arolina Harm Reduction Coalition [NCHRC], undated). As emergency first responders, law enforcement officers can rapidly administer naloxone, especially in rural jurisdictions where emergency medical services might not be as readily available (Davis e


s also have been shown to strengthen the relationship between law enforce -
ment and members of the community (Wagner et al., 2016). Fewer studies have examined the efficacy of law enforcement serving as an entry point to treatment. One nonrandomized


prehensive partnership among law enforcement, commu -
nity organizations, researchers, and the Washington/Baltimore High Intensity Drug Trafficking Areas (HIDTA) program. The goal of the initiative is to address the basic causes of drug use, rooted i


ted by another law enforcement expert, a naloxone deployment functions as a “handshake” with individuals with OUD and helps to build trust and rapport with officers, creat -
ing an entry point for treatment or other services either in the moment or w


including methadone, buprenorphine, and naltrexone, so that they can create an individualized treatment plan that will be most effective for them. Attendees argued that it is counterproductive for law enforcement to arrest individuals for possession


tant part of law enforcement
naloxone programs. Often, law enforcement agencies work with 9local or state partners or nonprofit organizations to implement
these programs. For example, the Deaths Avoided with Nalox -
one (DAWN) program was developed


takeholder coordination.
This panel featured the following five presentations:
• Baltimore City Health Department and Law Enforce -
ment Collaborative Efforts, by  Matthew Stefanko, Balti -
more City Health Department
• RxStat—Applying the NYPD’s Da


ans who would prevent crime) to note that coordination of public health and public safety efforts can start with considerable common ground. Central to overdose fatality reviews is the belief that overdoses are pre -
ventable through comprehensive in


ome unfocused. In the context of the opioid epi -
demic, attendees asserted that the primary indicator of success that stakeholders should pursue is reducing overdose deaths. Although the attendees generally agreed, one participant noted that an excl


that information to encourage individuals with OUD to take precautions that could reduce harm and prevent overdose. However, attendees noted that information sharing can sometimes be limited by the Health Information Portability and Accountability A


me into contact with drugs contain -
ing fentanyl, extremely powerful synthetic opioids with a high likelihood of causing overdose (Pagane et al., 1996; Burgess, Barnhart, and Checkoway, 1996; Herbert et al., 2006;  Collaboration was discussed as the


ics exposure, especially with the increasing opioid and fentanyl trends. He noted that the danger is often thought of as occurring at the scene, but it also can extend through the chain of custody to transport, packaging, testing, storage, and eventu


e topic and that standardized case reporting is necessary to better track the scope of the problem . Although participants were unaware
of any confirmed reports of officer fatalities from accidental opioid exposure, they acknowledged that appropriat


opioid epidemic. With the constant introduction of new drugs, forensic laboratories are on the front lines in terms of assess -
ing the shifts in drug use trends and their consequences. These substances are identified through samples submitted by la


r
Protection.
Although having officers trained to use field identification
kits has been in place in Phoenix, Arizona, since 2000, these
kits did not allow for presumptive testing for opioids until after 2012, according to Crump. With support from


opes. New technology can aid in the process, but much of
the knowledge required to remain current is acquired through outside partnerships and communication with other laborato -
ries, content analysis of websites catering to drug users, and the pee


 partnerships, and communities.
Public health experts stressed the value of this approach,
commenting that there is a common misperception that indi -
viduals with OUD will seek out substances of higher potency. Panelists noted that studies tend to


etailed notes on the cards as they talked in order to capture their reason -
ing on or reservations about a strategy or action category from the discussions. Participants were encouraged to move freely among the tables and, ultimately, to vote by pla


all differences in the actual prioritization scores. Instead, we use a clustering algorithm to identify natu -
ral groupings of high, medium, and low priorities among the items being prioritized. For this event, when we clustered all of the needs int


needs that are perceived to have barriers related to inadequate resourcing, inadequate technology, potential community and stakeholder concerns, or legal and regulatory issues. These are important strategies that should be priorities for additional


recognize emerging drug crises.
5
Although participation and group composition remained
largely constant during the panels and subsequent discussions, many participants departed from the workshop before the final prioritization session. The worksho


that Table 2. The 13 High-Priority Needs, by Category
Category Related High-Priority Need
Overdose response and treatment promotion • Broaden the use of MAT in the general population and increase accessibility.
• Promote nonenforcement police outreac


nication among stakeholders and useful methods for carrying out syndromic surveillance. Participants noted the need to establish relationships and communicate with diverse groups. Parties could use social media to provide information to the community


lder concerns received no votes, participants nevertheless made mul -
tiple suggestions about means to address community and stake -
holder concerns. Participants particularly suggested addressing community attitudes that would seek to keep facilitie


r studying, research, and communication could be helpful.
Create a trauma awareness early warning system for
law enforcement stress exposure . This need was derived from
the discussion following the panel on officer safety. Participants primarily


eceived enough total votes to place them in the top tier, they stand out because of this apparent suggestion from many participants that they might not be ready for implementation and barrier resolution until further research is carried out.
Explore


the opioid crisis will be a focus on connecting individuals with OUD to the medications that can treat the disorder. A strong body of evidence suggests that MAT is an effective means to treat OUD and reduce harm from opioid abuse as a long-term solu


re published on the topic. At the time of the invitations, panelists were pro -
vided with a brief description of the workshop’s focus areas.
Prioritization of Needs
As we described in the main body of the report, to prioritize the needs provided in


can Society of Addiction Medicine, Public Policy Statement: Definition of Addiction , Chevy Chase, Md., April 12, 2011. As of
July 23, 2019: https://www.asam.org/resources/definition-of-addiction
ASAM— See American Society of Addiction Medicine.
Bec


of July 23, 2019: https://www.whitehouse.gov/sites/whitehouse.gov/files/images/
Final_Report_Draft_11-1-2017.pdf
Clifasefi, Seema L., Heather S. Lonczak, and Susan E. Collins,
“Seattle’s Law Enforcement Assisted Diversion (LEAD) Program: Within-Su


ncreases in Synthetic Opioid–Involved Overdose Deaths—27 States, 2013–2014,” Morbidity and Mortality Weekly Report
, Vol.  65, No.  33, August 26, 2016, pp.  837–
843.
Green, Traci C., Nickolas Zaller, Wilson R. Palacios, Sarah E.
Bowman, Madeline R


 undated. As of July 23, 2019:  https://www.leadbureau.org
LEAD National Support Bureau— See Law Enforcement Assisted
Diversion National Support Bureau. Lee, Joshua D., Edward V. Nunes, Jr., Patricia Novo, Ken Bachrach,
Genie L. Bailey, Snehal Bhat


page, undated. As of August 1, 2019: http://www.ncai.org/initiatives/partnerships-initiatives/
ncai-opioid-initiative
National Institute on Drug Abuse, “Opioids,” webpage, undated. As
of July 23, 2019:  https://www.drugabuse.gov/drugs-abuse/opioid


n and Recovery Initiative, “Our Law
Enforcement Partners,” webpage, undated b. As of July 23, 2019: https://paariusa.org/our-partners
Police Executive Research Forum, Building Successful Partnerships
Between Law Enforcement and Public Health Agenci


. As of July 23, 2019: https://www.cbp.gov/newsroom/video-gallery/video-library/
fentanyl-real-deal
U.S. Department of Health and Human Services, Office of the
Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol,


chnology policy, criminal justice,
national security, and emerging technologies and innovation. His recent research involves the policy, procedure, and technology needs of criminal justice agencies, development planning and program evaluation in the


University of Denver, is carrying out a research effort to assess and prioritize technology and related needs across the criminal justice community. This initiative is a component of NIJ’s National Law Enforcement and Corrections Technology Center (N


Robust Stormwater
Management in  the Pittsburgh Region
A Pilot Study
Jordan R. Fischbach, Kyle Siler-Evans, Devin Tierney, Michael T. Wilson,
Lauren M. Cook, Linnea Warren May
CORPORATIONLimited Print and Electronic Distribution Rights
This documen


ing challenge of stormwater management in the
Pittsburgh metropolitan region. The City of Pittsburgh and other municipalities in Allegheny County, Pennsylvania, face significant challenges in meeting water-quality requirements and upgrading their ag


ar (Mgal.)  .............. 33
 3.3. Summ
ary Statistics for Three Precipitation Scenarios (Main Rivers
Planning Basin)  .......................................................................... 39
 3.4. Rece
nt Historical Simulated Overflows Compa


ferred to as a sanitary sewer overflow  (SSO). More than 9 billion gallons
(Bgal.) of sewer overflow in a typical year have led to violations of the U.S. Clean Water Act (33 U.S.C. 1251), along with state and county public health laws.
Adding to the


roximately
9.5 Bgal. of CSOs and SSOs can occur each year. Given the negative effects on water quality, ecosystems, and public health from these overflows, the U.S. Environmental Protection Agency in 2008, working with its state and local partners,


udy Uses a Participatory Approach and Robust Decision Making
Methods
The study is based on a participatory decision support framework and method for
improving decisions under deep uncertainty called Robust Decision Making (RDM). RDM is an iterative


plore
how the system might respond to plausible future scenarios reflecting the number of future wastewater customer connections, land-use changes, or climate change. All of these results are based on a “future without action,” in which the current


ual rainfall and slightly less intense daily storms.
• Land u
se: Three land-use scenarios were developed reflecting no population
growth (Current Land Use), moderate growth (Southwestern Pennsylvania Com -
mission [SPC] Growth), and high growth (2x


ute to overfl  ow increases but that no single factor is dominant. Th  e extent of increased vulnerability depends on the assumptions, but it ranges from 1.5 to 4.2 Bgal./year in additional overfl  ow volume (11 to 13.7 Bgal./year in total) when comp


s the names and assumptions used for each GSI strategy.
•
 Inflo
w and infiltration (I&I) reduction:  I&I is the result of an aging sewer
system with leaks in manholes and pipes, as well as some cases in which buried streams flow directly into the


verflows by 25 percent, while treatment expansion together with cleaning of the main intercep -
tors reduced overflows by 34 percent. I&I strategies alone reduced total overflow 5 to 19 percent, and GSI strategies reduced overflows 5 to 21 percent. T


itial set of assumptions used in strategy screening that are similar to those applied in other recent research. 480 MGD = treatment plant expansion; Clean = deep-tunnel interceptor cleaning.
RAND RR1673-S.34.0 6.0 8.0 10.0 12.0 14.0
Total overflow (B


