Following Trump’s Threats to Withdraw Hurricane Response Efforts, Murray, Wyden Push HHS For Commitment to Remain in Puerto Rico & U.S. Virgin Islands As Long As Public Health is At Risk

Weeks after Hurricane disasters, Puerto Rico & U.S. Virgin Islands continue to lack safe, running water, electricity, fuel, & other critical public health needs

President Trump has threatened to withdraw resources amid criticism over federal government’s response

In new letter, Sens. seek answers from Acting Sec. Hargan on resources HHS has devoted to Puerto Rico & U.S. Virgin Islands; Request information on access to health services, disease outbreaks, women’s health & safety, drug shortages, & more

Senators: Despite Trump’s threats, “there is considerable work to be done in the short- and long-term to respond to this growing public health crisis and ensure the situation does not become even direr”

(Washington, D.C.) —Senators Patty Murray (D-WA) and Ron Wyden (D-OR) are calling on Acting Secretary of the Department of Health and Human Services (HHS) Eric D. Hargan to provide clear information on the Department’s ongoing hurricane response effort in Puerto Rico and the U.S. Virgin Islands. Hurricanes Maria, Irma, and Harvey have ravaged these U.S. territories and several coastal states, destroying homes and infrastructure, displacing entire communities, and endangering the health and well-being of countless American citizens. 

In the letter, Senators Murray and Wyden express serious concerns regarding President Trump’s recent threats to withdraw resources for these areas and what impact this could have on HHS’s ongoing response efforts in Puerto Rico and the U.S. Virgin Islands as they face critical public health needs.

“We have…been alarmed by President Trump’s suggestion that he may withdraw resources from the hurricane response in Puerto Rico,” wrote the Senators. “We seek to understand how the Department will ensure that federal government resources remain available as long as Puerto Rico faces critical public health needs. There is considerable work to be done in the short- and long-term to respond to this growing public health crisis and ensure the situation does not become even direr.”

The Senator’s requested information by HHS on the following critical areas by no later than November 9, 2017:

• Staffing and Resource Needs
• Power Outages
• Access to Health Services
• Medicaid, Medicare, and the Children’s Health Insurance Program
• Disease Outbreaks
• Women’s Health and Safety
• Domestic Violence and Sexual Assault
• Human Services, Child Welfare, and Child Protection
• Early Learning and Care
• Mental Health and Substance Use Disorder  
• Drug Shortages

Full text of the letter below and PDF HERE.

October 26, 2017

The Honorable Eric D. Hargan

Acting Secretary

U.S. Department of Health & Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

Dear Acting Secretary Hargan:

We write to request information about the Department of Health and Human Services’ (HHS or the Department) hurricane response efforts in Puerto Rico and the U.S. Virgin Islands.  Over the past few weeks, Hurricanes Maria, Irma, and Harvey have ravaged many of the nation’s coastal states and island territories.  In addition to destroying homes and infrastructure, the hurricanes have displaced vulnerable populations and endangered their health and wellbeing.  The cumulative impact of the hurricanes has stretched resources thin, and we are concerned about whether HHS is providing an adequate response.  We have also been alarmed by President Trump’s suggestion that he may withdraw resources from the hurricane response in Puerto Rico,[1] and we seek to understand how the Department will ensure that federal government resources remain available as long as Puerto Rico and the U.S. Virgin Islands face critical public health needs.

There is considerable work to be done in the short- and long-term to respond to this growing public health crisis and ensure the situation does not become even direr.[2]  We are particularly concerned by reports of food, water, and fuel shortages even weeks after Hurricane Maria hit the islands.  Much of Puerto Rico and the U.S. Virgin Islands are still without electricity, and hospitals are running low on fuel to operate their generators. 

To help us better understand the Department’s ongoing hurricane response efforts, please respond to the following questions no later than November 9, 2017:

Staffing and Resource Needs

There have been challenges in distributing personnel and resources to areas with unmet needs during the hurricane response.  For example, the USNS Comfort arrived in San Juan earlier this month with capacity to serve 250, but as of last week, the Puerto Rico Department of Health has sent just 82 patients to the ship.[3]  In addition to the response in Puerto Rico and the U.S. Virgin Islands, HHS has deployed personnel and resources in response to recent hurricanes in Texas and Florida. 

