Full text
COVID-19
Lessons Can Help
Agencies Better
Prepare for Future
Emergencies
Report to Congressional Committees
August 2024
GAO-24-107175
United States Government Accountability Office
United States Government Accountability Office
Highlights of GAO-24-107175, a report to
congressional committees
August 2024
COVID-19
Lessons Can Help Agencies Better Prepare for Future
Emergencies
What GAO Found
The nation continues to recover from the public health and economic effects of
the COVID-19 pandemic. For example, COVID-19 was the tenth leading cause of
death in 2023, as compared to being the third leading cause of death in 2020 and
2021. Available data also show that inflation declined between March 2023 and
March 2024, but remained higher than pre-pandemic levels.
GAO identified lessons from the COVID-19 pandemic that could help federal
agencies better prepare for, respond to, and recover from future emergencies.
These lessons draw on GAO’s COVID-19 oversight work, which includes 428
recommendations to federal agencies and 24 matters for congressional
consideration as of April 2024. Of these recommendations, 220 remain open.
Moreover, these recommendations include those related to the three areas GAO
added to its High Risk List during the COVID-19 public health emergency:
1. the Department of Health and Human Services’ leadership and coordination
of public health emergencies,
2. the Department of Labor’s Unemployment Insurance system, and
3. the Small Business Administration’s emergency loans to small businesses.
Agencies across the government could improve their preparedness for future
emergencies by fully implementing GAO’s recommendations.
Lessons that could help federal agencies better prepare for future emergencies
fall into seven topic areas. These lessons highlight instances where government
agencies did well in responding to the pandemic, as well as instances where the
government response could have been much better.
Lessons Learned for Federal Agencies from the COVID-19 Pandemic
View GAO-24-107175. For more information,
contact Jessica Farb at (202) 512-7114 or
FarbJ@gao.gov.
Why GAO Did This Study
The COVID-19 pandemic brought
significant challenges to the nation's
public health and economy. Since
March 2020, Congress has provided
about $4.65 trillion in federal funds to
help the nation respond to and recover
from the pandemic. Agencies across
the government have worked to
implement the federal response.
The CARES Act includes a provision
for GAO to report regularly on the
public health and economic effects of
the pandemic and the federal
response. This report includes updates
on the public health effects and
economic conditions since the
pandemic, including updates on federal
COVID-19 relief funding. It also
describes lessons learned from the
pandemic that could help federal
agencies better prepare for future
emergencies.
To describe lessons learned for federal
agencies, GAO analyzed issued GAO
reports. GAO also collected
information on agency actions to
address GAO COVID-19
recommendations.
What GAO Recommends
GAO is making one new
recommendation to the Department of
the Treasury to include key lessons
from the COVID-19 emergency
financial assistance provided to the
aviation industry in its efforts to
compile resources to prepare for future
financial disasters. A Treasury official
told us that Treasury agrees with our
recommendation and will take steps to
implement it.
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GAO-24-107175
PLANNING IN ADVANCE
Advanced plans—including national-level strategies and department- and agency-level plans—provide vision for
how the federal government will respond to public health emergencies and are critical to the nation’s
preparedness and ability to implement a timely response. Agencies can further enhance their preparedness by
•
clearly defining their roles and responsibilities and those of their response partners in response plans,
and exercising these plans prior to emergencies;
•
understanding their capabilities and limitations and those of their response partners, and reflecting
these capabilities and limitations in response plans; and
•
building their capacity and collecting lessons to inform and update plans.
GAO found instances where federal agencies could improve their preparedness by taking such steps. For
example, the Department of the Treasury has not incorporated lessons GAO identified from the COVID-19
assistance programs to the aviation industry into its efforts to compile resources to prepare for future financial
disasters. Taking such steps could help Treasury make timely decisions and avoid encountering past challenges
when responding to future emergencies.
Further, GAO has made recommendations to federal agencies to improve their emergency response plans. For
example, GAO recommended that the Department of Health and Human Services develop plans outlining steps
to mitigate shortages in needed medical supplies, develop a comprehensive testing strategy, and develop an
approach for assessing and addressing known challenges and future risks associated with advanced
development and manufacturing of medical countermeasures, including vaccines.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
COLLABORATING WITH RESPONSE PARTNERS
Collaborating with response partners—including federal and nonfederal partners—before and during public health
emergencies can help agencies efficiently implement response activities and continue operations. Federal
agencies can facilitate this collaboration by identifying partners key to implementing the response, regularly
coordinating with identified partners, and ensuring partners understand their roles and responsibilities in
implementing the response.
GAO has made recommendations to agencies across the federal government to improve their collaboration with
response partners. For example, GAO recommended that the Department of Health and Human Services share
its plans to mitigate medical supply shortages with response partners and maintain up-to-date guidance for
partners on requesting and receiving assets from the Strategic National Stockpile.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
PROVIDING CLEAR AND TIMELY COMMUNICATIONS
Federal agencies can enhance their efforts to effectively administer relief funds, vaccines, and other critical
resources during a public health emergency by providing clear and timely information to
•
applicants and eligible entities of federal relief funds,
•
recipients of federal relief funds, and
•
the public.
GAO has made recommendations to federal agencies to improve their communications during public health
emergencies. For example, GAO recommended that the Small Business Administration develop a comprehensive
strategy for communicating with potential and actual program applicants in the event of an emergency. GAO
stated that its strategy should include guidelines for the types of information and timing of information to be
provided to program participants throughout an emergency.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
MANAGING PROGRAM INTEGRITY RISKS
Establishing controls and processes can help federal agencies manage program integrity risks when they must
disburse emergency relief funds quickly during an emergency. Specifically, prepayment controls and processes
can help agencies minimize the likelihood of improper payments and fraud. Further, postpayment controls and
processes can help agencies identify and recover improper and fraudulent payments when the quick
disbursement of funds makes prepayment controls difficult to apply fully.
GAO has made recommendations to federal agencies to better manage program integrity risks in emergency
assistance programs. For example, GAO recommended that the Department of Labor design and implement an
antifraud strategy for unemployment insurance programs that is consistent with leading practices outlined in
GAO’s Fraud Risk Framework.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
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GAO-24-107175
COLLECTING AND SHARING DATA
Collecting and sharing data can help federal agencies
•
effectively manage response activities, evaluate performance in meeting response program goals,
and make midcourse adjustments as needed;
•
target and administer relief fund programs; and
•
enhance the early detection of public health emergencies.
GAO has made recommendations to federal agencies to enhance their ability to collect and share data before
and during public health emergencies. For example, GAO recommended that the Department of Health and
Human Services develop a plan to establish an electronic nationwide public health situational awareness
network and identify measurable steps for completing this network.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
LEVERAGING EXISTING INFRASTRUCTURE
Leveraging the existing infrastructure—including programs, partnerships, and systems—can help federal
agencies implement timely activities to respond to a public health emergency and efficiently manage them.
Specifically, federal agencies can use existing infrastructure to facilitate the delivery of services, distribute
federal relief funds, and manage and oversee response programs.
GAO identified instances during the COVID-19 pandemic where federal agencies successfully leveraged the
existing infrastructure. For example, the Department of the Interior and the Indian Health Service leveraged
existing program mechanisms to efficiently distribute COVID-19 relief funds to tribal recipients during the
pandemic. GAO has made recommendations to federal agencies to seek such opportunities. Further, GAO
suggested that Congress consider enacting automatic increases in federal Medicaid spending during economic
downturns to increase federal Medicaid support in a more timely and targeted fashion.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
IMPLEMENTING PROGRAM FLEXIBILITIES
Implementing flexibilities—such as telehealth and telework—during a public health emergency can help federal
agencies
•
deliver services to program beneficiaries,
•
maintain activities to support critical operations, and
•
promote the safety of workers and the public.
GAO has recommended that federal agencies examine the extent to which flexibilities utilized during the
COVID-19 pandemic could be incorporated in standard operations or used during future emergencies. For
example, GAO recommended that the Food and Drug Administration fully assess whether and how alternative
tools could help meet drug oversight objectives when in-person inspections are not possible in the future.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Letter
1
Updates to Public Health, Economic, and Federal COVID-19
Relief Funding and Spending Data
4
Lessons from the COVID-19 Pandemic Can Help Federal
Agencies Better Prepare for Emergencies
13
Conclusions
62
Recommendation
62
Agency Comments
63
Appendix I
Matters for Congressional Consideration to Improve the
Transparency and Accountability of Emergency Relief Funds
66
Appendix II
GAO Contact and Staff Acknowledgments
68
Related GAO Products
69
Tables
Table 1: Major Spending Areas under COVID-19 Relief Funding
as of April 30, 2024
10
Table 2: Largest Unexpired Unobligated Balances under COVID-
19 Relief Funding as of April 30, 2024
11
Figures
Figure 1: Weekly Number of U.S. COVID-19-Associated Deaths,
January 2020 through April 2024
5
Figure 2: COVID-19 Relief Laws
9
Figure 3: Lessons Learned for Federal Agencies from the COVID-
19 Pandemic
13
Figure 4: Types of Entities Involved in Supporting Nationwide
Public Health Situational Awareness
52
Figure 5: Types of Medicaid Telehealth Modalities
60
Contents
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Abbreviations
ASPR
Administration for Strategic Preparedness and Response
CDC
Centers for Disease Control and Prevention
CFO
chief financial officer
CIADM
Centers for Innovation and Advance Development and
Manufacturing
CMS
Centers for Medicare & Medicaid Services
CPI
Consumer Price Index
DHS
Department of Homeland Security
DOD
Department of Defense
DOL
Department of Labor
DOT
Department of Transportation
FDA
Food and Drug Administration
FEMA
Federal Emergency Management Agency
HHS
Department of Health and Human Services
HRSA
Health Resources and Services Administration
IRS
Internal Revenue Service
OMB
Office of Management and Budget
SBA
Small Business Administration
SIGPR
Office of the Special Inspector General for Pandemic
Recovery
SLFRF
Coronavirus State and Local Fiscal Recovery Funds
USDA
United States Department of Agriculture
VA
Department of Veterans Affairs
VHA
Veterans Health Administration
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
441 G St. N.W.
Washington, DC 20548
August 1, 2024
Congressional Committees
The COVID-19 pandemic was an unprecedented global crisis resulting in
about 1.2 million reported deaths in the U.S. as of April 27, 2024.1 While
the Secretary of the Department of Health and Human Services (HHS)
terminated the federal public health emergency on May 11, 2023, the
nation is still recovering from the public health and economic effects of
the pandemic while working to identify and respond to new COVID-19
variants.2
Since March 2020, the CARES Act and five additional laws provided
about $4.65 trillion in federal funding to help the nation respond to and
recover from the pandemic.3 The COVID-19 response included a focus
1The death counts from the Centers for Disease Control and Prevention’s (CDC) National
Center for Health Statistics include those with COVID-19, coded to ICD-10 code U07.1, as
an underlying or contributing cause of death on the death certificate. Data are provisional
and subject to updates. Data for recent periods are incomplete because of the lag in time
between when deaths occur and when a death certificate is completed, submitted to the
National Center for Health Statistics, and processed for reporting. This delay can range
from 1 to 8 weeks or more. See Centers for Disease Control and Prevention, National
Center for Health Statistics, “United States COVID-19 Hospitalizations, Deaths,
Emergency Department (ED) Visits, and Test Positivity by Geographic Area,” accessed
May 6, 2024 https://covid.cdc.gov/covid-data-tracker/#maps_percent-covid-deaths.
2HHS first declared the COVID-19 pandemic a public health emergency under section 319
of the Public Health Service Act on January 30, 2020. In addition, on March 13, 2020, the
President declared COVID-19 a national emergency under the National Emergencies Act
and a nationwide emergency under section 501(b) of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (Stafford Act). The President also approved major
disaster declarations under the Stafford Act for all 50 states, the District of Columbia, five
U.S. territories, and certain Tribes. The national emergency declaration terminated on
April 10, 2023, and the Stafford Act declaration terminated on May 11, 2023.
3For the purpose of our review, the COVID-19 relief laws consist of the six laws providing
comprehensive relief across federal agencies and programs that the Department of the
Treasury uses to record and track COVID-19 relief spending, in accordance with guidance
issued by the Office of Management and Budget (OMB). These six laws are the American
Rescue Plan Act of 2021, Pub. L. No. 117-2, 135 Stat. 4; Consolidated Appropriations Act,
2021, Pub. L. No. 116-260, div. M and N, 134 Stat. 1182 (2020); Paycheck Protection
Program and Health Care Enhancement Act, Pub. L. No. 116-139, 134 Stat. 620 (2020);
CARES Act, Pub. L. No. 116-136, 134 Stat. 281 (2020); Families First Coronavirus
Response Act, Pub. L. No. 116-127, 134 Stat. 178 (2020); and the Coronavirus
Preparedness and Response Supplemental Appropriations Act, 2020, Pub. L. No. 116-
123, 134 Stat. 146. Further, the $4.65 trillion total reflects rescissions of COVID-19 relief
funding that were enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137
Stat. 10, 23-30, div. B, tit. I (June 3, 2023), and other laws.
Letter
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
on mitigating COVID-19 health risks and providing federal assistance to
support individuals and public and private entities. Agencies across the
federal government worked to implement this federal response.
The CARES Act includes a provision for GAO to report regularly on the
public health and economic effects of the pandemic and the federal
response.4 We have issued 11 comprehensive reports examining the
federal government’s continued efforts to respond to and recover from the
COVID-19 pandemic. In addition, we have issued over 200 standalone
reports, testimonies, and science and technology spotlights focused on
different aspects of the pandemic.
In our body of work on COVID-19 oversight, we have made 428
recommendations to federal agencies in addition to 24 matters for
congressional consideration to improve implementation, oversight, and
transparency of the federal response. We also made recommendations to
federal agencies to better prepare for future emergencies. As of April
2024, 220 of the recommendations from our COVID-19 oversight work
remain open. Federal agencies had fully addressed 198 of these
recommendations and partially addressed 35 of these recommendations.5
Additionally, Congress has taken steps to fully address two matters for
congressional consideration.
The 428 recommendations from our COVID-19 oversight work include
several we have made to agencies related to the three areas we added to
our High Risk List during the COVID-19 public health emergency: (1)
HHS’s leadership and coordination of public health emergencies, (2) the
Department of Labor’s (DOL) Unemployment Insurance system, and (3)
4Pub. L. No. 116-136, § 19010, 134 Stat. at 579–81. The American Rescue Plan Act of
2021 also includes a provision for GAO to conduct oversight of the COVID-19 response.
Pub. L. No. 117-2, § 4002, 135 Stat. at 78.
5Additionally, we closed 10 recommendations as not implemented or as no longer valid.
Reasons for closing recommendations as no longer valid include when a law has been
amended or repealed; when a program has been terminated, replaced, or changed; when
an office is terminated; or when the opportunity for implementation has passed, such as
with a pilot project. For example, we made a recommendation in September 2020 related
to collecting more complete data on COVID-19 cases and deaths in nursing homes
retrospectively back to January 1, 2020, and clarifying the extent to which nursing homes
reported data before May 8, 2020. As of October 2023, the recommendation remained
unimplemented. We determined that, at this point in time, retrospectively collecting data
prior to May 8, 2020, could prove burdensome for both nursing homes and HHS and
detract resources that could otherwise be used to support resident care. See
https://www.gao.gov/coronavirus/coronavirus-recommendations for more information on
our COVID-19 oversight recommendations.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
the Small Business Administration’s (SBA) emergency loans to small
businesses.6 For example, we recommended
•
HHS should develop a coordinated, department-wide action program
that encourages collaboration within HHS and includes external
stakeholders involved with the public health response to identify and
resolve challenges.7
•
DOL should develop and implement an antifraud strategy for
Unemployment Insurance programs that is consistent with leading
practices for preventing, detecting, and responding to fraud outlined in
GAO’s Fraud Risk Framework.8
•
SBA should ensure that it has identified external sources of data that
can facilitate the verification of applicant information and the detection
of potential fraud across programs, including loans made under the
Paycheck Protection Program and the COVID-19 Economic Injury
Disaster Loan program.9
This report includes key data updates on the public health effects and
economic conditions following the COVID-19 pandemic and the federal
response, including data updates on federal COVID-19 relief funding and
spending. It also describes lessons from the pandemic that could help
federal agencies better prepare for future emergencies.
To describe lessons from the COVID-19 pandemic that could help federal
agencies better prepare for future emergencies, we reviewed and
analyzed GAO reports and recommendations, including comprehensive
and standalone CARES Act reports. We reviewed additional selected
6The High Risk List identifies government operations with vulnerabilities to fraud, waste,
abuse, and mismanagement, or in need of transformation. We added HHS’s leadership
and coordination of public health emergencies and the Unemployment Insurance system
to our High Risk List in 2022. We added emergency loans to small businesses to the High
Risk List in 2021. GAO, High-Risk Series: Efforts Made to Achieve Progress Need to Be
Maintained and Expanded to Fully Address All Areas, GAO-23-106203 (Washington, D.C.:
Apr. 20, 2023).
7HHS is the federal agency responsible for leading the nation’s preparedness for and
response to public health emergencies. GAO, Public Health Preparedness: Mpox
Response Highlights Need for HHS to Address Recurring Challenges, GAO-24-106276
(Washington, D.C.: Apr. 18, 2024).
