Congressional Research Service R46834.1 (American Rescue Plan Act of 2021 (P.L. 117-2): Public Health, Medical Supply Chain, Health Services, and Related Provisions)
Summary
CRS report R46834, American Rescue Plan Act of 2021 (P.L. 117-2): Public Health, Medical Supply Chain, Health Services, and Related Provisions, coordinated by Johnathan H. Duff and Kavya Sekar, dated July 2, 2021. It describes ARPA as the sixth major legislative package addressing COVID-19 public health and health system challenges, and covers its public health, behavioral health, medical supply chain and health workforce provisions, most found in Title II and carried out largely by Department of Health and Human Services (HHS) agencies. The report summarizes funding for the Centers for Disease Control and Prevention (CDC) for the nationwide vaccination program, data modernization and assistance to state, local, territorial and tribal governments, for testing, surveillance and contact tracing, and for medical countermeasures.
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American Rescue Plan Act of 2021 (P.L. 117-2):
Public Health, Medical Supply Chain, Health
Services, and Related Provisions
July 2, 2021
Congressional Research Service
https://crsreports.congress.gov
R46834
SUMMARY
R46834
American Rescue Plan Act of 2021 (P.L. 117-2):
July 2, 2021
Public Health, Medical Supply Chain, Health
Johnathan H. Duff,
Services, and Related Provisions Coordinator
Analyst in Health Policy
The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) is the sixth major legislative
package in a series to address domestic public health and health system challenges Kavya Sekar, Coordinator
related to the Coronavirus Disease 2019 (COVID-19) pandemic—the most Analyst in Health Policy
consequential and widespread domestic infectious disease emergency in over a century.
This CRS report describes ARPA’s public health, behavioral health, medical supply
chain, and health-related workforce, services, and support provisions. These provisions
provide mandatory appropriations to support related activities. Most of these public
health-related provisions are found in Title II of the law. Many, but not all, of the provisions in this report are to be
carried out by agencies and offices based in the Department of Health and Human Services (HHS), particularly
those of the U.S. Public Health Service (PHS).
This report summarizes the following major ARPA provisions:
Public Health Infrastructure. ARPA provides substantial funding for the continued public
health response to the COVID-19 pandemic and more broadly for the nation’s public health
infrastructure and response capabilities. ARPA includes funding for the Centers for Disease
Control and Prevention (CDC) for the nationwide vaccination program, vaccine confidence
activities, data modernization, and assistance to state, local, territorial and tribal (SLTT)
governments, among others. It also provides funding to HHS and CDC for testing, surveillance,
and contact tracing, including tracking of variant viral strains.
Medical Countermeasures and Supply Chain. ARPA builds on previous COVID-19 relief acts
by providing funding to HHS for the research and development, manufacture, and purchase of
medical countermeasures related to COVID-19 (or any disease with pandemic potential). It also
provides funding for the Food and Drug Administration (FDA) to support medical
countermeasures and other activities. ARPA additionally provides funding for activities under the
Defense Production Act of 1950 related to the purchase, production, and distribution of medical
supplies related to addressing the COVID-19 pandemic, as well as public health needs for
infectious disease emergencies more broadly.
Health Workforce. ARPA provides funding to augment the public health and health care
workforce at the federal, state, and local levels. This funding includes financial support to recruit,
train, and retain new health workers. In addition, the law creates new programs targeting health
provider and public safety officer well-being and provides additional funding to further develop
the behavioral health workforce generally. ARPA also provides additional funding to increase the
number of providers who care for underserved and geographically isolated populations.
Health Care Infrastructure and Provider Support. ARPA provides additional funding to
certain types of health provider organizations, focusing on those that serve disadvantaged
populations (e.g., community health centers and support for family planning programs). It
includes provisions that specifically target rural health care providers and Certified Community
Behavioral Health Clinics (CCBHCs).
Mental Health and Substance Use. ARPA provides funding for Substance Abuse and Mental
Health Services Administration (SAMHSA) programs for community behavioral health activities.
Specifically, ARPA provides funding to SAMHSA’s largest block grant programs and for school-
based mental health, suicide prevention, childhood trauma, and pediatric mental health care
access via telemedicine.
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American Rescue Plan Act: Public Health and Related Provisions
Aging and Disability Services. ARPA provides funding for Administration for Community
Living (ACL) aging and disability services programs. The law provides funding to Older
Americans Act formula grant programs that provide nutrition and other supportive services with a
focus on vaccine outreach and education. It also provides funding to address social isolation,
funds the establishment of a National Technical Assistance Center on Grandfamilies and Kinship
Families, and grants additional funding to prevent, detect, and treat elder abuse, in part through
federal support to state Adult Protective Services (APS) programs.
Several of the programs funded by ARPA typically receive discretionary appropriations through the annual
appropriations process. Many of these programs receive mandatory appropriations for the first time through
ARPA. The funds for existing programs are generally provided “in addition to amounts otherwise available”—that
is, to supplement prior regular and COVID-19-related supplemental appropriations. Some ARPA provisions either
direct or allow for the funding of new activities; in these cases, the ARPA provision could generally serve as the
authorization for such activities. All ARPA appropriations in this report are for FY2021, and those funds are
available for multiple years or until expended.
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American Rescue Plan Act: Public Health and Related Provisions
Contents
Introduction ................................................................................................................... 1
Report Overview ....................................................................................................... 3
Public Health Infrastructure .............................................................................................. 8
Background .............................................................................................................. 8
Public Health Infrastructure Provisions ......................................................................... 9
Section 2301. Funding for COVID–19 Vaccine Activities at the Centers for
Disease Control and Prevention ........................................................................... 9
Section 2302. Funding for Vaccine Confidence Activities ......................................... 11
Section 2401. Funding for COVID-19 Testing, Contact Tracing, and
Mitigation Activities ........................................................................................ 12
Section 2402. Funding for SARS–CoV–2 Genomic Sequencing and Surveillance ........ 13
Section 2404. Funding for Data Modernization and Forecasting Center ...................... 14
Medical Countermeasures and Supply Chain ..................................................................... 16
Background ............................................................................................................ 16
Medical Countermeasures and Supply Chain Provisions ................................................ 17
Section 2303. Funding for Supply Chain for COVID-19 Vaccines, Therapeutics,
and Medical Supplies ....................................................................................... 17
Section 2304. Funding for COVID-19 Vaccine, Therapeutic, and Device
Activities at the Food and Drug Administration .................................................... 18
Section 3101. COVID-19 Emergency Medical Supplies Enhancement........................ 19
Health Workforce.......................................................................................................... 21
Background ............................................................................................................ 21
Health Workforce Provisions ..................................................................................... 22
Section 2501. Funding for Public Health Workforce ................................................ 22
Section 2502. Funding for Medical Reserve Corps .................................................. 23
Section 2602. Funding for National Health Service Corps......................................... 24
Section 2603. Funding for Nurse Corps ................................................................. 25
Section 2604. Funding for Teaching Health Centers that Operate Graduate
Medical Education ........................................................................................... 25
Sections 2703-2705. Funding for Behavioral Health for Health
Service Professionals ....................................................................................... 26
Section 2711. Funding for Behavioral Health Workforce Education and Training ......... 28
Health Care Infrastructure and Provider Support ................................................................ 28
Background ............................................................................................................ 28
Health Care Infrastructure and Provider Support Provisions ........................................... 29
Section 2601. Funding for Community Health Centers and Community Care .............. 29
Section 2605. Funding for Family Planning ............................................................ 30
Section 2713. Funding for Expansion Grants for Certified Community Behavioral
Health Clinics ................................................................................................. 31
Section 1002. Emergency Rural Development Grants for Rural Health Care, and
Section 9911. Funding for Providers Related to COVID-19.................................... 32
Section 11001. Indian Health Service .................................................................... 35
Mental Health and Substance Use.................................................................................... 37
Background ............................................................................................................ 37
Mental Health and Substance Use Provisions ............................................................... 38
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Sections 2701-2702. Funding for Block Grants for Community Mental Health
Services and Prevention and Treatment of Substance Abuse ................................... 38
Sections 2706-2707. Funding for Community-Based Funding for Local Substance
Use Disorder Services and Local Behavioral Health Needs .................................... 39
Section 2708. Funding for the National Child Traumatic Stress Network..................... 40
Section 2709. Funding for Project AWARE ............................................................ 40
Section 2710. Funding for Youth Suicide Prevention................................................ 41
Section 2712. Funding for Pediatric Mental Health Care Access ................................ 42
Aging and Disability Services ......................................................................................... 42
Background ............................................................................................................ 42
Aging and Disability Services Provisions .................................................................... 43
Section 2921. Supporting Older Americans and Their Families.................................. 43
Section 2922. National Technical Assistance Center on Grandfamilies and
Kinship Families ............................................................................................. 44
Section 9301. Additional Funding for Aging and Disability Services Programs ............ 46
Tables
Table 1. Brief Summaries of ARPA Public Health Provisions ................................................. 4
Appendixes
Appendix. Abbreviations Used in This Report ................................................................... 48
Contacts
Author Information ....................................................................................................... 50
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Introduction
The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) is the sixth major legislative package
in a series to address domestic public health and health system challenges related to the
Coronavirus Disease 2019 (COVID-19) pandemic—the most consequential and widespread
domestic infectious disease emergency in over a century. ARPA follows several earlier COVID-
19 pandemic response measures enacted in 2020. ARPA includes provisions addressing a number
of issues, such as tax credits, unemployment benefits, state fiscal relief, health, housing,
education, and food assistance, among others.
This report describes ARPA’s public health, behavioral health, medical supply chain, and health-
related workforce, services, and support provisions. Most of these public health-related provisions
are found in Title II of the law. Many, but not all, of the ARPA provisions in this report are carried
out by agencies and offices in the Department of Health and Human Services (HHS), especially
those of the U.S. Public Health Service (PHS). 1 This report does not address health care financing
provisions of ARPA, which are addressed in CRS Report R46777, American Rescue Plan Act of
2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare Provisions. This
report also does not address certain provisions specific to federal health care systems outside of
HHS; for example, provisions specific to the Veterans Health Administration.
ARPA follows five earlier major COVID-19-related relief laws that addressed public health and
related issues:
The Coronavirus Preparedness and Response Supplemental Appropriations Act,
2020 (P.L. 116-123), enacted on March 6, 2020.
The Families First Coronavirus Response Act (FFCRA, P.L. 116-127), enacted
on March 18, 2020.
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act, P.L. 116-
136), enacted on March 27, 2020.
The Paycheck Protection Program and Health Care Enhancement Act
(PPPHCEA, P.L. 116-139), enacted on April 24, 2020.
The Consolidated Appropriations Act, 2021 (P.L. 116-260), enacted on December
27, 2020. 2
Among other things, the prior COVID-19-related laws provided substantial funding, almost
entirely in the form of supplemental discretionary appropriations, to the U.S. Public Health
Service agencies and offices for COVID-19 pandemic response (as summarized in CRS Report
1 T he U.S. Public Health Service (PHS) comprises eight agencies and two offices within the Department of Health and
Human Services (HHS). T hese include the Agency for Healthcare Research and Quality (AHRQ), the Agency for
T oxic Substances and Disease Registry (AT SDR), the Centers for Disease Control and Prevention (CDC), the Food and
Drug Administration (FDA), the Health Resources and Services Administration (HRSA), the Indian Health Service
(IHS), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration
(SAMHSA). T he two HHS offices that are a part of the Public Health Service (PHS) are the Office of the Assistant
Secretary for Preparedness and Response (ASPR) and the Office of Global Affairs (OGA). T he Office of the Assistant
Secretary for Health (OASH) is responsible for leadership and coordination of the Public Health Service. Other HHS
operating divisions that are not a part of PHS include the Administration for Children and Families (ACF), the
Administration for Community Living (ACL), and the Centers for Medicare & Medicaid Services (CMS). See HHS,
“HHS Organizational Chart,” https://www.hhs.gov/about/agencies/orgchart/index.html.
2 Several divisions of P.L. 116-260, Consolidated Appropriations Act, 2021, included provisions that addressed public
health issues (in addition to the regular appropriations in the law), including Divisions M, N, BB and CC.
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R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th
Congress). Many of these agencies and offices receive additional funding through ARPA, as
summarized in this report.
ARPA was considered by Congress through the budget reconciliation process. 3 (For a summary of
the reconciliation process for ARPA, see “Budget Reconciliation Process” in CRS Report
R46777, American Rescue Plan Act of 2021 (P.L. 117-2): Private Health Insurance, Medicaid,
CHIP, and Medicare Provisions.) The funding in ARPA is distinct from the public health funding
provided in the supplemental appropriations divisions 4 of earlier relief measures: per budget
reconciliation requirements, it was provided in an authorizing rather than an appropriations
measure. 5 Thus, the funding in ARPA is classified as mandatory rather than discretionary
spending, because the funds are appropriated in an authorizing law. 6 The funding provided by
ARPA is appropriated for FY2021 and each of the appropriations identified in this report is
available for multiple years or until expended.
Many of the programs funded by ARPA are typically funded through the annual discretionary
appropriations process. Some programs receive mandatory appropriations for the first time
through ARPA. The ARPA funds for previously existing programs are generally provided “in
addition to amounts otherwise available”—that is, to supplement funds made available through
prior regular and supplemental appropriations laws.
In some instances, ARPA funding is for purposes specified in existing statutory authorizations, for
example, funding for youth suicide prevention in Section 2710. In others, ARPA funding is for
activities for which there is no preexisting dedicated program or program-specific statutory
authorization. For example, funding for the public health workforce in Section 2501 of ARPA is
not designated to an existing HHS statutory authority or program, but rather to the HHS Secretary
to carry out specified activities. In these cases, the ARPA provision could generally serve as the
authorization for such activities. In other instances, ARPA provides funding to be used broadly for
certain activities, but the act does not identify specific amounts for existing statutory authorities,
programs, or activities. For example, funding in Section 2402 is made available for genomic
sequencing and surveillance activities at the Centers for Disease Control and Prevention (CDC).
In these cases, executive branch officials and administering agencies would generally have
discretion to allocate ARPA funding for existing programs or use it to fund new activities.
Likewise, executive agencies would determine requirements for new activities funded through
ARPA pursuant to the parameters specified in that law. Even when ARPA funding supports
3 Consideration of ARPA began early in the 117 th Congress. On February 8, 2021, House Ways and Means Committee
Chairman Richard E. Neal released nine legislative proposals to be considered under the budget reconciliation
instructions. On February 27, 2021, the House passed these proposals as part of the American Rescue Plan Act of 2 021
(ARPA; H.R. 1319). On March 4, 2021, the Senate version of the American Rescue Plan Act of 2021, S.Amdt. 891 to
H.R. 1319, was offered. On Saturday March 6, 2021, the Senate adopted S.Amdt. 891 and subsequently passed H.R.
1319, as amended. On March 10, 2021, the House agreed to the Senate-passed version of H.R. 1319 as amended by
S.Amdt. 891. On March 11, 2021, the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) was signed into law.
T he versions of the bill passed on March 6 in the Senate and March 10 in the House are substantively identical to the
law as enacted.
4
Divisions of prior relief laws that included supplemental discretionary appropriation s for public health purposes
include Division A of the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 ( P.L. 116-
123); Division A of the Families First Coronavirus Response Act (FFCRA, P.L. 116-127); Division B of the
Coronavirus Aid, Relief, and Economic Security Act (CARES Act, P.L. 116-136); Paycheck Protection Program and
Health Care Enhancement Act (PPPHCEA, P.L. 116-139); and Division M of Consolidated Appropriations Act, 2021
(P.L. 116-260).
5 See CRS Report R44058, The Budget Reconciliation Process: Stages of Consideration.
6 For a discussion of discretionary versus mandatory appropriations mechanisms, see CRS Report R44582, Overview of
Funding Mechanisms in the Federal Budget Process, and Selected Examples.
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activities similar to existing programs, new activities may be established through ARPA
provisions. These new activities potentially may not be subject to the same requirements—such
as reporting requirements—as existing activities authorized elsewhere in law. In some cases,
ARPA provisions explicitly establish a new program, for example, the emergency pilot program
for rural health care in Section 1002.
In addition, unlike prior pandemic-related relief laws, several ARPA public health provisions are
not limited to pandemic-specific activities and may be used to address broader activities that have
been highlighted by the pandemic. For example, several of the appropriations in the “Public
Health Infrastructure” and “Medical Countermeasures and Supply Chain” sections allow funds to
be used for activities related to other pathogens or diseases in addition to COVID-19. Many of the
broader health-related infrastructure, workforce, and support program provisions in ARPA
provide funding for related activities broadly (rather than specifically in response to the
pandemic).
Report Overview
This report describes ARPA provisions related to public health, behavioral health, the medical
supply chain, and health-related workforce, services, and support. The provision summaries are
grouped under the following categorical report sections: (1) “Public Health Infrastructure,” (2)
“Medical Countermeasures and Supply Chain,” (3) “Health Workforce,” (4) “Health Care
Infrastructure and Provider Support,” (5) “Mental Health and Substance Use,” and (6) “Aging
and Disability Services.” These provisions are found mostly in Title II of ARPA. (Exceptions
include the medical supply enhancement provision in Title III, additional funding for aging and
disability services in Title IX, and three health care infrastructure and provider support provisions
in Titles I, IX, and XI, respectively.) Each report section includes a broad overview of the relevant
context for each policy area and continues with a brief summary of related ARPA provisions,
followed by the policy context (background) and a more detailed summary for each ARPA
provision. This report describes the law as enacted on March 11, 2021, and will not be updated to
track implementation or amendments to the law. Numbers that appear throughout this report may
not necessarily add to totals due to rounding. A table with abbreviations used throughout the
report is included in the Appendix.
The following is a snapshot of the ARPA provisions covered in this report:
Public Health Infrastructure. ARPA provides substantial funding for the continued public
health response to the COVID-19 pandemic and more broadly for the nation’s public health
infrastructure and response capabilities. ARPA provides funding to the CDC for the nationwide
vaccination program, vaccine confidence activities, data modernization, and assistance to state,
local, territorial, and tribal (SLTT) governments, among others. It also provides funding to the
HHS and CDC for testing, surveillance, and contact tracing, including tracking of variant viral
strains.
Medical Countermeasures and Supply Chain. ARPA builds on previous COVID-19
supplemental measures by providing funding to HHS for the research and development,
manufacture, and purchase of medical countermeasures related to COVID-19 or any disease with
pandemic potential. It also provides funding for the Food and Drug Administration (FDA) to
support medical countermeasures and other activities. ARPA provides funding for activities under
the Defense Production Act of 1950 related to the purchase, production, and distribution of
medical supplies related to combatting the COVID-19 pandemic, as well as public health needs
for infectious disease emergencies more broadly.
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Health Workforce: ARPA provides additional funding to augment the public health and health
care workforce at the federal, state, and local levels. This financial support includes funding to
recruit, train, and retain new health workers. In addition, the law creates new programs targeting
health provider and public safety officer well-being and provides additional funding to further
develop the behavioral health workforce generally. ARPA also provides additional funding to
increase the number of providers who care for underserved and geographically isolated
populations. This support includes funding for programs that train or that provide scholarships or
loan repayments to health providers who care for underserved populations.
