Building and Maintaining Infrastructure beyond the COVID-19 Pandemic (GAO-24-105891)
Summary
A GAO report to congressional committees, GAO-24-105891, dated November 2023, on public health preparedness. It states that the COVID-19 pandemic demonstrated the importance of a strong public health infrastructure, including a skilled workforce and physical infrastructure such as laboratories, to prepare for and respond to threats. It explains that the Centers for Disease Control and Prevention (CDC), part of the Department of Health and Human Services, is the primary federal agency responsible for helping strengthen jurisdictions' public health infrastructure and annually supports it. The report examines building and maintaining that infrastructure beyond the pandemic.
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United States Government Accountability Office
Report to Congressional Committees
November 2023
PUBLIC HEALTH
PREPAREDNESS
Building and
Maintaining
Infrastructure beyond
the COVID19
Pandemic
Accessible Version
GAO-24-105891
November 2023
GAO Highlights PUBLIC HEALTH PREPAREDNESS
Highlights of GAO-24-105891, a report to Building and Maintaining Infrastructure beyond the
congressional committees
COVID-19 Pandemic
Why GAO Did This Study What GAO Found
CDC is the primary federal agency The COVID-19 pandemic demonstrated the importance of a strong public
responsible for helping strengthen health infrastructure to prepare for and respond to threats, including a skilled
jurisdictions’ public health workforce, and physical infrastructure, such as laboratories. The Department
infrastructure to aid emergency
of Health and Human Services’ (HHS) Centers for Disease Control and
preparedness and response
capabilities. Prevention (CDC) annually supports public health infrastructure in
jurisdictions—states, localities, and territories—through two key
The CARES Act includes a provision preparedness programs: (1) Epidemiology and Laboratory Capacity for
for GAO to report on the federal Prevention and Control of Emerging Infectious Diseases and (2) Public
response to the COVID-19 pandemic.
Health Emergency Preparedness. The programs’ award amounts to
This report (1) describes CDC awards
to support jurisdictions’ public health jurisdictions from annual appropriations totaled about $845 million on
infrastructure for preparedness, and (2) average per year from fiscal year 2019 through 2022. Separately, in fiscal
examines challenges selected years 2021 through 2023, using supplemental appropriations from the most
jurisdictions and stakeholder groups recent COVID-19 relief law, CDC also provided jurisdictions with about $7.1
identified to building and maintaining billion in awards to enhance infrastructure. Of this, $3.5 billion can be used
such infrastructure. over 5 years for a new longer-term infrastructure investment to help with
GAO analyzed CDC’s data on awards future threats. Jurisdiction officials GAO spoke with cited important benefits
provided to jurisdictions using annual of awards from both annual and supplemental appropriations, such as
appropriations and certain supporting epidemiology staff and purchasing supplies for laboratories.
supplemental appropriations made in
response to the pandemic. Specifically, Selected jurisdictions and stakeholder groups identified several challenges
GAO analyzed annual award data from building and maintaining infrastructure to be sufficiently prepared for public
fiscal year 2018 (the year GAO last health threats. These include challenges in the following areas:
reported on award data) through 2022
(most recent data available at the time · Temporary public health funding. Officials from nearly all jurisdictions
of GAO’s review). GAO also analyzed and stakeholder groups expressed concern about the pattern of
data on awards using appropriations increased federal funding for an emergency response, followed by a
from the most recently enacted decrease in funding after that emergency ends. This pattern can make it
COVID-19 relief law—the American hard for jurisdictions to invest in long-term sustainable efforts to prepare
Rescue Plan Act of 2021. for future public health threats.
GAO interviewed officials from a · Varying levels of jurisdictional funding. Jurisdictions have primary
nongeneralizable sample of 12 responsibility to prepare for and respond to threats. However, there is
jurisdictions—selected based on variation in the amount of funding jurisdictions provide for preparedness
governance structure, funding and response. This affects the extent to which jurisdictions may need to
received, and rurality. GAO also
rely on CDC awards for such purposes, according to two stakeholder
interviewed representatives from 10
stakeholder groups representing public groups.
health professionals and policy · Building a public health workforce. Jurisdictions’ officials noted that
organizations, among others. because awards using COVID-19 supplemental appropriations were
temporary, workforce increases were also largely temporary. Even for the
GAO provided a draft of this report to
new award that can be used over 5 years, officials from eight jurisdictions
HHS for review and comment. HHS
provided technical comments, which noted concerns about permanently increasing their workforces because
GAO incorporated as appropriate. of uncertainty of longer-term funding. Officials from six jurisdictions and
five stakeholder groups also expressed concerns about the availability of
a sufficient public health workforce, due to burnout and other factors.
Jurisdictions are key partners in preparing for and responding to public health
threats. The infrastructure challenges they face can impact how quickly and
View GAO-24-105891. For more information,
effectively CDC and other response partners are able to contain these
contact Mary Denigan-Macauley at (202) 512- threats, as was demonstrated during the COVID-19 pandemic. According to
7114 or DeniganMacauleyM@gao.gov. CDC officials, increased and ongoing investments in public health
infrastructure are vital to the response to contain threats on a national level.
United States Government Accountability Office
Contents
GAO Highlights ii
Why GAO Did This Study ii
What GAO Found ii
Letter 1
Background 5
Jurisdictions Received about $845 Million Annually, Plus $7.1
Billion in Response to the COVID-19 Pandemic, for Public
Health Infrastructure 8
Challenges Selected Jurisdictions and Stakeholders Identified to
Building and Maintaining Public Health Infrastructure 20
Agency Comments 38
Appendix I: Other Centers for Disease Control and Prevention Efforts to Support Jurisdictions’ Public Health
Infrastructure 41
Appendix II: Centers for Disease Control and Prevention Awards to Jurisdictions for Public Health
Preparedness Infrastructure 45
Appendix III: Selected State, Local, and Territorial Health Department Profiles 51
Appendix IV: Selected Awards to Jurisdictions for Public Health Infrastructure from American Rescue Plan Act
of 2021 90
Appendix V: Additional Challenges to Managing Awards during Public Health Emergencies 96
Appendix VI: GAO Contact and Staff Acknowledgments 99
Tables
Table 1: CDC Annual Awards to States, Localities, and Territories
for Public Health Infrastructure 6
Table 2: Selected Jurisdictions’ Reported Uses of CDC Awards for
Infrastructure for Public Health Threats from Annual
Appropriations 14
Table 3: Examples of Other CDC Efforts to Support Jurisdictions’
Public Health Infrastructure 42
Table 4: CDC Awards to Jurisdictions through the Public Health
Emergency Preparedness (PHEP) Program from Annual
Appropriations, Fiscal Years 2019-2022 46
Page i GAO-24-105891 Public Health Preparedness
Table 5: CDC Awards to Jurisdictions through the Epidemiology
and Laboratory Capacity for Prevention and Control of
Emerging Infectious Diseases (ELC) Program from
Annual Appropriations, Fiscal Years 2019-2022 48
Table 6: Overview of CDC Awards to Jurisdictions for Workforce
and Laboratory Infrastructure from ARPA Supplemental
Appropriations 90
Table 7: CDC Strengthening U.S. Public Health Infrastructure,
Workforce, and Data Systems Grant Awards to
Jurisdictions, as of May 2023 92
Table 8: Challenges GAO Previously Reported on Related to
Federal Awards from Supplemental Appropriations
Provided in Response to Public Health Emergencies 97
Figures
Figure 1: CDC Awards to Jurisdictions for Infrastructure for Public
Health Threats from Annual Appropriations, Fiscal Years
2019-2022 9
Accessible data table for Figure 1: CDC Awards to Jurisdictions
for Infrastructure for Public Health Threats from Annual
Appropriations, Fiscal Years 2019-2022 10
Figure 2: CDC Awards to Jurisdictions through the ELC Program
from Annual Appropriations, FY 2022 12
Accessible text of Figure 2: CDC Awards to Jurisdictions through
the ELC Program from Annual Appropriations, FY 2022 12
Figure 3: Selected Jurisdictions and Stakeholder Groups Identified
“Boom and Bust” Pattern of Federal Public Health
Infrastructure Funding as a Challenge 23
Accessible text of Figure 3: Selected Jurisdictions and
Stakeholder Groups Identified “Boom and Bust” Pattern
of Federal Public Health Infrastructure Funding as a
Challenge 24
Figure 4: Selected Jurisdictions Identified Challenges to Building
and Maintaining a Public Health Workforce with Awards
from COVID-19 Supplemental Appropriations 32
Accessible text for Figure 4: Selected Jurisdictions Identified
Challenges to Building and Maintaining a Public Health
Workforce with Awards from COVID-19 Supplemental
Appropriations 32
Figure 5: Selected Jurisdictions and Stakeholder Groups Identified
Public Health Workforce Challenges 35
Page ii GAO-24-105891 Public Health Preparedness
Accessible text for Figure 5: Selected Jurisdictions and
Stakeholder Groups Identified Public Health Workforce
Challenges 35
Figure 6: California Public Health 53
Accessible text of Figure 6: California Public Health 54
Figure 7: Maine Public Health 57
Accessible text for Figure 7: Maine Public Health 58
Figure 8: Maryland Public Health 60
Accessible text for Figure 8: Maryland Public Health 61
Figure 9: South Carolina Public Health 63
Accessible text of Figure 9: South Carolina Public Health 64
Figure 10: Puerto Rico Public Health 66
Accessible text for Figure 10: Puerto Rico Public Health 67
Figure 11: U.S. Virgin Islands Public Health 69
Accessible text for Figure 11: U.S. Virgin Islands Public Health 70
Figure 12: Los Angeles County, California, Public Health 72
Accessible text for Figure 12: Los Angeles County, California,
Public Health 73
Figure 13: San Bernardino, California, Public Health 75
Accessible text for Figure 13: San Bernardino, California, Public
Health 76
Figure 14: San Francisco, California, Public Health 78
Accessible text for Figure 14: San Francisco, California, Public
Health 79
Figure 15: Portland, Maine, Public Health 81
Accessible text for Figure 15: Portland, Maine, Public Health 82
Figure 16: Baltimore, Maryland, Public Health (city) 84
Accessible text for Figure 16: Baltimore, Maryland, Public Health
(city) 85
Figure 17: Garrett County, Maryland, Public Health 87
Accessible text for Figure 17: Garrett County, Maryland, Public
Health 88
Abbreviations
ARPA American Rescue Plan Act of 2021
CDC Centers for Disease Control and Prevention
ELC Epidemiology and Laboratory Capacity for Prevention and Control
of Emerging Infectious Diseases
HHS Department of Health and Human Services
PHEP Public Health Emergency Preparedness
Page iii GAO-24-105891 Public Health Preparedness
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Page iv GAO-24-105891 Public Health Preparedness
441 G St. N.W.
Washington, DC 20548
Letter
November 7, 2023
Congressional Committees
The COVID-19 pandemic demonstrated the importance of a strong public
health infrastructure to prepare for and respond to threats and
emergencies, such as infectious diseases and extreme weather events.
Public health infrastructure includes the people, services, and systems
needed to promote and protect health, such as epidemiologists and
laboratory services, according to the Department of Health and Human
Services’ (HHS) Centers for Disease Control and Prevention (CDC).
State, local, and territorial governments (referred to in this report as
jurisdictions) are primarily responsible for leading the preparation for and
response to public health threats in their jurisdictions. When their
infrastructure capabilities are overwhelmed during an emergency
response, these jurisdictions can become reliant on support from the
federal government.
CDC is the primary federal agency responsible for helping strengthen
jurisdictions’ public health infrastructure to aid emergency preparedness
and response.1 In May 2018, we reported that annual CDC public health
preparedness award amounts to jurisdictions had generally decreased
over the years.2 We reported then that, according to CDC officials, such
decreases limited jurisdictional preparedness capacity—such as the
ability to maintain preparedness staff—which, in turn, increased the
1CDC strengthens such infrastructure by awarding funds to jurisdictions’ health
departments, among other support. The Administration for Strategic Preparedness and
Response within HHS also provides awards to jurisdictions’ health departments through
its Hospital Preparedness Program. The Hospital Preparedness Program funds and
promotes the development of health care coalitions–-groups of health care and response
organizations in defined geographic locations that coordinate emergency preparedness
and response activities for their members. For our recent work on this program and its
recipients’ experiences during the COVID-19 pandemic see GAO, Public Health
Preparedness: COVID-19 Medical Surge Experiences and Related HHS Efforts,
GAO-22-105461 (Washington, D.C.: Aug. 17, 2022).
Other federal agencies also make awards to jurisdictions to help communities prevent,
prepare for, and mitigate the effects of; respond to; and recover from emergencies.
However, these awards may not go directly to jurisdictions’ health departments, like the
CDC awards do. For example, the Federal Emergency Management Agency, a
component of the Department of Homeland Security, provides such awards to
jurisdictions’ emergency management agencies, according to its website.
2GAO, Infectious Disease Threats: Funding and Performance of Key Preparedness and
Capacity-Building Programs, GAO-18-362 (Washington, D.C.: May 24, 2018).
Page 1 GAO-24-105891 Public Health Preparedness
Letter
importance of supplemental appropriations to respond to public health
emergencies. HHS received such supplemental appropriations to respond
to the COVID-19 pandemic in 2020 and 2021, most recently from the
American Rescue Plan Act of 2021 (ARPA).3 HHS previously received
supplemental appropriations to respond to the Zika outbreak in 2016 and
the H1N1 influenza pandemic in 2009, as well as for other public health
emergencies.4
The CARES Act includes a provision for us to report on the federal
response to the COVID-19 pandemic.5 This report is also part of our body
of work on HHS’s leadership and coordination of public health
emergencies, which we identified as an area of high risk. We added this
topic to our High-Risk List in 2022, citing the critical need for the nation to
be prepared for, and effectively respond to, future public health threats
and emergencies.6
This report (1) describes awards CDC provided to jurisdictions’ health
departments to build and maintain infrastructure for public health threats
3A supplemental appropriation is an act appropriating funds in addition to those already
provided in an annual appropriation act. Supplemental appropriations provide additional
budget authority usually in cases where the need for funds is considered too urgent to be
postponed until enactment of the next regular annual appropriation bill. For COVID-19
supplemental appropriations to HHS, see 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.
4For Zika supplemental appropriations to HHS, see the Zika Response and Preparedness
Act, Pub. L. No. 114-223, div. B tit. I, 130 Stat. 857, 901. For H1N1 pandemic influenza
supplemental appropriations to HHS, see the Supplemental Appropriations Act, 2009,
Pub. L. No. 111-32, tit. VIII, 123 Stat. 1859, 1884.
5Specifically, the act requires us to monitor and oversee the federal government’s efforts
to prepare for, respond to, and recover from the pandemic. Pub. L. No. 116-136, §
19010(b), 134 Stat. 281, 580 (2020). 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. 4, 78. All of GAO’s reports related to the COVID-19 pandemic are
available on GAO’s website at https://www.gao.gov/coronavirus.
6GAO, 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)
and the New High-Risk Designation: HHS and Public Health Emergencies appendix in
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).
Page 2 GAO-24-105891 Public Health Preparedness
Letter
and emergencies using annual appropriations, as well as selected
COVID-19 supplemental appropriations, and (2) examines challenges
selected jurisdictions and stakeholder groups identified to building and
maintaining such infrastructure.
Public health infrastructure is broad. For the purposes of this report, we
focused on infrastructure needed to prepare for and respond to public
health threats and emergencies. We determined that this includes public
health workforce recruitment, hiring, and training; physical infrastructure,
such as laboratories and equipment; and other resources. Infrastructure
also includes data systems. We excluded the building of such systems
from our review as we have recently reported on HHS efforts to support
jurisdictions’ data systems.7 However, we included the workforce needed
to support such systems.
To describe awards CDC provided to jurisdictions’ health departments to
build and maintain infrastructure for public health threats and
emergencies, we analyzed CDC data on the amounts of awards that CDC
made to these entities from annual appropriations through two key
preparedness and capacity-building programs. We analyzed these data
from fiscal year 2018 (the year we last reported on these funds) through
2022 (the most recent data available at the time of our review). Tribes are
not direct recipients of awards through these annual preparedness
programs. Therefore, we excluded Tribes from our review. We also
analyzed data on awards CDC provided to jurisdictions’ health
departments using supplemental appropriations provided by ARPA.8
To assess the reliability of the annual and ARPA supplemental award
data, we reviewed agency documentation, such as reports provided by
7See, for example, GAO, COVID-19: Pandemic Lessons Highlight Need for Public Health
Situational Awareness Network, GAO-22-104600 (Washington, D.C.: June 23, 2022) and
the Public Health Data Collection and Standardization enclosure in COVID-19: Current
and Future Federal Preparedness Requires Fixes to Improve Health Data and Address
Improper Payments, GAO-22-105397 (Washington, D.C.: Apr. 27, 2022).
8ARPA is the most recent of the six enacted COVID-19 relief laws providing supplemental
appropriations to respond to the COVID-19 pandemic. ARPA and the CARES Act included
the largest amount of funding appropriated for state, local, territorial, and tribal
governments. The CARES Act was the third law enacted and therefore likely to be used
for immediate response needs. We chose to examine awards made using ARPA
supplemental funding in this review because, unlike awards provided with prior COVID-19
supplemental appropriations, some ARPA supplemental funding can explicitly be used for
activities beyond the COVID-19 pandemic. We included awards CDC provided to health
departments for infrastructure using ARPA supplemental appropriations; we excluded
awards for other jurisdictional entities, such as schools and correctional facilities.
Page 3 GAO-24-105891 Public Health Preparedness
Letter
jurisdictions, and compared the CDC data to the award amounts in this
documentation. We interviewed knowledgeable CDC officials about their
data systems and data validation processes. Lastly, we performed checks
of the data for consistency and completeness. Based on these steps, we
determined that the data for CDC annual and ARPA supplemental awards
included in our review were sufficiently reliable for our reporting purposes.
We also reviewed documents, such as CDC funding announcements and
agency guidance, to determine allowable uses of the funding and other
funding requirements, such as the allowable time periods to use the
funding.
To examine challenges with building and maintaining infrastructure, we
reviewed documentation from and interviewed a nongeneralizable sample
of officials from 12 jurisdictions and 10 stakeholder groups:
12 jurisdictions. We selected four states, six localities, and two
territories to obtain variation in the following characteristics: health
department governance structure (i.e., the relationship between state
health agencies and local health departments), source of funding for
localities (state vs. directly from CDC), and percent of rural population, as
calculated by the U.S. Census Bureau. We selected and interviewed
health department officials for the following 12 jurisdictions: California;
Maine; Maryland; South Carolina; Los Angeles County, Calif.; San
Bernardino, Calif.; San Francisco, Calif.; Portland, Maine; Baltimore, Md.;
Garrett County, Md.; Puerto Rico; and the U.S. Virgin Islands.9 To
characterize jurisdictions’ views throughout this report, we defined
modifiers to quantify jurisdictions’ views. For the purposes of this report,
“nearly all” represents nine to 11 jurisdictions, “many” represents six to
eight jurisdictions, and “some” represents three to five jurisdictions.
