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NAVAL 

POSTGRADUATE 

SCHOOL 

MONTEREY, CALIFORNIA 


THESIS 


THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR 

HOMELAND SECURITY PREPAREDNESS? 


by 


Kimberly Ann Petersen 


September 2014 

Thesis Advisor; 

Christopher Bellavita 

Second Reader: 

Alexander Garza 


Approved for public release; distribution is unlimited 




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THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR HOMELAND 
SECURITY PREPAREDNESS? 


6. AUTHOR(S) Kimberly Ann Petersen 


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Naval Postgraduate School 
Monterey, CA 93943-5000 


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Master’s Thesis 


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Prior to implementation of the Affordable Care Act (ACA), tens of millions of U.S. citizens were without health 
insurance coverage. Without health insurance, health care can be unaffordable or inaccessible, or both. Our ability to 
obtain health care is part of the homeland security preparedness puzzle. If the Affordable Care Act increases health 
insurance coverage and helps to control costs as promised, it has enormous potential to bolster homeland security 
simultaneously. This thesis asks, “How will the implementation of the Affordable Care Act positively impact 
homeland security in its efforts to achieve its all-hazards preparedness goal?” This thesis first draws the links between 
health insurance coverage, health care and homeland security. Using empirical evidence and deductive analysis, it 
then forward-maps the positive impacts ACA implementation is likely have on homeland security in the areas of 
health and economic security. Recommendations aimed at enhancing the positive effects of the ACA are provided, 
including expanding ACA access and benefits to immigrants, better educating the public on the ACA tax penalty, and 
utilizing grants to encourage state participation. 


14. SUBJECT TERMS 15. NUMBER OF 

health care, healthcare, Obamacare, Affordable Care Act (ACA), homeland security, Medicaid, health PAGES 
surveillance, health insurance 103 

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Unclassified 


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Approved for public release; distribution is unlimited 


THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR HOMELAND 

SECURITY PREPAREDNESS? 


Kimberly Ann Petersen 
Captain, Fremont, CA, Poliee Department 
B.A., Stanford University, 1994 


Submitted in partial fulfillment of the 
requirements for the degree of 


MASTER OF ARTS SECURITY STUDIES 
(HOMELAND SECURITY AND DEFENSE) 

from the 

NAVAL POSTGRADUATE SCHOOL 
September 2014 


Author: Kimberly Ann Petersen 


Approved by: Christopher Bellavita 

Thesis Advisor 


Alexander Garza, St. Louis University 
Seeond Reader 


Mohammed Hafez 

Chair, Department of National Security Affairs 



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IV 



ABSTRACT 


Prior to implementation of the Affordable Care Act (ACA), tens of millions of U.S. 
citizens were without health insurance coverage. Without health insurance, health care 
can be unaffordable or inaccessible, or both. Our ability to obtain health care is part of the 
homeland security preparedness puzzle. If the Affordable Care Act increases health 
insurance coverage and helps to control costs as promised, it has enormous potential to 
bolster homeland security simultaneously. This thesis asks, “How will the 
implementation of the Affordable Care Act positively impact homeland security in its 
efforts to achieve its all-hazards preparedness goal?” This thesis first draws the links 
between health insurance coverage, health care and homeland security. Using empirical 
evidence and deductive analysis, it then forward-maps the positive impacts ACA 
implementation is likely have on homeland security in the areas of health and economic 
security. Recommendations aimed at enhancing the positive effects of the ACA are 
provided, including expanding ACA access and benefits to immigrants, better educating 
the public on the ACA tax penalty, and utilizing grants to encourage state participation. 


V 



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VI 



TABLE OF CONTENTS 


I. INTRODUCTION.I 

A. PROBLEM SPACE.I 

B. BACKGROUND.4 

C. PURPOSE OF THE RESEARCH.8 

D. RESEARCH QUESTION.9 

II. LITERATURE REVIEW.II 

A. GOVERNMENT DOCUMENTS.II 

B. POPULAR MEDIA.14 

C. MEDICAL RESEARCH.14 

D. POLICY WRITINGS.15 

E. METHOD.16 

F. CHAPTER OUTLINES.17 

III. HEALTH CARE AND HOMELAND SECURITY: DRAWING THE LINKS ..19 

A. HOMELAND SECURITY REQUIRES A ROBUST, ACCESSIBLE 

HEALTH CARE SYSTEM.19 

B. BIOTERRORISM.20 

1. Bioterror and the Health Care Surveillance System.21 

2. Foodhorne Illnesses and the Health Surveillance System.24 

C. DISEASE PREVENTION.25 

1. Influenza Virus.27 

2. History of Influenza Pandemics.29 

3. Combating Pandemic Influenza.30 

D. NATURAL DISASTERS.32 

E. PSYCHOLOGICAL RECOVERY.33 

1. Terror Attacks and PTSD.34 

2. Active-Shooter Incidents and Mental Illness.36 

F. ECONOMICS.38 

G. SUMMARY.40 

IV. WHAT IS THE PATIENT PROTECTION AND AFFORDABLE CARE 

ACT?.41 

A. SHARED RESPONSIBILITY.43 

B. EXPANSION OF MEDICAID.47 

C. CONTROLLING COSTS.49 

D. IMPROVING QUALITY OF THE HEALTH CARE SYSTEM.49 

E. SUMMARY.50 

V. ANALYSIS.53 

A. HOW IS ACA MOST LIKELY TO POSITIVELY IMPACT 

HOMELAND SECURITY EFFORTS TO ACHIEVE ALL¬ 
HAZARDS PREPAREDNESS?.53 

B. HEALTH SURVEILLANCE SYSTEM.55 

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C. PREVENTIVE CARE.58 

D. DISASTER PREPAREDNESS.61 

1. Natural Disasters and Vulnerable Populations.64 

2. Strengthening of the Public Health System.65 

3. Mental Health Care.65 

4. Increased Economic Stability.66 

E. SUMMARY.70 

VI. WHERE DO WE GO FROM HERE?.71 

A. RECOMMENDATIONS AND POLICY ADJUSTMENTS.71 

B. EXTEND ACA BENEFITS TO IMMIGRANTS.71 

C. EDUCATE THE PUBLIC ON THE TRUE TAX PENALTY.74 

D. ADDRESS MEDICAID PREVENTIVE COVERAGE INEQUITY.75 

E. PROVIDE FINANCIAL INCENTIVES TO ENCOURAGE STATE 

PARTICIPATION IN ACA.76 

F. AREAS FOR FURTHER RESEARCH.77 

G. SUMMARY.77 

LIST OF REFERENCES.79 

INITIAL DISTRIBUTION LIST.89 


viii 




















LIST OF ACRONYMS AND ABBREVIATIONS 


ACA 

Affordable Care Aet; same as Patient Proteetion and Affordable 
Care Aet 

ACIP 

Advisory Committee on Immunization Praetiees 

CBO 

Congressional Budget Offiee 

CDC 

Centers for Disease Control 

CHIP 

Children’s Health Insurance Program 

COMPARE 

Comprehensive Assessment of Reform Efforts 

CMS 

Centers for Medicare and Medicaid Services 

CRS 

congenital rubella syndrome 

DNA 

deoxyribonucleic acid 

EIP 

Emerging Infections Program 

EMTAEA 

Emergency Medical Treatment and Active Eabor Act 

FDA 

Food and Drug Administration 

FPE 

federal poverty level 

GAO 

Government Accounting Office 

HCERA 

Health Care Education and Reconciliation Act 

HHS 

U.S. Health and Human Services Department 

HMO 

health maintenance organization 

HPP 

Hospital Preparedness Program 

IRS 

Internal Revenue Service 

NIMH 

National Institute for Mental Health 

OECD 

Organisation for Economic Co-operation and Development 

OHP 

Oregon Health Plan Standard 

RNA 

ribonucleic acid 

PPACA 

Patient Protection and Affordable Care Act; same as Affordable 
Care Act 

PTSD 

post-traumatic stress disorder 

VA/VHA 

Veterans Administration; Veterans Health Administration 


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X 



ACKNOWLEDGMENTS 


I am both indebted and grateful to Dr. Christopher Bellavita for his 
encouragement and unyielding demand for quality analysis. Thank you to the entire 
Naval Postgraduate School staff—instructors and support personnel alike—for your 
dedication to your work and your investment in others. I am grateful to Dr. Alexander 
Garza for the gift of time and expertise given to a student both unmet and unseen. I thank 
my command staff for pushing me to take this on, and for giving me the time and support 
necessary to finish. Surely the one person most responsible for allowing me to complete 
this project was my wife, Lupita. Although you have always managed the kids and run 
the household, thank you for adding yard work, shopping, and even coaching to your 
endless list of things to do. You are the glue that holds it all together. I love you. Thank 
you. 



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I. INTRODUCTION 


Health care has not traditionally been considered part of the homeland security 
enterprise. But as the public becomes more aware of the complexities and relationships 
between the systems involved, our view of what comprises the homeland security 
enterprise expands as well. 

A. PROBLEM SPACE 

The great poet Virgil pointed to the paramount importance of physical wellness 
with his simple quote, “Our greatest wealth is health.” But maintaining our health often 
requires professional assistance or medical intervention. For the vast majority of United 
States residents, health care is an inevitability. In 2010 alone, 80 percent of U.S. adults 
saw a health care professional at least once during the year,i and Americans average 18 
different doctors over a lifetime.^ Our ability to obtain health care is part of the homeland 
security preparedness puzzle. 

Homeland security’s mission has broadened since 2001 from a terror-centric 
focus to “a concerted national effort to ensure a homeland that is safe, secure, and 
resilient against terrorism and other hazards where American interests, aspirations, and 
way of life can thrive.”3 Much of this “all-hazards preparedness” mission has health care 
implications, such as protecting us from bioterror attack, identifying and mitigating 
emerging disease, or caring for the injured after a natural disaster. Ensuring that our 
“interests, aspirations and way of life can thrive” also necessitates some level of 
economic security.^ 


1 Schiller et al., Summary Health Statistics for U.S. Adults: National Health Interview Survey, Center 
for Disease Control, 2010, http://www.cdc.gov/nchs/data/series/sr_10/srl0_252.pdf, 12. 

^ “Survey: During Lifetime, Average Person Sees Nearly 20 Doctors,” press release. Practice Fusion, 
April 127, 2010, http://www.practicefusion.com/pages/pr/survey-patients-see-over-18-different-doctors-on- 
average.html 

3 U.S. Department of Homeland Security, Quadrennial Homeland Security Review Report 
(Washington, DC: U.S. Department of Homeland Security, 2010), 12. 

4 Ibid., 12. 


1 



In the United States, health eare is not an entitlement, but rather it is a privately 
funded and for-profit industry. The most eommon methods of finaneing our health eare 
eosts are private health insuranee polieies, which are obtained via job benefits, followed 
by government entitlement programs.^ 

According to a Center for Disease Control report, health insurance is a key 
indicator for access to health care.^ It is well-documented that uninsured Americans wait 
longer to seek medical care, present at a more advanced state of illness, and 
consequently, have poorer health outcomes than the insured population.^ A 2012 U.S. 
Census Bureau report estimated that upwards of 48.6 million Americans lacked health 
insurance at the time of its issuance.^ This lack of health insurance is a significant gap in 
the homeland security preparedness effort, which leaves us vulnerable to homeland 
security-related threats, such as emerging disease, contagion and bioterror attacks. 

Unfortunately, health care in America is an expensive proposition. As a nation, 
the U.S. currently spends 17.7 percent of its gross domestic product (GDP) on health 
care, while other economically advanced societies with some form of publicly-funded 
health care average only 9.3 percent of their GDP.9 U.S. health care costs increased three 
times faster than wages from 2000 to 2010,and half of all personal bankruptcies are 
caused in part by medical expenses.^ As Harvard M.D. and noted health care expert 


^ Carmen DeNavas-Walt et al., Income, Poverty, and Health Insurance Coverage in the United States: 
2011 (Washington, DC: U.S. Government Printing Office, 2012), 
http://www.census.gOv/prod/2012pubs/p60-243.pdf 

^ Robin A. Cohen and Barbara Bloom, Access to and Utilization of Medical Care for Young Adults 
Aged 20-29 Years: United States, 2008 (NHCS Data Brief no. 9) (Atlanta: GA, Centers for Disease Control 
and Prevention, 2010), http://www.cdc.gov/nchs/data/databriefs/db29.PDF, 1. 

^ Andew P. Wilper et al., “Health Insurance and Mortality in U.S. Adults,” American Journal of Public 
Health 99, no. 12 (2009): 2289. 

^ “The 2012 Statistical Abstract,” U.S. Census Bureau, 2012, 
http://www.census.gOv/compendia/statab/2012/tables/12s0155.pdf, 111 

9 Organisation for Economic Co-operation and Development (OECD), OECD Health Data 2013: How 
Does the United States Compare? (Paris, France: Organisation for Economic Co-operation and 
Development, 2013), 1-2. 

Health Care Cost Institute, Health Care Cost and Utilization Report: 2010, Health Care Cost 
Institute, 2012, www.healthcostinstitute.org/files/HCCI_HCCUR2010.pdf 

11 The Patient Protection and Affordable Care Act, H.R., 3590, 111* Cong. (2010), § 1501 (E), 125; 
David U. Himmelstein et al., “Medical Bankruptcy in the United States, 2007: Results of a National 
Study,” The American Journal of Medicine 122, no. 8 (2009), 741-746. 

2 



Steffie Woolhandler stated, “Unless you’re a Warren Buffett or Bill Gates, you’re one 
illness away from financial ruin in this country.”i2 As a result, 15.7 percent of the 
population lack insurance altogether, and a combined 42 percent of adults (over age 18) 
are considered either uninsured or underinsured. ^ 3 

In an effort to increase the number of uninsured Americans and reduce the overall 
costs of health care, the 111* United States Congress passed and President Barack 
Obama signed the Patient Protection and Affordable Care Act (PPACA, and hereafter 
referred to as “ACA”) into law on March 23, 2010. This federal law represents the largest 
health care overhaul since the introduction of Medicare and Medicaid in 1965. The 
legislation aims to expand health insurance coverage through a variety of means, 
including employer tax credits, subsidies, expansion of government insurance programs, 
regulations and mandates. Another primary aim is to control health care expenditures. 
Other goals of this lengthy and complex law include improved health care delivery, 
efficiency and transparency, and improved health care workforce training. The ACA 
survived Supreme Court review in June of 2012, and it goes into effect in stages through 
2019. 

Affordable, accessible health care has not, as of yet, reached the policy agenda of 
the homeland security community. This thesis will explore some of the likely impacts the 
implementation of the ACA will have on our homeland security system. The Affordable 
Care Act is potentially a substantial steppingstone towards achieving “all-hazards 
preparedness” and therefore warrants graduate-level research and focused attention. 


12 Theresa Tamkins, “Medical Bills Prompt More than 60 Percent of U.S. Bankruptcies,” CNN, June 
5, 2009, http://www.cnn.com/2009/HEALTH/()6/05/bankruptcy.medical.bills/ 

13 As used here, the designation of “underinsured” is determined by assessing financial risk against 
income (e.g., out-of-pocket medical expenses) totaled 10 percent of income or more. Cathy Schoen et ah, 
“How Many are Underinsured? Trends among U.S. Adults, 2003 and 2007,” Health Affairs 27, no. 4 
(2008):298-309, doi:10.1377/hlthaff27.4.w298 

1^ Democratic Policy Communication Committee, Patient Protection and Affordable Care Act: 
Detailed Summary, accessed September 9, 2013, 
http://www.dpc.senate.gov/healthreformbill/healthbill04.pdf 


3 



B. BACKGROUND 


Health care is an immense part of the United States’ economy, infrastructure, and 
dialogue, in large part due to its enormous—and constantly growing—costs. In 2011, the 
U.S. spent 17.7 percent of its gross domestic product on health care, which is eight 
percentage points higher than the average for other developed countries (9.3 percent), 
according to the Organisation for Economic Co-Operation and Development (OECD).!^ 
Even still, the United States is the lone industrialized nation in the world without a 
government-sponsored universal health care system, In the United States, health care is 
financed through a mix of private and employer-sponsored insurance, while specific 
groups are eligible for one of four entitlement programs: Medicaid, Medicare, the 
Veterans Health Administration, and Children’s Health Insurance Program (CHIP). 

Every other industrialized nation (e.g., Erance, the United Kingdom, Japan, 
Canada) in the world has some form of government-funded health care system in place. 
Each country’s system differs in its delivery and funding mechanism, but the underlying 
concept is that the government takes action to ensure widespread—or “universal”— 
coverage and sets minimum standards of care. Generally, this is achieved through 
legislation and regulation, while funding is generally accomplished, in whole or in part, 
by taxation. 

Some countries utilize a single-payer funding mechanism whereby the 
government, rather than privately-owned health insurance companies, pays for all health 
care expenses. The term “single-payer” refers to the fact that a single entity—the 
government—pays all costs. 

In some countries, such as Canada, most hospitals and medical facilities are 
privately owned, and the doctors are contractors who receive reimbursement from 
provincially based “Medicare” funds.Medical care is mostly free at the point-of-use for 


15 OECD, OECD Health Data 2013, 1-2. 

15 Wilper et al., “Health Insurance and Mortality in U.S. Adults,” 2289. 

1^ “Public vs. Private Health Care,” CBC News, December 1, 2006, 
http://www.cbc.ca/news2/background/heahhcare/public_vs_private.html 


4 



the care designated as “medically necessary.”!^ Insurance companies are prohibited from 
selling coverage redundant to services already covered by the government; however, they 
may sell supplemental coverage. 

In the United Kingdom, most health care facilities are owned by the government, 
and the health care providers are employed by the government. Both set-ups are 
considered single-payer systems. Both are funded primarily through taxation of the 
population. 

The U.S. health care system uses a fee-per-service funding mechanism, meaning 
that medical providers charge fees based on the services rendered. One criticism of this 
structure is that it can encourage unnecessary testing and other procedures because the 
provider is able to charge more money for the same outcome. 

The United States runs several health entitlement programs. Approximately 32.2 
percent of all Americans are currently eligible for health coverage or care through these 
four programs.! 9 The following is a brief description of their origins: 

• The Veterans Administration (VA) was established by Congress in 1930. 
The Veteran’s Health Administration (VHA) is a component of the VA 
that provides medical care.20 This program provides direct medical care in 
its hundreds of medical centers, outpatient, outreach and rehabilitation 
clinics, and nursing homes to all military veterans and their families. 
These facilities are owned and operated by the U.S. government, and 
provide no-cost or very low-cost medical services, depending upon the 
type of care needed, and the patient’s income. For example, all services 
provided for an injury sustained during military service is comprehensive 
and no-cost. Other services and medications would entail minimal co-pay. 

• In 1965, President Lyndon Johnson enacted two major health care 
entitlement programs: 

• Medicare was introduced as a medical insurance program for 
senior citizens, paid for by a federal tax collected over the life of 
the working retiree. 


!^ Canadian Institute for Health Information, Exploring the 70/30 Split: How Canada’s Health Care 
System is Financed (Ottawa, Canada: Canadian Institute for Health Information, 2005), 
https://secure.cihi.ca/free_products/FundRep_EN.pdf, 16. 

!9 OECD, OECD Health Data 2013, 1-2. 

20 U.S. Department of Veterans Affairs, “Health Programs for Veterans,” March 2014, 
http://www.va.gov/heahh/programs/index.asp 


5 



• Medicaid is a combined federal/state program, established as a 
safety-net for the poor. Individual states implement and manage 
discrete programs and are partially reimbursed by the federal 
government. 

• In 1997, the States Children’s Health Insurance Program (SCHIP or 
CHIP) was established, a federally funded program that expanded medical 
coverage for children in families that earn up to 200 percent of the federal 
poverty level (FPL). 

Ah of this matters because health care in America has become so costly, few can 
afford treatment without health insurance coverage or access to the entitlement programs. 
Cancer treatments of various forms range from a low of $5,000 for the initial treatment of 
melanoma, to over $100,000 for the initial treatment of brain cancer.21 In March of 2013, 
Steven Brill published an in-depth report in Time magazine highlighting the outrageous 
mark-ups on hospital charges for treatment, supplies, and medicine that oftentimes have 
no correlation whatsoever to their actual costs. Although a comprehensive look at health 
care charges is beyond the scope of this paper, repeated examples cited in the article 
show that consumers are routinely charged a mark-up of 10 times or more the actual cost 
of the item, with some mark-ups as high as 10,000 percent.22 

Some argue that America already provides universal health care coverage via the 
hospital emergency room. U.S. federal law requires U.S. hospital emergency rooms to 
provide care to all comers for emergency health care, vaccinations and treatment of 
communicable disease, regardless of immigration status or ability to pay. 23 This is a 
hidden cost ultimately shifted to the insured. According to the Institute of Medicine, 
when the uninsured cannot pay for their health care, eventually taxpayers shoulder the 


21 Angela B. Mariotto et al., “Projections of the Cost of Cancer Care in the U.S.: 2010-2020,” Journal 
of the National Cancer Institute 103, no. 2 (2011): 117-128, doi:10.1093/jnci/djq495 

22 The example on the cover of this article shows that one acetaminophen tablet costs about 1.5 cents, 
while one hospital marks it up 10,000 percent to $1.50 per pill. Steven Brill, “Bitter Pill: Why Medical 
Bills are Killing Us,” Time, March 4, 2013, 

http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf 

23 Emergency Medical Treatment and Active Labor Act, Pub. L. No. 113-142, 42 U.S. Code §1395dd 
(1986). 


6 



burden.24 It is true that more people are seeking treatment at the emergency room because 
of lack of other options; however, with the average cost of a single emergency room 
visit at $1,354 in 2011,^^ the emergency room often a last resort, especially for those who 
can least afford the bill. 