8GAO, Unemployment Insurance: Data Indicate Substantial Levels of Fraud during the
Pandemic; DOL Should Implement an Antifraud Strategy, GAO-23-105523 (Washington,
D.C.: Dec. 22, 2022).
9GAO, COVID Relief: Fraud Schemes and Indicators in SBA Pandemic Programs,
GAO-23-105331 (Washington, D.C.: May 18, 2023).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
documents, such as a report from the Office of the Special Inspector
General for Pandemic Recovery (SIGPR) on COVID-19 relief funds
provided to the aviation industry and public statements from the
Department of Justice on federal fraud-related cases involving federal
COVID-19 relief programs.10 We also interviewed officials from the
Department of the Treasury and collected information from various
federal agencies, including HHS, to identify actions they have taken as of
April 2024 to resolve some of our recommendations, such as
recommendations from our CARES Act reports.
We conducted this performance audit from November 2023 to August
2024 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
In our comprehensive reports, we tracked data related to the public health
effects of the COVID-19 pandemic. The following are updates to key data
discussed in those reports.
Over the course of the pandemic, the U.S. experienced multiple peaks
and lulls in the weekly counts of COVID-19-associated deaths—a key
indicator of COVID-19 severity—according to data from the Centers for
Disease Control and Prevention’s (CDC) National Center for Health
10We reviewed public statements from the Department of Justice from March 2020
through March 2024 to determine the status and characteristics of federal COVID-19
fraud-related cases. Specifically, we identified cases involving federal COVID-19 relief
programs, including the Paycheck Protection Program, the Economic Injury Disaster Loan
program, and the Unemployment Insurance program. We identified these cases by
searching for relevant Department of Justice press releases and analyzing corresponding
court documentation available in the Public Access to Court Electronic Records.
Updates to Public
Health, Economic,
and Federal COVID-
19 Relief Funding and
Spending Data
Public Health Effects of
the COVID-19 Pandemic
Mortality
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Statistics.11 The highest weekly numbers of COVID-19-associated deaths
occurred in January 2021 (with about 26,000 deaths) followed by January
2022 and April 2020. Since mid-2022, weekly COVID-19-associated
deaths have been much lower, with the peak in January 2023 reaching
about 3,900 deaths, according to the latest available data as of May 1,
2024. See figure 1.
Figure 1: Weekly Number of U.S. COVID-19-Associated Deaths, January 2020 through April 2024
Note: COVID-19-associated deaths are those with COVID-19 listed as an underlying (i.e., primary) or
contributing cause of death using the International Classification of Diseases, Tenth Revision (code
U07.1). Data are from CDC WONDER as of May 1, 2024. Death counts for certain weeks prior to
March 7, 2020, were suppressed due to small numbers. Data for 2020 and 2021 are final. Data from
2022 through April 2024 are provisional and subject to change.
Likewise, annual rates of COVID-19-associated deaths were higher in
2020 and 2021 than in 2022 and 2023. The rate of COVID-19-associated
deaths was about 116.7 deaths per 100,000 U.S. residents in 2020 and
peaked at 139.3 in 2021 before falling to 73.7 in 2022 and 22.4 in 2023.
11COVID-19-associated deaths are those with COVID-19 listed as an underlying (i.e.,
primary) or contributing cause of death using the International Classification of Diseases,
Tenth Revision (code U07.1). Data are from CDC WONDER as of May 1, 2024. Data for
2020 and 2021 are final. Data from 2022 through April 2024 are provisional and subject to
change. Of the COVID-19-associated deaths that occurred between 2020 and 2024,
COVID-19 was listed as the underlying cause in about 86 percent of deaths.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
COVID-19 was the third leading cause of death in 2020 and 2021, fourth
in 2022, and tenth in 2023.12
Over the course of the pandemic, surges in COVID-19 cases have
stressed hospital systems and negatively affected health care and public
health infrastructure, according to CDC. Similar to COVID-19-associated
deaths, the U.S. experienced peaks and lulls in the level of COVID-19
hospitalizations. At its height in January 2022, the number of adult and
pediatric patients with confirmed cases of COVID-19 occupying hospital
beds rose to nearly 152,000, with a subsequent peak being much lower.
COVID-19 hospitalizations reached approximately 42,000 in January
2023. COVID-19 hospitalizations then fell to just under 5,500 in June
2023 before rising again to approximately 30,600 in January 2024. Since
January 2024, COVID-19 hospitalizations have steadily declined and
totaled less than 5,000 at the end of April 2024.13 As of May 1, 2024,
hospitals are no longer required to report COVID-19 hospital admissions,
among other COVID-19-related indicators, to HHS. However, CDC
encourages ongoing, voluntary reporting of hospitalization data.
One public health effect of COVID-19 is long COVID, or post-COVID
conditions, which, according to CDC, refers to signs, symptoms, and
conditions that continue or develop after an initial COVID-19 infection.
According to estimates from the Census Bureau’s Household Pulse
Survey, conducted April 2 through April 29, 2024, about 18 percent of
adults in the U.S. aged 18 and older had experienced long COVID, and
about 5 percent were experiencing it at the time of the survey.14 CDC and
other researchers have used multiple approaches to estimate how many
people experience long COVID. According to CDC, estimates from these
12Deaths with COVID-19 listed as the underlying (i.e., primary) cause of death were used
to determine the ranking in the leading causes of death.
13These figures represent the 7-day rolling average of adult and pediatric patient case
counts reported by hospitals in U.S. states and territories and included in HHS’s COVID-
19 Reported Patient Impact and Hospital Capacity dataset, as of May 3, 2024.
14An estimated 17.8 percent (95 percent confidence interval:17.3 – 18.3) of U.S. adults
had ever experienced long COVID and 5.3 percent (95 percent confidence interval: 5.0 –
5.6) were currently experiencing long COVID at the time of the survey. Questions to
assess the prevalence of long COVID—meaning that there was a presence of symptoms
that lasted 3 months or longer—on the Household Pulse Survey are through an ongoing
partnership between the Census Bureau and the National Center for Health Statistics. The
data are released as part of the Census Bureau’s Experimental Statistical Products
Series. For more information, including limitations, see National Center for Health
Statistics, U.S. Census Bureau, Household Pulse Survey, 2022–2024. Long COVID,
accessed June 3, 2024, https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm.
Hospitalizations
Long COVID
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
different approaches can vary widely depending on factors such as who
was included in the study, as well as how and when the study collected
information.
In our comprehensive reports, we tracked data related to the economic
conditions following the COVID-19 pandemic. The following updates
describe selected trends we observed since the pandemic.
The national economy has continued to recover from the economic
downturn of early 2020, sparked by the COVID-19 pandemic. However,
economic growth has slowed from its 2021 rate, according to the Bureau
of Economic Analysis. Real gross domestic product grew by 5.8 percent
in 2021, but slowed to 1.9 percent in 2022, 2.5 percent in 2023, and 1.6
percent annual rate in the first quarter of 2024. The increase in the first
quarter of 2024 primarily reflected increases in consumer spending,
housing and business investment, and state and local government
spending. The strength of the national economic recovery will depend on
factors such as evolving geopolitical tensions and monetary policy
actions.
Based on data covering price trends through March 2024, inflation had
declined compared with a year ago but remained elevated compared with
pre-pandemic levels.15 Annual inflation indicators were 2.7 percent or
higher in March 2024, which was significantly lower than the 4.2 percent
15Inflation is the increase in the prices of goods and services over time and is typically
measured as the percentage change in those prices over a set period, often 1 year or 1
month. For example, an annual inflation rate of 2 percent means that the prices of goods
and services, on average, increased 2 percent over the past year. In previous work, we
identified a number of indicators of current and expected future inflation to help us monitor
households’ experiences with rising prices and assess the extent to which prices are likely
to continue to rise over time. See GAO, COVID-19: Additional Actions Needed to Improve
Accountability and Program Effectiveness of Federal Response, GAO-22-105051
(Washington, D.C.: Oct. 27, 2021).
Economic Conditions
following the COVID-19
Pandemic
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
in March 2023.16 Yet, inflation was still slightly higher than averages of
about 2 percent in recent decades.17
Indicators of more recent price pressures, including indicators that focus
on underlying inflation trends, have increased moderately. Specifically,
underlying inflation trends ranged from 0.3 percent to 0.5 percent in
January, February, and March 2024.18 These monthly trends indicate a
lack of further progress toward the easing of inflation in recent months.
The labor market has continued to recover from the pandemic, but job
growth showed signs of cooling according to DOL data on unemployment
and other labor market conditions through March 2024. The
unemployment rate remained low at 3.8 percent in March 2024 and was
only slightly higher than the 54-year record low of 3.4 percent in January
2023. Meanwhile, both the employment-to-population ratio and labor
force participation rate have changed little over the past year and
remained lower than in the pre-pandemic period.19 Additionally, as of
March 2024, hiring and job opening rates continued to fall over the past
year, suggesting the labor market has gradually cooled.
16Annual inflation indicators include the year-over-year changes in the Personal
Consumption Expenditures price index, the Consumer Price Index (CPI), the median CPI,
and the 16 percent trimmed mean CPI. The median CPI and 16 percent trimmed mean
CPI indicators focus on underlying inflation trends by omitting outliers.
17The Federal Reserve System’s Federal Open Market Committee determines the
direction of monetary policy by directing open market operations. It aims for annual
inflation of 2 percent on average over time and aims to achieve rates of inflation that are
above 2 percent for some time after periods during which inflation has been persistently
below 2 percent. See Federal Reserve, Federal Open Market Committee, “Statement on
Longer-Run Goals and Monetary Policy Strategy” (Washington, D.C.: Jan. 30, 2024),
accessed July 15, 2024, https://www.federalreserve.gov/monetarypolicy/historical-
statements-on-longer-run-goals-and-monetary-policy-strategy.htm.
18Measuring annual inflation provides a longer and potentially less volatile perspective on
inflation while monthly inflation is more useful for assessing whether recent price
pressures are waning or intensifying. Monthly inflation indicators include the month-over-
month changes in the Personal Consumption Expenditures price index, CPI, the median
CPI, and the 16 percent trimmed mean CPI.
19The employment-to-population ratio was 60.3 percent in March 2024, 0.2 percentage
points higher than in February 2024 and 0.8 percentage points lower than in February
2020. The labor force participation rate was 62.7 percent in March 2024, 0.2 percentage
points higher than in February 2024 and 0.7 percentage points lower than in February
2020. These differences likely reflect a combination of population aging and other pre-
pandemic trends, as well as a lasting negative effect of the pandemic.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Six laws provided about $4.65 trillion in funding to help the nation respond
to and recover from the COVID-19 pandemic. See figure 2.
Figure 2: COVID-19 Relief Laws
Note: The COVID-19 relief laws consist of the six laws providing comprehensive relief across federal
agencies and programs that the Department of the Treasury uses to record and track COVID-19 relief
spending, in accordance with guidance issued by the Office of Management and Budget.
In our comprehensive reports, we presented data tracking how agencies
were obligating and expending COVID-19 relief funding. The following are
updates to these data as of April 30, 2024, the most recent date for which
government-wide information was available at the time of our analysis.
The federal government obligated a total of $4.57 trillion of the $4.65
trillion in COVID-19 relief funding, as reported by federal agencies to
Treasury, in accordance with Office of Management and Budget (OMB)
guidance.20 Further, the federal government had expended about $4.41
trillion of this COVID-19 relief funding. For the top nine spending areas,
agencies reported that COVID-19 relief funding obligations totaled $3.69
trillion (81 percent of total obligations), and expenditures totaled $3.61
20Treasury records and tracks COVID-19 relief spending, in accordance with OMB
guidance. Amounts presented from Treasury’s Governmentwide Treasury Account
Symbol Adjusted Trial Balance System are the most recent available at the time of our
analysis. Federal agencies use this system to provide proprietary financial reporting and
budgetary execution information to Treasury. These amounts can fluctuate from month to
month, and they reflect appropriations, as well as transfers, adjustments, recoveries,
rescissions, and returns of unused indefinite appropriations. OMB’s guidance for recording
and tracking COVID-19 relief spending does not include increases in Medicaid and
Medicare spending; otherwise, the cumulative amount of funding as of April 30, 2024—the
most recent date for which government-wide information was available at the time of our
analysis—would be greater than about $4.65 trillion. Further, the $4.65 trillion total reflects
rescissions of COVID-19 relief funding enacted in the Fiscal Responsibility Act of 2023,
Pub. L. No. 118-5, 137 Stat. 10, 23-30, div. B, tit. I (2023), and other laws.
Federal COVID-19 Relief
Funding and Spending
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
trillion.21 Table 1 provides additional details on government-wide COVID-
19 relief funding, obligations, and expenditures by major spending areas
as of April 30, 2024.
Table 1: Major Spending Areas under COVID-19 Relief Funding as of April 30, 2024
Major spending area (dollars in billions)
COVID-19 relief
funding
Total
obligations
Total
expenditures
Economic Impact Payments (Department of the Treasury)
859.8
859.3
859.3
Business Loan Programs (Small Business Administration)
830.0
828.1
828.0a
Unemployment Insurance (Department of Labor)
697.9
697.5
689.0
Coronavirus State and Local Fiscal Recovery Funds (SLFRF)
(Department of the Treasury)
350.0
349.9
349.9b
Public Health and Social Services Emergency Fund
(Department of Health and Human Services)
337.3
332.6
298.6
Education Stabilization Fund (Department of Education)
277.3
277.3
236.0
Coronavirus Relief Fund (Department of the Treasury)
150.0
149.9
149.8
Supplemental Nutrition Assistance Programs (Department of
Agriculture)
121.0
98.4
102.3c
U.S. Coronavirus Refundable Credits (Department of the
Treasury)
98.8
92.2
92.2
Other areas (includes over 300 accounts)d
927.7
883.4
803.9
Totale
4,649.9
4,568.5
4,408.9
Source: GAO analysis of data from the Department of the Treasury and applicable agencies. | GAO-24-107175
Note: COVID-19 relief funding, obligation, and expenditure data shown for the major spending areas
are based on data reported by applicable agencies to Treasury’s Governmentwide Treasury Account
Symbol Adjusted Trial Balance System. Federal agencies use this system to provide proprietary
financial reporting and budgetary execution information to Treasury. These amounts can fluctuate
from month to month. COVID-19 relief funding is the cumulative amount of funding provided in the six
COVID-19 relief laws that Treasury uses to record and track COVID-19 relief spending, in accordance
with Office of Management and Budget guidance. Further, the $4.65 trillion total reflects rescissions
of COVID-19 relief funding enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137
Stat. 10, 23-30, div. B, tit. I (2023), and other laws. The most recent date for which government-wide
information was available at the time of GAO’s analysis was April 30, 2024.
aThe Small Business Administration’s Business Loan Program account includes activity for Paycheck
Protection Program loan guarantees and certain other loan subsidies. These expenditures relate
mostly to the loan subsidy costs (i.e., the loan’s estimated long-term costs to the U.S. government).
bMost of the SLFRF funds were allocated to states, the District of Columbia, and local governments.
In April 2024, GAO reported that as of September 30, 2023, which was the most recently available
data at the time of the report, states and the District of Columbia reported obligating 73 percent
($142.4 billion) and spending 53 percent ($103.7 billion) of their $195.8 billion in SLFRF awards. A
total of 26,442 localities—including cities, counties, and smaller localities—reported obligating 64
percent ($80.1 billion) and spending 47 percent ($59.4 billion) of their $126.1 billion in SLFRF awards.
21The remaining $927.7 billion in COVID-19 relief funding was used for other spending
areas. Agencies reported obligations totaling $883.4 billion and expenditures totaling
$803.9 billion in these other spending areas.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
See GAO, COVID-19 Relief: State and Local Fiscal Recovery Funds Spending as of September 30,
2023, GAO-24-107472 (Washington, D.C.: Apr. 10, 2024).
cDepartment of Agriculture officials told GAO that the Supplemental Nutrition Assistance Programs
spending amounts were not reported to the Governmentwide Treasury Account Symbol Adjusted
Trial Balance System correctly for April 2024. As a result, the reported expenditures are greater than
the obligations. Agriculture is working to identify the error and correct these amounts for future
reporting.
dSeveral provisions in the Families First Coronavirus Response Act and the American Rescue Plan
Act of 2021 authorized increases in Medicaid payments to states and U.S. territories. At the time of
enactment, the Congressional Budget Office estimated that federal expenditures from these
provisions would total approximately $76.9 billion through fiscal year 2030. The largest increase to
federal Medicaid spending is based on a temporary formula change rather than a specific
appropriated amount. Some of the estimated costs in this total are for the Children’s Health Insurance
Program, permanent changes to Medicaid, and changes not specifically related to COVID-19. This
increased spending is not accounted for in the funding provided by the COVID-19 relief laws and is
therefore not included in this table.
eAmounts shown in columns may not sum to the totals because of rounding.
As of April 30, 2024, $52.4 billion or 1 percent of the total amount of
funding provided for COVID-19 relief remained available for obligation
(unexpired unobligated balance). Additionally, $40.1 billion was expired
(expired unobligated balance), meaning that this amount was not
available for incurring new obligations but was available for recording
eligible obligation adjustments. Table 2 provides additional details on
funding, obligations, unobligated balances, and expenditures of
government-wide COVID-19 relief funding with the largest unexpired
unobligated balances.
