This is the accessible text file for GAO report number GAO-06-1092T entitled 'September 11: HHS Has Screened Additional Federal Responders for World Trade Center Health Effects, but Plans for Awarding Funds for Treatment Are Incomplete' which was released on September 8, 2006. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Testimony: Before the Subcommittee on National Security, Emerging Threats, and International Relations, Committee on Government Reform, House of Representatives: United States Government Accountability Office: GAO: For Release on Delivery Expected at 10:30 a.m. EDT: in New York, New York, Friday, September 8, 2006: September 11: HHS Has Screened Additional Federal Responders for World Trade Center Health Effects, but Plans for Awarding Funds for Treatment Are Incomplete: Statement of Cynthia A. Bascetta: Director, Health Care: GAO-06-1092T: GAO Highlights: Highlights of GAO-06-1092T, a testimony before the Subcommittee on National Security, Emerging Threats, and International Relations, Committee on Government Reform, House of Representatives Why GAO Did This Study: Responders to the World Trade Center (WTC) attack—individuals involved in rescue, recovery, or cleanup—included New York City Fire Department (FDNY) personnel, federal government workers, and others from New York and elsewhere. They were exposed to numerous hazards, and concerns remain about the long-term effects on their physical and mental health. In February 2006, GAO testified that four of the five key federally funded programs that were monitoring health effects in responders had made progress but that the Department of Health and Human Services’ (HHS) WTC Federal Responder Screening Program, implemented by the Office of Public Health Emergency Preparedness (OPHEP), lagged behind (GAO-06-481T). GAO also reported that the Congress appropriated $75 million in December 2005 to HHS’s Centers for Disease Control and Prevention (CDC) for monitoring and treatment for responders and that CDC was deciding how to allocate the funds. This statement updates GAO’s February 2006 testimony. GAO examined (1) progress made by HHS’s WTC federal responder program and (2) actions CDC has taken to award the $75 million appropriated. GAO reviewed program documents and interviewed HHS officials and others involved in WTC monitoring and treatment programs. What GAO Found: The WTC federal responder program has registered and screened additional federal responders since February 2006, and arrangements are being developed to screen responders who are former federal workers residing outside the New York area. An additional 1,385 federal responders have registered for screening, including 1,134 current federal workers and 251 former federal workers, bringing the total number registered as of late August 2006 to 1,762, including 283 former federal workers. Because the total number of federal responders is uncertain, the proportion of the total who have registered is unknown. As of late August 2006, Federal Occupational Health Services (FOH) had completed screening of 907 federal workers, 380 of whom were screened since February 2006. Under an OPHEP agreement with CDC’s National Institute for Occupational Safety and Health (NIOSH), former federal workers are being screened through the worker and volunteer WTC program, one of the five key federally funded programs. As of July 31, 2006, the worker and volunteer WTC program provided screenings to 13 former federal workers and scheduled 11 more, and 139 former workers had been screened by FOH as part of the 907 workers. Most of the former federal workers reside outside the New York area, where the worker and volunteer WTC program is located, and NIOSH is working to establish a national network of providers to screen these workers. CDC has awarded a small portion of the $75 million appropriated for screening, monitoring, and treatment and plans to make decisions about treatment coverage before awarding most of the funds. The agency plans to award the $75 million to the five organizations that the law identified as having priority for funding. CDC officials expect to make awards to the WTC Health Registry, the Police Organization Providing Peer Assistance (the POPPA program), and the New York City Police Foundation’s Project COPE over a 3-year period and to award funds to the FDNY WTC and worker and volunteer WTC programs in response to the treatment costs they incur. CDC officials have a proposed spending plan that allocates about $53.5 million for the latter two programs’ treatment costs, but the officials told GAO that because they are uncertain about how quickly treatment costs could deplete the available funds, they may need to make adjustments. Officials from the FDNY WTC and worker and volunteer WTC programs told GAO that they anticipated that their estimated portion of the funds would be depleted well before the end of 3 years. As of August 2006, CDC awarded about $4.5 million of the $75 million: about $1.9 million to the WTC Health Registry, $1.5 million to the FDNY WTC program, and almost $1.1 million to the worker and volunteer WTC program. In addition, CDC expects to award $1.5 million to the POPPA program and $3 million to Project COPE in September 2006. CDC is waiting to make further awards until it has reached certain decisions about the coverage of treatment services, such as which prescription drugs would be covered. CDC expects to begin making further awards around February 2007. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-1092T]. To view the full product, including the scope and methodology, click on the link above. For more information, contact Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov. [End of Section] Mr. Chairman and Members of the Subcommittee: Thank you for inviting me to participate in today's hearing on programs that monitor and provide treatment for health effects of the World Trade Center (WTC) terrorist attack on September 11, 2001.[Footnote 1] My testimony today updates information we reported to you in February 2006.[Footnote 2] An estimated 40,000 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 Staten Island site.[Footnote 3] These responders were exposed to numerous physical hazards, environmental toxins, and psychological trauma. Five years after the destruction of the WTC buildings, concerns remain about the long-term physical and mental health effects of the attack on responders as well as other affected individuals, including residents and workers. As we testified in September 2004,[Footnote 4] in the aftermath of the WTC attack, five key federally funded programs were implemented to assess the short-term, and in some cases long-term, effects on the physical and mental health of WTC responders. These programs are the FDNY WTC Medical Monitoring Program; WTC Medical Monitoring Program, which we refer to as the worker and volunteer WTC program;[Footnote 5] New York State responder screening program; WTC Health Registry;[Footnote 6] and the Department of Health and Human Services' (HHS) WTC Federal Responder Screening Program. We provided information on the progress of these monitoring programs[Footnote 7] in our February 2006 testimony.