Health Care Coalitions 2007-2011:  Yes, ASPR Had A Strategy

Health Care Coalitions 2007-2011: Yes, ASPR Had A Strategy

This is second part of a series that analyzes a disconnect between the healthcare system preparedness/healthcare coalition strategy of the U.S. Department of Health and Human Services and its implementation within the states.  Can read Part 1 here Part 1: 2002-2006, Prior To ASPR

On August 29, 2005, Hurricane Katrina struck New Orleans.  It was the costliest natural disaster in the history of the United States, as well as one of the five deadliest hurricanes.  Katrina is the most famous storm of the 2005 season, but she was not alone in her devastation.  She was joined by Wilma and Rita, as three of the six most intense Atlantic hurricanes ever documented.

And the 2005 hurricane season came on the heels of a 2004 season that decimated Florida with the landfall of four major hurricanes–Charley, Francis, Ivan, and Jeanne.  The two-year run of disrupting hurricanes put the Federal Emergency Management Agency (FEMA) under the gun and emergency management back on Congress' action agenda, after four years in the post-9/11 shadow of homeland security.

But make no mistake, it was Katrina that was the beacon of incompetence that shone on local and state officials in Louisiana and gave the George W. Bush administration a black eye that the President never fully recovered from; it was Katrina that illustrated gross deficiencies with the preparedness of healthcare facilities and the human services system, and it was Katrina that lead to such great human suffering and loss of life that health and medical preparedness rose from an issue competing for attention to the action agenda – from the back burner to the front burner.  

Rise To The Action Agenda:  Disaster –> Human Problem –> Political Problem

Two years after he departed the White House, in a 2010 interview with NBC News, former President Bush called his administration's response to Katrina one of the few moments during his eight years in the White House he wished he could do over.  Given all that he faced during his two terms, that is a powerful statement.  Bush criticized what he said was a “lack of crisp response” to Katrina at “all levels of government."

In his book Decision Points, Bush stated, "I should have recognized the deficiencies sooner and intervened faster... [t]he problem was not that I made the wrong decisions.  It was that I took too long to decide."  He continued, "Just as Katrina was more than a hurricane, its impact was more than physical destruction.  It eroded citizens' trust in their government.  It exacerbated divisions in our society and politics.  And it cast a cloud over my second term." The divisions in society Bush refers to are between rich and poor, Democrats and Republicans – between the black community and a conservative White House that failed to display an appearance of compassion.

One of the most personally painful assertions came when musical star Kanye West, during a nationally televised concert for hurricane relief, famously stated,"George Bush doesn't care about black people." He followed it up by releasing a song of the same title. Reflecting on the comment Bush writes, "I faced a lot of criticism as President. I didn't like hearing people claim that I lied about Iraq's weapons of mass destruction or cut taxes to benefit the rich. But the suggestion that I was racist because of the response to Katrina represented an all-time low." In a 2010 interview with Matt Lauer on the Today Show, Bush said, "As you read those words," Bush tells Lauer, "I felt 'em when I heard 'em, felt 'em when I wrote 'em and I felt 'em when I'm listening to 'em."

In a 2010 interview, West expressed regret for his comments, stating "I would tell George Bush in my moment of frustration, I didn't have the grounds to call him racist." He said he had been running on high emotions and as a human being had not chosen the right words.

The fact that Katrina had her own chapter in the former President's book and remains front of his mind years later, provides a powerful retrospective of her affect on him personally – and his legacy.  And it illustrates why Katrina moved to the top of Congress' action agenda and so greatly altered public policy in the months and years that followed.  It is important to note that Bush's regrets are not about levies, flooding, the destruction of property, or the cost of recovery.  No, to this day, his regrets are of the human suffering and loss of life that resulted, how it reflected on perceptions of his leadership and character, and how unprepared the Nation was to intervene.  You see, disasters are ultimately about people.

To that end, paradigm shifts in federal policy following disasters are about people. They are rarely driven by damage to property, unless the property is on Wall Street.  Insured or uninsured, repairs can be made, and communities rebuilt.  The same cannot be said for the human problems. Broken families and deep emotional scars cannot be fixed with new federal programs. 