Table 2: Largest Unexpired Unobligated Balances under COVID-19 Relief Funding as of April 30, 2024
Spending areas (dollars in billions)
COVID-19
relief funding
Total
obligations
Total
expenditures
Expired
unobligated
balance
Unexpired
unobligated
balance
Pension Benefit Guaranty Corporation
Funda
(Pension Benefit Guaranty Corporation)
77.8
53.9
53.9
0.0
23.8
U.S. Coronavirus Refundable Credits
(Department of the Treasury)
98.8
92.2
92.2
0.0
6.8
Public Health and Social Services
Emergency Fund
(Department of Health and Human
Services)
337.3
332.6
298.6
0.0
4.7
Disaster Relief Fundb
(Federal Emergency Management
Agency)
94.4
93.9
83.4
0.0
4.1
Tenant-Based Rental Assistance
(Department of Housing and Urban
Development)
6.2
3.6
3.3
0.0
2.7
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Spending areas (dollars in billions)
COVID-19
relief funding
Total
obligations
Total
expenditures
Expired
unobligated
balance
Unexpired
unobligated
balance
Emergency Connectivity Fund for
Educational Connections and Devices
(Federal Communications Commission)
7.2
6.0
4.5
0.0
1.7
State Small Business Credit Initiative
(Department of the Treasury)
9.7
8.8
2.8
0.0
0.9
Centers for Disease Control and
Prevention-Wide Activities and Program
Support
(Department of Health and Human
Services)
25.2
24.3
17.9
0.0
0.8
Other areas (includes over 250
accounts)
3,993.3
3,953.2
3,852.4
40.0c
6.9
Totald
4,649.9
4,568.5
4,408.9
40.1
52.4
Source: GAO analysis of data from the Department of the Treasury and applicable agencies. | GAO-24-107175
Note: COVID-19 relief funding, obligation, and expenditure data shown for the major spending areas
are based on data reported by applicable agencies to Treasury’s Governmentwide Treasury Account
Symbol Adjusted Trial Balance System. Federal agencies use this system to provide proprietary
financial reporting and budgetary execution information to Treasury. These amounts can fluctuate
from month to month. COVID-19 relief funding is the cumulative amount of funding provided in the six
COVID-19 relief laws that Treasury uses to record and track COVID-19 relief spending, in accordance
with Office of Management and Budget guidance. Further, the $4.65 trillion total reflects rescissions
of COVID-19 relief funding enacted in the Fiscal Responsibility Act of 2023, Pub. L. No. 118-5, 137
Stat. 10, 23-30, div. B, tit. I (2023), and other laws. The most recent date for which government-wide
information was available at the time of GAO’s analysis was April 30, 2024.
aUnder section 9704 of the American Rescue Plan Act of 2021, classified at 29 U.S.C. §§ 1305(i),
1432, the Pension Benefit Guaranty Corporation will receive the necessary funding from the General
Fund of the U.S. Treasury through fiscal year 2030 to provide payments to qualifying multiemployer
plans, as defined in this law, so that the plans can pay benefits at plan levels through the end of plan
year 2051. The requested amount will fund the Special Financial Assistance payments to qualifying
plans and the Pension Benefit Guaranty Corporation’s related administrative and operating expenses.
Neither the plans nor the Pension Benefit Guaranty Corporation are required to repay amounts
received under this American Rescue Plan Act of 2021-established program, which is funded by
appropriations from the General Fund of the U.S. Treasury.
bFunding provided to the Disaster Relief Fund is generally not specific to individual disasters.
Therefore, Treasury’s methodology for determining COVID-19-related obligations and expenditures
does not capture obligations and expenditures for the COVID-19 response based on funding other
than what was provided in the COVID-19 relief laws. Further, Treasury’s methodology includes all
obligations and expenditures based on funding in the COVID-19 relief laws, including those for other
disasters. In its Disaster Relief Fund Monthly Report dated May 7, 2024, the Department of
Homeland Security reported COVID-19-related obligations totaling $127.4 billion and expenditures
totaling $105.3 billion as of April 30, 2024.
cThe Department of Agriculture’s Supplemental Nutrition Assistance Program comprised about $34.0
billion, or 85 percent, of the total expired unobligated balance as of April 30, 2024.
dAmounts shown in columns may not sum to the totals because of rounding.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
A government-wide approach was needed to respond to and recover from
the unprecedented scope and scale of the COVID-19 pandemic. Based
on a review of our COVID-19 oversight work, as well as our oversight
work on other public health emergencies, we identified lessons learned
that federal agencies could use to better prepare for, respond to, and
recover from future public health emergencies. These lessons learned
highlight areas where government agencies did well in response to the
COVID-19 pandemic and areas where the government response could
have been improved. We categorized these lessons into seven topic
areas. See figure 3. Across these seven areas, federal agencies have
opportunities to enhance the nation’s preparedness for future public
health emergencies by taking steps to implement recommendations we
made in our body of work on COVID-19 oversight.
Figure 3: Lessons Learned for Federal Agencies from the COVID-19 Pandemic
Lessons from the
COVID-19 Pandemic
Can Help Federal
Agencies Better
Prepare for
Emergencies
Page 14
GAO-24-107175 COVID-19 Lessons for Federal Agencies
Lessons Learned on Planning in Advance
Advanced plans—including national-level strategies and department- and agency-level plans—
provide vision for how the federal government will respond to public health emergencies and are
critical to the nation’s preparedness and ability to implement a timely response.
To further enhance their preparedness, federal agencies should
•
clearly define their roles and responsibilities and those of their response partners in response
plans, and exercise these plans prior to emergencies;
•
understand their capabilities and limitations and those of their response partners, and reflect
these capabilities and limitations in response plans; and
•
build their capacity and collect lessons to inform and update plans.
We have found instances where federal agencies could improve their preparedness by taking such
steps. For example, the Department of the Treasury has not incorporated lessons GAO identified
from the COVID-19 assistance programs to the aviation industry into its efforts to compile
resources to prepare for future financial disasters. Taking such steps could help Treasury facilitate
timely decisions and avoid encountering past challenges when responding to future emergencies.
Further, we have made recommendations to federal agencies to improve their emergency
response plans. For example, we recommended that the Department of Health and Human
Services develop plans outlining steps to mitigate shortages in needed medical supplies, develop a
comprehensive testing strategy, and develop an approach for assessing and addressing known
challenges and future risks associated with advanced development and manufacturing of medical
countermeasures, including vaccines.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
National-level strategies. A whole-of-nation approach is needed to
prepare for, respond to, and recover from significant public health
emergencies, such as the COVID-19 pandemic. National-level strategies
that are developed prior to an emergency can provide vision for and
facilitate implementation of a timely response. Further, these strategies
inform federal departments’ and agencies’ emergency response plans
that guide their response activities. For example, the National Biodefense
Strategy provides strategic vision for preparedness and response
planning and outlines specific goals and objectives to help the nation
prepare for and respond to nationally significant biological incidents.22
The White House issued an update in October 2022 to the National
Biodefense Strategy, which was originally issued in 2018. We have
ongoing work to assess this updated strategy and actions to implement it.
As part of this work, we will continue to monitor implementation efforts
related to the updated strategy.
22As defined by the National Biodefense Strategy, biological incidents are: (1) any act of
biological warfare or terrorism, (2) a crime involving a biohazard, or (3) any natural or
accidental occurrence in which a biohazard harms humans, animals, plants, or the
environment.
Planning in Advance
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Our prior work has examined the 2018 National Biodefense Strategy. This
strategy included two goals that specifically address preparedness and
response actions needed to limit the effects of biological incidents. These
goals were meant to inform key federal agencies’—such as HHS and the
Department of Homeland Security (DHS)—interagency response and
crisis action plans for nationally significant biological incidents, such as
response plans to pandemics. However, we have reported gaps in
planning for and responding to nationally significant biological events,
such as the COVID-19 pandemic. These gaps have limited agencies’
ability to achieve preparedness and response goals outlined in the 2018
National Biodefense Strategy. For example:
•
In February 2020, we found that early efforts to implement the
strategy represented only the start of a process and a cultural shift
that may take years to fully develop, and agencies faced challenges
that they must overcome to ensure success in the long term.23 For
example, individual agencies faced a lack of planning and guidance to
support the implementation of an enterprise-wide approach to
biodefense.24
We recommended that HHS take steps to ensure that challenges
experienced early during the strategy’s implementation are
adequately addressed. As of February 2024, HHS communicated it
had taken some steps in collaboration with other federal agencies and
departments to address our recommendation; however, HHS no
longer has the authority to implement it. According to the updated
2022 National Biodefense Strategy, the White House now leads
efforts to implement the strategy. Our ongoing work will continue to
monitor implementation efforts related to the updated strategy.
•
In August 2021, we identified gaps in the nation’s biodefense
enterprise, which limited the federal government’s ability to implement
the preparedness and response goals of the National Biodefense
Strategy. We recommended that DHS, the Department of Defense
(DOD), HHS, and the U.S. Department of Agriculture (USDA) take
steps to define a set of capabilities that account for the unique
23See GAO, National Biodefense Strategy: Additional Efforts Would Enhance Likelihood of
Effective Implementation, GAO-20-273 (Washington, D.C.: Feb. 19, 2020).
24The biodefense enterprise is the whole combination of systems at every level of
government and the private sector that contribute to protecting the nation and its citizens.
It is composed of a complex collection of federal, tribal, state, local, territorial, and private
resources, programs, and initiatives designed for different purposes and dedicated to
mitigating both natural and intentional risk.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
elements specific to responding to nationally significant biological
incidents.25 As of March 2023, these departments had been working
with partners to comprehensively review the federal government’s bio-
preparedness policies and plans. According to the updated 2022
National Biodefense Strategy, the White House now leads efforts to
implement the strategy. Our ongoing work will continue to monitor
efforts to implement the updated strategy.
Department- and agency-level response plans. Department- and
agency-level response plans that are developed before emergencies
occur and are aligned with national strategies can further guide federal
efforts when responding to public health emergencies, such as the
COVID-19 pandemic. Without such plans, federal and response partners’
actions can be piecemeal and can cause confusion. For example, we
found that a comprehensive national plan could help the U.S. aviation
system streamline its response to emergencies.26 We had previously
reported that both the federal government and the aviation industry took
actions early in the pandemic intended to limit the spread of COVID-19
through air travel. We stated at the time that, while these actions were
helpful, some aviation stakeholders highlighted their piecemeal nature,
which may have contributed to confusion early in the pandemic.27
Early in the COVID-19 pandemic, we urged Congress to require the
Department of Transportation (DOT) to develop a national aviation
preparedness plan for communicable disease outbreaks. We had
previously recommended in 2015 that DOT develop such a plan, but the
recommendation remained unaddressed.28 In June 2020, we emphasized
that the absence of a national plan undermined the ability of the public
health and aviation sectors to coordinate a response or provide consistent
guidance to airports and airlines. We also noted the plan could serve as
25GAO, Biodefense: After-Action Findings and COVID-19 Response Revealed
Opportunities to Strengthen Preparedness, GAO-21-513 (Washington, D.C.: Aug. 4,
2021). In the context of emergency management and related functions, a capability is the
combination of leadership and organization, planning, personnel, training, equipment and
systems, and assessment needed to successfully execute a particular mission.
26GAO, Commercial Aviation: Key Lessons from COVID-19 Preparedness and
Emergency Financial Assistance to the Industry, GAO-24-106754 (Washington, D.C.: Mar.
18, 2024).
27GAO, Air Travel and Communicable Diseases: Status of Research Efforts and Action
Still Needed to Develop Federal Preparedness Plan, GAO-20-655T (Washington, D.C.:
June 23, 2020).
28GAO, Air Travel and Communicable Diseases: Comprehensive Federal Plan Needed for
U.S. Aviation System’s Preparedness, GAO-16-127 (Washington, D.C.: Dec. 16, 2015).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
the basis for testing communication mechanisms among responders and
ensure staff have received appropriate training to reduce exposure.
Furthermore, we noted that the existence of a national plan might have
reduced some of the confusion among aviation stakeholders and
passengers early in the pandemic.29
In December 2022, legislation was enacted that required DOT to develop
an aviation preparedness plan for communicable disease outbreaks.30 In
April 2024, officials within DOT’s Federal Aviation Administration told us
that they are drafting such a plan. As part of this process, officials are
coordinating internally within the administration; with other federal
agencies, including DHS and HHS; and international stakeholders. Once
that is complete, coordination will begin with other external stakeholders,
including airlines, airports, and labor organizations, according to the
Federal Aviation Administration. Officials anticipated finalizing the plan by
the end of December 2024.
DOT officials told us previously that they have used lessons learned from
the COVID-19 pandemic, as well as from the Ebola, SARS, and other
communicable disease outbreaks, to inform the draft plan. Finalizing the
forthcoming plan, including incorporating lessons learned from the
COVID-19 pandemic, will better position DOT and other aviation
stakeholders to address a communicable disease threat while minimizing
unnecessary aviation disruptions.
In addition to creating response plans, federal agencies should have a
coordinated, department-wide approach to identify and resolve
challenges encountered while implementing response plans during past
emergencies. Without such an approach, agencies are susceptible to
repeating past mistakes. For example, in April 2024 we reported that only
three of the six HHS component agencies that are involved in public
health emergency responses—the Administration for Strategic
Preparedness and Response (ASPR), CDC, and the Food and Drug
29GAO-20-655T.
30Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 105, 136 Stat. 4459,
5253-55 (2022).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Administration (FDA)—carry out their own after-action programs to
identify challenges from past public health emergencies.31
Further, we reported that coordination among the existing after-action
programs and with other component agencies was rare. Without creating
a department-wide after-action program, HHS is missing an opportunity to
improve its preparedness. To strengthen HHS’s ability to respond to
future emergencies, we recommended that HHS develop and implement
a department-wide after-action program that encourages collaboration
across HHS component agencies and includes relevant external
stakeholders.32 HHS concurred with our recommendations. Further, HHS
stated it is taking steps to address our recommendations by designating
ASPR as the lead to ensure swift identification and resolution of lessons
learned from public health emergencies through a centralized after-action
review process that will include relevant stakeholders.
Agencies should take steps to further enhance their preparedness for
future emergencies, including:
•
clearly defining roles and responsibilities for all parties involved with
implementing response plans and exercising those plans prior to
emergencies,
•
understanding their and their partners’ capabilities and limitations, and
•
building capacity while also collecting lessons to inform and update
plans.
Clearly defining roles and responsibilities. The scope and scale of the
COVID-19 pandemic highlighted the critical importance of clearly defining
the roles and responsibilities for the wide range of federal agencies and
other key partners involved when preparing for pandemics and
addressing unforeseen emergencies. A lack of clear roles and
responsibilities when preparing for an emergency has hampered the
federal response in the past. We have reported that a lack of clear roles
and responsibilities has been a recurring challenge in HHS’s efforts to
respond to the COVID-19 pandemic and other public health emergencies.
For example:
31The other three HHS component agencies involved with public health emergency
responses are the National Institutes of Health, the Indian Health Service, and the Health
Resources and Services Administration.
32GAO-24-106276.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
•
In April 2021, we reported that HHS did not clarify which HHS agency
was in charge—including which HHS agency was responsible for
managing infection prevention—when it helped repatriate U.S.
citizens from abroad and quarantined them domestically at the
beginning of the COVID-19 pandemic to prevent the spread of the
virus. As a result, confusion ensued, and HHS put repatriates, its own
personnel, and nearby communities at risk.33
•
In April 2024, we reported similar concerns related to HHS’s initial
response to the mpox outbreak, which was declared a public health
emergency in the U.S. in August 2022.34 The initial federal response
was spread across multiple HHS agencies. Several state and local
jurisdictions we interviewed said that HHS appeared to lack a central
point of coordination in the beginning, potentially slowing the
response. Additionally, in May 2024, we reported that there was
confusion at state, local, and territorial levels regarding how to request
and receive mpox supplies from the Strategic National Stockpile. This
occurred because HHS agencies involved with the stockpile had not
clearly defined roles and responsibilities, thereby complicating
response efforts.35
We have recommended that HHS take steps to clarify agency roles and
responsibilities to limit confusion and risks when responding to public
health emergencies. For example, we recommended that HHS revise or
develop new emergency repatriation response plans that clarify agency
roles and responsibilities, including which agency would be responsible
for evacuation and quarantine, during a pandemic.36
In response, HHS started a series of workgroup meetings with relevant
stakeholders to develop a Federal Emergency Repatriation Operations
Plan, among other documents. As of April 2024, HHS had drafted this
33GAO, COVID-19: HHS Should Clarify Agency Roles for Emergency Return of U.S.
Citizens During a Pandemic, GAO-21-334 (Washington, D.C.: Apr. 19, 2021).
34Mpox was formerly known as monkeypox. The World Health Organization
recommended the name change in November 2022.
35The Strategic National Stockpile is part of the federal medical response infrastructure
and can supplement medical countermeasures, such as vaccines and antivirals, needed
by Tribes, states, U.S. territories, and localities during public health emergencies. The
countermeasures in the stockpile can be used when the supply of these materials may not
be available or sufficient. GAO, Public Health Preparedness: HHS Should Address
Strategic National Stockpile Coordination Challenges, GAO-24-106260 (Washington,
D.C.: May 2, 2024).