Health Care Infrastructure and Provider Support. ARPA provides additional funding to
certain types of health provider organizations, focusing on those that serve disadvantaged
populations (e.g., community health centers and support for family planning programs). It
includes two provisions that specifically target rural health care providers. One of these
provisions creates a fund similar to the existing Provider Relief Fund (PRF) but with a new
funding stream available only to rural facilities. The other provision creates a new program within
the U.S. Department of Agriculture (USDA) that makes grants to rural facilities for a number of
purposes, including increased costs related to vaccine distribution.
Mental Health and Substance Use: ARPA provides funding for Substance Abuse and Mental
Health Services Administration (SAMHSA) programs for community behavioral health activities.
This funding includes support for SAMHSA’s largest block grant programs, school-based mental
health, suicide prevention, childhood trauma, and pediatric mental health care access via
telemedicine.
Aging and Disability Services: ARPA provides funding to the Administration for Community
Living (ACL) for aging and disability services programs. The law provides funding to Older
Americans Act (OAA) formula grant programs that provide nutrition and other supportive
services, with a focus on vaccine outreach and education and activities to address social isolation.
The law also funds the establishment of a National Technical Assistance Center on Grandfamilies
and Kinship Families, and provides additional funding to prevent, detect, and treat elder abuse, in
part through federal support to state Adult Protective Services (APS) programs.
Table 1 lists the ARPA provisions included in this report, organized by the categories outlined
above (the provisions are not organized sequentially). The table includes the section number, title,
a brief description of the provision, the duration of funding availability, and the CRS points of
contact for further questions. More information on each ARPA provision is found in the
corresponding section later in the report.
Table 1. Brief Summaries of ARPA Public Health Provisions
CRS
Section Period of Points of
Number Section Title Description of Section Availability a Contact
Public Health Infrastructure
2301 Funding for COVID-19 vaccine Section 2301 appropriates $7.5 billion to the CDC Director Until Sarah A.
activities at the Centers for Disease to plan, prepare for, promote, distribute, administer, monitor, expended. Lister
Control and Prevention and track COVID-19 vaccines. It also provides for additional Kavya
SLTT vaccination program grants for certain eligible grantees.b Sekar
2302 Funding for vaccine confidence Section 2302 appropriates $1 billion to the CDC Director to Until Sarah A.
activities strengthen vaccine confidence, provide further information expended. Lister
regarding vaccines, and to improve rates of vaccination Kavya
throughout the United States.b Sekar
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CRS
Section Period of Points of
Number Section Title Description of Section Availability a Contact
2401 Funding for COVID-19 testing, Section 2401 appropriates $47.8 billion to the HHS Secretary Until Kavya
contact tracing, and mitigation to carry out activities to detect, diagnose, trace, and monitor expended. Sekar,
activities SARS-CoV-2 and COVID-19 infections and related strategies Amanda K.
to mitigate the spread of COVID-19. Sarata,
Sarah A.
Lister
2402 Funding for SARS-CoV-2 genomic Section 2402 appropriates $1.75 billion to the CDC Director Until Kavya
sequencing and surveillance to expand and improve genomic sequencing and the expended. Sekar,
surveillance of pathogens, including SARS-CoV-2.b Amanda K.
Sarata,
Sarah A.
Lister
2404 Funding for data modernization and Section 2404 appropriates $500 million to the CDC Director Until Kavya
forecasting center to support public health data surveillance and infrastructure expended. Sekar
modernization initiatives, and to modernize the U.S. disease
warning system to forecast and track hotspots for COVID-19
and other emerging biological threats.b
Medical Countermeasures and Supply Chain
2303 Funding for supply chain for Section 2303 appropriates $6.05 billion to the HHS Secretary Until Kavya
COVID-19 vaccines, therapeutics, for medical countermeasure (MCM) research, development, expended. Sekar,
and medical supplies manufacture, production, and purchase to prevent, prepare Frank
for, or respond to COVID-19 or “any disease with potential Gottron
for creating a pandemic.”
2304 Funding for COVID-19 vaccine, Section 2304 appropriates $500 million to the HHS Secretary Until Agata
therapeutic, and device activities at for various MCM activities at FDA. expended. Bodie
the Food and Drug Administration
3101 COVID-19 emergency medical Section 3101 appropriates $10 billion to support DPA actions Until Michael H.
supplies enhancement related to the purchase, production, or distribution of medical September 30, Cecire,
supplies and equipment related to combatting COVID-19. 2025. Heidi M.
After September 30, 2022, appropriations may be used for Peters
any activity “necessary to meet critical public health needs”
related to any pathogen that has potential for creating a public
health emergency as determined by the President.
Health Workforce
2501 Funding for public health workforce Section 2501 appropriates $7.66 billion to the HHS Secretary Until Sarah A.
to establish, expand, and sustain the public health workforce, expended. Lister,
including the distribution of awards to state, local, and Elayne J.
territorial public health departments. Heisler
2502 Funding for Medical Reserve Corps Section 2502 appropriates $100 million to the HHS Secretary Until Sarah A.
to implement the MRC. expended. Lister
2602 Funding for National Health Service Section 2602 appropriates $800 million to the HHS Secretary Until Elayne J.
Corps to carry out the National Health Service Corps (NHSC) expended. Heisler
scholarship, loan repayment, and state loan repayment
programs.
2603 Funding for Nurse Corps Section 2603 appropriates $200 million to the HHS Secretary Until Elayne J.
to carry out the Nurse Corps program. expended. Heisler
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CRS
Section Period of Points of
Number Section Title Description of Section Availability a Contact
2604 Funding for teaching health centers Section 2604 appropriates $330 million to the HHS Secretary Until Elayne J.
that operate graduate medical to carry out the teaching health center program and award September 30, Heisler
education teaching health center development grants. 2023.
2703 Funding for mental health and Section 2703 appropriates $80 million to the HRSA Until Elayne J.
substance use disorder training for Administrator to award grants or contracts to specified expended. Heisler,
health care professionals, entities to plan, develop, operate, or participate in evidence- Johnathan
paraprofessionals, and public safety informed strategies to reduce suicide, burnout, mental health Duff
officers conditions and substance use disorders among health care
professionals and public safety officers.b
2704 Funding for education and Section 2704 appropriates $20 million to the CDC Director Until Elayne J.
awareness campaign encouraging to carry out a national education and awareness campaign to expended. Heisler,
healthy work conditions and use of encourage health care professionals, first responders, and Johnathan
mental health and substance use their employers to (1) prevent mental health and substance H. Duff
disorder services by health care use disorders and seek support and treatment, and (2) help
professionals identify risk factors in themselves and others and respond to
such risks.b
2705 Funding for grants for health care Section 2705 appropriates $40 million to the HRSA Until Elayne J.
providers to promote mental Administrator to award grants or contracts to health care expended. Heisler,
health among their health entities to establish or expand evidence-informed protocols Johnathan
professional workforce to promote mental health among their workforces.b H. Duff
2711 Funding for behavioral health Section 2711 appropriates $100 million to the HHS Secretary Until Elayne J.
workforce education and training to carry out the behavioral health workforce education and expended. Heisler
training (BHWET) program.
Health Care Infrastructure and Provider Support
2601 Funding for community health Section 2601 appropriates $7.6 billion to the HHS Secretary Until Elayne J.
centers and community care for grants or contracts for community health centers, or for expended. Heisler
grants specifically to FQHC-look-alikes, with not less than $20
million reserved for grants or contracts with Native Hawaiian
Health Care System entities.
2605 Funding for family planning Section 2605 appropriates $50 million to the HHS Secretary Until Angela
to carry out the PHSA Title X program. expended. Napili
2713 Funding for expansion grants for Section 2713 appropriates $420 million to the SAMHSA Until Johnathan
certified community behavioral Assistant Secretary for Mental Health and Substance Use for expended. H. Duff
health clinics grants to Certified Community Behavioral Health Clinics
(CCBHCs).b
1002 Emergency rural development Section 1002 appropriates $500 million to the USDA Until Alyssa R.
grants for rural health care Secretary to establish an emergency pilot program to provide September 30, Casey
grants “to be awarded by the Secretary based on rural 2023.
development needs related to the COVID-19 pandemic.”
9911 Funding for providers relating to Section 9911 appropriates $8.5 billion to the HHS Secretary Until Elayne J.
COVID-19 to make payments to eligible rural health care providers to expended. Heisler
account for lost revenue and increased health care-related
expenses due to COVID-19.
11001 Indian Health Service Section 11001 appropriates $6.094 billion to the HHS Until Elayne J.
Secretary for select IHS health services and public health expended. Heisler
activities, improvements to IHS facilities to respond to
COVID-19, and for potable water delivery.
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CRS
Section Period of Points of
Number Section Title Description of Section Availability a Contact
Mental Health and Substance Use
2701 Funding for block grants for Section 2701 appropriates $1.5 billion to the HHS Secretary Until Johnathan
community mental health services to carry out SAMHSA’s MHBG program. Any amount expended. H. Duff
awarded to a state from this amount must be expended by
September 30, 2025.
2702 Funding for block grants for Section 2702 appropriates $1.5 billion to the HHS Secretary Until Johnathan
prevention and treatment of to carry out SAMHSA’s SABG program. Any amount awarded expended. H. Duff
substance abuse to a state from this amount must be expended by September
30, 2025.
2706 Funding for community-based Section 2706 appropriates $30 million to the SAMHSA Until Johnathan
funding for local substance use Assistant Secretary for Mental Health and Substance Use (in expended. H. Duff
disorder services consultation with the CDC Director) to support “community-
based overdose prevention programs, syringe services
programs, and other harm reduction services.” b
2707 Funding for community-based Section 2707 appropriates $50 million to the SAMHSA Until Johnathan
funding for local behavioral health Assistant Secretary for Mental Health and Substance Use for expended. H. Duff
needs grants for specified activities to “address increased community
behavioral health needs worsened by the COVID-19 public
health emergency.” b
2708 Funding for the National Child Section 2708 appropriates $10 million to the HHS Secretary Until Johnathan
Traumatic Stress Network to carry out the National Child Traumatic Stress Initiative expended. H. Duff
“with respect to addressing the problem of high-risk or
medically underserved persons who experience violence-
related stress.”
2709 Funding for Project AWARE c Section 2709 appropriates $30 million to the HHS Secretary Until Johnathan
to carry out activities “with respect to advancing wellness and expended. H. Duff
resiliency in education.”
2710 Funding for youth suicide Section 2710 appropriates $20 million to the HHS Secretary Until Johnathan
prevention for youth suicide prevention activities. expended. H. Duff
2712 Funding for pediatric mental health Section 2712 appropriates $80 million to the HHS Secretary Until Elayne J.
care access for pediatric mental health care access. expended. Heisler
Aging and Disability Services
2921 Supporting Older Americans and Section 2921 appropriates $1.434 billion to the HHS Until Kirsten J.
their families Secretary to carry out select OAA statutory formula grant expended. Colello
programs.
2922 National Technical Assistance Section 2922 appropriates $10 million to the ACL Until Jared S.
Center on Grandfamilies and Administrator to establish a National Technical Center on September 30, Sussman
Kinship Families Grandfamilies and Kinship Families to provide training, 2025.
technical assistance, and resources for government programs,
nonprofit and other community-based organizations, and
Indian Tribes, tribal organizations, and urban Indian
organizations.b
9301 Additional funding for aging and Section 9301 appropriates $276 million to carry out EJA Until Kirsten J.
disability services programs activities under SSA Title XX, Subtitle B. Of that total, not expended. Colello
less than $100 million is reserved to enhance state APS
programs for each fiscal year.
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Source: CRS analysis of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2).
Notes: ACL = Administration for Community Living; APS = Adult Protective Services; BHWET = Behavioral
Health Workforce Education and Training; CCBHC = Certified Community Behavioral Health Clinic; CDC =
Centers for Disease Control and Prevention; COVID-19 = Coronavirus Disease 2019; DPA = Defense
Production Act of 1950 (P.L. 81-774); EJA = Elder Justice Act; FDA = Food and Drug Administration; FQHC =
Federally Qualified Health Center; FY = Fiscal Year; GME = Graduate Medical Education; HHS = Department of
Health and Human Services; HRSA = Health Resources and Services Administration; IHS = Indian Health Service;
MCM = Medical Countermeasures; MHBG = Community Mental Health Services Block Grant; MRC = Medical
Reserve Corps; NHSC = National Health Service Corps; OAA = Older Americans Act (P.L. 89 -73, as amended);
(Project) AWARE = Advancing Wellness and Resilience in Education; PHSA = Public Health Service Act; SABG =
Substance Abuse Prevention and Treatment Block Grant; SAMHSA = Substance Abuse and Mental Health
Services Administration; SARS-CoV-2 = the name of the virus that causes COVID-19; SLTT = State, Local,
Territorial, and Tribal; SSA = Social Security Act; USDA = U.S. Department of Agriculture.
a. “Period of availability” denotes the deadline for the federal government to obligate the funds.
b. Indicates ARPA provision where funding is appropriated to the HHS Secretary “acting through” the
specified HHS agency head. Specified HHS agency leadership includes the ACL Administrator, CDC
Director, HRSA Administrator, and SAMHSA Assistant Secretary for Mental Health and Substance Use.
c. Project AWARE stands for Advancing Wellness and Resiliency in Education.
Public Health Infrastructure
Background
The nation’s public health system, at both the federal and the state, local, territorial, and tribal
(SLTT) levels, is the foundation on which a successful outbreak or pandemic response rests.
Significant federal investments in the system followed the anthrax attacks of 2001. After that, the
threat of emerging infections continued, with an influenza pandemic in 2009, and U.S. domestic
cases of Ebola and Zika virus infections during outbreaks in 2014 and 2016, respectively. 7
Despite efforts to strengthen national public health capacity, according to some assessments, the
system has continued to face challenges with shortfalls in funding, staffing, technological
capability, and surge capacity. The National Academy of Medicine, in an April 2021 impact
assessment, noted several challenges that have long affected the nation’s public health system and
have now affected its response to the COVID-19 pandemic. These challenges included
institutional silos, inadequate and rigid funding streams, ambiguities over authority at different
levels, and neglected infrastructure and workforce development. 8 The National Health Security
Preparedness Index (NHSPI) is a public/private evaluation partnership that includes all 50 states
and the District of Columbia. The NHSPI 2020 evaluation found that although state and national
health security scores (called Index Values) continued to improve over prior years, the national
scores remained below 6 (out of 10) for the domains of “Community Planning and Engagement”
and “Healthcare Delivery.”9 Scores for “Countermeasure Management” were below 7 (out of 10).
7 CRS memorandum for general distribution, Historical Emergency Response Funding for Selected Infectious Disease
Outbreaks, May 21, 2020. Contact CRS to obtain a copy.
8 Karen DeSalvo, Bob Hughes, Mary Bassett, et al., Public Health COVID-19 Impact Assessment: Lessons Learned
and Compelling Needs, National Academy of Medicine, April 7, 2021, https://nam.edu/public-health-covid-19-impact-
assessment-lessons-learned-and-compelling-needs/.
9 Robert Wood Johnson Foundation and partners, National Health Security Preparedness Index, 2020 Release, undated,
figure 3, p. 5, https://nhspi.org/tools-resources/2020-key-findings/nhspi_2020_key_findings/. “Community Planning
and Engagement” includes actions to develop and maintain supportive relationships among government agencies,
community organizations, and individual households, and to develop shared plans for responding to disasters and
emergencies. “Healthcare Delivery” includes actions to ensure access to high-quality medical services across the
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The domestic response to the COVID-19 pandemic has strained the public health system with a
challenging rollout of disease testing, prolonged shortages of other critical supplies, multiple
disease surges that overwhelmed health care capacity in certain areas, and an unprecedented mass
vaccination campaign.
Through emergency supplemental discretionary appropriations in five previous COVID-19 relief
acts, Congress provided CDC with $15.3 billion. Much of this funding was provided for broad
purposes, such as “to prevent, prepare for, and respond to coronavirus,” while some of it was
provided to focus on testing or vaccination activities, among others. 10 Almost half of the CDC
funds were directed to extramural assistance (e.g., grants and cooperative agreements for SLTT
and some for foreign assistance). Appropriations to the HHS Secretary in the Public Health and
Social Services Emergency Fund (PHSSEF) provided additional funds for both broad and specific
public health purposes, such as $47.4 billion for expansion of testing, surveillance, and contact
tracing.
ARPA provides substantial funding for the continued public health response to the pandemic and
to support the nation’s public health infrastructure more broadly, including $10.75 billion to CDC
for activities such as the nationwide vaccination program, vaccine confidence activities, data
modernization, tracking of variant viral strains, and assistance to SLTT. ARPA provides almost
$48 billion to the HHS Secretary for testing, contact tracing, and surveillance.
Public Health Infrastructure Provisions
Section 2301. Funding for COVID–19 Vaccine Activities at the Centers for
Disease Control and Prevention
Background
COVID-19 vaccination is a means to reduce the spread of the disease and facilitate the
resumption of pre-pandemic activities. In general, for COVID-19 vaccines to effectively
reduce disease transmission, a large percentage of the population must be vaccinated. 11
Vaccination programs often aim to achieve herd immunity against an infectious disease. Extensive
vaccination short of the herd immunity threshold would still aid in curbing disease spread and
severe illness among the population. 12 Whether herd immunity for COVID-19 is achievable
continuum of care during and after disasters and emergencies.
10
CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
11
Centers for Disease Control and Prevention, “Benefits of Getting Vaccinated” April 2, 2021, at https://www.cdc.gov/
coronavirus/2019-ncov/vaccines/vaccine-benefits.html.
12
A population is said to have reached herd immunity to a disease when a sufficient percentage of that population
becomes immune to the disease, thus inhibiting ongoing transmission of the disease, which protects those who cannot
be vaccinated (e.g., persons with compromised immune systems). U.S. Government Accountability Office, Science &
T ech Spotlight: Herd Immunity for COVID-19, GAO-20-646SP, July 7, 2020, https://www.gao.gov/products/gao-20-
646sp.
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remains to be seen, with estimates ranging from 70%-90% of the population. 13 Given this
benchmark, public health experts generally recommend vaccinating as many people as possible. 14
COVID-19 mass vaccination planning for the United States has been underway since at least
September 2020. 15 As initial supplies of vaccine were limited, the plan outlined that vaccines
would be allocated to state health departments, which would then prioritize populations to receive
vaccines (with guidance from CDC) and redistribute the vaccine to local public health
departments and other partners for the purposes of mass administration. 16 Prior COVID-19
supplemental appropriations acts included funding for the vaccination campaign, particularly to
support the operations of programs run by state and local health departments. In addition to broad
funding for CDC public health activities, in the fifth COVID-19 pandemic supplemental measure
(P.L. 116-260), a total of $8.75 billion was made available to the CDC for “activities to plan,
prepare for, promote, distribute, administer, monitor, and track coronavirus vaccines to ensure
broad-based distribution, access, and vaccine coverage.”17 Of that total, at least $4.5 billion was
for SLTT grants or cooperative agreements.
Provision
Section 2301 appropriates $7.5 billion, to remain available until expended, to the CDC Director
for activities to plan, prepare for, promote, distribute, administer, monitor, and track COVID-19
vaccines. 18 The provision directs the CDC Director to (1) conduct activities to enhance, expand,
and improve nationwide COVID-19 vaccine distribution and administration (including activities
related to the distribution of ancillary vaccine supplies), and (2) provide technical assistance,
guidance, and support, and to award grants or cooperative agreements to SLTT public health
departments to improve COVID-19 vaccine distribution and administration. CDC and awardees
may use funds for facility enhancements, transportation for vaccinees, mobile vaccination units,
and other specified activities.
