BCHC Comments to Healthy Future Task Force Security Subcommittee

January 31, 2022

Dear Members the Healthy Future Task Force Security Subcommittee:

On behalf of the Big Cities Health Coalition (BCHC), I write in response to the request for information from the Healthy Future Task Force Security Subcommittee. We appreciate your leadership in seeking solutions to the complex health challenges facing our nation. BCHC is comprised of health officials leading more than 30 of the nation’s largest metropolitan health departments, who together serve more than 62 million – or one in five – Americans.

Our input is focused on questions related to pandemic preparedness and public health.

Supplemental appropriations for the United States’ early pandemic response and proposed transfers of funds illustrated the need for the Department of Health and Human Services (HHS) to act quickly and draw upon all available funding, despite the existence of the Infectious Disease Rapid Response Reserve Fund and the Public Health Emergency Fund. How can Congress better equip these funds, and other resources, to provide HHS with the support it needs to act nimbly with dedicated funding and without waiting for Congressional action?

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 (PHEF) and the Infectious Disease Rapid Response Reserve Fund (IDRRRF) be well resourced with no-year funds so that a response to the next emerging infectious disease outbreak can be stood up immediately.

The IDRRRF was a critical resource for CDC to stand up the response to COVID-19 while Congress developed and adopted supplemental funding legislation. The PHEF has not been sufficiently funded in decades. We recommend authorizing a mechanism such that the PHEF would have a dedicated source of funding that would be triggered when the Secretary declares a public health emergency. This may not negate the need for additional supplemental funding depending on the size or impact of the public health emergency, but will allow for a quicker initial response.

What other policy considerations should Congress examine concerning reauthorization of the Pandemic and All-Hazards Preparedness and Advancing Innovation Act?

There is a great need for an expanded, well-trained, and well-resourced 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, health care 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.).

CDC’s Public Health Emergency Preparedness (PHEP) Program is comprised of several subprograms, among which are the PHEP cooperative agreement program and CDC Preparedness and Response Capability. PHEP cooperative agreements assist public health departments respond to numerous public health threats, such as infectious diseases; natural disasters; and biological, chemical, and radiological events. Through both real funding decreases and inflation, funding for the PHEP Program has been reduced 48% since FY2003.

a. What level of funding is advisable for PHEP? Are there specific program components that should be prioritized for increases?

BCHC supports $1 billion for the PHEP program, the level at which the program was originally authorized. The continuous barrage of wide-scale public health emergencies, the COVID-19 pandemic being just one, demonstrate the need to invest in PHEP to rebuild and bolster our country’s public health preparedness and response capabilities. Our systems are stretched to the brink and will need increased and stable base funding for years to rebuild and improve. Further, it is imperative these dollars reach the local level in those communities that are not directly funded. Congress should require 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.

b. What additional activities would this increased funding permit CDC and State, territory, and local grantees to pursue? c. How might a revitalization of PHEP enable the United States to better respond to public health threats and emergencies?

Additional funding for PHEP on a consistent basis will allow health departments to hire more staff, exercise more frequently, and cross train non-preparedness health department staff. This will also increase the capacity of health departments to be better prepared for everyday emergencies. The number of emergencies that health departments must respond to are only increasing.

Social determinants of health are another key driver of healthcare spending. Individual behavior and social and environmental factors are estimated to account for 60% of health care costs. To what extent do federal health programs already account for and address social determinants of health?

All Americans should have the opportunity to make the choices that allow them to live a long, healthy life regardless of their income, education, race, or ethnic background. We need to stop thinking of health as something we get in hospitals and doctors’ offices, but instead as something that starts in our families, in our schools and workplaces, on our playgrounds and parks, and in the air we breathe and the water we drink.

Local health departments typically receive disease-specific federal funding with very specific directives and reporting requirement on the use of the funds. Congress can and should do more – through consistent funding over time – to enable communities to address the social determinants of health (SDOH) so they can be healthier and more resilient.

