September 11: Problems Remain in Planning for and Providing Health Screening and Monitoring Services for Responders
Published: 2007-09-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Six years after the attack on the World Trade Center (WTC), concerns persist about health effects experienced by WTC responders and the availability of health care services for those affected. Several federally funded programs provide screening, monitoring, or treatment services to responders. GAO has previously reported on the progress made and implementation problems faced by these WTC health programs, as well as lessons learned from the WTC disaster. This testimony is based on previous GAO work, primarily September 11: HHS Needs to Ensure the Availability of Health Screening and Monitoring for All Responders ( GAO-07-892 , July 23, 2007). This testimony discusses (1) status of services provided by the Department of Health and Human Services' (HHS) WTC Federal Responder Screening Program, (2) efforts by the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health (NIOSH) to provide services for nonfederal responders residing outside the New York City (NYC) area, and (3) lessons learned from WTC health programs. For the July 2007 report, GAO reviewed program documents and interviewed HHS officials, grantees, and others. In August and September 2007, GAO updated selected information in preparing this testimony.
section_title: What GAO Found
paragraphs: In July 2007, following a reexamination of the status of the WTC health programs, GAO recommended that the Secretary of HHS take expeditious action to ensure that health screening and monitoring services are available to all people who responded to the WTC attack, regardless of who their employer was or where they reside. As of September 2007 the department has not responded to this recommendation. As GAO reported in July 2007, HHS's WTC Federal Responder Screening Program has had difficulties ensuring the uninterrupted availability of screening services for federal responders. From January 2007 to May 2007, the program stopped scheduling screening examinations because there was a change in the program's administration and certain interagency agreements were not established in time to keep the program fully operational. From April 2006 to March 2007, the program stopped scheduling and paying for specialty diagnostic services associated with screening. NIOSH, the administrator of the program, has been considering expanding the program to include monitoring--that is, follow-up physical and mental health examinations--but has not done so. If federal responders do not receive monitoring, health conditions that arise later may not be diagnosed and treated, and knowledge of the health effects of the WTC disaster may be incomplete. NIOSH has not ensured the availability of screening and monitoring services for nonfederal responders residing outside the NYC area, although it recently took steps toward expanding the availability of these services. In late 2002, NIOSH arranged for a network of occupational health clinics to provide screening services. This effort ended in July 2004, and until June 2005 NIOSH did not fund screening or monitoring services for nonfederal responders outside the NYC area. In June 2005, NIOSH funded the Mount Sinai School of Medicine Data and Coordination Center (DCC) to provide screening and monitoring services; however, DCC had difficulty establishing a nationwide network of providers and contracted with only 10 clinics in seven states. In 2006, NIOSH began to explore other options for providing these services, and in May 2007 it took steps toward expanding the provider network. However, as of September 2007 these efforts are incomplete. Lessons have been learned from the WTC health programs that could assist in the event of a future disaster. Lessons include the need to quickly identify and contact responders and others affected by a disaster, the value of a centrally coordinated approach for assessing individuals' health, and the importance of addressing both physical and mental health effects. Consideration of these lessons by federal agencies is important in planning for the response to future disasters.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work on the implementation  of federally funded health programs for individuals affected by the  September 11, 2001, attack on the World Trade Center (WTC), as well as  lessons learned from responses to that disaster. Tens of thousands of  people served as responders in the aftermath of the WTC disaster,  including New York City Fire Department (FDNY) personnel, federal  government personnel, and other government and private-sector workers  and volunteers from New York and elsewhere. By responders we are  referring to anyone involved in rescue, recovery, or cleanup activities at or  near the vicinity of the WTC or the Staten Island site. These responders  were exposed to numerous physical hazards, environmental toxins, and  psychological trauma. Six years after the destruction of the WTC  buildings, concerns remain about the physical and mental health effects of  the disaster, the long-term nature of some of these health effects, and the  availability of health care services for those affected.
Following the WTC attack, federal funding was provided to government  agencies and private organizations to establish programs for screening,  monitoring, or treating responders for illnesses and conditions related to  the WTC disaster; these programs are referred to in this testimony as the  WTC health programs. The Department of Health and Human Services  (HHS) funded the programs as separate efforts serving different categories  of responders—for example, firefighters, other workers and volunteers, or  federal responders—and has responsibility for coordinating program  efforts. Officials involved in the administration and implementation of the  WTC health programs have derived lessons from their experiences that  could improve the design of such programs in the future.