10 stakeholder groups. We selected four stakeholder groups that
represent all state, local, or territorial health departments or laboratories;
one stakeholder group that represents public health professionals; three
think tanks that study public health and preparedness and produced
related reports; one group of academic researchers; and CDC’s main
9We also interviewed officials from Penquis-District 6 in Maine; we counted these
responses as responses from the state because decisions are made at the state level and
officials report to the state. We did not interview officials from localities in South Carolina,
Puerto Rico, and the U.S. Virgin Islands as these jurisdictions do not have separate local
health departments.
Page 4 GAO-24-105891 Public Health Preparedness
Letter
philanthropic partner organization.10 To characterize stakeholder groups’
views throughout the report, we defined modifiers to quantify their views.
For the purposes of this report, “nearly all” represents seven to nine
groups, “many” represents five to six groups, and “some” represents three
to four groups. We have also drawn on reports recently published by
several of the stakeholder groups that we interviewed. In doing so, we
took account of their methodological strengths and limitations.
To help ensure the accuracy of the facts and statements presented from
our interviews, we provided relevant excerpts of the draft report to the
jurisdictions and stakeholder groups we interviewed. We incorporated, as
appropriate, their technical comments. The views of the jurisdictions and
stakeholder groups interviewed are not generalizable beyond those
entities.
We also reviewed CDC documentation and interviewed agency officials to
identify steps CDC has taken to support jurisdictions’ building and
maintenance of infrastructure. We assessed CDC’s steps against CDC’s
goals and priorities to develop and strengthen jurisdictions’ public health
capabilities, including those related to preparedness and response.
We conducted this performance audit from March 2022 to November
2023 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
Background
CDC supports jurisdictions’ public health infrastructure for preparedness
activities by providing annual awards through two key preparedness and
10We interviewed representatives from the following stakeholder groups: Association of
State and Territorial Health Officials, National Association of County and City Health
Officials, Association of Public Health Laboratories, Council of State and Territorial
Epidemiologists, American Public Health Association, Trust for America’s Health,
Commonwealth Fund, de Beaumont Foundation, Columbia University Mailman School of
Public Health researchers, and the CDC Foundation. The CDC Foundation is an
independent, private nonprofit corporation established under the Public Health Service Act
to support and carry out activities for the prevention and control of diseases, disorders,
injuries, and disabilities, and for the promotion of public health. See 42 U.S.C. § 280e-11.
Page 5 GAO-24-105891 Public Health Preparedness
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capacity-building programs: (1) Epidemiology and Laboratory Capacity for
Prevention and Control of Emerging Infectious Diseases (ELC) and (2)
Public Health Emergency Preparedness (PHEP) cooperative agreements,
as shown in table 1.11 Preparedness activities are intended to build
capabilities that are critical to be able to effectively respond to a public
health threat or emergency.
Table 1: CDC Annual Awards to States, Localities, and Territories for Public Health Infrastructure
Jurisdictions funded as Examples of allowable
Program Purpose of fiscal year 2022 uses
Epidemiology Supports prevention and control of infectious diseases. 64 (50 states, 6 localities, Staff salaries, laboratory
and Laboratory Funding is generally either (1) cross-cutting funding that 8 U.S. territories and operations, purchase
Capacity for can be used for a range of needs related to epidemiology, freely associated states) equipment and supplies
Prevention and laboratory, and health information systems, leadership, and
Control of management, or (2) funding that must be used for specific
Emerging diseases, such as influenza and vector-borne diseases
Infectious (e.g., West Nile virus, which is transmitted by mosquitoes).
Diseases
Public Health Supports preparedness for “all-hazard” public health 62 (50 states, 4 localities, Staff salaries,
Emergency threats, including infectious diseases, extreme weather 8 U.S. territories and maintenance of
Preparedness events, or terrorist threats. freely associated states) preparedness plans,
training exercises,
purchase equipment and
supplies
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) documentation. | GAO-24-105891
Notes: The Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious
Diseases program funds the following six localities: Chicago, Ill.; Houston, Tex.; Los Angeles County,
Calif.; New York City, N.Y.; Philadelphia, Pa.; and Washington, D.C.
The Public Health Emergency Preparedness program funds the following four localities: Chicago, Ill.;
Los Angeles County, Calif.; New York City, N.Y.; and Washington, D.C.
The eight territories and freely associated states include American Samoa, Federated States of
Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and the U.S.
Virgin Islands.
ELC. ELC was established in 1995 with a goal of supporting capacity
building to combat domestic infectious disease threats. According to
CDC, jurisdictions’ health departments receive awards through ELC to
detect, prevent, and respond to the emerging threats posed by infectious
diseases.12 These awards support three core areas: (1) surveillance,
detection, and response; (2) prevention and intervention; and (3)
11These two programs are cooperative agreements. A cooperative agreement is a federal
award to a non-federal entity to carry out a public purpose. Unlike grants, cooperative
agreements generally provide for substantial involvement between the federal awarding
agency and the non-federal entity in carrying out the activity contemplated by the award.
12For more information, see https://www.cdc.gov/elc/elc-overview.html, accessed July 6,
2023.
Page 6 GAO-24-105891 Public Health Preparedness
Letter
communications, coordination, and partnerships. Amounts awarded to
jurisdictions’ health departments vary depending on the amounts that the
jurisdictions request and availability of funding, among other factors. ELC
is made up of different programs and projects, such as for influenza,
congenital syphilis, and vector-borne diseases. Jurisdictions can apply for
funding from all or some of the programs and projects based on the
needs of the jurisdiction. ELC does not include a requirement for
jurisdictions to match a percentage of funding provided by the federal
government, though CDC strongly encourages jurisdictions to leverage
other resources to promote sustainability.
PHEP. PHEP was established in 2002, in the aftermath of 9/11, when the
need for a public health emergency infrastructure became apparent,
according to CDC.13 The goal of the program is to prepare the nation for
all public health threats, including infectious diseases, extreme weather
events, or terrorist threats. Awards provided to jurisdictions’ health
departments through PHEP include three components: (1) base funding
adjusted to account for the population of the recipient jurisdiction, (2)
funding that supports chemical laboratories, and (3) Cities Readiness
Initiative funding that supports preparedness in the nation’s largest
localities—at least one in each state.14 Jurisdictions apply for PHEP
funding. PHEP award amounts are determined based on a formula and
include a 10 percent matching requirement; that is, for every $10 received
in federal funds, the recipient jurisdiction must make $1 available for the
same purpose, with a few exceptions.15
In addition to PHEP and ELC, CDC also supports jurisdictions’
infrastructure by
· awarding funds through the Preventive Health and Health Services
Block Grant Program, which allows recipients to address their own
13For more information, see https://www.cdc.gov/orr/readiness/public_health_adapts.htm,
accessed July 6, 2023.
14Through the Cities Readiness Initiative, CDC provides awards to support all-hazards
medical countermeasure distribution and dispensing planning and response capabilities.
CDC provided awards to 21 cities through the Cities Readiness Initiative in 2004, when
the initiative began, and has since expanded the program to provide awards to 72
localities.
15These matching requirements do not apply to Chicago, Los Angeles County, or
Washington, D.C. Additionally, any matching requirement of less than $200,000 is waived
for American Samoa, Guam, U.S. Virgin Islands, and Northern Mariana Islands.
Page 7 GAO-24-105891 Public Health Preparedness
Letter
unique public health needs and challenges, one of which could be
supporting infrastructure to prepare for public health threats; and
· embedding CDC staff into jurisdictions’ health departments, among
other efforts.
See appendix I for more information on the Preventive Health and Health
Services Block Grant Program, including jurisdictions that reported using
it for public health infrastructure, as well as other CDC efforts.
Jurisdictions Received about $845 Million
Annually, Plus $7.1 Billion in Response to the
COVID19 Pandemic, for Public Health
Infrastructure
Public Health Infrastructure Awards to Jurisdictions from
Annual Appropriations Remained Fairly Constant at about
$845 Million from Fiscal Year 2019 through 2022
CDC’s award amounts to jurisdictions from annual appropriations for
infrastructure to prepare for public health threats has remained about the
same in recent years. Specifically, CDC’s award amounts to jurisdictions
through PHEP and ELC from annual appropriations have been about
$845 million per year on average from fiscal year 2019 through 2022 (see
fig. 1).16 During that time, PHEP award amounts rose modestly and ELC
award amounts decreased somewhat.
16CDC has also used PHEP and ELC as mechanisms to make awards to jurisdictions
using supplemental appropriations to respond to specific infectious disease threats. For
example, PHEP has been used to provide awards to jurisdictions to help respond to the
Zika outbreak, Ebola, and H1N1 influenza pandemic, and ELC has been used in this
manner to respond to the COVID-19 pandemic, the Zika outbreak, Ebola, and other
events, such as hurricanes.
Page 8 GAO-24-105891 Public Health Preparedness
Letter
Figure 1: CDC Awards to Jurisdictions for Infrastructure for Public Health Threats
from Annual Appropriations, Fiscal Years 2019-2022
Page 9 GAO-24-105891 Public Health Preparedness
Letter
Accessible data table for Figure 1: CDC Awards to Jurisdictions for Infrastructure
for Public Health Threats from Annual Appropriations, Fiscal Years 2019-2022
Public Health Epidemiology and Epidemiology and
Emergency Laboratory Capacity Laboratory Capacity
Preparedness award for Prevention and for Prevention and
amounts Control of Emerging Control of Emerging
Supports Infectious Diseases Infectious Diseases
preparedness for disease-specific cross-cutting award
“all hazard” public award amounts amounts
health threats, Supports prevention Supports prevention
including infectious and control of and control of
diseases, extreme specific infectious infectious diseases
weather events, or diseases, such as generally
terrorist threats influenza and
vector-borne
diseases
2019 622.858 142.828 77.689
2020 622.85 145.476 85.339
2021 637.85 141.222 54.368
2022 651.789 147.323 49.707
Source: GAO analysis of CDC data. | GAO-24-105891
Note: CDC also has used the Public Health Emergency Preparedness (PHEP) and Epidemiology and
Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) programs to
make awards to jurisdictions using supplemental appropriations to respond to specific infectious
disease threats. For example, PHEP has been used to provide awards to jurisdictions to help respond
to the Zika outbreak, Ebola, and the H1N1 influenza pandemic, and ELC has been used in this
manner to respond to the COVID-19 pandemic, the Zika outbreak, Ebola, and other events, such as
hurricanes. This figure does not include awards made from supplemental appropriations. It is specific
to awards CDC provided to jurisdictions through PHEP and ELC from annual appropriations. Award
amounts are rounded and presented in nominal dollars; that is, amounts have not been adjusted for
inflation.
a
Award amounts for fiscal years 2019 and 2020 do not add to total due to rounding.
Awards provided through PHEP from annual appropriations. PHEP
accounted for 75 percent of CDC annual preparedness award amounts to
jurisdictions in the period of our review, ranging from about $623 million to
$652 million annually. PHEP award amounts to jurisdictions generally
remained the same from fiscal years 2011 to 2020, with modest increases
in both fiscal years 2021 and 2022.17 In those 2 years, CDC provided
increased funding for the Cities Readiness Initiative portion of the PHEP
program to support preparedness in the nation’s largest localities.
17We previously reported that annual awards provided through PHEP had decreased
since fiscal year 2002, from more than $900 million, and remained relatively stable from
fiscal year 2011 to 2017, when awards largely ranged from about $610 million to about
$620 million. See GAO-18-362.
Page 10 GAO-24-105891 Public Health Preparedness
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Disease-Specific Epidemiology and
Laboratory Capacity for Prevention and
Control of Emerging Infectious Diseases
(ELC) Awards
Funding for the ELC program comes from
many different centers within the Centers for
Disease Control and Prevention (CDC) as part
of the annual appropriations process,
according to CDC officials. Many of these
funds were appropriated for specific infectious
diseases. Therefore, jurisdictions may be
limited in their use of these awards to activities
related to specific disease types, such as
influenza or vector-borne diseases, depending
on the particular appropriation used to fund
the award.
Source: GAO summary of CDC information (information);
Dr_Microbe/stock.adobe.com (photo). | GAO-24-105891
Awards provided through ELC from annual appropriations. ELC
accounted for the remainder of CDC annual preparedness award
amounts to jurisdictions, ranging from about $195 million to $230 million
annually. ELC funding can be broken into two components: (1) disease-
specific and (2) cross-cutting—that is, funding that is not tied to a
particular disease.
Most of the awards that jurisdictions received through ELC were disease-
specific, ranging from 63 to 75 percent of the award amounts each year.
The ELC disease-specific awards are divided into separate amounts that
must be used for a wide range of targeted purposes (see fig. 2). None of
these awards can be used for general, cross-cutting preparedness efforts.
For example, ELC awarded funds for influenza cannot be used to hire
staff for disease-agnostic preparedness activities.
Page 11 GAO-24-105891 Public Health Preparedness
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Figure 2: CDC Awards to Jurisdictions through the ELC Program from Annual
Appropriations, FY 2022
Accessible text of Figure 2: CDC Awards to Jurisdictions through the ELC Program
from Annual Appropriations, FY 2022
ELC disease-specific ELC cross-cutting award 2022
award amounts amounts
Supports prevention and Supports prevention and
control of specific control of infectious
infectious diseases diseases generally
147 50 $197 dollars (in millions)
Jurisdictions received ELC disease-specific awards in separate
amounts that had to be used for the following specific purposes:
5 categories accounted for about $126 million:
· Health care-associated infections and antibiotic resistance
· Foodborne, waterborne, enteric, and environmentally transmitted
diseases
Page 12 GAO-24-105891 Public Health Preparedness
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· Vector-borne diseases (such as West Nile virus and Lyme disease)
· Vaccine-preventable diseases
· Influenza
Other categories accounted for the remainder:
· Non-influenza respiratory diseases
· Legionnaires’ disease
· Parasitic diseases
· Fungal infections
· Congenital syphilis
· Rabies
· Human papillomavirus
· Prion diseases
· Infants with congenital exposure to emerging infectious diseases and
other health threats
· Binational Border Infectious Disease Surveillance program
· Antibiotic-resistant gonorrhea
· • Global migration, border interventions, and migrant health
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) Epidemiology and Laboratory Capacity for Prevention and
Control of Emerging Infectious Diseases (ELC) information (information); GAO (icons). | GAO-24-105891
While disease-specific award amounts largely remained stable from fiscal
year 2019 through 2022, amounts for the cross-cutting portion of the ELC
program decreased in fiscal years 2021 and 2022. ELC award amounts
from annual appropriations will vary from year to year due to CDC
appropriations and new initiatives, jurisdictions’ funding requests, and
other factors, according to CDC.18 For example, in fiscal year 2020, CDC
provided nearly $23 million in cross-cutting awards through ELC as part
of the agency’s efforts to modernize public health data. In fiscal years
18ELC award amounts also vary based on whether jurisdictions are able to fully utilize
prior-year funds, according to CDC officials. For example, in fiscal year 2018, ELC award
amounts from annual appropriations were $160 million, substantially less than 2019 ELC
award amounts, as jurisdictions were allowed to use unexpended funds from the year
before.
Page 13 GAO-24-105891 Public Health Preparedness
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2021 and 2022, ELC award amounts were about $200 million each year,
similar to annual ELC award amounts in fiscal years 2016 and 2017.19
Officials we spoke with from selected jurisdictions reported using awards
through PHEP and ELC from annual appropriations for staff salaries,
purchasing supplies, training, and other infrastructure building and
maintenance purposes (see table 2).
Table 2: Selected Jurisdictions’ Reported Uses of CDC Awards for Infrastructure for Public Health Threats from Annual
Appropriations
Program Examples of uses for infrastructure according to jurisdiction officials
Public Health California. The state used 30 percent of its PHEP award amount for purposes such as helping to support the state’s
Emergency emergency operations center; 19 public health laboratories, including a disease surveillance system and several staff
Preparedness working on preparedness; and staff training on state hazard mitigation. The state distributed the remaining 70
(PHEP) percent of its PHEP award amount each year to local public health departments for preparedness efforts within their
jurisdiction. California was awarded about $44.4 million through PHEP in fiscal year 2022.
Maine. Awards through PHEP helped support the state’s public health laboratory, including laboratory staff, supplies,
and equipment. PHEP awards also supported state epidemiology staff and surveillance systems. The awarded funds
were also used to maintain the state’s warehouse space for receiving, staging, and storing emergency response
supplies. Maine was awarded about $5.5 million through PHEP in fiscal year 2022.
San Bernardino County (California). Awards through PHEP—allocated by the state—fully funded the salaries of all
but one of the public health preparedness and response program staff. The awarded funds also helped fund training,
medical and laboratory supplies, and other items. County officials reported receiving about $2.3 million of PHEP
funding awarded to the state in fiscal year 2022.
Epidemiology Maryland. Awards through ELC helped fund staff—such as epidemiologists who investigate outbreaks—laboratory
and Laboratory equipment, and health information technology for surveillance. Maryland was awarded about $5.1 million through
Capacity for ELC in fiscal year 2022.
Prevention and Los Angeles County (California). Awards through ELC helped support the county’s public health laboratory,
Control of including to fund several staff, purchase testing supplies, and maintain equipment. The awarded funds were also
Emerging used to support core data systems, detect and manage vector-borne disease and food-borne illness outbreaks, and
Infectious other efforts. The county was awarded about $3.8 million through ELC in fiscal year 2022.
Diseases
(ELC) U.S. Virgin Islands. Awards through ELC fully funded the salaries of the epidemiology staff and public health
laboratory staff. The awarded funds were also used for a database that supports reporting cases of infectious
diseases and for laboratory equipment and supplies. The territory was awarded about $1.2 million through ELC in
fiscal year 2022.
Source: GAO analysis of information from Centers for Disease Control and Prevention (CDC) and interviews with selected jurisdictions. | GAO-24-105891
Note: CDC also has used the PHEP and ELC programs to make awards to jurisdictions using
supplemental appropriations to respond to specific infectious disease threats. For example, PHEP
has been used to provide awards to jurisdictions to help respond to the Zika outbreak, Ebola, and the
H1N1 pandemic, and ELC has been used in this manner to respond to the COVID-19 pandemic, the
Zika outbreak, Ebola, and other events, such as hurricanes. This table does not include information
on use of awards made from supplemental appropriations. It is specific to awards CDC provided to
jurisdictions through PHEP and ELC from annual appropriations.
19We previously reported that ELC award amounts to jurisdictions from annual
appropriations had increased since fiscal year 2002, from about $100 million that year,
and were about $200 million in fiscal years 2016 and 2017. See GAO-18-362.
Page 14 GAO-24-105891 Public Health Preparedness
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See appendix II for awards to jurisdictions through PHEP and ELC from
fiscal year 2019 through fiscal year 2022 using annual appropriations.
See appendix III for profiles on each of the 12 selected jurisdictions,
including additional examples of how these jurisdictions have used
awards to build or maintain infrastructure.
