Coalition Comments on Efforts to Improve Our Nation’s Public Health and Medical Preparedness and Response Programs

June 4, 2021

Comments Related to Efforts to Improve Our Nation’s Public Health and Medical Preparedness and Response Programs

Dear Chair Murray and Ranking Member Burr:

I write to you on behalf of the Big Cities Health Coalition (BCHC), a forum for leaders of America’s largest metropolitan health departments to exchange strategies and collaboratively address issues to promote and protect the health and safety of the nearly 62 million people they serve. Our members have not only been on the frontlines of the pandemic response for the past year but have also experienced firsthand the field’s long-standing resource challenges. We very much appreciate the increased focus on public health prepared ness and response, including thinking beyond the current public health emergency, as well as this critically important opportunity to provide input for your forthcoming bipartisan legislation. We thank you for your foresight, leadership, and service inworking to promote and protect the public’s health.

If we’ve learned nothing from the past year, it is that our nation’s response to COVID-19 would have been very different if a robust, well-resourced governmental public health system comprised of career professionals had already and sufficiently been in place, even as there were extenuating political and messaging challenges coming out of the White House. As you both know, it is difficult, ineffective, and slow to “staff up” once an emergency has begun and temporary funds come piece meal. An effective response requires a strong preexisting public health infrastructure across all levels of government and all programs, so that we can be prepared for any emergency and can continue to operate all necessary (i.e. “routine”) public health programs.

For future responses, there must be a comprehensive federally led and resourced detection and response infrastructure, developed and carried out in tandem with local and state governments. It is critically important that states and locals are seen as true partners, providing situational awareness of what is happening on-the-ground and to inform what is needed for the response. That information from state and local updates should feed into an all-of-federal-government approach. The lack of a comprehensive national guidance and messaging during COVID-19 has, as you well know, led to a patchwork of activities across jurisdictions, which were not always based on science or data.

Similarly, we must assess the national response system and framework, ensuring that it is aligned with planning assumptions and commensurate with resources and infrastructure limitations, especially at local levels. We encourage funding for revised planning scenarios and assumptions from CDC and other federal partners with clear focus areas for preparedness planning, with realism on what is/isn’t accomplishable given current funding and staff levels.

Please find below recommendation to inform the development of legislation to improve the nation’s preparedness and response infrastructure and systems.

1. Strategies for strengthening and modernizing federal public health and medical preparedness and response systems and programs, including infrastructure, to better support states, localities, and Tribes

Funding

The lack of consistent funding over time for public health and emergency preparedness in general, and even more so in local jurisdictions, has necessitated Congress to repeatedly provide emergency supplemental funding to state and local health departments to stand up a response when major outbreaks occur, as was the case with H1N1, Ebola, and Zika. Therefore, we recommend that both the Public Health Emergency Fund and the Infectious Disease Rapid Response Reserve Fund be well resourced with no-year funds so that a response to the next emerging infectious disease outbreak can be stood up immediately.

Additional funding for the Public Health Emergency Preparedness Program(PHEP), Hospital Preparedness Program(HPP), and Quarantine Stations is also necessary for a well-prepared public health infrastructure. Congress should require the US Centers for Disease Control and Prevention (CDC) to provide a state-by-state report annually showing how much federal emergency preparedness funding, including COVID-19 response funding, is reaching the local level via state health departments.

New funding opportunities for large local health departments in 2021, such as CDC’s National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved Communities, Including Racial and Ethnic Minority Populations and Rural Communities(COVID Health Disparities), are greatly appreciated and should serve as a model for future funding opportunities to ensure local jurisdictions are not forgotten. As increasing investments are provided to the CDC, we urge you to work with its leaders and those at the Department of Health and Human Services (HHS) to ensure that resources get local and that dollars can be tracked for accountability purposes.

In addition to long-standing challenges around categorical funding, federal guidelines are often too restrictive, creating barriers to acquiring new equipment or needed space. Small changes, such as permitting federal funds to be used for construction or to incentivize hospitals to improve negative pressure capabilities, for example, would make a huge difference on the ground in the next emergency. Other suggestions are to support local, state, and national public health practice networks with reliable, consistent funding not tied to project areas and create strong connections to federal leadership so there are rapid and effective communication channels before an emergency occurs.

The federal government can also support preparedness through health care regulation and payment. This includes addressing regulatory and payment issues tied to difficult-to-discharge patients and updating CMS payment methods for long term care facilities to prioritize infection prevention.