We have previously reported on the implementation of these programs and  their progress in providing services to responders, who reside in all 50  states and the District of Columbia. In 2005 and 2006, we reported that one  of the WTC health programs, HHS’s WTC Federal Responder Screening  Program, which was established to provide one-time screening  examinations for responders who were federal employees when they  responded to the WTC attack, had accomplished little. HHS established  the program in June 2003, suspended it in March 2004, and resumed it in  December 2005. In September 2006, we reported that the program was  registering and screening federal responders and that a total of 907 federal  workers had received screening examinations. We also reported that the  National Institute for Occupational Safety and Health (NIOSH), the  component of HHS’s Centers for Disease Control and Prevention (CDC)  responsible for administering most of the WTC health programs, had  begun to take steps to provide access to screening, monitoring, and  treatment services for nonfederal responders who resided outside the New  York City (NYC) metropolitan area.
In September 2006 we also testified that CDC had begun, but not  completed, the process of allocating funding from a $75 million  appropriation made in fiscal year 2006 for WTC health programs for  responders. This was the first appropriation specifically available for  treatment for responders. We reported that in August 2006 CDC had  awarded $1.5 million from this appropriation to the FDNY WTC Medical  Monitoring and Treatment Program and almost $1.1 million to the New  York/New Jersey (NY/NJ) WTC Consortium for treatment-related  activities. We also reported that CDC officials told us they could not  predict how long the funding from the appropriation would support four  WTC health programs that provide treatment services.
My testimony today is primarily based on our report issued in July 2007.  As you requested, I will discuss (1) the status of services provided by the  WTC Federal Responder Screening Program, (2) NIOSH’s efforts to  provide services for nonfederal responders residing outside the NYC  metropolitan area, (3) NIOSH’s awards to grantees for treatment services,  and (4) lessons learned from WTC health programs.
To assess the status of services provided by the WTC Federal Responder  Screening Program, we obtained and reviewed program data and  documents from HHS, including applicable interagency agreements. We  interviewed officials from the HHS entities involved in administering and  implementing the program: NIOSH and two HHS offices, the Federal  Occupational Health Services (FOH) and the Office of the Assistant  Secretary for Preparedness and Response (ASPR). To assess NIOSH’s  efforts to provide services for nonfederal responders residing outside the  NYC metropolitan area, we obtained documents and interviewed officials  from NIOSH. We also interviewed officials of organizations that worked  with NIOSH to provide or facilitate services for nonfederal responders  residing outside the NYC metropolitan area, including the Mount Sinai  School of Medicine in NYC and the Association of Occupational and  Environmental Clinics (AOEC)—a network of university-affiliated and  other private occupational health clinics across the United States and in  Canada. To assess NIOSH’s awards to grantees for treatment services, we  obtained documents and interviewed officials from NIOSH. We also  interviewed officials from two WTC health program grantees from which  the majority of responders receive medical services: the NY/NJ WTC  Consortium and the FDNY WTC program. In addition, we interviewed  officials from the American Red Cross, which has funded treatment  services for responders. In our review of the WTC health programs, we  relied primarily on information provided by agency officials and contained  in government publications. We compared the information with  information in other supporting documents, when available, to determine  its consistency and reasonableness. We determined that the information  we obtained was sufficiently reliable for our purposes. To identify lessons  learned, we relied on previous work, for which we conducted interviews  with HHS officials, WTC health program officials, and experts in public  health. We also reviewed our previous work on the safety and health of  workers who responded to Hurricane Katrina. We performed the work  for the July 2007 report from November 2006 through July 2007—and  updated selected information in August and September 2007. We  performed the work to identify lessons learned from July 2005 through  September 2005 and updated this information in February 2006. All work  was conducted in accordance with generally accepted government  auditing standards.