Awards to Jurisdictions Totaled About $7.1 Billion from
Most Recent COVID19 Supplemental Appropriation
In light of the severity of the global COVID-19 pandemic, CDC provided
jurisdictions with about $7.1 billion in awards using ARPA supplemental
appropriations (the most recently enacted COVID-19 relief law) in fiscal
years 2021 through 2023 to build and maintain infrastructure. Of this
amount, CDC awarded about $3 billion that was largely to be used in the
short term. CDC provided an additional $4.1 billion—that jurisdictions can
use over 4 or 5 years—to support longer-term investment in needed
infrastructure.
Coronavirus State and Local Fiscal
Recovery Funds
The American Rescue Plan Act of 2021 also
established the Coronavirus State and Local
Fiscal Recovery Funds, administered by the
Department of the Treasury. The Coronavirus
State and Local Fiscal Recovery Funds
provided billions of dollars to jurisdictions to
help them recover from the fiscal effects of the
COVID-19 pandemic. Jurisdictions had broad
discretion in using the funding and could use
it to build public health infrastructure.
For example, South Carolina officials said
they were using these funds to build a new
public health laboratory that will better meet
their needs than the current laboratory.
For information on jurisdictions’ use of this
funding, see GAO, COVID-19: Current and
Future Federal Preparedness Requires Fixes
to Improve Health Data and Address Improper
Payments, GAO-22-105397 (Washington,
D.C.: Apr. 27, 2022)
Source: GAO analysis of federal and state information. |
GAO-24-105891
Short-term awards. Through a number of awards in fiscal years 2021
and 2022, CDC provided a total of about $3 billion to jurisdictions from
ARPA supplemental appropriations to help build their laboratory
Page 15 GAO-24-105891 Public Health Preparedness
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infrastructure and workforce capacity.20 (See appendix IV for more
information on the specific awards provided.) All of the awarded funding
was provided to jurisdictions as short-term (2- to 3-year) funding
specifically to respond to the COVID-19 pandemic, though some new
infrastructure could be used beyond the COVID-19 pandemic.
Jurisdictions reported using the awarded funding in a range of ways:
· Laboratory infrastructure. Public health laboratories were essential
to respond to a needed surge in testing during the COVID-19
pandemic. Maine used its awarded funds to expand its public health
laboratory capacity by purchasing equipment that has allowed staff to
conduct additional and more precise analyses of the genomic
sequences of viruses and other pathogens, according to officials.21
Los Angeles County is using its awarded funds to remodel and
expand its public health laboratory, officials said. Planned changes
include added space for molecular testing, supplies, and shipping
specimens. Officials said the changes will expand the county’s ability
to manage specimens during emergencies and boost their ability to
send testing supplies to partners and samples to CDC for testing.
They also noted that the expanded space will be permanent, but they
are looking for future funding to be able to retain new staff.
· Workforce. Maryland used its awarded funds from ARPA
supplemental appropriations to staff a critical care coordination center
with physicians and other public health workers, officials said. These
staff monitored the availability of critical care resources throughout the
state and helped hospitals match COVID-19 patients with available
resources, such as beds available in intensive care units. The center
remains in place and staff address critical care needs beyond those
related to COVID-19. For example, they help physicians identify
available hospital beds when patient transfers are necessary. Puerto
Rico used its awarded funds to hire regional coordinators to help
reach vulnerable communities and hard-to-reach populations,
20We focused on awards from ARPA supplemental appropriations that were provided to
jurisdictions’ health departments to build and maintain their infrastructure. We did not
focus on certain awards from ARPA supplemental appropriations that CDC provided to
jurisdictions for other entities’ use, such as $10 billion to support reopening schools; and
$1.3 billion to address COVID-19 in specific congregate settings, such as nursing homes
and jails.
21Genomic sequencing is a process scientists use to decipher the genetic material found
in an organism or virus, according to CDC.
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according to officials.22 We previously reported on the medical and
public health care needs during Hurricane Maria in Puerto Rico.
These included caring for the elderly, chronically ill, and people with
disabilities in isolated areas.23
Longer-term awards. In 2021, CDC also began using ARPA
supplemental funding to make awards that could be available for
jurisdictions’ use in the longer term. CDC first provided this longer-term
funding through its Disease Intervention Specialists Workforce
Development award in June 2021, and again in fiscal years 2022 and
2023, for a total of $600 million. Subsequently, CDC awarded about $3.5
billion in November 2022 and May 2023 through a newly created
infrastructure Strengthening U.S. Public Health Infrastructure, Workforce,
and Data Systems grant.
22For additional information on states’ uses of COVID-19 workforce funds, see GAO,
COVID-19: HHS Funds Allocated to Support Disproportionately Affected Communities,
GAO-23-105500 (Washington, D.C.: Jan. 24, 2023).
23For more information, see GAO, Disaster Response: HHS Should Address Deficiencies
Highlighted by Recent Hurricanes in the U.S. Virgin Islands and Puerto Rico, GAO-19-592
(Washington, D.C.: Sept. 20, 2019) and Disaster Assistance: FEMA Action Needed to
Better Support Individuals Who Are Older or Have Disabilities, GAO-19-318 (Washington,
D.C.: May 14, 2019).
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Funding to Improve Data Systems
According to the Centers for Disease Control
and Prevention (CDC), the COVID-19
pandemic has underscored the need for a
high-speed, modernized public health data
infrastructure. CDC has previously awarded
funds to jurisdictions for data modernization,
and awarded additional funds for data
systems through its new 5-year infrastructure
grant.
Many selected jurisdiction officials and
stakeholder groups commented on the
funding needed to improve jurisdictions’ data
systems. For example, officials from one
jurisdiction said they planned to use funding
from CDC’s new infrastructure grant to hire
several information technology staff, but that
the funding amount is small given expensive
data system investments.
For more information on public health data,
see GAO, COVID-19: Current and Future
Federal Preparedness Requires Fixes to
Improve Health Data and Address Improper
Payments, GAO-22-105397 (Washington,
D.C.: Apr. 27, 2022).
Source: GAO summary of CDC, jurisdiction, and stakeholder
information. | GAO-24-105891
The Strengthening U.S. Public Health Infrastructure, Workforce, and Data
Systems grant was intended to help meet short-term critical infrastructure
needs, as well as to fund investments to benefit jurisdictions in the longer
term. For example, awarded funds could be used to recruit and retain
epidemiologists, laboratory scientists, data analysts, and other staff. CDC
awarded $3 billion in November 2022 for jurisdictions’ public health
workforce.24 Additionally, CDC awarded $505 million through this award in
24In addition to the $3 billion from ARPA supplemental appropriations, CDC also awarded
$140 million through this grant from its fiscal year 2022 annual appropriation for
foundational capabilities activities—including surveillance, emergency preparedness, and
other key elements of public health. In fiscal year 2022, CDC received $200 million
through a new specific line item in its appropriation for public health infrastructure and
capacity. See Consolidated Appropriations Act, 2022, Pub. L. No. 117-103, div. H, tit. II,
136 Stat. 49, 448. CDC received $350 million for this line item in fiscal year 2023 and
requested $600 million in its congressional budget justification for fiscal year 2024. See
Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, div. H, tit. II, 136 Stat. 4459,
4860 (2022). According to CDC, this funding will be used to support jurisdictions’ public
health infrastructure.
CDC also awarded funding through the Strengthening U.S. Public Health Infrastructure,
Workforce, and Data Systems grant to three national partners to support the work of the
107 jurisdictions, such as by providing training and technical assistance. The funding for
these partners is not included in this report.
Page 18 GAO-24-105891 Public Health Preparedness
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May 2023 for core data modernization activities and for laboratory data
exchange activities.25 (See app. IV for funds awarded by jurisdiction
through this grant.)
According to CDC, this grant is intended to reflect a move toward more
flexible, cross-cutting funding to jurisdictions with hopes that jurisdictions
can use the awarded funds to make strategic investments that will have
lasting effects.
· Jurisdictions have more time to use CDC’s new infrastructure
grant. CDC’s new infrastructure grant has a 5-year period for
jurisdictions to use the awarded funds, rather than CDC’s 2- to 3-year
time period for previous awards from ARPA supplemental
appropriations. This can allow jurisdictions to support a preparedness
workforce ready to respond to future threats for a longer-term, for
example.
· Jurisdictions can use CDC’s new infrastructure grant for broad,
disease-agnostic purposes. This award funding is broader than the
initial awards CDC made using ARPA supplemental appropriations, in
part because it is explicitly focused on building infrastructure beyond
that needed to respond to the COVID-19 pandemic. The intent of
these awards is to strengthen infrastructure related to workforce, data,
and other areas for a cross-cutting range of infrastructure needs,
including preparedness for all types of public health emergencies.
· More jurisdictions were directly awarded grant funds. In addition
to all 50 states and eight territories and freely associated states, CDC
awarded grant funds directly to far more localities—49 cities and
counties in total—than it did with prior awards from annual
appropriations (PHEP and ELC) and initial awards to jurisdictions from
ARPA supplemental appropriations, which were often awarded to
25In addition to the $505 million from ARPA supplemental appropriations awarded for data
modernization, CDC also awarded $40 million for data modernization through this grant
from its appropriation for fiscal year 2023.
Page 19 GAO-24-105891 Public Health Preparedness
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seven or fewer localities.26 CDC officials said they did so in order to
support the “next level of infrastructure in the U.S. public health
system” (large cities and counties)—and to broaden the base of the
nation’s public health infrastructure.
Jurisdictional officials we spoke with planned to use this new grant for a
range of infrastructure needs, some of which would continue efforts that
began in response to the COVID-19 pandemic. For example, Maryland
officials plan to use the grant funds to invest in workforce training and
development to improve recruitment and retention. Puerto Rico officials
plan to expand COVID-19 surveillance efforts to include other infectious
diseases.
See appendix III for additional examples of jurisdictions’ use, and planned
use, of awards made with ARPA supplemental appropriations.
Challenges Selected Jurisdictions and
Stakeholders Identified to Building and
Maintaining Public Health Infrastructure
Officials from the 12 selected jurisdictions and 10 stakeholder groups we
interviewed identified several challenges to building and maintaining
infrastructure to be sufficiently prepared for future public health threats.27
These challenges can be grouped into two areas: (1) how infrastructure is
26CDC’s November 2022 awards went to 107 jurisdictions (50 states, eight U.S. territories
and freely associated states, and 49 cities and counties) for workforce and foundational
capabilities. States, territories, and freely associated states were eligible to apply for the
November 2022 awards, as were local health departments serving a county with a
population of 2 million or more, or a city with a population of 400,000 or more. CDC’s May
2023 awards for data modernization went to 64 jurisdictions (50 states, six localities,
including Washington, D.C., and eight U.S. territories and freely associated states); only
the jurisdictions that previously received Epidemiology and Laboratory Capacity for
Prevention and Control of Emerging Infectious Diseases supplemental awards for data
modernization were eligible to apply for those funds. For all of these awards, amounts
were based on population size and a U.S. Census Bureau measure of how at risk
neighborhoods are to the impact of disasters, including the COVID-19 pandemic.
27To characterize jurisdictions’ views throughout this report, we defined modifiers to
quantify jurisdictions’ views. For the purposes of this report, “nearly all” represents nine to
11 jurisdictions, “many” represents six to eight jurisdictions, and “some” represents three
to five jurisdictions. To characterize stakeholder groups’ views throughout the report, we
defined modifiers to quantify their views. For the purposes of this report, “nearly all”
represents seven to nine groups, “many” represents five to six groups, and “some”
represents three to four groups.
Page 20 GAO-24-105891 Public Health Preparedness
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funded, and (2) building a public health workforce. We have found that
CDC has taken actions to try to help mitigate these challenges, in
accordance with CDC’s goals and priorities to develop and strengthen
jurisdictions’ public health preparedness and response. The challenges,
and CDC’s related actions, are described in further detail below.
Challenges with Funding Infrastructure
Jurisdictions and stakeholder groups identified the following challenges
with regard to funding infrastructure necessary to prepare for and respond
to public health threats.
“Boom and bust” pattern of public health emergency funding.
Officials from nearly all selected jurisdictions and stakeholder groups
expressed concern about the pattern of an increase—or “boom”—in
federal funding to respond to a public health emergency, followed by a
decrease—or “bust”—once that emergency terminates and associated
funding runs out.28 More broadly, this pattern can make it hard for
jurisdictions to invest in long-term sustainable efforts to prepare for future
public health threats, officials from nearly all jurisdictions and stakeholder
groups noted. (See fig. 3.)
CDC officials also acknowledged that jurisdictions often have difficulty
maintaining infrastructure without a sustained and flexible funding source.
According to CDC, its new 5-year infrastructure grant is more flexible and
longer term. However, officials from some jurisdictions said they planned
to use the awarded funds to hire temporary staff rather than commit to
longer-term investments, due to the uncertainty around whether additional
funding will be available after the award is expended. According to CDC,
sustained public health infrastructure funding at all levels is needed to
ensure that health departments have resources to perform the essential
public health services and be ready to respond to emerging threats. CDC
plans to use a new specific line item in its annual appropriation for public
28For examples of supplemental appropriations to address past public health emergencies
and awards made using such appropriations, see GAO-18-362 and GAO, Zika
Supplemental Funding: Status of HHS Agencies’ Obligations, Disbursements, and the
Activities Funded, GAO-18-389 (Washington, D.C.: May 14, 2018).
Page 21 GAO-24-105891 Public Health Preparedness
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health infrastructure and capacity to support ongoing investment in
jurisdictions’ infrastructure.29
29In fiscal year 2022, CDC received $200 million through a new specific line item in its
appropriation for public health infrastructure and capacity. See Consolidated
Appropriations Act, 2022, Pub. L. No. 117-103, div. H, tit. II, 136 Stat. 49, 448. CDC
received $350 million for this line item in fiscal year 2023 and requested $600 million in its
congressional budget justification for fiscal year 2024. See Consolidated Appropriations
Act, 2023, Pub. L. No. 117-328, div. H, tit. II, 136 Stat. 4459, 4860 (2022).
Page 22 GAO-24-105891 Public Health Preparedness
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Figure 3: Selected Jurisdictions and Stakeholder Groups Identified “Boom and Bust” Pattern of Federal Public Health
Infrastructure Funding as a Challenge
Page 23 GAO-24-105891 Public Health Preparedness
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Accessible text of Figure 3: Selected Jurisdictions and Stakeholder Groups
Identified “Boom and Bust” Pattern of Federal Public Health Infrastructure Funding
as a Challenge
· “Boom”:
Jurisdictions receive awards from the Centers for Disease Control and
Prevention (CDC), made using supplemental appropriations, for
infrastructure to respond to a public health emergency
· “Boom and bust” pattern can make it hard to invest in long-term
sustainable efforts to prepare for threats
· “Bust”: Emergency federal funding is no longer available and
jurisdictions transition back to regular funding sources for
infrastructure, including CDC awards from annual appropriations
According to the Commonwealth Fund Commission on a National Public
Health System, “the “boom and bust” cycle of public health budgeting,
with surges in federal funding in response to emergencies followed by
budget retrenchments, makes it hard for state and local public health
agencies to invest in long term capacity building. While during the
pandemic period the federal government increased its support for public
health, this support represents a fiscal cliff. New hires become the
financial responsibility of local public health after funding sunsets. As a
result, state and local health officials are hesitating to invest in workforce
expansion.” /a/
Dr. Georges Benjamin, Executive Director of the American Public Health
Association, testified in June 2023 that “this yo-yo funding has to end,
where we put in a lot of money when something bad happens, often
comes a little late, not quite enough, and then we take it away too quickly,
and you can’t build a system like that.” /b /
Officials from nearly all of the 12 selected jurisdictions and
representatives from 10 stakeholder groups echoed these concerns.
Examples reported from selected jurisdictions on struggles to sustain, in
the long term, infrastructure built with federal awards from supplemental
appropriations include activities in the areas of community connections
and partnerships and surveillance and laboratory capacity.
Community connections and partnerships
· Funding expiration could mean the loss of ability to fund new public
health workers who have worked directly with local communities,
officials from one jurisdiction noted.
Page 24 GAO-24-105891 Public Health Preparedness
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· This jurisdiction increased its vaccination team during the COVID-19
pandemic from five to more than 100 staff using federal awards from
supplemental appropriations. This new team included ambassadors
who built trust between the health department and communities by
listening to residents’ concerns about the pandemic, providing
information about COVID-19, and helping residents navigate the
health care system.
· While this jurisdiction no longer needs this number of staff to help
specifically with COVID-19 vaccines, these new workers built
relationships with local communities and—if retained—could help
address other critical public health needs, such as helping residents
navigate a complex health care system, according to officials. Further,
losing these workers would require jurisdiction officials to train a new
group of workers when another threat arises, which takes time and is
not ideally done while also trying to respond, officials said.
· Further, the ebb and flow of federal funding erodes the trust of local
community groups who have partnered with jurisdictions during
various times of emergency, officials from the same jurisdiction said.
For example, officials from this jurisdiction said they may engage with
these community partners during an emergency response, when
awards from supplemental appropriations are available, but this
engagement may decrease if funding is not sustained during non-
emergency periods. This can lead to the community partners feeling
used and not as willing to help in the future.
Surveillance and laboratory capacity
· Officials from one jurisdiction said they used awards from
supplemental appropriations for the Zika outbreak to build up staff and
a mosquito surveillance program, but when that funding was no longer
available, they could not sustain that infrastructure. If the jurisdiction
has another mosquito-borne outbreak, it will need to rebuild the
infrastructure it had previously built for mosquito surveillance.
· One jurisdiction used awards from supplemental appropriations to
expand and improve its public health laboratory, but would need
longer-term funding to retain new laboratory staff and maintain new
equipment, according to officials from that jurisdiction.
Source: GAO analysis of information from 12 selected jurisdictions and 10 stakeholder groups (information); GAO and
iiierlok_xolms/stock.adobe.com (icons). | GAO-24-105891
a
The Commonwealth Fund Commission on a National Public Health System, Meeting America’s
Public Health Challenge: Recommendations for Building a National Public Health System That
Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust (June 2022).
b
Georges C. Benjamin, Executive Director, American Public Health Association, Looking Back Before
Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, testimony before House Energy
and Commerce Committee, Subcommittee on Oversight and Investigations, June 7, 2023.
Page 25 GAO-24-105891 Public Health Preparedness
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Additionally, certain unobligated funds appropriated by ARPA were
rescinded as part of the Fiscal Responsibility Act of 2023.30 This included
$400 million—$200 million per year for fiscal years 2024 and 2025—that
CDC would have provided to jurisdictions through its Disease Intervention
Specialists Workforce Development award, according to agency officials.
CDC awarded funds using ARPA supplemental appropriations through
this award in fiscal years 2021, 2022, and 2023 and planned to provide
additional awards to jurisdictions ($200 million annually) for a total of 5
years and $1 billion.
CDC officials explained that as a result of the rescission, jurisdictions will
stop hiring new staff and cancel other activities to retain current staff for
as long as possible. If jurisdictions are not able to retain staff through
alternative funding sources, this will reduce the number of staff ready to
address the next public health threat, according to CDC officials.