Sustained direct funding to local health departments for preventing epidemics, not just responding to them, is a missing piece of our public health infrastructure. In order to better prevent such outbreaks, federal resources must support data infrastructure and workforce development.

Workforce

As you well know, health departments across the country face significant workforce challenges to maintain robust staffing levels and recruit and retain needed professionals. Local and state health departments have lost nearly a quarter (23%) of their workforce since 2008, shedding over 50,000 jobs across the country. The deficiency is compounded by the age of the public health workforce –nearly 55% of public health professionals are over the age of 45 and almost a quarter of health department staff are eligible for retirement. Between those who plan to retire and those who plan to pursue opportunities in the private sector (often due to low wages), nearly half of the local and state health department workforce might leave over the next several years. Already, we are seeing turnover 10 to 15% of BCHC member health officials, many due to age and tenure, but no doubt also related to the tireless work of the last year. The impending “brain drain,” that we have all been worrying about for years, has arrived.

The Biden Administration’s recent workforce initiatives, investing$7.4 billion of the Congressionally-allocated American Rescue Plan(ARP)funding is an important step in building the workforce and the pipeline. Their commitment, and yours, in working to rebuild the public health infrastructure with the recent release of the President’s budget is important, and we urge you to consider the roadmap they put forth in that budget document.

We join our NACCHO colleagues in supporting a loan repayment program that would provide up to $35,000 per year per health professional in exchange for a two-year commitment to serve in a local, state, or tribal health department. Specifically we support the Public Health Workforce Loan Repayment Act authored by Senators Tina Smith (D-MN) and Cory Booker (D-NJ).As new staff and volunteers are brought into the field for the COVID-19 response, this is an added incentive to keep them long term. This legislation could help ensure that their valuable experience is harnessed and available before the next crisis hits.

There is a great need for an expanded, trained public health workforce at the state and local levels. We must ensure that public health agencies and partners have a sufficient, trained workforce across all disciplines that can be rapidly mobilized to respond as needed, without diminishing other essential public health services. Efforts must be made to ensure a baseline knowledge and understanding of the concepts of preparedness and response for public health workers, healthcare workers, providers and governmental officials so that the “language” of disaster response is understood and community-wide preparedness is improved. This effort could include required incident command training for all staff funded by federal grants (not just those funded by PHEP) and recommended baseline preparedness educational requirements as a part of licensing and continuing education for all licensed health care providers (MD, RN, RRT, Paramedics, etc.).

Data

It is now all too well documented that the governmental public health system’s data infrastructure, particularly at the state and local level, is lacking. As you are aware, the Health Information Technology for Economic and Clinical Health Act (HITECH) left out incentives for governmental public health to modernize their electronic records systems. A continued investment over the next decade at the CDC that provides funding to directly support state, local, tribal, and territorial health departments would transform today’s public health surveillance into a state of the art, secure, and fully interoperable system.

An immediate, large, and sustained tranche of federal funding must be given to not just states, or the CDC, but also local jurisdictions, to enable this21stcentury data infrastructure and strengthen information sharing from the federal to local level. Further, a state and/or local match should be considered to ensure that jurisdictions do not cut their own investments due to the influx of federal dollars. This investment should support not only updating/upgrading of technology, but also support simple articulated needs for things like laptops to enable telework. Several local jurisdictions, for example, could not get permission from their states to use federal dollars to purchase laptops so that staff could work from home during the pandemic response. Federal guidelines must direct the states to be as flexible as possible when distributing dollars to locals, and mandate a detailed accounting of how dollars are allocated and in what time frame(s).

Data modernization efforts must also include support for state and local vaccine registries for adults, which are woefully underfunded and underutilized. We need to build a national registry with timely and accurate data that includes information on sex, age, and race/ethnicity. Federal funding should also support development of response tools and software (e.g., inventory management, contact tracing) that are available to effectively support the critical work of public health at the local level.

There are five core data systems that support the public health surveillance enterprise: National Notifiable Disease Surveillance System(NNDSS), Electronic Case Reporting(ECR), Syndromic Surveillance, Electronic Vital Records System, and Laboratory Information Systems(LIS). These systems need modernization now to protect the health security of all Americans. It took CDC a very long time to stand up syndromic surveillance during this outbreak, using their flu and other similar surveillance systems. Even so, the capacity to do this kind of surveillance at the state and local level varies greatly across the country. Sufficient information exchange between local health departments and health systems/hospitals is also still lacking.