[Footnote 8] We noted that federal employees who responded in an official capacity in the aftermath of the WTC attack were eligible only for the federal responder program but that it had accomplished little and lagged behind the other four programs. The other programs had provided thousands of health screenings and collected information that could contribute to better understanding of the health consequences of the attack and improve treatment for affected individuals. Officials of the three programs that planned to conduct long-term health monitoring--the FDNY WTC program, the worker and volunteer WTC program, and the WTC Health Registry--told us they were concerned, however, that federal funding for their programs could end before sufficient monitoring occurred to identify all long-term health problems related to the WTC attack, some of which, such as cancer, might not appear until decades after exposure to a harmful agent.[Footnote 9] We also reported that HHS's Centers for Disease Control and Prevention (CDC) had recently received a $75 million appropriation to fund programs providing health screening, long-term monitoring, and treatment for WTC responders and was deciding how to allocate those funds.[Footnote 10] My testimony today revisits these issues. I will discuss (1) progress made by HHS's WTC Federal Responder Screening Program, and (2) actions CDC has taken to award the $75 million that the Congress appropriated to the agency in December 2005 for programs that provide screening, monitoring, or treatment for WTC responders. To assess progress made by HHS's WTC Federal Responder Screening Program, we obtained and reviewed program data and documents from HHS, including applicable interagency agreements and budget documents. We interviewed officials from the Agency for Toxic Substances and Disease Registry (ATSDR); CDC's National Institute for Occupational Safety and Health (NIOSH); Federal Occupational Health Services (FOH);[Footnote 11] and the Office of Public Health Emergency Preparedness (OPHEP). To determine actions taken by CDC to award funds from the $75 million appropriated, we obtained documents and interviewed officials from NIOSH and ATSDR. We also interviewed officials from organizations implementing programs designated in the appropriations act as having first priority for receiving the funds--including the Mount Sinai- Irving J. Selikoff Center for Occupational and Environmental Medicine, one of the clinical centers of the worker and volunteer WTC program; FDNY's Bureau of Health Services (FDNY-BHS); the New York City Department of Health and Mental Hygiene; the Police Organization Providing Peer Assistance (the POPPA program); and the New York City Police Foundation's Project COPE--and officials from the American Red Cross, which has funded treatment services for responders. We relied on data provided by agency officials and contained in government publications and did not independently verify the data we obtained. Although we could not independently verify the reliability of all of this information, we compared it with other supporting documents, when available, to determine data consistency and reasonableness. Based on these efforts, we believe the information we obtained is sufficiently reliable for this report. We conducted our work from July 2006 to September 2006 in accordance with generally accepted government auditing standards. In summary, since February 2006, HHS has registered and screened additional federal responders, and arrangements are being developed for screening responders who are former federal workers residing outside the New York metropolitan area. An additional 1,385 federal responders have registered for screening examinations, including 1,134 current federal workers and 251 former federal workers, bringing the total number registered on the WTC Federal Responder Screening Program Web site as of late August 2006 to 1,762, including 283 former federal workers. Because the total number of federal responders involved in the WTC disaster is uncertain, it is not possible to determine what proportion of the total number of federal responders have registered. As of late August 2006, FOH had completed screening examinations for a total of 907 federal workers; 380 of the 907 were screened since February 2006. Under an OPHEP agreement with NIOSH, screening examinations for former federal workers are to be provided through the worker and volunteer WTC program. As of July 31, 2006, the worker and volunteer WTC program provided screening examinations to 13 former federal workers and scheduled 11 more. Most of the former federal workers reside outside the New York metropolitan area, where the worker and volunteer WTC program is located, and NIOSH is working to establish a national network of providers to screen these workers. CDC plans to award the $75 million appropriated for screening, monitoring, and treatment to the five organizations that the law identified as having priority for funding. CDC officials expect to make awards to the WTC Health Registry, Project COPE, and the POPPA program over a 3-year period and to award funds to the FDNY WTC and worker and volunteer WTC programs in response to their treatment costs. CDC officials have a proposed spending plan that allocates about $53.5 million for the latter two programs' treatment costs, but the officials told us that because they are uncertain about how quickly treatment costs could deplete the available funds, they may need to make adjustments. Officials from the FDNY WTC and worker and volunteer WTC programs told us that they expected that their estimated portion of the appropriated funds would be depleted well before the end of 3 years. As of August 2006, CDC awarded about $4.5 million of the $75 million. The agency awarded about $1.9 million to the WTC Health Registry, $1.5 million to the FDNY WTC program, and almost $1.1 million to the worker and volunteer WTC program. In addition, CDC expects to award $1.5 million to the POPPA program and $3 million to Project COPE in September 2006. CDC is waiting to make further awards until it has reached certain decisions about the coverage of treatment services, such as which prescription drugs would be covered in the FDNY WTC and worker and volunteer WTC programs. CDC expects to begin making further awards around February 2007. Background: When the WTC buildings collapsed on September 11, 2001, an estimated 250,000 to 400,000 people in the vicinity were immediately exposed to a noxious mixture of dust, debris, smoke, and potentially toxic contaminants in the air and on the ground, such as pulverized concrete, fibrous glass, particulate matter, and asbestos. Those affected included people residing, working, or attending school in the vicinity of the WTC and thousands of emergency responders. Subsequently, an estimated 40,000 responders who were involved in some capacity in the days, weeks, and months that followed, including personnel from many government agencies and private organizations as well as other workers and volunteers, were also exposed.