Inherent in the concept of a true universal health care system is the idea that 
people can obtain preventive care and routine care for non-emergency medical issues at a 
reasonable price. Here is where the U.S. health care system has evolved into what health 
care expert Paul Starr terms the “American health-policy trap.” As he explains in his 
book. Remedy and Reaction, most of the insured public is reasonably satisfied with their 
coverage until a major health-event occurs, they experience a change in coverage, such as 
job-loss, or they experience a rescission of their health insurance by an insurer.27 Starr 
surmises the public may worry less about these types of occurrences than what would 
happen to their coverage in the event of major health care reform.28 In addition, many of 
those who do have coverage feel they have “earned” the coverage, while others have 
not.29 The idea of paying for anyone else’s health care seems dangerously close to 
socialism and possibly “un-American.” According to Starr, Americans seem to feel a 
moral sense that those with health insurance have earned it by maintaining employment, 
by serving in the military, or by reaching Medicare eligibility after a lifetime of work. On 


24 Institute of Medicine of the National Academies, Uninsurance Facts and Figures: Uninsurance 
Costs the Country More than You Think (Washington, DC: National Academies Press, 2004), 
http://www.iom.edu/~/media/Files/Report%20Files/2004/Insuring-Americas-Health-Principles-and- 
Recommendations/FactsheetSociety2.pdf, 1. 

25 Renee M. Gindi, Emergency Room Use among Adults Aged 18-64: Early Release of Estimates from 
the National Health Interview Survey, January-June 2011, Centers for Disease Control and Prevention, 
May 2012, www.cdc.gov/nchs/data/nhis/earlyrelease/emergency_room_usejanuary-june_201 l.pdf, 1. 

2® Agency for Healthcare Research and Quality, “Table 6: Emergency Room Services-Median and 
Mean Expenses per Person with Expense and Distribution of Expenses by Source of Payment: United 
States, 2011,” January, 2014, 

http://meps.ahrq.gov/data_stats/tables_co mpendia_hh_interactive.jsp?_SERVICE=MEPSSocketO&_PROG 
RAM^MEPSPGM.TC. SAS&File=HCF Y2011 &Table=HCF Y2011_PLEXP_E&VARHAGE&VAR2=SE 
X&VAR3=RACETH5C&VAR4=INSURCOV&VAR5=POVCATll&VAR6=MSA&VAR7=REGION& 
VAR8=HEALTH&VAR0H4-M7+44+64&VAR02=l&VAR03=l&VAR04=l&VAR05=l&VAR06=l 
&VAR07=l&VAR08=l&_Debug= 

27 Paul Starr, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (New 
Haven, CT: Yale University Press, 2011), 324. 

28 Ibid. 

29 Ibid., 237. 


7 



the other hand, people in other countries that do offer universal health care, such as 
Canada and the UK, consider it a right and a public need. 

The American policy trap is ironic, especially in light of the fact that we already 
pay taxes in several ways to fund health care for those that have not “earned” it: the 
government gives generous tax benefits to businesses that offer health insurance; 
hundreds of thousands of employees of the U.S. government enjoy publicly-financed 
health care; entitlement programs such as Medicaid, Medicare, CHIP and VHA costs 
total billions of taxpayer dollars annually. In addition, when the uninsured are treated in 
an emergency room, unpaid costs are eventually shifted to the insured or the government. 

C. PURPOSE OF THE RESEARCH 

Decreased access or inability to pay for health care has significant homeland 
security implications: our ability to manage bioterror events, influenza pandemic, 
emerging disease, post-disaster care, and the mentally ill is hampered. It is my theory that 
the implementation of the Affordable Care Act will aid our homeland security efforts by 
expanding health insurance coverage, and thereby health care access, to millions of U.S. 
residents. In addition to positive economic influences, these effects will have positive 
impacts on our health security. The goal of this research is to a describe the linkages 
between health care and homeland security, to provide an overview of the Patient 
Protection and Affordable Care Act, and to describe how its implementation will 
positively affect homeland security from two different perspectives: health security and 
economic security. Finally, I will make recommendations based on the research on 
implementation policies in order to improve the positive effects of the ACA on homeland 
security. 

Although this research will no doubt also highlight potentially negative 
consequences or repercussions that are likely to result from ACA implementation, this 
thesis focuses primarily on one side of the issue in order to thoroughly explore how the 
ACA can potentially aid health care, and to better understand why health care matters in 
the overall homeland security puzzle. Further research is warranted to explore potentially 
negative outcomes of ACA implementation. 


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D. RESEARCH QUESTION 

How will the implementation of the Affordable Care Aet positively impact 
homeland security in its efforts to achieve its all-hazards preparedness goal? 


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10 



II. LITERATURE REVIEW 


Because the ACA is new and has yet to be fully implemented, there is little to no 
secondary literature or research available on implementation outcomes. However, there is 
considerable literature on the topics and disciplines surrounding the research. There is the 
legislation itself (the Affordable Care Act) and the Supreme Court decision upholding it; 
government reports outlining homeland security strategy and goals; government reports 
estimating costs of the ACA; voluminous medical and health care research and policy 
writings from various sources; and of course, there is an endless amount of political, 
ideological, and popular discourse. Limited research is available on the direct relationship 
between homeland security and bioterrorism, emerging disease, and public health. 

A. GOVERNMENT DOCUMENTS 

The federal law Patient Protection and Affordable Care Act^o is the main primary 
source in this literature review. The Patient Protection and Affordable Care Act is 
generally referred to as the Affordable Care Act (ACA), which is also known informally 
as “Obamacare.” This federal statute is considered by some to be the largest overhaul of 
U.S. health care since the enactment of Medicare and Medicaid in 1965.31 The legislative 
document outlines the overall goals of the law, as well as the myriad of strategies and 
regulations to be employed in an effort to achieve those goals. Over a year in the making, 
the final bill was essentially a synthesis of a White House health care proposal, a Senate 
health care bill, and another from the U.S. House of Representatives. These were 
combined and passed by the 111*’’ Congress and signed by President Barack Obama on 
March 23, 2010. 

At its core, the bill aims to increase the number of Americans covered by health 
insurance, control health insurance costs, and improve the overall health care system. The 

30 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). 

31 Sheryl Gay Stolberg and Robert Pear, “Obama Signs Health Care Overhaul Bill, with a Flourish,” 
New York Times, sec. Money & Policy, March 23, 2010, 

http://www.nytimes.eom/2010/03/24/health/policy/24health.html; James Vicini and Jonathon Stempel, 

“U.S. Top Court Upholds Health Care Law in Obama Triumph,” Reuters, sec. Wrap Up, June 28, 2012, 
http://www.reuters.cotn/article/2012/06/28/usa-healthcare-court-idUSL2E8HS4WG20120628 


11 



main strategies outlined to achieve greater health insurance coverage are an expansion of 
Medicaid to higher income-earners, tax subsidies for employer-related coverage, the 
creation of state insurance “exchanges” where people can buy insurance on a sliding 
scale, and the “individual mandate,” which requires individuals to carry insurance or pay 
a penalty to the Internal Revenue Service (IRS). The ACA is multi-layered and complex. 
Its critics point to its massive length as one of its inherent problems. 

The Health Care Education and Reconciliation Act32 (HCERA) is another 
primary source document that goes hand-in-hand with the ACA. This law allowed the 
legislature a vehicle for immediate changes and corrections to the original ACA bill, as 
well as created some room in the budget for the ACA by addressing unrelated student 
loan issues. This bill was signed into law on March 30, 2010 by President Obama exactly 
one week after the ACA. The ACA and the HCERA are referred to together because they 
are very much intertwined. Although the laws were written and signed separately, they 
have been combined into a single working document. 

The ACA is a highly controversial piece of legislation and was fought by several 
entities all the way to the Supreme Court. On June 28, 2012, the Supreme Court 
announced a decision upholding the constitutionality of the core of the act. This decision. 
National Eederation of Independent Business v. Sebelius, outlines the court’s reasoning 
as to why it found the law constitutional. In its decision the Court referenced the 
Congress’ authority to collect taxes in order to aid the defense of the nation.34 An amicus 
curiae (“friend of the court” brief) submitted to the Court in support of the ACA provided 
this argument. Eegal scholar Philip Bobbitt argued in his amicus that the individual 
mandate is a reasonable form of taxation congress may impose to provide for the 


32 Health Care and Education Reconciliation Act, Pub. L. No. 111-152, 124 Stat. 1029 (2010). 

33 “National Federation of Independent Business et al. V. Sebelius,” last modified 2014, ScotUS Blog, 
http://www.scotusblog.com/case-files/cases/national-federation-of-independent-business-v-sebelius/ 

34 Ibid., 5. 


12 



common defense of the nation. He linked the eontemporary dangers of bioterror eoupled 
with lack of insurance as something that jeopardizes the nation as a whole. 35 

Several homeland seeurity reports outlining homeland seeurity strategies have 
been issued sinee September 11, 2001. These provide perspective on the homeland 
security mission and scope and their development sinee that defining moment on 9/11. 
Sueh doeuments inelude the Department of Homeland Seeurity’s National Strategy for 
Homeland Security reports from 2002 and 2010, the 2010 Quadrennial Homeland 
Security Review Report, and the Federal Emergeney Management Ageney’s Crisis 
Response and Disaster Resilience 2030 report. These reports show the evolution from the 
early, narrow foeus on terrorism, to an ever-expanding view that ineludes topies sueh as 
emerging disease and disaster preparedness. These writings outline federal guidelines and 
polieies aimed primarily at the Department of Homeland Seeurity, but also give guidanee 
to other government ageneies and the public at large. 

Other government reports sueh as those issued by the Center for Disease Control 
and the U.S. Census Bureau provide estimates for the numbers of Amerieans without 
health insuranee and estimates on national health eare spending. These reports are widely 
eited throughout the literature and seem to be eonsidered the eurrent, best estimates by 
parties on all sides of the health eare debate. Although these numbers are always in flux, 
the estimates are updated annually based on U.S. Census Bureau surveys. In addition, 
they ean be used to help inform eost estimates and help prediet the impaet of inereased 
health insuranee eoverage on morbidity and mortality rates. 

Government reports on eost-estimates abound and are updated regularly. The non¬ 
partisan Congressional Budget Offiee (CBO) and the Government Aeeounting Offiee 
(GAO) regularly issue reports projeeting eosts and impaets on the defieit. Eaeh time a 
report is issued, the numbers are adjusted, depending on most reeent estimates of 
uninsured, unemployed workers, families eligible for Medieaid, ete. 


35 Philip C. Bobbitt, Brieffor Professor Philip C. Bobbitt as Amicus Curiae in Support of Petitioners 
with Respect to the Individual Mandate (No. 11-396), 2012, 
http://www.yale.edu/lawweb/jbalkin/files/Philip_Bobbitt_Healthcare_Brief.pdf 


13 



B. POPULAR MEDIA 

One thing that does not ehange, regardless of future estimates, is the reports are 
then analyzed by the media in completely contradictory fashions depending on the 
interpreter’s agenda. With each report comes popular media commentary and analysis— 
some, such as Conservapedia, reporting how the latest estimate shows an enormous 
increase in spending, and the next article, such as found in the Washington Post, 

'in 

pointing out how the deficit will be reduced. Even when both of these statements are 
true, the analyses are most often written in a highly partisan manner, either critical or 
supportive of the estimated impacts. The same process occurs within the political arena, 
and the political stance is distributed via newspaper, Internet or sound-bite. For example, 
some insurance plans eligible for the Exchange may cover drugs that treat erectile 
dysfunction. It is also true that convicted sex offenders and other convicts will be allowed 
to purchase health insurance on the Exchange. These facts have been framed by some 
opposed to the AC A as voting “use taxpayer dollars to pay for Viagra for convicted child 
molesters and sex offenders. 

Because of the biases and agendas, it is difficult to separate fact from fiction when 
reading popular media analyses. If the reader checks the “facts” outlined in the media 
report against the referenced CBO or GOA report, the actual numbers cited may be 
correct, but the conclusions reached based on the same numbers are disparate. However, 
because the ACA has only begun, any conclusions right now are only estimates or best- 
guesses. It will be years before anyone will truly know the financial and societal impacts 
of the Affordable Care Act. 

C. MEDICAL RESEARCH 

Medical research is widely available on topics relevant to this thesis, including: 
the relationship between health insurance (or lack thereof) to morbidity and mortality, 

Conservapedia, s.v. “Obamacare,” August 25, 2013, http://www.conservapedia.com/ObamaCare 

37 Ezra Klein, “11 Facts about the Affordable Care Act,” The Washington Post, June 24, 2012, 
http://www.washingtonpost.eom/blogs/wonkblog/wp/2012/06/24/l 1-facts-about-the-affordable-care-act/. 

38 “Angle’s Shocking-and Misleading-Viagra Claim,” FactCheck, October 8, 2010, 
http://www.factcheck.org/2010/10/angles-shocking-and-misleading-viagra-claim/ 


14 



health insurance and vaccination rates, vaccination rates to the spread of preventable 
contagious diseases, and contagious diseases to morbidity and mortality. These reports 
are available in science-based, peer-reviewed journals, such as Journal of American 
Medical Association and Health Affairs. Such documents provide rigorously researched 
evidence to back up their conclusions. Several of these studies were conducted pre-9/11, 
but are still looked to as the gold-standard on their topic. 

D. POLICY WRITINGS 

An enormous amount of research and writing is available in the policy arena. 
Articles linking the relationship between health care and homeland security can be found 
across policy journals of all types including legal, ethical, political, health care, and 
homeland security. The post-9/11 literature is most relevant to this thesis. A fraction of 
this research explores the direct nexus between health care and homeland security, most 
often in two particular areas: 1) health care and its relationship with bioterrorism; and, 2) 
health care and its relationship to emerging disease. Generally, the health care angle is 
limited to a single, specific slice of the health care pie. For example, an article in Journal 
of Health and Human Services Administration explores “Terrorism and Emergent 
Challenges in Public Health,” while another article explores ethical challenges in 
preparing for bioterrorism,"^'^ and the issues that arise due to lack of universal health care 
access. There is also limited research available covering the connection between health 
care and disaster preparedness. These documents provided critical pieces of the 
information necessary for the writing of this paper. Although none speaks directly to the 
ACA, they provide an understanding of how health care impacts the homeland security 
mission, and how lack of access to health care creates substantial gaps in our security. 


39 Irene O’Boyle et al., “Terrorism and Emergent Challenges in Public Health, Journal of Health 
Human Service Administration 30, no. 4 (2008): 529-548. 

Matthew K. Wynia and Lawrence O. Gostin, “Ethical Challenges in Preparing for Bioterrorism: 
Barriers within the Health Care System, Journal Information 94, no. 7 (2004): 1096-1102. 


15 



E. METHOD 


The goal of this research is to a describe the linkages between health care and 
homeland security, to provide an overview of the Affordable Care Act, and to describe 
how its implementation will positively affect homeland security from two different 
perspectives: health security and economic security. The method used here involved 
researching the primary and secondary literature for evidence on how health care relates 
to homeland security, and how the ACA might positively impact homeland security 
preparedness. One method used to support claims and empirical evidence when available 
is deductive analysis. In conducting this research, the health and the economic 
perspectives were the most prevalent in the literature, and had the most data available. 
For these reasons, this thesis limits the discussion to these two areas. 

Primary literature was identified quickly as the actual health care legislation upon 
which all of this is built: the Patient Protection and Affordable Care Act, in combination 
with the Health Care and Education Reconciliation Act (now known as Public Law 111- 
148). The secondary literature was identified initially through searches for direct links 
between health care and homeland security. Very little research was available in this area, 
with the exception of writings on bioterrorism. The writings on bioterror led this 
researcher to information on unintended health care disasters, such as influenza 
pandemic, and emerging disease. Much of this information was contained in scientific 
medical literature, public health journals, and health policy literature. This led to a review 
of the government homeland security strategic documents to gain a sense of health care’s 
current role within the homeland security puzzle. Several case studies with health care 
implications were reviewed, such as the anthrax attack of 2001, the Aum Shinrikyo 
terrorist group actions in 1995, and the natural disaster in Joplin, Missouri in 2011. 

Significant study was given to how health insurance affects health, mortality, and 
income. Most of this secondary research was found in medical journals and public health 
literature. Potentially negative effects of ACA implementation on homeland security are 
acknowledged in this thesis, but not fully explored primarily due to difficulty finding data 
showing how expanded access to health care might harm homeland security 

preparedness. For this reason, the focus was narrowed to positive impacts. The 

16 



potentially negative impaets are worthy of exploration as well, and further researeh in this 
area would be a valuable eontribution to the overall pieture. 

Poliey reeommendations are given on ACA implementation with the aim of 
enhaneing its positive influenee on homeland seeurity preparedness. It must be 
aeknowledged that an enormous assumption has been made in eondueting this researeh: 
that the Affordable Care Aet will, at least to some degree, work as promised to expand 
health insurance coverage and improve access to health care for eligible parties. If the 
ACA is repealed before full implementation, or if it fails to expand health care coverage, 
then clearly the basis for this thesis disappears. 

F. CHAPTER OUTLINES 

In order to forward-map potential impacts of the ACA on homeland security, it is 
first necessary understand how health care, or lack thereof, relates to homeland security 
preparedness. Chapter III outlines explicit linkages as well as more subtle relationships 
between health care and homeland security. 

Chapter IV is an overview of the Patient Protection and Affordable Care Act, 
describing its goals, strategies and timelines. 

Chapter V provides an in-depth analysis on the various ways the research 
indicates the ACA will positively impact homeland security preparedness. 

Chapter VI provides a summary of this thesis, policy recommendations to 
improve ACA implementation and enhance its positive impacts on homeland security 
preparedness, and recommends areas of further study. 


17 



THIS PAGE INTENTIONALLY LEET BLANK 


18 



III. HEALTH CARE AND HOMELAND SECURITY: DRAWING 

THE LINKS 


When boiled down to its essential purpose, the entire foeus of the homeland 
seeurity system is to ensure the physieal health and safety of the U.S. population. So 
whether it is preventing eonventional terror attaeks, mitigating a bioterror or pandemie 
event, or reeovering from a massive hurrieane, a robust health eare system is an integral 
part of the homeland seeurity maehine. The health eare aspeet of homeland seeurity is 
often overlooked or seen as a totally unrelated system; however, health eare is a 
foundational eomponent of a funetional homeland seeurity enterprise. 

A. HOMELAND SECURITY REQUIRES A ROBUST, ACCESSIBLE 

HEALTH CARE SYSTEM 

The United States has twiee been shown how eritieal the health of its soldiers is to 
fighting wars. During the Revolutionary War, Ameriean soldiers fell vietim in large 
numbers to smallpox. Elizabeth Fenn estimates that smallpox killed more than 130,000 
North Amerieans during that time period.^^i British soldiers on the other hand, had 
developed some level of immunity through exposure to the disease in England and were 
barely affeeted.42 During World War I, the Spanish flu afflieted 294,000 allied troops, 
with 23,000 soldiers eventually sueeumbing.43 Still, that number is a drop in the bueket 
eompared to the number of Spanish flu deaths worldwide, whieh are estimated at over 50 
million.'^'^ 


Elizabeth A. Fenn, Pox Americana: The Great Smallpox Epidemic of1775-82 (New York: Hill and 
Wang, 2001), 370. 

Shane K. Green, “Bioterrorism and Health Care Reform: No Preparedness without Access,” Virtual 
Mentor 6, no. 5 (May 2004): 1. http://virtualmentor.ama-assn.org/2004/05/pfor2-0405.html 

Susan Peterson, “Epidemic Disease and National Security,” Security Studies 12, no. 2 (2002): 45. 

“Pandemic Flu History,” U.S. Department of Health & Human Services, accessed July 15, 2014, 
http://www.flu.gov/pandemic/history/ 


19 



The contemporary “war on terror” involves all Americans—terrorists consider 
civilians to be legitimate targets, as evidenced by 9/11, the Underwear Bomber,45 the 
Shoe Bomber,and the Boston Marathon bombing.If a terror group or a terrorist is 
willing to use biological or chemical weapons, it is likely we are all potential targets. In 
such an attack, health care will almost certainly play an important role in prevention, 
preparedness, detection, mitigation and recovery. 

B. BIOTERRORISM 

...the healthcare of all persons living in America is bound together: the 
protection of every American is no stronger than the weakest protection of 
any American. 

-Philip Bobbitt48 

As Professor Philip Bobbitt argued in his amicus curiae to the Supreme Court in 
support of the Affordable Care Act,49 health care is one of the bastions of homeland 
security defense. Detection, treatment, and even prevention of bioterror attacks are all 
functions of a robust health care system. Without an affordable health care system, 
accessible to all, homeland security suffers increased vulnerability to attacks utilizing 
bioweapons such as anthrax, smallpox, Ebola virus, or designer bioweapons. Potential 
weapons are not limited to distribution via inhalation or aerosolization, our open water 
supplies and unprotected food networks are vulnerable as well. 

Advances in biotechnology and the Internet have taken the knowledge needed to 
synthesize bioweapons out of the hands of a few skilled professionals and put it in the 


4^ On Christmas day, 2009, Umar Farouk Abdulmatallab attempted to detonate explosives hidden in 
his underwear while onboard Northwest flight #253 from Amsterdam to Detroit, Michigan. Wikipedia, s.v. 
“Underwear Bomber,” accessed July 15, 2014, http://en.wikipedia.org/wiki/Umar_Farouk_Abdulmutallab 

46 On December 21, 2001, Richard Colvin Reid attempted to detonate explosives packed into the soles 
of his shoes while onboard American Airlines flight #63 from Paris to Miami. Wikipedia, s.v. “Shoe 
Bomber,” http://en.wikipedia.org/wiki/Richard_Reid. Accessed July 15, 2014. 

4^ On April 13, 2013, brothers Tamerlan and Dzhokhar Tsamaev detonated two pressure cooker 
bombs near the finish line of the Boston Marathon, killing three people and injuring 264, Wikipedia, s.v. 
“Boston Marathon Bombing,” accessed July 15, 2014, 
http://en.wikipedia.org/wiki/Boston_Marathon_bombings 

48 Bobbitt, Brief for Professor Philip C. Bobbitt, 9. 

49 Ibid., 1-12. 


20 



public arena. Full genomic sequences are available on the Internet for the avian flu,^^ 
West Nile virus,and eountless others. Our own National Center for Bioteehnology 
Information, part of the U.S. Library of Seienees, provides information on its website on 
how to sequenee genomes, map chromosomes and do all sort of molecular biology that 
once was limited to speeially trained researehers.^2 Advanees in DNA teehnology, sueh 
as polymerase ehain reaetion (PCR) teehniques and reeombinant DNA teehnology, have 
made gene manipulation eommonplaee. In the future, an average seienee student eould be 
the next mass-murderer via designer disease. 

