advocacy group could undertake in this area. For example, he suggested becoming familiar with the State Medicaid Agency’s policy on out-of-state reimbursement, and working with the agency on cooperation and reimbursement for both in-state and out-of-state care. Educating and encouraging providers close to state borders to sign up for both states’ Medicaid network was another consideration along with drafting a model state Pediatric Emergency Preparedness Act to present to state legislators. Finally, he said, working with the Centers for Medicare & Medicaid Services (CMS) to help load the Disproportionate Share Hospital formula in favor of hospitals that join a regional disaster compact would be a good effort that could benefit from advocacy. The rest of this section gives varying financial perspectives of preparedness financing related to children, including the federal level, private insurer, hospital association, and private practice provider. Their considerations and suggestions can help to understand the biggest challenges in this area and where the opportunities for improvement lie.

HEALTH CARE SYSTEM POLICY

Emergency preparedness is built on the strength of everyday health care systems, and the financial stability and sustainability of private-sector health care delivery systems is an essential component of the health security of the nation, said Gregg Margolis, director of the Division of Health System Policy at the Office of the Assistant Secretary for Preparedness and Response. More than 90 percent of the health care delivered in the United States, both routine and during disasters and public health emergencies, is delivered in the private sector.

Health care financing is complex, Margolis said, and there are disparities in the financial stability of various health systems in the United States. Some health care systems report revenue minus expenses of hundreds of millions of dollars per year. Other health care systems, often those that serve vulnerable populations, are much less financially stable. Disasters disproportionately affect vulnerable populations, and pediatric populations in particular, and Margolis emphasized the need to address the financial stability of safety net providers that will be further stressed during public health emergencies and disasters.

Disasters affect the entire health care system. Although there is much discussion about emergency care or trauma care systems, a public health emergency also impacts the primary care system, long-term care, nursing



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