September 11
Improvements Needed in Availability of Health Screening and Monitoring Services for Responders Gao ID: GAO-07-1228T September 18, 2007Six years after the attack on the World Trade Center (WTC), concerns persist about health effects experienced by WTC responders and the availability of health care services for those affected. Several federally funded programs provide screening, monitoring, or treatment services to responders. GAO has previously reported on the progress made and implementation problems faced by these WTC health programs. This testimony is based on and updates GAO's report, September 11: HHS Needs to Ensure the Availability of Health Screening and Monitoring for All Responders (GAO-07-892, July 23, 2007). In this testimony, GAO discusses the status of (1) services provided by the Department of Health and Human Services' (HHS) WTC Federal Responder Screening Program, (2) efforts by the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health (NIOSH) to provide services for nonfederal responders residing outside the New York City (NYC) area, and (3) NIOSH's awards to WTC health program grantees for treatment services.
In July 2007, following a re-examination of the status of the WTC health programs, GAO recommended that the Secretary of HHS take expeditious action to ensure that health screening and monitoring services are available to all people who responded to the WTC attack, regardless of who their employer was or where they reside. As of early September 2007 the department has not responded to this recommendation. As GAO reported in July 2007, HHS's WTC Federal Responder Screening Program has had difficulties ensuring the uninterrupted availability of screening services for federal responders. From January 2007 to May 2007, the program stopped scheduling screening examinations because there was a change in the program's administration and certain interagency agreements were not established in time to keep the program fully operational. From April 2006 to March 2007, the program stopped scheduling and paying for specialty diagnostic services associated with screening. NIOSH, the administrator of the program, has been considering expanding the program to include monitoring, that is, follow-up physical and mental health examinations, but has not done so. If federal responders do not receive monitoring, health conditions that arise later may not be diagnosed and treated, and knowledge of the health effects of the WTC disaster may be incomplete. NIOSH has not ensured the availability of screening and monitoring services for nonfederal responders residing outside the NYC area, although it recently took steps toward expanding the availability of these services. In late 2002, NIOSH arranged for a network of occupational health clinics to provide screening services. This effort ended in July 2004, and until June 2005 NIOSH did not fund screening or monitoring services for nonfederal responders outside the NYC area. In June 2005, NIOSH funded the Mount Sinai School of Medicine Data and Coordination Center (DCC) to provide screening and monitoring services; however, DCC had difficulty establishing a nationwide network of providers and contracted with only 10 clinics in seven states. In 2006, NIOSH began to explore other options for providing these services, and in May 2007 it took steps toward expanding the provider network. NIOSH has awarded treatment funds to four WTC health programs in the NYC area. In fall 2006, NIOSH awarded $44 million for outpatient treatment and set aside $7 million for hospital care. The New York/New Jersey WTC Consortium and the New York City Fire Department WTC program, which received the largest awards, used NIOSH's funding to continue outpatient services, offer full coverage for prescriptions, and cover hospital care.
GAO-07-1228T, September 11: Improvements Needed in Availability of Health Screening and Monitoring Services for Responders
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GAO Highlights:
Highlights of GAO-07-1228T, a testimony before the Subcommittee on
Health, Committee on Energy and Commerce, House of Representatives.
Why GAO Did This Study:
Six years after the attack on the World Trade Center (WTC), concerns
persist about health effects experienced by WTC responders and the
availability of health care services for those affected. Several
federally funded programs provide screening, monitoring, or treatment
services to responders. GAO has previously reported on the progress
made and implementation problems faced by these WTC health programs.
This testimony is based on and updates GAO‘s report, September 11: HHS
Needs to Ensure the Availability of Health Screening and Monitoring for
All Responders (GAO-07-892, July 23, 2007). In this testimony, GAO
discusses the status of (1) services provided by the Department of
Health and Human Services‘ (HHS) WTC Federal Responder Screening
Program, (2) efforts by the Centers for Disease Control and
Prevention‘s National Institute for Occupational Safety and Health
(NIOSH) to provide services for nonfederal responders residing outside
the New York City (NYC) area, and (3) NIOSH‘s awards to WTC health
program grantees for treatment services.
For the July 2007 report, GAO reviewed program documents and
interviewed HHS officials, grantees, and others. In August and
September 2007, GAO updated selected information in preparing this
testimony.
What GAO Found:
In July 2007, following a re-examination of the status of the WTC
health programs, GAO recommended that the Secretary of HHS take
expeditious action to ensure that health screening and monitoring
services are available to all people who responded to the WTC attack,
regardless of who their employer was or where they reside. As of early
September 2007 the department has not responded to this recommendation.
As GAO reported in July 2007, HHS‘s WTC Federal Responder Screening
Program has had difficulties ensuring the uninterrupted availability of
screening services for federal responders. From January 2007 to May
2007, the program stopped scheduling screening examinations because
there was a change in the program‘s administration and certain
interagency agreements were not established in time to keep the program
fully operational. From April 2006 to March 2007, the program stopped
scheduling and paying for specialty diagnostic services associated with
screening. NIOSH, the administrator of the program, has been
considering expanding the program to include monitoring, that is,
follow-up physical and mental health examinations, but has not done so.
If federal responders do not receive monitoring, health conditions that
arise later may not be diagnosed and treated, and knowledge of the
health effects of the WTC disaster may be incomplete.
NIOSH has not ensured the availability of screening and monitoring
services for nonfederal responders residing outside the NYC area,
although it recently took steps toward expanding the availability of
these services. In late 2002, NIOSH arranged for a network of
occupational health clinics to provide screening services. This effort
ended in July 2004, and until June 2005 NIOSH did not fund screening or
monitoring services for nonfederal responders outside the NYC area. In
June 2005, NIOSH funded the Mount Sinai School of Medicine Data and
Coordination Center (DCC) to provide screening and monitoring services;
however, DCC had difficulty establishing a nationwide network of
providers and contracted with only 10 clinics in seven states. In 2006,
NIOSH began to explore other options for providing these services, and
in May 2007 it took steps toward expanding the provider network.
NIOSH has awarded treatment funds to four WTC health programs in the
NYC area. In fall 2006, NIOSH awarded $44 million for outpatient
treatment and set aside $7 million for hospital care. The New York/New
Jersey WTC Consortium and the New York City Fire Department WTC
program, which received the largest awards, used NIOSH‘s funding to
continue outpatient services, offer full coverage for prescriptions,
and cover hospital care.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-1228T].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at
(202) 512-7114 or bascettac@gao.gov.
