GAO-23-106554, COVID-19: GAO Recommendations Can Help Federal Agencies Better Prepare for Future Public Health Emergencies
- Issuer
- Government Accountability Office
- Document type
- PDF source document
- Date
- 2023-07-11
Summary
A U.S. Government Accountability Office report to congressional committees, GAO-23-106554, dated July 11, 2023, summarizing its COVID-19 oversight work. The report states that COVID-19 relief laws provided over $4.6 trillion as of April 30, 2023, and that GAO had made 386 recommendations to federal agencies, of which 134 were fully addressed, and raised 19 matters for congressional consideration. It highlights recommendations that HHS prioritize a public health situational awareness and biosurveillance network and that the Department of Labor develop an antifraud strategy for UI programs. It updates data on mortality, hospitalizations and long COVID, and lists five enclosures on public health preparedness, improper payments and fraud, vulnerable populations, distribution of funding, and the economy. The report closes with its list of committees and GAO contacts.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
United States Government Accountability Office
COVID-19: GAO Recommendations Can
Help Federal Agencies Better Prepare for
Future Public Health Emergencies
july 2023
gao-23-106554
Contents
3 Abbreviations
4 Introduction
Updates to Public Health, Economic and Federal COVID-19 Relief Funding
and Spending Data
6 Public Health Effects of the COVID-19 Pandemic
8 Economic Effects of the COVID-19 Pandemic
10 Federal COVID-19 Relief Funding and Spending
Enclosures
15 Public Health Preparedness
19 Improper Payments and Fraud
24 Vulnerable Populations
28 Distribution of Federal COVID-19 Funding
32 COVID-19 and the Economy
36 Additional Information
37 List of Committees
38 GAO Contacts and Contributors
2 GAO-23-106554 COVID-19 Oversight Summary
Abbreviations
BIA Bureau of Indian Affairs
CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
CPI Consumer Price Index
DOL Department of Labor
ERA Emergency Rental Assistance
FDA Food and Drug Administration
HHS Department of Health and Human Services
NOAA National Oceanic and Atmospheric Administration
OMB Office of Management and Budget
PUA Pandemic Unemployment Assistance
RRF Restaurant Revitalization Fund
SBA Small Business Administration
SSBCI State Small Business Credit Initiative
UI Unemployment Insurance
This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be
reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted
images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.
3 GAO-23-106554 COVID-19 Oversight Summary
U.S. Government Accountability Office
441 G St. N.W., Washington, DC 20458
July 11, 2023
Congressional Committees,
The COVID-19 pandemic has had an unprecedented effect on the nation’s public health and economy. As of the week ending May 13, 2023,
the U.S. had more than 1.1 million reported deaths attributed to COVID-19.1
Since March 2020, the CARES Act and five additional laws (COVID-19 relief laws)2 provided substantial federal funds (COVID-19 relief
funding)—over $4.6 trillion as of April 30, 20233—to help the nation respond to and recover from the pandemic. This COVID-19 pandemic
response included a focus on mitigating COVID-19 health risks by making vaccines widely available to the U.S. population and expanding
access to testing. As of May 10, 2023, about 70 percent of the eligible U.S. population—about 230 million individuals aged 5 and older—had
been fully vaccinated against COVID-19.4 Additionally, the COVID-19 relief laws appropriated and agencies administered emergency federal
assistance to support individuals and public and private entities, including local public health systems and private sector businesses. For
example, between March 2020 and March 2022, the Small Business Administration (SBA) made or guaranteed more than 16 million loans
and grants through the Paycheck Protection Program and the COVID-19 Economic Injury Disaster Loan program. These programs provided
about $1.1 trillion in emergency funding to help small businesses.
The Secretary of the Department of Health and Human Services (HHS) terminated the federal public health emergency for COVID-19 on
May 11, 2023.5 However, the nation is still recovering from the public health and economic effects of the pandemic and needs to be better
prepared for future emergencies. In our body of work on COVID-19 oversight, we have made 386 recommendations to federal agencies
and raised 19 matters for congressional consideration. The intent of these recommendations were for agencies to implement mid-
course corrections where appropriate and to increase transparency and accountability of the federal COVID-19 response and for future
emergencies. As of April 30, 2023, agencies had fully addressed 134 of these 386 recommendations and partially addressed 48. Of the 19
matters we raised to Congress, Congress had fully addressed two.
The 386 recommendations include several we have made since April 2022 (the date of our last comprehensive report on COVID-19 oversight)
that could help better prepare agencies for future emergencies. For example, we made the following recommendations that relate to two
areas we added to our High Risk List in 2022, (1) HHS leadership and coordination of public health emergencies and (2) the Unemployment
Insurance (UI)6 system:
• HHS should prioritize the development of the public health situational awareness and biosurveillance network—an interoperable
network of systems to facilitate sharing data and information to enhance early detection of and rapid response to potentially
catastrophic infectious disease outbreaks and other public health emergencies—to include designating a lead office for implementing it
and clearly defining roles and responsibilities.7
• The Department of Labor (DOL) should develop and implement an antifraud strategy for UI programs that is consistent with leading
practices from GAO’s Fraud Risk Framework.8
The CARES Act includes a provision for GAO to report regularly on the public health and economic effects of the pandemic and the federal
response.9 We have issued 10 comprehensive reports examining the federal government’s continued efforts to respond to, and recover
from, the COVID-19 pandemic. In addition, we have issued over 200 standalone reports, testimonies, and science and technology spotlights
focused on different aspects of the pandemic.10
This report includes several key data updates and five enclosures that summarize and highlight standalone reports issued from April 2022
(the date of our last comprehensive report) through April 2023 on the following topics: 11 public health preparedness, improper payments
and fraud, vulnerable populations, distribution of federal COVID-19 funding, and COVID-19 and the economy.
This report is based on work we previously conducted in accordance with generally accepted government auditing standards or our quality
assurance framework. More detailed information on our scope and methodology can be found in the reports cited in the enclosures.
10
comprehensive
200+
standalone
386
recommendations to
134
of 386 recommendations
reports products federal agencies fully addressed
4 GAO-23-106554 COVID-19 Oversight Summary
CONGRESSIONAL COMMITTEES
1
The Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics COVID-19 death counts in the U.S. are based on provisional
counts from death certificate data, which do not distinguish between laboratory-confirmed and probable COVID-19 deaths. Data are provisional and
subject to updates. In more recent weeks, the data are more likely to be incomplete due to an average delay of 1-2 weeks (a range of 1-8 weeks or longer)
for death certificate processing. See Centers for Disease Control and Prevention, National Center for Health Statistics, “Provisional Death Counts for
Coronavirus Disease 2019 (COVID-19),” accessed May 19, 2023, https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm.
2
For the purposes of our review, the COVID-19 relief laws consist of the six laws providing comprehensive relief across federal agencies and programs that
the Department of the Treasury uses to record and track COVID-19 relief spending in accordance with OMB guidance. These six laws are the American
Rescue Plan Act of 2021, Pub. L. No. 117-2, 135 Stat. 4; Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, div. M and N, 134 Stat. 1182 (2020);
Paycheck Protection Program and Health Care Enhancement Act, Pub. L. No. 116-139, 134 Stat. 620 (2020); CARES Act, Pub. L. No. 116-136, 134 Stat. 281
(2020); Families First Coronavirus Response Act, Pub. L. No. 116-127, 134 Stat. 178 (2020); and the Coronavirus Preparedness and Response Supplemental
Appropriations Act, 2020, Pub. L. No. 116-123, 134 Stat. 146.
3
For the purposes of our review, COVID-19 relief funding is the cumulative amount of funding provided in the COVID-19 relief laws. The most recent date for
which government-wide information was available at the time of our analysis is April 30, 2023. Consequently, the COVID-19 relief funding amounts reported
in this report do not reflect the permanent rescissions enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137 Stat. 10. Effective as of June
3, 2023, Title I of Division B of that act permanently rescinded the unobligated balances of certain COVID-19 relief funding. According to Department of the
Treasury officials, it will take time for the affected federal agencies to coordinate with Treasury and the Office of Management and Budget (OMB) in order
to determine the amounts of their unobligated funds and to request the requisite rescission warrants. Treasury anticipates that agencies will continue to
submit rescission warrant requests through September 30, 2023.
4
As of May 19, 2023, CDC counts individuals as being fully vaccinated if they received two doses on different days (regardless of time interval) of the two-
dose vaccines or received one dose of a single-dose vaccine. Seventeen percent of the population had received an updated booster dose vaccine. See
Centers for Disease Control and Prevention, “COVID Data Tracker: COVID-19 Vaccinations in the United States,” accessed May 19, 2023, https://covid.cdc.
gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total.
5
The Secretary of Health and Human Services first declared the COVID-19 pandemic a public health emergency under section 319 of the Public Health
Service Act on January 30, 2020. In addition, on March 13, 2020, the President declared COVID-19 a national emergency under the National Emergencies
Act and a nationwide emergency under section 501(b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act). The President
also approved major disaster declarations under the Stafford Act for all 50 states, the District of Columbia, five U.S. territories, and certain Tribes. The
national emergency declaration terminated on April 10, 2023, and the Stafford Act declarations terminated on May 11, 2023.
6
The High Risk List identifies government operations with vulnerabilities to fraud, waste, abuse, and mismanagement, or in need of transformation. GAO,
High-Risk Series: Efforts Made to Achieve Progress Need to be Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20,
2023).
GAO, COVID-19: Pandemic Lessons Highlight Need for Public Health Situational Awareness Network, GAO-22-104600 (Washington, D.C.: June 23, 2022).
7
8
GAO, Unemployment Insurance: Data Indicate Substantial Levels of Fraud During the Pandemic; DOL Should Implement an Antifraud Strategy, GAO-23-
105523 (Washington, D.C.: Dec. 22, 2022).
9
Pub. L. No. 116-136, § 19010, 134 Stat. at 579–81. The American Rescue Plan Act of 2021 also includes a provision for us to conduct oversight of the
COVID-19 response. Pub. L. No. 117-2, § 4002, 135 Stat. at 78.
10
For a complete list of our 10 comprehensive CARES Act oversight reports and other COVID-19 reports, see https://www.gao.gov/coronavirus.
11
The standalone reports summarized and highlighted in the enclosures were completed in response to the provisions enacted in the COVID-19 relief laws
related to GAO’s oversight role, as well as funds appropriated to GAO for this oversight purpose in the COVID-19 relief laws.
5 GAO-23-106554 COVID-19 Oversight Summary
Updates to Public Health, Economic, and Federal COVID-19 Relief Funding and Spending Data
Public Health Effects of the COVID-19 Pandemic
In our comprehensive reports, we tracked data related to the public health effects of the COVID-19 pandemic.
The following are updates to key data.
Higher-than-expected mortality
The number of deaths in the U.S. has been higher at certain
times during the pandemic than the expected number of
deaths based on data from 2019 and earlier, according to
data from the Centers for Disease Control and Prevention’s
(CDC) National Center for Health Statistics. Over the course
of the pandemic—from March 2020 through April 2023—the
U.S. experienced multiple peaks in weekly counts of deaths
that were higher than the expected range, followed by lulls
where deaths were within or close to the expected range.
(See figure.) The highest weekly number of deaths occurred
in January 2021, when deaths were 42 percent above the
expected range, while the most recent peak in December 2022
was 13 percent above the expected range. Deaths declined in
the first 3 months of 2023, returning to levels within or close
to the expected range.”
Hospitalizations
Over the course of the pandemic, surges in COVID-19 cases
have stressed hospital systems and negatively affected health
care and public health infrastructure, according to CDC. At
its peak in January 2022, the number of adult and pediatric
patients with confirmed COVID-19 occupying hospital beds
rose to nearly 152,000, then fell to just over 10,000 in April
2022. Between August 2020 and April 2023, the median
number of hospital beds occupied by adult and pediatric
patients with confirmed COVID-19 was 34,606. Over the first
four months of 2023, the number fell from a high of 41,894 in
early January to 9,713 at the end of April.
