Preliminary Hearing Transcript - Committee Holds Hearings on the

STENOGRAPHIC MINUTES Unrevised and Unedited **Preliminary Transcript** Not for Quotation or Duplication HEARING ON THE LACK OF HOSPITAL EMERGENCY SURGE CAPACITY: WILL THE ADMINISTRATION' S MEDICAID REGULATIONS MAKE IT WORSE? DAY ONE Monday, May 5, 2008 House of Representatives, Committee on Oversight and Government Reform, Washington, D.C. "This is a preliminary transcript of a Committee Hearing. It has not yet been subject to a review process to ensure that the statements within are appropriately attributed to the witness or member of Congress who made them, to determine whether there are any inconsistencies between the statements within and what was actually said at the proceeding, or to make any other corrections to ensure the accuracy of the record." Committee Hearings of the [I.S. HOUSE OF REPRESENTATIVES OFFICE OF TIIE CLERK OfÏice of Official Reporters HGO126.000 1 PAGE ]- RPTS DEAT{ z DCMN BURRELL 3 I{EARING ON THE LACK OF HOSPITAL EMERGENCY SURGE 4 5 CAPACITY: WILL THE ADMINISTRATION' S MEDICAID REGULATIONS MAKE IT WORSE? DAY ONE 7 Monday, May 5, 2008 House of Representatives, I 9 1_0 Committee on Oversiqht and Government Reform, 1_ l_ Washington, D.C. 1,2 1_3 The committee met, pursuant to caIl, àE 10:00 a.m., in Room 21-54, Rayburn House Office Building, Hon. Henry A. t4 Waxman [chairman of the committee] presiding. 15 Present: Representatives Waxman, Iatratson, Norton, Shays, 1,6 Issa, and Bilbray. l7 Staff Present: Phil Barnett, Staff Director and Chief 18 Counsel; Karen Lightfoot, Communications Director and Senior t9 Policy Advisor; 7\ndy Schneider, Chief Health Counsel; Sarah 20 Despres, Senior Health Counsel; Steve Cha, Professional Staff HGO]_26.000 PAGE 2t Member; Earley Green, Chief C1erk; Carren Audhman, Press 22 Assistant; E]Ia Hoffman, Press Assistant; Lenea1 Scott, 23 24 25 26 ¿l Information Systems Manager; Kerry Gutknecht, Staff Assistant; William Ragland, Staff Assistant; Latry Halloran, Minority Staff Director; .fennifer Safavian, Minority Chief Counsel for Oversight and Investigations; Christopher Bright, Minority Professional- Staff Member; 'Jill Schmaltz, Minority Professional Staff Member; .Tohn Cuaderes, Minority Senior Investigator & Policy Advisor; Benjamin Chance, Minority Professional Staff Member; Ali Ahmad, Minority Deputy Press Secretary; and Todd Greenwood, Minority Professional Staff Member. 28 29 30 31 32 HGO]_26 .000 PAGE 33 34 35 36 37 38 39 40 41, 42 43 44 45 46 47 48 49 50 51_ 52 53 54 55 56 57 of the committee will please come to order. Today \¡te're holding the first of 2 days of hearings on the impact of the administration's Medicaid regulations on hospital emergency surge capacity, the ability of hospital emergency rooms to respond to a sudden influx of casualties from a terrorist attack. The committee held a hearing in 'June of 2007 on the Nation's emergency care crisis. We heard from emergency care physicians that America's emergency departments are already operating over capacity. We're warned that if the Nation d.oes not add.ress the chronic overcrowding of emergency rooms their ability to respond to a public health disaster or terrorist attack will be severely jeopardized. The Department of Health and Human Services was represented at that hearing, but despite the warnings the Department has issued three Medicaid regulations that will reduce Federal funds to public and teaching hospitals by tens of billions of dollars over the next 5 years. The committee held a hearing on these and other Medicaid regulations in November of 2007. An emergency room physician told us that if these regulations are allowed to go ínto effect, the Nation's emergency rooms will take a devastating financial Chairman V'IAXMAN. The meeting hir. The two hearings that we will be holding this week will focus on the impact of these Medicaid regulations orl our HGOI_26 .000 PAGE 58 capacity to respond to the most likeIy terrorist attack, one 59 using bombs or other conventional explosives. Today we will be hearing from an independent expert on 60 6I terrorism, an emergency room physician, a trauma surgeon' a 62 nurse with expertise in emergency preparedness, and a State responsible for planning for disasters like a 63 official 64 65 66 terrorist attack. On Wednesday, we'11 hear testimony from the two Federal officials with lead responsibility for Homeland Security and for Medicaid, the Secretary of Homeland Security, Michael 67 68 Chertoff, and the Secretary of Health and Human Services, 69 Michael Leavitt. In preparation for this hearing the committee majority 70 7l staff conducted a survey of emergency room capacity in five attack, 72 cities considered at greatest risk of a terrific 73 Washington, D.C., Ne\lrr York, Los Angeles, Chicago and Houston, 74 as well as Denver and Minneapolis, where the nominating 75 conventíons will be held later this year. The survey took 76 place on Tuesday, March 25 at 4230 in the afternoon. 77 Thirty-four Level l- trauma centers participated in the 78 79 80 81_ survey. 82 the survey found was truly alarming. The 34 hospitals surveyed did not have sufficient ER capacity to treat a sudden influx of victims from a terrorist bombing. The hospitals had virtually no free intensive care unit beds Vühat HGO]_26.000 83 84 85 86 87 88 89 90 9L 92 93 94 95 96 97 98 99 1_00 101 L02 l_ 03 to treat the most seriously injured casualties. The hospitals did not have enough regular inpatient beds to handle the less seriously injured victims. The situation in Washington, D.C. and Los Angeles was particularly dire. There was no available space in the emergency rooms at the main trauma centers servíng Washington, D.C. One emergency room \^tas operating at over 200 percent of capacity. More than half the patients receiving emergency care in the hospital had been diverted to hallways and waiting rooms for treatment. And in Los Angeles three of the five Level 1 trauma centers v/ere so overcrowded that they went on diversion, which means they closed their doors to new patients. If a terrorist attack had occurred in Washington, D.C. or Los Angeles on March 25 when we did our survey, the consequences could have been catastrophic. The emergency care systems were stretched to the breaking point and had no capacity to respond to a surge of victims. Our investigation has also revealed what appears to be a complete breakdown in communications between the Department of Homeland Security and the Department of Health and Human Services 104 1_05 t_06 107 In October of 2007, the President issued Homeland Security Directive No. 21-. The directive requires the Secretary of HHS to identify any regulatory barriers to HGO126.000 108 PAGE 6 public health and medical preparedness that can be eliminated 1-09 by appropriate regulatory action. It also requires the 1_1_0 Secretary of HHS to coordinate with the Secretary of DHS to ensure we maintain a robust capacity to provide emergency 11"2 care. Yet when the committee requested documents reflecting 1_1-3 an analysis of the potential implications of the Medicaid regulations on hospital emergency surge capacity, neither TT4 1_L5 department was able to produce a single document. This is incomprehensible. It appears that Secretary 1-l.6 Leavitt signed regulations that will take hundreds and 1"1"7 1_18 millions of dollars away from hospital emergency rooms r]-9 without once considering the impact on national preparedness. ]-20 And it appears that Secretary Chertoff never raised a single t2t obj ection. L22 The Department of Health and Human Services was t23 represented at the committee's .Tune 2OO7 hearing on emergency The importance of adequate Federal funding for ]-24 care crisis. ]-25 emergency and trauma care \^/as repeatedly stressed by the 126 expert witnesses at the hearing. If Secretary Leavitt 127 approves the Medicaid regulations without considering their ]-28 impact on preparedness and consulting with Secretary ]-29 Chertoff, that would be a shocking and inexplicable breach of 130 responsibilities 131 The most damaging of the administration's Medicaid ]-32 regulations will go into affect on May 26th, just 3 weeks 1_ 1_ 1- HGO]_26.000 PAGE 133 from today. As the House voted overwhelmingly, the t34 regulation should be stopped until their true impacts can be understood. I don't know whether the House legislation will t36 pass the Senate or, if it does, whether the bill will survive ]-3'7 a threatened presidential veto. But I do know that Secretary Leavitt and Secretary Chertoff have the power to stop these 1_3 I And I intend ]-39 destructive regulations from going into effect. L40 to ask them whether they will use their authority to protect l-3 5 T4L hospital emergency rooms. 142 443 The Federal Government has poured billions of dollars into homeland security since the 9/IL attack, âs 1,44 investigations by this committee have documented much of this ]-45 investment was squandered on boondoggle contracts. This was t46 evident after Hurricane Katrina when our capacity to respond 147 fel1 tragically short. The question we will be exploring today and on Tr'Iednesday 1-48 t49 is whether a key component of our national response hospital l_50 emergency rooms will be ready when the next dísaster strikes. I want to recognize Mr. Shays. He is acting as the l_5L 452 ranking Republican for today. 1_53 [The information follows:] L54 ******** INSERT 1_-X ******** HGO]_26. 000 PAGE 8 Mr. SHAYS. Thank you, Mr. Chairman. I appreciate, 156 Chairman ütraxman, your calling today's hearing to review the t57 relationship between emergency medical surge capacity and the sad reality we must 158 Medicaid reimbursement policies. 159 contend with every day is the need to be ready for that one ]-60 horrible day when terrorism sends mass casualties to an .J,6L already overburdened medical system. Medicaid reimbursement policies may need to change to 162 163 better support large urban emergency and trauma centers, but 1-64 those changes alone will never assure adequatesurge capacity. 1-65 We cannot afford to build and maintain idle trauma waiting for the tragic day we pray never comes 466 facilities t_55 they will be needed. In 2004, 10 terrorist bombs exploded simultaneously on 1_68 'J"69 commuter trains in Madrid, Spain, killing 177 people and r70 injuring more than 2000. The nearest hospital had to absorb t7r and care for almost 300 patients in a very short time. In the event of a similar attack here our hospitals will 1-72 1-73 be tasked with saving the greatest number of lives while 1J.74 confronting a large surge of patients and coping with the 1-67 when of the worried well. Many will arrive suffering t76 injuries not typically seen ín emergency departments. t77 Medical staff will be facing the crisis with imperfect r78 information about the causes and scope of the event and under ]-79 severe emotional stress. To reduce the stress and treat mass ]-75 wave HGOI_26.000 casualties effectively decisions need to be made, resources 181 allocated, and communication established now, not during the t82 unexpected but perhaps inevitable catastrophic event. Today's hearing is intended to focus on a single aspect 183 ]-84 of emergency preparedness, Federal reimbursement policies and 1_85 their implications for Level l- trauma centers in major 1_86 metropolitan areas. 187 I appreciate Chairman Waxman's perspective on the 188 administration' s proposed Medicaid regul-ation changes and 189 join him in voting for a moratorium on their implementation. l_90 But I am concerned that a narrohr focus on just one component L9t of medical prepäredness risks oversimplifying the far more 192 complex realities the health system wilt face when 1,93 confronting a catastrophic event. 194 Stabilizing Medicaid pa)¡ment policies alone won't guarantee readiness against bombs or epidemics any more than 1_95 L96 an annual cost to assure people they're safe against L97 inflation or recession. It is a factor to be sure, but not L98 the sole or even the determinative element to worry about ]-99 when disaster strikes. We should not miss this opportunity to address the full 200 20r range of interrelated issues that must be woven together to 202 build and maintain a prepared health system. That being 203 said, there is no question emergency departments are 204 overcrovüded, often are understaffed and operatíng with 180 HGO]_26.000 PAGE 1-O strained resources on a day-to-day basis. Ambulances are 206 often diverted to distant hospitals and patients are parked 207 in substandard areas while waiting for an inpatient bed. 208 Ln 2006, the Institutes of Medicine, IOM, found few 209 financial incentives for hospitals to address emergency room 2!O overcrowding. Admissions from emergency departments are 2tt often the lowest priority because patients from other areas 2t2 of the hospital generate more revenue. This is not to 2]-3 disparage hospitals. They operate on tight margins and must 21-4 navigate challenging, often perverse financial incentives, 21,5 including Federal reimbursement standards. Strong 21,6 management, regional cooperation and greater hospital 21-7 efficiencies offer some hope for alleviating the strain on 21,8 emergency departments, but during a catastrophic event 219 bringing so-called surge capacity online involves very 220 different elements. In a mass casualty response regional capacity is more 22L Hospitals 222 important than any single hospital capability. 223 that normally compete with each other need to be prepared to 224 share information about resources and personnel. They need 225 to agree beforehand to cancel elective surgeries, move 226 noncritical patients and expand beyond the daily triage and 227 intake rates. 228 Unlike daily operations, surge and emergency response 229 requires interoperable and backup communication systems, 205 HGOl_26.000 PAGE 11 230 234 232 233 234 235 236 237 238 239 240 interoperable and backup communication systems, altered standards of care, unique lega1 liability determinations and transportation logistics. Should regional resources or capacity prove inadequate, State assets will be brought to bear. Available beds and patients will need to be tracked in realtime so resources can be efficiently and effectively matched with urgent needs. Civilian and even military transportation systems will have to be coordinated. If needed, Federal resources and mobile units will be integrated 24L 242 243 244 245 246 247 248 249 250 254 252 253 254 into the ongoing response. All of these levels and systems have to fa11 into place in a short time during a chaotic situation. So it is clear daity emergency department operations are at best an indirect and imperfect predictor of emergency response capabilities. The better approach is for 1oca1, State and the Federal Governments to plan for mass casualty scenarios and exercise those p1ans. That \^tay specif ic gaps can be identified and funding can be targeted to address disconnects and dysfunctions in the regional response. Fluctuating per capita Medicaid payments probably will not and often cannot be used to fund those larger structural elements of surge capacity. Today's hearing can be an opportunity to evaluate all the elements of emergency medical preparedness. We value the expertise our witnesses bring to this important discussion, HGO126.000 255 256 257 258 PAGE t2 and we look forward to their testimony. 259 260 26L 262 263 264 265 266 267 very much. Mr. Shays. While the rules provide for just the chairman and the ranking member to give opening statements, I do want to give an opportunity for the two other members that are with us to Chairman T/'IAXMAN. Thank you make any comments they wish to make. Ms. Watson. Ms. VIATSON. Thank you very much, Mr. Chairman the Los Angeles County board of supervisors visited Capitol Hill last 268 269 270 week. And the number one theme that continued to surface in my conversations with many of the supervisors vtas the widening gap between the demand for Medicare/Medicaid assistance and the administration's neh¡ regulations that will limit the amount of Medicaid/Medicare reimbursement to the State. The administration estimates that the total fiscal 27r 272 273 274 275 276 277 278 279 but a committee report, based on States that responded to the committee's request for information, concludes that the change in regulations would reduce Federal payments to States by 49.7 billion over the next 5 years. The cost to California alone is estimated to be 1-0.8 billion over 5 impact of the regulatory changes of 1-5 biIlion, years. Mr. Chairman, âs you well know, in the case of California the reductions and Federal funding would HGOL26.000 PAGE 1_3 280 28L 282 283 284 285 286 287 destabili.ze an already fragile medical care delivery service for low income residents and the uninsured. The impact of these changes will be far reaching and potentially catastrophic. In the last year we have witnessed the closing of many of King/Drew's hospital medical facilities located in Watts, California. The emergency care facility has been closed now for some time. The impact of this closing is that residents from this underserved area of Los Angeles are transported to other areas of town and the critical minutes that are needed to administer care to save lives are nolv 288 289 290 Iost. The impact of King/Drew closing has had a cascading 291 292 2'93 294 29s 296 297 298 299 300 30L 302 303 304 effect on all the other area hospitals, including those outside of the Los Angeles area, that now must pick up the slack. I cannot ímagine what would happen in these areas in the case of a mass catastrophic event such as a terrorist attack using conventional explosives or a natural disaster since they are already suffering from a lack of adequate emergency medical care facilities. So I look forward to the testimony from today's witnesses who are experts in medicine and medical delivery services and counterterrorism. Again, thank yoü, Mr. Chairman, for holding this hearing. Chairman VüAXMAN. Thank you, Ms. Watson. Mr. Issa. HGO]_26.000 PAGE L4 30s 306 307 308 Mr. ïSSA. Thank you, Mr. Chairman, for holding this hearing. I ask that my entire opening statement be put in the record. Chairman WAXMAN. Vüithout objection. HGO126.000 309 PAGE 15 [Prepared statement of Mr. Issa follows:] 310 ******** CoMMïTTEE INSERT ******** HGO]-26.000 3 l_l- PAGE L6 3]-2 3 l_3 3]-4 315 31-6 31-7 3 1_8 3 1_9 320 321" 322 323 324 325 326 327 328 329 330 331 332 333 Mr. ISSA. Mr. Chairman, I'm troubled with today's hearing for one reason. I think there's a legitimate problem, overcro\^rding of our emergency rooms. That overcrowding comes from a combination of illega1 immigration, lega1 immigration and a pattern of going to emergency rooms I when in fact urgent care would be a better alternative. think it is part of a bigger problem we particularly in California face that we have in fact a large amount of uninsured. But they are not insured, they are insured at the emergency room. That overcrohlding needs to be dealt withAnd I trust that on a bipartisan basis in good time we will deal with the challenges created by i1Iega1 immigration, individuals who either because of that or because thev lack insurance are choosing the emergency room over more effective and efficient delívery systems Having said that, I particularly am concerned that a partisan amateur survey was done in order to justify or politicize today's hearing. It's very clear both by the ranking member's opening statement and by the facts that we will clearly see here today that a survey of emergency rooms done by Democrat staff for the purpose of getting the ansvter they wanted, which was of course we're overcro!