[End of section]
Testimony:
Before the Subcommittee on Health, Committee on Energy and Commerce,
House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 10:00 a.m. EDT:
Tuesday, September 18, 2007:
September 11:
Improvements Needed in Availability of Health Screening and Monitoring
Services for Responders:
Statement of Cynthia A. Bascetta:
Director, Health Care:
GAO-07-1228T:
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss our work on the implementation
of federally funded health programs for individuals affected by the
September 11, 2001, attack on the World Trade Center (WTC).[Footnote 1]
Tens of thousands of people served as responders in the aftermath of
the WTC disaster, including New York City Fire Department (FDNY)
personnel, federal government personnel, and other government and
private-sector workers and volunteers from New York and elsewhere. By
responders we are referring to anyone involved in rescue, recovery, or
cleanup activities at or near the vicinity of the WTC or the Staten
Island site.[Footnote 2] These responders were exposed to numerous
physical hazards, environmental toxins, and psychological trauma. Six
years after the destruction of the WTC buildings, concerns remain about
the physical and mental health effects of the disaster, the long-term
nature of some of these health effects, and the availability of health
care services for those affected.
Following the WTC attack, federal funding was provided to government
agencies and private organizations to establish programs for screening,
monitoring, or treating responders for illnesses and conditions related
to the WTC disaster; these programs are referred to in this testimony
as the WTC health programs.[Footnote 3],[Footnote 4] The Department of
Health and Human Services (HHS) funded the programs as separate efforts
serving different categories of responders--for example, firefighters,
other workers and volunteers, or federal responders--and has
responsibility for coordinating program efforts.
We have previously reported on the implementation of these programs and
their progress in providing services to responders,[Footnote 5] who
reside in all 50 states and the District of Columbia. In 2005 and 2006,
we reported that one of the WTC health programs, HHS's WTC Federal
Responder Screening Program, which was established to provide onetime
screening examinations for responders who were federal employees when
they responded to the WTC attack, had accomplished little.[Footnote 6]
HHS established the program in June 2003, suspended it in March 2004,
and resumed it in December 2005. In September 2006, we reported that
the program was registering and screening federal responders and that a
total of 907 federal workers had received screening
examinations.[Footnote 7] We also reported that the National Institute
for Occupational Safety and Health (NIOSH), the component of HHS's
Centers for Disease Control and Prevention (CDC) responsible for
administering most of the WTC health programs, had begun to take steps
to provide access to screening, monitoring, and treatment services for
nonfederal responders who resided outside the New York City (NYC)
metropolitan area.[Footnote 8]
In September 2006 we also testified that CDC had begun, but not
completed, the process of allocating funding from a $75 million
appropriation made in fiscal year 2006 for WTC health programs for
responders.[Footnote 9],[Footnote 10] This was the first appropriation
specifically available for treatment for responders. We reported that
in August 2006 CDC had awarded $1.5 million from this appropriation to
the FDNY WTC Medical Monitoring and Treatment Program and almost $1.1
million to the New York/New Jersey (NY/NJ) WTC Consortium for treatment-
related activities. We also reported that CDC officials told us they
could not predict how long the funding from the appropriation would
support four WTC health programs that provide treatment services.
My testimony today is primarily based on our report issued in July
2007.[Footnote 11] As you requested, I will discuss the status of (1)
services provided by the WTC Federal Responder Screening Program, (2)
NIOSH's efforts to provide services for nonfederal responders residing
outside the NYC metropolitan area, and (3) NIOSH's awards to grantees
for treatment services.
To assess the status of services provided by the WTC Federal Responder
Screening Program, we obtained and reviewed program data and documents
from HHS, including applicable interagency agreements. We interviewed
officials from the HHS entities involved in administering and
implementing the program: NIOSH and two HHS offices, the Federal
Occupational Health Services (FOH)[Footnote 12] and the Office of the
Assistant Secretary for Preparedness and Response (ASPR).[Footnote 13]
To assess the status of NIOSH's efforts to provide services for
nonfederal responders residing outside the NYC metropolitan area, we
obtained documents and interviewed officials from NIOSH. We also
interviewed officials of organizations that worked with NIOSH to
provide or facilitate services for nonfederal responders residing
outside the NYC metropolitan area, including the Mount Sinai School of
Medicine in NYC and the Association of Occupational and Environmental
Clinics (AOEC)--a network of university-affiliated and other private
occupational health clinics across the United States and in Canada. To
assess the status of NIOSH's awards to grantees for treatment services,
we obtained documents and interviewed officials from NIOSH. We also
interviewed officials from two WTC health program grantees[Footnote 14]
from which the majority of responders receive medical services: the NY/
NJ WTC Consortium[Footnote 15] and the FDNY WTC program. In addition,
we interviewed officials from the American Red Cross, which has funded
treatment services for responders. In our review of the WTC health
programs, we relied primarily on information provided by agency
officials and contained in government publications. We compared the
information with information in other supporting documents, when
available, to determine its consistency and reasonableness. We
determined that the information we obtained was sufficiently reliable
for our purposes. We conducted our work from November 2006 through July
2007--and updated selected information in August and September 2007--in
accordance with generally accepted government auditing standards.
In brief, we reported in July 2007 that HHS's WTC Federal Responder
Screening Program had had difficulties ensuring the uninterrupted
availability of screening services for federal responders and that
NIOSH, the administrator of the program, was considering expanding the
program to include monitoring but had not done so. We also reported
that NIOSH had not ensured the availability of screening and monitoring
services for nonfederal responders residing outside the NYC
metropolitan area, although it had recently taken steps toward
expanding the availability of these services. As a result of our
assessment of these programs, we recommended that the Secretary of HHS
expeditiously take action to ensure that screening and monitoring
services are available for all responders, including federal responders
and nonfederal responders residing outside of the NYC metropolitan
area. As of early September 2007 the department has not responded to
this recommendation. Finally, we also reported that NIOSH had awarded
and set aside treatment funds totaling $51 million from its $75 million
appropriation for four NYC-area programs.