This provision also provides for additional SLTT vaccination program grants for certain eligible
grantees according to an allotment formula proportional to the CDC Public Health Emergency
Preparedness cooperative agreement allotments for FY2020 (as specified). 19 The provision
requires the HHS Secretary to determine which grantees received allocations of CDC grant funds
13 Christie Aschwanden, “Five Reasons why COVID Herd Immunity is Probably Impossible,” Nature, March 18, 2021;
Jon Cohen, “How Soon Will COVID-19 Vaccines Return Life to Normal?” Science, February 16, 2021; and Mayo
Clinic, “Herd Immunity and COVID-19 (Coronavirus): What You Need to Know,” March 3, 2021,
https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808.
14 Gypsyamber D’Souza and David Dowdy, What is Herd Immunity and How Can We Achieve it with COVID-19?,
Johns Hopkins Bloomberg School of Public Health, April 6, 2021, https://www.jhsph.edu/covid-19/articles/achieving-
herd-immunity-with-covid19.html.
15 U.S. Department of Health and Human Services, “ T rump Administration Releases COVID-19 Vaccine Distribution
Strategy,” press release, September 16, 2020.
16 U.S. Department of Health and Human Services, “COVID-19 Vaccine Distribution: T he Process,” March 17, 2021,
at https://www.hhs.gov/coronavirus/covid-19-vaccines/distribution/index.html; and Centers for Disease Control and
Prevention, “COVID-19 Pandemic Vaccination Planning: Update for State and Local Public Health Programs,” press
release, August 4, 2020.
17 CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
18 Section 2301 appropriates funding to the HHS Secretary “acting through” the CDC Director.
19 T he Public Health Emergency Preparedness (PHEP) cooperative agreement is a grant program that provides annual
funding to 62 state, territorial, and local grantees. It is authorized by Public Health Service Act, §319C-1 [42 U.S.C.
§247d–3a]. See CDC, “ Public Health Emergency Preparedness (PHEP) Cooperative Agreement ,”
https://www.cdc.gov/cpr/readiness/phep.html.
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American Rescue Plan Act: Public Health and Related Provisions
for their vaccination programs under Title III of Division M of Consolidated Appropriations Act,
2021 (P.L. 116-260), that were less than they would have received by following the alternative
proportional allocation directed in this section, and to award the difference to such grantees
within 21 days of enactment.
This provision does not specify how much of the total appropriation is to be awarded as SLTT
grants or cooperative agreements, and generally gives discretion to CDC to determine SLTT
award amounts (aside from the required supplemental awards).
Section 2302. Funding for Vaccine Confidence Activities
Background
Vaccine confidence refers to the trust that the general public has in the safety and efficacy of
vaccines as life-saving measures, as well as the policies and processes underpinning vaccine
development and safety assurance. 20 Lapses in vaccine confidence may contribute to vaccine
hesitancy, which refers to members of the public delaying or refusing vaccination, despite
availability. 21 Vaccine hesitancy is often multifactorial, driven by confidence, access, awareness,
among other factors. A rise in vaccine hesitancy may contribute to a rise in vaccine-preventable
disease, as fewer people opt to receive the vaccine. 22 Although national vaccination coverage
rates for most recommended childhood vaccines meet target levels, these rates obscure
underlying trends in recent years where a third of young children have delayed or missed at least
one recommended vaccine. 23 CDC has found that the measles outbreaks in 2018 and 2019—the
highest levels of U.S. measles cases since the early 1990s—were driven, in part, by widespread
misinformation about vaccines in certain communities. 24
Although surveys show fewer Americans declining to be vaccinated for COVID-19 over time, 25
CDC has stated that an increase in vaccine confidence may increase vaccine uptake and in turn
lessen the severity of the COVID-19 pandemic. 26 Some studies have found associations between
exposure to COVID-19 vaccine misinformation and declines in vaccination intent. 27
20
U.S. Department of Health and Human Services, “ Featured Priority: Vaccine Confidence,” August 6, 2019, at
https://www.hhs.gov/vaccines/featured-priorities/vaccine-confidence/index.html.
21
For a practical example on how vaccine confidence can influence the resurgence of communicable disease, see
National Vaccine Advisory Committee, Assessing the State of Vaccine Confidence in the United States;
Recommendations from the National Vaccine Advisory Committee, November, 2015, pp. 573-595,
https://www.hhs.gov/sites/default/files/nvpo/about/vaccines/nvac-vaccine-confidence-public-health-report-2015.pdf.
22 Eve Dube, Caroline Laberge, Maryse Guay, et al., “Vaccine Hesitancy: An Overview,” Human Vaccines and
Immunotherapeutics, vol. 9, no. 8 (August 1, 2013), pp. 1763-1773.
23
National Academy of Medicine, Vaccine Access and Hesitancy Part One of a Workshop Series Proceedings of a
Workshop- in Brief, August 2020, p. 3.
24 Ibid., and CDC, “Measles Cases and Outbreaks,” last updated March 9, 2021, https://www.cdc.gov/measles/cases-
outbreaks.html.
25
See for example Emmarie Huetteman, “ Covid Vaccine Hesitancy Drops Among All Americans, New Survey
Shows,” Kaiser Health News, March 30, 2021, https://khn.org/news/article/covid-vaccine-hesitancy-drops-among-
americans-new-kff-survey-shows/.https://khn.org/news/article/covid-vaccine-hesitancy-drops-among-americans-new-
kff-survey-shows.
26 Centers for Disease Control and Prevention, “Vaccinate with Confidence,” April 5, 202 1, at https://www.cdc.gov/
vaccines/covid-19/vaccinate-with-confidence.html.
27 See, for example, Sahil Loomba, Alexandre de Figueiredo, Simon J. Piatek, et al., “Measuring the Impact of COVID -
19 Vaccine Misinformation on Vaccination Intent in the UK and USA,” Nature Human Behavior, vol. 5 (2021), pp.
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Provision
Section 2302 appropriates $1 billion to the CDC Director, 28 to remain available until expended, to
(1) strengthen vaccine confidence in the United States (and its territories and possessions ); (2)
provide further information and education with respect to vaccines authorized for emergency use
or licensed by the FDA;29 and (3) to improve rates of vaccination throughout the United States
and its territories and possessions. The provision refers to the Public Health Service Act (PHSA)
Section 313 authority for a public awareness campaign on the importance of vaccinations,
established in Section 311 of Division BB of Consolidated Appropriations Act, 2021 (P.L. 116-
260). Section 2302 does not address COVID-19 vaccines specifically, and thus may be used to
fund efforts to boost confidence for vaccines other than those for COVID-19.
Section 2401. Funding for COVID-19 Testing, Contact Tracing, and
Mitigation Activities
Background
COVID-19 testing and contact tracing efforts continue to be critical in the effort to reduce
community transmission of COVID-19 infection. Throughout the pandemic, efforts to boost
testing, contact tracing, and associated activities have faced numerous challenges, including lack
of coordination and disjointed efforts among states; supply chain issues; ongoing stress on the
nation’s public health and laboratory infrastructure; and difficulties scaling up contact tracing
programs and obtaining information on contacts from exposed individuals. 30 A prior relief law,
PPPHCEA (P.L. 116-139), required HHS to submit testing strategy reports to Congress every 90
days until funds under the act are expended; these reports had been submitted to Congress three
times in 2020. 31 The Government Accountability Office (GAO) has noted that these strategies did
not meet best practices for national strategy formulation and, in particular, did not provide clear
and explicit goals, activities, and performance measures.32 Upon assuming office, President Biden
established a COVID-19 Pandemic Testing Board to coordinate testing efforts nationally through
an executive order 33 issued on January 21, 2021, a component of his national strategy for
pandemic response. 34 The Biden Administration has not yet published a comprehensive national
testing strategy.
337-48.
28 Section 2302 appropriates funding to the HHS Secretary “acting through” the CDC Director.
29 CRS Report R46427, Development and Regulation of Medical Countermeasures for COVID-19 (Vaccines,
Diagnostics, and Treatments): Frequently Asked Questions.
30
Karen DeSalvo, Bob Hughes, Mary Bassett, et al., Public Health COVID-19 Impact Assessment: Lessons Learned
and Compelling Needs, National Academy of Medicine, April 7, 2021, https://nam.edu/public-health-covid-19-impact-
assessment-lessons-learned-and-compelling-needs/; John Schneider, Willie Love, Laura Rusie et al., “COVID-19
Contact T racing Conundrums: Insights From the Front Lines,” American Journal of Public Health, April 7, 2021; and
CRS In Focus IF11774, COVID-19 Testing Supply Chain.
31
U.S. Government Accountability Office, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its
Second Year, GAO-21-387, March 31, 2021, pp. 90-91, https://www.gao.gov/assets/gao-21-387.pdf.
32 U.S. Government Accountability Office, COVID-19 Critical Vaccine Distribution, Supply Chain, Program Integrity,
and Other Challenges Require Focused Federal Attention , January 2021, pp. 79-90, https://www.gao.gov/assets/gao-
21-265.pdf.
33 Executive Order 13996, 86 Federal Register 7197, January 21, 2021.
34 White House, National Strategy for the COVID-19 Response and Pandemic Preparedness, January 2021, p. 12,
https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-
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Previous COVID-19 pandemic relief acts included funds to support public health efforts to
increase testing capacity, expand and train contact tracing and case investigation staff, and
improve internal and public data sharing. 35 In particular, PPPHCEA (P.L. 116-139) and
Consolidated Appropriations Act, 2021 (P.L. 116-260), supplemental appropriations provided a
total of $47.4 billion specifically for the expansion of testing, contact tracing and related
activities. These funds were in addition to several other broad accounts and funding that could be
used for testing-related purposes. 36 As reported by GAO in March 2021, HHS reported total
obligations of $42.9 billion for testing-related activities as of February 28, 2021. 37
Provision
Section 2401 appropriates $47.8 billion to the HHS Secretary, to remain available until expended,
to carry out activities to detect, diagnose, trace, and monitor SARS–CoV–2 (the virus that causes
COVID-19) and COVID-19 infections, and related strategies to mitigate the spread of COVID-
19. Funds are to be used to carry out the following pandemic response activities: (1) implement a
national testing, contact tracing, surveillance, and mitigation strategy; (2) provide grant or
cooperative agreement funding and technical guidance to SLTT public health departments for this
effort; (3) support the development, manufacture, procurement, and distribution of supplies
necessary for administering tests (e.g., personal protective equipment), and the acquisition,
construction, renovation, or alteration of nonfederal sites used for the production of COVID-19
tests and related supplies; (4) invest in improving laboratory and contact tracing capacity,
including through academic and research labs, community testing sites and organizations, and
mobile testing services, as well as investments with respect to quarantine and isolation of
contacts; (5) support public health data sharing through information technology, data
modernization, and reporting; (6) provide grants to SLTT to improve the public health workforce;
and (7) cover administrative and program support costs.
This provision does not specify how much of the total appropriation is to be awarded as SLTT
grants or cooperative agreements, and generally gives discretion to the HHS Secretary to
determine SLTT award amounts.
Section 2402. Funding for SARS–CoV–2 Genomic Sequencing
and Surveillance
Background
Coronaviruses constantly change and mutate. The emergence of new variants may lead to
increased transmissibility, different symptoms and severity of disease, different groups at risk of
the virus and disease, and/or decreased effectiveness of medical countermeasures (e.g., vaccines,
treatments). Identifying and tracking virus variants primarily relies on genomic surveillance—
ongoing and systematic genomic sequencing of virus samples collected from patients to classify
sequences and identify epidemiological characteristics associated with certain sequences. 38
Pandemic-Preparedness.pdf.
35 CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
36 Ibid.
37
U.S. Government Accountability Office, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its
Second Year, GAO-21-387, March 31, 2021, p. 92, https://www.gao.gov/assets/gao-21-387.pdf.
38 CDC, “ SARS-CoV-2 Variant Classifications and Definitions,” https://www.cdc.gov/coronavirus/2019-ncov/cases-
updates/variant-surveillance/variant-info.html.
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Genomic surveillance is complex, involving not only sequencing viral genomes, but also
developing capabilities to process and analyze large volumes of data. Such efforts involve
specialized equipment, software, personnel, and bioinformatics expertise, as well as coordinated
strategies to identify and prioritize patient samples for sequencing and to determine subsequent
public health and health care responses.39
CDC has expanded genomic surveillance efforts nationally in late 2020 and early 2021 through
several efforts, including by collecting patient samples from states and other jurisdictions for
sequencing, by partnering with commercial and other laboratories, and by facilitating genomic
surveillance capacity within jurisdictions through grant funding. CDC has used appropriations
available in several prior supplemental appropriations acts to fund these efforts. 40
Provision
Section 2402 appropriates $1.75 billion to the CDC Director, to remain available until expended,
to (1) conduct, expand, and improve activities to sequence genomes, identify mutations, and
survey the circulation of pathogens, including SARS-CoV-2; (2) award grants and cooperative
agreements to SLTT public health departments and laboratories to increase genomic surveillance
capacity, including by using genome sequencing to identify outbreaks and clusters of diseases or
infections such as COVID-19, and developing response strategies based on such data; (3) enhance
and expand informatics capabilities of the public health workforce; and (4) award grants to
construct, alter, or renovate facilities to improve genomic sequencing and surveillance capacity.
While the provision header refers to “SARS-CoV-2,” the provision language refers to genomic
surveillance and sequencing of pathogens broadly; therefore, the funding may have implications
for genomic surveillance for other pathogens and diseases.
Section 2404. Funding for Data Modernization and Forecasting Center
Background
The public health response to an infectious disease emergency involves many types of data—in
the context of the COVID-19 pandemic, this has included data on testing, cases, hospitalizations,
and deaths, among others. While the public health sector collects and analyzes such data to
inform its response efforts, much of the data rely on records and reporting from mostly private
health care entities, such as laboratories and hospitals. Data reporting requirements and systems
are often governed by law and policy at the state and subfederal levels. Prior to the pandemic,
public health data sharing often relied on outdated means of exchange, such as by paper or fax-
based methods as well as manual data input processes.
In 2014, following broad implementation of interoperable electronic health records in the health
care system, CDC initiated a surveillance strategy to modernize the means of data exchange
39 James S. Koopman and Betsy Foxman, “Chapter 26: Using Genetic Sequence Data for Public Health Surveillance,”
in Transforming Public Health Surveillance: Proactive Measures for Prevention, Detection and Response (Elsevier:
2016), ed. Scott JN McNabb, J Mark Conde, Lisa Ferland et al., pp. 362 -363; and Kelsey Lane Warmbrod, Rachel
West, Matthew Frieman et al., Staying Ahead of the Variants: Policy Recommendation to Identify and Manage Current
and Future Variants of Concerns, Johns Hopkins Bloomberg School of Public Health: Center for Health Security,
Feburary 2021, https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2021/20210216-covid19-
variants.pdf; and CRS In Focus IF11789, COVID-19 Variants: Vaccines, Diagnostics, and Therapeutics.
40 CRS In Focus IF11789, COVID-19 Variants: Vaccines, Diagnostics, and Therapeutics; and CDC, “Genomic
Surveillance for SARS-CoV-2 Variants,” https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-
surveillance.html.
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between the public health and health care sectors, including by facilitating electronic reporting of
death records, disease cases, and laboratory results. CDC received specific funding of $50 million
to support these efforts starting in FY2020 appropriations (P.L. 116-94), following a white paper
by the Council of State and Territorial Epidemiologists (CSTE) calling for the creation of a
“public health data superhighway” to facilitate automatic, interoperable public health data
exchange. 41 Still, by the time of the pandemic, reliance on nonelectronic or inefficient reporting
methods remained pervasive in the public health system, affecting the timeliness, completeness ,
and accuracy of data for response. 42
In addition, public health responses to infectious disease threats often rely on forecasting, or
estimates of the future spread of infectious diseases and projected impacts of various public
health interventions on disease spread (e.g., stay-at-home orders, mask mandates). During the
COVID-19 pandemic, disease forecasting efforts were affected by several challenges: inherent
scientific uncertainties; availability and quality of the underlying data; differing methodologies
and purposes for models; and disagreements or misunderstandings about how to interpret and use
model outputs for decisionmaking. 43 Dozens of different models and forecasts of varying quality
were created by research institutions around the country, adding to the confusion and
uncertainty. 44 Some observers have advocated for creating a national disease forecasting center,
similar to the National Weather Service, to coordinate and lead such efforts and serve as an “early
warning system” for infectious disease threats. 45
Prior COVID-19 relief measures provided CDC with broad funding to support public health
surveillance, data modernization, and disease forecasting. In particular, CDC received not less
than $500 million in the CARES Act (P.L. 116-136) specifically for “public health data
surveillance and analytics infrastructure modernization.” With these new funds, CDC has
expanded electronic reporting of test results, cases, and deaths. It has also begun to make
investments to more broadly modernize public health data systems and sharing across
jurisdictions, systems, and sectors.46 Through an executive order issued on January 26, 2021, the
Biden Administration established a coordinated interagency structure to improve and modernize
public health data for pandemic response and other public health threats. 47
41 T he white paper is available from Council of State and T erritorial Epidemiologists, “CST E Releases White Paper—
Driving Public Health in the Fast Lane,” press release, October 1, 2019, https://www.cste.org/news/474011/CST E-
Releases-White-Paper—Driving-Public-Health-in-the-Fast-Lane.htm.
42
CRS Report R46588, Tracking COVID-19: U.S. Public Health Surveillance and Data.
43 U.S. Government Accountability Office, Science and Tech Spotlight: COVID-19 Modeling, GAO-20-582SP, June
2020, https://www.gao.gov/assets/gao-20-582sp.pdf.
44 Jin Jin, Neha Agarwala, Prosenjit Kundu, et al., “T ransparency, Reproducibility, and Validation of COVID-19
Projection Models,” Johns Hopkins Bloomberg School of Public Health: COVID-19 School of Public Health Insights,
June 22, 2020, https://www.jhsph.edu/covid-19/articles/transparency-reproducibility-and-validation-of-covid-19-
projection-models.html.
45 See, for example, Sara Del Valle, “We Need to Forecast Epidemics like we Forecast the Weather,” STAT News, July
27, 2020.
46
CDC, “ CDC Data Modernization Initiative - Notable Milestones: 2019-2021,” https://www.cdc.gov/surveillance/
surveillance-data-strategies/milestones_2019-2020.html.
47 Executive Order 13994, “Ensuring a Data-Driven Response to COVID–19 and Future High-Consequence Public
Health T hreats,” 86 Federal Register 15, January 26, 2021.
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Provision
Section 2404 appropriates $500 million to the CDC Director, 48 to remain available until
expended, to support public health data surveillance and infrastructure modernization initiatives
and to establish, expand, and maintain efforts to modernize the United States disease warning
system to forecast and track hotspots for COVID-19, virus variants, and other emerging
biological threats. These efforts include academic and workforce support for analytics and
informatics infrastructure and data collection systems. Though the provision header refers to a
“center,” the provision language does not explicitly direct funds to be used to establish a center.
In addition, the provision language refers to “other emerging biological threats”; therefore, the
funds may have implications for public health data and forecasting efforts broader than those
specifically in response to the COVID-19 pandemic.
