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President Obama's declaration of swine flu as a national emergency last week wasn't intended to panic the public. It was meant to afford hospitals greater liberty to bypass various regulations and set up emergency treatment centers off site and still receive payment from Medicare, Medicaid, or the State Children's Health Insurance Program.

But the declaration gives federal officials the ability to go further, and some public health experts say that they should, citing concern about the already-strained capacity at hospitals and clinics, and also about the impact of caring for the uninsured.

"It remains to be seen how broadly they're going to use these powers," said Jeffrey Levi, executive director of Trust for America's Health, a nonprofit public health advocacy group. "One of the things that has not been addressed is the need to figure out how to pay for the care of the uninsured in a pandemic. [Obama's declaration] permits some flexibility in Medicare and Medicaid benefit reimbursements. If that can be used to ensure that people have coverage for care, then they won't delay seeking care. They could do emergency enrollment in Medicaid for people who are otherwise eligible [but haven't signed up]. They could go beyond that if they wanted to."

However, a spokeswoman for the Health and Human Services Department's Centers for Medicare and Medicaid Services doubts that the declaration will have much effect on the uninsured.

Already, many federally funded community health centers, which provide free or low-cost primary care to low-income people, are swamped, although thanks to economic stimulus money they are better prepared than they otherwise might have been. At one health center, people coming in with influenza-like illness increased the patient load by 40 percent, said Mollie Melbourne, director of emergency management at the National Association of Community Health Centers. "It was already a busy site."

Centers are increasing hours of operation and asking staff members to work additional days, Melbourne said. "We have phone triage, telling people whether to stay home, come into the center, or go to another level of care if that's warranted."

The American Hospital Association isn't tracking the percentage of hospitals' H1N1 patients who are uninsured, even though a large influx could burden hospitals with significant financial liability.

But capacity is equally worrisome, particularly when it comes to young people. More than half of H1N1 patients between September 1 and October 10 were under 24, and that age group accounted for 23 percent of deaths. "Of the pediatric deaths, [the thought] for a long time was that it was people with chronic illnesses, but what they're finding is that 30 percent of kids who died have no other medical history. And that should be scary," said Donald Thompson, senior director of the medical and public health program at George Mason University law school. "This is looking alarmingly like 1918," when the worldwide Spanish flu pandemic killed 50 million to 100 million people in a year.

Although most hospitals in the past treated children, said Roslyne Schulman, senior associate director of policy at the American Hospital Association, "now most of the care for children is in children's hospitals. Because of the way H1N1 is presenting itself, children's hospitals are the ones getting impacted the fastest, and they have been hardest hit at this point."

Schulman said that the AHA has been hearing anecdotally around the country that intensive care units, especially pediatric units, are "stretched to the max. Shortages of anti-viral agents, vaccine; shortages of respirators; surgical mask shortages. There's a lot of activity now with flu, and capacity is getting filled up," she said. Levi added that some communities don't have pediatric ICUs.

Thompson said that federal and state officials also should take into account physician liability, to allow doctors to treat patients differently than they might under a normal workload. "A physician is held to a standard of care, which means doing everything for a patient. Doing the right diagnostic tests, and if they're not sure, do additional tests, and if they aren't sure, admit to the hospital." But when doctors are inundated with patients, they need some legal protection to allow them to move quicker, he said.

In the end, Melbourne said, "what we really need now is long-term health care reform. We don't have enough primary-care places for people to go and to treat the uninsured."

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