1. How is HHS dividing its resources in response to the hurricanes?  What considerations have gone into HHS’s division of resources?
2. How has the hiring freeze implemented across the Department earlier this year affected response efforts?  How has the hiring freeze affected the Department’s ability to deploy disaster response resources, while also completing its other work unrelated to disaster response?
3. Please explain how the hiring freeze affected the number of National Disaster Medical System (NDMS) reservists able to be deployed in hurricane response efforts. 
4. Is a hiring freeze still in place within any HHS operating divisions or agencies? 
5. How has HHS coordinated with other federal government agencies to ensure medical and public health needs are being met, including in instances where HHS has insufficient capacity?

Power Outages

The hurricanes have resulted in power outages, which can create unique health risks such as heat-related illness and carbon monoxide poisoning.  Power outages pose especially grave risks to individuals who depend on medical devices that require power.  In Puerto Rico, approximately 80 percent of residents still do not have power and 40 percent do not have running water.[4]  It could take four to six months to restore power to the island.[5]  In the U.S. Virgin Islands, the initial wave of power restoration is scheduled to occur this week.[6] 

1. How is HHS addressing the health risks associated with these potentially long-term power outages?
2. Using alternative sources of electricity such as generators amid a power outage can cause carbon monoxide to accumulate in enclosed structures.[7]  What best practices, if any, is HHS sharing with hospitals relying on generators amid power outages related to the Hurricanes? 
3. How is HHS working to identify and provide support to individuals who depend on medical devices that require power?
4. What safety information is HHS providing to consumers of food, water, and drugs in areas without power?

Access to Health Services

The hurricanes have resulted in temporary closures of a number of medical facilities, limiting access to inpatient and outpatient care.[8]  The facilities that remain open are overpopulated, yet lacking in medical supplies to treat the influx of patients.[9]  A recent report found that dialysis patients have seen treatment hours reduced by 25 percent, given fuel shortages to run generators.  Much of Puerto Rico’s telecommunications grid also remains down, meaning federal and local public health officials are unaware of unmet medical needs.  Kenneth Mapp, the Governor of the U.S. Virgin Islands, has said that hospitals on St. Thomas and St. Croix – the territory’s two most populated islands – will have to be torn down and rebuilt.[10]  There have been reports of generators being stolen, shutting down one of the few remaining working cell towers.[11]  Community health centers, for which funding lapsed at the end of September and has yet to be reauthorized, continue to face power and communications challenges.[12]  Community health centers play an outsized role in Puerto Rico, serving 10 percent of the island’s population, including some of the island’s poorest residents.[13]

1. How is HHS working to ensure the hospitals, clinics, and community health centers that remain open have adequate resources, particularly with respect to staffing, medical supplies, and fuel, to meet patient needs?
2. How is HHS ensuring that it has accurate information about medical needs around the island?
3. How is HHS working with local health officials to reopen and restock medical facilities that remain closed or understocked? 
4. How is HHS working with facilities that remain closed to support efforts to reopen?

Medicaid, Medicare, and the Children’s Health Insurance Program

The impact of the hurricanes has also demonstrated the critical importance of key safety net health care programs like Medicaid and the Children’s Health Insurance Program (CHIP).  Following natural disasters like Hurricane Katrina, previous administrations have proactively worked with states to ensure access to health care for vulnerable individuals impacted by the disasters.  Given the capped nature of Puerto Rico and the U.S. Virgin Island’s Medicaid programs, we are particularly concerned about the impact of Hurricane Maria on these already stressed health systems and programs.  We are also concerned about evacuees who have left disaster impact areas and need access to essential health care in other areas or states. It is imperative that these individuals are able to access the care they need and that providers are reimbursed accordingly.

In Puerto Rico when an individual becomes eligible for Medicare he or she is automatically enrolled into Part A but the individual must actively enroll into Part B during an initial enrollment period.[14]  If the individual fails to enroll in Part B during this time period but enrolls at a later date, the beneficiary’s Part B premium is increased in perpetuity.  The hurricane recovery efforts may be preventing newly-eligible beneficiaries in Puerto Rico from enrolling into Part B in a timely manner – resulting in lasting financial consequences.  