Background:
The tens of thousands of individuals[Footnote 16] who responded to the
September 11, 2001, attack on the WTC experienced the emotional trauma
of the disaster and were exposed to a noxious mixture of dust, debris,
smoke, and potentially toxic contaminants, such as pulverized concrete,
fibrous glass, particulate matter, and asbestos. A wide variety of
health effects have been experienced by responders to the WTC attack,
and several federally funded programs have been created to address the
health needs of these individuals.
Health Effects:
Numerous studies have documented the physical and mental health effects
of the WTC attacks.[Footnote 17] Physical health effects included
injuries and respiratory conditions, such as sinusitis, asthma, and a
new syndrome called WTC cough, which consists of persistent coughing
accompanied by severe respiratory symptoms. Almost all firefighters who
responded to the attack experienced respiratory effects, including WTC
cough. One study suggested that exposed firefighters on average
experienced a decline in lung function equivalent to that which would
be produced by 12 years of aging.[Footnote 18] A recently published
study found a significantly higher risk of newly diagnosed asthma among
responders that was associated with increased exposure to the WTC
disaster site.[Footnote 19] Commonly reported mental health effects
among responders and other affected individuals included symptoms
associated with post-traumatic stress disorder (PTSD), depression, and
anxiety. Behavioral health effects such as alcohol and tobacco use have
also been reported.
Some health effects experienced by responders have persisted or
worsened over time, leading many responders to begin seeking treatment
years after September 11, 2001. Clinicians involved in screening,
monitoring, and treating responders have found that many responders'
conditions--both physical and psychological--have not resolved and have
developed into chronic disorders that require long-term monitoring. For
example, findings from a study conducted by clinicians at the NY/NJ WTC
Consortium show that at the time of examination, up to 2.5 years after
the start of the rescue and recovery effort, 59 percent of responders
enrolled in the program were still experiencing new or worsened
respiratory symptoms.[Footnote 20] Experts studying the mental health
of responders found that about 2 years after the WTC attack, responders
had higher rates of PTSD and other psychological conditions compared to
others in similar jobs who were not WTC responders and others in the
general population.[Footnote 21] Clinicians also anticipate that other
health effects, such as immunological disorders and cancers, may emerge
over time.
Overview of WTC Health Programs:
There are six key programs that currently receive federal funding to
provide voluntary health screening, monitoring, or treatment at no cost
to responders.[Footnote 22] The six WTC health programs, shown in table
1, are (1) the FDNY WTC Medical Monitoring and Treatment Program; (2)
the NY/NJ WTC Consortium, which comprises five clinical centers in the
NY/NJ area;[Footnote 23] (3) the WTC Federal Responder Screening
Program; (4) the WTC Health Registry; (5) Project COPE; and (6) the
Police Organization Providing Peer Assistance (POPPA) program.[Footnote
24] The programs vary in aspects such as the HHS administering agency
or component responsible for administering the funding; the
implementing agency, component, or organization responsible for
providing program services; eligibility requirements; and services.
Table 1: Key Federally Funded WTC Health Programs, June 2007:
Program: FDNY WTC Medical Monitoring and Treatment Program;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: FDNY Bureau of Health
Services;
Eligible population: Firefighters and emergency medical service
technicians;
Services provided:
* Initial screening;
* Follow-up medical monitoring;
* Treatment of WTC-related physical and mental health conditions.
Program: NY/NJ WTC Consortium;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: Five clinical centers,
one of which, the Mount Sinai-Irving J. Selikoff Center for
Occupational and Environmental Medicine, also serves as the
consortium's Data and Coordination Center (DCC);
Eligible population: All responders, excluding FDNY firefighters and
emergency medical service technicians and current federal employees[A];
Services provided:
* Initial screening;
* Follow-up medical monitoring;
* Treatment of WTC-related physical and mental health conditions.
Program: WTC Federal Responder Screening Program;
HHS administering agency or component: NIOSH[B];
Implementing agency, component, or organization: FOH;
Eligible population: Current federal employees who responded to the WTC
attack in an official capacity;
Services provided:
* Onetime screening;
* Referrals to employee assistance programs and specialty diagnostic
services[C].
Program: WTC Health Registry;
HHS administering agency or component: Agency for Toxic Substances and
Disease Registry (ATSDR);
Implementing agency, component, or organization: NYC Department of
Health and Mental Hygiene;
Eligible population: Responders and people living or attending school
in the area of the WTC or working or present in the vicinity on
September 11, 2001;
Services provided:
* Long-term monitoring through periodic surveys.
Program: Project COPE;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: Collaboration between
the NYC Police Foundation and Columbia University Medical Center;
Eligible population: New York City Police Department (NYPD) uniformed
and civilian employees and their family members;
Services provided:
* Hotline, mental health counseling, and referral services;
some services provided by Columbia University clinical staff and some
by other clinicians.
Program: POPPA program;
HHS administering agency or component: NIOSH;
Implementing agency, component, or organization: POPPA program;
Eligible population: NYPD uniformed employees;
Services provided:
* Hotline, mental health counseling, and referral services;
some services provided by trained NYPD officers and some by mental
health professionals.
Source: GAO analysis of information from NIOSH, ATSDR, FOH, FDNY, the
NY/NJ WTC Consortium, the NYC Department of Health and Mental Hygiene,
the POPPA program, and Project COPE.
Note: Some of these federally funded programs have also received funds
from the American Red Cross and other private organizations.
[A] In February 2006, ASPR and NIOSH reached an agreement to have
former federal employees screened by the NY/NJ WTC Consortium.
[B] Until December 26, 2006, ASPR was the administrator.
[C] FOH can refer an individual with mental health symptoms to an
employee assistance program for a telephone assessment. If appropriate,
the individual can then be referred to a program counselor for up to
six in-person sessions. The specialty diagnostic services are provided
by ear, nose, and throat doctors;
pulmonologists;
and cardiologists.
[End of table]
The WTC health programs that are providing screening and monitoring are
tracking thousands of individuals who were affected by the WTC
disaster. As of June 2007, the FDNY WTC program had screened about
14,500 responders and had conducted follow-up examinations for about
13,500 of these responders, while the NY/NJ WTC Consortium had screened
about 20,000 responders and had conducted follow-up examinations for
about 8,000 of these responders. Some of the responders include
nonfederal responders residing outside the NYC metropolitan area. As of
June 2007, the WTC Federal Responder Screening Program had screened
1,305 federal responders and referred 281 responders for employee
assistance program services or specialty diagnostic services. In
addition, the WTC Health Registry, a monitoring program that consists
of periodic surveys of self-reported health status and related studies
but does not provide in-person screening or monitoring, collected
baseline health data from over 71,000 people who enrolled in the
Registry.[Footnote 25] In the winter of 2006, the Registry began its
first adult follow-up survey, and as of June 2007 over 36,000
individuals had completed the follow-up survey.