ìJded at the emergency room, is self-serving and unfortunately short - sighted. The number of beds that coul-d be made available in a 334 335 HGOI_26. 000 PAGE I7 hospital, the number of health care professionals, doctors, 337 nurses and the l-ike that could be brought to bear within a 338 period of time would have been part of any effective analysis 339 of what the surge capacity could be, the number of patients 340 who, although in the hospital, could be removed to other 34r facilities of lesser capability to make room for severely 342 injured people Although this would not change the fact that if we had a 343 344 Madrid type occurrence, even in a city l-ike Los Angeles, 2000 345 severely injured people would strain our capacity in the 346 first few hours. And undoubtedly, undoubtedly, just like a 347 200-car pileup on the 405, we would have loss of life that we 348 would have not have in a lesser occurrence. 349 do believe that the challenges of Medicare and 350 Medicaid in dealing with escalating costs, and particularly for California the cost of reimbursement which has not been 35l_ 352 sufficient, needs to be looked at. I hope that we can work 3s3 on a bipartisan basis to deal with these problems. I hope 354 that today's hearings will in fact cause us all to understand 355 the causes and the cures for overcrowding of our emergency 336 356 357 358 359 360 rooms. However, I must reiterate that the Federal response for this type of emergency needs to be to pay to train and to pay to test for these kinds of emergencies. That's the appropriate area for the Federal Government to deal with in HGO126.000 PAGE 18 36L 362 363 364 36s 366 367 368 369 370 37]372 373 374 375 376 377 378 379 380 3 81_ addition to providing certain life saving resources such as mass antibiotics like Cipro and of course also smallpox and other vaccinations in case of an attack. These are the Federal responses that \^/ere agreed to after 9/lt on a bipartisan basis, and I would trust that at a minimum we would not aI1ow an issue such as how much is reimbursed to California on a day-to-day basis to get in the way of making sure that we ful1y fund those items which would not and could not be funded locally or by States. Mr. Chairman, I look forward to today's hearing. You have a distinguished panel that I believe can do a great deal to have us understand the problem. With that, I yield back. Chairman VùAX}IAN. Our witnesses today do amount to a very distinguished panel and we're looking forward to hearing from them. Dr. Bruce Hoffman is Professor of the Edmund A. lfalsh Schoo1 of Foreign Service at Georgetown University here to discuss mass casually events involving conventional explosives in general and suicide terrorism in particular. He will also discuss his research on the Australian, British and Israeli--and British responses to these tlpes of terrorist attacks. Dr. Wayne Meredith is a Professor and Chairman of the Department of General Surgery at Wake Forest University Baptist Medical Center. In his role as a trauma surgeon Dr. Meredith will discuss the clinical importance of immediate 382 383 384 385 HGO126.000 386 387 3BB PAGE A9 response to trauma such as that resulting from a blast attack as well as the importance of adequate financing to maintain coordinated trauma care system. a 389 390 3 91_ 392 393 394 39s 396 397 398 399 400 4 01_ 402 403 404 405 406 407 Dr. Colleen Conway-Vüelch is the Dean of the School of Nursing at. Vanderbilt University. She'11 discuss the implications of the Medicaid regulations for hospital emergency and trauma care capacity, including whether States or localities will be able to hold hospitals harmless against the loss of Federal funds that will result from the regulations. Dr. Roger Lewis is an Attending Physician and Professor in the Department of Emergency Medicine at Harbor-UCLA Medical Center. He will discuss the connections between emergency department crowding, surge capacity and disaster preparedness. He will also discuss the impact of the Medicaid regulations on his hospital, which participated in the majority staff snapshot survey. Dr. Lisa Kaplowítz ís the Deputy Commissíoner for Emergency Preparedness and Response at the Virginia Department of Health. She will present the State perspective on emergency preparedness in response to mass casualty events, including the lessons learned from the Virginia Tech shootings. We're pleased to have you all here today. vüe welcome 408 409 41"0 you to our hearing. It's the policy of this committee that HGO126.000 PAGE 20 4tt 41-2 41-3 41-4 all $/itnesses that testify before us do so under oath. So if you would please rise and raise your right hand, I would appreciate it. [Witnesses sworn. ] will indicate that each of 41-6 the witnesses answered in the affirmative. Your prepared 4t7 statements will be made part of the record in fu11. What 4]-8 we'd líke to ask you to do is to acknowledge the fact that 4t9 there's a clock that will be running, indicating 5 minutes. 420 For the first 4 minutes it will be green, for the last minute 42L will be orange, and then when the time is up it will be red. 422 And when you see the red light we would appreciate it if you 423 would try to conclude your oral presentation to us. If you 424 need another minute or so and it is important to get the 425 points across, w€'re not going to be so rigid about it, but 426 this is some way of trying to keep some time period that's 427 fair to everybody. 428 Dr. Hoffman, 1et's start with you. There's a button on 429 the base of the mike, w€'d like to hear what you have to say. 4]-5 Chairman WAXMAN. The record HGO]_26.000 430 STATEMENTS OF BRUCE HOFFNIAN, VüALSH SCHOOL OF FOREIGN GEORGETOWN PAGE 2a PH.D., PROFESSOR, EDMUND A. PROGRÄM, 43r 432 433 434 435 436 437 SERVICE, SECURITY STUDTES VüAYNE UNIVERSITY; ,JAY MEREDITH, M.D., PROFESSOR AND CHAIRMAN, DEPARTMENT OF GENERAL SURGERY, WAKE FOREST UNIVERSTTY BAPTIST MEDICAL CENTER; . COLLEEN CONWAY-TiüELCH, PH.D., PH.D., DEAI\T, VANDERBILT SCHOOL OF NURSING; ROGER LEVüIS, DEPARTMENT OF EMERGENCY M.D., MEDICINE, HARBOR-UCLA MEDTCAL CENTER; AND I-,ISA KAPLOVüITZ, ,M.D., DEPUTY COMMISSION FOR 438 439 EMERGENCY PREPAREDNESS AND RESPONSE, VIRGINTA DEPARTMENT OF HEALTH 440 STATEMENT OF BRUCE HOFFMAN, PH.D. 44L 442 443 444 445 446 447 448 449 450 45L Mr. HOFFMAN. Thank you, Mr. Chairman, for the opportunity to testify before this committee on this important issue. As a counterterrorism specialist and a Ph.D., not an M.D., let me share.with the committee my impressions of the unique challenges conventional terrorist bombings and suicide attacks present. This is not a place to have a wristwatch, Dr. Shmuel "Shmulik'r Shapira observed as we looked at X-rays of suieide bombing victims in his of f ice in .Terusalem's Hadassah Ein Kerem Hospital nearly 6 years ago. The presence of such foreign objects in the bodies of his patients no longer HGOI_26 .000 PAGE 22 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 surprised Dr. Shapira, a pioneering figure in the field called terror medicine. lve had cases with a nail in the neck or nuts and bolts in the thigh, a ball bearing in the skuI1, he recounted. Such are the weapons of terrorists today, nuts and bo1ts, screws and ball bearings or any metal shards or odd bits of broken machinery that can be packed together with enough homemade explosive or military ordnance and then strapped to the body of a suicide terrorist dispatched to attack any place people gather. Accerding to one estimate, the total cost of a tlpical Palestinian suicide operation, for example, is about $1-50. Yet for this--yet this modest sum yields a very attractive return. On average suicide operations worldwide ki11 about four times as many persons as other kinds of terrorist attacks. In Israel the average is even higher, inflicting six times the number of deaths and rouglnl-y 26 times the number of casualties than other acts of terrorism. 469 Despite the potential array of atypical medical 470 contingencies that the United States health system could face 47r if confronted with mass casualty events, MCE, resulting from 472 terrorist attacks using conventional explosives, it is not 473 clear that we are sufficiently prepared. Historically the 474 bias and most MCE planning has been towards the worst case 475 scenarios, often containing weapons of mass destruction, such 476 as chemical, biological, radiological and nuclear weapons, on HGO126.000 477 478 479 480 48]482 483 484 485 PAGE 23 the assumption that any other MCEs, including those where conventional explosions are used, could simply be addressed as a lesser included contingency. By contrast, Israeli surgeons have found that the metal debris and other anti-personnel matter packed around the explosive charge causes injury to victims, victims that are completely atypical of other emergency traumas in severity, complexity and number. Unlike gunshot wounds from high velocity bullets that 486 generally pass through the victim, for instance, these 487 secondary fragments remain lodged in the victim's body. 488 Indeed, although much is known about the ballistic 489 characteristics of high velocity bullets and shrapnel used in research has yet to be done on 490 miJ-itary ordnance, very little 49t the ballistic properties of the improvised and anti-personnel 492 materials used in terrorist bombs. The over pressure caused by the explosion is especially 493 494 damaging to the air filled organs of one's body. For this 495 reason the greatest risk of injury are to the lungs, 496 gastrointestinal tract and auditory system. The lungs are 497 498 499 500 501 the most sensitive organ. And ascertaining the extent of damage can be particularly challenging given that signs of respiratory failure may not appear until up to 24 hours after the explosion. And over 40 percent of victims injured by secondary HGO126.000 PAGE 24 502 503 504 505 506 fragments from bombs suffer multiple wounds in different places of their body. By comparison fewer than 10 percent of gunshot victims typically are wounded in more than one place on their body. A'single victim may thus be affected in a variety of radically different ways. 507 In addition, severe burn injuries may have been 508 sustained by victims on top of all the above trauma. Thus injuries account for 25 percent of terrorist victims 509 critical 51_0 in Israel overall compared with 3 percent with 511_ nonterrorism- related inj uries . Australia's principal experiences with terrorist MCEs 51-2 51_3 has primarily been as a result of the Octobter 2002 bombings 5r4 in Bali, Indonesia, where 9l- Australian citizens hrere killed 51-5 and 66 injured. The survivors hrere air lifted to Darwin where the vast majority were treated at the Royal Darwin 51,6 51-7 Hospital. 518 549 520 52]522 523 524 525 526 Forty-five percent of these survivors were suffering from major trauma and all had severe burns. The large number of burn victíms presented a special challenge to the Roya1 Darwin ltospital, âs indeed no one hospital in the entirety of Australia had the capacity or capabilities to manage that many blast and burn victims. Accordingly, the Australian medical authorities decided to move them to other hospitals across Australia. Irondon's emergency preparedness and response ín the HGO126.000 527 PAGE 25 event of terrorist MCEs had been based on New York City's 528 529 530 53L experience with the 9/LL attacks. However, the suicide bombings of the three subway cars and bus on 7 'Ju1y 2005 hlas 532 533 534 535 536 537 538 s39 540 544 542 543 544 545 546 547 548 549 550 55L a significantly different medical challenge. In New York City on 9/11- many persons died and only a few survived. The opposite occurred on 7 / 7 when only a sma1l proportion of victims lost their lives, 52 persons tragically, but more than 10 times that number were injured. London's long experience with lrish terrorism, coupled with extensive planning, driIls and other exercises ensured that the city's emergency services responded quickly and effectively in a highly coordinated manner. But even London's well-honed response to the MCE on 7/7/05 was not without problems. For example, communications between first responders with hospitals or their control rooms were not as good as they should have been, which resulted in uneven and inappropriate distribution of casualties among area hospitals. What emerges from this discussion the medical communities emergency response and preparedness for terrorist MCEs involving conventional explosions and suicide attacks are two main points: First, that there are lessons we can learn from other countries' experiences with terrorist bombings and suicide attacks that would significantly improve and speed our recovery should terrorists strike here. HGO126.000 552 s53 554 555 556 557 558 559 560 561_ PAGE 26 Israel, Australian, Britain and others are highly relevant examples. The second is that the best way to save as many lives as possible after a terrorist bombing or suicide attack is for physicians and other health care workers to undergo intensive training and preparation before an attack, including staging 562 563 564 565 566 567 s6B s69 570 57L 572 573 574 575 5'76 drills at hospitals to cope with sudden overflow of victims with a variety of injuries from terrorist attacks. Medical professionals and first responders must also understand that the specific demands of responding to bombings and suicide attacks are uniquely challenging. Death and injury may come not only from shrapnel and projectiles, but also from collapsed and pulverized vital organs, horrific burns, seared lungs and internal bleed.ing. It is crucial that emergency responders evaluate their response protocols and be prepared for the unusual circumstances created by bomb attacks. Moreover, given the increased financial stress on our Nation's heal-th system in general and urban hospitals in particular, any degradation of our existing capabilities will pose major challenges to our Nation's readiness for attack. Indeed, the opposite is required, a strengthening of our capabilities of hospitals and for the emergency services that we require to effectively respond to a terrorist MCE involving conventional bombing and suicide attacks. HGO 126.000 PAGE 27 577 Thank you. 578 [Prepared statement of Mr. Hoffman follows:] 579 ******** INSERT 1-1 ******** HGOr_26.000 PAGE 28 580 581_ Chairman VüAXtvlAN. Thank you verîy much, Dr. Hoffman. Dr. Meredith. STATEMENT OF JAY ÏdAYNE MEREDITH, M.D. 582 583 584 585 586 587 588 589 590 5 91_ 592 s93 594 595 596 597 598 599 600 6 01_ Dr. MEREDITH. Thank you, Chairman Waxman, Representative Shays, distinguished members of the community, and guests. Thank you for the opportunity to appear before you today to discuss the impact of the proposed Medicaid regulations \^re have on trauma centers and trauma center preparedness ín our country. My name is Ïrlayne Meredith. I' m the Chairman of the Surgery Department at lrlake Forest University School of Medicine, and I volunteer as the Medical Director of Trauma Programs at the American College of Surgeons. What is trauma? Trauma is a major public health problem of which I am sure you are aware, but want to emphasize for you it is. the number one killer of people under the age of 44. That means if your children or grandchildren are going to die the reason they are going to die is most 1ikely going to be from an injury. And the appropriate best way to keep that injury from happening is to have them treated in a trauma center, to make a trauma center available to them. That's been shown to reduce their risk of dying from a HGOI_26.000 PAGE 29 602 603 604 605 606 607 608 serious 25 percent. That's better than many other treatments that we consíder standard treatment for anr¡ other condition. It is not standard treatment across America today because trauma center care, the systems are disorganized, the availability of trauma centers for providing that system are disorganized. Trauma care is emergent, but not all emergency care is It requires a 609 trauma care. These are serious injuries. 610 leve1 of readiness of the hospital, it requires a level of 6tL expertise of the people to be there to make it so that they 612 can be available when it occurs 61-3 I've had. the great privilege of treating well over 6t4 l-0,000 patients over the years who have survived and overcome 6 1_5 signif icant injuries. .fust a sma1l sampling of those 616 patients include such patients as Greg Thomas, who was a 6t7 4O-year old social worker riding to work. He was struck by a 618 car and severely injured, he was wish-boned, tearing your leg 61,9 apart and splitting your body halfway up the middle. He--he 620 had a crushed chest, his pelvis was broken in two, his left 62L 1eg finally had to be amputated, but he was able to survive 622 because he got to a trauma center immediatefy, he had the 623 kind of care he required. He now comes back to vofunteer at 624 our hospital to help with the psychological help for other 625 people that are being treated there. ,Josh Brown was being a good Samaritan, stopped to help 626 HGO]_26.000 PAGE 30 627 628 629 630 631 a tire, was struck by a car while he was doing that. Arrived bleeding to death in shock, and he had available to him a team of people waiting 24/7 to be available to take care of him and is therefore able to be someone change discharged. And a story I particularly 632 633 like, ilason Hong was a 634 63s 636 637 638 639 student at our co11ege. He worked--he was working in his family's convenience store in town. The convenience store r,.ras robbed. He was shot in his thigh, striking a major artery and vein in his thigh and was bleeding to death from that. Took him to the trauma center immediately. V'Ie opened his 1"9, stanched the bleeding which was profuse. Repaired those injuries by taking vein from his other 1eg and placing 640 641, 642 643 644 645 646 647 648 649 650 651_ it there. He survived, and, kept his 1eg. Now he ultimately came back to d.ecide he wanted to be a doctor. He is now graduating from medical school this May and he will be joining our residency and starting to be a surgery resident in ,Ju1y of this year. Trauma centers have to be prepared to respond on a minute's notice for all kinds of trauma, including those of terrorist attacks. They are the baseline of readiness, in my opinion, for any sort of capability to be prepared for the everyday type of terrorism that we can expect. Are they ready? Unfortunate--and could they meet the surge of 450 type victims that occurred at 9/LL? I think the HGOI_26. 