, the National Guard, which would
be called up, they wouldn't get there immediately, but they
would be called up, rely on the hospitals for a large part of
their plans for response.
Chairman Waxman. Before my time is expired, let me just ask
one last question. We talked about whether we're prepared and
what the consequences would be for Medicaid funding to the
States. Medicaid, of course, is health care for the very poor.
Whether people agree or not about this particular issue on the
Medicaid regulations, it will reduce Federal Medicaid revenues
to Level 1 trauma centers and other hospitals throughout the
country. Now, when that loss of Federal funds, which probably
will vary from hospital to hospital, and for some Level 1
trauma centers, will these losses be substantial, forcing
reductions in services and degrading emergency response
capacity?
Dr. Meredith.
Dr. Meredith. Without question, that is one of my greatest
fears as a result of this, is that the trauma centers which
serve as the nucleus for this preparedness piece and for the
problems that occur every day, every car wreck, the No. 1
killer of Americans under the age of 44, will not be able to
survive without--if they have this much drop loss to their
bottom line, they won't be able to do the things it takes to be
able to be ready on an every day basis, much less be able to
participate in any sort of surge. And that is frightening to me
as a trauma surgeon.
Chairman Waxman. Thank you very much.
Mr. Shays.
Mr. Shays. Thank you very much, Mr. Chairman.
Dr. Lewis, are you familiar with research conducted at
Johns Hopkins University and published in the Society for
Academic Emergency Medicine that found there are key
differences between daily surge capacity and catastrophic surge
capacity? Specifically the research found that, quote, daily
surge is predominantly an economic hospital-based issue with
much of the problem related to in-patient capacity but with the
consequences concentrated in the emergency department. By
contrast, catastrophic surge has significantly more components.
Do you agree with the statement?
Dr. Lewis. I agree with the statement, absolutely. The
point that was being made----
Mr. Shays. Translate. Give me some meaning to this. Tell me
what it means.
Dr. Lewis. I think the distinction that's being made has to
do with the ability of the hospital to respond to every day
fluctuations in the need for care. For example, when there's a
multi-car vehicle incident on the 405, and many of the
hospitals in Los Angeles County have difficulty responding to
those things but are able to respond by bringing in overtime
staff, bringing in staff that aren't usually covered by the
budget but for this one time can be brought in to open up beds
that although physically available are not covered by nursing
staff, those kinds of thing. However, doing that on a day-to-
day basis over a fiscal year drives the hospital into the red.
And so there are economic constraints on our ability to deal
with so-called daily surge. In the setting of a mass casualty
incident or a disaster surge, obviously there are some
extraordinary things that would be done. I think the critical
question is the extent with which those critical things could
be done and how effective they would be given the number of
acutely ill patients who in fact could not be moved out of the
hospital.
Mr. Shays. Thank you.
Dr. Meredith, did you want to comment on it? You just
seemed to light up a bit.
Dr. Meredith. Well, I think there is a lot--that's exactly
right, and there's a lot of truth to that. You're much more
able to lift a 300-pound weight if it's on your foot than you
can if it's just sitting in the room. So we are able to be able
to surge differently for an emergency and for a short period of
time than you can do for a long period of time. There's also a
disproportionate availability of bed capacity in our hospitals
between the big urban and the Level 1 trauma hospitals and the
smaller rural hospitals so that if you just look at the overall
bed capacity over the country, it's mismatched between where
these would occur, where the capacity is and so forth.
Mr. Shays. Mr. Chairman, I would request unanimous consent
that the following articles published in the Society for
Academic Emergency Medicine be entered into the record. There
are 1, 2, 3, 4 of them. And I have them listed here if I could.
Chairman Waxman. Without objection, they will be entered in
the record.
[The information referred to follows:]
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Mr. Shays. Thank you very much.
Dr. Hoffman, I find it nonsensical that we talk about the
capacity in emergency centers and so on, that we are strained,
when particularly in California my sense is that a lot of this
deals with the uncompensated care, not the undocumented worker
because that doesn't describe them. It's individuals who are
literally here illegally. Is there any sense of a disconnect
when we say we are providing national security for our homeland
when in fact we allow individuals to literally come into this
country at will, then call them undocumented, as if somehow
they don't represent a national security issue?
Mr. Hoffman. Well, Congressman, it's an issue somewhat
outside of my ken. In looking at the terrorist threat, I would
say, when one focuses back on 9/11, all of the 19 hijackers
entered the country, firstly, legally and withproper
documentation. So certainly you're right in pointing to the
threat that illegal aliens and undocumented people have, but I
think the threat is even much wider than that.
Mr. Shays. But isn't it the responsibility of the National
Government to defend its borders. And we have a visa process
and so on that let's us know who is here and who is not. People
here illegally are here without our knowledge. Doesn't that
strike you as somewhat absurd to then suggest that we have the
capability to deal with a potential terrorist threat?
Mr. Hoffman. I think the lesson that 9/11 teaches us is
that we have to have the kind of dynamic and flexible approach
that can deal at multiple levels.
Mr. Shays. Let me ask you, those in the hospital, how is it
that we need to be able to deal with a surge capacity when we
are dealing in a sense with a surge of illegal immigrants? How
do we sort that out? How does that fit into the equation? Isn't
it a fact that illegal residents tend to use the emergency
facilities of a hospital more than just knocking on--going
through the regular process of interacting with a doctor?
Unless we have, and we have expanded our community-based health
care clinics, but without community-based health care--let me
ask it this way. Aren't these facilities being overworked by
the fact that we have illegal residents who are using these
facilities?
Dr. Lewis. It is not my impression that any significant
part of the overcrowding or the use of the resources is
directly tied to the illegal immigrants who work in Los Angeles
County.
Mr. Shays. How would you know that? Do you find out if
they're here illegally?
Dr. Lewis. One often finds out when one is taking a social
history and asking about family background, travel history,
that sort of thing.
Mr. Shays. So you're under oath right now, and you're
saying that, under oath, you do not believe that you have an
overuse of these facilities by people who have no other ability
to have health care, and that this is not in any way caused by
illegal immigrants?
Dr. Lewis. Let me just ask a clarifying question. When you
use the term ``overuse,'' do you mean any use?
Mr. Shays. Any use.
Dr. Lewis. If you define any use of our emergency
department by people who are in the country illegally, the
answer is, absolutely, there is such use. If you mean overuse
in the sense that the use is disproportionate because of their
illegal status, I believe the answer is no.
Mr. Shays. I actually mean both. Why wouldn't it be?
Logically it would seem to me to make sense that if they had
nowhere else to go, they're going to go to the hospital. That's
what we are encountering on our side in the East Coast. Every
hospital tells me that you have an overuse in our emergency
wards by people who simply have no other place to go.
Dr. Lewis. I think that we're mixing a couple of different
distinctions. My impression, and I have not collected data on
this and I'm not prepared to give you numbers, is that most of
the illegal immigrants when they have nonurgent medical
conditions choose to seek care in a variety of outpatient
facilities that are scattered around the city, and they don't
actually want to come to the emergency department. The second,
if I could just answer the second part of your question.
Mr. Shays. Make it shorter, though, please.
Dr. Lewis. When you are told that a significant burden on
the system is by people who have nowhere else to go, the
majority of those people are legal residents or citizens of
this country who have no place else to go because they don't
have health insurance, not because of their legal status.
Mr. Shays. Thank you.
I yield the balance of my time.
Mr. Issa. Thank you.
Dr. Lewis, I'll followup in this same area. And I agree
with you as a fellow Californian that we can't have it both
ways. We can't say that the uninsured seek emergency room care
disproportionately because they can go there, they essentially
are covered by the umbrella of last resort because they're poor
and uninsured, and then not use the term broadly uninsured
rather than illegal versus legal, etc. So, although I think
illegal represents more than perhaps you're saying, I think it
is appropriate, at least in California, to look at it in terms
of the uninsured using the emergency room as essentially the
guaranteed insured area for the poor and uninsured.
I'm concerned about this survey that was done. You
participated in the survey. And UCLA Medical Center that day
said that there were 14 patients boarded by the emergency
department presumably waiting for in-patient beds to become
available. How do you explain the fact that you had 14 in-
patient beds available that same day? Wouldn't it be fair to
assume that, to a certain extent, you could have made them all,
you could have put them all in immediately if you gave them the
highest priority? And rather, quite frankly, there has to be
some credibility to the reserve for higher-paying accounts,
wouldn't be that correct?
Dr. Lewis. No.
Mr. Issa. So you're saying that you had 14 boarded patients
and you had 48 in-patient beds available and that--I'm trying
to understand. Clearly you had beds available, and you could
have shifted people into them, isn't that correct?
Dr. Lewis. I believe that you are making a common
misinterpretation of the information that was given to you, and
I've seen the same information. It has to do with how one
defines an available bed. To a hospital administrator, an
available bed is a bed that is physically there; you walk in
the room, there is a bed, and there is no patient in it.
Mr. Issa. OK. So as a followup, what you're saying is you
were not staffed to put people into those beds?
Dr. Lewis. That's a very important distinction because the
staffing is directly related to the level of hospital
resources.
Mr. Issa. And I just would like to followup.
Chairman Waxman. The gentleman's time is up, but did you
complete your answer?
Dr. Lewis. No. I was trying to make the point that the
issue has to do with staffing. And therefore, when one is
trying to get data on the number of available beds, especially
in the setting of disaster preparedness, the important question
is what number of beds are available or could be staffed in the
next few hours. And I don't believe the questionnaire was clear
in that regard.
Mr. Issa. Mr. Chairman, I know you went on for a little
while. This will be very short.
Chairman Waxman. The gentleman's time is expired.
Ms. Watson.
Ms. Watson. Mr. Chairman, I think some of the questions
that are being asked of the witnesses ought to be asked of the
Members sitting up here who make the policy.
Dr. Lewis, I am so glad you're here. I am intimately
familiar with the situation down in Watts, CA, and Martin
Luther King Hospital. And when that hospital's Medicare funds
were pulled and Medicaid funds were reduced, many of the
patients that would have gone to King had to come to
surrounding hospitals. They're overcrowded. And I know on the
day of the survey, 33 of your ER patients were being treated in
chairs or hallways. I have been in that situation myself in one
of our most prominent hospitals waiting 2 hours and 15 minutes,
and people had been there for 4 days. We have a critical
problem in our community, in our county hospital system. And we
probably have one of the largest ones in the State in the Los
Angeles area. The day we took this survey, was that an unusual
day for your hospital?
Dr. Lewis. In reviewing the numbers, and I should clarify
that I was not working that day, but in reviewing the numbers
that were submitted, my impression was that was a slightly less
busy than usual day. It was done on a weekday.
Ms. Watson. Now, Saint Francis Hospital, you're aware of
it?
Dr. Lewis. Yes.
Ms. Watson. Is a DSH hospital, and it, too, is
complaining--Doctors Hospital. I can name all the hospitals in
the area. I chaired the Health and Human Services Committee in
Sacramento in the Senate for 17 years. I am intimately aware of
our problem. What is it that we need to have a functional and
comprehensive care system for the indigent? And I know you're
not in the business of doing the work of immigration officials
and seeking; you treat people as needed. What would you want to
see in this Los Angeles County area, and maybe some of the rest
of you in other States would want to respond, too, that would
make our system viable to care for the needy, to care for the
people who come through your doors, regardless of whether
they're there legally or illegally?
Dr. Lewis. If I was limited to a single answer----
Ms. Watson. Yes.
Dr. Lewis [continuing]. My answer would be an increase in
the number of available in-patient beds in the hospital that
are staffed by qualified nursing personnel who are available 24
hours, 7 days a week.
Ms. Watson. When Dr. Levitt--thank you for your response.
When Dr. Levitt cut the Medicare dollars from King, or from
L.A. County, that was 50 percent of the resources. So it
impacted all of not only the county hospitals but private
hospitals as well. Staffing of emergency personnel, what would
you like to see there, and you talked about other beds, but
emergency and trauma?
Dr. Lewis. The most pressing shortage that we have right
now in Los Angeles County is related to nurses in the emergency
department. There's a nationwide nursing shortage. The working
conditions and the stress level in the emergency department
makes it not a popular long-term career choice for the best
nurses. And that is the most pressing immediate personnel need
that we have.
Ms. Watson. OK. How do we solve that problem, and I will
ask that of all of the witnesses?
Dr. Welsh.
Dr. Conway-Welsh. I have several suggestions. The amount of
Federal dollars that are available for nurses to go back to
school and to become either BSNs or masters-prepared nurses is
very, very limited. The faculty scholarship program is very,
very limited.
Let me take a little bit different cut though on your
question about what could be done. The School of Nursing at
Vanderbilt has just received status as a clinic, a nurse-run
faculty clinic, as an FQHC. That process took us almost 10
years to be designated as an FQHC. There are schools of nursing
all over this country that close their clinics once their
education dollars run out from HRSA because they can't maintain
it because all of our patients are indigent and poor. An
increase in the amount of FQHC support would be extremely
helpful.
And then the last point I might make is that we have many,
many nurse practitioners who are not able to practice in the
full scope of their practice because of State problems with the
Medical Practice Act and the Nurse Practice Act. We need a
Federal preemption that would allow the current nurse
practitioners to practice in the full scope of practice.
The other thing that we need to do is nurses are hunters
and gatherers in hospitals. There's 30 to 40 percent of what
they do that they shouldn't be doing. But the system doesn't
allow them to give that up. There's not enough support of the
non-nurse personnel for nurses to stop being hunters and
gatherers. We would significantly address the nursing shortage
in this country if we could just allow nurses to nurse and if
we could fully utilize our nurse practitioners.
Chairman Waxman. Thank you, Ms. Watson.
Mr. Issa, you're now recognized for just 5 minutes.
Mr. Issa. Thank you, Mr. Chairman.
Can I ask unanimous consent to submit eight documents into
the record that reflect the Commonwealth of Virginia's
emergency response preparedness, both alone and in conjunction
with the rest of the National Capital Region?
Chairman Waxman. We'll review the documents before we're
willing to give unanimous consent, and we'll see if we can get
the unanimous consent.
Mr. Issa. So you're reserving an objection?
Chairman Waxman. I object until I get a chance to review
the documents.
Ms. Watson. Mr. Chairman can we see the documents, too? I
don't want to vote unless I know what it is.
Mr. Issa. Mr. Chairman, here are the documents.
Dr. Lewis, because I ended the last round, I was just going
to comment that in your own statement, you had said that you
had surge capacity; you could bring in people that you wouldn't
otherwise have, but it would put you into the red. And I'm not
going to further elaborate because of the shortness of time,
but if you have 48 beds and you don't fill them and 14 people
say boarded, to me it sounds like you were unwilling to go into
the red in order to board those people. But you did have 48
capacity, assuming those higher cost resources were available,
but your hospital chose not to do it that day.
Dr. Kaplowitz, I'm very intrigued by your testimony, these
documents that are pending going into the record. If I
understand you correctly, if there were a significant crash or
something on the Orange Line or Blue Line today representing
dozens or even maybe 100 significant injuries, you would be
prepared to put together the resources to take care of that. Is
that correct?
Dr. Kaplowitz. We would be working very closely with the
District of Columbia and Maryland in terms of appropriate
distribution of patients working through EMS as well as the
hospitals. We would activate our Northern Virginia coordinating
hospital, which is at Innova Fairfax, and do the best we can
for optimal distribution of patients. I can't tell you what
would happen. You know, first of all, that could be anywhere.
Mr. Issa. Sure, I understand on a given day that you can't
answer. But in general, and we'll go back to Virginia Tech.
Virginia Tech was an example of the worst of all worlds, a
place you didn't expect it, a weather condition that wasn't
cooperative and hospitals that generally were not prepared. And
yet the response, looking back, you were able to rise using
resources as you could transport people and/or--people one
direction or the other. Is that correct?
Dr. Kaplowitz. Virginia Tech was not truly a mass casualty
event. It stressed rural hospitals. And we were prepared to
pull in people. However, no hospital was pushed beyond what
they were capable of doing and wasn't hundreds of people at the
same time.
Mr. Issa. And, Doctor, I know it's always unfair to do
hypotheticals, but in general, the amount of times that America
is going to be attacked in mass by a dirty bomb, chemical
attack or aircraft from the sky, compared to the amount of time
in which an airplane crashes as it is landing in Iowa, a DC-10,
the Blue Line does have an electrical failure and people are
damaged or burned, a gasoline truck on the 405 jackknives and
bursts into flames, a fire in a refinery, such as Long Beach, a
widespread hurricane or tornado that injures many; aren't all
of these dramatically more likely? And I'll be self-serving and
say, since it happens every year in America, every single year
one or more of these, actually almost all of them happen at
least once or twice a year, mass casualties occur every year in
America. Isn't it true that, in fact, if we take the war on
terror, the likelihood of another attack like 9/11 completely
out of the scenario, that the need is greater in frequency and
even likelihood of dozens or hundreds of people needing care,
isn't it greater based on these? And I will throw in just one
more for good measure, Dr. Lewis, an earthquake in Northridge?