[Footnote 12] Health Effects: A wide variety of physical and mental health effects have been observed and reported among people who were involved in rescue, recovery, and cleanup operations and among those who lived and worked in the vicinity of the WTC.[Footnote 13] Many health effects have persisted or worsened over time. 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. A recent 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 14] Commonly reported mental health effects among responders and other affected individuals included symptoms associated with posttraumatic stress disorder--an often debilitating disorder that can develop after a person experiences or witnesses a traumatic event, and which may not develop for months or years after the event. Behavioral effects such as alcohol and tobacco use and difficulty coping with daily responsibilities have also been reported. Monitoring Programs: The five programs that were created for monitoring the health of WTC responders vary in aspects such as the implementing agency (i.e., federal, state, or local governments or private organizations) and eligibility requirements. (See table 1.) Each program received federal funding, the majority of which was provided by the Department of Homeland Security's Federal Emergency Management Agency (FEMA),[Footnote 15] as part of the approximately $8.8 billion in federal assistance that the Congress appropriated to FEMA for response and recovery activities after the WTC disaster.[Footnote 16] FEMA is authorized to use a portion of its WTC-related funding for screening and long-term monitoring of responders.[Footnote 17] With regard to treatment, however, FEMA may generally fund only short-term care after a disaster, such as emergency medical services, and not ongoing clinical treatment.[Footnote 18] FEMA entered into interagency agreements with HHS to fund most of the health monitoring programs. OPHEP, which coordinates and directs HHS's emergency preparedness and response program, entered into separate interagency agreements with FOH to implement the federal responder screening program for current federal workers and with NIOSH to implement the screening program for former federal workers. Table 1: Key Federally Funded WTC Health Monitoring Programs: Program: FDNY WTC Medical Monitoring Program[B]; Implementing agency or organization: FDNY Bureau of Health Services (FDNY-BHS); Eligible population: Firefighters and emergency medical technicians; Completed monitoring activities, as reported by GAO in September 2005[A]: Through June 2005, 15,284 firefighters and emergency medical technicians received screening examinations, and 522 of these participants completed a follow-up examination; Federal funding: $4.8 million was provided beginning in October 2001 for initial program; additional $25 million is available through June 2009. Program: WTC Medical Monitoring Program (worker and volunteer WTC program)[B]; Implementing agency or organization: Five clinical centers, one of which, the Mount Sinai-Irving J. Selikoff Center for Occupational and Environmental Medicine, also serves as a data and coordination center[C]; Eligible population: Rescue and recovery workers and volunteers,[D] excluding NYC firefighters and emergency medical technicians; Completed monitoring activities, as reported by GAO in September 2005[A]: Through June 2005, 14,110 people received screening examinations, and 1,699 of these participants completed a follow-up examination; Federal funding: $15.9 million was provided for initial program;[E] additional $56 million is available through July 2009. Program: New York State responder screening program[F]; Implementing agency or organization: New York State Department of Health; Eligible population: New York State employees and National Guard personnel who responded to the WTC attack in an official capacity; Completed monitoring activities, as reported by GAO in September 2005[A]: As of November 2003, 1,677 employees and National Guard personnel received screening examinations; Federal funding: $2.4 million was provided in January 2002 and is available through mid-January 2007.[G]. Program: WTC Health Registry[H]; Implementing agency 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[I]; Completed monitoring activities, as reported by GAO in September 2005[A]: As of November 2004, the program completed baseline data collection through interviews with the 71,437 people who enrolled in the registry;[J] in 2005, the program updated contact information obtained at the time of enrollment; Federal funding: $20 million was provided beginning in July 2002,[K] and as of September 2005, additional funding of about $3 million had been provided.l. Program: WTC Federal Responder Screening Program; Implementing agency or organization: HHS Office of Public Health and Emergency Preparedness (OPHEP); Federal Occupational Health (FOH) Services; and CDC's National Institute for Occupational Safety and Health (NIOSH); Eligible population: Federal workers who responded to the WTC attack in an official capacity[M]; Completed monitoring activities, as reported by GAO in September 2005[A]: From June 2003 through March 2004, 394 screening examinations were completed. When the program resumed in December 2005, an additional 133 examinations were completed as of early February 2006; Federal funding: $3.74 million was provided beginning in March 2003 and is available through December 2006. Source: GAO analysis of information from ATSDR, FDNY, Mount Sinai, National Center for Environmental Health, New York City Department of Health and Mental Hygiene, New York State Department of Health, and NIOSH. Some of the information in this table originally appeared as tables 1 and 2 in GAO-06-481T. [A] GAO-05-1020T. The monitoring activities completed by the WTC Federal Responder Screening Program are as reported by GAO in February 2006 (GAO-06-481T). The monitoring methods used by all programs except the WTC Health Registry consist of screening examinations that include a medical questionnaire and physical examination; the Registry's monitoring method is a telephone-based health and exposure interview. [B] The FDNY WTC Medical Monitoring Program and the WTC Medical Monitoring Program constitute the WTC Responder Health Consortium. NIOSH established the consortium in March 2004 to coordinate the health monitoring of the two programs and to facilitate data sharing. [C] The other clinical