4 to $1.59 per gallon, with many scenarios above the reference value of $0.35 per gallon. Strategies including treatment plant expansion alone or together with interceptor cleaning, by contrast, yield good cost-effectiveness performance across the fu


above (poor) the threshold of $0.35 per gallon.
Using statistical algorithms and visualization tools, several key drivers were iden -
tified common to both strategies: (1) future climate uncertainty (represented as average annual rainfall); and (2)


ible future changes, by contrast, shows that source
reduction with GSI is more cost-effective in higher-rainfall scenarios . Of course,
all strategies show improved cost-effectiveness with more rainfall, but the relative cost-
efficiency improvemen


r regional stormwater management. The analysis shows that large-scale investments in source reduction could help reduce overflow but with a wide range Summary    xxv
of uncertainty regarding cost-effectiveness and relative strategy performance. It al


s as part of an adaptive plan. Our analysis is suggestive, but not yet conclusive, about what a robust and adaptive strategy might entail.xxviiAcknowledgments
This pilot study was possible only through active and sustained engagement with many
partn


throughout the research effort, overseeing workshop logistics and countless revisions to the draft manuscript. Robert Lempert and Debra Knopman served as RAND co–principal investigators, overseeing all three urban climate adaptation pilot efforts, an


The study builds on recent RAND efforts to support improved deci -
sionmaking in response to climate and other uncertainties (e.g., Fischbach et al., 2015) and is one of three pilot studies centered around a new framework for urban adaptation 2    Ro


 somewhere in the system, drain -
ing a mix of untreated stormwater and wastewater into one of the three rivers. Some portions of the county have sanitary sewer overflows (SSOs), where wastewater flows
1  In addition, there is a fourth river, the Yo


t, inadequate stormwater drainage (Balingit, 2013). Some municipalities regularly face rainfall flooding, which can damage homes, businesses, and municipal infrastruc -
ture and can increase the risk of landslides.
The Pittsburgh region’s stormwater


 the proposed inclusion of “source reduction”—that
is, investments to reduce or prevent groundwater or stormwater from entering the existing sewer system “at the source,” thereby freeing up capacity and reducing overflows. Source reduction approache


lowing:
•
 How mig
ht the region’s vulnerability to future stormwater runoff and sewer over -
flow change with a changing climate and population patterns?
• To what e
xtent could CSOs and SSOs be reduced using innovative approaches,
either in curren


 of stormwater and wastewater simula -
tion models originally developed by ALCOSAN to support quantitative scenario anal -
ysis. Appendix C details the technical inputs and methods applied to develop scenarios for this study. In Appendix D, we descri


fl  ow through Allegh-
eny County. Figure 2.1 shows a map of the 25 watersheds within the county’s border.
However, urbanization and the region’s long history with natural resource extraction and heavy industry have taken a major toll on the health


ovide conveyance to the treatment plant. However, when the capacity of the system is overwhelmed, typically during wet weather events, a mixture of untreated stormwater and sewage overflows from the system and is released into a river or stream. Impo


.
 Overflows in Pittsburgh and other ALCOSAN communities are high, but
they are comparable to those in older American cities with combined sewer systems.
Milwaukee, Wisconsin, has a similar-sized system, for example, and previously faced
8 to 9


l ratepayers (3 Rivers Wet Weather, undated-a).
ALCOSAN has similarly initiated meetings involving policymakers, managers,
and engineers to facilitate municipal coordination on green infrastructure projects. These meetings served to highlight the v


cted to prevent more than 5 Bgal. of wastewater from reaching waterways each year, yielding systemwide reductions in CSO and SSO volumes of 56  percent and 90 percent, respectively. ALCOSAN estimated that ratepayers could face rate increases of appro


gion: A Pilot Study
consent orders and agreements with PADEP. Municipalities facing CWA compliance
violations participated with ALCOSAN in the creation of the WWP to help ensure that it would address all wastewater issues facing the service area (AL


lems, and considers potential solutions for follow-up in Phase II. The final plan will focus on developing a model ordinance for stormwater management and other key elements highlighted in Phase I, but it could also contribute to subsequent Regional


es Stitt of PWSA, August 16, 2016.18    Robust Stormwater Management in the Pittsburgh Region: A Pilot Study
Stormwater Source Reduction and Green Stormwater Infrastructure
As noted in the previous section, one approach under active consideration fo


ver -
flow control plans (USEPA, 2014), and the approach is being studied and implemented at scale as part of LTCPs or other climate adaptation efforts in other major metro -
politan areas, including Philadelphia; Seattle; Washington, D.C.; and New Y


ation to systematically consider how outcomes could vary across a wide range of plausible assumptions about the future.
RDM then uses statistics and visualizations to investigate the resulting large data -
base of model runs and help identify those


olicy choices) to consequences (change in risk) and used visualization tools to help the stakeholders envision vulner -
abilities and trade-offs, engage in an iterative process of “what if” with the data, and deliberate with one another over decision


management were also actively conducting or supporting local planning efforts. This group included experts from ALCOSAN; PWSA;
3 Rivers Wet Weather; Michael Baker Jr., Inc.; CDM Smith; Mott MacDonald; Landbase Systems; and Ethos Collaborative. Othe


around urban stormwater management within Allegh -
eny County. We employed the XLRM process first set forth in Lempert, Popper, and Bankes (2003) to organize the conversations and relevant outputs. In the XLRM abbreviation, M stands for the goals to


e workshops was reducing flood risk to resi -
dents and property, either from events that exceed system capacity (e.g., basement
backups, manhole overflows) or from stormwater flow itself on hillsides and in valleys during severe rainfall events. Pa


ants identified a range of policy levers that could address these goals. These included traditional gray infrastructure (tunnels, pipes, treatment, and storage); stormwater source reduction via GSI or through improved repair, retrofitting, opera -
ti


nt could dramatically alter the
range of feasible solutions for local and regional planners.
Finally, some participants noted that some proposed stormwater policy levers,
particularly stormwater GSI, have not yet been tested or proven at a large s


s broad scope to identify a set of discrete analysis steps that
could be accomplished within the time frame and resources of this pilot study. The XLRM elements bolded in Table 2.1 represent those that we were able carry forward into the technical a


study, we employ RDM with currently available
simulation modeling tools. The process to translate this scope into a series of techni -
cal inputs for the analysis is briefly described, along with analysis results, in Chapters Three and Four, with mo


 inputs related to population growth and land use and present sewer overflow results across these scenarios in turn. All overflow scenarios are then combined to show the complete uncertainty analysis, and we high -
light a handful of system outfalls


 ALCOSAN models will also exist in the adapted models used in this analysis . This is an important limitation
in this context, as simulation modeling to support urban stormwater, wastewater, and water-quality planning is a challenging and evolving s


equires more than
50 central processing unit (CPU)-hours, which can be completed in roughly a 24-hour span when using a server or multicore computer that can run several basin models simultaneously. To scale the study to be able to test many variabl


LCOSAN’s original modeling assumptions.
Table 3.2 summarizes the annual volume of sewer overflows by planning basin
simulated in the RAND model after the bias correction is applied. These results closely match ALCOSAN’s Existing Conditions modeled


lated for the vulnerability analysis.
1  The RDM literature sometimes uses the term future  to describe a specific realization or mapping of assump -
tions to consequences. This is distinguished from a “scenario” or “decision-relevant scenario,” whi


nsider long-term climate change effects on their systems.
Recent Local Investigations Rely on a “Typical Year” Approach
Allegheny County’s weather is influenced from systems moving from the Gulf of Mexico, Canada, and the U.S. Central Plains.
 Mean y


ded and main -
tained by 3 Rivers Wet Weather (undated-a). In this case, the 1 km
2 of observed pre-
cipitation data was reformatted and used directly as inputs for the SWMM models for the years 2004 to 2013.
Climate Downscaled Hydrology
Additional c


longer. The Higher Total Rainfall scenario, alterna -
tively, uses the MM5I-HadCM3
3 simulation. This scenario projects the largest increase
in total annual rainfall and slightly less-intense daily storms than the Higher Intensity Rainfall scenario.


s of average rainfall or frequency of intense storms, and it is too soon to tell which of these futures might be more or less likely to occur.
Final Climate Scenarios
The resulting outputs from the downscaling analysis are two climate-adjusted precip


fecting sewer over -
flows. Using the adapted modeling system described earlier, we evaluated annual over -
flows from the 2003 Typical Year and the subsequent decade (2004 to 2013) (Recent Historical), holding wastewater customer connections and lan


 at cur-Figure 3.4
Rainfall and Overfl  ows by Month, 2003 Typical Year and Recent Historical
RAND RR1673-3.40 1 2 3 4 5 6 7 8 9 10
Monthly rainfall (inches)012345678Overflow (Bgal./month)
NOTE: Monthly rainfall volumes represent the unweighted avera


native storm patterns to better estimate plausible future vulnerability.Figure 3.6
Map of Recent Historical Overfl  ows by Outfall
NOTE: Circles represent CSO outfalls; diamonds show SSO outfalls. Selected outfalls, including interceptor
relief over/


en combined with other scenario dimensions because of computing costs.
As described in Appendix C, we developed a fixed additive term at the outfall
level based on a comparison of ALCOSAN modeled results and then applied the same additive term to e


se regulations could help to limit or avoid increases in impervious cover in Allegheny County municipali -
ties, essentially reducing the likelihood of such scenarios as SPC Growth or 2xPGH.
Population Growth Projections
The first step in creating t


 All Simulated Scenarios
Th  e fi  nal step in this analysis of vulnerability was to simulate all combinations of the
scenarios described earlier. Average annual overfl  ow volumes are shown in Figure 3.10, using the same format as prior results.
Wh


ll 13.7 1.1 12.69.5
CSO SSO
NOTE: The vertical gray line shows the estimated total over/f_low using Current Connections, Current Land
Use, and the 2003 Typical Year rainfall for visual comparison purposes.  52    Robust Stormwater Management in the


l. For convenience, we will use this scenario for selected results through the remainder of this chapter.
Figure 3.12 shows the change occurring at each outfall between the baseline (Cur -
rent Connections/Current Land Use/Recent Historical) and thi


r points with darker red shades indicate outfalls likely to disproportionately contribute
to future overflows. The top pane shows all outfalls, while the bottom pane provides a zoom and
highlights 12 outfalls contributing a substantial fraction of


 8 648 1
Higher Total
Rainfall665 9 669 4
SPC Growth Recent
Historical635 4 653 1
Higher Intensity
Rainfall682 12 657 2
Higher Total
Rainfall699 15 683 6
2xPGH Recent Historical 728 19 683 6
Higher Intensity
Rainfall778 28 684 6
Higher Total
R


tify and test a range of proposed planning-level strategies intended to improve system function or reduce the flow of stormwater into the system during rainfall events. In Chapter Five, we then evaluate a promising subset of these strategies across t


d
Stakeholder Advisors during participatory workshops and sensitivity testing conducted by the modeling team.
However, there were various policy levers not evaluated in this pilot study because
of time and resource limitations. These included most


 is sized for 1.5 inches of rain -
fall). Results from a sensitivity analysis (Appendix D) show a significant perfor -Comparing Source Reduction and Wastewater Policy Levers    61
mance improvement with “high-flow” sites (i.e., high loading ratio). B


ay not be realistic. Such an aggressive strategy would likely
need to deploy a variety of technologies beyond bioretention alone, and all installa -
tions would be subject to slope, soil, and other engineering conditions. These strategies would requ


originally targeted for gray infrastructure, Washington, D.C., plans to use GSI to control nearly 500 impervious acres to manage stormwater by 2030 (District of Columbia Water and Sewer Authority, 2015). In the coming years, cities with substantial


as of the system with separate stormwater and wastewater pipes). The levels of assumed I&I reductions are shown in Table 4.3, where R1, R2, and R3 are the short-, medium- and longer-term RDII responses (see Appendix D).64    Robust Stormwater Managem