Officials from one jurisdiction made the decision to fill only a few of their
existing vacancies given the rescission. More than half of their positions
remain vacant, and most will not be filled, according to officials from this
jurisdiction. These officials said that the loss of this funding has
“eviscerated” the jurisdiction’s plan to have a highly competent cross-
trained outbreak response team.
Officials from another jurisdiction said they plan to use CDC’s new 5-year
infrastructure grant to cover the 2 years of award funds that were
rescinded. However, according to jurisdiction officials, using this grant to
cover the rescission impedes this jurisdiction’s ability to use those funds
to strengthen and provide more robust public health planning and
response for future public health threats and emergencies.
CDC award amounts from annual appropriations have supported
less as costs have increased. Officials from many jurisdictions told us
that they have been less able to rely on awards through PHEP and ELC
from annual appropriations to cover staff costs, as those costs have
increased while the award amounts have remained flat over the years,
unadjusted for inflation. Officials from one jurisdiction told us that the
jurisdiction used its award provided through PHEP to support 24 percent
of salaries of staff that work on preparedness for public health threats,
down from 33 percent of staff salaries covered by its award 5 years prior.
30See Pub. L. No. 118-5, div. B, tit. I, § 2(15), 137 Stat. 10, 24.
Page 26 GAO-24-105891 Public Health Preparedness
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Braiding: Combining Funds with Other
Funds
To cover staff costs, officials from nearly all
jurisdictions told us they often combine, or
braid, funds—including federal and state
funds—to fully support salaries of staff in
needed positions. This means these staff may
work on multiple programs at once; some
could be related to supporting the health
departments’ preparedness and response
activities, and others may not be.
Some jurisdictions and stakeholder groups
reported that the process of braiding multiple
funding sources to cover staff salaries is
administratively challenging for staff. For
example, it can require a lot of time, resources,
and coordination to track time spent on each
program for reporting purposes.
To braid funds to address public health needs
and maintain proper oversight of the funds,
jurisdictions must track each funding source to
ensure it complies with each program’s
requirements.
Source: GAO summary of information from interviews with
selected jurisdictions and stakeholder groups (information);
Eva Almqvist/stock.adobe.com (photo). | GAO-24-105891
To help manage such funding gaps, jurisdictions often combine funding
sources—known as braiding. For example, jurisdictional staff may work
on influenza surveillance activities 25 percent of their time (funded by
awards through ELC from annual appropriations) and work on other
activities (funded by other sources and perhaps not related to
preparedness) for the remaining portion.
If other funding sources are not available for the health departments,
preparedness activities may be scaled back. Such scaling back may
leave those impacted activities more vulnerable to threats. In response to
this concern, CDC officials stated that they support sustainable funding
for public health infrastructure. As noted previously, CDC plans to use a
new specific line item in its annual appropriation for public health
Page 27 GAO-24-105891 Public Health Preparedness
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infrastructure and capacity to support ongoing investment in jurisdictions’
infrastructure.
Disease-specific awards are of limited use for preparedness and
initial response to public health threats. Officials from some
stakeholder groups told us that disease-specific award funding is needed
and has led to benefits, including development of staff with expertise in a
disease. However, officials from many jurisdictions and nearly all
stakeholder groups said disease-specific award funding can limit flexibility
for preparedness and response. Representatives from one stakeholder
group noted that flexibility is critical for building cross-cutting capacity
needed to prepare for future emergencies. Specifically, disease-agnostic
funding that can be used flexibly and is sustained over time is needed to
both strengthen capacity for health departments between emergencies
and to scale up quickly during them. Officials from one jurisdiction said
they “do not have cross-cutting funding that is cohesive, substantial, and
sustainable” and that they use a “patchwork of funds to create” their
public health infrastructure.
Jurisdictions have a limited ability to use disease-specific awards
provided through ELC from annual appropriations for building or
maintaining baseline infrastructure. This is also the case for other
disease-specific awards they receive from CDC, such as awards to
address HIV/AIDS prevention, sexually transmitted disease control,
tuberculosis control, or chronic diseases in their communities.
During an initial response to a public health emergency, jurisdictions may,
with CDC and HHS approval, temporarily reassign certain staff.31
However, according to some jurisdiction officials, while reassignment may
be available, such reassignment can take away from ongoing public
31When the HHS Secretary has declared a public health emergency, states and Tribes
can seek HHS approval to temporarily reassign state, local, and tribal public health
department or agency personnel funded, in whole or in part, by certain federal programs,
such as CDC disease-specific programs. If approved, reassignment authorizations are
valid for no more than 30 days or until HHS determines that the public health emergency
no longer exists, whichever comes first. In cases in which a public health emergency lasts
longer than 30 days, the jurisdiction may request a personnel reassignment extension.
See 42 U.S.C. § 247d(e). See also GAO, Public Health Emergencies: HHS Needs to
Better Communicate Requirements and Revise Plans for Assessing Impact of Personnel
Reassignment, GAO-17-187 (Washington, D.C.: Jan. 9, 2017).
Also, for more information on federal funding available for an initial response to a public
health threat, see GAO, Public Health Preparedness: HHS Reserve Funding for
Emergencies, GAO-23-106102 (Washington, D.C.: Aug. 15, 2023).
Page 28 GAO-24-105891 Public Health Preparedness
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health work, leaving these public health issues unaddressed. For
example, reassigning staff for the COVID-19 response affected work on
sexually transmitted infections, according to officials from one jurisdiction.
Those officials stated that sexually transmitted infection cases in the
jurisdiction, including syphilis, had been increasing and the rise was
exacerbated by reassignment of these staff to the COVID-19 pandemic
response.
Jurisdictions may also redirect disease-specific funding to other activities
with CDC approval. However, officials from one jurisdiction said that they
were unable to redirect certain disease-specific awards—such as for
HIV/AIDS—to the initial mpox response because that funding had already
been exhausted.
According to CDC officials, disease-specific awards are intended to fund
programs for particular diseases.32 However, CDC officials also said that
disease-specific awards limit jurisdictions’ flexibility to address broader
infrastructure needs, infectious disease threats, and future needs as they
arise. CDC officials told us that the agency consistently receives requests
from jurisdictions for additional cross-cutting awards through ELC from
annual appropriations beyond what the agency can provide. According to
these officials, ELC cross-cutting funding offers important flexibility to
respond to infectious disease threats and support cross-cutting infectious
disease infrastructure needs, such as the workforce. For example, ELC
provides support for cross-cutting infectious disease positions, which
allows recipients to hire for positions that suit their needs, such as
regional epidemiologists that may be assigned to local health
departments. Positions supported with cross-cutting funds can also be
quickly redirected to support priorities or responses as the need arises.
Varying levels of jurisdictional funding for infrastructure.
Jurisdictions have the primary responsibility for preparation for and
response to public health threats and emergencies. They are key
preparedness and response partners with the federal government and the
first line of defense against threats. However, there is variation in the
amount of funding jurisdictions provide to health departments for public
32CDC reported that disease-specific awards to health departments—such as for
surveillance capacity for a particular disease—are meant to allow the departments to
detect changes or outbreaks that would otherwise go unnoticed if these awards were for
general public health activities. For example, CDC has seen accomplishments in
surveillance for fungal diseases; food safety, including foodborne or waterborne
pathogens activities; and antibiotic resistance as a result of disease-specific awards.
Page 29 GAO-24-105891 Public Health Preparedness
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health infrastructure, including for preparedness and response, according
to two stakeholder groups. As a result, the extent to which jurisdictions
may rely on CDC awards for building and maintaining infrastructure
varies. However, the degree to which this reliance occurs by jurisdiction is
unclear due to differences in measuring such information, according to
one stakeholder group.
Our interviews with officials from the 12 selected jurisdictions found
variation in the amount of funding jurisdictions dedicate to infrastructure.
For example, officials from one jurisdiction told us that the state had
recently appropriated new funding meant specifically to fill gaps in state
and local infrastructure, including to be better prepared for future public
health threats. Conversely, officials from another jurisdiction said that
their locality does not receive additional funding from the state for
infrastructure to prepare for and respond to public health threats.
One stakeholder group that tracks states’ reported changes in their public
health funding most recently found that at least 34 states reported that
their funding for public health was stable or had increased; but at least 13
states had reduced their funding from fiscal year 2021 to 2022.33
Separately, because there is no minimum set of standards that
jurisdictions have to meet for public health services, the preparedness
activities provided can vary by jurisdiction (see text box).
33This stakeholder group examined state-reported funding for public health generally,
which includes funding for infrastructure for emergency preparedness and response. The
stakeholder group also found that Washington, D.C. reported an increase in its funding for
public health during the time period. Three states did not provide public health funding
data for fiscal year 2022 and therefore could not be examined for the time period. See,
Trust for America’s Health, Ready or Not: Protecting the Public’s Health From Diseases,
Disasters, and Bioterrorism (March 2023).
Page 30 GAO-24-105891 Public Health Preparedness
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Standardization of public health services
No minimum standard has been set for public health capabilities, according to a recent report by the Commonwealth Fund, an
organization that supports independent research to promote high-performing and equitable health care.
As a result, how well a health department protects the population it serves from public health threats varies, according to the
report. For more information, see the Commonwealth Fund Commission on a National Public Health System, Meeting America’s
Public Health Challenge: Recommendations for Building a National Public Health System That Addresses Ongoing and Future
Health Crises, Advances Equity, and Earns Trust (June 2022).
The Centers for Disease Control and Prevention (CDC) does have a set of national standards to guide public health preparedness
planning. These are a set of 15 capability standards designed to advance the emergency preparedness and response capacity of
state and local public health systems, according to CDC documentation. Jurisdictions that receive awards through the Public
Health Emergency Preparedness program do not have to “meet” these standards to receive funding, but they are required to use
them as they plan, operationalize, and evaluate their ability to prepare for, respond to, and recover from public health
emergencies.
Accreditation is another method jurisdictions can use to provide more standardization of services. According to the Public Health
Accreditation Board, accreditation ensures the public that the jurisdiction has established core public health capabilities, and
accreditation could help advance performance more consistently across health departments. Accreditation is not a requirement to
receive award funding from CDC, but many jurisdictions we spoke with said they used the accreditation process as a tool to help
ensure they were meeting basic preparedness and broader public health needs and continually trying to improve.
Source: GAO summary of information from interviews with documentation from selected jurisdictions, stakeholder groups, and CDC. | GAO-24-105891
Challenges Building a Public Health Workforce
Officials from some jurisdictions we interviewed reported that the
temporary nature of awards from supplemental appropriations made it
challenging to quickly build a workforce to respond to the COVID-19
pandemic, as well as maintain that workforce to be prepared for future
public health threats. For example, officials from many jurisdictions noted
that the temporary nature of the awards provided led them to hire
primarily temporary staff. Officials from these jurisdictions noted hesitancy
to hire permanent positions without a signal that there will be sustainable
funding beyond the awards from ARPA supplemental appropriations—
even with the new 5-year infrastructure grant funding CDC provided. See
fig. 4 for these and additional challenges jurisdictions reported with regard
to building and maintaining a workforce with supplemental award funding.
Page 31 GAO-24-105891 Public Health Preparedness
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Figure 4: Selected Jurisdictions Identified Challenges to Building and Maintaining a Public Health Workforce with Awards
from COVID-19 Supplemental Appropriations
Accessible text for Figure 4: Selected Jurisdictions Identified Challenges to
Building and Maintaining a Public Health Workforce with Awards from COVID-19
Supplemental Appropriations
Hiring quickly was challenging.
Hiring quickly enough to maximize the 2-year time frames of some
awards from supplemental appropriations proved challenging, according
to many jurisdictions. Examples of challenges identified by one or more
jurisdictions include the following:
Page 32 GAO-24-105891 Public Health Preparedness
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· It took time to develop, post, receive applications, and interview for a
new staff position, time jurisdictions may not have when quickly
responding to an emergency. It could take 2 to 10 months, officials
from one jurisdiction noted, to create a new position from approval to
posting, even before recruitment and hiring began.
· Hiring positions in high demand during an emergency—such as
contact tracers, epidemiologists, case investigators, and other health
care professionals—required even more time for recruitment.
· Potential candidates may not have applied because they wanted to be
hired for permanent positions or may not have accepted positions
because they wanted higher salaries offered by other entities with less
limited funding.
· Jurisdictions had to go through the hiring cycle multiple times because
of the limited number of applications received.
· Jurisdictions may be required to obtain approval for new positions
from jurisdictional leadership—such as the governor or legislature—
which takes time.
· Jurisdictions needed to hire additional support staff—such as human
resources staff—to have the capacity to bring on other staff, including
response personnel.
Temporary hiring helped, but also created additional recruitment
and retention challenges.
To help address hiring needs, many jurisdictions reported using
temporary staffing measures, specifically contracting with the CDC
Foundation and others to bring temporary staff on more quickly.a One
jurisdiction told us it could take about 2 weeks to 1.5 months to hire
contract staff, compared with lengthier time frames to hire permanent
staff.
While these temporary positions provided relief, many jurisdictions also
reported challenges. Examples of challenges identified by one or more
jurisdictions include the following:
· Hiring contractors was costlier than permanent staff.
· Contract staff were typically paid higher salaries and therefore were
difficult to convert to permanent positions that generally offered lower
salaries. Officials from one jurisdiction noted that their permanent staff
felt undervalued as a result of salary inequities between them and
contract staff.
· Short-term contract staff concerned that jurisdictions will not continue
to fund their positions, sometimes began looking for other roles as
Page 33 GAO-24-105891 Public Health Preparedness
Letter
their contracts neared the end of the funding period. This exacerbated
existing staffing issues.
· New hires, including temporary hires, must be trained at a
considerable time and expense. Such investments by jurisdictions are
lost or seem imprudent if staff are not retained permanently.
Source: GAO analysis of information from interviews with 12 selected jurisdictions (information); inspiring.team/stock.adobe.com
(illustrations). | GAO-24-105891
a
The CDC Foundation is an independent, private nonprofit corporation established under the Public
Health Service Act to support and carry out activities for the prevention and control of diseases,
disorders, injuries, and disabilities, and for the promotion of public health. See 42 U.S.C. § 280e-11.
During the COVID-19 pandemic, the CDC Foundation—with financial support from CDC and some
private donors—hired about 4,000 public health professionals to support state, local, territorial, and
tribal health departments, the Foundation reported.
Beyond these workforce challenges, jurisdictions have experienced (and
we have previously reported on) other challenges to managing awards
from supplemental appropriations during emergencies, such as managing
and tracking a large influx of funding. See appendix V for more
information, including challenges identified in prior GAO work.
Separately, officials and representatives from many jurisdictions and
stakeholder groups reported concerns with the availability of a sufficient
public health workforce to be prepared for future threats, due to burnout
and other factors. (See fig. 5.)
Page 34 GAO-24-105891 Public Health Preparedness
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Figure 5: Selected Jurisdictions and Stakeholder Groups Identified Public Health Workforce Challenges
Accessible text for Figure 5: Selected Jurisdictions and Stakeholder Groups
Identified Public Health Workforce Challenges
Public health staff in high demand; can be hard to compete with
other employers
· Public health staff—such as nurses, microbiologists, and information
technology experts—are in high demand, according to officials and
representatives from many jurisdictions and some stakeholder groups.
Challenges hiring for jurisdictions include:
· Difficulty competing with private sector salaries, according to officials
and representatives from some jurisdictions and stakeholder groups.
Page 35 GAO-24-105891 Public Health Preparedness
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· For example, nurses and others can earn more in hospitals and other
health care settings
· Officials from some jurisdictions stated that their rules do not allow
competitive salaries or incentives, including signing bonuses for in-
demand staff.
· Relatedly, some jurisdictions have not increased salaries in 20 years,
according to representatives from one stakeholder group.
Staff burn-out and attrition
· High workloads from the long-term response to the COVID-19
pandemic, have led to burnout, and in many cases attrition, in
preparedness and response staff, according to officials from nearly all
jurisdictions we spoke with.
· A recent peer-reviewed study estimated that nearly half of all
employees in a sample of 96 state and local public health agencies
left their jobs between 2017 and 2021.
· This included ¾ of employees age 35 or younger or with 5 or fewer
years of experience in 2017. Among those age 35 and younger
responding to the 2021 survey, top reasons for considering leaving
included pay, lack of opportunities for advancement, and work
overload and burnout.a
· Burnout from working long hours over many months contributed to
staff retirements during the COVID-19 pandemic, officials from some
jurisdictions said.
· Attrition is high in one jurisdiction’s communicable disease program as
staff are spread thin performing the work of four to five people each, in
addition to working overtime during the COVID-19 pandemic, officials
in one jurisdiction said.
· The lack of knowledge and expertise due to the time it takes to train
newly hired staff or the loss of critical health department employees,
was a concern cited by many jurisdictions and stakeholder groups.
Officials from one jurisdiction said that building expertise, including
filling positions for leadership roles, has been especially difficult for
their health department. Many newly hired staff are new to the field
and cannot easily replace the leadership that leaves.
Source: GAO analysis of information from 12 selected jurisdictions and 10 stakeholder groups (information);
iiierlok_xolms/stock.adobe.com (icons). | GAO-24-105891
a
See J. P. Leider, B. C. Castrucci et al., “The Exodus of State and Local Public Health Employees:
Separations Started Before and Continued Throughout COVID-19,” Health Affairs, vol. 42, no. 3
(March 2023). This study was based on data from the Public Health Workforce Interests and Needs
Survey (PH WINS), a national survey of state and local health department staff, as well as the staff
lists assembled to field the two surveys that were used to determine staff departures between 2017
Page 36 GAO-24-105891 Public Health Preparedness
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and 2021. The study’s analytic sample included 96 agencies (46 state health agencies, 25 big-city
health departments, and 25 local health departments) that participated in the PH WINS survey in both
2017 and 2021. The sample was not representative of all public health agencies, as it did not include
small agencies, as well as larger agencies that did not participate in both years. The study did not
capture the reasons why staff left their jobs between 2017 and 2021 or whether they left for another
government public health position, or specifically in 2021, were moved to a separate COVID-19
response division. The 2021 survey had a 35 percent response rate.
Recent studies have indicated that more staff are needed to create a
workforce to support public health in jurisdictions. (See text box.)
However, the challenges to building and supporting such a workforce are
complex. For example, according to one recent study of health
departments in five selected states, even if CDC or jurisdictions provide
additional funding in this area, the nation’s public health workforce
challenges will continue until public health is a more attractive career path
with higher pay, improved working conditions, and more training and
promotion opportunities.34 For examples of actions CDC has taken to try
to support the public health workforce, such as through awarding grants
to support the public health workforce, see appendix I.
