Abstract
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The National Association of County and City Health Officials (NACCHO) represents the nation's nearly 3,000 local government health departments. We offer below the collective local perspective on the health security challenges confronting our nation and provide strategic and programmatic recommendations for the Trump Administration and our new Congress on how best to foster local capacity to prepare and respond quickly to ever-present public health emergencies and threats.
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Federal funding streams that support governmental public health's ability to detect, protect against, prepare for, respond to, and recover from public health emergencies include the Centers for Disease Control and Prevention's (CDC's) Public Health Emergency Preparedness Program, the Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement, the Core Infectious Disease Program, and the Environmental Health Program, as well as the Assistant Secretary for Preparedness and Response's (ASPR's) Hospital Preparedness Program and the Medical Reserve Corps. Unfortunately, these programs have been flat-funded or significantly cut over the past decade. Without sustained funding, governmental public health struggles to find the resources to address larger-scale emergencies and must seek supplemental funding from Congress.
• Public Health Emergency Preparedness Grants (PHEP)—PHEP grants are awarded to 50 state, 4 large city (Chicago, Los Angeles County, New York City, and Washington, DC), and 8 territorial health departments. PHEP grants strengthen local and state public health departments’ capacity and capability to effectively plan for, respond to, and recover from public health emergencies like terrorist threats, infectious disease outbreaks, natural disasters, and biological, chemical, nuclear, and radiological emergencies. More than 55% of local health departments rely solely on federal funding for emergency preparedness.
• Hospital Preparedness Program (HPP)—Administered by ASPR, the Hospital Preparedness Program (HPP) provides funding to 50 state, 4 large city (Chicago, Los Angeles County, New York City, and Washington, DC), and 8 territorial health departments to enhance healthcare system planning and response at the state, local, regional, and territorial levels. HPP supports regional healthcare coalitions (HCCs), which are formal collaborations among healthcare and public health organizations focused on strengthening medical surge and other healthcare preparedness capabilities. There are 496 HCCs nationwide, comprised of 23,790 members.
• Medical Reserve Corps (MRC)—Administered by ASPR, the Medical Reserve Corps was created in 2002 after the terrorist attacks of September 11 to establish a way for medical, public health, and other volunteers to address local health and preparedness needs. The program includes 200,000 volunteers enrolled in 1,000 units in all 50 states and territories. Two-thirds of MRC units are based in local health departments. MRC volunteers provide an important community service, both filling gaps in routine health services and responding in emergency situations.
• Core Infectious Diseases (CID) Program—The CID Program provides funding to 50 states and 6 cities (Chicago, Houston, Los Angeles County, New York City, Philadelphia, and Washington, DC) to identify and monitor the occurrence of known infectious diseases, identify newly emerging infectious diseases, and identify and respond to outbreaks. CID includes funding to address antibiotic resistance, emerging infections, healthcare-associated infections, infectious disease laboratories, high-consequence pathogens, and vector-borne diseases.
• Epidemiology and Lab Capacity (ELC) Grants—The ELC grant program is a single grant vehicle for multiple programmatic initiatives that goes to 50 state health departments, 6 large cities (Chicago, Houston, Los Angeles County, New York City, Philadelphia, and Washington, DC), Puerto Rico, and the Republic of Palau. The ELC grants strengthen local and state capacity to perform critical epidemiology and laboratory work by detecting, tracking, and responding to known infectious disease threats and maintaining core capacity to be the nation's eyes and ears on the ground to detect new threats as they emerge.
• Environmental Health Programs—The environmental health programs at CDC include the Healthy Homes and Lead Poisoning Prevention Program, and the Clean Water program, Environmental Health Laboratory Program. Additionally, in the National Center for Emerging and Zoonotic Infectious Diseases, funding is provided for CDC's vector-borne disease response and food safety activities. Funding helps to provide surveillance capacity for state health departments. Most of the environmental health grants are targeted at the state level. Some of the environmental health programs, including healthy homes and lead poisoning prevention and climate and health, fund city health departments that are particularly affected by these issues.
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National health security is a state in which the nation and its people are prepared for, protected from, and resilient in the face of incidents with health consequences. Local health departments play a key role in achieving national health security by preparing their communities for disasters, responding when emergencies occur, and lending support through the recovery process. To ensure that federal, state, and local governmental public health can effectively respond to emerging infectious diseases and other natural and man-made disasters, NACCHO supports the creation of a strong, sustained public health emergency response fund.
Section 319 of the Public Health Service Act established a Public Health Emergency Fund. Under current statute, upon declaration of a public health emergency by the Secretary of Health and Human Services (HHS), resources in the fund can be disbursed. However, Congress has not allocated money to the existing fund in decades. The existence of a strong, sustained public health emergency response fund would enable surge funding to support an immediate response to a health emergency and prevent the incident from becoming more deadly and costly. Given the challenges and significant time it took Congress to pass supplemental funding to address Ebola and then Zika, allocating money to the existing fund (or an equivalent new public health response fund) could enable the expeditious deployment of resources to the federal government and out into the field.
Public health emergencies are increasing in frequency. In 2009, 2014, and 2016, the Administration requested emergency supplemental appropriations to respond to public health emergencies for H1N1, Ebola, and Zika. Each time, local public health departments responded despite cumbersome processes for accessing funding. In the midst of an emergency, it is hard to apply for funding and adhere to administrative requirements that often come with supplemental disbursements. A response fund should reduce the administrative burden and streamline requests that come on an as-needed basis (rather than require a funding opportunity announcement after the fact). If administrative burden remains high, it may not be practicable to access the funds.
Along with additional dedicated response funding, experts need to be given additional authority to act in an emergency. According to CDC, only $2.5 million of their budget is designated to respond to emergencies, leaving the agency waiting for Congress to grant them permission to shift existing funds or to grant them new funds to respond to an emergency, such as a disease outbreak. This lack of authority stands in stark contrast to the Federal Emergency Management Agency (FEMA), which has $13 billion at its discretion to respond to natural disasters.
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The Secretary of HHS is authorized under Section 319 of the Public Health Service Act to make grants, provide awards for expenses, enter into contracts, and conduct supporting investigations into the cause, treatment, or prevention of infectious diseases. To facilitate timely local public health response to disasters, the HHS Secretary should exercise her or his existing authorities to:
• Access “no-year” funds appropriated to the Public Health Emergency Fund for state and local response, minimizing local reporting requirements on emergency response activities. • Grant extensions or waivers on data or reporting requirements, notify Congress, and publish Federal Register notices promptly after granting an extension or waiver as required. • Allow state and local governments to access the General Services Administration federal supply schedule and vendors for response services. • Allow state and local governments to temporarily reassign public health department or agency personnel who are funded through programs authorized under the PHS Act to immediately respond to a public health emergency.
Unlike other kinds of emergency funding, public health emergency funding offers the potential to avert disaster. While disease outbreaks and other public health incidents are inevitable, if addressed early, many consequences can be prevented. Funding and support delivered at the right time can and has saved lives. By providing sustainable funding for core public health programs and financing a sustained public health emergency response fund, the Trump Administration and Congress can ensure local capacity for public health disaster response and recovery and protect the health and safety of all Americans.