36GAO-21-334.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
plan and anticipated finalizing it in early summer 2024. To close this
recommendation, HHS and its component agencies will have to
demonstrate that they have agreed upon a plan that outlines agency roles
and responsibilities, including those for an evacuation and quarantine, in
the event of a pandemic.
We also recommended that HHS exercise repatriation response plans
before a public health emergency to test the plans and update relevant
plans based on lessons learned.37 Regularly exercising preparedness
plans with all response partners allows all involved parties to practice
operationalizing the plans. Further, regularly exercising plans can help
identify any gaps in procedures or barriers to plan implementation,
including a lack of clarity around roles and responsibilities, so that they
can be addressed before an actual event occurs.
In response to our recommendation, HHS has conducted two repatriation
exercises. While these are positive steps, we have also previously stated
that we are monitoring for HHS to conduct exercises with all relevant
stakeholders, including other federal agencies, based on agreed upon
repatriation plans in response to a pandemic. As noted above, HHS is
working to finalize its Federal Emergency Repatriation Operations Plan,
among other documents. To close this recommendation, HHS and its
component agencies will need to conduct exercises with all relevant
stakeholders based on agreed upon guidance that outlines agency roles
and responsibilities in response to a pandemic.
Understanding agencies’ and response partners’ capabilities and
limitations. It is important for federal agencies to understand their and
their response partners’ capabilities and limitations, and that these
capabilities and limitations are reflected in federal response plans. ASPR,
the agency within HHS responsible for leading and coordinating all
matters related to federal public health and medical preparedness, relies,
in part, on partners to respond to emergencies. However, our prior work
has shown that ASPR did not have a complete understanding of the
capabilities and limitations of response partners, which created a
vulnerability. For example, in September 2019 we reported that the
agency did not have a full understanding of the capabilities and limitations
of its support agencies, including DOD, DHS, and the Department of
Veterans Affairs (VA), during the response to the catastrophic destruction
in the U.S. Virgin Islands and Puerto Rico caused by Hurricanes Maria
37GAO-21-334.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
and Irma in 2017. Consequently, ASPR’s needs were not always aligned
with the resources that its support agencies could provide, resulting in
some deployed resources not being properly and efficiently utilized.38
We have also identified concerns with ASPR’s capabilities to fully execute
its preparedness and emergency response activities, particularly as these
responsibilities have increased. ASPR’s additional responsibilities include
managing the Strategic National Stockpile and leading the medical
product industrial base expansion effort to help establish a more resilient
medical product supply chain for the nation. This was an area of concern
during the COVID-19 pandemic and remains a concern.
Further, as we reported in January 2024, ASPR had not identified critical
areas within it that needed workforce assessments or developed a plan to
conduct them. It also had not conducted an agency-wide workforce
assessment to prioritize the skills and competencies of greatest need to
achieve the agency’s goals and mission.39 Without conducting these
assessments, ASPR cannot be assured that its workforce has the skills
and competencies in place to perform its responsibilities and ultimately
meet its mission of leading the nation’s response to public health
emergencies.
To improve its capabilities to fully execute emergency response activities,
we recommended that ASPR establish specific goals and performance
measures to use for its new hiring office, identify the critical areas that
need workforce assessments, develop plans to implement them, and
conduct an agency-wide workforce assessment. HHS neither agreed nor
disagreed with two of our recommendations and agreed with the other
two recommendations. In its comments, HHS discussed plans to support
workforce assessment efforts, among other steps to address our
recommendations.
Building capacity and collecting lessons to inform plans. Building
capacity, collecting lessons from prior emergencies, and using this
38GAO, Disaster Response: HHS Should Address Deficiencies Highlighted by Recent
Hurricanes in the U.S. Virgin Islands and Puerto Rico, GAO-19-592 (Washington, D.C.:
Sept. 20, 2019). This report included seven recommendations to ASPR, including that
ASPR develop agreements with support agencies that include response capability and
limitation information. As of May 2024, ASPR had taken steps to close six of these
recommendations.
39GAO, Public Health Preparedness: HHS Emergency Agency Needs to Strengthen
Workforce Planning, GAO-24-106108 (Washington, D.C.: Jan. 16, 2024).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
information to inform response programs and plans can improve federal
agencies’ preparedness for future public health and other emergencies.
For example, the Veterans Health Administration (VHA) would be better
prepared to quickly estimate resource needs to allow better management
and planning by enhancing its modeling capacity. VHA requested
supplemental funding to continue operations to meet its mission when the
COVID-19 pandemic emerged in 2020 but was not prepared to estimate
the amount of supplemental funding needed during such a catastrophic
event.
In February 2024, we reported that the agency did not have the modeling
capacity to enable it to prepare estimates of the supplemental funding it
needed in the event of another pandemic or other catastrophic event.
Specifically, VHA lacked modeling capacity, including data collection and
the ability to run budget simulations on a continual basis, to systematically
assess and manage the risk of catastrophic events.40 We recommended
that the VA Undersecretary for Health should enhance VA’s analytical
modeling capacity to better enable VHA to prepare estimates of
supplemental funding needed to address catastrophic events. VHA
concurred with our recommendation and outlined actions to address it,
including chartering a workgroup to evaluate appropriate models and
estimate required resources needed in the event of specific catastrophic
events, such as a pandemic.
Federal agencies can also better prepare for future emergencies by
leveraging lessons learned and incorporating them into response
programs and plans. For example:
•
Federal agencies can leverage economic lessons from SBA’s
Paycheck Protection Program to inform support programs for smaller
businesses affected by emergencies. We previously reported that
studies have shown that the Paycheck Protection Program increased
employment in small businesses, generally improved their financial
conditions, and likely strengthened local labor markets. However, we
found that some portion of the program assistance did not initially go
to areas hit hardest by the pandemic and that smaller businesses
40GAO, Veterans Affairs: Improvements Needed in Estimating Funding for Potential
Future Health Emergencies, GAO-24-106359 (Washington, D.C.: Feb. 8, 2024) and
Veterans Affairs: Projection, Use, and Oversight of COVID-19 Relief Funding,
GAO-23-105730 (Washington, D.C.: Nov. 29, 2022).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
faced challenges obtaining program assistance, which may have
limited the effect of the program.41
In response to such concerns, Congress and SBA made a series of
changes that increased lending to businesses that faced challenges
obtaining loans, such as targeting minority-owned businesses, in later
phases of the program’s implementation. By considering relevant
economic conditions and accounting for the unique needs of smaller
businesses, agencies could better target relief programs to the
hardest hit areas and improve accessibility to federal funds for smaller
businesses during emergencies.
•
Federal agencies can better prepare for future emergencies by
collecting and sharing lessons learned from contracting in response to
the COVID-19 pandemic. However, HHS and DHS, two of the top five
agencies with the highest COVID-19 contract obligations as of August
31, 2020, did not include lessons learned as part of their COVID-19
response review even though they identified contracting challenges.
Establishing mechanisms to formally collect and share lessons
learned from stakeholders involved with contracting will help ensure
agencies can apply lessons learned and positive processes in
response plans for future emergencies.42 DHS has since taken action
to establish mechanisms to collect and share contracting lessons
learned from future response efforts. As of April 2024, HHS has
ongoing efforts to collect and share such lessons learned.
•
HHS can be better prepared to meet the nations’ need for medical
countermeasures during emergencies and when responding to threats
of widespread illness posed by emerging infectious diseases,
including new COVID-19 variants, by incorporating approaches to
address known challenges in new plans and programs. Medical
countermeasures are drugs, vaccines, and devices to diagnose, treat,
prevent, or mitigate the health effects of exposure to chemical,
radiological, nuclear, or biological agents, including viruses. Many
41GAO, COVID-19: Current and Future Federal Preparedness Requires Fixes to Improve
Health Data and Address Improper Payments, GAO-22-105397 (Washington, D.C.: Apr.
27, 2022); Paycheck Protection Program: Program Changes Increased Lending to the
Smallest Businesses and in Underserved Locations, GAO-21-601 (Washington, D.C.:
Sept. 21, 2021); and COVID-19: Federal Efforts Could Be Strengthened by Timely and
Concerted Actions, GAO-20-701 (Washington, D.C.: Sept. 21, 2020).
42GAO, COVID-19 Contracting: Opportunities to Improve Practices to Assess Prospective
Vendors and Capture Lessons Learned, GAO-21-528 (Washington, D.C.: July 29, 2021).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
factors make it difficult to rapidly develop and manufacture medical
countermeasures in response to public health emergencies.
HHS created the Centers for Innovation and Advance Development
and Manufacturing (CIADM) program in 2012 in response to
challenges in developing countermeasures during prior emergencies.
Under this program, HHS awarded funding to three contractors to
establish sites to develop countermeasures. HHS used these sites to
support the manufacturing of COVID-19 vaccines. However, program
limitations, such as sites not receiving consistent funding and
production work from HHS or external manufacturing partners,
hindered the CIADM program’s effectiveness.
In 2022, HHS announced that it was ending the CIADM program and
developing a new program model for rapid countermeasure
production intended to replace it. We reported in February 2023 that
HHS’s plans for this new program model were not fully developed,
and it was unclear as to how the program model will address or
mitigate known challenges and future risks. To avoid repeating the
challenges of the CIADM program, we recommended that HHS
incorporate into the development of its new program model an
approach to systematically assess and respond to known challenges
and future risks associated with advanced development and
manufacturing of medical countermeasures. HHS concurred with our
recommendation and stated it will work to ensure its new model
program aligns with the principles outlined in our recommendation.43
•
Treasury could be more prepared for future financial disasters by
including lessons learned from COVID-19 financial assistance
programs to the aviation industry as part of its efforts to compile
resources, specifically policies and procedures from programs it has
implemented. Treasury had to quickly design several COVID-19
financial assistance programs, including the $46 billion loan program
for aviation and other eligible businesses under Section 4003 of the
CARES Act. This effort was challenging as Treasury had to establish
program infrastructure, develop credit standards, and draft loan
documents in a short time frame and under difficult circumstances.
In December 2020, we reported that although Treasury’s policies and
procedures for evaluating loan applications were generally consistent
43GAO, Public Health Preparedness, HHS Should Plan for Medical Countermeasure
Development and Manufacturing Risks, GAO-23-105713 (Washington, D.C.: Feb. 2,
2023).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
with internal controls, the program could have been improved.44 In
particular, at that time we reported that providing emergency financial
assistance through multiple programs or multiple paths within a
program may better accommodate businesses of varied types and
sizes, and that Treasury should clearly communicate timelines for
actions to align lender and borrower expectations, among other
things. In addition, our prior work has shown that providing federal
assistance to businesses facing emergency circumstances requires
clear and consistent information be communicated to applicants and
eligible entities.45
In May 2023, SIGPR reported on a $700 million loan that Treasury
made through the loan program to Yellow Corporation, a trucking
company formerly known as YRC Worldwide.46 While Yellow
Corporation was not a part of the aviation industry, the loan program
was available to businesses critical to maintaining national security.47
The SIGPR report found deficiencies in Treasury’s approach to
reviewing, approving, and disbursing this loan. Recognizing the need
to act quickly while also having policies and procedures in place
before executing loans, SIGPR recommended that Treasury develop
a contingency plan for financial disasters. Doing so would provide a
framework for future direct lending programs and reduce
implementation time and the possibility of errors and omissions.
In our prior work, we have emphasized that considering lessons
learned can help Congress and Treasury provide financial assistance
to businesses in a timely manner, while also ensuring adequate
safeguards to minimize the risk to the federal government from a
44GAO, Financial Assistance: Lessons Learned from CARES Act Loan Program for
Aviation and Other Eligible Businesses, GAO-21-198 (Washington, D.C.: Dec.10, 2020).
45GAO-21-198 and GAO, Commercial Aviation: Key Lessons from COVID-19
Preparedness and Emergency Financial Assistance to the Industry, GAO-24-106754
(Washington, D.C.: Mar. 18, 2024).
46Office of the Special Inspector General for Pandemic Recovery, Audit of the U.S.
Department of the Treasury’s Process for Its Direct Loan to YRC, Worldwide, Inc. Under
Section 4003 of the CARES Act, SIGPR-A-22-005 (Alexandria, Va.: May 11, 2023).
47We also reported in December 2020 that Treasury executed the loan in July 2020 before
it had finalized procedures for evaluating applications. See GAO-21-198. On February 5,
2024, Yellow Corporation announced it had fully repaid its loan, including $700 million in
principal and more than $151 million in interest.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
borrower not repaying the loan.48 We have also identified collecting
and sharing information and knowledge gained from positive and
negative experiences as a key practice of a lessons learned
process.49
In April 2024, Treasury officials told us they are compiling resources
to prepare for future financial disasters and expect to complete this
effort by the end of 2024. Specifically, officials are compiling policies
and procedures from the COVID-19 financial assistance programs
provided to the aviation industry and lending programs Treasury
operated under the Troubled Asset Relief Program.50 However, in
doing so, they have not included lessons we and other auditing
entities have identified for emergency financial assistance programs.
Treasury officials told us that they have not endeavored to create a
specific plan for financial assistance programs for future crises
because each scenario requiring emergency financial assistance is
unique. Further, officials told us that Treasury does not have the
resources to design plans that would respond to the varied
contingencies that may arise. As such, Treasury officials said they are
compiling resources that could be useful across sectors and goals for
future financial assistance, such as liquidity of funds and employment
retention. Including lessons we identified and those identified by other
external entities could help Treasury create a broad framework for
future financial assistance programs, by not only documenting past
procedures but also noting general lessons from implementing the
recent assistance programs for the aviation industry. This can help
Treasury improve its future relief programs and avoid encountering
some of the challenges it faced in the past. Given the need to act
quickly in financial disasters, it would be beneficial for Treasury to
include lessons learned in this effort to enable decisionmakers to
make timely decisions in the future.
48GAO-21-198.
49GAO, Household Hazardous Waste Removal: EPA Should Develop a Formal Lessons
Learned Process for Its Disaster Response, GAO-22-104276 (Washington, D.C.: Mar. 17,
2022).
50The Emergency Economic Stabilization Act of 2008, designed to restore liquidity and
stability to the financial system and to preserve homeownership, authorized Treasury to
create the Troubled Asset Relief Program to assist borrowers struggling to make their
mortgage payments. Pub. L. No. 110-343, 122 Stat. 3765.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Key open recommendations. We have made recommendations to
federal agencies to improve their emergency response planning. These
included recommendations to HHS to develop plans outlining actions the
federal government will take to help mitigate shortages in needed medical
supplies; to develop a comprehensive testing strategy to allow for a more
coordinated pandemic testing approach; and to systematically assess and
respond to known challenges and future risks associated with advanced
development and manufacturing of medical countermeasures, such as
vaccines.
Agencies across the federal government have taken steps to address
some of our recommendations to improve their preparedness for public
health emergencies. However, agencies should take additional steps to
strengthen their ability to prepare for, respond to, and recover from public
health emergencies, including:
•
HHS should develop and implement a coordinated, department-wide
after-action program that encourages collaboration among HHS’s
component agencies and includes relevant stakeholders involved in
each public health response.
•
HHS’s ASPR should establish specific goals and performance
measures to use for its new hiring office, identify the critical areas that
need workforce assessments, develop plans to implement them, and
conduct an agency-wide workforce assessment.
•
HHS should update emergency repatriation response plans that clarify
agency roles and responsibilities, including those for an evacuation
and quarantine, during a pandemic. Further, HHS should conduct
regular exercises with relevant stakeholders to test plans in response
to a pandemic and update them based on lessons learned.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Lessons Learned on Collaborating with Response Partners
Collaborating with response partners—including federal and nonfederal partners—before and during
public health emergencies can help agencies efficiently implement response activities and continue
operations. To help facilitate this collaboration, federal agencies should
•
identify partners key to implementing the response and regularly coordinate with them throughout
the response, and
•
ensure their response partners understand their respective roles and related responsibilities in
implementing the response.
We have made recommendations to federal agencies to improve their coordination with response
partners before and during public health emergencies. For example, we recommended that the
Department of Health and Human Services share its plans to mitigate shortages in medical supplies
with response partners and maintain up-to-date guidance for partners on requesting and receiving
assets from the Strategic National Stockpile.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
Identifying and coordinating with partners. Federal agencies can
enhance the response to a public health emergency by identifying
relevant federal and nonfederal partners and regularly coordinating with
them. Public health emergencies may result in wide-ranging challenges
that no single agency can address. This requires federal agencies to
collaborate with one another and with other partners—such as Tribes,
states, U.S. territories, localities, and the private sector—to implement
response activities. Our work has highlighted instances during the
COVID-19 pandemic where federal agencies and private entities
successfully collaborated to achieve response goals, including developing
and administering vaccines. For example:
•
In January 2022, we reported that collaboration between federal
agencies and private sector partners enhanced activities to quickly
develop and manufacture COVID-19 vaccines for the public.51 To help
make safe and effective vaccines available as quickly as possible, the
federal government announced the creation of a partnership between
HHS and DOD in April 2020, which began as Operation Warp Speed
and later became the HHS-DOD COVID-19 Countermeasures
Acceleration Group. HHS and DOD then made awards to vaccine
companies and others to help them make vaccines available.