And the media cycle directly influences the scope and speed of policy changes. Without a free press to display the human cost of disasters, necessary changes would be far less likely. Americans cannot resist watching disasters play out on television, and the 24-hour news cycle is more than happy to oblige with non-stop must see reality TV.  Showing a massive structure fire, an earthquake, a hurricane, or a tornado is a ratings draw.  Property damage, unless it is one's own, is just a good action thriller.

But when the images on the screen transition from the destruction of property to the suffering and death of people, the mood shifts to sadness. Compassion and empathy reign.  It is still good for ratings, but the action thriller becomes a depressing real-life drama that people cannot turn off.  That is until the drama plays on and the suffering continues for days and weeks, as it did in Katrina.  Eventually, people grow numb and cannot bare to watch.  It is then that must see reality TV transitions to an investigative series that seeks the cause of the suffering, who is to blame, and why the government is not acting faster.

And when the "breaking news" takes the camera inside a long-term care center where 35 elderly residents drowned, sadness becomes anger.  People want answers!  You see, when the suffering and loss of life is perceived as unnecessary, the American people want accountability and action from the leaders they elected–action that ensures such tragedy never happens again. 

It was only four years earlier that a fire at the World Trade Center went from a must see action thriller to a painful drama series. Shock, disbelief, and anger reigned as human suffering and loss of life moved front and center.  Then, only a week later, anthrax attacks delivered via the U.S. postal system killed five, sickened 17 others, and caused a Nationwide panic.  And the American people expected their elected leaders to do "something."

And Congress acted.  The Homeland Security Act and the Public Health Security and Bioterrorism Preparedness and Response Act became law in 2002.

And, as a result, Katrina was a human problem that was not supposed to happen.  After all, between 2002 and 2006, Congress had sent hundreds of millions of dollars to the National Bioterrorism Hospital Preparedness Program (NBHPP) and the Public Health Emergency Preparedness Program (PHEP).  Not to mention, the runaway money train known as the Homeland Security Grant Program (HSGP).

So, in 2006, Congress acted – again.

Congress' Acts: PAHPA –> ASPR

Congress responded to Katrina by enacting the Post Katrina Emergency Management Reform Act (PKEMRA) and the Pandemic and All Hazards Preparedness Act (PAHPA).

The PKEMRA was signed by President George W. Bush on October 4, 2006.  The act amended the Homeland Security Act of 2002 to, among other things, reestablish emergency management as a federal priority. It was PKEMRA that restored authority to the Federal Emergency Management Agency (FEMA) surrendered when it was absorbed by the Department of Homeland Security (DHS) in 2003. The lesson from Katrina was clear; emergency management still mattered in the post 9/11 world. 

PAHPA was signed by the President on December 19, 2006. The act amended the Public Health Service Act (PSA) to, among other things, establish ASPR in HHS, mandate preparedness for those with functional needs, and require a Quadrennial National Health Security Strategy. It was the purpose of PAHPA “to improve the Nation’s public health and medical preparedness and response capabilities for emergencies, whether deliberate, accidental, or natural.”

PAHPA was intended to shift health and medical preparedness from a laser focus on Bioterrorism and Pandemic Flu to an "all-hazards" approach. It directly targeted the public health, healthcare, and human services (Emergency Support Function [ESF] #8) failures illuminated by Katrina – the human problems.  Though there were many breakdowns found in the investigations that followed, the most publicized involved the unconscionable shelter conditions at the Superdome and the estimated 215 bodies recovered from hospitals and nursing homes as the flood waters receded.

As we discussed in our highly controversial column, CMS Emergency Preparedness Rule:  A Shift From The Carrot To The Stick For Healthcare Providers?, the greatest number of bodies recovered from a single hospital was 45 at Memorial Hospital, which was chronicled in the award winning book Five Days at Memorial authored by Pulitzer Prize winner, Sheri Fink.  And it was St. Rita's nursing home that became the public face for long-term care preparedness failures, when 35 elderly residents drowned in their wheelchairs and beds.  The owners were criminally charged, tried, and acquitted.  The St. Rita's case is chronicled in the book Flood of Lies, written by James Cobb, the attorney who successfully defended the owners.

In Part One, we stated that the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 was a big deal deal for HHS, and it was.  But PAHPA trumped it, as it established Emergency Support Function (ESF) #8 as a federal priority on par with ESF #4 – Firefighting, ESF #9 – Search and Rescue, and ESF #11 – Public Safety, Law Enforcement and Security.  And to be given a new Assistant Secretary by legislative mandate and funding to hire a robust staff dedicated solely to health, medical, and human services preparedness was a game changer.

