THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR
HOMELAND SECURITY PREPAREDNESS?
Kimberly Ann Petersen
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THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR HOMELAND
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Naval Postgraduate School
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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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Approved for public release; distribution is unlimited
THE AFFORDABLE CARE ACT: A PRESCRIPTION FOR HOMELAND
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)
NAVAL POSTGRADUATE SCHOOL
Author: Kimberly Ann Petersen
Approved by: Christopher Bellavita
Alexander Garza, St. Louis University
Chair, Department of National Security Affairs
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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.
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TABLE OF CONTENTS
A. PROBLEM SPACE.I
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
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
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
IV. WHAT IS THE PATIENT PROTECTION AND AFFORDABLE CARE
A. SHARED RESPONSIBILITY.43
B. EXPANSION OF MEDICAID.47
C. CONTROLLING COSTS.49
D. IMPROVING QUALITY OF THE HEALTH CARE SYSTEM.49
A. HOW IS ACA MOST LIKELY TO POSITIVELY IMPACT
HOMELAND SECURITY EFFORTS TO ACHIEVE ALL¬
B. HEALTH SURVEILLANCE SYSTEM.55
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
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
LIST OF REFERENCES.79
INITIAL DISTRIBUTION LIST.89
LIST OF ACRONYMS AND ABBREVIATIONS
Affordable Care Aet; same as Patient Proteetion and Affordable
Advisory Committee on Immunization Praetiees
Congressional Budget Offiee
Centers for Disease Control
Children’s Health Insurance Program
Comprehensive Assessment of Reform Efforts
Centers for Medicare and Medicaid Services
congenital rubella syndrome
Emerging Infections Program
Emergency Medical Treatment and Active Eabor Act
Food and Drug Administration
federal poverty level
Government Accounting Office
Health Care Education and Reconciliation Act
U.S. Health and Human Services Department
health maintenance organization
Hospital Preparedness Program
Internal Revenue Service
National Institute for Mental Health
Organisation for Economic Co-operation and Development
Oregon Health Plan Standard
Patient Protection and Affordable Care Act; same as Affordable
post-traumatic stress disorder
Veterans Administration; Veterans Health Administration
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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
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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
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-
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.
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),
^ 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,
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.
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
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
1^ Democratic Policy Communication Committee, Patient Protection and Affordable Care Act:
Detailed Summary, accessed September 9, 2013,
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,
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,
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
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
• 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),
!9 OECD, OECD Health Data 2013, 1-2.
20 U.S. Department of Veterans Affairs, “Health Programs for Veterans,” March 2014,
• 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
• 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,
23 Emergency Medical Treatment and Active Labor Act, Pub. L. No. 113-142, 42 U.S. Code §1395dd
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),
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,
RAM^MEPSPGM.TC. SAS&File=HCF Y2011 &Table=HCF Y2011_PLEXP_E&VARHAGE&VAR2=SE
27 Paul Starr, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (New
Haven, CT: Yale University Press, 2011), 324.
29 Ibid., 237.
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
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.
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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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,
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,
34 Ibid., 5.
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,
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,
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,
38 “Angle’s Shocking-and Misleading-Viagra Claim,” FactCheck, October 8, 2010,
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.
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
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.
THIS PAGE INTENTIONALLY LEET BLANK
III. HEALTH CARE AND HOMELAND SECURITY: DRAWING
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
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,
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.
...the healthcare of all persons living in America is bound together: the
protection of every American is no stronger than the weakest protection of
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,
48 Bobbitt, Brief for Professor Philip C. Bobbitt, 9.
49 Ibid., 1-12.
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,
^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
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,
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,
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,
^2 Christopher F. Chyba and Alex L. Greninger, “Biotechnology and Bioterrorism: An Unprecedented
World,” Survival 46, no. 2 (2004): 146.
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,
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,
article-1.13 73 864#commentpostform
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
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,
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,”
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
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,
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-
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,
24 Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines (Atlanta, GA:
Centers for Disease Control and Prevention, 2002).
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),
Malcolm Gladwell, “Talk of the Town,” New Yorker, October 29, 2001, 33.
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
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,
Richard J. Webby and Robert G. Webster, “Are We Ready for Pandemic Influenza?” Science 302,
no. 5650 (2003): 1519.
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
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),
Centers for Disease Control and Prevention, Smallpox Response Plan and Guidelines.
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
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.
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
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
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
86 Ibid., 21.
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
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,
^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).
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
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),
94 Jesse Preussner, “Examination of FEMA and the Relationship with a Community after a Disaster”
(Master’s thesis, Kansas State University, 2012), 10.
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,
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,
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.
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,
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-
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,
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,
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,
110 As used here, “severe mental illness” includes but it not limited to psychiatric conditions such as
schizophrenia, major depression, bi-polar disorder, etc.
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
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
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),
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,
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.
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.
11^ Congressional Budget Office, “Health Care,” accessed July 29, 2014,
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.
121 The Medicare Newsgroup, “Medicare FAQs,” July 29, 2014,
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),
123 Ibid., 1.
“we believe that the rising cost of health care represents perhaps the most significant
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.
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,
127 The Patient Protection and Affordable Care Act, §1501 (E), 125; Himmelstein et at, “Medical
Bankruptcy in the United States,” 741-746.
IV. WHAT IS THE PATIENT PROTECTION AND AFFORDABLE
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
• 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.
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
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),
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),
133 Democratic Policy Communication Committee, Patient Protection and Affordable Care Act:
134 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010),
135 The actual penalties are the flat fee or one percent of income, whichever is higher. This will be
further explored in Chapter VI.
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
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
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-
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
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).
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).
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
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,
“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
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
• 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
• 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).
156 Ibid., §4001.
• The Secretary of Health and Human Services will establish a national
strategy to improve health care service delivery, patient outcomes and
• 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
• 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.
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
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.
THIS PAGE INTENTIONALLY LEET BLANK
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.
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
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,
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,
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.
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).
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 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
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
(1) Strengthening epidemiologic capacity for identifying and monitoring for
(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.
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
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/
• Herpes zoster
• Human papillomavirus
• Influenza (flu shot)
• Measles, mumps, rubella
• Tetanus, diphtheria, pertussis
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.
cost of the vaccine itself, which means that the doctor sometimes ends up subsidizing
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
3. enhancing health care workforce education and training to improve
access to and the delivery of health care services for all
4. providing support to the existing health care workforce to improve
access to and the delivery of health care services for all
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-
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), §5001.
189 Ibid., §5202.
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
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
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.
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),
Public Health Emergency, “Hospital Preparedness Program,” July 16, 2014,
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
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-
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.
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
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.
203 Edward Welch, “Preventing School Shootings: A Public Health Approach to Gun Violence”
(master’s thesis. Naval Postgraduate School, 2013).
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,
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.
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),
210 Congressional Budget Office, Estimates for the Insurance Coverage, 21.
212 U.S. Government Accountability Office, Medicaid Expansion.
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.
215 Jack Hadley et ah, “Covering the Uninsured in 2008: Current Costs, Sources of Payment, and
Incremental Costs,” Health Affairs 27 (2008): 399—415.
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
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.
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
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
• 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
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
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
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
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.
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
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
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).
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-
229 “xiie Lowdown on the Health Insurance Penalty,” November 22, 2013, Kip linger,
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,
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-
233 “Health Insurance Marketplaces,” Common Wealth Fund, accessed July 30, 2014,
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
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.
As Shane Green notes in his article, “Bioterrorism and Health Care Reform: No
Preparedness Without Access,”
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
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