In brief, we reported in July 2007 that HHS’s WTC Federal Responder  Screening Program had had difficulties ensuring the uninterrupted  availability of screening services for federal responders and that NIOSH,  the administrator of the program, was considering expanding the program  to include monitoring but had not done so. We also reported that NIOSH  had not ensured the availability of screening and monitoring services for  nonfederal responders residing outside the NYC metropolitan area,  although it had recently taken steps toward expanding the availability of  these services. As a result of our assessment of these programs, we  recommended that the Secretary of HHS expeditiously take action to  ensure that screening and monitoring services are available for all  responders, including federal responders and nonfederal responders  residing outside of the NYC metropolitan area. As of September 2007 the  department has not responded to this recommendation. We also reported  that NIOSH had awarded and set aside treatment funds totaling $51 million  from its $75 million appropriation for four NYC-area programs. Finally,  important lessons have been learned from the WTC health programs that  could assist in the event of a future disaster. These include the need to  quickly identify and contact responders and others affected by a disaster,  the value of a centrally coordinated approach for assessing individuals’  health, and the importance of addressing both physical and mental health  effects.
subsections: section_title: Background
paragraphs: The tens of thousands of individuals who responded to the September 11,  2001, attack on the WTC experienced the emotional trauma of the disaster  and were exposed to a noxious mixture of dust, debris, smoke, and  potentially toxic contaminants, such as pulverized concrete, fibrous glass,  particulate matter, and asbestos. A wide variety of health effects have  been experienced by responders to the WTC attack, and several federally  funded programs have been created to address the health needs of these  individuals.
subsections: section_title: Health Effects
paragraphs: Numerous studies have documented the physical and mental health effects  of the WTC attacks. Physical health effects included injuries and  respiratory conditions, such as sinusitis, asthma, and a new syndrome  called WTC cough, which consists of persistent coughing accompanied by  severe respiratory symptoms. Almost all firefighters who responded to the  attack experienced respiratory effects, including WTC cough. One study  suggested that exposed firefighters on average experienced a decline in  lung function equivalent to that which would be produced by 12 years of  aging. A recently published study found a significantly higher risk of  newly diagnosed asthma among responders that was associated with  increased exposure to the WTC disaster site. Commonly reported mental  health effects among responders and other affected individuals included  symptoms associated with post-traumatic stress disorder (PTSD),  depression, and anxiety. Behavioral health effects such as alcohol and  tobacco use have also been reported.
Some health effects experienced by responders have persisted or  worsened over time, leading many responders to begin seeking treatment  years after September 11, 2001. Clinicians involved in screening,  monitoring, and treating responders have found that many responders’  conditions—both physical and psychological—have not resolved and have  developed into chronic disorders that require long-term monitoring. For  example, findings from a study conducted by clinicians at the NY/NJ WTC  Consortium show that at the time of examination, up to 2.5 years after the  start of the rescue and recovery effort, 59 percent of responders enrolled  in the program were still experiencing new or worsened respiratory  symptoms. Experts studying the mental health of responders found that  about 2 years after the WTC attack, responders had higher rates of PTSD  and other psychological conditions compared to others in similar jobs who  were not WTC responders and others in the general population.  Clinicians also anticipate that other health effects, such as immunological  disorders and cancers, may emerge over time.
section_title: Overview of WTC Health Programs
paragraphs: There are six key programs that currently receive federal funding to  provide voluntary health screening, monitoring, or treatment at no cost to  responders. The six WTC health programs, shown in table 1, are (1) the  FDNY WTC Medical Monitoring and Treatment Program; (2) the NY/NJ  WTC Consortium, which comprises five clinical centers in the NY/NJ  area; (3) the WTC Federal Responder Screening Program; (4) the WTC  Health Registry; (5) Project COPE; and (6) the Police Organization  Providing Peer Assistance (POPPA) program. The programs vary in  aspects such as the HHS administering agency or component responsible  for administering the funding; the implementing agency, component, or  organization responsible for providing program services; eligibility  requirements; and services.