Medical Countermeasures and Supply Chain
Background
At the onset of the pandemic, there were few treatment options for COVID-19 and no vaccines
available to prevent the disease. Increased demand for personal protective equipment (PPE) and
other medical supplies disrupted medical product supply chains, resulting in shortages. This
situation highlighted larger issues about U.S. reliance on foreign sources of medical products and
the federal government’s ability to oversee the supply chain and mitigate future disruptions. 49
A critical part of the COVID-19 public health response has been the development and
manufacture of medical countermeasures (MCMs), that is, medical products that may be used to
treat, prevent, or diagnose conditions associated with emerging infectious diseases or chemical,
biological, radiological, or nuclear agents. MCMs include biologics (e.g., vaccines, monoclonal
antibodies), drugs (e.g., antimicrobials, antivirals), and medical devices (e.g., diagnostic tests,
PPE). 50 The federal government—primarily through the National Institutes of Health (NIH), the
Biomedical Advanced Research and Development Authority (BARDA), the FDA, and the
Department of Defense (DOD)—has supported the research and development (R&D), regulation,
manufacture, and purchase of MCMs for COVID-19.51 In addition, the Trump and Biden
Administrations have taken actions related to the Defense Production Act (DPA) to support the
domestic manufacture of MCMs for COVID-19, including vaccines, PPE, diagnostics, and
related supplies. 52 The DPA confers presidential authorities to mobilize domestic industry to
expand production and allocation of goods, materials, and services. As a result of these efforts, a
number of treatments and vaccines for COVID-19 are now available, and millions of Americans
48 Section 2404 appropriates funding to the HHS Secretary “acting through” the CDC Director.
49 For additional information, see CRS Report R46628, COVID-19 and Domestic PPE Production and Distribution:
Issues and Policy Options; CRS Report R46507, FDA’s Role in the Medical Product Supply Chain and Considerations
During COVID-19; and CRS In Focus IF11488, Personal Protective Equipment (PPE) and COVID-19: FDA
Regulation and Related Activities.
50 For additional information, see CRS Report R46427, Development and Regulation of Medical Countermeasures for
COVID-19 (Vaccines, Diagnostics, and Treatments): Frequently Asked Questions.
51 Under the T rump Administration, these efforts, particularly those related to vaccines, were conducted primarily
under Operation Warp Speed (OWS), an interagency partnership between HHS and DOD. T he Biden Administration
had indicated that OWS would be restructured and renamed.
52 CRS Insight IN11470, Defense Production Act (DPA): Recent Developments in Response to COVID-19, and CRS
Insight IN11593, New Presidential Directives on the Defense Production Act (DPA) and the COVID-19 Pandemic.
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have been vaccinated. However, medical product shortages and supply chain vulnerability
concerns have continued throughout the pandemic.53
Previous COVID-19 supplemental measures provided funding for the R&D, regulation,
manufacture, and purchase of COVID-19 MCMs. This funding was provided to accounts within
NIH, FDA, and DOD, as well as to the Public Health and Social Services Emergency Fund
(PHSSEF) under the HHS Office of the Secretary. The PHSSEF receives annual appropriations
for the routine operations of several HHS offices, including the Office of the HHS Assistant
Secretary for Preparedness and Response (ASPR), where BARDA resides. This account is also
used for one-time or short-term funding, such as emergency supplemental appropriations. 54
ARPA continues the efforts of previous COVID-19 supplemental measures by providing $6.05
billion in funding to HHS for the R&D, manufacture, and purchase of MCMs related to COVID-
19 or any disease with pandemic potential, as well as $500 million for FDA activities to support
MCM regulatory and other activities. ARPA also provides $10 billion for activities under the DPA
related to the purchase, production, and distribution of medical supplies related to combatting the
COVID-19 pandemic, as well as public health needs more broadly.
Medical Countermeasures and Supply Chain Provisions
Section 2303. Funding for Supply Chain for COVID-19 Vaccines, Therapeutics,
and Medical Supplies
Background
Many operating divisions within HHS support research and development related to infectious
diseases, as well as the development, manufacture and—for emergency circumstances in
particular—procurement of medical products such as vaccines, therapeutics, and medical
supplies. 55 These include, but are not limited to, ASPR, BARDA, FDA, CDC, and NIH, each of
which has played a major role in the federal response to develop, manufacture, and make
available medical products for COVID-19. In particular, NIH and BARDA have supported
medical product research and development, and BARDA has awarded contracts and other
agreements to private companies for the development, manufacture, and purchase of MCMs such
as vaccines, therapeutics, and ancillary medical supplies (e.g., needles, syringes, vials). For these
response efforts, HHS has partnered with additional agencies and departments, such as DOD.56
From the five COVID-19 supplemental appropriations measures enacted in 2020, a total of not
less than $4.8 billion (accounting for transfers) was made available to NIH, and a total of not less
than $24.2 billion was specifically designated for BARDA (through set-asides in the PHSSEF
account), with additional funds that could be allocated to the agency from broad appropriations in
53 FDA, “ Medical Device Shortages During the COVID-19 Public Health Emergency,” accessed March 31, 2021,
https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/medical-device-shortages-during-
covid-19-public-health-emergency. See also CRS Insight IN11544, Supply Chain Considerations for COVID-19
Vaccine Manufacturing, and CRS Insight IN11560, Operation Warp Speed Contracts for COVID-19 Vaccines and
Ancillary Vaccination Materials.
54 CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
55
HHS, “About HHS,” 2021, https://www.hhs.gov/about/index.html.
56 CRS Report R46427, Development and Regulation of Medical Countermeasures for COVID-19 (Vaccines,
Diagnostics, and Treatments): Frequently Asked Questions.
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the PHSSEF account. In addition, funds for CDC and FDA have been made available, in part, to
support those agencies’ research and manufacturing efforts. 57
Provision
Section 2303 appropriates $6.05 billion to the HHS Secretary, to remain available until expended,
for various MCM activities to prevent, prepare for, or respond to COVID-19, the SARS-CoV-2
virus and related variants, or “any disease with potential for creating a pandemic.” These
activities include research, development, manufacturing, production, and purchase of vaccines,
therapeutics, and ancillary medical supplies.
This provision is notable in two ways. First, this provision gives the HHS Secretary discretion to
allocate funds among the various HHS operating divisions, without specifying which operating
divisions are to receive funds or how much each are to receive. In typical discretionary
appropriations acts, funds for MCM-related purposes are appropriated to HHS accounts that fund
specific agencies or offices within HHS; for example, appropriations are made to NIH Institute
and Center (IC) accounts or to the PHSSEF account that funds BARDA. Second, this provision
provides these funds to prevent, prepare for, or respond to any disease with potential for creating
a pandemic—not COVID-19 alone. Therefore, an undefined amount of funds may be used for
and/or remain available to support MCM activities for other infectious disease threats.
Section 2304. Funding for COVID-19 Vaccine, Therapeutic, and Device
Activities at the Food and Drug Administration
Background
FDA regulates the safety, effectiveness, and quality of MCMs through premarket and pos tmarket
activities. With respect to its premarket work, FDA has granted marketing approval, clearance,
and emergency use authorization (EUA) to COVID-19 therapeutics, vaccines, diagnostics, and
other medical devices (e.g., respirators and ventilators).58 In addition, FDA has issued guidance to
facilitate COVID-19 MCM development and marketing authorization. As part of its postmarket
work, FDA has monitored medical product shortages59 and worked with the pharmaceutical
industry and federal partners to accelerate the adoption of advanced manufacturing technologies
(i.e., technologies that may improve product quality, reduce shortages, and speed time to
market). 60
57
CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
58 FDA, Emergency Use Authorization, “ Coronavirus Disease 2019 (COVID-19) EUA Information,”
https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-
use-authorization#covid19euas.
59
See for example, FDA, “ Medical Device Shortages During the COVID-19 Public Health Emergency,” accessed
March 31, 2021, https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/medical-device-
shortages-during-covid-19-public-health-emergency; and “Drug Shortages,” accessed March 31, 2021,
https://www.fda.gov/drugs/drug-safety-and-availability/drug-shortages.
60 FDA, “Accelerating the Adoption of Advanced Manufacturing T echnologies to Strengthen Our Public Health
Infrastructure,” January 15, 2021, https://www.fda.gov/news-events/fda-voices/accelerating-adoption-advanced-
manufacturing-technologies-strengthen-our-public-health. See also, FDA, “Advanced Manufacturing,” updated January
16, 2021, https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/advanced-manufacturing.
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Previous COVID-19 supplemental measures provided funding to FDA for various regulatory
activities. Across four of the five supplemental laws, FDA received a total of $218 million. 61 This
included $196 million to the agency’s salaries and expenses account to “prevent, prepare for, and
respond to coronavirus domestically and internationally.”62 These funds were to be used for
activities such as pre- and postmarket work on MCMs, EUAs, monitoring of medical product
supply chains, advanced manufacturing, and related administrative activities. In addition,
PPPHCEA (P.L. 116-139) directed a transfer of $22 million from the PHSSEF to FDA to support
activities associated with “diagnostic, serological, antigen, and other tests, and related
administrative activities.”63
Provision
Section 2304 provides $500 million to the HHS Secretary, to remain available until expended, for
various MCM activities at FDA. Such activities include FDA’s evaluation of continued
performance, safety, and effectiveness of COVID-19 vaccines, therapeutics, and diagnostics,
including with respect to emerging SARS-CoV-2 variants; facilitation of advanced continuous
manufacturing activities related to the manufacture of vaccines and related materials; inspections
related to manufacturing of vaccines, therapeutics, and devices that were delayed or canceled
because of COVID-19; review of devices authorized for use for the treatment, prevention, or
diagnosis of COVID-19; and oversight of the supply chain and mitigation of COVID-19 MCM
shortages.
Section 3101. COVID-19 Emergency Medical Supplies Enhancement
Background
The Defense Production Act of 1950 (DPA) confers broad presidential authorities to mobilize
domestic industry in service of the national defense, defined in statute as various military
activities and “homeland security, stockpiling, space, and any directly related activity” (50 U.S.C.
§4552), including emergency preparedness activities under the Stafford Act, which has been used
for public health emergencies. DPA authorities include (1) provisions under Title I to prioritize
contracts and allocate scarce goods, materials, and services; (2) financial incentives under Title III
to expand productive capacity for critical materials and goods; and (3) coordination, information
gathering, and other supporting provisions under Title VII. 64
Actions under DPA authorities are generally funded through typical or supplemental agency
appropriations, with the exception of Title III projects, which receive direct appropriations
through the DPA Fund. The DPA Fund is a statutory, “no year” DPA account managed by DOD
but statutorily available for Title III actions across the federal government. Although DPA Fund
monies may carry over, the statute places an annual cap of $750 million, beyond which funds
may be forfeited. However, the CARES Act temporarily lifted this cap for two years from
enactment, or through late March 2022.
61 CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
62 P.L. 116-123, Division A; P.L. 116-136, Division A; and P.L. 116-260, Division M.
63
P.L. 116-139, Division B.
64 CRS Insight IN11619, New COVID-19 Defense Production Act (DPA) Actions: Implementation Considerations;
CRS Insight IN11229, Stafford Act Assistance for Public Health Incidents; and CRS Report R43767, The Defense
Production Act of 1950: History, Authorities, and Considerations for Congress.
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Prior to the enactment of ARPA, the use of DPA Fund monies, particularly $1 billion appropriated
under the CARES Act, was a source of dispute between congressional and DOD leadership. 65 The
dispute centered on DOD’s use of DPA Fund monies, which included investments in the
nonmedical defense industrial base. 66 In all, approximately two-thirds of CARES Act DPA Fund
appropriations were obligated for defense industrial base investments, rather than for domestic
health-related investments. In January 2021, the Biden Administration issued several executive
orders invoking the DPA to augment pharmaceutical supply chains to address the COVID-19
pandemic, particularly for vaccines. In a February 2021 briefing, White House COVID-19 Supply
Chain Coordinator Timothy W. Manning noted that the Biden Administration’s DPA efforts
required congressional appropriations to achieve their intended effects. 67
Provision
Section 3101 provides $10 billion to support DPA actions under Titles I, III, and VII (i.e., all
active DPA titles) with respect to the “purchase, production (including the construction, repair,
and retrofitting of government-owned or private facilities as necessary), or distribution of medical
supplies and equipment (including durable medical equipment) related to combatting the COVID-
19 pandemic.” The legislation specifies various relevant articles, including in vitro diagnostic
products and their chemical or material components; personal protective equipment (PPE), such
as face masks, nitrile gloves, and N95 respirators; as well as “drugs, devices, and biological
products” authorized for treating or preventing COVID-19, such as vaccines. Funds are available
until September 30, 2025. However, after September 30, 2022, appropriations may be used for
any activity “necessary to meet critical public health needs,” with respect to any pathogen that has
potential for creating a public health emergency, as determined by the President.
Compared with typical and previous DPA-related appropriations made to the DPA Fund, Section
3101 more directly appropriates funding for health and medical countermeasures for infectious
diseases. According to the accompanying explanatory statement on the bill, the House Financial
Services Committee—the DPA’s statutory committee of jurisdiction in the House of
Representatives—specifies an expectation that the funds be used exclusively for health and
medical resources, primarily employed by HHS, and appropriated in a new HHS account other
than the DPA Fund. 68 The House report language also describes a clear intent to appropriate those
funds to HHS, which is consistent with the original House Financial Services Committee bill text,
which also cited HHS directly. 69 Section 3101 contains other novelties with regard to DPA-related
65 For more information, see CRS Report R46628, COVID-19 and Domestic PPE Production and Distribution: Issues
and Policy Options.
66 For a selection of congressional inquiries related to the DPA fund, see U.S. Congress, House Financial Services,
Letter to DOD and HHS, July 14, 2020, at https://financialservices.house.gov/uploadedfiles/
ltr_to_hhs_and_fema_7142020.pdf; and Letter from Hon. James E. Clyburn, Chairman, House Select Subcommittee on
the Coronavirus Crisis; Hon. Maxine Waters, Chairwoman, House Committee on Financial Services; Hon. Carolyn B.
Maloney, Chairwoman, House Committee on Oversight and Reform; and Hon. Stephen F. Lynch, Chairman, Hous e
Subcommittee on National Security, to Hon. Mark T . Esper, Secretary of Defense, October 2, 2020, at
https://coronavirus.house.gov/sites/democrats.coronavirus.house.gov/files/2020-10-
02.Clyburn%20Waters%20CBM%20SFL%20%20to%20Esper -%20DOD%20re%20CARES%20Act.pdf.
67
CRS Insight IN11619, New COVID-19 Defense Production Act (DPA) Actions: Implementation Considerations, and
CRS Insight IN11593, New Presidential Directives on the Defense Production Act (DPA) and the COVID-19
Pandemic.
68 Chairwoman Maxine Waters, “American Rescue Plan Act of 2021,” Explanatory Statement on H.R. 1319,
Congressional Record, daily edition, vol. 167, part 45 (March 10, 2021), p. H1281, https://www.congress.gov/117/
crec/2021/03/10/CREC-2021-03-10-pt1-PgH1196.pdf.
69 U.S. Congress, House Committee on the Budget, American Rescue Plan Act of 2021: Report of the Committee on the
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appropriations. As it does not make use of the DPA Fund, Section 3101 does not amend or modify
the DPA Fund’s annual cap. Instead, funds are available for use until September 30, 2025. In
addition, because Section 3101 makes funding available for all actions under the DPA, the $10
billion may set a new precedent, given that past DPA-related appropriations were made only to
the Title III account (the DPA Fund), and other actions were funded from non-DPA
appropriations. 70
Health Workforce
Background
COVID-19 pandemic preparedness and response has required mobilization of the public health
workforce and the patient care workforce to test, treat, and vaccinate patients. For both
workforces, the pandemic revealed underlying challenges related to workforc e shortages overall,
in certain disciplines, and in specific geographic locations. In addition, the pandemic may have
exacerbated issues related to clinician burnout. One survey found that 52% of providers reported
experiencing burnout and 62% reported that worry or stress during the pandemic has adversely
affected their mental health. 71
Though concerns about the patient care workforce have persisted throughout the pandemic, prior
pandemic response measures did not include additional funding for federal workforce programs,72
such as those administered by the Health Resources and Services Administration (HRSA) to
support training for the primary care, public health, and behavioral health workforces. These laws
did, however, provide substantial funding to support public health workforce support, as
discussed below. Historically, the federal government has supported some programs to train the
clinical and public health workforces.
ARPA provides additional funding for new and existing federal programs to augment the public
health and health care workforce at the federal, state, and local levels, including $7.66 billion to
recruit, train, and retain new public health workers. The law also creates new programs to target
health provider and public safety officer well-being and provides additional funding to programs
that support developing the behavioral health workforce generally. ARPA also provides additional
funding for existing programs that seek to increase the number of providers who care for
underserved and geographically isolated populations. This financial support includes additional
Budget, report to accompany H.R. 1319 together with minority views, 117 th Cong., 1 st sess., February 21, 2021, H.Rept.
117-7 (Washington: GPO, 2021), https://www.congress.gov/117/crpt/hrpt7/CRPT-117hrpt7.pdf.
70
For more discussion of the potential impact of this issue, see CRS Insight IN11619, New COVID-19 Defense
Production Act (DPA) Actions: Implementation Considerations, by Michael H. Cecire, Nina M. Hart, and Heidi M.
Peters.
71 Scott Clement, Cece Pascual, and Monica Ulamanu, “Stress on the Front Lines of Covid-19: Health Care Workers
Share the Hardest Part of Working During the Pandemic,” Washington Post, April 6, 2021,
https://www.washingtonpost.com/health/2021/04/06/stress-front-lines-health-care-workers-share-hardest-parts-
working-during-pandemic/. Other studies have shown increased anxiety, depression, sleep problems, and distress
among health care workers during the COVID-19 pandemic. See, for example, Ashley E. Muller, Elisabet V. Hafstad,
Jan P. W. Himmels, et al., “ T he Mental Health Impact of the COVID-19 Pandemic on Healthcare Workers, and
Interventions to Help T hem: A Rapid Systematic Review,” Psychiatry Research, vol. 293 (November 2020).
72 States license health care providers and determine their scope of practice. T o increase the workforce available to
provide clinical care, states have waived a number of licensure requirements. See, for example, Federation of State
Medical Boards, U.S. States and Territories Modifying Requirements for Telehealth in Response to COVID-19, March
31, 2021, https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-
response-to-covid-19.pdf.
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funding for existing programs that train health providers in outpatient settings who provide care
to underserved populations, as well as for programs that provide scholarship and loan repayments
to health providers in exchange for providing care to underserved populations. The additional
funding does not require that the new providers work in COVID-19-related health care. The
funding represents an increase to existing programs that in some cases substantially exceeds
recent annual program funding levels.
Health Workforce Provisions
Section 2501. Funding for Public Health Workforce
Background
The nation’s public health workforce is expected to prepare for and respond to public health
emergencies, such as the opioid epidemic and COVID-19 pandemic, as well as to routine
community health burdens, such as diabetes and sexually transmitted infections. This workforce
has decreased since 2010, based in part on state budget constraints, uncertain funding sources,
and other factors. According to a 2019 survey of state health departments by the Association of
State and Territorial Health Officials (ASTHO), 73
the [State Health Agency] SHA workforce comprises a diverse group of people who work
in fields ranging from administrative work and financial operations to healthcare and
environmental health. Between 2010 and 2019, the overall SHA workforce decreased by
15.3% from 108,059 to 91,540 full-time equivalents (FTEs). On average, the workforce
has decreased by over 5,500 FTEs every three years since 2010.