Dr. Meredith. Yes, it is, and we're not ready to deal with
that. Whether you survive an injury in America today on
Interstate 40 from Wilmington, NC, to Barstow, CA, depends on
how well you get hurt and how well the trauma system is
organized between those two points.
Mr. Issa. And, Dr. Kaplowitz, I'm particularly intrigued
because you seem to be positive in saying that, at least within
the resources available, Northern Virginia and Virginia in
general has done a good job of being prepared. And I'm
particularly concerned because I'm a Californian, and it
appears as though California feels they're not prepared. Could
you comment further on why you feel fairly prepared within the
resources available?
Dr. Kaplowitz. Preparedness is all relative. We've put a
great many things in place to go beyond where we were on 9/11.
I can't tell you how we would handle hundreds, you know,
whether people would be happy with how we handled hundreds. We
would have a plan, a communication system.
Mr. Issa. One final question for the panel. If I had a
billion dollars sitting in the center of this room and I gave
it to you for preparation, training for these mass events or I
spread it around the country to staff up or reimburse Medicaid,
which would you rather have that billion dollars go to,
assuming there was only one pile of $1 billion available today?
Dr. Kaplowitz. I would like to see our emergency
departments and our capability, able to function on a daily
basis. Because much as I've talked about surge, I also agree
that if we don't do a better job on handling emergencies on a
daily basis, we're going to be at a disadvantage when there is
a mass casualty event. We have to be able to empty our
emergency rooms more rapidly because that's going to be even
more important in an emergency event. Again, I'm positive in
terms of what we've put in place in the kinds of
communications. However, I recognize full well the stresses on
our emergency system on a daily basis, and we can't ignore
that. They're interrelated.
Mr. Issa. Mr. Chairman, I would appreciate it if the others
could answer for the record which way they would spend the
money or if you would like to give them additional time.
Chairman Waxman. Well, whichever of you want to respond.
Yes, Dr. Lewis.
Dr. Lewis. I agree absolutely with what Dr. Kaplowitz said.
But in addition, I would like to point out that even if one
chose to spend the $1 billion on training and equipment and
things that would only be used in those very unusual events
that you pointed out, one of the key decisions is whether we
want to be prepared for the most likely of those catastrophic
events or whether we want to instead be prepared for the least
likely, meaning bioterrorism or nerve agents.
Mr. Issa. Good point.
Dr. Conway-Welsh. I would take the $1 billion and apply it
to the public health infrastructure in our country. That is
critical to any kind of a response in any kind of a disaster.
And we are in grave danger of a really crumbling public health
infrastructure in our country.
Dr. Meredith. You could fund the Federal infrastructure to
support the States to develop trauma systems for $20 million or
$10 million--million, million dollars. You know, you'll drop
that on the way to work in the morning. So that should be done.
The next piece is just to your question, Representative
Issa, can we plan to surge on a daily basis and always be ready
nationwide? I don't think that is do-able or the smart way to
do it. But I do think we are not ready on a daily basis to do
what we have to do every day. And that frightens me immensely
because we're not prepared for the bomb in a cafe or the mall
or a bus falling off a bridge because we don't have the
capacity on the every day basis.
Mr. Hoffman. This isn't exactly my expertise, but I would
say that I agree completely with Dr. Lewis' statement. And I
would point out that as unlikely as a terrorist attack may or
may not be in the future of the United States, I think that the
American people would expect that, years after 9/11, we would
be prepared adequately to respond to any kind of threat like
that.
Chairman Waxman. Thank you. And of course, they would
expect we're not going to make things worse by Medicaid cuts.
Ms. Norton.
Ms. Norton. Thank you, Mr. Chairman.
And I must say, because I represent the city, I'm
especially grateful that you brought some sunlight to this
really urgent problem as we face Medicaid cuts. I want to note
that I have constituents from Anacostia High School who would
be very much affected if in fact there was such an event here.
Mr. Chairman, since 9/11, I've been trying to get funds out
for what are called ER-1. It was to be a demonstration here.
People came from hospitals all over the country to see how we
did it here and then to see if they could replicate it. And
essentially it would add to the Metropolitan Hospital Center a
surge capacity and a way to quickly add on that capacity.
I want to--my concern, I will say to the panel, is that you
have a mix of residents here. So if you try to separate out who
you're talking about, undocumented, poor, who overuse, of
course, emergency rooms from the ordinary emergency, you're
going to have a hard time, which is why this ER-1 notion was to
try to say this is the place, it is close to the Capitol, to
send trauma victims. We have a burn center, for example. They
brought people there from Virginia after 9/11. On top of
600,000 people who live here, we've got 200,000 Federal workers
and other workers who just come in every day and go out,
creating a potential for a true catastrophic situation. They
won't be able to get out on the roads. Some of them will try to
get out if they are hurt. So the point is to let them know
quickly what the place is to go.
Now, Virginia, and Dr. Kaplowitz you testified about what
Virginia is trying to do with what money it had, and that
caught my attention, placing key, according to your testimony,
key supplies and medications in various places. Of course,
Virginia went through 9/11 and trying to deal with surge in its
various hospitals. I would like to ask you, and then that
inclined me to look at how much in Medicaid funds Virginia
would lose to see whether Medicaid funds were implicated. And I
learned that Virginia--and when we talk about Virginia,
Maryland and the District of Columbia, we're talking about one
place virtually, except that if the event occurred here, unlike
the Pentagon, if the event occurred here in this crowded space
and people went to various hospitals, you would only make the
situation worse, which is why we're working on this ER-1. The
administration has supported it. We have not been able to get
it through appropriations, even though they found considerable
support for it.
Virginia would lose $93 million in Federal Medicaid funds
over the next 5 years. I'm trying to discern what impact the
loss of Federal Medicaid funds would have on the surge capacity
they're trying to create out of whole cloth.
Dr. Kaplowitz. I've been thinking about that, knowing I was
going to be here today. I know you've heard from Dr. Sheldon
Retchin, who spoke about the impact on the VCU health system.
Again, if we lose much of the capability to handle emergencies
on a daily basis, it's going to definitely put us at a
disadvantage.
I know full well how much Level 1 trauma centers depend on
Medicaid funding in general, not only for trauma care but in
general, whether it's the VCU health system or Innova Fairfax.
And I'm very, very concerned of the impact it's going to have
on the ability of those facilities to function, not only in an
emergency but on a daily basis. And they do work together. It's
hard to expect a facility to add surge if they're to stressed
on a daily basis. Nonetheless, we are planning for surge
capability, surge beds for an emergency no matter what the
situation is on a daily basis. We have to plan for the
emergency and recognize that there are stresses on a daily
basis. So I know there's going to be enormous impact on a
number of facilities, especially our Level 1 trauma centers on
a daily basis. It will impact their ability to surge in
emergencies. That's not going to stop us from continuing to
plan for that large event looking at distribution of patients
and hoping facilities respond appropriately.
Ms. Norton. Level 1 trauma centers are the ones that,
because they are the hospitals that have the greatest capacity,
tend to be the ones that are overcrowded?
Dr. Kaplowitz. Absolutely. There's one other point here
that's not related to Medicaid funding but related to surge.
And that is the concern that hospitals have of the funding
they're going to receive after an emergency. I bring this up
because it's a major issue when hospitals are talking about
surging in emergencies. Most hospitals, most health care is
private. And there's been a lot of discussion and stress about
what kind of reimbursement they would get in responding to
emergencies. They're going to respond, but are they going to be
dramatically hurt financially?
Ms. Norton. Following 9/11, it was easier to get funds out
after the fact, and this is what's so frustrating to me.
Because in the face of a catastrophe and living in a country
that doesn't prepare for anything, money went out. But
preparing for such an event is very bothersome. I am concerned,
and I would like finally to ask this, if in fact these patients
are distributed to the trauma centers wherever they are in a
place like the District of Columbia, rather than to have a
place that is specially outfitted to deal with traumas, if you
would tell me how an emergency room is supposed to decide how
to quickly separate the traumas that come, let us say from the
District of Columbia, the other people who have serious
emergency problems who come in, the people who shouldn't be in
the emergency room but perhaps should be referred? I mean, I'm
worried about the chaos of just sending everybody to trauma
centers in the first place.
Dr. Meredith, did you have an----
Chairman Waxman. The gentlelady's time is expired but we'll
get an answer to the question.
Dr. Meredith. The trauma center itself is designed to do
that exact question. A lot of work has been done to define what
kind of patient is the trauma patient and how should they move.
And those questions are answered. There are about 230 Level 1
trauma centers and about 320 Level 2 trauma centers, so we're
talking about saving 550-ish maybe between that and 600
hospitals that are a core of the safety net for patients in the
country.
Ms. Norton. Thank you.
Mr. Chairman, I want to just say I'm very concerned that if
people simply go to the hospital closest to them as opposed to
the hospital that in fact has been most prepared to handle the
surge from the event, all of the placement that Virginia is
trying to do for example, kind of a little bit everywhere
without Medicaid funds, will not serve us well in the event of
a truly major capacity. If I may say so Virginia was not the
kind of event that we in the District of Columbia are most
afraid of following 9/11.
Chairman Waxman. Thank you, Ms. Norton.
I want to ask this. We have a health care system in this
country that's the most expensive in the world, and yet we have
47 million people who are uninsured. Most of them are working
people, and they don't have insurance. So if they get sick,
they go to the emergency room. If they don't have insurance,
the hospital doesn't get paid for the care that they're given.
So hospitals then have to figure out how to survive
economically without getting paid for a lot of these emergency
room patients. Isn't it true that the people that are in
hospitals today because of this whole crazy system we have are
some of the sickest people, unlike in other countries where
they're not the sickest, they're not the ones that you just
can't deny hospital care, but in our country, it's the sickest?
Is that right, Dr. Meredith, do you know.
Dr. Meredith. I don't know. It's a hard system to figure
out, and I work in it every single day.
Chairman Waxman. Well, it's a hard system to figure out.
But let's look at the system. There's not enough money in the
system for all the people who use it who don't have health
insurance coverage.
Now, does it make any sense--Dr. Hoffman, does it advance
the goal of Homeland Security for the Federal Government to
then be withdrawing funds from Level 1 trauma centers, whether
through the Medicaid program or some other funding source? Is
it reasonable for the Federal Government to assume that States
and localities are going to make up these losses to the
hospitals or the market forces will make up for the short fall?
Mr. Hoffman. Mr. Chairman, you know, I think we've already
learned the lesson of not being adequately prepared before 9/
11, so, no, it doesn't make sense from my perspective as a
terrorist analyst.
Chairman Waxman. As a terrorist analyst.
How about those of you who are in the medical field? Does
it make sense when you're struggling to keep these hospitals
going under ordinary circumstances and trying to find out how
to fund them for the Federal Government to withdraw Medicaid
funds?
Dr. Meredith. Market forces will not make up for the loss
that this money represents to the safety net hospitals and to
these few trauma centers, I'm certain, because of the way the
patients are moved around now. They will still get those
patients. And when it represents such a loss that they can't
sustain it, they will stop being trauma centers, and we'll lose
them from the system, and it will be tragic.
Chairman Waxman. A lot of hospitals are already closing
their doors for the emergency rooms because they can't afford
to keep them open.
Dr. Kaplowitz, you're trying to find out how to plan,
you're trying to plan for an ordinary catastrophe or a
terrorist kind of catastrophe. Does it help your planning
efforts when the Federal Government withdraws money from the
Medicaid program or some other funding source?
Dr. Kaplowitz. Not at all. And as I mentioned already,
we're very grateful for getting some funding for emergency
planning. But that's only a fraction of the funds hospitals
receive. It couldn't then begin to replace the Medicaid dollars
or the other dollars they need to maintain their
infrastructure. So absolutely it makes no sense at all to lose
that much funding.
Chairman Waxman. Now, some people say disasters are local.
Local communities need to prepare for a terrorist bombing or
similar attack. But it's also true that the Federal Government
has a responsibility here, which starts with at least doing no
harm. And that means not withdrawing Federal Medicaid funds
that now support Level 1 trauma centers in the highest risk
cities. I wanted to pursue another point about how we prepare
for a terrorist attack. There has been, Dr. Hoffman,
evaluations of potential terrorist attacks. In fact, I think
the Centers for Disease Control brought together a panel. Is it
the consensus of people looking at possible terrorist attacks,
if we're going to have one, it's going to be using conventional
weapons rather than a weapon of mass destruction?
Mr. Hoffman. Absolutely. Again, I don't think we can rule
out any potentiality. But certainly the higher probability
event is conventional explosives and perhaps with suicide
attacks.
Chairman Waxman. In fact, according to the CDC report that
was produced, they said a terrorist bombing attack in the
United States would be a predictable surprise, like a hurricane
is a predictable surprise, or a major automobile traffic
accident could be a predictable surprise. Yet the Federal
Government, under existing law, has a responsibility for
developing national medical surge capacity to respond to a mass
casualty event, such as a terrorist attack with weapons of mass
destruction. Last October, the President issued Homeland
Security Presidential Directive No. 21, which established a
national strategy for public health and medical preparedness
for this kind of an event. It's crucial that we be prepared for
an event using a dirty bomb or biological weapon. But I don't
know that there's any national strategy to prepare for or
respond to a terrorist attack using conventional explosives,
such as happened in Madrid or here in Oklahoma City or at
Centennial Park in Atlanta. Dr. Hoffman, is there such a
Federal response being prepared by this administration that
says, the buck stops here?
Mr. Hoffman. No, my understanding is that incidents like
terrorist attacks involving conventional explosives are viewed
to a lesser included contingency, and the assumption has long
been, going back from what I testified before a subcommittee of
this committee that Congressman Shays chaired nearly a decade
ago, is that generally these more conventional types of
terrorist attacks don't receive the same type of attention that
the high end, less likely threats do.
Chairman Waxman. Well, this is exactly what we want to ask
the Secretary of Health and Human Services and the Secretary of
Homeland Security. What is the Federal Government doing? What
do we have in place? What are we planning in case a predictable
event such as a terrorist attack occurs. And some people think
that's partisan to ask those questions. I think it is something
we ought to be asking on a bipartisan basis.
Mr. Shays.
Mr. Shays. Thank you. Dr. Hoffman, Hadassah Hospital in
Jerusalem has a facility that has a whole floor designed for a
surge capacity, but they have no doctors to man it. In other
words, it's--and it is there for a potential chemical attack,
and so on, where they can isolate patients and so on. I see the
logic of doing that, but I don't see the logic of staffing it.
And so then they compromise and they bring other people in from
different places. Isn't that a model that makes sense for the
United States?
Mr. Hoffman. Well, sir, I used to think I was in a
depressing field studying terrorism until I sat on this panel
with my distinguished colleagues. And given everything that
I've heard about the capacity of our trauma centers this
morning, it's a different situation.
Mr. Shays. I don't know why it's different. They have to
deal with a terrorist attack and that's what we're talking
about right now. I mean, you know, Dr. Lewis, your hospital was
kind of shut down for a while because they required you to have
more people present. I mean the requirements changed and so it
took a while to get back up to speed because of, I think, new
regulations; is that correct?
Dr. Lewis. I don't believe our hospital was shut down at
any time.
Mr. Shays. I mean--you know what I'm making reference to.
Do you want to explain it?
Dr. Lewis. Actually I'm not sure. Are you talking about a
citation we received in response to long waiting times in the
emergency department?
Mr. Shays. Right. I meant only--I'm sorry, I didn't mean
hospital, I meant in the emergency room. This is not a trick
question. I mean, the point that I'm trying to make was that
you had to staff it at certain level and you weren't able do
that, correct?
Dr. Lewis. The citation was in response to delays in seeing
patients with acute medical conditions because of the long
waiting time in the emergency department.
Mr. Shays. Right, but----
Dr. Lewis. Let me try to answer your question. The staffing
was simply a way of more quickly screen--additional staffing to
screen those patients.
The question you asked about how Israel is different, one
very important way that Israel is different is that because of
the constant concern over mass casualty incidents they do not
allow their emergency departments to become overcrowded. And
one way they accomplish that is that if the emergency
department becomes overburdened they immediately move those
patients up into non-normal treatment areas inside the hospital
so the emergency department does not get gridlocked. And that's
a reflection of their greater day-to-day awareness of this
threat.