The WTC health programs that are providing screening and monitoring are  tracking thousands of individuals who were affected by the WTC disaster.  As of June 2007, the FDNY WTC program had screened about 14,500  responders and had conducted follow-up examinations for about 13,500 of  these responders, while the NY/NJ WTC Consortium had screened about  20,000 responders and had conducted follow-up examinations for about  8,000 of these responders. Some of the responders include nonfederal  responders residing outside the NYC metropolitan area. As of June 2007,  the WTC Federal Responder Screening Program had screened 1,305  federal responders and referred 281 responders for employee assistance  program services or specialty diagnostic services. In addition, the WTC  Health Registry, a monitoring program that consists of periodic surveys of  self-reported health status and related studies but does not provide in- person screening or monitoring, collected baseline health data from over  71,000 people who enrolled in the Registry. In the winter of 2006, the  Registry began its first adult follow-up survey, and as of June 2007 over  36,000 individuals had completed the follow-up survey.
In addition to providing medical examinations, FDNY’s WTC program and  the NY/NJ WTC Consortium have collected information for use in  scientific research to better understand the health effects of the WTC  attack and other disasters. The WTC Health Registry is also collecting  information to assess the long-term public health consequences of the  disaster.
section_title: Federal Funding and Coordination of WTC Health Programs
paragraphs: Beginning in October 2001 and continuing through 2003, FDNY’s WTC  program, the NY/NJ WTC Consortium, the WTC Federal Responder  Screening Program, and the WTC Health Registry received federal funding  to provide services to responders. This funding primarily came from  appropriations to the Department of Homeland Security’s Federal  Emergency Management Agency (FEMA), as part of the approximately  $8.8 billion that the Congress appropriated to FEMA for response and  recovery activities after the WTC disaster. FEMA entered into  interagency agreements with HHS agencies to distribute the funding to the  programs. For example, FEMA entered into an agreement with NIOSH to  distribute $90 million appropriated in 2003 that was available for  monitoring. FEMA also entered into an agreement with ASPR for ASPR  to administer the WTC Federal Responder Screening Program. A   $75 million appropriation to CDC in fiscal year 2006 for purposes related  to the WTC attack resulted in additional funding for the monitoring  activities of the FDNY WTC program, NY/NJ WTC Consortium, and the  Registry. The $75 million appropriation to CDC in fiscal year 2006 also  provided funds that were awarded to the FDNY WTC program, the NY/NJ  WTC Consortium, Project COPE, and the POPPA program for treatment  services for responders. An emergency supplemental appropriation to  CDC in May 2007 included an additional $50 million to carry out the same  activities provided for in the $75 million appropriation made in fiscal year  2006. The President’s proposed fiscal year 2008 budget for HHS includes  $25 million for treatment of WTC-related illnesses for responders.
In February 2006, the Secretary of HHS designated the Director of NIOSH  to take the lead in ensuring that the WTC health programs are well  coordinated, and in September 2006 the Secretary established a WTC Task  Force to advise him on federal policies and funding issues related to  responders’ health conditions. The chair of the task force is HHS’s  Assistant Secretary for Health, and the vice chair is the Director of NIOSH.  The task force reported to the Secretary of HHS in early April 2007.
section_title: WTC Federal Responder Screening Program Has Had Difficulties Ensuring the Availability of Screening Services, and NIOSH Has Considered Expanding the Program to Include Monitoring
paragraphs: HHS’s WTC Federal Responder Screening Program has had difficulties  ensuring the uninterrupted availability of services for federal responders.  First, the provision of screening examinations has been intermittent. (See  fig. 1.) After resuming screening examinations in December 2005 and  conducting them for about a year, HHS again placed the program on hold  and suspended scheduling of screening examinations for responders from  January 2007 to May 2007. This interruption in service occurred because  there was a change in the administration of the WTC Federal Responder  Screening Program, and certain interagency agreements were not  established in time to keep the program fully operational. In late  December 2006, ASPR and NIOSH signed an interagency agreement giving  NIOSH $2.1 million to administer the WTC Federal Responder Screening  Program. Subsequently, NIOSH and FOH needed to sign a new  interagency agreement to allow FOH to continue to be reimbursed for  providing screening examinations. It took several months for the  agreement between NIOSH and FOH to be negotiated and approved, and  scheduling of screening examinations did not resume until May 2007.
