How the National Disaster Medical System (NDMS) Could Help Pay for #COVID-19 Treatment (and Lead to #MedicareForAll)

By Lambert Strether of Corrente.

I keep noticing how civilized countries are handling #COVID-19 (Bangkok Post: “Virus covered by universal health care“) in contrast to our own (Politico: “Schumer calls for Medicare to cover coronavirus vaccine that is still in development.” Come on, man. Over-65s only? No coverage for testing? Really?). So I was intrigued when I saw the following tweet from Carlos Mucha, responding to Sarah Kliff:

(Mucha has a lot of credibility in certain circles, because he was the modern originator of the MMT-adjacent Trillion Dollar Coin concept, legitimized as not cray cray by Politico here, and don’t @ me. Mucha is, in other words, good at combining lateral thinking with complete legality, and this NDMS reimbursement concept sounds like it could solve a lot of our problems mitigating #COVID-19.)

In this post, I’ll only look at the NDMS reimbursement concept, because I suspect that’s what most readers are reallly interested in. I hope at some future point, to take a look at NDMS itself, because it seems to be that rare thing in government these days: An agency with operational capability. (Googling turns up very little Beltway news on NDMS, but a lot of home-town stories about NDMS people who were deployed into emergency situations, upon their homecomings.) My real hope for this post — and this is exactly what happened with the Trillion Dollar Coin, which propagated from the blogs outward — is that that the idea will propagate into the mainstream media, and thence to either the administration, or the campaigns, or both.

To the reimbursement concept. First, a Public Health Emergency has been declared for #COVID-19, so NDMS reimbursesments can kick in. It seems to be hospitals who are reimbursed, not patients, but I assume that’s all to the good. (Pause here to envision some insane liberal scheme to reimburse patients through tax credits, after means-testing them.) From the Department of Health and Human Services (HHS):

As part of the Trump Administration’s government-wide efforts to provide relief to those affected by Hurricane Irma, the U.S. Department of Health and Human Services (HHS) activated a program to help hospitals and medical facilities providing care to people affected by Irma. This is the first time HHS has activated the program in response to a natural disaster since a devastating earthquake hit Haiti in 2010.

The program, called the National Disaster Medical System (NDMS) Definitive Care Reimbursement Program, reimburses medical facilities and hospitals for the definitive medical care[1] costs of patients medically evacuated following disasters. These patients are directed to NDMS-designated hospitals and medical facilities and tracked through Federal Coordinating Centers managed by the Departments of Veterans Affairs and Defense.

And here are the NDMS coverage guidelines in detail. First, eligibility:

A condition of NDMS coverage is that the patient is transported via Federal assets, processed through a FCC, and referred to facilities or practitioners for Definitive Medical Care. The NDMS tracks all patients who are transported via Federal assets and thus, are eligible for coverage under this program.

OK, organize an NDMS #COVID-19 program to provide transport as — follow me closely here — the gateway to NDMS reimbursement as a universal concrete material benefit (probably good for standardizing protocols anyhow): And now the providers:

Only providers who currently participate in either Medicare or Medicaid are eligible for reimbursement. All providers who participate in Medicare will be reimbursed based upon their Medicare rates. Any provider who does not participate in Medicare but does actively participate in Medicaid will be reimbursed based upon their Medicaid rates.

Next, covered services:

Generally, any medically necessary service which is authorized under Medicare Part A, Medicare Part B or a State’s Medicaid program is eligible for reimbursement as long as the NDMS patient sustained one of the following:

  • Injuries or illnesses resulting directly from a specified public health emergency; or
  • Injuries, illnesses and conditions requiring essential medical services necessary to maintain a reasonable level of health temporarily not available as a result of the public health emergency; or
  • Injuries or illnesses affecting authorized emergency response and disaster relief personnel responding to the public health emergency.

That would seem to cover not only #COVID-19, but testing for #COVID-19.

The program ends after 30 days; IIRC #COVID-19 runs its course in two weeks.

Finally, the benefit guidelines:

The NDMS Reimbursement Program will pay primary under the following circumstances:

  • The patient is uninsured.
  • The patient is covered only by Medicaid.

    The patient is only covered by other state or local payer of last resort.

For individuals with private coverage (e.g., employment-based coverage), the NDMS Definitive Care Reimbursement Program may make a secondary payment to cover the difference between the full NDMS payment amount and the other payer’s allowance(s). However, NDMS does not cover co-pays, deductibles or coinsurance associated with the patient’s other coverage other coverage(s)— this includes any Medicare or Medicaid co-pays, deductibles or coinsurance.