Mr. Shays. So but the bottom line is they have a surge
capacity in space, not necessarily in terms of doctors on duty
and nurses on duty. And it would strike me that's part of the
model. It would strike me that part of the model that we have
to work on is better coordination and how we move patients and
so on. And we're connecting two things that maybe need to be
connected. But in the process we're really talking about two
separate issues. One, do you have the capability to deal with
your basic emergency needs day in and day out? I mean I'd love
to know--I'd love to keep going because I'd love to know is
there a rule of thumb with so much population you need a trauma
1, a trauma 2 and a trauma 3. Some States may not have it. I
think West Virginia doesn't. Is there--should every hospital
have an emergency facility? And I understand that some don't
now. You know, so those are all legitimate, you know, questions
that I have no answer to.
Dr. Lewis. I'd just like to comment that there are standard
rules regarding for a population of a given size the number of
inpatient hospital beds. Prior fiscal pressures have forced
many hospitals to reduce the number of inpatient beds that they
either maintain physically or maintain staffing for. So fiscal
pressures over the last 10 or 15 years have resulted in most or
at least many metropolitan areas having a number of inpatient
beds far below the originally recommended number.
Mr. Shays. Right.
Dr. Lewis. That's the direct cause of the ED overcrowding
that we've been talking about. So there are rules of thumb and
we violate them.
Mr. Shays. But what would be a shame in this process is I
happen to have opposed the changes in requirements. And we
voted to try to hold them, but what would be a shame would be
to not be having the dialog about all the other things that
don't take money necessarily, but talk about coordination,
which we're not even getting into.
Dr. Kaplowitz, my understanding is Virginia does a better
job of anticipating these kinds of challenges.
Dr. Kaplowitz. Well, we've had to out of necessity but I
wanted to make the comment about Israel. I've been there.
Israel provides health care coverage for everybody in their
population.
Mr. Shays. Right.
Dr. Kaplowitz. Their facilities are not under the same
financial stresses as ours are here. Not only do they deal with
suicide bombing, but every single one of their hospitals is a
hospital when they have a war. It's a different mindset, but
the fact that everybody has coverage, everybody has a medical
home, it's made an enormous difference in terms of their
emergency preparedness and the stresses on their individual
hospitals.
Mr. Shays. Let me just end with this comment. First, one
area where the administration doesn't get enough credit is the
effort they have gone with community-based health care clinics.
We've expanded from 10 million to about 16, 17 million people
covered. That's one area where they do deserve credit. And
there's areas where they, you know, rightfully should be
criticized.
I happen to be on legislation cosponsoring with Jim
Langevin that says we're going to go to universal coverage
giving--providing the same health care benefits that Federal
employees have as a choice to everyone. Where I have my big
disconnect, and it seems like it's an issue we don't want to
ever discuss in this country, is how we deal with the 13 to 20
million people who are here illegally. They are not
undocumented. Undocumented means that somehow all they have to
do is be documented. By not being documented they are here
illegally and they are here illegally. And it doesn't seem to
come up. And I know for a fact these are folks that don't have
coverage and intuitively they are going to go wherever they can
get help and they are going to go to emergency wards. And the
fact that we like want to dance around this just blows me away.
That's my comment.
Dr. Kaplowitz. I did want to make a comment about a public
health study that has shown that recent immigrants actually
used less medical care than the rest of Americans. This was
brought up in the recent series about disparities in care. So
while I acknowledge that there are significant numbers of
people who may we here illegally, they actually used less
medical care than----
Mr. Shays. And let me tell you why I think that is an
irrelevant statement. They use less care and when they do use
it they go where they can get it, which is an emergency ward.
And therefore the logic is that when they do use it, they are
using it there.
Dr. Kaplowitz. They----
Mr. Shays. Thank you.
Dr. Kaplowitz. I will add another comment. They are not
only going to emergency rooms. I'm on the board of a free
clinic--free clinics--an enormous amount of care, including to
undocumented persons. So they don't all go to emergency rooms.
Mr. Shays. They go to community-based health care clinics,
we know that, and that's one thing the administration has done
well.
Chairman Waxman. I want to raise a point that I think this
issue of illegal immigrants is a red herring.
Mr. Shays. Why?
Chairman Waxman. The reason it is a red herring is that
illegal immigrants are not eligible for Medicaid, they are not
eligible for Medicare. They may get private insurance, and if
they do, their insurance company is paying the bills based on
their payment to the insurance company.
Mr. Shays. But isn't that----
Chairman Waxman. I'll take a time and then I'll let you
take a time.
Mr. Shays. Thank you. OK, no problem.
Chairman Waxman. I'm not going to get interrupted.
So when the people who are illegal come to an emergency
room, it's usually as a result of a trauma.
Dr. Lewis and Dr. Meredith, from your experience and
knowledge of what goes on in emergency rooms, are most of the
people in emergency rooms for trauma undocumented aliens or are
they people that don't have insurance coverage when the
hospital ends up with a bad debt?
Dr. Meredith. Most of the people in the emergency
departments are not for trauma, they are for other emergency
conditions. Trauma is very important to me, but a smaller part
of what goes on in emergency departments. Most of the patients
who are trauma patients are not undocumented or illegal, they
are a spectrum of American civilization. They--everybody gets
hurt, and they are a complete spectrum of people, a complete
spectrum of people. We take care of them all. We just stop
their bleeding, that's all we can do.
Chairman Waxman. Dr. Lewis.
Dr. Lewis. I agree with the statement, trauma is a
nondiscriminate force and it doesn't ask you about your
legality status before you get hurt.
Chairman Waxman. Now, let's say Dr. Meredith rightfully
pointed out that emergency care is not just trauma care. So
someone gets sick, and they don't know where else to go, and
they don't have health insurance and they end up in an
emergency room. Of course that's the most expensive setting for
people to get health care, which is one of the problems in our
non-system of health care in the country. People get seen and
treated in the most expensive way. They could go to a community
health clinic.
When you see people who come in because they have no health
insurance with a minor problem, do they get something
extraordinary? Do they get a lot of time and attention which
will encourage them to come back with these smaller problems?
Dr. Lewis. It is my impression that the--if we're focusing
specifically on illegal immigrants in Los Angeles County who
come to my hospital, my impression is that the vast majority
have attempted to seek care in other facilities first for the
same problem, except for acute serious illness that couldn't be
treated anywhere else. And occasionally they find that the
community health clinics, some of which are federally
supported, some of which are just free-standing, have been
unable to take care of their problem because it has either
gotten worse despite treatment or there has been some
complication. But it is my impression the vast majority of them
attempt other avenues for seeking medical care before they come
to my department.
Chairman Waxman. Now there are 47 million people without
health insurance. I've heard an estimate that there may be as
many as 5 million illegal immigrants. Now 47 to 5, of those 5
million illegal immigrants, some of them have health insurance,
isn't that true? They have a job where they are provided health
insurance, probably most of them don't. And if they need health
care, they'll go to a clinic. It's the right thing to do for us
to have put in more money into the community health centers
programs. But it doesn't deal with the problem that we have.
Let's say 47 plus 5, 52 million people. Yet if something
terrible happens to them they have to go to get care
immediately, they are not going to go to a clinic, they are
going to go to an emergency room.
What should the Federal response be for emergency rooms
that are facing 47 plus 5, 52 million people without insurance?
Well, the hospitals can't turn them away. Well, what most
hospitals do if they are private hospitals they will close
their emergency room. And then if they don't have an emergency
room, these people have to go to places where there are
emergency rooms. But if those emergency rooms are already
overburdened, they are diverted to other emergency rooms. Isn't
that what happens?
Dr. Lewis. Yes, that's correct. And although I don't have a
good suggestion for what the Federal Government should do, what
I am sure that it should not do is reduce the funding for those
safety net hospitals prior to having a viable alternative
solution.
Chairman Waxman. And certainly they shouldn't do it without
finding out what the consequences are. That's what's so
shocking to me about these Medicaid cuts. The Center for
Medicaid Services and the Department of Health and Human
Services never even did an evaluation of what the impact would
be if these kinds of cuts took place. They simply said we'll
let the States and local governments figure out how to deal
with this.
Well, it seems like they are trying to make the States and
local governments have to deal with everything. And at least
when it comes to a terrorist attack there certainly ought to be
a Federal responsibility. I believe there ought to be a Federal
responsibility for all people in this country who don't have
access to health care because this is distorting our whole
health care system. So that's why I say it is a red herring to
say the problem is all these illegal immigrants. It's not just
that. That's an over simplification and a diversion from the
much more serious problem that this administration for 7 years
has not given us any ideas except maybe give a tax break--which
is inadequate to even buy health insurance--to a lot of people
who couldn't then afford to buy health insurance even with that
tax break.
Mr. Shays, I will recognize you for the last 5 minutes, and
then we will continue.
Mr. Shays. Thank you. And I would be happy to have you
interrupt me if you'd like--I mean to ask a question.
Chairman Waxman. No, I will not interrupt you.
Mr. Shays. What I'm looking for is meaningful dialog. I
don't have any dog in this race. I mean I'm just trying to
understand something. And I get confused because in the
Medicare Modernization Act funds were included for hospitals in
States with high numbers of illegal immigrants because these
hospitals complained about the problem of illegal immigrants
who were in fact stressing their hospitals. So you know----
Chairman Waxman. In the Medicare----
Mr. Shays. In the Modernization Act.
Chairman Waxman. Do any of you know whether that's
accurate, because I don't believe that's accurate.
Mr. Shays. The question I have is first off, I do not
believe that this is the cause of the problem. I think it is a
part of the problem. It is news to me that if we have anywhere
from 13 to 20 million people there illegally, that only 5
million don't have health coverage. That's news to me. And we
have 13--we have 12 million people who are here legally who are
documented, but not citizens. We have a range between 13 and 20
million who are not here legally. They are here illegally and I
make an assumption, maybe incorrectly, that a majority don't
have health care. Because it would really be surprising to
think that 85 percent of Americans have health care, but you
know undocumented workers have that same average or even half
that.
I happen to believe that we need to have universal
coverage. All I want is an answer from folks who are there that
my understanding is you got two options for someone without
health care. You go to a community-based health care clinic or
you go to the emergency ward. I mean, I don't know if there are
other options. And so it strikes me that we are stressing the
emergency rooms. And they are hugely costly. I went where I had
three stitches. The hospital got into a dispute with the
insurer and sent me a bill for 1,300 bucks for three stupid
stitches. Had I gone somewhere else it wouldn't have been
obviously that expensive.
And so I'm just trying to make the point to you, Henry,
that I think that we spend a fortune on health care, far more
than other countries, and that we keep saying well, we just
have to spend more money. We're at 18 percent of our gross
domestic product and I don't think we can actually find a lot
more money. And so what I struggle with is are there things
that don't involve money where we can deal with the surge
capacity.
And Dr. Hoffman, you didn't seem to want to jump in on some
of this, like all of a sudden this was outside your expertise.
But it strikes me that we can learn from what other places do.
And they don't put a lot more money in, they have extra bed
space with no doctors.
What I was confused by Dr. Lewis in the dialog with Mr.
Issa, you said, well, we have 45 beds, but they are unmanned.
Is that a bad thing that they are unmanned? Is it good that you
have this space in case you have a need for surge capacity?
And another question I ask all of you, aren't there times
when we're going to have to break the rules of so many nurses
and so many doctors when you have an emergency. Then it seems
to me you throw it out the window, you may have doctors working
overtime, nurses working overtime and some rules being broken
during a surge--a needed surge.
Dr. Lewis. First of all, I agree with you 100 percent that
there are issues of coordination and response to major, very
infrequent events that could be used without substantial
funding to improve our ability to respond. I think there's no
question that is correct.
The issue regarding the unstaffed beds in the hospital has
something to do with the funding source. We're a publicly
funded institution. The vast majority of our funds either come
from or come through Los Angeles County. These are public
funds. Such--the similar kind or type that you're responsible
for administering.
Our hospital administrators cannot make a decision to go
over their budget and staff those beds. It is not their
authority. It is a public process that's overseen by the board
of supervisors, who I understand were here recently. So it's--I
got the impression or the implication was made that a hospital
administrator was not staffing them to avoid losing money.
That's not the case. It is just not an option.
Second, with respect to the money that is already being
spent in preparedness, I think a number of us have tried to
point out the disconnect between the most likely unusual mass
casualty incidents and the types of incidents that seem to have
been focused on by the existing hospital preparedness program.
That program used to have the term, I believe, bioterrorism in
its name. They took out the bioterrorism part of the name, but
still maintained most of the focus on supplies and equipment
that are related to relatively unlikely events.
So one thing that we can do without asking for additional
money is to focus on the most likely events, and I'm not
talking about the everyday surge events, the most likely true
mass casualty incidents.
And then last, I'd like to simply point out that in Los
Angeles County the public funds that support our institution,
part of them come from tax revenues. Those tax revenues are
driven by the economic activity in that area. I'm in no
position to speculate regarding what the effect of removing
those illegal workers would be from our economy, but I'm not
actually sure that the net effect on the funding of our health
care system would be beneficial. I actually think it would
probably be detrimental. Clearly a health economist would have
to look at that, hopefully one not driven by partisan concerns.
Chairman Waxman. Thank you, Mr. Shays.
Ms. Watson, did you----
Ms. Watson. I sure do. And I just want to say, I don't
think it's really clear to some Members that if you are an
illegal immigrant you are not eligible, you're not eligible for
Medicare and Medicaid.
As Dr. Lewis astutely notes, there are some Federal
policymakers who still do not see the relationship between
maintaining robust emergency and trauma care capacity and a
successful homeland defense strategy. Hello.
I would like to ask Dr. Hoffman and Dr. Kaplowitz, both of
whom know a great deal about emergency preparedness and
response, to help us connect the dots. While there is much
dispute about whether the Medicaid regulations are justified,
there's no dispute that they will reduce the amount of Federal
Medicaid revenues to Level 1 trauma centers and other hospitals
throughout the country.
There is also no dispute that the loss of Federal funds
will vary from hospital to hospital and that for some Level 1
trauma centers these losses will be substantial, potentially
forcing reductions in services and degrading their emergency
response capacity.
So Mr. Hoffman, does it advance the goal of Homeland
Security for the Federal Government to be withdrawing funding
from Level 1 trauma centers whether through the Medicaid
program or some other funding source? And is it reasonable for
the Federal Government to assume that States or localities will
make up these losses to the hospitals or that market forces
will make up for the shortfall?
Mr. Hoffman--Dr. Hoffman, excuse me.
Mr. Hoffman. Well, I think certainly not in those cities,
for instance, that the Department of Homeland Security have
identified at least the most likely threat of a terrorist
attack.
Ms. Watson. Excuse me, when you say most likely those
areas, how do you define the areas that are most likely the
target of terrorist attacks?
Mr. Hoffman. Well, the Department of Homeland Security and
also private risk management firms have assessed on a variety
of indicators in terms of terrorist interests, in terms of the
vulnerability facilities in those cities, which cities in the
United States would be more likely than others perhaps.
Ms. Watson. Would you consider the West Coast or Los
Angeles area?
Mr. Hoffman. Certainly Los Angeles and southern California.
San Francisco probably falls into that category as well.
Ms. Watson. OK.
Mr. Hoffman. I mean given the pattern of terrorists, and
certainly since 9/11 there is a very high concentration of
these activities, fortunately not yet in the United States but
overseas in major cities that are at least if not the capital
of their nations, then at least are business centers or
transportation hubs.
Ms. Watson. I just wanted to hear your response. Thank you.
Mr. Hoffman. But if I could just finish for a second?
Ms. Watson. Yes.
Mr. Hoffman. I would go back to what Dr. Kaplowitz said
about Israel, which I think is absolutely correct, is that
their energy services are not as over stressed in terms of
their personnel as it appears in the United States. London by
contrast though I think is very similar to the United States in
that respect with emergency rooms that have--that already are
burdened by a health system with lots of people in urban areas
coming into them. You can see the difference in the response of
the London hospitals to the July 7, 2005 attacks. There I think
the coordination was not as good, even though they had
extensive drills and extensive training, the planning--the
system broke down in essence because there were insufficient
personnel on that because the systems themselves were stressed.
Ms. Watson. Dr. Kaplowitz, as a State official you've been
involved in a great deal of planning for emergency preparedness
and response throughout Virginia. Does it help your planning
efforts when the Federal Government withdraws funding from
Level 1 trauma centers, whether through the Medicaid program or
some other funding sources?