Long COVID
One public health effect of COVID-19 is long COVID, or post-
COVID conditions, which refers to signs, symptoms, and
conditions that continue or develop after an initial COVID-19
infection, according to CDC. According to estimates from the
Census Bureau’s Household Pulse Survey, conducted April 26
through May 8, 2023, just over 15 percent of adults in the U.S.
aged 18 and older had experienced long COVID, and about
6 percent were currently experiencing it at the time of the
survey.'* These percentages varied by demographic and other
characteristics. For example, survey estimates indicated that
adult females were nearly twice as likely as adult males to
have experienced long COVID.
FIGURE: HIGHER-THAN-EXPECTED MORTALITY IN THE U.S., MARCH 2020 THROUGH APRIL 2023
Weekly number of deaths
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Mar 2020 Jun 2020 Sept 2020 Dec 2020 Mar 2021 Jun 2021
Observed deaths within the upper
bound of expected variation
Sept 2021
Observed deaths above the upper
bound of expected variation
Dec 2021 Mar 2022 Jun 2022 Sept 2022 Dec 2022 Apr 2023
| Upper bound of expected variation in mortality
GAO-23-106554 = COVID-19 Oversight Summary
PUBLIC HEALTH EFFECTS OF THE COVID-19 PANDEMIC
12
CDC’s National Center for Health Statistics COVID-19 death counts in the U.S. are based on provisional counts from death certificate data, which do not
distinguish between laboratory-confirmed and probable COVID-19 deaths. The excess range of deaths are those that exceeded the upper-bound threshold
of expected deaths calculated by the National Center for Health Statistics on the basis of variation in mortality in prior years. As in prior reports, we continue
to report excess deaths based on the more conservative upper bound estimate of expected deaths. For further details on CDC’s methodology, see Centers
for Disease Control and Prevention, National Center for Health Statistics, “Excess Deaths Associated with COVID-19,” accessed May 11, 2023, https://www.
cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm.
These figures represent the 7-day rolling average of adult and pediatric patient case counts reported by hospitals in U.S. states and territories and includ-
13
ed in HHS' COVID-19 Reported Patient Impact and Hospital Capacity dataset, as of May 8, 2023.
An estimated 15.1 percent (95 percent confidence interval: 14.7 - 15.6) had ever experienced long COVID and 5.6 percent (95 percent confidence interval:
14
5.3 - 5.9) were currently experiencing long COVID. U.S. Census Bureau, “Household Pulse Survey 2022-2023: Long COVID,” accessed June 8, 2023, https://
www.cdc.gov/nchs/covid19/pulse/long-covid.htm.
Beginning in June 2022, the National Center for Health Statistics added questions to the Household Pulse Survey to assess the prevalence of long COVID.
The online survey includes questions about the presence of symptoms of COVID-19 that lasted 3 months or longer. The Household Pulse Survey data are
released as part of the Census Bureau’s Experimental Statistical Products Series (see https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm#techni-
cal_notes for information on limitations).
7 GAO-23-106554 COVID-19 Oversight Summary
Updates to Public Health, Economic, and Federal COVID-19 Relief Funding and Spending Data
Economic Effects of the COVID-19 Pandemic
In our comprehensive reports, we tracked data related to the economic effects of the COVID-19 pandemic.
The following updates describe selected trends we observed during the pandemic.
The national economy has continued to recover from the challenges, especially for low-income households, and can
economic downturn of early 2020 that was sparked by the reduce the pace of economic growth. In recent months,
COVID-19 pandemic. However, economic growth has slowed housing was the largest contributor to inflation, but the home
and specific areas of the economy we are monitoring saw price and rent data typically used to estimate current inflation
mixed performance in recent months. Real gross domestic indicators can reflect price trends that significantly lag current
product grew by 5.9 percent in 2021, but slowed to 2.1 percent economic conditions.18 Current data indicate that year-over-
in 2022 and to a 1.1 percent annual rate in the first quarter of year growth in home prices and rents have declined in recent
2023, according to the Bureau of Economic Analysis. The war months, suggesting that future indicators of inflation may be
in Ukraine, the reopening of China’s economy, and increased lower. These trends are consistent with indicators of inflation
uncertainty in financial markets following recent bank failures expectations, which are significantly below current measured
are among the factors that will likely affect the pace of inflation.
economic growth going forward.
The unemployment rate has continued to fall since the
Inflation indicators were mixed in recent months.15 According pandemic began, but the labor force has not recovered as
to data covering price trends through April 2023, price quickly, according to DOL data. The unemployment rate
pressures increased in April 2023 following decreases in decreased to 3.4 percent in April 2023, similar to the 54-
February and March. Monthly inflation indicators increased year record low of 3.4 percent in January 2023. Meanwhile,
in April 2023, including indicators that focus on underlying both the employment-to-population ratio and labor
inflation trends.16 Annual inflation indicators were about force participation rate have increased over the past year,
5 percent or higher—substantially higher than the averages of but remained 0.7 percentage points lower than in the
about 2 percent in recent decades.17 Some level of inflation prepandemic period.19 Additionally, real average hourly
on average can help promote stable economic conditions, earnings for all employees, seasonally adjusted, were 0.5
but persistently high levels of inflation can cause financial percent lower in April 2023 compared to a year ago, indicating
that wage growth did not keep up with inflation over this time
period.
We and others have reported on the fiscal conditions of state
and local governments during the COVID-19 pandemic. For
example, we reported in 2021 that, in the aggregate, state and
local governments experienced revenue declines after the
onset of the pandemic during the second quarter of 2020, but
rebounded in the third and fourth quarters
of 2020.20 The National Association of State Budget Officers
has also reported that state revenues performed considerably
better in fiscal years 2021 and 2022 than anticipated due in
large part to the federal assistance that pumped additional
funds into the economy.21 Additionally, the Urban Institute
reported that preliminary data for the first quarter of 2023
indicate substantial weakness in overall state tax revenue
collections, as well as in major sources of state tax revenues.
This weakness was expected and is partly in response to state
policy actions, including tax rate cuts and rebate payments.22
8 GAO-23-106554 COVID-19 Oversight Summary
ECONOMIC EFFECTS OF THE COVID-19 PANDEMIC
Inflation is the increase in the prices of goods and services over time and is typically measured as the percentage change in those prices over a set period,
15
often 1 year or 1 month. For example, an annual inflation rate of 2 percent means that the prices of goods and services, on average, increased 2 percent
over the past year.
In previous work, we identified a number of indicators of current and expected future inflation to help us monitor households’ experiences with rising
prices and assess the extent to which prices are likely to continue to rise over time. See GAO, COVID-19: Additional Actions Needed to Improve Accountability
and Program Effectiveness of Federal Response, GAO-22-105051 (Washington, D.C.: Oct. 27, 2021).
16
Monthly inflation indicators include the month-over-month changes in the Personal Consumption Expenditures price index, the Consumer Price Index
(CPI), the median CPI, and the 16 percent trimmed mean CPI. The median CPI and 16 percent trimmed mean CPI indicators focus on underlying inflation
trends by omitting outliers.
Annual inflation indicators include the year-over-year changes in the Personal Consumption Expenditures price index, the CPI, the median CPI, and the 16
17
percent trimmed mean CPI. The Federal Reserve System’s Federal Open Market Committee aims for annual inflation of 2 percent on average over time and
aims to achieve rates of inflation that are above 2 percent for some time after periods during which inflation is persistently below 2 percent. See the Federal
Open Market Committee’s 2023 Statement on Longer-Run Goals and Monetary Policy Strategy.
Housing is the largest component of the CPI, and housing inflation is measured using the index for shelter, which includes both rent and owners’
18
equivalent rent. Recently, there has been a divergence in the official CPI housing price measure and measures using other home and rent price data. The
official CPI measure lags the other housing price measures by four quarters, which has implications for understanding inflation dynamics. See Adams, B. et
al, “Disentangling Rent Index Differences: Data, Methods, and Scope,” Working Paper No. 22-38 (Federal Reserve Bank of Cleveland, 2022).
The employment-to-population ratio was 60.4 percent in March and April 2023, 0.2 percentage points higher than in February 2023 and 0.5 percentage
19
points higher than in April 2022. The labor force participation rate was 62.6 percent in March and April 2023, 0.1 percentage points higher than in February
2023 and 0.4 percentage points higher than in April 2022.
GAO, State and Local Governments: Fiscal Conditions During the COVID-19 Pandemic in Selected States, GAO-21-562 (Washington, D.C.: July 15, 2021).
20
National Association of State Budget Officers, The Fiscal Survey of States (Washington, D.C.: Fall 2022).
21
Urban Institute, Continued Weakness and Variability in State Tax Revenues (Washington, D.C.: May 2023).
22
9 GAO-23-106554 COVID-19 Oversight Summary
Updates to Public Health, Economic, and Federal COVID-19 Relief Funding and Spending Data
Federal COVID-19 Relief Funding and Spending
as of April 30, 2023
covid-19 relief laws
Six laws provided about $4.7 trillion key budget terms
American Rescue Plan Act of 2021 COVID-19 relief funding is the cumulative amount
2021 of funding provided in the six COVID-19 relief laws
Consolidated Appropriations Act, 2021 Divisions M and N that Treasury uses to record and track COVID-19 relief
spending, in accordance with the Office of Management
and Budget's (OMB) guidance. These amounts can
Paycheck Protection Program and Health Care
2020
fluctuate from month to month. Increased spending in
Enhancement Act Medicaid and Medicare is not included in OMB guidance
CARES Act for recording and tracking of COVID-19 relief spending
and is therefore not included in the amounts presented.
Families First Coronavirus Response Act
Coronavirus Preparedness and Response
Supplemental Appropriations Act, 2020 An obligation is a definite commitment that creates a
legal liability of the U.S. government for the payment of
goods and services ordered or received, or a legal duty
In our comprehensive reports, we presented data tracking on the part of the U.S. government that could mature
how agencies were obligating and expending COVID-19 into a legal liability by virtue of actions on the part of
another party that are beyond the control of the U.S.
relief funding. The following are updates to these data as of government.
April 30, 2023, the most recent date for which government-
wide information was available at the time of our analysis.
An expenditure is the actual spending of money, or
Since March 2020, six COVID-19 relief laws have provided an outlay. Expenditures include some estimates, such
as estimated subsidy costs for direct loans and loan
a cumulative amount of about $4.7 trillion in funding for guarantees.
pandemic response and recovery, as reported by federal
agencies to the Department of the Treasury, in accordance
with Office of Management and Budget (OMB) guidance.23
The federal government had obligated a total of $4.5 trillion Unobligated balance is the portion of funding that
has not yet been obligated and includes unexpired and
and expended $4.2 trillion (97 and 91 percent, respectively) of expired funding.
this COVID-19 relief funding.
The major spending areas shown in Table 1 below represent
$3.6 trillion, or 78 percent, of the total amounts provided. For Unexpired unobligated balance is the cumulative
amount of funding that remains available for incurring
these eight spending areas, agencies reported obligations new obligations based on the period of availability for
totaling $3.6 trillion and expenditures totaling $3.4 trillion. the funding (e.g., 1-year, multiyear, no-year).
Table 1 provides additional details on funding, obligations,
and expenditures of government-wide COVID-19 relief funds
by major spending areas as of April 30, 2023. Expired unobligated balance is the cumulative
amount of fixed-period funding (e.g., 1-year or 3-year)
that is no longer available to enter into new obligations
As of April 30, 2023, $104.3 billion, or 2 percent of the total because the funding’s period of availability has ended.