Recent studies on the workforce needed to support overall public health
One stakeholder group’s 2021 study—supported in part In a different stakeholder group’s 2021 epidemiology
by CDC—estimated that states and localities would capacity assessment, state epidemiologists indicated
need to hire at least 80,000 full-time staff, almost an 80 they needed more than 6,300 epidemiologists at state
percent increase, to build adequate public health health departments nationwide—an almost 2,200
infrastructure and provide a minimum set of public increase from levels at the time of the survey—to
health services. A former CDC director has publicly provide basic public health services.b
acknowledged the findings of this study.a
Source: GAO analysis of stakeholder information. | GAO-24-105891
a
See de Beaumont Foundation, Staffing Up: Workforce Levels Needed to Provide Basic Public Health
Services for All Americans, October 2021. The 80,000 full-time equivalents were estimated to be
needed prior to the COVID-19 pandemic and therefore do not account for vacancies in this workforce
resulting from the pandemic. Staff positions include those for all-hazards, chronic disease and injury,
and communicable disease, among others. This estimate was based on data from three states and
170 local health departments in four states prior to the COVID-19 pandemic and does not represent
workforce needs in U.S. territories and freely associated states or Tribal Nations.
See also Rochelle Walensky, CDC Director, Preparing for and Responding to Future Public Health
Security Threats, testimony before the House Committee on Energy and Commerce, Subcommittee
on Health, May 11, 2023.
b
See Council of State and Territorial Epidemiologists, 2021 Epidemiology Capacity Assessment,
2021. This national survey of state and territorial epidemiologists found that state epidemiologists
from the 50 states and D.C. expressed a need for 2,196 more epidemiologists at state health
departments to provide basic public health services in all program areas, including preparedness.
Adding those positions would result in an ideal total of 6,331 epidemiologists—a 53 percent increase
over the 4,135 epidemiologists at the time of the survey. The survey was administered in all 50
34Michael S. Sparer and Lawrence D. Brown, “Politics and the Public Health Workforce:
Lessons Suggested from a Five-State Study,” The Milbank Quarterly, Vol. 0, No. 0 (2023):
1-26.
Page 37 GAO-24-105891 Public Health Preparedness
Letter
states, Washington, D.C., and the eight U.S. territories from January 2021 to April 2021, and obtained
a response rate of 100 percent from the 50 states and Washington, D.C.
Because jurisdictions are key partners in preparing for and responding to
public health threats, the infrastructure challenges they face can impact
how quickly and effectively CDC and other response partners are able to
contain these threats. This was acutely demonstrated during the COVID-
19 pandemic, when infrastructure became overwhelmed, helping the virus
to spread nationwide. According to CDC officials, increased and ongoing
investments in public health infrastructure is vital to the response to
contain threats on a national level.
Agency Comments
We provided a draft of this report to HHS and the Department of the
Treasury for review and comment. HHS provided technical comments,
which we incorporated as appropriate. Treasury did not have any
comments on the report.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, the Secretary
of the Treasury, and other interested parties. In addition, the report is
available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. GAO staff who made key
contributions to this report are listed in appendix VI.
Mary Denigan-Macauley
Director, Health Care
Page 38 GAO-24-105891 Public Health Preparedness
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List of Addressees
The Honorable Patty Murray
Chair
The Honorable Susan Collins
Vice Chair
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
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
Chair
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
Page 39 GAO-24-105891 Public Health Preparedness
Letter
The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable James Comer
Chairman
The Honorable Jamie Raskin
Ranking Member
Committee on Oversight and Accountability
House of Representatives
The Honorable Jason Smith
Chairman
The Honorable Richard Neal
Ranking Member
Committee on Ways and Means
House of Representatives
Page 40 GAO-24-105891 Public Health Preparedness
Appendix I: Other Centers for Disease Control
and Prevention Efforts to Support
Jurisdictions’ Public Health Infrastructure
Appendix I: Other Centers for
Disease Control and Prevention
Efforts to Support Jurisdictions’
Public Health Infrastructure
The Centers for Disease Control and Prevention (CDC) annually provides
awards to jurisdictions (states, localities, and territories) to support their
public health infrastructure through the Public Health Emergency
Preparedness and Epidemiology and Laboratory Capacity for Prevention
and Control of Emerging Infectious Diseases cooperative agreements.1 In
addition, CDC also awards a block grant and has other efforts to support
jurisdictions’ public health infrastructure.
CDC Preventive Health and Health Services Block Grant
CDC provides awards through its Preventive Health and Health Services
Block Grant Program annually to states, territories and freely associated
states, and Washington, D.C. to address public health needs.2
Jurisdictions that receive awards through this block grant are to
implement local strategies to address any of the wide ranging objectives
identified in the Department of Health and Human Services’ national
Healthy People initiative—an initiative that aims to guide health promotion
and disease prevention efforts.3 Jurisdictions set their own goals and
program objectives, and decide how to use the award based on their
communities’ needs. They can opt to use the funds for objectives related
to certain aspects of public health infrastructure, but that is not required.
CDC does not specify or allocate funding to any specific purpose, except
1A cooperative agreement is a federal award to a non-federal entity to carry out a public
purpose. Unlike grants, cooperative agreements generally provide for substantial
involvement between the federal awarding agency and the non-federal entity in carrying
out the activity contemplated by the award.
2CDC also awards this block grant to two Tribes, which were not included in the scope of
our review.
3Department of Health and Human Services, “Healthy People 2030: Building a Healthier
Future for All,” accessed August 2, 2023, https://health.gov/healthypeople.
Page 41 GAO-24-105891 Public Health Preparedness
Appendix I: Other Centers for Disease Control
and Prevention Efforts to Support
Jurisdictions’ Public Health Infrastructure
for the Sex-Offense Set-Aside required in statute, according to agency
officials.
Officials we spoke with from the selected jurisdictions in our review told
us they sometimes used these block grant funds to support infrastructure
to prepare for public health threats.4 Maine officials said they used the
block grant funds for epidemiology staff, local plans for emergency
preparedness, and other infrastructure purposes. Maryland officials, in
contrast, said they mostly used the funds for unfunded or poorly funded
areas, such as heart disease, diabetes, and other chronic diseases.
Other CDC Efforts
Our review of agency documentation shows that CDC also annually
supports jurisdictions’ public health infrastructure by assigning CDC staff
to work in jurisdictions’ health departments, funding other efforts to
strengthen the public health workforce, and providing technical assistance
and other support. See table 3 for examples.
Table 3: Examples of Other CDC Efforts to Support Jurisdictions’ Public Health Infrastructure
Type Description
CDC staff Career CDC funds and assigns Career Epidemiology Field Officers to work in jurisdictions’ health
assigned to Epidemiology departments to strengthen public health preparedness. These officers provide mentorship and train
work in Field Officers state, local, and territorial staff in public health emergency management.
jurisdictions Program · CDC centrally funds these positions through the Public Health Emergency Preparedness
(PHEP) program. As of December 2022, CDC centrally funded 38 such officers, with additional
placements planned. In addition, several health departments have opted to use awarded
funding they receive through PHEP for additional officers.
· Assignments are requested by jurisdictions and are for at least 2 years initially. They can be
renewed, subject to availability of funds and program needs.
· Among the program’s objectives are a) developing and sustaining essential public health
security capabilities, such as disease detection, containment, and distribution of medical
countermeasures; b) integrating public health, public, and private medical capabilities; and c)
evaluating preparedness and response capabilities.
4We selected four states, six localities, and two territories to obtain a variety of the
following characteristics: health department governance structure (i.e., the relationship
between state health agencies and local health departments), how localities receive
funding (through the state or directly from CDC), and percent of rural population, as
calculated by the U.S. Census Bureau. We selected and interviewed health department
officials for the following 12 jurisdictions: California; Maine; Maryland; South Carolina; Los
Angeles County, Calif.; San Bernardino, Calif.; San Francisco, Calif.; Portland, Maine;
Baltimore, Md.; Garrett County, Md.; Puerto Rico; and the U.S. Virgin Islands.
Page 42 GAO-24-105891 Public Health Preparedness
Appendix I: Other Centers for Disease Control
and Prevention Efforts to Support
Jurisdictions’ Public Health Infrastructure
Type Description
Preparedness CDC assigns staff as Preparedness Field Assignees to fill jurisdictions’ personnel and
Field Assignee preparedness capacity gaps. This program provides boots-on-the-ground support to state and local
Program preparedness programs and provides early-career professionals with additional experience in state
and local emergency preparedness and response.
· CDC funds these positions through the PHEP program. As of December 2022, CDC funded 27
positions, with plans to expand the program.
· Assignments are requested by jurisdictions and are for at least 3 years initially. They can be
renewed, subject to availability of funds and program needs.
· Among the program’s goals are strengthening state and local capacity to prepare for, detect,
respond to, and recover from public health emergencies.
Other efforts to Strengthening In 2018, CDC awarded cooperative agreements to 39 national partners for a 5-year effort to help
strengthen the Public Health strengthen the nation’s public health infrastructure and improve the delivery of public health
public health Systems and services.a Sixteen of those partners were to provide capacity-building assistance to state, local,
workforce Services territorial, and tribal health departments. Those partners included, for example, national
through associations that represented state, local, and territorial health departments, as well as
National epidemiologists, infectious disease staff, chronic disease specialists, and other components of the
Partnerships to state, local, territorial, and tribal health department workforce.
Improve and Capacity-building assistance could include technical assistance, training, information sharing, and
Protect the other activities.
Nation’s Health
Other efforts Technical Examples of CDC-facilitated technical assistance include:
assistance · CDC subject matter experts provide technical assistance to jurisdictions on public health
emergency preparedness issues, such as operational readiness.
· CDC has funded national partners to provide technical assistance and other support to
jurisdictions to aid jurisdictions’ efforts to strengthen their public health infrastructure.
Training CDC has provided training opportunities for the public health workforce, such as the following.
· CDC offers courses and continuing education activities on topics such as emergency
management, epidemiology, infectious diseases, laboratory services, and workforce
development.
· CDC partnered with the Council of State and Territorial Epidemiologists to offer the Data
Science Team Training program, an on-the job training program designed to enhance data
science capacity at state, territorial, local, and tribal public health agencies.
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) information. | GAO-24-105891
a
A cooperative agreement is a federal award to a non-federal entity to carry out a public purpose.
Unlike grants, cooperative agreements generally provide for substantial involvement between the
federal awarding agency and the non-federal entity in carrying out the activity contemplated by the
award.
Additionally, using COVID-19 supplemental appropriations, CDC had
planned to expand its Public Health Fellowship programs to enhance the
public health workforce, as well as Public Health AmeriCorps, a new effort
to recruit and train public health workers. However, remaining COVID-19
supplemental funding for the Public Health Fellowship programs
Page 43 GAO-24-105891 Public Health Preparedness
Appendix I: Other Centers for Disease Control
and Prevention Efforts to Support
Jurisdictions’ Public Health Infrastructure
expansion and Public Health AmeriCorps were rescinded as part of the
Fiscal Responsibility Act of 2023, according to CDC officials.5
5See Pub. L. No. 118-5, div. B, tit. I, § 2(18), 137 Stat. 10, 24.
Page 44 GAO-24-105891 Public Health Preparedness
Appendix II: Centers for Disease Control and
Prevention Awards to Jurisdictions for Public
Health Preparedness Infrastructure
Appendix II: Centers for Disease
Control and Prevention Awards to
Jurisdictions for Public Health
Preparedness Infrastructure
The Centers for Disease Control and Prevention’s (CDC) Public Health
Emergency Preparedness (PHEP) and Epidemiology and Laboratory
Capacity for Prevention and Control of Emerging Infectious Diseases
(ELC) cooperative agreements are the agency’s two key programs that
provide awards to jurisdictions—states, localities, and territories and
freely associated states—for infrastructure to prepare for public health
threats, using funding from annual appropriations.1
· Awards through PHEP from annual appropriations support
preparedness for “all-hazard” public health threats, including
infectious diseases, extreme weather events, or terrorist threats. As of
fiscal year 2022, CDC provided awards through PHEP to 62
jurisdictions (50 states, four localities, and eight U.S. territories and
freely associated states).
· Awards through ELC from annual appropriations support prevention
and control of infectious diseases. As of fiscal year 2022, CDC
provided awards through ELC to 64 jurisdictions (50 states, six
localities, and eight U.S. territories and freely associated states).
See tables 4 and 5 for awards through PHEP and ELC from annual
appropriations to jurisdictions from fiscal year 2019 through fiscal year
2022.
1A cooperative agreement is a federal award to a non-federal entity to carry out a public
purpose. Unlike grants, cooperative agreements generally provide for substantial
involvement between the federal awarding agency and the non-federal entity in carrying
out the funded activity.
CDC also has used PHEP and ELC to make awards to jurisdictions using supplemental
appropriations to respond to specific threats. For example, PHEP has been used to
provide awards to jurisdictions to help respond to the Zika outbreak, Ebola, and the H1N1
influenza pandemic, and ELC has been used in this manner to respond to the COVID-19
pandemic, the Zika outbreak, Ebola, and other events, such as hurricanes.
Page 45 GAO-24-105891 Public Health Preparedness
Appendix II: Centers for Disease Control and
Prevention Awards to Jurisdictions for Public
Health Preparedness Infrastructure
Table 4: CDC Awards to Jurisdictions through the Public Health Emergency Preparedness (PHEP) Program from Annual
Appropriations, Fiscal Years 2019-2022
Amount in dollars
2019 2020 2021 2022
States Alabama 9,054,221 8,740,894 8,892,198 9,021,541
Alaska 5,447,600 5,169,900 5,210,000 5,760,000
Arizona 12,446,524 12,164,945 12,695,698 13,142,567
Arkansas 6,894,830 6,558,883 6,666,795 6,662,659
California 41,896,344 42,272,321 44,070,003 44,440,891
Colorado 10,368,137 10,066,666 10,407,154 10,828,721
Connecticut 7,842,523 7,514,989 7,693,758 7,756,083
Delaware 5,075,000 5,312,726 5,383,535 5,405,020
Florida 30,329,229 30,596,524 31,844,745 32,589,946
Georgia 16,429,205 16,188,726 16,818,599 17,715,933
Hawaii 5,075,000 5,627,369 5,315,643 5,642,210
Idaho 5,075,000 5,546,900 5,246,538 5,382,980
Illinois 16,296,979 16,052,302 16,541,884 16,606,455
Indiana 11,527,724 11,238,343 11,575,238 11,702,107
Iowa 7,053,143 6,718,250 6,825,471 7,158,236
Kansas 6,600,607 7,009,071 6,778,745 6,818,460
Kentucky 8,293,772 8,348,507 8,510,043 8,553,495
Louisiana 8,672,294 9,102,809 8,934,209 8,919,448
Maine 5,075,000 5,542,500 5,210,000 5,510,000
Maryland 11,399,141 11,105,328 11,510,060 11,777,135
Massachusetts 12,943,677 13,031,996 13,421,314 13,800,043
Michigan 16,185,611 16,309,591 16,711,689 16,981,692
Minnesota 11,164,582 11,235,645 11,559,800 12,131,089
Mississippi 6,527,773 6,936,267 6,655,374 6,601,489
Missouri 10,987,397 10,691,802 11,007,602 11,383,901
Montana 5,075,000 5,542,500 5,210,000 5,210,000
Nebraska 5,329,627 5,726,102 5,446,141 5,483,678
Nevada 7,258,599 6,924,768 7,157,460 7,297,816
New Hampshire 5,447,600 5,280,301 5,345,470 5,663,127
New Jersey 15,400,178 15,144,167 15,725,569 16,344,236
New Mexico 6,638,183 6,664,176 6,760,227 6,949,221
New York 18,544,755 18,683,356 19,480,531 19,763,713
North Carolina 15,356,128 15,108,972 15,545,983 15,894,002
Page 46 GAO-24-105891 Public Health Preparedness
Appendix II: Centers for Disease Control and
Prevention Awards to Jurisdictions for Public
Health Preparedness Infrastructure
2019 2020 2021 2022
North Dakota 5,075,000 5,169,900 5,210,000 5,210,000
Ohio 17,356,642 17,502,622 18,042,980 18,224,028
Oklahoma 7,693,590 7,742,012 7,910,584 7,950,479
Oregon 8,109,807 8,161,938 8,382,359 8,444,226
Pennsylvania 18,782,276 19,315,104 19,517,788 19,783,265
Rhode Island 5,447,600 5,271,773 5,336,988 5,369,497
South Carolina 9,917,925 9,979,562 10,217,636 10,404,117
South Dakota 5,075,000 5,542,500 5,210,000 5,210,000
Tennessee 11,198,104 11,654,608 11,636,659 12,135,779
Texas 39,141,025 39,129,703 40,952,164 42,270,242
Utah 7,157,125 6,823,464 7,004,062 7,461,137
Vermont 5,447,600 5,169,900 5,210,000 5,210,000
Virginia 14,857,347 14,966,098 15,481,874 15,885,898
Washington 12,756,443 12,478,656 12,955,078 13,507,141
West Virginia 5,556,448 5,196,440 5,255,093 5,229,883
Wisconsin 11,333,547 11,404,763 11,623,201 11,917,508
Wyoming 5,075,000 5,169,900 5,210,000 5,210,000
Localities Chicago 9,715,194 9,651,560 10,070,627 10,207,392
Los Angeles 20,235,667 19,648,468 20,733,030 20,923,151
County
New York City 18,790,865 18,608,800 19,398,987 20,055,935
Washington, D.C. 6,831,442 6,467,129 6,548,017 6,527,834
Territories American Samoa 411,385 412,042 422,440 413,424
and freely Federated States 467,114 468,367 488,764 478,510
associated of Micronesia
states
Guam 532,702 534,657 550,942 543,123
Marshall Islands 408,616 409,243 426,964 418,761
Northern Mariana 410,851 411,502 425,119 408,982
Islands
Palau 374,215 374,474 380,471 370,357
Puerto Rico 6,522,620 6,560,315 6,613,160 6,653,125
U.S. Virgin Islands 465,667 466,904 478,140 466,932
Total 622,858,200 622,850,000 637,850,603 651,788,620
Source: GAO summary of Centers for Disease Control and Prevention (CDC) information. | GAO-24-105891
Page 47 GAO-24-105891 Public Health Preparedness
Appendix II: Centers for Disease Control and
Prevention Awards to Jurisdictions for Public
Health Preparedness Infrastructure
Table 5: CDC Awards to Jurisdictions through the Epidemiology and Laboratory Capacity for Prevention and Control of
Emerging Infectious Diseases (ELC) Program from Annual Appropriations, Fiscal Years 2019-2022
Amount in dollars
2019 2020 2021 2022
States Alabama 3,010,949 2,786,412 1,985,192 1,895,343
Alaska 2,198,044 2,360,438 2,298,907 2,216,487
Arizona 3,973,064 4,124,917 3,152,987 2,868,459
Arkansas 2,377,216 2,449,146 1,016,332 2,126,337
California 9,809,677 10,104,112 10,339,906 10,362,274
Colorado 5,607,249 6,022,658 5,765,586 5,999,774
Connecticut 3,438,639 3,519,939 2,483,833 2,559,951
Delaware 1,453,443 1,779,045 1,356,732 2,603,053
Florida 5,100,662 5,031,249 4,668,440 4,123,281
Georgia 3,795,427 3,991,569 3,619,330 3,521,597
Hawaii 3,239,651 3,297,631 2,172,006 1,943,945
Idaho 1,303,939 1,493,749 1,476,699 1,570,357
Illinois 4,345,353 4,270,602 2,058,357 1,887,316
Indiana 3,469,969 3,483,728 3,091,126 2,804,594
Iowa 3,590,280 3,552,691 3,623,171 3,197,687
Kansas 2,504,757 2,469,389 2,112,149 2,339,429
Kentucky 2,949,602 3,367,323 2,644,053 2,596,633
Louisiana 2,379,214 2,509,141 1,636,652 2,142,594
Maine 2,483,075 2,631,866 2,218,038 2,293,626
Maryland 5,075,761 5,378,313 5,326,569 5,144,569
Massachusetts 6,195,880 6,032,616 5,281,171 6,800,136
Michigan 6,544,249 6,557,202 6,144,918 6,694,072
Minnesota 9,110,666 9,238,467 8,398,793 8,553,088
Mississippi 1,874,895 2,060,093 1,757,487 1,301,827
Missouri 1,754,550 2,007,361 1,672,082 1,558,132
Montana 2,031,678 1,869,473 1,744,124 1,648,729
Nebraska 3,188,722 3,277,952 2,800,041 3,220,876
Nevada 2,277,390 2,939,527 2,590,580 2,084,665
New 2,454,181 2,704,758 2,220,483 1,978,069
Hampshire
New Jersey 3,647,888 3,513,962 2,856,603 3,554,807
New Mexico 2,786,787 3,233,913 2,705,762 2,637,756
New York 9,166,551 10,328,731 9,138,399 8,645,809
North Carolina 3,984,913 3,929,435 3,077,800 3,041,076
Page 48 GAO-24-105891 Public Health Preparedness
Appendix II: Centers for Disease Control and
Prevention Awards to Jurisdictions for Public
Health Preparedness Infrastructure
2019 2020 2021 2022
North Dakota 1,625,008 1,611,044 1,532,864 1,396,048
Ohio 4,175,762 4,530,634 3,618,072 3,584,552
Oklahoma 1,848,118 2,078,703 1,816,868 2,346,818
Oregon 3,685,357 3,896,941 3,113,419 2,894,936
Pennsylvania 4,895,626 4,785,075 4,224,511 3,351,687
Rhode Island 2,502,574 2,396,464 2,129,096 2,082,650
South Carolina 2,998,885 2,922,316 2,675,988 2,589,107
South Dakota 1,373,406 1,388,902 1,265,408 1,353,475
Tennessee 7,679,562 8,377,034 7,419,816 7,507,419
Texas 5,381,154 4,959,840 4,185,501 3,995,395
Utah 5,602,616 6,176,813 5,377,078 5,471,840
Vermont 1,792,334 1,896,253 1,732,946 1,824,340
Virginia 4,223,932 4,429,490 4,170,703 5,104,364
Washington 8,800,972 9,412,090 9,078,502 8,856,117
West Virginia 1,656,477 1,720,094 1,166,050 954,235
Wisconsin 7,260,406 7,660,458 6,420,125 5,703,549
Wyoming 1,502,790 1,828,474 1,443,906 1,369,717
Localities Chicago 2,292,836 2,206,179 1,820,923 1,982,590
Houston 2,277,708 2,697,022 1,867,096 1,649,214
Los Angeles 4,105,908 4,945,876 4,125,687 3,808,296
County
New York City 8,250,353 8,355,609 4,298,101 4,783,905
Philadelphia 1,877,926 1,796,063 1,708,410 1,688,458
Washington, 2,239,392 2,564,102 2,356,350 2,136,994
D.C.