1. Bioterror and the Health Care Surveillance System 

The initial identifieation of a bioterror attaek requires a funetional health eare 
surveillanee system. Unless the attaeker(s) announees the speeifies of the attaek, or the 
eountry’s biosensors are aetivated by the biologieal weapon, it is likely we would only 
become aware of a biological attack via the health eare system’s surveillanee program. 
Hospitals, health eare providers and elinieal laboratories around the U.S. routinely report 
infectious disease diagnoses and food and water-borne illnesses to the Centers for 
Disease Control and Prevention (CDC). The CDC manages the Emerging Infections 
Program (EIP) as part of its Division of Preparedness and Emerging Infections. The EIP 
is a network of 10 state health departments^^ and their eollaborators that inelude loeal 
health departments and health care providers, elinieal laboratories, academie institutions, 
and other federal agencies. These institutions gather data on disease outbreaks and 
foodborne illnesses. The EIP compiles data and analyzes it. Onee it spots elusters or 


Guang-Wu Chen et af, “Genomic Signatures of Human versus Avian Influenza A Viruses,” 
Emerging Infectious Diseases 12, no. 9 (September 2006): 1353-1360, doi: 10.3201/eidl209.060276 

Robert S. Lanciotti, Gregory D. Ebel, Vincent Deubel, Amy J. Kerst, Severine Murri, Richard 
Meyer, Michael Bowen, Nancy McKinney, William E. Morrill, Mary B. Crabtree, Laura D. Kramer, and 
John T. Roehrig, “Complete Genome Sequences and Phylogenetic Analysis and West Niles Virus Strains 
Isolated from the United States, Europe and the Middle East,” Virology 298, no. 1, June 20, 2002, 96-125, 
http://ac.els-cdn.com/S0042682202914492/l-s2.0-S0042682202914492-main.pdf?_tid=5bdllb66-179a- 
Ile4-ae5f-00000aacb35f&acdnat=1406691426_5f9b0d3d7741a04199a96b2f2ebf5d2d. 

^2 National Center for Biotechnology Information, U.S. National Library of Medicine, “Genome,” 
accessed March 28, 2014, http://www.ncbi.nlm.nih.gov/genome 

California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, 
Oregon, and Tennessee 


21 



identify outbreaks, it eommunieates and eollaborates with state and loeal health eare 
networks and regulatory ageneies sueh as the Food and Drug Administration (FDA) in an 
effort to traee the origin of the disease and find appropriate treatments. 

Strength of the health care surveillance system aside, if the sickened do not report 
for diagnosis and treatment, the entire system is rendered ineffective. And if the sickened 
merely wait longer to report for treatment because they lack health insurance, they are 
more likely to have poor health outcomes, which can worsen the overall effect of the 
outbreak.55 A perfect example would be the anthrax attack of 2001, which occurred only 
one week after the defining act of terrorism against America. With anthrax infection, 
early diagnosis and treatment are critical factors in determining whether the victim lives 
or dies.In the 2001 event known as “Amerithrax,”^^ 22 individuals were infected with 
the anthrax spores, five of whom died, after a still unconfirmed suspect^s sent the spores 
through the mail. Anthrax is treatable via antibiotics if correctly diagnosed early enough 
in the progression of the illness. In order to diagnose the disease, the stricken must 
present to a health care provider. Decades of research has shown a strong association 
between health insurance and access to health care.^^ In other words, if people have 
health insurance, they are more likely to go to the doctor when they are ill. Conversely, a 


Centers for Disease Control and Prevention, “Emerging Infections Programs,” October 11, 2011, 
http://www.cdc.gov/ncezid/dpei/eip/index.html. 

Wilper et al., “Health Insurance and Mortality in U.S. Adults,” 2289-2295. 

The other critical factor is whether the victim suffers from inhalation infection a more virulent form 
of the disease; Wikipedia, s.v. “Anthrax,” last modified July 25, 2014, http://en.wikipedia.org/wiki/Anthrax 

“Amerithrax” was the FBI’s name for the 2001 anthrax investigation. Wikipedia, s.v. “Amerithrax,” 
last modified August 3, 2014, http://en.wikipedia.org/wiki/Amerithrax Citation? 

58 Federal prosecutors declared in August of 2008 that Bruce Ivins, a scientist at a government 
biodefense lab, was responsible for the attack. Ivins committed suicide in July of 2008. Whether he was 
actually responsible for the attacks is still a major controversy. Wikipedia, s.v. “Amerithrax,” last modified 
August 3, 2014, http://en.wikipedia.org/wiki/Amerithrax Citation? 

59 Catherine Hoffman and Julia Paradise, “Health Insurance and Access to Health Care in the United 
States,” HnnaA of the New York Academy of Sciences 1136 (June, 2008): 149-160, 
http://onlinelibrary.wiley.com/doi/10.1196/annals. 1425.007/pdf 


22 



lack of health insurance equals worse health outcomes because patients wait longer to 
seek care and present at a later stage of illness.^*’ 

Anthrax is not contagious; a person sickened with anthrax cannot pass the disease 
to another person. If a bioattack involves a contagious disease, early identification and 
treatment are even more critical. In such a case we would be vulnerable to the initial 
infections as well as the ensuing spread. Without accessible health eare, the laek of 
assessment, isolation and quarantine would allow the disease to spread unchecked. 

An example of how 48 million uninsured Americans create a homeland security 
gap would be a low-tech suicide attack, such as one where a terrorist self-infects with an 
Ebola virus. The various Ebola viruses have mortality rates ranging from 34 pereent to 90 
percent. Early detection, reporting, and treatment would be eritical to minimizing 
deaths. By waiting longer to seek treatment, the stricken would eontinue infecting others 
and exacerbate the rate of spread, particularly during the incubation period. The results 
could be devastating. Christopher Chyba and Alex Greninger highlight this danger in 
their artiele, “Biotechnology and Bioterrorism; An Unprecedented World,” in which they 
point out that 

because most dangerous contagious pathogens (smallpox, plague, SARS) 

have ineubation periods longer than international flight travel times, it is 

crucial that international disease surveillance and response be improved 

along with its domestic counterpart. ^2 

A similar scenario was dramatized in the 1995 movie Outbreak starring Dustin 
Hoffman fighting an Ebola-like viral epidemic. This was a life-imitates-art event, as an 
Ebola outbreak oceurred in Zaire only a few months after the film’s release, killing 250 


Wilper, et al., Health Insurance and Mortality in U.S. Adults, 2289; Jack Hadley, “Sicker and 
Poorer—The Consequences of being Uninsured: A Review of the Research on the Relationship between 
Health Insurance, Medical Care Use, Health, Work, and Income,” supplemental issue. Medical Care 
Research and Review 60, no. 2 suppl (June 2003), 3S—75S. 

Joseph F. Wamala et al., “Ebola Hemorrhagic Fever Associated with Novel Virus Strain, Uganda, 
2007-200S,” Emerging Infectious Disease 16, no. 7 (July 2010): 1087-1092, 
http://wwwnc.cid.gOv/eid/article/16/7/09-1525.htm 

^2 Christopher F. Chyba and Alex L. Greninger, “Biotechnology and Bioterrorism: An Unprecedented 
World,” Survival 46, no. 2 (2004): 146. 


23 



people, out of 315 infected patients.^3 translated to a mortality rate of 81 percent. An 

intentional Ebola attack was nearly a reality that same year when the Japanese cult- 
tumed-terrorist organization Aum Shinrikyo was found in possession of a stolen Ebola 
virus.Eortunately, authorities interceded before the Ebola virus was used, but not 
before Aum Shinrikyo conducted a successful chemical-weapon attack using the nerve 
agent sarin. In March of 1995, the cult conducted a spectacular chemical attack on five 
Tokyo subway trains simultaneously. Participants left 11 plastic bags filled with sarin on 
the ground and poked holes in the bags with umbrellas to release the chemical. Twelve 
people were killed, and more than 5,500 people reported injuries. 

2. Foodborne Illnesses and the Health Surveillance System 

The health surveillance system is critical in identifying foodborne or water-borne 
illnesses as well, whether accidental or intentional. In 1984, followers of Bhagwan Shree 
Rajneesh sprinkled the salad bars with salmonella in 11 restaurants in a town in Oregon. 
Their intention was to incapacitate the voting population of the area so their own 
candidate would win the local election. In the incident, 750 people were severely 
sickened with food poisoning, although there were no fatalities.In this case, the health 
surveillance system did not solve the mystery or prove culpability in the Rajneesh attack, 
but it did trace the source of the salmonella to the salad bars. Bioterror is here, and the 
health care surveillance system has an important role in our ability to detect it. 

EoodNet is the health surveillance program tasked with watching for food and 
water-borne illnesses. It is part of the Emerging Infections Program administered by the 
Centers for Disease Control. EoodNet is constantly identifying and alerting us to less 

^3 Centers for Disease Control and Prevention, “Ebola Hemorrhagic Fever,” accessed July 15, 

2014http://www.cdc.gov/vhEebola/resources/outbreak-table.html 

William Rosenau, “Aum Shinrikyo’s Biological Weapons Program: Why Did It Fail?” Studies in 
Conflict and Terrorism 24, no. 4 (2001): 289-301. 

^3 Gavin Cameron, “Multi-Track Microproliferation: Lessons from Aum Shinrikyo and A1 Qaida,” 
Studies in Conflict and Terrorism 22, no. 4 (1999): 277-309. 

Mara Bovsun, “750 Sickened in Oregon Restaurants as Cult Known as the Rajneeshees Spread 
Salmonella in Town of the Dalles,” New York Daily News, sec. News, June 15, 2013, 
http://www.nydailynews.com/news/justice-story/gum-poison-bioterrorrists-spread-salmonella-oregon- 
article-1.13 73 864#commentpostform 


24 



sinister foodborne outbreaks in the U.S.^^ A visit to the Food and Drug Administration’s 
Food Reealls and Outbreaks webpage lists five foodborne disease outbreaks investigated 
in 2010, seven in 2012, and five at the mid-point of 2013.^^ FoodNet is perhaps a non- 
traditional partner in the homeland seeurity system, but its mission is to protect the public 
from foodborne infections and to prevent similar situations from happening in the future. 

The health surveillance system’s role in drug safety in the U.S. was displayed in 
an event that began in the summer of 2012. In September of that year the health 
surveillance system identified several fungal meningitis outbreaks clustered in the 
northeastern states of the U.S. As of July, 2013, 749 people were sickened and 61 people 
had died related to a non-contagious fungal meningitis. In cooperation with state and 
local health departments and the Food and Drug Administration, the Centers for Disease 
Control investigated the clusters. The CDC determined the outbreak was linked to the use 
of injectable steroids from lots mixed by the New England Compounding Center, located 
in Framingham, Massachusetts.It was determined the compounding company was not 
following proper sterilization procedures in mixing the drugs. Although these food and 
drug-related outbreaks were not attacks or even intended events, they demonstrate the 
critical role the health care surveillance system plays in maintaining our country’s health 
security. 

C. DISEASE PREVENTION 

Another way that a robust and accessible health care system aids homeland 
security is through prevention. Vaccines are one of the tools used to prevent bioattacks, 
or at least to manage a successful attack. Homeland security experts have long considered 

A “foodborne outbreak” as defined by the FDA is when two or more people contract the same 
illness after eating or drinking the same contaminated food or drink. Food and Drug Administration, 
“Voluntary National Retail Food Regulatory Program Standards,” U.S. Department of Health and Human 
Services, January, 2013, 

http://www.fda.gov/downloads/food/guidanceregulation/retailfoodprotection/programstandards/ucm372411 
.pdf, 1-3. 

Food and Drug Administration, “Food Recalls and Outbreaks,” U.S. Department of Health & 

Human Services, http://www.fda.gov/Food/RecallsOutbreaksEmergencies/Outbreaks/ucm349461.htm, 
accessed July 2013. 

Centers for Disease Control and Prevention, “Multistate Fungal Meningitis Outbreak Investigation,” 
2013, http://www.cdc.gov/hai/outbreaks/meningitis.html 


25 



smallpox a potential bioweapon, henee the stoekpiling of the smallpox vaeoine sinee 
9/11. Smallpox is an infeetious disease eaused by the virus variola major or variola 
minor. The more eommon and more virulent form, variola minor, has a mortality rate of 
about 30 pereent.’^o The disease was present throughout the world for tens of thousands of 
years, but was eradieated via a worldwide vaeeination program prior to 1980. The 
smallpox virus only exists now in laboratory stoekpiles.^i One of the eoneems post-9/11 
was the stoekpiles would be pilfered and used to intentionally reintroduce the virus to 
humans. The U.S. currently has 300 million doses of smallpox vaccine in stockpiles 
around the U.S.—enough to vaccinate nearly the entire population. Recently, the U.S. 
government purchased enough of a new smallpox medication to treat two million 
people."72 However, for the vaccination process and the treatment process to be successful 
in the event of an outbreak, the population will need access to health care providers. The 
Department of Homeland Security’s fact sheet on what to do in the event of a bioterror 
directs us as follows: “People in the group or area that authorities have linked to exposure 
who have symptoms that match those described should seek emergency medical 

attention.”23 

It is likely in the event of such a dramatic scenario as a smallpox attack, the U.S. 
government will set up emergency distribution centers, where all people will receive 
prophylaxis antibiotics, without regard for health insurance or payment, as outlined in the 
Center for Disease Control’s Smallpox Response Plan and GuidelinesP^ So perhaps the 
smallpox vaccination program serves as a model for universal health care access. 


20 Centers for Disease Control and Prevention, “Smallpox: Fact Sheet,” 2004, 
http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp. 

21 Ibid. 

22 Donald G. McNeil, Jr., “Wary of Attack with Smallpox, U.S. Buys up a Costly Drug,” The New 
York Times, sec. Health, March 12, 2013, http://www.nytimes.eom/2013/03/13/health/us-stockpiles- 
smallpox-drug-in-case-of-bioterror-attack.html?pagewanted=all 

23 National Department of Engineering, National Research Council, and Department of Homeland 
Security, Biological Attack: Human Pathogens, Biotoxins and Agricultural Threats (Washington, DC: 
National Academy of Sciences, 2004), http://www.dhs.gov/xlibrary/assets/prep_biological_fact_sheet.pdf, 
46. 

24 Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines (Atlanta, GA: 
Centers for Disease Control and Prevention, 2002). 


26 



1 . 


Influenza Virus 


Perhaps one of the best examples of health eare and homeland seeurity linkages is 
the influenza virus, eommonly known as “the flu.” The flu’s presenee is so eonsistent it 
has its own season. In addition, it annually kills more people than all those felled by 
terrorism eombined. Influenza pandemics have killed literally millions of people during 
the last century alone. 

As Malcolm Gladwell wrote in 2001: 

That we have chosen to worry more about anthrax than about the flu is 
hardly surprising. The novel is always scarier than the familiar, and the flu 
virus, as far as we know, isn’t being sent through the mails by terrorists. 

But it is a strange kind of public-health policy that concerns itself more 
with the provenance of illness than with its consequences; and the 
consequences of flu, year in, year out, dwarf everything but the most 
alarmist bioterror scenarios. 

While it is true that the general public tends to ignore the security implications of 
the flu, the homeland security community does not. Rather, those tasked with homeland 
security understand the deadly nature of influenza and its potential to devastate our 
health, our economy, and our society. Mitigating influenza pandemic is part of homeland 
security planning in many industrialized nations. Although this fight lacks the glamour of 
combating bioterror, the reality is influenza pandemic is much more likely to occur. In 
fact, it is inevitable. 

People are familiar with influenza symptoms as most people likely have 
experienced the respiratory illness at least once in their lifetime: the fever, the sore throat, 
the chills, achy muscles and the vomiting or diarrhea. For many, the disease progresses 
into pneumonia, dehydration, and for some, life-threatening complications. There is no 
cure for influenza. Antiviral medications have only recently become available to speed up 
the virus’s cycle or to inhibit its ability to replicate, which shortens the duration of the 
illness. However, antivirals are not a cure. 

Standing Senate Committee on Social Affairs, Science and Technology, Canada’s Response to the 
2009 HlNl Influenza Pandemic (Ottawa: Canadian Senate, 2010), 
http://www.parl.gc.ca/content/sen/committee/403/soci/rep/repl5decl0-e.pdf 

Malcolm Gladwell, “Talk of the Town,” New Yorker, October 29, 2001, 33. 


27 



Influenza is an RNA virus^^ of the family orthomyxoviridae. It is an infectious 
disease carried in both the avian and mammal populations. RNA viruses regularly mutate 
as they replicate; they evolve quickly, re-assorting into new subtypes. When new strains 
appear, they spread more easily and cause more illness because there is less immunity 
among the human host. 

Influenza viruses are categorized by their type (or strain) and subtype. The types 
or strains are classified as A, B, or C. Types A and C can carried by humans or animals. 
Type A is easily transferred from human to human and considered the greatest risk for 
pandemic. The type B strain only affects humans, but it has not been associated with 
global pandemic. Type C tends to produce only mild illness in humans and has not been 
associated with global pandemic. 

Strains are further categorized by their two surface proteins into subtypes: the 
hemagglutinin, or “H” protein, and the neuraminidase, or “N” protein. There are 16 H 
types and 9 N types that can combine in any manner.One example is the modern 
“HlNl.” The influenza subtypes currently circulating in the human population are the HI 
and the H3. Because these strains have been around during this generation’s lifetime, 
most humans have built up some resistance. However, because the RNA virus is 
constantly re-assorting, the HlNl virus people caught in their childhood is not exactly the 
same HlNl virus circulating today. If they are infected with today’s HlNl, their bodies 
will have antibodies from the earlier bout. These will not be able to prevent the new 
illness, but they will help people fight the current strain, moderating symptoms and 
shortening the length of the infection. 

Other influenza subtypes, such as H5 and H7 are primarily carried in birds and 
pigs, hence the nicknames “bird flu” and “swine flu.” Although influenza is ubiquitous in 

An RNA virus has ribonucleic acid as its genetic material, as opposed to DNA, or deoxyribonucleic 

acid. 

Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines. 

Health Canada, Highlights from the Canadian Pandemic Influenza Plan for the Health Sector, 2006, 
http://www.phac-aspc.gc.ca/cpip-pclcpi/hl-ps/pdkCPIP-highlights-2006_e.pdf, 6. 

Richard J. Webby and Robert G. Webster, “Are We Ready for Pandemic Influenza?” Science 302, 
no. 5650 (2003): 1519. 


28 



the avian population, it does not generally cause birds to become sick. On occasion, 
genetic re-assortment allows the virus to make the jump from the bird or pig population 
to the human population. This most often occurs when humans are in close contact with 
carriers, such as in the poultry or pork industries. Viruses that make the jump to the 
human population are extremely lethal because humans have no resistance to the strains 
imparted by the animals. Humans infected by avian flu suffer mortality rates as high as 
60 percent. As of yet, no avian or swine flu strain that has jumped from the animal 
reservoir to the human population has proven contagious. An avian or swine flu that can 
transmit from human-to-human would be a worst-case scenario for world health. 

Human-to-human transmission of contagious influenza viruses occur when an 
infected person coughs or sneezes droplets into the air or onto surrounding surfaces. An 
uninfected person can breathe in the droplets, or touch them with a hand and transfer 
them to his or her own eye or mucus membranes, which gives the virus a portal into the 
body. The flu virus is very hardy, and it can survive for more than 24 hours on certain 
hard surfaces. 

2. History of Influenza Pandemics 

When a virulent influenza virus causes a global outbreak, this is called a 
pandemic. Several major flu pandemics have made their way around the world during 
the past century. For example, the 1918 influenza pandemic is referred to as the Spanish 
flu. This was caused by a strain of the HlNl virus and was estimated to have infected one 
third of the global population; it caused anywhere from 25-100 million deaths. In 1957, 
a novel H2N2 virus caused a pandemic and was coined the Asian flu. This strain 
circulated among the population until replaced in 1968 by the H3N2 Hong Kong flu 
virus. The most recent pandemic was caused in 2009 by another HlNl subtype. The 

U.S. Department of Health & Human Services, 2009 HlNl Influenza Improvement Plan 
(Washington, DC: The White House, 2012). 

Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines. 

U.S. Department of Homeland Security, Pandemic Influenza Preparedness, Response, and 
Recovery Guide for Critical Infrastructure and Key Resources (Washington, DC: The White House, 2006), 
11 . 

Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines. 


29 



resurfacing of the HlNl virus in 2009 was a surprise to the worldwide homeland security 
community, as almost all recent planning had focused on a human-to-human 
transmissible avian flu virus (H5N1) that was predicted to appear. 

Homeland security organizations around the world recognize the influenza 
pandemic as a legitimate threat to their country’s ability to function and survive. In the 
U.S. Homeland Security’s 2006 Pandemic Influenza Guide for Critical Infrastructure 
and Key Resources report, the situation is painted as dire: 

The mounting risk of a worldwide influenza pandemic poses numerous 
potentially devastating consequences for critical infrastructure in the 
United States. A pandemic will likely reduce dramatically the number of 
available workers in all sectors, and significantly disrupt the movement of 
people and goods, which will threaten essential service and operations 
within and across our nation’s CI/KR sectors. 

Flu pandemics generally appear in waves over the course of several months or even 
years. Often each wave of illness lasts between six and eight weeks. 

3. Combating Pandemic Influenza 

Because there is no cure for influenza, generally accepted strategies to combat 
pandemic include health surveillance and identification, vaccine research and production, 
antiviral medication, social distancing, and individual risk-reduction techniques. These 
strategies are specifically promoted by the U.S. homeland security agencies. 

Early detection and identification of new influenza strains is critical to the 
management and mitigation of the disease. Most industrialized nations take part in health 
surveillance reporting partnerships. Communication goes hand-in-hand with surveillance. 
These organizations compile and track reports and communicate their analysis to other 
health care participants, other reporting agencies, and various levels of government 
worldwide. 

As new outbreaks are spotted, the viruses are sent for testing and identification. 
Antigenic drift makes the influenza virus a moving target for vaccinations; this year’s 


85 Ibid., 2. 


30 



HlNl vaccination will not work as well against next year’s HlNl virus. For this reason, 
it is impossible to stockpile vaccinations long-term. And vaccine production takes time— 
six months is considered a realistic amount of time to produce large-scale amounts of 
vaccine. When a new strain appears and begins to sicken people or birds, the virus needs 
to be identified immediately so that vaccine production can be initiated as soon as 
possible. 