Interventions targeting the SDOH could have a tremendous impact on the health and well-being of many people by preventing hardship before it happens. Local public health departments understand these conditions and are working tirelessly to eliminate the inequities. Despite their collective resolve, these departments are stretched thin. Many lack the staffing and funds to adequately address SDOH, and all continue to dedicate significant resources to COVID-19.

We must invest more in preventing poor health and promoting policies and practices that support good health. This requires sustained and substantial investments in the health of communities, including a livable wage, paid leave, safe and healthy housing, and access to critical infrastructure like lead-free pipes and sidewalks.

The CDC currently receives just $3 million in federal funding to conduct interventions targeting SDOH. Funds are used to develop community health pilots that seek to identify and learn from multi-sector coalitions with demonstrated success addressing the social determinants of health. These pilots feature partnerships with community organizations that can provide direct, on-the ground services to their constituencies, and broad focus, understanding that the health of a community is a complicated, interconnected challenge. With additional funding, CDC could expand these community pilots, initiate a national SDOH intervention plan, provide technical assistance to communities, and continue to build the evidence base to better understand health disparities. A comprehensive approach is needed, with sustained funding, to be able to move the dial on health disparities and build healthier communities.

Another critical component to addressing SDOH is data collection across sectors both public and private. Standardizing how we ask those questions will help us better understand the challenges our communities faces and help us focus our work on addressing those challenges. What we can learn from a standardized approach to addressing social determinants of health in every person in our city ranges from how to help individuals in need when we see them, to uncovering population health issues that may be solved more efficiently and effectively.

The COVID-19 pandemic has called attention to some populations’ distrust of public health departments and officials, whether through historical wrongs or because of skepticism of more recent public health measures. How can Congress work to bolster Americans’ confidence in public health institutions?

Governmental public health is a diffuse system that has been underfunded for decades and organized differently with varying authorities depending on the jurisdiction. The federal public health agencies are stove pipes with unique authorities and funding. Better coordination across the federal government is critical as well as with state, local, tribal and territorial health departments. There will never be a single voice or person that speaks for all of governmental public health, however investing in communications capacity and workforce is critical. With disease specific funding, public health departments must cobble together resources and staff to support communications. In addition, additional investment in communication and behavioral science is needed. Lastly, Congress is an important voice in lifting up and supporting governmental health. Public attacks on governmental public health officials only serves to erode the public’s trust in all of our government institutions.

Vaccines are perhaps the greatest public health tool, yet the COVID-19 pandemic demonstrated how widespread vaccine hesitancy is nationwide, fueled by misinformation campaigns or Americans’ lack of knowledge about the importance and efficacy of vaccines. Prior to the pandemic, vaccination rates for numerous vaccine preventable diseases were in decline, resulting in what were previously rare epidemics of measles in some U.S. cities. During the pandemic, lockdowns and hesitancy to visit health care sittings has resulted in millions of children, and even adults, missing important routine vaccinations. a. How can the federal government work to reverse both short- and long-term declines in vaccination against vaccine preventable diseases? b. How can the federal government better support State and local partners in educating Americans on the efficacy and safety of vaccines and combating misinformation? c. Some Americans remain unvaccinated for many vaccine preventable diseases, not because of opposition to vaccines, but because of lack of insurance coverage or access to health care services. How can the federal government better address the needs of this population?

The CDC Immunization Program directly funds 50 states, six large, BCHC member cities (Chicago, Houston, New York City, Philadelphia, San Antonio, and Washington, D.C.), and eight territories for vaccine purchase and immunization program operations. In addition to the challenges of the COVID-19 pandemic and continuing disease outbreaks, recent growth of electronic health records and compliance with associated regulations, new vaccines and school requirements have increased the complexity of vaccine management. Additional base funding to health departments is needed for each grantee to sustain improvements supported by emergency funding and maintain sound and efficient immunization infrastructure.