1. How is HHS working with states and territories to ensure impacted individuals and evacuees have access to needed health care coverage and services, including temporary Medicaid eligibility, streamlined eligibility, moratoriums on redeterminations for already-eligible Medicaid beneficiaries,  and self-attestation of income and displacement status?
2. Does HHS plan to issue any guidance to states and territories regarding Medicaid coverage of individuals and evacuees impacted by the hurricanes, including 1115 waivers similar to those issued after Hurricane Katrina to ensure impacted individuals have access to Medicaid coverage and needed care?
3. When does HHS expect Puerto Rico to run out of their current federal Medicaid funding under their capped Medicaid program given the increased pressure placed on the Medicaid program by Hurricane Maria?  How is HHS working with the U.S. Virgin Islands and other states and territories to address the increased financial pressure placed on Medicaid programs by the hurricanes?
4. Does HHS plan to formally request additional funding under the Medicaid program for states and territories to provide health care coverage and services to impacted individuals and evacuees, as was provided in the Deficit Reduction Act of 2005 post-Hurricane Katrina?
5. In addition to Medicaid, the Children’s Health Insurance Program is also vitally important to ensuring children have access to necessary health care coverage, including after devastating events like the recent hurricanes. For example, Puerto Rico received nearly $180 million in federal funding to provide health care coverage to children through CHIP in fiscal year 2016 alone.[15]  When does HHS expect Puerto Rico, the U.S. Virgin Islands, and other states impacted by the hurricanes to run out of federal CHIP funding if Congress does not act to extend funding for the program?  How would this impact the ability of affected territories and states to respond to the health care needs of children in families affected by the hurricanes?
6. HHS has announced special enrollment periods for certain disaster-impacted individuals who wish to enroll or disenroll into Medicare Advantage, Part D or exchange plans.[16]  Does HHS plan to offer a similar special enrollment period for individuals in Puerto Rico who are not able to enroll in Medicare Part B during the initial enrollment period due to the impact of Hurricane Maria?  How does HHS plan to address the Medicare Part B late enrollment penalties levied against those beneficiaries?

Disease Outbreaks

The hurricane aftermath has produced an environment that breeds disease and other health risks.  Public health officials are reporting at least four deaths from leptospirosis, a bacterial infection that can lead to kidney damage, liver failure, and meningitis.[17]  The lingering standing water is also a breeding ground for mosquitoes, which may result in an increase in mosquito-borne diseases like dengue, chikungunya, and Zika.  Finally, the lack of running water has resulted in an increase in diseases like pink eye and skin rashes, as basic hygiene needs go unmet.

20. What surveillance efforts are in place to diagnose and track disease in Puerto Rico and the U.S. Virgin Islands? 

1. Does HHS have a plan, in coordination with other agencies, for ensuring there is accessible drinking water in Puerto Rico and the U.S. Virgin Islands?

22. What efforts are being made to communicate with individuals about how to protect themselves from infectious disease?

23. It has been reported that there is not lab capacity to test for leptospirosis in Puerto Rico.[18]  Is there any diagnostic lab capacity in Puerto Rico and the U.S. Virgin Islands at this time?  If not, are there plans to install labs to perform diagnostics on the islands?

Women’s Health and Safety

Oral contraceptive access is of particular concern amid these disasters because oral contraceptives must be taken on a daily basis at a consistent time to be the most effective, and packs must be renewed every twenty-eight days.  Numerous studies have shown that natural disasters disrupt availability of contraception and access to family planning services, which may lead to higher rates of unplanned pregnancy.[19]

24. How is HHS ensuring access to contraception as hospitals and pharmacies remain closed or inaccessible?

25. What efforts are being made to increase access to long-acting reversible contraceptives?

26. Is HHS helping to provide emergency contraception to individuals who may need it due to a sexual assault or lack of access to other methods of contraception?

Domestic Violence and Sexual Assault

Survivors of domestic violence and their children face increased health and safety risks in the aftermath of natural disasters.  In the wake of Hurricane Andrew, calls to a local domestic violence help line increased by 50 percent, and more than one-third of residents surveyed “reported that someone in their home had lost verbal or physical control in the two months after the hurricane.” [20]  Similarly, after Hurricane Katrina, the Louisiana Coalition Against Domestic Violence received reports that women were being battered by their partners in emergency shelters.[21]  Studies have also shown that the rates of child abuse are disproportionately higher in the months following natural disasters.[22]

Natural disasters can also lead to an increase in reported sexual assaults and violence.[23] Many of the circumstances that can contribute to sexual violence against women often exist during a hurricane response, including a lack of communal support systems for vulnerable individuals and lack of protection or security in shelters.[24] 

27. Where is HHS directing domestic violence survivors, with their children as needed, to go when domestic violence shelters are closed or destroyed in the wake of the hurricanes?  What is HHS doing to ensure domestic violence survivors have access to the resources they need?