Antiviral medications are new to the war on influenza. The 2009 pandemic was 
the first pandemic where antiviral medications were available. As noted earlier, these 
medications cannot cure the disease, but they can moderate the virulence and shorten the 
duration of the cycle. It is possible to stoekpile antiviral medications. 

Social distancing is another strategy for managing pandemic. Limiting a sick 
person’s contact with other people is an obvious way to limit the influenza’s spread. 
More aggressive social distancing techniques include quarantine, prohibitions on large 
social gatherings, canceling school, limiting travel and work, or even closing borders. 
Individual flu prevention techniques include the time-honored recommendations such as 
frequent hand-washing, avoiding touching your eyes or nose, coughing and sneezing into 
a tissue or sleeve rather than the hand, frequently disinfecting surfaces, and staying home 
when sick. 

The U.S. has done significant planning for influenza pandemic. Many of the 
mitigations require a robust, accessible health care system; early vaccinations, 
medications, and treatment allocated in a way that will help sustain the community’s 
ability to treat patients and prevent societal breakdown. This translates to ensuring the 
care of the health care workers, public safety personnel, and essential infrastructure 
employees early on so that these systems continue to function properly throughout the 
pandemie. 


86 Ibid., 21. 


31 



D. NATURAL DISASTERS 


The health eare system is eentral to the mitigation of natural disasters. Major 
natural disasters often result in substantial loss of life, aecompanied by multitudes of 
injuries. Injured parties need medical treatment, which is always provided at the local 
level during the early stages of response.Local hospitals cannot request state and 
federal help until their own capacity is exceeded. 

“Surge capacity” is an idea central to disaster preparedness. The American 
College of Emergency Physicians defines surge capacity as “a measurable representation 
of ability to manage a sudden influx of patients.The general concept is that all 
hospitals and health care facilities should be able to accommodate a sudden increase in 
patients due to a mass casualty incident, pandemic, etc. Quantitative benchmarks for 
surge capacity as outlined by the Hospital Preparedness Program include the ability to 
care for 500 patients per million for infectious disease events and 50 per million in other 
mass-casualty events. 

Events such as the Joplin, Missouri, tornado demonstrate the need for a robust, 
accessible health care system. On May 22, 2011, an EE-590 tornado struck Joplin, 
Missouri and killed 161 people and injured approximately 1371 more.^i This is 
considered the deadliest U.S. tornado since 1947. In addition to rendering total 
destruction along a path three-quarters of a mile wide and six miles long through central 
Joplin, the tornado destroyed a hospital and a high school. The damage at the hospital, St. 
John’s Medical Center, was catastrophic. Windows imploded, injuring nearly all 
occupants. Several patients were sucked out of the emergency room windows, and power 

Amy H. Kaji, Kristi L. Koenig and Roger J. Lewis, “Current Hospital Disaster Preparedness,” 
Journal of the American Medical Association 298, no. 18 (2007): 2188-2190. 

American College of Emergency Physicians, “Clinical Practice and Management,” October 2011, 
http://www.acep.org/Clinical—Practice-Management/Health-Care-System-Surge-Capacity-Recognition,- 
Preparedness,-and-Response/ 

^9 Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines. 

90 This is the highest tornado rating possible on the Enhanced Fujita tornado scale, used in the United 
States and Canada to measure tornado strength based on the damage they cause. 

91 Federal Emergency Management Agency, The Response to the 2011 Joplin, Missouri, Tornado 
Lessons Learned Study (Washington, DC: Federal Emergency Management Agency, 2011). 


32 



to the hospital was knocked out. Patients dependent on ventilators quickly died. Other 
patients were evacuated to the parking lot, and a triage area was set up for current 
patients as well as those arriving from the community post tornado. 

Emergency medical response to Joplin in the immediate aftermath was impacted 
because ambulance service was partially controlled by the damaged St. John’s Hospital. 
Patients from all over began arriving via personal cars and pickups. Other triage centers 
were established throughout the city, and hundreds of people were treated early on after 
the event. Medical supplies ran low, and ambulances provided by outside communities 
began treating on-site, rather than transporting patients to hospitals.^2 

During the longer-term recovery phase, Joplin tornado survivors not only had to 
deal with the loss of their homes, but many also faced substantial medical bills incurred 
from the treatment of injuries sustained in the disaster. The financial hardship brought on 
by medical bills was often compounded by the loss of jobs. ^3 As a final, circular insult, 
job loss sometimes resulted in the loss of health insurance. 

Although FEMA disaster funds are available to assist individuals with disaster- 
related injuries on a case-by-case basis,^^ medical bills are not FEMA’s primary area of 
focus. FEMA is not meant to be a supplemental health insurance agency. Increased 
access to affordable medical care would clearly aid in natural disaster recovery. 

E. PSYCHOLOGICAL RECOVERY 

Within the priorities of the homeland security community, psychological care has 
not historically been high on the list. With increased frequency and awareness of terrorist 
attacks and the ever-upward trend toward active-shooter incidents, more focus has been 
placed on post terror-attack psychological care and the care and treatment of the mentally 
ill in general. Psychological care can be an important component of post terror-attack 

92 Ibid. 

93 Jamie Rodriguez, How Legal Aid of Western Missouri Is Helping the Community Recover from the 
Joplin Tornado (Chicago, IL: Sargent Shriver National Center on Poverty Law, 2012), 
http://povertylaw.org/communication/advocacy-stories/rodriguez 

94 Jesse Preussner, “Examination of FEMA and the Relationship with a Community after a Disaster” 
(Master’s thesis, Kansas State University, 2012), 10. 


33 



healing for some survivors and witnesses, even to those that witness it from thousands of 
miles away.95 Reeent mass-homieide events sueh as the Batman shooting,96 the Sandy 
Hook shooting,97 and the Washington Navy Yard^^ ineident have prompted public calls 
for revamping, or at least revisiting, how we deal with mental illness and our delivery of 
care to the mentally ill population. 

Psychological care—or any medical care, for that matter—is not cheap. A quick 
Internet search on the out-of-pocket cost to visit a psychiatrist shows advertisements for 
about $75 per session. Fees can range much higher, of course, with many Internet 
advertisements for care beginning at $250. Under the current health care model, 
Americans with health insurance coverage pay some combination of monthly premiums 
plus co-pays for each health care visit and medications. Health insurance coverage makes 
psychological care more affordable in most cases, at least giving the option of treatment 
to a person in need of care. 

1. Terror Attacks and PTSD 

The purpose of terrorism is the infliction of psychological pain upon the targeted 
group. 99 It is certainly evident from our country’s reaction to 9/11 that a terror attack 
does exactly what it is intended to do: sow fear. A nationwide longitudinal study 
conducted one year after 9/11 showed that two months after the attack, more than 17 


96 Roxane Cohen Silver, E. Alison Holman, Daniel N. McIntosh, Michael Poulin, and Virginia Gil- 
Rivas, “Nationwide Longitudinal Study of Psychological Responses to September 11,” Journal of the 
American Medical Association 2%%, no. 10(2002): 1235-1244, 
http://mysite.du.edu/~dmcintos/PDF/Silver%20et%20al.%20Responses%20to%209- 
1 l,%20JAMA,%202002.pdf 

96 On July 20, 2012, James Holmes carried out a mass shooting at the showing of film The Dark Night 
Rises in Aurora, Colorado. Twelve people were killed, and 70 were injured; Wikipedia, s.v. “Aurora 
Shooting,” accessed July 27, 2014, http://en.wikipedia.org/wiki/Batman_shooting 

97 On December 14, 2012, Adam Lanza shot and killed 20 children and six adults at Sandy Hook 
Elementary School in Newton, Connecticut; Wikipedia, s.v. “Sandy Hook Shooting,” accessed July 27, 
2014, 2014http://en.wikipedia.org/wiki/Sandy_Hook_Elementary_School_shooting 

9^ On September 16, 2013, Aaron Alexis shot and killed 12 people and injured three others at the 
headquarters of the Naval Sea Systems Command in Washington, DC; Wikipedia, s.v. “Navy Yard 
Shooting,” accessed July 27, 2014, http://en.wikipedia.org/wiki/Navy_Yard_Shooting 

99 Adrienne S. Butler, Allison M. Panzer and Lewis R. Goldfrank, “Developing Strategies for 
Minimizing the Psychological Consequences of Terrorism through Prevention, Intervention, and Health 
Promotion,” in Preparing for the Psychological Consequences of Terrorism: A Public Pdealth Strategy, 
National Research Council (Washington, DC: The National Academies Press, 2003), 99. 


34 



percent of those surveyed outside of New York City reported some 9/11-related post- 
traumatic stress. That number later dropped to 5.8 percent after six months had passed. 
The point to note is that those affected did not need to be actual victims or first-hand 
witnesses: “the psychological effects of a major national trauma are not limited to those 
who experience it directly.”loi 

A Time magazine article examined the literature on chronic psychological 
problems that developed as a result of terror attacks. 102 Prospective and longitudinal 
studies showed that a proportion of terror-attack survivors develop post-traumatic stress 
disorderi*’^ (PTSD) or other chronic psychological problems, although rarely exceeding 
30 percent. 104 Even at less than 30 percent, the numbers of people potentially at risk for 
developing PTSD or other chronic conditions could be quite large. 

Using the recent Boston Marathon bombing as an example, official tolls of the 
number of wounded was set at 264.105 By taking 20,000 race participants into account 
and around 500,000 spectators, scores of people who were not physically wounded could 
be considered survivors. If we are to use the estimate of 5.8 percent found in the 
longitudinal study authored by Roxanne Silver et ah, out of the 264 wounded, we would 
expect about 15 people would eventually develop PTSD. If we were to expand that 
percentage to other runners and spectators who were not wounded, but were present at 
the race, the number of persons at-risk for PTSD could jump into the tens of thousands 
(30,313) quite quickly. 


mu Silver et al., “Nationwide Longitudinal Study,” 1235. 

101 Ibid., 1235. 

102 Ruth Davis Konisberg, “9/11 Psychology: Just How Resilient Were We?” Time, Sept. 8, 2011. 

103 According to the National Institute of Mental Health (NIH), post-traumatic stress is an anxiety 
disorder that some people develop after seeing or living through a traumatic event. National Institute of 
Mental Health, “Post-Traumatic Stress Disorder (PTSD),” U.S. Department of Health & Human Services, 
2013, http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=58 

104 Silver et al., “Nationwide Longitudinal Study,” 1235. 

105 Deborah Katz, “Injury Toll from Marathon Bombs Reduced to 264,” The Boston Globe, sec. 
Health & Wellness, April 24, 2013, http://www.bostonglobe.com/lifestyle/health- 

wellness/2013/04/23/number-injured-marathon-bombing-revised- 
downward/NRpaz5mmvGquP7KMA6XsIK/story.html 


35 



According to the National Institute for Mental Health (NIMH), the proper 
treatment for PTSD is psyehotherapy, medieations, or both. 1^6 in cases where PTSD 
sufferers do not have health insuranee, psyehotherapy and medieations may be finaneially 
out of reach. A 2012 report from the Congressional Budget Offiee reported that a year of 
treatment for reeent eombat veterans diagnosed with PTSD eost $8,300 for the first year 
of treatment alone. 1^7 Other options, such as treatment in hospitals and private dimes, 
eould cost substantially more than seeing a regular psyehiatrist. Medications as a form of 
treatment eould range from hundreds to thousands of dollars, depending on the type of 
medieine, whether generies are available, the eourse of treatment, ete. Costs eould 
quiekly beeome unmanageable without health insuranee eoverage, leaving thousands of 
people without the ability to obtain affordable mental health eare. 

2. Active-Shooter Incidents and Mental Illness 

Since Dylan Klebold and Eric Harris roamed the halls of Columbine High School 
in 1999 killing 12 people and injuring 21, mass-homicide or “active-shooter” events have 
captured the attention of the public. Besides Columbine, some of the more memorable 
events in the past decade were Virginia Tech (2007),!*’* Northern Illinois University 
(2008),and more recently, the Batman Shooting (2012), Sandy Hook Elementary 
(2012), and the Navy Yard shooting (2013). These tragedies and others not listed here 
involved a suspect that exhibited signs of severe mental illness well before their actions 
culminated in mass-murder. With each tragedy of this nature, there are renewed cries for 
stronger gun-laws and better management of the severely mentally ill.no 

106 National Institute of Mental Health, “Post-Traumatic Stress Disorder (PTSD).” 

107 Congressional Budget Office, The Veterans Health Administration’s Treatment of PTSD and 
Traumatic Brain Injury among Recent Combat Veterans (Washington, DC: Congressional Budget Office, 
2012 ). 

108 On April 16, 2007, student Seung-Hui Cho shot and killed 32 people and injured 17 others at 
Virginia Polytechnic Institute. Wikipedia, s.v. “Virginia Tech Massacre,” accessed July 27, 2014, 
http://en.wikipedia.org/wiki/Virginia_Tech_massacre 

109 On February 14, 2008, former student Steven Kazmierczak shot and killed five people and injured 
21 more on the campus of Northern Illinois University in DeKalb, Illinois. Wikipedia, s.v. “Northern 
Illinois University Shooting,” accessed July 27, 2014, 
http://en.wikipedia.org/wiki/Northem_Illinois_University_shooting 

110 As used here, “severe mental illness” includes but it not limited to psychiatric conditions such as 
schizophrenia, major depression, bi-polar disorder, etc. 

36 



Health insurance is an important factor mental health treatment for the mentally 
ill. A study from 2001 showed that over 36 percent of a group of people diagnosed as 
“seriously mentally ill” said that one reason they did not receive treatment was that their 
“health insurance would not cover treatment,” while 44 percent said that treatment was 
“too expensive.”! 

In the early 1970s in the United States, a combination of factors led to the closing 
of residential psychiatric hospitals nationwide, As a result, thousands upon thousands 
of mentally ill persons were returned to the community with little or no follow up care or 
medication. 113 Michael Biasotti’s 2011 Naval Postgraduate School thesis on the mentally 
ill noted. 

Mentally ill individuals released into the community without resources or 
treatment many times became homeless or involved in otherwise 
preventable criminal activity. The criminal justice system as a whole has 
thus seen significant increases in: police interactions with the mentally ill, 
increases in the size of the mentally ill population in prisons and jails, and 
the size of the mentally ill homeless population.! i^ 

Severe mental illnesses are conditions that can respond to treatment, but they 
rarely “go away.” Most severe psychiatric diseases are life-long conditions characterized 
by relapse and remission; however, they are treatable and often manageable. According 
to the National Alliance on Mental Illness Fact Sheet, “Treatment outcomes for people 
with even the most serious mental illnesses are comparable to outcomes for well- 
established general medical or surgical treatments for other chronic diseases. The early 
treatment success rates for mental illnesses are 60-80 percent.”! i^ 


111 Ronald C. Kessler et al., “The Prevalence and Correlates of Untreated Serious Mental Illness,” 
Health Services Research 36 (December 2001), 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1089274/pdC'hsresearch00007-0020.pdf, 996. 

112 David Mechanic and David A. Rochefort, “Deinstitutionalization: An Appraisal of Reform,” 
Annual Review of Sociology 16 (1990): 301-327. 

113 Michael C. Biasotti, “Management of the Severely Mentally Ill and its Effects on Homeland 
Security” (master’s thesis. Naval Postgraduate School, 2011) 2. 

114 Ibid., 17. 

113 National Alliance on Mental Illness, Mental Illness: Treatment Saves Money and Makes Sense, 
2007, 

http://www.nami.org/Template.cfm?Section=Policy&TemplateAContentManagement/ContentDisplay.cfm 
&ContentID=44613, 1. 


37 



When an active-shooter or mass-homicide event does occur, the victims face 
physical injuries and sometimes economic hardships if they are lucky enough to survive. 
An article in the Mercury News in July of 2012 highlighted the enormous medical bills 
facing survivors of the Batman shooting who were uninsured.Although it is not 
known precisely how many victims were uninsured at the time of the shooting, local 
demographics suggested a high rate of uninsurance. According to the article, one out of 
three people in Colorado are either uninsured or underinsured, and the highest rate of 
uninsurance is among the 18-34 age group, the same age range of many of the Batman 
shooting victims. One victim highlighted in the Mercury News article was Caleb 
Medley, who at the time of the article was in critical condition with a head wound. His 
family was working to raise $500,000 to cover medical bills and other expenses. 
Fortunately for the Batman victims, three of the five hospitals that treated the wounded in 
this case either limited or forgave the medical bills altogether. While this generosity is 
admirable, it is the exception rather than general practice. 

F. ECONOMICS 

The economics of health care matters because of its enormous cost to the federal 
government, state governments, and individual Americans. Growth in health care 
spending is “one of the central fiscal challenges facing the federal government,” 
according to the Congressional Budget Office.An aging population, increased 
enrollment in Medicare and Medicaid programs, and overall rising health care costs 
continue to drive spending projections higher. 

In 2011, the U.S. spent 17.7 percent of its gross domestic product on health care, 
which is eight percentage points higher than the average for other developed countries 
(9.3 percent), according to the Organisation for Economic Co-Operation and 


Colleen Slevin and Kristen Wyatt, “Medical Bills Loom in Colorado,” San Jose Mercury News, 
sec. Local, June 27, 2012. 

117 Ibid. 

11^ Congressional Budget Office, “Health Care,” accessed July 29, 2014, 
http://www.cbo.gov/topics/health-care 


38 



Development (OECD)/^^ Per capita spending averaged $8,508, which was two-and-a- 
half times more than the OECD average, and more than double per capita spending as 
compared to other relatively rich countries, such as Erance and Sweden, which averaged 
$5,600 per capita/^® 

In 2011 alone, the government spent $549.1 billion on Medicare coverage for 
48.7 million recipients. This accounted for roughly 15 percent of the national budget and 
21 percent of overall U.S. health care spending. States participating in the ACA will 
expand Medicaid eligibility, increasing costs for the state/federal partnership further. 
Estimated costs for expansion will be explored in Chapter V. 

With health care cost rising so rapidly, even those with employer-sponsored 
insurance are feeling the effects. Eor example, between 1999 and 2008, the total premium 
for insurance (employer plus employee share) for single-person coverage increased 114 
percent, from $2,196 to $ 4 , 704,122 xhe employee’s share alone increased 127 percent 
from $318 to $721,123 During that same time period, the total premium for family 
coverage increased 119 percent from 1999 to 2008; $5,791 to $12,680,124 The employee 
share increased from $1,543 to $3,354, an increase of 117 percent.'^^ This matters 
because more and more of the American paycheck is dedicated to health care, and this 
threatens to undermine our ability to receive affordable care without sacrificing in other 
areas. In 2008, the Social Security Advisory Board report on health care costs warned. 


119 OECD, OECD Health Data 2013, 1-2. 

120 Ibid. 

121 The Medicare Newsgroup, “Medicare FAQs,” July 29, 2014, 
http://www.medicarenewsgroup.com/news/medicare-faqs/individual-faq?faqId=bddee68a-7fef-4d85-bc4d- 
2cb8ealc59db 

122 Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits: 
Annual Survey 2008 (Menlo Park, CA: Henry J. Kaiser Family Foundation, 2008), 
http://kaiserfamilyfoundation.files.wordpress.eom/2013/04/7790.pdf, 30. 

123 Ibid., 1. 

124 Ibid. 

125 Ibid. 


39 



“we believe that the rising cost of health care represents perhaps the most significant 


126 

threat to the long-term economic security of workers and retirees.” 

Affordable, accessible health care for all individuals could substantially improve 
individual economic security; currently half of all personal bankruptcies are caused in 
part by medical expenses. As individuals age, they tend to get sicker, consume more 
health care, and need more medications. These lead to greater out-of-pocket costs, right at 
the time of life where income either levels off (retirement) or begins to decrease. 

G. SUMMARY 

This chapter illustrates several of the primary connections between health care 
and homeland security and makes the case for why health care should be considered a 
homeland security issue. Some connections are obvious, such as the need for victims of a 
bioterror attack to access health care, the role vaccinations might play in mitigating a 
smallpox outbreak or an influenza pandemic. Other connections are less intuitive, such as 
the role health care can play in managing mental illness, PTSD, recovery from acts of 
terrorism, or potentially preventing mass-shootings. The pillars of homeland security 
preparedness are prevention, preparedness, mitigation, response, and recovery; health 
care has a significant role within each component. It is clear that accessible, affordable 
health care is a critical part of the homeland security system and a foundational element 
of the all-hazards preparedness puzzle. 

The next chapter will focus on the Affordable Care Act itself and provide an 
overview of its primary goals and strategies for achieving those goals. 


126 Social Security Advisory Board, The Unsustainable Cost of Health Care, 2009, 
http://www.ssab.gov/documents/TheUnsustainableCostofHealthCare_508.pdf, 1. 

127 The Patient Protection and Affordable Care Act, §1501 (E), 125; Himmelstein et at, “Medical 
Bankruptcy in the United States,” 741-746. 


40 



IV. WHAT IS THE PATIENT PROTECTION AND AFFORDABLE 

CARE ACT? 


The health eare system in the United States is a combination of public and private 
organizations with different funding mechanisms. Hospitals in the U.S. are split between 
non-profit (2,894), for-profit (1,068) or government owned ( 1 , 037 ).1^8 Most public and 
private hospitals, medical facilities, and health care providers bill patients on a fee-per- 
service basis, meaning that they charge a certain fee for each service rendered. Generally 
speaking, fee-per-service health care in the U.S. is extraordinarily expensive, but it is 
made more affordable via health care insurance. Some private hospitals and medical 
facilities are part of a health maintenance organization (HMO) or managed care facilities. 
In these arrangements, the HMO acts as a liaison between the patient and health care 
provider and/or health insurance company on a pre-paid basis. The medical provider 
agrees to treat patients according to the HMO’s guidelines, while the patient pays a 
monthly fee, rather than paying a fee-per-service. 

