Homeland Security Watch

News and analysis of critical issues in homeland security

October 9, 2010

Health Care Reform and National Security? Connecting the Dots

Filed under: Biosecurity,Preparedness and Response — by Jessica Herrera-Flanigan on October 9, 2010

Today’s guest columnist is Dr. Gloria N. Eldridge, a health and security policy analyst in the Washington, D.C. area, who offers her thoughts on the nexus between health care reform and national security.

We have all been bombarded since the 2008 elections with politicians or pundits projecting what national health reform proposals or the actual bill will mean in terms of our family member’s visits to the doctor’s office, the money coming out of our pockets for health care expenses, or our choice of health insurance carrier in the future. What about connecting the dots between policy sectors and considering what the measure means for national security and our preparedness for a homeland security event?

The twin bills of national health reform, The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) and the Health Care and Education Reconciliation Act (HCERA, P.L. 111-152) of 2010 bolstered national security.  The United States is better prepared for a homeland security event, such as a terrorist attack or a natural disaster, after national health reform than before.  For one, every American will have insurance coverage in case they require health services after an event.  Second, Medicaid eligibility is rationalized with all individuals with incomes below 133% of the federal poverty level (FPL) eligible for coverage.  Previously, Medicaid’s cobbled eligibility standards left most poor single adults and others uninsured and state officials scrambling to negotiate federal financing for the uninsured’s health services costs after an event.  Sixteen million uninsured, a half of those newly covered under the 2010 measure, are scheduled to receive coverage under the new Medicaid rules.  Third, national, state, and local officials will not have to build and negotiate institutional frameworks in the wake of an event.  Instead, these institutional frameworks will be in place ahead of time.  The politics of building institutions can, therefore, be removed from our response.

September 11, 2001, Terrorist Attacks in New York City

Consider the events following the September 11, 2001 terrorist attacks.  New York City’s (NYC) Medicaid computer systems were damaged during the attacks, and state and city officials had to negotiate with the federal government regarding financing the health care of the uninsured.  The Medicaid program, a program financed by both federal and state dollars, became an instrument of the homeland security state.  A temporary public health insurance program called Disaster Relief Medicaid (DRM) was created, and nearly 350,000 New Yorkers – including many who were uninsured — enrolled within four-months after the attacks (Kaiser 2002).  In designing DRM, the requirements of a planned Medicaid waiver initiative called Family Health Plus, scheduled for implementation in the fall of 2011, were used.  Medicaid maintains federal minimum requirements for state governments but states retain the ability to “waiver” federal requirements through petitions.  For DRM, the usual NYC eligibility levels for parents were expanded from 87 percent to 133 percent and for single adults and childless couples from 50 percent to 100 percent of the FPL (Kaiser 2002).  Pre-reform Medicaid required an assets and resources test in order for individuals to be eligible, while the DRM did not.  DRM also implemented minimal documentation requirements, brief interviews, and the ability to use services right away (Kaiser 2002).

August 29, 2005, Hurricane Katrina hits The Gulf Coast

In the days following the Katrina disaster, Congressional action was proposed in the Emergency Health Care Relief Act of 2005 (S.1716), introduced by Senate Finance Chairman Chuck Grassley of Iowa and Ranking Member Max Baucus (D – MT) on September 14, 2005. The proposed legislation provided for temporary federally funded Medicaid coverage to low-income individuals affected by the hurricane.  It also planned to provide $800 million for uncompensated care provided to the uninsured hurricane victims (Lambrew and Shalala 2006).  This approach, however, was not supported by the G.W. Bush Administration.  Instead, Medicaid financing, through the waiver process, provided financing of health needs of many evacuees across state lines, as the hurricane created a Diaspora of more than a million evacuees to every state in the nation (Lambrew and Shalala 2006).

As Diane Rowland testified before the Subcommittee on Oversight and Investigations, U.S. House Committee on Energy and Commerce, “Under these waivers, states could provide up to five months of Medicaid or SCHIP coverage to eligible groups of survivors and could also create an uncompensated care pool to reimburse providers for uncompensated care costs.  The waivers did not allow states to expand coverage for adults without dependent children, regardless of income, and did not include any funding to support the temporary coverage or uncompensated care pools. Federal funding did not become available until the Congress authorized $2 billion for the Medicaid coverage and uncompensated care pools nearly six months after the storm through the Deficit Reduction Act of 2005” (Rowland 2007).