Second, the program’s provision of specialty diagnostic services has also  been intermittent. After initial screening examinations, responders often  need further diagnostic services by ear, nose, and throat doctors;  cardiologists; and pulmonologists; and FOH had been referring responders  to these specialists and paying for the services. However, the program  stopped scheduling and paying for these specialty diagnostic services in  April 2006 because the program’s contract with a new provider network  did not cover these services. In March 2007, FOH modified its contract  with the provider network and resumed scheduling and paying for  specialty diagnostic services for federal responders.
In July 2007 we reported that NIOSH was considering expanding the WTC  Federal Responder Screening Program to include monitoring  examinations—follow-up physical and mental health examinations—and  was assessing options for funding and delivering these services. If federal  responders do not receive this type of monitoring, health conditions that  arise later may not be diagnosed and treated, and knowledge of the health  effects of the WTC disaster may be incomplete. In February 2007, NIOSH  sent a letter to FEMA, which provides the funding for the program, asking  whether the funding could be used to support monitoring in addition to  the one-time screening currently offered. A NIOSH official told us that as  of August 2007 the agency had not received a response from FEMA.  NIOSH officials told us that if FEMA did not agree to pay for monitoring of  federal responders, NIOSH would consider using other funding. According  to a NIOSH official, if FEMA or NIOSH agrees to pay for monitoring of  federal responders, this service would be provided by FOH or one of the  other WTC health programs.
section_title: NIOSH Has Not Ensured the Availability of Services for Nonfederal Responders Residing outside the NYC Metropolitan Area
paragraphs: NIOSH has not ensured the availability of screening and monitoring  services for nonfederal responders residing outside the NYC metropolitan  area, although it recently took steps toward expanding the availability of  these services. Initially, NIOSH made two efforts to provide screening and  monitoring services for these responders, the exact number of which is  unknown. The first effort began in late 2002 when NIOSH awarded a  contract for about $306,000 to the Mount Sinai School of Medicine to  provide screening services for nonfederal responders residing outside the  NYC metropolitan area and directed it to establish a subcontract with  AOEC. AOEC then subcontracted with 32 of its member clinics across the  country to provide screening services. From February 2003 to July 2004,  the 32 AOEC member clinics screened 588 nonfederal responders  nationwide. AOEC experienced challenges in providing these screening  services. For example, many nonfederal responders did not enroll in the  program because they did not live near an AOEC clinic, and the  administration of the program required substantial coordination among  AOEC, AOEC member clinics, and Mount Sinai.
Mount Sinai’s subcontract with AOEC ended in July 2004, and from August  2004 until June 2005 NIOSH did not fund any organization to provide  services to nonfederal responders outside the NYC metropolitan area.  During this period, NIOSH focused on providing screening and monitoring  services for nonfederal responders in the NYC metropolitan area. In June  2005, NIOSH began its second effort by awarding $776,000 to the Mount  Sinai School of Medicine Data and Coordination Center (DCC) to provide  both screening and monitoring services for nonfederal responders residing  outside the NYC metropolitan area. In June 2006, NIOSH awarded an  additional $788,000 to DCC to provide screening and monitoring services  for these responders. NIOSH officials told us that they assigned DCC the  task of providing screening and monitoring services to nonfederal  responders outside the NYC metropolitan area because the task was  consistent with DCC’s responsibilities for the NY/NJ WTC Consortium,  which include data monitoring and coordination. DCC, however, had  difficulty establishing a network of providers that could serve nonfederal  responders residing throughout the country—ultimately contracting with  only 10 clinics in seven states to provide screening and monitoring  services. DCC officials said that as of June 2007 the 10 clinics were  monitoring 180 responders.