In addition to providing medical examinations, FDNY's WTC program and
the NY/NJ WTC Consortium have collected information for use in
scientific research to better understand the health effects of the WTC
attack and other disasters. The WTC Health Registry is also collecting
information to assess the long-term public health consequences of the
disaster.
Federal Funding and Coordination of WTC Health Programs:
Beginning in October 2001 and continuing through 2003, FDNY's WTC
program, the NY/NJ WTC Consortium, the WTC Federal Responder Screening
Program, and the WTC Health Registry received federal funding to
provide services to responders. This funding primarily came from
appropriations to the Department of Homeland Security's Federal
Emergency Management Agency (FEMA),[Footnote 26] as part of the
approximately $8.8 billion that the Congress appropriated to FEMA for
response and recovery activities after the WTC disaster.[Footnote 27]
FEMA entered into interagency agreements with HHS agencies to
distribute the funding to the programs. For example, FEMA entered into
an agreement with NIOSH to distribute $90 million appropriated in 2003
that was available for monitoring.[Footnote 28] FEMA also entered into
an agreement with ASPR for ASPR to administer the WTC Federal Responder
Screening Program. A $75 million appropriation to CDC in fiscal year
2006 for purposes related to the WTC attack resulted in additional
funding for the monitoring activities of the FDNY WTC program, NY/NJ
WTC Consortium, and the Registry.[Footnote 29] The $75 million
appropriation to CDC in fiscal year 2006 also provided funds that were
awarded to the FDNY WTC program, the NY/NJ WTC Consortium, Project
COPE, and the POPPA program for treatment services for responders. An
emergency supplemental appropriation to CDC in May 2007 included an
additional $50 million to carry out the same activities provided for in
the $75 million appropriation made in fiscal year 2006.[Footnote 30]
The President's proposed fiscal year 2008 budget for HHS includes $25
million for treatment of WTC-related illnesses for responders.
In February 2006, the Secretary of HHS designated the Director of NIOSH
to take the lead in ensuring that the WTC health programs are well
coordinated, and in September 2006 the Secretary established a WTC Task
Force to advise him on federal policies and funding issues related to
responders' health conditions. The chair of the task force is HHS's
Assistant Secretary for Health, and the vice chair is the Director of
NIOSH. The task force reported to the Secretary of HHS in early April
2007.
WTC Federal Responder Screening Program Has Had Difficulties Ensuring
the Availability of Screening Services, and NIOSH Was Considering
Expanding the Program to Include Monitoring:
HHS's WTC Federal Responder Screening Program has had difficulties
ensuring the uninterrupted availability of services for federal
responders. First, the provision of screening examinations has been
intermittent. (See fig. 1.) After resuming screening examinations in
December 2005[Footnote 31] and conducting them for about a year, HHS
again placed the program on hold and suspended scheduling of screening
examinations for responders from January 2007 to May 2007. This
interruption in service occurred because there was a change in the
administration of the WTC Federal Responder Screening Program, and
certain interagency agreements were not established in time to keep the
program fully operational. In late December 2006, ASPR and NIOSH signed
an interagency agreement giving NIOSH $2.1 million to administer the
WTC Federal Responder Screening Program.[Footnote 32] Subsequently,
NIOSH and FOH needed to sign a new interagency agreement to allow FOH
to continue to be reimbursed for providing screening examinations. It
took several months for the agreement between NIOSH and FOH to be
negotiated and approved, and scheduling of screening examinations did
not resume until May 2007.[Footnote 33]
Figure 1: Timeline of Key Actions Related to the WTC Federal Responder
Screening Program:
[See PDF for image]
Source: GAO analysis of information from ASPR, FOH, NIOSH, and FEMA.
Note: The WTC Federal Responder Screening Program serves current
federal employees who responded to the WTC attack in an official
capacity. In February 2006, ASPR and NIOSH reached an agreement to have
former federal employees screened by the NY/NJ WTC Consortium.
[A] In December 2006 the Office of Public Health and Emergency
Preparedness became ASPR. We refer to that office as ASPR throughout
this figure, regardless of the time period being discussed.
[B] In providing referrals for specialty diagnostic services, FOH
schedules and pays for the diagnostic services.
[C] After HHS placed the program on hold, FOH completed examinations
that had already been scheduled.
[End of figure]
Second, the program's provision of specialty diagnostic services has
also been intermittent. After initial screening examinations,
responders often need further diagnostic services by ear, nose, and
throat doctors; cardiologists; and pulmonologists; and FOH had been
referring responders to these specialists and paying for the services.
However, the program stopped scheduling and paying for these specialty
diagnostic services in April 2006 because the program's contract with a
new provider network did not cover these services.[Footnote 34] In
March 2007, FOH modified its contract with the provider network and
resumed scheduling and paying for specialty diagnostic services for
federal responders.
In July 2007 we reported that NIOSH was considering expanding the WTC
Federal Responder Screening Program to include monitoring examinations-
-follow-up physical and mental health examinations--and was assessing
options for funding and delivering these services. If federal
responders do not receive this type of monitoring, health conditions
that arise later may not be diagnosed and treated, and knowledge of the
health effects of the WTC disaster may be incomplete. In February 2007,
NIOSH sent a letter to FEMA, which provides the funding for the
program, asking whether the funding could be used to support monitoring
in addition to the onetime screening currently offered. A NIOSH
official told us that as of August 2007 the agency had not received a
response from FEMA. NIOSH officials told us that if FEMA did not agree
to pay for monitoring of federal responders, NIOSH would consider using
other funding. According to a NIOSH official, if FEMA or NIOSH agrees
to pay for monitoring of federal responders, this service would be
provided by FOH or one of the other WTC health programs.