Discussion and Conclusions

Although members of Congress, and the American public, may not have thought of national health reform as a national security issue, it does prepare us for a national event – whether a natural disaster or terrorist threat.  Now that the 2010 national health reform is passed, all Americans will have health insurance if they require it after a major event.  In fact, the legislation requires all Americans to have health insurance.  State health insurance exchanges are being developed to assist with access to coverage.  Also, Medicaid is more rational with all Americans under 133% of poverty covered by the program.  This establishes financing guidelines between the federal and state governments, and it makes very clear the individuals who will receive that coverage ahead of time.  The health financing institutions developed during national health reform — whether the new health insurance exchanges or rationalized Medicaid eligibility – are in place.  The country will not have to negotiate these policy institutions shotgun.  This removes the political calculus that comes with developing health financing institutions from our post-event agenda.  We can focus on our nation’s security and our people’s health without the bipartisan wrangling that accompanies the creation of new institutional structures.

References

The Kaiser Commission on Medicaid and the Uninsured and United Hospital Fund.   “New York’s Disaster Relief Medicaid: Insights and Implications for Covering Low-Income People,” August 2002.

Lambrew, Jeanne M. and Donna E. Shalala.  “Federal Health Policy Response to Hurricane Katrina: What It Was and What It Could Have Been,” JAMA 296, no. 11: 1394 – 1397, September 20, 2006.

Rowland, Diane.  “Health Care In New Orleans: Before and After Katrina,” Testimony before the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, United States House of Representatives, March 13, 2007.

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19 Comments »

Comment by Dan O'Connor

October 9, 2010 @ 9:13 am

Thank you for taking the time to contribute. I don’t pretend to be an expert in this arena but I would like to share some thoughts. I have read this several times and would like to discuss some key points, hopefully not pulling out of context, but focusing on the language.

“The United States is better prepared for a homeland security event, such as a terrorist attack or a natural disaster, after national health reform than before.”. “

With all due respect and deference to Dr. Eldridge’s point of view, I disagree
with her assertion that we will be better prepared in the event of an attack. According to Dr. Eldridge, the twin bills of national health reform, The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) and the Health Care and Education Reconciliation Act (HCERA, P.L. 111-152) of 2010 bolstered national security.

How so? It is perhaps a semantic argument, but how does health care, put forth in this context bolster national security? Because of our current economic situation and our national inability to curtail spending, how does incurring continued large amounts of debt, bolster our security? Is it counter intuitive? What other spending programs and/or national projects, whether they be critical infrastructure and general infrastructure maintenance and hardening, defense spending, research, energy, etc will have a contracted funding line further reduced to meet this new requirement?

“For one, every American will have insurance coverage in case they require health services after an event. Second, Medicaid eligibility is rationalized with all individuals with incomes below 133% of the federal poverty level (FPL) eligible for coverage.”.

I believe this statement needs further clarification. How does this bolster National Security? The mechanics of a terrorist incident would also have, what could be semantically argued as a localized or confining affect; within that context, the surge capacity of local, state, regional, and potentially national assets to meet the surge is far more important than nationalizing health care. Moving past terrorism and focus on a cataclysmic natural disaster… we just recently completed National Preparedness month and it had little affect on the vast majority of Americans. Would redistribution of Americans, businesses, and deconstruction of urban epicenters be more effective in mitigating natural disasters than pushing forth what appears to be an ideological and ill prepared National health care plan?

“Previously, Medicaid’s cobbled eligibility standards left most poor single adults and others uninsured and state officials scrambling to negotiate federal financing for the uninsured’s health services costs after an event.” How many people required immediate health care following the terrorist attacks of 2001? The data from 2005 may be more conducive to making this argument have some readiness merit, but what other factors were in place and/or not mentioned in order to not grasp a full, objective, not partisan picture? This is the real crux of the argument, perhaps flawed by my layman’s point of view.

I would like to hear the Dr expound on how radical amplification of costs in a government that is perpetually in the “red” constitutes readiness. And within the context of health care as a form of readiness, how it ties into National Security? To further her argument, why haven’t we re-purposed health care as wellness care and shifted the focus of response to prevention by national behavior modification as it relates to health, diet, exercise, and obesity?

The current machination of the proposed National health care debate does not take into account some of the more obtuse or opaque impacts our lack of potable water, our food industry, our factory farming, agriculture, and processed foodstuff impacts our health and wellness. So which is more detrimental to National Security, high fructose corn syrup or weapons of mass destruction? The data speaks to one being the other, but that may affect the corn lobbies success…

What affect does undocumented workers/illegal immigration have on affecting both our National Security and the cost of health care? What also of the increasing litigious nature of Americans and the ever increasing premiums Doctors must carry? Are all the tests a diagnostic tool for enhanced detection or part of an institutional risk mitigation strategy to reduce lawsuits? All of the aforementioned are parts of the problem, yet not addressed, so the health care panacea is not addressing national security from a strategic perspective, but a political one with an ideology in lieu of a solution.

With the subtle sarcasm pushed aside, this current plan does little if anything to enhance our National readiness and security.

