NRF: Is ESF-8 Full of Holes? Part 3

The Federal Emergency Management Agency (FEMA) has emphasized private-sector integration going back to the National Response Plan (NRP) in 2004. So given their guidance, why does it remain challenging for emergency managers to get the private sector's attention? And why has the public-private disconnect been especially problematic with Emergency Support Function (ESF) 8?

This post is the last of a three-part series analyzing why ESF-8 continues to be challenging for emergency managers and public health departments.?Part 1?studied the evolution of the National Response Framework (NRF) Base Plan versus the stagnation of the ESFs, especially ESF-8.

And in?Part 2?looked at two ESF-8 blind spots, FEMA's misapplication of terms around health care, emergency medical, and human services and the absence of associated definitions, and the ESF-8 Annex's loose horizontal integration preparedness evolution at the?U.S. Department of Health and Human Services (HHS).

Today we finish with a third problem for ESF-8: The Nation's healthcare and human service systems are inconsistently divided across economic sectors and jurisdictions – and they live predominantly in the private sector. And as we discussed in?Part 1, the NRF is not a law or regulation, so it carries little weight with most private sector entities.

Before digging in, let's be clear that there is little more FEMA can do to encourage emergency managers to connect their preparedness efforts with private sector entities. Unlike their oversights with terms, definitions, and horizontal integration, the lack of preparedness engagement from the private sector is challenging, especially in the highly regulated health care, emergency medical, and human services systems.

That problem lay in the fact that the private sector is not interested in the NRF, which may be why ESF-8 is full of holes. Well, at least partly why.

The Private Sector

Let's start by understanding the private sector and why it contributes to the complexity of ESF-8.

Private sector entities have a fiduciary duty to remain laser-focused on profitability and avoid actions that bring exposure to legal liability. And when we say private sector, that includes not-for-profit (NFP) or nonprofit (NPO) entities. Yes, even NFPs and NPOs must be "profitable." The only difference is that, unlike for-profit corporations, they cannot distribute their profits to individuals.

So, all private sector entities, including those delivering health care, emergency medical, and human services, are businesses with similar core concerns. Unfortunately, these concerns and the fact that preparedness is a cost center rather than a revenue center, makes gaining traction difficult for emergency managers.?

Private corporations are creatures of state governments and are for-profit, not-for-profit (NFP), or nonprofit organizations (NPOs). And some, but not all, NPOs are considered non-governmental organizations (NGOs) – think American Red Cross and The Salvation Army.

All private entities are subject to each state's unique laws and regulations. So when it comes to ESF-8, emergency managers and public health administrators must understand the state-specific enabling legislation and regulations for private health care, emergency medical, and human services providers. Regardless of whether for-profit, NFP, or NPO, unlike ESF-4, Firefighting, ESF-13, Public Safety and Security, and most other ESFs, ESF-8 can only run with the private sector on board.

For-profit organizations are distinct in that they operate to make money – a profit – for people. And the business owner earns an income and may also pay shareholders and investors from the profits. Approximately 20% of the Nation's healthcare system is for-profit, and Wall Street's appetite to grow earnings for investors from an industr that makes up nearly 20% of the Nation's gross domestic product (GDP) has them aggressively swallowing up and consolidating NPO providers.

And for-profit providers – a growing number now owned by private equity funds seeking short-term gains – are known to hyperfocus on cost-cutting, reducing liability, and taking on debt to distribute to shareholders. As such, they are prone to avoid transparency and collaboration with government entities during a crisis. Especially state governments, which are the "burdensome" regulators of health care, emergency medical, and human services providers and the licensors of their employees.

The lack of trasparency and collaboration is often true with NPO providers, particularly those consolidated as part of outsized systems with numerous facilities across a region. The larger these organizations grow, the more bureaucratic they become and are less likely to be ingrained in the community. However, though finances still matter, one generally finds a more collaborative approach in rural communities with small NPO providers that own one or few facilities.

It's still a neighbor helps neighbor thing in rural America.

When it comes to NPOs and NFPs, it's easy to assume they are the same thing. However, they are business structures with different tax implications, governance, and functions. For example, health care, emergency medical, and human services providers, which serve the public good and provide public benefit, are NPOs. In contrast, youth baseball organizations, civic groups, and political committees are NFPs.

So, for emergency management purposes, health care, emergency medical, and human services providers are either public, for-profit, or NPOs. As a result, how each is legally enabled, restrained, or exposed to liability can be unique in each state.

And that's why, when it comes to ESF-8, policy analysis must precede policy development and planning. There is no cookie-cutter plan.