The Congress should also instruct the CDC to evaluate the current electronic lab reporting system. Demographic data was, and still remains, challenging to collect, which, according to some, is due to existing electronic lab reporting systems. CDC should assess and report to Congress the status of these systems, and dollars should be provided to upgrade the systems as necessary.

Federal entities need to take both federal capacity and local health department experiences into account when making future recommendations in order to accurately detect emerging infectious diseases. For example, many large local jurisdictions are in favor of a centralized data collection tool and technology systems with standardized capacity metrics, immunization records, and definitions, and would be eager to collaborate with the CDC and partners to ensure this tool is created in such a way that its uptake will be swift and effective.

2. Ensuring sufficient public health and medical capacity to continue providing critical services to at-risk populations. This includes applying lessons learned from COVID-19 to address health disparities in future public health preparedness and response efforts

As Senator Murray recently said, “this crisis is no great equalizer but rather a force which perpetuates and deepens the injustices that black communities, Latino communities, tribal communities, people with disabilities and so many others face… caused by a long history of systemic racism and underfunding and those in charge have a responsibility to acknowledge the problem and do everything they can to close that gap.”

Senator Murray accurately highlighted that health disparities and inequities in the United States are neither new nor unique to COVID-19, but instead driven by structural and social determinants of health, including hundreds of years of systemic racism. In order to adequately address the disproportionate impact of COVID-19 on communities of color, we must act now to ensure those most impacted are reached and resourced and treat racism as a public health crisis by examining not just our health systems, but also looking at the very fabric of our economy and our communities.

Achieving equity and good health for future generations, BCHC’s mission, will not be easy. Acting on racism through a public health lens may help to reframe the conversation and illustrate that we are all only as healthy as the least healthy among us –as this pandemic too has shown. Doing so will mean rebuilding our communities, and in some cases, the systems within which we operate, so that each and every person, no matter where they live, the color of their skin, or where they were born, has the opportunity to live a healthy, full, and productive life.

Concretely, first steps will require additional funding for community-based organizations (CBOs) and faith-based organizations (FBOs) to address everyday health disparities and mitigate those disparities ahead of a disaster; local funding for staff who can maintain partnerships, incorporate CBOs and FBOs into planning processes, and provide compensation for CBOs and FBOs; and local funding to hire subject matter experts on focused topics, such as disability services. Supporting jurisdictions now to create mechanisms to be able to rapidly fund and collaborate with CBOs and FBOs to work directly with communities who are disproportionately impacted and/or difficult to reach during a response will allow for a faster, more effective and more equitable response. The Biden Administration has started to support such partnerships with ARP dollars, and the impact of these dollars should be evaluated to consider future investments.

Finally, the federal government can do small things to move the needle as well, such as ensuring CDC produce guidance documents and other content in multiple languages to increase reach to vulnerable populations and alleviate burden on local jurisdictions. Thinking more long-term, in order to actually address disparities, we must make long-term investments in communities in order to rebuild trust in medical and public health systems.

3. Strengthening readiness within the medical countermeasure enterprise to ensure that countermeasures can be rapidly identified and advanced through clinical development and manufacturing and appropriately deployed and distributed when a new public health threat is identified

Structures must be in place to rapidly ramp up not only diagnostics and other medical countermeasures, but also related infrastructure to gather/aggregate data for situational awareness. The Assistant Secretary for Preparedness (ASPR) at HHS was meant to be a coordinator in this regard –ramping up in an emergency –but was never sufficiently funded or staffed to do so.

The Strategic National Stockpile (SNS)is meant to be used in a national emergency, such as a pandemic or terrorist attack, to support the on-the-ground response across the country. The mission of the SNS must be clarified by Congress so that all stakeholders are clear about its utility moving forward. Congress can ensure that states have some level of cache when the next emergency arrives. The federal government, through CDC and/or ASPR, could offer guidance to health departments and health systems about what should be procured.

A formula for both what is needed and what is funded could be enacted based on population, with a federal and state/local jurisdiction share. These same population formula could be used to determine if local jurisdictions can be funded directly to stockpile goods. For example, those local jurisdictions with populations over 500,000, as was the threshold for funding in the Coronavirus Aid, Relief, and Economic Security Act (CARES)or the 107 jurisdictions CDC funded in their COVID Health Disparities grant program, could be deemed eligible rather than going through their state to procure needed supplies.