We found that by making awards to multiple vaccine companies, the
agencies mitigated risks to meeting their vaccine goals. For instance,
working with multiple companies reduced the risk of failure due to
51GAO, COVID-19: HHS and DOD Transitioned Vaccine Responsibilities to HHS, but
Need to Address Outstanding Issues, GAO-22-104453 (Washington, D.C.: Jan. 19, 2022).
Collaborating with
Response Partners
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
safety, efficacy, or manufacturing issues. We also found that the
coordination between agencies and vaccine companies helped
alleviate supply chain issues. For instance, HHS and DOD utilized the
Defense Production Act to support manufacturing efforts by providing
priority access to necessary materials.52
•
In July 2021, we reported CDC’s coordination with the private sector
played a critical role in administering COVID-19 vaccines in nursing
homes and other long-term care facilities. CDC established the
Pharmacy Partnership for Long-Term Care Program, an agreement
with pharmacy partners to conduct COVID-19 vaccination clinics for
residents and staff of long-term care facilities, including nursing
homes, in October 2020. As part of the program, vaccines were
provided at no cost to residents, staff, and the facilities.
Additionally, the pharmacy partners—including CVS, Walgreens, and
Managed Health Care Associates Inc.—managed the entire
vaccination process at certain facilities. This included storing,
handling, and transporting vaccines; administering vaccines; and
fulfilling reporting requirements. We reported in March 2021 that many
of the vaccinations in nursing homes and other long-term care
facilities were administered through these partnerships.53 Between
December 2020 and May 2021, the partnership program administered
more than 8.3 million doses of COVID-19 vaccines, according to
CDC.54
During the COVID-19 pandemic, we found instances where federal
agencies did not regularly coordinate with response partners, and
important opportunities to enhance response outcomes were missed. For
example:
•
In September 2020, we found that the Federal Emergency
Management Agency (FEMA) could enhance its efforts to distribute
COVID-19 supplies—including personal protective equipment,
52Contracts with a priority rating under the Defense Production Act require a contractor to
give preference to these contracts over any other unrated contracts if the contractor
cannot meet all required delivery date needs for all contracts. See 50 U.S.C. § 4511.
53GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021).
54GAO, COVID-19: Continued Attention Needed to Enhance Federal Preparedness,
Response, Service Delivery, and Program Integrity, GAO-21-551 (Washington, D.C.: July
19, 2021).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
ventilators, and COVID-19 testing supplies—by coordinating with its
response partners.55 During the pandemic, FEMA was responsible for
distributing these supplies to its response partners, including tribal,
state, local, and territorial governments.
To help it make decisions on how supplies would be allocated
throughout the pandemic, FEMA reviewed supply requests submitted
by its partners. However, we reported that FEMA’s response partners
faced challenges tracking the agency’s fulfillment of supply requests,
which made it difficult for them to then determine what additional
supply requests they needed to make. For example, an official from
one state told us that they were not told when supplies would arrive,
and shipments would “just show up” without advance notice. Another
state official said that the FEMA regional office did not always specify
where the supplies went or to whom they were delivered.
We recommended that FEMA work with its partners on solutions to
help states enhance their ability to track the status of supply requests
and plan for supply needs for the remainder of the pandemic
response. Although the agency disagreed with our recommendation, it
took several actions that addressed it. For instance, in 2022, FEMA
released an updated distribution management plan guide that,
according to FEMA, provided actionable guidance for tribal, state,
local, and territorial agencies to effectively and efficiently distribute
critical resources in the community.
•
In May 2024, we reported that additional coordination with Tribes
would help the federal government better prepare for future
emergencies that may require Strategic National Stockpile assets.56
HHS documentation and our interviews with selected Tribes and tribal
organizations revealed various concerns Tribes had with requesting
and receiving stockpile assets during recent emergencies, including
the COVID-19 pandemic and the mpox public health emergency.
These concerns included Tribes’ issues with receiving assets due, in
part, to infrastructure or geography. For example, officials from one
Tribe as well as a former official from another Tribe reported
challenges with having the equipment and infrastructure needed to
receive and store delivered assets.
55GAO-20-701.
56GAO-24-106260.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
While ASPR has made progress in defining pathways for how Tribes
can request Strategic National Stockpile assets, it has not assessed
how it will address unique tribal challenges related to receiving assets.
Engaging with Tribes to assess these issues could help HHS and
Tribes be better equipped to deliver and receive assets respectively,
and they can collectively strengthen preparedness and response
efforts for future incidents. We recommended that ASPR formally
designate an entity to regularly engage with Tribes and relevant
stakeholders to (1) assess the unique challenges, such as
infrastructure and geography, that could affect the delivery of assets
in the Strategic National Stockpile to Tribes during future emergencies
and (2) develop options for how to address those challenges. The
agency agreed with our recommendation.
Coordination between federal and nonfederal partners could also help
federal agencies address challenges adopting vaccine development
technologies and approaches that may enhance the nation’s ability to
respond to infectious diseases. While vaccinations are a key part of
individual and community health, vaccine development is complex and
costly. In November 2021, we reported that innovative technologies and
approaches may enhance the nation’s ability to respond to infectious
diseases. For example, reverse vaccinology using computer-based
analytics to assess a pathogen’s genetic information to accelerate the
understanding of pathogens and their antigens—combined with existing
research—helped researchers develop some COVID-19 vaccines more
quickly and effectively.
However, key challenges may hinder the adoption of these innovative
technologies and approaches. We identified nine policy options for
policymakers, including federal agencies, to help address these
challenges and economic challenges. For example, policymakers have
opportunities to improve preparedness by supporting public-private
partnerships that would help identify and respond to disease pathogens
with pandemic potential.57
Communicating roles and responsibilities to response partners. To
effectively coordinate with response partners during a public health
emergency, federal agencies should ensure that response partners
understand their respective roles and related responsibilities in
implementing the response. Federal agencies should ideally define the
57GAO, Vaccine Development: Capabilities and Challenges for Addressing Infectious
Diseases, GAO-22-104371 (Washington D.C.: Nov. 16, 2021).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
roles and responsibilities of their partners in response plans and
communicate these prior to an emergency. When roles are not
established in advance of an emergency, federal agencies should do this
early in the response. Our work during the COVID-19 pandemic indicated
that when the roles and responsibilities of response partners are not
clearly defined and communicated, agencies cannot be assured that their
partners take timely actions needed to implement response activities. For
example:
•
In April 2021, we found that DOD’s depot management did not
consistently take actions to ensure continued operations during the
COVID-19 pandemic because depot personnel lacked clear guidance
from DOD on their roles and responsibilities.58 Long-term disruptive
events like pandemics can diminish military readiness if personnel
who repair and maintain complex weapon systems and equipment at
DOD’s depots are physically away from the workplace for weeks or
months.59
DOD issued a memorandum on March 20, 2020, notifying the
Defense Industrial Base, which includes DOD depots, that they were
identified as a critical infrastructure sector and had a special
responsibility to maintain their normal work schedule.60 However,
DOD had not developed guidance or a communication plan to ensure
that depot management and personnel were aware of their mission-
essential status and the need to support readiness. Further, we
reported that the roles and responsibilities of depot personnel as
mission-essential personnel were not always clear to depot leadership
and personnel. As a result, depot management improvised their
operation plans, causing some depots to pause or reduce operations,
and others to shift schedules rather than maintaining normal work
schedules.
We made two recommendations that DOD take steps to ensure that
its depot management and personnel are made aware of their
mission-essential status and the need to support readiness during a
58GAO, Depot Maintenance: DOD Should Improve Pandemic Plans and Publish Working
Capital Fund Policy, GAO-21-103 (Washington D.C.: Apr. 6, 2021).
59The Army, Marine Corps, Navy, and Air Force operate 21 depots that are crucial to
sustaining military readiness. 10 U.S.C. § 2476.
60Department of Defense, Undersecretary of Defense (Acquisition and Sustainment),
Defense Industrial Base Essential Critical Infrastructure Workforce, Memorandum to the
Defense Industrial Base (March 20, 2020).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
long-term crisis affecting the depot workforce. DOD concurred with
our recommendations and addressed them through various actions,
such as establishing a website to communicate guidance to DOD
personnel, including depot staff, and publishing a plan detailing the
steps it will take to communicate mission-essential status during a
pandemic.61
•
In May 2024, we reported that ASPR could enhance the response to
public health emergencies by addressing challenges jurisdictions
identified regarding coordination with the federal government around
Strategic National Stockpile assets during the COVID-19 pandemic
and the mpox public health emergency.62 We found that jurisdictions
lacked up-to-date information from federal agencies on their roles and
current processes for requesting and receiving stockpile assets,
resulting in confusion among jurisdictions during recent public health
emergency responses.
Specifically, there is no formal documented agreement between
ASPR and CDC that details each agency’s roles and responsibilities
related to stockpile operations, according to Strategic National
Stockpile officials. Further, we found ASPR lacked standard operating
procedures for updating key guidance based on the most current
information. For example, the main guidance for requesting and
managing stockpile assets was last updated in 2014.
We recommended that ASPR should work with CDC to clearly define
its and CDC’s roles and responsibilities related to the Strategic
National Stockpile in a formal document and share that document with
jurisdictions. Additionally, we recommended that ASPR develop
standard operating procedures outlining how and when guidance
documents, such as those for requesting and receiving Strategic
National Stockpile assets, are updated. If ASPR develops these
standard operating procedures, jurisdictions will be more likely to have
access to updated guidance that reflects current processes and, in
turn, improve response efforts.
61DOD’s Pandemic Operations Plan states that, at the outbreak of a pandemic, the Office
of the Under Secretary of Defense for Acquisitions and Sustainment will notify the
Defense Industrial Base and contractor workforce that they are mission-essential
personnel who provide essential services required to meet national security commitments
to the federal government and U.S. military.
62GAO-24-106260.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Key open recommendations. We have made recommendations to
federal agencies to improve their coordination with response partners
before and during public health emergencies. These included
recommendations for HHS to provide response partners with the
agency’s plans to mitigate shortages in needed medical supplies, and to
ensure it maintains up-to-date guidance for response partners on the
processes for requesting and receiving vaccines and other assets from
the Strategic National Stockpile.
Agencies across the federal government have taken steps to address
some of our recommendations to enhance collaboration between federal
and nonfederal partners. Yet, agencies could further improve their ability
to efficiently implement response activities by taking additional actions to
address other recommendations that remain open, including:
•
ASPR should develop standard operating procedures outlining how
and when guidance documents, including guidance on requesting and
receiving assets from the Strategic National Stockpile, are updated.
ASPR should also formally designate an entity to regularly engage
with Tribes and relevant stakeholders to assess the unique challenges
that could affect the delivery of assets from the Strategic National
Stockpile to Tribes during future emergencies and to develop options
for how to address those challenges.
•
SBA should—in coordination with FEMA and the Department of
Housing and Urban Development and with input from key recovery
partners—develop and implement an interagency plan to help ensure
the availability and use of quality information to support federal
agencies involved in disaster recovery in identifying access barriers or
disparate outcomes.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Lessons Learned on Providing Clear and Timely Communications
Federal agencies can enhance their efforts to effectively administer relief funds, vaccines, and
other critical resources during a public health emergency by providing clear and timely
information to the
•
applicants and eligible entities of federal relief funds,
•
recipients of federal relief funds, and
•
the public.
We have made recommendations to federal agencies to improve their communication during
public health emergencies. For example, we recommended that the Small Business
Administration develop a comprehensive strategy for communicating with potential and actual
program applicants in the event of a disaster, and that its strategy should include guidelines for
the types of information and timing of information to be provided to program participants
throughout a disaster.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
Communications to relief fund applicants and eligible entities.
Federal agencies can better ensure that eligible entities have the
information they need to seek federal assistance by communicating clear,
timely information on federal relief programs, such as program goals,
eligibility requirements, and funding time frames. This is especially true
when the federal funds are provided through new or expanded programs,
as applicants may not have prior experience navigating federal financial
assistance programs. However, we found that federal agencies did not
always provide clear and timely information to applicants and eligible
entities of COVID-19 relief fund programs and recommended that
agencies take action to strengthen their communications.
Our body of work on COVID-19 financial assistance programs for the
aviation industry showed that federal agencies’ communication with
airports and other applicants and eligible entities was inconsistent. The
COVID-19 pandemic caused an unprecedented and sudden drop in
demand for U.S. passenger airlines. Three COVID-19 relief laws enacted
in 2020 and 2021 made $132 billion in assistance available to airlines,
aviation and other businesses, and airports across four selected
programs—Treasury’s Payroll Support Program and CARES Act loan
program and DOT’s Airport Grants Program and Aviation Manufacturing
Jobs Protection Program.
•
For the Payroll Support Program and CARES Act loan program, we
found that Treasury did not communicate eligibility requirements and
time frames clearly to applicants. For instance, according to our
September 2020 report, industry associations including those
Providing Clear and
Timely Communications
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
representing regional and small aviation companies reported that a
lack of clear information on program eligibility and other requirements
contributed to challenges navigating the Payroll Support Program
application.63 Similarly, in December 2020, we reported that, for the
CARES Act loan program, Treasury did not communicate a time
frame for evaluating applications and making loans.64 As a result,
businesses were unsure when Treasury would execute loans, which
complicated their decision-making while awaiting loan decisions,
according to industry associations and applicants.65
According to Treasury officials, the emergency nature of the programs
and emphasis on quickly distributing funds limited the amount of time
Treasury had to conduct the outreach it typically does when
implementing new programs. Previously, we reported that the
government should ensure adequate transparency by establishing an
effective communication strategy, which could include sharing
timelines, to help ensure an understanding of the matters at hand.66
Ensuring such transparency creates additional tasks for an agency
busy establishing a new program. Yet, investing time in such tasks
could help avoid problems caused by a lack of communication, such
as confusion about the motivations behind program actions and
decisions.
•
We found that program applicants were more complimentary of DOT’s
communication regarding the Airport Grants Program and Aviation
Manufacturing Jobs Protection Program. In November 2020, we
reported that, for the Airports Grants Program, DOT generally
provided timely guidance and assistance to applicants, according to
selected airport sponsors and airport association representatives that
we spoke with.67 Further, in October 2021 we reported that industry
associations were generally complimentary of DOT’s communication
regarding the Aviation Manufacturing Jobs Protection Program,
63GAO-20-701.
64GAO-21-198.
65For example, the CARES Act loan program required businesses not to reduce their
employee levels by more than 10 percent from March 24, 2020, through September 30,
2020. However, many businesses had substantial drops in revenue—in some cases drops
greater than 95 percent—following the onset of the pandemic and had to make tradeoffs
related to maintaining employment levels while awaiting loan decisions.
66GAO-21-198.
67GAO, COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response, GAO-21-191 (Washington, D.C.: Nov. 30, 2020).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
although some industry associations expressed challenges with the
clarity of some DOT guidance.68
Communications to relief fund recipients. After relief funds have been
awarded, federal agencies should continue to provide clear and timely
information to help program recipients effectively manage their awards.
For instance, agencies should communicate information on topics such
as allowable uses of funds, time frames for using funds, and reporting
requirements. This information can be provided through guidance or in
responses to inquiries from recipients.
In our December 2023 report, we found that Treasury took steps to help
state and local recipients manage their COVID-19 relief funds, but further
actions could help ensure more timely and helpful assistance.69 In April
2021, Treasury established the Contact Center to respond to inquiries
about programs that it administered, including the Coronavirus State and
Local Fiscal Recovery Funds (SLFRF).70
However, state and local officials identified a lack of timely and helpful
assistance from the Contact Center as a challenge to managing these
funds. For example, officials in five of 18 selected states we met with told
us that, in some instances, they either received no response from
Treasury to a question or received a response to a time-sensitive
question after a deadline had elapsed. Treasury officials told us that
limited funding available to administer the SLFRF had affected their ability
to assist recipients through the Contact Center.71
68GAO-22-105051.
69GAO, COVID-19 Relief: Treasury Could Improve Its Administration and Oversight of
State and Local Fiscal Recovery Funds, GAO-24-106027 (Washington D.C.: Dec. 14,
2023).
70In March 2021, the American Rescue Plan Act of 2021 appropriated $350 billion through
the SLFRF to help tribal governments, states, localities, the District of Columbia, and U.S.
territories cover costs stemming from the negative health and economic effects of the
COVID-19 pandemic.
71In September 2022, Treasury notified SLFRF recipients of the funding constraints
affecting its ability to provide ongoing support to SLFRF and other COVID-19 relief
program recipients served by the Contact Center. Treasury reduced and later shut down
these activities because it said it had limited funds to support these efforts. Treasury
subsequently reopened its phone support and increased the number of Contact Center
staff after receiving authority in the Consolidated Appropriations Act, 2023, to use certain
unobligated funds to cover administrative expenses necessary to respond to the COVID-
19 pandemic.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Treasury officials also told us that responding to IT- or SLFRF policy-
related questions can result in longer Contact Center response times.72
This is because the questions were more complex and needed to be
referred to staff in other Treasury offices, such as those who manage and
administer the SLFRF program. Further, we found that Treasury had
assessed the number of staff it needed in its Contact Center, but not the
staffing needs in other offices the Contact Center relied on to address IT-
or SLFRF policy-related questions. Without a comprehensive assessment
of staffing needs, Treasury’s Contact Center was less able to provide the
timely and helpful information that states and localities needed to
effectively manage their awards. To improve communications, we
recommended that Treasury comprehensively assess staffing needs for
the Contact Center to ensure that it is able to respond timely to SLFRF
recipients’ requests for assistance and with information that meets their
needs. Treasury agreed with our recommendation and told us it has
begun such an assessment.