centers are located at the Long Island Occupational and Environmental Health Center, the New York University School of Medicine, the City University of New York's Queens College, and the University of Medicine and Dentistry of New Jersey's Robert Wood Johnson Medical School. The responsibilities of the Mount Sinai data and coordination center include coordination of the clinical centers, outreach and education, quality assurance, and data management. [D] The worker and volunteer WTC program excludes NYC firefighters and emergency medical technicians, as they are eligible for FDNY's program. The program initially excluded responders who were paid as New York State employees for their WTC work and were eligible for the New York State responder screening program. That program ended its screening examinations in November 2003, and as of February 2004, New York State responders became eligible for the worker and volunteer WTC program. Beginning in February 2006, former federal workers enrolled in the HHS WTC Federal Responder Screening Program were eligible to be screened in the worker and volunteer WTC program. [E] Of this amount, $11.8 million was provided beginning in July 2002 through funds appropriated to CDC, and $4.1 million was provided in fiscal year 2003 through an interagency agreement with FEMA. [F] The New York State program ended its screening examinations in November 2003. [G] The primary program activity since November 2003 has been data analysis. [H] The registry includes health and exposure information obtained through interviews with participants and was designed to track participants' health for 20 years and to provide data on the long-term health consequences of the WTC attack. [I] Participants in the other WTC monitoring programs may also participate in the registry program. [J] Registry officials told us that final enrollment numbers may be revised pending internal verification of data. [K] The grant agreement is between ATSDR and the New York City Department of Health and Mental Hygiene. However, ATSDR contracted directly with Research Triangle Institute, a private not-for-profit organization, for most of the work to establish the registry, and about $16 million of the $20 million went directly from ATSDR to Research Triangle Institute. [L] The Environmental Protection Agency provided $2 million of these funds. In addition, CDC and ATSDR provided $500,000 each. [M] Screening examinations for current federal workers are provided by FOH under an agreement with OPHEP. Screening examinations for former federal workers are provided by NIOSH through the worker and volunteer WTC program. [End of table] We reported in February 2006 that four of the five monitoring programs had made progress in screening and monitoring affected individuals and gathering data.[Footnote 19] (See table 1.) These four programs--the FDNY WTC Medical Monitoring Program, the worker and volunteer WTC program, the New York State responder screening program, and the WTC Health Registry--had collected information that monitoring officials said could be used by researchers to help better understand the health consequences of the attack and improve treatment, such as by identifying which types of treatment are effective for specific conditions. In contrast to the progress made by the other programs, the HHS WTC Federal Responder Screening Program had lagged behind and accomplished little.[Footnote 20] The program was established to provide free voluntary medical screening examinations for federal workers[Footnote 21] whom their agencies sent to respond to the WTC disaster from September 11, 2001, through September 10, 2002,[Footnote 22] and who were not eligible for any other WTC health monitoring program.[Footnote 23] Through March 2004, the program--which started about a year later than the other WTC monitoring programs--completed screenings of 394 federal workers.[Footnote 24] HHS put the program on hold in January 2004, when it stopped scheduling new examinations, because it wanted to resolve several operational issues, including HHS's determination that FOH did not have the authority to provide examinations to people who are no longer in federal service. Under an agreement between OPHEP and FOH that was established in July 2005, the program resumed providing examinations for current federal workers in December 2005, and in February 2006, OPHEP executed an agreement with NIOSH calling for NIOSH to arrange for the worker and volunteer WTC program to provide examinations to former federal workers. Many participants in the monitoring programs required additional testing or needed treatment for health problems that were identified during screening examinations. The FDNY WTC Medical Monitoring Program referred participants to the FDNY Bureau of Health Services, but the other programs primarily referred participants to their primary care physician or to privately funded programs available to responders, such as treatment services provided by the Mount Sinai clinical center that are funded by the American Red Cross. We previously reported that officials told us that finding treatment services for such participants was an important, but challenging, part of the programs' responsibility.[Footnote 25] For example, officials from the worker and volunteer WTC program stated that identifying providers available to treat participants became a major part of their operations, and was especially difficult when participants lacked health insurance. New Federal Funding for Monitoring and Treatment: In December 2005, the Congress appropriated $75 million to CDC to fund programs providing baseline screening, long-term monitoring, and health care treatment for emergency services and recovery personnel who responded to the WTC disaster. The law required CDC to give first priority to programs coordinated by the FDNY-BHS, Mount Sinai-Irving J. Selikoff Center for Occupational and Environmental Medicine, and New York City Department of Health and Mental Hygiene, which have existing monitoring programs, and to programs coordinated by the POPPA program and Project COPE.