In early 2006, NIOSH began exploring how to establish a national program  that would expand the network of providers to provide screening and  monitoring services, as well as treatment services, for nonfederal  responders residing outside the NYC metropolitan area. According to  NIOSH, there have been several challenges involved in expanding a  network of providers to screen and monitor nonfederal responders  nationwide. These include establishing contracts with clinics that have the  occupational health expertise to provide services nationwide, establishing  patient data transfer systems that comply with applicable privacy laws,  navigating the institutional review board process for a large provider  network, and establishing payment systems with clinics participating in a  national network of providers. On March 15, 2007, NIOSH issued a formal  request for information from organizations that have an interest in and the  capability of developing a national program for responders residing  outside the NYC metropolitan area. In this request, NIOSH described the  scope of a national program as offering screening, monitoring, and  treatment services to about 3,000 nonfederal responders through a  national network of occupational health facilities. NIOSH also specified  that the program’s facilities should be located within reasonable driving  distance to responders and that participating facilities must provide copies  of examination records to DCC. In May 2007, NIOSH approved a request  from DCC to redirect about $125,000 from the June 2006 award to  establish a contract with a company to provide screening and monitoring  services for nonfederal responders residing outside the NYC metropolitan  area. Subsequently, DCC contracted with QTC Management, Inc., one of  the four organizations that had responded to NIOSH’s request for  information. DCC’s contract with QTC does not include treatment  services, and NIOSH officials are still exploring how to provide and pay for  treatment services for nonfederal responders residing outside the NYC  metropolitan area. QTC has a network of providers in all 50 states and the  District of Columbia and can use internal medicine and occupational  medicine doctors in its network to provide these services. In addition,  DCC and QTC have agreed that QTC will identify and subcontract with  providers outside of its network to screen and monitor nonfederal  responders who do not reside within 25 miles of a QTC provider. In June  2007, NIOSH awarded $800,600 to DCC for coordinating the provision of  screening and monitoring examinations, and QTC will receive a portion of  this award from DCC to provide about 1,000 screening and monitoring  examinations through May 2008. According to a NIOSH official, QTC’s  providers have begun conducting screening examinations, and by the end  of August 2007, 18 nonfederal responders had completed screening  examinations, and 33 others had been scheduled.
section_title: NIOSH Awarded Funding for Treatment Services to Four WTC Health Programs
paragraphs: In fall 2006, NIOSH awarded and set aside funds totaling $51 million from  its $75 million appropriation for four WTC health programs in the NYC  metropolitan area to provide treatment services to responders enrolled in  these programs. Of the $51 million, NIOSH awarded about $44 million for  outpatient services to the FDNY WTC program, the NY/NJ WTC  Consortium, Project COPE, and the POPPA program. NIOSH made the  largest awards to the two programs from which almost all responders  receive medical services, the FDNY WTC program and NY/NJ WTC  Consortium (see table 2). In July 2007 we reported that officials from the  FDNY WTC program and the NY/NJ WTC Consortium expected that their  awards for outpatient treatment would be spent by the end of fiscal year  2007. In addition to the $44 million it awarded for outpatient services,  NIOSH set aside about $7 million for the FDNY WTC program and NY/NJ  WTC Consortium to pay for responders’ WTC-related inpatient hospital  care as needed.
The FDNY WTC program and NY/NJ WTC Consortium used their awards  from NIOSH to continue providing treatment services to responders and to  expand the scope of available treatment services. Before NIOSH made its  awards for treatment services, the treatment services provided by the two  programs were supported by funding from private philanthropies and  other organizations. According to officials of the NY/NJ WTC Consortium,  this funding was sufficient to provide only outpatient care and partial  coverage for prescription medications. The two programs used NIOSH’s  awards to continue to provide outpatient services to responders, such as  treatment for gastrointestinal reflux disease, upper and lower respiratory  disorders, and mental health conditions. They also expanded the scope of  their programs by offering responders full coverage for their prescription  medications for the first time. A NIOSH official told us that some of the  commonly experienced WTC conditions, such as upper airway conditions,  gastrointestinal disorders, and mental health disorders, are frequently  treated with medications that can be costly and may be prescribed for an  extended period of time. According to an FDNY WTC program official,  prescription medications are now the largest component of the program’s  treatment budget.
The FDNY WTC program and NY/NJ WTC Consortium also expanded the  scope of their programs by paying for inpatient hospital care for the first  time, using funds from the $7 million that NIOSH had set aside for this  purpose. According to a NIOSH official, NIOSH pays for hospitalizations  that have been approved by the medical directors of the FDNY WTC  program and NY/NJ WTC Consortium through awards to the programs  from the funds NIOSH set aside for this purpose. By August 31, 2007,  federal funds had been used to support 34 hospitalizations of responders,  28 of which were referred by the NY/NJ WTC Consortium’s Mount Sinai  clinic, 5 by the FDNY WTC program, and 1 by the NY/NJ WTC  Consortium’s CUNY Queens College program. Responders have received  inpatient hospital care to treat, for example, asthma, pulmonary fibrosis,  and severe cases of depression or PTSD. According to a NIOSH official,  one responder is now a candidate for lung transplantation and if this  procedure is performed, it will be covered by federal funds. If funds set  aside for hospital care are not completely used by the end of fiscal year  2007, he said they could be carried over into fiscal year 2008 for this  purpose or used for outpatient services.