NIOSH Has Not Ensured the Availability of Services for Nonfederal
Responders Residing outside the NYC Metropolitan Area:
NIOSH has not ensured the availability of screening and monitoring
services for nonfederal responders residing outside the NYC
metropolitan area, although it recently took steps toward expanding the
availability of these services. Initially, NIOSH made two efforts to
provide screening and monitoring services for these responders, the
exact number of which is unknown.[Footnote 35] The first effort began
in late 2002 when NIOSH awarded a contract for about $306,000 to the
Mount Sinai School of Medicine to provide screening services for
nonfederal responders residing outside the NYC metropolitan area and
directed it to establish a subcontract with AOEC.[Footnote 36] AOEC
then subcontracted with 32 of its member clinics across the country to
provide screening services. From February 2003 to July 2004, the 32
AOEC member clinics screened 588 nonfederal responders nationwide. AOEC
experienced challenges in providing these screening services. For
example, many nonfederal responders did not enroll in the program
because they did not live near an AOEC clinic, and the administration
of the program required substantial coordination among AOEC, AOEC
member clinics, and Mount Sinai.
Mount Sinai's subcontract with AOEC ended in July 2004, and from August
2004 until June 2005 NIOSH did not fund any organization to provide
services to nonfederal responders outside the NYC metropolitan
area.[Footnote 37] During this period, NIOSH focused on providing
screening and monitoring services for nonfederal responders in the NYC
metropolitan area. In June 2005, NIOSH began its second effort by
awarding $776,000 to the Mount Sinai School of Medicine Data and
Coordination Center (DCC) to provide both screening and monitoring
services for nonfederal responders residing outside the NYC
metropolitan area. In June 2006, NIOSH awarded an additional $788,000
to DCC to provide screening and monitoring services for these
responders. NIOSH officials told us that they assigned DCC the task of
providing screening and monitoring services to nonfederal responders
outside the NYC metropolitan area because the task was consistent with
DCC's responsibilities for the NY/NJ WTC Consortium, which include data
monitoring and coordination. DCC, however, had difficulty establishing
a network of providers that could serve nonfederal responders residing
throughout the country--ultimately contracting with only 10 clinics in
seven states to provide screening and monitoring services.[Footnote 38]
DCC officials said that as of June 2007 the 10 clinics were monitoring
180 responders.
In early 2006, NIOSH began exploring how to establish a national
program that would expand the network of providers to provide screening
and monitoring services, as well as treatment services, for nonfederal
responders residing outside the NYC metropolitan area.[Footnote 39]
According to NIOSH, there have been several challenges involved in
expanding a network of providers to screen and monitor nonfederal
responders nationwide. These include establishing contracts with
clinics that have the occupational health expertise to provide services
nationwide, establishing patient data transfer systems that comply with
applicable privacy laws, navigating the institutional review
board[Footnote 40] process for a large provider network, and
establishing payment systems with clinics participating in a national
network of providers. On March 15, 2007, NIOSH issued a formal request
for information from organizations that have an interest in and the
capability of developing a national program for responders residing
outside the NYC metropolitan area.[Footnote 41] In this request, NIOSH
described the scope of a national program as offering screening,
monitoring, and treatment services to about 3,000 nonfederal responders
through a national network of occupational health facilities. NIOSH
also specified that the program's facilities should be located within
reasonable driving distance to responders and that participating
facilities must provide copies of examination records to DCC. In May
2007, NIOSH approved a request from DCC to redirect about $125,000 from
the June 2006 award to establish a contract with a company to provide
screening and monitoring services for nonfederal responders residing
outside the NYC metropolitan area. Subsequently, DCC contracted with
QTC Management, Inc.,[Footnote 42] one of the four organizations that
had responded to NIOSH's request for information. DCC's contract with
QTC does not include treatment services, and NIOSH officials are still
exploring how to provide and pay for treatment services for nonfederal
responders residing outside the NYC metropolitan area.[Footnote 43] QTC
has a network of providers in all 50 states and the District of
Columbia and can use internal medicine and occupational medicine
doctors in its network to provide these services. In addition, DCC and
QTC have agreed that QTC will identify and subcontract with providers
outside of its network to screen and monitor nonfederal responders who
do not reside within 25 miles of a QTC provider.[Footnote 44] In June
2007, NIOSH awarded $800,600 to DCC for coordinating the provision of
screening and monitoring examinations, and QTC will receive a portion
of this award from DCC to provide about 1,000 screening and monitoring
examinations through May 2008. According to a NIOSH official, QTC's
providers have begun conducting screening examinations, and by the end
of August 2007, 18 nonfederal responders had completed screening
examinations, and 33 others had been scheduled.
NIOSH Awarded Funding for Treatment Services to Four WTC Health
Programs:
In fall 2006, NIOSH awarded and set aside funds totaling $51 million
from its $75 million appropriation for four WTC health programs in the
NYC metropolitan area to provide treatment services to responders
enrolled in these programs. Of the $51 million, NIOSH awarded about $44
million for outpatient services to the FDNY WTC program, the NY/NJ WTC
Consortium, Project COPE, and the POPPA program. NIOSH made the largest
awards to the two programs from which almost all responders receive
medical services, the FDNY WTC program and NY/NJ WTC Consortium (see
table 2). In July 2007 we reported that officials from the FDNY WTC
program and the NY/NJ WTC Consortium expected that their awards for
outpatient treatment would be spent by the end of fiscal year
2007.[Footnote 45],[Footnote 46] In addition to the $44 million it
awarded for outpatient services, NIOSH set aside about $7 million for
the FDNY WTC program and NY/NJ WTC Consortium to pay for responders'
WTC-related inpatient hospital care as needed.[Footnote 47]
Table 2: NIOSH Awards to WTC Health Programs for Providing Treatment
Services, 2006:
(Dollars in millions)
WTC health program: NY/NJ WTC Consortium;
Amount of award[A]: $20.8;
Date of award: October 26, 2006.
WTC health program: FDNY WTC Medical Monitoring and Treatment Program;
Amount of award[A]: 18.7;
Date of award: October 26, 2006.
WTC health program: Project COPE;
Amount of award[A]: 3.0[B];
Date of award: September 19, 2006.
WTC health program: POPPA program;
Amount of award[A]: 1.5[C];
Date of award: September 19, 2006.
WTC health program: Total amount of awards;
Amount of award[A]: $44.0;
Source: NIOSH.
[A] Amount is rounded to the nearest $0.1 million.
[B] NIOSH will provide $1 million annually to Project COPE beginning in
September 2006 through September 2008, for a total award of $3 million.