Further, there should also be a matching program to incentivize states to spend their dollars on preparedness. All too often, “wealthier” states spend dollars to prepare and “poorer” states do not. Thus, federal resources, in the event of an emergency, often go first to those who failed to allocate sufficient state and local resources to prepare. There needs to be a minimum level of preparedness in states and localities across the country as dictated by the federal government.

Federal leadership is critical to ensure that the SNS has sufficient resources to acquire medical countermeasures and materials, as well as the logistical support to manage, track, and distribute assets to public health and health care stakeholders. Decisions on need and what to send must be made according to subject matter experts; logistical support from FEMA for efficient distribution can then follow.

Congress, in particular, can facilitate increased transparency and provide sufficient funding for the upkeep of the SNS. Recognizing that there is a need to exercise some level of caution regarding what is in the SNS, there is still plenty of information that can and should be shared with state/local partners and Congress. Congress should also require reporting on status of the SNS, including expenditures and expiration dates of goods.

In terms of maximizing efficiency of deployment and distribution, we recommend developing and growing national-level partnerships with major healthcare systems, acute care systems, long term care facilities, federally qualified health centers, retail pharmacies, and private employers so medical countermeasures can be distributed efficiently and directly to points of dispensing while ensuring transparency at the local level. Additionally, we recommend increasing federal capacity to deploy medical countermeasures to their intended location using a point-to-point distribution model or increasing additional support to local jurisdictions (either through national-level partnerships with supply chain or logistics companies or providing funding for purchasing, warehouses, maintenance, inventory management systems, etc.).

4. Modernizing the development of medical countermeasures to address public health threats

The development of medical countermeasures must be grounded in equity and social justice principles, with a particular focus on those disproportionately impacted. This process should involve engaging CBOs and FBOs to inform development and to build trusted partnerships. In order to ensure that development of medical countermeasures includes implementation considerations from the outset(e.g., distribution, dispensing, public communications, and community engagement), state and local health departments must be involved early and often.

It is vital to acknowledge the wide range of threats that medical countermeasures can address and invest in capabilities that build infrastructure and preparedness, including partnerships with private sector partners (for instance, countermeasures and mitigation for climate related health threats require better built environment planning). Incentives from the federal government to the private sector and non-profit product developers can encourage development of countermeasures where there is no commercial market. As such, there should be a specific line item in the Biomedical Advanced Research and Development Authority (BARDA) appropriations for developing medical countermeasures to address emerging infectious disease.

There continues to be a market failure where companies that have been supported in part by BARDA to develop new antibiotics go bankrupt due to the inability of the company to recoup its research and development expenses. As you are aware, we are running out of options in treating some antibiotic-resistant organisms. Consideration should be given to federal support of post-market incentives to encourage the development of new antibiotics. This could include subscription purchasing models or other outside-the-box incentives. There are a number of legislative proposals such as Sens. Michael Bennet (D-CO) and Todd Young’s (R-IN) PASTEUR Actor Sen. Tina Smith’s$2 billion prize fund to incentivize development. Guaranteed purchasing at a reasonable price is the only way to ensure the supply will (a) be there when needed and (b) address subsequent demand or lack thereof when seeking to limit use due to stewardship.

5. Improving and securing the supply chain for the U.S.’s critical medical supplies needed to swiftly address public health threats

The federal government could have federalized the supply chain and actively used the Defense Production Act at the outset of the pandemic, which the Biden Administration did more of once they took office. States should neither have been instructed that they should procure their own supplies nor told that they were on their own. This created chaos in the limited supply chain and led to additional costs and logistical challenges for each state, as well as those in localities across the country. In the future, the federal government must ensure there is adequate infrastructure and funding to domestically produce critical medical supplies (such as personal protective equipment) and vaccine supplies, production, and fill/finish.

In closing, it is clear that long-term, sustainable, and predictable investments in public health preparedness, detection, and response planning are needed to ensure that our big city health departments, like our members, Public Health Seattle-King County, in Washington, and Mecklenburg County Public Health, in North Carolina, are able to prepare for future emergencies, so that the “next COVID-19” is not nearly as harmful to our communities.

We again thank you for the HELP Committee’s focus on, and dedication to, the critical issue of public health preparedness, and your personal leadership. We appreciate the opportunity to share these recommendations and welcome the opportunity to discuss them with you further. Please do not hesitate to contact me at juliano@bigcitieshealth.org.

Regards,

Chrissie Juliano, MPP 
Executive Director 
Big Cities Health Coalition