After receiving NIOSH’s funding for treatment services in fall 2006, the  NY/NJ WTC Consortium ended its efforts to obtain reimbursement from  health insurance held by responders with coverage. Consortium officials  told us that efforts to bill insurance companies involved a heavy  administrative burden and were frequently unsuccessful, in part because  the insurance carriers typically denied coverage for work-related health  conditions on the grounds that such conditions should be covered by state  workers’ compensation programs. However, according to officials from  the NY/NJ WTC Consortium, responders trying to obtain workers’  compensation coverage routinely experienced administrative hurdles and  significant delays, some lasting several years. Moreover, according to  these program officials, the majority of responders enrolled in the program  either had limited or no health insurance coverage. According to a labor  official, responders who carried out cleanup services after the WTC attack  often did not have health insurance, and responders who were  construction workers often lost their health insurance when they became  too ill to work the number of days each quarter or year required to  maintain eligibility for insurance coverage.
According to a NIOSH official, although the agency had not received  authorization as of August 30, 2007, to use the $50 million emergency  supplemental appropriation made to CDC in May 2007, NIOSH was  formulating plans for use of these funds to support the WTC treatment  programs in fiscal year 2008.
section_title: Lessons from WTC Health Programs Could Assist with Response to Future Disasters
paragraphs: Officials involved in the WTC health programs implemented by  government agencies or private organizations—as well as officials from  the federal administering agencies—derived lessons from their  experiences that could help with the design of such programs in the  future. Lessons include the need to quickly identify and contact  responders and others affected by a disaster, the value of a centrally  coordinated approach for assessing individuals’ health, and the  importance of addressing both physical and mental health effects.
Officials involved in WTC monitoring efforts discussed with us the  importance of quickly identifying and contacting responders and others  affected by a disaster. They said that potential monitoring program  participants could become more difficult to locate as time passed. In  addition, potential participants’ ability to recall the events of a disaster  may decrease over time, making it more difficult to collect accurate  information about their experiences and health. However, the time it takes  to design, fund, approve, and implement monitoring programs can lead to  delays in contacting the people who were affected. For example, the WTC  Health Registry received funding in July 2002 but did not begin collecting  data until September 2003—2 years after the disaster. From July 2002  through September 2003, the program’s activities included developing the  Registry protocol, testing the questionnaire, and obtaining approval from  institutional review boards. Our work on Hurricane Katrina found that no  one was assigned responsibility for collecting data on the total number of  response and recovery workers deployed to the Gulf and no agency  collected it.
Furthermore, officials from the WTC health programs told us that health  monitoring for future disasters could benefit from additional centrally  coordinated planning. Such planning could facilitate the collection of  compatible data among monitoring efforts, to the extent that this is  appropriate. Collecting compatible data could allow information from  different programs to be integrated and contribute to improved data  analysis and more useful research. In addition, centrally coordinated  planning could help officials determine agency roles so important aspects  of disaster response efforts are not overlooked. For example, as we  reported in March 2007, federal agencies involved in the response to the  Hurricane Katrina disaster disagreed over which agency should fund the  medical monitoring of responders. We recommended that the relevant  federal agencies involved clearly define their roles and resolve this  disagreement so that the need may be met in future disasters. In general,  there has been no systematic monitoring of the health of responders to  Hurricane Katrina.