Before moving on to strategy, let's take a moment to review.  Katrina was a big storm that struck a major metropolitan area. She delivered property damage that lead to unconscionable human suffering and loss of life – a human problem.  The local, state, and federal response was "less than crisp," which played out on must see TV for months.  The human problem grew into a political problem that found its way onto Congress' action agenda.  Congress enacted the PKEMRA and PAHPA, which the White House was responsible for implementing through Executive Branch agencies, DHS and HHS.

Seventeen months after Katrina, it was time for HHS to develop their strategy and implementation plan, and put the new HPP on the ground at the state and local level.  Would ASPR translate PAHPA into agency strategy in a manner consistent with legislative intent?  Would their strategy be translated into an implementation plan consistent with strategic intent?  Would their oversight of sub-awardees be consistent with the intent of their implementation plan?

 Let's take them one at a time.

ASPR's Strategy

Yes, ASPR appears to have developed a rational preparedness strategy consistent with Congress' intent.  And they appear to have incorporated what was learned from the health, medical, and human services problems illuminated by Katrina.  From a strategic perspective, they appear to have been on target from day-one.

On July 25, 2006, five months before he signed PAHPA into law, President Bush appointed Rear Admiral W. Craig Vanderwagen to lead ASPR. He was confirmed by the U.S. Senate and sworn into office as the first Assistant Secretary for Preparedness and Response on March 23, 2007. He held the position until replaced by President Obama's appointee, Dr. Nicole Lurie, in July of 2009.

Vanderwagen is not one that could be labeled a "political hack."  He had served as a commissioned officer in the US Public Health Service (USPHS) for 28 years before his appointment, and deployed numerous times to disaster environments around the world, including four months in Louisiana for Hurricane Katrina. He knew first hand what had gone wrong in Louisiana; he understood that no single type of healthcare facility could possibly manage the medical surge that occurs during the catastrophic, and he could see that response is doomed if cross-cutting relationships are not built beforehand through preparedness.

And with ASPR he had a blank slate, a healthy budget, and a legislative mandate; he had access to some of the brightest minds, both within government and the private and not for profit sectors, and he had at his disposal a myriad of after action reports and investigative reports from both chambers of Congress, the White House, and other many others.

From a strategy perspective, Vanderwagen and his team clearly understood what needed to be done and appeared to set the course accordingly.

In September of 2007, ASPR worked with the CNA Corporation to review, update and publish the Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies (MSCC Handbook), which was first published in 2004. The MSCC Handbook, Second Edition, carried forward the strategies of the first edition with only minor changes necessary to incorporate the requirements of Homeland Security Presidential Directive (HSPD) 5 and the first edition of the National Response Plan (NRP).

As with the first edition, Chapter 1 covered, "Management of Individual Healthcare Assets (Tier 1)," and Chapter 2 covered, "Management of the Healthcare Coalition (Tier 2)." These chapters are discussed in greater detail in Part One. ASPR affirmed a strategy that was clearly rooted in multidisciplinary coalitions and the preparedness of facilities from across the healthcare sector.

In May of 2009, ASPR again worked with the CNA Corporation to publish a companion to the MSCC Handbook. The Medical Surge Capacity and Capability: The Healthcare Coalition in Emergency Response and Recovery Handbook provides guidance to healthcare planners on how to develop, implement, and maintain cost-effective and response-oriented Healthcare Coalitions.  And when FY2009 closed that fall, ASPR published a two-year retrospective titled, From Hospitals To Healthcare Coalitions, Transforming Health Preparedness In Our Communities.

The report's introduction letter from Assistant Secretary, Dr. Nicole Lurie states, "The Hospital Preparedness Program (HPP) has become a critical component of community resilience and enhancing the response capabilities of our healthcare system.  This Cooperative Agreement Program provides funding to States toward this end."  Yes, the "Hospital Preparedness Program has become a critical component of community resiliency and enhancing the response capabilities of the healthcare system."

And the report went on to state the HPP Vision: "Communities prepared to meet the healthcare needs of their citizens in response to and recovery from disasters"

Strategy? Check!