This balance, however, generally remains available for
amount of funding provided for COVID-19 relief, remained 5 additional fiscal years after expiration for recording
available for obligation (unexpired unobligated balance). and adjusting obligations properly chargeable to the
Additionally, $27.6 billion was expired (expired unobligated fixed-period funding’s period of availability. For example,
this balance remains available to record previously
balance), meaning that this amount was not available for unrecorded obligations or to make upward adjustments
incurring new obligations but was available for recording in previously underrecorded obligations, such as
contract modifications properly within scope of the
eligible obligation adjustments. Table 2 below provides original contract. At the end of the fifth fiscal year, the
additional details on funding, obligations, unobligated expired account holding this balance is closed, and any
balances, and expenditures of government-wide COVID-19 remaining balance is canceled, returning all remaining
funds to the General Fund of the U.S. Treasury.
relief funding.
10 GAO-23-106554 COVID-19 Oversight Summary
Table 1: Major Spending Areas Under COVID-19 Relief Funding
as of April 30, 2023
COVID-19 relief Total Total
Major spending area (dollars in billions) funding obligations expenditures
Economic Impact Payments 859.4 858.8 858.8
Department of the Treasury
Business Loan Programs 833.0 828.1 828.0a
Small Business Administration
Unemployment Insurance 701.6 699.0 690.7
Department of Labor
Coronavirus State and Local Fiscal Recovery Funds 350.0 349.9 349.8
Department of the Treasury
Public Health and Social Services Emergency Fund 345.7 325.4 282.1
Department of Health and Human Services
Education Stabilization Fund 277.7 277.3 176.6
Department of Education
Coronavirus Relief Fund 150.0 149.9 149.8
Department of the Treasury
Supplemental Nutrition Assistance Programs 121.1 98.3 97.9
Department of Agriculture
Other areas (includes over 300 accounts)b 1,011.5 932.2 793.3
Total c
4,650 4,518.9 4,227.1
Source: GAO analysis of data from the Department of the Treasury and applicable agencies. | GAO-23-106554
Note: COVID-19 relief funding, obligations, and expenditure data shown for the major spending areas are based on data reported by applicable agencies to Treasury's
Governmentwide Treasury Account Symbol Adjusted Trial Balance System. Federal agencies use this system to report proprietary financial reporting and budgetary execution
information to Treasury. These amounts can fluctuate from month to month. COVID-19 relief funding is the cumulative amount of funding provided in the six COVID-19 relief
laws that Treasury uses to record and track COVID-19 relief spending, in accordance with OMB guidance.
The most recent date for which government-wide information was available at the time of our analysis is April 30, 2023. Consequently, the COVID-19 relief funding amounts
reported in this report do not reflect the permanent rescissions enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137 Stat. 10. Effective as of June 3, 2023, Title
I of Division B of that act permanently rescinded the unobligated balances of certain COVID-19 relief funding.
a
The Small Business Administration’s Business Loan Program account includes activity for Paycheck Protection Program loan guarantees and certain other loan subsidies.
These expenditures relate mostly to the loan subsidy costs (i.e., the loan’s estimated long-term costs to the U.S. government).
b
Several provisions in the Families First Coronavirus Response Act and the American Rescue Plan Act of 2021 authorized increases in Medicaid payments to states and U.S.
territories. At the time of enactment, the Congressional Budget Office estimated that federal expenditures from these provisions would total approximately $76.9 billion
through fiscal year 2030. The largest increase to federal Medicaid spending is based on a temporary formula change rather than a specific appropriated amount. Some of the
estimated costs in this total are for the Children’s Health Insurance Program, permanent changes to Medicaid, and changes not specifically related to COVID-19. This increased
spending is not accounted for in the funding provided by the COVID-19 relief laws and is therefore not included in this table.
Because of rounding, amounts shown in columns may not sum to the totals.
c
11 GAO-23-106554 COVID-19 Oversight Summary
Table 2: Largest Unexpired Unobligated Balances Under COVID-19 Relief Funding
as of April 30, 2023
Unexpired Expired
COVID-19 relief Total unobligated unobligated Total
Spending areas (dollars in billions) funding obligations balance balance expenditures
Pension Benefit Guaranty Corporation Funda 77.6 47.4 30.2 0.0 45.9
Pension Benefit Guaranty Corporation
Public Health and Social Services Emergency Fund 345.7 325.4 20.3 0.0 282.1
Department of Health and Human Services
Business Loans Program Account 833.0 828.1 3.4 1.9 828.0
Small Business Administration
U.S. Coronavirus Refundable Credits 74.4 71.1 3.3 0.0 71.1
Department of the Treasury
CDC-Wide Activities and Program Support 26.4 23.2 3.2 0.0 15.0
Department of Health and Human Services
Transit Infrastructure Grants 69.5 66.5 3.2 0.0 55.0
Department of Transportation
Emergency Rental Assistance 46.5 46.5 3.2 0.0 46.2
Department of the Treasury
Tenant-Based Rental Assistance 6.2 3.1 3.1 0.0 2.2
Department of Housing and Urban Development
Other areas (includes over 250 accounts) 3,170.5 3,107.7 34.3 25.6b 2,881.7
Total c
4,650 4,518.9 104.3 27.6 4,227.1
Source: GAO analysis of data from the Department of the Treasury and applicable agencies. | GAO-23-106554
Note: COVID-19 relief funding, obligations, and expenditure data shown for the major spending areas are based on data reported by applicable agencies to Treasury's
Governmentwide Treasury Account Symbol Adjusted Trial Balance System. Federal agencies use this system to report proprietary financial reporting and budgetary execution
information to Treasury. These amounts can fluctuate from month to month. COVID-19 relief funding is the cumulative amount of funding provided in the six COVID-19 relief
laws that Treasury uses to record and track COVID-19 relief spending, in accordance with OMB guidance.
The most recent date for which government-wide information was available at the time of our analysis is April 30, 2023. Consequently, the COVID-19 relief funding amounts
reported in this report do not reflect the permanent rescissions enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137 Stat. 10. Effective as of June 3, 2023, Title
I of Division B of that act permanently rescinded the unobligated balances of certain COVID-19 relief funding.
a
Under section 9704 of the American Rescue Plan Act of 2021, the Pension Benefit Guaranty Corporation will receive the necessary funding from the General Fund of the U.S.
Treasury through fiscal year 2030 to provide payments to qualifying multiemployer plans, as defined in this law, so that the plans can pay benefits at plan levels through the
end of plan year 2051. The requested amount will fund the Special Financial Assistance payments to qualifying plans and Pension Benefit Guaranty Corporation’s related
administrative and operating expenses. Neither the plans nor the Pension Benefit Guaranty Corporation are required to repay amounts received from this American Rescue
Plan Act of 2021-established program, which is funded by appropriations from the General Fund of the U.S. Treasury.
b
The Department of Agriculture's Supplemental Nutrition Assistance Program comprised about $22.5 billion, or 82 percent of the total expired unobligated balance as of April
30, 2023.
Because of rounding, amounts shown in columns may not sum to the totals.
c
12 GAO-23-106554 COVID-19 Oversight Summary
FEDERAL COVID-19 FUNDING AND SPENDING
23
The COVID-19 relief laws consist of the six laws providing comprehensive relief across federal agencies and programs that Treasury uses to record and
track COVID-19 relief spending, in accordance with OMB guidance. The COVID-19 relief funding amounts reported in this report, however, do not reflect the
permanent rescissions enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137 Stat. 10. Effective as of June 3, 2023, Title I of Division B of that
act permanently rescinded the unobligated balances of certain COVID-19 relief funding. According to Department of the Treasury officials, it will take time
for the affected federal agencies to coordinate with Treasury and OMB in order to determine the amounts of their unobligated funds and to request the
requisite rescission warrants. Treasury anticipates that agencies will continue to submit rescission warrant requests through September 30, 2023.
Amounts presented from Treasury's Governmentwide Treasury Account Symbol Adjusted Trial Balance System are the most recent available at the time of
our analysis. Federal agencies use this system to report proprietary financial reporting and budgetary execution information to Treasury. These amounts
can fluctuate from month to month, and they reflect appropriations, as well as transfers, adjustments, recoveries, rescissions, and returns of unused
indefinite appropriations. OMB's guidance for recording and tracking COVID-19 relief spending does not include increases in Medicaid and Medicare
spending; otherwise, the cumulative amount of funding as of April 30, 2023 —the most recent date for which government-wide information was available at
the time of our analysis —would be greater than about $4.7 trillion.
13 GAO-23-106554 COVID-19 Oversight Summary
Enclosures
• Public Health Preparedness
• Improper Payments and Fraud
• Vulnerable Populations
• Distribution of Federal COVID-19 Funding
• COVID-19 and the Economy
cares act update
Public Health
Preparedness
Selected GAO Findings and Recommendations
Over a decade of prior work has demonstrated deficiencies in the Department of Health and Human
Services’ (HHS) ability to execute its role leading federal efforts to prepare for and respond to
public health emergencies. Some areas of deficiencies, which hindered the nation’s response to
the COVID-19 pandemic, include establishing clear roles and responsibilities for a wide range of key
federal, state, local, tribal, territorial, and nongovernmental partners; and providing clear, consistent
communication to key partners and the public. Aspects of public health preparedness and response
include access to diagnostic testing and medical countermeasures—drugs, vaccines, and supplies—
and access to real-time information about emerging threats.
We summarize key reports issued from April 2022 through April 2023 below. For status updates to
any recommendations from the reports summarized or included as related work, see https://www.
gao.gov/coronavirus.
COVID-19 Tests
Why It Matters COVID-19: FDA Took Steps to Help Make Tests Available; Policy for Future Public Health Emergencies
Needed (GAO-22-104266)
Catastrophic public In May 2022, we reported on the Food and Drug Administration’s (FDA) oversight of tests for COVID-19.
We examined, among other things, (1) the actions FDA took to help make COVID-19 tests available for
health events—such as use, (2) the number of tests FDA authorized and those for which it exercised enforcement discretion, and
(3) FDA’s monitoring of these tests after they were available for use.
a pandemic—can cause
hundreds of thousands What we found
After flaws in HHS’s first diagnostic test for COVID-19 contributed to the delayed rollout of testing
of casualties, threaten
nationwide, FDA, within HHS, took several actions aimed at rapidly increasing the availability of
our national security, COVID-19 tests in the United States. For example, FDA granted emergency use authorizations for
COVID-19 tests and, in February and March 2020, issued policies that enabled some tests to be used
weaken our economy, and without first obtaining an authorization.24 Under these policies, FDA exercised enforcement discretion to
damage public morale and not object to use of these tests before they were authorized.
confidence. The COVID-19 By September 30, 2021, FDA had exercised its enforcement discretion for 370 tests. FDA officials told
pandemic highlighted the us they had concerns about the lack of review for these unauthorized tests, and as the number grew,
the risks of this policy began to outweigh the benefits. Nevertheless, FDA did not update its COVID-19
importance of national test policy with the intention of phasing out the agency’s use of enforcement discretion and reducing
efforts to prepare for, the number of unauthorized tests until November 2021. Until FDA develops a policy for the use of
respond to, and recover 24
Typically, FDA must approve, license, or clear a new product before it can be marketed in the United States. See 21 U.S.C. § 355 (drugs); 21 U.S.C. §§ 360e(c) and 360(k)
(devices); and 42 U.S.C. § 262 (biologics). However, during an emergency, FDA may temporarily allow the use of products that have not been approved, licensed, or cleared
from such events. by issuing an emergency use authorization, provided certain statutory criteria are met. See 21 U.S.C. § 360bbb-3. For example, it must be reasonable to believe that the
product may be effective and that the known and potential benefits outweigh known and potential risks.