The majority of the U.S. population obtains private health insurance through 
employer-sponsored insurance for the employee (or the employee’s family member) or 
through government entitlement programs. A small percentage purchase private 
insurance out-of-pocket, and the rest are uninsured. Here is the breakdown of health 
insurance coverage in America according to the U.S. Census Bureau report in 2011:129 

• 63.9 percent are covered by private insurance—197.3 million people 

• 55.1 percent have employer-sponsored coverage—170.1 million 
people 

• 8.8 percent buy coverage out-of-pocket—27.2 million people 

• 32.2 percent are covered by government insurance—99.5 million people 

• 15.7 percent are uninsured—48.6 million people 

The Patient Protection and Affordable Care Act was passed by Congress and 
signed into law on March 23, 2010. It was almost immediately amended by the Health 

128 American Hospital Association, “Fast Facts on U.S. Hospitals,” (Chicago, IL: Health Forum, 

2014), accessed July 23, 2014, http://www.aha.org/research/rc/stat-studies/fast-facts.shtml, 1. 

129 DcNavas-Walt et ah. Income, Poverty, and Health Insurance Coverage, 21. 


41 



Care Education and Reconciliation Act, signed one week later on March 30, 2010. 
Although the two were passed and signed as separate laws, they work and are referred to 
together. Passage of the ACA and HCERA are considered by many to be most significant 
reforms to health care in America since the 1965 introduction of Medicare and 
Medicaid. 130 in its combined bill form, the ACA and the HCERA make up a 906-page 
tome; its length and complexity are daunting. This chapter outlines the most fundamental 
framework of the law in order to provide a baseline understanding of how it will affect 
homeland security, as covered in the next chapter. 

The primary goals of the ACA are to expand insurance coverage to all eligible 
U.S. residents, control health care costs, and improve the overall functioning of the health 
care system. The ACA is set out in 10 separate titles, with the first nine addressing one 
component of reform, and Title X listing amendments to the law. The intended goal of 
each section is self-evident by title: 

• Title I: “Quality, Affordable Health Care for All Americans” 

• Title II: “Role of Public Programs” 

• Title III: “Improving the Quality and Efficiency of Health Care” 

• Title IV: “Prevention of Chronic Disease and Improving Public Health 

• Title V: “Health Care Workforce” 

• Title VI: “Transparency and Program Integrity” 

• Title VII: “Improving Access to Innovative Medical Therapies” 

• Title VIII: “Community Eiving Assistance Services and Supports” 

• Title IX: “Revenue Provisions” 

• Title X: “Strengthening Quality, Affordable Health Care for all 
Americans” 

In designing the ACA, the authors chose two primary strategies for expanding 
health insurance coverage. The first is through a concept termed “shared 


^30 Stolberg and Pear, “Obama Signs Health Care Overhaul Bill;” Vicini, Stempel, and Biskupic, 
“U.S. Top Court Upholds Health Care.” 

131 Jeanne S. Ringel et al., Analysis of the Patient Protection and Affordable Care Act (HR 3590) 
(Santa Monica, CA: Rand, 2010), 

http://www.rand.org/content/dam/rand/pubs/research_briefs/2010/RAND_RB9514.pdf, 2. 


42 




responsibility,”132 which mandates that individuals and employers do their part in 
expanding insurance coverage across the population. The second major strategy aims 
to expand state Medicaid coverage. 134 

A. SHARED RESPONSIBILITY 

The concept of “shared responsibility” is a fundamental underpinning of the 
ACA. In order to be financially sustainable, the insurance pool must be expanded across 
the entire population. If insurance companies are allowed to pick and choose clients from 
only the young and healthy population, then the sick and elderly will suffer from lack of 
coverage. In contrast, insurance companies must expand its coverage of the young and 
healthy, in order to underwrite costs for the sick and elderly. 

The “individual mandate” is the most controversial part of the ACA. Effective 
January 1, 2014, it requires all individuals to carry some “minimum level” of insurance 
coverage or pay a penalty to the Internal Revenue Service at tax time. Section 26 U.S.C. 
§5000A(a) states: “An applicable individual shall for each month beginning after 2013 
ensure that the individual, and any dependent of the individual who is an applicable 
individual, is covered under minimum essential coverage for such month.” The penalty 
for not maintaining coverage will be $95 in 2014, $350 in 2015, $750 in 2016, and 
indexed thereafter, to be paid to the Internal Revenue Service at tax time.i35 For those 
under age 18, the penalty will be one-half the amount for adults, levied against the adult 
responsible for that juvenile. The ACA provides tax credits to people with lower incomes 
on a sliding scale in order to subsidize insurance purchases made on an exchange. 

The individual mandate was upheld by the Supreme Court in its ruling on June 
28, 2012. At issue was whether the individual mandate was an illegal tax. Chief Justice 

132 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), 

§5000A(b). 

133 Democratic Policy Communication Committee, Patient Protection and Affordable Care Act: 
Detailed Summary. 

134 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), 
§1396a(a)(10)(A)(i)(VIII). 

135 The actual penalties are the flat fee or one percent of income, whichever is higher. This will be 
further explored in Chapter VI. 


43 



John Roberts delivered the majority opinion that “the (individual) mandate may be 
upheld as within Congress’s power to “lay and eollect Taxes,”136 and that “Congress may 
also ‘lay and eollect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for 
the common Defence and general Welfare of the United States.”’i37 Put simply, 
“Congress may tax and spend.”i38 There are several exceptions to compliance with the 
individual mandate: religious objectors. Native American tribe members, taxpayers with 
incomes less than 100 percent of the federal poverty level (FPL), those without coverage 
for less than three months, those with an approved hardship waiver, the incarcerated, and 

1 TQ 

individuals in the country illegally are not required to purchase insurance. 

The ACA imposes several regulations upon the business community to increase 
insurance coverage as part of the shared responsibility tactic. One rule mandates that 
larger businesses with over 200 employees must automatically enroll new employees in a 
qualifying health insurance plan. Another rule targets small businesses that employ 50- 
200 people and allows them to buy insurance through the exchanges. Employers that do 
not follow the guidelines will pay penalties at tax time ranging from $350-$3,000 per un¬ 
enrolled employee. Employers that do follow the guidelines will receive tax credits. 
Originally, this part of the ACA was set to go into effect starting January 1, 2014. 
However, on July 2, 2013, President Obama announced a delay in the implementation of 
this portion of the law until 2015. On the White House Blog post titled, “We’re Listening 
to Businesses about the Health Care Law,” senior advisor to the president, Valarie Jarrett, 
wrote, “we’re giving businesses more time to comply. delay has created a lot of 
confusion that has yet to be sorted out. 


136 “National Federation of Independent Business et al. V. Sebelius,” last modified 2014, ScotUS 
Blog, http://www.scotusblog.com/case-files/cases/national-federation-of-independent-business-v-sebelius/, 

2 . 

137 u.S. Const., Art. I, §8, cl. 1. 

138 “National Federation of Independent Business et al. V. Sebelius,” 5. 

139 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). 

140 Valarie Jarrett, “We’re Listening to Businesses about the Health Care Law,” The White House 
Blog, July 2, 2013, http://www.whitehouse.gov/blog/2013/07/02/we-re-listening-businesses-about-health- 
care-law 


44 



The ACA requires fully-partieipating states to establish a health benefit exehange 
to help individuals and small employers obtain eoverage. The exchanges are managed by 
the states but are really just central gathering points for private insurers. In order for 
health insurance companies to qualify for an exchange they must offer plans that meet the 
essential benefit requirements as spelled out by the Department of Health and Human 
Services. This will allow consumers to make “apples to apples” comparisons across 
insurance packages in deciding on coverage plans. As of this writing, 16 states and 
Washington, DC, are operating their own exchanges. 

For those living in states that choose not to create exchanges. Health and Human 
Services has established a national public option exchange, called the Health Insurance 
Marketplace. This can be accessed at https://www.healthcare.gov/ . Seven states have 
chosen not to stand up their own exchange but have entered into a state/federal 
partnership, where the state’s customers access the National Public Option Exchange, but 
the state conducts the plan management and consumer service. Seven other states have a 
similar partnership with the federal government, wherein the state is only responsible for 
plan management. In addition, 19 states have declined to have any involvement in 
exchanges, and their residents must access the National Public Option Exchange without 
the state’s participation. One state—Utah—runs a small-business marketplace exchange, 
while its residents utilize the National Public Option Exchange for the individual 
marketplace. See this website for up-to-date information on state exchange participation: 
http ://www. commonwealthfund. org/Maps-and-Data/State-Exchange-Map. aspx . 

Health insurers qualifying for the exchange offer four distinct levels of health 
insurance coverage: bronze, silver, gold and platinum. Each provides increasing 
percentages to be paid by the insurer, ranging from 60 percent at the bronze level up to 90 
percent at the platinum level. A fifth level—a lower benefit catastrophic plan—is 
available only to those under age 30 (a population considered to be healthier on average) 
and to those otherwise exempt from the individual mandate. As of this writing, the state 
of Washington is the only participating state that does not offer catastrophic coverage 
plans. 


45 




Individual purchasers earning below 400 pereent of the FPL are eligible to buy 
insurance at the exchange if they are not eligible for insurance through their employers, 
or otherwise eligible for one of the entitlement programs. Subsidies in the form of tax 
credits will be given to those eligible for exehange purchases on a sliding seale for those 
earning between 100 percent and 400 pereent of the FPL.i^i Illegal immigrants are not 
eligible for exehange purehases or tax credits. Additionally, legal immigrants must live 
here legally for five years before beeoming eligible for exchange purchases. 

Another ACA reform allowing coverage expansion of the insurance pool permits 
young people to stay on their parents’ insurance up to the age of 26. This part of the law 
became effective September 23, 2010 and has already contributed to significant gains in 
health insuranee eoverage for adults between the ages of 19-25. This will be discussed 
further in the next chapter. 

The ACA put several regulations into place to ensure that health insurance 
eompanies cannot cherry-pick only from the healthy population: 1^2 

• Insurance eompanies eannot refuse coverage based on health status 
(physical or mental), pre-existing eonditions, claims experience, genetic 
information, history of domestic violence or other health-related factors 1^3 

• Insurance companies may not cancel or reseind policies 

• Premiums can vary only by age, family structure, geography, actuarial 
value, tobaeco use, and participation in a health promotion program, but 
not by more than a three-to-one ratio 

• No lifetime limits on benefits 

• Eliminates unreasonable annual limits on benefits 


The Federal Poverty Level determined by HHS based on U.S. Census information on a yearly 
basis, and published under Federal Poverty Guidelines at http://aspe.hhs.gov/poverty/13poverty.cfm. 
Amounts vary slightly in some states. For 2013, the FPL in the 48 contiguous states and the District of 
Columbia for a family of one is $11,490, increasing with the addition of each family member. The FPL for 
a family of four is $23,550. 

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). 

143 Ibid. 


46 



B. EXPANSION OF MEDICAID 


The second major prong of the insurance expansion effort is state Medicaid 
expansion. Medicaid is a state/federal program, primarily funded by the federal 
government, and managed by the states. Nationwide, Medicaid funding averaged 23 
percent of the states’ total spending in fiscal year 2011, the largest portion of states’ 
budgets. Medicaid began in 1965 as a safety-net for the poor, but it has expanded to 
now cover a broader set of the population. Each state is managed differently and has 
some flexibility in whom it covers. Generally speaking, most state Medicaid programs 
cover low income women with children, pregnant women, children in low-income 
families, the elderly (over 65), and people with certain disabilities, such as blindness. 
The median threshold for Medicaid eligibility for working parents as of January, 2012 
was 63 percent of the FPL. 1^6 Furthermore, 17 states limit Medicaid eligibility to parents 
earning less than 50 percent of the FPL. 1^7 Some states choose to cover low-income, 
childless adults, while others do not. 

As originally written, the ACA directed all states to expand their Medicaid 
coverage to childless adults earning up to 133 percent of the FPL. 1^8 penalty for not 
doing so was to potentially lose their state Medicaid funding altogether. This part of the 
bill was intended to motivate states to participate in the ACA; however, many saw the 
tactic akin to blackmail. 

This highly controversial piece of the law was finally decided upon by the 
Supreme Court. Chief Justice John Roberts in the majority opinion concluded, “The 
Medicaid expansion violates the Constitution by threatening States with the loss of their 


U.S. Government Aceountability Office, Medicaid Expansion: States ’ Implementation of the 
Patient Protection and Affordable Care Act (GAO-12-821) (Washington, DC: U.S. Government 
Accountability Office, 2012). 

145 Ibid. 

146 Ibid. 

147 Ibid. 

148 Because five percent of an applicant’s income is disregarded, the effective threshold is 138 percent 
of the FPL. Therefore, the literature sometimes uses 138 percent as the eligibility threshold number for 
Medicaid eligibility. 


47 



existing Medicaid funding if they decline to comply with the expansion.”i49 xhis means 
that each state may individually decide whether to expand its Medicaid program. 

In states that choose not to expand Medicaid, individuals and families with 
incomes between 100-400 percent of the FPL will be eligible for federal subsidies on the 
exchange, whereas in states choosing to expand, only people earning between 133 and 
400 percent FPL are eligible for the subsidies. In order to offset the states’ costs of 
Medicaid expansion, from 2014 to 2017, the federal government will pay for 100 percent 
of the difference between a state’s current Medicaid eligibility level and the ACA 
minimum. Federal contributions to the expansion will drop to 95 percent in 2017 and 
remain at 90 percent after 2020 . 1^0 applies to the newly-covered population only. 
This means that states with low numbers of Medicaid recipients stand to gain the most 
money in expanding their program. At the time of this writing, 26 states plus DC are 
participating, 21 are not, and three are undecided.There is no provision prohibiting 
states from choosing to expand Medicaid at a later date.^^^ 

In addition to expanding Medicaid, the ACA mandates that the states maintain 
income eligibility levels for Children’s Health Insurance Program (CHIP) through 
September of 2019. CHIP is another state/federal cooperative entitlement program aimed 
at covering children in low-income families. Children in families earning less than 200 
percent of the FPL are eligible. Services provided through CHIP are more comprehensive 
than those generally provided to adults. Additionally, services include dental and vision, 
in addition to general health care and preventive care. The ACA will increase federal 
funding match rate by 23 percent between 2014 and 2019.1^3 

“National Federation of Independent Business et al. V. Sebelius,” 3. 

Kansas Health Institute, ACA Medicaid Expansion: Enrollment and Cost Estimates for Kansas 
Policymakers (Topeka, KA: Kansas Health Institute, 2012), http://m.kha- 
net. org/criticalissues/kancareexpansion/kancareexpansionresources/kl 01289. aspx, 2. 

The latest information on the state-participation count with a daily update can be found 
here:http://www.advisory.com/daily-briefing/resources/primers/medicaidmap, accessed March 18, 2014. 

152 “Where the States Stand on Medicaid Expansion,” The Daily Briefing, May 28, 2014, 
http://www.advisory.com/daily-briefing/resources/primers/medicaidmap 

“Children’s Health Insurance Program Financing,” Centers for Medicare and Medicaid Services, 
accessed July 16, 2014, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- 
T opics/F inancing-and-Reimbursement/Childrens-Health-Insurance -Program-F inancing. html 


48 



C. CONTROLLING COSTS 

The ACA puts several regulations into place aimed at controlling the ever-rising 
costs of health care. The below list is not comprehensive, but it illustrates some of the 

highlights: 154 

• A qualified plan offered through the Exchange must limit its cost sharing 
in such a way that annual deductibles cannot exceed the amounts allowed 
in health savings accounts ($2,000 for an individual, and $4,000 for a 
family of four) 

• Insurance companies may only use the following factors to set premiums: 
age, family structure, geography, actuarial value, tobacco use, and 
participation in a health promotion program. Premiums many not vary 
more than three-to-one. 

• The ACA places a cap on insurance company administrative expenditures 

• Requires no cost-sharing for certain preventive services and 
immunizations 

• Enhances the Medicare Part D prescription drug benefit coverage, a.k.a. 
the “donut hole” 

The ACA increases funding for community clinics as a method of providing some 
level of health care to those without insurance coverage. These clinics are open to all 
comers, including illegal immigrants. It is hoped that by increasing the number of low- 
cost or no-cost community clinics, more uninsured will choose to be treated there, rather 
than at the higher-cost emergency rooms. 

D. IMPROVING QUALITY OF THE HEALTH CARE SYSTEM 

The ACA contains several guidelines and regulations aimed at improving the 
overall quality of the health care system: 155 

• The President shall establish a council to be known as the “National 
Prevention, Health Promotion and Public Health Council” 156 


154 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). 

155 Ibid. 

156 Ibid., §4001. 


49 



• The Secretary of Health and Human Services will establish a national 
strategy to improve health care service delivery, patient outcomes and 
public health 

• The President will convene an Interagency Working Group on Health Care 
Quality to collaborate on the development and dissemination of quality 
initiatives consistent with the national strategy 

• Medicare and Medicaid payments will be linked to quality health 
outcomes 

• Specifically encourages the development of new patient care models 

• Focuses improvements on rural care 

• Providers in rural areas eligible for increased fees 

• More funding for ground and air ambulances in rural areas 

• Creates a new program to develop community health teams to improve 
community-based, coordinated care 

The ACA attempts to improve the U.S. health care system in a multitude other 
ways, such as increasing the size and capability of the health care workforce, preventing 
chronic disease, and improving public health. It beyond the scope of this thesis to 
enumerate all the regulations and intricacies of a 906-page law; however, this chapter 
provides the basic outline of the main objectives and mandates. 


E. SUMMARY 

The Affordable Care Act is most significant health care reform effort in the past 
generation, written with the lofty goals of 1) expanding health care to all eligible U.S. 
residents, 2) controlling health care costs, and 3) improving the overall quality of health 
care in America. The term “homeland security” is not mentioned anywhere in the 
expressed legislative goals. In fact, the term is used only a handful of times (10) 
throughout the document and only then to identify some of the participants to specific 
councils or to specify how a person is required to prove his or her immigration status and 
eligibility for participation. Regardless, if the ACA does succeed in expanding health 
insurance coverage, controlling costs, and improving health care, these achievements will 


50 



have the seeondary effect of also improving homeland security’s all-hazard preparedness 
efforts, particularly from the health perspective and the economic perspective, as will be 
outlined in the next chapter. 


51 



THIS PAGE INTENTIONALLY LEET BLANK 


52 



V. ANALYSIS 


A. HOW IS ACA MOST LIKELY TO POSITIVELY IMPACT HOMELAND 

SECURITY EFFORTS TO ACHIEVE ALL-HAZARDS PREPAREDNESS? 

The fact that millions of U.S. residents do not possess health insurance negatively 
affects our collective safety and homeland security preparedness level. The consequences 
of uninsurance and its relation to homeland security are discussed here. Implementation 
of the Affordable Care Act will expand health insurance to millions of U.S. residents not 
currently covered. This expansion has significant potential to positively impact homeland 
security preparedness in a variety of ways. These potential impacts are explored in this 
chapter, both from the health perspective and the economic perspective. 

According to a report by the Institute of Medicine, 43 percent of working-age 
adults who did not have health insurance reported that they chose not to see a doctor for a 
medical problem in a one-year time period; in contrast, only 10 percent of working-age 
adults who did have coverage for the entire year reported not seeing a physician for a 
medical issue.Jack Hadley’s comprehensive analysis of 51 studies in Sicker and 
Poorer—The Consequences of Being Uninsured: A Review of the Research on the 
Relationship between Health Insurance, Medical Care Use, Health, Work, and Income 
finds “the uninsured receive fewer preventive and diagnostic services, tend to be more 
severely ill when diagnosed, and received less therapeutic care.”i^^ Numerous studies 
over the long-term have shown that uninsured Americans are less likely to obtain 
preventive health care, care for chronic conditions and more likely to suffer from 
undiagnosed medical conditions. As a result, uninsurance is associated with a higher rate 
of mortality^^^ and decreased access to health care.'^*^ 


Institute of Medicine of the National Academies, Uninsurance Facts and Figures. 

Hadley, “Sicker and Poorer,” 3S. 

Centers for Disease Control and Prevention, “Emerging Infections Programs.” 

160 Nicole Lurie et al., “Termination from Medi-Cal: One Year Later,” New England Journal of 
Medicine 314, no. 19 (1986): 1268. 


53 



In the National Strategic Narrative, authors Captain Wayne Porter and Colonel 
Mark Mykleby promote the idea that seeurity means more than physical safety, “for 
Americans, security is very closely related to freedom, because security represents 
freedom from anxiety and external threat, yfeeJom from disease and poverty... [emphasis 
added].They urge us to focus on, among other things, “quality health care and 
education” and the prioritization of “a sustainable infrastructure of education, health 
and social services to provide for the continuing development and growth of America’s 
youth.” While Porter and Mykleby do not advocate for any particular type of health 
care system or structure, they point out that health care is an integral part of a secure and 
prosperous society. Griffen Trotter echoes the idea that basic health care provides a 
foundation for a physical infrastructure that promotes “a social and physical that 
enhances the quality and security of ordinary lives... Health, in and of itself, 
contributes to one’s sense of security, and health care is a component of maintaining 
one’s health. 

The Congressional Budget Office estimates that the ACA will bring down the 
proportion of uninsured, nonelderly adults in the U.S. from 20 percent to 11 percent, 
Some early proof that implementation of the ACA will equate to health insurance 
coverage gains can already be found. As noted earlier in this paper, the ACA goes into 
effect in stages. One of the earliest prongs of the law went into effect on September 23, 
2010. This aspect of the ACA allowed young adults to remain on their parents’ insurance 


161 Wayne Porter and Mark Mykleby, A National Strategic Narrative (Washington, DC: Woodrow 
Wilson Center, 2011), 6, 

http://www.wilsoncenter.org/sites/default/files/A%20National%20Strategic%20Narrative.pdf 

162 Ibid., 10. 

163 Ibid., 13. 

164 Griffen Trotter, “Emergency Medicine, Terrorism and Universal Access to Healthcare: A Potent 
Mixture for Erstwhile Knights-Errant,” in In the Wake of Terror: Medicine and Morality in a Time of 
Crisis, ed. Jonathan D. Moreno (Cambridge, MA: MIT Press, 2003), 143. 

165 Congressional Budget Office, Estimates for the Insurance Coverage Provisions of the Affordable 
Care Act Updated for the Recent Supreme Court Decision (Washington, DC: Congressional Budget Office, 
2012 ). 