[Footnote 26] The mission of the POPPA program, which offers peer-to-peer mental health counseling to New York City Police Department (NYPD) officers, is to reduce unresolved emotional trauma that can result in problems ranging from poor performance to suicide. The POPPA program counseled over 5,000 NYPD officers in the 10 months following the WTC attack. Project COPE, a collaboration of the New York City Police Foundation and Columbia University Medical Center, uses a hotline and outreach efforts to encourage NYPD uniformed and civilian employees to obtain mental health services, which are provided by Columbia University Medical Center and private providers. As of August 2006, over 18,000 employees had attended educational sessions held at police facilities, and over 5,000 had received individual counseling or therapy consultations. HHS Has Registered and Screened Additional Federal Responders, and Arrangements for Screening Former Federal Workers outside the New York Metropolitan Area Are under Development: Since February 2006, an additional 1,385 federal responders have registered for screening examinations, bringing the total number registered on the WTC Federal Responder Screening Program Web site to 1,762 as of late August 2006, including 283 former federal workers. Because the total number of federal responders involved in the WTC disaster is uncertain, it is not possible to determine what proportion of the total number of federal responders have registered. HHS's efforts to conduct outreach to federal agencies resulted in the identification of 2,200 federal responders. As of late August 2006, FOH had completed screening examinations for a total of 907 federal workers, 380 of whom were screened since February 2006. Through OPHEP's agreement with NIOSH, the worker and volunteer WTC program has provided screening examinations to 13 former federal workers and scheduled 11 more. Most of the former federal workers reside outside the New York metropolitan area, where the worker and volunteer WTC program is located, and NIOSH is working to establish a national network of providers to screen these workers. HHS's Outreach Resulted in Registration of Additional Federal Workers Involved in WTC Disaster Response: HHS reported that as of late August 2006, a total of 1,762 federal responders had registered for screening examinations on the WTC Federal Responder Screening Program Web site, including 1,479 current federal workers and 283 former federal workers. Of the 1,762 federal responders who registered, 1,385 had registered since February 2006, including 1,134 current federal workers and 251 former federal workers. It is not possible to determine what proportion of the total number of federal responders involved in the WTC disaster have registered because the total number involved is uncertain. In determining the total number of individuals eligible for its program, the WTC Health Registry developed an estimate of 8,621 federal responders, based on information from 31 federal agencies in the New York area and information from FEMA on 22 Urban Search and Rescue teams that were deployed to the WTC area.[Footnote 27] This estimate does not account for all federal responders from other geographic areas. As we reported previously, in the aftermath of the WTC disaster, HHS did not have a comprehensive list of all federal agencies and federal responders who were involved. In an effort to develop such a list, OPHEP and ATSDR entered into an agreement in April 2005 for ATSDR-- which had developed the WTC Health Registry--to identify and register federal responders.[Footnote 28] Under the agreement, ATSDR, through a contractor, contacted federal agencies, developed a list of WTC federal responders, and conducted outreach to encourage the responders to register on the new Web site that the contractor established.[Footnote 29] As a result of this effort, 46 federal agencies were identified and provided contact information for 2,200 federal responders.[Footnote 30] The agreement between OPHEP and ATSDR expired on April 30, 2006, ending the outreach efforts to federal agencies.[Footnote 31] Under an agreement with OPHEP, NIOSH assumed responsibility for maintaining the WTC Federal Responder Screening Program Web site through December 31, 2006.[Footnote 32] HHS Has Screened Additional Current Federal Workers: As of late August 2006, FOH had completed screening examinations for a total of 907 of the federal workers who had registered;[Footnote 33] 380 of the 907 were screened since February 2006.[Footnote 34] Under its agreement with OPHEP, FOH is responsible for regularly retrieving from the registration Web site requests for screening examinations for current federal workers and for assigning individuals to a provider for screening.[Footnote 35] FOH officials told us that they contact the individual and the provider to inform them of the need to arrange an appointment for screening. The program relies on individuals to call the designated provider and schedule their appointment. FOH officials told us that individuals who have registered do not always contact the provider to schedule an appointment or may not keep an appointment or call to reschedule it. FOH officials said that they have attempted to contact such individuals but often received no response. We reported in our February 2006 testimony that under the July 2005 agreement FOH clinicians can refer current federal workers for follow- up care if the screening examination--which includes a medical questionnaire, clinical tests such as a chest X-ray, and a full physical examination--reveals significant physical or mental health symptoms.[Footnote 36] On July 31, 2006, FOH told us that it had referred 39 current federal workers with mental health symptoms to an FOH employee assistance program (EAP) for counseling;[Footnote 37] 24 to ear, nose, and throat specialists; 19 to pulmonary medicine specialists; and 1 to a cardiology specialist. Screening of Former Federal Workers Has Resumed, but Group Is Widely Dispersed and Nationwide Network of Providers Is Still Being Established: As of late August 2006, 283 former federal workers had registered to receive screening examinations, which under OPHEP's agreement with NIOSH are to be provided by the worker and volunteer WTC program.[Footnote 38] Under the agreement, former federal workers receive a one-time examination comparable to the examination that FOH is providing to current federal workers. As of July 31, 2006, 13 screening examinations had been completed and 11 were scheduled. These completed and scheduled examinations are in addition to the 139 former federal workers that FOH screened after the WTC Federal Responder Screening Program resumed because FOH thought they were current federal workers.