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Funding Public Health Emergency Preparedness in the United States The historical precedents that support state and local leadership in preparedness for and response to disasters are in many ways at odds with the technical demands of preparedness and response for incidents affecting public health. New and revised laws and regulations, executive orders, policies, strategies, and plans developed in response to biological threats since 2001 address the role of the federal government in the response to public health emergencies. However, financial mechanisms for disaster response—especially those that wait for gubernatorial request before federal assistance can be provided—do not align with the need to prevent the spread of infectious agents or efficiently reduce the impact on public health. We review key US policies and funding mechanisms relevant to public health emergencies and clarify how policies, regulations, and resources affect coordinated responses. (Am J Public Health. 2017;107: S148–S152. doi:10.2105/AJPH.2017. 303956)

Rebecca Katz, PhD, MPH, Aurelia Attal-Juncqua, MS, and Julie E. Fischer, PhD

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mergency preparedness and response start at the local level, with the city and county officials, state governors, and tribal leaders who are the first to respond to any disaster. Authorities over emergency management functions are historically delegated to state and local governments. Responsibilities for biological threats rest with state and local public health departments, emergency response agencies, and public and private health care institutions—organizations that often lack clear funding mechanisms or well-defined authorities for sustained preparedness activities, with no shortage of competing priorities.1 Large-scale events, however, often exceed local management capacities, leading to federal interventions. In 2016 alone, the federal government made assistance available to state governments for 103 declared disasters and emergencies, including fires, natural disasters, and one public health crisis caused by manmade water contamination.2 We outline legal and funding mechanisms in the United States to clarify federal policies, regulations, and resources that affect coordinated responses at all levels of government to infectious disease outbreaks and other biological health crises.

and responsibilities for emergency preparedness and response, particularly for biological events. After the terrorist attacks of September 11, 2001, Congress approved the creation of the Department of Homeland Security (DHS) to act “as a focal point regarding natural and manmade crises and emergency planning” for the federal government.3 Following the 2001 anthrax assaults, Congress also granted new resources and authorities to the Department of Health and Human Services (HHS) and its operating divisions, including the Centers for Disease Control and Prevention (CDC), to coordinate preparedness and response for bioterrorism and other events.4 Widespread coordination failures during Hurricane Katrina in 2005, including in the federal response to complex public health challenges that followed the storm, underscored the limited capabilities of the DHS to organize federal response activities as well as ambiguities in national guidance for “all-hazards” emergency preparedness and response. The Katrina experience, coupled with concerns over the emergence of potentially pandemic influenza, prompted

Congress to establish the office of Assistant Secretary for Preparedness and Response within the HHS and to strengthen federal programs to mobilize assistance to states for immediate and extraordinary action to protect public health.5 In addition to the establishment of new offices, the federal government created a series of planning and guidance documents to better coordinate preparedness and response efforts. The National Response Framework defines the general roles, responsibilities, and coordination structures for federal, state, and local entities during all types of disasters or emergencies.6 The Emergency Support Function and Support Annexes to the National Response Framework outline how federal agencies will provide coordinated assistance in core areas commonly required for disaster response. The Incident Annexes to the Federal Interagency Operational Plan similarly address coordination of the federal response to specific risks and threats. Both the Public Health and Medical Services Annex (Emergency Support Function #8) and the Biological Index Annex designate the HHS the coordinating agency for federal preparedness and

ABOUT THE AUTHORS

EMERGENCY PREPARDENESS AND PLANNING In the last 15 years, the federal government reframed the roles

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Rebecca Katz, Aurelia Attal-Juncqua, and Julie E. Fischer are with the Center for Global Health Science and Security, Georgetown University Medical Center, Washington, DC. Correspondence should be sent to Rebecca Katz, 305 SW Medical Dental Bldg, 3900 Reservoir Rd NW, Washington, DC 20057 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 25, 2017. doi: 10.2105/AJPH.2017.303956

