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.
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.