[Footnote 39] A key challenge in providing screening examinations to former federal workers has been that a large number do not reside in the New York metropolitan area, where the worker and volunteer WTC program is based. The 283 former federal workers who have registered for screening examinations reside in 40 states, and about 240 of them reside outside the New York metropolitan area. NIOSH officials said that making arrangements to screen these widely dispersed responders has presented challenges, such as ensuring that the arrangements comply with federal privacy protections. NIOSH is negotiating with the Association of Occupational and Environmental Clinics (AOEC)[Footnote 40] in an effort to establish a national network of providers to screen these federal workers. CDC Has Awarded a Small Portion of the $75 Million Appropriation and Plans to Make Decisions about Treatment Coverage before Awarding Most of the Funds: CDC plans to award the $75 million appropriated for screening, monitoring, and treatment to the five organizations that the law identified as having priority for funding. CDC officials expect to make awards to the WTC Health Registry, Project COPE, and the POPPA program over a 3-year period and to award funds to the FDNY WTC and worker and volunteer WTC programs in response to their treatment costs. CDC officials have a proposed spending plan but told us that because they are uncertain about how quickly treatment costs could deplete the available funds, they may need to make adjustments. Officials from the FDNY WTC and worker and volunteer WTC programs told us that they expected that their estimated portion of the appropriated funds would be depleted well before the end of 3 years. As of August 2006, CDC awarded about $4.5 million of the $75 million--about $1.9 million to the WTC Health Registry, $1.5 million to the FDNY WTC program, and almost $1.1 million to the worker and volunteer WTC program. In addition, CDC expects to award $1.5 million to the POPPA program and $3 million to Project COPE in September 2006. CDC is waiting to make further awards until agency officials have reached certain decisions about the coverage of treatment services, such as which prescription drugs would be covered in the FDNY WTC and worker and volunteer WTC programs. CDC expects to begin making further awards around February 2007. CDC Plans to Award the $75 Million to the Five First-Priority Organizations: CDC has decided to award the $75 million for screening, monitoring, and treatment that was appropriated to the agency in December 2005 to the five organizations identified as having first priority for funding.[Footnote 41] The organizations to which CDC plans to provide funds are: * the FDNY WTC program, for monitoring and treatment; * the worker and volunteer WTC program, for monitoring and treatment; * the WTC Health Registry, for monitoring; * Project COPE, for treatment; and: * the POPPA program, for treatment. CDC plans to make awards through cooperative agreements with the programs.[Footnote 42] In general, it plans to send letters to the organizations inviting them to submit applications for funding; the applications would then undergo a two-stage peer review process. At the first stage a panel of outside experts would assess the merit of the application, and at the second stage CDC officials would determine the amount of funding the applicant would receive. CDC has made preliminary decisions about how to allocate the $75 million among the five organizations. As of September 1, 2006, CDC's proposed spending plan indicated that awards would be made in the following way: * $53.5 million for treatment and $8 million for monitoring, to be divided between the FDNY WTC and worker and volunteer WTC programs;[Footnote 43] * $9 million for the WTC Health Registry; * $3 million for Project COPE; and: * $1.5 million for the POPPA program. CDC officials expect to make awards to the WTC Health Registry, Project COPE, and the POPPA program over a 3-year period, but are not sure over what period they will make awards to the FDNY WTC and worker and volunteer WTC programs. A CDC official told us that the agency would award funds to the latter two programs in response to the treatment costs they incur. He said that agency officials are uncertain about how quickly treatment costs could deplete the available funds, because CDC does not know how many additional people will seek monitoring and what the extent of their treatment needs will be. For example, previous media reports about illnesses diagnosed in responders have resulted in increases in responders seeking examinations. Officials from the FDNY WTC and worker and volunteer WTC programs told us that they expected that their estimated portion of the appropriated funds would be depleted well before the end of 3 years. CDC has developed a proposed spending plan that indicates that about 36 percent of the funds would be awarded by the end of fiscal year 2007 and about 63 percent would be awarded during fiscal year 2008, although a CDC official told us that, depending on the extent of treatment needs, the funds could be used more quickly. The current plan is based in part on an agreement CDC made with the American Red Cross in April 2006.[Footnote 44] According to a CDC official, under this agreement, American Red Cross funds would be used for the treatment services that are eligible for American Red Cross support--such as basic clinical examinations and certain tests-- for as long as such funds are available and the CDC funds would be used to cover other program expenses--such as infrastructure costs, more sophisticated diagnostic tests, and the conversion of medical records into an electronic format. CDC Has Awarded about $4.5 Million of the $75 Million Appropriated: As of August 2006, CDC had awarded a total of about $4.5 million of the $75 million to the WTC Health Registry, FDNY WTC program, and worker and volunteer WTC program. According to CDC officials, the WTC Health Registry applied for about $1.9 million in April 2006 for continuation of its collection of health data, and CDC awarded the registry $1.9 million in May 2006 and about $56,000 in July 2006.[Footnote 45] On August 10 and 11, 2006, respectively, the worker and volunteer WTC and FDNY WTC programs submitted applications to CDC for funds related to treatment services. In response to these applications, CDC made what an agency official termed emergency awards to the FDNY WTC and worker and volunteer WTC programs on August 11, 2006.[Footnote 46] CDC provided $1.5 million to the FDNY WTC program for leasing treatment space that previously had been provided by New York City at no cost. CDC provided almost $1.1 million to the worker and volunteer WTC program to hire an additional physician to help reduce the 3-to 4-month waiting time for treatment appointments that recently developed at the Mount Sinai clinical center, as well as to hire three administrators and a medical assistant. Officials from the clinical center told us that this waiting time had developed because additional people were seeking monitoring due to media reports about illnesses diagnosed in responders and because the proportion of responders who needed to be referred for treatment had increased. In addition to having awarded about $4.5 million, CDC plans to award an additional $4.5 million in September 2006. In spring 2006, CDC invited Project COPE and the POPPA program, two programs that provide mental health services to members of the NYPD, to apply for funding through a peer review process. In their applications, the POPPA program requested $1.5 million over 3 years, and Project COPE requested funding of $3 million over 3 years. CDC received their applications in June and July, respectively, and plans to implement the application review process in time to