CMS Emergency Management Rule:  Part 4 - Sandy Meets The President

CMS Emergency Management Rule: Part 4 - Sandy Meets The President

This is the fourth and final part of our article looking at the proposed emergency preparedness rule published by the Centers for Medicaid & Medicare Services (CMS) on December 27, 2013.  If you have not been following, you may want to start with Part One.  Without Parts One, Two, and Three you may find yourself a bit confused.

We left off Part Three in the aftermath of Hurricane Katrina pondering the curious absence of meaningful regulatory reform for healthcare providers.  And we wondered aloud what could have possibly changed to embolden the federal policy wonks to break out the Stick.

bParati Carrots, Sticks, and Twigs Image

Current Chicago Mayor and former White House Chief of Staff, Rahm Emanuel has been quoted as stating, "you never let a serious crisis go to waste.  And what I mean by that it's an opportunity to do things you think you could not do before."  The Mayor's point is spot on, whether one leans right or left.

Lean right, and a terrorist attack on U.S. soil provides the justification to go to war in Iraq.  Lean left, and the BP oil spill opens the door to force new regulation on big oil.  You see, to the Mayor's point, despite what one wants to get done, or knows needs to get done, the law of timing is in effect.

Avoiding The Rule

So, was Sandy sexier than Katrina?  To the poor souls living through either storm, the term sexy likely never crossed their minds.

Let's put sexy in context:  Was Governor Chris Christie sexier than Governor Kathleen Blanco?  Was Mayor Michael Bloomberg sexier than Mayor Ray Nagin?  Is the financial and media capitol of the world sexier than the crawfish capitol of the world?  Is Craig Fugate sexier than Michael Brown?  Is President Obama Sexier than President Bush?  Is Wall Street sexier than Bourbon Street?  No!  Not in that way! 

The point is that it became easy to dismiss Katrina as a disaster that could not happen anywhere else.  New Orleans is a bathtub; the government built the levies wrong, the Governor was over her head, the Mayor did not order healthcare facilities to evacuate, FEMA director Brownie was a political hack, and FEMA was a shell of its former self, buried in the Department of Homeland Security.

And of course, the federal government had not been providing enough preparedness Carrots for healthcare facilities to handle such an event.

For those in the federal government who did not want to let a serious crisis go to waste, the law of timing might have appeared to be in effect.  The problem is, despite the carnage in New Orleans, it was not.  You see, the priorities and ideation of the President and his administration ultimately determines what agency policies move and at what pace.

In 2006, George W. Bush held the Presidency.  The Bush administration leaned to reducing government's role in the private sector, a tenor that reverberated throughout the Executive Branch.  To force new regulation onto predominantly private and not-for-profit healthcare providers was unlikely to happen.

So, with the Stick out of the arsenal, the path to healthcare system disaster preparedness was left again to the Twig and the Carrots.  The Pandemic and All Hazards Preparedness Act (PAHPA) of 2006 authorized the U.S. Department of Health and Human Services (HHS) to continue offering Carrot Opportunities to the States for the Hospital Preparedness Program (HPP).  And as discussed earlier, the States would be required to offer Sub Carrot Agreements to hospitals--70% to hospitals. 

Oh Sandy Baby...

On October 22, 2012, Hurricane Sandy began its dismantling of the East Coast.  Yes, it was a big storm.  But, New York and New Jersey are not bathtubs.  They had been through many storms.  No Problem.

No problem that is, until they met Sandy.  Like Katrina, she was special.  She was nothing like they had ever seen before.  Disasters have a funny way of surprising us.  Until one has lived through the catastrophic, they cannot comprehend the catastrophic.

Maybe it is like our great grandparents who lived through the great depression and kept their money in a pillow case.  They never looked at money or banks the same way again.  But, no mater how much they talked to us about it, we just could never see it happening to us.

That is likely why healthcare facilities in the New York region, despite receiving millions in federal preparedness Carrots, were so quickly calling for a bailout after Sandy hit the coast.  To be fair, healthcare facilities that are not hospitals, likely received little or no Carrots.  Nonetheless, the number of post landfall evacuations of healthcare facilities and the challenges of providing food, water, medications, and heat for residents in a variety of healthcare facilities, gave hint that the law of timing may be in effect.

Much like Katrina, Sandy's landfall was front and center on the 24-hour news cycle, as was the response and short-term recovery.  The evacuation of Langone Medical Center played out on live television with nurses carrying infants down dark stairs.  Families were interviewed begging to know the location of loved ones who were in a healthcare facility that had evacuated. 

Unlike Katrina, the federal response to Sandy was quick, organized, and effective.  Because of the Post-Katrina Emergency Management Reform Act, FEMA had its authority restored, was run by a real emergency manager, and could pre-deploy assets to the region.  Arguably, the federal response was greatly improved.  But for those sitting in the dark without heat or food, the improvement was likely not enough.

For those representing healthcare providers in Washington, few aspersions were available to cast that could take the pressure off providers who struggled to care for their patients.  It was difficult to explain why the fuel and power supply for hospital generators remained in the basement, why ambulances desperately needed for emergency calls had to be diverted for evacuation, and why facilities lost track of where patients were sent after being evacuated from nursing homes and hospitals.

Never Let A Serious Crisis Go To Waste

After Katrina, self regulation prevailed and preparedness Carrot Opportunities were increased exponentially.  On exam day, October 22, 2012, and for weeks thereafter, it became self-evident that the law of timing was in effect.

The tremendous human suffering and loss of life in Sandy alone would not be enough to drive new regulation.  Nor would the absence of plausible aspersions.  Right or wrong, forcing new regulation upon the private sector requires political will. 

Yes, Sandy was a sexier storm than Katrina.  But, the reason that the 121 page emergency preparedness rule proposed by CMS has seen the light of day is that it aligns with the ideology of President Obama and his administration.  And for this reason, it will be enacted before the next President is sworn in.

The rule is necessary and is here to stay.  It may be tweaked before enactment, but is unlikely to be overhauled. 

About Karl Schmitt

Karl Schmitt Photo Karl is the passionate Founder of He is on a mission to align the disaster preparedness programs of healthcare institutions with those of emergency management, public health, and others in the public, private, and not-for-profit sectors who care for the physical, mental, and spiritual health of people each day. Learn more about him here. He can be reached at

Karl Schmitt, MPA

Karl Schmitt, MPA

Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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