15 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
enforcement discretion regarding unauthorized tests in a future 2019 act and did not establish an appropriate management and
public health emergency—including the conditions under which governance structure. Without a management and governance
FDA would begin and end such discretion—the agency could face structure to oversee the activities required by law, HHS and the
the risk that unauthorized tests could be used for an extended federal government likely will continue to lack the comprehensive
period of time, even when a sufficient number of authorized capabilities needed to allow for the timely response to infectious
tests are available. This could hamper an effective response and disease outbreaks like COVID-19.
recovery during a future crisis.
As of March 2022, after more than 2 years of experience in
Our recommendation responding to the COVID-19 pandemic, HHS had not taken steps
FDA should develop a policy for the use of enforcement discretion to identify, document, and share all challenges and lessons
regarding unauthorized tests in future public health emergencies. learned that public health entities experienced during the
The policy should include the conditions under which FDA would pandemic—information it could incorporate in its planning and
begin and end the use of such discretion. FDA concurred with our implementation of the public health situational awareness and
recommendation and as of April 2023 had begun taking action biosurveillance network. Until HHS takes these steps, opportunities
toward implementation. Specifically, FDA officials told us that the to improve the response to ongoing and future public health
agency is in the process of developing a general policy for the use emergencies by learning from past challenges will likely be missed.
of enforcement discretion for unauthorized tests in public health
emergencies, which will take into account lessons learned from Our recommendations
both the COVID-19 and monkeypox public health emergencies. HHS should prioritize the development of the public health
situational awareness and biosurveillance network. We made 12
recommendations related to this, including that HHS designate
a lead operational division for implementation of statutory
Public Health Situational Awareness Network
requirements and clearly define its roles and responsibilities;
COVID-19: Pandemic Lessons Highlight Need for Public Health commit to a deadline for finalizing the work plan to implement
Situational Awareness Network (GAO-22-104600) the 2019 act's requirements, and ensure the work plan is fully
implemented; and incorporate lessons learned from the COVID-19
In June 2022, we reported on the status of the public health pandemic into plans for implementing this network. HHS
situational awareness and biosurveillance network, which federal concurred with 10 of the 12 recommendations. The department
law over 16 years ago required HHS to establish.25 The Pandemic stated that the remaining two were under review. As of April 2023,
and All-Hazards Preparedness and Advancing Innovation Act of all of the recommendations remained open.
2019 reiterated the need for this network and included statutory
requirements related to enhancing
its capability.26 We examined (1) Figure: Types of Entities That Are to Share Information to Support Nationwide Public Health
the extent to which HHS has made Situational Awareness
Poison Control Local Health
progress toward implementing Centers Departments
the requirements in the 2019 act;
and (2) the challenges and lessons State Health State, Local, Emergency
Territorial, and
learned from COVID-19 that HHS Departments
Tribal
Medical Services
could incorporate in planning for this
network.
What we found
Department of
Health and Human
Nationwide
The federal government does not Services Public Health
have the public health situational Situational
awareness network required by law. Awareness
Federal Healthcare
This network could have been used Departments Providers
to provide vital information to better Clinics
manage a timely COVID-19 response.
HHS had made minimal progress Department of
Homeland Hospitals
toward establishing the network, in Department Veterans
Security of Agriculture
part because the department failed Health
Department of Defense Administration
Department of Defense Military Health System
to prioritize the requirements of the
Source: GAO analysis of Department of Health and Human Services data. | GAO-22-104600
Pandemic and All-Hazards Preparedness Act, Pub. L. No. 109-417, 120 Stat. 2831 (2006).
25
Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019, Pub. L. No. 116-22, 133 Stat. 905 (2019).
26
16 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Strategic National Stockpile for regularly managing risks, HHS and Congress lack assurance
the department is most effectively preparing for public health
Public Health Preparedness: HHS Should Address Strategic National
Stockpile Requirements and Inventory Risks (GAO-23-106210) emergencies.
In October 2022, we reported on the Strategic National Stockpile, Our recommendations
a multibillion-dollar inventory of drugs, vaccines, supplies, and HHS should, among other things, update its procedures for
other medical countermeasures that can be used in emergencies. Strategic National Stockpile inventory planning reviews and
We examined, among other things, the process used to make manage risks associated with inventory gaps. HHS concurred
inventory decisions. This report is part of a larger body of work that with our three recommendations, but as of April 2023 had not
includes reports about the challenges related to the immediate addressed them.
Strategic National Stockpile COVID-19 response and longer-
standing challenges related to the management and contents of
the Strategic National Stockpile.
What we found
HHS completed its Strategic National Stockpile reviews to
inform inventory decisions for fiscal years 2023 and 2024 after
not completing these reviews for fiscal years 2020 through
2022.27 However, these reviews did not meet most statutory
requirements enacted in 2019. Also, HHS had not updated its
procedures to account for those new requirements. Until HHS
updates its procedures, the agency risks not meeting the statutory
requirements designed to give Congress additional information
about the Strategic National Stockpile inventory.
Furthermore, our analysis of the Strategic National Stockpile
reviews showed that the stockpile contained most of the
recommended types of medical countermeasures, but not in the
recommended quantities. HHS officials noted these gaps were due
to budget constraints and acknowledged that these gaps present
risks, including being underprepared to respond to a public
health emergency. However, the completed reviews lacked key
information needed for managing these risks and communicating
them to stakeholders, including Congress. Without an approach
27
GAO reported in August 2022 that to guide inventory purchases from 2015 through 2019, HHS used a multistep process involving interagency experts, which resulted in annual Strategic National Stockpile reviews with inventory
recommendations.
Considerations for Congress
In January 2022, we added HHS leadership and coordination of public health emergencies—including extreme weather events, infectious
disease outbreaks, pandemics, and intentional acts—to our High Risk List.28 The deficiencies we have identified are longstanding concerns
that will take time and commitment to address; however, addressing them is paramount as the nation continues to face new threats while
recovering from the COVID-19 pandemic.
HHS has announced some agency reform efforts, including elevating the Administration for Strategic Preparedness and Response to a
stand-alone agency alongside other HHS agencies, according to an HHS statement. This is intended to ultimately allow the Administration
for Strategic Preparedness and Response to more effectively and efficiently mobilize a coordinated national emergency response. However,
as outlined in our most recent High Risk Report, there is more to be done to address the deficiencies in HHS’s ability to perform its role of
leading the nation’s preparedness for, and response to, public health emergencies, and congressional oversight will be important as HHS
addresses these concerns.
28
GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds and Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington, D.C.: Jan. 27. 2022); and High-Risk Series: Efforts Made to Achieve
Progress Need to be Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20, 2023).
17 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Other Related GAO Work
Issued from April 2022 through April 2023
Drug Manufacturing: Public Health Preparedness: Public Health Preparedness: Public Health Preparedness:
FDA Should Fully Assess Its HHS Should Plan for Medical HHS Could Improve Oversight COVID-19 Medical Surge
Efforts to Encourage Innovation, Countermeasure Development of Research Involving Enhanced Experiences and Related HHS
GAO-23-105650 (Mar. 10, 2023) and Manufacturing Risks, Potential Pandemic Pathogens, Efforts, GAO-22-105461
GAO-23-105713 (Feb. 2, 2023) GAO-23-105455 (Jan. 18, 2023) (Aug. 17, 2022)
Air Travel and Communicable Contact Tracing for Air Travel:
Diseases: Federal Leadership CDC’s Data System Needs
Needed to Advance Research, Substantial Improvement,
GAO-22-104579 (July 28, 2022) GAO-22-105018 (July 11, 2022)
Ongoing GAO work
GAO has ongoing work, including in the following areas:
• Economic incentives for development of therapeutics for • HHS’s public health preparedness and response data
potential pandemics capabilities
• HHS’s Administration for Strategic Preparedness and Response • Public health infrastructure funding
workforce planning • U.S. Strategic National Stockpile inventory distribution
18 GAO-23-106554 COVID-19 Oversight Summary
cares act update
Improper
Payments
and Fraud
Selected GAO Findings and Recommendations
Our work shows that the risk of improper payments, including from fraud, greatly increased
during the pandemic. We have identified some programs as particularly susceptible to improper
payments, including greatly expanded existing programs and new programs created in response
to the COVID-19 pandemic. Also, as federal agencies sought to expedite payments to individuals
Why It Matters and businesses affected by the pandemic, agencies used some processes that we have previously
reported can increase fraud risk.
Billions of taxpayer dollars We summarize key reports issued from April 2022 through April 2023 below. For status updates to
are at risk due to improper any recommendations from the reports summarized or included as related work, see https://www.
gao.gov/coronavirus.
payments, including from
fraud. Although this has
Unemployment Insurance
been a longstanding
Unemployment Insurance: Data Indicate Substantial Levels of Fraud during the Pandemic; DOL Should
issue, the risk of improper Implement an Antifraud Strategy (GAO-23-105523)
payments dramatically
In December 2022, we reported on matters relating to the scope and severity of fraudulent activity
increased during the in the Unemployment Insurance (UI) system during the pandemic. We examined what measures
COVID-19 pandemic. and estimates indicate about the extent of UI fraud during the pandemic and the extent to which the
Department of Labor (DOL) designed and implemented a strategy to manage UI fraud risks. This report
Federal agencies estimated is part of a larger body of work examining the UI system during the COVID-19 pandemic.
about $247 billion in
What we found
improper payments in fiscal Measures and estimates indicate substantial levels of fraud and potential fraud in UI during the
pandemic. Although no national estimate of UI fraud has been reported that covers all UI programs and
year 2022, a large increase
the full period of pandemic spending, DOL has reported estimates of fraud for regular UI payments. If
compared to the estimate the lower bound of DOL’s 2021 estimated national fraud rate for the regular UI program was extrapolated
to total spending across all UI programs during the pandemic, it would suggest over $60 billion in
of about $140 billion for
fraudulent UI payments. The actual amount of fraud in UI programs during the pandemic may be
fiscal year 2017. The extent substantially higher than this estimated $60 billion lower limit. We have ongoing work to calculate a
comprehensive estimate of UI fraud.
of fraud associated with
COVID-19 relief programs DOL has taken steps to address UI fraud risks. For example, DOL issued guidance, provided funding
to states, and deployed teams to recommend improvements to state UI programs. While these steps
is significant and could help prevent, detect, and respond to fraud, as of December 2022, DOL had not developed an antifraud
further increase, since strategy based on leading practices in GAO’s Fraud Risk Framework. Without an antifraud strategy,
DOL is not able to ensure that it is addressing the most significant fraud risks facing the UI system in
many investigations alignment with the Fraud Risk Framework.
are under way.
19 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Figure: Federal Agencies Need to Improve Fraud Risk Management Efforts in Five Areas
requirements, which direct grantees to
provide data that was missing or inaccurately
Designating an Assessing Designing and Using data Managing
entity to lead fraud risks implementing analytics to fraud risks in reported from prior quarters.30 Without better
fraud risk an antifraud manage fraud emergencies data collection and reporting, Congress
management strategy risks
and Treasury will lack information on the
program’s outcomes.
Our recommendation
DOL should develop and implement an antifraud strategy for UI Additionally, our review of Treasury data highlights improper
programs that is consistent with leading practices from GAO’s Fraud payment risks in the ERA program, but Treasury has not conducted a
Risk Framework. DOL partially agreed with the recommendation but detailed risk assessment. Treasury completed an improper payment
as of April 2023 had not addressed it. risk assessment for the ERA program in September 2022 that focused
on the risk of improper payments in Treasury’s disbursement of
ERA allocations to grantees. However, this risk assessment did not
account for missing data or duplicative payments to households.