000 PAGE 31- 652 6s3 654 655 result--the answer to that is no. We're not ready to be able to surge at that 1eve1 the way trauma centers are set up today. Saving people--there are other studies the National Foundation for Trauma Care, which I was the founding member 6s6 657 6s8 6s9 660 661, 662 663 664 of the board, also did a study about a year and a half ago which showed that our overall preparedness with trauma centers is about C-minus, íf you look at that, for being prepared in our trauma centers to surge to a terrorist event. Saving people from the brink of death, however, ot from everyday trauma, even a terrorist attack, is costly and it's resources intensive but absolutely necessary. Our trauma care delivery system has several requirements all of which must be met. 66s 666 667 Coordinated trauma system care. I talked in the very beginning statement that got you off track, Mr. Shays, extemporaneously talked about our lack of a coordinated system across our country. It is a very patchhlork quilt of system currently and it needs to be organized. The workforce issues. Trauma surgeons are in great 668 669 670 67L 672 673 ç74 675 676 debt. We have a tremendous lack of trauma surgeons. Over half of our surgery--of our trauma fellowships go unfi11ed, we have no nurses. V'Ie have--if you more than regionalize trauma care there are not as many neurosurgeons in America today as there are emergency rooms in America today. There Hco126.000 677 32 678 679 680 6 81_ 682 683 684 685 686 687 688 689 690 691, 692 693 694 69s 69.6 697 698 699 700 70L is not one--if they stayed in the house all the time, lived there, were chained there, could not Ieave, there aren't as many neurosurgeons in America as there are emergency rooms. I¡'Iorkforce shortage is going to be something that you--that we'11 be facing dramatiJally going forward. Trauma centers have to have sufficient resources to care for all their victims and to do the cost shifting it takes to take care of the uncompensated care and prepare for them. vüe must be prepared for the trauma that we see every day. ,Jason Hong gets shot in the 1eg on an everyday basis. We need to be prepared for the catastrophic events, the bridge collapses that occurred in Minnesota. VrIe need to prepare for natíonaI disasters whether they are Katrina 1evel or just earthquakes or tornados. And we need to be prepared for the major events that could occur from terrorísm, which I think are more like1y to be bombing in a cafe than they are an anthrax attack or some major bio event, I think is much more 1ike1y. So trauma centers are threatened by that. The effects of the Medicaid changes will be dramatic in our hospital. It is estimated it will cost us--let me see. Medicaid regulations is not something--it will be $36 million from our hospital. It currently costs about ç4-l/2 million of infrastructure to keep the trauma center alive. And we use about $13 million in costs in uncompensated care. Add to that $36 million our trauma center will go under. I¡üe will HGO126.000 702 PAGE 33 703 704 not be a part of the infrastructure for health care in our part of the region. We serve western--a11 of western North Caro1ina. So with that I'11 truncate my remarks and thank you for I just beg you to stop the Medicaid cuts and enact 706 this. fu11y funded the trauma 707 H.R. 561-3, the Dingell-Murphy biII, 708 systems planning program and ensure maintenance of systems 709 and adequately fund H.R. 5942, the 7r0 Towns-Burgess-Waxman-Blackburn legislation, and fully fund 7 1"1 the hospital preparedness program and hospital partnership 712 grants to ensure the highest leve1 of preparedness, funding 7L3 for all hospitals and most particularly for trauma centers. 7:l.4 I want to thank the committee for having these hearings and 71-5 to thank you for having me participate in them. 716 IPrepared statement of Dr. Meredith follows:] 705 717 ******** INSERT 1--2 ******** HGOI_26.000 PAGE 34 7r8 71-9 Chairman WAXtvlAN. Thank you very much, Dr. Meredith. Dr. Welch. STATEMENT OF COLLEEN CONV'IAY-WELCH, PH.D. 720 72L 722 723 724 725 726 727 728 729 730 734 732 733 734 735 736 737 738 739 morning. My name is Colleen Conway-Vüelch. L' ve been Dean at the School of Nursing at Vanderbilt for 24 years. Chairman V'IA)$4AN. Would you pulI the mike just a little closer? You don't have to move closer, pu11 the mike closer. Dr. CONüIAY-I^IELCH. Thank you. Over the last decade, however, I have taken a special interest in the area of emergency preparedness. I am here today to make the link between the consequences of reduced Medicaid funding, a fragmented public health infrastructure, and a reduced level of emergency preparedness, and to urge the committee to recommend a moratorium on these actions until at least March of 2009. I want to make three specific points about ímplementation of the following three changes, limiting Medicaid payments to public providers on1y, dropping Medicaid funding for graduate medical education and limiting Medicaid dollars for services in out patient settings If the changes anticipated for May 26Lh occur, it will Dr. CONWAY-WELCH. Good HGOr-26.000 PAGE 35 740 74L be virtually impossible to fix these rules legislatively DHHS in a will be hard pressed 742 to effectively respond HSPD 21, which directs the Department 743 to look at regulations that impact emergency preparedness. If Medicaid dollars are reduced in these three areas, a 744 745 reduction in personnel and readiness wí1I occur in our 746 hospitals and emergency departments across the country and, 747 even worse, it will occur in the midst of a serious and 748 intractable nursing and nursing faculty shortage and limit 749 our abílity to respond to a disaster, particularly a blast or 750 explosive injury with serious burns. 75L It is also reasonable to assume that States, includíng 752 Tennessee, will not hold the providers harmless if Federal 753 matching funds are 1ost. There would be no easy way to 754 redirect or make up money to those who are losing it, such as 755 the medical schools and safety net provider hospitals. Even 756 if the State were able to redirect State dollars to areas 757 e1ígib1e for a Federal match, those funds would most like1y 758 be distributed in Tennessee to the managed care organízations 759 and then be part of the overall payment structure of all of 760 our hospitals. 76r I want to speak no$r specifically to the three changes. 762 Number one, limiting p.ayment only to providers who are a unit 763 of government puts our rura1, community, private, and 764 501 (c) (3) hospitals at even greater risk since they must rushed and piecemeal manner. And HGO126. 000 36 765 766 already pick up the slack of escalating numbers of uncompensated care and are tied to a public health 767 infrastructure that is increasingly unfunded, unavailable and In Tennessee this would result in 768 marginally functional. 769 only one hospital, Nashville Metro General Hospital, being 770 included. The TennCare Medicaid program would lose over $200 77t million per year in matching funds. This would put al-I of 772 the hospitals in Tennessee, except Metro General, in a 773 position of cost shifting and service reductions, as well as 774 limiting access even further. For example, Vanderbilt already provides more than ç240 775 I to million a year in uncompensated care. Tiühile I'm discussing 777 Tennessee, these are issues across the country. All disasters are local, that is true, and conventional 778 779 explosive attacks are especially loca1. The casualties are 780 immediate and nobody should expect outside help for at least 78L 24 hours. Only a true system of local, functional, 782 systematically linked emergency departments and hospitals can 783 address the casualties of this most probable form of attack. Proposal tlrro, eliminating Federal support for graduate 784 785 medical education programs will resul-t in a reduction of 786 medical residents in a wide variety of settings, including They will also 87 ERs, trauma burn and intensive care units. 788 not have the support of my skilled trauma nurses since these 789 numbers will be reduced as well. '7 HGO126.000 PAGE 37 790 As an example, in Tennessee the four medical schools in the State would lose ç32 million annually. These schools 792 also serve as the safety net providers and would be forced to 793 reduce their numbers of students. Proposal three, limiting the amount and scope of 794 795 Medicaid payment for outpatient services will weaken our ER 796 ability to handle a surge of victims. Our large hospitals 797 will quickly experience automobile gridlock. ft is also absurd to think about evacuating hospitals in 798 799 a time of disaster with the high acuity 1eve1 we maintain At 800 every single d"y, including patients on ventilators. I0L Vanderbilt, for example, the burn unit and the ICUs are 802 already at capacity. If disaster hits, health care providers 803 will need to be dispatched to community and rural clinics to 804 help theq care for patients with serious injuries who cannot 80s be transported or accommodated by hospitals. As clinics, w€ 806 do services and personnel commensurate with reduced Medicaid 807 do11ars. Their ability to avoid triage and care to patients 79r will be significantly impacted. Federal disaster preparedness money that comes to 809 Tennessee is much appreciated. However, Federal money does 81- 0 I 1-1 not require an outcome of increased documented operatiåna1 81_2 capacity building and it should. Tabletop exercises are I 1_3 marginally useful, are an income opportunity for Beltway 8r4 bandits. However, lessons learned from one exercise are not 808 HGO126.000 815 PAGE 38 necessarily apptied to the next. To many health care professionals of both political 816 8r7 parties in the field of emergency preparedness, it appears 818 that DHHS and DHS do not have a mechanism to assess and monitor the extent to which States, counties and cíties have 8 1-9 820 the capability and game plan in place to respond to a 82t disaster such as a blast explosion and are not able to 822 provide guidance on which to base these p1ans. 823 824 825 826 827 There is no one place anywhere in our Nation or at any leve1 of government where one can go to receive reliable 828 829 830 831_ 832 833 834 835 836 837 838 839 information on resources; for example, how many burn beds there are in Tennessee or how many ICU beds there are in Nevada. There is no one-stop shop to answer it on a Federal level and disasters are frequently not limited to one State. So regional statistics and information are needed. For example, Tennessee has 48 burn beds, 28 of which are at Vanderbil-t and the eight Southeast States have a total of 240, but I had to go to the American Burn Association to get those numbers. In summary, I am encouraging a moratorium on these Medicaid changes, a requirement that coordination between and among various Federal, State and local entities be enhanced to achieve a double whammy; namely, improving emergency preparedness response while improving the fractured publíc health infrastructure. It is important to point out that HGO]_26.000 39 840 ð4 t_ continued cuts to providers negatively impact every servlce a 842 843 844 845 846 847 848 849 850 85L 852 853 854 855 8s6 857 858 859 860 I61_ 862 863 hospital provides. Vanderbilt has historically soaked up these reductions and looked for other sources of revenue, but that is becoming more and more difficult. It is logical to assume that we would have to cut such programs as helicopter transport, HIV/AIDS programs and certain medical and surgical specialties, including emergency preparedness. We now support emergency preparedness in a robust wây, but we would need to limit our participation and regional drilIs and internal administrative planning, âs well as reduce our commitment or eliminate stockpiling of medical supplies and equipment that are critical. In conclusion, please extend the moratorium until next year. Charge DHHS and DHS to thoughtfully work together to address the declining public health infrastructure from the prospective of improving our emergency preparedness, and urge that the rules be withdrawn since Congress did not direct their propagation. A simple and immediate cut in Medicaid funding to these three areas is not a thoughtful solution, will not work and will have a devastating effect on our hospitals and providers to respond in a disaster. In the final analysis if these rules are enacted as proposed when our citi zens need us most, w€ will not be there. Thank you. HGO126.000 864 PAGE ] 40 IPrepared statement of Ms. Conway-Vüelch follows: 865 ******** INSERT l_-3 ******** HGO126.000 866 867 PAGE 4T Chairman WAXMAN. Thank you very much, Dr. Welch. Dr. Lewis. STATEMENT OF ROGER 868 LEWIS, M.D., PH.D. 869 870 87l. 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 Dr. LEWfS. Mr. Chairman, members of the committee, thank you for inviting me. My name is Roger Lewis. I'm a Professor and Attending Physician at the Department of Emergency Medicine at Harbor-UCLA Medical Center, and I've been working as a physician at that hospital since 1,987. Harbor-UCT,A Medical Center is a publicly fund.ed Level ltrauma center and a teaching hospital. I¡'Ie're also a Federally funded disaster resource center and in that capacity work with eight of the surrounding community hospitals to ensure disaster preparedness and, in the event of a disaster, an effective disaster response serving a population of approximately 2 million people. I¡{e're proud of that work and believe it is important. Over the last 5 or 10 years my colleagues and I at Harbor-UCLA have witnessed an extraordinary increase in the demand for emergency care services of all t)¡pes. Vüe have seen an increasing volume in the number of patients who come to our emergency department and in their degree of illness and their need for care HGOI_26..000 PAGE 42 888 889 890 891 892 893 894 B9s 896 897 898 899 900 9 01_ 902 903 904 905 906 907 908 909 910 9II 91-2 At the same time \¡/e've had a constant decrease in our available inpatient hospital resources and this has predictably 1ed to a frequent occurrence of emergency department gridlock and overcrowding. Patients wait hours to be seen, ambulances carrying sick individuals are diverted to hospitals that are farther a\^Iay and admitted patients in the emergency may wait hours or days for an inpatient bed. Now I became an emergency physician because I wanted to be the kind of doctor that could treat anybody at the time of their greatest need. And similarly, my institution is proud of its work as a disaster resource center because it wants to be the kind of institution that can provide for the community as a whole in its time of greatest need. It never occurred to me during my training that I'd be in the position in which patients that I knew clearly needed to be treated in minutes instead had to wait for hours, that ambulances carrying sick patients would be diverted to hospitals farther ahlay, or that we would pretend'that hospitals that have no available beds and a full emergency department would have adequate surge capacity to respond to the most like1y type of mass casualty incidents; namely, the results of a conventional explosive. Yet that is exact the situation in which we find ourselves. Now in trying to think about how to illustrate this situation several people suggested to me that I give an HGO126.000 9 1_3 PAGE 43 anecdote, that T teI1 a patient's story. And without detracting from the important examples that have been given 9 l_5 by the other panel members, I would just like to comment that 9t6 I don't think any single patient's story really captures the 9t7 scope and the impact of the problem. This is the situation in which one has to think carefully about the meaning of the 9l_8 9L9 statistics that are widely available. In fact, yesterday's anecdote, those stories about 920 92L individuals who deteriorate in the emergency department or on 922 the way to the hospital because their ambulance has been 923 diverted, a,re rea11y today's norm. These events are 924 happening every day. Right no\^I an ambulance in this country >23 is diverted from the closest hospital approximately once 91-4 926 g27 every minute. There is a common misconception that emergency 928 929 930 department overcrowding is caused by mísuse of an emergency department by patients who have routine illnesses or could be 93L 932 933 934 935 936 937 treated in urgent care settings. This is clearly not true. Numerous studies done by nonpartisan investigators have shown that only 1-4 percent of patients in the emergency department have routine illnesses that can be treated elsewhere. And much more importantly, those patients use a very small fraction of the emergency department resources and virtually never require an inpatient bed. Emergency department overcrowding is a direct result of HGO126.000 938 PAGE 44 inadequate and decreasing hospital inpatient capacity. It is 939 940 94]942 a hospital problem, not an emergency department problem. There is a direct cause and effect relationship between the hospital resources, inpatient capacity, emergency department overcrov¡ding and surge capacíty. The hospital preparedness program, a Federally funded program that is intended to increase disaster preparedness, 943 944 945 946 947 has focused on bioterrorism and on the provision of supplies and equipment for partiiipating 948 949 950 951- 952 9s3 954 955 9s6 957 958 959 960 961 962 hospitals. And whereas these things are important, they focus on one of the less probable t14pes of mass casualty incidents and do not in any way directly address surge capacity. For my hospital the proposed Medicaid rules are estimated to result in a 9 percent decrease in the total That would have an exponential funding for the institution. effect on the degree of overcrowding and directly resul-t in reductions in our inpatient capacity. For Los Angeles County as a whole the projected impact is ç245 million. That would require a reduction to services equal to one acute care hospital and trauma center. V'Ie have already witnessed what happens in our area with the closure of such a hospital. So in summary, hospitals and emergency departments across the United States increasingly function over capacity and prior fiscal pressures have resulted in a reduction in the number of inpatient beds and overcrowd.ing. Current HGO126.000 963 964 PAGE 45 Federal programs intended to enhance disaster response 96s 966 967 968 969 970 971 972 capability have emphasized supplies and equipment and it largely ignored surge capacity. The proposed Medicaid regulations will directly result in further reductions in hospital ED capacity and ironically specifically target the trauma centers, teaching hospitals and public institutions whose surge capacity we must maintain if they are to function at the time of a disaster. Thank you very much, Mr. Chairman. fPrepared statement of Dr. Lewis follows:] ******** INSERT 973 I-4 ******** HGOI-26.000 974 PAGE 46 RPTS MERCHANT DCMN SECKMAN 975 976 977 Chairman WAXMAN. Thank you very much, Dr. Lewis. Dr. Kaplowitz. [Prepared statement of Dr. Lewis follows:] 978 979 ******** INSERT 2-1_ ******** HGOI_26. 