Dr. Kaplowitz. Not at all. I need those facilities to
survive. And I know what kind of stress they are under on a
daily basis. You remove Medicaid funding, it could be
disastrous. We have seen any number of hospitals need to close
their doors. The last thing I need is for any more hospitals to
not be able to survive financially. And the stressors for
trauma centers are enormous. The additional cost it takes to
keep your trauma center open is significant. And these
facilities are functioning with very small margins. So I need
them to be able to function and stay open, and I need them to
maintain their expertise in order to appropriately respond to
emergencies.
I've been at the Health Department almost 6 years. In my
prior life I was at the VCU health system for 20 years,
including working in hospital administration, and I know what
kind of stress that facility is under on a day-to-day basis.
You take away significant Medicaid funding, it's going to be
disastrous. And the sameis true of all trauma centers in the
Commonwealth.
Ms. Watson. Thank you for that.
Chairman Waxman. Thank you, Ms. Watson. And I want to thank
this panel. I think you've given us a lot of good information,
some of it quite startling, and I think we have to pay a lot of
attention to it and ask the people in charge, the Secretary of
Health and Human Services and the Secretary of Homeland
Security, both of whom are going to be here Wednesday, how to
respond to some of these concerns what the Federal Government
is doing and at least find out whether we're doing harm with
some of the proposals that are being pushed.
That concludes our hearing today--oh, yes, there was one
item, Mr. Issa requested unanimous consent to put in documents.
I have no objection. Does anybody?
Ms. Watson. No objection.
Chairman Waxman. Without objection, those documents will be
part of the record. We stand adjourned.
[The information referred to follows:]
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[Whereupon, at 12:30 p.m., the committee was adjourned.]
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THE LACK OF HOSPITAL EMERGENCY SURGE CAPACITY: WILL THE
ADMINISTRATION'S MEDICAID REGULATIONS MAKE IT WORSE? DAY TWO
WEDNESDAY, MAY 7, 2008
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 9:31 a.m., in
room 2154, Rayburn House Office Building, Hon. Henry A. Waxman
(chairman of the committee) presiding.
Present: Representatives Waxman, Cummings, Tierney, Norton,
McCollum, Van Hollen, Murphy, Sarbanes, Davis of Virginia,
Shays, Issa and Sali.
Staff present: Phil Barnett, staff director and chief
counsel; Karen Nelson, health policy director; Karen Lightfoot,
communications director and senior policy advisor; David
Rapallo, chief investigative counsel; Andy Schneider, chief
health counsel; John Williams, deputy chief investigative
counsel; Sarah Despres, senior health counsel; Steve Cha,
professional staff member; Earley Green, chief clerk; Zhongrui
``JR'' Deng, chief information officer; Leneal Scott,
information systems manager; Kerry Gutknecht, William Ragland,
Miriam Edelman, and Jennifer Owens, staff assistants; Sheila
Klein, office manager/general assistant to the staff director;
Larry Halloran, minority staff director; Jennifer Safavian,
minority chief counsel for oversight and investigations; Keith
Ausbrook, minority general counsel; Christopher Bright, Jill
Schmaltz, Benjamin Chance, and Todd Greenwood, minority
professional staff members; Patrick Lyden, minority
parliamentarian and member services coordinator; and Ali Ahmad,
minority deputy press secretary.
Chairman Waxman. The meeting will please come to order.
Today we are holding the second of 2 days of hearings on the
impact of the administration's Medicaid regulations on the
ability of our Nation's emergency rooms to respond to a sudden
influx of casualties from a terrorist attack.
On Monday we heard from the leading experts that the
emergency rooms in our Nation's premier trauma centers have
little or no surge capacity. We learned from them that many
Level I trauma centers do not have the capacity to respond to a
terrorist bombing like the one that happened in Madrid in 2004.
And we learned that the administration's new Medicaid
regulations are expected to make these problems worse by
cutting off crucial funding.
The hearing left us with a number of important questions,
which we hope to answer this morning. Why would the Department
of Health and Human Services, knowing that the Nation's
emergency care system is already stretched to the breaking
point, withdraw billions of Federal dollars from the hospitals
that provide the most comprehensive emergency care to the most
seriously injured? Why would the Department of Health and Human
Services take this drastic step without first considering the
impact of its actions on emergency preparedness or consulting
with the agency with lead responsibility for homeland security?
Why would the Department of Homeland Security, which is the
Federal agency with lead responsibility for protecting the
Nation from terrorist attacks, stand by while local emergency
surge capacity is compromised?
The impact of the Medicaid regulations on our health care
safety net is not a partisan issue. Last month Republicans in
the House joined with Democrats in passing bipartisan
legislation that would postpone the regulations and give
Secretary Leavitt and Secretary Chertoff an opportunity to
reevaluate their implications for homeland security.
The issue we are considering today is one that concerns all
Americans: how to ensure that we have a robust response
capacity in our emergency rooms. If the unthinkable happens,
and we have learned that the unthinkable can happen, lives will
be lost unless emergency care is immediately available. If a
major city experiences a terrorist bombing like the one that
occurred in Madrid, there will be a golden hour, an hour in
which the fate of those who are injured will be determined,
whether the most severely injured survive or die. The Federal
Government's job is to do everything possible to ensure that
emergency care resources are ready during that golden hour.
Certainly our government should not be taking actions that
undermine the prospect of an effective emergency response. That
is why we are having this hearing today, and that is why I look
forward to the testimony of the two men in charge, Secretary
Chertoff and Secretary Leavitt.
[The prepared statement of Chairman Henry A. Waxman
follows:]
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Chairman Waxman. But before we go on, I want to recognize
Mr. Davis for an opening statement.
Mr. Davis of Virginia. Well, thank you, Mr. Chairman. As
you said, we are here today to discuss two issues, Medicaid
reimbursement regulations and the hospital surge capacity in
response to predictable, some say inevitable, mass-casualty
events. And we are fortunate to have two very distinguished
witnesses to inform our discussion. Welcome Secretary Leavitt
and Secretary Chertoff. We appreciate your taking your valuable
time to be with us today.
As we learned from Monday's testimony on these same
subjects, the nexus between Medicaid payments to hospitals and
emergency preparedness may seem intuitive, but it is not by any
means proven. Extrapolating directly from daily emergency
department utilization rates to catastrophic surge capacity
overlooks complex and interrelated factors that differentiate
single-facility financial management from the broader resources
needed to mount a coordinated regional disaster response. But
extrapolate the committee did in releasing a 1-day snapshot of
hospital emergency room occupancy in seven major cities and
concluding it painted a complete picture of surge capacity.
Consulting the issues of Medicaid reimbursement and
terrorism preparedness simultaneously oversimplifies and
obscures both issues. I happen to agree with Chairman Waxman,
we ought to know more about the impact of the administration's
proposed regulation changes before exacting further cost
savings from an already stressed health care system. But
wrapping that issue in the mantle of terrorism creates the
false impression solving the problem of emergency room capacity
on Tuesday means we are ready for doomsday. It does not. As one
peer-reviewed study put it, surge capacity planning involves
ensuring the ability to rapidly mobilize resources in reaction
to such a sudden unexpected increase in demand regardless of
baseline conditions.
It is just too simple and fiscally untenable to say there
can never be cost savings in Medicaid as long as we are not
ready for a Madrid-style attack. Both Medicaid efficiencies and
preparedness need to be pursued, not one pitted against the
other. So I hope we can move beyond limited snapshots and talk
about the dynamic range of factors in addition to baseline
facility funding that make up real surge capacity organization,
leadership, standards of care, medical education and training,
interoperable communications, transportation coordination and
information technologies.
Finally, we appreciate the fact that our witnesses made a
tough choice to be here today. As we speak, the Federal
Government is conducting a national continuity of operations
exercise, testing many of the response elements needed to treat
a surge of trauma patients. I hope the exercise goes well in
their absence, and trust the committee's approach to these
issues will continue to be constructive and supportive of
executive branch efforts to prepare the Nation for catastrophic
events. Thank you.
Chairman Waxman. Thank you very much, Mr. Davis.
[The prepared statement of Hon. Tom Davis follows:]
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Chairman Waxman. Because of time constraints, we will leave
the record open for all Members to insert an opening statement
in the record.
But we will go right to our very distinguished witnesses,
and we are privileged to have both capable Secretaries with us
today with distinguished careers in public service.
Secretary Michael Chertoff served as the Secretary of
Homeland Security since February 2005. That capacity is a
challenge. He has a challenging and critical responsibility to
lead the Nation's efforts to prepared for, protect against,
respond to and recover from terrorist attacks, major disasters
and other catastrophic emergencies, whether man-made or natural
disasters, that affect our homeland. And before taking the helm
at the Department of Homeland Security, Secretary Chertoff
served as a judge on the Third Circuit Court of Appeals. Prior
to that he served as Assistant Attorney General of the Criminal
Division at the Department of Justice.
Secretary Michael Leavitt has been the Secretary of the
Department of Health and Human Services since January 2005. As
Secretary of HHS, he is responsible for managing a daunting
array of medical, public health and human services programs.
HHS is the lead Federal agency for public health and medical
preparedness and response. And before coming to HHS, Secretary
Leavitt was the Administrator of the Environmental Protection
Agency. He also served as Governor of Utah for three terms, and
during his 11 years as Governor, Utah was recognized six times
as one of America's best-managed States. We are pleased to have
both of you here with us.
I don't know which one of you wants to go first. Secretary
Leavitt--both of your prepared statements will be in the record
in full. We would like to ask you to make your oral
presentation to us now.
STATEMENT OF MICHAEL O. LEAVITT, SECRETARY OF HEALTH AND HUMAN
SERVICES
Secretary Leavitt. Good morning, Mr. Chairman. And thank
you very much, Ranking Member Davis and other members of the
committee. I am very pleased to discuss HHS leadership role in
the public health and medical emergency preparedness efforts,
as well as HHS and CMS efforts to ensure that Medicaid pays
appropriately for services that are delivered to Medicaid
recipients.
As you know, local, State and Federal agencies have a
shared responsibility for ensuring that the Nation is prepared
for emergencies. In that context permit me to briefly discuss a
few of the emergency preparedness efforts that are currently
being led by HHS.
On October 18, 2007, President Bush signed the Homeland
Security Presidential Directive No. 21 [HSPD-21]. It
established a new national strategy for public health and
medical preparedness. HSPD-21 mandates the development of an
implementation plan. HHS chairs the interagency writing team
that drafted the implementation plan that is currently in the
process of being finalized.
As part of the implementation plan, HHS is implementing an
Emergency Care Coordinating Center. This new center will serve
as a coordinating focal point for emergency care as an
enterprise. The ECC, as we have come to know it, charter is
being finalized, and we anticipate to have the center up and
running by the end of this year.
The National Response Framework Emergency Support Function
[ESF] 8, titled the Public Health and Medical Services
Function, provides a mechanism for coordinating Federal
assistance to State, tribal and other local resources in
response to a medical disaster.
The Secretary of Health and Human Services leads all of the
Federal public health and medical response to public health
agencies. The Secretary of HHS also coordinates through his
Assistant Secretary or ASPR all of the ESF 8 preparedness,
response and recovery actions. The National Disaster Medical
System [NDMS], transferred from the Department of Homeland
Security to HHS, remains the tip of the spear, if you will, as
the Federal disaster health care response capacity.
Over the past 5 years, the Hospital Preparedness Program
has provided more than $2.6 billion to fund the development of
medical surge capacity at the State and local level. As part of
our pandemic planning, we have asked grantees to report
participating hospitals' ability to track beds electronically,
to report to the grantee's emergency operations center within
60 minutes of a request.
From 2002 to 2007, the Public Health Emergency Preparedness
Program has provided $5.6 billion to State, local, tribal and
territorial public health departments. This program has greatly
increased the preparedness capabilities of the public health
departments.
Now turning briefly to Medicaid, it is important to
remember that Medicaid is fundamentally a Federal-State
commitment to provide health care for Medicaid beneficiaries.
First and foremost, our responsibility is to assure that these
low-income children, pregnant women and people with
disabilities are able to receive high-quality and appropriate
care when they need it.
The package of recent Medicaid regulatory activity will
help enable, or to ensure rather, that Medicaid is paying
providers appropriately for services delivered to Medicaid
recipients, and that those services are effective, and that
taxpayers are receiving the full value of the dollars that are
spent through Medicaid.
GAO and the Office of Inspector General at HHS have
provided policymakers with numerous reports on various areas in
which States inappropriately engage in activities that maximize
Federal revenues. These rules address these types of abuses
head on. It addresses them by ensuring that the Federal
Medicaid dollars are matching actual State payments for actual
Medicaid expenses to actual Medicaid beneficiaries. Medicaid is
already an open-ended Federal commitment for Medicaid services
for Medicaid recipients. It should not become a limitless
account for State and local programs and agencies to draw
Federal funds for non-Medicaid purposes.
In conclusion, as I have mentioned earlier, HHS is working
diligently to improve our Nation's emergency preparedness and
our medical surge capacity, and we have made extensive funding
available to hospitals through the States specifically to this
end.
Medicaid, however, is fundamentally a partnership that
relies on both States and the Federal Government to contribute
their share of the cost of the program. Allowing for the
continuation of abusive practices that shift costs to the
Federal Government is not an appropriate way to ensure our
Nation's preparedness. We are committed through our emergency
preparedness efforts to continue to make progress and to make
funding available to States while acting through these Medicaid
rules to provide greater stability in the program and equity to
the States. And I want to thank you for the opportunity of
being here to testify.
Chairman Waxman. Thank you, Secretary Leavitt.
[The prepared statement of Secretary Leavitt follows:]
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Chairman Waxman. Secretary Chertoff.
STATEMENT OF MICHAEL CHERTOFF, SECRETARY OF HOMELAND SECURITY
Secretary Chertoff. Thank you, Mr. Chairman. Good morning,
Ranking Member Davis and other members of the committee.
Let me just take a few moments now since my full statement
will be in the record to put into perspective what the role of
the Department of Homeland Security is with respect to the
issue of preparedness and response, one dimension of which, but
only one dimension of which, is the issue of mass care in the
event of some kind of a terrorist attack or natural disaster.
But I also underscore the fact that the planning and execution
of a response to an attack, particularly with respect to the
issue of mass care, would implicate not only HHS, but would
also require the participation of the Department of Defense and
Department of Veterans Affairs. They have a major role to play
in furnishing the resources and capabilities necessary to
respond to a medical emergency, and their capabilities are
built into our plan. So it is not merely a matter of HHS.
Basically what I would like do is describe the role that we
play in any kind of a response, and, therefore, what role we
play in planning in the lead-up to the possibility of a
response. As you know, under the National Response Framework
and the National Incident Management System, the Department of
Homeland Security plays the role of incident coordinator,
incident manager. That does not mean that we are exercising
command and control over other departments and agencies. That
would be prohibited as a matter of law.
What we do do is bring to the table the agencies that will
play a role. There is a lead agency designated for particular
functions; in the case of mass terrorists, the Department of
Health and Human Services. That is a designation that is both
prescribed by statute as well as by HSPD 5 and HSPD-21. Our
role then would be to coordinate and deconflict the various
capabilities that we bring to the table and the roles and
responsibilities of the lead agency and other agencies, so
that, for example, in the case of an attack, let's say a
conventional attack, we would obviously have to coordinate the
law enforcement response, although the lead agency there would
be the Department of Justice. There might well be a security
response, in which case we would be coordinating with the
Department of Defense and the National Guard. And to the extent
there was a mass casualty response, the mission assignment for
carrying that out would be to HHS, but there would be support
provided by the Department of Veterans Affairs and the
Department of Defense. This is all done under the rubric of
what we call Emergency Support Function 8, and the actual
undertaking would be coordinated through the National Response
Coordination Center.
As part of the preparation for this, we engage in a variety
of planning exercises. And with respect to the issue of mass
care, again we look to the Department of Health and Human
Services to take the lead with respect to identifying what the
gaps are with respect to potential surge capability, what the
available resources are, and what are the most efficacious ways
to provide those resources. That is done with the understanding
that the initial response obligation lies upon State and local
public health officials. Therefore, they must participate in
the planning, and it is their responsibility to make sure that
they are planning in a way that is synchronized with us.
We also recognize, however, that these capabilities would
likely be overwhelmed in 24 hours, or maybe 48 hours. That is
why we have capabilities such as the National Disaster Medical
System, which is run by HHS. We would look to the Department of
Defense to provide mobile field hospitals and other kinds of
medical capabilities, which we would move into the arena as
quickly as possible. The National Guard would obviously play a
major role. And, again, if there were some particular issue
like a chemical attack or a dirty bomb attack, there would be
specialized capabilities by the military that would be called
into play.