Emergency Rental Assistance
We reviewed ERA1 payments made to households in 2021 and
Emergency Rental Assistance: Treasury’s Oversight is Limited by found evidence that grantees may have made duplicative payments
Incomplete Data and Risk Assessment (GAO-23-105410) despite a statutory requirement that grantees ensure that rental
assistance provided not be duplicative of other federally-funded
In December 2022, we reported on the Department of the Treasury’s rental assistances to the extent feasible. For example, we found
oversight of the Emergency Rental Assistance (ERA) program, a that about 2 percent of the households assisted (about 43,000
new program created in response to the COVID-19 pandemic that households) received payments from more than one grantee. These
provided over $46 billion to grantees, such as local governments, payments accounted for about 6 percent of all payments reported by
to help low-income households at risk of housing instability pay grantees in 2021. Without a more detailed assessment of improper
rent and utilities. We examined, among other things, Treasury’s ERA payment risks at the household level, Treasury’s awareness of such
data collection and oversight efforts. This report is part of a body of risks and oversight of the ERA program will be limited.
work related to administration and oversight challenges in the ERA
program. Our recommendations
Treasury should complete a detailed assessment of improper
What we found payment risks for the ERA program and improve the program’s
As of November 2022, Treasury had not collected and reported data collection and reporting. Treasury agreed with our three
complete data on ERA payments and recipients as required under recommendations. As of April 2023, these recommendations
the authorizing statute.29 For example, the performance measures remained open.
Treasury reported publicly for the first three quarters of 2021 that
were disaggregated by demographics were missing for 44 percent
to 55 percent of households served. The high proportion of missing
data was largely driven by grantee nonreporting in those quarters. Restaurant Revitalization Fund
Reporting levels improved for the fourth quarter of 2021; data were Restaurant Revitalization Fund: Opportunities Exist to Improve
missing for 19 percent of households served for that period. Treasury Oversight (GAO-22-105442)
has taken some steps to improve data completeness and accuracy.
In July 2022, we reported on the Small Business Administration’s
In September 2022, Treasury officials told us they were testing (SBA) oversight of the Restaurant Revitalization Fund (RRF), a
and monitoring grantees’ data submissions and following up with program initiated in response to the pandemic to support eligible
grantees for clarification and potential updates when the agency entities suffering revenue losses from the COVID-19 pandemic. We
identified incomplete and erroneous reporting. In addition, in examined, among other things, SBA’s internal controls and fraud risk
November 2022, the Office of Management and Budget (OMB) management practices and SBA’s efforts to monitor recipients. This
approved Treasury’s guidance on ERA1 closeout reporting report is part of a body of work related to the RRF program.
The Consolidated Appropriations Act, 2021, requires Treasury to collect and report six performance measures disaggregated by demographics (race, ethnicity, and gender) from all grantees on at least a quarterly basis. Pub. L. No.
29
116-260, div. N, tit. V, § 501(g), 134 Stat. at 2075 (codified at 15 U.S.C. § 9058a(g)).
30
In December 2020, the Consolidated Appropriations Act, 2021 authorized Treasury to disburse about $25 billion to ERA grantees, which we refer to as ERA1. Pub. L. No. 116-260, div. N, tit. V, § 501(a)(1), 134 Stat. at 2069-70
(codified at 15 U.S.C. § 9058a). Pursuant to OMB’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, federal awarding agencies, along with their grant recipients, must undergo a
“closeout” process. Treasury developed closeout reporting requirements for grantees in an effort to comply with 2 C.F.R. § 200.344.
20 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
What we found
From May to July 2021, just over 100,000 businesses (40 percent
of eligible applicants) received funding through this program,
which received total appropriations of $28.6 billion. SBA used
lessons learned from emergency programs it had previously
managed (such as the Paycheck Protection Program) to improve
program design and increase safeguards. For instance, the agency
emphasized pre-award controls that prevented over 30,000
potentially fraudulent or ineligible applications from receiving
awards.
However, we found weaknesses in the design and operation of
pre-award controls. For example, SBA worked with restaurant
industry partners to help process applications and considered
such applications to be low risk, but over 4,000 recipients who
applied through such a channel have been flagged for suspected
fraud or ineligibility, including an alleged fraudster who received $8
million. SBA officials said they did not plan to assess whether the
pre-award controls operated as expected because they completed
a fraud risk assessment for RRF and concluded the program’s
controls were sufficient to mitigate fraud risk. However, this risk
assessment did not analyze the efficacy of pre-award controls.
Assessing controls and addressing deficiencies would help inform
SBA’s controls for future programs.
Additionally, SBA requires recipients to report annually on fund use
but could take additional steps to identify fraudulent or ineligible
awards. SBA has not proactively used data analytics or information
from enforcement entities to identify potentially fraudulent award
recipients. By taking steps to proactively identify fraudulent or
ineligible award recipients, SBA would be better positioned to
oversee this program if Congress decides to use the RRF again in
the future.
Our recommendations
SBA should assess pre-award controls and address deficiencies,
and take additional steps to identify fraudulent or ineligible
awards, among other things. SBA agreed or partially agreed with
two recommendations and disagreed with five recommendations,
including to assess pre-award controls. We maintain that all seven
recommendations are valid, as discussed in our report. As of April
2023, these recommendations remained open.
21 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Considerations for Congress
The pandemic further exacerbated the longstanding problem of improper payments and greatly increased related fraud risks. Through our
COVID-19 work, we recommended 12 actions Congress could take to improve oversight of emergency relief funds, including the following:31
• Pass legislation requiring OMB to provide guidance for agencies to develop plans for internal control that would immediately be ready for
use in future emergencies or crises, and requiring agencies to report these plans to OMB and Congress.
• Amend the Payment Integrity Information Act of 2019 to
• designate all new federal programs making more than $100 million in payments in any one fiscal year as "susceptible to significant
improper payments" for their initial years of operation, and
• reinstate the requirement that agencies report on their antifraud controls and fraud risk-management efforts in their annual financial
reports.
• Establish a permanent analytics center of excellence to aid the oversight community in identifying improper payments and fraud.
As of April 2023, these matters for congressional consideration remained open. We continue to believe that such actions will increase
accountability and transparency in federal spending in both emergency and nonemergency periods.
In addition, through our COVID-19 work, we added several programs to our High Risk List based, in part, on their risk for improper payments.
Congressional oversight will be important as DOL and SBA implement changes to meet GAO’s criteria for removal from the High Risk List.
• In June 2022, we added the UI system to our High Risk List due to long-standing challenges in meeting the needs of unemployed workers
and mitigating financial loss, which were exacerbated by the historical job loss during the COVID-19 pandemic.32 Although Congress created
four temporary UI programs to support workers during this time, unprecedented demand for benefits and the need to quickly implement
the new programs challenged states’ administrative capabilities and increased risks of improper payments, including from fraud.
• In March 2021, we added emergency loans for small businesses to our High Risk List, noting that the limited controls built into the approval
processes for SBA’s Paycheck Protection Program and COVID-19 Economic Injury Disaster Loans program created the risk of hundreds of
millions of dollars in improper payments, including those resulting from fraud. During the COVID-19 pandemic, SBA made or guaranteed
billions of dollars in emergency loans and grants quickly to help many small businesses in need. However, SBA initially lacked finalized
plans to oversee the two programs. Further, SBA’s failures in spring 2020 to provide data and documentation on a timely basis to us for the
Paycheck Protection Program and the COVID-19 Economic Injury Disaster Loans program impeded our initial efforts to ensure transparency
and accountability for the programs.
• In April 2023, we reported that SBA had made progress in implementing controls to improve oversight of its emergency loans, but that it
could further improve its fraud risk management and related efforts.33
• In May 2023, we reported on fraud schemes in SBA’s pandemic relief programs, including the Paycheck Protection Program, COVID-19
Economic Injury Disaster Loans, Shuttered Venue Operators Grant, and RRF. We found that SBA had assisted more than 10 million small
businesses through these programs, but in some instances relief funds went to those who sought to defraud the government. For example,
in the 330 Paycheck Protection Program and COVID-19 Economic Injury Disaster Loans fraud cases we reviewed, federal prosecutors
had filed bank fraud, wire fraud, money laundering, identity theft, and other charges against 524 individuals. As a result of our findings, we
made two recommendations to SBA to improve its fraud prevention and detection efforts. SBA concurred with both recommendations,
and according to officials, the agency is taking actions to improve its related efforts.34
GAO, COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response, GAO-21-191 (Washington, D.C.: Nov. 30, 2020); COVID-19: Current and Future Federal Preparedness Requires Fixes to Improve Health Data and
31
Address Improper Payments, GAO-22-105397 (Washington, D.C.: Apr. 27, 2022); and Emergency Relief Funds: Significant Improvements Are Needed to Ensure Transparency and Accountability for COVID-19 and Beyond, GAO-22-105715
(Washington, D.C.: Mar. 17, 2022).
32
GAO, Unemployment Insurance: Transformation Needed to Address Program Design, Infrastructure, and Integrity Risks, GAO-22-105162 (Washington, D.C.: June 7, 2022); and High-Risk Series: Efforts Made to Achieve Progress Need to
be Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20, 2023).
GAO, High-Risk Series: Efforts Made to Achieve Progress Need to be Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.: Apr. 20, 2023).
33
GAO, COVID Relief: Fraud Schemes and Indicators in SBA Pandemic Programs, GAO-23-105331 (Washington, D.C.: May 18, 2023).
34
22 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Other Related GAO Work
Issued from April 2022 through April 2023
Emergency Relief Funds: Unemployment Insurance: COVID Relief: SBA Could Coronavirus Food Assistance
Significant Improvements DOL Needs to Address Improve Communications Program: USDA Should
Are Needed to Address Fraud Substantial Pandemic UI Fraud and Fraud Risk Monitoring Conduct More Rigorous Reviews
and Improper Payments, and Reduce Persistent Risks, for Its Arts and Entertainment of Payments to Producers,
GAO-23-106556 (Feb. 1, 2023) GAO-23-106586 (Feb. 8, 2023) Venues Grant Program, GAO-22-104397 (Sept. 8, 2022)
GAO-23-105199 (Oct. 11, 2022)
Unemployment Insurance:
Transformation Needed to
Address Program Design,
Infrastructure, and Integrity
Risks, GAO-22-105162
(June 7, 2022)
Ongoing GAO work
GAO has ongoing work, including in the following areas:
• COVID-19 overpayment recoveries • Managing improper payments for emergency assistance
programs
• Estimation of UI fraud during the pandemic
• UI fraud-related assistance and recoveries
• Federal COVID-19 fraud-related cases
• HHS oversight of the Provider Relief Fund
23 GAO-23-106554 COVID-19 Oversight Summary
cares act update
Vulnerable
Populations
Selected GAO Findings and Recommendations
Our recent work demonstrated that certain vulnerable populations have been disproportionately
affected by the COVID-19 pandemic. These populations include people from certain racial and
ethnic groups, nursing home residents, children, those who are pregnant, those with low incomes,
and those with limited English proficiency. Federal agencies, including the Department of Health
and Human Services (HHS), have taken steps in response. For example, starting in 2020, HHS began
requiring nursing homes to routinely test staff for COVID-19 based on parameters established by
the department. As the nation continues to recover from the pandemic, federal agencies should
continue to focus on efforts to address the challenges these populations face, including reducing
disparities that were exacerbated by the pandemic.
We summarize key reports issued from April 2022 through April 2023 below. For status updates to
any recommendations from the reports summarized or included as related work, see https://www.
gao.gov/coronavirus.
Maternal Health During the Pandemic
Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic (GAO-23-105871)
Why It Matters In October 2022, we reported on selected maternal health indicators during the pandemic. We
described what available data show about maternal health outcomes and disparities during the
pandemic and HHS agencies’ efforts to address them.