54 



plans up to age 26. This is a gain of seven years beyond when children “aged-out” of 
coverage prior to the ACA. 

A study published in Health Affairs journal in January of 2013 studied the early 
effects of the ACA on health insurance coverage and access to care for young adults. The 
study by Benjamin Sommers et al. notes that between September of 2010 and December 
of 2011, approximately three million uninsured adults between the ages of 19-25 gained 
health insurance coverage as a result of the ACA.i^^ 

This particular study demonstrated that not only did more young adults enjoy 
coverage gains, but also enjoyed increased access to care, which is ultimately one of the 
primary goals of the law.i®^ As Shane Green noted in 2004, “A nation’s greatest defense 
against bioterrorism, both in preparations for and in response to an attack, is a population 
in which an introduced biological agent cannot get a foothold, i.e., healthy people with 
easy access to care.”^^^ 

By expanding health insurance to 33 million more people through the 
implementation of the ACA, the results of these studies support the likelihood that this 
newly insured population will overall seek medical care earlier on, be in a better state of 
health when seen, and have better health outcomes. This will have positive ripple effects 
for homeland security in dealing with emerging disease, bioterror, flu pandemic, mental 
illnesses, and potentially economic security. 

B. HEALTH SURVEILLANCE SYSTEM 

An effective health surveillance system requires that those stricken by illness or 
disease—^whether accidentally contracted or intentionally afflicted—seek treatment from 

166 group health plan and a health insurance issuer offering group or individual health insurance 
coverage that provides dependent coverage of children shall continue to make such coverage available for 
an adult child (who is not married)until the child turns 26 years of age.” Patient Protection and Affordable 
Care Act, Pub. L. No. 111-148, 124 Stat. 132 (2010), §2714(a). 

Benjamin D. Sommers, Thomas Buchmueller, Sandra L. Decker, Colleen Carey, and Richard 
Kronick, “The Affordable Care Act has Led to Significant Gains in Health Insurance and Access to Care 
for Young Adults” Health Affairs 32, no. 1 (January 2013), 165. 

168 Ibid., 170. 

169 Green, “Bioterrorism and Health Care Reform: No Preparedness without Access,” 2. 


55 



a health care professional. The health care professional works to diagnose the problem, 
prescribe care, mitigate further spread, and report the illness as necessary to the health 
care community and possibly the government. This process is critical to our nation’s 
security in the event of a bioterror attack, such as with an Ebola virus or anthrax attack. 
The same holds true in managing contagious diseases such as influenza or newly 
emerging diseases. The sooner an illness or disease is correctly diagnosed, the more 
options remain available to help mitigate the spread or effect. Delays in diagnoses and 
therefore the development of appropriate treatments can have a limiting effect on both the 
health care community’s and the homeland security community’s choices and options in 
managing the spread and effect of the affliction. 

Jack Hadley’s analysis showed statistically significant and positive support for the 
hypothesis that having health insurance or greater medical care use improves health: 
seven of the 10 natural experiments analyzed, six of the seven longitudinal studies, 29 of 
35 of the observational studies showed “statistically significant results consistent with a 
positive relationship between health insurance or medical care use and health.”i^o 

According to author G. Kenny, the uninsured received only 55 percent of the 
medical services received by the insured. Increased health insurance coverage 
correlates with an increased use of health care services,which is likely to increase the 
chance of earlier identification and mitigation of disease. This is good news for homeland 
security. The uninsured are more than four times more likely than the insured to delay 
needed medical care or forego it altogether due to cost concerns.^^3 gy increasing the 
number of insured Americans, we also increase the likelihood that those with contagious 
diseases will seek treatment earlier on, allowing health professionals to identify, treat and 
mitigate disease spread more successfully. This would include diseases of concern to the 


Hadley, “Sicker and Poorer,” 14S. 

Genevieve M. Kenney, Stacey McMorrow, Stephen Zuckerman, and Dana E. Goin,”A Decade of 
Health Care Access Declines for Adults Holds Implications for Changes in the Affordable Care Act,” 
Health Affairs 31, no. 5 (2012): 899-908. 

1^2 Institute of Medicine of the National Academies, Uninsurance Facts and Figures. 

173 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 132 (2010), §2714(a). 

56 



homeland security community such as influenza virus, or any disease that has the ability 
to spread from person-to-person. 

A 2012 report from the Office of the Director of National Intelligence focused on 
“megatrends” and future possibilities for the global world in the year 2030.1^4 One area 
of focus was the increasing likelihood that viruses previously unknown in humans would 
continue to cross over from the animal reservoir to humans due to increased livestock 
production and human encroachment into the jungles. Examples of prior occurrences 
include a prion disease in cattle that jumped to humans in 1980 to cause variant 
Creutzeldt-Jacob disease in humans and the bat corona virus transferring to humans in 
2002, known now as SARS.i^^ These diseases can be devastating to the human 
population, due to the lack of prior exposure, as well as the lag-time required to diagnose 
the disease and develop treatments. 

The same is true for any emerging disease, regardless of source. Early detection, 
identification, and mitigation are particularly critical with emerging diseases. New 
viruses appear on a daily basis. Viruses utilize RNA rather than DNA in the reproductive 
process. The RNA process is not as exact as the DNA process, and the reproductions vary 
in their genetics compared to the parent. This phenomenon is termed “antigenic drift,” 
and it makes viruses a moving target in terms of vaccination and treatment. As an 
example, there are multiple strains of the rhinovirus (the common cold) circulating at any 
one time. By the time a rhinovirus has passed through a given population, it will be 
genetically different than the strain that touched off the contagion. 

Early medical care, diagnosis, and treatment are particularly critical when dealing 
with newly emerging diseases that are more dangerous than the rhinovirus, such as 
hemorrhagic viruses like the Ebola virus. These viruses have an extremely high mortality 
rate, as high as 90 percent in some cases,and for many there are no known cures. 
When there are no cures for such deadly diseases early identification and quarantine 

Office of the Director of National Intelligence, Global Trends 2030: Alternative Worlds. 

175 Ibid. 

175 Anthony Sanchez et at, “Reemergence of Ebola Virus in Africa,” Emerging Infectious Diseases 1, 
no. 3 (July, 1995), doi: 10.3201/eid0103.950307, http://wwwnc.cdc.gOv/eid/article/l/3/95-0307.htm 


57 



become the primary management tools. Increased health insurance coverage makes the 
U.S. better positioned to find and manage emerging diseases earlier on in an outbreak. 

The same holds true for the health surveillance system as it relates to food safety: 
an increase in the number of Americans with health insurance is likely to increase the 
health surveillance system’s ability to help us in spotting food-safety issues. More 
insured people will seek medical care earlier on, which allows the surveillance system to 
pick up on patterns sooner. 

One subtitle of the ACA is specifically aimed at improving the public health 
surveillance system: Subtitle C—Strengthening Public Health Surveillance Systems, § 
2821, “Epidemiology-Laboratory Capacity Grants.” The section appropriates funding 
(subject to availability) for a grant program that would award grants to state, local, and 
tribal health departments “to assist public health agencies in improving surveillance for, 
and response to, infectious diseases and other conditions of public health importance 
by,”i7V 

(1) Strengthening epidemiologic capacity for identifying and monitoring for 
infectious disease; 

(2) Enhancing laboratory practices including reporting processes; 

(3) Improving information and information exchange systems; and, 

(4) Developing and implementing prevention and control strategies. 

C. PREVENTIVE CARE 

Another way the ACA would accomplish improved health security for U.S. 
residents is through increased access to preventive care. The ACA mandates that insurers 
cover certain preventive services, as recommended by the U.S. Preventive Services Task 
Eorce. This task force is comprised of “an independent panel of non-Eederal experts in 
prevention and evidence-based medicine and is composed of primary care providers 
(such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, 
and health behavior specialists).The task force makes recommendations for primary 

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), §2821. 

U.S. Preventive Services Task Force, “U.S. Preventive Services Task Force,” 
http://www.uspreventiveservicestaskforce.org/index.html, accessed July 31, 2014. 


58 



care providers and health systems aimed at improving health. It assigns grades “A,” “B,” 
“C,” “D,” or “I” to its own recommendations, indicating the certainty that providing the 
service is beneficial. 

For example, the task force recommends blood pressure screening in adults, and it 
assigns that specific recommendation a grade of “A.” This indicates that a high-level of 
certainty that the net benefit of providing blood pressure screening to adults is substantial. 
Any recommendation given a grade of “B” indicates either a high certainty that the net 
benefit is moderate, or a moderate certainty that the net benefit is moderate to 
substantial. 179 § iqqj of the AC A mandates Medicare, new and existing private 
individual plans, and new and existing small-group plans to cover all “A” and “B”-rated 
preventive recommendations without cost-sharing; there are now 53 “A” or “B”-rated 
services, i^n 

The ACA also mandates that certain specified vaccinations be offered without 
cost-sharing. 181 The Advisory Committee on Immunization Practices is a group of 
medical and public health experts that develop recommendations on how to use vaccines 
to control disease in the U.S.182 The ACIP develops the vaccination schedules for child 
and adult populations. Currently, they recommend 23 different vaccines, such as 
measles/mumps/rubella (MMR), influenza, smallpox, etc. 183 Of these 23 vaccines, 10 are 
mandated by the ACA to be covered with no cost sharing. 184 

• Hepatitis A 

• Hepatitis B 


179 Sara E. Wilensky and Elizabeth A. Gray, “Existing Medicaid Beneficiaries Left Off the Affordable 

Care Act’s Preventation Bandwagon,”//ea/t/i 32, no. 7 (July, 2013): 1188. 

180 “Grandfathered” plans are not subject to this requirement. A current list of these services can be 
accessed here: http://www.uspreventiveservicestaskforce.org/uspstf7uspsabrecs.htm. 

181 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), §2713. 

182 Centers for Disease Control and Prevention, “Advisory Committee on Immunization Practices 
(ACIP),” http://www.cdc.gov/vaccines/acip/, accessed July 31, 2014. 

183 Centers for Disease Control and Prevention, “Vaccine Recommendations of the ACIP,” last 
modified March 7, 2014, http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. 

184 pgj. ^ cun'ent list of no-cost vaccinations, go to: https://www.healthcare.gov/what-are-my- 
pre V enti ve -care -bene fits/ 


59 



• Herpes zoster 

• Human papillomavirus 

• Influenza (flu shot) 

• Measles, mumps, rubella 

• Meningoeoeeal 

• Pneumoeoeeal 

• Tetanus, diphtheria, pertussis 

• Varieella 

Expanding insuranee to a larger pereentage of the population, eombined with 
mandating no-eost vaeeinations will very likely result in an inereased number of 
Amerieans who reeeive the reeommended vaeeinations. A Canadian study eondueted in 
2008 is provided below as support for this eonelusion. 

Kwong et al. eondueted a widely-eited study in 2008 on a Canadian vaeoination 
program: In 2000, Ontario, Canada implemented a universal influenza immunization 
program and provided free flu vaeeines to the entire population age six months and older. 
As a result, vaeeination rates rose from an average of 18 pereent of the population (the 
average in 1996-1997) to 38 pereent of the population from 2000-2004. Sinee the 
introduetion of that universal vaeeination program, the researehers found that influenza- 
assoeiated deaths deereased 74 pereent, and influenza-assoeiated use of health eare 
faeilities also deereased. It is reasonable to prediet that by inereasing free aeeess to 10 
different vaeeines to millions more people, an inerease in those vaeeination rates is likely, 
as was seen in Canada. 

Another way the ACA will likely inerease the U.S. influenza vaeeination rate is 
via inereasing reimbursement rates to physieians. In 2013 and 2014, the ACA will 
inerease reimbursements to physieians who provide speeified vaeeinations up to 100 
pereent of the Medieare level. Currently, the reimbursement to doetors barely eovers the 


Jeffrey C. Kwong e af, “The Effect of Universal Influenza Immunization on Mortality and Health 
Care Use,” PLoSMedicine 5, no. 10 (2008): 3. 


60 




cost of the vaccine itself, which means that the doctor sometimes ends up subsidizing 

it. 186 


D. DISASTER PREPAREDNESS 

If its mandates are implemented as written, the ACA is likely to bolster our 
disaster preparedness efforts is through its push for an increase in number of health care 
workers, and its push for increased training. Title V of the ACA, “Health Care 
Workforce,” Subtitle A, § 5001 spells out the goals of this section: 

The purpose of this title is to improve access to and the delivery of health 
care services for all individuals, particularly low income, underserved, 
uninsured, minority, health disparity, and rural populations by: 

1. gathering and assessing comprehensive data in order for the health 
care workforce to meet the health care needs of individuals, 
including research on the supply, demand, distribution, diversity, 
and skills needs of the health care workforce; 

2. increasing the supply of a qualified health care workforce to 
improve access to and the delivery of health care services for all 
individuals; 

3. enhancing health care workforce education and training to improve 

access to and the delivery of health care services for all 

individuals; and 

4. providing support to the existing health care workforce to improve 

access to and the delivery of health care services for all 

individuals. 

The law dedicates hundreds of pages spelling out specific strategies and funding 
designed to increase the supply of the health care workforce, such as federally supported 
student loan funds, a nursing student loan program, 1^9 recruitment and retention 
programs for specialty health care workers, such as pediatric health care providers, grants 


Association of State and Territorial Health Officials, Increase in Vaccine Administration Rates: 
Summary of State Stakeholder Meetings, 2012, http://www.astho.org/Programs/Immunization/Increase-in- 
Vaccine-Administration-Rates 

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), §5001. 

188 Ibid. 

189 Ibid., §5202. 


61 



for states and local programs,and funding for a National Health Services Corps.If 
these mandates are realized, the health care workforce will see real increases in its 
numbers and improvements in its training. All of these things continue to be identified as 
areas where the U.S. health care system must focus in order to truly prepare for inevitable 
natural disasters. 

Specific to disaster preparedness, §5210 establishes the Ready Reserve Corps for 
service in time of national emergency. The purpose of such a corps “is to fulfill the need 
to have additional Commissioned Corps personnel available on short notice ...to assist 
regular Commissioned Corps personnel to meet both routine public health and emergency 
response missions.” The AC A states that the Ready Reserve Corps shall “be available 
and ready for involuntary calls to active duty during national emergencies and public 
health crises, similar to the uniformed service reserve personnel. 

An Internet search for the Ready Reserve Corps quickly leads to the United 
States’ Public Health Service’s website, http://ccmis.usphs.gov/ccmis/readyreserve.aspx, 
which describes the origin and mission of the Ready Reserve Corps. Health care 
professionals may sign up on that site to become a Ready Reserve Corps member and 
subject to active duty upon activation by the Surgeon General for the purpose of disaster 
relief. 

At a philosophical level author Griffen Trotter argues that improved access to 
health care enhances disaster preparedness by improving the relationship between health 
care seekers and providers by increasing trust and kinship “because health care personnel 
are more apt to be viewed as public servants.”1^3 He also argues that greater government 
involvement and control of the health care system could improve “political pathways” to 
build-in disaster preparedness into the health care system and possibly even increase the 
sense of ownership for disaster planning by the average citizen. 1^4 These claims lack 

190 Ibid, §5206. 

191 Ibid, §5207. 

192 Ibid, §5210. 

193 Griffen Trotter, “Emergency Medicine,” 144. 

194 Ibid. 


62 




evidence at this time, but perhaps deserve further attention as ACA implementation 
comes to fruition. 

A common theme in the disaster preparedness arena is the need for improvement 
in surge capacity. “Surge capacity” describes the ability to provide adequate medical 
evaluation and care during events that exceed the limits of the normal medical 
infrastructure of an affected community. 1^5 it is the ability of hospitals—emergency 
rooms (ER) in particular—to accommodate an influx of patients due to any sort of natural 
disaster, mass casualty, or major medical event. While most of us assume that the health 
care system is prepared to provide adequate care during major health events, the reality is 
that the current trend toward “just-in-time” delivery of supplies has actually decreased 
health care’s surge capacity. 

Three primary elements influence a hospital’s surge capacity: staff, 
supplies/equipment, and structure. The term “staff’ includes doctors, nurses, technicians, 
and anyone else related to providing health care in the hospital setting. “Supplies and 
equipment” would entail any sort of medical supplies necessary to provide medical 
treatment, such as wound care items, blood and plasma, medications, diagnostic 
equipment, beds, etc. Finally, “structure” refers to the physical location, as well as the 
health care infrastructure, to include pre-planning, response protocols, use of the Incident 
Command System, etc. 

The Hospital Preparedness Program (HPP) is a federally managed program that 
sets guidelines and benchmarks to help local hospitals prepare for public health 
emergencies. The HPP is overseen by the Assistant Secretary of Preparedness and 
Response, under the U.S. Department of Health and Human Services. According to its 
website, the HPP “provides leadership and funding through grants and cooperative 
agreements to States, territories, and eligible municipalities to improve surge capacity 
and enhance community and hospital preparedness for public health emergencies. 

U.S. Department of Health & Human Services, “What is a Medical Surge?” in Medical Surge 
Capacity Handbook (Washington, DC: U.S. Department of Health & Human Services, 2014), 
http://www.phe.gov/Preparedness/planning/mscc/handbook/chapterl/Pages/whatismedicalsurge.aspx 

Public Health Emergency, “Hospital Preparedness Program,” July 16, 2014, 
http://www.phe.gov/PREPAREDNESS/PLANNING/HPP/Pages/defauh.aspx 

63 



The benchmark for hospital surge capacity as outlined by the HPP is 500 patients 
per one million for infectious disease events and 50 patients per one million for mass 
casualty eventsT^^ In layman’s terms, a hospital must be able to manage overflow 
capacity when a major health event occurs. This requires extra bed space, medical 
supplies, and staff The reality is that many ER’s are constantly overloaded on a day-to- 
day basis. The 1986 Emergency Medical Treatment and Active Eabor Act (EMTAEA) 
requires all emergency rooms to provide emergency health services to patients, 
regardless of citizenship, legal status, or ability to pay. 1^9 When the uninsured are sick, 
they go to the emergency room. In the end, the general public underwrites the cost via 
taxes. 


1. Natural Disasters and Vulnerable Populations 

During a response to natural disasters, caring for victims already in poor health 
presents an added level of challenge. According to the CDC, “lack of access to routine 
health care is a leading cause of mortality after disasters.Those suffering from 
chronic diseases, such as cancer, diabetes, heart disease, stroke, or chronic respiratory 
disorders, need routine medical care and regular access to medicines in addition to care 
for whatever injuries were sustained in the emergency. Other vulnerable populations 
include pregnant women, the elderly, and those with disabilities. When natural disasters 
strike, managing injuries to those with special medical needs is more difficult, and it also 
requires more medical resources than a healthy person would with similar injuries. The 
ACA promises to increase access to health care. As has already been shown earlier in this 


197 Kaji et al., “Current Hospital Disaster Preparedness,” 2188. 

198 The EMTALA requires all hospitals that accept Medicare payments from Health & Human 
Services to provide emergency health care, regardless of ability to pay. Because nearly all hospitals accept 
Medicare payments, nearly all hospitals are affected. 

11^1^ Centers for Medicare and Medicaid Services, “Emergency Medical Treatment & Labor Act,” 
March 26, 2012, http://www.cms.gov/Regulations-and- 
guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/ 

700 Ali H. Mokdad et al., “When Chronic Conditions Become Acute: Prevention and Control of 
Chronic Diseases and Adverse Health Outcomes during Natural Disasters,” Prevention of Chronic Diseases 
2, no. Supplemental 1 (2005): 1. 


64 



thesis, better aceess to health care leads to a healthier population. Moreover, a healthier 
population is overall more resilient to natural disasters. 

2. Strengthening of the Public Health System 

The American Public Health Association’s 2011 publication on the ACA’s 
implications for public health improvement spells out all the various ways the ACA 
intends to positively impact overall public health by transforming “our ‘sick care’ system 
into one that focuses on prevention and health promotion. ”201 This report points out the 
critical need to focus on establishing a “sufficiently sized, adequately trained workforce” 
needed to “promote and protect the nation’s health.”202 As noted earlier in this chapter, 
several sections of the ACA focus directly on these topics. 

3. Mental Health Care 

The ACA requires eligible insurance plans to provide a certain level of mental 
health services. It also prohibits rejection based on prior health conditions, including 
mental health diagnosis. It is difficult to predict how this will affect the homeland 
security system; however, it is unlikely to impact it in a negative manner. Major lone 
wolf attacks often involve subjects with a long history of documented mental illness, as 
outlined in Edward Welch’s Naval Postgraduate School master’s thesis, “Preventing 
School Shootings: a Public Health Approach to Gun Violence.” Welch’s thesis 
systematically sets out an argument that lone wolves are a homeland security issue. 
Whether one accepts this as a homeland security issue or not, it is difficult to see how 
increased access to mental health care could have a negative impact on homeland 
security. 

Under Title V Health Care Workforce of the ACA § 5306 entitled, “Mental and 
Behavioral Health Education and Training Grants,” aims to increase the numbers of 


201 Taryn Morrissey, The Affordable Care Act’s Public Health Workforce Provisions: Opportunities 
and Challenges (Washington, DC: American Public Health Association, 2011): 3. 

202 Ibid 

203 Edward Welch, “Preventing School Shootings: A Public Health Approach to Gun Violence” 
(master’s thesis. Naval Postgraduate School, 2013). 


65 



mental health care workers and improve their training. 204 xhis section authorizes the 
Secretary of Health and Human Services to establish and award grants to institutions of 
higher education “to support the recruitment of students for, and education and clinical 
experiences of the students in” obtaining baccalaureate, master’s or doctoral degrees, 
internships, and residency programs for behavioral and mental health services. If this 
portion of the ACA is successfully implemented, it is likely to have a positive effect on 
the overall numbers of mental health providers, as well as improving their access to 
training. While the resulting impact on homeland security is not immediately 
quantifiable, it will be a step in the right direction. 

4. Increased Economic Stability 

Health care costs for individuals, for employers, and the nation have grown at 
alarming rates. Since 1960, spending on health care has increased an average of 2.3 
percentage points more than gross domestic product (GDP) growth on an annual basis. In 
I960, national health expenditures were measured at five percent of the GDP; however, 
in 2011, national health expenditures had climbed to nearly 18 percent,205 according to a 
December, 2013 health policy report in the New England Journal of Medicine. The most 
surprising news recently regarding the rising costs of health care is that this trend appears 
to be slowing. Real spending for health care grew only 0.8 percent in 2012,206 a 
slowdown in growth that has taken analysts by surprise. 

