Katrina's true tragedy unfolds.

The House and Senate committees investigating government response to Hurricane Katrina broke through the fog of partisan recriminations this winter. Michael Brown, President George W. Bush's appointee as director of the Federal Emergency Management Agency (FEMA), confessed that federal officials obsessed with the threat of terrorism disregarded the certainty of recurring natural disasters. The bipartisan Government Accountability Office (GAO) chimed in with a report charging that the federal government ignored decade-old recommendations resulting from studies of Hurricane Andrew.

Sen. Susan Collins (R-Maine), chair of the Senate Homeland Security and Governmental Affairs Committee, reminded witnesses and the public that government response to Hurricane Katrina began as a remarkable success, in which more than a million people successfully left the area of greatest danger. "The initial evacuation from New Orleans in advance of the storm went relatively well," said Collins. "Then, so to speak, the wheels came off. Those without access to transportation out of the region found themselves stranded, high and dry, but only in the figurative sense. Among those left behind were thousands of elderly, disabled, and disadvantaged residents."

And that, of course, has been the true tragedy of Hurricane Katrina: Its impact was greatest on nursing home residents and staff, and others who could not easily leave New Orleans. Although nursing homes were required to maintain evacuation plans, only 21% of area nursing homes were reportedly evacuated before the storm. More than 200 SNFs and board-and-care facilities initially chose not to evacuate, in part because federal and state funders had refused to compensate nursing homes for the costs of previous evacuations. When these facilities decided to activate their evacuation plans, it was too late. According to Joseph Donchess, executive director of the Louisiana Nursing Home Association, nursing home operators often could not call for help after the flooding began. Even when their requests reached responsible authorities, they did not appear to be given high priority.

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Sean R. Fontenot, former chief of the planning division, Louisiana Office of Homeland Security and Emergency Preparedness, told Collins's committee that a statewide disaster exercise called "Hurricane Pam" had revealed the problems that led to the stranding of hundreds of nursing home residents. The Hurricane Pam exercise was supposed to be the first step in FEMA's planning and preparation for a catastrophic hurricane that could hit Southeast Louisiana. That assistance had been delayed for several years because of budget shortfalls and FEMA's insistence on using private contractors to support the planning process. In July 2004, however, all government emergency-planning agencies participated in a rehearsal of a devastating storm and its aftermath.

Fontenot testified that "this planning exercise was developed to work on a 'bridging document' that would form a bridge from the local to state to federal levels. In the initial concept, the exercise was set up to last for 14 days, with all participants involved for the full two weeks. However, FEMA headquarters said the price for an event that long was too high. So, the exercise was reduced to eight days." In addition, because of the exercise's resulting tight time frame, local emergency management officials were not as involved as state and federal officials in coping with "Hurricane Pam."

The Hurricane Pam scenario underscored that approximately 100,000 residents in the New Orleans area would not be able to leave the city unassisted--far beyond the resources of the state's National Guard. Following the exercise, with the advice of federal officials, Louisiana transferred the responsibility for emergency transportation from the National Guard to the Louisiana Department of Transportation and Development.

This proved to be a serious mistake, in part because the Department of Transportation and Development owned very few vehicles suitable for evacuating residents. Department Secretary Johnny B. Bradberry told Senate staff members in January that he had done nothing to honor an agreement he had signed in April 2005 that said his department would be responsible for planning the evacuation of the frail in an emergency. Instead, he testified that his focus was on improving the plan for the mass evacuation of the general population by creating a system that opened all the major highway lanes moving away from New Orleans. This "contraflow" plan is credited with helping perhaps 1.2 million residents get out of harm's way.

Dr. Kevin Stephens, director of the New Orleans Health Department, testified that starting in late 2004 he had tried to create his own plan with bus companies, riverboat owners, and Amtrak to evacuate the city's special-needs population. Negotiations were incomplete when Katrina hit, Dr. Stephens said, in part because of liability questions. Bradberry's last-minute attempts to enlist school buses and other municipal vehicles for transportation of nursing home residents and hospital patients were frustrated by failing communications, the evacuation of most of the bus drivers, and the loss of vehicles to the rapidly advancing flood waters.

The last potential source of help was the military and the National Guard. Fontenot explained to the Senate committee that the State of Louisiana had not expected that the military would be able to mount a rapid evacuation effort: "It has always been common knowledge within emergency management that the locals and the states would have to be prepared to sustain themselves for a period of 48 to 72 hours before they could expect major federal resources to be on the scene. It has always been taught in emergency management that the federal government is not a first responder. There are some exceptions to this with the Coast Guard and other agencies, but for the most part, the federal government is not a first responder."

Despite this common wisdom, the GAO found that military support to areas affected by Hurricane Katrina involved about 20,000 active duty troops and 50,000 National Guard members. Although this was the largest mobilization of the U.S. military for any domestic disaster, it was not sufficiently targeted to respond to the needs of stranded nursing home residents.

A few political partisans and noisy pundits are still trying to point the finger of blame for Katrina at incompetent or uncaring officials of "the other" political party. In contrast, most of the witnesses reporting to Collins acknowledged a long list of failures indicating there was no coordinated or tested plan in the first place to evacuate the frail, sick, or poor. As a result, the witnesses said, patients sat in hospitals and nursing homes for days without electricity, fuel, air-conditioning, or sufficient food. "It is natural for all of us to believe that fault lies with someone else," said Bradberry. "The real truth is Katrina moved faster than we did. All of us on the local, state, and the federal levels were overwhelmed, undermined, and outmuscled by Mother Nature."

The one clear fault that could be laid with government efforts is the failure to spend enough money to ensure that the lessons of "Hurricane Pam" and other disaster exercises were reflected in new and better plans. Michael Brown is correct when he says that FEMA repeatedly faced budget shortfalls after it was incorporated into the federal Department of Homeland Security, but penny-pinching on natural disaster planning was not unique to his agency. CMS and Congress also share responsibility for failing to include disaster planning and evacuation as part of the reimbursable expenses of long-term care facilities.

Before Katrina, the resulting "cost savings" might have been seen as necessary budgetary restraint. Now, according to Sen. Joseph Lieberman (D-Conn.), "emergency planning that does not make provisions for society's most vulnerable--the aged, the sick, the poor--is not just operationally unacceptable, it is morally unacceptable."

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