In 2019, only 9.9% of the workforce represented staff who focus on preparedness efforts. 74
The National Association of County & City Health Officials (NACCHO) 75 reported a similar
trend among the workforce in local health departments (LHDs), saying,
Since 2008, the estimated number of LHD full-time equivalents (FTEs) decreased from
162,000 to 136,000 in 2019—a decrease of approximately 16%.... During roughly that
same time period, the overall population increased by about 8%. Despite a slight increase
in the number of both FTEs and all employees from 2016 to 2019 … the workforce has not
fully recovered from the cuts suffered during and after the Great Recession. 76
According to ASTHO, from 2015 through 2018, HHS funding (excluding Medicare and
Medicaid) provided about 22% of SHA revenues overall through various awards to support public
health activities, including hiring, training, and retention of staff to carry out these activities. 77
73 AST HO is a national nonprofit organization representing U.S. state and territorial public health officials and staff.
See Association of State and T erritorial Health Officials, “About Us,” https://www.astho.org/About/.
74 Association of State and T erritorial Health Officials (AST HO), “Data Brief: State Public Health Resources and
Capacity,” March 23, 2020, https://www.astho.org/Research/Data-and-Analysis/Data-Brief-on-State-Public-Health-
Resources-and-Capacity/.
75 NAACHO is a national nonprofit organization representing U.S. local public health department officials and staff.
See National Association of County & City Health Officials, “About Us,” https://www.naccho.org/about.
76 NACCHO, “NACCHO’s 2019 Profile Study: Changes in Local Health Depar tment Workforce and Finance Capacity
Since 2008; Research Brief,” May, 2020, https://www.naccho.org/uploads/downloadable-resources/2019-Profile-
Workforce-and-Finance-Capacity.pdf. T he brief refers to the Great Recession of 2007-2009.
77 Calculated by CRS from AST HO, “AST HO Profile of State Public Health,” vol. 4, Funding; Modal 4: Expenditures,
All States, undated, https://www.astho.org/profile/#openModal4.
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This federal funding level was sustained during the survey period, whereas revenues from state
sources declined. 78
The five COVID-19 pandemic supplemental appropriations measures enacted in 2020 provided
substantial additional financial assistance that nonfederal public health agencies have used or can
use to hire, train, and retain staff for the pandemic response, among other expenditures. This
assistance included not less than $2.45 billion to CDC for grants to SLTT health organizations,
among other funding. 79
Provision
Section 2501 appropriates $7.66 billion to the HHS Secretary, to remain available until expended,
to carry out activities to establish, expand, and sustain the public health workforce. These funds
are to be used in part to make awards to state, local, and territorial public health departments 80 to
carry out the following activities, in particular:
Recruit, hire, and train public health workers to serve in specified roles, including
community health work, case investigation and contact tracing, epidemiology
and laboratory analysis, information management, communications, and any
other positions as may be required to prevent, prepare for, and respond to the
COVID-19 pandemic. These workers may be employed by the jurisdictional
health department or by nonprofit private or public organizations that have
expertise in implementing public health programs and established relationships
with the jurisdiction, particularly in medically underserved areas.
Acquire personal protective equipment, data management and other technology,
and other necessary supplies.
Pay administrative costs and activities necessary for awardees to implement
activities funded under this section.
Make subawards to local health departments for these activities.
Funding provided by this section is not designated to an existing HHS agency, program, project,
or activity. Its implementation is presumably left to the HHS Secretary’s discretion. Of note, other
sections in ARPA (e.g., Sections 2401, 2402) also provide funding in part to support the public
health workforce. 81
Section 2502. Funding for Medical Reserve Corps
Background
The Medical Reserve Corps (MRC), authorized under PHSA Section 2813, is a nationwide cadre
of volunteers who are recruited, rostered, and trained by local entities to assist with the response
to public health emergencies. 82 According to HHS, the MRC “comprises approximately …
185,000 volunteers in roughly 800 community-based units located throughout the United States
78
Ibid.
79 CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
80 T ribal public health departments are not explicitly mentioned in Section 2501. However, tribal entities may receive
funds through states or local public health departments.
81 See the “ Public Health Infrastructure Provisions” section of this report.
82 T he MRC is authorized in PHSA §2813; 42 U.S.C. 300hh–15.
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and its territories.”83 MRC units may serve as local response assets and may, under state authority,
be deployed within a state or be offered to another state as a form of mutual aid. 84
MRC units typically do not receive federal funding to recruit, train, or deploy. Rather, HHS
provides technical assistance, and it has received an annual appropriation of approximately $6
million per year in recent years to do so. 85
Provision
Section 2502 appropriates $100 million to the HHS Secretary, to remain available until expended,
to implement the MRC by reference to its authority in PHSA Section 2813. 86
Section 2602. Funding for National Health Service Corps
Background
The National Health Service Corps (NHSC) provides scholarships and loan repayments to certain
health professionals in exchange for providing care in a health professional shortage area
(HPSA). Health professionals receiving these benefits commit to working for a period of time
that varies based on the length of the scholarship or the number of years of loan repayment
received. 87 The NHSC consists of three programs: (1) a federal scholarships program authorized
in PHSA Section 338A, (2) a federal loan repayment program authorized in PHSA Section 338B,
and (3) a state-operated loan repayment program authorized in PHSA Section 338I. The State
Loan Repayment program authorized in PHSA Section 338I provides one-to-one matching grants
for states to operate loan repayment programs that are similar to the federally run programs but
that give states flexibility to expand the types of providers eligible, the amounts available for loan
repayment, and the length of the service commitment.
The NHSC receives mandatory funding from the Community Health Center Fund (CHCF), which
provided $310 million for the program in FY2021. For FY2021, the NHSC also received $120
million in discretionary appropriations for loan repayment for substance use treatment providers,
with $15 million of that amount reserved to place providers at Indian Health Service (IHS)
facilities. 88
Provision
Section 2602 appropriates $800 million to the HHS Secretary, available until expended, to carry
out the NHSC scholarship, loan repayment, and state loan repayment programs, by referencing
authorities under PHSA Sections 338A, 338B, and 338I. The provision reserves $100 million for
83
HHS, Office of the Assistant Secretary for Preparedness and Response (ASPR), “Medical Reserve Corps,”
https://www.phe.gov/about/oem/prep/Pages/mrc.aspx.
84 For an overview of state-to-state mutual aid for emergency response, see Federal Emergency Management Agency
(FEMA), “Emergency Management Assistance Compact (EMAC): Overview for National Response Framework,”
undated, https://www.fema.gov/pdf/emergency/nrf/EMACoverviewForNRF.pdf.
85 HHS, “ Civilian Volunteer Medical Reserve Corps,” Public Health and Social Services Emergency Fund:
Justification of Estimates for Appropriations Committee, FY2021, undated, pp. 54-58, https://www.hhs.gov/sites/
default/files/fy-2021-phssef-cj.pdf.
86
42 U.S.C. §300hh–15(a), Volunteer Medical Reserve Corps.
87 CRS Report R44970, The National Health Service Corps.
88 T he National Health Service Corps has received a total of $430 million in combined mandatory and discretionary
appropriations since FY2019.
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the state loan repayment program. It waives the program’s matching requirement and specifies
that a state may use no more than 10% of its award for administering the state loan repayment
program.
Section 2603. Funding for Nurse Corps
Background
The Nurse Corps program, authorized under PHSA Section 846, provides scholarships and loan
repayments to certain health professionals in exchange for providing care in a health professional
shortage area for a period of time (the required service time varies, based on the length of the
scholarship or the number of years of loan repayment received). Though the program is similar to
the NHSC, it includes a broader range of nurses than are eligible for the NHSC (e.g., registered
nurses are eligible) and permits individuals to fulfill their service commitment at hospitals, while
the NHSC permits service commitments only at critical access hospitals and Indian Health
Service hospitals. 89 For FY2021, the Nurse Corps program received $88.6 million in discretionary
appropriations.
Provision
Section 2603 appropriates $200 million to the HHS Secretary for the Nurse Corps program, by
reference to its authority in PHSA Section 846, which is available until expended.
Section 2604. Funding for Teaching Health Centers that Operate Graduate
Medical Education
Background
The Teaching Health Center Graduate Medical Education (THCGME) program, authorized under
PHSA Section 340H, provides direct and indirect graduate medical education (GME) payments to
support medical and dental residents training at qualified teaching health centers (i.e., outpatient
health care facilities that provide care to underserved patients). 90 Direct GME payments support
resident and preceptor salaries, while indirect payments are intended to provide for the indirect
costs associated with training residents (e.g., higher patient costs due to additional tests that
residents order as part of their training). 91 The program supports the costs of residents in training,
but it has not provided funds to develop new programs or to offset the costs of becoming eligible
(i.e., the accreditation process).
PHSA Section 749A authorizes grants to develop new teaching health centers (THCs), which
were first authorized in 2010 but have never been funded. THCGME, which provides payments
for the residents in training, has received direct appropriations since it began in 2011. Most
recently, the THCGME program received $126.5 million for each of FY2021 through FY2023 in
Section 301 of Division BB of the Consolidated Appropriations Act, 2021 (P.L. 116-260). Prior to
this extension, the program had received a number of shorter-term extensions. The lack of stable
funding may make it challenging for THCs to expand the number of residents in training or for
89 CRS Report R44970, The National Health Service Corps; and HRSA, “Apply to the Nurse Corps Loan Repayment
Program,” https://bhw.hrsa.gov/funding/apply-loan-repayment/nurse-corps.
90 CRS Report R44376, Federal Support for Graduate Medical Education: An Overview.
91 Ibid.
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new programs to develop. THCGME payments support residents currently in training; however,
programs need to become accredited and recruit faculty and potential residents before residents
begin their training. In addition, residency training at a THC is generally three years, which is a
longer interval than several of the funding extensions for the program. The lack of stable funding
may impede the development of new programs and deter potential residents from considering
these programs. 92
Provision
Section 2604 appropriates $330 million to the HHS Secretary for the teaching health center
program to remain available until September 30, 2023. These amounts may be used for GME
payments for teaching health centers authorized under PHSA Section 340H and for grants for
teaching health center development authorized under PHSA Section 749A. The section permits
funds to be used to make GME payments that would exceed the amount appropriated for the
program in a given fiscal year and the capped amount used to determine the program’s direct and
indirect graduate medical education payment amounts.
The provision specifies that ARPA funds may be used to
make payments to establish newly approved THCGME programs;
increase the per-resident amount that THCGME programs receive by $10,0000
per resident trained;
make payments to existing programs to maintain residency positions;
make GME payments to existing programs to add new residents;
award teaching health center development grants; and
provide for the administrative and other costs related to THCGME programs.
Sections 2703-2705. Funding for Behavioral Health for Health
Service Professionals
Background
Concerns about the mental health and well-being of the health professional and first responder
workforce preceded the COVID-19 pandemic, but the pandemic exacerbated these concerns.93
Health care professionals may experience significant stress, burnout, and/or be exposed to
traumatic events in doing their jobs. Compounded over time, exposure to traumatic events or
stressful job demands may contribute to diminished mental health and wellness. Prior to the
pandemic, the National Academy of Medicine (NAM) had undertaken the Clinician Wellbeing
and Resilience project94 at the request of a number of provider organizations that recognized
92
For program funding information through 2020, see CRS Report R46331, Health Care-Related Expiring Provisions
of the 116th Congress, Second Session.
93 T homas Bodenheimer and Christine Sinsky, “From T riple to Quadruple Aim: Care of the Patient Requires Care of
the Provider,” Annuals of Family Medicine, vol. 12, no. 6 (November 2014), pp. 573 -576, for historical information;
and Victor J. Dzau, Darrell Kirch, and T homas Nasca, “Preventing a Parallel Pandemic —A National Strategy to
Protect Clinicians’ Well-Being,” New England Journal of Medicine, vol. 383 (August 6, 2020), pp. 513-515.
94 National Academy of Medicine, “ Action Collaborative on Clinician Well-Being and Resilience,” https://nam.edu/
initiatives/clinician-resilience-and-well-being/.
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mental health and burnout issues within their workforce. 95 After March 2020, NAM’s work
expanded to address issues that arose during the pandemic and to share strategies to mitigate
burnout. This work focused on strategies that could be undertaken for all types of health
professionals at all levels, from students to licensed professionals. It also focused on individual-,
workplace-, and system-level interventions that could be undertaken to reduce burnout and
increase provider well-being.
Although HHS supports the provision of mental health prevention and treatment services
generally, few federal programs focus explicitly on improving the mental well-being of the health
workforce. Rather, existing federal programs target mental health more broadly or provide
support during emergency situations. 96 For example, SAMHSA supports education and training,
prevention programs, early intervention activities, treatment services, and technical assistance—
including sometimes for specific populations (such as health care personnel). Through an
interagency agreement with the Federal Emergency Management Agency (FEMA), SAMHSA
operates the Crisis Counseling Assistance and Training Program (CCP), which provides
behavioral health outreach and psycho-educational services to individuals in areas affected by
disasters. CCP is not specifically designed for health workers, but the program can serve them as
response personnel. 97
Provisions
Section 2703 appropriates $80 million to the HRSA Administrator, 98 to remain available until
expended, to award grants or contracts to specified entities to plan, develop, operate, or
participate in evidence-informed strategies to reduce suicide, burnout, and mental health
conditions and substance use disorders among health care professionals and public safety officers.
Grantees are required to develop training targeted to health professions (including students,
trainees, paraprofessionals and their employers) and public safety officers and their employers.
Grants must be awarded in a manner that considers the needs of rural and medically underserved
communities and must be awarded to health professional schools, academic health centers, state
and local government, Indian Tribes (ITs) or Tribal Organizations (TOs), employers of health care
professionals and public safety officers, or other appropriate public or private nonprofit entities or
consortia of such entities.
Section 2704 appropriates $20 million to the CDC director, 99 to remain available until expended,
in consultation with the medical professional community, to carry out a national evidence-based
education and awareness campaign directed at health care professionals, first responders, and the
employers of such professionals. The campaign is required to encourage this workforce to (1)
prevent mental health and substance use disorders and seek support and treatment, and (2) help
identify risk factors in themselves and others and respond to such risks.
Section 2705 appropriates $40 million, to remain available until expended, for HRSA to award
grants or contracts to health care entities, as specified, to establish or expand evidence-informed
95 National Academy of Medicine, “ Action Collaborative on Clinician Well-Being and Resilience: Sponsors,”
https://nam.edu/initiatives/clinician-resilience-and-well-being/sponsors/.
96 For more information, see CRS Report R46555, Federal Efforts to Address the Mental Health of First Responders:
Resources and Issues for Congress.
97 SAMHSA, Practitioner Training; Disaster Technical Assistance Center (DTAC); Crisis Counseling Assistance
Program (CCP), https://www.samhsa.gov/dtac/ccp.
98 Section 2703 appropriates funding to the HHS Secretary “acting through” the HRSA Administrator.
99 Section 2704 appropriates funding to the HHS Secretary “acting through” the CDC Director.
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protocols to promote mental health among their workforce.100 Grants must be awarded in a
manner that considers the needs of rural and medically underserved communities.
Section 2711. Funding for Behavioral Health Workforce Education
and Training
Background
PHSA Section 756 authorizes the Behavioral Health Workforce Education and Training
(BHWET) Program, which was codified in the Helping Families in Mental Health Crisis Reform
Act of 2016 (Division B of the 21st Century Cures Act, P.L. 114-255). 101 The program provides
grants to support the training of the behavioral health workforce, including paraprofessionals. The
program was amended in the Substance Use-Disorder Prevention that Promotes Opioid Recovery
and Treatment for Patients and Communities Act (SUPPORT Act, P.L. 115-271), which added
language specifying that providers trained in trauma-informed care are eligible to participate. The
SUPPORT Act extended the program’s authorization of appropriations of $50 million for each
fiscal year through FY2023. 102 For FY2021, the program received an appropriation of $112
million in the Consolidated Appropriations Act, 2021.
Provision
Section 2711 appropriates $100 million to the HHS Secretary, available until expended, for the
BHWET program by reference to its authority in PHSA Section 756.
Health Care Infrastructure and Provider Support
Background
In response to the COVID-19 pandemic, some health care providers limited in-person visits and
cancelled elective procedures to reduce the spread of COVID-19, prepare for COVID-19 patients,
and conserve medical supplies such as PPE. As a consequence, some providers reported forgone
revenue and/or significant financial challenges, making it difficult to sustain services. 103 To
address these concerns, the Provider Relief Fund (PRF) was established in the CARES Act. In
total, the Provider Relief Fund has received $178 billion for grants to be awarded to health care
providers for lost revenue and increased expenses due to the pandemic. 104 Separate from PRF,
prior COVID-19 pandemic response laws also included funding for specific types of providers,
including health centers that receive grants to provide care to underserved populations regardless
of their ability to pay, and facilities that receive funding from the Indian Health Service (IHS).
Further, ARPA provides additional funding to certain types of health providers—generally those
that target disadvantaged populations (e.g., community health centers and support for family
100 Section 2301 appropriates funding to the HHS Secretary “acting through” the HRSA Administrator.
101 CRS Report R44718, The Helping Families in Mental Health Crisis Reform Act of 2016 (Division B of P.L. 114 -
255).
102 CRS Report R45423, Public Health and Other Related Provisions in P.L 115 -271, the SUPPORT for Patients and
Communities Act.
103 For more information on the PRF, see CRS Insight IN11438, The COVID-19 Health Care Provider Relief Fund.
104 CRS Insight IN11438, The COVID-19 Health Care Provider Relief Fund.
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planning programs). Some of these funding programs are tailored to specific purposes related to
the COVID-19 pandemic, while others are available for health care infrastructure and provider
support more broadly.
Rural facilities faced financial challenges prior to the pandemic that may have been exacerbated
by it. 105 Though rural facilities received support from the PRF, data suggest that rural providers
have not received a proportionate share from the fund. 106 Research examining the effects of the
pandemic on hospitals also found that rural hospitals fared worse than other hospitals because
they were financially challenged prior to the pandemic—the pandemic further exacerbated such
challenges. 107 ARPA includes two provisions that specifically target rural health care providers.
One creates a fund that is similar to the PRF, but with a new funding stream available only to
rural facilities. The other creates a new program within the USDA to make grants to rural
facilities for a number of purposes, including increased costs related to vaccine distribution.
Unlike other sections of this report, several of the below provisions are not in Title II of ARPA
(three of six provisions are in Titles I, IX, and XI, respectively).
Health Care Infrastructure and Provider Support Provisions
Section 2601. Funding for Community Health Centers and Community Care
Background
The federal health center program, authorized by PHSA Section 330 and administered by HRSA,
provides grants to not-for-profit organizations and state and local government entities to operate
outpatient health centers. Participation in the program requires grantees to provide care regardless
of a patient’s ability to pay, and grant funding is provided to support this care. These centers are
also required to be located in medically underserved areas (MUAs) or to provide care to a
population that is designated as underserved. 108 Health centers are part of the health care safety
net, and they have received a total of $2 billion in funding under three of the five COVID-19
supplemental appropriations measures. 109 In general, funds have been used to supplement existing
health centers. Funds made available under PPPHCEA for testing were also used for grants to
Federally Qualified Health Center (FQHC) look-alikes, which are facilities similar to health
centers in terms of location, services provided, and population served, but that do not receive
PHSA Section 330 grants. 110
105 Karyn Schwartz and T ricia Neuman, Funding for Health Care Providers During the Pandemic: An Update, Kaiser
Family Foundation, Policy Watch, Washington, DC, March 24, 2021, https://www.kff.org/policy-watch/funding-for-
health-care-providers-during-the-pandemic-an-update/.