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mobilize federal resources and briefly describes their outcomes. The Stafford Act. The main legal authority for providing federal support during a disaster or an emergency is the Robert T. Stafford Relief and Emergency Assistance Act. If an incident is deemed beyond the capabilities of an affected state, the governor can submit a request for a disaster declaration to the president via one of ten regional offices of the Federal Emergency Management Agency (FEMA), identifying needs and specific requests for support from the federal government.9 During fiscal year (FY) 2004 through FY2011, the president approved 539 of 629, or 86%, of governors’ requests for disaster declarations.10 Between FY2012 and June 2017, there were an additional 284 major disaster declarations.11 The type of federal assistance and funding that can be authorized under the Stafford Act depends on

coordination regarding public health events.7

When Local Resources Are Overwhelmed Federal planning guidance assumes that state and local authorities will lead the initial response to a disaster or emergency, with federal measures coming into play only under certain conditions. The federal response to disasters or emergencies can be activated through four possible routes: (1) a presidential declaration under the Stafford Act, (2) a presidential declaration under the National Emergencies Act (NEA), (3) declaration of a public health emergency by the secretary of the HHS, or (4) congressional action to enact legislation for supplemental appropriations.8 The pathway generally depends on the type of emergency or disaster. Table 1 summarizes recent actions to

the type of declaration issued by the president—either a “major disaster” or an “emergency.” The declaration of a major disaster (defined as any natural catastrophe, including a hurricane, storm, earthquake, drought, fire, or flood, that exceeds state and local response capabilities) provides broad authorities for federal assistance, including support for essential services and supplies, reducing immediate threats to public health and safety, and restoring infrastructure; it also supports longterm assistance to mitigate hazards to the community and aid to affected individuals and households. The Stafford Act defines an emergency more broadly as any occasion in which federal assistance is required to save lives and to protect property and public health and safety or to lessen or avert the threat of a catastrophe. An emergency declaration also authorizes federal emergency assistance to state and local governments, but

the scope of assistance is limited to emergency protective measures (excluding “permanent” hazard mitigation efforts). There is no cap on the amount of funds that can be made available for a major disaster, but there is a $5 million cap for emergencies. When the 2000 West Nile virus outbreak in New York and New Jersey received an emergency declaration under the Stafford Act, it set a precedent for using this mechanism to mobilize federal assistance during an infectious disease outbreak. Outbreaks, however, are not included in the Stafford Act definition of major disasters, and there is no precedent for declaring a biological event a major disaster.12,13

The National Emergencies Act. The NEA does not directly authorize federal assistance programs or any specific funding. Instead, the NEA authorizes the president to declare a national

TABLE 1—Previous Public Health Events and Routes for Funding Past Incidents of Public Health Concern Past Areas of Public Health Concern

2000 West Nile Virus Outbreak, New Jersey

2005 Hurricane Katrina, Louisiana

2009 H1N1 Pandemic

2014 Ebola Outbreak

Gubernatorial

Yes

Yes

No

No

2016 Zika Outbreak, Puerto Rico & Florida Florida: No

request for

Puerto Rico: Yes

assistance Type of

Presidential Emergency

Presidential Emergency

declaration

Declaration under the

Declaration under the

a nationwide public health

a public health emergency

issued

Stafford Act

Stafford Act; Presidential

emergency under section 319

in Puerto Rico under section

Major Disaster Declaration

of the Public Health Service

319 of the Public Health

under the Stafford Act

Act; Presidential Declaration

Service Act

HHS secretary declared

HHS secretary declared

of National Emergency Funding provided

$2.44 million in Public Assistance grants; $2.44 million in Emergency Work

$19.6 billion in Individual

Presidential request for

Presidential Emergency

Presidential Emergency

Assistance, Public Assistance, and Hazard Mitigation grant

emergency supplemental appropriations granted:

Funding request for $6.16 billion with $5.4 billion

Funding request for $1.9 billion (February 2016) with

programs (over a decade)

$6.15 billion (and $5.80 billion

granted: $3.7 billion for

$1.1 billion granted as part

in additional contingent

international efforts,

of Continuing Resolution

funding); $4.54 billion of $5.8

$1.1 billion for the domestic

(September 2016)

billion contingency funding

response, $515 million for

provided

R&D

Note. HHS = US Department of Health and Human Services; R&D = research and development.