We have greatly reduced our response capability due to fiscal restraint and degree of indebtedness. I would also like to hear the Dr’s point of view on the IRS distributing a 1099 for health care as income and using a legal loophole capture alleged unreported income or health care estimates as income that will generate more government revenue (TAXES) and help offset the cost of the health bill. When in doubt, tax them out… We are already burdened with a foreign policy construct that appears to be unsustainable but there is not a great deal of debate on reducing our global influence or reducing our financial aid packages that are either keeping the world placated or pushed back from the precipice of anarchy. It all plays when one tries to define National Security.

And how does this health care point of view create readiness and resilience? What is the measure of effectiveness or metric used to measure this new found readiness? Is it surge capacity? Is it surge capability i.e. more Dr’s, nurses, trauma units etc? Carefully reading this passage;
September 11, 2001, Terrorist Attacks in New York City
“Consider the events following the September 11, 2001 terrorist attacks. New York City’s (NYC) Medicaid computer systems were damaged during the attacks, and state and city officials had to negotiate with the federal government regarding financing the health care of the uninsured. The Medicaid program, a program financed by both federal and state dollars, became an instrument of the homeland security state. A temporary public health insurance program called Disaster Relief Medicaid (DRM) was created, and nearly 350,000 New Yorkers – including many who were uninsured — enrolled within four-months after the attacks (Kaiser 2002).”. The key statement or theme I hear is temporary…..a surge capacity…..
And here as well;
August 29, 2005, Hurricane Katrina hits The Gulf Coast
“In the days following the Katrina disaster, Congressional action was proposed in the Emergency Health Care Relief Act of 2005 (S.1716), introduced by Senate Finance Chairman Chuck Grassley of Iowa and Ranking Member Max Baucus (D – MT) on September 14, 2005. The proposed legislation provided for temporary federally funded Medicaid coverage to low-income individuals affected by the hurricane.”
Again, the language is clear; temporary… a surge capacity to meet amplified needs of a region after an event.
“Although members of Congress, and the American public, may not have thought of national health reform as a national security issue, it does prepare us for a national event – whether a natural disaster or terrorist threat”. It was not thought of as a national security issue because it is not one. And there is no data or construct that I am aware of to further the argument that we will have an enhanced readiness from this program. How can anyone address health care as national security when our children…the future… are too fat to fight?

http://tinyurl.com/y3ldkdo or http://tinyurl.com/2cgjcxk/

So really, health care, in its current construct and ideological bent do little if anything in preparing the Nation.

One could make the argument that health care in its currently introduced form diminishes readiness by not addressing wellness, shunts revenue, and prohibits corrective action. If one were to combine this phenomena with the already diminishing pool of eligible young men and women capable of serving in the all volunteer Army (another debate on its efficacy and its poor representation of a cross section of America another time) one could see the complete lack of potency of health care as a National Security “force multiplier”

We have already seen some of the manifestations of this health care on business and expected costs. Perhaps McDonalds and 3M are bluffing, but this law was never intended to solve a problem, nor was it ever about enhancing National Security.

“We can focus on our nation’s security and our people’s health without the bipartisan wrangling that accompanies the creation of new institutional structures.” Again, with appropriate deference, this appears more as ideology than advocacy for the nation. I applaud Dr. Eldridge’s point of view and putting this forward as a possibility. But in my humble opinion, the logic is flawed and does not stand up to scrutiny as it relates to an enhanced and prepared citizenry nor does it greatly increase our National Security. Perhaps her introduction of this to the fold will spark renewed debate and discussion.

If National Security is not one thing it is all things and behavior is far more important than benefits.

Once again, thank you for sharing your point of view

Comment by William R. Cumming

October 9, 2010 @ 1:04 pm

Well DAN many of your points are grounded in sound reasoning but in fact the bottom line position of Dr. Eldridge is correct. Placing health care response and financing on a sounder basis than the current private rationing system can only strengthen domestic resilience. And that strengthening is what Homeland Security is all about. Stever Aftergood of FAS posted recently a seminal report on Civil Defense issued in 1948, including health care as an issue for civil defense and national security and homeland security in the domestic arena. You might be surprised how forward thinking the document from 1948 is in fact. Issued prior to the explosion of an atom bomb by the Soviet Union is provides a fundamental analysis that should be read by all involved in civil security and resilience issues sometimes known as national or homeland security. In addition to posting on the FAS website which is searchable I posted the full report on my blog at Vacation Lane Blog under baseline docs. I also sent a copy to Phil. The reason for doing that is I think how barren and juvenile the civil security thinking has been since 9/11/01. Today right now no metropolitan area of any size in the US can cope with more than 700 massive trauma patients at the same time. We were very lucky that proposition has not been tested and of course on 9/11 most victims died and did not survive the event as major trauma patients. But DAN’s points should be discussed in detail because again today, right now, IMO HHS is far outshining DHS in the quality of its thinking and analysis on resilience and civil security.