Territories American 284,280 237,373 13,000 382,200
and freely Samoa
associated Federated 225,330 216,665 155,796 155,509
states
States of
Micronesia
Guam 920,067 813,246 817,953 231,456
Marshall 384,855 499,085 272,517 397,349
Islands
Northern 868,588 1,018,675 693,292 699,287
Mariana
Islands
Palau 519,555 511,662 446,627 260,750
Puerto Rico 1,021,075 1,371,190 1,070,675 1,350,680
U.S. Virgin 1,120,501 1,194,312 1,138,831 1,210,804
Islands
Page 49 GAO-24-105891 Public Health Preparedness
Appendix II: Centers for Disease Control and
Prevention Awards to Jurisdictions for Public
Health Preparedness Infrastructure
2019 2020 2021 2022
Total 220,517,674 230,815,092 195,590,419 197,040,089
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) information. | GAO-24-105891
Page 50 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Appendix III: Selected State,
Local, and Territorial Health
Department Profiles
This appendix presents information about selected jurisdictions’ (states,
localities, and territories) health department characteristics and federal
awards for public health infrastructure to prepare for and respond to
threats.
Jurisdictions have wide latitude on how to organize and operate their
health departments—there is no standard for how they must be structured
and thus, wide variation exists across jurisdictions. For example, state
public health agencies may be part of larger departments or stand-alone
agencies within state government. Additionally, the relationship between
state health departments and local public health units differs across
states, and typically falls into one of the following types of governance
structures, according to the Centers for Disease Control and Prevention’s
(CDC) website:1
· Centralized or largely centralized structure. Local health units are
primarily led by employees of the state and governed by the state.
· Decentralized or largely decentralized structure. Local health units
are primarily led by employees of the local government and governed
by the local government.
· Shared or largely shared structure. Local health units are either (1)
primarily led by employees of the state and some, if not all, authorities
reside with the local government, or (2) primarily led by employees of
the local government and some, if not all, authorities reside with the
state government.
· Mixed structure. Some local health units are led by employees of the
state and some are led by employees of local government. There is a
mix of centralized, decentralized, and shared governance structures;
no single structure predominates.
1See CDC, “Health Department Governance,” accessed Aug. 1, 2023,
https://www.cdc.gov/publichealthgateway/sitesgovernance/index.html. CDC’s website is
based on information from the Association of State and Territorial Health Officials.
Page 51 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Jurisdictions’ health departments may also seek accreditation.
Accreditation of health departments was established with support from
CDC and the Robert Wood Johnson Foundation to help provide more
standardization of services, though accreditation is not a requirement to
receive federal funding, including CDC awards. According to the Public
Health Accreditation Board, accreditation ensures the public that the
jurisdiction has met standards and such accreditation could help advance
performance more consistently across health departments.
For our review, we selected four states, six localities, and two territories to
obtain a variety of the following characteristics: health department
governance structure, localities that receive funding through the state
versus directly from the CDC, and percent of rural population, as
calculated by the U.S. Census Bureau. We selected and interviewed
health department officials for the following 12 jurisdictions: California;
Maine; Maryland; South Carolina; Los Angeles County, Calif.; San
Bernardino, Calif.; San Francisco, Calif.; Portland, Maine; Baltimore, Md.;
Garrett County, Md.; Puerto Rico; and the U.S. Virgin Islands.2 The
following figures provide information on public health in each of the 12
selected jurisdictions.
2We also interviewed officials from Penquis-District 6 in Maine; we counted their
responses as responses from the state because decisions are made at the state level and
officials report to the state. We did not interview localities in South Carolina, Puerto Rico,
and the U.S. Virgin Islands as these jurisdictions do not have local health departments.
Page 52 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 6: California Public Health
Page 53 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text of Figure 6: California Public Health
California California Public Health
Population Size (2022) 39,029,342
Population Type (% rural/urban): 5.8 percent rurala
Public Health Governance Structure:b Decentralized / Largely decentralized
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact Over the past 5 years, California’s medical
and health coordination center has been
activated for more than 2,000 days for over
30 different emergencies and has been
continuously activated since August of
2019. These emergencies include extreme
weather events such as wildfires, droughts,
and storms, as well as oil spills and other
incidents.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual Appropriations,
Fiscal Year 2022
Public Health Emergency $44.44 million
Preparedness (PHEP) Cooperative
Agreement
Epidemiology and Laboratory $10.36 million
Capacity for Prevention and
Control of Emerging Infectious
Diseases (ELC) Cooperative
Agreement
Preventive Health and Health $3.02 million amount used for
Services Block Grant public health infrastructure
CDC Awards from American Rescue Plan Act of 2021 (ARPA)
Supplemental Appropriations, Fiscal Years 2021-2023
Strengthening U.S. Public Health $144.99 million
Infrastructure, Workforce, and Data
Systemsd (2023)
Epidemiology and Laboratory $71.44 million
Capacity for Prevention and
Control of Emerging Infectious
Diseases (ELC) Cooperative
Page 54 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Agreement Supplemental (2021-
2022)
Cooperative Agreement for $173.38 million
Emergency Response: Public
Health Crisis Response (2021)
Disease Intervention Specialists $45.79 million
Workforce Development (2021-
2023)
Examples of Use of Awards from Annual Appropriations
California has typically disbursed 70 percent of awards received through
PHEP to local public health departments. The remaining 30 percent has
funded:
· the state’s 19 public health laboratories, primarily for the surveillance
system and several preparedness staff to ensure surge readiness,
· the state’s emergency operations center,
· environmental and occupational health experts for future responses,
and
· state hazard mitigation training for staff.
Awards received through ELC have been used for laboratories, including
staff and supplies; disease investigators; and the foodborne illness
program.
Examples of Use of Awards from ARPA Supplemental
Appropriations
· The Disease Intervention Specialists Workforce Development award
was used to
· hire eight disease intervention specialists that will be cross trained
in all communicable diseases in order to be available for surge
capacity and outbreak response for other infectious diseases as
needed.
· Plans for Strengthening U.S. Public Health Infrastructure, Workforce,
and Data Systems grant funding include
· increasing capacity to double the number of public health students
placed for internships/practicums each semester, and
Page 55 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
· a conference to increase exposure and inform students about
career pathways with the state.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Decentralized/largely decentralized governance indicates that local
government employees primarily lead their local health departments and local governments govern
their local health units.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 56 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 7: Maine Public Health
Page 57 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 7: Maine Public Health
Maine Maine Public Health
Population Size (2022) 1,385,340
Population Type (% rural/urban): 61.4 percent rurala
Public Health Governance Structure:b Mixed
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact Given Maine’s climate, vaccinators and
testing staff who provide drive-thru testing
or vaccine clinics may have to be outside in
15 degrees Fahrenheit. These
temperatures require cold weather parkas
or reflective gear to keep public health
responders safe.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual Appropriations, CDC Awards from American Rescue
Fiscal Year 2022 Plan Act of 2021 (ARPA)
Supplemental Appropriations, Fiscal
Years 2021-2023
Public Health $5.5 million Strengthening U.S. $16.41 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Workforce, and Data
Agreement Systemsd (2023)
Epidemiology and $2.29 million Epidemiology and $6.36 million
Laboratory Capacity Laboratory Capacity
for Prevention and for Prevention and
Control of Emerging Control of Emerging
Infectious Diseases Infectious Diseases
(ELC) Cooperative (ELC) Cooperative
Agreement Agreement
Supplemental (2021-
2022)
Preventive Health and $1.31 million Cooperative $8.86 million
Health Services Block amount used Agreement for
Grant Emergency Response:
for public Public Health Crisis
health Response (2021)
infrastructure Disease Intervention $3 million
Specialists Workforce
Development (2021-
2023)
Page 58 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through PHEP have funded: The Cooperative Agreement for Emergency
· laboratories, including the purchase of Response: Public Health Crisis Response
laboratory equipment and supplies, funded:
· a legacy information technology · public health activities in Portland and
emergency response platform with Bangor, and
information such as hospital resources · creation and hiring of 21 limited, short-
and bed tracking, and term positions to help with the COVID-
· staff support for field epidemiology. 19 response and related local public
health needs throughout the state.
Preventive Health and Health Services
Block Grant funding has been used for Plans for Strengthening U.S. Public Health
staffing in epidemiology, emergency Infrastructure, Workforce, and Data
response at the community level, and local Systems grant funding include
health improvement plans for emergency · retaining local staff hired for the
preparedness. COVID-19 pandemic response,
including extending 20 limited period
staff positions from 1 year to 5 years,
· adding three new positions related to
workforce and data modernization,
· expanding recruitment efforts to reach
a wide and diverse pool of applicants,
and
· further modernizing information
management systems.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Mixed governance indicates that some local health units are led by
employees of the state and some are led by employees of local government.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 59 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 8: Maryland Public Health
Page 60 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 8: Maryland Public Health
Maryland Maryland Public Health
Population Size (2022) 6,164,660
Population Type (% rural/urban): 14.4 percent rurala
Public Health Governance Structure:b Shared / Largely Shared
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact Medicaid financing is co-located in the
Maryland Department of Health, which
provides advantages when collaborating on
an emergency response. For the COVID-19
response, Medicaid staff assisted in
understanding how the flexibilities offered
during the state of emergency would impact
individuals and assisting with
communication regarding vaccines and
treatments.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual Appropriations, CDC Awards from American Rescue
Fiscal Year 2022 Plan Act of 2021 (ARPA)
Supplemental Appropriations, Fiscal
Years 2021-2023
Public Health $11.78 million Strengthening U.S. $55.81 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Workforce, and Data
Agreement Systemsd (2023)
Epidemiology and $5.14 million Epidemiology and $13.90 million
Laboratory Capacity Laboratory Capacity
for Prevention and for Prevention and
Control of Emerging Control of Emerging
Infectious Diseases Infectious Diseases
(ELC) Cooperative (ELC) Cooperative
Agreement Agreement
Supplemental (2021-
2022)
Preventive Health and $399,063 amount Cooperative $36.36 million
Health Services Block used for public health Agreement for
Grant infrastructure Emergency Response:
Public Health Crisis
Response (2021)
Disease Intervention $6 million
Specialists Workforce
Development (2021-
2023)
Page 61 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through ELC have funded: The Cooperative Agreement for Emergency
· laboratory infrastructure and Response: Public Health Crisis Response
equipment—such as a biomedical funded the hiring of staff to bolster public
refrigerator and a centrifuge, health preparedness during the COVID-19
response, such as
· core health information technology
surveillance functions, and · epidemiologists, and
· staff, such as epidemiologists and · administration staff (such as human
outbreak investigators, who work resources staff to hire more quickly).
across program areas and who can Plans for Strengthening U.S. Public Health
respond before a public health Infrastructure, Workforce, and Data
emergency is declared. Some staff Systems grant funding include supporting
positions are fully supported with ELC · human resources and procurement
awards and others are partially capacity, and
supported with ELC awards, as well as
funding from other sources. · workforce investment, such as offering
training and development programs to
attract new workers and to encourage
retention of existing workers.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Shared/largely shared governance indicates that local health units are either
(1) primarily led by employees of the state and some, if not all, authorities reside with the local
government, or (2) primarily led by employees of the local government and some, if not all, authorities
reside with the state government.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 62 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 9: South Carolina Public Health
Page 63 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text of Figure 9: South Carolina Public Health
South Carolina South Carolina and Public Health
Population Size (2022) 5,282,634
Population Type (% rural/urban): 32.1 percent rurala
Public Health Governance Structure:b Centralized with no local public health
departments
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact South Carolina officials said that they are
heading toward a “funding cliff” in 2024 and
do not know whether they will receive
sustained funding. “You do not lay off
firefighters after they put out the fire with
the hopes of hiring them as needed in the
future,” according to state officials.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual Appropriations, CDC Awards from American Rescue
Fiscal Year 2022 Plan Act of 2021 (ARPA)
Supplemental Appropriations, Fiscal
Years 2021-2023
Public Health $10.4 million Strengthening U.S. $55.65 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Workforce, and Data
Agreement Systemsd (2023)
Epidemiology and $2.59 million Epidemiology and $10.99 million
Laboratory Capacity Laboratory Capacity
for Prevention and for Prevention and
Control of Emerging Control of Emerging
Infectious Diseases Infectious Diseases
(ELC) Cooperative (ELC) Cooperative
Agreement Agreement
Supplemental (2021-
2022)
Preventive Health and $1.25 million Cooperative $31.11 million
Health Services Block amount used Agreement for
Grant Emergency Response:
for public Public Health Crisis
health Response (2021)
infrastructure Disease Intervention $8.34 million
Specialists Workforce
Development (2021-
2023)
Page 64 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Examples of Use of Awards from ARPA
Annual Appropriations Supplemental Appropriations
Awards through PHEP have funded most The state allocated $104 million from the
of the state’s agency coordination center, Department of the Treasury’s Coronavirus
which conducts public health State and Local Fiscal Recovery Funds to
preparedness, and is the primary construct a new public health laboratory.e
operations center for: The current aging laboratory:
· staff coordination, · lacks space for staffing and
· decision-making support, instrumentation,
· coordination of resources, and · is unable to sustain routine testing due
· exchange of information, among other to repeated system failures, and
things. · is reaching near maximum capacity for
Public health preparedness bureau staff, electrical power needed to operate the
funded through PHEP, operate the center building.
and develop response plans when the The goal of the new laboratory is to improve
center is activated to respond to an testing abilities, expand capacity, and
infectious disease, hurricane, earthquake, increase the biosafety level to adequately
or other event. address biosafety pandemic practices.
Staff in the center may also be funded with
ELC awards, depending on the emergency
and allowable costs.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Centralized governance indicates that local health units are primarily led by
employees of the state and governed by the state.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
e
The Coronavirus State and Local Fiscal Recovery Funds are administered by the Department of the
Treasury and provided billions of dollars to jurisdictions to help them recover from the fiscal effects of
the COVID-19 pandemic. Jurisdictions had broad discretion in using the funding and could use it to
build public health infrastructure.
Page 65 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 10: Puerto Rico Public Health
Page 66 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 10: Puerto Rico Public Health
Puerto Rico Puerto Rico Public Health
Population Size (2022) 3,221,789
Population Type (% rural/urban): 8.1 percent rurala
Public Health Governance Structure:b Centralized
Accredited by the Public Health No
Accreditation Board?c
Interesting Fact Puerto Rico has been in a state of
emergency for at least the last 12 years,
including for hurricanes, such as Hurricane
Maria, and infectious diseases, such as
Zika.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual Appropriations, CDC Awards from American Rescue
Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-
2023
Public Health $6.65 million Strengthening U.S. $42.94 million
Emergency Public Health
Preparedness Infrastructure,
(PHEP) Cooperative Workforce, and Data
Agreement Systemsd (2023)
Epidemiology and $1.35 million Epidemiology and $6.09 million
Laboratory Capacity Laboratory Capacity
for Prevention and for Prevention and
Control of Emerging Control of Emerging
Infectious Diseases Infectious Diseases
(ELC) Cooperative (ELC) Cooperative
Agreement Agreement
Supplemental (2021-
2022)
Preventive Health and $553,500 Cooperative $19.68 million
Health Services Block amount used Agreement for
Grant Emergency
for public Response: Public
health Health Crisis
infrastructure Response (2021)
Disease Intervention $5.75 million
Specialists Workforce
Development (2021-
2023)
Page 67 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through PHEP have funded the Plans for Strengthening U.S. Public Health
majority of the Department of Health’s Infrastructure, Workforce, and Data
contractors and employees’ salaries. Systems grant funding include:
Awards through ELC award have funded: • transitioning contract employees to
• a coordinator for the ELC influenza permanent positions, with fringe benefits,
program, and such as insurance; and
• at least five medical technologists in the • hiring a workforce development director
laboratory. and information technology project director.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Centralized governance indicates that local health units are primarily led by
employees of the state and governed by the state.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 68 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 11: U.S. Virgin Islands Public Health
Page 69 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 11: U.S. Virgin Islands Public Health
U.S. Virgin Islands U.S. Virgin Islands Public Health
Population Size (2022) 87,146a
Population Type (% rural/urban): 4.9 percent ruralb
Public Health Governance Structure:b Centralized
Accredited by the Public Health No
Accreditation Board?c
Interesting Fact PHEP award amounts are determined
based on population. Because the U.S.