; we do not consider the cost of ongoing operations and maintenance (O&M) or the expected service life of a project, both of which are important for accurately assessing the full “life-cycle” cost of a strat -
egy. O&M costs were excluded because of


cost green roofs.
I&I Reduction Capital Costs
Table 4.4 also shows the I&I cost assumptions used in this analysis. The pipe repair costs are based on cost data from actual repair efforts in the region (ALCOSAN, 2015a), and manhole repair costs were


n the Existing Conditions model and the average-year pre-
cipitation (modified in 2003). All screening strategies are evaluated relative to the FWOA model results.
•
 GSI: Th
ere are five variations of GSI; the assumptions and parameters of those
s


g the treatment plant is expected to reduce overflows by 2.5 Bgal./year
(26-percent reduction), and expanding the treatment plant and removing debris from the main interceptors reduce overflows by 3.3 Bgal./year (a reduction of 34 percent). These st


ed strategy reduces 5.9 Bgal./year in overfl  ows—17 percent less than the total of the
three strategies in isolation.
Figure 4.4 shows results for the same set of 30 screening strategies, where the
x-axis and y-axis are the total system CSO and S


 greatest overflow reduction at the lowest cost. Results show the following:
•
 GSI (S
trategies 1 through 5): Assuming $304,000 per impervious acre
controlled,3 the total cost of GSI strategies that control 10 to 40 percent of DCIA
within the comb


example, Strategies 19 and 23 provide roughly the same overflow reduction (4.3 Bgal./year), but Strategy 23 is expected to cost nearly $1.3 billion less.
Conclusion
In this chapter, we formulated a set of regional, planning-level source reduction st


nitial planning-level source reduction
strategies considered in this analysis is able to eliminate SSO volumes, and most still yield substantial remaining CSO volumes and average hours in overflow per year. Incorporating future uncertainty only exac


ward in the application of high-performance computing for stormwater scenario analysis, but our ability to explore additional scenarios and strate-gies was nevertheless limited by the cost of these computing resources. As a result, in this portion of


runoff area that is tributary to the GSI. Given the substantial uncertainty associated with GSI in terms of flow reduction when implemented at a high number of sites across the region, these two scenarios were developed as bounding cases to help cha


ins relatively constant at 0.4 to
0.5 Bgal./year with Higher Intensity Rainfall.
By contrast, the performance of GSI-20 remains constant or declines slightly
across land-use scenarios with greater impervious cover. For example, the overflow reduc


cal
(2013)12.7 11.9 0.8 11.5 1.3 0.4
2xPGH Higher Intensity
Rainfall (2038)13.6 12.0 1.6 11.6 2.0 0.4
2xPGH Higher Total Rainfall
(2038)14.0 12.5 1.5 12.1 1.9 0.4
NOTE: Table shows Future Connections wastewater customer scenario results only. All


ansion and cleaning the main intercep -
tors, reduces overflows to 6.2 to 9.4 Bgal./year (a reduction of 3.3 to 4.7 Bgal./year) across the uncertain scenarios, a further reduction of 800 to 900 Mgal./year compared with Strategy 12. Coupling treatment


more targeted and refined approach in PWSA analysis, focusing on priority sewersheds and developing more detailed design concepts, likely explains the difference in performance.84    Robust Stormwater Management in the Pittsburgh Region: A Pilot Stud


pe of policy lever. These uncer -
tainties are briefly summarized in the following section, and the uncertain factors and Robust Decision Making Strategy Comparison    85
ranges chosen are discussed in detail in Appendix D of this report. Table 5.3 p


pipe repair costs are based on three data sources; the low and mid-values are
based on cost data from actual repair efforts in the region (ALCOSAN, 2015b), and
the high value is the default for 8-inch pipes in the Philadelphia Water Department (Phi


in
support of RDM analysis and scenario discovery (Bryant and Lempert, 2010; Groves and Lempert, 2007; Lempert, Popper, and Bankes, 2003). We developed a 100-point LHS sample across the cost uncertainty dimensions listed in Table 5.3 and included se


eduction for a regional sewer system like ALCOSAN’s. Over a long period of implementation (ten to 20 years), costs could plausibly end up at the lower end because of technological improvement, evolving best practice, and econo -
mies of scale. Altern


s, across all scenarios, the overfl  ow reduction achieved by a treatment plant expansion is always or nearly always highly cost-eff  ective, even in scenarios in which expansion costs are up Figure 5.3
Cost-Effectiveness for Selected Strategies, All


clude interceptor cleaning and yield similarly very wide cost-effectiveness ranges.
Strategy 27, to which we refer as the Combined Source Reduction Strategy through
the remainder of this discussion for convenience, includes a treatment plant expans


llustration. The figure includes regret in terms of over -
flow reduction (y-axis) and cost-effectiveness (x-axis) for each of the eight remaining strategies. Points are sized to show the median remaining overflows with the strat -
egy in place. An i


pear above the upper-right corner of the plot area and are
omitted for clarity.
RAND RR1673-5.40.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 0.16
Median cost-effectiveness regret ($/gal. reduced)0.00.51.01.52.02.53.03.5Median overflow reduction regret (Bg


or average GSI capital cost per impervious acre controlled. The areas highlighted in yellow show the set of assumptions that that yield acceptable cost-effectiveness, with the dashed red lines showing the specific thresholds identified in part with s


.57.0Total overflow (Bgal./year)
0.10 0.50Cost-effectiveness ($/gal.)Robust Decision Making Strategy Comparison    95
Th  is pattern changes when we look at the climate scenarios with plausible future
rainfall increases (bottom half of plot). Here,


s, identify which
uncertain factors were most often leading to cost-effectiveness results in excess of $0.35 per gallon (Figure 5.5, red-shaded region). For this strategy, the results showed that a similar subset of uncertainties—in this case, avera


t Decision Making Strategy Comparison    97
Figure 5.7
Scenario Discovery Results for a Combined Source Reduction Strategy (Strategy 27)
$41576%
RAND RR1673-5.7150 200 250 300 350 400 450 500 550 600
Average GSI cost per impervious acre (2016 $ thous


tion in scenarios with more rainfall, they could yield long-term benefits and investment value. Conversely, if rainfall volumes are not increasing or cost and per -
formance targets cannot be achieved, source reduction might not “pay off” well when c


 program focused on high-inflow areas of the separated sewer system, or combinations of both—appear to yield notable overflow reduction ben -
efits that can be cost-effective under plausible future assumptions. Cost-effectiveness of treatment expansi


have grown in the past decade, with sewer overflows increasing from approximately 9.5 Bgal./year in a 2003 Typical Year simulation to a ten-year average of 11 Bgal./year for 2004 to 2013, when holding other system characteristics constant. These incr


mpervious cover in the combined sewer area over addressing potential new growth.
Expanding WWTP capacity or cleaning existing deep interceptors could
represent low-regret, near-term options.  Next, we identified and tested a range of
proposed plann


e of cost-effectiveness from $0.11 per gallon to $0.67 per gallon.
None of the strategies combining treatment plant expansion with intercep -
tor cleaning and source reduction fully eliminates sewer overflows. This analysis tested a wide range of pr


$353,000).
Rainfall uncertainty is also a key driver for a Combined Source Reduction Strat -
egy. As with Strategy 2, this strategy is increasingly cost-effective as average annual rainfall increases and the climate scenario becomes more adverse. Str


ate, population growth, or land-use changes. Infrastruc -
ture planning and design based only on a 2003 Typical Year could yield a system that is not resilient to these changes, meaning that overflows could still occur regularly even after these inve


general, help support continued progress toward regional collaboration on
stormwater planning.
Source reduction could help reliably reduce overflows, but additional
research is needed to fully define a long-term, adaptive strategy. This analysis su


e the full range of uncertainty associated with current
system vulnerability or future strategy performance. Our results are based on a limited
number of uncertain factors and scenarios evaluated. Although we modeled more than 500 unique scenario a


ake into account the timing or phasing of proposed investments, the expected service life of projects, O&M or detailed project life-cycle costs, or ratepayer affordability—all of which limit the utility of the strategy comparisons and cost-effectiven


ongahela
USEPA U.S. Environmental Protection Agency
WPAC Watershed Plan Advisory Committee
WWP Wet Weather Plan113References
3 Rivers Wet Weather, homepage, undated-a. As of March 20, 2017:
http://www.3riverswetweather.org/
———, “About the Wet Weat


etWeatherPlan/
DraftWWPFullDocument/tabid/176/Default.aspx
———, “Appendix C: GSI Cost Literature Review,” Starting at the Source: How Our Region Can
Work Together for Clean Water , Pittsburgh, Pa., 2015a.
———, Starting at the Source: How Our Region


ndated. As of March 21, 2017:
http://city.milwaukee.gov/commoncouncil/District10/
Stormwater-and-Sewer-Capacity.htm#.V9mN6xRu7iQ
Collins, T., J. Kline, K. Vallianos, and C. Fox, Ecology and Recovery: Allegheny County , Pittsburgh,
Pa.: Studio for


eveloping Key Indicators for Adaptive Water Planning,” Journal of Water Resources Planning and Management ,
Vol. 141, No. 7, 2015.116    Robust Stormwater Management in the Pittsburgh Region: A Pilot Study
Groves, David G., Jordan R. Fischbach, Eva


r Public Policy and Economic Development, “A Primer on Home Rule,” Wilkes-Barre, Pa., 2009. As of March 20, 2017: http://www.institutepa.org/PDF/Research/APrimeronHomeRule0809.pdf
Kansas City, Missouri, Water Service Department, Overflow Control Prog


alchange.gov/
Michael Baker Jr., Inc., Allegheny County Stormwater Management Plan Phase 1 Report , Moon
Township, Pa., December 2014. Milly, P., J. Betancourt, M. Falkenmark, R. Hirsch, Z. W. Kundzewicz, D. Lettenmaier, and R. J.
Stouffer, “Statio


ce Conference, Charlotte, N.C., April 28–29, 2014. As of March 20, 2017: http://www.cisa.sc.edu/ccrc/pdfs/2014/Presentations/
ODonnell_Assessing%20Cost%20Effectiveness%20of%20Green%20Infrastructure.pdf
Office of the Mayor William Peduto, “Statement


www.elibrary.dep.state.pa.us/dsweb/Get/Document-108470/2700-BK-DEP4494.pdf
Tarr, J. A., and T. F. Yosie, “Critical Decisions in Pittsburgh Water and Wastewater Treatment,”
in J. A. Tarr, ed., Devastation and Renewal: An Environmental History of Pitt


13.
Volkening, Aaron, photo of bioswale, Flickr, 2010.
Walker, W., M. Haasnoot, and J. Kwakkel, “Adapt or Perish: A Review of Planning Approaches for
Adaptation under Deep Uncertainty,” Sustainability , Vol. 5, No. 3, 2013, pp. 955–979.
Water Envi


e the trade-offs among them.
 This research is intended to support improved stormwater, wastewater, and climate
resilience planning in the Pittsburgh region. The intended audience includes local government
agencies and regional authorities addressi


SOCIAL AND ECONOMIC WELL-BEING
Access to Medical
Treatment for Injured Workers in California
Year 3 Annual Report
Kandice A. Kapinos, Cheryl K. Montemayor
Prepared for the California Department of Industrial RelationsThe RAND Corporation is a resear


eral practice  (n = 4,879).