The COVID-19 highlighted the importance of having a modern and robust Immunization Information System (IIS) in health departments, particularly for adult immunization. Additional and sustained funds are needed to support the purchase and maintenance of technology, recruitment and retention of staff, training for the current and future workforce, as well as engagement with the health care community to facilitate onboarding of physicians to the IIS.

In addition, barriers to immunization must be removed, particularly financial ones, as they result in missed opportunities for vaccine uptake. While Congress continues to take action to remove barriers to immunizations, challenge remain. For example:

• Medicare Part D has co-pays for covered vaccines, while Medicare Part B has zero co-pays. There must be equity across Medicare with low or no copays for ACIP recommended vaccines.
• Medicaid is a 50-state system with wide variability in reimbursement for administration for vaccines. This must be addressed or there is no incentive for providers – both pediatric and adult – to provide vaccines if they continue to lose money in providing vaccines.
• For private insurance, while the Affordable Care Act requires plans to provide first dollar coverage for ACIP recommended vaccines, this is not always the case. Many providers, including pharmacies, are deemed out of network and therefore there can be large copays for preventive vaccines.

The beginning of the COVID-19 pandemic illustrated the insufficiency of States’ public health laboratory testing capacity and surveillance activities. What specific problems contributed to the challenges many States encountered? Which problems remain to be addressed by Congress, and what solutions might Congress pursue to enhance public health laboratory testing capacity and surveillance?

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 reach local jurisdictions as well, to enable 21st century 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 an 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).

As noted above, 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.

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.

The COVID-19 pandemic highlighted the need for agile, adaptable public health agencies unencumbered by activities and actions beyond the scope of their core mission. a. What reforms can be made to modernize and streamline Federal public health agencies? b. What reforms, if any, are needed to Federal public health agencies to ensure an unencumbered, agile, and adaptable public health response? What actions covered by such agencies fall outside the scope of their core missions and should be moved, repealed, streamlined, or otherwise addressed?

Sustained funding to support the mission – prevention of disease, as well as the ability to maintain a readiness to respond – is needed. As the keeper of the purse and the branch of government responsible for being a “check” on the Executive, the Congress can support HHS and its agencies with funding and much needed accountability. Congress should require yearly reports on expenditures, as well as readiness indicators. Finally, this funding should support a host of prevention activities, such as drills and professional and/or workforce development not just for HHS itself, but local and state health departments as well.

What other policy considerations should Congress examine concerning improving public health and public health infrastructure?

Importantly, federal funding and workforce support must be designated to communities across the country and not stop at the state level to distribute. Health departments working in the nation’s largest metropolitan areas must have rapid access to sustained and long-term funding to build their workforce, which includes not just public health generalists or specialists, but also all the skill sets that it takes to run a well-functioning organization: human resources, grants and contracts specialists, policy advisors, and communications experts, to name just a few. These latter types of positions are often not covered by disease specific grants from the federal government, which is a challenge then to building up the workforce. In most cases, it takes an incredibly long time for dollars to get to our member health departments when they are passed through the state. While it is not realistic to think about the federal government directly allocating funds to thousands of local health departments, it is possible – and moreover likely more efficient – to reach the nation’s largest ones directly. With COVID-19 relief funding, CDC has begun to directly fund jurisdictions of 400,000 or more in population in some instance, such as the 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. We strongly support this and would like to see CDC do this regularly.

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.

As we think about public health funding, we cannot continue the “boom and bust” cycles that have resulted in chronically underfunding the system. This has hampered our pandemic response and will hamper future ones as well. We must look for mechanisms to improve recruitment and retention in the governmental public health workforce, whose skillsets are in even higher demand since the beginning of the pandemic. The growth and retention of the public health workforce should specifically focus on racial and ethnic diversity to address issues of trust, confidence, and representation of the diversity of the residents served by the health department, a concern which certain workforce programs may exacerbate.