So that is the general role that we play in coordinating
these issues. We have engaged in planning, strategic planning,
on a number of scenarios, including some with medical
dimensions, again looking to HHS as the principal lead in
identifying what the requirements are, identifying where the
gaps are, and formulating a way in which those gaps can be
plugged.
Thank you, Mr. Chairman.
Chairman Waxman. Thank you very much.
[The prepared statement of Secretary Chertoff follows:]
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Chairman Waxman. Without objection, we are going to begin
questioning with 10-minute rounds, first controlled by the
Chair and second controlled by Mr. Davis. After that we will go
back to the 5-minute rule.
I am going to start off the questions myself.
Secretary Leavitt and Chertoff, we are here to answer the
very simple question, if we had a terrorist attack like what
happened in Madrid, with conventional bombs or suicide bombers,
which most terrorist experts say is most likely, not the
unthinkable weapons of mass destruction, but if the
unthinkable, unlikely terrorist attack using conventional
weapons occurred, would we be prepared to deal with it?
Now, many experts have told us that if we had something
like an attack on a commuter train where, as in Madrid, 177
people were killed and more than 2000 were injured, we wouldn't
have the surge capacity in some of our major cities to deal
with those people in the Level I trauma centers or even in the
emergency rooms.
Secretary Chertoff, do you think we have the capacity to
deal with such an attack?
Secretary Chertoff. I do, Mr. Chairman. Now, I want to note
that HHS is currently engaged in a systematic survey of
capacities and plans across the country, so there is going to
be a definitive answer to this. And there is no doubt some
communities are better prepared than others. But I don't have
to speculate about it.
I remember we had a bridge collapse in Minneapolis some
months ago. That was exactly the kind of event that you are
talking about. It was not a terrorist event, but it was one
which certainly posed challenges to casualties. My
understanding is that in Minneapolis things worked very well.
Chairman Waxman. Thirteen people went to the emergency room
under those circumstances. We could have hundreds, if not
thousands, of people rushed into emergency rooms.
Secretary Chertoff. We have had air crashes, we have had
other disasters. I can't give you a definitive statement with
respect to a particular city. What I can tell you is I am not
sure that the day-to-day capacity rates of emergency rooms is a
prediction of the capability of the emergency system to deal
with a disaster.
Chairman Waxman. Have you delegated that to HHS?
Secretary Chertoff. HHS has a principal responsibility, to
my understanding.
Chairman Waxman. Well, let me read to you what your Chief
Medical Officer Jeff Runge told the House Appropriations
Committee last month. He said, ``I don't think anybody who has
looked would be under the mistaken notion that we are
adequately prepared for a hospital surge. We have squeezed all
the capacity out of the hospitals' budgets, and it's just not
there.''
He went on to say, ``We frankly don't have a lot of
solutions for it. Surge capacity does just not exist in the
world of hospitals.''
Mr. Runge did say the Federal assets could be brought to
the scene of a bombing, as did you earlier, but that could take
some period of time, maybe a day or more, which may be too long
for many critically injured victims.
So your own expert does not think we are prepared. Why, do
you disagree with Dr. Runge's assessment?
Secretary Chertoff. I wasn't here for the testimony. I
think it depends on the number of people. If there are--I can
certainly imagine an attack of a dimension that would overwhelm
local resources. That is the very premise of what our position
is with respect to planning. It is the recognition that the
Federal Government would have to step in and surge. And
obviously since we are doing a gap analysis, I am going to be
the first person to tell you there are undoubtedly gaps that
need to be plugged, some of which are planning, and some of
which are capability gaps.
What I can't tell you is that this is simply a matter of
emergency rooms. I think it is a much more complicated issue
than that. I will also obviously acknowledge I am awaiting to
get more precision in the results of the HHS study with respect
to the country as a whole.
Chairman Waxman. Well, I don't doubt it is more complicated
than one factor or another, but what I fear, and what the
experts told us a couple days ago, is if we go ahead with these
Medicaid cuts, withdrawing billions of dollars from hospitals
that have Trauma I centers and emergency rooms, we will be
making the problem worse. We will make it less sure that we can
even meet the response that we found so inadequate in our
survey on March 25th. At that time the staff called Los
Angeles, and three of the five Level I hospitals that were so
overcrowded, they simply shut their doors. There wasn't even a
terrorist attack. They shut their doors and said divert these
people somewhere else. And Washington, DC, both Level I trauma
centers surveyed, they are over capacity and treating patients
in hallways and waiting rooms.
So if in the middle of this inadequate capability of our
emergency rooms to deal with ordinary problems we had a
terrorist attack, I just think that if we go ahead with the
billions of cuts in Medicaid funds for those institutions, we
are making the problem worse. The first thing at the Federal
level is at least not do any harm. I think a lot of people can
ask how is it possible that 6 years since 9/11, nearly 3 years
after Hurricane Katrina, we have spent billions of taxpayer
dollars on homeland security, and yet our emergency systems are
not in place?
I don't doubt that you have very good intentions and a lot
of helpful initiatives, but the problem is that the positive
effect of these programs, which involve grants of millions of
dollars, are going to be overwhelmed when we pull out billions
of dollars in some of these Medicaid cuts.
We were told Monday that the Medicaid regulations will
cripple hospital emergency rooms. The head of Virginia's
emergency response program said you take away significant
Medicaid funding, it is going to be disastrous. An expert from
UCLA said the regulations would cripple emergency care in Los
Angeles.
Secretary Leavitt, do you think these experts are wrong?
Secretary Leavitt. Mr. Chairman, I think we are dealing
with two fundamentally different assumptions. They are
fundamentally different assumptions in two areas. The first is
the way surge capacity works, and that we would have to rely on
hospitals as the bed for surge capacity. The second is that the
mission of Medicaid is the assurance of emergency preparedness.
Let me deal with the first one, surge capacity and the way
it works.
Chairman Waxman. I am asking about the Medicaid, the
Medicaid cuts by these new regulations. I know we contacted you
and your Department, and we asked for every document that you
might have that would indicate that you--if you did an analysis
to find out what the impact would be of these Medicaid
regulations. And I think we might have even sent the same
request to the Department of Homeland Security. And we found
that there was not a single analysis of the effects of the
Medicaid regulations on our Nation's emergency rooms. If that
is the case--maybe we haven't received it, but if that is the
case, no analysis has been done. I just think that is
irresponsible.
Secretary Leavitt. Mr. Chairman, we have exercises on a
regular basis, and the people from CMS sit at the same table as
those from our Assistant Secretary for Preparedness and
Response. Medicaid's mission, however, is not emergency
preparedness; it is to provide health care to people, not to
support institutions. Now, at HHS we have a very important
Assistant Secretary for Preparedness and Response who is tasked
with that responsibility. We have made substantial investments
in developing surge capacity.
Chairman Waxman. Did he do an analysis of what the impact
would be of the Medicaid regulations that withdraw money from
these institutions?
Secretary Leavitt. He manages emergency response, not
Medicaid. The analysis on Medicaid was based on the fact that
the funds were being drawn for purposes that we believe were
inappropriate under the mission of Medicaid, which we believe
to be helping people, not supporting institutions.
Chairman Waxman. Well, they help people by supporting
institutions. Our public hospitals are absolutely dependent on
the Medicaid dollars. They have so many people that come into
emergency rooms that have no insurance, and the hospitals then
have to shift the cost. And then if they find that Medicaid is
not going to pay them for graduate medical education or other
functions that they serve, they just have to give up the
expensive things like Level I trauma centers. That is what they
are telling us. But it looks like they never told you because
they were never asked the question of what the impact would be
with these Medicaid cuts.
Secretary Leavitt. Mr. Chairman, it probably won't surprise
you that I hear similar expression from those who run schools,
who say, we need to have more money for our schools, and if we
can find a way to get Medicaid money to support our school
effort, it will help our schools. I hear a similar thing from
those who run child welfare programs; if we could just get some
Medicaid money, it would help us, and they stretch it over to
health care. Medicaid was not intended to be our emergency
response mechanism.
Chairman Waxman. It wasn't intended, but, in fact, it is.
Secretary Chertoff, you are head of the Homeland Security.
You have designated this issue of health care functioning to
HHS, and yet they are saying that they don't know what the
impact is going to be of these cuts.
Congress always holds hearings after the fact. After
Hurricane Katrina and that disaster, we held hearings, and we
asked, how could this happen? This is a hearing to find out if
we are prepared. I don't want it on my conscience years after a
terrorist attack, God forbid, that we realize that we didn't do
what was necessary because the bureaucracies weren't
functioning the way they should, the planning wasn't taking
place, that there was money being withdrawn so that the whole
system, which is all very fragile in this country for health
care, wasn't able to function when it came to emergency care or
preparedness for a surge of victims of a terrorist attack. I
don't want it on my conscience.
Do you feel that you can tell us today that your conscience
would say that we are doing all that we need to do, Secretary
Leavitt and Secretary Chertoff?
Secretary Leavitt. Mr. Chairman, I share with you the worry
about surge capacity. It is a responsibility that I have and we
have at HHS. I also worry about the long-term sustainability of
Medicaid. Medicaid was not designed nor intended to be the
source of money that we use to design an effective surge
capacity strategy in this country. We do have a means by which
that should be done. If Congress in its wisdom believes that
more money is needed for more surge capacity, we need to use
the intended vehicle. We need to apply it to a logical,
thoughtful strategy. That logical and thoughtful strategy will
not include emergency rooms being the only place where surge
capacity takes place. There is not an emergency room in America
that you can't build a scenario for that will blow the doors
off in a very short period of time.
Chairman Waxman. So you feel good about the situation?
Secretary Leavitt. No, that is not what I said at all, Mr.
Chairman. I said I don't feel good about the situation, but I
don't believe Medicaid is the way to solve it.
Chairman Waxman. And you think we ought to give other
money, but we haven't been asked to give other money for this
purpose.
Secretary Chertoff, how do you feel?
Secretary Chertoff. I actually agree with Secretary Leavitt
on this. I think that I am the last person to tell you I think
we are done. I think that we are--and I have been involved in
more specifically looking at the issue of emergency response in
the Gulf States. But more generally I think we need to be
identifying gaps based on planning done at a Federal, State and
local level. And then if we need to plug the gaps with money,
the money ought to be targeted to plug the gaps.
Where I am seeing a bit of a disconnect, I have no reason
to believe that giving more Medicaid money to hospitals is
going to result in that money being spent specifically on those
items which would be required to deal with a surge situation.
Nor is it obvious to me that the only solution in this surge
situation is the emergency rooms.
So the question to me would be do they need to have
additional beds in storage? Do they need to have additional
ventilators or medication or things of that sort? And if, in
fact, there is a gap, that ought to be directly funded, but
with the understanding that money is going to be spent on those
issues. I have no reason to believe that Medicaid funding in a
hospital is necessarily going to be dedicated to emergency
response as opposed to something else.
Chairman Waxman. A lot of it is being dedicated to this
now, and that money is going to be withdrawn, and it is a
sizable amount of money.
I have taken up 13 minutes, and I am going to give 13
minutes to Mr. Davis.
Mr. Davis of Virginia. Thank you, Mr. Chairman.
Secretary Leavitt, let me start with you. Thanks for being
here. Regardless of one's views on the regulation, I am
concerned about using Medicaid reimbursement to support
emergency medical preparedness because it is an imperfect
financial tool. In my experience, hospitals use additional
revenues created through reimbursement policy. They can be
reinvested in ways that may not improve emergency capacity, as
Secretary Chertoff just noted. For example, hospitals may more
regularly reinvest in expanding capacity for profitable
services, orthopedics for example.
Do you think that additional Medicaid reimbursement
necessarily results in improved emergency surge capacity?
Secretary Leavitt. There is no evidence that it does.
Mr. Davis of Virginia. Thank you very much.
I mean, Medicaid is the fastest-growing part of the Federal
budget. It is the fastest-growing part of States' budgets as
well. And to allow this to continue without tampering and
looking at ways that we can improve service, but at the same
time cut back costs means there won't be money for a lot of
other things in the budget downstream.
Let me ask you this, Secretary Leavitt. For the Homeland
Security Presidential Directive No. 21, it is my understanding
that there is a stakeholder group that is working on the
different financial levers available to improve preparedness.
The group is looking at Medicare, Medicaid, private payer,
grant funding and market forces. How does this group's work
inform future funding decisions made at the Department?
Secretary Leavitt. That group is looking at that question
as well as many, many others to form this question. Until I
receive their report, I don't know what they will say. I think
it is clear that homeland security is everyone's second job. We
all have a primary job. The job of Medicaid is to take care of
people who are poor or indigent or disabled, and States are
using ambiguities in the law to try and tap that fund for many
different reasons.
Mr. Davis of Virginia. Because it is the largest part of
their budget?
Secretary Leavitt. And they have determined----
Mr. Davis of Virginia. Even in economic downturns when
their revenues are less, the Medicaid costs are going up.
Secretary Leavitt. In fact, Mr. Davis, I would make the
point that Medicaid is the single greatest influence on State
budgets right now.
Mr. Davis of Virginia. I agree.
Secretary Leavitt. And if you wanted to see why States were
not investing and why they were looking for ways in which they
could divert Federal funds into schools and to child welfare
and to public health and public safety, it is because Medicaid
is pushing all those things out and crowding them out. Their
capacity to do that is being compromised by the fact that the
program is growing so fast.
Mr. Davis of Virginia. And understand this, 10, 12 years
ago it was really not a factor in State governments the way it
is today.
Secretary Leavitt. I was elected Governor in 1993, and I
would have to check this, but I believe it was in the
neighborhood of 6 percent of the State budget. Today, again, I
would have to check, but I am guessing it is like every other
State in that it is close to 20 percent. That means every one
of those dollars is crowding out education, it is crowding out
higher education, it is crowding out public response and
preparedness, all of the things we are talking about.
Mr. Davis of Virginia. So in point of fact, putting more
money into this may have the opposite effect?
Secretary Leavitt. Well, it has had the opposite effect.
Mr. Davis of Virginia. The Homeland Security Presidential
Directive No. 21 requires that the group review financial
incentives that improve preparedness without increasing health
care costs. There are economic reasons that hospitals have not
increased emergency department capacity or the number of
inpatient beds. How does the health system increase capacity
without increasing costs?
Secretary Leavitt. Well, I want to emphasize in this
process the whole concept of all--of being--of all perils
response. Everything we do to prepare, for example, for a
pandemic helps us for a bioterrorism event. Anything we can do
that will use the same assets for multiple things allows us to
expand capacity without expanding costs. The idea of sharing
assets.
The way our surge capacity is designed to work, we know
that there is a scenario for every hospital, no matter how big,
no matter how well funded, no matter how sophisticated, that
the capacity will exceed their ability to deal with that. And
therefore every hospital and every community needs to have a
surge capacity plan that allows them to use schools that may,
in fact, have been mothballed. Or I have seen plans where
shopping centers are converted into surge capacity. I have
actually witnessed during Katrina convention centers being
turned into hospitals, and very good hospitals, in the context
of 24 hours.
So surge capacity is about using existing assets to convert
to hospital capacity very quickly. It is not simply using the
emergency room. If you were to look at any emergency room in
this country, you would see that at least half of what is there
at any given moment would not be considered absolutely
critical. And if we turn into an emergency, those will be moved
away or asked to be deferred, and we will have substantial
capacity that would not have been evident in the snapshot that
was taken that the chairman referred to.
Mr. Davis of Virginia. Thank you.
I would like to ask unanimous consent that a Wall Street
Journal article, Nonprofit Hospitals Once for the Poor Strike
It Rich, be included in the hearing record.
Chairman Waxman. Without objection.
[The information referred to follows:]
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Mr. Davis of Virginia. Thank you.
The majority staff report on the status of emergency
departments looked at 34 hospitals and found that many were
operating at or above capacity. Three hospitals were diverting
ambulances, including one hospital that is undergoing a major
expansion that includes the recent purchase of 3 million pounds
of travertine imported from Tivoli, Italy, and 569 flat-panel
TVs. Another hospital that, according to the majority report,
had patients in overflow spaces and borders has also undergone
a significant expansion that included a new women's hospital
with marble in the lobby, and flat-screen TVs, and birthing
rooms. Both of these hospitals are nonprofits and appears that
they have sufficient resources to invest in marble and TVs, but
not enough to invest in emergency departments.
Is this typical, and is this appropriate in your view?
