After three months of hospital pleas for various levels of bioterrorism funding, the U.S. House of Representatives last week passed a $2.7 billion package that provides no direct funding for hospitals. The bill is a major setback for the hospital lobby, which hurt its own cause by repeatedly changing its price tag for better disaster preparedness.
When congressional staffers earlier this year pressed hospital leaders on how much money it would take to prepare hospitals for potential biological attacks, American Hospital Association officials responded with a quick back-of-the-envelope response: $27 billion.
That number-nearly two and a half times what Medicare spent on nursing-home care in 2000-raised some eyebrows on Capitol Hill. Some lawmakers and aides feared it was an end-run by the AHA, which was having trouble getting its Medicare agenda heard in the national-defense frenzy that followed the terrorist attacks on Sept. 11.
The AHA went back to the drawing board twice and finally came up with a slimmed-down number-$11.3 billion (Nov. 5, p. 6). But apparently, that's still much higher than lawmakers believe the hospitals need. The House bill passed last week provides no direct spending for hospitals. It does, however, include $1 billion in grants to help states, local governments and providers with disaster planning; would-be recipients would have to apply for the money. The remaining money in the House bill would be divvied up to fund other preparedness efforts coordinated by HHS and the Centers for Disease Control and Prevention (See chart). A leading Senate bill, not expected to come up for a vote until next year, contains just $370 million for hospitals.
"Everybody's going to be asking for big sums," said Sen. William Frist (R-Tenn.), a chief sponsor of the Senate bill. "Everybody can spend tenfold, twentyfold what's in (the Senate bill)."
It was the latest chapter in a long year of setbacks for the AHA. The organization has seen its agenda for more Medicare dollars fizzle this year as the federal government returned to deficit spending. In addition, lawmakers have contented themselves with about $20 billion in new Medicare hospital spending enacted in the past two years.
Meanwhile, AHA lobbyists have sometimes tested their own credibility as they've floated a variety of messages on Capitol Hill, from workforce shortages to regulatory relief to emergency preparedness, in their pursuit of new dollars.
Catching the money train
The organization's desire to jump aboard the federal money train was demonstrated last week. The AHA and its affiliated group the American Organization of Nurse Executives represented two of the nine groups that announced they had formed a partnership to push lawmakers to strengthen communities' ability to respond to biological, chemical or nuclear attacks.
A major focus of the Partnership for Community Safety will be to seek funding for hospitals to expand capacity so they can treat large numbers of casualties resulting from terrorist attacks or other disasters.
"You have to have a commitment of resources," AHA President Richard Davidson said at a Dec. 11 press conference to announce the partnership's formation. "The legislation that's being considered comes somewhat short. That's putting it politely. So we've got a lot of work to do."
The partnership found itself falling behind lawmakers, however. Just one day after the press conference, the House voted 418-2 to pass legislation sponsored by House Energy and Commerce Committee Chairman W.J. "Billy" Tauzin (R-La.) and senior Democrat John Dingell (D-Mich.). That legislation earmarks $2.7 billion to combat bioterrorism.
Whether that money can be spent wisely, if it materializes at all, is subject to some dispute, as is from whose purse it should come. Stephen Prior, research director for the national security health policy center at the Potomac Institute for Policy Studies, a not-for-profit think tank based in Arlington, Va., said the failure to examine local vulnerabilities, such as agricultural targets in rural areas or drinking water supplies in urban areas, means that it's unclear exactly what capabilities hospitals need.
"A lot of people are now crying out, `We need money,"' Prior said. "(But) there's no point in spending it unless it fits within somebody's plan. What I'm not clear about is whether the template for a hospital in the middle of the Midwest is the same as the template for a hospital in Washington, D.C."
"I think we should wait and study some of this stuff before we start throwing billions of dollars around," said Elizabeth Wright, director of government relations for Citizens Against Government Waste, a watchdog group. "People are taking advantage of some of the emergency funding that's out there."