But strategy and implementation are very different animals. To this day, ASPR's preparedness strategy is nearly identical to that of 2007, yet there was a perception at the state and local level that they had invented some crazy new wheel when they rolled out the new five-year project period in July of 2012, which made healthcare coalitions the cornerstone of HPP going forward.

So, if ASPR published and promoted a strategy that few at the state and local level appear to have been aware of, was it not implemented in a manner consistent with strategic intent? No.

ASPR's Implementation

If we assume that federal implementation begins when the policy wonks publish the strategy and ends when the fiscal gurus receive the signed cooperative agreements back from the Awardees (50 states, 4 separately funded cities, 5 U.S. Territories, and 3 freely associated states), yes, ASPR appears to have implemented the HPP consistent with strategic intent.

Our research has uncovered documents and testimony that, unexpectedly, demonstrates consistent linkage between ASPR's strategy and policy implementation dating back to 2007.  And I say unexpectedly, because the hypothesis going in was the opposite.

When asked for comment on whether there had been a disconnect between strategy and policy, a spokesperson for ASPR provided the following, "Our strategy and policy have been consistent.  In 2007, there were two competitively awarded grants on top of the HPP cooperative agreement:  (1) the Healthcare Facilities Partnership Program and (2) the Healthcare Facilities Emergency Care Partnership Program.  Both of these competitive awards focused on healthcare coalitions and community/regional partnerships."

The Healthcare Facilities Emergency Care Partnership Program identified was backed with $25,000,000 that would result in 1-3 awards ranging from $8,000,000 and $25,000,000.  And the Healthcare Facilities Partnership Program was a $15,000,000 program that would result in 6-30 awards ranging from $500,000 and $2,500,000.  Yes, those numbers are millions.   So, the best-case scenario for the 2007 agreement was 33 new healthcare coalitions, which, if implemented, would be a very impressive start.  The number of coalitions established, and whether similar opportunities were offered in subsequent years is not yet known.  A cursory search for supporting documentation yielded none, and answers to follow up questions requested from ASPR could not be provided before the publication deadline. Stay tuned!

The competitive programs offered, clearly targeted the strategy adopted.  But, the HPP cooperative agreement missed the mark.  In reference to the agreement, the spokesperson provided the following. "For the HPP cooperative agreement guidance in 2007, an additional consideration for the funding strongly encouraged states to continue and, in some cases, begin developing healthcare partnerships to build community/regional medical capability."

If sub-awardees are expected to allocate their funds to achieve the capabilites, ASPR failed to promote their broader strategy. The 2007 HPP agreement project description leads off with a section titled "Level One Required Sub-Capabilities," which stated, "To continue building on previous years’ work, and to meet the applicable preparedness goals described in section 2802(b) of the PHS Act, award recipients shall use FY 2007 funding to build the following capabilities:"

  1. Interoperable Communications Systems
  2. Bed Tracking System
  3. Emergency Systems for Advance Registration Volunteer Health Professionals (ESAR-VHP)
  4. Fatality Management Plans
  5. Hospital Evacuation Plans

Given that the Assistant Secretary was not sworn in until March of 2007 and the transfer of the program from the Health Resources Services Administration (HRSA) was in process, the 2007 agreement likely did not receive the necessary focus.  The fact that there were two additional funding opportunities targeting regional partnerships and coalitions put the overall package for 2007 on-target with strategy. Not a bulls eye, but on the target.

In 2008, the HPP cooperative agreement shifted in support of the broader strategy.  ASPR's spokesperson stated, "In 2008, the Medical Surge Capacity and Capability handbook was highlighted directly in the HPP grant guidance and partnership/coalition development was added as a Level One Sub-capability for the use of grant funds."

As indicated, the MSCC Handbook was outlined on page 3 of the agreement and there were changes to the Level-One Sub-capabilities, which, in addition to adding Partnership/Coalition Development, added Medical Evacuation/Shelter In Place.  Hospital Evacuation Plans appear to have been incorporated into Medical Evacuation/Shelter In Place.

In reference to the 2008 agreement, the spokesperson continued, "ASPR’s expectations for partnership/coalition development included planning and developing memoranda of understanding to share assets, personnel, and information; develop plans to unify management of healthcare during a public health emergency; and integrate communication with jurisdictional command in the area.  Including community and other healthcare organizations in a partnership/coalition is also detailed in the guidance."