[C] NIOSH will provide $500,000 annually to the POPPA program beginning
in September 2006 through September 2008, for a total award of $1.5
million.
[End of table]
The FDNY WTC program and NY/NJ WTC Consortium used their awards from
NIOSH to continue providing treatment services to responders and to
expand the scope of available treatment services. Before NIOSH made its
awards for treatment services, the treatment services provided by the
two programs were supported by funding from private philanthropies and
other organizations. According to officials of the NY/NJ WTC
Consortium, this funding was sufficient to provide only outpatient care
and partial coverage for prescription medications. The two programs
used NIOSH's awards to continue to provide outpatient services to
responders, such as treatment for gastrointestinal reflux disease,
upper and lower respiratory disorders, and mental health conditions.
They also expanded the scope of their programs by offering responders
full coverage for their prescription medications for the first time. A
NIOSH official told us that some of the commonly experienced WTC
conditions, such as upper airway conditions, gastrointestinal
disorders, and mental health disorders, are frequently treated with
medications that can be costly and may be prescribed for an extended
period of time. According to an FDNY WTC program official, prescription
medications are now the largest component of the program's treatment
budget.
The FDNY WTC program and NY/NJ Consortium also expanded the scope of
their programs by paying for inpatient hospital care for the first
time, using funds from the $7 million that NIOSH had set aside for this
purpose. According to a NIOSH official, NIOSH pays for hospitalizations
that have been approved by the medical directors of the FDNY WTC
program and NY/NJ WTC Consortium through awards to the programs from
the funds NIOSH set aside for this purpose. By August 31, 2007, federal
funds had been used to support 34 hospitalizations of responders, 28 of
which were referred by the NY/NJ WTC Consortium's Mount Sinai clinic, 5
by the FDNY WTC program, and 1 by the NY/NJ WTC Consortium's CUNY
Queens College program. Responders have received inpatient hospital
care to treat, for example, asthma, pulmonary fibrosis,[Footnote 48]
and severe cases of depression or PTSD. According to a NIOSH official,
one responder is now a candidate for lung transplantation and if this
procedure is performed, it will be covered by federal funds. If funds
set aside for hospital care are not completely used by the end of
fiscal year 2007, he said they could be carried over into fiscal year
2008 for this purpose or used for outpatient services.
After receiving NIOSH's funding for treatment services in fall 2006,
the NY/NJ WTC Consortium ended its efforts to obtain reimbursement from
health insurance held by responders with coverage.[Footnote 49]
Consortium officials told us that efforts to bill insurance companies
involved a heavy administrative burden and were frequently
unsuccessful, in part because the insurance carriers typically denied
coverage for work-related health conditions on the grounds that such
conditions should be covered by state workers' compensation programs.
However, according to officials from the NY/NJ WTC Consortium,
responders trying to obtain workers' compensation coverage routinely
experienced administrative hurdles and significant delays, some lasting
several years. Moreover, according to these program officials, the
majority of responders enrolled in the program either had limited or no
health insurance coverage. According to a labor official, responders
who carried out cleanup services after the WTC attack often did not
have health insurance, and responders who were construction workers
often lost their health insurance when they became too ill to work the
number of days each quarter or year required to maintain eligibility
for insurance coverage.
According to a NIOSH official, although the agency had not received
authorization as of August 30, 2007, to use the $50 million emergency
supplemental appropriation made to CDC in May 2007, NIOSH was
formulating plans for use of these funds to support the WTC treatment
programs in fiscal year 2008.
Concluding Observations:
Screening and monitoring the health of the people who responded to the
September 11, 2001, attack on the World Trade Center are critical for
identifying health effects already experienced by responders or those
that may emerge in the future. In addition, collecting and analyzing
information produced by screening and monitoring responders can give
health care providers information that could help them better diagnose
and treat responders and others who experience similar health effects.
While some groups of responders are eligible for screening and follow-
up physical and mental health examinations through the federally funded
WTC health programs, other groups of responders are not eligible for
comparable services or may not always find these services available.
Federal responders have been eligible only for the initial screening
examination provided through the WTC Federal Responder Screening
Program. NIOSH, the administrator of the program, has been considering
expanding the program to include monitoring but has not done so. In
addition, many responders who reside outside the NYC metropolitan area
have not been able to obtain screening and monitoring services because
available services are too distant. Moreover, HHS has repeatedly
interrupted the programs it established for federal responders and
nonfederal responders outside of NYC, resulting in periods when no
services were available to them.
HHS continues to fund and coordinate the WTC health programs and has
key federal responsibility for ensuring the availability of services to
responders. HHS and its agencies have recently taken steps to move
toward providing screening and monitoring services to federal
responders and to nonfederal responders living outside of the NYC area.
However, these efforts are not complete, and the stop-and-start history
of the department's efforts to serve these groups does not provide
assurance that the latest efforts to extend screening and monitoring
services to these responders will be successful and will be sustained
over time. Therefore we recommended in July 2007 that the Secretary of
HHS take expeditious action to ensure that health screening and
monitoring services are available to all people who responded to the
attack on the WTC, regardless of who their employer was or where they
reside. As of early September 2007 the department has not responded to
this recommendation.
Mr. Chairman, this completes my prepared remarks. I would be happy to
respond to any questions you or other members of the subcommittee may
have at this time.
Contacts and Acknowledgments:
For further information about this testimony, please contact Cynthia A.
Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Helene F. Toiv, Assistant Director;
Hernan Bozzolo; Frederick Caison; Anne Dievler; and Roseanne Price made
key contributions to this statement.
[End of section]
Appendix I: Abbreviations:
AOEC: Association of Occupational and Environmental Clinics:
ASPR: Office of the Assistant Secretary for Preparedness and Response:
ATSDR: Agency for Toxic Substances and Disease Registry:
CDC: Centers for Disease Control and Prevention:
DCC: Data and Coordination Center:
FDNY: New York City Fire Department:
FEMA: Federal Emergency Management Agency:
FOH: Federal Occupational Health Services:
HHS: Department of Health and Human Services:
NIOSH: National Institute for Occupational Safety and Health:
NYC: New York City:
NY/NJ: New York/New Jersey:
NYPD: New York City Police Department:
POPPA: Police Organization Providing Peer Assistance:
PTSD: post-traumatic stress disorder:
WTC: World Trade Center:
[End of section]
Related GAO Products:
September 11: HHS Needs to Ensure the Availability of Health Screening
and Monitoring for All Responders. GAO-07-892. Washington, D.C.: July
23, 2007.