Secretary Leavitt. Well, it is not appropriate, in my mind.
I don't know how typical it is. I think the point you are
making is a good one, and that is many times the lack of
emergency room capacity is because the administration of the
hospital has chosen not to invest there because it didn't, in
fact, assist their business model.
Mr. Davis of Virginia. And, in fact, by raising Medicare
reimbursement and diverting that money to pay for marble floors
and flat-screen televisions really doesn't go anywhere to solve
this problem, does it?
Secretary Leavitt. You made the point earlier that there is
no assuredness or no guarantee that money coming from Medicaid
would going into emergency preparedness, and there is no direct
link.
Mr. Davis of Virginia. The question is if we want to look
at surge capacity, perhaps Medicaid is not the best way to look
at that.
Secretary Leavitt. Indeed, Mr. Davis, it is not. I want to
emphasize I believe that there are deficiencies in our surge
capacity. I just don't believe Medicaid dollars is the source
of funds that ought to be directed or looked to to link to that
solution.
Mr. Davis of Virginia. Thank you.
Secretary Chertoff, thanks for being with us today. Does
DHS have the expertise to determine the appropriateness of any
of the following matters as it relates to Medicaid? Let me go
through them. Whether public providers should be limited to
cost in Medicaid reimbursement.
Secretary Chertoff. No, we rely on HHS. Frankly, the whole
issue of Medicaid is not actually within our purview. So the
short answer is no, we don't have the expertise.
Mr. Davis of Virginia. Do you have the expertise to
determine the appropriateness of the definition of unitive
government for health providers that treat Medicaid patients?
Secretary Chertoff. No.
Mr. Davis of Virginia. How about the appropriateness of
graduate medical education payments in Medicaid?
Secretary Chertoff. No.
Mr. Davis of Virginia. How about the scope of
rehabilitation services?
Secretary Chertoff. No.
Mr. Davis of Virginia. How about the appropriateness of the
administrative claims for schools?
Secretary Chertoff. No.
Mr. Davis of Virginia. The definition of the scope of
outpatient services?
Secretary Chertoff. No.
Mr. Davis of Virginia. The definition of the scope of
targeted case management services.
Secretary Chertoff. No.
Mr. Davis of Virginia. Thank you.
The National Response Framework encompasses a broad array
of functions and entities.
Secretary Chertoff. Correct.
Mr. Davis of Virginia. For example, transportation,
communication, roads, utility and public work infrastructure
may all be heavily used in an emergency; however, these
facilities also have important functions unrelated to disaster
response or homeland security. Therefore it seems imprudent to
describe any service that might have a role in an emergency as
a homeland security activity.
How do you determine what functions are primarily related
to homeland disaster compared to those that are tangentially
related?
Secretary Chertoff. Well, I agree with you. The key
philosophy is what is directly related, and the way we go about
that is we put together a plan. We analyze what are the core
capabilities that we have to have to respond effectively. We
then identify and survey whether there are gaps in those
capabilities, and then we determine what is the best way to
plug those gaps.
Mr. Davis of Virginia. Thank you.
Mr. Shays.
Mr. Shays. Thank you both for being here, and thank you,
Mr. Chairman, for having this hearing.
I am wrestling with the fact that I think we are really
dealing with two issues. We are dealing with the health care
issues and the needs of our hospitals, and we are dealing with
a potential catastrophic event and a surge capacity. I would
like to know from each of you who has the responsibility?
First, has there been a study done that looks at the entire
United States to say how many Trauma I, Trauma II and Trauma
III centers we need and ideally where they should be located?
Secretary Leavitt. Mr. Shays, with respect to emergencies,
we are currently doing a study right now under the matter that
was referred to earlier.
Mr. Shays. Can you move the mic a little closer?
Secretary Leavitt. Yes. We are currently doing a study
under HSPD-21, the group that was referred to earlier. However,
I can also tell you that we are asking and requiring grantees
of HHS for pandemic preparedness to give us information about
their surge capacity plan. Between those two, we will have a
very good idea in the future as to what the capacity is and
where our gaps are.
I would also like to make the point----
Mr. Shays. When do you think that would be done?
Secretary Leavitt. We expect it to be done by the end of
this year so that we can make the report before the end--
conclusion of this term.
But I would like you to know that we already have the
capacity at any given moment to determine where rooms and beds
are available anywhere in the country within a reasonably short
period of time. During Katrina I was constantly updated as to
how many beds we had anywhere in a region that we could move
patients to. This is an important part of the way surge
capacity works. We are discussing surge capacity today as to
what you can put into an emergency room at any given hour. That
is not the way surge capacity works.
Mr. Shays. I want to make sure that my colleague has time.
I would like a brief comment from both of you as to who is
ultimately responsible for this issue, because it seems to me
like when two people are, no one is.
Secretary Leavitt. I think we both agree HHS has
responsibility for any matter related to medical response in a
disaster.
Mr. Shays. And so it would be your job, not DHS, to
determine how many Trauma I, II and III units we need around
the country.
Secretary Leavitt. Well, it will be our determination to
determine how many we have, what our gap is and how best to
respond to that.
Mr. Shays. Thank you.
Mr. Issa. Thank you.
Governor, I will continue along that line. With 259 trauma
centers in the country, 5 in San Diego, 4 in Utah, it is very
clear that in San Diego we have as much capacity for our 2
million people in a relatively small area as Utah has in a huge
area. For all practical purposes, in the case of disasters of
any sort, take the Northridge earthquake, aren't we essentially
always assuming for homeland security that they are going to be
in high-risk areas, where ultimately the people of Utah or
Oklahoma or Wyoming could just as easily have a huge disaster
affecting thousands of people over an area that could not
possibly concentrate the types of hospitals that we have in Los
Angeles or San Diego? So ultimately isn't the planning for
major disasters more about the essential planning and training
and ability to move people than it ever will be about having
operational extra spaces in one location?
Secretary Leavitt. Yes. There is no one area of the country
capable of handling their own surge in an event of sufficient
size to require that kind of capacity.
Chairman Waxman. Mr. Davis, your time has expired.
Ms. McCollum.
Ms. McCollum. Mr. Chairman, the report conducted by the
committee highlights serious challenges confronting hospital
emergency rooms, and crowding is a serious problem. The
American College of Emergency Physicians released a report last
month that addresses the crowding issue. The report asks what
causes crowding, and it responds, ``Over the years the reasons
for crowding have included seasonal illnesses, visits by the
poor and the uninsured who have nowhere else to turn except the
safety net provided by emergency departments. This country can
continue to expand the capacity of emergency rooms, to serve as
a provider of last resort for the uninsured and the mentally
ill, or Congress can work to provide universal health care for
all Americans. The choice is ours.''
Mr. Chairman, I don't know about the situation in New York,
Washington, Chicago, Houston, Denver or Los Angeles. I have
never visited an emergency in any of those cities, so I will
take this report's findings as accurate. But I live in
Minnesota, and I need to set the record straight.
First, the report inaccurately states that Minneapolis is
hosting the 2008 Republican Convention. The convention will
take place in St. Paul, MN, my congressional district, with
Minneapolis accommodating many of the visitors. This
distinction is important, especially for the St. Paul
officials, first responders, health care professionals involved
in preparing to meet the needs of 40,000 visitors, including
the President of the United States and Republican nominee for
President.
Second, the report examines Hennepin County Medical Center,
which is an excellent hospital and a Level I trauma center
located in Minneapolis. In the event of an emergency at the
national Republican convention, Regions Hospital in St. Paul,
an excellent facility, will be the primary responder, with the
hospital examined in the report providing support.
What concerns me about this report is it examines
Minneapolis solely as the presence of the national convention,
yet it evaluates emergency room capacity on a random day, March
25, 2008. During the 4 days in September when the Republicans
gather in St. Paul, there will be significant additional
resources available to ensure a safe, enjoyable convention.
There will also be an emergency plan and considerable assets in
place to respond to any foreseen event.
The Department of Homeland Security designated the national
party conventions as a national special security event. This
Congress appropriated $50 million to each host city to ensure
coordination is seamless between Homeland Security, Secret
Service, local and State law enforcement and their first
responders.
Finally, while I fully understand the use of Madrid
terrorist attacks as a standard for assessing casualty
preparedness, real American tragedies like the Oklahoma City
bombing, Hurricane Katrina, Virginia Tech shooting could also
have been used as models.
In the Twin Cities we don't need to investigate emergency
room capacity using a telephone survey. Our first responders
were forced to respond to an emergency in real time. Only 9
months ago on August 1, 2007, at 6:05 during rush hour, 8 lanes
of traffic on Interstate 35W, the bridge, it collapsed into the
Mississippi River. That night 13 people died, many my
constituents. And more that 110 patients required emergency and
medical attention. The bridge collapsed due to structural
failure. It just as easily could have been the result of a
terrorist attack, but the disaster tested the very hospital in
the committee's report.
Hennepin County Medical Center and hospitals from the
entire Twin Cities metropolitan area responded heroically,
professionally and efficiently. Their response was not a
simulation or a blind phone survey, it was real. And people are
alive today because of that response.
Mr. Chairman, I have statements from Hennepin County
Medical Center, Regions Medical Center, St. Paul's chief of
police, Minnesota Hospital Association, I would like to have
the committee's permission to enter these into the committee
report.
Chairman Waxman. Without objection, that will be the order.
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Chairman Waxman. The gentlelady's time has expired.
Mr. Sali.
Mr. Sali. Thank you, Mr. Chairman.
Secretary Chertoff, border security is an important issue
affecting Idahoans, and the need for secure travel documents I
think they consider equally as important. Do you have any
security concerns specifically with the use of matricula
consular cards, passport cards, NEXUS and Sentry and PASS
cards?
Secretary Chertoff. First, Mr. Chairman, I guess I do have
to observe when I was invited here, I thought the topic was
going to be medical surge. It is hard for me to see the
correlation here, so I have to ask you whether you want me to
answer this. But if you do, I will go ahead and answer.
Chairman Waxman. Well, the rules allow each Member to ask
questions.
Secretary Chertoff. On any topic.
Well, the short answer is I think certainly our NEXUS cards
and Sentry cards, our PASS cards which are about to be issued
by the Department of State are secure. They reflect a
substantial step forward in improving the security of our
documentation. Likewise our laser border-crossing cards.
The matricula consular is not an American-issued card, so I
can't warrant or vouch for the security of that. We don't rely
upon that for purposes of allowing people to come across the
border.
Mr. Sali. I think there is a relation here. I hear concerns
for many areas of the country that part of the problem in
hospitals is that they are overrun with illegal aliens in
specific places. And part of the problem in dealing with the
problem of illegal aliens is making sure that we have legal
ways for people come to our countries that are secure in fact.
Was there a recall on the NEXUS, Sentry or PASS cards
during the last year or two?
Secretary Chertoff. Not that I am aware of.
Chairman Waxman. Mr. Sali, it is your time to ask
questions, but you are off the topic for which we have invited
the Secretaries to speak, I guess Secretary Chertoff will have
to decide whether he is prepared to respond. But----
Mr. Sali. Well, Mr. Chairman----
Secretary Chertoff. I could find out. I didn't come
prepared to talk about it.
Mr. Sali. Perhaps the Secretary would be willing to respond
to some of these questions in writing----
Secretary Chertoff. Sure.
Mr. Sali [continuing]. If I submit them to the committee.
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Mr. Sali. And if I may continue, do you share the concern
that the presence of illegal aliens in our country is affecting
the ability of our hospitals to respond in a surge situation?
Secretary Chertoff. Well, I don't know if I would connect
it to a surge, but I would agree that I am aware that the
presence of people who are in this country illegally does
strain emergency rooms on a day-to-day basis, because often
these people don't have health care through their employers, so
they are relying on the emergency room as a kind of primary
care facility. And that is one of the things we hoped to
address when we took up the issue of comprehensive immigration
reform, but as everybody now knows, that didn't take off in the
Senate. So in the meantime our approach is to enforce the
existing laws as vigorously as possible.
Mr. Sali. Secretary Leavitt, let me ask you the same
question. Do you share that concern about the presence of
illegal aliens, overwhelming at times, on the emergency room
and hospital capabilities in our country, and if you do, what
is your office doing to relieve that situation?
Secretary Leavitt. Again, there is no connection
necessarily between surge capacity. But there is little
question that many of those who go to emergency rooms to be
treated are here without proper documentation. Our Department
does provide substantial assistance to hospitals to pay for
those, but there is no question about the fact that it is a big
part of the problem.
Mr. Sali. How much does your agency pay for treatment for
illegal aliens each year?
Secretary Leavitt. That is not a number I have off the top
of my head. It is a big number.
Mr. Sali. You will get that for me, though?
Secretary Leavitt. I would be happy to respond in writing,
to the degree we have that information.
Mr. Sali. I have heard both of you say today that the
presence of illegal aliens is not directly related to the
surge, and yet both of you have said that illegal aliens use
emergency rooms as their primary care doorway, if you will,
into the health-care system.
Secretary Leavitt. This is an important point, and I want
to clarify it. On a day-to-day basis, in an emergency room,
there are many people who are there for what essentially could
be a clinic, not necessarily an emergency. In such a setting,
they would be asked to take their health-care problem or defer
it for another time, and that capacity would be used for the
surge. Virtually any emergency room would have somewhere
between 30 to 50 percent of its capacity used in that way.
So when we say that they are overflowing, they are not
overflowing necessarily with people who are in life-and-death
situations. Surge capacity would clear those out in the kind of
emergency we are talking about to be treated in another way or
on a different day.
Chairman Waxman. The gentleman's time has expired.
Mr. Sarbanes.
Mr. Sarbanes. Thank you, Mr. Chairman.
On that last point, we had testimony on Monday that
suggested that a relatively small percentage of the ED volume
is from non-urgent kinds of care. So I think that is a red
herring. We are really talking about people coming into
emergency rooms that need emergency care.
We had a number of hearings on the effect of these Medicaid
regulations. Going back last year, in June, we were told by a
panel of experts that the emergency rooms are at the breaking
point and the ability of emergency department personnel to
respond to a public health disaster is in severe peril.
In November, the American College of Emergency Physicians
said that if the regulations we are discussing today went into
effect, ``The Nation's public hospitals and emergency
departments will sustain a devastating fiscal blow from which
recovery may be impossible.''
And the National Association of Public hospitals--and, by
the way, public hospitals are the ones really getting hit
between the eyes. We had a description of a nonprofit hospital
engaged in some purchases, which I am not sure I would
necessarily defend myself, but let's not get off on that
tangent. We are talking about the impact largely on public
hospitals, which are the ones that would suffer the most from
implementation of this regulation. The Association of Public
Hospitals said, ``These regulations have the potential to
devastate essential safety-net hospitals and health systems in
many parts of the country.''
So what is it that these experts understand that the two of
you don't understand about the impact these regulations are
going to have?
Secretary Leavitt. Mr. Sarbanes, let me describe for you,
as a former Governor, what is happening with respect to public
hospitals and where I believe we ought to be turning to remedy
this.
It is not unusual at all, in our public hospital setting,
we agree to pay public hospitals an increment more than what we
do normal hospitals. Many States are taking that increment more
and essentially taking it off the table, putting it into their
general revenues, and then using that increment more to pay the
match that they are supposed to be paying for Medicaid.
This is essentially a dispute between partners. We are
saying to the States, we want you to put up real dollars, not
our dollars recycled, so that you don't have to put up as much
money.
Mr. Sarbanes. Let me take that line of thinking and move it
slightly in a different direction.
First of all, I want to challenge a premise that I thought
I heard in your testimony, that perhaps hospitals are not at
the center of any kind of disaster response. And you talk about
these other things, convention centers being set up on a short-
term basis or schools or so forth.
But you both agree that when there is an emergency or a
disaster, hospital emergency rooms are where people go, are
they not?
I mean, I represented hospitals for 16 years. Any kind of
disaster or occurrence in the community that created pressure,
the first place they come, the first place they come, because
they can't think of any other place to go, is to the emergency
room. True?
Secretary Leavitt. Mr. Sarbanes, there is no hospital in
America that can keep enough spare capacity warm all the time
just in case we have a major catastrophic event.
Mr. Sarbanes. Let me ask you this question.
Secretary Leavitt. You can develop a scenario that will
blow the doors off any emergency room in America----
Mr. Sarbanes. The doors are already blown off. This is the
thing. There is this notion that we are waiting for these surge
situations. But as a practical matter, we have a surge already.
When you look at the boarding that is going on, the diversions
that are going on, the fact that the beds in the hospitals for
inpatient admissions are completely full, we are talking about
a surge happening right now.