Too bad about the co-pays and deductibles (and that Medicare and VA aren’t integrated, so we had true single payer.) One could, I imagine, do a little lateral thinking and get thrown off one’s insurance program by not making payments, thereby becoming “uninsured,” but there are probably better solutions to be had. (I’d also welcome comments from readers far more experienced in disentangling benefits programs than I am.)

It remains only to determine who activates the NDMS. From DOD INSTRUCTION 6010.22 NATIONAL DISASTER MEDICAL SYSTEM (NDMS):

In accordance with Section 300hh-11 of Title 42, U.S.C., HHS activates the NDMS or specific capabilities of the NDMS, depending on the situation. The Secretary of HHS activates the appropriate FCCs by notifying the VA and DoD program managers in writing. Activation may be in response to:

(1) A national emergency, domestic disaster, or in support of a homeland security event.

(2) The Secretary of HHS declaring a public health emergency in accordance with Section 300hh-11 of Title 42, U.S.C.

As we know, HHS has already declared #COVID-19 a public health emergency, so President Trump could order HHS to activate NDMS tomorrow.

Of course, the reimbursement procedure outlined is trying to be #MedicareForAll, albeit on an emergency basis for a single disease, so Trump might be considered to be unlikely to activate it. On the other hand, if Trump really wants to own the libs — and what good conservative doesn’t? — this would be a wonderful way to do it; Steve Bannon could be called in to handle the re-branding (“LibertyCare”).

Speculating wildly: It has not escaped our notice that if a Sanders administration wished to implement #MedicareForAll by executive fiat, it would begin by declaring that the 55,000 deaths per year caused by our current, for-profit system constitute a public health emergency. And don’t they?

Comments welcome from readers really expert in navigating these programs!


[1] The best definition I can find: “Definitive care is usually considered the domain of the hospital and of larger facilities and implies the resolution of the condition needing treatment.” Subject to correction with those who have experienced it, “definitive care” does not seem designed to deny care.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Samuel Conner

    I’m a little uneasy about the “transported by Federal assets” language.

    If you think you have COVID-19 symptoms and drive yourself to the nearest participating facility, are you included? Am I misunderstanding the meaning of this language?

    I have the impression that the number of people who are “covered” via ACA but are reluctant to seek care due to the “co-expenses” is not small. Add to that fear that the necessary testing to ascertain definitively if one is infected 1) may not be cheap, 2) may not be covered and 3) may need to be repeated multiple times.

    It looks like a step in the right direction, but there still seems to be an awful lot of gatekeeping.

    1. Tim

      Better yet, catch a $1500 taxi (aka ambulance) ’cause you waited really long to get help.

      Yeah, not to be negative, but after the government student loan help progams.. you’d have to be some kind of idiot to voluntarily go to a hospital under this program and think you’d actually make it out the other end without a massive bill.

      This changes the calculus not one iota for the little guy that has the option of keeping going to work hoping they are strong enough to fight off the virus and keep bread on the table, or risk getting quarantined, fired from your job and stuck with a massive healthcare bill on a technicality.

      The 3rd world results of a pandemic in this country are baked into the cake thanks to neoliberalism.

  2. Susan the other

    Excellent point Lambert: “…if the Sanders administration wished to implement #MedicareForAll by executive fiat, it would begin by declaring that the 55,000 deaths per year caused by our current for-profit system constitute a public health emergency. And don’t they?” Or, Trump could really topple both the Democrats and congress by implementing NDMS. Since Covid is so contagious and will take at least 2 years to corral, M4A could well be established and very popular by then. And when Covid does subside, not enough people will have the means left to buy private “health” insurance – in fact private insurance might go under pretty quickly all on its own, maybe even in one last craven effort to pocket any excess premiums.

    1. GramSci

      Yes, this an excellent opportunity for Trump to run left.

      But the timing is delicate. He wants the DNC to nominate non-Bernie first. If only CORVID-19 would follow orders, the leaders could have their way.

      1. jrs

        But then he loses most of his Republican supporters. If people think those folks wouldn’t fight M4A … if the death toll is massive maybe, but … I’m not sure they wouldn’t fight it even then.

        Yes Trump “runs” left, like Obama “ran” left, only Trump delivers even less. And Bloomberg runs on getting it done, whatever that is. It don’t mean a thing. And the Republicans that will vote for Trump pretty much know it’s all a game and that the rich will get tax cuts and the poor will get next to nothing. Many are in the con and like it.

        Besides running left might hurt the STOCK MARKET!!!