I also posted on my blog a proposed draft Executive Order to supersede E.O. 12656 and become the first truly all-hazards Executive Order issued by any President of the United States and allow attention to be paid to the civil crisis management and response system including health policy. I fear that the major new stovepipe created since 9/11/01 impacting civil security is not the law enforcement/homeland security/homeland defense split but the stovepiping of medical issues which so critically underlay resilience.

So here is to more dialogue between DAN and the good Doctor so we or at I can understand their arguments better. And while we are at it I will just pick one issue not addressed by any legislation but critical to health care and homeland security–the blood supply! This issue will dominate any mass casualty situation and with the recent fining of the ARC [American Red Cross] for $16M for its failed blood program, a warning shot should be recognized by all. I personally negotiated through a priority for military casulties in Desert Storm when that critical supply was in major shortfall. Who will do it when needed now? Perhaps DAN and the Dr. can address that subject. No blood no resilience. No blood no national security. No blood no homeland security. No blood no domestic civil security.

Comment by William R. Cumming

October 9, 2010 @ 1:13 pm

The FAS URL for the 1948 report set forth below:

1948 report to the Secretary of Defense on “Civil Defense for National Security” here:

http://www.fas.org/irp/agency/dhs/fema/civildef-1948.pdf

Comment by Gloria N. Eldridge

October 9, 2010 @ 1:50 pm

Mr. O’Connor, thank you for your thoughtful response to my blog entry. Let me first address a general valid point that you make throughout your comments — we are not more secure if the initiative positions the country in fiscal peril.

For this, I can refer you the Congressional Budget Office conclusion:

CBO and JCT estimate that enacting both pieces of legislation—H.R. 3590 and the reconciliation proposal—would produce a net reduction in federal deficits of $143 billion over the 2010–2019 period as result of changes in direct spending and revenues. That figure comprises $124 billion in net reductions deriving from the health care and revenue provisions and $19 billion in net reductions deriving from the education provisions. (CBO Letter to Speaker Pelosi, March 20, 2010.)

Pre-reform America (which I consider us to be in currently) includes an industrial sector that exports American jobs oversees (Blinder 2006); a banking sector, where more than 60% of American bankruptcies are accounted for by medical causes (Himmelstein et al. 2007); a labor market where job lock restricts the autonomy of decision making and the opportunity to achieve (Madrian 2006, Cutler & Madrian 1998, Gruber & Madrian 2002, Gruber 2000, and Baicker & Chandra 2005); and an employer base where the numbers of employers that offer health insurance are dropping simultaneous to the price of health insurance increasing (Nichols and Axeen 2008). This is not security.

Further, in the 2010 reform legislation, there are several mechanisms to improve the efficiency of health care delivery — including new initiatives in accountable care organizations and medical home models, as well as new initiatives in wellness and prevention.

As for a metric, let’s take a metric of what national health reform does for our bottom line: $124 billion in net reductions over the 2010–2019 period.

Comment by Dan O'Connor

October 9, 2010 @ 3:03 pm

Bill;

There is a bit of irony in many of my points being grounded in sound reasoning but “. . . in fact the bottom line position of Dr. Eldridge is correct . . .”. a hard thing to do !

As I said I lack some of the gravitas in the policy dept.

Gloria; welcome aboard!

Thanks for sharing your point of view.

To your ancillary points;

“Pre-reform America (which I consider us to be in currently) includes an industrial sector that exports American jobs oversees (Blinder 2006); a banking sector, where more than 60% of American bankruptcies are accounted for by medical causes (Himmelstein et al. 2007); a labor market where job lock restricts the autonomy of decision making and the opportunity to achieve (Madrian 2006, Cutler & Madrian 1998, Gruber & Madrian 2002, Gruber 2000, and Baicker & Chandra 2005); and an employer base where the numbers of employers that offer health insurance are dropping simultaneous to the price of health insurance increasing (Nichols and Axeen 2008). This is not security.”

I agree with you 100%.

I also don’t think government is the answer, not from the “it’s socialism” soap box per se, but more from the insidious but perhaps necessary bureaucracy that it creates and probably requires. Coupled with the tendency to underestimate costs and overestimate savings, this duality of inverse proportion creates gaps and within those gaps, shortfalls in revenue and excesses in expenditure. The Government has not exhibited the acumen to run such a program effectively. Hyperbole perhaps, but debatable nonetheless.

Also, I would like to rely on the CBO and JCT for their projections, but until they realize the $124 billion in net reductions, it’s just projected fiction.

I like your term “pre-reform America”… it a more accurate term and better suited than “pre regulated America”.

This argument, coupled with education, security, and economics must be buttressed with behavior modification and expectation management. And, until it transcends representation that only has its own self interest at hand, the “camps” will only entrench further.

Nevertheless, a healthier, more robust citizenry is necessary to exhibit resilience to the unknown future. To that end we both probably agree.

I look forward to other interactions/discussions on this matter and our mutual efforts to build a stronger more resilient nation.