The Nuances

Successful implementation of ESF-8 requires emergency managers and public health administrators to know the landscape of their jurisdictions' healthcare, emergency medical, and human services systems. Beyond learning each provider's resources and capabilities, understanding whether they are public or private can help determine the potential tools available to engage them in preparedness and response.

Public sector providers may be owned and operated by a state, county, or municipal government. And this matters because, during a crisis, emergency managers and public health administrators must know whether the governor, mayor, or county administrator holds sway over a facility management's actions. Right or wrong, when under a disaster declaration, government agencies often count on the political hammer to get other agents of government in line.

Further, when it comes to preparedness activities, a government entity has the authority to mandate engagement by the managers of its subordinate units. So, for public sector health care, emergency medical, and human services providers, the NRF and ESF-8 could be made to matter.

On the other hand, if owned privately, knowing whether a health care, emergency medical, and human services provider is for-profit or an NPO helps determine whether specific laws or regulations may apply differently. As mentioned previously, each state is unique and may have different expectations of NPO providers than for-profit providers.

Also, understanding whether a provider is a locally owned mom-and-pop or one facility in a large consolidated operation helps set expectations for how much they will collaborate in a crisis. Often, private facilities under the umbrella of a large corporation have access to more sophiticated backup resources in a disaster but may not be as invested in the community and willing to share information and resources.

And federally, on the preparedness front, the community benefit provision of the Affordable Care Act (ACA) only applies to NPO hospitals. As such, as I wrote about in?Will Hospitals Fund Health Care Coalitions? NPOs may be open to using community benefit dollars to financially support community-wide preparedness activities, including their regional health care coalition (HCC).

Public Health Meets Health Care, Emergency Medical, and Human Services

To start, one must understand that, as I wrote in?Public Health: It's Not Healthcare, one cannot dump public health and health care in a bucket and market it as a single discipline. They are not. And human service and emergency medical services have their nuances. And that's why state and local health departments struggle with the ESF-8 mission. So much of it is out of their wheelhouse.

According to the?World Health Organization?(WHO), "Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life?among the population as a whole. Its activities aim to provide conditions in which people can be healthy and?focus on entire populations, not on individual patients or diseases."

So between the core mission of "public health" and the fact that it lives in the public sector, the comfort zone for administrators lies in their communities' overall health and wellness, not health care for individuals. And their services are generally delivered without expense to the individual – because doing so provides community benefit.

On the contrary, health care is about?triaging, diagnosing, and treating individual patients?– whether one has difficulty breathing from congestive heart failure during a flood evacuation or has been impaled by a 2x4 during an F-5 tornado. And emergency medical services (EMS) do the same outside a health care facility and transport the individual to definitive care, which is generally a hospital.

Suppose the patient in the previous examples showed up at the local health department. In that case, they will immediately call 911 for EMS to triage, treat,?and?transport the patient to a hospital where they can receive definitive health care. And unlike public health, with few exceptions related to charity care, someone or some organization must pay the EMS and health care bills.

So, maybe the better title for ESF-8 should be simply "Health." Yeah, you guessed it. That's a story for another time.

So, why did FEMA bundle public health, health care, emergency medical, and human services into ESF-8? Well, maybe it's just convenient, or...

1. The NRF, like FEMA, is a public sector thing, and they need a government entity to take accountability for its implementation at the federal, state, and local levels.
2. State and local governments generally do not have "health care" departments to lead what FEMA titles "medical services."
3. Some public health departments deliver some "human services," including behavioral health. And sometimes, they also co-locate with community health centers (CHCs).
4. Public health departments are the only consistent part of the Nation's "health system" that lives in the public sector – and accepts federal preparedness funding.?

Yes, ESF-8 is a single, enormous function under the NRF – and most state and local emergency operations plans (EOPs) – because public health is, well, public. And further, FEMA only knows the federal government's structure – where HHS is the Wizard of ESF-8. That is, under a single agency, they manage all the programs and dollars that address the activities FEMA has identified as necessary under ESF-8.

Unfortunately, there is no ESF-8 Wizard with HHS's broad mission at the state and local levels. Instead, most states prefer to break up the many health and human services programs managed by HHS into boutique agencies with narrow missions.?

But of course, all preparedness funding opportunities from the Centers for Disease Control and Prevention (CDC) and the HHS Administration for Preparedness and Response (ASPR) are routed only to state health departments. But I'm sure they share the money with the other agencies to ensure the ESF-8 mission is covered, right?

It may be time to break up ESF-8. Yeah. Say it with me. That's a story for another time.

If you need help with ESF-8 policy analysis and how it intersects with ESF-6 and access and functional needs support services in your jurisdiction, touch base.