Virgin Islands’ population has decreased
after the hurricanes in recent years, officials
anticipate that their future PHEP award
amounts will decrease. Officials said the
U.S. Virgin Islands will still need to conduct
activities for the PHEP award—including
building community partnerships—even
with reduced funding.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual Appropriations, CDC Awards from American Rescue
Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-
2023
Public Health $466,932 Strengthening U.S. $7.91 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Workforce, and Data
Agreement Systemsd (2023)
Epidemiology and $1.21 million Epidemiology and $1.54 million
Laboratory Capacity Laboratory Capacity
for Prevention and for Prevention and
Control of Emerging Control of Emerging
Infectious Diseases Infectious Diseases
(ELC) Cooperative (ELC) Cooperative
Agreement Agreement
Supplemental (2021-
2022)
Preventive Health and $0 amount used for Cooperative $760,742
Health Services Block public health Agreement for
Grant infrastructure Emergency
Response: Public
Health Crisis
Response (2021)
Page 70 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
CDC Awards from Annual Appropriations, CDC Awards from American Rescue
Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-
2023
Disease Intervention $3 million
Specialists Workforce
Development (2021-
2023)
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through ELC have funded: The Disease Intervention Specialist
• epidemiologists, Workforce Development award was used
to support mpox outreach activities.
• staff in a certified public health laboratory,
and
• an online database that keeps track of all Plans for Strengthening U.S. Public Health
reportable diseases. Infrastructure, Workforce, and Data
Systems grant funding include:
• hiring a chief health strategist, program
manager, workforce coordinator, process
improvement director, pediatrician, data
modernization coordinator, surveillance
officer, and a labor relations specialist, as
well as nurse practitioners; and
• making software, hardware, and
equipment improvements to data
infrastructure.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
Data from the 2020 U.S. Census were the most recent data available for U.S. Virgin Islands.
b
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
c
Public health governance structure indicates the relationship between state health departments and
local public health units. Centralized governance indicates that local health units are primarily led by
employees of the state and governed by the state.
d
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
e
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 71 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 12: Los Angeles County, California, Public Health
Page 72 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 12: Los Angeles County, California, Public Health
Los Angeles County, CA Los Angeles County Public Health
Population Size (2022) 9,721,138
Population Type (% rural/urban): 0.89 percent rurala
Public Health Governance Structure:b CA is Decentralized / Largely decentralized
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact The health department in Los Angeles
County covers 86 cities, with varying
degrees of public services, such as mayors
or fire chiefs. Additionally, the cities of Long
Beach and Pasadena are within Los
Angeles County’s geographic boundaries,
but have their own health departments and
governments.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual CDC Awards from American Rescue
Appropriations, Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-2023
Public Health $20.92 million Strengthening U.S. $98.10 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Agreement Workforce, and Data
Systemsd (2023)
Epidemiology and $3.81 million Epidemiology and $49.91 million
Laboratory Capacity for Laboratory Capacity for
Prevention and Control Prevention and Control
of Emerging Infectious of Emerging Infectious
Diseases (ELC) Diseases (ELC)
Cooperative Agreement Cooperative Agreement
Supplemental (2021-
2022)
Preventive Health and N/Ae Cooperative Agreement $59.71 million
Health Services Block for Emergency
Grant Response: Public
Health Crisis Response
(2021)
Disease Intervention $19.80 million
Specialists Workforce
Development (2021-
2023)
Page 73 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
• public health laboratory staff; The ELC Cooperative Agreement
• acute communicable disease control and Supplemental award was used for various
communication support services programs; COVID19 related activities, including:
• core emergency response capabilities and • providing hundreds of testing sites
biosurveillance; and throughout the county,
• emergency response units for location • providing transportation to clinics and
based response efforts, such as chemical vaccination nurses to homebound
spills and environmental emergencies. community members,
• creating a hospital outreach unit for
infection control to expand outreach,
Awards through ELC have funded:
• engagement with nursing homes to
the public health laboratory, including improve infectious disease control, and
testing supplies, courier services for
specimens, and training. • laboratory construction and remodeling.
the communicable disease program,
including:
• a nursing home infection control staff
member;
• a hospital reporting system for hospital
infections; and
• boosting influenza vaccination coverage.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Decentralized/largely decentralized governance indicates that local
government employees primarily lead their local health departments and local governments govern
their local health units.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
e
CDC does not provide Preventive Health and Health Services block grant funding directly to the
locality, and officials told us that Los Angeles County does not receive block grant funds from the
state.
Page 74 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 13: San Bernardino, California, Public Health
Page 75 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 13: San Bernardino, California, Public Health
San Bernardino County, CA San Bernardino County Public Health
Population Size (2022) 2,193,656
Population Type (% rural/urban): 5.38 percent rurala
Public Health Governance Structure:b CA is Decentralized / Largely decentralized
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact San Bernardino County is using new funds
appropriated by the state to create new
positions and fill workforce gaps. Officials
said they will also use these funds to
improve recruitment and retention, given
their challenges with offering salaries
competitive with surrounding counties’
public health departments that pay more.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual CDC Awards from American Rescue Plan
Appropriations, Fiscal Year 2022 Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-2023
Public Health N/Ad Strengthening U.S. $20.72 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Agreement Workforce, and Data
Systemsd (2023)
Epidemiology and N/Ad Epidemiology and N/Ad
Laboratory Capacity for Laboratory Capacity for
Prevention and Control Prevention and Control
of Emerging Infectious of Emerging Infectious
Diseases (ELC) Diseases (ELC)
Cooperative Agreement Cooperative Agreement
Supplemental (2021-
2022)
Preventive Health and N/Ad Cooperative Agreement N/Ad
Health Services Block for Emergency
Grant Response: Public
Health Crisis Response
(2021)
Disease Intervention N/Ad
Specialists Workforce
Development (2021-
2023)
Page 76 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through PHEP (received through Plans for Strengthening U.S. Public Health
California) funded staff positions and Infrastructure, Workforce, and Data
supplies including: Systems grant funding include:
• a microbiologist supervisor and • hiring new public health staff, training
supervisory public health microbiologist public health staff, strengthening workforce
who are assigned to the public health planning, and supporting the public health
laboratory, workforce;
• laboratory and medical supplies, and • strengthening community partnership
• costs associated with staff attending development and engagement;
training workshops. • implementing data infrastructure
improvements and a new electronic health
record system; and
• strengthening organizational
competencies with respect to information
technology, human resources, financial
management, and contract and
procurement services.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Decentralized/largely decentralized governance indicates that local
government employees primarily lead their local health departments and local governments govern
their local health units.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
CDC does not provide this award directly to the locality, though the locality may receive some award
funds through the state. For example, San Bernardino County received some PHEP funds awarded
to California.
e
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 77 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 14: San Francisco, California, Public Health
Page 78 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 14: San Francisco, California, Public Health
San Francisco,CA San Francisco County Public Health
Population Size (2022) 808,437
Population Type (% rural/urban): 0.0 ppercent rurala
Public Health Governance Structure:b CA is Decentralized / Largely decentralized
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact San Francisco is both a city and a county. It
is densely populated, and diverse, with
more than 28 languages spoken within its
7-by-7 square-mile area. Officials told us
that it is important to recruit staff from the
community, including people of color, and
they aim to incorporate health equity in
their recruitment and training processes.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual CDC Awards from American Rescue
Appropriations, Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-2023
Public Health N/Ad Strengthening U.S. $9.82 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Agreement Workforce, and Data
Systemsd (2023)
Epidemiology and N/Ad Epidemiology and N/Ad
Laboratory Capacity for Laboratory Capacity for
Prevention and Control Prevention and Control
of Emerging Infectious of Emerging Infectious
Diseases (ELC) Diseases (ELC)
Cooperative Agreement Cooperative Agreement
Supplemental (2021-
2022)
Preventive Health and N/Ad Cooperative Agreement N/Ad
Health Services Block for Emergency
Grant Response: Public
Health Crisis Response
(2021)
Disease Intervention $6.74 million
Specialists Workforce
Development (2021-
2023)
Page 79 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Examples of Use of Awards from ARPA
Annual Appropriations Supplemental Appropriations
Awards through PHEP (received through Plans for Disease Intervention Specialists
California) funded: Workforce Development award funds are to
• training to increase multi-agency support permanent, fulltime positions
coordination across all levels of including an epidemiologist, medical
government, improve the quality and director, three program coordinators, and a
processes for delivering public information health care analyst, as well as initiatives
and guidance, and sustain a ready to related to standardization of hiring and
deploy workforce; and professional development, among others.
• purchase of equipment and supplies to
increase surge capability in the public Plans for Strengthening U.S. Public Health
health laboratory, and personal protective Infrastructure, Workforce, and Data
equipment for public health responders. Systems grant funding include workforce
development and hiring staff to address key
gaps, such as in data and training
infrastructure, public relations, and support
internship opportunities.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Decentralized/largely decentralized governance indicates that local
government employees primarily lead their local health departments and local governments govern
their local health units.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
CDC does not provide this award directly to the locality, though the locality may receive some
awards funds through the state. For example, San Francisco received some PHEP funds awarded to
California.
e
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
Page 80 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 15: Portland, Maine, Public Health
Page 81 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 15: Portland, Maine, Public Health
Portland, ME Portland Public Health
Population Size (2022) 68,424
Population Type (% rural/urban): 0.0 ppercent rurala
Public Health Governance Structure:b ME is Mixed
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact The Portland Public Health Division is the
only accredited local health department in
Maine.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual CDC Awards from American Rescue
Appropriations, Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-2023
Public Health N/Ad Strengthening U.S. N/Ad
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Agreement Workforce, and Data
Systemsd (2023)
Epidemiology and N/Ad Epidemiology and N/Ad
Laboratory Capacity for Laboratory Capacity for
Prevention and Control Prevention and Control
of Emerging Infectious of Emerging Infectious
Diseases (ELC) Diseases (ELC)
Cooperative Agreement Cooperative Agreement
Supplemental (2021-
2022)
Preventive Health and N/Ad Cooperative Agreement N/Ad
Health Services Block for Emergency
Grant Response: Public
Health Crisis Response
(2021)
Disease Intervention N/Ad
Specialists Workforce
Development (2021-
2023)
Page 82 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through the PHEP Cities Portland received about $46 million from
Readiness Initiative (received through the Department of the Treasury’s ARPA
Maine) funded: Coronavirus State and Local Fiscal
• staff, though the program has not been Recovery Funds, a portion of which was
fully staffed for a few years; and used to:e
• the purchase of equipment, such as • fund the renovation of, and moving to, a
vaccination coolers and thermometers, that new office building where the city’s health
were used during the COVID19 pandemic and human services programs would be
to support emergency medical services and colocated;
the city’s vaccination efforts. • support community partners responding
to different facets of public health crises,
such as behavioral health and mental
health crisis training; and
• respond to the needs of about 2,000
asylum seekers, including housing and
mental health needs.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Mixed governance indicates that some local health units are led by
employees of the state and some are led by employees of local government.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
CDC does not provide this award directly to the locality, though the locality may receive some award
funds through the state. For example, Portland received some PHEP funds awarded to Maine.
e
The Coronavirus State and Local Fiscal Recovery Funds are administered by the Department of the
Treasury and provided billions of dollars to jurisdictions to help them recover from the fiscal effects of
the COVID-19 pandemic. Jurisdictions had broad discretion in using the funding and could use it to
build public health infrastructure.
Page 83 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 16: Baltimore, Maryland, Public Health (city)
Page 84 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 16: Baltimore, Maryland, Public Health (city)
Baltimore, MD Baltimore Public Health
Population Size (2022) 569,931
Population Type (% rural/urban): 0.0 ppercent rurala
Public Health Governance Structure:b MD is Shared / Largely Shared
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact Baltimore operates independently from
Maryland’s health department. According to
its website, the city health department is the
oldest, continuously-operating health
department in the U.S.—established in
1793 in response to a yellow fever
outbreak.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual CDC Awards from American Rescue
Appropriations, Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations,
Fiscal Years 2021-2023
Public Health N/Ad Strengthening U.S. $8.43 million
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Agreement Workforce, and Data
Systemsd (2023)
Epidemiology and N/Ad Epidemiology and N/Ad
Laboratory Capacity for Laboratory Capacity for
Prevention and Control Prevention and Control
of Emerging Infectious of Emerging Infectious
Diseases (ELC) Diseases (ELC)
Cooperative Agreement Cooperative Agreement
Supplemental (2021-
2022)
Preventive Health and N/Ad Cooperative Agreement N/Ad
Health Services Block for Emergency
Grant Response: Public
Health Crisis Response
(2021)
Disease Intervention $4.49 million
Specialists Workforce
Development (2021-
2023)
Page 85 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through PHEP (received through Plans for the Disease Intervention
Maryland) funded: Specialists Workforce Development award
• staff salaries, including preparedness include the hiring of new staff:
staff, and a contracted position for • 47 disease intervention specialists,
readiness and planning support; and • an epidemiologist to assist with
• supplies such as medical supplies for identification of unusual shifts in morbidity
nurse shelter bags. and potential outbreaks, and
Awards through ELC (received through • an information technology specialist
Maryland) funded antibioticresistant devoted to the city’s HIV/sexually
gonorrhea susceptibility testing. transmitted diseases prevention program.f
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Shared/largely shared governance indicates that local health units are either
(1) primarily led by employees of the state and some, if not all, authorities reside with the local
government, or (2) primarily led by employees of the local government and some, if not all, authorities
reside with the state government.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
CDC does not provide this award directly to the locality, though the locality receives some award
funding through the state. For example, Baltimore received some PHEP funds awarded to Maryland.
e
The award amount in this row also includes funding from CDC’s annual appropriation, which the
agency used to fund a portion of the Strengthening U.S. Public Health Infrastructure, Workforce, and
Data Systems grant.
f
According to the website, the HIV/sexually transmitted diseases prevention program aims to help
prevent the spread of sexually transmitted diseases across Baltimore City. It operates two clinics that
hold more than 30,000 patient visits per year.
Page 86 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Figure 17: Garrett County, Maryland, Public Health
Page 87 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Accessible text for Figure 17: Garrett County, Maryland, Public Health
Garrett County, MD Garrett County Public Health
Population Size (2022) 28,579
Population Type (% rural/urban): 84.2 percent rurala
Public Health Governance Structure:b MD is Shared / Largely Shared
Accredited by the Public Health Yes
Accreditation Board?c
Interesting Fact Garrett County used the ELC Cooperative
Agreement Supplemental award to hire an
epidemiologist, which was the first time the
health department had one on staff.
CDC Awards for Public Health Infrastructure
CDC Awards from Annual CDC Awards from American Rescue
Appropriations, Fiscal Year 2022 Plan Act of 2021 (ARPA) Supplemental
Appropriations, Fiscal Years 2021-2023
Public Health N/Ad Strengthening U.S. N/Ad
Emergency Public Health
Preparedness (PHEP) Infrastructure,
Cooperative Agreement Workforce, and Data
Systemsd (2023)
Epidemiology and N/Ad Epidemiology and N/Ad
Laboratory Capacity for Laboratory Capacity for
Prevention and Control Prevention and Control
of Emerging Infectious of Emerging Infectious
Diseases (ELC) Diseases (ELC)
Cooperative Agreement Cooperative Agreement
Supplemental (2021-
2022)
Preventive Health and N/Ad Cooperative Agreement N/Ad
Health Services Block for Emergency
Grant Response: Public
Health Crisis Response
(2021)
Disease Intervention N/Ad
Specialists Workforce
Development (2021-
2023)
Page 88 GAO-24-105891 Public Health Preparedness
Appendix III: Selected State, Local, and
Territorial Health Department Profiles
Examples of Use of Awards from Annual Examples of Use of Awards from ARPA
Appropriations Supplemental Appropriations
Awards through PHEP (received through The Strengthening U.S. Public Health
Maryland) funded staff salaries, including a: Infrastructure, Workforce, and Data
• public health emergency planner, Systems grant has been used to:
• public information officer, • hire a grant writer, and
• vital health officer, and • promote key personnel to encourage
retention.
• medical deputy health officer.
Source: GAO analysis of information collected through documents and interviews with the Centers for Disease Control and Prevention
(CDC) and officials from the California Department of Public Health (information); GAO (map); Scott/stock.adobe.com (photo). | GAO-
24-105891
a
The U.S. Census Bureau’s 2020 data show the percent of the population that is rural versus urban
within this area.
b
Public health governance structure indicates the relationship between state health departments and
local public health units. Shared/largely shared governance indicates that local health units are either
(1) primarily led by employees of the state and some, if not all, authorities reside with the local
government, or (2) primarily led by employees of the local government and some, if not all, authorities
reside with the state government.
c
The Public Health Accreditation Board recognizes health departments—including state, local, and
tribal health departments—for meeting national accreditation standards.
d
CDC does not provide this funding directly to the locality, though the locality may receive some
award funding through the state. For example, Garrett County received some PHEP funds awarded
to Maryland.
Page 89 GAO-24-105891 Public Health Preparedness
Appendix IV: Selected Awards to Jurisdictions
for Public Health Infrastructure from American
Rescue Plan Act of 2021
Appendix IV: Selected Awards to
Jurisdictions for Public Health
Infrastructure from American
Rescue Plan Act of 2021
In fiscal years 2021 through 2023, the Centers for Disease Control and
Prevention (CDC) provided about $7.1 billion in awards to jurisdictions
(states, localities, and territories) using American Rescue Plan Act of
2021 (ARPA) supplemental appropriations. Most of these awards were
focused on building workforce and laboratory infrastructure capacity.1
(See table 6 for an overview of these awards.)
Table 6: Overview of CDC Awards to Jurisdictions for Workforce and Laboratory Infrastructure from ARPA Supplemental
Appropriations
Type Purpose Funding
Public health Cooperative Recruit, hire, train, and retain public $2 billion awarded in June 2021, can be used
workforce Agreement for health workers for COVID-19 through June 2024
Emergency Response: response, including local health staff Recipients: 64 jurisdictionsa
Public Health Crisis
Response
Community Health Deploy community health workers to $18.5 million awarded (more than $9 million per
Workers for COVID mitigate the COVID-19 pandemic’s year) in 2021 and 2022, can be used through
Response and impact in populations at high risk and July 2024
Resilient in hardest-hit communities Recipients: 2 states and 3 localities
Communitiesb
Disease Intervention Expand, train, sustain, and support $600 million awarded ($200 million per year) in
Specialists Workforce Disease Intervention Specialists June 2021 through February 2023
Development workforce to strengthen public health Recipients: 59 jurisdictionsc
departments’ capacity to mitigate the
spread of COVID-19 and other
infections
1We focused on awards from ARPA supplemental appropriations that were provided to
jurisdictions’ health departments to build and maintain their public health infrastructure.