be in a position to make awards in September 2006. CDC Is Waiting to Award Additional Funds for Treatment Until It Makes Decisions about Coverage: CDC does not plan to award additional funds from the $75 million to the FDNY WTC and worker and volunteer WTC programs until it makes certain decisions about the coverage of treatment services. These decisions include determining which medical conditions will be covered;[Footnote 47] developing a prescription drug formulary, that is, the list of drugs that will be covered; and determining the extent to which inpatient care will be covered. CDC officials said that they expected to make the coverage decisions in late 2006 and that they would obtain input from the American Red Cross and the programs. A CDC official told us that making decisions about which prescription drugs to cover could be the greatest challenge CDC and the programs face, because of the potentially high cost of drugs needed to treat responders. An FDNY WTC program official said that prescription drug costs are a looming financial problem for the FDNY WTC program. The CDC official told us that the most common diagnoses of WTC responders-- gastroesophageal reflux disease, obstructive pulmonary disease, and mental health conditions--frequently are treated with prolonged and expensive drug therapy. For example, medications for respiratory therapy can cost $1,000 a month and may continue for a year. The FDNY WTC program official estimated that 100 percent coverage of prescriptions for firefighters and emergency medical technicians could cost $10 million to $18 million per year and potentially consume all of the funding that CDC would provide to the program. Clinicians at the worker and volunteer WTC clinical center at Mount Sinai stated that spending on prescription drugs at their center was increasing by $5,000 to $10,000 each month and amounted to $60,000 in July 2006. Another coverage decision that CDC faces is to determine the extent to which inpatient care will be covered. Currently, the FDNY WTC and worker and volunteer WTC programs provide only outpatient care, but officials involved with these programs believe that the treatment funds from the $75 million should cover some inpatient care, such as when a responder's WTC-linked asthma becomes exacerbated to an extent that requires hospitalization. CDC officials told us that they plan to reach decisions about treatment coverage in fall 2006. They also plan to invite the FDNY WTC and worker and volunteer WTC programs to submit applications for treatment funding in the fall. If the applications are submitted by December 2006, CDC officials expect to be able to review them in time to provide funding to the programs by February 2007. CDC is also in the process of resolving issues related to providing access to screening, monitoring, and treatment services for WTC responders, including former federal workers, who reside outside the New York metropolitan area. CDC is negotiating with AOEC about possibly using AOEC clinics around the country to provide these services. CDC officials told us they intend that monitoring and treatment services available to responders around the country would be comparable to services provided by the worker and volunteer WTC program. 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. Contact and Acknowledgments: For further information about this testimony, please contact Cynthia A. Bascetta at (202) 512-7101 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; Fred Caison; Anne Dievler; Keyla Lee; and Roseanne Price made key contributions to this statement. [End of section] Appendix I Abbreviations: AOEC: Association of Occupational and Environmental Clinics: ATSDR: Agency for Toxic Substances and Disease Registry: CDC: Centers for Disease Control and Prevention: EAP: employee assistance program: FDNY: New York City Fire Department: FDNY-BHS: New York City Fire Department Bureau of Health Services: 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: NYPD: New York City Police Department: OPHEP: Office of Public Health Emergency Preparedness: POPPA: Police Organization Providing Peer Assistance: WTC: World Trade Center: FOOTNOTES [1] A list of abbreviations used in this testimony is in app. I. [2] GAO, 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). See also 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). [3] The Staten Island site is the landfill that is the off-site location of the WTC recovery operation. [4] GAO, September 11: Health Effects in the Aftermath of the World Trade Center Attack, GAO-04-1068T (Washington, D.C.: Sept. 8, 2004). [5] This program was formerly known as the WTC Worker and Volunteer Medical Screening Program. In this testimony, we refer to the program as the worker and volunteer WTC program. [6] The WTC Health Registry also includes residents and other workers affected by the attack. [7] In this testimony, we use the term monitoring program to refer to both one-time screening programs and programs that include initial screening and periodic follow-up monitoring. [8] GAO-06-481T. [9] At that time, funding for the FDNY WTC and worker and volunteer WTC programs was available through mid-2009, and funding for the WTC Health Registry was available through April 29, 2008. [10] See Department of Defense Appropriations Act, 2006, Pub. L. No. 109-148, §5011 (b), 119 Stat. 2680, 2814 (2005). These funds are available to CDC until expended. [11] FOH is a part of HHS's Program Support Center. [12] The responders included firefighters; law enforcement officers; emergency medical technicians and paramedics; morticians; health care professionals; and other workers and volunteers, including those in the construction and ironwork trades, heavy equipment operators, mechanics, engineers, truck drivers, carpenters, day laborers, and telecommunications workers. Numerous federal, state, and New York City agencies sent personnel to respond to the WTC disaster. [13] See, for example, CDC, "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); CDC, "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); CDC, "Surveillance for World Trade Center Disaster Health Effects among Survivors of Collapsed and Damaged Buildings," Morbidity and Mortality Weekly Report, vol. 55 (2006); and 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). [14] Banauch et al., "Pulmonary Function," vol. 174, no. 3 (2006). [15] FEMA is the agency responsible for coordinating federal disaster response efforts under the National Response Plan. [16] FEMA provided funds to HHS to support screening and long-term monitoring efforts from funds appropriated for disaster relief and emergency response to the September 11, 2001, terrorist attacks. 