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emergency, which in turn allows the president to activate emergency provisions in other statutes and executive orders.14 The NEA grants the president extraordinary powers to respond to threats to the safety or well-being of the American people, under strong (if rarely exercised) congressional checks.15 In October 2009, the president declared the H1N1 influenza pandemic a national emergency, authorizing the secretary of the HHS (under emergency provisions in Section 1135 of the Social Security Act) to temporarily waive certain requirements under Medicare, Medicaid, the State Children’s Health Insurance Program, and the Health Insurance Portability and Accountability Act. This permitted US health care facilities increased flexibility in providing affected populations with access to care.16

Public Health Service Act. Under section 319 of the Public Health Service Act, the HHS secretary may declare a disease, disorder, outbreak, or bioterrorist attack a public health emergency (PHE).17 The HHS secretary declared a PHE for H1N1 influenza in the United States in 2009 and for Zika virus in Puerto Rico in 2016.18 PHE declarations allow the HHS to waive certain federal regulatory and reporting requirements (in some cases, only after the concomitant declaration of a national emergency or major disaster); enter into grants and contracts as needed; allow states to temporarily reassign personnel supported with federal funds; and mobilize federal resources (directly and through assistance to states) to support disease surveillance, investigations, and control measures. A PHE declaration also authorizes the secretary to access

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federal funds from the Public Health Emergency Fund.19,20

Federal Funding Federal public health preparedness programs are generally funded through routine congressional appropriations. Appropriations for domestic health security fluctuate from year to year and do not necessarily include contingency funds to respond to biological events. When an emergency or crisis arises, additional funds may be mobilized through special contingency funds or through congressional supplemental appropriations. Since 2003, Congress has approved emergency supplemental appropriations for SARS, H5N1, H1N1, Ebola, and Zika. During the West African Ebola crisis in 2014 and 2015, for example, Congress appropriated $5.4 billion through emergency supplemental funding for preparedness and response, 69% of which was

dedicated to the international response; the remainder went toward domestic efforts ($1.1 billion) and research and development ($515 million).21 The Disaster Relief Fund (DRF), managed by FEMA, is the primary source of funds for federal assistance to states following the declaration of a major disaster or emergency under the Stafford Act. The DRF receives congressional appropriations annually; funds remain available until used and are carried over at the end of the fiscal year.22 In FY2016, Congress allocated $661 million in base funding to the DRF, in addition to its carryover balance.23 The Public Health Emergency Fund (PHEF; Figure 1), created in 1983, falls under the authority of the HHS. The HHS secretary is authorized to access PHEP funds following the declaration of a PHE. Like the DRF, the PHEF was established as a “no year”

account, with an initial appropriation of $30 million.21 However, no appropriations to the PHEF since FY1999 have been noted; the account maintains a zero balance since at least 2012.19 Neither Congress nor recent administrations have explicitly addressed the steady exhaustion of funding in the PHEF as a deliberate policy decision.

RECOMMENDATIONS The mere existence of federal mechanisms to mobilize assistance to state and local governments does not guarantee adequate and timely funding during an outbreak (especially since the “no year” PHEF was depleted in 2012). In February 2016, the Obama administration requested $1.9 billion in emergency funding for Zika virus research and response efforts. Political contentions delayed passage of emergency

Public Health Emergency Occurs

Stafford Act Presidential Major Disaster Declaration

Stafford Act Presidential Emergency Declaration

Public Health Emergency Declaration by the HHS Secretary

NOT ELIGIBLE

Authority of the President/FEMA to provide support from the Disaster Relief Fund

Authority of the HHS Secretary to provide support from the Public Health Emergency Fund

$5 MILLION CAP

FUND EMPTY

NEA Presidential Declaration NO DESIGNATED FUNDING CONVEYED

Note. FEMA = Federal Emergency Management Agency; HHS = Department of Health and Human Services; NEA = National Emergencies Act.