Officials also told us that efforts to address health effects should be  comprehensive—encompassing responders’ physical and mental health.  Officials from the NY/NJ WTC Consortium told us that the initial planning  for their program had focused primarily on screening participants’  physical health and that they originally budgeted only for basic mental  health screening. Subsequently, they recognized a need for more in-depth  mental health screening, including greater participation of mental health  professionals, but the program’s federal funding was not sufficient to  cover such screening. By collaborating with the Mount Sinai School of  Medicine Department of Psychiatry, program officials were able to obtain  philanthropic funding to develop a more comprehensive mental health  questionnaire, provide in-person psychiatric screening, and, when  necessary, provide more extensive evaluations. Our work on Hurricane  Katrina found problems with the provision of mental health services  during the response to the disaster. Not all responders who needed mental  health services received them. For example, it was difficult to get mental  health counselors to go to the base camps where workers lived during the  response and to get counselors to provide services during off-hours to  workers who did not have standard work schedules.
section_title: Concluding Observations
paragraphs: Screening and monitoring the health of the people who responded to the  September 11, 2001, attack on the World Trade Center are critical for  identifying health effects already experienced by responders or those that  may emerge in the future. In addition, collecting and analyzing information  produced by screening and monitoring responders can give health care  providers information that could help them better diagnose and treat  responders and others who experience similar health effects.
While some groups of responders are eligible for screening and follow-up  physical and mental health examinations through the federally funded  WTC health programs, other groups of responders are not eligible for  comparable services or may not always find these services available.  Federal responders have been eligible only for the initial screening  examination provided through the WTC Federal Responder Screening  Program. NIOSH, the administrator of the program, has been considering  expanding the program to include monitoring but has not done so. In  addition, many responders who reside outside the NYC metropolitan area  have not been able to obtain screening and monitoring services because  available services are too distant. Moreover, HHS has repeatedly  interrupted the programs it established for federal responders and  nonfederal responders outside of NYC, resulting in periods when no  services were available to them.
HHS continues to fund and coordinate the WTC health programs and has  key federal responsibility for ensuring the availability of services to  responders. HHS and its agencies have recently taken steps to move  toward providing screening and monitoring services to federal responders  and to nonfederal responders living outside of the NYC area. However,  these efforts are not complete, and the stop-and-start history of the  department’s efforts to serve these groups does not provide assurance that  the latest efforts to extend screening and monitoring services to these  responders will be successful and will be sustained over time. Therefore  we recommended in July 2007 that the Secretary of HHS take expeditious  action to ensure that health screening and monitoring services are  available to all people who responded to the attack on the WTC, regardless  of who their employer was or where they reside. As of September 2007 the  department has not responded to this recommendation.
Finally, important lessons have been learned from the WTC disaster. These  include the need to quickly identify and contact responders and others  affected by a disaster, the value of a centrally coordinated approach for  assessing individuals’ health, and the importance of addressing both  physical and mental health effects. Consideration of these lessons by  federal agencies is important in planning for the response to future  disasters.
Mr. Chairman, this completes my prepared remarks. I would be happy to  respond to any questions you or other members of the committee may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this testimony, please contact Cynthia A.  Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Helene F. Toiv, Assistant Director; Hernan  Bozzolo; Frederick Caison; Anne Dievler; and Roseanne Price made key  contributions to this statement.
section_title: Appendix I: Abbreviations
section_title: Related GAO Products
paragraphs: September 11: HHS Needs to Ensure the Availability of Health Screening  and Monitoring for All Responders. GAO-07-892. Washington, D.C.:   July 23, 2007.
Disaster Preparedness: Better Planning Would Improve OSHA’s Efforts  to Protect Workers’ Safety and Health in Disasters. GAO-07-193.  Washington, D.C.: March 28, 2007.
September 11: HHS Has Screened Additional Federal Responders for  World Trade Center Health Effects, but Plans for Awarding Funds for  Treatment Are Incomplete. GAO-06-1092T. Washington, D.C.: September 8,  2006.
September 11: Monitoring of World Trade Center Health Effects Has  Progressed, but Program for Federal Responders Lags Behind.  GAO-06-481T. Washington, D.C.: February 28, 2006.
September 11: Monitoring of World Trade Center Health Effects Has  Progressed, but Not for Federal Responders. GAO-05-1020T. Washington,  D.C.: September 10, 2005.
September 11: Health Effects in the Aftermath of the World Trade Center  Attack. GAO-04-1068T. Washington, D.C.: September 8, 2004.
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