1 In the Year 2 report, we analyzed some of the Version 2.0 data, but the California Department of Industrial
Relations  had converted the data back to Version 1.0 (see K


a Division of Workers’ Compensati on
E&M evaluation and management
ED emergency department
MD medical doctor
NPI National Provider Identifier
NPPES National Plan and Provider Enumeration System
PCP primary care provider
TIN Taxpayer Iden


ividual practitioners (e.g., in the case of a large physician practice or delivery system).
Individual practitioners occasionally bill under multiple TINs. Thus, using the NPI will result in
larger counts of providers .
The structure of Version 2


  that we
might expect DIR  and DWC to have the most influence in affecting for workers with workplace
injuries, because these measures  typically include rules and regulations imposed by payers
systemwide. Process measures reflect aspects of the


o a bill line
record—provided in a given calendar year. Then, any access measures at the provider  level
would include all providers that delivered a med ical service within the calendar year. Similarly,
any access measures using this approach at


tic Sample Size

2016
Service  year sample
Number of claims  705,979
Number of bill lines  16,548,253
Number of providers  76,950
Injury  year sample
Number of claims  393,839
Number of bill lines  10,740,977
SOURCE: RAND analysis


 are listed in Figure 3-17
• type of service ; categories  are based on place of service and procedure codes on the bill
and bill line records that are listed  in Figure 3-58
• county and region of the state ( see Figure 3-3 for regions ).


spitals,
ambulatory facilities (surgical and physical therapy), durable medical equipment suppliers, optometrics, home
health, and orthotics supplie rs.  8 Figure 3-1. Number of Providers , by Specialty

SOURCE: RAND analysis of  WCIS Medical B


ment of Insurance , Workers’ Compensation Research and Evaluation
Group, 2018) . The Texas rate is lower  than California’s , but this is partly because the
denominator in that analysis was  “treating physicians ,” whereas we are using all treating


we also examin ed the
number of bill lines or medical services per provider over the course of the year. On average,
providers delivered 208.1 medical services per year across all specialties. In Figure 3-2, we
present the average number of  medic


claim in 2016, however, were other surgery and dental providers , at $3,830
and $3,017, per claim, respectively. Pathology had both  the lowest total annual payment per
provider and the lowest average pay ment per provider , at $1,074 and $123, res


Results by Geography
Number of Providers
In Figure 3-3, we show the total number of providers with claims in 2016  (blue bars) and the
percentage of all WC medical bills (claims) for  injured workers  treated in  California (red
squares) with


d all injured workers
with an injury in 2016 for 12 months . First, we show the number of claim s with each type of
service (blue bars) and the percentage of all claims with each type of service ( red squares) in
Figure 3-5. Ninety-four percent of


, o steopathic manipulative treatment
• other: alcohol and drug abuse treatment; composite measures; diagnostic radiology services;
diagnostic/screening processes or results; enteral and parenteral therapy; outpatient prospective payment
system


 Distribution of the Number of Days Between Injury and First E&M Visit with a PCP

SOURCE: RAND analysis of WCIS Medical Bill data, Version 2 .0 from 2016 .
 21 4. Discussion and Summary
This study, as mandated by Section 5307.2  of the Califo


 . The specialty and provider type categories
were not exactly comparable across the two samples  (we have tried to group them roughly by
shading groups together) . For example, because we broke out all nonprac titioner services into the
“all othe


 provider  22%
Anesthesiology  3%
Family medicine/general practice  5%
MD general provider  10%
Internal medicine – general  0.4%
Other MDs  2%
Internal medicine – cardiology  0.5%
Physician specialist  12%
Internal medicine – onco


ology had  the lowest total annual
payment per provider and the lowest average payment per claim , at $1,074 and $123,
respectively .
• There was significant variation by region and county across all measures.
• Ninety-four percent of claims inc


ogy Tests';
else if (97010 <= proc_num <= 97799) and ^(97151 <= proc_num <= 97158) then tos_detail = 'Physical
Medicine and Rehab Evals';
else if (97810 <= proc_num <= 97814) then tos_detail = 'Acupuncture Procedures';
else if 98925 <= proc_nu


en tos = 'Prosthetics/Or thotic Procedures';
else do;
tos = 'Other';
if 'A0021' <= procedure_cd <= 'A0999' then tos_detail = 'Ambulance';
else if 'A4206' <= procedure_cd <= 'A8004' then tos_detail = 'Medical And Surgical Supplies';
else if


ia Health Care Foundation, California Physicians: Who They Are, How They Practice ,
California Health Care Almanac, August 2018. As of June 6, 2019:
https://www.chcf.org/wp -
content/uploads/2018/08/CAPhy siciansAlmanacWhoTheyAre2017.pdf
Califor


2016 Update , Oakland, Calif., August
24, 2017. As of May 21, 2019:
https://www.wcirb.com/sites/default/files/documents/
170824_ca_wc_med ical_agg_pymt_trends_report.pdf


Benjamin Lee Preston, Tom LaTourrette, James R. Broyles, R. J. Briggs,
David Catt, Christopher Nelson, Jeanne S. Ringel, Daniel A. WaxmanUpdating the Costs
of Compliance for California’s Hospital Seismic Safety StandardsCORPORATIONFor more informa


f compliance, the affordability of the legislation for hospitals, and the exploration of policy alternatives that could reshape how SB 1953 is implemented in the future. In addition, we identify the various factors that influence how hospitals priori


................................................................. 22
Table 4.3. SB 1953 Compliance Status, by Hospital Building (as of September 2018) .............. 22	Table 4.4. Key Factors Influencing Hospital Decisionmaking on SB 1953 Compliance


passage of SB 1953, hospitals have been assessing the implications of the legislation for their business planning and implementing structural and nonstructural upgrades to comply with the standards. These upgrades have been expensive for hospitals.


al project advisory committee, composed of
hospital representatives, former hospital executives, and consulting engineers, for their
participation and willingness to provide their perspectives on the scope of the study and key issues associated wit


h
other hospitals.7
The damage to hospitals highlighted their continued vulnerabilities to seismic events and the
potential health and safety issues that could arise because of damaged hospitals. In particular, the


tions, service provision, and the health and well-being of Californians. On the other hand, in the event of a major seismic event, there is a public benefit to having hospitals that can remain operational and continue to provide health care services.


earch pathways:
• First, this study represents an update to two prior studies conducted by the RAND
Corporation (published in 2002 and 2007 by the California HealthCare Foundation).
11
This update analyzes the likely magnitude of the costs of both


xt decade. This includes identification of the
key factors that hospitals must weigh in determining how and when to undertake seismic compliance projects.
Chapter 5 presents updated cost estimates for compliance with SB 1953. We focus on post-
202


ailable for download at www.rand.org/t/RR3059.    5 2. Study Background
History of Hospital Seismic Safety Legislation
Origins of the Alfred E. Alquist Act
The modern incarnation of seismic building standards for California hospitals dates back


ar  Policy Change  Implications
1973 Alquist Act passed  Required new acute care hospitals to be designed and constructed to
remain standing and operational after a major seismic event. Administration
of the new requirements was delegated to OS H


akers to conclude that additional steps were needed to enhance the seismic resilience of California hospitals. A key observation was that hospitals built after the 1973 Alquist Act generally performed well structurally, although they experienced nons


, 2030
SPC-5 Buildings in compliance with the structural provisions of the Alquist
Hospital Facilities Seismic Safety Act and reasonably capable of providing
services to the public following strong ground motion  May be used beyond
January  1, 20


.
18
This led OSHPD to pursue a more refined classification of hospital buildings, reducing the
number of SPC-1 buildings by half.19 In 2010, OSHPD implemented an emergency regulation
that raised the threshold for SPC-1 classification, which allow


l be on meeting this next level of compliance associated with the SPC-2 buildings within hospital facilities—many of which were constructed in the 1950s, 1960s, and 1970s and pose nontrivial challenges to structural upgrades.
Concerns in recent yea


uires enhanced resilience of laboratory areas, pharmaceutical services, radiological services, and central and sterile supply areas. Meanwhile, NPC-4 focuses on architectural, mechanical, and electrical equipment. To reduce vulnerability to disruptio


 flexibility with NPC requirements.
Just as SPC-4D provided a mechanism for greater flexibility in bringing SPC-1 and SPC-2 buildings into compliance, OSHPD’s most recent policy modification is the introduction of a new NPC category—NPC-4D (see Tabl


ia Building Standards Code Update for the California Hospital Association ,
Sacramento, Calif.: Office of Statewide Health Planning and Development,  2018.
  12 departments at both remained open.26 Although not directly transferable to the Califor


ents Canceled at Anchorage Area Hospitals,”
Alaska Public Media, November 30, 2018.
27 J. Gillengerten, “Estimated Cost of Structural R etrofits,” paper presented at the  SB 1953 Seismic Compliance
Meeting, California Healthcare Association, Sacr


to hinder the ability of hospitals to keep pace with trends in health care practice, particularly
the shift toward greater use of outpatient services.
• The 2007 report also identified some policy alternatives, including continuing with
business-a


mer hospital executives, and private-sector structural engineers. The committee convened via conference call every other week and served to provide high-level input on key compliance-related issues of concern to hospitals, provide technical clarifica


osts of SB
1953, assessing those social costs was beyond the scope of this analysis. Given that most hospital revenue in California comes from Medicare, Medi-Cal, and private health insurers using established reimbursement schemes, providers cannot


ress common barriers to
compliance, enhance flexibility in achieving compliance, and reduce overall costs of compliance.
In so doing, we first examined approaches to seismic resilience for other types of critical infrastructure (Chapter 7), followe


ire costs of SB 1953 implementation, and hospitals have to pay those costs up front. Benefits are realized only if there is a significant seismic event, and it is not clear whether the potential future benefits of being able to continue to operate wi


ed that the focus of SB 1953 on general acute care hospitals does not fully account for this trend. Rather, this focus creates path dependence around inpatient infrastructure and reduces opportunities to make investments in other delivery models. The


of California hospital buildings are noncompliant with respect to NPC requirements than with SPC requirements.
Given the above, hospital representatives frequently noted that the dominant benefit generated by
seismic regulations is likely the prev


equire some seismic upgrade, with 815 (26 percent) requiring SPC upgrades and 1,951 (63 percent) requiring NPC upgrades.