Communications to the public. Agencies need to provide clear and
timely information to the public because the public’s participation is critical
to implementing an effective federal response. We previously reported
that administering vaccines to individuals was a key component of the
federal response to mitigate the effect of the COVID-19 pandemic on the
public’s health. Our work examining federal agency vaccination efforts
during the pandemic has highlighted the critical importance of providing
clear and timely information to the public to support vaccine use. For
example:
•
In September 2020, we reported that clarity on the federal
government’s plans for distributing and administering vaccine, as well
as timely, clear, and consistent communication to stakeholders and
the public about those plans, was essential. Representatives of state,
local, and territorial health officials, and health care providers we
interviewed emphasized the need for the federal government to
develop and share plans for the distribution and administration of
COVID-19 vaccines before one becomes available.73
At that time, we recommended that HHS, with the support of DOD,
establish a time frame for documenting and sharing a national plan for
72IT-related inquiries included those related to using Treasury’s online reporting portal to
submit required SLFRF reports. SLFRF policy-related inquiries included questions on
allowable uses of funds.
73GAO-20-701.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
distributing and administering COVID-19 vaccines. Further, such a
plan should be consistent with best practices for project planning and
scheduling, and it should outline an approach for how efforts will be
coordinated across federal agencies and nonfederal entities. Due to
widespread distribution and administration of COVID-19 vaccines, the
time frame for implementation of this recommendation has passed.
However, our past work and the work of others have demonstrated
that proper planning—including incorporating best practices for project
planning and scheduling and sharing information with stakeholders in
a timely manner—is critical to the success of distributing and
administering any licensed or authorized vaccine. Thus, we continue
to believe it is important for agencies to develop and communicate,
including with the public, vaccine distribution plans when
implementing the response to future emergencies.
•
We found that a lack of clear and timely information from federal
agencies contributed to challenges managing public expectations. In
January 2021, we reported that early vaccine distribution efforts did
not match public expectations, with initial numbers of distributed
vaccines falling short of expectations set by HHS and DOD’s
Operation Warp Speed partnership.74 Additionally, we have reported
that a lack of clear and timely guidance from agencies on which
populations should be prioritized for initial doses made it challenging
for health officials and health care providers to manage the public’s
expectations about when individuals could get vaccinated.75 As we
found in our prior work examining the federal response to the H1N1
pandemic, the failure to manage public expectations can undermine
government credibility and the public’s participation in vaccination
efforts.76
•
In April 2021, we reported that health care providers lacked
authoritative, science-based information to combat misinformation and
74GAO, COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity, and
Other Challenges Require Focused Federal Attention, GAO-21-265 (Washington D.C.:
Jan. 28, 2021).
75GAO, COVID-19: Efforts to Increase Vaccine Availability and Perspectives on Initial
Implementation, GAO-21-443 (Washington D.C.: Apr. 14, 2021) and COVID-19: HHS
Agencies’ Planned Reviews of Vaccine Distribution and Communication Efforts Should
Include Stakeholder Perspectives, GAO-22-104457 (Washington D.C.: Nov. 4. 2021).
76GAO, Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated
into Future Planning, GAO-11-632 (Washington, D.C.: June 27, 2011).
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vaccine hesitancy.77 In our November 2021 report, selected
stakeholders told us that while CDC’s education materials helped
state and local health officials and health care providers address the
public’s concerns about the safety of COVID-19 vaccines, these
materials would have been more useful had CDC released them
earlier.78
•
Engaging communities as part of a vaccine communication strategy
can help agencies combat factors that decrease receptivity to
government response efforts. In our September 2023 report, we found
that the U.S. Agency for International Development played a role in
vaccinating the world against COVID-19, spending nearly $1 billion to
assist 125 countries with their vaccination efforts.79 To help achieve
its goal of vaccinating 70 percent of the population in each country,
the agency supported various efforts to combat factors that had
decreased vaccine demand. These efforts included a communication
strategy for addressing issues related to disinformation and perceived
low risk of infection, and working with community leaders and other
influential community members, such as well-known athletes and
musicians, to generate demand.
Key open recommendations. Our work has highlighted the need for
federal agencies to provide clear and timely information to the public to
effectively administer relief funds, vaccines, and other critical resources.
We have made recommendations to federal agencies to improve the
clarity and timeliness of communications around relief program goals and
requirements and plans for distributing vaccines during the COVID-19
pandemic.
Agencies have taken steps to address some of our recommendations.
Taking additional steps to implement our recommendations that remain
open could facilitate federal agencies’ continued efforts to provide support
to those affected by the COVID-19 pandemic and improve their response
to future public health emergencies. For example:
•
Treasury should comprehensively assess staffing needs for the
Contact Center to ensure that it is able to provide timely and helpful
assistance to recipients of SLFRF awards. Further, Treasury should
77GAO-21-443.
78GAO-22-104457.
79GAO, COVID-19: USAID Plans to Share Lessons Learned from Efforts to Meet Global
Vaccination Goal, GAO-23-105579 (Washington D.C.: Sept. 27, 2023).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
update and implement the agency’s documented policies and
procedures for monitoring recipients’ use of SLFRF awards to reflect
lessons learned from reviewing recipients’ project and expenditure
reports.
•
SBA should develop a comprehensive strategy for communicating
with potential and actual program applicants in the event of a disaster.
Such a strategy should provide guidelines for the types of information
and timing of information to be provided to program participants
throughout a disaster. The types of information to be addressed in the
strategy could include processing steps and time frames applicants
might experience through different stages of the loan process.
Lessons Learned on Managing Program Integrity Risks
Establishing controls and processes to mitigate and address financial risks can help federal
agencies reduce the likelihood of improper payments and fraud when they must disburse
emergency relief funds quickly during a public health emergency.
•
Prepayment controls and processes can help agencies minimize the likelihood of improper
payments and fraud.
•
Postpayment controls and processes can help agencies identify and recover improper and
fraudulent payments when the quick disbursement of funds makes prepayments controls
difficult to apply fully.
We have made recommendations to federal agencies to better manage program integrity risks in
emergency assistance programs. For example, we recommended that the Department of Labor
design and implement an antifraud strategy for unemployment insurance programs that is
consistent with leading practices for preventing, detecting, and responding to fraud outlined in
GAO’s Fraud Risk Framework.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
During a public health emergency, it is important that federal agencies get
relief funds out quickly to those affected by the emergency while ensuring
appropriate controls and processes are in place to reduce the likelihood
of improper payments and fraud. Improper payments and fraud are two
distinct concepts that are related but not interchangeable. While all
fraudulent payments are considered improper, not all improper payments
are due to fraud. For example, improper payments can be overpayments
Managing Program
Integrity Risks
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
or underpayments that result from error or a lack of agency oversight.80
Fraudulent payments are different from other types of improper payments
because they generally involve individuals or entities intentionally or
knowingly providing false information, such as incorrect eligibility or
identity information, to receive a benefit from the federal government.81
While the full extent of fraud associated with COVID-19 relief funds will
never be known with certainty, estimated fraud in certain relief fund
programs is in the hundreds of billions. For example, in September 2023,
we estimated the amount of fraud in DOL’s unemployment insurance
programs during the pandemic—from April 2020 through May 2023—was
likely between $100 billion and $135 billion.82 Further, SBA’s Office of
Inspector General estimated that, as of June 2023, SBA had disbursed
over $200 billion in potentially fraudulent pandemic relief loans, which is
approximately 17 percent of SBA’s total COVID-19 spending.83
In April 2024, GAO estimated total direct annual financial losses to the
government from fraud to be between $233 billion and $521 billion, based
on data from fiscal years 2018 through 2022.84 The data include time
periods and programs with and without pandemic-related spending.
Therefore, the estimate includes, but is not limited to, pandemic-related
80The Payment Integrity Information Act of 2019, codified at 31 U.S.C. §§ 3351-58,
defines improper payments as any payments that should not have been made or that
were made in an incorrect amount (including overpayments and underpayments) under
statutory, contractual, administrative, or other legally applicable requirements. Improper
payments include any payment to an ineligible recipient or for an ineligible service,
duplicate payments, payments for services not received (except where authorized by law),
and any payment for an incorrect amount. 31 U.S.C. § 3351(4). Executive agency
estimates of improper payments also treat as improper any payments whose propriety
cannot be determined due to lacking or insufficient information. 31 U.S.C. § 3352(c)(2).
81GAO, Improper Payments and Fraud: How They Are Related but Different,
GAO-24-106608 (Washington, D.C.: Dec. 7, 2023).
82GAO, Unemployment Insurance: Estimated Amount of Fraud during Pandemic Likely
Between $100 Billion and $135 Billion, GAO-23-106696 (Washington, D.C.: Sept. 12,
2023).
83This estimate includes loans from the Paycheck Protection Program, COVID-19
Economic Injury Disaster Loan program, and Targeted Advances and Supplemental
Targeted Advances from the COVID-19 Economic Injury Disaster Loan program. See
Small Business Administration, Office of Inspector General, COVID-19 Pandemic EIDL
and PPP Loan Fraud Landscape, White Paper Report 23-09 (June 27, 2023).
84GAO, Fraud Risk Management: 2018-2022 Data Show Federal Government Loses an
Estimated $233 Billion to $521 Billion Annually to Fraud, Based on Various Risk
Environments, GAO-24-105833 (Washington, D.C.: Apr. 16, 2024).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
spending fraud. While the upper range of the estimate is associated with
higher-risk environments like the pandemic, it is not possible to break out
a subset of our government-wide estimate to describe pandemic program
fraud.
We further reported that the COVID-19 pandemic is a recent example of
how factors such as the effectiveness of federal fraud risk management
and the nature of new fraud threats can substantially impact the scale of
fraud. We have previously reported on the heightened fraud risk
environment associated with some pandemic programs.85 These prior
reviews provided observations about varying fraud risk environments by
program and across delivery years, as well as the standalone estimate of
unemployment insurance fraud during the pandemic.
Additionally, the Department of Justice has brought federal fraud-related
charges against individuals or entities in cases involving federal COVID-
19 relief programs. We analyzed the department’s public statements and
court documentation and found, from March 2020 through March 2024, at
least 1,998 individuals or entities facing charges were found guilty or
liable.86 This includes fraud-related charges in cases involving SBA’s
small business programs, DOL’s unemployment insurance programs, and
Treasury’s economic impact payments, among other programs. Of the
85GAO-23-105331; Emergency Relief Funds: Significant Improvements Are Needed to
Ensure Transparency and Accountability for COVID-19 and Beyond, GAO-22-105715
(Washington, D.C.: Mar. 17, 2022); and GAO-23-106696.
86The federal government may enforce laws through civil or criminal action. Such action
may be resolved through a trial, a permanent injunction, a civil settlement, or a guilty plea.
Our analysis is limited to the cases we identified from public sources and may not include
all criminal and civil cases charged by the Department of Justice as of March 31, 2024.
Additionally, details of fraud cases and schemes presented in court documents may not
be complete. Further, cases that reach the prosecution stage in the fraud identification life
cycle represent a fraction of the instances of fraud or all possible fraud cases.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
individuals found guilty, at least 1,596 had been sentenced as of March
31, 2024, and many have also been ordered to pay restitution and fines.87
There were also federal fraud-related charges pending against at least
632 other individuals or entities involving federal COVID-19 relief
programs, as of March 31, 2024.88 The number of individuals or entities
facing fraud-related charges from COVID-19 relief programs will likely
continue to increase, as these cases take time to develop, and the statute
of limitations has been extended to 10 years to prosecute individuals who
committed fraud related to the Paycheck Protection Program and the
COVID-19 Economic Injury Disaster Loan program. Additionally, there are
ongoing legislative efforts in Congress to extend the statute of limitations
for various other programs. For example, DOL’s Inspector General has
requested that Congress extend the statute of limitations for fraud for the
pandemic relief Unemployment Insurance programs.89
By applying the leading practices identified in GAO’s Framework for
Managing Improper Payments in Emergency Assistance Programs and
Framework for Managing Fraud Risks in Federal Programs, agencies can
better plan for and take a more strategic approach toward managing
improper payments and fraud when implementing the federal response to
future public health emergencies.90 These frameworks instruct agencies
87The range in length of prison sentencing varies, in part, based on factors such as prior
convictions and whether there were other charges in addition to COVID-19-related fraud.
Courts refer to the United States Sentencing Commission Guidelines to determine the
particular sentence in each individual case. Under 28 U.S.C. § 994, the Guidelines should
reflect a variety of factors and considerations to determine an appropriate sentence. The
Guidelines set a base offense level and then add or subtract levels due to aggravating or
mitigating circumstances, such as the dollar amount of the loss caused by the offense and
the defendant’s criminal history, ultimately arriving at a suggested sentencing range.
Additionally, many of the defendants we reviewed were convicted on additional charges
beyond fraud against COVID-19 relief programs, which would affect the length of their
sentences. Sentences ranged from probation to 30 years in prison and court ordered
restitution amounts ranged from zero to over $70 million.
88A charge is merely an allegation, and all defendants are presumed innocent until proven
guilty beyond a reasonable doubt in a court of law.
89The Pandemic Unemployment Fraud Recoupment Act (S. 1018) contains provisions that
would address this request. As of July 17, 2024, this bill has not been passed by
Congress.
90GAO, A Framework for Managing Improper Payments in Emergency Assistance
Programs, GAO-23-105876 (Washington D.C.: July 13, 2023) and A Framework for
Managing Fraud Risks in Federal Programs, GAO-15-593SP (Washington D.C.: July 28,
2015).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
to implement internal controls and leading practices that can help them
prevent, detect, and recover improper and fraudulent payments.
The need—and requirements—for agencies to take action to address
fraud was reiterated in our February 2023 testimony, which identified
agencies’ continued lag in implementing fraud risk management activities
as a major factor contributing to pandemic programs’ exposure to fraud.91
In addition, we have suggested that Congress take legislative actions to
help address agencies’ shortcomings in their applications of fundamental
internal controls and fraud risk management practices. See appendix I for
additional information on these legislative actions.
Prepayment controls. When administering federal emergency relief fund
programs, federal agencies can implement prepayment controls and
processes at the beginning of the program or as soon as possible after
program implementation to help prevent improper payments and fraud.
We previously reported that agencies did not have appropriate internal
controls to prevent, detect, and recover improper and fraudulent
payments when administering some COVID-19 relief programs.92 We also
found instances where some agencies that lacked appropriate internal
controls at the start of the pandemic strengthened those controls as the
programs matured.
For example, SBA quickly set up its pandemic relief programs to rapidly
respond to the adverse economic conditions small businesses faced.
However, this was done at the expense of appropriate financial and other
safeguards, which left SBA’s programs susceptible to improper payments
and fraud. Our work examining SBA’s small business programs—
particularly the Paycheck Protection Program and the COVID-19
Economic Injury Disaster Loan program—identified funds provided to
ineligible businesses and to legitimate business owners who falsely self-
certified their eligibility, among other things.
Other fraud controls to mitigate these misrepresentations were either not
in place or were not effective. We reported in March 2024 that, as the
programs matured and SBA implemented our recommendations, SBA
improved its oversight and incorporated lessons learned from the
Paycheck Protection Program and the COVID-19 Economic Injury
91GAO, Emergency Relief Funds: Significant Improvements Are Needed to Address Fraud
and Improper Payments, GAO-23-106556 (Washington, D.C: Feb. 1, 2023).
92GAO-23-106556.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
Disaster Loan program into its other relief programs.93 We estimated that,
as of the end of fiscal year 2023, SBA’s use of additional safeguards in
the Paycheck Protection Program and other COVID-19 programs had
resulted in more than $12 billion in savings.
We also reported that, by examining fraud schemes that emerged during
the COVID-19 pandemic, agencies can identify controls that can be
implemented to mitigate fraud risks when administering relief programs in
response to future emergencies.94 For example, the COVID-19 pandemic
saw an increase in the frequency and volume of identity-related fraud,
particularly in the areas of unemployment insurance and small business
relief programs.95 These developments will likely continue to challenge
future federal emergency assistance efforts. Therefore, agencies can
assume applicant identity information will be compromised and should
implement prepayment controls to verify applicant identity when
implementing relief programs in response to future emergencies.96
Postpayment controls. Agencies should prioritize prepayment controls
and avoid relying on the “pay and chase model,” which refers to the
practice of waiting to address improper payments and fraud until after
payments have been made. However, establishing postpayment controls
and processes can help agencies identify and recover improper payments
and fraudulent payments when the quick disbursement of funds makes
prepayment controls difficult to apply fully. Agencies should act promptly
to recover payments—the more time passes, the less likely payments will
be recovered.
Accordingly, agencies should establish processes to identify and recover
improper and fraudulent payments when they begin administering federal
relief fund programs or as soon as possible after program
implementation. However, we found that many agencies that
administered COVID-19 relief programs lacked controls and processes
93GAO, Small Business Administration: Progress and Work Remaining to Implement Key
Management Improvements, GAO-24-107395 (Washington, D.C.: Mar. 6, 2024).
94GAO, COVID-19: Insights and Actions for Fraud Prevention, GAO-24-107157
(Washington, D.C.: Nov. 14, 2023).
