Coalition Comments on PREVENT Act

February 4, 2022

Dear Chair Murray and Ranking Member Burr:

On behalf of the Big Cities Health Coalition (BCHC), I write to share feedback on the Prepare for and Respond to Existing Viruses, Emerging New Threats, and Pandemics (PREVENT) Act. BCHC is comprised of health officials leading more than30 of the nation’s largest metropolitan health departments, who together serve nearly 62 million – or one in five – Americans. Our membership includes both the Seattle-King County and Mecklenburg County health officials, who, like their colleagues across the country, work every day to keep their communities as healthy and safe as possible.

We thank you for your continued leadership and support for our nation’s public health systems during the ongoing COVID-19 pandemic – and for thinking ahead to the next pandemic or similar emergency. We respectfully share the below comments on the PREVENT Act and look forward to working with you to ensure it is enacted and subsequently funded to strengthen the public health system.

Importantly, the PREVENT Act addresses a number of key lessons learned from the COVID-19 response, including much discussion about accurate, timely, interoperable data systems. It also goes a long way to injecting increased and necessary accountability and transparency into the work of the Department of Health and Human Services (HHS), in particular around the Strategic National Stockpile (SNS). While we share specific details below, we want to underscore how important it is and will be to (1) fund many of these recommendations at the highest levels possible moving forward, and (2) directly resource and engage large urban health departments in federal level programs and assets. Many of our health departments respond to emergencies at the scope and scale of state health departments, all too often with limited access to dollars and tangible assets.

Title I –Strengthening Federal Leadership and Accountability

The proposed language in Subtitle A, Federal Leadership and Accountability, builds on key lessons learned from the ongoing COVID-19 pandemic.

Section 101: BCHC welcomes a comprehensive review of the response. While as written our members, local governmental officials, are specifically barred from participating on the National Task Force on the Response of the US to the COVID-19 Pandemic, we believe it is critically important that local and state health officials who were part of the on-the-ground response in form the deliberations of the Task Force. Further, we are pleased that meetings will be public along with the report’s findings (that do not compromise national security).

Section 102: BCHC is supportive of the requirement for the development of a CDC strategic plan and reporting on the implementation of the plan on a regular basis. To accompany this plan, we recommend the addition of authorization for a Professional Judgment Budget or Presidential Bypass Budget for the CDC. Other health agencies such as the National Cancer Center, National Institutes of Health Office of AIDS Research, and the CDC 317 vaccination program submit such Professional Judgement Budgets, so there is precedent for this approach. Suggested bill language could read: “The Committee directs the CDC and ATSDR to submit a report to the Committee in conjunction with the fiscal year 2024 and every fiscal year thereafter a Congressional Budget Justification detailing a professional judgment on the necessary budget and infrastructure requirements to fully operationalize the strategic plan in fiscal year 2024 and every fiscal year thereafter. This report shall also include an assessment of current agency capabilities related to public health. This professional judgment should be linked to the strategic plan, consider the changing public health landscape of a steady-state program, and be prepared independently of the President’s budget request and Administration and agency priorities.“

In regards to Senate confirmation of the CDC Director, BCHC has previously suggested that this is one option to be considered, along with other accountability mechanisms such as a “governing board,” akin to a local Board of Health, that would provide greater Agency oversight and guard against undue politicization of policy and practice. This proposed change should not be taken lightly and should not occur in the middle of a pandemic that has been hyper politicized. Given the realities of the current political environment and the difficulty in achieving consensus on many important policies currently before the Congress, it is worrisome to think about not having an Agency head in place in a public health emergency due to a political appointment process. We believe that this change is one that should be more fully discussed and vetted, including among public health stakeholders and the Committee. At its core, governmental public health is, and needs to remain, a non-partisan discipline based in data and practice, the mission of which is simply to protect people from undue death and disease. Any Administration, regardless of party, should have a leader at CDC who is both well versed in and has on-the-ground experience in the practice of public health. How best to ensure that the CDC Director can do his or her job appropriately and without inference remains an open question that we look forward to discussing with the Committee.

BCHC agrees that there should be accountability for CDC provided by the authorizing and appropriations committees, and that the CDC Director should testify before Congress on a regular basis to discuss progress on pandemic preparedness as well as other important public health challenges.

Section 103: Adding additional clarity to the role of the Assistant Secretary for Preparedness and Response (ASPR) would help streamline future responses. Requiring the ASPR to regularly appear before Congress and publicly release an annual report to Congress on the state of public health preparedness would add much needed transparency. We would encourage the inclusion of specific reporting requirements about use and distribution of funds to address CBRN, emerging infectious diseases, and antimicrobial resistance, and how they achieve the goals and responsibilities of the ASPR.