One policy intervention is the establishment of a public health loan repayment program. Modelled after the National Health Service Corps, this program is one way to improve recruitment and retention in governmental public health and bring needed skillsets to health departments across the country. Specifically, we support the Public Health Workforce Loan Repayment Act authored by Representatives Michael Burgess (R-TX-26) and Jason Crow (D-CO06) to reauthorize the Public Health Workforce Loan Repayment Program. 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.

Please share any brief additional comments or recommendations that were not properly addressed with the above prompted questions.

We urge Congress to continue to assess its approach to addressing the opioid epidemic. Big city and county health departments are often among the first to detect emerging trends in drug use, overdoses, deaths, hospitalizations, and drug treatment, and recognize hyperlocal hotspots. They are then also the first to respond to them, working to mitigate the impact of overdose and other harmful effects of substance use, such as disease transmission. They pilot, implement, test, and study innovative strategies that are often expanded to the state, regional, and national level.

Our members on the front lines of responding to this epidemic and yet receive little-to-no dedicated or direct funding to address and prevent the impact that substance use is having on our communities. Instead, local health departments compete for small amounts of grant funds that are insufficient to address the scale of the problem.

We recommend the following:

• Provide resources and expand the scope of CDC’s programing beyond opioid overdose prevention and surveillance. Local and state health departments must address the rising use of polysubstances, including psychostimulants.
• Eliminate waiver and training requirements related to certain medication-assisted treatments, such as those around prescribing Buprenorphine that have effectively become barriers to treatment and are restricting access.
• Increase availability of Naloxone and similar overdose reversal drugs by both exploring options for the federal government to bulk-purchase naloxone for distribution to local health departments and allowing over-the-counter access and/or expanding use of “standing orders,” where a doctor issues a written order that can be dispensed by a pharmacist or other designee(s), without the prescribing doctor being present.
• Increase availability of fentanyl testing strips to the general public by exempting them from drug paraphernalia laws.
• Shield localities exploring implementation of evidence-based and practice-informed harm reduction services, such as overdose prevention sites, from federal prosecution.
• Increase resources to expand current overdose surveillance systems to improve information on full scope of burden of SUDs, associated infectious disease outbreaks, and also to include nonfatal overdose events and reversals.
• Increase access to syringe services programs through federal dollars and leadership to support comprehensive Syringe Service Programs (SSPs).

To build safer, more resilient communities, we must also focus on preventing violence. Violence occurs in several different, yet interconnected, forms. Community gun violence, domestic violence, bullying and childhood violence have profound negative impacts on individuals, families and communities. These negative impacts can include high levels of trauma, increased levels of mental illness and substance use, as well as reduced levels of health, well-being and economic opportunity across impacted communities. Violence, like many public health challenges, is preventable. Yet historically, most investments are directed to addressing its aftermath. Communities can be safer by investing in a comprehensive approach to prevent violence, one that supports individuals and families, and by extension, the community at large.

Specifically, we recommend the following:

• Strengthen funding and other policy mechanisms that support community prevention, as well as implementation of violence interruption and trauma informed approaches that are proven to work.
• Create a CDC-led comprehensive, multisector response to violence that addresses social, emotional, and mental health in addition to physical health in partnership with local public health agencies.
• Provide increased funds to the CDC for firearm prevention research.
• Implement and fully fund a nationwide infrastructure to collect a key set of indicators regarding violence in communities and identify those indicators that measure community resilience.

Thank you again for soliciting stakeholder feedback as you develop policy recommendations to increase the health security and resilience of Americans. We appreciate your willingness to examine these important issues with a lens to strengthening our federal, state, and local capacity and infrastructure. Please do not hesitate to contact me at juliano@bigcitieshealth.org for additional information.

Sincerely,

Chrissie Juliano, MPP
Executive Director

cc: Molly Brimmer
Andrew Keyes
Shane Hand