95GAO-23-105876.
96GAO-24-107157.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
that would have helped them promptly identify and recover improper and
fraudulent payments. For example:
•
In September 2022, we reported that limitations in USDA’s process for
reviewing payments made through the Coronavirus Food Assistance
Program may have undermined USDA’s ability to detect improper
payments.97 In 2020 and 2021, USDA’s Farm Service Agency
provided $31 billion in aid to 965,651 producers of agricultural
commodities—including crops, dairy, and livestock—through the
program to offset losses and increased costs associated with the
COVID-19 pandemic. These payments were made based on self-
certified claims but were subject to the agency’s postpayment
reviews, including spot checks to review producers’ claims and
supporting materials.
However, we identified several limitations that may have undermined
the agency’s ability to identify improper payments using its spot check
reviews. These limitations included the Farm Service Agency’s (1)
national office not fully considering risk factors when selecting
producers to include in the spot check sample, (2) county offices not
consistently adding producers with questionable claims to the spot
check sample, and (3) state offices not monitoring the quality of
county offices’ spot checks.
We made four recommendations for the Farm Service Agency to
conduct more rigorous reviews of Coronavirus Food Assistance
Program applications. The agency generally agreed with our
recommendations and took steps to address the limitations we
identified related to its spot check reviews. Additionally, as of April
2024, the Farm Service Agency’s county offices had completed
additional spot checks, but reporting and analysis were ongoing. We
will review the agency’s process for these additional spot checks
when they are complete and assess whether these actions are
responsive to our recommendation.
•
We found that the Health Resources and Services Administration
(HRSA) did not promptly implement certain postpayment controls and
processes in the Provider Relief Fund. The Provider Relief Fund was
created in March 2020 to provide COVID-19 relief funds to health care
providers and ensure access to essential health care services. The
97GAO, Coronavirus Food Assistance Program: USDA Should Conduct More Rigorous
Reviews of Payments to Producers, GAO-22-104397 (Washington, D.C.: Sept. 8, 2022).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
agency conducted a fraud risk assessment in 2021 and 2022 to help it
identify fraud risks in the program as well as gaps in its existing
controls and processes to address identified risks. In its 2021
assessment, the agency found that it had not documented analytic
processes for what types of problematic payments should be flagged
for further review and procedures for responding to allegations of
potential fraud. To reduce risks, HRSA recommended that it
document and standardize such processes and procedures. Despite
making this recommendation in 2021, it took the agency until March
2023 to implement new standardized processes to flag problematic
payments for review and until June 2023 to finalize procedures for
responding to potential fraud.
Additionally, in October 2021, we reported that HRSA was slow to
implement processes for recovering improper payments. We
recommended that HRSA finalize procedures and seek postpayment
recovery of any Provider Relief Fund overpayments, unused
payments, and payments not properly used.98 HRSA finalized its
recovery processes in December 2022. In September 2023, we
reported that HRSA had addressed our recommendation based on
our review of its recovery processes and plan for seeking recovery of
all types of payments in need of recovery.99
Key open recommendations. Our work has highlighted the importance
of establishing controls and processes to manage program integrity risks.
Federal agencies can be better positioned to manage improper payments
and fraud risks during emergencies by implementing effective processes
and controls to manage risks under normal conditions. Agencies can
further improve their preparedness for emergencies by promptly
implementing our recommendations and recommendations from their
inspectors general. For example, in 2018, we recommended that the
Internal Revenue Service (IRS) take steps to improve its efforts
to authenticate taxpayers. IRS had not fully implemented
these recommendations at the onset of the COVID-19 pandemic,
and subsequently IRS officials raised concerns that fraudsters could be
taking economic impact payments intended for eligible recipients. By
taking actions to address the open recommendations prior to the COVID-
19 pandemic, IRS might have had better controls and safeguards in place
during the emergency to manage improper payment risks and help
98GAO-22-105051.
99GAO, COVID-19 Provider Relief Fund: HRSA Continues to Recover Remaining
Payments Due from Providers, GAO-23-106083 (Washington, D.C.: Sept. 21, 2023).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
ensure that eligible individuals in need of economic impact payments
received them.
Additionally, we have made recommendations to agencies across the
federal government to mitigate program integrity risks in emergency
assistance programs. Agencies have taken steps to address some of our
recommendations to mitigate program integrity risks. However, additional
actions could help federal agencies better manage such risks. For
example:
•
USDA’s Farm Service Agency should conduct additional reviews of
Coronavirus Food Assistance Program payments and use a more
risk-based approach to select producers for review.
•
The Centers for Medicare & Medicaid Services (CMS) should conduct
fingerprint-based criminal background checks for high-risk provider
types who enrolled during the COVID-19 public health emergency,
such as when CMS revalidates these providers’ information.
•
DOL should design and implement an antifraud strategy for
unemployment insurance programs based on a fraud risk profile that
is consistent with leading practices as provided in the Fraud Risk
Framework.
Lessons Learned on Collecting and Sharing Data
Collecting and sharing data can help federal agencies
•
effectively manage response activities, evaluate performance in meeting response goals,
and make any midcourse adjustments as needed;
•
target and administer relief fund programs; and
•
enhance the early detection of public health emergencies.
We have made recommendations to federal agencies to enhance their ability to collect and share
data before and during public health emergencies. For example, we recommended that the
Department of Health and Human Services complete a plan that includes actions for establishing
an electronic nationwide public health situational awareness network and identify measurable
steps for completing actions to establish the network.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
Managing response activities and evaluating performance. By
collecting data, federal agencies can better manage the response and
make timely decisions during a public health emergency. Our work
examining the federal response to the COVID-19 pandemic found that
Collecting and Sharing
Data
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without collecting necessary data, some agencies faced challenges
making decisions to inform response activities and evaluating their
performance in meeting response program goals. For example:
•
In September 2020, we reported that CDC lacked the data it needed
to prioritize the allocation of health resources among populations most
affected by the pandemic.100 As the nation’s health protection agency,
CDC collected and reported data on COVID-19 cases,
hospitalizations, deaths, and other indicators of the pandemic by race
and ethnicity. However, we found that race and ethnicity information in
the data reported to CDC by states and other entities was often
incomplete. For instance, in March 2021, we found CDC lacked
information on patients’ race and ethnicity for almost half of reported
COVID-19 cases (47.2 percent) and vaccinations (46.7 percent).101
We recommended that CDC take steps to collect more complete
data.102 CDC agreed and took various actions that addressed our
recommendation. For instance, in May 2021, agency officials stated it
had conducted listening sessions with community health workers
serving racial and ethnic communities and rural populations to gather
input on the importance of collecting race and ethnicity data. Officials
also stated that the agency planned to use this information to inform
the development of appropriate messages to educate communities
about the importance of providing race and ethnicity data when
receiving health care services, among other things. Further, in August
2021, CDC officials stated that monitoring and assessing the
completeness of race and ethnicity data in its COVID-19 data systems
remains a priority, and that addressing the completeness and quality
of demographic data is also part of larger, ongoing initiatives.
•
In September 2021, we reported that USDA was unable to fully
evaluate the performance of the Farmers to Families Food Box
program in meeting the goals USDA established for the program
because the agency did not collect needed data.103 Through the
program—which began in May 2020 and ended in May 2021—USDA
contracted with distributors to purchase and deliver fresh fruits and
100GAO-20-701.
101GAO-21-387.
102GAO-20-701.
103GAO, USDA Food Box Program: Key Information and Opportunities to Better Assess
Performance, GAO-21-353 (Washington D.C.: Sept. 8, 2021).
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vegetables, dairy, and meat products across the country. Its specific
program goals included (1) providing food to those in need, (2)
helping companies that supply and distribute goods to retain jobs, and
(3) supporting domestic producers faced with declining demand.
USDA determined that the program met its goal of providing food to
those in need.
However, we found that USDA could not determine whether the
program had achieved its other two goals—specifically, job retention
and supporting domestic producers—because it did not collect
necessary data to evaluate the program’s performance in meeting
these goals. USDA officials said they did not collect these data
because they implemented the program under tight time frames. We
recommended that USDA take steps to help ensure it will apply the
lesson learned regarding collecting and analyzing data to assess
program goals when implementing future emergency food assistance
programs. In April 2022, USDA reported that it had plans to apply this
lesson learned to future programs.
Administering relief fund programs. By improving data systems,
federal agencies can enhance their ability to effectively administer relief
fund programs during future emergencies. Federal agencies use data
systems to carry out various program responsibilities. However, we found
some agencies experienced challenges utilizing data systems to manage
COVID-19 relief fund programs. For example, we found that outdated
data systems contributed to challenges in the unemployment insurance
programs administered by state workforce agencies under the oversight
of DOL.104 State workforce agencies relied extensively on data systems,
but many were legacy systems developed in the 1970s and 1980s. In
June 2022, we noted that DOL’s Office of Inspector General found legacy
systems were one of the causes of states’ inability to detect and recover
fraudulent payments.105 Specifically, state officials reported that their data
systems did not have the capability to perform cross-matches—a method
used to detect improper payments—for such a large volume of claims.
Additionally, security vulnerabilities in legacy systems may pose a privacy
risk as claimants’ personally identifiable information could become more
easily accessible to criminals.
104GAO, Unemployment Insurance: DOL Needs to Further Help States Overcome IT
Modernization Challenges, GAO-23-105478 (Washington D.C.: July 10, 2023).
105GAO, Unemployment Insurance: Transformation Needed to Address Program Design,
Infrastructure, and Integrity Risks, GAO-22-105162 (Washington D.C.: June 7, 2022).
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Enhancing the early detection of public health emergencies. Data
systems enable officials across levels of government to share information,
thus playing an important role in efforts to enhance the response to future
public health emergencies. We previously reported that having a national
public health situational awareness capability—that is, a capability for
health care providers and public health officials at all levels of government
to share real-time information—would help federal agencies detect
emerging threats and prepare the response.106 Figure 4 provides an
illustration of the types of entities that have a role in sharing information to
support nationwide public health situational awareness.
Figure 4: Types of Entities Involved in Supporting Nationwide Public Health Situational Awareness
106GAO, Public Health Emergencies: Data Management Challenges Impact National
Response, GAO-22-106175 (Washington, D.C.: Sept. 22, 2022).
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Since 2006, federal laws have required that HHS take steps toward
improving the nation’s situational awareness of threats related to public
health emergencies.107 Specifically, HHS was required to establish an
electronic nationwide public health situational awareness capability to
facilitate sharing data and information to enhance both the early detection
of, and rapid response to, infectious disease outbreaks and other public
health emergencies.108
In 2017, we made three recommendations that HHS take steps toward
meeting its mandate to establish a nationwide public health situational
awareness capability by creating an integrated project team to conduct all
activities required to establish and operate the capability. HHS has not
fully addressed these recommendations.109 While our work during the
COVID-19 pandemic indicated HHS had made progress toward meeting
its mandate, additional actions are still needed. For example:
•
We reported in September 2020 that HHS launched a new data
platform—HHS Protect—in April 2020 to help integrate COVID-19
data and other types of health information collected by various
federal, state, and local public health and commercial entities.110 HHS
officials told us that they believe this platform has helped the agency
in meeting its mandate to establish an electronic system to support
public health situational awareness capabilities.
We agreed that HHS has implemented several systems related to
public health situational awareness and biosurveillance.111 However,
the law called for a near real-time nationwide public health situational
awareness capability consisting of interoperable systems to enable
107Pandemic and All-Hazards Preparedness Act, Pub. L. No. 109-417, 120 Stat. 2831
(2006); Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, Pub. L. No.
113-5, 127 Stat. 161 (2013); Pandemic and All-Hazards Preparedness and Advancing
Innovation Act of 2019, Pub. L. No. 116-22, 133 Stat. 905 (2019).
108See 42 U.S.C. § 247d-4.
109GAO, Public Health Information Technology: HHS Has Made Little Progress toward
Implementing Enhanced Situational Awareness Network Capabilities, GAO-17-377
(Washington, D.C.: Sept. 6, 2017).
110GAO-20-701.
111HHS defines biosurveillance as the process of gathering, integrating, interpreting, and
communicating essential information related to all-hazards threats or disease activity
affecting human, animal, or plant health to achieve early detection and warning, contribute
to overall situational awareness of the health aspects of an incident, and enable better
decision-making at all levels.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
the simultaneous sharing of information needed to enhance situational
awareness at the federal, tribal, state, and local levels of public
health.112 This capability does not exist today.113
•
In June 2022, we reported that states and public health organizations
experienced several challenges and identified lessons learned related
to managing and sharing information during the pandemic, and that
HHS can use these insights to inform its efforts to meet its
mandate.114 For instance, one state reported that because of the lack
of interoperability among its health department systems, public health
officials and stakeholders had to manually input data into different
systems. Public health organizations told us that health-related
information sharing was a challenge because states and local
jurisdictions had separate vaccination management systems, limited
visibility into other states’ data, and no visibility into vaccination data
at the federal level.
Additionally, most states that responded to a survey we administered
and public health organizations we met with identified lessons learned
related to improving public health data reporting. These included
standardizing and sharing data among federal entities and states to
improve surveillance needs and collaborating with response
partners—including states, territories, and local and tribal entities—to
reduce reporting duplicative data.
Key open recommendations. We have made recommendations to
federal agencies to improve data collection and data sharing capabilities.
Federal agencies have taken steps to address some of these
recommendations. However, additional actions could help enhance the
response to future emergencies. For example:
•
HHS should complete a plan that includes actions for establishing an
electronic nationwide public health situational awareness network and
develop a project management plan that identifies measurable steps
for completing actions to establish the network.
•
HHS should prioritize the development of the public health situational
awareness and biosurveillance network by designating a lead
112See 42 U.S.C. § 247d-4(c).
113GAO, COVID-19: Pandemic Lessons Highlight Need for Public Health Situational
Awareness Network, GAO-22-104600 (Washington, D.C.: June 23, 2022).
114GAO-22-104600.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
operational division for the implementation of the Pandemic and All-
Hazards Preparedness and Advancing Innovation Act of 2019.
•
HHS should ensure that the lead operational division for implementing
its mandate request that state, territory, and local public health
officials share their lessons learned from the COVID-19 pandemic
with HHS, and incorporate lessons learned from the COVID-19
pandemic into its plans for implementing the situational awareness
and biosurveillance network.
Lessons Learned on Leveraging Existing Infrastructure
Leveraging the existing infrastructure—including programs, partnerships, and systems—can help
federal agencies implement timely activities to respond to a public health emergency and
efficiently manage them. Specifically, federal agencies can use existing infrastructure to
•
facilitate the delivery of services and distribute federal relief funds, and
•
manage and oversee response programs.
We identified instances during the COVID-19 pandemic where federal agencies successfully
leveraged the existing infrastructure. For example, the Department of the Interior and the Indian
Health Service leveraged existing program mechanisms to efficiently distribute COVID-19 relief
funds to tribal recipients during the pandemic. We also made recommendations to federal
agencies to seek such opportunities. Further, Congress may wish to consider enacting automatic
increases in federal Medicaid spending during economic downturns to increase federal Medicaid
support in a more timely and targeted fashion.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
Leveraging infrastructure to deliver services and distribute relief
funds. Congress has leveraged the Medicaid program to quickly increase
funding to states and ensure that eligible individuals maintained access to
essential health care services during the COVID-19 pandemic and other
times of crisis.115 Most of the enhanced federal funding resulted from a
6.2 percent temporary increase in the federal matching rate for state and
territorial Medicaid programs provided in the Families First Coronavirus
Response Act.116 To receive the enhanced federal funding during the
pandemic, states were required to provide continuous coverage for
certain beneficiaries who were enrolled in Medicaid on or after March 18,
115GAO-22-105397 and GAO, Medicaid in Times of Crisis, GAO-21-343SP (Washington,
D.C.: Feb. 17, 2021).
116Pub. L. No. 116-127, div. F, § 6008, 134 Stat. 178, 208 (2020).
Leveraging Existing
Infrastructure
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
2020, through the end of the month in which the public health emergency
ended, among other requirements.
Under this policy, enrollment grew by over 30 percent, from about 64
million in February 2020 to about 86 million in February 2023. Spending
for the enhanced federal funding totaled about $118 billion from January
2020 through March 2023. Congress ended the continuous enrollment
requirement as of March 31, 2023, and the enhanced matching funds as
of December 31, 2023.117 In July 2024, we reported on state and federal
efforts to redetermine eligibility and disenroll individuals who are no
longer eligible, referred to as “unwinding,” and have ongoing work
examining the outcomes of that process on Medicaid enrollment.118
Further, we have previously recommended that Congress consider
automatic increases in federal Medicaid spending during economic
recessions based on each state’s increased unemployment and
decreased revenues. Implementing an automatic, temporary change
would increase federal Medicaid support in a more timely and targeted
fashion.119
Using existing programs and mechanisms to administer billions of dollars
in COVID-19 relief funds helped meet the needs of U.S. territories, Tribes,
states, localities, and others and alleviate challenges when distributing
funds. For example:
•
Throughout the pandemic, we reported on the expansion of CMS’s
Accelerated and Advanced Payments Program to provide support to
Medicare suppliers and providers during the pandemic. This program
provides loans to providers and suppliers during times when there is a
disruption in claim submission and processing, including during the
COVID-19 pandemic. Under the expanded program, active Medicare
providers and suppliers could apply for loans up to 100 percent or 125
percent of the Medicare payments they received for the prior 3-month
or 6-month period, depending on provider or supplier type. While no
new loans related to the COVID-19 pandemic have been made under
117Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 5131, 136 Stat. 4459,
5949 (2022).