We did not focus on certain awards from ARPA supplemental appropriations that CDC
provided to jurisdictions for other entities’ use, such as $10 billion to support reopening
schools; and $1.3 billion to address COVID-19 in specific congregate settings, such as
nursing homes and jails.
Page 90 GAO-24-105891 Public Health Preparedness
Appendix IV: Selected Awards to Jurisdictions
for Public Health Infrastructure from American
Rescue Plan Act of 2021
Type Purpose Funding
Strengthening U.S. Hire, retain, support, and train the $3 billion awarded in November 2022, can be
Public Health public health workforce used through November 2027.
Infrastructure, Recipients: 107 jurisdictionsd
Workforce, and Data
Systems Grant -
Workforce
Development
Laboratory Epidemiology and Enhance laboratory resources $385 million awarded in 2021 to 64 jurisdictions
infrastructure Laboratory Capacity through awards focusing on specific to detect, monitor, mitigate, and prevent the
for Prevention and laboratory capabilities, construction spread of COVID-19 in health care settings; this
Control of Emerging and renovation, the Laboratory funding partially supported laboratory
Infectious Diseases Response Network, and laboratory infrastructuref
(ELC) programs data exchangee $240 million awarded in 2021 to 64 jurisdictions
for advanced molecular detection, sequencing,
and analytics, can be used through July 2024f
$175 million awarded in 2021 to 5 states and 2
localities to construct or renovate public health
laboratories, can be used through July 2024
$83.7 million awarded in 2021 and 2022 to
varying jurisdictions for the Laboratory
Response Network, laboratory data exchange,
and advanced molecular detection
Strengthening U.S. Develop a seamless, bidirectional, $200M awarded in May 2023, can be used
Public Health automated Laboratory Data Exchange through November 2027
Infrastructure, ecosystem, including advancing Recipients: 64 jurisdictionsf
Workforce, and Data Electronic Laboratory Reporting and
Systems Grant - Data Electronic Test Ordering and Results
Modernization implementation
Initiative: Laboratory
Data Exchange
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) information. | GAO-24-105891
Notes: The awards cited above include those that CDC provided to jurisdictional health departments
to build and maintain infrastructure using supplemental appropriations from the American Rescue
Plan Act of 2021 (ARPA). These awards were available for jurisdictions’ use for 2 to 5 years,
depending on the award. The awards do not include those that CDC provided to jurisdictions for other
entities’ use, such as funding to support reopening schools; and to address COVID-19 in specific
congregate settings, such as nursing homes and jails.
Funding for the Strengthening U.S. Public Health Infrastructure, Workforce, and Data Systems grant
includes annual and ARPA appropriations.
a
The 64 jurisdictions included 50 states, six localities (including Washington, D.C.), and eight U.S.
territories and freely associated states. Additionally, one Tribe received this award; Tribes were
excluded from our review and therefore the award amount in this row does not included funding to
this Tribe.
b
The majority of the Community Health Workers for COVID Response and Resilient Communities
awards were funded with supplemental appropriations from the CARES Act, which is not included in
our review and therefore award amounts using CARES Act supplemental appropriations are not
reflected in this table. A portion of this award also went to Tribes and ambulance districts; these
entities were excluded from our review and therefore the award amount in this row does not include
funding to these entities.
c
The 59 jurisdictions included 50 states, seven localities (including Washington, D.C.), and two U.S.
territories. In June 2021, CDC awarded an initial $200 million, from ARPA supplemental
appropriations, to these jurisdictions and had planned to award similar amounts each year for the
Page 91 GAO-24-105891 Public Health Preparedness
Appendix IV: Selected Awards to Jurisdictions
for Public Health Infrastructure from American
Rescue Plan Act of 2021
remainder of the 5-year funding period, for a total of $1 billion. However, the Fiscal Responsibility Act
of 2023 rescinded certain unobligated funds appropriated by ARPA, including funds CDC had
planned to use for this award. See Pub. L. No. 118-5, § 2(15) 137 Stat. 10, 24.
d
The 107 jurisdictions included 50 states, 49 localities (including Washington D.C.), and eight U.S.
territories and freely associated states.
e
The Laboratory Response Network, established by CDC in 1999, is network of federal, state, local,
veterinary, and other laboratories that can respond to emerging infectious diseases, biological and
chemical threats, and other public health emergencies.
f
The 64 jurisdictions included 50 states, six localities (including Washington D.C.), and eight U.S.
territories and freely associated states.
The largest of these awards during this time period was CDC’s new
Strengthening U.S. Public Health Infrastructure, Workforce, and Data
Systems grant. For this new infrastructure grant, award amounts were
based on population size and a U.S. Census Bureau measure of how at-
risk neighborhoods are to the impact of disasters, including the COVID-19
pandemic (referred to as the Community Resilience Estimates). (See
table 7 for award amounts individual jurisdictions received through this
grant.)
Table 7: CDC Strengthening U.S. Public Health Infrastructure, Workforce, and Data
Systems Grant Awards to Jurisdictions, as of May 2023
States Amount in Dollars
Alabama 57,537,352
Alaska 10,458,805
Arizona 26,518,938
Arkansas 35,812,005
California 144,993,860
Colorado 42,675,169
Connecticut 37,226,765
Delaware 13,087,139
Florida 180,132,441
Georgia 99,379,906
Hawaii 16,793,669
Idaho 20,240,774
Illinois 101,748,454
Indiana 60,705,614
Iowa 33,179,837
Kansas 30,904,660
Kentucky 43,486,429
Louisiana 53,621,418
Maine 16,408,004
Page 92 GAO-24-105891 Public Health Preparedness
Appendix IV: Selected Awards to Jurisdictions
for Public Health Infrastructure from American
Rescue Plan Act of 2021
States Amount in Dollars
Maryland 55,805,575
Massachusetts 62,580,778
Michigan 95,621,393
Minnesota 50,849,718
Mississippi 37,198,526
Missouri 58,926,854
Montana 13,774,591
Nebraska 16,930,858
Nevada 14,667,605
New Hampshire 15,298,312
New Jersey 93,185,453
New Mexico 26,642,518
New York 131,513,529
North Carolina 88,171,085
North Dakota 10,643,660
Ohio 110,490,898
Oklahoma 31,751,322
Oregon 36,415,563
Pennsylvania 115,444,383
Rhode Island 13,781,145
South Carolina 55,648,694
South Dakota 12,057,054
Tennessee 60,246,248
Texas 187,971,495
Utah 30,189,997
Vermont 9,320,925
Virginia 79,763,834
Washington 54,566,972
West Virginia 22,095,213
Wisconsin 53,506,756
Wyoming 8,629,029
Localities Amount in Dollars
Alameda County (California) 15,353,152
Austin (Texas) 11,941,809
Baltimore City (Maryland) 8,428,472
Boston (Massachusetts) 8,994,809
Page 93 GAO-24-105891 Public Health Preparedness
Appendix IV: Selected Awards to Jurisdictions
for Public Health Infrastructure from American
Rescue Plan Act of 2021
Localities Amount in Dollars
Chicago (Illinois) 33,358,673
Columbus (Ohio) 9,020,511
Dallas County (Texas) 27,134,379
Denver (Colorado) 8,511,546
Detroit (Michigan) 9,248,900
Douglas County (Nebraska) 7,244,358
Duval County (Florida) 10,651,584
City of El Paso (Texas) 9,881,233
El Paso County (Colorado) 7,830,856
Fulton County (Georgia) 10,535,511
Harris County (Texas) 25,091,359
Hillsborough County (Florida) 15,112,397
Houston (Texas) 28,689,219
Kansas City (Missouri) 7,087,394
King County (Washington) 19,157,230
Long Beach (California) 6,719,638
Los Angeles County (California) 98,097,207
Louisville (Kentucky) 9,551,259
Maricopa County (Arizona) 39,760,988
Marion County (Indiana) 11,177,883
Mecklenburg County (North Carolina) 11,451,205
Miami-Dade County (Florida) 29,051,823
City of Milwaukee (Wisconsin) 8,151,554
Minneapolis (Minnesota) 6,142,604
Multnomah County (Oregon) 9,093,218
Nashville and Davidson County 8,578,283
(Tennessee)
New York City (New York) 103,315,139
Oklahoma City and County (Oklahoma) 9,661,176
Orange County (California) 27,054,028
Philadelphia (Pennsylvania) 22,158,817
Pima County (Arizona) 11,924,381
Riverside County (California) 22,604,360
Sacramento County (California) 15,264,533
San Antonio (Texas) 21,543,094
San Bernardino County (California) 20,715,347
San Diego County (California) 28,273,128
Page 94 GAO-24-105891 Public Health Preparedness
Appendix IV: Selected Awards to Jurisdictions
for Public Health Infrastructure from American
Rescue Plan Act of 2021
Localities Amount in Dollars
San Francisco (California) 9,818,147
Santa Clara County (California) 16,515,503
Shelby County (Tennessee) 11,452,467
Southern Nevada Health District (Nevada) 22,889,114
Tarrant County (Texas) 20,162,748
Tulsa (Oklahoma) 8,351,233
Virginia Beach (Virginia) 6,003,499
Wake County (North Carolina) 10,927,123
Washington, D.C. 10,328,059
Territories and freely associated states Amount in Dollars
American Samoa 7,206,933
Federated States of Micronesia 7,857,361
Guam 8,654,235
Marshall Islands 7,610,339
Northern Mariana Islands 7,277,541
Palau 6,928,951
Puerto Rico 42,943,557
U.S. Virgin Islands 7,908,911
Source: GAO analysis of Centers for Disease Control and Prevention (CDC) information. | GAO-24-105891
Notes: In November 2022, CDC awarded $3.14 billion to 107 jurisdictions to help meet short-term
critical infrastructure needs, as well as to fund investments to benefit jurisdictions in the longer term.
These awards were the first awards made as part of CDC’s new Strengthening U.S. Public Health
Infrastructure, Workforce, and Data Systems grant program. According to CDC, this funding will be
used to support jurisdictions’ public health infrastructure, including $3 billion for jurisdictions’ public
health workforce and $140 million for foundational capabilities, which could include surveillance,
emergency preparedness, and other key elements of public health. For these awards, CDC used $3
billion from ARPA supplemental appropriations and $140 million from CDC’s annual appropriation for
fiscal year 2022. In fiscal year 2022, CDC received $200 million through a new specific line item in its
appropriation for public health infrastructure and capacity. See Consolidated Appropriations Act,
2022, Pub. L. No. 117-103, div. H, tit. II, 136 Stat. 49, 448. CDC received $350 million for this line
item in fiscal year 2023 and requested $600 million in its congressional budget justification for fiscal
year 2024. See Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, div. H, tit. II, 136 Stat.
4459, 4860 (2022).
In May 2023, CDC awarded an additional $545 million to 64 jurisdictions for data modernization: $345
million for core data modernization activities and $200 million for laboratory data exchange activities.
For these awards, CDC used $505 million from ARPA supplemental appropriations and $40 million
from its annual appropriation for fiscal year 2023. Only the jurisdictions that previously received
awards from Epidemiology and Laboratory Capacity for Prevention and Control of Emerging
Infectious Diseases for data modernization were eligible to apply for those funds.
Page 95 GAO-24-105891 Public Health Preparedness
Appendix V: Additional Challenges to
Managing Awards during Public Health
Emergencies
Appendix V: Additional
Challenges to Managing Awards
during Public Health
Emergencies
During our review, officials from some of the 12 selected jurisdictions we
interviewed identified additional challenges with managing awards made
using COVID-19 supplemental appropriations. Though additional awards
during the COVID-19 pandemic have bolstered their response efforts,
jurisdictions shared the following challenges.
· Challenges related to spending large amounts of awarded funds
quickly. Officials from the Centers for Disease Control and
Prevention (CDC)—which provided multiple awards to jurisdictions
during the COVID-19 pandemic—told us that all jurisdictions awarded
additional funding from supplemental appropriations during public
health emergencies, including the COVID-19 pandemic, have noted
limitations in their ability to quickly absorb and mobilize the volume of
funds awarded over a short period.
· Challenges with flexibility. Officials from many jurisdictions told us
that some CDC awards from supplemental appropriations provided in
response to the COVID-19 pandemic had limited flexibility, such as
being able to be used for the mpox response.
· Challenges managing various awards with heavy workloads.
Managing the awards from supplemental appropriations during the
COVID-19 pandemic, such as tracking and reporting, was
complicated and took a lot of staff resources, according to some
jurisdictions. The pace and amount of award funding in response to
the COVID-19 pandemic made it particularly difficult to manage,
according to officials from one jurisdiction we interviewed, given the
jurisdiction’s small workforce and insufficient staff early in the
pandemic.
The challenges identified in our review are similar to some of the
challenges identified in our prior work examining federal awards from
supplemental appropriations provided in response to public health
Page 96 GAO-24-105891 Public Health Preparedness
Appendix V: Additional Challenges to
Managing Awards during Public Health
Emergencies
emergencies. See table 8 for challenges identified in prior GAO work by
challenge category.
Table 8: Challenges GAO Previously Reported on Related to Federal Awards from Supplemental Appropriations Provided in
Response to Public Health Emergencies
Type of challenge Examples
Spending large In January 2023, we reported that five states described challenges preparing and executing contracts with other
amounts of awarded organizations to implement programs supported by Centers for Disease Control and Prevention (CDC) awards
funds quickly from supplemental appropriations provided in response to the COVID-19 pandemic. These state officials cited
factors such as the amount of time required for state contracting processes, and the need to ensure that
organizations meet contract requirements. Additionally, we reported that according to officials from two states,
sometimes the limited capacity of local community-based organizations constrained state and local health
departments’ ability to allocate these awarded funds.a
In April 2022, we reported that states and localities generally experienced more challenges with COVID-19
supplemental appropriations for new programs than with existing programs. Some state and local COVID-19
relief programs and related awards, such as the Coronavirus State and Local Fiscal Recovery Funds, were
newly created under the COVID-19 relief laws. For example, states may have struggled to develop needed
infrastructure to manage newer programs, according to officials from the three states and several associations
we spoke with.b
Identifying allowable In April 2022, we reported that there may be some confusion among states and localities about which streams
uses of awarded of awarded funding should be used for specific purposes when allowable uses are similar and overlap with
funds other programs, according to association officials.b
In July 2021, we reported that Coronavirus Relief Fund recipients found the Department of the Treasury’s
guidance on eligible uses of the awarded funds to be unclear. For example, some states needed additional
guidance on eligible uses of the awards, which delayed their transferring funds to subrecipients, such as local
governments. In addition, unclear guidance increased the risk of recipients’ noncompliance with award
requirements.c
In May 2018, we reported that restrictions on authorized activities for awards from supplemental appropriations
in response to the Zika outbreak added administrative burdens for officials while they were busy responding to
that outbreak.d
In June 2011, we reported that states receiving awards from supplemental appropriations in response to the
H1N1 influenza pandemic found it difficult to plan and manage response activities due to the different award-
use limitations, according to the Association of State and Territorial Health Officials.e
Managing various In January 2023, we reported that officials from two states told us it was challenging to allocate funds from
awards with heavy multiple, large awards from supplemental appropriations while simultaneously addressing the emergent and
workloads dynamic health needs of the pandemic.a
In April 2022, we reported that states and localities may face challenges managing and meeting the various
reporting requirements for multiple awards. Officials from one association we interviewed then told us there
were concerns that some reporting requirements were duplicative and that it would be helpful to have more
alignment among reporting requirements for different awards from supplemental appropriations.b
In May 2018, we reported that jurisdictions cited various time frames among multiple awards from supplemental
appropriations while responding to the Zika outbreak as a source of added administrative burdens for officials to
manage while responding to the outbreak.d
Page 97 GAO-24-105891 Public Health Preparedness
Appendix V: Additional Challenges to
Managing Awards during Public Health
Emergencies
Type of challenge Examples
Hiring In January 2023, we reported that officials from all five selected states told us they experienced challenges
hiring qualified personnel to fill needed positions using CDC awards from supplemental appropriations.a
· Officials from three states said this was due to increased competition in hiring from a limited workforce and
the time-limited nature of positions supported by these funds.
· Two states also reported facing delays recruiting for new positions due to the length of time it took to obtain
state approval to create these positions, according to our interviews with state officials and review of state
documents.
Other In May 2018, we reported that recipients of awards from supplemental appropriations in response to the Zika
outbreak cited challenges with adjusting their plans when awarded funding was more or less than anticipated.d
In June 2011, we reported that some local officials said that the specific requirements of awards from
supplemental appropriations in response to the H1N1 influenza pandemic were heavily weighted toward
vaccination activities, but neither flexible nor sufficient enough to address epidemiology and laboratory
expenses.e
Source: GAO. | GAO-24-105891
a
GAO, COVID-19: HHS Funds Allocated to Support Disproportionately Affected Communities,
GAO-23-105500 (Washington, D.C.: Jan. 24, 2023).
b
See the COVID-19 Relief Funding to States and Localities enclosure in GAO, COVID-19: Current
and Future Federal Preparedness Requires Fixes to Improve Health Data and Address Improper
Payments, GAO-22-105397 (Washington, D.C.: Apr. 27, 2022).
c
See the Coronavirus State and Local Relief and Recovery Funds enclosure in GAO, COVID-19:
Continued Attention Needed to Enhance Federal Preparedness, Response, Service Delivery, and
Program Integrity, GAO-21-551 (Washington, D.C.: Jul. 19, 2021).
d
GAO, Zika Supplemental Funding: Status of HHS Agencies’ Obligations, Disbursements, and the
Activities Funded, GAO-18-389 (Washington, D.C.: May 14, 2018).
e
GAO, Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated into Future
Planning, GAO-11-632 (Washington, D.C.: Jun. 27, 2011).
Page 98 GAO-24-105891 Public Health Preparedness
Appendix VI: GAO Contact and Staff
Acknowledgments
Appendix VI: GAO Contact and
Staff Acknowledgments
GAO Contact
Mary Denigan-Macauley, (202) 512-7114, DeniganMacauleyM@gao.gov
Staff Acknowledgments
In addition to the contact named above, Deirdre G. Brown (Assistant
Director), Sarah Resavy (Analyst-in-Charge), Robin Burke, Giao N.
Nguyen, Catherine Paxton, Erin B. Pearson, and Celia C. Sawyerr made
key contributions to this report. Also contributing were Todd Anderson,
Jennie Apter, Kaitlin Farquharson, Diona Martyn, Eric Peterson, Shana
Sandberg, and Roxanna Sun.
Page 99 GAO-24-105891 Public Health Preparedness
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Government Accountability Office, 441 G Street NW, Room 7125, Washington,
DC 20548
Public Affairs
Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Strategic Planning and External Liaison
Stephen J. Sanford, Managing Director, spel@gao.gov, (202) 512-4707
U.S. Government Accountability Office, 441 G Street NW, Room 7814,
Washington, DC 20548
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- Our copy
- gao-24-105891.pdf
- Original
- www.gao.gov