35 OSHPD , “Hospital Building Data,” data set, accessed September 2018.
3


ors Influencing Hospital Decisionmaking on SB 1953 Compliance Strategies
Decision Factor  Implications
Community needs The needs of communities with respect to demand for different types of
health  care services influence long- term hospital bus


communities. This emphasis on serving communities creates obligations for hospitals to consider the effects of SB 1953 compliance on their ability to meet identified community needs. For example, seismic construction projects that disrupt service pr


include mandatory improvements associated with compliance with other building codes (see “Code Requirements,” below), but they may also be voluntary improvements. For example, hospitals may choose to pursue actions to modernize the facilities and ser


Budgeting, Accounting and Financial Management ,
Vol. 23, No. 1,  2011,  pp. 31–68.
39 One exogenous  pressure that all hospital businesses face regardless of ownership type is the continuing change s
to government reimbursement rates and policies


epartments and health care services to new locations, the need to complete work in active areas of the hospital can nevertheless be a significant source of disruption. For example, completing NPC work in active operating rooms necessitates either tak


tion for available contractors and labor. This could drive up the costs of construction, above what has been witnessed historically, and therefore the costs of compliance.
The anticipation of future cost increases could ultimately influence the typ


on for seismic compliance cannot be isolated from other types of additional construction work associated with a seismic project, because the two are inherently linked. This creates incentives for hospital owners to undertake other types of constructi


direct costs.
• Forced retrofit: In the absence of opportunities to acquire new land or rebuild in place,
the options available to hospitals may be limited to retrofitting existing noncompliant
buildings. The pursuit of this option assumes that th


monitoring projects to ensure
that construction proceeds in accordance with the building code. Necessary changes to the plan that are encountered during construction may trigger a change order, which requires approval by OSHPD. As noted by hospital


ther hand, such a delay tactic can be risky if greater flexibility fails to materialize. As a consequence, hospitals have taken different strategies with respect to how proactive they have been in achieving compliance. Some hospitals made early inves


other activities and whether the project accomplishes all of the seismic upgrading needed.

55 Although  SPC-3 and SPC -4 buildings are compliant with SB 1953, these categories are for particular types


te has not been verified by the hospitals themselves.

56 This means moving services and operations a round the hospital to allow access to areas requiring construction
work .
57 These are constructi


d 1.5  ´ box height (i.e., the difference between the 75th  and 25th  percentiles ) with
maximum and minimum data points as bounds. See Table 5.1  for information about data sources .
Adjustments to Cost Data
The SPC retrofit cost estimates are fo


h nonseismic-related code requirements, such as access for disabled persons, seismic upgrading sometimes leads to larger and fewer rooms. And, often, hospital owners choose to change the size and number of beds or rooms for other reasons. For all the


Without
beds  14 $507,277 $3,615,237  $10,334,482
NOTE: See Table 5.1  (row 3) for information about data sources .

Table 5.3. NPC -2 to NPC -5 Retrofit Costs from  Sample Data
Building
Group  Number in
Sample  Cost per Building
 NPC


nation of the two is impossible to determine a priori. Representatives for many hospitals we met with noted that they are still engaged in an extended decisionmaking process and have yet to develop upgrade plans.
In light of this uncertainty, we dev


acement—we can examine total costs in terms of the relative proportions of
these two approaches used. Figure 5.2 uses a simple linear interpolation to show the statewide escalated total cost of compliance as a function of the proportion of complianc


lifornia would eliminate the need for these assumptions. The seventh assumption refers to neglecting cases in which hospitals are unable to make the investments needed to comply with SB 1953 and are compelled to close buildings rather than attain com


 rooms have windows, larger diagnostic and test facilities). In this perspective, some portion of costs for projects nominally attributed to seismic compliance is actually part of a background trend of
(nonseismic) capital reinvestment spending to o


hospital’s resilience to earthquakes and reduce the risk of earthquake damage immediately reducing hospital capacity and services offered in the wake of a major seismic event. However, the financial stress imposed by its requirements could also forc


 47 • improving occupancy rates by improving referral networks and market visibility
• shifting toward a greater mix of outpatient services
• changing the coding of services—i.e., upcoding—to receive higher reimbursement rates
• delaying capital i


ation can inform current and future policy assessment of hospital seismic requirements in an effort to balance seismic safety, affordability, and adverse effects on the populations served.  48 Methods for Characterizing Hospital Financial Distress


 50 teaching

62 We estimate that approximately 75 percent of California hospitals currently have credit ratings  from Moody’ s,
Fitch, or S&P. It is normal for fiscal entities below a certain size to


n particular or the hospital industry at large, as researchers

66 Langabeer , 2006.
67 Z. H. Ramamonjiarivelo, “Is Privatization the Solution to the Financial Distress of Public Hospitals? ” Academy


nprofit groups. Not-for-profit hospitals may benefit from philanthropic funds from other community organizations or private donors, and public hospitals can tap into tax revenue and other sources of public funds. Additionally, hospitals have a public


in the short term to invest in aging assets.
• Days cash on hand indicates the strength of financial reserves relative to operating costs,
another measure of short-term liquidity. Days in accounts receivables is a measure of the
efficiency of col


 The resulting financial
data can be mapped to 406 of the 418 general acute care hospitals for which OSHPD provides building-level data.
85
Current Status of California Hospital Finances
California hospitals exhibit a wide degree of financial he


 70% 80% 90% 100%
All Hospitals (406)
CAH (34)
Private- MHS (225)
Private- Non-MHS (71)
Public - Non-Healthcare District (19)
Public - Healthcare District (38)
Academic (11)
High Medi-Cal (170)Severe Financial Distress Potential for Financial Distres


hospital districts that often effectively lack these public-sector benefits. Hospital districts are special districts unique to California that do not have other sources of revenue and, more important, struggle from a lack of visibility to convince v


icult;
small size
Public—
non–health
care district  100 100 100 Contributors: Owned by strong fiscal
institutions; a ccess to other public funds
outside hospital revenue
Affordability of Seismic Requirements
The seismic retrofit requirement


ties have well over 50 percent of hospital beds that are associated with noncompliant hospitals. Thirty-one percent of California

88 The OSHPD cost utilization data did not provide the number of beds


onal costs would significantly increase the overall cost impact and long-term liabilities on hospitals’ balance sheets, as discussed in the prior chapter. We expect this would further exacerbate the impact on certain types of hospitals, noted below.


s  $25.3B  81,414 $311K
CAH $0.9B  1,467 $647K
Private, MHS  $16.0 B 50,280 $318K
Private, n on-MHS  $4.9B  14,624 $336K
Public, n on–h ealth care district  $0.9B  6,993 $130K
Public, h ealth care district  $2.5B  5,145 $481K
Academic $1.


l types using published financial distress assessment methods that have recently been applied to acute care hospitals. The affordability research we presented shows that current and SB 1953–imposed financial distress have a tendency to affect certain


ly, deferment of capital investments in new  63 buildings or technologies would indirectly present an opportunity cost to patients who
otherwise could have benefited from such investments. It is impossible for us to predict
whether hospitals will t


ormed this role, and in select cases individual actors (large water and energy utilities, for example) have performed their own vulnerability assessments. The impetus to make necessary modifications has involved a mix of legislative mandates to make


of the Federal Energy Regulatory Commission, Bureau of Reclamation, and Army Corps of Engineers. The vast majority of these structures were built 50 to 100 years ago, before engineering and construction practices evolved to mitigate seismic risk.
Da


ts where necessary. For local government or utility-owned dams, DSOD does not mandate retrofitting but instead exercises its power to force dam operators to lower water levels to acceptable risk levels, which serves as an impetus by effectively reduc


rea and Southern California metropolitan regions. For the Bay Area, major pipelines carrying water from the Sierra Nevada mountains cross East Bay fault zones on their way to providing water to 4 million Bay Area residents, and multiple reservoirs si


mentioned necessary conditions. In this case, there are few to no capacity limitations for comprehensive vulnerability screening, given that each entity owns the responsibility for managing its infrastructure and has sufficient expertise (or access t


smically active areas are vulnerable to collapse or major damage in an earthquake.
108 California has been more proactive than other states and the federal government,
having adopted seismic design practices in the early 1970s following the 1971 San


l highway funds (28 percent), and proposition bonds (8 percent) was used to allocate the cost burden between individual users and the state and federal governments.
113 The state bridge program, costing $2.8
billion, was funded by a mix of propositi


9.
  71 consequences similar to if many hospitals in a region had extremely reduced capacity or were
rendered useless after a major seismic event.
Multiple past efforts within the legislature have failed to introduce statewide retrofit
programs


 Control Board, “Study Session on Consideration of Tenant Protections and Costs Associated
with the City of Santa Monica ’s Mandatory Seismic Retrofit Program ,” letter from Tracy Condon  to the Rent
Control Board commissioners, October 12, 2017 .


nd other sectors is in the ability to finance the necessary retrofit projects.
First, before discussing individual project financing, a comment is warranted on overall
sector costs. As has been noted within the hospital industry, total costs are qu


ment managerial actions that generate higher profit margins to increase funding for infrastructure projects, but this may be insufficient. In regard to public financing, only a handful of hospitals across California owned by state, county, or municip


nd on a variety of infrastructure, services, and other institutions. Hurricane Maria in Puerto Rico in 2017 and similar experiences show that interruptions in access to more-routine care for chronic conditions can significantly elevate morbidity and


t illustrate a range of policy instruments.
129
As a benchmark for comparison, we begin by assessing the status quo. Next, we analyze four
broad sets of alternative policy options that policymakers may adopt to achieve the goals of SB 1953 while a


y 2030, hospital
buildings that are not in substantial compliance with these standards (SPC-2 buildings) must be retrofitted (typically to SPC-4D or higher standards), demolished, replaced, or converted to nonacute use. Failing that, hospitals then


riving these decisions.
Distributional Effects and Equity
Hospitals bear all the initial outlays for SB 1953 projects under the status quo.
133 Other things
being equal, financially stressed hospitals are more at risk for exiting the general acu


odels
One way to reduce the impact of seismic events on patients and encourage more hospitals to
invest in seismic improvements is to lower the costs of SB 1953 to hospitals by spreading them more broadly among beneficiaries of the policy. Arguabl


e used to support retrofits, new construction, or both.
Reducing the cost of financing investments in seismic retrofits and new construction is
another way to reduce the costs to hospitals and facilitate greater seismic safety investment on their


ich $576  million  remained outstanding.
Given that data gathered for this research show that a single hospital retrofit project has costs on the order of $100
  81 expanded program. As we noted, Cal-Mortgage is presently available to public and no


t Ending November 30, 2018 ,
Sacramento, 2018.
142 More generally, this type of program would benefit only hospitals that have not yet met the requirements of SB
1953. Some might argue that such a policy is unfair because it rewards hospitals tha


als in Los Angeles County were evacuated after the Northridge earthquake, regional capacity proved adequate to absorb this loss. On an ongoing basis, hospitals