Comment by Gloria N. Eldridge

October 9, 2010 @ 4:05 pm

Dear Mr. Cumming,

I share your concerns with the stovepipe, as opposed to integrated, approach to biosecurity in our homeland defense strategy. I have downloaded your posting of the Report to the Secretary of Defense by the Office of Civil Defense Planning, “Civil Defense for National Security.” I plan to review the document in much greater detail.

We have already outlined just in a few blogs a number of performance measures and indicators that could be part of an updated version of the section on medical care.

–Surge capability by metropolitan area (numbers of medical staff available, number of individuals that could be treated after a homeland security event, number of trauma beds, drive times to trauma centers, plans in place ahead of time for emergency response to an event (Yes/No)).

–Blood supply (capacity in reserve for a major event, number of individuals that could be treated, number of units available by metropolitan area, operational plans in place to regenerate the blood supply in the case of a major event by metropolitan area/coordinated nation-wide)

There are several measures we would need to add in Pharmaceutical/Vaccine Availability Operations and Mobility Strategy in response to a potential act of chemical or biological warfare. There are several modeling techniques that could assist with projections.

Is it possible that now that we have rationalized our health insurance financing system to the point where every individual will have to identify an insurance option that we can turn to other fundamental cornerstones of medical and biosecurity?

Comment by William R. Cumming

October 9, 2010 @ 4:30 pm

Note that the “Free Clinics” seem to have become part of the frontline should health in all its various forms become the “central front” through bioterrorism, pandemics etc. and uncertain treatment by those in other parts of the health sector seems to ignore preparedness generally including mobilization strategies. Protecting the “herd” through biosurveillance and vaccines seems to be generally behind the so-called “curve”! Hey it is one world as far as health. And perhaps as far as National and Homeland and Civil security. Compartmentalization of strategy and funding seems to be the weak link in the chain mail of our society.

Comment by Gloria N. Eldridge

October 9, 2010 @ 5:01 pm

More generally, and this is true for most areas of homeland security preparedness, my blog entry was intended to emphasize the need for removing politics and hard line bargaining between political actors from post-event response. In the cases of 9-11 and Katrina, Medicaid waivers were negotiated after the fact — and, in the case of the Katrina disaster, there was bitter political wrangling and precious energy spent between political parties in arriving at a solution.

This is due to three “laws of nature/politics”:(1) Institutions needed to be built, and this involves politics; (2) Homeland security necessarily involves federalism and intergovernmental relations; by definition this means policy bargaining between the various levels of government; and (3)National health reform — and any event that appears to possibly affect this debate– has been an issue of bitter debate for 100 years.

I do not mean to suggest that we attempt to move against the laws of nature (or in this case political science)– removing policy bargaining from institutional design or issues of intergovernmental relations. We do need, to the extent possible,to negotiate the institutions for homeland security preparedness and response ahead of time.

Designing institutions, particularly those involving multiple governments, always involves politics. This general point holds for all areas of homeland security preparedness, as they all involve building institutional systems and intergovernmental relations. The time for this hard policy bargaining is now, not after a natural disaster or a terrorist attack. After an event, is a time to come together, to let the institutions we have designed do their work, and then to regroup in order to make improvements.

Comment by William R. Cumming

October 9, 2010 @ 8:03 pm

Dr. Eldridge your last comment is very instructive. The multidisciplinary aspects of Homeland Security are one of the things that interest me the most. Unfortunately, the Science Committees are largely shut out of review of HS/EM program/functions/activities. In the HOUSE the Stafford Act oversight is focused NOT in the Homeland Security Committee which is a mishmash of personalities but in the Transportation and Infrastructure Committees which treat disaster response and recovery largely as a PUBLIC WORKS problem. Neither the Judiciary Committees, the INTEL Committees, or the Armed Services Committee see HS/EM largely as a civil security problem but they also demonstrate their ignorance almost daily on health preparedness and response.
But let’s forget the HILL for the moment and talk about an administration that I voted for in 2008. They have placed a person whose life was spent in foreign intelligence collection, analysis, and dessemination at the top of the HS/EM pyramid. Others even in his “resilience” group are not multidisciplinary in their approach or even knowledgeable about federalism or civil security or health preparedness and recovery from public health threats including bioterror. Clearly as always there are some bright lights but they are buried. The deficiencies of the legal profession as leaders in the public service are clear and the lack of broad gauge is a huge problem. I come out of that profession and analysis can be the strenght of lawyers but rarely synthesis. Unfortunately in the land of the blind best known as HS/EM there is rarely available a “one-eyed man” to lead them so they try and lead each other. The Public Administration types have identified the trench warfared between bureacracies as a huge problem viewing often correctly that the federal budget is a zero sum game. I win you lose. OMB rarely employs those who have a comprehensive understanding of administration and preparedness. The devil is in the details. You have correctly identified a “wicked issue”! So your suggestions and insight are welcome. And yes the time for hard bargaining is now before the problem of a NUDET in a major city or an effective bioterror attack or even a related matter like “Mad Cow” disease which could destroy a major sector of the economy. DID DHS really need to spend largely without result $50 on IT systems and technology. There are those including foreign interests that hope that the US as the oldest and richest democracy [Republic] does not figure this all out. That is my worry! So thanks for the efforts reflected in your post and comments. Very helpful to me even if I don’t agree with all of your points. Thansk again!