Now, let me ask you this question: If a hospital is
underfunded, understaffed and underequipped in its main
operations and main functions, is it better or less prepared
for a surge, in your view?
Secretary Leavitt. This question ought to be directed to
those who administer and invest in the hospital. Most of the
hospitals----
Mr. Sarbanes. I am just asking your personal opinion. If a
hospital in its core function is underfunded, underequipped and
understaffed, is it better or less prepared for an emergency in
a surge?
Secretary Leavitt. Obviously they are less prepared.
Mr. Sarbanes. They are less prepared. Well, that is the
situation many of the hospitals are in.
So this fascinating but, I think, largely false distinction
between funding that is going just for a surge as opposed to
funding that is going to what Medicaid core functions should
be, this is a red herring, at best.
And we have to strengthen the underlying core function and
structure and infrastructure of our public hospital system and
other parts of our health-care system if we are going to be
able to respond to this surge.
Thank you.
Chairman Waxman. And we shouldn't be cutting money out of
it if they are already not prepared to deal with the problems.
Mr. Issa, you are recognized.
Mr. Issa. Well, thank you, Mr. Chairman.
And I certainly think that it has been good to wait a
little while to go today, because I think Mr. Sali's questions,
although they seemed to start on a tangent, finished pretty
cogently.
Secretary Chertoff, the link that you did agree exists
between our inability to either stop illegal immigration or the
absence of their having an alternate insurance plan that would
put them into the normal front-door of hospital and urgent care
and other places rather than emergency rooms and trauma centers
is a significant part of the overcrowding and the underfunding
today.
From your side, Homeland Security, you seem to very much
agree that is part of the problem you face when looking at
surge capacity today, is can you get those centers freed up in
time of emergency.
So my question to you is, do you feel comfortable that even
though a nonscientific, partisan telephone survey found that,
lo and behold, these seven trauma centers were overcrowded on a
given day, or emergency rooms, that those would be reasonably
free-upable for the kind of catastrophic emergencies we might
have in the case of a dirty bomb or some other terrorist
attack?
Secretary Chertoff. Well, I agree with Secretary Leavitt.
My understanding--of course, the expertise really resides with
his Department, but it certainly makes sense to me. My
understanding is that, in a true emergency, people who are in
the emergency room using it for primary care or for something
less than an emergency would be asked to leave, and many of
them would.
I also agree with Secretary Levitt there is probably some
point at which no emergency center, no matter how well-funded,
is going to be able to handle what would be a truly mass event.
And that is why we have these backup systems in place.
There is no question that a catastrophic event is going to
be bad. It is not going to be pleasant. But I think that we
would expect the emergency room to clear out all but the
priority cases in order to handle them.
Mr. Issa. I certainly agree. And certainly there are
doctors who have been serving in capacities other than urgent
care whose experience in surgery and other areas would quickly
be brought in post-triage to do it.
Governor Leavitt, you know, the title of this hearing today
I think is significant, because it starts off and it says,
``The Lack of Hospital Emergency Surge Capacity: Will the
Administration Medicare Regulations Make It Worse?''
Yesterday, or the day before yesterday, I asked the panel--
who all felt that overcrowding was a problem and so on but
differed on whether they could handle emergencies. Virginia
said, ``We did handle emergencies. We believe we are well-
organized, even here in the District,'' while other areas did
not.
One of the interesting things was, I said, ``Here is a
billion dollars. How would you spend it? Would you spend it on
training and preparation for an emergency, or how else would
you spend it?'' To a person, the panel said, ``I would spend it
on day-to-day, routine costs. I would simply absorb a billion
dollars.''
Governor, certainly you have the background to understand
that $1 billion is a lot of money. But the cost of injuries in
America today is estimated to be $300 billion in medical costs.
A billion, $2 billion, $3 billion, if it is not used for
preparation training, emergency facilities and planning, even
$3 billion or $4 billion added into the system, will it in fact
increase surge capacity if it is simply spent on a daily basis?
Secretary Leavitt. Our significant concern with moneys that
we give to States is that they are focused on increasing surge
capacity. We have put nearly $7 billion, through different
departments other than Medicaid, into emergency preparedness
and specifically into surge capacity. And I believe that if we
were just to send Medicaid money, it would be absorbed into the
hospital overhead.
Mr. Issa. And, Governor, following up, because the time is
limited, essentially aren't we dealing exactly with that here
today? That if, in fact, we don't carefully make sure that
these funds do not get diverted and do not cover up for
problems, including illegal immigration, to quote the other
Member, but all kinds of problems of the underinsured, aren't
we, by definition, making ourselves less capable if we don't
take action to ensure that it goes into planning and training
and preparation, rather than absorbing what clearly appears to
be an everyday problem in America that was neither created by
September 11th nor would be rectified by a few billion more
dollars here or there?
Secretary Leavitt. Every community needs a plan, every
community needs to train, every community needs to exercise.
And that is what much of our money goes to, and should.
Mr. Issa. Governor, my time is short, but you did deal with
the problems of illegal immigration. You dealt with the problem
of your emergency rooms and the impact of the underinsured.
Isn't that a separate issue that we should concentrate on
finding solutions for but not mix it with today's hearing on
surge capacity directly related to 9/11-type events?
Secretary Leavitt. We have dealt with three specific and
different issues today: surge capacity, the effect of illegal
immigration, and Medicaid regulations. All three are separate.
All three are important issues.
Mr. Issa. Thank you.
Thank you, Mr. Chairman.
Chairman Waxman. Secretary Leavitt, could you furnish for
the record how that $7 billion you claimed is going to help the
hospitals?
Secretary Leavitt. What I said, Mr. Chairman, was we have
spent nearly $7 billion on local and emergency preparedness,
including surge capacity in hospitals. And, certainly, we can
provide how that has been spent.
Chairman Waxman. And how much of that has been surge
capacity?
Secretary Leavitt. That is not a figure I have.
Chairman Waxman. If you could give it to us for the record,
we would appreciate it.
We now have Mr. Murphy.
Mr. Murphy. Thank you very much, Mr. Chairman.
Welcome, Secretary Leavitt and Secretary Chertoff.
For the last 4 years, before I came to Congress, I was the
chairman of Connecticut's Public Health Committee in our
legislature charged with this very issue, making sure that we
had appropriate surge capacity and everyday capacity in our
hospitals.
And, Mr. Leavitt, I was reading through your testimony, and
it is dazzling, at some level, the amount of bureaucracy and
commissions that we have created around this issue: ACD, NVSB,
ECCC, ASPR, NRF. And I am sure these are worthy commissions; I
am sure they are looking at important questions. But as
somebody who is doing this on the ground floor, this is all new
to me.
As a State policymaker, we knew that Medicaid was not just
about supporting people, it was about supporting institutions
as well. They are one and the same. You can't help people
unless you have institutions that are there and willing to do
the work. So the distinction, I guess, is a little bit
troubling to me.
But we also didn't know too much about these grants that
were coming to us, because we really knew that in order to keep
these hospitals up and running, in order to keep capacity
working, we needed Medicaid. We couldn't do it with grants
alone.
Mr. Leavitt and Mr. Chertoff, if the staff has it ready, I
would like to just draw your attention to a chart. And this, I
think, gets at Chairman Waxman's question about the amount of
money that is going to hospital preparedness grants. This is, I
think, a fair representation of, over the last several years,
the amount of money that has been going into hospital
preparedness grants, starting at $498 million in 2003, dropping
now to a proposed $362 million in the proposed budget for the
coming fiscal year--a pretty sharp decrease. And $362 million
over 50 States spreads pretty thin.
The real rub here is when you compare it to the Medicaid
cuts, if we can put that chart up now. Now, this is the grant
money that States are getting, $362 million proposed in the
next year, compared to the impact of the Medicaid cuts.
Now, this is the State Medicaid director's estimates. If
you take the CBO estimates, you are still talking about five
times the amount of Medicaid cuts as you are talking in grant
money to hospitals. And I think every State appreciates that
grant money, but it is a drop in the bucket compared to what
hospitals are going to face with regard to these Medicaid cuts.
I guess I ask this to you, Secretary Leavitt. Do you have
concerns that these grants, dwindling year by year, are going
to be dwarfed by the size of these cuts? And though those cuts
are going to obviously see their way through the entirety of a
hospital's operation, no doubt much of it is going to end up in
the emergency room.
Do you have a concern that these cuts, these Medicaid
cuts--you say they are to support individuals; they inevitably
have to support institutions in order to support the
individuals--are going to dwarf those grants?
Secretary Leavitt. Mr. Murphy, the distinction on
institutions and people is not one that we have arbitrarily
made. It is in the statute.
Over time, States have inappropriately claimed Medicaid
dollars in a number of categories, which had the direct
impact--I know you know this as a State legislator--of crowding
out all of the other activities, including the development of
public health and emergency systems.
Medicaid was not designed, nor is it intended, to support
institutions. Money should be directed to people. We support
people. We support poor people, pregnant mothers and the
disabled. This is not intended to be a hospital entitlement.
Now, I understand that they have come to rely on it, in
some cases. That is precisely the reason that we are pushing
back to the fee-based consultants who are driving this on the
basis of their getting a piece of the action to push Medicaid
into every area of State government. It is not just emergency
preparedness. It is in schools. It is in child welfare. It is
in all the places that the States are not adequately funding,
they are trying to get a garden hose into the Medicaid fund.
Mr. Murphy. But we are not talking about those places
today. We are talking about institutions that are indisputably
linked to health care, which are hospitals.
And the fact is you say it is about supporting individuals,
but the money doesn't go to individuals. It goes to
institutions. It goes to doctors. It goes to hospitals. It goes
to outpatient clinics. Because we know we need those places up
and running.
So let me just shift to a related question, and this is
building off of Mr. Sarbanes's questions.
You talk about the fact that ultimately this isn't going to
happen in emergency rooms. If something enormous happens, you
are going to have to build something outside of the emergency
room. But doesn't that capacity, whether it exists in the
physical confines of the emergency room or not, rely on the
assets that exist right now in those emergency rooms?
If we are gutting the capacity of hospital emergency
delivery systems, in terms of equipment, in terms of personnel,
in terms of expertise, it seems to me, Mr. Leavitt and Mr.
Chertoff, that this directly impacts your ability to then move
that capacity offsite, even if it isn't onsite at the hospital
grounds.
Secretary Leavitt. Again, this is a very important point,
Mr. Murphy. We are bringing capacity in. In the first 24 hours
of an emergency, we are dependent upon local assets. And that
is where you clear out the emergency room, you take anyone who
is nonessential out of the hospital. You make capacity.
Within 24 hours, we have the NDMS system there. We have as
many as 6,000 beds we can bring from all over the country. We
then go to another phase where we start taking patients into
capacity. At any given moment, we know how many hospital beds
are available in the area.
We are not dependent upon the hospital facilities, except
for that 24-hour period. And that is why we exercise and train
for all of the other aspects on surge capacity.
Mr. Murphy. And I appreciate that. I know enough about how
these things work to know that they still do draw upon local
resources, they still do draw upon other hospitals, upon other
capacity in the system. And, as Mr. Sarbanes and others have
suggested here today, we have maxed out both the emergency and
nonemergency capacity of our health-care systems to the point
that extra capacity, even in the 48 and 72-hour window, simply
doesn't exist.
Now, you can fly it from in from all over the country, but
I think this problem exists across the board. Our medical
technicians, our emergency medical personnel, are working 24/7
just to handle existing capacity right now, never mind being
able to move over to an emergency when it does happen.
My time has expired, Mr. Chairman.
Chairman Waxman. Thank you, Mr. Murphy.
Mr. Duncan.
Mr. Duncan. Thank you, Mr. Chairman.
Secretary Leavitt, I have to be very quick because they
have a vote going on. But a few days ago, we were given figures
that, in the 10 years leading up to 2006, Medicaid payments to
Tennessee hospitals went up from $245 million to $607 million.
I am sure that you have no idea of what those exact figures
are, but do you think that every State has received similar-
type increases, more than doubling over the last 10 years?
Secretary Leavitt. Well, States have clearly seen dramatic
increases. We have seen a dramatic increase in the overall
program. Tennessee may have been somewhat unique because of
TennCare.
Mr. Duncan. And would it be fair, then, to say that, in
those 10 years, inflation has averaged around 3 percent a year,
so those payments to hospitals have gone up several times above
the rate of inflation? Do you think that is fair?
Secretary Leavitt. Medicaid is growing at two to three
times inflation.
Mr. Duncan. Two to three times the rate of inflation. So
payments to the hospitals have gone way up over the past 10
years?
Secretary Leavitt. The Medicaid money going to hospitals
has dramatically increased over the past decade.
Mr. Duncan. All right. Thank you very much.
Chairman Waxman. Mr. Tierney.
Mr. Tierney. Thank you, Mr. Chairman.
Thank you, gentlemen, for being here today.
Secretary Chertoff, I want to ask you a little bit about
your role or your involvement in these Medicaid rules that were
issued. In your testimony, you said that, ``Medical surge
capacity is a critical element of our local, State and national
resiliency.''
But I don't see any evidence, I don't think we have been
able to find any evidence of your Department expressing any
concern about these Medicaid rules to anybody, and particularly
with respect to the impact they might have on emergency rooms
or the ability to respond to an attack or a natural disaster.
Did you consult with Secretary Leavitt about these rules
before they were issued?
Secretary Chertoff. No, because I don't think that these
Medicaid rules are particularly closely connected to the
question of whether there is surge capacity necessary to meet
an emergency.
Mr. Tierney. So you were aware of them but just chose not
to get involved, or you weren't even aware that they were being
considered?
Secretary Chertoff. I don't think I was particularly aware
of it, nor would I have expected to be made aware of it.
Mr. Tierney. The staff interviewed Dr. Runge from your
staff, your Chief Medical Officer. It is his role, apparently,
to coordinate between the Department of Health and Human
Services, to make sure that hospitals and the medical system
are prepared for a disaster or for an incident.
They asked Dr. Runge if he had reviewed or commented on the
regulations, and he also said he had no communications with
anyone at HHS about it. And he said that there was no
discussion within the Department of Homeland Security about the
rules.
That is pretty consistent with your testimony, as well, on
that?
Secretary Chertoff. It is.
Mr. Tierney. If he supposed to be the point person for
medical preparedness, I just don't understand how he completely
ignores rules which are certainly going to have some impact? Or
is it your position they are absolutely going to have no impact
at all on emergency rooms?
Secretary Chertoff. Here is where I think we are having
some disagreement. Everything has impact on everything. So, in
some sense, the economic health of the country has an impact on
homeland security. But if I used that logic, I would be
involved also in the subprime mortgage crisis, because that
affects State budgets; I would be involved in gas tax and
gasoline prices, because that has an impact. Even for a
Department which has sometimes been accused of having too broad
mandate, that goes several bridges too far.
Our focus, with respect to working with HHS, is to assure
that there is a planning effort under way, that we are
identifying gaps, and that we are coming up with specific
measures that will plug the gaps.
And I have to say I agree with Secretary Leavitt; I don't
think that Medicaid funding and reimbursement rules have
anything more than a very indirect connection with this issue.
And if I took the position that every indirect impact on
homeland security made it my business, we would become the
Office of Management and Budget instead of the Department of
Homeland Security.
Mr. Tierney. I do think there is a disconnect between what
we are talking about here. I have a difficult time thinking
that you don't see a more direct relationship between the
status of our hospitals' capacity and emergency rooms' capacity
to deal with these things than a mortgage. That is a bit of a
difference there between the two, and I would hope you would
get that distinction.
Secretary Chertoff. No, I don't say that I don't think
emergency care and the health-care system isn't more connected.
I think that Medicaid reimbursement, which is not specifically
targeted to putting money away for emergencies, is, I think,
several degrees of separation from the kinds of much more
specific issues that we are focused on, in terms of getting
ready for emergencies.
Mr. Tierney. But I find it interesting that your Department
didn't even look at the prospect that reducing Medicaid funding
might have an impact on hospitals' overall operations,
including the impact on emergency rooms and capacity in case of
a surge incident. I would think that is the type of thing that
you are assigned to do and Dr. Runge is assigned to do, to at
least raise the issue and think about it and move on from
there.
The staff asked Dr. Runge how he justified this lack of
communication with HHS about the rule. What he said was, ``We
are focused on threats that can kill hundreds of thousands, not
hundreds.'' A little insensitive, I would think, to----
Secretary Chertoff. Well, I wasn't there for the interview;
I can't read his mind. But I think what he was trying to draw a
distinction between is the very real issue of day-to-day
capability of the medical system to deal with day-to-day kinds
of issues, which is a perfectly important and significant
matter but not one that falls within the purview of my
Department, as compared to dealing with the issues that do rise
to the level or do specifically involve homeland security, like
a pandemic flu or a major catastrophe, where we do focus on the
issue of surge.