28. How is HHS ensuring children have access to resources they may need to report abuse and receive necessary physical and mental health treatment?

29. How is HHS supporting sexual assault providers? What is HHS doing to make sure sexual assault survivors have appropriate health care services and other supports?

Human Services, Child Welfare, and Child Protection

The damage caused by hurricanes can have disastrous effects on the health and well-being of children and families.  When businesses shutter and jobs are lost, many families lose their only source of income, increasing the strain on basic assistance programs to help families make ends meet.  In recognition of these challenges, in the wake of Superstorm Sandy, Congress provided impacted states with almost $475 million in Social Services Block Grant funding to help cover social service and reconstruction expenses.[25]

30. What is HHS doing to help states and territories serve families who are struggling with job loss and income loss?  What basic assistance resources, such as cash assistance and other material supports, exist?

1. What is HHS doing to help foster care agencies and foster care providers ensure children in foster care have access to safe and secure placements and are receiving adequate health (including mental health) services?

32. What is HHS doing to ensure states and territories are meeting federal foster care requirements under Title IV-E of the Social Security Act, especially those related to case plan and case review requirements?

Early Learning and Care

Hurricanes take a significant toll on children and families, including families with young children.  Hurricane Katrina damaged more than 200 Head Start facilities, nearly half of which remained closed long after the hurricane.[26]  For many children and families, early learning and care programs, including Head Start, provide critical services to meet their basic and educational needs.  These needs are exacerbated during natural disasters, making it even more important to restore the learning environment.  In addition, given child care facilities are among impacted businesses and community services, it can be particularly problematic for parents to find new employment when they lack access to child care.  Early learning and care providers, including Head Start providers, are also critical for helping children and families who have been displaced outside of the affected areas. 

33. How is HHS working to ensure that Head Start programs in states and territories have the resources necessary to open and serve children and families, including by meeting their increased need for comprehensive services?

34. How is HHS supporting Head Start programs across the country that have experienced an increase in children enrolled in programs as a result of the hurricanes?

35. What is HHS doing to help states and territories meet the child care needs of families impacted by the recent hurricanes, both in the affected areas and where children and families have been displaced?

Mental Health and Substance Use Disorders

Hurricanes can exacerbate mental health needs and conditions in the short and long terms.  One study found that a year after Hurricane Katrina, hurricane survivors experienced an increase in suicidal thoughts, more than doubling the proportion of people who experience suicidal thoughts from 2.8 percent to 6.4 percent.  Likewise, another study found that a year after Hurricane Katrina, the number of survivors with diagnoses like depression and psychosis doubled.[27] 

Stressful situations, such as a natural disaster, can also present a challenge to those in treatment for a substance use disorder (SUD), especially when existing sources of treatment are disrupted. Additionally, natural disasters and the trauma associated with them can lead to the development or exacerbation of a SUD, and a break in services and treatment can mean that those individuals are at risk of relapse.  After Hurricane Katrina, the rate of hospitalizations for substance use disorder increased approximately 30 percent.[28]

36. How is HHS addressing short-term mental health needs?  How is HHS preparing for long-term mental health needs?

37. How is HHS ensuring that children and young adults have access to resources to address their mental health needs?

38. How is HHS ensuring that people with substance use disorder have the services and treatment they need?

Drug Shortages

The United States relies heavily on prescription drug and medical device manufacturing in Puerto Rico, which produces seven of the top 10 drugs sold worldwide and constitutes 72 percent of the islands exports.  Shortly after Hurricane Maria, Food and Drug Administration (FDA) officials warned that patients could experience “critical shortages” of needed pharmaceuticals.[29]  FDA Commissioner Scott Gottlieb has warned of the potential for drug shortages and has already taken action to prevent shortages by working with manufacturers to allow temporary importation of sodium chloride.  More than 40 drugs manufactured on the island could face shortages.

39. How is HHS ensuring that it has accurate information about potential drug shortages around the island?

40. How is FDA working with manufacturers to understand and prevent potential drug shortages on the mainland United States?  Specifically, which pharmaceuticals are at risk of shortage? 

1. How is HHS coordinating with FEMA and/or DOD to transport needed drugs from storage on Puerto Rico to the mainland United States?

42. How is HHS coordinating with FEMA and/or DOD to restore power to manufacturing facilities?

We share your commitment to organizing a rapid, effective hurricane response as this crisis unfolds.  Thank you in advance for your attention to this matter. 

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