106 Amy Lotven, “Senate Approves Amendment Boosting Provider Relief Fund,” Inside Health Policy, February 5,
2021, https://insidehealthpolicy.com/daily-news/senate-approves-amendment-boosting-provider-relief-fund.
107 Christi A. Grimm, Principle Deputy Inspector General, Hospitals Reported That the COVID-19 Pandemic Has
Significantly Strained Health Care Delivery, HHS Office of the Inspector General, OEI-09-21-00140, Washington, DC,
March 2021, https://oig.hhs.gov/oei/reports/OEI-09-21-00140.pdf.
108
CRS Report R43937, Federal Health Centers: An Overview.
109 See discussion in the “Health Resources and Services Administration” section in CRS Report R46711, U.S. Public
Health Service: COVID-19 Supplemental Appropriations in the 116th Congress.
110 See Appendix B of CRS Report R43937, Federal Health Centers: An Overview. T hese are defined in statute at
Section 1861(aa)(4)(B) of the Social Security Act.
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Provision
Section 2601 appropriates $7.6 billion to the HHS Secretary, to remain available until expended,
for PHSA Section 330 grants or contracts to federal health centers or for grants specifically to
FQHC look-alikes. Section 2601 also reserves $20 million of the amount appropriated for grants
or contracts with Native Hawaiian Health Care System entities as specified. The provision
specifies uses of these funds for COVID-19-related activities, including those related to vaccines,
testing, treatment, and the acquisition of mobile equipment or the making of infrastructure
modifications for these purposes. Funds may also be used to hire personnel to assist with these
activities. Entities receiving funds under this section may use the amounts received for pandemic -
related expenses that were incurred since the declaration of Public Health Emergency by the HHS
Secretary, effective January 27, 2020.
Section 2605. Funding for Family Planning
Background
The PHSA Title X Family Planning Program provides grants to public and nonprofit agencies for
family planning services, research, and training. 111 It is the only domestic federal program
dedicated solely to family planning and related preventive health services. 112 In 2019, PHSA Title
X served 3.1 million clients; 87% were female, 64% had incomes at or below the federal poverty
guidelines, and 84% had incomes at or below 200% of the federal poverty guidelines. 113
During the COVID-19 pandemic, PHSA Title X clinics have continued to provide services. 114
CDC released guidance on “ensuring access to family planning services during COVID-19,” for
example through telehealth, curbside pickup, providing a one-year supply of oral contraceptives,
and providing an advance supply of emergency contraception. 115 According to John Snow, Inc., a
survey conducted in May 2020 found that 87% of PHSA Title X providers reported that they were
providing telehealth services, compared with 11% about a year earlier. 116
111
CRS In Focus IF10051, Title X Family Planning Program .
112 Office of Population Affairs, Office of the Secretary, Department of Health and Human Services, “Compliance With
T itle X Requirements by Project Recipients in Selecting Subrecipients,” 81 Federal Register 61640, September 7,
2016, https://www.federalregister.gov/d/2016-21359/p-10.
113
Christina Fowler, Julia Gable, Beth Lasater, et al., Family Planning Annual Report: 2019 National Summary, Office
of Population Affairs, Office of the Assistant Secretary for Health, Department of Health and Human Services,
Washington, DC, September 2020, pp. ES-2, 25, https://opa.hhs.gov/sites/default/files/2020-09/title-x-fpar-2019-
national-summary.pdf.
114
T itle X Grantee Profiles have examples of grantees’ COVID-19 responses. HHS, Office of Population Affairs,
Learn More About Our Grantees, https://opa.hhs.gov/grant-programs/title-x-service-grants/title-x-turns-50#learn.
115
Centers for Disease Control and Prevention, Ensuring Access to Family Planning Services During COVID-19,
https://www.cdc.gov/reproductivehealth/contraception/covid-19-family-planning-services.html. T he T itle X-funded
Reproductive Health National T raining Center also released COVID-19 resources for T itle X providers,
https://rhntc.org/search?keys=covid.
116 John Snow, Inc. (JSI), Telemedicine: The Future of Family Planning Care, July 7, 2020, https://www.jsi.com/
telemedicine-the-future-of-family-planning-care/. JSI is a public health management consulting and research
organization that manages the T itle X-funded Reproductive Health National T raining Center.
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The Consolidated Appropriations Act, 2021, appropriated $286.5 million in annual discretionary
funding for PHSA Title X in FY2021, the same as the FY2020 funding level. 117 Prior to ARPA,
the program had received the same annual appropriations level since FY2014. 118
Provision
Section 2605 appropriates $50 million to the HHS Secretary, to remain available until expended,
for the Title X program. 119
Section 2713. Funding for Expansion Grants for Certified Community
Behavioral Health Clinics
Background
Section 223(a) of the Protecting Access to Medicare Act of 2014 (P.L. 113-193) authorized
funding to improve community-based behavioral health services through a demonstration
program to establish certified community behavioral health clinics (CCBHCs). CCBHCs are
facilities operated by nonprofit organizations or governmental or tribal entities that offer a
comprehensive range of services, including risk assessment, outpatient mental health and
substance use treatment, case management, psychiatric rehabilitation services, peer and family
supports, 24-hour crisis management, and primary care medical services, among others. To be
certified, CCBHCs are required to maintain partnerships with other health and social service
providers.
In 2015, 24 states received planning grants. In 2016, eight states were selected to participate in
the initial demonstration program. These states received an enhanced Medicaid federal medical
assistance percentage (FMAP, i.e., federal matching) rate for CCBHC services, and the CCBHCs
in these states received an enhanced payment rate through a prospective payment system
methodology. Two additional states were added to the demonstration program in 2020.
FY2020 appropriations (P.L. 116-94) authorized a CCBHC Expansion grant program and
provided $200 million to fund this part of the program. Grants awarded under the expansion grant
program provided up to $2 million to facilities that met the certification criteria to increase access
and improve the quality of their behavioral health services. (Only CCBHCs in the demonstration
program receive the enhanced Medicaid FMAP rate.) In 2020, 33 states participated in the
CCBHC Demonstration and Expansion Grant programs.
In the previous COVID-19 supplemental measures, a total of not less than $850 million was made
available for the CCBHC Expansion grant program. 120 For FY2021, the CCBHC program
117
P.L. 116-260, Consolidated Appropriations Act, 2021, Division H, T itle II; P.L. 116-94, Further Consolidated
Appropriations Act, 2020, Division A, T itle II, 133 Stat. 2558.
118 P.L. 115-245, Department of Defense and Labor, Health and Human Services, and Education Appropriations Act,
2019, and Continuing Appropriations Act, 2019, Division B, T itle II, 132 Stat. 3070; P.L. 115-141, Consolidated
Appropriations Act, 2018, Division H, T itle II, 132 Stat. 716; P.L. 115-31, Consolidated Appropriations Act, 2017,
Division H, T itle II, 131 Stat. 521; P.L. 114-113, Consolidated Appropriations Act, 2016, Division H, T itle II, 129 Stat.
2602; P.L. 113-235, Consolidated and Further Continuing Appropriations Act, 2015, Division G, T itle II, 128 Stat.
2468; P.L. 113-76, Consolidated Appropriations Act, 2014, Division H, T itle II, 128 Stat. 365 .
119
T his provision increases the funds available for this program in FY2021 by 17%, the first increased funding level for
the program since FY2014.
120 T he CARES Act included not less than $250 million of the total appropriation for SAMHSA, and Division M of the
Consolidated Appropriations Act, 2021, included not less than $600 million.
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received $250 million in discretionary appropriations in the Consolidated Appropriations Act,
2021.
Provision
Section 2713 appropriates $420 million to the SAMHSA Assistant Secretary for Mental Health
and Substance Use, 121 to remain available until expended, for grants for Certified Community
Behavioral Health Clinics pursuant to Section 223(a) of the Protecting Access to Medicare Act of
2014. 122
Section 1002. Emergency Rural Development Grants for Rural Health Care,
and Section 9911. Funding for Providers Related to COVID-19
Background
As noted above, in response to the COVID-19 pandemic, some health care providers limited in-
person visits and cancelled elective procedures to reduce the spread of COVID-19, to prepare for
an influx of COVID-19 patients, and to conserve PPE. As a consequence, some providers
reported forgone revenue and significant financial challenges, making it difficult to sustain
services. 123 This situation was particularly challenging for providers that had struggled financially
prior to the pandemic, as was the case for a number of rural hospitals. 124
To address some of the providers’ financial concerns, the PRF was established in the CARES Act.
The fund provided grants to health care providers for lost revenue and increased expenses due to
the COVID-19 pandemic. The PRF was written with broad language, giving the Administration
discretion both in how funds could be allocated and in the potential application and
documentation requirements. The most recent amendment to the fund authority created some
statutory requirements for the fund and its future uses. Specifically, the Consolidated
Appropriations Act, 2021, defined uses of the fund, defined lost revenue to reflect the definition
in the HHS Frequently Asked Questions released in June 2020, and specified application
processes, among other things.125
HHS has allocated the PRF using general and targeted distributions. Among the targeted
distributions was an allocation of $11.3 billion for rural facilities (rural providers and suppliers
were also eligible for general distributions). This targeted distribution provided funds to rural
hospitals (including critical access hospitals), rural health clinics, and rural community health
centers. 126 Notably, rural clinician practices or suppliers did not receive funds as part of this
allocation.
121 Section 2713 appropriates funding to the HHS Secretary “acting through” the SAMHSA Assistant Secretary fo r
Mental Health and Substance Use.
122 42 U.S.C. §1396a note.
123
For more information on the PRF, see CRS Insight IN11438, The COVID-19 Health Care Provider Relief Fund.
124
Christi A. Grimm, Principle Deputy Inspector General, Hospitals Reported That the COVID-19 Pandemic Has
Significantly Strained Health Care Delivery, HHS Office of the Inspector General, OEI-09-21-00140, Washington, DC,
March 2021, https://oig.hhs.gov/oei/reports/OEI-09-21-00140.pdf.
125
T he current reporting requirements that use the June 2020 definition of lost revenue can be found at HHS, “General
and T argeted Distributions Post -Payment Notice of Reporting Requirements,” January 15, 2021, https://www.hhs.gov/
sites/default/files/provider-post-payment-notice-of-reporting-requirements-january-2021.pdf.
126 CRS Insight IN11438, The COVID-19 Health Care Provider Relief Fund; and HHS, Provider Relief Fund: CARES
Act Provider Relief Fund: General Information: T argeted Distributions,” https://www.hhs.gov/coronavirus/cares-act-
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The various COVID-19 pandemic response measures have also included funds that target rural
health providers and that include funds targeted to rural communities as part of a broader focus on
underserved populations. Specifically, the fourth COVID-19 relief measure, PPPHCEA, included
$225 million for grants to rural health clinics (RHCs)—small outpatient clinics located in rural
areas—for COVID-19 testing. These funds could be used “for building or construction of
temporary structures, leasing of properties, and retrofitting facilities as necessary to support
COVID–19 testing.”127 Division M of Consolidated Appropriations Act, 2021 also included $300
million for the CDC to target “high-risk and underserved populations, including racial and ethnic
minority populations and rural communities.” Similarly, that measure also included not less than
$2.5 billion to the PHSSEF account for “strategies for improving testing capabilities and other
purposes ... in high-risk and underserved populations, including racial and ethnic minority
populations and rural communities as well as identifying best practices for states and public
health officials to use for contact tracing in high-risk and underserved populations, including
racial and ethnic minority populations and rural communities.”128
In addition to HHS support for rural providers both during and prior to the pandemic, the USDA
Rural Development agency administers some programs that support rural health care facilities
and telemedicine. 129 For example, the Community Facilities programs finance the construction,
improvement, or purchase of equipment for essential community facilities in rural areas,
including health care facilities. The Distance Learning and Telemedicine Program provides grants
to eligible entities in rural areas to fund the acquisition of distance learning and telemedicine
equipment and software.
In recent years, Congress has increasingly directed USDA to address rural health care access,
particularly through assistance to rural hospitals. For example, the Agriculture Improvement Act
of 2018 (2018 farm bill; P.L. 115-334) authorized USDA to use loans or loan guarantees under
certain rural business or infrastructure programs to refinance rural hospital debt if such
refinancing would preserve access to a health service in a rural community or meaningfully
improve the financial position of the hospital. 130 In the FY2020 and FY2021 Agriculture
Appropriations Acts, Congress provided a total of $3 million to USDA to provide technical
assistance to improve the long-term operations and financial health of rural hospitals. 131
Provisions
Section 1002 appropriates $500 million to the USDA Secretary to establish an emergency pilot
program to provide grants “to be awarded by the Secretary based on rural development needs
related to the COVID-19 pandemic.” The provision authorizes grant funds to be used to
increase capacity for vaccine distribution;
provider-relief-fund/general-information/index.html#phase15.
127 See PHSSEF account in T itle I, Division B of P.L. 116-139. See also HHS, HRSA, “HHS Provides $225 Million for
COVID-19 T esting in Rural Communities,” press release, May 20, 202 0, https://public3.pagefreezer.com/content/
HHS.gov/31-12-2020T 08:51/https://www.hhs.gov/about/news/2020/05/20/hhs-provides-225-million-for-covid19-
testing-in-rural-communities.html.
128 See CDC and PHSSEF appropriations in Division M of P.L. 116-260.
129 USDA Rural Development is the mission area within USDA responsible for rural infrastructure and economic
development assistance. For more information, see CRS Report RL31837, An Overview of USDA Rural Development
Programs.
130 P.L. 115-334, §6103.
131 P.L. 116-94, Division B, T itle VII, §753, provided $1 million, and P.L. 116-260, Division A, T itle VII, §770
provided $2 million.
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provide medical supplies to increase medical surge capacity;
reimburse for revenue lost during the COVID-19 pandemic, including revenue
lost prior to the awarding of the grant;
increase telehealth capabilities;
construct temporary or permanent structures to provide health care services,
including vaccine administration and testing;
support staffing needs for vaccine distribution and testing; and
engage in any other efforts to support rural development determined to be critical
to address the COVID-19 pandemic, including nutritional assistance to
vulnerable individuals, as determined by the USDA Secretary.
Eligible applicants include public bodies, nonprofit corporations or associations, and federally
recognized Indian tribes. Grants must support facilities that are loc ated in, and primarily serve,
low-income, rural areas. Appropriated funds are to remain available through FY2023. The
provision authorizes USDA to use up to 3% of funds for administrative purposes and up to 2% of
funds to provide technical assistance to eligible applicants, including assistance in identifying and
planning for facility needs, applying for financing, and improving the management of the facility.
Section 9911 creates a new Section 1150C of the Social Security Act (SSA), “Funding for
Providers Relating to COVID-19.” The provision appropriates $8.5 billion to make payments to
rural health care providers to account for lost revenue and increased health care-related expenses
due to COVID-19. These funds are available until expended. The provision also specifies
application requirements for providers to receive funds and use of funds, and defines key terms in
ways that are substantively similar to those specified in Division M of the Consolidated
Appropriations Act, 2021, for the PRF. The provision defines an eligible health care provider
differently than in Division M of Consolidated Appropriations Act, 2021, and in prior laws
appropriating funds to the PRF, which did not specify that providers needed to be in specific
geographic locations or be enrolled in specific public programs to participate. ARPA defines an
eligible health care provider for these payments as a Medicare, Medicaid, or CHIP provider or
supplier that provides COVID-19 diagnoses, testing, or care and is a rural provider or supplier.
The provision further defines rural providers and suppliers as
a provider or supplier that is a rural provider or is treated as a rural provider
under the Medicare statute (as defined); 132
a provider or supplier that is not located in a rural area, but is determined by the
HHS Secretary to serve rural patients;
a rural health clinic (as defined); 133
a home health, hospice, or long-term services and supports provider or supplier
that provides supplies or services in an individual’s home that is located in a rural
area (as defined);134 or
any other rural provider or supplier as defined by the HHS Secretary.
132 SSA §§1886(d)(2)(D) and 1886(d)(8)(E), respectively.
133 SSA §1861(aa)(2).
134 SSA §1886(d)(2)(D).
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Section 11001. Indian Health Service
Background
The Indian Health Service (IHS) provides health care to American Indian and Alaska Native
populations. Such health care is provided either directly—by providing funds for Indian Tribes
(ITs) or Tribal Organizations (TOs) to operate health care facilities—or through grants to Urban
Indian Health Organizations (UIOs) to provide care to American Indians and Alaska Natives in
urban areas. 135 More than two-thirds of IHS facilities are operated by ITs/TOs through contracts
or compacts authorized under the Indian Self-Determination and Education Assistance Act
(ISDEAA, P.L. 93-638). ITs/TOs generally contract or compact for services that IHS would have
otherwise provided by entering into a funding agreement that delineates the services funded under
the agreement.
IHS generally provides services free of charge to approximately 2.6 million eligible American
Indians and Alaska Natives in 37 states. 136 Available services vary by facility, and when services
are not available, IHS may refer patients to outside providers through its purchased/referred care
(PRC) program. Though IHS facilities do not charge directly for services, they may bill for
services provided to IHS beneficiaries who have coverage through public programs (e.g.,
Medicaid) or private insurance. The amount received from third-party reimbursements varies by
facility, but some tribal facilities report that more than half of their budgets comes from third-
party revenue. 137
Funding has been provided to IHS for COVID-19 pandemic response, in part, because of the
agency’s role as a direct health care provider. In that role, the agency supports testing, treatment,
and vaccination services for its service population, which has been disproportionally affected by
the pandemic. A number of IHS areas, including the Navajo area, experienced early and sustained
outbreaks of COVID-19 infections. Data show high COVID-19 mortality rates among American
Indians and Alaska Natives compared with other racial and ethnic groups. 138 IHS, like other
health systems, experienced increased demand for intensive COVID-related services, while
seeing declining revenue because of cancelled or delayed routine and elective care. 139 In addition
to providing health services related to COVID-19, IHS supports certain public health and health
education activities (similar to those of CDC). IHS also has several public health workforce
programs, including public health nursing programs and the community health representative
135 T he Indian Health Service (IHS) also provides grants to Urban Indian Organizations (UIOs) that operate smaller
health facilities in urban areas. T hese facilities vary in terms of the services available, with some providing
comprehensive services, whereas others provide information and referral services. Outside of the grants they receive,
UIOs are generally not eligible for funds from the overall IHS budget, with some exceptions. See CRS Report R43330,
The Indian Health Service (IHS): An Overview.
136 HHS, IHS, Fiscal Year 2021 Indian Health Service Justification of Estimates, https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf. Facilities operated
by IHS are prohibited to charge for services; facilities operated by Indian T ribes, T ribal Organizations, or UIOs may
charge for services.
137 Christopher D. Chavis, Indian Health 101: Fulfilling a Promise, National Indian Health Board, Washington, DC,
November 17, 2020, p. slide 19, https://www.nihb.org/aian-heritage-month/wp-content/uploads/2020/11/Indian-Health-
101.pdf.
138
Jessica Arrazola et al., COVID-19 Mortality Among American Indian and Alaska Native Persons—14 States,
January–June 2020, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly (69)(49), Atlanta,
GA, December 11, 2020, https://www.cdc.gov/mmwr/volumes/69/wr/mm6949a3.htm?s_cid=mm6949a3_w.