FIGURE 1—Federal Funding Mechanisms in the Rapid Response to an Infectious Disease or Biological Public Health Emergency: United States

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appropriations legislation acceptable to both Congress and the White House. In August 2016, the HHS secretary declared the Zika virus outbreak a PHE in Puerto Rico. This declaration technically permitted the government of Puerto Rico to apply for funding for prevention and response activities, but the exhaustion of the PHEF limited viable options. At the end of September 2016, Congress agreed to provide $1.1 billion to support Zika virus prevention, control, and research as part of a continuing resolution. 24 In the meantime, more than 30 000 cases were reported in Puerto Rico and 139 locally acquired cases were reported in Florida by the beginning of November 2016.25 Decision-makers at many levels have called for new— sometimes exceptional— coordination and funding mechanisms for responses to Zika and other biological events. For example, in 2016, Representative Rosa DeLauro proposed to update the PHEF Act, including allocating $5 billion to the existing PHEF. Representatives Hal Rogers and Kevin McCarthy introduced legislation to create an alternative $300 million emergency fund for public health crises, referred to as a “FEMA for public health,” as part of a larger health spending bill.26 Reasons for developing a novel funding mechanism, as opposed to funding the existing PHEP (with or without statutory changes for activating funds), have not been articulated. In order for the federal government to be better prepared to respond rapidly to emerging biological threats and PHEs, we propose a series of recommendations to enhance coordination, ensure expeditious funding

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appropriations, and maintain accountability. We recommend (1) revitalizing the PHEF, (2) improving federal coordination, and (3) identifying clear triggers for action.

Recommendation 1: Revitalizing the PHEF A standing fund to support federal assistance to state and local governments during outbreaks and other PHEs does not have to be created “from scratch,” as the PHEF already exists. The 1983 law authorizing the PHEF should be updated as needed, starting with an annual appropriation proportionate to state and local needs during recent outbreaks.

Recommendation 2: Agency Coordination Making the PHEF viable creates the need for clear coordination between the DHS and HHS on types of disasters, phases of funding, and determination of lead agency. A PHE declaration by the HHS secretary will allow mobilization of funds immediately for a timely and effective response to outbreaks, without waiting for a state request. It will need to be determined, however, whether a PHE declaration effectively preempts a declaration under the Stafford Act, whether funds will have to be committed or expended within the 90-day window of the PHE declaration, and whether there will be a ceiling on PHEF awards to state and local governments. Alternatively, it may be decided that there should be a process by which states could request a major disaster declaration following the immediate response to the outbreak, allowing a transition to hazard mitigation funding and the forms of public assistance allowed under the Stafford Act. Federal

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entities will need to work together closely to answer these questions, provide guidance to state and local partners, and create tracking systems to ensure that funds are spent appropriately to mitigate the consequences and recover from a PHE.

Recommendation 3: Mobilization Triggers Reinvigorating the PHEF also requires the development of clear triggers to define contingencies under which the HHS secretary should immediately consider a PHE declaration. State-level laboratories and epidemiologists contribute to the rapid detection of emerging public health events and communicate information on biological risks to both senior state and federal officials. Routinely, the Laboratory Response Network—an integrated network of state and local public health, federal, and military laboratories—provides diagnostic capacity to detect biological events and other PHEs across the United States. These networks allow rapid detection and reporting of events at the state and federal levels for decision-making. Criteria could be developed that would escalate consideration for a PHE declaration (e.g., a confirmed Select Agent, outbreaks, events that meet the criteria for a potential PHE of International Concern under the International Health Regulations). This could possibly circumvent subjectivity in the assessment of whether an event exceeds state and local capacities, an issue that has plagued the Stafford Act declaration process. The historical precedents that support state and local leadership in preparedness for and response to disasters are in many ways at odds with the technical demands of biological risk preparedness and response. New and revised laws and regulations,

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executive orders, policies, strategies, and plans developed in response to biological threats since 2001 address the role of the federal government in the response to PHEs. However, financial mechanisms for disaster response—especially those that wait for gubernatorial request before federal assistance is provided— do not align with the need to prevent the rapid spread of infectious agents. Ensuring that technical and financial resources can be quickly mobilized does not necessarily depend on development of new federal coordinating structures, but on operationalizing existing mechanisms and capacities. CONTRIBUTORS R. Katz and J. E. Fischer contributed to the conceptualization and design of this commentary. A. Attal-Juncqua conducted initial research and analysis. All authors contributed equally to the drafting of the article.