000 PAGE 47 980 STATEMENT OF LISA I(APLOWÏTZ, M.D. 981_ 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 l_000 1_001 1,002 Mr. Chairman, Members of the Committee. I'm Lisa Kaplowitz. I'm Deputy Commissioner for Emergency Preparedness and Response for Virginia Department of Health. In that role, I'rTr responsible for doth the public health and health care response to any emergency. And we take a very all-hazards approach to emergencies in Virginia. Virginia is large and diverse and has been impacted by any number of emergencies since 9/Ll. Certainly v/e were impacted by the Pentagon, which is located within Arlington County, but we have experienced the anthrax attack, sniper episode, Virginia Tech and multiple weather emergencies. A few lessons from g/i-i-. First of all, this truly was a mass fatality event, not rea11y a mass casualty event. But we certainly have learned that one key to response is coordination of all the health care facilities in the area, cross borders in the national capital region,- that's Virginia, Vüashington, D.C. and Maryland. And we all need to work together, both in the NCR and throughout the Commonwealth. I^Ie knew we needed a much improved communication system among health care facilities and with public health communications rea11y was inadequate during I(APLOVüITZ. Good morning Dr. HGOI_26.000 r_003 1_004 PAGE We 48 9/Il. mass had no back-up communications present. V'Ie needed a fatality p1an, and we needed to include mental- health planning in all emergency planning. 1_0 05 1006 The Congress allocated funds for both public health and 1007 health care preparedness as a result of 9/ll and anthrax. I 1_008 won't spend a lot of time on the public health 1009 preparedness--I'm responsible for that--except to mention l-010 that we have coordinated our public health and health care 1011_ response. They work very closely together. t012 In terms of our health care system preparedness, the key to our success has been partnership with the hospital 0 1_3 1_014 association which contracts with hospitals throughout the t_015 Commonwealth, and we got buy-in from the hospitals very quickly. VrIe also do regional planning. We have three 101_6 hospital planning regions, a hospital coordinator and a 1,0L7 regional coordinating center for each of our regions. 101_8 The funding from ASPR has been very, very valuable. 1_01_9 1,020 It's enabled us to purchase redundant communication systems ao2L for hospitals, to develop a statewide Web based tracking 1-022 system. We can norr.r track beds in a realtime basis throughout ao23 the Commonwealth during any emergency. We've purchased ao24 supplies and equipment often done on a regional or statewide that are to25 basis. This has included portable facilities 1,026 located in four regions of the Commonwealth and can be moved L027 all around. V'Ie've purchased ventilators that are the same 1_ HGO1,26.000 PAGE 49 lo28 to29 103 0 103 1 ]-032 r_033 1034 103 5 1036 1037 103 8 103 9 1_040 104l_ to42 1_043 to44 1_045 LO46 ]-047 to48 to49 1050 105 1 ]-052 ventilators statewide that are being used in hospitals so people know how to use them. We've purchased over 300 ventilators for use in a surge. We've purchased antivirals and antibiotic medication located in hospitals. And we've developed a volunteer management system. Before I move on to trauma and burn care systems, I do want to say that the ASPR funds are very valuable but are only a fraction of hospital funding for emergency response. The trauma system in Virginia was established in 1980. We now have five Level 1 trauma centers, three Level 2 and five Level 3 centers in the Commonwealth. vüe have three burn centers, for a total of 37 burn beds within the Commonwealth. Our general assembly did a study in 2004 documenting a large amount of unreimbursed trauma care. In 2003, it amounted to over ç44 mi11ion, and r know it's vastly greater than that 5 years 1ater. As a result of this study, the general assembly did create a trauma fund which helps with our reimbursed care but, again, only provides a fraction of unreimbursed care. It's based on fees for reinstatement of driver's license and DUI violations. I do want to talk a 1itt1e bit about lessons learned from Virginia Tech. Nobody expected to have a shooting event, a mass shooting event in rural Virginia, such as occurred a year ago. What many people don't realize is that, because of the winds and the sno\¡¡, none of the injured could HGO]_26.000 1_0s3 1_054 1_0ss PAGE 50 2 3 be transported to a Level l- trauma center or even a Level trauma centers; on€ was not a designated trauma center. had planned for this, recognizing that all facilitíes trauma center. The three closest hospitals, two were Level V'Ie 1056 ]-057 need 1058 1059 1060 1061_ 1062 1_063 the capability of handling trauma care. And \,rre're very proud of the fact that none of the injured transported to hospitals from Norris HaII died. That's due to our coordination of EMS, as well as hospitals, public health and our regional coordinating center. So some of our lessons learned from Virginia Tech concerning mass trauma include the need for coordination of all parts of public health in the health care system. 1,064 1065 Cross training is key. This has been mentioned already. In a mass casualty event, all facilities need to be able to to67 handle trauma care. That not only involves supplies but i_068 training of staff in all facilities. We have purchased 1-069 supplies for all facilities in the Commonwealth to handle a 1070 certain level of trauma and burn care. We know that burn ro71- care will be key here, and we want all facilities to be able 1,072 to handle that. And we need a real time patient tracking l_073 system which didn't exist, and we're working very closely on LO74 that noh/ so that patients can be tracked from the time EMS picks them up until the time they're in the hospital and, 1_075 L07 6 unfortunately, for our chief medical examiner as wel1. I,tle're L077 very fortunate to have a very strong Medical Examiner's to66 HGO126.000 1_078 PAGE 51 Office because this was a crime scene and had to be handled to79 as a crime scene, and they handled it very welI. We need to recognize that at any mass casualty event, 1080 So, in terms of trauma surge 1_081_ there will be fatalities. !082 planning in Virgínia, we've focused on a number of different 1_083 aspects here: 1084 l_085 l_086 l_087 Again, as I mentioned, purchase of key supplies and medications for burn and trauma care in all facilities, and this has been very basic, looking at basic supplies to be stockpiled. Training of physicians and staff in all hospitals to provide basic trauma and burn care, because t,rre don't know l_089 where trauma is going to occur, and we'Il need the help of 1_090 1-091 all our facilities. Training of EMS and hospital staff on appropriate t092 1_093 triage. Unfortunately, during a mass casualty event, wê ]-094 v/on't have the luxury of transporting people to solely our 1-095 trauma centers. But üre're ver)¡ dependent on these centers to have the expertise that they can then use to train others. 1-096 l.097 And we need mass fatality planning as a component of L098 mass casualty planning. I \n/as asked to make a few comments about our recent l-099 t_l_00 tornadoes. I¡'Ie were fortunate; nobody died as a result of l_l_01_ those tornadoes, and there were only three serious injuries. L1,02 But I will say that there was excellent communication among 1088 HGO126.000 L1_03 PAGE 52 the hospitals in the area. Once again, this was a very ruralLto4 area. They communicated we1l. lve ca11ed on our medical reserve corps to heIp. Our public health folks vrere l_l_05 l_106 available immediately and are working in the area no\¡¡. So LtoT our planning has really paid off there. A few comments in summary. llospital and health system l_l_ 0 8 l_l_09 emergency preparedness can be achieved only through close l_l_1_0 collaboration and regional planning efforts for public health and health care. There must be a system prepared to respond, Ltt2 especially for mass casualty and fatality events. 1_3 Preparedness is tested not only through exercises but through LIL4 actual- events. We do an after-action report for every single 1_1-15 event and take our lessons learned to modify our pIans. A l.1,r6 coordinated trauma system is essential, but we have to have a 1.II7 well thought out trauma and health care surge plan to effectively respond to large-scale events. Trauma care IIt9 provided only through designated trauma centers will not be 1,r20 adequate, but we need those centers as resources to train l_ 1_ l_ l_ 1_ 1- 1_1_1_8 1,I2I 1,r22 others. V'Ie desperately need continued Federal funding for public TI23 tL24 tL25 tL26 IL27 health and health care preparedness. Our CDC and ASPR funds have been very valuable, but I need to point out that it's only a fraction of the moneys used for preparedness. It's a relatively sma1l amount in the Commonwealth. It doesn't even come close to covering, for example, unreimbursed care, and HGO]_26. 000 PAGE 53 r]-28 1,L29 11-3 0 t-131 1-r32 L1-3 3 it's not for operational funding. But it has been very val-uable, and I plead with you not to have further cuts in either CDC or ASPR fundíng. Thank you again for the opportunity to share Virginia's p1ans, challenges and accomplishments, and f'11 be glad to answer questions. IPrepared statement of Dr. Kaplowitz follows:] ******** INSERT IT34 2-2 ******** HGO126.000 1_l_3 54 much. We're going to tt36 proceed with questions where l-0 minutes will be controlled by tt37 the majority; 10 minutes controlled by the minority; and then 113 8 we'Il go right to the S-minute rule. But before I even begin questions, let me just get for 113 9 'J,140 the record something that I'm not sure I fu11y understand, tt4L Dr. Kaplowitz. ÌrÏhat is a Level 1 trauma center? What is a rt42 Leve1 2 trauma center? V'lhat is an emergency room? How do LL43 these all fit in as you plan for emergency preparedness? Dr. KAPLOWITZ. Well, actua11y, many people on the panel 11,44 ]-1,45 are better able to discuss the differences of Level l, 2 and t1-46 3. Level l- trauma centers require expertise to be present within the fatality all the time, to be able to handle any 1,147 1,148 level of trauma. Level 2 and Level 3, some of that expertise ]-1"49 can be outside the facility but available very quickly. So, 1-1-50 again, Level l- trauma centers have tremendous costs just to L1-51 maintain that ability to provide trauma care. And that's a r1-52 big part of what costs a great deal to maintain trauma LL53 centers. It's not only the care per se, but the infrastructure as well as a quality improvement p1an, which 1,1"54 we have a very good one in Virginia. t_1_55 Emergency rooms are places where people can show up for 1_156 tr57 emergency care in any facility, whether they're a designated 1158 trauma center or not. I will say that there are fewer and 1_1_59 fewer designated trauma centers in the Commonwealth because 5 Chairman WAXMAN. Thank you very HGO126.000 r- r_6 PAGE 55 of the cost to maintain a trauma center. It's been very, 1 very difficult and becoming more and more expensive, and ta62 that's been very problematic. Chairman WAXMAN. Thank you very much. l_163 As I indicated in my opening statement, w€ asked the 1-164 1_L65 staff to do a survey of emergency care capacity in seven U.S. At the time of the survey, none of the 34 Level I 1"]-66 cities. 1-167 trauma centers that participated had enough treatment spaces in their emergency rooms to handle the victims of a terrorist 11_68 It69 attack like the one that happened in Madrid in 2004. In 1,L7 0 fact, more than half of the ERs were already operating above aaTa capacity. That means, ofl an average day, patients \^/ere 1472 already being treated in hallwâys, waiting rooms and 1,I73 administrative off ices . Dr. Meredith, should the findings in this survey be of rt14 ]-L75 concerns to Americans? Dr. MEREDITH. Yes, sir. I think the capacity available tt76 tt77 today in our safety net hospitals is a problem, it is a tt78 threat. If you think about a bottle-neck theory, the LL19 patients are building up in the emergency departments, not 1_8 0 because there's so many patients coming to them who shouldn't 1 be there but because there's no place for them to go. The ILB2 ability for our hospitals to absorb them just in terms of l_t-ðJ numbers of beds and numbers of doctors that take care of 4184 patients is lacking. And that's what's causing this 0 1_1_6 1_ 1_1_8 HGO]_26.000 11_85 PAGE 56 1-186 rt8'7 1188 118 9 1_l_90 t]-9a lt92 1193 r1,94 1_195 ttg6 1,1,97 1_198 tL99 L200 L201, buildup. And the other pieces, one of the strategies is to move patients around, but as several of the other people on our panel have said, most of the kinds of patients that are occupying intensive care unit beds, ventilator beds, burn unit beds are not going to be very easily moved. They will be very difficult to move. Arrd to move them from the Level 1 trauma centers and the burn units to other facilities is probably not the best way to manage them. So it's a problem. Chairman V'IA)CMAN. It's been over 6 years since we suffered the attacks on 9/1-1-. Are our emergency rooms prepared to handle a surge of victims that could result from a terrorist attack? Dr. MEREDITH. If you just--no, sir. I will just te1l you from going to trauma center to trauma center, and I've been in a lot of them, there is very little surge capacity available in the trauma centers in the safety net hospitals emergency department overflow overloading and L202 L203 in our country today. of the striking findings of the survey is how overcror^Ided emergency rooms are on a normal day. This d"y, when our staff cal1ed the trauma centers and emergency rooms in the major cities, was just an ordinary d"y, and they \^rere already having overcapacity. They had to treat patients in hallways and waiting rooms. I would like to ask, is overcro\^rding in emergency rooms jeopardizing the Chairman WAXMAN. One L204 L205 L206 ]-207 1_208 L209 HGOL26.000 1,210 1,21,L PAGE 5'7 t2L2 L2t3 t2t4 r2a5 121,6 t2t7 t2t8 t2t9 1-220 122t 1,222 1-223 t224 1-225 1,226 1_227 health of patients and the ability of hospitals to provide the best care possible? Dr. Lewis. Dr. LEWIS. First of all, the day that that survey was conducted was a t14gica1 day, at least in Los Angeles. During that week in the prior 4 days we had been on diversion--I'm sorry, in the prior week, we had been on diversion for more than the equivalent of 4 days. So that was a tlpical situation. It absolutely negatively impacts the availability of the emergency department resources and the ability of patients to receive care for emergent medical conditions. There are delays in treating patients with chest pains, patients with potentially important infections and with a wide variety of illnesses and injuries. Chairman WAXMAN. WelI, the ability to respond to a bombing, such as occurred in Madrid, is called surge capacity. Surge capacity depends on more than just the emergency room. A hospital needs enough resources in places L228 like the intensive care unit and hospital beds. But in the L229 survey by committee staff, the problems extended beyond the r230 emergency room. one major problem is something calIed 1231_ boarding. Could you te11 us, Dr.--who is best? Dr. Lewis. r232 What is boarding, and what impact does this have on emergency L233 room abilities to deal with a surge? L234 Dr. LEhIIS. Mr. Chairman the term boardinq refers to the HGO126.000 PAGE 5B t235 1-236 holding of a patient. Chairman WAXMAN. Is your mike on? Dr. LEWIS. Yes, it is. The term boarding refers to the 1237 1,238 use of emergency department treatment spaces for the holding r239 of patients who are il1 enough to require admission to the L240 hospital, whose emergency care has been completed, they have 1"24]' been stabilized, and who the decision has been made to admit 1242 them into the hospital but there is no room in the hospital ]-243 to treat that patient. Boarding has a number of important a244 effects. The two most important effects are a reduction in ]-245 the quality of care for that individual patient, because they ]-246 are not receiving the ICU care in a comfortable and 1,247 streamlined environment. But more ímportantly from my point a248 of view and the purpose of this hearing is it reduces the ]-249 total effective capacity of that emergency department. On a ]-250 ty¡rical day in my emergency department, for example, 125t one-quarter or as much as a third of the treatment spaces and 1-252 the most intensive treatment spaces may be taken up by a ]-253 boarder once we get to the afternoon hours, and that reduces L254 the effective size of my emergency department by that a25s 4256 percentage. r257 1-258 1-259 in Madrid was a terrorist bombing, just a bombing, and not a--when I say "just a bombing, " not weapons of mass destruction or anything catastrophic other than what a terrorist attack using bombs Chairman VüAXMAN. V'Iell, what happened HGO126.000 PAGE 59 20 1260 1-26r 1262 can producei 89 patients needed to be hospitalized, and needed critical ]-263 L264 1-265 1266 care. But not one of the hospitals surveyed had that many in-patient beds or critical care beds. In fact, the average hospital surveyed only had five intensive care unit beds, just a fraction of the 29 critical care beds Dr. needed in Madrid. Six hospitals had no ICU beds at all. Lewis and Dr. Conway-I¡'Ie1sh, are you concerned about these findings? 