While the COVID-19
What we found
pandemic had an Maternal deaths—those resulting from complications related to pregnancy and childbirth—totaled
just over 1,200 in 2021 compared to about 750 in 2019, according to Centers for Disease Control and
unprecedented effect on the
Prevention (CDC) data.35 Additionally, COVID-19 was reported as a contributing cause of death in one-
nation, it presented unique quarter of maternal deaths in 2020 and 2021.
challenges for vulnerable
CDC data also show racial and ethnic disparities in the rate of maternal deaths per 100,000 live births,
populations and, in which worsened during the pandemic. For example, compared to White (not Hispanic or Latina)
women, the maternal death rate increased significantly for Black or African-American (not Hispanic or
some cases, exacerbated
Latina) women between 2019 and 2020 and was significantly higher in both 2020 and 2021. Specifically,
some health care and the maternal death rate for Black or African American (not Hispanic or Latina) women was 44.0 per
100,000 live births in 2019 and increased to 55.3 in 2020 and 69.9 in 2021. In contrast, White (not
educational disparities Hispanic or Latina) women had death rates of 17.9, 19.1, and 26.6, respectively.
these populations
HHS officials and stakeholders, including researchers, advocacy groups, and professional organizations,
experienced prior to the told us the pandemic exacerbated the effects of social determinants of health—factors such as access
pandemic. We reported provisional 2021 data in October 2022. In March 2023, CDC released final maternal mortality data for 2021 that showed a higher number and rate of maternal
35
deaths than we previously reported.
24 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
to care, transportation, or technology; living environment; and Figure: Percentage of Residents Who Experienced Depression and
employment—on maternal health disparities. For example, service Unexplained Weight Loss, by Year
reductions in public transportation and child care worsened existing EXPERIENCED DEPRESSION EXPERIENCED UNEXPLAINED WEIGHT LOSS
barriers to accessing care. Percentage of nursing home residents Percentage of nursing home residents
70 20 19.3
63.9 61.5
60.2 17.4
HHS agencies initiated various efforts during or in response to the 60 58.7
16 14.8 15.0
50
pandemic to address maternal health outcomes and disparities, 12
40
such as supporting research, issuing guidance, and providing 30 8
technical assistance. 20
4
10
0 0
2018 2019 2020 2021 2018 2019 2020 2021
Nursing Home Infection Prevention and Control
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen deficiencies specific to COVID-19 and other respiratory diseases,
Oversight of Infection Prevention and Control (GAO-22-105133) state survey agencies will continue to face uncertainty about how to
inspect nursing homes for adherence to infection prevention control
In September 2022, we reported on federal oversight of infection requirements.
prevention and control in nursing homes in light of the COVID-19
pandemic. We described any changes in resident health before Our recommendations
and during the pandemic as indicated by Centers for Medicare CMS should establish minimum training standards for infection
& Medicaid Services (CMS) data. Also, we examined the infection preventionists; collect infection preventionist staffing data and use
prevention and control actions CMS and CDC have taken in nursing these data to determine whether the current staffing requirement is
homes before and during the pandemic, among other objectives. sufficient; and provide additional infection prevention and control
This report is part of a larger body of work examining COVID-19 in guidance. CMS concurred with one recommendation regarding
nursing homes. establishing minimum training standards for infection preventionists,
and it neither agreed nor disagreed with the two others. As of March
What we found 2023, these recommendations remained open.
Our analysis of CMS data showed that seven of the eight key
indicators of nursing home resident mental and physical health
that we reviewed worsened at least slightly in 2020, the first year of Pandemic Learning for High-Poverty Students and
the pandemic, compared to the years prior to the pandemic. Six of English Learners
these key indicators continued to worsen in the second year of the Pandemic Learning: Teachers Reported Many Obstacles for High-
pandemic. See the figure for two examples of key indicators. Nursing Poverty Students and English Learners As Well As Some Mitigating
home officials and national organizations we interviewed attributed Strategies (GAO-22-105815)
this worsening, in part, to the isolation residents experienced from
the limitations CMS placed on visitation or group activities in nursingIn May 2022, we reported on obstacles to learning and strategies to
homes during the pandemic to limit the transmission of COVID-19. mitigate learning loss for high-poverty students, English learners, and
students in grades K-2. This report was part of a series issued in the
CMS and CDC took actions on infection prevention and control prior spring of 2022. The series highlighted key findings from our nationally
to and during the COVID-19 pandemic. For example, prior to the generalizable survey of general education teachers and discussion
pandemic, CMS required nursing homes to designate an infection groups with teachers, principals, and parents that we conducted to
preventionist on staff. This person is a trained employee responsible understand the impact of COVID-19 on public K-12 education.
for the home’s infection prevention and control program, and
was crucial to nursing homes during the pandemic. During the What we found
pandemic, CMS and CDC provided infection prevention resources Our survey of public K-12 teachers showed that teachers with certain
to nursing homes. However, we found areas where CMS could take vulnerable student populations were more likely to have students
additional actions, including strengthening oversight of the infection who faced significant obstacles to learning and an increased risk of
preventionist role and clarifying infection prevention and control falling behind academically during the 2020-2021 school year.
guidance.
For example, we estimated that teachers with a high percentage
Until CMS sets minimum training standards for infection of high-poverty K-5 students learning virtually for the majority
preventionists, nursing homes will not know which training of the 2020-2021 school year were about 23 times more likely to
programs are adequate. Additionally, until CMS clarifies guidance have students who lacked an appropriate workspace—one free
on the scope and severity examples for infection prevention control of distractions—compared to all other K-5 teachers. Additionally,
25 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
we estimated that teachers in a virtual environment with a high
percentage of English learners (at least 20 percent) were more
likely than their peers to have students who regularly struggled
with understanding lessons and completing assignments, among
other things.
Teachers indicated that they used a variety of strategies to address
learning loss for these populations. For example, teachers with
a high percentage of English learners reported that small group
work in person and one-on-one check-ins between teachers and
students were effective in mitigating learning loss for at least half of
their students.
Considerations for Congress
Sustained congressional oversight of agencies’ efforts to address the effects of the pandemic is important. The pandemic highlighted existing
problems and disparities and, in some cases, exacerbated the existing problems. For example:
• A growing body of work shows that the COVID-19 pandemic exposed and worsened longstanding infection prevention and control
problems in nursing homes. As the nation moves forward, proper infection prevention and control procedures will remain critical to
ensuring resident safety against not only the threat of COVID-19, but also other infectious diseases. HHS’s continued leadership in
prioritizing infection prevention and control—in coordination with other federal, state, and private entities—is critical to better protecting
nursing home residents from the enduring risks of declining health and premature death posed by infections.
• The COVID-19 pandemic worsened some maternal health outcomes, and racial and ethnic disparities in maternal health outcomes
persisted during this period. HHS’s continued attention to efforts focused on reducing maternal deaths and disparities in maternal health
outcomes is important as the nation recovers from the pandemic.
26 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Other Related GAO Work
Issued from April 2022 through April 2023
COVID-19 in Nursing Homes: COVID-19 in Nursing Homes: Social Security Administration: Pandemic Learning: Less
Experts Identified Actions Outbreak Duration Averaged Remote Service Delivery Academic Progress Overall,
Aimed at Improving Infection 4 Weeks and Was Strongly Increased During COVID-19, but Student and Teacher Strain,
Prevention and Control, Associated with Community More Could Be Done to Assist and Implications for the Future,
GAO-23-105613 (Mar. 20, 2023) Spread, GAO-23-104291 Vulnerable Populations, GAO-22-105816 (June 8, 2022)
(Dec. 15, 2022) GAO-23-104650 (Nov. 17, 2022)
Pandemic Learning: As
Students Struggled to Learn,
Teachers Reported Few
Strategies as Particularly Helpful
to Mitigate Learning Loss,
GAO-22-104487 (May 10, 2022)
Ongoing GAO work
GAO has ongoing work in several areas, including the following:
• Accessibility and accommodations for higher education students
with disabilities
• Maternal health outcomes
27 GAO-23-106554 COVID-19 Oversight Summary
cares act update
Distribution of
Federal COVID-19
Funds
Selected GAO Findings and Recommendations
Federal agencies that managed new programs serving communities and individuals
disproportionately impacted by the COVID-19 pandemic faced challenges in disbursing funds.
These agencies had to take steps, such as creating new distribution mechanisms, that delayed
payments to fund recipients. In turn, the recipients—including in state, local and tribal entities, as
Why It Matters well as individuals—faced challenges in accessing and using the funds, especially for new programs.
Common challenges that recipients within state, local, and tribal entities reported include hiring and
capacity challenges, such as workload issues.
Since March 2020, Congress
We summarize key reports issued from April 2022 through April 2023 below. For status updates to
and the administration
any recommendations from the reports summarized or included as related work, see https://www.
have provided about $4.7 gao.gov/coronavirus.
trillion in COVID-19 relief
funding to help the nation Pandemic Unemployment Assistance to Contingent Workers
respond to and recover Pandemic Unemployment Assistance: Federal Program Supported Contingent Workers amid Historic
Demand, but DOL Should Examine Racial Disparities in Benefit Receipt (GAO-22-104438)
from the pandemic.
Agencies across the In June 2022, we reported on the Pandemic Unemployment Assistance (PUA) program, which
temporarily expanded unemployment benefits to workers generally ineligible for unemployment
federal government faced insurance, such as self-employed and contingent workers. We examined, among other things, (1)
challenges as officials how state implementation of PUA varied, and (2) how PUA benefit receipt varied by demographic
characteristics. This report is part of a larger body of work examining the unemployment insurance
worked to quickly distribute system, including PUA, during the COVID-19 pandemic.
the authorized funding
What we found
while ensuring proper As states implemented the new PUA program in spring 2020, they faced high demand for the assistance,
oversight. These challenges and that demand generally remained high through June 2021. The program expired on September 6,
2021. As of April 30, 2022, over $131 billion in PUA compensation had been paid to claimants, according
were exacerbated when to the Department of Labor (DOL). Most states started paying PUA claims by the end of May 2020,
according to data reported to DOL. However, some states did not immediately start paying a substantial
officials had to stand up
number of claimants. For example, one of the five states we chose for our review reported making its
new programs or scale first PUA payments on May 21, 2020, but had paid fewer than 1,000 PUA claimants their first benefits
by the end of May. This state reported paying about 6,000 PUA claimants their first benefits in June,
up existing programs,
followed by about 17,000 PUA claimants in July 2020. The state officials we talked to said they faced
such as to distribute relief urgency to pay PUA benefits; however, IT and staffing challenges, among other things, contributed
to payment delays. Some workers we spoke with reported waiting months to receive their first PUA
funds to populations payment after losing their jobs.
disproportionately
In our review of aggregated claimant data from four of the five states, we found substantial racial and
impacted by the pandemic. ethnic disparities in PUA benefit receipt in three states. For example, in two states, the percentage of
28 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Black applicants who received PUA was about half that of White Figure: HHS Agencies’ Allocations of Selected Funds to Programs
applicants. In one of these states, the percentages of Hispanic/Latino Supporting Communities Disproportionately Affected by COVID-19
and American Indian/Alaskan Native PUA applicants who received
benefits were also substantially lower than White applicants. Results
$29
$33 billion
from two national surveys showed similar disparities in receipt Allocated with
an agency
of unemployment insurance. Various factors could contribute
to these disparities, including systemic inequities such as how billion People over age 65
People with certain
medical conditions
Certain racial
and ethnic groups
recommendation
to support
states reviewed claims, whether fraudsters more frequently used Allocated to
programs
certain demographics when filing, or individual biases. Without specifically
supporting
comprehensive information about the extent or causes of inequities disproportionately $14 billion
affected Allocated with no
in PUA benefit receipt and in the unemployment insurance system communities People living in People in People who have requirement or
recommendation
nationwide, DOL may be challenged to effectively monitor state rural areas congregate settings not been vaccinated
to support a
practices or meet its goals of advancing racial, geographic, and
Note: Amounts do not sum to $75 billion in COVID-19 relief funding due to rounding.
gender equity in the unemployment insurance system.