September 11: HHS Has Screened Additional Federal Responders for World
Trade Center Health Effects, but Plans for Awarding Funds for Treatment
Are Incomplete. GAO-06-1092T. Washington, D.C.: September 8, 2006.
September 11: Monitoring of World Trade Center Health Effects Has
Progressed, but Program for Federal Responders Lags Behind. GAO-06-
481T. Washington, D.C.: February 28, 2006.
September 11: Monitoring of World Trade Center Health Effects Has
Progressed, but Not for Federal Responders. GAO-05-1020T. Washington,
D.C.: September 10, 2005.
September 11: Health Effects in the Aftermath of the World Trade Center
Attack. GAO-04-1068T. Washington, D.C.: September 8, 2004.
Footnotes:
[1] A list of abbreviations used in this testimony is in app. I.
[2] The Staten Island site is the landfill that is the off-site
location of the WTC recovery operation.
[3] In this testimony, "screening" refers to initial physical and
mental health examinations of affected individuals. "Monitoring" refers
to tracking the health of individuals over time, either through
periodic surveys or through follow-up physical and mental health
examinations.
[4] One of the WTC health programs, the WTC Health Registry, also
includes people living or attending school in the area of the WTC or
working or present in the vicinity on September 11, 2001.
[5] See, for example, GAO, September 11: HHS Has Screened Additional
Federal Responders for World Trade Center Health Effects, but Plans for
Awarding Funds for Treatment Are Incomplete, GAO-06-1092T (Washington,
D.C.: Sept. 8, 2006). A list of related GAO products is included at the
end of this testimony.
[6] See GAO, September 11: Monitoring of World Trade Center Health
Effects Has Progressed, but Not for Federal Responders, GAO-05-1020T
(Washington, D.C.: Sept. 10, 2005), and September 11: Monitoring of
World Trade Center Health Effects Has Progressed, but Program for
Federal Responders Lags Behind, GAO-06-481T (Washington, D.C.: Feb. 28,
2006).
[7] See GAO-06-1092T.
[8] In general, the WTC health programs provide services in the NYC
metropolitan area.
[9] Department of Defense Appropriations Act, 2006, Pub. L. No. 109-
148, § 5011(b), 119 Stat. 2680, 2814 (2005).
[10] See GAO-06-1092T.
[11] See GAO, September 11: HHS Needs to Ensure the Availability of
Health Screening and Monitoring for All Responders, GAO-07-892
(Washington, D.C.: July 23, 2007).
[12] FOH is a service unit within HHS's Program Support Center that
provides occupational health services to federal government departments
and agencies located throughout the United States.
[13] ASPR coordinates and directs HHS's emergency preparedness and
response program. In December 2006 the Office of Public Health and
Emergency Preparedness became ASPR. We refer to that office as ASPR
throughout this testimony, regardless of the time period discussed.
[14] NIOSH provides funds to the programs through cooperative
agreements, but refers to award recipients as grantees. Therefore, in
this testimony we use the term grantee when referring to NIOSH's award
recipients.
[15] In previous reports we have also referred to this program as the
worker and volunteer WTC program.
[16] There is not a definitive count of the number of people who served
as responders. Estimates have ranged from about 40,000 to about 91,000.
[17] See, for example, Centers for Disease Control and Prevention,
"Mental Health Status of World Trade Center Rescue and Recovery Workers
and Volunteers--New York City, July 2002-August 2004," Morbidity and
Mortality Weekly Report, vol. 53 (2004); "Physical Health Status of
World Trade Center Rescue and Recovery Workers and Volunteers--New York
City, July 2002-August 2004," Morbidity and Mortality Weekly Report,
vol. 53 (2004); and "Surveillance for World Trade Center Disaster
Health Effects among Survivors of Collapsed and Damaged Buildings,"
Morbidity and Mortality Weekly Report, vol. 55 (2006). See also G. I.
Banauch et al., "Pulmonary Function after Exposure to the World Trade
Center in the New York City Fire Department," American Journal of
Respiratory and Critical Care Medicine, vol. 174, no. 3 (2006); G.
Izbicki et al., "World Trade Center 'Sarcoid Like' Granulomatous
Pulmonary Disease in New York City Fire Department Rescue Workers,"
Chest, vol. 131 (2007); and K. Wheeler et al., "Asthma Diagnosed after
September 11, 2001 among Rescue and Recovery Workers: Findings from the
World Trade Center Health Registry," Environmental Health Perspectives,
[hyperlink, http://dx.doi.org/10.1289/ehp.10248] (downloaded Aug. 27,
2007).
[18] Banauch et al., "Pulmonary Function."
[19] Wheeler et al., "Asthma Diagnosed."
[20] R. Herbert et al., "The World Trade Center Disaster and the Health
of Workers: Five-Year Assessment of a Unique Medical Screening
Program," Environmental Health Perspectives, vol. 114, no. 12 (2006).
[21] For example, see R. Gross et al., "Posttraumatic Stress Disorder
and Other Psychological Sequelae among World Trade Center Clean Up and
Recovery Workers," Annals of the New York Academy of Sciences, vol.
1071 (2006). M. Perrin et al., "Differences in PTSD Prevalence and
Associated Risk Factors among World Trade Center Disaster Rescue and
Recovery Workers," American Journal of Psychiatry, vol. 64 (2007).
[22] In addition to these programs, a New York State responder
screening program received federal funding for screening New York State
employees and National Guard personnel who responded to the WTC attack
in an official capacity. This program ended its screening examinations
in November 2003.
[23] The NY/NJ WTC Consortium consists of five clinical centers
operated by (1) Mount Sinai-Irving J. Selikoff Center for Occupational
and Environmental Medicine; (2) Long Island Occupational and
Environmental Health Center at SUNY, Stony Brook; (3) New York
University School of Medicine/Bellevue Hospital Center; (4) Center for
the Biology of Natural Systems, at CUNY, Queens College; and (5)
University of Medicine and Dentistry of New Jersey Robert Wood Johnson
Medical School, Environmental and Occupational Health Sciences
Institute. Mount Sinai's clinical center, which is the largest of the
five centers, also receives federal funding to operate a data and
coordination center to coordinate the work of the five clinical centers
and conduct outreach and education, quality assurance, and data
management for the NY/NJ WTC Consortium.