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8. Association of State and Territorial Health Officials. Emergency authority & immunity toolkit. Key federal laws and policies regarding emergency authority and immunity. Preparedness Series. 2016. Available at: http://www.astho.org/ Programs/Preparedness/Public-HealthEmergency-Law/Emergency-Authorityand-Immunity-Toolkit/Key-FederalLaws-and-Policies-Regarding-EmergencyAuthority-and-Immunity. Accessed July 15, 2016. 9. Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 USC 5170a, §402 (2013). 10. US Government Accountability Office. Federal disaster assistance. September 2012. GAO-12–838. Available at: http:// www.gao.gov/assets/650/648162.pdf. Accessed December 20, 2016. 11. Federal Emergency Management Agency. FEMA disaster declarations summary—open government dataset. Available at: https://www.fema.gov/ media-library/assets/documents/28318. Accessed July 11, 2017. 12. Liu E. Would an influenza pandemic qualify as a major disaster under the Stafford Act? 2008. CRS Report RL34724. Available at: https://fas.org/ sgp/crs/misc/RL34724.pdf. Accessed July 8, 2017. 13. Swendiman KS, Jones NL. The 2009 influenza pandemic: selected legal issues. 2009. CRS Report R40560. Available at: http://research.policyarchive.org/19830. pdf. Accessed July 8, 2017. 14. National Emergencies Act, 50 USC §1601-1651 (1976). 15. Thronson P. Toward comprehensive reform of America’s emergency law regime. March 23, 2013. University of Michigan Journal of Law Reform, Vol. 46, No. 2. Available at: https://papers. ssrn.com/sol3/papers.cfm?abstract_ id=2056822. Accessed December 30, 2016.

Estimates for Appropriations Committees. 2016. Available at: https://www.hhs. gov/sites/default/files/budget/fy2016/ fy2016-public-health-social-servicesemergency-budget-justification.pdf. Accessed July 14, 2017. 20. Public Health Service Act Amendment, Public Health Emergency Fund, 42 USC 247d (1983). 21. Kates J, Michaud J, Wexler A, Valentine A. The US response to Ebola: status of the FY2015 Emergency Ebola Appropriation Global Health Policy. 2015. Available at: http://kff.org/globalhealth-policy/issue-brief/the-u-sresponse-to-ebola-status-of-the-fy2015emergency-ebola-appropriation. Accessed August 1, 2016, 2016. 22. Lindsey B. FEMA’s Disaster Relief Fund: overview and selected issues. 2014. CRS Report R43537. Available at: https://fas.org/sgp/crs/homesec/ R43537.pdf. Accessed July 8, 2017. 23. Dept of Homeland Security. Disaster Relief Fund: Monthly Report as of December 31, 2015. 2016. Available at: https://www.dhs.gov/sites/default/files/ publications/FEMA%20-%20Disaster% 20Relief%20Fund%20-%20Monthly% 20Report%20-%20December%202015. pdf. Accessed July 14, 2017. 24. Sullivan P. Congress approves continuing resolution, including $1.1 billion in Zika response funding. The Hill. 2016. Available at: http://thehill.com/policy/ healthcare/298394-congress-approves11b-in-zika-funds. Accessed July 12, 2017. 25. Centers for Disease Control and Prevention. November 2016 Zika case counts in the US. 2016. Available at: http://www.cdc.gov/zika/geo/unitedstates.html. Accessed November 17, 2016. 26. Supplemental Appropriation to the Public Health Emergency Fund, Public Health Emergency Preparedness Act, HR4525, 114th Cong (2015–2016).

16. The White House. Declaration of a national emergency with respect to the 2009 H1N1 influenza pandemic. October 24, 2009. Available at: https://babel. hathitrust.org/cgi/pt?id=mdp. 39015090373682;view=1up;seq=1. Accessed July 14, 2017. 17. Public Health Service Act, 42 USC §247d (2013). 18. US Dept of Health and Human Services. HHS declares a public health emergency in response to the Zika outbreak. 2016. Available at: https://www. hhs.gov/about/news/2016/08/12/hhsdeclares-public-health-emergency-inpuerto-rico-in-response-to-zikaoutbreak.html. Accessed December 30, 2016. 19. Dept of Health and Human Services. FY2016 Public Health and Social Services Emergency Fund: Justification of

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