        1. clarky90

          I am an elderly, Christian Conservative. I completely support (if I lived and voted in the USA) universal free (or almost free) health care, with private options: as we have here in NZ.

          The us (good)/them (bad) POV is… jaundiced…. Open your eyes to the suffering of all of your fellow citizens: left and right.

          1. Titus

            Indeed, how kind you are, in that kindness in caring for others is answer to getting what people need to feel secure in this life.

      2. False Solace

        While this is a cool thought experiment, and I thank Lambert for the discussion, Trump’s track record is of talking left (to get elected) and governing right. He’s made merciless cuts to health care spending, including cutting the global pandemic preparedness team on the NSC and within the CDC. He proposes cut after cut to Medicare and SS and food stamps. If he was going to “move left” on anything he would have taken action on drug prices, a total non-brainer and a campaign promise, but he hasn’t lifted a damn finger. Why am I supposed to believe he’s suddenly going to impose quasi-universal healthcare now, for a disease he called a hoax?

        Trump honestly believes “we can’t afford it” and he has no actual agenda aside from getting reelected. That means his governance defaults to neoliberal, and the neoliberal mantra is “render unto Caesar (the markets) or die”. He fired all his populist advisers. He throws red meat to his fans at his rallies but that solely consists of demonizing Democrats, foreigners, and now socialism. He coasts on the economy and has never proposed any legislation that would help workers or improve health care in this country. He’s politically invested in minimizing the outbreak to keep the stock market happy.

        Trump’s record as president is a carbon cutout Republican who continued all 7 wars but will maybe end one eventually and never lifted a finger to help a non-millionaire. Forgive me if I don’t buy this at all.

        1. ObjectiveFunction

          But as a wise man said, 240some days is a long time in pandemic / politics.

          If caseloads and attended billing horror stories mount, Trump may not feel he is able to stonewall that long, no matter how squirmy the GOP ‘Cold Turkey With Jesus’ wing may get. It’s leadership.

          Plus, while he’s said all kinds of stuff in the past, and is not agreement capable, Trump was vocally for single payer for a good portion of his public life. ‘Pay your own freight, deadbeat sickies’, is no more of a deeply felt ‘values’ issue with him than anything else. Popularity uber alles.

  3. marym

    Am I reading this correctly that the only people whose out-of-pocket circumstances would be changed are people who are uninsured?

    1. Lee

      It seems as if it might work out that way. I imagine that private insurers would be on the hook for their policy holders’ healthcare costs. OTOH, if they failed to accurately factor costs of pandemic such as this into their calculations, it could put serious dent in their solvency.

      As for care being free to the uninsured, the working poor and those too damaged to be able to navigate through the eligibility requirements deserve to catch a break once in awhile. And most particularly if I am at risk of catching something from them.

      1. marym

        I’m also fine with the uninsured getting medical care for the reasons you state.

        I don’t think I see the argument that this program, at least from the high-level description in the post, presents a practical foundation (or at least as practical as the Medicare/Medicaid infrastructure) toward single payer, rather than another kludge added to our multiplicity of systems.

  4. VietnamVet

    Excellent. Thanks.

    If the politicians wanted to and if they broke with their donors, the federal government could fight the coronavirus pandemic and fund it with fiat money like South Korea or Singapore. They haven’t and won’t. Mike Bloomberg and Elizabeth Warren have released plans to fight the outbreak that are dead in the water unless they are elected President. America will have to fight the pandemic with what it has until January 2020. The only chance for immediate change would come if an Insider residing in the Hamptons or Beverly Hills dies of COVID 19.

    Kirkland WA is next door to Microsoft’s Headquarters in Redmond WA. Six deaths already in Washington State. Globalists are hugely impacted by the Coronavirus Pandemic but they are the ones trying to get Donald Trump gone. The Elite are rediscovering the ancient truth that their wealth doesn’t protect them from the Pale Horseman.

    Until nationalist oligarchs start dying, the Wuhan coronavirus will be fought by 50 State Departments of Health with limited personnel and state budgets. Calculations (50% infection, 1% deaths) indicate that around a million will die early. The Trump Administration is simply following earlier precedents. Similar mortality rates from the opioid crisis and the higher death rate of the uninsured raised no red flags.

    Those who can afford to shelter in place, have prepped and wash their hands constantly should make it through and be vaccinated next year. Where the poor can’t afford for-profit healthcare and where the public health system breaks down; many won’t see the New Year.

    1. VietnamVet

      Correction; Inauguration Date is January 21, 2021. Old Age and an Ex-Smoker are why I am taking this personally.