Jack Spencer, a defense analyst with the Heritage Foundation in Washington, describes hospitals as "woefully unprepared" because they lack the equipment, training and backup capacity.
He said the AHA's figure for preparing hospitals could be close to the mark, but he added, "The federal government ought to spend less than half of that. Communities have to take some of this on themselves. The primary objective of the federal government has to be support, to provide guidelines and to educate people at the local level. The state and local governments need to take on the responsibilities to make sure their people are protected from this very real threat."
Other groups seeking money
The AHA isn't alone in trying to capitalize on bioterrorism fears. The Federation of American Hospitals, for example, is seeking a change in law that would allow for-profit hospitals to receive disaster assistance funds from the Federal Emergency Management Agency. For-profit hospitals are barred from receiving such funds under current law.
The Catholic Health Association joins the American Public Health Association-one of the groups that is part of the AHA community-readiness coalition-in calling for new investment in the public health infrastructure.
"The current bills, if they are funded, will be a down payment," Mohammad Akhter, M.D., executive director of the American Public Health Association, said at the press conference announcing the coalition's formation. "What we need is a sustained commitment."
Drug manufacturers, meanwhile, want to be protected from liability related to death or harm resulting from vaccinations, as well as getting antitrust relief for companies that collaborate to develop vaccines or drug treatments to combat potential bioterrorist attacks.
And the pursuit of bioterrorism dollars came as Congress neared the end of a fractious session. An embarrassing end-of-session dispute over how to spur the economy has made lawmakers all the more eager to pass bipartisan legislation to address fears heightened by the Sept. 11 attacks and subsequent anthrax outbreaks.
The tendency for interest groups to try to piggyback their needs onto a popular cause isn't surprising, given the amount of money on the table, one congressional expert said.
"Any piece of legislation that appears to be on a fast track has additional baggage added to it in an opportunistic way because it is so hard to get legislation through our complex congressional process," said Robert Reischauer, a former head of the Congressional Budget Office who is president of the Urban Institute in Washington.
He added: "At the same time, if the load becomes excessive, the leadership will strip off excess baggage to make sure that the train moves out of the station."
AHA says it's unscathed
But as they've led the chorus asking Congress for special treatment as part of the homeland defense push, AHA officials said the group's image isn't suffering from the missteps on bioterrorism funding or its sometimes-wandering agenda this year.
Richard Pollack, the AHA's executive vice president, acknowledged disappointment at this year's legislative results, but he said that the federal government's return to budget deficits, combined with a recession and the aftermath of the September attacks, created a different environment for healthcare lobbyists.
"Last year, (Congress had) big surpluses, and the issue was prioritizing where we wanted to reinvest the surpluses," Pollack said. "There was a totally different political environment. This past year was a lot harder. Because of the environment, we were handling and continue to handle multiple issues."
On bioterrorism funding, AHA spokesman Richard Wade said the original $27 billion figure had been based on what it would take for 5,000 U.S. hospitals to treat 1,000 casualties, an unlikely event.
When congressional officials expressed skepticism about that scenario, the AHA came up with a different scenario, in which the 2,200 rural hospitals in the U.S. treated only 200 patients each, while urban hospitals were projected to treat 1,000 each, Wade said. That scenario was only two-thirds as costly, at $18 billion.
The final $11.3 billion figure was based on harder data about the costs of purchasing such items as personal protective gear, extra pharmaceutical supplies, communications equipment and disease surveillance capabilities.
But even so, the changing number caused its own share of confusion on Capitol Hill. The day before the AHA announced its proposed funding needs, Sen. Edward Kennedy (D-Mass.), the co-sponsor of Frist's bioterrorism-response-bill, said hospitals were asking for $18 billion.
"By and large our credibility has to be intact because every member of Congress can find out immediately (what the facts are)," Wade said. "They have a real fast way of checking us out. They can call the hospital in their districts and check things out."