143 Chang and Jacobson, 2010.   83 with


o postearthquake health care that includes consideration of nonhospital resources.
As a third alternative, policymakers could create a market akin to a pollution cap-and-trade
system to drive the allocation of regionally tailored compliance requir


ations to address equity concerns and secure buy -
in from market participants. In either trading system, regulators would need to consider the time  horizon of the
underlying rights and requirements. Would the rights be of a one -shot nature, with


lization policies would first need to determine both the optimal size and scope of each region and the number of compliant beds that each region requires. Although the regional structure implied by the Hospital Preparedness Program’s cooperative agre


iance. Administrators would then need to spend resources to ensure smooth adoption and best use of the options this policy presents.
Under a bilateral trading system in particular, policymakers would need to give some
attention to antitrust concer


their normal capital replacement
schedule
• customize deadlines based on project characteristics by type or complexity of the
building project
• allow rolling deadlines for sequencing construction or retrofitting of multiple buildings
on the sam


 comply. Alternatively, policymakers could instead determine the maximal time they are willing to extend hospitals to retrofit for SB 1953.
Other Considerations
Timing-flexibility options have at least two implications beyond hospitals. First, ext


In practice, the effectiveness of such a policy depends on the expected time saved per project. Estimating potential time saved presents substantial challenges and makes calibrating this policy to achieve a desired level of response highly impractic


these costs would fall as well. Additionally, hospitals would benefit by spending less time shut down for retrofits or by bringing new hospitals online sooner.
Feasibility
 The fact that OSHPD has recently undertaken other process changes demonstr


he others. Rather, each
alternative has its advantages and disadvantages relative to each other and to the status quo. The relative magnitude of the advantages and disadvantages, however, is difficult to assess at this point because it would depend


buildings. By placing cost estimates of SB 1953 in a larger policy context, this study provides a foundation for a discussion of how policy can effectively ensure the seismic resilience not just for California’s hospitals but the state’s health care


old buildings from service. Requiring hospitals to link the timing of these actions to imposed deadlines in 2020 and 2030 reduces the flexibility of hospitals to make capital investments when and where they will be most advantageous. Synchronizing c


while the higher value assumes that all hospitals replace their SPC-2 buildings with new construction. However, because hospitals will pursue a mix of retrofit and new construction, neither value is realistic. Rather, the actual cost will fall somew


tified as experiencing severe financial stress. After including in the analysis of financial stress the potential costs of SB 1953 compliance that individual hospitals might incur, the proportion of hospitals with some or severe financial stress incr


is report does not make specific policy recommendations regarding whether SB 1953
should continue to be implemented as is, altered to change how the costs of seismic resilience are
distributed throughout society (e.g., use of public subsidies), or


with hospitals to maintain compliance with legislative requirements of SB 1953 while pursuing opportunities to address common barriers to compliance. Such collaborative relationships between OSHPD and hospitals enable


d the Hospital Building Safety Board to advise
OSHPD on the implementation of the Alquist Seismic Safety Act and act as a board of
appeals for hospital facilities in regard to seismic safety and fire and life safety issues.  1973
SB 961  This legi


s bill permitted a hospital to receive an additional two-year extension to the January 1,
2008  deadline  on top of the existing two-year extension. It also reopened the window for
hospitals to qualify for the up -to-two-year extension available to


f the bill and required the application to include a timetable, as specified.  2015
AB 908  This bill authorized a hospital in the Tarzana neighborhood in Los Angeles that received
specified extensions to request an additional extension, as specifi


018. As of March 20, 2019:
https://mavensnotebook.com/2018/01/03/earthquake-resilience-southern-californias-water-distribution-systems/
Babbitt, Donald H., Improving Seismic Safety of Dams in California, Sacramento: California
Department of Water


Program,” webpage, June 2014. As
of March 20, 2019:  http://www.dot.ca.gov/hq/paffairs/about/retrofit.htm
California Department of Water Resources, “Lake Perris and Perris Dam Projects,” webpage,
undated. As of March 20, 2019:  https://water.ca.g


ction 15097.125) to Chapter 1 of Division 12.5 of, the Health and Safety Code, Relating to Building Standards, and Making an Appropriation Therefor, September 21, 1994. As of March 20, 2019: http://www.leginfo.ca.gov/pub/93-94/bill/sen/sb_1951-2000/s


ch 20, 2019:
http://www.catc.ca.gov/programs/prop1b/lbsra/docs/LBSRA_guidelines_052908.pdf
Capps, C., D. Dranove, and C. Ody, “The Effect of Hospital Acquisitions of Physician Practices
on Prices and Spending,” Journal of Health Economics, Vol. 59


hronicle.com/bayarea/article/Crews-topping-off-Calaveras-Dam-shoring-up-Bay-13245983.php
Gillengerten, J., “Estimated Cost of Structural Retrofits,” paper presented at the SB 1953
Seismic Compliance Meeting, California Healthcare Association, Sacr


Recovery and Closure: Managerial Incentives and Political Costs,” Journal of Public
Budgeting, Accounting and Financial Management, Vol. 23, No. 1, 2011, pp. 31–68.
Mallett, William J., Nicole T. Carter, and Peter Folger, Earthquake Risk and U.S.


 March 20, 2019: https://www.healthcaredesignmagazine.com/architecture/californias-wise-retreat-seismic-overreaction/
Public Law 111-148, Patient Protection and Affordable Care Act, March 10, 2010. As of
December 27, 2018:
https://www.govinfo.gov/


mergency Response,” in John F. Hall, ed.,
Northridge Earthquake, January 17, 1994: Preliminary Reconnaissance Report, Oakland,
Calif.: Earthquake Engineering Institute, 1994, pp. 87–93. As of March 20, 2019:  http://www.desastres.hn/docum/crid/Sept


o exacerbate this stress. There are options for providing regulatory relief or flexibility to hospitals: public subsidies to share the costs of compliance or reduce financi ng costs, additional flexibility in compliance deadlines,
new standards for


Developing a Robust
Water Strategy for Monterrey, Mexico
Diversification and Adaptation for
Coping with Climate, Economic, and
Technological Uncertainties
Edmundo Molina-Perez, David G. Groves, Steven W. Popper,
Aldo I. Ramirez, Rodrigo Crespo-E


nagement strate-gies that account for climate change.
About RAND Social and Economic Well-Being
RAND Social and Economic Well-Being is a division of the RAND Corporation that
seeks to actively improve the health and social and economic well-being of


d be inappropriate unless Monterrey experiences very high-demand growth and extremely adverse local climate conditions in the long term.
The second phase of our research project—described in this report—built upon
the tools initiated during the fir


nt sequence that meets Monterrey’s water planners’ reliability objective while minimizing investment costs. The resulting database is a rich set of cases showing how different assumptions about uncertain future conditions trigger the implementation o


o options fall into three groups. The first, with low cost-regret levels but high reliability regret, are portfolios that rely on small-scale and low-cost projects. The second group, with high reliability but high cost regret, includes portfolio alte


hich water demand is lower than 14.6 cubic meters per second (m
3/s) and the scenarios under which water
demand is higher than 19.1 m3/s is US $4 billion. This reinforces the message that sig -
nificant savings may be achieved if water demand is man


collaboration with many part -
ners whose collective contributions, support, and feedback proved invaluable. We
thank and acknowledge Eugenio Clariond Reyes-Retana and Alfonso Garza-Garza, presidents of Fondo de Agua Metropolitano de Monterrey (FAMM


 [Monterrey Water and Sewage Services]
RDM Robust Decision Making1CHAPTER ONE
Water Planning in Monterrey: Future Uncertainties and
Political Gridlock
1.1. Introduction
Monterrey, located in Mexico’s northern state of Nuevo León, is the country’s t


no longer possible to predict the potential effects of climate change on the basins from which the city’s water supply is drawn (López-Garcia, Man-zano, and Ramirez, 2017).
In response to such challenges, the Fondo de Agua Metropolitano de Monterrey


supply.
Figure 1.2
Historical Growth in Water Demand in Monterrey, 1980–2015
NOTES: Time series of historical water demand in Monterrey. The vertical axis denotes mean yearly water
demand in m3/s. The horizontal axis denotes the historical record c


 distant ecosystem. As a result, the prospect of the project was met with strong opposition by different actors within the local water-planning community.
3 In response, proponents of the project emphasized the urgent
3 We use the term “MWP [Monterr


ategy for Monterrey’s Water Plan.
Monterrey needs a robust, adaptive water-management strategy to ensure that the
water needs of the region are met even as these needs remain deeply uncertain. This strategy must also use limited public resources wi


formance. Chapter Four describes in detail different options to improve the long-term performance of the water system and the robust, adaptive plan that was identified and incorporated into Monterrey’s latest water plan. Chapter Five summarizes the s


t of assumptions about a deeply uncertain future may well prove
inadequate or even harmful if another future comes to pass.
Complications arising from deep uncertainty appear to be undermining previous
consensus in many policy areas on what constit


velopment and comparison, as described in Figure 2.1 and Appen -
dix A. RDM begins with a decision-framing step in which the key uncertainties, deci -
sion options, performance measures, and models are defined. This information is gen -
erally gather


hat had three objectives: (1) Describe the man -
date and scope of the study; (2) communicate relevant findings; and, most important, (3) engage in a constructive discussion with participants regarding how to improve the study and make it more releva


n RDM
analysis, using the XLRM framework (X = uncertainties, L = options and strategies, R = model relationships, M = performance measures). In this framework, the cat -
egory uncertainties  (X) represents exogenous factors over which the decisionma


ate level, these options could be placed into two groups:
(1) infrastructure options that expand the current system’s supply capacity by exploit -Table 2.2
Scope of RDM Analysis
Uncertainties (X)
1. Water-demand drivers
• Ec
onomic growth
• Popu
l


te a solution but instead to provide decisionmakers with much better strategic insight into their near-term options and how to modify their adaptation strategies for the medium and long terms. See Section 2.5 for more elaborations on the performance


storical water demand from 1981 to 2016 and a set of plau -
sible future demand projections through 2050. The future projections are derived from a detailed exploratory analysis of plausible future water demand using an econometric water-demand model


probability. Higher probabilities are associated with lower constant flows that can be delivered, lower probabili -
ties are associated with higher flows that can be delivered. Table 2.3
Supply Sources for Monterrey
Source Sustainable Supply (m3/s)


he aquifers present challenging geological compositions (i.e., limestones, shales, and karstic stones) and locations that could potentially produce less water than anticipated, as the risk of fracture is higher. At the same time, based on the city’s


 the cost and reliability attributes can be favorable as part of a portfolio of water-management options. Furthermore, as costs decline with grow -
ing technological efficiency, desalination projects become increasingly favorable. Thus, trends in des


of options that could be
implemented to expand the city’s water infrastructure. Over the course of this study, we interacted closely with local stakeholders to define and characterize a comprehensive list of such options for inclusion in the MWP. Th


 of the options would complement one another (e.g., an injec -
tion well and new groundwater wells), while others depend on interdependent water sources (e.g., Cuchillo II Dam, La Libertad Dam, and Tunnel San Francisco II) or are affected differently


he study.
2.4.1. Traditional Water-Management Options
Table 2.4 lists the complete set of infrastructure options considered, excluding tariffs. Each option is described in terms of its total investment cost—including both con -
struction and operati