Section 104: Similar to the Task Force, the Public Health Information and Communication Advisory Committee, while much needed, should be sure to include external experts in not just communications, but also public health practitioners from the local and state level to ensure that recommendations are realistic and actionable. The Advisory Committee should not just focus on best practices, but also culture competence and multilingual resources.

Section 111: We agree that a key piece of updating the CDC Public Health Emergency Preparedness (PHEP) cooperative agreement as suggested in Subtitle B, State and Local Readiness, is increasing coordination with other governmental entities within a jurisdiction. This should also include ensuring that dollars reach local health departments and the communities they serve. As with the recent CDC grant program to address COVID disparities that went to nearly 50 large cities and counties, sending dollars directly to these communities is often more efficient for both state and local management. Large metro areas can and should spend dollars as they see fit (within the confines of the grants) rather than have to negotiate with state leaders and navigate state needs and wants. This is particularly true in the hyper political environment we find ourselves in with the COVID response.

Where not possible to directly fund local communities, reporting back to CDC, and sharing publicly, state expenditures of PHEP dollars cannot be stressed enough. States should report what dollars were sent to whom in what timeframe to help assess the impact of the funds.

Title II –Improving Public Health Preparedness and Response Capacity

The proposed language in Subtitle A, Addressing Disparities and Improving Public Health Emergency Response, also builds on lessons learned from the ongoing COVID-19 pandemic.

Section 201: While the grants authorized are needed, how the HHS Office of Minority Health and CDC interact with these funding streams and activities should be considered before creating a new and/or different funding streams. Further, these type of activities are hyperlocal so to whom the grant dollars flow is important.

Another critical component to addressing the Social Determinants of Health (SDoH) is data collection across both the public and private sectors. Standardizing how these questions are asked will help us all better understand the challenges our communities face and focus the work to best address those challenges.

Subtitle B, Improving Public Health Data illustrates perhaps the biggest lesson learned during COVID –the need for robust, accurate, and timely public health data to identify disease trends and inform policy decisions at all levels of government. In addition to what is specifically drafted in this legislation, which we further comment on below, we need to remind the Committee that data are neither a state owned, nor a federal owned, resource. Large metro health departments, in particular, are both a contributor to, and a prime stakeholder of, data. These health departments also need access to timely, accurate data, along with their colleagues at the state and federal level. We cannot continue to contribute to a siloed data infrastructure as we make much needed investments to the system as a whole. It is critically important to have local representation at the table as discussions are had about data collection and use, and what a truly modern, interoperable data system should look like.

Sections211 and 212: Updating surveillance systems and genomic sequencing across the entire public health system will improve our future pandemic response. 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. That said, we appreciate recent investments in CDC’s Data Modernization Initiative (DMI), including $50 million in FY2020, as well as $50 million in FY 2021, $500 million in the CARES Act, and approximately $300 million in the American Rescue Plan Act. While those investments in federal systems must be maintained, we cannot realize the potential of data modernization without also modernizing foundational public health systems at the local and state level.

A continued investment of at least $7.84 billion over the next 5 years, and sustained, annual investments over the next decade, at not only the CDC, but also directly supporting state, local, tribal, and territorial health departments is needed to transform today’s public health surveillance into a state of the art, secure, and fully interoperable system. Further, this funding is essential to attract, train, and retain the diverse workforce needed across the governmental public health enterprise to build, implement, and sustain a modern public health data infrastructure across the U.S.

Section 213: Instructing CDC to create and disseminate public health data standards will have a real impact in the field and is something that local health departments have requested previously. It is important to consider how what is proposed in Section 213 would and should interact with ongoing data modernization activities at the CDC, much of which has been dictated by previous emergency spending packages (per our comments above).

Specific to the discussion of data use agreements with external entities, Subparagraph(c)(2), “local health departments, where applicable,” should be inserted (line 21) in addition to state health departments and laboratories. Many big cities/counties have not only their own data systems, but also their own public health labs that should not be overlooked in data use agreements and processes at all levels of government.

While we appreciate the need for the federal government to receive reportable data from health systems and other partners, it is also critical that these data be reported to local health departments. A truly interoperable data system would mean that when a hospital, for example, entered a reportable condition into their system, it would be sent to the local, state, and federal government for use as appropriate.