139 See CRS Insight IN11333, COVID-19 and the Indian Health Service.
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program, which trains American Indians and Alaska Natives to provide health-promotion and
disease-prevention activities. 140
In prior COVID-19 supplemental appropriations measures, IHS received supplemental
discretionary funding totaling $1.1 billion provided to agency accounts and a total of not less than
$1.8 billion in directed transfers and set-asides, either (1) to agency accounts or (2) to be allocated
at the discretion of the IHS Director in other accounts. In total, accounting for transfers and set-
asides, budgetary resources of at least $2.8 billion were made available either to IHS accounts or
at the direction of the IHS Director. In addition, a total of not less than $320 million was reserved
for tribal entities (i.e., ITs/TO/UIOs) from funds that were appropriated to other HHS accounts ,
but not specifically directed to IHS in prior COVID-19 supplemental appropriations measures.
Provision
Section 11001 appropriates a total of $6.094 billion to IHS to remain available until expended. It
specifies the following uses of these funds:
$5.48 billion for health services and public health activities, which includes
$2 billion for lost reimbursements;
$500 million for PRC;
$140 million for information technology, telehealth infrastructure, and IHS’s
electronic health record system; 141
$84 million for UIOs;
$600 million for vaccine-related activities, including activities that may
relate to detecting, diagnosing, monitoring, and tracing COVID-19 and
expanding the public health workforce;
$1.5 billion to detect, diagnose, and monitor COVID-19, including vaccine-
related activities and activities related to expanding the public health
workforce;
$240 million to establish, expand, and sustain a public health workforce,
including for vaccine, testing, or disease mitigation purposes; and
$420 million for mental health and substance abuse prevention and treatment
services, where funds may be for infrastructure, telehealth, or facilities for
mental health and substance abuse prevention and treatment services;
$600 million to lease, purchase, construct, alter, renovate, or equip health
facilities to respond to the COVID-19 virus; and
$10 million for potable water delivery.
The section specifies that funds appropriated in this provision are to be used to restore amounts
incurred to prevent, prepare, or respond to the pandemic that were incurred from January 30,
140 For information on IHS’s public health workforce programs, see HHS, IHS, Fiscal Year 2021 Indian Health Service
Justification of Estimates, https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/
documents/FY_2021_Final_CJ-IHS.pdf, pp. 135-155.
141 Upgrading IHS’s health information technology infrastructure and its electronic health record has been a long-term
agency priority not specific to COVID-19. IHS, like other health system has increased its use of telehealth during
COVID-19. For information about IHS information technology modernization efforts, see U.S. Department of Healt h
and Human Services, Indian Health Service, FY2021, “Justification of Estimates for Appropriations Committees,”
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-
IHS.pdf, pp. 94-103.
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2020, through the date of enactment (March 11, 2021). The section also specifies that any funds
made available to IT/TOs under ISDEAA contracts or compacts are made on a one-time basis and
may be used only for the purposes specified in this section.
Mental Health and Substance Use
Background
Circumstances surrounding the pandemic—including lifestyle changes instituted to prevent the
spread of the virus—appear to have negatively affected the mental health of many Americans. 142
Studies show elevated levels of emotional distress, anxiety, depression, substance use, and drug-
related overdoses in 2020 and early 2021 compared with the same time period in previous
years. 143 On account of these increases, CDC reported that “support systems to mitigate mental
health consequences as the pandemic evolves will continue to be urgently needed.”144 In addition,
physical distancing measures and temporary stay-at-home orders associated with the pandemic
have altered the service delivery for mental health and substance use treatment. Many behavioral
health service providers have increased their use of telehealth modalities to deliver treatment. 145
Still, limits on face-to-face service provision and other economic consequences of the pandemic
have led to clinic closures and other reductions to treatment service capacity. 146
Emergency financial support for behavioral health activities provided in the previous
supplemental COVID-19 funding measures sought to address the high demand for mental health
and substance use disorder treatment services and decreased capacity in the system. The
Substance Abuse and Mental Health Services Administration (SAMHSA) is the federal agency
primarily responsible for supporting community-based mental health and substance abuse
treatment and prevention services. SAMHSA received a total of $4.7 billion in supplemental
appropriations in the CARES Act ($425 million) and Consolidated Appropriations Act, 2021
142
See, for example, Colin Planalp, Giovann Alarcon, and Lynn Blewett, 90 Percent of U.S. Adults Report Increased
Stress due to Pandemic, State Health Access Data Assistance Center (SHADAC), Minneapolis, MN, May 26, 2020,
https://www.shadac.org/SHADAC_COVID19_Stress_AmeriSpeak-Survey. For more information, see CRS Report
R46831, Behavioral Health During the COVID-19 Pandemic: Overview and Issues for Congress.
143
See, for example, Anjel Vahratian, Stephen J. Blumberg, Emily P. T erlizzi, et al., Symptoms of Anxiety or
Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic - United States,
August 2020-February 2021, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report
(MMWR) vol. 70, March 26, 2021, https://www.cdc.gov/mmwr/volumes/70/wr/mm7013e2.htm; and Liz Hamel,
Audrey Kearney, Ashley Kirzinger, et al., Coronavirus: Reopening, Schools, and the Government Response, Kaiser
Family Foundation, KFF Health T racking T racking Poll - July 2020, July 27, 2020, https://www.kff.org/coronavirus-
covid-19/report/kff-health-tracking-poll-july-2020/.
144 Mark E. Czeisler, Rashon I. Lane, Emiko Petrosky, et al., Mental Health, Substance Use, and Suicidal Ideation
During the COVID-19 Pandemic - United States, June 24-30, 2020, Centers for Disease Control and Prevention,
Morbidity and Mortality Weekly Report (MMWR), vol. 69, no. 32, Atlanta, GA, August 14, 2020, p. 1055.
145
Ateev Mehrotra, Michael Chernew, and David Linesky, The Impact of the COVID-19 Pandemic on Outpatient
Care: Visits Return to Prepandemic Levels, but Not for All Providers and Patients, T he Commonwealth Fund, New
York, NY, October 15, 2020, https://www.commonwealthfund.org/publications/2020/oct/impact-covid-19-pandemic-
outpatient-care-visits-return-prepandemic-levels.
146
T he National Council for Behavioral Health, Demand for Mental Health and Addiction Services Increasing as
COVID-19 Pandemic Continues to Threaten Availability of Treatment Options, National Council for Behavioral Health
Member Survey Polling Presentation, Washington, DC, September 2020, https://www.thenationalcouncil.org/press-
releases/demand-for-mental-health-and-addiction-services-increasing-as-covid-19-pandemic-continues-to-threaten-
availability-of-treatment-options/.
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($4.25 billion). These measures provided funding for emergency substance use and mental health
needs, children’s mental health, suicide prevention, and SAMHSA’s state block grant programs.
ARPA continues the efforts of the previous COVID-19 supplemental measures by providing
funding to SAMHSA for community behavioral health activities. The measure provides funding
for SAMHSA’s largest block grant programs, school-based mental health, suicide prevention,
childhood trauma, and pediatric mental health care access via telemedicine.
Mental Health and Substance Use Provisions
Sections 2701-2702. Funding for Block Grants for Community Mental Health
Services and Prevention and Treatment of Substance Abuse
Background
SAMHSA provides most of its financial support for community-based behavioral health activities
through two block grants authorized in Title XIX of the PHSA: the Community Mental Health
Services Block Grant (MHBG) and the Substance Abuse Prevention and Treatment Block Grant
(SABG). 147 Both block grant programs distribute funds to states (including the District of
Columbia and territories) according to a statutory formula. 148 The states, in turn, distribute funds
to local government entities and nonprofit organizations for behavioral health-related treatment
and prevention activities in accordance with a required state plan. Of the total $4.25 billion made
available to SAMHSA in Division M of the Consolidated Appropriations Act, 2021, $1.65 billion
was designated for each of the MHBG and SABG. For FY2021, the MHBG and SABG received
$737 million and $1.8 billion in annual appropriations, respectively. 149
Provisions
Section 2701 appropriates $1.5 billion to the HHS Secretary for SAMHSA’s Community Mental
Health Services Block Grant (MHBG) to remain available until expended. Any amount awarded
to a state shall be expended by the state by September 30, 2025.
Section 2702 appropriates $1.5 billion to the HHS Secretary for SAMHSA’s Substance Abuse
Prevention and Treatment Block Grant (SABG) to remain available until expended. Any amount
awarded to a state shall be expended by the state by September 30, 2025.
147 For more information, see CRS Report R46426, Substance Abuse and Mental Health Services Administration
(SAMHSA): Overview of the Agency and Major Programs.
148
See PHSA T itle XIX. For more information, see CRS Report R46426, Substance Abuse and Mental Health Services
Administration (SAMHSA): Overview of the Agency and Major Programs.
149 Provided in Division H of Consolidated Appropriations Act, 2021 ( P.L. 116-260).
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Sections 2706-2707. Funding for Community-Based Funding for Local
Substance Use Disorder Services and Local Behavioral Health Needs
Background
In the previous COVID-19 supplemental measures, a total of not less than $340 million was made
available for emergency substance abuse or mental health needs. 150 These funds provide crisis
intervention services, mental and substance use disorder treatment, and other related recovery
supports for children and adults affected by the COVID-19 pandemic. 151 SAMHSA gave states
significant flexibility in how they use these funds to support behavioral health-related activities.
Of note, since FY1990, annual appropriations for HHS agencies have generally included a
provision prohibiting any funds from being used for syringe service programs (i.e., programs in
which sterile needles or syringes are made available to injection drug users in exchange for used
needles or syringes to mitigate the spread of related infections, such as hepatitis C and
HIV/AIDS). 152 Starting in FY2016, the provision was modified to allow funds provided in the
annual appropriations acts to be used for syringe service programs under the following
conditions: (1) federal funds may not be used to purchase the needles, but may be used for other
aspects of such programs; (2) the state or local jurisdiction must demonstrate, in consultation with
CDC, that it is experiencing, or is at risk for, a significant increase in hepatitis infections or an
HIV outbreak due to injection drug use; and (3) the program must be operating in accordance
with state and local law.
Provisions
Section 2706 appropriates $30 million to the SAMHSA Assistant Secretary for Mental Health and
Substance Use (in consultation with CDC) for overdose prevention programs and related
activities. 153 Specifically, it requires SAMHSA to award grants to certain entities for specified
activities to support “community-based overdose prevention programs, syringe services
programs, and other harm reduction services.” Grants shall be used for preventing and controlling
the spread of infectious diseases, distributing opioid overdose reversal medications, connecting
individuals with education and services, and encouraging individuals with SUDs to reduce the
negative health impacts of substance use.
Section 2707 appropriates $50 million to the SAMHSA Assistant Secretary for Mental Health and
Substance Use to address community behavioral health needs. 154 Specifically, it requires
150 Not less than $100 million in the third measure and not less than $240 million in the fifth measure.
151 Eligibility included territories and tribes/tribal organizations. See Substance Abuse and Mental Health Services
Administration, Emergency Grants to Address Mental Health and Substance Use Disorders during COVID-19,
Funding Opportunity Announcement FG-20-006, April 1, 2020, https://www.samhsa.gov/grants/grant-announcements/
fg-20-006.
152
T he one exception is the FY1992 Labor-HHS Appropriations Act (P.L. 102-170), which appears to have included
no such provision. Since the provision’s inception in FY1990, there has been variation in its sco pe and application
during certain fiscal years. For example, the Labor-HHS Appropriations Act for FY1998 (P.L. 105-78) made the ban
subject to action by the HHS Secretary. T he Labor-HHS Appropriations Acts for FY2010 (P.L. 111-117, Division D)
and FY2011 (P.L. 112-10, Division B) applied the ban only in locations that local authorities determined to be
inappropriate.
153 Section 2707 appropriates funding to the HHS Secretary “acting through” the SAMHSA Assistant Secretary for
Mental Health and Substance Use.
154 Section 2922 appropriates funding to the HHS Secretary “acting through” the SAMHSA Assistant Secretary for
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SAMHSA to award grants to certain entities to “address increased community behavioral health
needs worsened by the COVID-19 public health emergency.” Grants shall be used for promoting
care coordination, training the behavioral health workforce, expanding evidence-based integrated
models of care, providing behavioral health services through telehealth, and expanding preventive
care and crisis intervention services.
Section 2708. Funding for the National Child Traumatic Stress Network
Background
The National Child Traumatic Stress Network was established under PHSA Section 538 as part of
the National Child Traumatic Stress Initiative to improve behavioral health services for children
exposed to traumatic events. 155 Grant funding supports the development and promotion of
effective community practices, mostly through information and trainings by a network of centers.
The National Child Traumatic Stress Network program is administered by SAMHSA. Of the total
amount in Division M of the Consolidated Appropriations Act, 2021, made available to
SAMHSA, $10 million was designated for the National Child Traumatic Stress Network. For
FY2021, the National Child Traumatic Stress Initiative received $72 million in annual
discretionary appropriations in Division H of Consolidated Appropriations Act, 2021.
Provision
Section 2708 appropriates $10 million to the HHS Secretary, available until expended, for PHSA
Section 538 and activities related to the National Child Traumatic Stress Initiative “with respect
to addressing the problem of high-risk or medically underserved persons who experience
violence-related stress.”
Section 2709. Funding for Project AWARE
Background
Administered by SAMHSA, Project AWARE (Advancing Wellness and Resilience in Education)
provides competitive grants designed to identify children and youth in need of mental health
services, increase access to mental health treatment, and promote mental health literacy among
teachers and school personnel. 156 The grants are available to states and other eligible entities.
Project AWARE consists of three components: (1) Project AWARE State Educational Agency
(SEA) grants (known as Project AWARE State or SEA grants), (2) Mental Health Awareness
Training (MHAT) grants, and (3) Resiliency in Communities After Stress and Trauma (ReCAST)
grants.
The purpose of the AWARE State grants is to build or expand the capacity of State Educational
Agencies, in partnership with State Mental Health Agencies, to (1) increase awareness of mental
health issues among school-aged youth, (2) provide training for school personnel and other adults
to detect mental health issues, and (3) connect school-aged youth with behavioral health issues
Mental Health and Substance Use.
155
For more information, see https://www.samhsa.gov/child-trauma.
156 U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services
Administration (SAMHSA), Justification of Estimates for Appropriations Committees for FY2020,
http://www.hhs.gov/budget.
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and their families to needed services. 157 Project AWARE State grantees use funds to train teachers
and other school personnel on mental health awareness and how to connect school-aged youth to
needed services. Other activities may include school-based mental health and wellness programs,
increased mental health services for school-aged youth, and implementation of evidence-based
mental health interventions, among others.
Project AWARE does not have an explicit authorization in statute. Project AWARE operates
through SAMHSA’s general Priority Mental Health Needs of Regional and National Significance
(Mental Health PRNS) authorities under PHSA Section 520A.
Of the total amount in Division M of the Consolidated Appropriations Act, 2021, made available
to SAMHSA, $50 million was appropriated to SAMHSA’s Project AWARE program. For
FY2021, Project AWARE received $107 million in annual discretionary appropriations in
Division H of Consolidated Appropriations Act, 2021.
Provision
Section 2709 appropriates $30 million to the HHS Secretary, to remain available until expended,
to carry out PHSA Section 520A “with respect to advancing wellness and resiliency in
education.”
Section 2710. Funding for Youth Suicide Prevention
Background
SAMHSA supports several suicide prevention initiatives, including the National Strategy for
Suicide Prevention, which focuses on adult suicide prevention, and the Garrett Lee Smith (GLS)
State and Campus suicide grant programs, which address youth and young adult suicide. In 2004,
the Garrett Lee Smith Memorial Act (P.L. 108-355) explicitly authorized three suicide prevention
programs at SAMHSA under PHSA Sections 520E and 520E-2—two grant programs and a
resource center. Specifically, the law authorized SAMHSA to support the planning,
implementation, and evaluation of statewide youth suicide early intervention and prevention
strategies; to provide grants to institutions of higher education to reduce student mental health
problems; and to fund a national technical assistance center for suicide prevention. In FY2021,
SAMHSA received $90 million to carry out suicide prevention activities, with roughly half
designated for youth suicide prevention.
The prior COVID-19 supplemental measures provided a total of not less than $100 million for
suicide prevention generally, including not less than $50 million in the CARES Act and not less
than $50 million in Division M of the Consolidated Appropriations Act, 2021.
Provision
Section 2710 appropriates $20 million to the HHS Secretary to remain available until expended
for carrying out PHSA Sections 520E and 520E–2 with respect to youth suicide prevention
activities.
157 SAMHSA, Project AWARE (Advancing Wellness and Resiliency in Education) State Education Agency Grants,
Funding Opportunity Announcement, October 24, 2018, available at https://www.samhsa.gov/grants/grant-
announcements/sm-19-003.
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Section 2712. Funding for Pediatric Mental Health Care Access
Background
In 2016, the 21st Century Cures Act added a new PHSA Section 330M, which created the
Pediatric Mental Health Care Access program within the HRSA Maternal and Child Health
Bureau. The program provides grants or cooperative agreements to states to promote behavioral
health integration into pediatric primary care using telehealth. 158 The program funds 21 statewide
or regional programs that provide teleconsultation, training, and technical assistance to pediatric
primary care providers to diagnose, treat, and refer children with behavioral health conditions. 159
The program authorization of appropriations was $9 million for the period FY2018-FY2020 to
carry out the grant program. The program received an appropriation of $10 million for each of
FY2018 through FY2021.
Provision
Section 2712 appropriates $80 million to the HHS Secretary, to remain available until expended,
to carry out PHSA Section 330M for pediatric mental health care access.
Aging and Disability Services
Background
Many older adults and individuals with disabilities rely on federally funded programs that provide
nutrition and other supportive services in order to live independently in their communities. 160
Amidst the ongoing COVID-19 pandemic, older adults and those with certain chronic conditions
are at higher risk for severe illness if infected with the virus. Physical distancing measures and
stay-at-home orders associated with the pandemic have affected nutrition programs that many
older adults rely on for their daily nutrition intake. For example, nutrition services at group meal
sites are no longer available or accessible. Alternatively, other nutrition services, such as home-
delivered meals (e.g., “meals on wheels”), have been in greater demand as older adults adhere to
recommendations to avoid gathering with individuals outside their household. In addition,
caregiving to individuals of all ages has faced increased challenges during the pandemic , with the
disruption of in-person child care, distance education for school-age children, and maintaining
home and community-based long-term services and supports for older adults and individuals with
disabilities. In particular, grandfamilies and kinship families may be vulnerable to economic
hardship due to challenges associated with increased food and housing insecurity during the
158 HHS, HRSA, “Pediatric Mental Health Care Access Program,” https://mchb.hrsa.gov/training/projects.asp?
program=34.
159
HHS, HRSA, Justification of Estimates for Appropriations Committees for FY2021, https://www.hrsa.gov/sites/
default/files/hrsa/about/budget/budget-justification-fy2021.pdf, pp. 215-218.
160 About 10.9 million older persons were served by Older Americans Act (OAA) state formula grant programs under
T itle III of the act, including the provision of 149.8 million home-delivered meals; 73.2 million congregate meals; 20.4
million rides to medical appointments, grocery stores, and other activities; 49.3 million hours of personal care,
homemaker, and chore services; and 12.1 million hours of adult day care/adult day health services in 2019. U.S.