We developed a tariff optimization tool for exploring an alternative tariff sched -
ule. This tool first estimates the price-demand elasticity for potable water across dif -
Table 2.5
Monterrey’s Water-Tariff Segments and Shares of Consumption
Segmen


 identify the conditions under which a water-system configuration (i.e. infrastructure and regulations) does not meet the management objectives and to compare the perfor -
mance of alternative strategies in the near, medium, and long terms. In this s


me. An econometric autoregressive distributed lag (ARDL) demand model is
used to define the demand projections in a way that accounts for variation across time and geography. Similarly, a Markov autoregressive hydrological model (MARHM) is used to g


jections with the
54 hydrological projections for a “full factorial” design of 648 futures. Next, for each of these 648 futures, random values of groundwater assumptions are combined (rang -
ing between 70 and 130 percent of the current estimate) t


s. The third experimental design allows for the direct comparison of experimental design 1 and experimental design 2 under two alternative policy levers sets: one that considers only infrastructure investments and another that expands this original s


set of futures reflecting uncertainty. The results of these simulations are examined to identify the main drivers of vulnerability. In the optimal strategies stage (described in Chapter Four), the IAM calculates the optimal portfolio of options acro


erable otherwise.
As an example, Figure 3.1 shows projected total water demand for Monterrey over
time (line) and sources of supply (colored stacked bars) for a future in which demand growth is projected to grow slower than current trends (e.g., fi


 -
ability level of Monterrey’s current water system for each plausible future for the first experimental design described in Chapter Two. Recall that this design is built around uncertainties in demand, hydrology, and groundwater availability. Figur


nd groundwater availability (panels). The color legend describes the estimated level of reliability. The “x” indicates results in which reliability is below 97 percent. cms = cubic meters per second. Higher groundwater availability Lower groundwater


uencing of these elements, as well as data inputs into each component.Medium-term
signpost
conditions
Medium-term
contingent
optionsLong-term
signpost
conditions
Long-term
contingent
optionsPortfolio of
low-regret,
near-term
options
2016–2026 2027


ld set for our analysis. At the same time, this example also shows that the cost of meeting this threshold increases as higher water-demand scenarios are faced—from US $154 million under the water-
1 By definition, those courses of action that perfor


liability objective cannot be achieved, even with all projects implemented.
Table 4.3 summarizes the percentage of times that an option is implemented in
the optimal portfolio across the full set of futures, disaggregated by the implementa -
tion p


folios Across Futures Ensemble, by Time and Change in Water Demand and Flow
2016–2026 2027–2038 2039–2050
Water-Demand Growth Levels
Low Medium High Low Medium High Low Medium High
Monterrey Country
Groundwater WellWetter conditions 100% 72% 96% 10


he results shown in Table 4.2 provide only partial guidance for which options would be low regret in the first period. While one approach might be just to include the options that appear most often in the near term (left panel of Table 4.2), this wou


 procedure yields nine different low-regret portfolios that could be
implemented during the first decision period (Table 4.6).
There are important differences among these near-term portfolios, as they are
tailored toward different futures. For inst


Groundwater
WellLa
Libertad
DamShallow
Wells: La
UnionWW
Injection
Well Project
Obispado
Groundwater Well27% 25% 21% 8% 17% 16% –10% 6% 100%
La Libertad Dam22% 27% 29% 24% 28% 29% –21% 21% 9% 100%
La Union Shallow Wells19% 25% 29% 18% 23% 48%


rn, allows us to identify a Pareto frontier in the first decision period—in this case, the set of points that define the trade-off surface along which any improvement on cost regret would entail more reliability regret and vice versa.
Figure 4.2 show


t combine La Libertad Dam, efficiency, and groundwater options (i.e., P1, P2, P3, and P5) but also a project portfolio that relies only on the Cuchillo II Dam (P6). Thus, these groups describe fundamentally different approaches to executing near-term


n in the second and third deci -
sion periods and, as a result, fewer options for adaptation. In contrast, if Monterrey’s water planners decide to implement one of the low cost-regret alternatives, there might be greater supply vulnerability in the n


al deci -
sions with decision nodes that denote a decision to be made on an uncertain factor. For choosing the best split, the algorithm computes two statistics: (1) entropy, which measures how homogenous class values are (i.e., purity of the end-nod


cribes the main attributes of the different options, presents the near-term portfolio analysis, presents the decision trees for each near-term portfolio, and summarizes the reliability for the selected robust adaptive strategy.
Monterrey water plann


%) = 100
No actionCost (million US $) = 0Reliability (%) = 100
Panuco aqueduct
Vicente Guerrero DamCuchillo II DamWW Injection Well ProjectCost (million US $) = 2,758Reliability (%) = 100Enhancing the Resilience of Monterrey’s Water System Through a


ld suffice for meeting the reliability objectives in the second period. This desalination investment would also be appropriate if demand grows at a medium level or if demand grows at a medium-high level and groundwater availability turns out to be co


est represented by the time interval that a drought affects these sources. If the duration during which these basins remain below historical mean conditions is sufficiently large, then more projects are needed for meeting Monterrey’s water plan -
ner


00
No action
Cost (million US $) = 0Reliability (%) = 100
No actionCost (million US $) = 0Reliability (%) = 99Efficiency
Cost (million US $) = 100 Reliability (%) = 100
EfficiencyCost (million US $) = 100 Reliability (%) = 100Desalination plantEffici


aptive strategy than P6.
Finally, the implementation costs estimated at each decision node in both adap -
tive plans reveal the huge economic opportunity that exists in managing water-demand growth. For instance, in the case of the adaptive strategy


 basins (cms)Vulnerability
condition
Vulnerable
Not vulnerable60   Developing a Robust Water Strategy for Monterrey, MexicoFigure 4.8
Monterrey Adaptive Water Plan Based on P2 Under an Alternative Tariff Schedule
Demand (cms) <= 14.16
Demand (cms) >


er-demand
scenarios considered, as seen in Figure 4.8. These differences are more evident in the long term. For example, if demand is low, medium-low, or medium, the number of projects required for meeting the reliability objective is lower than in


ovide to other water-planning initiatives in Latin America.
5.1. An Adaptive Master Plan: Robust Options and Critical Signposts
We estimated reliability levels of Monterrey’s current water system across a diverse set
of uncertainties regarding f


ing in the network’s efficiency is also an important element for robustness of the system.
For the medium- and long-term evolution of Monterrey’s water system, we find
that vulnerabilities are best addressed from an adaptive planning perspective.


y without adequate computational tools. To better analyze other project proposals, such as increasing forest cover, permeable pavements, and urban densifica -
tion, it would be necessary to develop new tools and integrate these aspects into the IAM d


he system’s reliability, other criteria—such as water- distribution inequality and environmental impacts of project alternatives—can be explicitly considered as performance metrics.
5.3. Lessons for Water Planning in Latin America
The water-plannin


rities across alternatives, which can be conducive to the development of more cost-effective and robust expansion strategies. 69APPENDIX A
Robust Decision Making Methodology
RDM uses a number of techniques to conduct analyses when deep uncertainty is


 we are assessing. There may be opposing views difficult to refute with the information available and so this too can become a matter for RDM analy -
sis. Finally, we need to be able to assess different outcomes that we may observe with different ass


ices for Monterrey’s water infrastructure across many futures. This is described in more detail in section 2.7 of this report.
Cases may be generated to model a wide range of proposed candidate strategies
across many different plausible futures. Th


ically those
scenarios that make a difference in discriminating among the choices before us. The
“boxes” proposed by the data-mining algorithms in effect provide precise descriptions of stressful future scenarios that are meaningful for the decisio


de-offs among alternative adaptive strategies.  Robust Decision Making Methodology   73
Step 5: New Options and Strategies
In response to analysis in steps 2–4, additional options and futures and strategies may
be defined. For example, the initial c


gle consumer over time. In this study, as a result of our collabora -
tion with SADM, the panel data used for estimating the model compose the full set of SADM’s consumer-demand records from January 2012 to December 2015.
1
These records were also s


l station data relevant to the
different water-supply sources. The contributing basins for each one of the proposed project alternatives were delimited through the Thiessen polygons spatial weighting method and the available isohyetal information.


e and water-supply 78    Developing a Robust Water Strategy for Monterrey, Mexico
enhancing alternative considered in this study. RiverWare uses physical-balance equa -
tions and discrete equations to describe the interrelation between river basins,


. (2018c).
Dynamic Optimization Engine
We developed also a dynamic optimization model that estimates the best investment
path for a specific combination of future circumstances. This optimization routine is forward looking as it identifies the best


bed in the previous paragraphs is an
extremely useful computational laboratory to be used in the context of a RDM analy -
sis. On the one hand, the water-demand and hydrological models allow the exploration of diverse potential demand and supply con


 of the group. Additionally, we split these aggre-gated hydrological-change scenarios into three periods matching the dynamic optimi-zation decisions (near term [2016–2026], medium term [2027–2038], and long term
[2039–2050]) and also added further


a metropolitana,” Monterrey, Mexico: Fondo de Agua Metropolitano de Monterrey, 2017b.
Deser, Clara, Adam Phillips, Vincent Bourdette, and Haiyan Teng, “Uncertainty in Climate Change
Projections: The Role of Internal Variability,” Climate Dynamics ,


David G., Robert J. Lempert, Debra Knopman, and Sandra H. Berry, Preparing for an
Uncertain Future Climate in the Inland Empire: Identifying Robust Water-Management Strategies ,
Santa Monica, Calif.: RAND Corporation, DB-550-NSF, 2008. As of April


st
Decision Making , Washington, D.C.: World Resources Institute, 2011.
Lempert, Robert J., Steven W. Popper, and Steven C. Bankes, Shaping the Next One Hundred Years: New Methods for Quantitative, Long-Term Policy Analysis , Santa Monica, Calif.:


, J. Ross, C 4.5: Programs for Machine Learning , San Mateo, Calif.: Morgan Kaufmann,
1993.
Ramírez, A., L. Herrera, S. Ramírez, and D. Gómez, “Modelación estocástica de precipitaciones,”
2018a.
Ramírez, A., L. Herrera, S. Ramírez, D. Gómez, E. T


wakkel, “Deep Uncertainty,” in Saul I. Gass and Michael C. Fu, eds., Encyclopedia of Operations Research and Management Science , 3rd ed., New York:
Springer, 2013, pp. 95–402. SOCIAL AND ECONOMIC WELL-BEING
www.rand.org
RR-3017-FAMM 9 781977 402745


SOCIAL AND ECONOMIC WELL-BEING
2018 National Survey of
Health Attitudes
Description and Top-Line Summary Data
Katherine Grace Carman, Anita Chandra, Sarah Weilant, Carolyn Miller,
Margaret Tait
Prepared for the Robert Wood Johnson Foundation
 Limit


measure detail, technical reports, and other infor -
mation, can be found at www.cultureofhealth.org (RWJF, undated).
Researchers from RAND and RWJF jointly conducted the research reported here; the
report is intended for individuals and organizati


......................................... 28
Q7. You said the following programs are a top priority. Of these which would you consider
to be the highest priority? Of these which would you consider to be the lowest priority?  ...... 29
Q8. Please in


4d. When Americans living in rural communities need health care, do you think it is
easier or harder for them to get the care they need than it is for those who live in urban  areas, or is there not much of a difference?
 ..........................


 challenge like a plant closure, major
incident of community violence?  ....................................................................... 55
Q33a. If yes: As a result of this event, were you temporarily or permanently displaced from
your hom


n Action Framework and selected measures to advance these goals. The Action Framework and 35 measures were selected as a means of defining, operationalizing, and measuring the United States’ progress toward this goal.
This report describes the 2018 R


cription and Top-Line Summary Data
ally representative internet panels whose members are recruited via probability-based sampling
methods. Both provide computers and internet connections for respondents who do not have them at the time of panel recr


eristics of the sample. The weighted results are pre-sented separately for each panel sample and for the total. xiiiAcknowledgments
We appreciate reviews of Scott Keeter (independent) and Kirsten Becker (RAND). We thank
Larry L. Bye, Alyssa Ghirarde


n areas specifically. These action areas and drivers work toward the outcome area of a Cul -
ture of Health: improved population health, well-being, and equity . The outcome area is the key
result of activities in each action area. We briefly outlin


ction area includes three drivers: the built and physical environment, the social and economic environment, and related policies and governance that support healthier communities.
Action Area 4 focuses on strengthening the integration of health serv


ure of Health mea -
sures. However, in the context of making health a shared value, there were large gaps in our 4    2018 National Survey of Health Attitudes: Description and Top-Line Summary Data
understanding of the perspectives of individuals liv


ing so, we drew on findings from broader stakeholder-engagement efforts undertaken as part of the larger Culture of Health development (Acosta et al., 2016; Martin et al., 2017). Second, we reviewed relevant literature and surveys to identify potenti


easure Whether We Are Moving Toward a Culture of Health: Assessing Action Area 1, Making Health a Shared Value
Expectations to Track
Over time in a Culture of Health, more U.S. adults would:Domains
What are the types of things we need to know to as


ces on health (e.g., peer, family,
neighborhood, and workplace drivers of health); values related to national and community investment for health and well-being; behaviors around health and well-being, including civic engagement on behalf of health;


concepts from the review.
In addition, we reviewed surveys, concept scales, and model questionnaires previously known to the team. Table 2.2 lists surveys that we identified through this process that contributed to the design of this survey. We revi


Health (Wellness Forum Health, 2017) Not applicable
Personal Health Experience Scale Alyssa T. Brooks et al. (Brooks et al., 2013) 2013
Sense of Community Index Community Science (Chavis, Lee, and Acosta, 2008) Not applicable
NOTE: Items shown as not


 to better align with our Culture of Health Action Framework and drivers. If we could use existing measures, we looked at available psy -
chometric properties, including reliability and construct validity, though the latter was often not available fo


y, we also include the ques -
tion number from the previous survey.
Survey Length
The resulting survey contained 34 questions, some with subquestions or multiple parts. The median time to complete the survey was between 18 and 19 minutes.
Randomizat


d importance
Religion and spirituality Q22 2 and 5 Health status and experience with
health and importance
Impact of others health Q23 2 and 5 Health status and experience with
health and importanceSurvey Overview    13
data set. Respondents in bot


ealth status and experience with
health and importance
Live in other country Q34 2 and 5 Health status and experience with health and importanceTable 2.3—continued14    2018 National Survey of Health Attitudes: Description and Top-Line Summary Data


weighting, a statistical
adjustment. To create weights to match the distribution of characteristics in our sample as closely as possible to that of the population from the 2018 Current Population Survey (CPS), we used a raking algorithm, following t


ng for smartphones, our survey contained sev -
eral large tables—for example, for Question 1, which asked the respondent to rate many differ -
ent things on one screen. These tables can be difficult for respondents using smartphones, and we cannot be


of the action area making health a shared value . Then,
we specifically used the survey to collect data for three of the 35 national Culture of Health measures. All measures are associated with the action area making health a shared value .
Although


pectation for Well-Being
This measure provides insight on the current landscape of public opinion and attitudes regard -
ing community investment in health and well-being. We calculated this measure using Ques -
tions 2 through 6, which asked respond


d good diet (Chavis, Lee, and Acosta, 2008).
For our measure, we separately calculated a score for each of the two subscales. Each
scale contains six questions. We measured the membership subscale with items A through F of Question 17. The emotional


f Health Attitudes: Description and Top-Line Summary Data
Recognized Influence of Physical and Social Factors on Health
Q1. Here is a list of some things that may affect people’s health and well-being. Please rate
each on a scale from 1 to 5 where 1


n 1.7 1.8 1.7
Neighborhood options for healthy food and exercise 0.4 1.5 1.3
Examples set by people around you 1.0 0.9 0.9
Housing quality 1.7 0.6 0.6
Amount of social support 0.7 0.4 0.5
Where a person lives 0.5 0.5 0.5
Community safety 0.2 0.4 0.4


ople do not have to always rely on cars
or
Making sure that there is public transportation, sidewalks for walking, and bike lanes available so that people do not have to always rely on cars
Note on randomization: Half of the sample received the first


y
foods are
for sale at
affordable
prices in
communities
where they
are not.Making sure
that there are
safe, outdoor
places to
walk and be
physically
active in
communities
where there
aren’t any.Making sure
that there
is decent
hou


to do more to make sure that everyone has [‘an equal’/’a fair and just’] opportunity to be healthy
SampleStrongly
DisagreeSomewhat
DisagreeNeither Agree
Nor DisagreeSomewhat
Agree Strongly Agree Missing
ALP ( n = 2,479) 3.1 4.2 13.9 31.6 46.5 0.6


Panel
(n = 4,708)2.3 5.7 20.7 39.6 30.9 0.8
Total 2.1 6.4 19.4 39.9 31.3 0.9
E. Being educated is a result of the choices you have made
SampleStrongly
DisagreeSomewhat
DisagreeNeither Agree
Nor DisagreeSomewhat
Agree Strongly Agree Missing
ALP (


 of the sample saw Q13a and half saw Q13b.
SampleLocal
GovernmentsState
GovernmentsFederal
GovernmentsNo Government
Can Lower This
Number Missing
ALP ( n = 1,226) 22.8 11.7 19.3 45.6 0.5
KnowledgePanel
(n = 2,319)15.7 14.8 16.6 51.1 1.7
Total 1


nts who selected each item as a top three
reason for longer life expectancy.
Access to a good education
Sample Not Selected Selected
ALP ( n = 2,479) 83.4 16.6
KnowledgePanel ( n = 4,708) 85.0 15.0
Total 84.6 15.4
Access to health careSample Not Se


ate who will address this issue
Sample Very WillingSomewhat
WillingNeither Willing
Nor UnwillingSomewhat
Unwilling Very Unwilling Missing
ALP ( n = 2,479) 38.0 21.4 21.9 5.8 10.6 2.3
KnowledgePanel
(n = 4,708)30.6 23.0 28.2 6.1 10.5 1.6
Total 33.


008).
NOTE: The order of Questions 17A–17P was randomized for each respondent.42    2018 National Survey of Health Attitudes: Description and Top-Line Summary Data
B. I can recognize most of the members of this community
Sample Not at All Somewhat Mo


t of this community for a long time
Sample Not at All Somewhat Mostly Completely Missing
ALP ( n = 2,479) 18.3 27.8 30.8 19.7 3.4
KnowledgePanel
(n = 4,708)15.6 32.7 32.7 17.7 1.2
Total 16.2 31.4 32.3 18.4 1.6
SOURCE: Sense of Community Index (Chavi


r community. For each, please indicate what impact (positive, negative, or no impact) this group has on the health of your community. If the impact is both positive and negative, please indicate whether the overall impact is more positive or negative


Total 40.1 57.5 2.4
B. Voted for or against a candidate for public office because of his/her position on other issues such as
education, public safety, or community funding
Sample Yes No Missing
ALP ( n = 2,479) 57.5 39.9 2.6
KnowledgePanel ( n = 4


ES: RAND and RWJF.
Q21. Would you say that in general your health is excellent, very good, good, fair, or poor?
Sample Excellent Very good Good Fair Poor Missing
ALP ( n = 2,479) 10.5 37.5 33.6 13.4 2.5 2.5
KnowledgePanel (n = 4,708)10.3 36.0 36.7 12


th issue or condition or because of disability?
Sample Yes No Missing
ALP ( n = 2,479) 15.2 82.3 2.5
KnowledgePanel
(n = 4,708)12.0 86.4 1.5
Total 13.2 85.0 1.8
SOURCES:  RAND and RWJF.
Q28. Is there a place that you usually go to when you are sick


 lives]
Sample Covered Not Covered Not Sure Missing
ALP ( n = 2,479) 14.1 72.4 8.3 5.2
KnowledgePanel
(n = 4,708)13.9 77.9 6.8 1.4
Total 14.5 75.5 7.2 2.7
TRICARE or other military health care, including VA health care
Sample Covered Not Covered Not


o Missing
ALP ( n = 2,479) 28.1 69.4 2.5
KnowledgePanel
(n = 4,708)23.9 74.6 1.6
Total 25.0 73.2 1.9
SOURCES:  RAND and RWJF.
Q33a. If yes: As a result of this event, were you temporarily or permanently displaced from
your home or community?
Sampl


1.2 0.3 0.2 0.2 0.0 0.0
a The period indicates true 0 (rather than a number that has been rounded down to 0.)
Respondents by Level of Family Income, in Dollars
SampleLess Than
10,000 10,000–24,999 25,000–49,999 50,000–74,999 75,000–99,999100,000 or


s/research_reports/RR1391.html
Centers for Disease Control and Prevention, 2010 Behavioral Risk Factor Surveillance System Questionnaire ,
November 18, 2009. As of January 4, 2016:
http://www.cdc.gov/brfss/questionnaires/pdf-ques/2010brfss.pdf
———,