      1. Brooklin Bridge

        I hear you. Based on our inaccessible medical system and what Trump is doing re. covid-19, one would think this was the greatest opportunity in a century to get rid of medicare by getting rid of everyone who uses it.

    2. The Rev Kev

      Damn. I forgot about Microsoft having their headquarters in Washington State. What happens if the Microsoft Redmond campus has to be quarantined with nobody allowed in or out? That Microsoft Surface tablet may not be such a winner with a name like that now. And you can only do so much work from home until those people fall sick as well.

  5. Ford Prefect

    I think there is going to be a very interesting aspect to this disease. The very serious cases and fatalities appear to be people over 50, especially over 65, which is much of the age of senior political and corporate leadership. Many of the policies that they have in place, such as no paid sick leave for many workers, etc. will increase spread. However, the younger workers are less likely to get a severe case even if they are more likely to come in to work sick where they can pass it on to the older people.

    For example, an Iranian VP died already. So will the US senior political and corporate leadership simply hide from the population for the next few months?

    1. JacobiteInTraining

      The more they hide, the more irrelevant they become, and the less they hide…the more likely they are to become irrelevant in a different way.

      Sadly, this applies to the good as well as the bad, but….many of the ‘good’ have said little and done less to stop the ‘bad’ and thus….well….kids, now is the time to take over, and find a batter way.

  6. Anon

    A condition of NDMS coverage is that the patient is transported via Federal assets, processed through a FCC, and referred to facilities or practitioners for Definitive Medical Care. The NDMS tracks all patients who are transported via Federal assets and thus, are eligible for coverage under this program.

    I’m sure a legal authority could be found to declare all local fire/medical responders to be part of a federal task force. Federal law enforcement uses this trick when they team up with state and local law enforcement, and it effectively converts the state/local personnel into federal agents. I don’t see why the same trick couldn’t be used to turn local ambulances and personnel into federal assets.

  7. Noel Nospamington

    Most Canadians consider our southern neighbour USA to be a defacto 3rd world country, since the measure of a society is how it treats its poorest and most vulnerable.

    COVID-19 has very much placed a spotlight on this.

    So far here in Canada we have had 27 confirmed cases, all of which have been traced to international travel, and no deaths. In my province of BC (British Columbia) with only 5 million people, has tested far more people for COVID-19 than the entire USA. Compare this to the 6 deaths from COVID-19 in the USA for a disease with an estimated 2% mortality rate, hinting at thousands of untested infected individuals in the USA likely spreading this disease in their communities.

    Universal health care (without any usage fees such as copays or deductables) and mandatory employer paid sick days really makes a difference during a pandemic.

    The only possible silver lining from the horrible misery from this disease, is that it is much more harmful on older people who statistically are much more likely to vote for extreme right wing parties (such as Republicans and Tories). And this may have a positive effect on upcoming federal elections in several countries.

  8. Brooklin Bridge

    Instead of effective ideas such as using the NDMS in a state of emergency, what I fear we are going to get instead is making light of this pandemic and keeping a lid on it as much as possible.

    Here is a very sobering and troubling interview with Amanpour and Dr. Paul Offit (vaccinology expert) in which Amanpour helps Dr. Offit make light of the whole thing (Influenza will cause 10x more deaths this year, just like the flu, open the airports, and so on). A breathtakingly insouciant call to go forth and multiply:

  9. Rodger Malcolm Mitchell

    It’s not “lateral” thinking. It’s “Lets-come-up-with-a-convoluted-solution-to-our-already-ignorant-idea” thinking.

    The ignorant idea (or ideas) are:
    “Somehow, the U.S. government can run out of its own sovereign currency, the U.S. dollar,” or
    “The federal deficit is unsustainable,” or
    “The federal government has to live within its means,” or
    “Federal finances are just like personal finances,” or
    “Federal finances are just like state and local government finances,” or
    “Bigger deficits require additional federal taxes,” or
    “The federal debt is a ticking time bomb.”

    All the pols, the media, and the phony economists who espouse the above ideas don’t know what the heck they are talking about, or (more likely) are intentionally trying to fool the public into not asking for federal benefits.

    The simple fact is that the federal government could pay for no deductible Medicare for All, including long-term care for all simply by paying for it. No taxes needed. No FICA needed. No federal borrowing needed. JUST PAY FOR IT.

    And no, it would not cause inflation, because inflations – all of them –are caused by SCARCITIES, not by deficit spending.

    So we can keep “lateral thinking” in order to circumvent stupid thinking, or we simply can teach and acknowledge the facts.

    The world is round, not flat, and the federal government is Monetarily Sovereign. Period.

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