1267 Dr. LEhIIS. Obviously I'm concerned about the f indings. 4269 One of the comments that's made in response to data like that 127 0 is this idea that many of those patients could be rapidly L27L moved out of the hospital in the event of an unexpected and L272 catastrophic event. But, in fact, the information on L273 intensive care unit availability is particularly problematic L274 because those are patients that are too ill even to be in the ]-275 normal treatment area of the hospital. So, âs was mentioned r276 by some of my colleagues, those patients are virtually 1,277 impossible to move out. And so those spaces if they are used L27 I are truly encumbered and will not be available even in the L279 setting of a mass casualty incident. Dr. Welsh. L280 L28t Dr. CONWAY-WELSH. There is another issue to that as ]-282 well, and that is automobile gridlock. Many of our emergency 1-283 rooms have not been designed to handle a large influx of 1,284 private vehicles, which is what would happen. And ï know, at !268 HGO]_26.000 PAGE 60 L285 L286 L287 L288 L289 L290 L29L L292 L293 L294 L295 L296 L297 Vanderbilt, if we got 50 cars lined up for our ER, that's it. I mean, they're not going anywhere. So I think that the gridlock íssue as a concern for our emergency rooms is also very rea1. I think Dr. Lewis made an important point when he said that the ER overcrowding, if you wi1l, is actually a hospital problem. And I believe that that is absolutely correct. And we're trying to fix something piecemeal when there's much larger problems, of which you are well ahlare, that realIy need to be addressed in a coordinated fashion bv DHS and DHHS. Chairman V'IAXMAN. Could you expand on that? L298 L299 1_300 1-301 L302 1-303 L3 04 V'Iell, the role of coordination and guidance among those two offices is, frankly, very murky. And there is--if we recall the problems that happened with Katrina, it was sort of a right hand not knowing what the left hand was doing. There was, frankly, nobody to step in as a parent and say, you will play well in the sand box, you Dr. CONVüAY-VüELSH. l_305 t_3 06 L307 1_308 13 09 will get this done. And there was a 1ot of uproar between it's a State issue or a Fed.eral issue or a city issue. That simply has to be stopped. Chairman I¡'IAXMAN. It's been suggested that all of these things are supposed to be handled at the local level. The State ought to be able to coordinate emergency services. The hospitals ought to be prepared for whatever needs they might HGO]_26.000 1_310 1_311_ PAGE 67. have. Some people have said that it won't rea11y matter whether a hospital ER is operating way above capacity or even under diversion. If a bombing occurs, hundreds of casualties 1_313 need immediate care, then the hospital will simply clear out L3A4 all patients who don't have life-threatening conditions. And 1_315 if a local ER somehow can't create enough capacity, then care 13 16 will be available in neighboring hospitals, in nearby 1-31-7 communities or from emergency response teams deployed by the l_318 Federal Government. I wonder, is this grounded in reality, 1-319 or is this an exercise in denial about the lack of emergency L320 care surge capacity at the cities at the highest risk of a t32t terrorist attack? V'Ihichever one of you wants to respond. 4322 Dr. CONWAY-WELSH. I think Tennessee accepts the 1-323 responsibility that we must care for our own citizens 1,324 Frequently there are, particularly with blast explosions that 1325 can occur across State lines. Something else that is a real L326 problem is that, f.or instance, the National Guard, which ]-327 would be caIled up, they wouldn't get there immediately, but 1-328 they would be ca11ed up, rely on the hospitals for a large ]-329 part of their plans for response. 1_330 Chairman VüA)014N. Let me, before my time is expired, but just ask one last question. Because we talked about whether 1_3 3 1332 we're prepared and what the consequences would be for 1_333 Medicaid funding to the States. Medicaid, of course, is ]-334 health care for the very poor. Whether people agree or not 1,312 1_ HGO126. 000 PAGE 62 1335 1_336 about this particular issue on the Medicaid, it will reduce Federal Medicaid revenues to Level l- trauma centers and other 1337 1338 1_339 1_34 0 hospitals throughout the country. Now, when that loss of Federal funds, which probably wiII vary from hospital to hospital, and for some Level l- trauma centers, will these losses be substantial, forcing reductions in services and degrading emergency response capacity? L34t L342 ]-343 ]-344 L34 5 1J.346 L347 1348 1,349 t_350 1_3 5 1_ L352 1353 ]-354 1355 1-356 1_357 l_358 1_359 Dr. Meredith Dr¡ MEREDITH. Without question, that is one of my greatest fears as a result of this, is that the trauma centers which serve as the nucleus for this preparedness piece and for the probl-ems that occur every d"y, every car wreck, the number one killer of Americans under the age of 44, will not be able to survive without--if they have this much drop loss to their bottom 1ine, they \¡ron't be able to do the things it takes to be able to be ready on an every day basis, much less be able to participate in any sort of surge. And that is frightening to me as a trauma surgeon. Chairman T/'IAXMAN- Thank you very much. Mr. Shays. Mr. SHAYS. Thank you very much, Mr. Chairman. Dr. Lewis, are you familiar with research conducted at .fohns Hopkins University and published in the Society for Academic Emergency Medicine that found there are key differences between daily surge capacity and catastrophic HGO]_26.000 PAGE 63 1360 13 61_ surge capacity? Specifically the research found that, quote, daily surge is predominantly an economic hospital-based issue ]-362 with much of the problem related to ín-patient capacity but 13 63 with the consequences concentrated in the emergency ]-364 department. By contrast, catastrophic surge has 13 65 significantly more components. 1366 Do you agree with the statement? 1-367 Dr. LEWIS. I agree with the statement, absolutely. The point that was being made-1_368 1-369 Mr. SHAYS. Translate. Give me some meaning to this. 1-37 0 TeIl me what it means. Dr. LEWIS. I think the distinction that's being made t37t 1372 has to do with the ability of the hospital to respond to ]-373 every day fluctuations in the need for care. For example, r37 4 when there's a multi-car vehicle incident on the 405, and ]-375 many of the hospitals in Los Angeles County have difficulty L37 6 responding to those things but are able to respond by t377 bringing in overtime staff, bringing in staff that aren't L378 usually covered by the budget but for this one time can be L379 brought in to open up beds that although physically availabl-e l_380 are not covered by nursing staff, those kinds of thing. l_3 8 However, doing that on a day-to-day basis over a fiscal year 1,382 dríves the hospítal into the red. And.so there are economic 1383 constraints on our ability to deal with so-caI1ed daily 13 84 surge. In the setting of a mass casualty incident or a t_ HGO]_26.000 85 PAGE 64 disaster surge, obviously there are some extraordinary things question is the 1386 that would be done. I think the critical things could be done and how ]-387 extent with which those critical 8I effective they would be given the number of acutely i11 patients who in fact could not be moved out of the hospital. 1_3 89 1_3 1_-? 1_390 13 91 ]-392 1_3 93 ]-394 13 95 4396 ]-397 1_398 ]-399 1400 1404 ]-402 l_403 L404 ]-405 1-406 ]-407 1_408 Mr. SHAYS. Thank you. Dr. Meredith, did you want to comment on it? You just seemed to light up a bit. Dr. MEREDITH. Well, I think there is a Iot--that's exactly right, and there's a lot of truth to that. You're much more able to lift a 300-pound weight íf it's on your foot than you can if it's just sitting in the room. So we are able to be able to surge differently for an emergency and for a short period of tíme than lrou can do for a long period of time. There's also a disproportionate availability of bed capacity in our hospitals between the big urban and the Level 1 trauma hospitals and the smaller rural hospitals so that if you just look at the overall bed capacity over the country, it's mismatched between where these would occur, where the capacity is and so forth. Mr. SHAYS. Mr. Chairman, I would request unanimous consent that the following articles published in the Society for Academic Emergency Medicine be entered into the record. There are 1-, 2, 3, 4 of them. And I have them listed here if I could. ]-409 HGOI_26.000 L41,0 L41.L PAGE 65 Chairman VüAXMAN. lVithout objection, they will be entered in the record. [The information follows: ] L412 1,41-3 ******** CoMMITTEE INSERT ******** Hco126.000 1-414 PAGE 66 ]-4r5 t4t6 L4t7 t4t8 t4t9 L420 ]-421, 1422 1,423 r424 ]-425 1,426 L427 L42B a429 1"430 L43A 1-432 1433 1-434 l_435 1-436 1437 L438 Mr. SHAYS. Thank you very much. Dr. Hoffman, I find it nonsensical that we talk about the capacity in emergency centers and so on, that we are strained., when particul ariry in California my sense is that a lot of this deals with the uncompensated care, not the undocumented worker because that doesn't describe them. It's individuals who are literally here iI1egaIly. Is there any sense of a disconnect when we say we are providing national security for our homeland when in fact we a1low individuals to litera11y come into this country at will, then call them undocumented, as if somehow they don't represent a national security issue? Mr. HOFFMAN. WeIl, Congressman, it's an issue somewhat outside of my ken. In looking at the terrorist threat, I would say, when one focuses back on 9/1-1-, all of the 19 hijackers entered the country, firstly, legally and withproper documentation. So certainly you're right in pointing to the threat that illegal aliens and undocumented peopte have, but I think the threat is even much wider than that. Mr. SHAYS. But isn't it the responsibility of the National Government to defend íts borders. And we have a visa process and so on that let's us know who is here and who is not. People here i1lega1Iy are here without our knowledge. Doesn't that strike you as somewhat absurd to HGO126.000 PAGE 67 then suggest that we have the capability to deal with a ]-440 potential terrorist threat? Mr. HOFFMAN. I think the lesson that 9/LL teaches us is t44L L442 that we have to have the kind of dynamic and flexible 1439 L443 approach that can deal at multiple levels. L444 L445 1-446 1447 1448 1-449 lJ.450 Mr. SHAYS. Let me ask you, those in the þospital, how is it that we need to be able to deal with a surge capacity when we are dealing in a sense with a surge of illegal immigrants? How do we sort that out? How does that fit into the equation? Isn't it a fact that iIIegal residents tend to use !h" emergency facilities of a hospital more than just knocking on--going through the regular process of interacting t45r L452 L453 1-454 L455 L456 L457 1-458 1-459 wíth a doctor? Unless we have, and we have expanded our community-based health care clinics, but without community-based health care--let me ask it this way. Aren't these facilities being overworked by the fact that we have i11egaI residents who are using these facilities? Dr. LEhIIS. It is not my impression that any significant part of the overcrowd.ing or the use of the resources is directly tied to the i11ega1 immígrants who work in Los Angeles County. Mr. SHAYS. How would you know that? Do you find out if t46r they' re here i1lega1Iy? Dr. LEWIS. One often finds out when one is taking a 1462 ]-463 social history and asking about family background, travel L460 HGO]_26.000 1,464 PAGE 68 history, that sort of thing. Mr. SIAYS. So you're under oath right now, and you're 4465 ]-466 saying that, under oath, you do not believe that you have an by people who have no other ]-467 overuse of these facilities 1,468 ability to have health care, and that this is not in any way ]-469 caused by iI1ega1 immigrants? ]-470 Dr. LEWIS. Let me just ask a clarifying question. V{hen 1,471 you use the term rroveruse, " do you mean any use? Mr. SHAYS. Any use. 1472 ]-473 Dr. LEWIS. If you define any use of our emergency ]-474 department by people who are in the country iI1ega11y, the L475 ans!ìrer is, absolutely, there ís such use. If you mean 147 6 overuse in the sense that the use is disproportionate because 1-477 of their il1egaI status,I believe the answer is no. Mr. SHAYS. I actually mean both. Why wouldn't it beZ r47 I 1-479 Logically it would seem to me to make sense that if they had nowhere else to go, they're going to go to the hospital. 1_480 T48I That's what hre are encountering on our side in the East 1482 Coast. Every hospital te11s me that you have an overuse in 14 83 our emergency wards by people who simply have no other place 1-484 to go. 1485 Dr. LEWIS. I think that we're mixing a couple of My impression, and I have not 1,486 different distinctions. 1,487 collected data on this and I'm not prepared to give you 1488 numbers, is that most of the i11ega1 immigrants when they HGO]_26.000 PAGE a 69 L489 L490 have nonurgent medical conditions choose to seek care in variety of outpatient facilities that are scattered around L49L the city, and they don't actually want to come to the L492 emergency department. The second, if I could just answer the t493 second part of your question. Mr. SHAYS. Make it shorter, though, please. L494 Dr. LEWIS. When you are told that a significant burden 1495 ]-496 on the system is by people who have nowhere. else to go, the L497 majority of those people are 1ega1 residents or cíEizens of 1,498 this country who have no place else to go because they don't L499 have health insurance, not because of their 1ega1 status. Mr. SHAYS. Thank you. l_500 I yield the balance of my time l_501 Mr. ISSA. Thank you. t502 Dr. Lewis, I'11 fo11ow up in this same area. And I L503 1504 agree with you as a fe11ow Californian that we can't have it 1505 both ways. T¡'Ie can't say that the uninsured seek emergency r-506 room care disproportionately because they can go there, they ]-507 essentíal1y are covered by the umbrella of last resort because they're poor and uninsured, and then not use the term l_5 08 broadly uninsured rather than i1lega1 versus 1ega1, êt 1-509 l_5 0 cetera. So, although I think illegal represents more than perhaps you're saying, I think it is appropríate, at least in 1_5 L5L2 California, to look at it in terms of the unínsured using the 1_5 1_3 emergency room as essentially the guaranteed insured area for r_ 1_ 1_ HGO]_26.000 PAGE 70 the poor and uninsured. I'm concerned about this survey that was done. You 151_5 participated in the survey. And UCLA Medical Center that day 1_516 t5t7 said that there \^¡ere 1-4 patients boarded by the emergency 1_51_8 department presumably waiting for in-patient beds to become 1519 available. How do you explain the fact that you had 14 4520 in-patient beds available that same day? Wouldn't it be fair 1,521 to assume that, to a certain extent, you could have made them ]-522 all, you could have put them all in immediately if you gave And rather, quite frankly, there ]-523 them the highest priority? t524 has to be some credibility to the reserve for higher-paying 1,525 accounts, wouldn't be that correct? Dr. LEWIS. No. 1-526 Mr. ISSA. So you're saying that you had 14 boarded 1-527 1-528 patients and you had 48 in-patient beds available and that L529 that--I'm trying to understand. Clearly you had beds 1_53 0 available, and you could have shifted peopte into them, isn't 1_53 L that correct? Dr. ITEWIS. I believe that you are making a common ]-532 misinterpretation of the information that was given to You, 1_533 4534 and I've seen the same information. It has to do with how t_535 one defines an available bed. To a hospital administrator, t_536 an available bed is a bed that is physically there; you walk r537 in the room, there is a bed, and there is no patient in it. 153 I Mr. ISSA. Okay. So as a fol1ow-up, what you're saying 1-5t4 HGO]_26.000 1_53 9 PAGE 7A is you were not staffed to put people into those beds? Dr. LEWIS. That's a very important distinction because 1-540 t54r the staffing is directly related to the level of hospital L542 l_543 resources. ]-544 l_54 5 ]-546 1,547 1_54 8 ]-549 1_550 1_551_ ]-552 L553 1l.554 L555 L556 ]-557 1558 1_55 9 1_56 0 Mr. ISSA. And I just would like to follow up. Chairman WAXMAN. The gentleman's time is up, but did you complete your answer? Dr. LEWIS. No. I was trying to make the point that the issue has to do with staffing. And therefore, when one is trying to get data on the number of available beds, especially in the setting of disaster preparedness, the important question is what number of beds are available or could be staffed in the next few hours. And I don't believe the questionnaire was clear in that regard. Mr. ISSA. Mr. Chairman, I know you went on for a littIe whi1e. This will be very short. Chairman VüAXMAN. The gentleman's time is expired. Ms. Watson. l_561 ]-562 1563 Mr. Chairman, I think some of the questions that are being asked of the witnesses ought to be asked of the Members sitting up here who make the policy. Dr. Lewis, I am so glad you're here. I am intimately familiar with the situation down in T¡fatts, California, and Martin Luther King Hospital. And when that hospital's Ms. VüATSON. Medicare funds were pu1led and Medicaid funds h¡ere reduced, HGO]_26.000 PAGE 72 1564 r-565 many 1566 1567 1568 1569 1_570 t57t 4572 ]-573 L57 4 L575 L57 6 ]-577 1,57 8 1579 1580 1_5 8 1- 1,582 1_583 ]-584 1_585 1586 ]-587 1_588 of the patients that would have gone to King had to come to surrounding hospitals. They're overcrowded. Arrd I know on the day of the survey, 33 of your ER patients were being treated in chairs or hallways. I have been in that situation myself in one of our most prominent hospitals waiting 2 hours and l-5 minutes, and people had been there for 4 days. Vüe have a critical problem in our community, in our county hospital system. And we probably have one of the largest ones in the State in the Los Angel-es area. The day we took this survey, was that an unusual day for your hospital? Dr. LEVüIS. In reviewing the numbers, and I should clarify that I r^/as not working that d"y, but in reviewing the numbers that $/ere submitted, my impression was that was a slightly less busy than usual day. It was done on a weekday. Ms. WATSON. Now, Saint Francis Hospital, you're aware of it? Dr. IJEVüIS. Yes. Ms. WATSON. Is a DSH hospital, and it, too, is complaining--Doctors Hospital. I can name all the hospitals in the area. I chaired the Health and Human Services Committee in Sacramento in the Senate for 17 years. I am intimately aware of our problem. V'Ihat is it that we need to have a functional and comprehensive care system for the indigent? And I know you're not in the business of doing the work of immigration officials and seekitg; you treat people HGOL26.000 l_589 PAGE 73 1590 15 91- as needed. V'Ihat would you want to see in this Los Angeles County area, and may'be some of the rest of you in other States would want to respond, too, that would make our system 4592 viable to care for the needy, to care for the people who come 1_5 93 through your doors, regardless of whether they're there 1594 l_595 legally or il1ega11y? Dr. LEV'IIS. If I was limited to a single answer-Ms. WATSON. Yes. :-596 ]-597 l_598 t_5 99 1600 l_6 0L Dr. LEWIS. --my answer would be an increase in the number of available in-patient beds in the hospital that are staffed by qualified nursing personnel who are available 24 hours, Tdaysaweek. Ms. V'IATSON. Vühen Dr. Levitt--thank you for your response. When 4602 L603 Dr. l,evitt cut the Medicare dollars from King, or L604 from L.A. County, that was 50 percent of the resources. So 1-605 it impacted all of not only the. county hospitals but private Staffing of emergency personnel, what :l.606 hospitals as well. L607 would you like to see there, and you talked about other beds, L608 but emergency and trauma? Dr. LEWIS. The most pressing shortage that we have L609 right now in Los Angeles County is related to nurses in the l_6L0 t6tr emergency department. There's a nationwide nursing shortage. The working conditions and the stress 1evel in the emergency t61,2 a613 department makes it not a popular long-term career choice for HGOI_26.000 PAGE 74 the best nurses. And that is the most pressing immediate personnel need that we have. 1_6 1_5 Ms. WATSON. Okay. How do we solve that problem, and I t6t6 ]-6L7 will ask that of all of the witnesses? Dr. Welsh. 