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. [17] Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-7 117, Stat. 11, 517. [18] The Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, authorizes FEMA to, among other things, make appropriated funds available for disaster relief and emergency assistance. Pub. L. No. 93-288, 88 Stat. 143 (1974), as amended. The Stafford Act does not specifically authorize ongoing clinical treatment. [19] GAO-06-481T. [20] GAO-06-481T. [21] For this program, a federal worker is defined as being either a permanent, temporary, or intermittent federal employee. [22] In addition to the federal responder program, we identified three other, smaller-scale programs that were implemented by two federal agencies to assess the health of their own employees who responded in the aftermath of the WTC attack. The Army established two screening programs--one specifically for Army Corps of Engineers personnel and one that was designed as a voluntary medical screening for Army military and civilian personnel, including contractors. As of August 2004, 92 Corps of Engineers employees had participated in the first program, with 40 receiving follow-up examinations, and 162 employees had completed and returned questionnaires in the second program. In the third program, 88 employees of the U.S. Marshals Service, within the Department of Justice, had obtained a one-time assessment including a screening questionnaire and a medical examination as of August 2005. [23] According to a FEMA official, federal workers who did not receive official orders from their agencies to respond to the WTC disaster are not eligible for the WTC Federal Responder Screening Program. According to an official of the worker and volunteer WTC program, federal workers who volunteered on their own in the aftermath of the disaster were eligible to participate in that screening program. [24] We testified in February 2006 that OPHEP entered into an agreement with FOH in April 2003 to provide screening examinations for federal workers who had responded to the WTC disaster and that these examinations began in June 2003. [25] GAO-06-481T. [26] Both organizations operate independently of the New York City Police Department. [27] This estimate consisted of 5,122 responders from the 31 federal agencies and 3,499 responders from the 22 Urban Search and Rescue teams. [28] Before the federal responder program was placed on hold in January 2004, its principal action to communicate with the federal responders had been to place program information and registration forms on FEMA's National Disaster Medical System Web site. [29] See "The WTC Federal Responder Screening Program," https://wtcophep.rti.org/, downloaded Aug. 30, 2006. [30] Of the 90 other agencies contacted, 60 were determined to be ineligible because some were found to be nongovernmental agencies, some did not have federal workers at the WTC or Staten Island site, and some, such as the Department of Defense, participated in other screening programs; 21 opted to contact their federal workers on their own; and 9 refused to provide information. [31] ATSDR spent $372,961 of the $491,000 OPHEP originally allocated to the activities carried out under this agreement. The $491,000 was part of $3.74 million that FEMA had provided to OPHEP to develop and implement a monitoring program for federal responders. According to OPHEP, it will reallocate the $118,039 remaining from its expired agreement with ATSDR to FOH or NIOSH for screening, depending on where there is a need. [32] According to OPHEP officials, FEMA funds are to expire at this time. [33] Some of these federal workers registered on FEMA's National Disaster Medical System Web site, which was used before the WTC Federal Responder Screening Program Web site was created. [34] The 907 workers screened by FOH include 139 former federal workers that FOH screened after the program resumed because FOH thought they were current federal workers. In addition, FOH also screened an unknown number of former federal workers before the federal program was placed on hold, and they would also be included in the 907. FOH officials told us that they have taken steps to ensure that they can better identify which registered workers are current federal employees. [35] Individuals are assigned to either an FOH clinic or a private provider participating in FOH's network, based on their proximity to either type of provider. Appointments are made within 50 miles of an individual's designated zip code. [36] The estimated cost of each screening examination is between $400 and $500, and additional costs may be incurred depending on the need for further diagnostic testing. [37] FOH can refer individuals with mental health symptoms to an FOH EAP for a telephone assessment. If appropriate, the individual can then be referred to an EAP counselor for up to six in-person sessions. [38] This agreement also provides for examinations for other federal responders who are ineligible to receive examinations from FOH, such as Department of Defense employees, and responders having intermittent periods of federal employment such as Urban Search and Rescue workers. [39] When FOH officials realized those individuals were former federal workers, they communicated this information to NIOSH so NIOSH could take responsibility for any follow-up care the workers might need. [40] The AOEC is a nonprofit organization committed to improving the practice of occupational and environmental health through information sharing and collaborative research. The AOEC consists of a network of university-affiliated and other private clinics across the United States and in other countries. [41] Within CDC, NIOSH has lead responsibility for making decisions about the $75 million, and ATSDR is involved in decisions relating to the WTC Health Registry. [42] A cooperative agreement is a mechanism used to provide financial support when substantial interaction is expected between a federal agency and a state, local government, or other recipient carrying out the funded activity. [43] Any funds not needed for monitoring could be used for treatment. [44] This agreement provides for the American Red Cross to assist CDC in estimating program costs and developing the federally funded treatment programs. [45] The registry subsequently applied for an additional $1 million to support its operations through April 2007. [46] The official told us that CDC was able to make these awards so quickly after receiving the applications because agency officials had been discussing the programs' needs for treatment funds with program officials for several months and the programs had provided draft applications a week before submitting the final applications. [47] The medical conditions that now receive treatment funded by the American Red Cross provided the baseline for conditions that will be included. CDC will determine whether any additional conditions will be included and will continue to assess whether all appropriate conditions are included over time. 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