Comment by William R. Cumming

October 9, 2010 @ 8:07 pm

Correct the figure should have been $50B!

Comment by Dan O'Connor

October 9, 2010 @ 8:15 pm

Excellent comments on both accounts.

Comment by Gloria N. Eldridge

October 9, 2010 @ 8:54 pm

Thank you both. This is a very interesting discussion. You mentioned the federal budget process and its zero sum game. This is a particularly tough problem for initiatives subject to PAYGO. You do not get credit for making decisions that save the federal government money. For example, any money invested into prevention efforts do not translate into getting “credits” for the money saved to the federal government. Depending on the amount of the investment, this may be a disincentive to spend on items like prevention because of the technicalities of budget scoring.

Comment by Philip J. Palin

October 10, 2010 @ 5:38 am

Above Dr. Eldredge references some post-Katrina political wrangling related to health care policy. In doing so I perceive she offers a key insight regarding the core value of homeland security (if any). She writes:

This is due to three “laws of nature/politics”:(1) Institutions needed to be built, and this involves politics; (2) Homeland security necessarily involves federalism and intergovernmental relations; by definition this means policy bargaining between the various levels of government; and (3)National health reform — and any event that appears to possibly affect this debate– has been an issue of bitter debate for 100 years.

I do not mean to suggest that we attempt to move against the laws of nature (or in this case political science)– removing policy bargaining from institutional design or issues of intergovernmental relations. We do need, to the extent possible,to negotiate the institutions for homeland security preparedness and response ahead of time.

Designing institutions, particularly those involving multiple governments, always involves politics. This general point holds for all areas of homeland security preparedness, as they all involve building institutional systems and intergovernmental relations. The time for this hard policy bargaining is now, not after a natural disaster or a terrorist attack. After an event, is a time to come together, to let the institutions we have designed do their work, and then to regroup in order to make improvements.

There is a need for a self-consciously interdisciplinary, inter-governmental, and public-private cadre of policy/strategy brokers. Something similar was originally intended for both emergency management and National Security Council. Over time each has become more and more operationally and tactically distracted.

If homeland security is ever going to be meaningfully more than an uneasy consolidation of pre-existing elements, it needs to be characterized by effective brokers who have the skill and influence to do deals while the sun still shines.

Comment by Not The Insured, But The First Responder Who Requires Your Assistance Defense Secretary et al

October 10, 2010 @ 5:46 am

To the esteemed participants herein, while much of this discussion is reasonable and yes, if more insured we can assume a better response given major catastrophic event(s),yet first, the worsening promise of an economy riddled wth politicizing at the detriment of the public is quite evident. This our beloved Republic in this year of 2010 is in fact at least 13 trillion times in deficit and it is not the obvious victims here on Main Street USA I (we) worry about (ourselves) it is the apparent deficit riddled local economies and statewide politicians who continue to waste monies and have very little idea of administering a first response whether in budget response or in coordinating in case of calamity –

You Dr. Eldrige who have direct access to the Secretary of Defense…well, before this gentleman leaves (retires) from his troops in Afghanistan, Iraq and in the midst of planned attack on the UAE and Saudi Arabia et al by the “Brutes of Tehran” sponsored by the “KGB Putinites” — let all know that as this economy worsens and it will…without doubt and while you all worry about how the we the people will get treated, it is teh first responders who need help and plenty of it in financing and traning for just such a calamity –

I (we) here on Main Street USA call upon all those responsible to secure monies from teh federal coffers to financially support at least 35% of the local first response budgets in the metropolitan cities across America and never mind leaving it in the hands of incompetents – local politicians.