1_6 l_8 Dr. CONVüAY-VüELSH. I have several suggestions. The 16L9 1-620 amount of Federal dollars that are available for nurses to go t62L back to school and to become either BSNs or masters-prepared The faculty scholarship L622 nurses is very, very limited. L623 program is very, very limited. Let me take a little bit different cut though on your 1624 ]-625 question about what could be done. The Schoo1 of Nursing at ]-626 Vanderbilt has just received status as a clinic, a nurse-run 1,627 faculty clinic, âs an FQHC. That process took us almost l-0 ]-628 years to be designated as an FQHC. There are schools of ]-629 nursing all over this country that close their clinics once 163 0 their education dollars run out from HRSA because they can't t63t maintain it because all of our patients are indígent and l-632 poor. An increase in the amount of FQHC support would be 1633 extremely helpful. And then the last point I miqht make is that we have L634 ,rot able to practice L63 5 many, many ,r,rr". pr".ti-tioners *rr] "t" ]-636 in the ful1 scope of their practice because of State problems ]-637 with the Medical Practice Act and the Nurse Practice Act. We 1_638 need a Federal preemption that would aI1ow the current nurse t6\4 HGOI_26.000 PAGE 15 practitioners to practice in the full scope of practice. The other thing that we need to do is nurses are hunters ]-640 t64L and gatherers in hospitals. There's 30 to 40 percent of what L642 they do that they shouldn't be doing. But the system doesn't ]-643 aI1ow them to give that up. There's not enough support of ]-644 the non-nurse personnel for nurses to stop being hunters and ]-645 gatherers. Vüe would significantly address the nursing ]-646 shortage in thís country if we could just a11ow nurses to 1647 nurse and if we could fulIy utilize our nurse practitioners. ]-648 Chairman V'IÐffAN. Thank you, Ms. I¡rÏatson. Mr. Issa, you're now recognízed for just 5 minutes. ]-649 165 0 Mr. ISSA. Thank you, Mr. Chairman. 1_651_ Can I ask unanimous consent to submit eight documents ]-652 into the record that reflect the Commonwealth of Virginia's l_653 emergency response preparedness, both alone and in L654 conjunction with the rest of the Natíonal Capital Region? l_655 Chairman WAXlvlAN. We'11 review the documents before ]-656 r¡re're willing to give unanimous consent, and we'11 see if we ]-657 can get the unani-mous consent. 1658 [The informatíon follows: ] ]-639 1,659 ******** CoMMITTEE INSERT ******** HGO126.000 1660 L661" PAGE 76 L662 L663 L664 L665 1,666 Mr. ISSA. So you're reserving an objection? Chairman WAXMAN. I object until I get a chance to review the documents. Ms. VüATSON. Mr. Chairman can we see the documents, too? I don't want to vote unless I know what it is. Mr. ISSA. Mr. Chairman, here are the documents. Dr. Lewis, because I ended the last round, I was just going to comment that in your own statement, You had said that you had surge capacity; you could bring in people that you wouldn't otherwise have, but it would put you into the 1667 1,668 ]-669 167 0 1,671 1,672 1-673 1,67 4 ]-675 ]-67 6 red. And I'm not going to further elaborate because of the shortness of time, but if you have 48 beds and you don't fill them and l-4 people say boarded, to me it sounds like you were unwilling to go into the red in order to board those people. But you did have 48 capacity, assuming those higher cost resources were available, but your hospital chose not to do it that day. Dr. Kaplowitz, I'm very intrigued by your testimony, 1677 L67 I these documents that are pending going into the record. If I 1,67 9 understand you correctly, if there were a significant crash 1_680 or something on the Orange Line or Blue Line today 1-681_ representing dozens or even maybe a hundred significant L682 injuries, you would be prepared to put together the resources to take care of that. Is that correct? r-683 Dr. KAPLOWITZ. We would be working very closely with L684 HGO126.000 t_6 PAGE 77 the District of Columbia and Maryland in terms of appropriate L686 distribution of patients working through EMS as well as the t687 hospitals. We would activate our Northern Virginia l_688 coord.inating hospital, which is at Innova Fairfax, and do the I can't L689 best we can for optimal distribution of patients. 16 90 teII you what would happen. You know, first of all, that 85 t69L ]-692 could be anywhere. Mr. ISSA. Sure, I understand on a given day that you 1-693 can't answer. But in general, and we'll go back to Virginia ]-694 Tech. Virginia Tech was an example of the worst of all 1-695 worlds, a place you didn't expect it, a weather condition 1,696 that wasn't cooperative and hospitals that generally were not prepared. And yet the response, l-ooking back, yoü were able lJ.697 1,698 to rise using resources as you could transport people ]-699 andfor--people one direction or the other. Is that correct? 1700 Dr. KAPLOWITZ. Virginia Tech was not truly a mass r7 0l casualty event. It stressed rural hospitals. And we htere t7 02 prepared to pu11 in people. However, flo hospital was pushed L7 03 beyond what they \^rere capable of doing and wasn't hundreds of people at the same time. L7 04 Mr. ISSA. And, Doctor, I know it's always unfair to do L7 05 hypotheticals, but in general, the amount of times that L7 06 t7 07 America is going to be attacked in mass by a dirty bomb, 1_708 chemical attack or aircraft from the sky, compared to the 1,7 09 amount of time in which an airplane crashes as it is landing HGO]_26.000 171_0 PAGE 78 17tA 1-712 1,71-3 in lowa, a DC-1-0, the Blue Line does have an electrical failure and people are damaged or burned, a gasoline truck the 405 jackknives and bursts into .flames, a fire in a on refinery, such as Long Beach, a widespread hurricane or 1,71-4 tornado that injures many; aren't all of these dramatically And I'11 be self-serving and say, since it ]-71-5 more likely? t716 happens every year in America, every single year one or more t717 of these, actually almost all of them happen at least once or t7t8 twice a year, mass casualties occur every year in America. t7t9 Isn't it true that, in fact, if we take the war on terror, 1720 the likelihood of another attack like 9/11, completely out of ]-721 the scenario, that the need is greater in frequency and even 1,722 likelihood of dozens or hundreds of people needing care, ]-723 isn't it greater based on these? And I will throw in just L724 one more for good measure, Dr. Lewis, âfl earthquake in 1"7 25 Northridge? Dr. MEREDITH. Yes, it is, and we're not ready to deal t727 with that. Vühether you survive an injury in America today on L728 Interstate 40 from Vüilmington, North Carolina, to Barstow, L729 California, depends on how well you get hurt and how wel-l the L730 trauma system is organtlzed between those two points. Mr. ISSA. Arfd, Dr. Kaplowitz, I'm particularly L73L L732 intrigued because you seem to be positive in saying that, ât ]-733 least within the resources available, Northern Virginia and ]-734 Virginia in general has done a good job of being prepared. 1-726 HGO126.000 PAGE 79 1735 ]-736 And I'm particularly concerned because I'm a Californian, and it appears as though California feels they're not prepared. ]-737 Could you comment further on why you feel fairly prepared ]-738 within the resources available? 1,739 Dr. KAPLOWITZ. Preparedness is all relative. We've put 1,7 40 a great many things in place to go beyond where we \^Iere on a74t 9/Ll. T can't tel1 you how we would handle hundreds, yoü 1-7 42 know, whether people would be happy with how we handled 1-7 43 hundreds. We would have a p1an, a communication system. 4744 Mr. ISSA. One final question for the panel. If I had a 1,7 45 billion dollars sitting ín the center of this room and I gave ]-746 it to you for preparation, training for these mass events or 1747 I spread it around the country to staff up or reimburse ]-748 Medicaid, which would you rather have that billion dollars go 49 to, assuming there was only one pile of $1 billion available 1_7 L750 today? t75L 1-752 ]-753 ]-754 ]-755 1756 ]-757 1_758 4759 f would like to see our emergency departments and our capability, able to function on a daily basis. Because much as I've talked about surge, I also agree that if we don't do a better job on handling emergencies on a daily basis, w9're going to be at a disadvantage when there is a mass casualty event. We have to be able to empty our emergency rooms more rapidly because that's going to be even more important in an emergency event. Again, I'flr positive in terms of what we've put in place in the kinds of KAPLOVüITZ. Dr. HGO]_26.000 60 61, PAGE 80 1_7 communications. However, I recognize ful1 well the stresses on our emergency system on a daily basis, and we can't ignore t7 1762 1-7 63 17 64 t7 65 t7 66 1-7 re interrelated. Mr. ISSA. Mr. Chairman, I would appreciate it if the others could ans\ÀIer for the record which way they would spend the money or if you would like to give them additional time. Chairman WAXMAN. Vle11, whichever of you want to that. They' 67 respond. t768 L769 177 0 Yes, Dr. Lewis. 4771 1772 ]-773 1774 1j-775 L776 L777 Dr. LEWIS. I agree absolutely with what Dr. Kaplowitz said. But in addition, I would like to point out that even if one chose to spend the $1 billion on training and equipment and things that would only be used in those very unusual events that you pointed out, one of the key decisions is whether we want to be prepared for the most like1y of those catastrophic events or whether \^te wanL to instead be prepared for the least Iike1y, meaning bioterrorism or nerve agent.s Mr. ISSA. Good point. Dr. CONWAY-WELSH. I would take the $1- billion and apply 1779 it to the public health infrastructure in our country. That 1_780 is critical to any kind of a response in any kind of a L7 8I ]-782 disaster. And we are in grave danger of a really crumbling t7 83 public health infrastructure in our country. Dr. MEREDITH. You could fund the Federal infrastructure t7 84 L778 HGOI_26.000 1_785 PAGE B1- 1-786 1,7 87 to support the States to develop trauma systems for $20 million or $10 million--mí11ion, million dollars. You know, you'11 drop that on the way to work in the morning. So that should be done. The next piece is just to your question, Representative 1788 17 89 Issa, can we plan to surge on a daily basis and always be t79t ready nationwide? I don't think that is do-able or the smart But I do think \¡'re are not ready on a daily r792 way to do it. ]-793 basis to do what we have to do every day. And that frightens ]-794 me immensely because we're not prepared for the bomb in a ]-795 cafe or the ma1I or a bus falling off a bridge because we 1,7 96 don't have the capacity on the every day basis. Mr. HOFFMAN. This isn't exactly my expertise, but I 1,7 97 ]-798 would say that I agree completely with Dr. Lewis' sta.tement. t7 99 And I would point out that as unlikely as a terrorist attack t_800 may or may not be in the future of the United States, I think l_8 0 that the American people would expect that, years after 9/A1-, L802 we would be prepared adequately to respond to any kind of l_803 threat like that. 18 04 Chairman WAXMAN. Thank you. And of course, they would l_805 expect we're not going to make things htorse by Medicaid cuts. 4790 1_ 18 06 Ms. Norton. Ms. NORTON. Thank you, Mr. Chairman. And I must sây, because I represent the city, I'm r807 1808 1809 especially grateful that you brought some sunlight to this HGOL26. 000 1-810 1_811 1-BT2 1_813 r-B 1_4 PAGE 82 really urgent problem as v/e face Medicaid cuts. I want to note that I have constituents from Anacostia High School who would be very much affected if in fact there was such an event here. i-81_5 r_816 1,81,7 1- 818 1-819 Mr. Chairman, since 9/1-1, I've been trying to get funds out for what are calIed ER-]-. It \ÂIas to be a demonstration here. People came from hospitals all over the country to see how we did it here and then to see if they could replicate it. And essentially it would ad.d to the Metropolitan Hospital Center a surge capacity and a way to quickly add on that capacity. I want to--my concern, I will say to the panel, is that t82L 4822 you have a mix of residents here. So if you try to separate r823 out who you're talking about, undocumented, poor, who L824 overuse, of course, emergency rooms from the ordinary 1825 emergency, you're going to have a hard time, which is why t826 this ER-l- notion was to try to say this is the pIace, it is 1,827 close to the Capitol, to send trauma victims. We have a burn 1,828 center, for example. They brought people there from Virginia 1,829 after 9/1-L. On top of 600,000 people who live here, \rrre've got 2OO,OO0 Federal workers and other workers who just come t_830 183 1 in every day and go out, creating a potential for a true They won't be able to get out on the L832 catastrophic situation. L833 roads. Some of them will try to get ou! if they are hurt. So the point is to let them know quickly what the place is to l_834 L820 HGO126.000 183 5 r_83 6 PAGE 83 go. Now, Virginia, and Dr. Kaplowitz yo:u testified about r-837 what Virginia is trying to do with what money it had, and r-83I that caught my attention, placing k"y, according to your testimony, key supplies and medications in various places. i-83 9 184 0 Of course, Virginia went through 9/L1' and trying to deal with 1,84r surge in its various hospitals. I would like to ask Yoü, and L842 then that inclined me to look at how much in Medicaid funds 1843 Virginia would lose to see whether Medicaíd funds v/ere 1,844 implicated. And I learned that Virginia--and when we talk r845 about Virginia, Maryland and the District of Columbia, we're except that if the event ]-846 talking about one place virtually, ]-847 occurred here, unlike the Pentagon, íf the event occurred l_84I here in this crowded space and people went to various ]-849 hospitals, you would only make the situation \^/orse, which is 1850 why we're working on this ER-l-. The administration has 1_851 supported it. We have not been able to get it through ]-852 appropriations, even though they found considerable support l_853 for it. Virginia would lose $93 million in Federal Medicaid 18s4 1855 funds over thê next 5 years. f' m trying to discern what 1856 impact the loss of Federal Medicaid funds would have on the r857 surge capacity they're trying to create out of whole cloth. Dr. I(APLOWITZ . I've been thinking about that, knowing I 1_858 was going to be here today. I know you've heard from Dr. 1-85 9 HGO]_26.000 1860 l_86l_ PAGE 84 Sheldon Retchin, who spoke about the impact on the VCU health system. Again, if we lose much of the capability to handte L862 emergencies on a daily basis, it's going to definitely put us at a disadvantage l_863 I know futl weII how much Level 1 trauma centers depend L864 l_865 on Medicaid funding in general, not only for trauma care but L866 in general, whether j-t's the VCU health system or Innova t867 Fairfax. And I'm very, very concerned of the impact it's going to have on the ability of those facilities to function, 186 I 1-869 not only in an emergency but on a daily basis. And they do work together. It's hard to expect a facility to add surge 1_870 L87L if they're to stressed on a daily basis. Nonetheless, \¡¡e are L872 planning for surge capability, surge beds for an emergency no L873 matter what the situation is on a daily basis. We have to plan for the emergency and recognize that there are stresses 1,87 4 ]-875 on a daily basis. So I know there's going to be enormous especially our Level l-. L816 impact on a number of facilities, ]-877 trauma centers on a daily basis. It will impact their L878 ability to surge in emergencies. That's not going to stop us L879 from"continuing to plan for that large event looking at 1-880 distribution of patients and hoping facilities respond 1_881 appropriately. Ms. NORTON. Level 1 trauma centers are the ones that, t882 1_883 because they are the hospitals that have the greatest l_884 capacity, tend to be the ones that are overcrowded? HGO]_26.000 85 PAGE 85 Dr. I{APLOWITZ . absolutely. There' s one other point 1_886 here that's not related to Medicaid funding but related to 1887 surge. And that is the concern that hospitals have of the 1888 funding they're going to receive after an emergency. I bring r_889 this up because it's a major issue when hospitals are talking 18 90 about surging in emergencies. Most hospitals, most health 18 91 care is private. And there's been a 1ot of discussion and t892 stress about what kind of reimbursement they would get in r_8 93 responding to emergencies. They're going to respond, but are a894 they going to be dramatically hurt financially? Ms. NORTON. Following g/al, it was easier to get funds 1895 1,896 out after the fact, and this is what's so frustrating to me. ]-897 Because in the face of a catastrophe and living in a country 1_8 98 that doesn't prepare for anything, money went out. But 1899 preparing for such an event is very bothersome. I am 1_900 concerned, and I would like finally to ask this, if in fact 1901 these patients are distributed to the trauma centers wherever 1-902 they are in a place like the District of Columbia, rather 19 03 than to have a place that is specially outfítted to deal with 1904 traumas, if you would teII me how an emergency room is 1_905 supposed to decide how to quickly separate the traumas that ]-906 come, 1et us say from the District of Columbia, the other L907 people who have serious emergency problems who come in, the people who shouldn't be in the emergency room but perhaps 1-908 1_909 should be referred? I mean, I'm worried about the chaos of l_8 HGO]_26.000 PAGE 86 just sending everybody to trauma centers in the fírst place. L911 Dr. Meredith, did you have an-Chairman WAXMAN. The gentlelady's time is expired but L9t2 L913 we'11 get an answer to the question. t9t4 Dr. MEREDITH. The trauma center itself is designed to L915 do that exact question. A Iot of work has been done to t9t6 define what kind of patient is the trauma patient and how L9L7 should they move. And those questions are answered. There 191_8 are about 230 Level 1- trauma centers and about 320 Level 2 T919 trauma centers, so \nle're talking about saving 550-ish maybe 1,920 between that and 600 hospitals that are a core of the safety 192t net for patients in the country. 