The spokesperson went on to explain that in 2009 ASPR initiated a new three-year project period that provided for consistency for fiscal years 2009, 2010, and 201l.  The agreements included a capabilities-based planning approach for healthcare systems and retained partnership/coalition development as a Level-One Sub-capability.  On the first page, under Purpose, the agreement broadly defined healthcare systems to be multidisciplinary, including both inpatient and outpatient facilities. The agreement states, "For the purposes of this CA, healthcare systems (E.g., sub-awardees) are composed of hospitals and other healthcare facilities which are defined broadly as any combination of the following:  outpatient facilities and centers (E.g., behavioral health, substance abuse, urgent care), inpatient facilities and centers (E.g., trauma, State and Federal veterans, long-term, children's, tribal), and other entities (E.g., poison control, emergency medical services, CHCs, nursing, etc.)."

The 2009 agreement, which continued in form for 2010 and 2011, again outlined the MSCC Handbook, and the Level-One Sub-capabilities remained unchanged from those in the 2008 agreement, including Partnership/Coalition Development.  Also in 2009, ASPR commissioned published a companion to the MSCC Handbook titled, Medical Surge Capacity and Capability: The Healthcare Coalition In Emergency Response and Recovery. The publication reinforced ASPR's commitment to the strategy outlined in the second edition of the MSCC Handbook.

On July 1, 2012 ASPR rolled out the new five-year project period in alignment with the CDC Public Health Emergency Preparedness Program.  Part-three of this series will pick up with analysis of ASPR's strategy, implementation, and oversight of the first two years of the project period.

Implementation?  Check!

If ASPR developed a strategy consistent with legislative intent, and effectively implemented it consistent with strategic intent, why did it not translate to like implementation for the 62 Awardees? Was oversight to blame? Yes.

ASPR's Oversight

If we assume that oversight begins when the Awardee signs and returns the cooperative agreement to ASPR and ends 30-days following the end of the fiscal year, something has gone awry with the oversight necessary to ensure ASPR's strategy hits the ground at the local level. And not just in year one or two, but every year between 2007 and 2012.

It would be easy to put the disconnect solely on the Principle Investigators for the 62 Awardees who signed on the dotted line. After all, is it not their responsibility to interpret the guidance, seek counsel, and translate the federal strategy into guidance for their sub-awardees? Is it not their responsibility for sub-recipient monitoring of their sub-awardees? It would be easy to put it all on their shoulders, but somewhat unfair.

The problem is, implementing federal preparedness strategy Nationally can be likened to pouring it through an upside down funnel. A focused strategy is implemented through a uniform cooperative agreement, only to be interpreted differently by the principle investigators and grant managers for 62 Awardees. And when Awardees seek clarification from federal project officers, the guidance provided by each comes in different shades.

After reading the federal guidance and taking into account opinions received from their project officers, each Awardee devises a strategy for their state.  And they implement the strategy via a sub-grant that they must then pour into another upside down funnel.  And the sub-awardees, of course, each interpret the grant differently...

The number of stakeholders makes oversight a bear for ASPR and each of the Awardees. Maybe that is why the outcome locally rarely resembles the desired federal strategy. It is much like the game Chinese Whispers, where one person whispers a message to another, which is passed through a line of people until the last player announces the message to the entire group. It generally elicits a good laugh from everyone.

No none is laughing at the state of healthcare system preparedness today

Unfortunately, to uncover the details of how each of the 62 Awardees interpreted, implemented, and managed their agreements would require far more horsepower than we have here at bParati today.  And maybe it just doesn't matter at this point. Maybe it is time to write off the first decade of HPP as lessons learned?  Maybe the new five-year project that period kicked off in July of 2012 is our Mulligan? 

Maybe ASPR's strategy is now supported by a tighter, more concise cooperative agreement?  Maybe oversight will be more consistent?  Maybe, people are finally starting to "get it?"

Maybe not?

Stay tuned.  Shine On and keep doing good for the greater good! 

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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In all we do, we seek to reduce human suffering and loss of life caused by disasters.

We get it done by connecting the preparedness efforts of healthcare organizations, emergency management agencies, and public health departments through effective, financially self-sustaining healthcare coalitions.

Yes, we believe healthcare coalitions are the path forward.

Karl Schmitt, Passionate Founder & CEO, bParati

Karl SchmittPassionate Founder & CEO

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