Each level of government may use the data differently, but all need it to carry out sound public health practice. All too often, critical public health data reported to the state or the federal government is not shared with local health departments who are making decisions about policy or practice in their communities in real time. Finally, as additional requirements and standards are put into place, we also want to ensure that we are not overburdening our health care partners with duplicate or inconsistent reporting requirements.

Section 214: Continuing to monitor and invest in forecasting and outbreak analytics will also strengthen our future response and has already proved valuable as data were shared around the anticipated Omicron surge. This will require ongoing investment to maintain and modernize forecasting capabilities and technology.

As this Committee knows, the public health workforce has been under-resourced for decades, and there are several important proposals in Subtitle C, Revitalizing the Public Health Workforce.

Section 221: BCHC wholeheartedly supports the Public Health Workforce Loan Repayment Program as a means to increase the current and future pipeline. This program would provide a vital tool for recruitment and retention of frontline public health professionals at local, state, and Tribal health departments. We appreciate that the program would require a three-year service commitment and provide up to $50,000 annually in loan repayment, which will set the program up to be successful in helping health departments attract and retain high level talent into the field. We would encourage the inclusion of language to treat loan repayment akin to that of the National Health Service Corps program whereby they are exempt from federal income and unemployment taxes. In addition, we also support the call for a GAO study on the public health workforce.

Section 223: BCHC supports providing the Secretary immediate hiring authority to improve public health emergency response capacity. We have seen in prior health emergencies, not just COVID, how challenging it is to quickly and effectively staff up a response team at the federal, state, and local level.

Title III –Accelerating Research and Countermeasure Discovery

Section 303: BCHC supports efforts to increase the arsenal of tools to diagnose, mitigate, prevent, or treat harm from any biological agent or toxin, including emerging infectious diseases, chemical, radiological, or nuclear agents that may cause a public health emergency. We are concerned, however, that the legislation does not squarely address a pandemic that is already upon us and will only get worse –antimicrobial resistance (AMR). In addition, we believe it is critically important that state and local health departments are consulted on the front end as BARDA is supporting product development to minimize barriers to the use of these products for the last mile for which they are responsible. This includes considerations of equity and use in resource constrained environments.

Title IV –Modernizing and Strengthening the Supply Chain for Vital Medical Products

Section 404: These provisions put forth much needed parameters around the transparency and predictability of the SNS. Public health stakeholders in states and localities must know how assets will be distributed and what the SNS looks like overall. Previously this has been a black box and practitioners have not known what to expect.

The additional transparency measures, such as reporting to Congress about supply chain authorities, also will support future response. We urge that all of these reports to Congress be considered for public release/review recognizing possible national security issues. At a minimum, the fact that reports have in fact been delivered to Congress, and perhaps some high-level summary that can be shared with stakeholders across the field, would go a long way towards achieving joint understanding of the assets in the SNS.

Section 410: BCHC supports the pilot program to support state-level stockpiles. This is a much needed development, but can be strengthened in two key ways. First, there should be a maintenance of effort requirement built into the program so that states have an incentive to be prepared rather than wait for federal assets to arrive. Second, we urge you to consider engaging at least a few large metro health departments in this pilot to study the similarities and/or differences in ability to establish, expand, and/or maintain stockpiles needed in a public health emergency.

In addition to dollars, literal assets, such as doses of vaccine or testing kits, were one of the biggest challenges in big cities and counties across the country throughout the COVID pandemic. Local health departments in all but a small handful of jurisdictions were at the whim of state decisionmakers, even in the country’s largest cities, to get access to much needed resources to prevent and respond to COVID. In states where there are large metro areas that serve huge swaths of people, it is often more efficient to distribute resources directly to local health departments.

Finally, as you well know, there is much to be done to improve the nation’s pandemic preparedness across the board. Authorizing is an important step and will only be successful if properly implemented and sufficiently funded. It will also be important to ensure that reauthorization of the Pandemic and All Hazards Preparedness and Advancing Innovation Act (PAHPAIA) dovetails with the important changes put forth in the PREVENT Act.

Again, we thank you for your leadership and support for the central role of governmental public health in pandemic preparedness and response. BCHC looks forward to working with you to rebuild and strengthen the public health system at all levels of government. Due to time constraints, we were unable to incorporate specific feedback from BCHC members our comments. We would, therefore, welcome the opportunity to meet with you and a few of our member health officials as the process continues.

As always, please do not hesitate to contact me at juliano@bigcitieshealth.org for additional information.

Sincerely,

Chrissie Juliano, MPP
Executive Director