191_ 0 1922 L923 ]-924 ]-925 ]-926 ]-927 Ms. NORTON. Thank you. ]-928 Lg2g l_93 0 193 t_ J-932 L933 1934 Mr. Chäirman, I want to just say I'm very concerned that if people simply go to the hospital closest to them as opposed to the hospital that in fact has been most prepared to handle the surge from the event, all of the placement that Virginia is trying to do for example, kind of a litt1e bit everywhere without Medicaid funds, will not serve us well in the event of a truly major capacity. If I may say so Virginia was not the kind of event that we in the District of Columbia are most afraid of following 9/Ll-. Chairman I¡IÐruAN. Thank you, Ms . Norton. I want to ask this. Vüe have a health care system in this country that's the most expensive in the worId, and yet HGO126.000 1_93 5 PAGE 87 million people who are uninsured. Most of them ]-936 are working people, and they don't have insurance. So if t937 they get sick, they go to the emergency room. If they don't have insurance, the hospital doesn't get paid for the care 193 8 193 9 that they're given. So hospitals then have to figure out how 1940 to survive economically v/ithout getting paid for a 1ot of a94r these emergency room patients. Isn't it true that the people ]-942 that are in hospitals today because of this whole crazy 1,943 system we have are some of the sickest people, unlike in 1,944 other countries where they're not the sickest, they're not ]-945 the ones that you just can't deny hospital care, but in our we have 47 country, it's the sickest? Is that right, Dr. Meredith, do you know. 1,947 Dr. MEREDITH. I don't know. It's a hard system to t948 L949 figure out, and I work in it every single day. Chairman VüAXMAN. Wel1, it's a hard system to f igure L95 0 L951 out. But 1et's look at the system. There's not enough money ]-952 in the system for all the people who use it who don't have L946 1953 1,954 1955 1-956 4957 1958 ]-959 health insurance coverage. Nora/, does it make any sense--Dr. Hoffman, does it advance the goal of Homeland Security for the Federal Government to then be v\¡ithdrawing funds from Level 1 trauma centers, whether through the Medicaid program or some other funding source? It's reasonable for the Federal Government to assume that States or localities--is it reasonable for the HGO]_26.000 l_960 PAGE 88 Federal Government to assume that States and localities are 1,96L going to make up these losses to the hospitals or the market ]-962 ]-963 ]-964 L965 ]-966 1-967 1_968 ]-969 ]-97 0 forces will make up for the short faII? Mr. HOFFMAN. Mr. Chairman, you know, I think we've already learned the lesson of not being adequately prepared before 9/1-1-, so, Do, it doesn't make sense from my perspective as a terrorist analyst Chairman WAXVIAN. As a terrorist analyst. How about those of you who are in the medical field? Does it make sense when you're struggling to keep these hospitals going under ordinary circumstances and trying to L97I find out how to fund them for the Federal Government to withdraw Medicaid funds? t972 1,973 Dr. MEREDITH. Market forces will not make up for the ]-97 4 loss that this money represents to the safety net hospitals L975 and to these few trauma centers, I'm certain, because of the t9'76 way the patients are moved around no\ÂI. They will sti11 get t977 those patients. And when it represents such a loss that they 1978 can't sustain it, they will stop being trauma centers, and 1-97 9 we'11 lose them from the system, and it will be tragic. Chairman WAXIIAN. A lot of hospitals are already closing r-980 their doors for the emergency rooms because they can't afford 1_981 t982 l_983 ]-984 to keep them open. Dr. Kaplowitz, you're trying to find out how to plan, you're trying to plan for an ordinary catastrophe or a HGOI_26.000 PAGE 89 1985 1986 a987 1988 198 9 1_990 1,991, :l.992 1993 ]-994 1-995 terrorist kind of catastrophe. Does it help your planning efforts when the Federal Government withdra\^ts money from the Medicaid program or some other funding source? Dr. KAPLOWITZ. Not at all. And as I mentioned already, we're very grateful for getting some funding for emergency planning. But that's only a fraction of the funds hospitals receive. It couldn't then begin to replace the Medicaid dollars or the other dollars they need to maintain their infrastructure. So absolutely it makes no sense at all to lose that much funding. disasters are Iocal. Local communities need to prepare for a terrorist bombing or similar attack. But it's also true that the Federal Government has a responsibility here, which starts with at least doing no harm. And that means not withdrawing Federal Medicaid funds that now support Leve1 l- trauma centers in the highest risk cities. I wanted to pursue another point about how we prepare for a terrorist attack. There has been, D:r. Hoffman, evaluations of potential terrorist attacks. In fact, I think the Centers for Disease Control brought together a pane1. Is it the consensus of people looking at possible terrorist attacks, if \¡te're going to have one, it's going to be using conventional terrorist weapons rather than a weapon of mass destruction? Mr. HOFFMAN. Absolutely. Again, I don't think we can Chairman V'IÐffAN. Notr/, some people say ]-996 ]-997 1-998 1-999 2000 200L 2002 2003 2004 2005 2006 2007 2008 2009 HGO]_26.000 201_0 PAGE 90 20L1, 20]-2 20]-3 201-4 20]-5 20]-6 20L7 20]-8 20:l.9 2020 202]zv¿¿ 2023 2024 2025 2026 2027 2028 2029 2030 203]- But certainly tl" higher rule out any potentiality. probability event is conventional explosives and perhaps with suicide attacks. Chairman WAXMAN. In fact, according to that report that was produced, they said a terrorist bombing attack in the U.S. would be a predictable surprise, like a hurricane is a predictable surprise or a major automobile traffic accident could be a predictable surprise. Yet the Federal Government under existing law has a responsibility for developing a national medical surge capacity to respond to a mass casualty event, such as a terrorist attack with weapons of mass destruction. In last October, the President issued Homeland Security Presidential Directive 2t, which established a national strategy for public health and medical preparedness for this kind of an event. It's crucial that we be prepared for that kind of event using a dirty bomb or biochemical hreapon. But I don't know that there's any national strategy to prepare for or respond to a terrorist attack using conventional explosives, such as happened in Madrid or here in Oklahoma City or at Centennial Park in Atlanta. Dr. Hoffman, is there such a Federal response being prepared by this administration that says, the buck stops here? HGO126.000 PAGE 9A 2032 2 RPTS DEAN DCMN BURRELL [1-2 033 2034 2035 2036 2037 :00 p.m.] 2038 2039 2040 2041, 2042 2043 Mr. HOFFMAN. No, Ry understanding is that incidents like terrorist attacks involving conventional explosives are viewed to a lesser included contíngenCY, and the assumption has long been, going back from what I testified before a subcommittee of this committee that Congressman Shays chaired nearly a decade âgo, is that generally these more conventional tlpes of terrorist attacks don't receive the same type of attention that the high end, less 1ike1y threats Uo: 2044 2045 2046 2047 Chairman WAXMAN. I¡IeII, this is exactly what we want to Human ask the Secretary of Health and Services and the \ÂIe Secretary of Homeland Security. V'Ihat is the Federal Government doing? What do we have in 'place? What are 2048 2049 2050 planning in case a predictable event such as a terrorist attack occurs. And some people think that's partisan to ask those questions. I think it is something we ought to be asking on a bipartisan basis. 205]. 2052 2053 2054 2055 2056 Mr. Shays. Mr. SHAYS. Thank you. Dr. Hoffman, Hadassah Hospital in .ferusalem has a facility that has a whole floor designed for a surge capacity, but they have no doctors to man it. In other words, it's=-and it is there for a potential chemical HGO126.000 2057 2 PAGE 92 058 2059 2060 2064 2062 2063 2064 2065 2066 2067 2068 2069 207 0 207L 2072 2073 207 4 2075 207 6 2077 2078 2079 2080 20Bt attack, and so on, where they can isolate patients and so on. I see the logic of doing that, but I don't see the logic of staffing it. And so then they compromise and they bring other people in from different places. Isn't that a model that makes sense for the United States? Mr. HOFFIvIAN. We1l, sir, I used to think I was in a depressing field studying terrorism until I sat on thís panel with my distinguished colleagues. And given everything that I've heard about the capacity of our trauma centers this morning, it's a different situation. Mr. SHAYS. I don't know why it's different. They have to deal with a terrorist attack and that's what we're talking about right now. I mean, you know, Dr. I-,ewis, your hospital was kind of shut down for a while because they required you to have more people present. I mean the requirements changed and so it took a while to get back up to speed because of, I think, ne\^r regulationsi is that correct? Dr. LEWIS. I don't believe our hospital was shut down at any time Mr. SHAYS. I mean--you know what I'm making reference to. Do you want to explain it? Dr. LETi,IIS. Actually I'm not sure. Are you talking about a citation hre received in response to long waiting times in the emergency department? Mr. SHAYS. Right. I meant only--I'm sorly, ï didn't HGO126.000 PAGE 93 2082 2083 2084 2085 2086 2087 2 088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2L00 2TOL 2L02 21-03 2104 21-05 21,06 hospital, I meant in the emergency room. This is not a trick question. I mean, the point that I'm trying to make \¡ras that you had to staf f it at certain level and you weren't able do that, correct? Dr. LEWIS. The citation was in response to delays in seeing patients with acute medical conditions because of the Iong waiting time in the emergency department. Mr. SHAYS. Right, but-Dr. LEWIS. Let me try to anshrer your question. The staffing was simply a way of more quickly screen--additional staffing to screen those patients. The question you asked about how Israel is dífferentr, one very important way that Israel is different is that because of the constant concern over mass casualty incidents they do not al1ow their emergency departments to become overcroh¡ded. And one way they accomplish that is that if the emergency department becomes overburdened they immediately move those patients up into non-normal treatment areas ínside the hospital so the emergency department does not get gridlocked. And that's a reflection of their greater day-to-day ahrareness of this threat. Mr. SHAYS. So but the bottom line is they have a surge capacity in space, not necessarily in terms of doctors on duty and nurses on duty. And it would strike me that that's part of the model. It would strike me that part of the model mean HGOI-26. 000 PAGE 2!07 2to8 2to9 2tt0 2ttL 2rt2 21,13 2tt4 2tt5 2Lt6 2LL7 2LL8 2LL9 2L20 2L2l z Lzz 2]-23 2L24 2L25 2L26 2L27 2L2B 2L29 2L30 2L31, that we have to work on is better coordination and how we move patients and so on. And we're connecting two things that maybe need to be connected. But in the process \nle're really talking about two separate issues. One, do you have the capability to deal with your basic emergency needs day in and day out? I mean I'd love to know--I'd l-ove to keep going because I'd love to know is there a rule of thumb with so much population you need a trauma 7, a trauma 2 and a trauma 3. Some States may not have it. I think West Virginia doesn't. Is there--should every hospital have an emergency facility? And I understand that some don't now. You know, so those are all legitimate, you know, questions that I have no answer to. Dr. LEV'IIS. I'd just like to comment that there are standard rules regarding for a population of a given size the number of inpatient hospital beds. Prior fiscal- pressures have forced many hospitals to reduce the number of inpatient beds that they either maintain physically or maintain staffing for. So fiscal pressures over the last l-0 or 15 years have resulted in most or at least many metropolitan areas having a number of inpatient beds far below the originally recommended number. Mr. SHAYS. Right. Dr. LEVüIS. That's the direct cause of the ED overcro\^¡ding that we've been talking about . So there are HGO]_26 .000 PAGE 95 2132 2]-33 21,34 21-35 2L36 2]-37 2L38 2]-39 2]-40 21,4L 2142 2]-43 2L44 2:l'45 rules of thumb and we violate them. Mr. SHAYS. But what would be a shame in this process is I happen to have opposed the changes in requirements. And we voted to try to hold them, but what would be a shame would be to not be having the dialogue about all the other things that don't take money necessarily, but talk about coordination, which we're not even getting into. Dr. Kaplowitz, my understanding is Virginia does a better job of anticipating these kinds of challenges. Dr. I(APLOVüITZ. WeIl, wê've had to out of necessity but I wanted to make the comment about Israel. T.' ve been there. Israe1 provides health care coverage for everybody in their population. Mr. SHAYS. Right. Dr. I(APLOWITZ. Their facilities are not under the same 2r46 2r47 financial stresses as ours are here. Not only do they deal 2L48 with suicide bombing, but every single one of their hospitals 2L49 is a hospital when they have a hlar. It's a different 2t50 mindset, but the fact that everybody has coverage, everybody 2L51, has a medical home, it's made an enormous difference in terms 21-52 of their emergency preparedness and the stresses on their 2L53 individual hospitals. Mr. SHAYS. Let me just end with this comment. First, 2]-54 2r55 one area where the administration doesn't get enough credit 2]-56 is the effort they have gone with community-based health care Hco126.000 2a57 PAGE 96 clinics. We've expanded from 10 million to about 16, 1'7 21-58 million people covered. That's one area where they do And there's areas where they, you know, 2159 deserve credit. rightfully should be criticized. 21,60 I happen to be on tegislation cosponsoring with ¡im 2t6t Langevin that says \,r¡e' re going to go to universal coverage 21,62 2r63 giving--providing the same health care benefits that Federal 2]-64 employees have as a choice to everyone. Where I have my big an issue we don't want to 21-65 disconnect, and it seems like it's 2L66 ever discuss in this country, is how we deal with the 1-3 to 2167 20 million people who are here iI1ega1Iy. They are not 2]-68 undocumented. Undocumented means that somehow all they have 2]-69 to do is be documented. By not being documented they are And it doesn't and they are here illegally. 247 0 here illegally 217'J" seem to come up. And I know for a fact these are folks that 2172 don't have coverage and intuitively they are going to go 21-73 wherever they can get help and they are going to go to 21,7 4 emergency wards. And the fact that we like want to dance 2175 around this just blows me away. That's my comment. Dr. I(APLOWITZ. I did want to make a comment about a 21,77 public health study that has shown that recent immigrants 2'J,7 8 2r79 actually used less medical care than the rest of Americans. This was brought up in the recent series about disparities in 21,80 2t8r care. So while I acknowledge that there are significant 21,7 6 HGO126.000 97 2lB2 21-83 numbers of people who may we here iIIegaIIy, they actually used l-ess medical care than- - 2]-84 2]-85 2]-86 2187 2LBB Mr. SHAYS. And 1et me te11 you why I think that is an irrelevant statement. They use less care and when they do use it they go where they can get it, which is an emergency ward. Arrd therefore the logic is that when they do use it, they are using it there Dr. I(APLOWITZ . TheY- 2]-89 Mr. SHAYS. Thank vou. 2L90 Dr. KAPLOWITZ. I will add another comment. They are 21-9L 2192 not only going to emergency rooms - L' m on the board of a 2]-93 free clinic--free clinics--an enormous amount of care, 2t94 including to undocumented persons. So they don't all go to 2r95 ¿Lto emergency rooms. Mr. SHAYS. They go to community-based health care 2L97 clinics, w€ know that, and that's one thing the admÍnistration has done welI. 21-98 Chairman WAXMAN. I want to raise a poínt that I think 2r99 2200 this issue of i11egal immigrants is a red herring220]. 2202 Mr. SHAYS. V'Ihy? 2203 2204 2205 2206 it is a red herring is that i]1ega1 immigrants are not eligible for Medicaid, they are not eligible for Medicare. They may get private insurance, and if they do, their insurance company is paying the bills Chairman VIAXMAN. The reason based on their payment to the insurance company. HGOI_26.000 PAGE 98 Mr. SHAYS. But isn't that-Chairman WAXMAN. f'11 take a time and then I'11 1et you 2208 2209 take a time. Mr. SHAYS. Thank you. Okay, no problem. 22tO 22tt Chairman WAXMAN. T' m not going to get interrupted. So when the people who are i11egal come to an emergency 2212 221,3 room, it's usually as a result of a trauma. Dr. Lewis and Dr. Meredith, from your experience and 2214 22]-5 knowledge of what goes on in emergency rooms, are most of the 2216 people in emergency rooms for trauma undocumented aliens or 2217 are they people that don't have insurance coverage when the 221,8 hospital ends up with a bad debt? Dr. MEREDITH. Most of the people in the emergency 2249 2220 departments are not for trauma, they are for other emergency 2221" conditions. Trauma is very important to me, but a smaller 2222 part of what goes on in emergency departments. Most of the patients who are trauma patients are not undocumented or ¿¿¿5 2224 i11egal, they are a spectrum of American civilization. 