[24] Project COPE and the POPPA program provide mental health services
to members of the New York City Police Department (NYPD) and operate
independently of the NYPD.
[25] The WTC Health Registry also provides information on where
participants can seek health care.
[26] FEMA is the agency responsible for coordinating federal disaster
response efforts under the National Response Plan.
[27] See Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-
7, 117 Stat. 11, 517; 2002 Supplemental Appropriations Act for Further
Recovery from and Response to Terrorist Attacks on the United States,
Pub. L. No. 107-206, 116 Stat. 820, 894; Department of Defense and
Emergency Supplemental Appropriations for Recovery from and Response to
Terrorist Attacks on the United States Act, 2002, Pub. L. No. 107-117,
115 Stat. 2230, 2338; and 2001 Emergency Supplemental Appropriations
Act for Recovery from and Response to Terrorist Attacks on the United
States, Pub. L. No. 107-38, 115 Stat. 220-221.
[28] Pub. L. No. 108-7, 117 Stat. 517.
[29] The statute required CDC, in expending such funds, to give first
priority to specified existing programs that administer baseline and
follow-up screening; clinical examinations; or long-term medical health
monitoring, analysis, or treatment for emergency services personnel or
rescue and recovery personnel. It required CDC to give secondary
priority to similar programs coordinated by other entities working with
the State of New York and NYC. Pub. L. No. 109-148, § 5011(b), 119
Stat. 2814.
[30] U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq
Accountability Appropriations Act, 2007, Pub. L. No. 110-28, ch. 5, 121
Stat. 112, 166 (2007).
[31] The program previously suspended examinations from March 2004 to
December 2005. See GAO-06-481T.
[32] The agreement was a modification of ASPR's February 2006
interagency agreement with NIOSH that covers screenings for former
federal employees.
[33] Before an agreement between NIOSH and FOH could be signed, the
agreement between ASPR and NIOSH required several technical
corrections. The revised ASPR-NIOSH agreement extended the availability
of funding for the WTC Federal Responder Screening Program to April 30,
2008.
[34] In April 2006, FOH contracted with a new provider network to
provide various services for all federal employees, such as
immunizations and vision tests. The contract with the new provider
network did not cover specialty diagnostic services by ear, nose, and
throat doctors; cardiologists; and pulmonologists. Although the
previous provider network had provided these services, the new provider
network and the HHS contract officer interpreted the statement of work
in the new contract as not including these specialty diagnostic
services.
[35] According to the NYC Department of Health and Mental Hygiene,
about 7,000 nonfederal and federal responders residing outside the NYC
metropolitan area have enrolled in the WTC Health Registry.
[36] Around that time, NIOSH was providing screening services for
nonfederal responders in the NYC metropolitan area through the NY/NJ
WTC Consortium and the FDNY WTC program. Nonfederal responders residing
outside the NYC metropolitan area were able to travel at their own
expense to the NYC metropolitan area to obtain screening services
through the NY/NJ WTC Consortium.
[37] In early 2004, AOEC applied to NIOSH to use its national network
of member clinics to provide screening and monitoring for nonfederal
responders residing outside the NYC metropolitan area, but NIOSH
rejected AOEC's application for several reasons, including that the
application did not adequately address how to coordinate and implement
a monitoring program with complex data collection and reporting
requirements.
[38] Contracts were originally established with 11 clinics in eight
states, but 1 clinic discontinued its participation in the program
after conducting one examination. The 10 active clinics are located in
seven states: Arkansas, California, Illinois, Maryland, Massachusetts,
New York, and Ohio. Of the 10 active clinics, 7 are AOEC member
clinics.
[39] According to NIOSH and DCC officials, efforts to provide
monitoring services to federal responders residing outside the NYC
metropolitan area may be included in the national program.
[40] Institutional review boards are groups that have been formally
designated to review and monitor biomedical research involving human
subjects, such as research based on data collected from screening and
monitoring examinations.
[41] Department of Health and Human Services, Sources Sought Notice:
National Medical Monitoring and Treatment Program for World Trade
Center (WTC) Rescue, Recovery, and Restoration Responders and
Volunteers, SSA-WTC-001 (Mar. 15, 2007).
[42] QTC is a private provider of government-outsourced occupational
health and disability examination services.
[43] Some nonfederal responders residing outside the NYC metropolitan
area may have access to privately funded treatment services. In June
2005 the American Red Cross funded AOEC to provide treatment services
for these responders. As of June 2007, AOEC had contracted with 40 of
its member clinics located in 27 states and the District of Columbia to
provide these services. An American Red Cross official told us in
September 2007 that funding for AOEC to provide treatment services
would continue through June 2008.
[44] As of June 2007, DCC identified 1,151 nonfederal responders
residing outside the NYC metropolitan area who requested screening and
monitoring services and were too ill or lacked financial resources to
travel to NYC or any of DCC's 10 contracted clinics.
[45] In August 2007 a NIOSH official told us that NIOSH did not expect
that all of these funds would be spent by September 30, 2007.
[46] In addition to funding from NIOSH, the FDNY WTC program and the
NY/ NJ WTC Consortium received funding in 2006 from the American Red
Cross to provide treatment services. In September 2007 an official from
the American Red Cross told us that it was the organization's
understanding that most of the clinics in the NY/NJ WTC Consortium had
expended the American Red Cross funds but that one of the Consortium's
clinics was expected to request a no-cost 6-month extension up to the
end of calendar year 2007. The American Red Cross had already granted a
similar extension for the same period to the FDNY WTC program.
[47] Of the $24 million remaining from the $75 million appropriation to
CDC, NIOSH used about $15 million to support monitoring and other WTC-
related health services conducted by the FDNY WTC program and NY/NJ WTC
Consortium. ATSDR awarded $9 million to the WTC Health Registry to
continue its collection of health data.
[48] Pulmonary fibrosis is a condition characterized by the formation
of scar tissue in the lungs following the inflammation of lung tissue.
[49] The NY/NJ WTC Consortium now offers treatment services at no cost
to responders; however, prior to fall 2006 the program attempted when
possible to obtain reimbursement for its services from health insurance
carriers and to obtain applicable co-payments from responders.
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