Experts do not agree on the causes of the slowed growth in costs. Some believe 
that it is explained by the recession, as health care cost trends generally mirror general 
economic trends; others theorize that efforts to control costs, including aspects of the 
ACA, might be responsible. 

The drivers of cost increases are better understood. General inflation, technology 
and research costs, tax-subsidies for employer insurance, entitlement program costs, and 

Patient Protection and Affordable Care Act, §5306. 

205 David Blumenthal, Kristof Stremikis and David Cutler, “Health Care Spending—A Giant Slain Or 
Sleeping?” The New England Journal of Medicine 369, no. 26 (2013): 2551, 
http://www.nejm.org/doi/pdf710.1056/NEJMhprl310415 

206 Ibid. 


66 



the supply-and-demand (for profit) system in the U.S. have all been shown to influence 
health care costs ever upward.207 According to the Government Accounting Office, the 
aging population will be the primary driver of health care spending increases through 
2029. The number of baby-boomers who turn 65 and become eligible for Medicare will 
increase from 7,600 per day in 2011, to 11,000 per day in 2029.208 

The non-partisan Congressional Budget Office has studied the potential economic 
effects of the AC A on federal government spending repeatedly since 2009. Its initial cost 
estimate report was done in November of 2009, prior to the Supreme Court decision in 
June of 2012 that essentially allowed states to opt out of Medicaid expansion. 209 in July 
of 2012, the CBO updated its estimate to take this change into account. As the CBO 
authors admit, precise calculations are impossible at this time. Even so, rough estimates 
have repeatedly indicated that in the aggregate, federal spending outlays will increase 
initially over the first few years of ACA implementation but will be offset by savings on 
health care spending and revenues, which will result in a net deficit savings between the 
years 2012-2022.210 After 2022, spending and the federal deficit will increase, but at a 
slower rate than it would without ACA implementation.2i i 

States have legitimate concerns regarding how the ACA will affect their bottom 
line. According to the Government Accountability Office’s 2012 report, across fiscal 
years 2012-2020, state budget directors believe that three aspects of Medicaid expansion 
will contribute to increased costs:2i2 

1) administration costs for Medicaid enrollment; 

2) information technology system costs to support enrollment; and 

3) enrolling previously eligible, but not enrolled individuals. 

207 Ibid. 

208 U.S. Government Accountability Office, The Federal Government’s Long-Term Fiscal Outlook: 
Fall 2012 Update (GAO-13-148SP) (Washington, DC: U.S. Government Accountability Office, 2012): 14. 

209 Congressional Budget Office, Patient Protection and Affordable Care Act: Cost Estimate, 2009 
(Washington: DC: 2009), 

littp://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/107xx/docl0731/reid_letter_l l_18_09.pdf 

210 Congressional Budget Office, Estimates for the Insurance Coverage, 21. 

211lbid. 

212 U.S. Government Accountability Office, Medicaid Expansion. 


67 



Effects of the ACA on state spending, particularly in regard to Medicaid 
expansion, is still an unanswered question, but several renowned research groups are 
researching the possible outcomes. Carter Price, Associate Mathematician, and Christine 
Eibner, Senior Economist at the RAND Corporation, have published an article in Health 
Affairs in June of 2013 that compares the financial effects on states’ spending under both 
“opt-in” (to Medicaid expansion) and “opt-out” scenarios, as well as some other 
hypothetical scenarios for partial expansions that are not actually allowed under current 
law. Price and Eibner used the RAND Comprehensive Assessment of Reform Efforts 
(COMPARE) micro-simulation tool to model the effects of different implementation 
scenarios. Although full details of this study will not be reported here, in summary, the 
RAND researchers found that Medicaid expansion provided participating states an 
overall a higher rate of insurance coverage, lower short-term (state/local) costs for 
delivering uncompensated care, and a higher federal revenues, taxes and ACA-related 
benefits.213 According to the authors, “We conclude in terms of coverage, cost, and 
federal payments, states would do best to expand Medicaid. ”214 

Another way states stand to gain from the ACA is from lower spending on health 
care for the uninsured. Expanded health insurance coverage translates to less cost for 
uncompensated care. Jack Hadley et al. found that uncompensated care for the uninsured 
population cost $56 billion in 2008.215 When taking medical inflation into account, this 
number will be approximately $80 billion in 2016.216 The same study estimated that 
states and local governments pay about 30 percent of this amount. So even though the 
states are not paying to cover the uninsured via entitlement program, they still pay an 
enormous bill for their health care costs. 

At an individual level, increased health care coverage has been found to have a 
positive effect on the pocketbook. Jack Hadley’s comprehensive study from 2003 

213 Carter C. Price and Christine Eibner, “For States that Opt Out of Medicaid Expansion: 3.6 Million 
Fewer Insured and $8.4 Billion Less in Federal Payments,” Health Affairs 32, no. 6 (2013): 1035. 

214 Ibid. 

215 Jack Hadley et ah, “Covering the Uninsured in 2008: Current Costs, Sources of Payment, and 
Incremental Costs,” Health Affairs 27 (2008): 399—415. 

216 Ibid. 


68 



concludes: “This review finds that there is a substantial body of researeh supporting the 

hypotheses that having health insuranee improves health and that better health leads to 

higher labor foree partieipation and higher ineomef’^i^ Inereased health insuranee would 

reduee bankrupteies related to health events. Hadley finds that improving health status 

from “fair or poor to very good or exeellent” would inerease both work effort and annual 

218 

earnings by approximately 15 pereent to 20 pereent. 

The initial implementation of the AC A at the beginning of 2014 left everyone 
eonfused about how it would affeet individuals finaneially. Patterns were not 
immediately apparent. Some individuals and families purehasing insurance on the 
exehanges experieneed signifieant inereases over what they were paying before, while 
others were relieved to find they would save money. Further adjustments will oecur in 
late 2014 when insurance companies set their rates for 2015. It will be some time before 
patterns emerge and rates stabilize. 

Two Brookings Institute researehers reeently eondueted an in-depth study on how 
the ACA might affeet ineome distribution aeross ineome elasses by the year 2016. 
Although ineome redistribution was not one of the stated goals of the health eare law, the 
researchers found that “the ACA may do more to change the income distribution than any 
other reeently enaeted law.”2i9 They estimate that the ACA will boost the net ineomes of 
the poorest 20 pereent of U.S. residents by about six pereent, and the net ineome of the 
bottom 10 percent by seven percent. Net ineome will fall slightly (less than one pereent) 
aeross other ineome elasses.^20 The authors of this partieular study point out the myriad 
of limitations in their own study, due to the ACA’s length and eomplexity. Only time will 
tell the true finaneial impaet of ACA implementation. 


212 Hadley, “Sicker and Poorer,” 60S. 

218 Ibid., 3S. 

219 Henry J. Aaron and Gary Burtless, Potential Effects of the Affordable Care Act on Income Equality 
(Washington, DC: Brookings Institute, 2014): 1. 

220 Ibid., 1-44. 


69 



E. SUMMARY 


Expanding health insurance coverage, controlling health care costs, and 
improving the quality of health care are primary goals of the ACA. According to the 
studies researched here, this will likely have positive ripple effects for homeland security 
in dealing with emerging disease, bioterror, flu pandemic, mental illnesses, and economic 
security. 


70 



VI. WHERE DO WE GO EROM HERE? 


As outlined to this point, the Affordable Care Aet has signifieant potential to 
bolster the homeland security goal of all-hazards preparedness. The ACA will not, by 
itself, fully protect the U.S. population from all biological threats, emerging diseases, or 
food and water-borne illnesses. Health insurance and expanded health care access do not 
provide a magical shield from such dangers. However, the ACA is an important step 
toward improved access to affordable health care for eligible U.S. residents and is a 
foundational improvement for homeland security all-hazards preparedness. 

A. RECOMMENDATIONS AND POLICY ADJUSTMENTS 

As currently written, the ACA contains some clear gaps that could be addressed 
through policy adjustments. Through these policy changes, the positive influence on 
homeland security could be further enhanced from both the health and economic 
perspectives. Here are several recommendations aimed at increasing the ACA’s positive 
impact on homeland security preparedness: 

• Allow illegal immigrants to purchase health insurance on the Exchanges 

• Treat legal immigrants as equal to U.S. residents in regards to ACA 

mandates and benefits 

• Educate the public on the true tax penalty for those who do not purchase 
health insurance 

• Correct the inequity of Medicaid preventive coverage for new 

beneficiaries vs. existing beneficiaries 

• Design and implement grant programs to encourage greater state 

participation in efforts to expand health insurance coverage 

B. EXTEND ACA BENEFITS TO IMMIGRANTS 

One of the most notable gaps in the Affordable Care Act is its failure to cover the 
immigrant population. Over 11 million illegal immigrants are not eligible for any of the 
ACA benefits, and they are specifically prohibited from purchasing health insurance on 
the exchanges. Even legal immigrants must establish residency for five years before 
gaining eligibility for ACA benefits. According to Shane Green, communities without 

71 



access to care “are more vulnerable to infeetious diseases and therefore might be 
eonsidered the nation’s Aehilles’ heel in a bioterrorism attaok.”22i The same is true for 
any infeetious disease, regardless of souree. 

A speeifie example is the outbreak of rubella that oeeurred in a primarily 
immigrant eommunity in Westchester County, New York, in 1997. Rubella, also known 
as the German measles or the three-day measles, is eommon ehildhood disease eaused by 
the rubella virus. The disease is eharaeterized by a red bumps in the form of a rash on the 
face, trunk, and limbs, and it is usually mild, resolving within three days. However, in 
some eases severe—even fatal—eomplieations ean oeeur. The biggest eoncem with 
rubella is with pregnant women. If a pregnant mother eontraets rubella during the first 20 
weeks of pregnaney, the virus ean eause congenital rubella syndrome (CRS) in the fetus, 
and the pregnancy ends in misearriage 20 pereent of the time .222 Infants surviving the 
CRS often suffer a variety of birth defeets and problems and eontinue to harbor the virus, 
whieh endangers other newborns and pregnant mothers with further contagion. 223 
Rubella vaeeines were developed in 1969. They are currently administered in the United 
States as part of the measles/mumps/rubella (MMR) series, and overall have proven quite 
sueeessful. 

In 1997, however, a rubella outbreak oeeurred in a elose-knit, immigrant 
eommunity in New York. Between Deeember of 1997 and May of 1998, 95 oases of 
rubella were reported in Westchester County, primarily to foreign-born Hispanios (63 
peroent)224 from oountries where rubella vaooination programs either did not exist or 
were newly implemented. Foreign-born viotims (88) had no history of inooulation, and 
hailed from Guatemala, Colombia, Mexioo, Eouador, and Portugal. The seven U.S. bom 
viotims also had no history of vaccination. 


22lGreen, “Bioterrorism and Health Care Reform: No Preparedness without Access,” 2. 

222 Wikipedia, s.v. “Rubella,” March 28, 2014, 
http://en.wikipedia. 0 rg/wiki/Rubella#Signs_and_symptoms 

223 “Rubella Outbreak—Westchester, New York, 1997-1998, Morbidity and Mortality Weekly Report 
48, no 26(1999): 560, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4826a2.htm 

224 Ibid. 


72 



Alarmed, local health authorities ramped up vaccination education and efforts. 
Health officials identified leaders in the Hispanic communities and developed 
partnerships to educate the population. Public education materials were published in 
Spanish and English, and vaccines were distributed at work sites throughout the county. 
By May of 1998, more than 4,500 rubella vaccinations were distributed, and the last 
confirmed case of rubella in that community was reported in May of 1998.225 

This outbreak in an immigrant community provides a case study for why it makes 
more sense from a homeland security perspective to extend ACA eligibility (and 
therefore access to recommended vaccines) to all U.S. residents, regardless of 
immigration status. A vulnerable population can serve as an unnecessary reservoir of 
otherwise preventable disease. Disease does not check immigration status—vulnerability 
to disease within the illegal immigrant population increases the risk of disease for 
everyone. In addition, the effectiveness of the health surveillance system is diminished 
when 11 million illegal immigrants have less access to health care, as outlined in Chapter 
III. 

Allowing illegal immigrants to purchase plans on the exchanges makes sense for 
the entire U.S. population. It would do several things: further spread the financial risk 
inherent in the insurance industry; increase access to vaccination and preventive care; and 
give the U.S. a better chance of spotting emerging disease, bioterror attacks, or food and 
water-safety issues at an earlier stage. All of these benefits could be realized at little cost 
to the government or taxpayer, since illegal immigrants would not be eligible for the 
expanded Medicaid programs, nor the tax credits available to U.S. citizens. 

The U.S. Congress should consider expanding all ACA mandates and benefits to 
all legal U.S. residents, rather than requiring residency for five years, as this would 
enhance homeland security from both the health and economic perspective in the same 
ways outlined above. In addition, from an ethical standpoint, someone who is in the U.S. 
legally should be extended the same rights and protections as U.S. citizens, as they are in 
other areas of law, such as in criminal law. 


225 Ibid. 


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A state senator in California is eurrently attempting to extend some ACA benefits 
to illegal immigrants at the state level. California State Senator Rieardo Lara of Bell 
Gardens is carrying Senate Bill 1005, which would provide two avenues for 
undocumented immigrants to obtain health insurance. First, the bill would expand Medi- 
Cal (California’s Medicaid program) eligibility to undocumented immigrants and allow 
those earning less than 138 percent of the federal poverty level to apply. Second, the bill 
would create a separate exchange program where undocumented immigrants who earn 
more than 138 percent of the FPL could purchase insurance plans. ^26 Senator Lara’s team 
has not yet provided cost estimates for the bill, but it is currently being reviewed in 
committee. 

C. EDUCATE THE PUBLIC ON THE TRUE TAX PENALTY 

Another recommendation for enhancing the positive homeland security 
implications for the ACA is to develop a nationwide program that is aimed at educating 
the public regarding the tax penalty assessment for those that do not obtain health 
insurance. 

The commonly-held wisdom regarding the penalty is that in 2014, the penalty for 
failing to carry health insurance is a $95 flat fee, rising to $325 in 2015, $695 in 2016, 
and adjusted for inflation after that.227 xhis fiat fee seems like a cheap alternative to some 
healthy people, many of whom have decided to forego health insurance and pay the 
penalty. What they are learning now is that the penalty is actually the greater of either 
$95 or one percent of the yearly household income. Only the amount of income above the 
tax filing threshold ($10,150 for an individual) is used to calculate the penalty. The 
maximum penalty is the national average yearly premium for a bronze plan. 

To calculate the tax penalty for 2014, a single adult with a household income 
below $19,650 would pay the $95 flat rate and $47.50 for each uninsured child under 18, 


226 Laurel Rosenhall, “More Could Get Care,” San Jose Mercury News, sec. Local, February 16, 2014. 

227 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). 


74 



up to a maximum of $ 285,228 A single adult with a household income above $19,650 
would pay an amount based on the one percent rate, capped at the national average of the 
bronze plan. If household income is below $10,150, then no penalty is owed. Higher 
household income requires that the calculation be done using the one percent rate, which 
potentially increases the penalty as high as $ 4500-$5 0 00229 —depending on the national 
average yearly premium for a bronze plan. In 2015, the flat fee penalty will increase to 
$325 per person or two percent of income for higher earners. In 2016 and later years the 
flat fee penalty will be $695 per person or two-and-a-half percent of income. After that, it 
will be adjusted for inflation. 

The take-home lesson is that for higher income earners, the tax penalties will be 
substantially higher than the flat fees being advertised. Educating the public on the true 
potential tax penalties might incentivize choosing health insurance over penalties. 

D. ADDRESS MEDICAID PREVENTIVE COVERAGE INEQUITY 

As noted in Chapter V, § 1001 of the AC A mandates that new and existing private 
individual health insurance plans, new and existing small-group insurance plans, and 
Medicare cover all “A” and “B”-rated preventive recommendations without cost-sharing. 
In contrast, the rules for Medicaid are different. States that choose to expand Medicaid do 
not have to cover existing beneficiaries for these same preventive services. States are only 
required to extend the no-cost sharing coverage to new Medicaid beneficiaries. 

The fact that some states have chosen not to expand such no-cost benefits to 
current Medicaid beneficiaries is not only a gap in the homeland security puzzle, but also 
a needless imbalance and ethical dilemma—why should newly eligible Medicaid patients 
receive better benefits than current patients? Future legislative adjustments to the ACA 
should eliminate this disparity by requiring states that expand Medicaid to provide no- 
cost sharing preventive care to both current and new beneficiaries. 

228 “yjje Fee You Pay if You Don’t Have Health Coverage,” U.S. Centers for Medicare and Medicaid 
Services, accessed March 28, 2014, https://www.heahhcare.gov/what-if-someone-doesnt-have-heahh- 
coverage-in-2014/ 

229 “xiie Lowdown on the Health Insurance Penalty,” November 22, 2013, Kip linger, 
http://m.kiplinger.com/article/insurance/T027-C001-S003-the-lowdown-on-the-heahh-insurance- 
penahy.html 


75 



E. PROVIDE FINANCIAL INCENTIVES TO ENCOURAGE STATE 

PARTICIPATION IN ACA 

One of the primary goals of the ACA is to expand health insuranee eoverage. As 
has been shown in this thesis, expanding health insurance coverage confers significant 
gains to the homeland security preparedness efforts. Achieving these gains is tied to the 
expansion of health insurance coverage but not necessarily to the ACA as the vehicle. If 
health insurance coverage gains are achieved through other means, this would also confer 
benefits on homeland security preparedness. 

Since the Supreme Court offered its split decision in 2012 that supported the 
individual mandate but struck down penalties designed to force Medicaid expansion, only 
16 states plus Washington, DC, have chosen to open their own exchanges, and 26 states 
plus Washington, DC, have chosen to expand Medicaid.230 Many of the states that have 
declined to run an exchange or expand Medicaid have the highest per capita uninsured 
populations in the country, as well as low health ratings. Texas, New Mexico, 
Mississippi, Louisiana, and Nevada have the top-five highest rates of uninsurance in the 
country.231 The Commonwealth Fund Scorecard ranked Texas, Mississippi, Nevada and 
Louisiana in the bottom quartile of states in regards to health care quality, access, cost 
and outcomes in a 2014 report, and New Mexico in the third-lowest quartile.232 Texas, 
Louisiana and Mississippi have declined to either run an exchange or expand 
Medicaid.233 Without delving too deeply into the politics of this situation, these states are 
also highly Republican with little political appetite for implementing the ACA. 

The federal government should consider developing other means to motivate 
these states in particular to expand health insurance. One idea is to tie grant money to 


230 latest information on the state-participation count with a daily update can be found 
here:http://www.advisory.com/daily-briefing/resources/primers/medicaidmap, accessed March 18, 2014. 

231 Gallup Well Being, “Uninsured: Highest Percentage in Texas, Lowest in Mass.” August 19, 2009, 
http://www.gallup.com/poll/122387/uninsured-highest-percentage-texas-lowest-mass.aspx 

232 “Common Wealth Fund Ranks States’ Health, Finding Big Differences,” The Daily Briefing, May 
2, 2014, http://www.advisory.eom/Daily-Briefing/2014/05/02/Commonwealth-Fund-ranks-states-health- 
fmding-big-differences 

233 “Health Insurance Marketplaces,” Common Wealth Fund, accessed July 30, 2014, 
http://www.commonwealthfund.org/Maps-and-Data/State-Exchange-Map.aspx^ 


76 



health insurance coverage. For example, the Health and Human Services Department 
could offer grants to states that either increase their insured population by a certain 
percentage or to reach a certain threshold. This tactic would remove the political 
connotations associated with the ACA. States would be free to develop their own 
programs for increasing health insurance coverage in a manner acceptable for that 
political climate. 

Another idea is to develop a homeland security media campaign aimed at helping 
the general public make the connection between health and homeland security. For 
example, Health and Human Services could develop commercials with messages such as, 
“Do your part to protect America: get vaccinated!” or, “Anyone can help fight terrorism. 
It starts with you: get health insurance and get healthy.” Such messages might help 
Americans better understand the links between health care, health insurance and security, 
and move us beyond the political rhetoric associated with the ACA. 

F. AREAS FOR FURTHER RESEARCH 

The research conducted here was focused only on the potentially positive effects 
of the ACA on homeland security preparedness. To be sure, there are many potentially 
negative effects as well. One important example is the possibility that increased 
government spending on health care will reduce the amount of funding available for 
homeland security. There is also a chance that by expanding health care to a larger 
population that we will actually decrease the overall quality of our health. Increased 
health care accessibility could lead to overloaded health care facilities, increased wait 
times, and lower quality care. Increased health care cost controls through the ACA could 
lower the financial incentive for people to go into the health care fields, which would 
again negatively affect our health care and therefore our homeland security preparedness. 
All of these arguments remain unresolved and deserving of future research. 

G. SUMMARY 

As Shane Green notes in his article, “Bioterrorism and Health Care Reform: No 
Preparedness Without Access,” 


77 



With the U.S. presently engaged in a ‘war on terror,’ in whieh not only 
soldiers but also civilians are targets, a healthy fighting force is no longer 
enough to ensure national security; the time has come for this country to 
take up reforms that promote the health of all Americans. 

The perspective on health care must change so it becomes viewed as part and parcel of 
homeland security preparedness by the civilian community and the government. 

Health care and homeland security are inextricably linked. Investment in health 
care confers benefits upon U.S. homeland security all-hazards preparedness because 
increased health insurance coverage through the ACA equals increased access to health 
care, which equals improved health. This in turn equals improved homeland security 
preparedness and a more resilient population. The Affordable Care Act is already 
considered the largest health care reform in America in one-hundred years, and only time 
will tell if it is a game-changer for homeland security preparedness as well. But if the 
Affordable Care Act does deliver even in part on its promise to improve access to health 
care, then homeland security all-hazards preparedness is likely to improve in kind. The 
health of homeland security depends on the health of our population: the ACA promises 
to improve both. 