2225 They--everybody gets hurt, and they are a complete spectrum 2226 of people, a complete spectrum of people. T¡'Ie take care of We just stop their bleeding, that's all we can do. 2227 them all. Chairman VüAXMAN. Dr . Lewis 2228 Dr. LEV'IIS. I agree with the statement, trauma is a 2229 2230 nondiscriminate force and it doesn't ask you about your 2231, Iegality status before you get hurt. 2207 . HGOI_26.000 PAGE 99 2232 2233 2234 2235 2236 2237 2238 2239 2240 2241, 2242 2243 2244 2245 2246 2247 2248 2249 2250 225L ¿23¿ 2253 2254 2255 2256 let's say Dr. Meredith rightfully pointed out that emergency care is not just trauma care. So someone gets sick, and they don't know where else to go, and they don't have health insurance and end up in emergency rooms to see somebody to see what needs to be done. Of course that's the most expensive setting for people to get health care, which is one of the problems in our non-system of health care in the country. People get seen and treated in the most expensive way. They could go to a communitlr health clinic. When you see people who come in because they have no health insurance with a minor problem, do they get something extraordinary? Do they get a lot of time and attention which will encourage them to come back with these smaller problems? Dr. LEVüIS. It is my impression that the--if we're focusing specifically on i11ega1 immigrants in Los Angeles County who come to my hospital, ffiy ímpression is that the vast majority have attempted to seek care in other facilities first for the same problem, except for acute serious illness that couldn't be treated anywhere e1se. Arrd occasíonally they find that the community health clinics, some of which are federally supported, some of which are just free-standing, have been unable to take care of their problem because it has either gotten worse despite treatment or there has been some complication. But it is my impression the vast Chairman Ii'IA)NAN. No\ar, HGO126.000 2257 PAGE 1-OO 2258 2259 2260 2261 2262 2263 2264 2265 2266 2267 2268 2269 227 0 227'J" majority of them attempt other avenues for seeking medical care before they come to my department. Chairman vüA)ffÄN. Now there are 47 million people without health insurance. I've heard an estimate that there may be as many as 5 million il1ega1 immigrants. Now 47 to 5, of those 5 million i11ega1 immigrants, some of them have health insurance, isn't that true? They have a job where they are provided health insurance, probably most of them don't. And if they need health care, they'11 go to a clinic and it's the right thing to do for us to have put in more money into the community health centers programs. But it doesn't deal with the problem that we have- Let's say 47 plus 5, 51 million people. Yet if something terrible happens to them they have to go to get care immediately, they are not going to go to a clinic, they are going to go to an emergency room. 2272 2273 227 4 should the Federal response be for emergency that are facing 47 plus 5, 52 million people without TVhat rooms 2275 2276 2277 22',78 2279 2280 228]- insurance? VüeIl, the hospitals can't turn them away. Vle11, what most hospitals do if they are private hospitals they will close their emergency room. And then if they don't have an emergency room, they have--then these people have to go to places where there are emergency rooms. But if those emergency rooms are already overburdened, they are diverted to other emergency rooms. Isn't that what happens? HGO]_26.000 PAGE 1_ 01 zzó¿ 2283 2284 2285 2286 2287 2288 2289 2290 229L 2292 2293 2294 2295 2296 2297 2298 2299 2300 230L 2302 2303 2304 2305 2306 Dr. LEWIS. Yes, that's correct. And although I don't have a good suggestion for what the Federal Government should do, what I am sure that it should not do is reduce the funding for those safety net hospitals prior to having a viable alternative solution. Chairman WAxlrlAN. And certainl-y they shouldn't do it hrithout finding out what the consequences are. That'S what'S so shocking to me about these Medicaid cuts. The Center for Medicaid Services and the Department of Health and Human Services never even did an evaluation of what the impact would make--on what the impact would be if these kinds of cuts took place. They simply said we'11 let the States and locaI governments figure out how to deal with this. vüeI1, it seems like they are trying to make the states and local governments have to deal with everything. And at least when it comes to a terrorist attack there certainly ought to be a Federal responsibility. I believe there ought to be a Federal responsibility for all people in this country who don't have access to health care because this is distorting our whole health care system. So that's why I say it is a red herring to say the problem is all these iI1ega1 immigrants. It's not just that, that's an over simplification and a diversion from the much more serious problem that this administration for 7 years has not given us any ideas for, except maybe give a tax break, which is HGO126.000 2307 PAGE L02 who inadequateto even buy health insurance to a lot of people couldn't then afford to buy health insurance even with that 2309 tax break. Mr. Shays, I will recognize you for the last 5 minutes, 23L0 231"t and then we will continue. Mr. SHAYS. Thank you. And I would be happy to have you 231-2 23t3 interrupt me if you'd like--I mean to ask a question. Chairman WAXMAN. No, I will- not interrupt you. 231,4 Mr. SHAYS. What I'm looking for is meaningful dialogue. 231"5 I don't have any dog in this race. I mean I'm just trying 23:l.6 23L7 to understand something. And I get confused. because in the 23r8 Medicare Modernization Act funds hlere included for hospitals 23a9 in States with high numbers of illegal immigrants because 2320 these hospitals complained about the problem of iIlegaI 232]- immigrants who were in fact stressing their hospitals - So 2308 2322 you know- - 2323 2324 2325 2326 2327 2328 2329 2330 2331_ In the Medicare-Mr. SIIAYS. In the Modernization Act. Chairman WAxtvlAN. Do any of you know whether that's accurate, because I don't believe that's accurate. Mr. SHAYS. The question I have is first off, I do not believe that this is the cause of the problem. I think it is a part of the problem. It is news to me that if we have anywhere from l-3 to 20 million people there i11ega11y, that only 5 million don't have health coverage. That's nelr¡s to Chairman V'IAXMAN. HGO126.000 PAGE 1-03 2332 2333 2334 2335 2336 2337 2338 2339 2340 234L 2342 2343 2344 2345 2346 2347 2348 2349 2350 me. And we have l-3--we have 12 million people who are here 1egaI1y who are documented, but not citizens. We have a range between 13 and 20 million who are not here lega1Iy. They are here i11ega11y and I make an assumption, maybe incorrectly, that a majority don't have health care. Because it would really be surprising to think that 85 percent of Americans have health care, but you know und.ocumented workers have that same average or even half that. I happen to believe that we need to have universal coverage. All I want is an answer from folks who are there that my underslanding is you got two options for someone without health care. You go to a community-based health care clinic or you go to the emergency ward. I mean, I don't know if there are other options. And so it strikes me that we are stressing the emergency rooms. And they are hugely costly. I went where I had three stitches. The hospital got into a dispute with the insurer and sent me a bill for l-,300 bucks for three stupíd stitches. Had I gone somewhere else it wouldn't have been obviously that expensive. And so I'm just trying to make the point to you, Henry, that I think that we spend a fortune on health care, far more than other countries, and that we keep saying wel1, wê just have to spend more money. We're at 18 percent of our gross domestic product and T don't think we can actually find a 1ot more money. And so what I struggle with is are there things 235L 2352 2353 2354 2355 2356 HGO]_26 .000 PAGE to4 2357 that don't involve capacity. And money where we can deal with the surge 2358 2359 2360 236]2362 2363 2364 2365 2366 2367 Dr. Hoffman, you didn't seem to want to jump in on some of this, like all of a sudden this was outside your expertise. But it strikes me that we can learn from what other places do. And they don't put a lot more money in, they have extra bed space with no doctors. v[hat I was confused by Dr. Lewis in the dialogue with Mr. Issa, you said, weII, w€ have 45 beds, but they are unmanned. Is that a bad thing that they are unmanned? Is it good that you have this space in case you have a need for surge capacity? And another question I ask all of you, aren't there 2368 2369 237 0 237L 2372 2373 237 4 times when we're going to have to break the rules of so many nurses and so many doctors when you have an emergency. Then 2375 237 6 2377 2378 237 9 it seems to me you throw it out the window, you may have doctors working overtime, nurses working overtime and some rules being broken during a surge--a needed surge. Dr. IJEVIIS. First of all, I agree with you 100 percent that there are issues of coordination and response to major, very infrequent events that could be used v¡ithout substantial funding to improve our ability to respond. I think there's no question that that is correct. The issue regarding the unstaffed beds in the hospital has something to do with the funding source. We're a 2380 2384 HGO126.000 PAGE l_05 2382 2383 2384 2385 2386 2387 23 88 2389 2390 239L 2392 2393 2394 publicly funded institution. The vast majority of our funds either come from or come through Los Angeles County. These are public funds. Such--the similar kind or tlpe that you're responsible for administering. Our hospítal administrators cannot make a decision to go over their budget and staff those beds. It is not their authority. It is a public process that's overseen by the board of supervisors, who I understand \Àrere here recently. got the impression or the implication was made So it's--I that a hospítal administrator was not staffing them to avoid losing money. That's not the case. It is just not an option. Secondly, with respect to the money that is already 2395 2396 2397 2398 2399 2400 240L 2402 being spent in preparedness, I think a number of us have tried to point out the disconnect between the most Iikely unusual mass casualty incidents and the tlnpes of incidents that seem to have been focused on by the existing hospital preparedness program. That program used to have the term, I believe, bioterrorism in its name. They took out the bioterrorism part of the name, but sti1l maintained most of the focus on supplies and equipment that are related to 2403 2404 2405 2406 relatively unlikely events. So one thing that we can do without asking for additional money is to focus on the most 1ikely events, and I'm not talking about the everyday surge events, the most HGO126. 000 106 2407 1ike1y true mass casualty incidents. And then 1ast1y, I'd like to simply point out that in 2408 2409 24tO Los Angeles County the public funds that support our institution, part of them come from tax revenues. Those tax 241-r revenues are driven by the economic activity in that area. 24L2 I'm in no position to speculate regarding what the effect of 24t3 removing those i11ega1 workers would be from our econoñy, but 24L4 I'm not actually sure that the net effect on the funding of I actually think 24L5 our health care system would be beneficial. it would probably be detrimental. Clearly a health economist 241,6 24L7 would have to look at that, hopefully one not driven by partisan concerns. 241_8 24]-9 Chairman WAXMAN. Thank you, Mr. Shays. Ms. Watson, did you-2420 242L Ms. WATSON. I sure do. And I just want to sãy, I don't 2422 think it's really clear to some members that if you are an 2423 i1Iega1 immigrant you are not eligible, you're not eligible 2424 for Medicare and Medicaid. As Dr. Lewis astutely notes, there are some Federal 2425 do not see the relationship between 2426 policy makers who still 2427 maintaining robust emergency and trauma care capacity and a 2428 successful homeland defense strategy. He11o. I would like to ask Dr. Hoffman and Dr. Kaplowitz, both 2429 2430 of whom know a great deal about emergency preparedness and 243r response, to help us connect the dots. While there is much HGO126.000 2432 2433 2434 PAGE tO1 2435 2436 2437 2438 2439 dispute about whether the Medicaid regulations are justified, there's no dispute that they will reduce the amount of Federal Medicaid revenues to Level 1 trauma centers and other hospitals throughout the country There is also no dispute that the loss of Federal funds will vary from hospital to hospital and that for some Leve1 trauma centers these losses will be substantial, potentially 1- forcing reductions in services and degrading their response capacity. So emergency 2440 2441_ 2442 2443 2444 2445 2446 244',7 2448 2449 2450 2451- 2452 . 2453 2454 2455 2456 Mr. Hoffman, does it advance the goal of Homeland Security for the Federal Government to be withdrawing funding from Level 1 trauma centers whether through the Medicaid program or some other funding source? And is it reasonable for the Federal Government to assume that States or localities will make up these losses to the hospitals or that market forces will make up for the shortfall? Mr. Hoffman--Dr. Hoffman, excuse me. Mr. HOFFMAN. V{e11, I think certainly not in those cities, for instance, that the Department of Homeland Security have identified at least the most 1ike1y threat of a terrorist attack. Ms. V'TATSON. Excuse me, when you say most likely those areas, how do you define the areas that are most 1ike1y the target of terrorist attacks? Mr. HOFFMAN. Well, the Department of Homeland Security HGOI_26. 000 PAGE 1_08 2457 and also private risk management firms have assessed on a 2458 2459 2460 246L 2462 2463 variety of indicators in terms of terrorist interests, in terms of the vulnerabilíty facilities in those cities, which cities in the United States would be more 1ike1y than others perhaps. Ms. V'IATSON. Would you consider the V'Iest Coast or Los Angeles area? 2464 2465 2466 2467 2468 Mr. HOFFMAN. Certainly Los Angeles and southern Catifornia. San Francisco probably falIs into that category as well Ms. WATSON. Okay. Mr. HOFFMAN. I mean given the pattern of terrorísts, 2469 and certainly since 9/1,1 there is a very high concentration fortunately not yet in the United States 247 0 of these activities, 247r but overseas in major cities that are at least if not the 2472 capital of their nations, then at least are business centers 2473 2474 or transportation hubs. Ms. I/üATSON. I just wanted to hear your response. you. Thank 2475 2476 2477 247 B Mr. HOFFMAN. 'But if I could just finish for a second? Ms. WATSON. YCS. 2479 2480 248]- Mr. HOFFMAN. I would go back to what Dr. Kaplowitz said about Israel, which I think is absolutely correct, is that their energy services are not as over stressed in terms of their personnel as it appears in the United States. London HGO126.000 2482 PAGE 1-09 2483 2484 2485 2486 2487 2488 2489 2490 by contrast though I think is very similar to the United States in that respect with emergency rooms that have--that already are burdened by a health system with lots of people in urban areas coming into them. You can see the difference in the response of the London hospitals to the 7/'7/05 attacks. There I think the coordination was not as good, even though they had extensive drills and extensive training, the planning--the system broke down in essence because there vrere insufficient personnel on that because the systems themselves \Àrere stressed. 249t 2492 Dr. Kaplowitz, as a State of f ícia1 you've 2493 been involved in a great deal of planning for emergency Does it help 2494 preparedness and response throughout Virginia. 2495 your planning efforts when the Federal Government withdra$ts 2496 funding from Level l- trauma centers, whether through the 2497 Medicaid program or some other funding sources? Dr. KAPLOVüITZ. Not at all. I need those facilities to 2498 2499 survive. And I know what kind of stress they are under on a 2500 daily basis. You remove Medicaid funding, it could be 250t disastrous. We have seen any number of hospitals need to 2502 close their doors. The last thing I need is for any more And the 2503 hospitals to not be able to survive fínancíally. 2504 stressors for trauma centers are enormous. The additional 2505 cost it takes to keep your trauma center open is significant. 2506 And these facilities are functioning with very smal1 Ms. VüATSON. HGOI_26.000 PAGE 1-]-O 2507 2508 2509 25tO 25At 251,2 251,3 2544 2515 2516 2517 margins. So I need them to be able to function and stay open, and I need them to maintain their expertise in order to appropriately respond to emergencies. I've been at the Health Department almost 6 years. In my prior life I was at the VCU health system for 20 years, including working in hospital administration, and I know what kind of stress that facility is under on a day-to-day basis. You take away significant Medicaid funding, it's going to be disastrous. And the sameis true of aII trauma centers in the Commonwealth. Ms. WATSON. Thank you for that. Chairman WAXMAN. Thank you, Ms. Watson. And 2518 2519 2520 I want to thank this paneI. I think you've given us a lot of good information, some of it quite startling, and I think we have 252r to pay a 1ot of attention to it and ask the people in charge, 2522 the Secretary of Health and Human Services and the Secretary 2523 of Homeland Security, both of whom are going to be here 2524 V'Iednesday, how to respond to some of these concerns what the 2525 Federal Government is doing and at least find out whether 2526 \¡rre're doing harm with some of the proposals that are being 2527 pushed. 2528 2529 2530 2531, That concludes our hearing today--oh, yês, there was one item, Mr. Issa requested unanimous consent to put in documents. I have no objection. Does anybody? Ms . V'IATSON. No obj ection. HGOI_26.000 PAGE 1-1-1- 2532 2533 Chairman VüA)ruAN. V'Iithout objection, those documents 2534 will be part of the record. VrIe stand adjourned. [The information follows: ] ******** INSERT 2535 3-1 ******** HGOr-26.000 PAGE LT2 2536 [The information follows: ] 2537 ******** INSERT 3-2 ******** HGO126.000 PAGE 113 2538 lWhereupon, at 12:30 p.m., the committee was adjourned. J