But our main focus is on those matters that have a direct
relationship. Are we stockpiling enough? Do we have a plan? Do
we have a delivery mechanism? Do the localities have a plan?
And there we do interface with HHS, not only Dr. Runge, but I
personally talk to Secretary Leavitt about these issues. But
much more tightly related to the specific need to have an
emergency preparedness capability than Medicaid funding, which
has to do with the overall economic health of the medical
system, which is, frankly, a much broader issue than my
Department's focus.
Mr. Tierney. Well, I guess it could be seen that way, but
it could be narrowed down to when there is a serious, severe
cut in financing, it will affect the operations of a hospital,
including those that you are directly concerned with. I would
like to think your Department gets involved at that capacity.
That is not indirect; that is pretty direct.
My time is up, and I yield back. Thank you.
Chairman Waxman. The gentleman's time has expired.
Ms. Norton.
Ms. Norton. Thank you, Mr. Chairman.
I want to thank both these witnesses for being here.
I am particularly grateful for this hearing, because I am
afraid I am more deeply implicated than some because of my
representation of the District of Columbia. I have worked
closely, of course, in my work on the Homeland Security
Committee with Secretary Chertoff.
Secretary Leavitt, I worked with your predecessor on
something called ER-1. I am particularly concerned about this
place, not only because I represent 600,000 people here, but
because all of official Washington is here, 200,000 Federal
workers, and because this is a prime target for terrorism.
This discussion about trying to separate out Medicaid from
other money is important because we want money used for what it
is intended. But you certainly can't treat a hospital as if it
were not an organism with core functions that treat private and
poor patients alike, as if you could collapse the part that
treats Medicaid patients. And I think that is what some of us
have been trying to get at.
I want to ask you about the hospitals here. We have three
trauma centers here. Two of them were surveyed in this survey,
and they were extensively above capacity. No available
treatment spaces in the hospital. Only six had intensive care
unit beds. One could not participate in the survey because it
was so overcrowded that it had to stop taking, accepting new
patients at all.
My good friends on the other side of this dais cite the
Washington Hospital Center emergency room as a model for the
country. It is a very good emergency room. That is what I
worked with on so-called ER-1. I will get to that in a minute.
But since they cite the Washington Hospital Center, I went
to the head of the emergency room, Dr. Mark Smith, and Dr.
Smith confirmed the findings of the survey and, in addition,
said he had twice as many patients as he did treatment spaces.
They are putting them in the corridors and administrative
offices. They are putting them in waiting rooms. And he said he
had a major problem with preparedness.
Now, I understand triage. I also hope we are not ever in
the position of what I would believe would be chaotic triage,
if everybody surged in one place. For that reason, here in the
Nation's Capital, I have been working with the administration--
actually we have almost gotten it through several times--on at
least one hospital that would have surge capacity, so that
everybody would know in advance, don't put all these Federal
workers close to the nearest hospital. This is the one that is
prepared. It has huge capacity--it would have a huge capacity.
A lot of private money would go into this, some Federal money.
Now, my question is this: If you cut billions of dollars of
what amounts to safety-net funding from hospitals, you are also
including these trauma centers here in the Nation's Capital.
Can you assure this committee that, even with such very severe
Medicaid cuts, the hospitals in the Nation's Capital are
prepared for a mass event here and to accept patients in the
event of a mass event here?
I would further ask Secretary Leavitt if he supports ER-1.
First, I want to know, are you saying to this committee, in
the face of a survey that you are aware of, that in the event
of a major or mass event here, that the hospitals, even with
the cuts that are on the table, could, in fact, manage that
event?
Secretary Leavitt. Ms. Norton, I will tell you that the
Washington, DC, area engages in regular planning exercises I
think as well as any place in the country. I want to restate:
Am I saying that surge capacity is acceptable everywhere in the
country? No.
Ms. Norton. I am not asking about that. I am asking about
the place where Members of Congress, the President of the
United States, where members of the Cabinet, where 600,000
residents are here, where 200,000 workers are here, three
traumas centers--I am being very specific. I am not focusing on
elsewhere. I am focusing on target No. 1.
Can you say you are prepared?
Secretary Leavitt. I am not the person to answer that. The
person in my Department would be Rear Admiral Vanderwagen, who
was not invited to the hearing today. And I am sure he would be
happy to meet with you and give you his reaction to the
preparedness.
Ms. Norton. I have to indicate that, as the Secretary, I
would think you would know whether or not the Nation's Capital
is prepared for a mass event.
Secretary Leavitt. I live here, just like you do, and I am
anxious for that to be the case.
Ms. Norton. And that troubles me, both as a member of the
Homeland Security Committee and as a member of this committee,
that you cannot answer that question.
Do you support ER-1 surge capacity?
Secretary Leavitt. Is the project at George Washington?
Ms. Norton. It is the project at Washington Medical Center.
Secretary Leavitt. I am aware of the project by title. I do
not know enough about it to respond at this hearing. If you
would like, I would be pleased to respond in writing.
Ms. Norton. I very much appreciate it.
And thank you, Mr. Chairman.
Chairman Waxman. Thank you, Ms. Norton.
Mr. Cummings.
Mr. Cummings. Thank you very much, Mr. Chairman.
Secretary Leavitt, perhaps the thing that most confuses me
about your actions is why you did not consider the impact of
your Medicaid regulations on emergency preparedness.
Last June, the committee had a hearing on the state of
emergency medical care in the United States. At the hearing,
concerns were raised about the effect of the Medicaid
regulations on hospital emergency rooms. As a result, the
committee wrote to the Centers for Medicare and Medicaid
Services to ask whether CMS, which issued the rules, had
consulted with the Assistant Secretary for Preparedness, who is
the official in your Department in charge of emergency
response.
Astonishingly and unbelievably, CMS responded that it,
``did not specifically request input from the Office of the
Assistant Secretary for Preparedness because that office is not
likely to have expertise in Medicaid financing.''
The committee wrote you again in November. In this letter
the committee specifically requested, ``all documents relating
to the potential impact of the Medicaid regulations on
emergency care and trama services.'' In February, the
Department responded to the committee's request. I want to read
to you from this letter. And it says, ``The Department has not
found responsive documents.''
According to this letter, your staff searched for
responsive documents in five different parts of the Department:
the Office of the Secretary, the Office of the Assistant
Secretary for Preparedness, the Health Resources and Services
Administration, the Centers for Disease Control, and CMS. Yet
not one of those offices had done any analysis of the impact of
the regulations on emergency care.
Secretary Leavitt, how can you possibly explain this?
Hospitals across the Nation are telling us that your
regulations will devastate their emergency rooms, yet you did
not even consider this issue, according to what I just read.
Secretary Leavitt. The rule change we are proposing is not
about surge capacity or hospital health. It is about States who
have been claiming inappropriately funds that they are using to
recirculate to pay their fair share with Federal funds.
Medicaid is not a program to support hospitals. Medicaid is
a program to support people who are poor, people who are
pregnant and people who are disabled. It was not intended nor
is its purpose, nor should it be managed, to be the source of
funds for surge capacity.
Mr. Cummings. Let me just go a little bit further. You were
specifically asked to consider the impacts of your rules on
trauma centers and emergency rooms. Over a year ago, Chairman
Waxman and over 150 other Members of Congress wrote to you to
urge you to consider these issues.
Let me read to you from our letter: ``We are writing to
request that you withdraw the proposed rule. The proposal would
threaten the capacity of safety-net hospitals to deliver
critical but unprofitable services, such as trauma centers,
burn units and emergency departments.''
Yet, still, you prepared no analysis. This appears to be a
case of willful blindness. Perhaps it would be better stated if
I said it appears to be ``eyes wide shut.'' It seems that you
are deliberately ignoring the impacts that your rules will have
on emergency care and preparedness in our Nation. That is
irresponsible, and, to be frank with you, it is quite
dangerous.
Secretary Leavitt, the preamble to the proposed Medicaid
regulations read, ``With respect to clinical care, we
anticipate this rule's effect on actual patient services to be
minimal. While States may need to change reimbursement or
financing methods, we do not anticipate that the services
delivered by governmentally operated providers or private
providers will change.''
In response to these regulations, your Department received
over 400 written comments, all of which expressed opposition to
the rule or to portions of the rule. And I would like to read
just a sample of one of those. It is from the Society of
Academic Emergency Medicine.
And it says, ``This proposal will jeopardize the viability
of public and other safety-net hospitals. It will also
jeopardize the viability of our emergency medicine teaching
programs, which has long-reaching downstream effects on the
quality of emergency care in this country. We believe that
Medicaid cuts of this magnitude projected under this proposed
rule will adversely affect access and the viability of our
Nation's safety-net providers.''
So I am just wondering, do you have a comment on that?
Secretary Leavitt. Yes, I do. This rule is about States not
paying their fair share, and it is a dispute between partners.
We are mutually committed. If States will step up and do their
share, we will ours. But this is about paying for people, not
for institutions.
We are following the law. We are trying to push back where
people or States and other programs within State governments
are trying to make up for deficiencies that have occurred in
State governments by tapping Medicaid funds. And someone needs
to do it, because the Medicaid program is unsustainable in its
current course; I made the point earlier.
Many of the programs in States are being crowded out by
Medicaid. And it is being crowded out because we continue to
use it for virtually every aspect of State government. Anyone
in State government who thinks they can find some connection to
Medicaid is attempting it. And we have to do this in a way to
keep the integrity of the fund, so that we know we are paying
for health care for people, not for institutions, and we are
not making up for States who aren't doing their share.
Mr. Cummings. I see my time is up.
Chairman Waxman. Secretary Leavitt, with all due respect, I
think you are ignoring reality. You are saying that you want to
cut back on a system that is getting Federal dollars
inappropriately, and they should make up the money at the State
and local level. They are not going to be able to make up that
money in a recession. The income is not coming into the States.
And you never asked your partners, the States, what the
impact would be to make these kinds of withdrawals of the
Federal share of the Medicaid funds that go to the
institutions, especially public hospitals that are funded
exclusive by the taxpayers. At the minimum, I would have
thought that you would have wanted to ask the question of what
the impact would be, so you would know.
You insist that is not going to have this kind of impact.
Yet, when you put our rules, the Society for Academic Emergency
Medicine said, ``This proposal will jeopardize the viability of
public and other safety-net hospitals. It will jeopardize the
viability of our emergency medicine teaching programs.''
Parkland Hospital in Texas said they received Medicaid
payments of $90 million annually and that, without this
funding, Parkland may be forced to drastically scale back their
services in the Trauma I center, the level Trauma I center.
You have all these others--the president of the University
of California, the University of California academic medical
centers. You have all these comments. And we looked at the
rulemaking record; the fact is you ignored these comments. You
didn't adjust the policy in response to these comments in the
final rule, and you did prepare an analysis to the effect of
the Medicaid regulations would be minimal impact on care being
provided by the States.
How can that be? Isn't that irresponsible?
Secretary Leavitt. Mr. Chairman, it is responsible for me
to follow the law and assure that the States are doing their
job. Otherwise, we are not being a wise steward of limited
Medicaid funds.
This is a dispute between partners, between the Federal
Government and the States. And the Federal Government is
saying, you can't take money we have given you extra for these
hospitals, put them back into your general fund, and then use
them to pay your share. Just give us real money, give us value,
give us--for real patients.
This is not about surge capacity. It is about a
relationship between the States and the national Government----
Chairman Waxman. The consequences will be the institutions
that provide the safety net to the very poor in our society
will not be able to continue to function and provide those
services.
It just seems to me you are judging your actions on an
ideology without having established the record. You didn't come
to Congress and ask for those changes. You are trying to put
them into effect on your own.
Fifty Governors have asked us to at least put a halt on
this so they can be studied, which they should have been
studied before they were put into place. An overwhelming
majority of the House of Representatives has put a hold on
these regs until we can look at them further.
I think that you ought to withdraw these regulations and
let's see what the impact will be. Let's know that we are not
doing any harm to the ability for hospitals around the country
to deal with the problems that they may face, not just day to
day, but in a terrorist attack.
Secretary Leavitt. It is not surprising to me that you can
unite 50 Governors around the proposition that the Federal
Government should pay their share. And that is essentially what
this amounts to.
Many States have improperly used money that has come from
the Federal Government for the purpose of supporting the
hospitals we are talking about, have taken it off the table,
and then used it to pay their share.
This is about States not paying their fair share. And I
would think we would all be united in saying, if we are going
to have a partnership, then everyone out to pay real dollars
for real value for real patients.
Chairman Waxman. Did you consult with Secretary Chertoff to
tell him that there may be some impact around the country on
the ability to deal with a terrorist attack?
Secretary Leavitt. This is a dispute between the Federal
Government and the States on Medicaid financing.
Chairman Waxman. You didn't inform Secretary Chertoff of
that?
Secretary Leavitt. We regularly consult on the larger
strategic issues related to our joint mission. This is not one
of them.
Chairman Waxman. Did you do an evaluation to know what the
impact would be on these hospitals if these regs went into
place?
Secretary Leavitt. Medicaid is not intended to support
institutions. It is intended to support people.
Chairman Waxman. But it does support these institutions,
because people without insurance go to these hospitals. People
who are injured go to these hospitals. If you withdraw the
money from the hospitals because you have a theory that the
States ought to come up with more money, it means, as we were
told by Dr. Roger Lewis, who is an emergency room physician at
UCLA, a nationally recognized expert in hospital emergency
preparedness, he said, ``Those of us who work on the front
lines of the medical care system believe it is irrational that
an emergency care system that is already overwhelmed by the
day-to-day volume of acutely ill patients would be able to
expand its capacity on short notice in response to a terrorist
attack.'' He said, ``If a bomb went off in Los Angeles and
injured hundreds or thousands, LA would not have the emergency
room capacity to care for the wounded.''
In your statement to the Congress, you emphasize the
support the Federal Government is giving States and localities
to improve this emergency preparedness. And we asked Dr. Lewis,
and he said they were getting $433,000 in a preparedness grant,
and he was very grateful for it, but the cost of these Medicaid
changes would mean they would go without $50 million. He said
that is 100 times more than the Medicaid cuts they would get on
these preparedness grants, and they are going to be in very,
very sad shape.
Do you take what he had to say seriously? Do you think he
is just fronting for the States because they want to rejigger
their money around?
Secretary Leavitt. Mr. Chairman, over the course of the
last 3 years, I have been in virtually every State and met with
the emergency community, and the record is replete with my
statements of concern about surge capacity. It is not at the
level we want it to be. We have many areas in which we can
improve. But Medicaid is not the source of funds to do that.
If the Congress of the United States views that there is a
need for more dollars, we have ways in which we can funnel
directly to the hospital funds that are necessary to improve
their surge capacity.
Medicaid was intended to be for people, not for
institutions. And every institution I know would like to drag a
garden hose over into the Medicaid fund and be able to tap it,
because their fund isn't what they would like it to be.
We need to be disciplined. We need to ensure that these
disputes are resolved between the States and the Federal
Government so that we have a true partnership, not just one
that relies entirely on the Federal Government.
Chairman Waxman. Well, I must say, with all due respect,
your actions make absolutely no sense. The tiny grants you are
giving to hospitals can't possibly offset the impact of cutting
billions of dollars from those programs.
I must say, as we conclude this hearing, I find it very
discouraging. We know the Nation's emergency rooms are already
at the breaking point. We know a terrorist bombing is a
predictable surprise. We know that local emergency room
capacity is critical to saving lives in that golden hour
following an attack. We know that public and teaching hospitals
operate many of our Nation's most critical emergency rooms and
trauma centers.
We know that the Medicaid regulations will reduce funding
to these institutions by hundreds of millions of dollars each
year. We know that these cuts will further undermine the
ability of these hospitals to respond to a terrorist bombing.
We know that these regulations will go into effect in 3 short
weeks.
And yet the Secretaries that are in the position to avoid
this harm will not take any action. I think it is regrettable.
I must say, this is not just a disagreement. I think it is
a substantial breach in what I think is our mutual
responsibility to make sure that we can deal with a homeland
security attack, which could amount to a tragedy.
I thank you both for being here. We hear the bells; there
is a vote on the House floor.
I do want to ask unanimous consent that the record be held
open for Members to ask further questions and get responses in
writing.
We stand adjourned.
[Whereupon, at 11:15 a.m., the committee was adjourned.]
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