118GAO, Medicaid: Federal Oversight of State Eligibility Redeterminations Should Reflect
Lessons Learned after COVID-19, GAO-24-106883, (Washington, D.C.: July 18, 2024).
119GAO, COVID-19: Opportunities to Improve Federal Response and Recovery Efforts,
GAO-20-625 (Washington, D.C.: June 25, 2020) and Medicaid: Prototype Formula Would
Provide Automatic Targeted Assistance to States during Economic Downturns,
GAO-12-38 (Washington, D.C.: Nov. 10, 2011).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
this program since January 2021, accelerated and advance payments
helped some providers with cash flow issues early in the pandemic.120
•
In September 2023, we reported that officials in U.S. territories told us
they experienced fewer challenges administering and reporting on
pre-existing federal programs that received additional money
compared with programs that were newly created in COVID-19 relief
funding legislation.121 Similarly, in December 2022, we reported that
the Department of the Interior and the Indian Health Services, two
federal agencies with substantial experience working with Tribes,
leveraged existing program mechanisms to distribute COVID-19 relief
funds to tribal recipients during the pandemic. In contrast, agencies
that lacked experience working with Tribes faced challenges when
administering relief fund programs, which affected the timeliness and
equity of relief fund allocations to recipients.122
Leveraging infrastructure to manage and oversee response
programs. Leveraging existing programs facilitated the administration
and oversight of COVID-19 relief funds during the pandemic. The CARES
Act appropriated $25 billion to the Federal Transit Authority to support the
transit industry through its Urbanized Area and Rural Area formula
programs. Using these funds, the federal agency provided grants to state
Departments of Transportation, local public transit systems, and Tribes to
support and expand transit services, including services provided through
buses, subways, and ferries in urban, rural, and tribal areas. Agency
officials reported few challenges implementing CARES Act provisions and
monitoring CARES Act grants, in part, because the funds were provided
for existing programs that have procedures for administration and
oversight.123
Leveraging existing data systems during the COVID-19 pandemic helped
some federal agencies collect data needed to make program decisions
and oversee relief funds. For example:
120For example, see GAO-22-105397 and GAO-20-625.
121GAO, COVID-19: U.S Territory Experiences Could Inform Future Federal Relief,
GAO-23-106050 (Washington, D.C.: Sept. 19, 2023).
122GAO, COVID-19 Relief Funds: Lessons Learned Could Improve Future Distribution of
Federal Emergency Relief to Tribal Recipients, GAO-23-105473 (Washington, D.C.: Dec.
15, 2022).
123GAO-20-625 and GAO-20-701.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
•
In March 2023, we reported that CMS leveraged an existing data
collection system to gather nursing home data to inform its program
decisions. Specifically, CMS began requiring nursing homes to report
data at least on a weekly basis—such as COVID-19 cases and
deaths, access to personal protective equipment, and staffing
shortages—to CDC’s existing national infection surveillance system,
the National Healthcare Safety Network, in May 2020. CMS officials
said collecting these data were critical to their response in nursing
homes.124
•
Federal agencies can leverage Treasury’s free payment integrity
service, as well as existing program or agency data, to detect
potential fraud. A leading practice in fraud data analytics is to conduct
data mining and matching. For example, as we reported in May 2023,
over the course of its COVID-19 pandemic response, SBA increased
its use of data analytics to facilitate fraud detection and began using
the Department of the Treasury’s Do Not Pay service in 2021 to
screen applicants.125
We recommended that SBA take steps to further leverage existing
data sources. Specifically, we recommended that SBA ensure that it
had identified external sources of data that can facilitate the
verification of applicant information and the detection of potential fraud
across programs. Further, we recommended that SBA develop a plan
for obtaining access to those external sources of data. As of May
2024, SBA has taken some steps to identify and develop a plan to
access such data sources.
Key open recommendations and congressional consideration. We
identified instances during the COVID-19 pandemic where federal
agencies successfully leveraged programs, partnerships, and systems
that facilitated the implementation and management of a timely response.
Federal agencies should continue to seek opportunities to leverage
existing infrastructure, particularly when responding to future public health
emergencies. For example, SBA should
•
ensure it has and utilizes mechanisms to facilitate cross-program data
analytics, and
124GAO, COVID-19 in Nursing Homes: Experts Identified Actions Aimed at Improving
Infection Prevention and Control, GAO-23-105613 (Washington, D.C.: Mar. 20, 2023).
125GAO-23-105331.
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
•
continue taking steps to identify external data sources that could aid in
fraud prevention and detection and develop a plan to obtain access to
those data sources.
Further, Congress may wish to consider enacting automatic increases in
federal Medicaid spending during economic downturns based on each
state’s increased employment and decreased revenues. Implementing
this automatic, temporary change would increase federal Medicaid
support in a more timely and targeted fashion.
Lessons Learned on Implementing Program Flexibilities
Implementing flexibilities—such as telehealth and telework—during a public health emergency can
help federal agencies
•
deliver services to program beneficiaries,
•
maintain activities to support critical operations, and
•
promote the safety of workers and the public.
We have recommended that federal agencies examine the extent to which flexibilities utilized during
the COVID-19 pandemic could be incorporated in standard operations or used during future
emergencies. For example, we recommended that the Food and Drug Administration fully assess
whether and how alternative inspection tools could help meet drug oversight objectives when in-
person inspections are not possible in the future.
Source: GAO (text); Kinder/stock.adobe.com (icons). | GAO-24-107175
Implementing program flexibilities. Implementing program flexibilities
helped some federal agencies—such as CMS, FDA, and DOD—provide
services to program beneficiaries, maintain operations to carry out their
missions, and promote the safety of workers and the public during the
COVID-19 pandemic. For example:
•
Telehealth services played a critical role in maintaining Medicaid
beneficiaries’ access to health care during the COVID-19 pandemic.
While states had the flexibility to cover telehealth services prior to the
pandemic, we reported in March 2022 that, in the five states we
reviewed, the number of beneficiaries receiving telehealth services
and the number of services provided via telehealth increased
exponentially within the first 12 months of the pandemic.126 Expanding
126GAO, Medicaid: CMS Should Assess Effect of Increased Telehealth Use on
Beneficiaries’ Quality of Care, GAO-22-104700 (Washington, D.C.: Mar. 31, 2022).
Implementing Program
Flexibilities
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
the use of telehealth during the pandemic helped to mitigate
pandemic-specific obstacles to receiving care while reducing patients’
risk of exposure to COVID-19, according to Medicaid officials in six
states we reviewed. During this time, a variety of modalities were
used by state Medicaid programs to deliver health care services via
telehealth, as shown in figure 5.
Figure 5: Types of Medicaid Telehealth Modalities
•
During the COVID-19 pandemic, FDA largely paused on-site drug
inspections and instead relied on alternative tools to help it carry out
its mission of ensuring the safety and quality of drugs. Specifically, the
agency utilized its various alternative inspection tools, including
inspections conducted by foreign regulators, review of records and
other information, drug sampling and testing, and remote interactive
evaluation involving teleconferences, livestream video, and screen
sharing of data and documents.127 In January 2021, we reported that
the agency used its alternative tools to identify and take some
127GAO, Drug Safety: FDA Should Take Additional Steps to Improve Its Foreign
Inspection Program, GAO-22-103611 (Washington, D.C.: Jan. 7, 2022).
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
regulatory actions against manufacturing establishments with
deficiencies.128
•
DOD utilized and implemented various flexibilities as part of its efforts
to promote the health of service members during the COVID-19
pandemic while continuing operations. In our June 2021 report, we
found that DOD encouraged maximizing telework to the extent
practicable to reduce service members’ risk of exposure.129 Further,
we found that DOD utilized telehealth services to promote safety while
ensuring service members’ access to health care services. For
instance, in February 2022, we reported that telehealth was a
valuable tool in providing mental health care during the COVID-19
pandemic, according to DOD officials and military service officials.130
Key open recommendations. Our COVID-19 oversight work found that
implementing program flexibilities helped some federal agencies continue
providing services and maintain oversight activities during the pandemic.
Such flexibilities also enhanced their ability to protect the safety of
workers and the public by minimizing their risk of being exposed to
COVID-19.
We have recommended that federal agencies examine flexibilities utilized
during the pandemic to determine whether they can be incorporated into
standard operations or utilized during future emergencies. While agencies
have taken steps to address some of these recommendations, additional
actions could help agencies better understand flexibilities utilized during
the pandemic. For example:
•
CMS should comprehensively assess the quality of Medicare
services, including audio-only services, delivered using telehealth
during the public health emergency. Such an assessment could
include leveraging evidence from related efforts led by other HHS
agencies.
•
FDA should fully assess the agency’s alternative inspection tools and
consider whether these tools or others could provide the information
needed to supplement regular inspection activities or help meet its
128GAO-21-265.
129GAO, COVID-19: DOD Has Focused on Strategy and Oversight to Protect Military
Servicemember Health, GAO-21-321 (Washington, D.C.: June 3, 2021).
130GAO, Defense Health Care: DOD Expanded Telehealth for Mental Health Care during
the COVID-19 Pandemic, GAO-22-105149 (Washington, D.C.: Feb. 3, 2022).
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drug oversight objectives when inspections are not possible, for
instance, during a future public health emergency.
Throughout the COVID-19 pandemic, federal agencies implemented
COVID-19 relief programs; partnered with other federal agencies and
private entities to develop and administer vaccines; and conducted a
range of other actions to help the nation respond to and recover from the
pandemic. We have made hundreds of recommendations to federal
agencies and over 20 matters for congressional consideration to improve
implementation, oversight, and transparency of the federal response.
Across the federal government, agencies can help the nation prepare for,
respond to, and recovery from future public health emergencies by taking
steps to implement our recommendations that remain open.
Reflecting on federal agencies’ emergency response actions and our
recommendations can reveal lessons from the COVID-19 pandemic for
federal agencies. These lessons can help federal agencies identify
actions that successfully facilitated the implementation of the federal
response and should be incorporated into future emergency response
plans. Other lessons can help federal agencies identify weaknesses in
their response to the pandemic and identify areas for improvement. As
the nation continues to recover from the pandemic and identifies and
responds to new COVID-19 variants, we will continue to identify lessons
learned. Incorporating these lessons can further enhance agencies’
preparedness for future emergencies.
Without including lessons learned in response plans, federal agencies
could miss opportunities to improve their ability to plan for, respond to,
and recover from emergencies. For example, Treasury has begun
compiling resources, including the policies and procedures from its
COVID-19 aviation assistance programs, to prepare for future financial
disasters. However, we found that Treasury has not incorporated lessons
from the COVID-19 emergency financial assistance provided to the
aviation industry, including lessons we identified and those identified by
other auditing entities, into its efforts. By doing so, Treasury can facilitate
timely decisions to quickly implement programs, such as direct lending
programs, in response to future financial disasters and potentially reduce
program risks, such as the possibility of errors and omissions.
The Secretary of the Treasury should include key lessons from the
COVID-19 emergency financial assistance provided to the aviation
industry, including those lessons identified by GAO and other auditing
Conclusions
Recommendation
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
entities, in the department’s ongoing efforts to compile resources to
prepare for future financial disasters. (Recommendation 1)
We provided the relevant draft sections of this report to Treasury and
DOT for review and comment. A senior counsel with the Department of
the Treasury stated via email that Treasury agrees with our
recommendation and will take steps to implement it. Treasury also
provided technical comments, which we incorporated as appropriate.
DOT did not have any comments on the relevant draft report sections.
We are sending copies of this report to the appropriate congressional
committees, the Office of Management and Budget, and certain executive
branch agencies. In addition, this report is available online at no charge
on the GAO website at https://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at 202-512-7144 or farbj@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report. GAO staff who made key contributions to this report are
listed in appendix II.
Jessica Farb
Managing Director, Health Care
Agency Comments
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
List of Congressional Committees
The Honorable Patty Murray
Chair
The Honorable Susan Collins
Vice Chair
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Bernard Sanders
Chair
The Honorable Bill Cassidy, M.D.
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rand Paul, M.D.
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Tom Cole
Chairman
The Honorable Rosa L. DeLauro
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
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The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable James Comer
Chairman
The Honorable Jamie Raskin
Ranking Member
Committee on Oversight and Accountability
House of Representatives
The Honorable Jason Smith
Chairman
The Honorable Richard Neal
Ranking Member
Committee on Ways and Means
House of Representatives
Appendix I: Matters for Congressional
Consideration to Improve the Transparency
and Accountability of Emergency Relief Funds
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GAO-24-107175 COVID-19 Lessons for Federal Agencies
During emergencies, federal agencies must get relief funds out quickly
while ensuring appropriate financial safeguards are in place. We found
early in the COVID-19 pandemic that agencies gave priority to swiftly
distributing funds and implementing new programs. However, tradeoffs
were made that limited progress in achieving transparency and
accountability goals. Specifically, we found significant shortcomings in the
application of fundamental internal controls and financial and fraud risk
management practices. As a result, billions of dollars were at risk for
improper payments, including those from fraud, providing limited
assurance that programs effectively met their objectives. To help address
these shortcomings, we have made the following 10 matters for
congressional consideration to enhance the transparency and
accountability of federal spending.1
•
Congress should pass legislation requiring the Office of Management
and Budget (OMB) to provide guidance for agencies to develop plans
for internal control that would then immediately be ready for use in, or
adaptation for, future emergencies or crises and requiring agencies to
report these internal control plans to OMB and Congress. (Matter for
Congressional Consideration 1)
•
Congress should amend the Payment Integrity Information Act of
2019 to designate all new federal programs making more than $100
million in payments in any one fiscal year as “susceptible to significant
improper payments” for their initial years of operation. (Matter for
Congressional Consideration 2)
•
Congress should amend the Payment Integrity Information Act of
2019 to reinstate the requirement that agencies report on their
antifraud controls and fraud risk management efforts in their annual
financial reports. (Matter for Congressional Consideration 3)
•
Congress should establish a permanent analytics center of excellence
to aid the oversight community in identifying improper payments and
fraud. (Matter for Congressional Consideration 4)
•
Congress should clarify that (1) chief financial officers (CFO) at CFO
Act agencies have oversight responsibility for internal controls over
financial reporting and key financial management information that
includes spending data and improper payment information; and (2)
executive agency internal control assessment, reporting, and audit
requirements for key financial management information, discussed in
an existing matter for congressional consideration in our August 2020
1GAO-22-105715.
Appendix I: Matters for Congressional
Consideration to Improve the Transparency
and Accountability of Emergency Relief
Funds
Appendix I: Matters for Congressional
Consideration to Improve the Transparency
and Accountability of Emergency Relief Funds
Page 67
GAO-24-107175 COVID-19 Lessons for Federal Agencies
report, include internal controls over spending data and improper
payment information. (Matter for Congressional Consideration 5)
•
Congress should require agency CFOs to (1) submit a statement in
agencies’ annual financial reports certifying the reliability of improper
payments risk assessments and the validity of improper payment
estimates, and describing the actions of the CFO to monitor the
development and implementation of any corrective action plans; and
(2) approve any methodology that is not designed to produce a
statistically valid estimate. (Matter for Congressional Consideration 6)
•
Congress should consider legislation to require improper payment
information required to be reported under the Payment Integrity
Information Act of 2019 to be included in agencies’ annual financial
reports. (Matter for Congressional Consideration 7)
•
Congress should amend the DATA Act to extend the previous
requirement for agency inspectors general to review the
completeness, timeliness, quality, and accuracy of their respective
agency data submissions on a periodic basis. (Matter for
Congressional Consideration 8)
•
Congress should amend the DATA Act to clarify the responsibilities
and authorities of OMB and Department of the Treasury for ensuring
the quality of data available on USAspending.gov. (Matter for
Congressional Consideration 9)
•
Congress should amend the Social Security Act to accelerate and
make permanent the requirement for the Social Security
Administration to share its full death data with the Department of the
Treasury’s Do Not Pay working system. (Matter for Congressional
Consideration 10)
As of April 2024, all 10 of these matters for congressional consideration
remain open; however, Congress has taken some steps to address some
of them. For example, the Enhancing Improper Payment Accountability
Act (H.R. 8343), which was introduced and referred to the House
Committees on the Budget and on Oversight and Accountability on May
10, 2024, and reported out of the Committee on the Budget on May 16,
2024, includes provisions that would reinstate the requirement for
agencies to report on their antifraud controls and fraud risk management
efforts in their annual financial report. However, as of July 2024, a full
vote in the House of Representatives has yet to be scheduled.
Appendix II: GAO Contact and Staff
Acknowledgments
Page 68
GAO-24-107175 COVID-19 Lessons for Federal Agencies
Jessica Farb, 202-512-7114 or farbj@gao.gov
In addition to the contacts named above, Raymond Sendejas (Assistant
Director), Kristin Ekelund (Analyst-in-Charge), Sonia Chakrabarty, Derry
Henrick, Ying Hu, and David Jones made key contributions to this report.
Appendix II: GAO Contact and Staff
Acknowledgments
GAO contact
Staff
Acknowledgments:
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