I am calling for an immediate and direct 35% federal subsidy of all first response to the metropolitan cities to better equip and train firefighters, police and EMT’s as first responders to the calamity you worry about as far as we having insurance…this direct federal budget assistance Dr. Eldride and you the Secretary of Defense who has no business leaaving his post for at least an additional year as you full well understand the peril we are embroiled in and given your experience with more than one administration and how teh process works…out of duty and commitment to this beloved country, you are enjoined in every way to stay vigilant at your post and put pressure on the present administration – of which I am not a fan whatsoever nor to the Republic charade as well – for it is not whether we have insurance, but whether we have trained, readied and supported first responders whose acreeres are not at the whim of poliicians and a declining America for the facts are facts and Dr. Eldridge, the much respected participants of this blog and you the Secretary of Defense, the ominous clouds are hovering and the fact is, in the next 12-14 months, this great nation, our beloved America is headed into further precipitous decline and given any calamity far worse than Katrina which has taken us five years to make substantial progress, we are broke and our men and women who truly serve the public in emergency first response, men and women I would give my Life to in support, states are bankrupt in not only coffer, but in leadership and it is not who is insured or not…during the bio/chem calamity we expect…it will not be the political clowns we see gridlocked within the beltway or the “local” who portray indifference to those “entrusted” to serve who will respond, but our heros, the first responders and while I have offered to relocate to serve as a civilian in military troop/logistics support in Afghan/Iraq, let’s use your influence to secure funding to train our own here and support the first responder for it will be these “medics” in the front line of our metropolitan city streets who need our support NOW!

Your discussion herein has been very informative and we here on Main Street USA hope to hear more from you on this very important subject of insurance – healthcare reform and Homeland Security which unfortunately itself is compromised of far too many political appointees who know little of what is about to happen as the story continues to unfold in a detrimental way for our nation as the budget deficit continues to skyrocket, the US currency erodes and the incompetncies of this White House and both the Republicans and Democrats show very little concern in their pledge in oath to support and uphold the US Constitution and the security of our nation….

We are at great peril and to you Mr. Secretary of Defense, this is no time for an experienced gentleman at the helm to step down…these next 12-14 months will be very telling and it is you, the DoD,the good folks at NSA and other agencies who are truly devoted to the heart and pulse of this great nation and who we need as no time in history has this country been at the brink of the peril which exists today from those within (Goldman Sachs et al) or from those who seek our demise and whose sword and hands are already red with the blood of our youth who have served us all and with the greatest sacrifice these men and women can give to their country….

God Bless America!

Without our first responders prepared to respond to multiple events and bio/chem attack and if they are to remain at the whim of local clowns and misspent budgets now in deficit state by state, we need not worry about insurance for we placed far too much significance on the wrong priority….

Christopher Tingus
PO Box 1612
Harwich, MA 02645
chris.tingus@gmail.com

Comment by Gloria N. Eldridge

October 10, 2010 @ 7:17 am

Mr. Tingus,

Thank you for your post. It brings up an issue that I was hoping would come up in discussion. On September 29, the 9/11 First Responder bill passed the House. Below I have provided a few news clips on its passage. Detractor’s arguments included that it is just another entitlement program. Thus, the history of entitlement programs is — again– affecting the homeland security debate.

By the way,9 years is a long time to wait for treatment/financing of that treatment of a major health condition.

Does anyone have any thoughts regarding if we are any better placed than we were on 9/11/2001 to address the financing of first responder’s health care in the future?

(From the House Energy and Commerce Website, which has text of the bill in pdf, http://energycommerce.house.gov).

House Passes Bill to Provide 9/11 First Responders with Health Care
Publications
Wednesday, 29 September 2010

Today, the House of Representatives passed H.R. 847, The James Zadroga 9/11 Health and Compensation Act by a vote of 268-160. The legislation would establish first responder and community treatment and monitoring programs to help people affected by exposure to toxic air and other debris after the attack on 9/11.

From Kaiser Health News at http://www.kaiserhealthnews.org/Daily-Reports/2010/September/29/9-11-responders-health.aspx

Topics: Politics, Public Health, Delivery of Care, Health Costs

Sep 29, 2010

CongressDaily: “At the urging of what one aide called 12 ‘pushy’ New York lawmakers, House Democratic leaders plan to bring to the floor today legislation that would extend healthcare aid to 9/11 first responders. … The $7.4 billion measure would provide health monitoring and treatment benefits to first responders and survivors of the Sept. 11, 2001, terrorist attacks. … The bill’s supporters told the leadership they want to challenge Republican opponents of the measure to cast another recorded vote against it and force them to defend those votes. House Republicans have said the bill creates ‘a massive new entitlement program’ and oppose the reopening of the compensation fund.” (Fung, 9/29).

The Hill: “The bill is expected to get the 218 votes needed to pass; it garnered 255 votes in July when it came up under suspension of the rules, which requires a two-thirds majority for passage” (Pecquet, 9/28).

Comment by Gloria N. Eldridge

October 10, 2010 @ 7:35 am

Mr Tingus,

You bring up an extremely important point regarding the federalism/intergovernmental relations of homeland security when you propose a 35% federal subsidy for first responder preparation. Here are my thoughts:

States/localities must be involved in response and delivery of services. However, the federal government must participate in the financing of preparation for and the actual response and delivery of services. This could be law of nature/politics #4: States and localities do not have the fiscal capacity to adequately prepare for or respond to a major homeland security event. The federal government must be involved in financing this preparation and response.