234 Green, “Bioterrorism and Health Care Reform: No Preparedness without Access,” 1; Fenn, Pox 
Americana, 1. 


78 



LIST OF REFERENCES 


Aaron, Henry J. and Gary Burtless. Potential Effects of the Affordable Care Act on 
Income Equality. Washington, DC: Brookings Institute, 2014. 

Assoeiation of State and Territorial Health Offieials. Increase in Vaccine Administration 
Rates: Summary of State Stakeholder Meetings. 2012. 
http ://www. astho. org/Programs/Immunization/Increase-in-V accine- 
Admini stration-Rates 

Biasotti, Miehael C. “Management of the Severely Mentally Ill and its Effects on 
Homeland Security.” Master’s thesis. Naval Postgraduate School, 2011. 

Blumenthal, David, Kristof Stremikis, and David Cutler. “Health Care Spending—A 
Giant Slain or Sleeping?” The New England Journal of Medicine 369, no. 26 
(2013): 2551-2557. http://www.nejm.org/doi/pdf/10.1056/NEJMhprl310415 

Bobbitt, Philip C. Brief for Professor Philip C. Bobbitt as Amicus Curiae in Support of 
Petitioners with Respect to the Individual Mandate (No. 11-396). 2012. 
http://www.yale.edu/lawweb/jbalkin/fdes/Philip_Bobbitt_Healthcare_Briefpdf 

Bovsun, Mara. “750 Sickened in Oregon Restaurants as Cult Known as the Rajneeshees 
Spread Salmonella in Town of the Dalles.” New York Daily News, sec. News. 

June 15, 2013. http://www.nydailynews.com/news/justice-story/guru-poison- 
bioterrorrists-spread-salmonella-oregon-article-1.1373864#commentpostform 

Brill, Steven. “Bitter Pill: Why Medical Bills are Killing Us,” Time, March 4, 2013. 

http://www.uta.edu/faculty/story/23 ll/Misc/2013,2,26,MedicalCostsDemandAnd 
Greed.pdf 

Butler, Adrienne S., Allison M. Panzer and Eewis R. Goldfrank. “Developing Strategies 
for Minimizing the Psychological Consequences of Terrorism through Prevention, 
Intervention, and Health Promotion.” In Preparing for the Psychological 
Consequences of Terrorism: A Public Health Strategy, National Research Council 
(99-134). Washington, DC: The National Academies Press, 2003. 

Canadian Institute for Health Information. Exploring the 70/30 Split: How Canada’s 

Health Care System is Einanced. Ottawa, Canada: Canadian Institute for Health 
Information, 2005. https://secure.cihi.ca/free_products/PundRep_EN.pdf 

Cameron, Gavin. “Multi-Track Microproliferation: Lessons from Aum Shinrikyo and A1 
Qaida.” Studies in Conflict and Terrorism 22, no. 4 (1999): 277-309. 

CBC News. “Public vs. Private Health Care.” December 1, 2006. 

http://www.cbc.ca/news2/background/healthcare/public_vs_private.html 


79 



Centers for Disease Control and Prevention. Smallpox Response Plan and Guidelines. 
Atlanta, GA; Centers for Disease Control and Prevention, 2002. 

Chen, Guang-Wu, Shih-Cheng Chang, Chee-Keng Mok, Yu-Luan Lo, Yu-Nong Kung, 
Ji-Hung Huang, Yun-Han Shih, Ji-Yi Wang, Chiayn Chiang, Chi-Jene Chen, and 
Shin-Ru Shih. “Genomic Signatures of Human versus Avian Influenza A 
WimsQS.'" Emerging Infectious Diseases 12, no. 9 (September 2006): 1353-1360. 
doi: 10.3201/eidl209.060276 

“Children’s Health Insurance Program Financing.” Centers for Medicare and Medicaid 
Services. Accessed July 16, 2014. http://www.medicaid.gov/Medicaid-CHIP- 
Program-Information/By-Topics/Financing-and-Reimbursement/Childrens- 
Health-Insurance-Program-Financing.html 

Chyba, Christopher F. and Alex L. Greninger. “Biotechnology and Bioterrorism: An 
Unprecedented World.” Survival 46, no. 2 (2004): 143-162. 

Cohen, Robin A. and Barbara Bloom. Access to and Utilization ofMedical Care for 

Young Adults Aged 20-29 Years: United States, 2008 (NHCS Data Brief no. 9). 
Atlanta: GA, Centers for Disease Control and Prevention, 2010. 
http ://www. cdc .gov/nchs/data/ databriefs/db29 .PDF 

Congressional Budget Office. Estimates for the Insurance Coverage Provisions of the 
Affordable Care Act Updated for the Recent Supreme Court Decision. 
Washington, DC: Congressional Budget Office, 2012. 

Congressional Budget Office. The Veterans Health Administration’s Treatment of PTSD 
and Traumatic Brain Injury among Recent Combat Veterans. Washington, DC: 
Congressional Budget Office, 2012. 

The Daily Briefing. “Common Wealth Fund Ranks States’ Health, Finding Big 
Differences.” May 2, 2014. http://www.advisory.com/Daily- 
Brieling/2014/05/02/Commonwealth-Fund-ranks-states-health-finding-big- 
differences 

The Daily Briefing. “Where the States Stand on Medicaid Expansion.” May 28, 2014. 
http://www.advisory.com/daily-briefmg/resources/primers/medicaidmap 

DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith. Income, Poverty, 
and Health Insurance Coverage in the United States: 2011. Washington, DC: 
U.S. Government Printing Office, 2012. 
http://www.census.gOv/prod/2012pubs/p60-243.pdf 

Federal Emergency Management Agency. The Response to the 2011 Joplin, Missouri, 
Tornado Lessons Learned Study. Washington, DC: Eederal Emergency 
Management Agency, 2011. 


80 



Fenn, Elizabeth A. Pox Americana: The Great Smallpox Epidemic of1775-82. New 
York: Hill and Wang, 2001. 

Food and Drug Administration. “Voluntary National Retail Food Regulatory Program 
Standards.” Fl.S. Department of Health and Human Services. January, 2013. 
hhp ://www. fda.gov/downloads/food/guidanceregulation/retailfoodprotection/prog 
ramstandards/ucm372411 .pdf 

Gindi, Renee M. Emergency Room Use among Adults Aged 18-64: Early Release of 
Estimates from the National Health Interview Survey, January-June 2011. 

Centers for Disease Control and Prevention. May 2012. 

www.cdc. gov/nchs/data/ nhis/earlyrelease/emergency_room_use j anuary- 

june_2011.pdf 

Gladwell, Malcolm. “Talk of the Town.” The New Yorker. October 29, 2001. 

Green, Shane K. “Bioterrorism and Health Care Reform: No Preparedness without 
Access.” Virtual Mentor 6, no. 5 (May 2004): 1-3. http://virtualmentor.ama- 
assn.org/2004/05/pfor2-0405.html 

Hadley, Jack. “Sicker and Poorer—The Consequences of being Uninsured: A Review of 
the Research on the Relationship between Health Insurance, Medical Care Use, 
Health, Work, and Income.” Supplemental issue. Medical Care Research and 
Reviewed, no. 2 (2003): 3S-75S. doi: 10.1177/1077558703254101. 

Hadley, Jack, John Holahan, Teresa Coughlin, and Dawn Miller. “Covering the 

Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs.” 
Health Affairs 27 (2008): 399-415. 

Health Canada. Highlights from the Canadian Pandemic Influenza Plan for the Health 
Sector. 2006. http://www.phac-aspc.gc.ca/cpip-pclcpi/hl-ps/pdf/CPIP-highlights- 
2006_e.pdf 

Himmelstein, David U., Deborah Thorne, Elizabeth Warren, and Steffie Woolhandler. 
“Medical Bankruptcy in the United States, 2007: Results of a National Study.” 
The American Journal of Medicine 122, no. 8 (2009).741-746. 

Health Care Cost Institute. Health Care Cost and Utilization Report: 2010. Health Care 
Cost Institute. 2012. www.heahhcostmsthute.org/liles/HCCI_HCCUR2010.pdf 

Hoffman, Catherine and Julia Paradise. “Health Insurance and Access to Health Care in 
the United States.” Annals of the New York Academy of Sciences 1136 (June, 
2008): 149-160. http://onlmelibrary.wiley.eom/doi/10.l 196/annals. 1425.007/pdf 


81 



Institute of Medicine of the National Academies. Uninsurance Facts and Figures: 

Uninsurance Costs the Country More than You Think. Washington, DC: National 
Academies Press, 2004. 

http://www.iom.edu/~/media/Files/Report%20Files/2004/Insuring-Americas- 

Health-Principles-and-Recommendations/FactsheetSociety2.pdf 

Jarrett, Valarie. “We’re Listening to Businesses about the Health Care Law.” The White 
House Blog. July 2, 2013. http://www.whitehouse.gov/blog/2013/07/02/we-re- 
listening-businesses-about-health-care-law 

Kaiser Family Foundation and Health Research and Educational Trust. Employer Health 
Benefits: Annual Survey 2008. Menlo Park, CA: Henry J. Kaiser Family 
Foundation, 2008. 

http ://kaiserfamilyfoundation. fdes .wordpress. com/2013/04/7790.pdf 

Kaji, Amy H., Kristi L. Koenig, and Roger J. Lewis. “Current Hospital Disaster 

Preparedness.” Journal of the American Medical Association 298, no. 18 (2007): 
2188-2190. 

Kansas Health Institute. ACA Medicaid Expansion: Enrollment and Cost Estimates for 
Kansas Policymakers. Topeka, KA: Kansas Health Institute, 2012. http://m.kha- 
net.org/criticalissues/kancareexpansion/kancareexpansionresources/kl01289.aspx 

Katz, Deborah. “Injury Toll from Marathon Bombs Reduced to 264.” The Boston Globe, 
sec. Health & Wellness. April 24, 2013. 

http://www.bostonglobe.eom/lifestyle/health-wellness/2013/04/23/number- 

injured-marathon-bombing-revised- 

downward/NRpaz5mmvGquP7KMA6XsIK/story.html 

Kenney, Genevieve M., Stacey McMorrow, Stephen Zuckerman, and Dana E. Goin, “A 
Decade of Health Care Access Declines for Adults Holds Implications for 
Changes in the Affordable Care Act,” Health Affairs 31, no. 5 (2012): 899-908. 

Kessler, Ronald C., Patricia A. Berglund, Martha E. Bruce, J. Randy Koch, Eugene M. 
Easka, Philip J. Eeaf, Ronald W. Mandersheid, Robert A. Rosenheck, Ellen E. 
Walters, and Philip S. Wang. “The Prevalence and Correlates of Untreated 
Serious Mental Illness.” Health Services Research 36 (December 2001): 996- 
1007. 

http://www.ncbi.nlm.nih.gOv/pmc/articles/PMC1089274/pdf/hsresearch00007- 

0020 .pdf 

Klein, Ezra. “11 Eacts about the Affordable Care Act.” The Washington Post. June 24, 
2012. http://www.washingtonpost.eom/blogs/wonkblog/wp/2012/06/24/ll-facts- 
about-the-affordable-care-act/ 

Konisberg, Ruth Davis. “9/11 Psychology: Just How Resilient Were We?” Time, Sept. 8, 

2011 . 


82 



Kwong, Jeffrey C., Therese A. Stukel, Jenny Lim, Allison J. MeGeer, Ross EG Upshur, 
Helen Johansen, Christie Sambell, William W. Thompson, Deva Thiruchelvam, 
and Fawziah Marra. “The Effeet of Universal Influenza Immunization on 
Mortality and Health Care Use.” PLoSMedicine 5, no. 10 (2008): 1-13. 

Eurie, Nicole, Nancy B. Ward, Martin E. Shapiro, Claudio Gallego, Rati Vaghaiwalla, 
and Robert H. Brook. “Termination from Medi-Cal: One Year Eater.” New 
England Journal of Medicine MA, no. 19 (1986): 1266-1268. 

Mariotto, Angela B., K. Robin Yabroff, Yongwu Shao, Eric J. Eeuer and Martin E. 

Brown. “Projections of the Cost of Cancer Care in the U.S.: 2010-2020.” Jowma/ 
of the National Cancer Institute 103, no. 2 (2011): 117-128. 
doi:10.1093/jnci/djq495 

McNeil, Jr., Donald G. “Wary of Attack with Smallpox, U.S. Buys up a Costly Drug.” 
The New York Times, sec. Health. March 12, 2013. 

http://www.nytimes.eom/2013/03/13/health/us-stockpiles-smallpox-drug-in-case- 

of-bioterror-attack.html?pagewanted=all 

Mechanic, David and David A. Rochefort. “Deinstitutionalization: An Appraisal of 
RelormT Annual Review of Sociology 16 (1990): 301-327. 

Mokdad, Ali H., George A. Mensah, Samuel E. Posner, Eddie Reed, Eduardo J. Simoes, 
and M. M. Engel. “When Chronic Conditions Become Acute: Prevention and 
Control of Chronic Diseases and Adverse Health Outcomes during Natural 
Disasters.” Prevention of Chronic Diseases 2, no. Supplemental 1 (2005): 1-4. 

Morrissey, Taryn. The Affordable Care Act’s Public Health Workforce Provisions: 
Opportunities and Challenges. Washington, DC: American Public Health 
Association, 2011. 

National Alliance on Mental Illness. Mental Illness: Treatment Saves Money and Makes 
Sense. 2007. 

http://www.nami.org/Template.cfm?Section=Policy&Template=/ContentManage 
ment/ContentDisplay.cfm&ContentID=44613 

National Department of Engineering, National Research Council, and Department of 
Homeland Security. Biological Attack: Human Pathogens, Biotoxins and 
Agricultural Threats. Washington, DC: National Academy of Sciences, 2004. 
http://www.dhs.gov/xlibrary/assets/prep_biological_fact_sheet.pdf 

O’Boyle, Irene, James A. Johnson, Michelle Simms, and Robert Metzroth. “Terrorism 
and Emergent Challenges in Public Health. Journal of Health Human Service 
Administration 30, no. 4 (2008): 529-548. 


83 



Organisation for Economic Co-operation and Development. OECD Health Data 2013: 
How Does the United States Compare? Paris, France: Organisation for Eeonomie 
Co-operation and Development, 2013. 

Peterson, Susan “Epidemic Disease and National Security.” Security Studies 12, no. 2 
(2002): 45. 43-81. 

Porter, Wayne and Mark Mykleby. A National Strategic Narrative. Washington, DC: 
Woodrow Wilson Center, 2011. 

Preussner, Jesse. “Examination of FEMA and the Relationship with a Community after a 
Disaster” Master’s thesis, Kansas State University, 2012. 

Price, Carter C. and Christine Eibner. “For States that Opt Out of Medieaid Expansion: 

3.6 Million Fewer Insured and $8.4 Billion Less in Federal Payments.” Health 
Affairs 32, no. 6 (2013): 1030-1036. 

Ringel, Jeanne S., Federico Girosi, Amado Cordova, Carter C. Priee, and Elizabeth A. 

McGlynn. Analysis of the Patient Protection and Affordable Care Act (HR 3590). 
Santa Monica, CA: Rand, 2010. 

http://www.rand.org/content/dam/rand/pubs/research_briefs/2010/RAND_RB951 
4.pdf 

Rodriguez, Jamie. How Legal Aid of Western Missouri Is Helping the Community 

Recover from the Joplin Tornado. Chieago, IE: Sargent Shriver National Center 
on Poverty Law, 2012. http://povertylaw.org/eommunieation/advoeacy- 
stories/rodriguez 

Rosenau, William. “Aum Shinrikyo’s Biological Weapons Program: Why Did It Fail?” 
Studies in Conflict and Terrorism 24, no. 4 (2001): 289-301. 

Rosenhall, Laurel. “More Could Get Care.” San Jose Mercury News, see. Local. February 
16, 2014. 

“Rubella Outbreak—Westchester, New York, 1997-1998. Morbidity and Mortality 
Weekly Report 48, no 26 (1999): 560-563. 
http://www.odc.gov/mmwr/preview/mmwrhtml/mm4826a2.htm 

Sanohez, Anthony, Thomas G. Ksiazek, Pierre E. Rollin, Clarence J. Peters, Stuart T. 
Niohol, Ah S. Khan, and Brian W. J. Mahy. “Reemergence of Ebola Virus in 
MvicsLC Emerging Infectious Diseases 1, no. 3 (July, 1995): 96. doi: 
10.3201/eid0103.950307. 

Schiller, Jeannine S., Jaoqueline W. Lucas, Brian W. Ward, and Jennifer A. Peregoy, 
Summary Health Statistics for U.S. Adults: National Health Interview Survey. 
Center for Disease Control. 2010. 
http ://www. ode .gov/nchs/data/ series/ sr_l 0/sr 10_252.pdf 


84 



Schoen, Cathy, Sara R. Collins, Jennifer L. Kriss, and Miehelle Doty. “How Many are 

Underinsured? Trends among U.S. Adults, 2003 and 2007.” Health Affairs 27, no. 
4 (2008): 298-309. doi:10.1377/hlthaff.27.4.w298 

Slevin, Colleen and Kristen Wyatt. “Medieal Bills Loom in Colorado.” San Jose Mercury 
News, sec. Local, June 27, 2012. 

Silver, Roxane Cohen E. Alison Holman, Daniel N. McIntosh, Michael Poulin, and 

Virginia Gil-Rivas. “Nationwide Longitudinal Study of Psychological Responses 
to September 11.” Journal of the American Medical Association 288, no. 10 
(2002): 1235-1244. 

http ://mysite.du.edu/~dmcmtos/PDF/Silver%20et%20al.%20Responses%20to%2 
09-1 l,%20JAMA,%202002.pdf 

Social Security Advisory Board. The Unsustainable Cost of Health Care. 2009. 

http://www.ssab.gov/documents/TheUnsustamableCostofHealthCare_508.pdf 

Sommers, Benjamin D., Thomas Buchmueller, Sandra L. Decker, Colleen Carey, and 
Richard Kronick. “The Affordable Care Act has Led to Significant Gains in 
Health Insurance and Access to Care for Young Adults” Health Affairs 32, no. 1 
(2013): 165-174. 

Standing Senate Committee on Social Affairs, Science and Technology. Canada’s 

Response to the 2009 HINI Influenza Pandemic. Ottawa: Canadian Senate, 2010. 
http://www.parl.gc.ca/content/sen/committee/403/soci/rep/repl5decl0-e.pdf 

Starr, Paul. Remedy and Reaction: The Peculiar American Struggle over Health Care 
Reform. New Haven, CT: Yale University Press, 2011. 

Stolberg, Sheryl Gay and Robert Pear. “Obama Signs Health Care Overhaul Bill, with a 
Flourish.” New York Times, sec. Money & Policy. March 23, 2010. 
http://www.nytimes.eom/2010/03/24/health/policy/24health.html 

Tamkins, Theresa. “Medical Bills Prompt More than 60 Percent of U.S. Bankruptcies.” 
CNN. June 5, 2009. 

http://www.cnn.eom/2009/HEAFTH/06/05/bankruptcy.medical.bills/ 

Trotter, Griffen. “Emergency Medicine, Terrorism and Universal Access to Healthcare: 

A Potent Mixture for Erstwhile Knights-Errant.” In In the Wake of Terror: 
Medicine and Morality in a Time of Crisis, edited by Jonathan D. Moreno (143- 
166). Cambridge, MA: MIT Press, 2003. 

U.S. Department of Health & Human Services, 2009 HINI Influenza Improvement Plan. 
Washington, DC: The White House, 2012. 


85 



U.S. Department of Health & Human Services. “What is a Medical Surge?” Medical 
Surge Capacity Handbook. Washington, DC: U.S. Department of Health & 
Human Services, 2014. 

hhp://www.phe.gov/Preparedness/planning/mscc/handbook/chapterl/Pages/whati 
smedicalsur ge. aspx 

U.S. Department of Homeland Security. Pandemic Influenza Preparedness, Response, 
and Recovery Guide for Critical Infrastructure and Key Resources. Washington, 
DC: The White House, 2006. 

U.S. Department of Homeland Security. Quadrennial Homeland Security Review Report. 
Washington, DC: U.S. Department of Homeland Security, 2010. 

U.S. Government Accountability Office. The Federal Government’s Long-Term Fiscal 
Outlook: Fall 2012 Update (GAO-13-148SP). Washington, DC: U.S. 

Government Accountability Office, 2012. 

U.S. Government Accountability Office. Medicaid Expansion: States ’ Implementation of 
the Patient Protection and Affordable Care Act (GAO-12-821). Washington, DC: 
U.S. Government Accountability Office, 2012. 

Vicini, James and Jonathon Stempel. “U.S. Top Court Upholds Health Care Law in 
Obama Triumph.” Reuters, sec. Wrap Up. June 28, 2012. 
hhp://www.reuters.com/article/2012/06/28/usa-heahhcare-court- 
idUSL2E8HS4WG20120628 

Wamala, Joseph F., Luswa Lukwago, Mugagga Malimbo, Patrick Nguku, Zabulon Yoti, 
Monica Musenero, William Mbabazi et al. “Ebola Hemorrhagic Fever Associated 
with Novel Virus Strain, Uganda, 2007-2008.” Emerging Infectious Disease 16, 
no. 7 (July 2010): 1087-1092. http://wwwnc.cid.gOv/eid/article/16/7/09-1525.htm 

Webby, Richard J. and Robert G. Webster. “Are We Ready for Pandemic Influenza?” 
Science 302, no. 5650 (2003): 1519-1522. 

Welch, Edward. “Preventing School Shootings: A Public Health Approach to Gun 
Violence.” Master’s thesis. Naval Postgraduate School, 2013. 

Wilensky, Sara E. and Elizabeth A. Gray, “Existing Medicaid Beneficiaries Left Off the 
Affordable Care Act’s Preventation Bandwagon,” Health Affairs 32, no. 7 (July, 
2013): 1188-1195. 

Wilper, Andrew P., Steffie Woolhandler, Karen E. Easser, Danny McCormick, David H. 
Bor, and David U. Himmelstein. “Health Insurance and Mortality in U.S. Adults.” 
American Journal of Public Health 99, no. 12 (2009): 2289-2295. 


86 



Wynia, Matthew K. and Lawrence O. Gostin. “Ethical Challenges in Preparing for 

Bioterrorism: Barriers within the Health Care System. Journal Information 94, 
no. 7(2004): 1096-1102. 


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