The agencies also allocated $33 billion to other programs, with
Our recommendations guidance recommending that awardees—often state health
DOL should advise Congress and other policymakers on future departments—use the funds to support such communities.
options to support unemployed contingent workers and examine
the extent and causes of inequities in the receipt of PUA. DOL The five states we reviewed allocated funds they received from five
agreed with the first recommendation and partially agreed with the CDC programs to support a range of COVID-19 efforts, including
second recommendation. As of April 2023, both recommendations testing, vaccination, and other response efforts in disproportionately
remained open. affected communities. However, health department officials from all
five states reported capacity challenges that constrained their efforts
to allocate and use the CDC funds, including hiring and workload
issues and the limited capacity of local partners.
Public Health Relief Funds to Disproportionately
Affected Communities
COVID-19: HHS Funds Allocated to Support Disproportionately Relief Funds to Tribal Recipients
Affected Communities (GAO-23-105500) COVID-19 Relief Funds: Lessons Learned Could Improve Future
Distribution of Federal Emergency Relief to Tribal Recipients (GAO-23-
In January 2023, we reported on how the Department of Health 105473)
and Human Services (HHS) allocated funds from the Public Health
and Social Services Emergency Fund to support communities In December 2022, we reported on federal efforts to provide COVID-19
disproportionately affected by the COVID-19 pandemic. We relief funds to Tribes and their members and tribal entities (tribal
described (1) how much four HHS agencies allocated to support recipients).36 We examined (1) approaches selected federal agencies
these communities, and (2) how a sample of states allocated used to administer programs that provided COVID-19 funds to tribal
selected funding to support such communities. recipients, and (2) lessons learned that could improve future federal
relief to these recipients. This report is part of a larger body of work
What we found that includes reports addressing federal agencies’ administration of
HHS provided $75 billion in pandemic relief funding to the Centers COVID-19 relief funds for tribal recipients.37
for Disease Control and Prevention (CDC) and three other agencies
within HHS. CDC received over half of the funding. These four HHS What we found
agencies directed $29 billion (or about a third) of this funding to As of December 2022, Congress had appropriated at least $43.6
programs that specifically support communities disproportionately billion in COVID-19 relief funds for several existing and new federal
affected by COVID-19; most of these funds were directed to an array programs serving tribal recipients.38 The agencies we reviewed used
of new programs established during the COVID-19 pandemic. These various approaches, some required by statute, to provide relief
programs included the National Initiative to Address COVID-19 funds. These approaches determined the steps tribal recipients had
Health Disparities Among Populations at High Risk and Underserved to take to access and use the funds. In some cases, agencies used
Communities, and the Rural Tribal COVID-19 Response Program. existing program structures to quickly distribute relief funds to tribal
For the purposes of this report, the term “Tribes” refers to Indian Tribes that have been federally recognized. As of June 2023, there were 574 such Tribes. Federally recognized Tribes and individuals who meet the applicable statutory
36
and regulatory definitions of “Indian” have a unique political status and are eligible for certain federal programs, benefits, and services because of that status. For the purposes of this report, we refer to individuals eligible to receive
benefits and services based on their political status as “tribal members.”
For example, see GAO, COVID-19: Lessons Learned from Interior and Treasury’s Administration of CARES Act Funds Could Improve Federal Emergency Relief to Tribes, GAO-22-104349 (Washington, D.C.: Oct. 29, 2021).
37
Existing programs refers to those that were in place before the pandemic. The $43.6 billion includes appropriations for programs for which Native Hawaiians, in addition to tribal recipients, are eligible.
38
29 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
recipients, who generally did not have to take action to access to streamline the agency’s process for distributing funds to tribal
and use the funds. In other cases, agencies had to develop new recipients. As a result, according to these officials,
programs and took longer to distribute funds to recipients, who NOAA transferred the Fisheries Disaster Assistance line
had to take steps such as applying for the funds. item appropriation for tribal fishery recipients to BIA to distribute
to Tribes via BIA’s contracts and compacts. Leveraging BIA’s
For example, within several weeks of the enactment of the CARES existing mechanisms enabled NOAA to distribute funds more
Act, the Bureau of Indian Affairs (BIA) in the Department of the quickly and reduce administrative burden on the agency
Interior began distributing funds to Tribes that had existing and Tribes, according to NOAA officials. Based on our work,
self-determination contracts and self-governance compacts.39 we recommended that Congress consider providing future
In contrast, the Department of the Treasury had to set up the emergency relief that it wants distributed as quickly as possible
Coronavirus Relief Fund program and—because Treasury had in a manner that enables agencies to distribute it through existing
not previously distributed payments to tribal recipients—create mechanisms and structures, as we discuss below.
a new distribution mechanism, among other steps. This delayed • Increase federal capacity and expertise for working with tribal
distribution of the funds, according to Treasury officials. recipients. Greater capacity and expertise could improve future
federal administration of emergency funding for these recipients.
We identified lessons learned from agencies’ administration While some agencies in our review had substantial experience in
of relief funds that could improve future federal relief for tribal working with Tribes, other agencies’ lack of such experience
recipients, some of whom reported experiencing administrative led to challenges for these agencies and recipients that negatively
burden with certain relief funds, such as burdensome applications affected the timeliness and equity of relief funding allocations.
or reporting requirements. For example: For example, agency officials’ lack of familiarity with tribal
• Use existing mechanisms such as contracts and compacts governments and revenue structures contributed to delayed
with Tribes. Such mechanisms can enable agencies to disbursements of the Coronavirus Relief Fund and the Small
more quickly distribute funds to tribal recipients and mitigate Business Administration’s Paycheck Protection Program. Each
administrative burden for agencies and Tribes. Some agencies of the agencies we looked at in our report is implementing
transferred some of their appropriations to agencies that had an action plan that includes building capacity and expertise,
existing mechanisms in place to distribute funds to tribal in response to a 2021 presidential memo. The agencies’
recipients. For example, in response to comments received implementation and sustainment of these plans will enable them
during consultations with Tribes, National Oceanic and to better meet the unique needs of Tribes and tribal communities
Atmospheric Administration (NOAA) officials explored options in future emergency situations.
39
Self-determination contracts allow Tribes to assume responsibility for managing the program’s day-to-day operations, with federal agencies providing technical oversight to ensure the Tribe meets contract terms and reporting
requirements. Self-governance compacts transfer administration of the program to Tribes and provide the Tribes with some flexibility in program administration. To be eligible for participation in self-governance compacting, a
Tribe must demonstrate financial stability and management capability, among other things.
Considerations for Congress
Congress considers multiple priorities when drafting emergency relief legislation, such as getting funds to recipients quickly and including
mechanisms to ensure that funds are distributed in a controlled manner so that they are used as Congress intended. Through our COVID-19
body of work, we have made recommendations to Congress aimed at helping federal agencies to distribute emergency relief funds quickly
while maintaining appropriate safeguards.
• For example, in our December 2022 report on relief funds to tribal recipients, we recommended that Congress consider, when seeking
to provide these recipients with emergency relief that it wants to be distributed as quickly as possible, providing this relief in a manner
that explicitly enables agencies to distribute it through existing mechanisms and structures such as self-determination contracts and self-
governance compacts, as appropriate. Because not all agencies have existing mechanisms for quickly distributing funds to tribal recipients
or the authority to transfer funds to other agencies that do, providing agencies with the explicit authority to use established mechanisms
could help ensure tribal recipients can more quickly access these funds. It also would ensure minimal additional administrative burden on
Tribes and agencies while leveraging existing program reporting mechanisms for accountability.
• In another example, as noted above, through our COVID-19 body of work, we have recommended 12 actions Congress could take to
improve oversight of emergency relief funds, including actions that could improve accountability for new programs. For example, in March
2022 we suggested that Congress should designate all new federal programs distributing more than $100 million in any one fiscal year as
“susceptible to improper payments,” and, thus, subject to more timely improper payment reporting requirements.
30 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Other Related GAO Work
Issued from April 2022 through April 2023
COVID-19 Relief: Funding and
Spending as of Jan. 31, 2023,
GAO-23-106647 (Feb. 28, 2023)
Ongoing GAO work
GAO has ongoing work, including in the following areas:
• Accountability for Bureau of Indian Education spending of • States’ experiences with COVID-19 relief funding
COVID-19 funds • States' use of the Coronavirus State and Local Fiscal
• COVID-19 sub-award reporting Recovery Fund
• COVID-19 relief funding in U.S. territories • The Department of Veterans Affairs COVID-19 funding
projections and program objectives
• Localities' use of the Coronavirus State and Local Fiscal
Recovery Fund
31 GAO-23-106554 COVID-19 Oversight Summary
cares act update
COVID-19 and
the Economy
Selected GAO Findings and Recommendations
In recent reports, we examined a number of key federal programs designed to support the economy
during the pandemic and address some lingering economic effects. During the first months of the
pandemic, multiple agencies provided timely assistance to help alleviate the financial hardships
faced by individuals and businesses, such as through Unemployment Insurance (UI) payments
to individuals and through loans to businesses from the Paycheck Protection Program and
COVID-19 Economic Injury Disaster Loan program. These programs provided direct support aimed
at preventing detrimental outcomes from worsening. The Federal Reserve also initiated several
Why It Matters emergency lending programs to support the flow of credit to various parts of the economy affected
by the pandemic.
After the emergence of the As the pandemic moved into its third year, several programs continued to support businesses still
COVID-19 pandemic in early recovering, including the State Small Business Credit Initiative (SSBCI). We made recommendations
aimed at helping federal agencies improve their management of these programs to better meet the
2020, the U.S. experienced needs of intended recipients, including small businesses and individuals, among other goals.
historic levels of job loss
We summarize key reports issued from April 2022 through April 2023 below. For status updates to
and economic contraction.
any recommendation from the reports summarized or included as related work, see https://www.
Congress appropriated gao.gov/coronavirus.
and agencies provided
State Small Business Credit Initiative
over $4 trillion in federal State Small Business Credit Initiative: Improved Planning Could Help Treasury Limit Additional Delays
assistance broadly to (GAO-23-105293)
support individuals and In February 2023, we reported on the SSBCI, a preexisting program reauthorized in March 2021 to
many public and private support small businesses recovering from the economic effects of the COVID-19 pandemic.40 Through
this program, the Department of the Treasury was authorized to provide up to $10 billion to states,
entities. The economy has territories, the District of Columbia and tribal governments to support lending and investment programs
recovered substantially for small businesses, as well as technical assistance funds to provide certain businesses with financial
and other advisory services. We examined, among other objectives, (1) jurisdictions’ planned use of
since the pandemic began, SSBCI funds to meet program objectives, and (2) Treasury’s completion of key implementation steps for
but there are still some SSBCI.
lingering effects from the What we found
All 50 states, all five U.S. territories, the District of Columbia, and 283 tribal governments applied to
pandemic. For example,
participate in this program.41 By September 2022, some states had begun to receive SSBCI funding, and
labor market disruptions
This program originally operated from 2010 through 2017 after it was created and authorized in response to the 2007-2009 financial crisis. It was reauthorized in the
40
continue to affect some American Rescue Plan Act of 2021. Pub. L. No. 117-2, § 3301(a), 135 Stat. at 67–72.
41
According to Treasury data, these tribal governments submitted an application either individually or as part of a consortium. According to Treasury officials, the agency had
industries. received over 400 Notices of Intent to apply to SSBCI from tribal governments by December 2021. According to Treasury officials, Treasury identified 582 tribal governments as
eligible to apply to the program, including 574 federally recognized Tribes and eight component bands of those Tribes.
32 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Figure: Overview of Flow of Funds in State Small Business Credit Our recommendations
Initiative (SSBCI) Treasury should fully incorporate certain best practices for project
scheduling in its planning efforts for this program. Treasury agreed to
Department of review options in line with our recommendation. As of April 2023, the
the Treasury
recommendation remained open.