Department of Health and Human Services, Administration for Community Living, AGing Integrated Database
(AGID), State Program Reports, Data at a Glance, https://agid.acl.gov/DataGlance/SPR/.
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pandemic. 161 In addition, evidence suggests an increase in the prevalence of elder abuse during
the pandemic. 162
Additional funding for aging and disability services programs and activities provided in the
previous COVID-19 relief measures sought to address increased demand for nutrition and other
supportive services to older adults, people with disabilities, and their family caregivers. It also
provided additional funding for the prevention, detection, and treatment of abuse among seniors
and people with disabilities, as well as addressing quality of care in long-term care settings. The
Administration for Community Living (ACL), within HHS, is responsible for supporting older
adults and people with disabilities to live independently in the community. ACL received a total
of $1.295 billion in additional appropriations through prior COVID-19 relief measures, including
in FFRCA ($250.0 million), the CARES Act ($870.0 million), and Division N of Consolidated
Appropriations Act, 2021 ($175.0 million). These measures provided funding for senior nutrition
services; supportive services, including transportation and homemaker or chore services, as well
as respite and other services to support family caregivers; and abuse prevention, among other
activities.
ARPA continues the efforts of the previous COVID-19 relief measures by providing funding to
ACL for aging and disability services programs. The law provides funding to OAA formula grant
programs that provide nutrition and other supportive services with a focus on vaccine outreach
and education and activities to address social isolation. The law also funds the establishment of a
National Technical Assistance Center on Grandfamilies and Kinship Families, and provides
additional funding to prevent, detect, and treat elder abuse, in part through federal support to state
Adult Protective Services (APS) programs.
Aging and Disability Services Provisions
Section 2921. Supporting Older Americans and Their Families
Background
The Older Americans Act (OAA; P.L. 89-73, as amended) is the primary federal vehicle for the
delivery of social and nutrition services for older persons.163 These include supportive services,
congregate nutrition services (meals served at group sites such as senior centers, schools,
churches, and senior housing complexes), home-delivered nutrition services, family caregiver
support, community service employment, the long-term care ombudsman program, and services
to prevent the abuse, neglect, and exploitation of older persons. The OAA also supports grants to
older Native Americans, as well as research, training, and demonstration activities.
The act establishes statutory funding formulas to determine allotments to states and U.S.
territories for programs under Title III, Grants for State and Community Programs on Aging, and
Title VII, Allotments for Vulnerable Elder Rights Protection Activities. Annual grants awarded to
states, the District of Columbia, and U.S. territories are distributed based on a statutory funding
formula that takes into account each state or territory’s relative share of the total U.S. population
161 Generations United, 2020 State of Grandfamilies Report, October 2020, p. 19, https://www.gu.org/app/uploads/
2020/10/2020-Grandfamilies-Report-Web.pdf.
162 E-Shien Chang and Becca R. Levy, “High Prevalence of Elder Abuse During the COVID-19 Pandemic: Risk and
Reslience Factors,” The American Journal of Geriatric Psychiatry, January 19, 2021, https://doi.org/10.1016/
j.jagp.2021.01.007.
163 For further background on the OAA, see CRS Report R43414, Older Americans Act: Overview and Funding.
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aged 60 and older (aged 70 and older for the Title III-E, National Family Caregiver Support
Program). Under Title VI, Grants for Native Americans, funding is provided to eligible tribal
organizations for nutrition, supportive services, and family caregiver services and supports.
Provision
Section 2921 appropriates $1.434 billion to the HHS Secretary, to remain available until
expended, for certain OAA statutory formula grant programs in the following amounts:
$460.0 million for Supportive Services and Senior Centers (Title III-B);
$750.0 million for Congregate and Home-Delivered Nutrition Services (Title III-
C);
$44.0 million for Preventive Services (Title III-D);
$145.0 million for National Family Caregiver Support Program (Title III-E);
$25.0 million for Grants for Native Americans (Title VI); and
$10.0 million for Long-Term Care Ombudsman Program (Title VII).
For funding provided for Supportive Services and Senior Centers, the provision specifies funding
is available for services made available in the previous fiscal year; efforts related to COVID-19
vaccination outreach and education; and activities to address social isolation among older
individuals. Such activities may include investments in technological equipment and other
solutions to alleviate the negative health effects of social isolation due to stay-at-home orders
during the public health emergency.
Section 2922. National Technical Assistance Center on Grandfamilies and
Kinship Families
Background
In 2018, an estimated 2.7 million children were living with grandparents or other kin
householders (including relatives and nonrelatives) and without their parents. 164 A grandparent or
a family member may have to care for a relative child for many reasons, such as death of the
child’s parents. For example, parental substance abuse and incarceration are often cited as reasons
why a grandparent or family member provides care. 165 Furthermore, when compared with the
general population, grandparents in these settings are more often female, non-White,
unemployed, and living in poverty. 166
Congress passed the Supporting Grandparents Raising Grandchildren Act (P.L. 115-196, enacted
July 7, 2018), in response to the increasing role grandparents play as primary caretakers to
grandchildren. This act established the Advisory Council to Support Grandparents Raising
Grandchildren. The advisory council first met in August 2019 and published its first annual report
in November 2020. 167 Around the same time, the advisory council finalized 22 recommendations
164 U.S. Government Accountability Office, Child Welfare and Aging Programs: HHS Could Enhance Support for
Grandparents and Other Relative Caregivers, gao-20-434, July 2020, p. 11, https://www.gao.gov/assets/gao-20-
434.pdf.
165
Ibid., p. 20.
166 Ibid., p. 15.
167 Administration for Community Living, Advisory Council to Support Grandparents Raising Grandchildren, Year
One Progress Report: Supporting Grandparents Raising Grandchildren Act, November 2020, https://acl.gov/sites/
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intended to advance change and improve supports to kinship families and grandfamilies of all
ages. 168 The recommendations touched on several areas, including awareness and outreach;
caregiver engagement; services and supports; financial and workspace security; and research,
data, and evidence-based practices. Recommendations 5.1, 5.2, and 5.3 are particularly relevant
to this provision:
Recommendation 5.1: Establish a national approach for obtaining, analyzing, and
disseminating relevant data on kinship families and grandfamilies.
Recommendation 5.2: Increase, support, and sustain research and development, including
adequate investments for evaluating programs that support kinship families and
grandfamilies.
Recommendation 5.3: Increase the promotion, translation, and dissemination of
promising practices, model approaches, and evidence-informed and evidence-based
practices to support kinship families and grandfamilies.
Grandfamilies and kinship families face a number of challenges that make them particularly
vulnerable during the COVID-19 pandemic. Advocates have cited the disparate impact of
COVID-19 on communities of color as one such challenge, given the high proportion of non-
White grandfamilies. Moreover, a survey of caregivers showed that the COVID-19 pandemic has
created a significant potential for food and housing insecurity. 169 Caregivers responding to this
survey noted a reduction in available services in general during the COVID-19 pandemic. 170 The
advisory council published an emergency preparedness resource list for grandfamilies and kinship
families specifically in response to the pandemic. 171
Provision
Section 2922 appropriates $10 million to the ACL Administrator, 172 to remain available through
September 30, 2025, to establish a National Technical Center on Grandfamilies and Kinship
Families to provide training, technical assistance, and resources for government programs,
nonprofit and other community-based organizations, and Indian Tribes, tribal organizations, and
urban Indian organizations. This section requires the center to focus primarily on serving
grandfamilies and kinship families in which the primary caregiver is an adult aged 55 or older, or
in which a child has one or more disabilities. It requires the center to conduct the following
activities:
default/files/RAISE_SGRG/SGRGProgressReport2020_Final.pdf.
168 Administration for Community Living, Advisory Council to Support Grandparents Raising Grandchildren, Final
Recommendations, October 20, 2020, https://acl.gov/sites/default/files/programs/2020-12/
SGRG%20Recommendations%20Final%20Web.pdf.
169 Generations United, 2020 Grandfamilies Infographic, October 2020, Generations United, 2020 State of
Grandfamilies Report, October 2020, p. 19, https://www.gu.org/app/uploads/2020/10/2020-Grandfamilies-Report-
Web.pdf.
170
Rosenthal, M., Littlewood, K., and Cooper, L., (2020, October 5 -9). “Lifting Up the Voices of 600 Caregivers in the
Pandemic: GrOW’s Grand-families during COVID-19 Study,” conference presentation, A Call to Action to Change
Child Welfare, Kempe Center International Virtual Conference, October 5 -9, 2020,
https://www.grandfamilieswork.org/s/GrOWs-Lifting-Up-the-Voices-of-600-Caregivers-in-the-Pandemic-Kempe-
Conference-citation.pdf.
171 Administration for Community Living, Advisory Council to Support Grandparents Raising Grandchildren, COVID-
19/Emergency Preparedness Resources, August 25, 2020, https://acl.gov/sites/default/files/programs/2020-08/8-25-
2020_Emergency%20Preparedness%20for%20Kinship%20Families%20and%20Grandfamilies_shorterTOC_508acces
sible_FINAL.pdf.
172 Section 2922 appropriates funding to the HHS Secretary “acting through” the ACL Administrator.
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to engage experts regarding the development and identification of evidence-
based, evidence-informed, and exemplary practices or programs related to a
range of health, social, and economic issues;
to encourage and support the implementation of evidence-based, evidence-
informed, and exemplary practices or programs to support families and to
promote coordination of services;
to facilitate learning across certain specified entities for providing technical
assistance, resources, and training to individuals and entities across systems that
directly work with grandfamilies and kinship families;
to help certain specified entities plan and coordinate responses to assist
grandfamilies and kinship families during emergencies and disasters; and
to help certain specified entities promote equity and implement culturally and
linguistically appropriate approaches as the programs and organizations serve
grandfamilies and kinship families.
The funds appropriated under this provision can be used to establish the center either directly,
through grants, or through contracts.
Section 9301. Additional Funding for Aging and Disability Services Programs
Background
Elder abuse and neglect, also referred to as elder mistreatment, are considered to be “intentional
actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a
vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder or
failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” Such
actions may involve physical or psychological abuse, financial exploitation, neglect, or
abandonment. 173
Elder abuse is a complex issue. As such, it often leads to calls for a multifaceted policy response
that combines public health interventions, social services programs, and law enforcement. To
address this complexity, the Elder Justice Act (EJA) was enacted as part of the Patient Protection
and Affordable Care Act (ACA, P.L. 111-148, as amended) and contained certain public health
and social services approaches to the prevention, detection, and treatment of elder abuse. Several
of the Elder Justice Act provisions amended the Social Security Act (SSA), which incorporated
elder justice into a renamed Title XX, Block Grants to States for Social Services and Elder
Justice, and added a new Subtitle B, Elder Justice.
The EJA authorizes entities to address the federal coordination of elder abuse prevention
activities, such as establishment of the Elder Justice Coordinating Council. It also authorizes the
administration of new grant activities and other specified reports and studies. 174 Specifically, SSA
Section 2042(b) requires the HHS Secretary to establish a grants program to enhance state and
U.S. territories Adult Protective Services (APS) programs, which are social services programs
established through legislation enacted in all 50 states, the District of Columbia, Guam, Puerto
Rico, and the U.S. Virgin Islands. APS programs serve seniors and adults with disabilities by
offering a system for reporting and investigating abuse, as well as by providing social services to
173 Richard J. Bonnie and Robert B. Wallace, eds., Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging
America, National Research Council (Washington, DC: National Academy Press, 2003).
174 §6703(a) through (c) of the ACA.
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victims. Annual grants awarded to states, the District of Columbia, and U.S. territories are to be
distributed based on a statutory funding formula that takes into account each state’s or territory’s
relative share of the total U.S. population aged 60 years and older. For each of FY2011 through
FY2014, it authorized to be appropriated $100.0 million for annual grants to enhance APS
programs.
Elder Justice and Adult Protective Services activities receive some annual funding through the
discretionary appropriations process under the Labor-HHS-Education account, “Aging and
Disability Services Programs,” administered by ACL. Since FY2015, Congress has instructed
HHS to use a portion of the department’s annual appropriations for Elder Justice and Adult
Protective Services. For FY2021, the joint explanatory statement accompanying the Consolidated
Appropriations Act, 2021 (P.L. 116-260), directed HHS to reserve $12 million to the Elder Justice
and Adult Protective Services program and an additional $2 million to grants to address state
guardianship laws and procedures as authorized under SSA Section 2042(c)(3).175 In prior years,
ACL funding under the Elder Justice and Adult Protective Services program has also been used
for related activities authorized under OAA. 176 With respect to COVID-19 relief, the
Consolidated Appropriations Act, 2021, also provided $100 million in discretionary supplemental
funding for the COVID-19 response. 177 This amount is available for EJA activities, of which no
less than $50 million is designated for SSA Section 2042(b) grants to enhance state APS
programs. 178
Provision
Section 9301 amends SSA Title XX to add a new Section 2010 entitled “Additional Funding for
Aging and Disability Services Programs.” It appropriates $276 million, to remain available until
expended, to carry out EJA activities under SSA Title XX, Subtitle B. From this total, $88 million
is available for FY2021 and $188 million is available for FY2022. The provision seeks to ensure
that not less than $100 million in total funds is made available to carry out activities authorized
under SSA Section 2042(b) to enhance state APS programs for each fiscal year. For FY2021, this
$100 million threshold would be met by a combination of the new $88 million made available by
this provision and funds previously provided for this purpose.
175 Explanatory statement submitted by Rep. Lowey, Chairwoman of the House Committee on Appropriations,
regarding the House Amendment to the Senate Amendment to H.R. 133, Consolidated Appropriations Act, 2021,
Congressional Record, December 21, 2020, pp. H8632, H8640, H8679-H8681, https://www.congress.gov/116/crec/
2020/12/21/CREC-2020-12-21.pdf-bk4.
176
Specifically, OAA Section 411, which authorizes the Assistant Secretary to make available research, demonstration,
and training grants or contracts with states and other entities on a range of aging-related activities, and OAA Section
752, which authorizes competitive grants to states to promote comprehensive elder justice systems.
177 Division M of P.L. 116-260.
178 Of the $100.0 million appropriated for activities authorized under the Elder Justice Act, ACL announced that $93.9
million would be available for “Grants to Enhance Adult Protective Services to Respond to COVID-19,” 86 Federal
Register 7726, February 1, 2021, https://www.federalregister.gov/d/2021-02091/. Another $4.0 million of that amount
would be available for “Grants to Enhance Capacity of Long-T erm Care Ombudsman Programs to Respond to
Complaints of Abuse and Neglect of Residents in Long-T erm Care Facilities During the COVID-19 Public Health
Emergency,” 86 Federal Register 7728, February 1, 2021, https://www.federalregister.gov/d/2021-02092. ACL also
announced two new elder justice funding opportunities, Grants to Enhance State Adult Protective Serv ices and Elder
Justice Innovation Grants, on April 7, 2021, https://acl.gov/news-and-events/announcements/new-elder-justice-
funding-opportunities.
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Appendix. Abbreviations Used in This Report
Acronym Definition
ACA Patient Protection and Affordable Care Act (P.L. 111-148, as amended)
ACL Administration for Community Living
AIDS Acquired Immunodeficiency Syndrome
APS Adult Protective Services
ARPA American Rescue Plan Act (P.L. 117-2)
ASPR Assistant Secretary for Preparedness and Response (HHS)
ASTHO Association of State and Territorial Health Officials
BARDA Biomedical Advanced Research and Development Authority (HHS)
BHWET Behavioral Health Workforce Education and Training
CARES Act Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136)
CCBHC Certified Community Behavioral Health Clinic
CCP Crisis Counseling Assistance and Training Program
CDC Centers for Disease Control and Prevention (HHS)
CHCF Community Health Center Fund
CHIP State Children’s Health Insurance Program
COVID-19 Coronavirus Disease 2019
DOD Department of Defense
DPA Defense Production Act of 1950 (P.L. 81-774)
DTAC Disaster Technical Assistance Center (SAMHSA)
EJA Elder Justice Act
EUA Emergency Use Authorization (FDA)
FDA Food and Drug Administration (HHS)
FEMA Federal Emergency Management Agency
FFCRA Families First Coronavirus Response Act (P.L. 116-127)
FQHC Federally Qualified Health Center
FTE Full-Time Equivalent
GAO U.S. Government Accountability Office
GLS Garrett Lee Smith Suicide Prevention Grants (SAMHSA)
GME Graduate Medical Education
HHS Department of Health and Human Services
HIV Human Immunodeficiency Virus
HRSA Health Resources and Services Administration (HHS)
IC NIH Institute and Center
IHS Indian Health Service (HHS)
ISDEAA Indian Self-Determination and Education Assistance Act (P.L. 93-638)
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Acronym Definition
IT Indian Tribe
JSI John Snow, Inc.
KFF Kaiser Family Foundation
LHD Local Health Department
MCM Medical Countermeasures
MHBG Community Mental Health Services Block Grant (SAMHSA)
MHFA Mental Health First Aid
MMWR Morbidity and Mortality Weekly Report (CDC)
MRC Medical Reserve Corps (HHS)
MUA Medically Underserved Area
NACCHO National Association of County and City Health Officials
NAM National Academy of Medicine
NHSC National Health Service Corps (HRSA)
NHSPI National Health Security Preparedness Index
NIH National Institutes of Health (HHS)
OAA Older Americans Act of 1965 (P.L. 89-73, as amended)
OWS Operation Warp Speed
PHEP Public Health Emergency Preparedness
PHSA Public Health Service Act
PHSSEF Public Health and Social Services Emergency Fund
PPE Personal Protective Equipment
PPPHCEA Paycheck Protection Program and Health Care Enhancement Act (P.L. 116-139)
PRC Purchased/Referred Care
PRF Provider Relief Fund
PRNS Priority Mental Health Needs of Regional and National Significance
(Project) Advancing Wellness and Resilience in Education
AWARE
R&D Research and Development
ReCAST Resiliency in Communities After Stress and Trauma
RHC Rural Health Clinic
SABG Substance Abuse Prevention and Treatment Block Grant (SAMHSA)
SAMHSA Substance Abuse and Mental Health Services Administration (HHS)
SEA State Educational Agency
SHA State Health Agency
SHADAC State Health Access Data Assistance Center
SLTT State, Local, Tribal and Territorial
SSA Social Security Act
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Acronym Definition
SUPPORT Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients
Act and Communities Act (P.L. 115-271)
THC Teaching Health Center
THCGME Teaching Health Center Graduate Medical Education
TO Tribal Organization
UIO Urban Indian Organization
USDA U.S. Department of Agriculture
Author Information
Johnathan H. Duff, Coordinator Michael H. Cecire
Analyst in Health Policy Analyst in Intergovernmental Relations and
Economic Development Policy
Kavya Sekar, Coordinator Victoria R. Green
Analyst in Health Policy Analyst in Health Policy
Agata Bodie Angela Napili
Analyst in Health Policy Senior Research Librarian
Kirsten J. Colello Hassan Z. Sheikh
Specialist in Health and Aging Policy Analyst in Public Health Emergency Management
Elayne J. Heisler Jared S. Sussman
Specialist in Health Services Analyst in Health Policy
Sarah A. Lister Taylor R. Wyatt
Specialist in Public Health and Epidemiology Analyst in Public Health Emergency Management
Alyssa R. Casey
Analyst in Agricultural Policy
Acknowledgments
Former CRS Analyst in Health Economics Simi V. Siddalingaiah contributed to this report. CRS Research
Assistant Isaac Nicchitta assisted with the tables for this report.
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under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
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