Any block grant or matching grant developed should not be a blank check — or create incentives for creative state financing federal money draw down — but come with stipulations (and possibly even performance measurement of) successful development and implementation of first response training and development.

Comment by Gloria N. Eldridge

October 10, 2010 @ 7:47 am

Mr. Palin,

I generally agree with you and appreciate your insight. As you say:

There is a need for a self-consciously interdisciplinary, inter-governmental, and public-private cadre of policy/strategy brokers.

I would like to re-post a comment by Mr. Cumming in 141239 that is tangentially related:

I fear that the major new stovepipe created since 9/11/01 impacting civil security is not the law enforcement/homeland security/homeland defense split but the stovepiping of medical issues which so critically underlay resilience.

Proposed conclusion: We need homeland security policy brokers who work across the stovepipe lines of traditional American Executive branch departments, legislative committees, and bureaucratic policy sectors.

Comment by Philip J. Palin

October 10, 2010 @ 7:56 am

Dr. Eldridge:

I apologize for misspelling your name in my first post. In my experience “silos of excellence” are a problem across the enterprise. I don’t have any confident ability to triage which silo is most life-threatening. But it sounds like you and I agree on the need for effective “homeland security policy brokers.” Have you seen an effective way to empower and nurture such folks?

Comment by William R. Cumming

October 10, 2010 @ 7:58 am

Well responding to the last two comments. “First Responders” are even defined in statute to include EMT and public health issues. See for example various pieces of the Fire Prevention and Control Act of 1974, as amended codified in Title 15 of the US Code if memory serves. RAND released an excellent report on First Responder safety in May 2007 I believe. Also NIOSH and OSHA have done some really important work.
The extract from Chris’ Comment below is important:
“I am calling for an immediate and direct 35% federal subsidy of all first response to the metropolitan cities to better equip and train firefighters, police and EMT’s as first responders to the calamity . . .”

Here is the problem identified with clarity. The reason, the First Response community is a national asset and counted on in planning, prevention, preparedness, and response and recovery by the federal government but even in good years barely funding the activity and almost never salaries and expenses. This is not a new issue.

EM and disaster ops are premised on competent state ops. This may or may not happen. But oddly there is a strange twist to this whole saga. DOD operates with the understanding that despite its direct funding through the Federal Budget it has many many hidden subsidies from the STATE and LOCAL and private sector and the civil sector of the US Government. Example! Veterans Department–one of the largest and most competent generally health care ops in the world. But having helped manuver VA into NDMS in my time in government the mythology that VA is a veterans asset only and not a national asset has led to many odd things in public administration. Right now DOD has exceeded its direct capacity of about 50,000 in its own medical system for severely injured soldiers, sailors, airmen and women, and trying to figure out a way to offload that burden. Jacques Gansler used to argue that there is only one economy and I believe that was correct. But if you look at the 100 top defense contractors and percentage of their work that is DOD related it seems incorrect. The problem is that both direct and indirect costs are subsidized for these contractors by various tax mechanisms including security clearance issues that seem to involve manipulation of lives as much as protecting the State.
Since this thread talks about Health Care a very very important delegation was made post-9/11 when both EPA and HHS were delegated original classification authority for the first time in US history. Before that they could only derivatively classify. So the entirety of the issues are as Dr. Eldridge very complex but my problem is that many lobbyists and even bureacrats don’t want the public or Congress to know and actively subvert disclosure of the real connections. You could argue that Congress could protect itself but not under current arrangements. I would start of course by limiting the military liaison efforts on the HILL which are in fact paid DOD lobbyists.
What are needed are systems and processes to develop understanding of these various connections. And by the way why does the NSC end up with so many serving or retired military that dominate its appointees and staff? To ask is to answer! The military sees itself as the foremost guardian of National Security but they always see it primarily as organized violence. Even Samuel Huntington in his otherwise excellent book “The Soldier and The STATE” argued that the military was the last bastion of our democracy. I just don’t see it that way. But hey agreeing to disagree is one of the facets of democracy I enjoy the most. It will be interesting to see when the next presidential or vice presidential candidate is nominated who careered in the military.

And always interested me that the Surgeon General and Public Health Service enjoy ed the trappings of the military. Why one might ask? Do uniforms compensate for low pay and long hours? Where is the RESERVE CORPS of the Public Health Service in the planning for health care catastrophic events!
I have been bitterly criticized on another blog to which I provide comments–actually a list serve–in which I argued that I think this Secretary HHS gets it and understands well Dr. Eldrige’s points. And is well ahead of the Secretary of DHS in understanding the real sinews of American power–health care is not soft power as I have pointed out with the blood issue–but in fact hard power, just previously unrecognized. In WWII many men drafted were rejected for health reasons, often malnutrion, so if it bodies you are looking for perhaps that is another analytic framework you can start with. The point is get the US to use its inherent comparative advantages during large-scale national domestic civil crisis situations. They will happen but will we be prepared?

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