Allocations transferred
Jurisdictions
(states, territories, the
Federal Reserve Lending Programs
District of Columbia,
and tribal governments) Federal Reserve Lending Programs: Risks Remain Low in Related Credit
Markets, and Main Street Loans Have Generally Performed Well (GAO-
Optional 23-105629)
Contracted entity Lenders or
(jurisdictions may contract co-investors
with an entity of another In December 2022, we reported on the Federal Reserve’s emergency
state, for-profit third parties, lending programs (facilities) authorized in response to the economic
or nonprofits to administer Private capital
SSBCI programs) (in accordance with SSBCI effects of the COVID-19 pandemic to ensure the flow of credit to
program terms: 1:1 private
SSBCI funds
matching; 10:1 private
leverage ratio)
various parts of the economy. We examined, among other objectives,
(1) trends in credit markets that the facilities targeted, and (2) the
Small businesses status and performance of Main Street Lending Program loans, which
held the largest amounts of outstanding assets of the facilities that
most states and territories planned to use the funding for a mix of received CARES Act-appropriated funds. This report is part of a larger
lending and equity investment programs.42 For example, to meet the body of work examining the Federal Reserve’s emergency lending
objective of providing support to very small businesses and those programs.
owned by socially and economically disadvantaged individuals,
officials from 12 selected states said they planned to leverage What we found
existing partnerships with lenders, small business development Over the life of the Federal Reserve’s facilities that received CARES
centers, and other community groups. Act-appropriated funds, they conducted about $41 billion in
transactions designed to support the flow of credit to employers,
We reported that Treasury could improve its planning for the consumers, small and mid-sized businesses, state and local
administration of this program. Although Treasury hired program governments, and nonprofit organizations. Available indicators
office staff and conducted outreach to stakeholders, it extended suggested that credit market risks have remained low in the targeted
program deadlines multiple times. Additionally, Treasury began sectors since the facilities ceased extending credit in January 2021,
disbursing capital program funds later than it planned, partly including corporate, small business, and municipal credit markets.
because it required more time and resources than anticipated to However, some vulnerabilities remained. While near-term risks in the
support first-time participants and establish guidelines for new credit markets supported by the facilities remained manageable, the
program components. For example, Treasury officials noted they effects of factors such as rising interest rates and high inflation levels
needed more time and resources to provide support to tribal could make these markets vulnerable in the near future.
governments, which had not previously participated in SSBCI
because they were not eligible for the original program.43 Significant As of September 30, 2022, the Main Street Lending Program facilities,
implementation steps also remained, such as reviewing remaining which supported loans made to small and mid-sized businesses and
applications and implementing compliance monitoring and nonprofits, held about $11.2 billion in outstanding assets. Of the 1,830
performance measurement plans. loans made through the program, 1,453 loans remained outstanding
as of that date. Additionally, most borrowers were making required
However, Treasury’s planned efforts have not fully incorporated interest payments on time. Our analysis of Federal Reserve Bank of
certain best practices we previously developed for reliable project Boston data found that 365 loans (about 20 percent) were fully repaid
scheduling. For example, Treasury’s work plan has not identified and less than 1 percent had resulted in losses.
which staff or contractors would be responsible for each activity.
Treasury would be better positioned to establish and communicate
reliable time frames for the SSBCI program, a key program for
reaching businesses that historically have faced difficulties obtaining
access to finance, if it fully incorporates these best practices into its
plans.
The SSBCI program types include capital access, loan guarantee, collateral support, loan participation, venture capital, and other equity investment programs.
42
The reauthorized SSBCI program retains key features of the original program, but it also includes an allocation for Tribal governments and allocations for very small businesses and those owned and controlled by socially and
43
economically disadvantaged individuals. Tribal governments were not eligible for the original program.
33 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Pandemic Unemployment Insurance Programs helped maintain consumer spending, which in turn helped support
overall economic stability. In the discussion groups that we held
Unemployment Insurance: Pandemic Programs Posed Challenges,
and DOL Could Better Address Customer Service and Emergency in six states, some participants shared experiences that were
Planning (GAO-22-104251) consistent with these empirical studies. For example, participants
in all 12 of our discussion groups said they used the pandemic UI
In June 2022, we reported on the three federally funded temporary benefits to pay for expenses such as food, rent, utilities, and health
UI programs created through the CARES Act in response to the care. In seven of the groups, recipients said they used the benefits
COVID-19 pandemic. We examined, among other objectives, (1) for child care expenses.
the Department of Labor’s (DOL) support and monitoring of these
programs, and (2) what is known about the economic effects of In addition, studies conducted during the pandemic noted
the expansion of UI benefits for individuals and the economy that specific occupations, such as service-oriented or low-
during adverse times. This report is part of a larger body of work paying occupations in the restaurant industry, experienced
examining the UI system during the COVID-19 pandemic. more layoffs and reductions in hours than other occupations.
The studies added that because these low-wage occupations
What we found disproportionately employ people of color or women, UI expansion
DOL took steps to support and monitor states’ implementation likely also prevented existing inequities among these groups from
of the pandemic UI programs. As of April 30, 2022, DOL reported getting worse.
that about $658 billion in compensation had been paid under
the pandemic UI programs. However, DOL could have better Our recommendations
assisted states with customer service challenges. According DOL should identify and provide UI customer service best practices
to DOL’s website, the agency is responsible for ensuring and assess lessons learned from the pandemic. DOL partially
customer satisfaction in the UI system and had taken steps to agreed with the first recommendation and agreed with the second.
incorporate customer service into its UI modernization efforts, As of April 2023, DOL had implemented the first recommendation
including providing states with technical assistance and funding by providing best practices to states and had taken actions to
opportunities. However, it had not identified and provided states address the second recommendation.
with comprehensive customer service best practices. If DOL were
to assess lessons learned from its response to the pandemic, the
agency would be better prepared for future crises that could lead
to challenges for the states and the people they serve through the
UI system.
The empirical studies we reviewed showed that the expansion of
UI programs during adverse times, such as the Great Recession
of 2007-2009 and the COVID-19 pandemic, helped stabilize the
economy and prevented detrimental outcomes from worsening.
Selected studies showed that UI expansion during economic crises
Considerations for Congress
In June 2022, we reported that a transformation is needed to address the UI program’s design, infrastructure, and integrity risks.44 DOL has
efforts under way to reform the UI system, with one stated vision being to modernize the UI system so that it could provide a lifeline to all
workers in the modern economy. Sustained congressional attention and oversight of DOL’s efforts could help ensure the transformed system
is structured to serve the workers of our modern and evolving economy.
GAO, Unemployment Insurance: Transformation Needed to Address Program Design, Infrastructure, and Integrity Risks, GAO-22-105162 (Washington, D.C: June 7, 2022)
44
34 GAO-23-106554 COVID-19 Oversight Summary
public health improper payments vulnerable distribution of federal covid-19 and
preparedness and fraud populations covid-19 funding the economy
Other Related GAO Work
Issued from April 2022 through April 2023
Money Market Mutual Funds:
Pandemic Revealed Unresolved
Vulnerabilities, GAO-23-105535
(Feb. 2, 2023)
Ongoing GAO work
GAO has ongoing work, including in the following areas:
• CARES Act Title IV Federal Reserve Facilities
• Pandemic insurance for businesses
• State Small Business Credit Initiative Part 2
35 GAO-23-106554 COVID-19 Oversight Summary
Additional Source Information for Images and Figures
This page contains credit, copyright, and other source information for images, tables, or figures in this product when that
information was not listed adjacent to the image, table, or figure.
Front Cover Page 23
Images (left to right): Images (left to right):
• Suzi Media/stock.adobe.com • GAO file photo
• Sagittarius Pro/stock.adobe.com • Vitalii Vodolazskyi/stock.adobe.com
• WESTOCK/stock.adobe.com • GAO analysis of Small Business Administration data (information)
• Pormezz/stock.adobe.com and GAO (icons)
• hanmaomin/stock.adobe.com • GAO file photo
Pattern: Aruno/stock.adobe.com • Mr Doomits/stock.adobe.com
Page 4 Page 24
Image: trekandphoto/stock.adobe.com Image: Meeko Media/stock.adobe.com
Page 6 Page 25
Figure: GAO analysis of Centers for Disease Control and Prevention's Figure: GAO analysis of Centers for Medicare & Medicaid Services
National Center for Health Statistics data. data.
Page 8 Page 26
Image: deberarr/stock.adobe.com Pattern: Aruno/stock.adobe.com
Page 10 Page 27
Images (left to right): Images (left to right):
• GAO (information) • Mikel Allica/stock.adobe.com
• GAO (information and icons) • Studio Romantic/stock.adobe.com
• GAO file photo
Page 14 • Natee Meepian/stock.adobe.com
Pattern: Aruno/stock.adobe.com • Suzi Media/stock.adobe.com
Page 15 Page 28
Image: ManuPadilla/stock.adobe.com Image: Vadim/stock.adobe.com
Page 16 Page 29
Figure: GAO analysis of Department of Health and Human Services Figure: GAO analysis of Department of Health and Human Services
data. data (information); GAO (illustrations).
Page 17 Page 30
Pattern: Aruno/stock.adobe.com Pattern: Aruno/stock.adobe.com
Page 18 Page 31
Images (left to right): Image: Centers for Disease Control and Prevention, Alissa Eckert,
• Pond5 Dan Higgins
• GAO file photo
• JHDT Productions/stock.adobe.com Page 32
• Chokchaipoo/stock.adobe.com Image: Leigh Trail/stock.adobe.com
• Pitipat/stock.adobe.com
• Chartphoto/stock.adobe.com Page 33
Figure: GAO analysis of Department of the Treasury documents.
Page 19
Image: Philip Steury/stock.adobe.com Page 34
Pattern: Aruno/stock.adobe.com
Page 20
Figure: GAO (information and icons). Page 35
Image: GAO file photo
Page 22
Pattern: Aruno/stock.adobe.com
36 GAO-23-106554 COVID-19 Oversight Summary
List of Committees
The Honorable Patty Murray The Honorable James Comer
Chair Chairman
The Honorable Susan Collins The Honorable Jamie Raskin
Vice Chair Ranking Member
Committee on Appropriations Committee on Oversight and Accountability
United States Senate House of Representatives
The Honorable Ron Wyden The Honorable Jason Smith
Chairman Chairman
The Honorable Mike Crapo The Honorable Richard Neal
Ranking Member Ranking Member
Committee on Finance Committee on Ways and Means
United States Senate House of Representatives
The Honorable Bernard Sanders
Chair
The Honorable Bill Cassidy, M.D.
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rand Paul, M.D.
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Kay Granger
Chairwoman
The Honorable Rosa L. DeLauro
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives
37 GAO-23-106554 COVID-19 Oversight Summary
GAO Contacts and Contributors
About GAO
The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people.
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Subscribe to our RSS Feeds or Email Updates.
Listen to our Podcasts.
Visit GAO on the web at https://www.gao.gov.
U.S. Government Accountability Office, 441 G Street NW, Washington, DC 20548.
This work of the United States may include copyrighted material, details at https://www.gao.gov/copyright.
Contact Us
For more information, contact:
Jessica Farb, Managing Director, Health Care, farbj@gao.gov, (202) 512-7114.
Chuck Young, Managing Director, Public Affairs, YoungC1@gao.gov, (202) 512-4800.
A. Nicole Clowers, Managing Director, Congressional Relations, ClowersA@gao.gov, (202) 512-4400.
Key Contributors
Jessica Bryant-Bertail, Tara Congdon, Kaitlin Dunn, Drew Long, Ray Sendejas, and Roxanna T. Sun.
38 GAO-23-106554 COVID-19 Oversight Summary
File and source
- File
- 23-106554-recommendations-future-emergencies-jul2023.pdf
- Size
- 5,091,427 bytes
- SHA-256
- 0a8b72ad86c193d792ea53fe9668b56780434894e89daff2d5026441cd5ad304
- Original
- www.gao.gov