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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

(II)

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

HENRY A. WAXMAN, California, Chairman

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

JOHN A. YARMUTH, Kentucky

BRUCE L. BRALEY, Iowa

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

JIM COOPER, Tennessee

CHRIS VAN HOLLEN, Maryland

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

JOHN P. SARBANES, Maryland

PETER WELCH, Vermont

——— ———

TOM DAVIS, Virginia

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

VIRGINIA FOXX, North Carolina

BRIAN P. BILBRAY, California

BILL SALI, Idaho

JIM JORDAN, Ohio

PHIL SCHILIRO, Chief of Staff

PHIL BARNETT, Staff Director

EARLEY GREEN, Chief Clerk

LAWRENCE HALLORAN, Minority Staff Director

(III)

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 ConwayWelch, 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, HarborUCLA 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

(1)

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

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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

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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

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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.

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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 reVerDate 11-MAY-2000 12:18 Jan 14, 2009 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 C:\DOCS\45290.TXT KATIE PsN: KATIE
18

search 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.

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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.

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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 antipersonnel 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

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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

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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 $41⁄2 million of infrastructure to keep the

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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.

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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.

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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

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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 sysVerDate 11-MAY-2000 12:18 Jan 14, 2009 Jkt 000000 PO 00000 Frm 00084 Fmt 6633 Sfmt 6633 C:\DOCS\45290.TXT KATIE PsN: KATIE
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tem 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.

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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.

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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

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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 inpatient 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

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hospital will simply clear out all patients who don’t have lifethreatening 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.

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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 communitybased 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.

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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 higherpaying 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?

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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

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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.

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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

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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

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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

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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

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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

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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.

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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?

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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.

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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

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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

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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.

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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

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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

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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.

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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.

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[Whereupon, at 12:30 p.m., the committee was adjourned.]

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(175)

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

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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.

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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 highquality 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

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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 reVerDate 11-MAY-2000 12:18 Jan 14, 2009 Jkt 000000 PO 00000 Frm 00209 Fmt 6601 Sfmt 6601 C:\DOCS\45290.TXT KATIE PsN: KATIE
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sources. 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?

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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.

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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

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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.

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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.

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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.

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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.

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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.’’

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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, MinVerDate 11-MAY-2000 12:18 Jan 14, 2009 Jkt 000000 PO 00000 Frm 00233 Fmt 6601 Sfmt 6601 C:\DOCS\45290.TXT KATIE PsN: KATIE
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nesota 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.

[The information referred to follows:]

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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.

[The information referred to follows:]

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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 nonurgent kinds of care. So I think that is a red herring. We are really

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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.

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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

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partment, 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 posttriage 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?

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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

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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

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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?

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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.

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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

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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 socalled 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

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ing 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

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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.’’

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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 longreaching 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.

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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?

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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.

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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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