MEMORANDUM October 9, 2014

Subject: Funding History for Public Health and Hospital Preparedness Grants to States
From: Sarah A. Lister, Specialist in Public Health and Epidemiology, 7-7320
This memorandum was prepared to enable distribution to more than one congressional office.

This memorandum presents funding information for two grant programs administered by agencies in the
Department of Health and Human Services (HHS) to bolster the readiness of states and localities to
respond to public health emergencies such as natural disasters, disease outbreaks, and bioterrorism. These
are the Public Health Emergency Preparedness (PHEP) cooperative agreement and the Hospital
Preparedness Program (HPP) cooperative agreement. These two grant programs were established
administratively by HHS and funded through supplemental appropriations in the winter of 2001-2002.
They were subsequently explicitly authorized.
1
Please contact me with any questions.
Public Health Emergency Preparedness (PHEP) Cooperative Agreement
From FY2002 through FY2014, Congress provided more than $10 billion in cooperative agreement funds
to states and territories to strengthen public health system capacity for the response to public health
threats
2
(see Figure 1). Nominal annual funding decreased about 29% from its highest level, $940 million
for FY2002, to $663 million for FY2014.
3

The Public Health Emergency Preparedness (PHEP) cooperative agreement is administered by the HHS
Centers for Disease Control and Prevention (CDC).
4
Funding is provided according to a statutory formula
to 62 grantees, comprising all 50 states, 8 territories and freely associated states, and 4 major cities: the
District of Columbia, New York City, Los Angeles County, and Chicago.
5
Congress established the
statutory formula to fund all states following the 2001 terrorist attacks. Prior to that, smaller amounts of
1
See CRS Report RL31263, Public Health Security and Bioterrorism Preparedness and Response Act (P.L. 107-188):
Provisions and Changes to Preexisting Law, by C. Stephen Redhead, Donna U. Vogt, and Mary Tiemann. See also CRS Report
RL33589, The Pandemic and All-Hazards Preparedness Act (P.L. 109-417): Provisions and Changes to Preexisting Law, by
Sarah A. Lister and Frank Gottron.
2
A cooperative agreement is defined by the Centers for Disease Control and Prevention (CDC) as an award of financial
assistance that is used to enter into the same kind of relationship as a grant; and is distinguished froma grant in that it provides
for substantial involvement between the Federal agency and the recipient in carrying out the activity contemplated by the award.
CDC Glossary, http://www.cdc.gov/od/pgo/funding/grants/glossary.shtm#gloss_c.
3
As described in the notes for Figure 1, the percentage change is approximate because the FY2002 and FY2014 amounts are not
strictly comparable.
4
See CDC, http://www.cdc.gov/phpr/coopagreement.htm.
5
Public Health Service Act, 319C-1 [42 U.S.C. 247d3a].


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funding (e.g., $66.7 million in total for FY2001
6
) were awarded to some states each year on a competitive
basis.
The PHEP cooperative agreement program has been challenging for federal managers and state awardees
alike. It has been helpful in expanding technical capacity, such as laboratory and information technology
infrastructure; it has been less successful in ensuring a stable, competent workforce for public health
emergency management.
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State and local health departments have had some difficulty staffing their
preparedness programs. They cite public health workforce shortages and the challenge of recruiting with
annual discretionary or soft funding, a challenge exacerbated by the recent recession.
8
In addition,
federal managers have had difficulty developing meaningful and measurable performance goals for the
program.
9
Finally, PHEP funding supports preparedness activities. It is not intended to serve as a source
of funds for response efforts once an incident occurs.
Figure 1. Funding History for Public Health Emergency Preparedness (PHEP) State Grants

Sources: Compiled by CRS from annual CDC congressional budget justifications, http://dhhs.gov/asfr/ob/docbudget/, and
text of the public laws presented.
Notes: Amounts include funds for Advanced Practice Centers and Centers for Public Health Preparedness, when funded;
amounts do not include supplemental appropriations for smallpox vaccination (FY2003) or pandemic influenza (FY2006
and FY2009). Amounts for FY2012 through the FY2015 request are adjusted to reflect implementation of the CDC
Working Capital Fund (WCF), a revolving fund that pays for centralized agency services. Funds formerly provided to
CDCs Cross-cutting Activities account are now distributed among program accounts, which then transfer funds to the
6
CDC, Justification of Estimates for Appropriations Committees, FY2003, p. 229.
7
See for example CDC, 2013-2014 National Snapshot of Public Health Preparedness, 2014, http://www.cdc.gov/phpr/pubs-
links/2013/download.html; and Trust for Americas Health, Outbreaks: Protecting Americans from Infectious Diseases,
December 2013, p. 15ff., http://healthyamericans.org/reports/outbreaks2013/.
8
See for example National Association of County and City Health Officials (NACCHO), Local Health Department J ob Losses
and ProgramCuts: Findings from the 2013 Profile Study, research brief, J uly 2013, http://www.naccho.org/topics/infrastructure/
lhdbudget/.
9
See for example GAO, National Preparedness: Improvements Needed for Measuring Awardee Performance in Meeting
Medical and Public Health Preparedness Goals, GAO-13-278, March 2013, www.gao.gov/assets/660/653259.pdf.


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WCF for services used. The adjustment has the effect of increasing program account levels. As a result, amounts for
FY2012 and later years are not comparable to amounts for FY2011 and earlier years. CDC, http://www.cdc.gov/fmo/topic/wcf/
index.html. The amount for FY2013 reflects sequestration as required under the Budget Control Act (BCA, P.L. 112-25).
BT Act is the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, P.L. 107-188. PAHPA is the
Pandemic and All-Hazards Preparedness Act, P.L. 109-417. PAHPRA is the Pandemic and All-Hazards Preparedness
Reauthorization Act of 2013, P.L. 113-5. PB is Presidents budget request.
PAHPRA authorizes the appropriation of $642 million for each of FY2014 through FY2018. The two earlier laws
authorized the specified amounts for one fiscal year, as shown, and such sums as may be necessary for each of several
subsequent fiscal years.
Hospital Preparedness Program (HPP) Cooperative Agreement
The Hospital Preparedness Program (HPP) has provided more than $5 billion in cooperative agreement
funds to state and territorial governments from FY2002 through FY2014, to work with private healthcare
facilities and systems in ensuring regional surge capacity in the event of a mass casualty incident
10
(see
Figure 2). Nominal annual funding peaked at $515 million for FY2003, and has since decreased about
50% from that level, to $255 million for FY2014.
The HPP is currently run by the HHS Assistant Secretary for Preparedness and Response (ASPR).
Congress first authorized and funded the HPP in 2002, establishing a statutory formula that provides HPP
awards to the same 62 grantees that receive CDC PHEP cooperative agreement awards.
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Figure 2. Funding History for Hospital Preparedness Program (HPP) State Grants

Sources: Compiled by CRS from HHS annual Budget in Brief and congressional budget justification documents,
http://dhhs.gov/asfr/ob/docbudget/.
Notes: Amounts include funds for the Emergency System for Advance Registration of Health Professionals (ESAR-VHP).
BT Act is the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, P.L. 107-188. PAHPA is the
10
HHS, ASPR, Hospital Preparedness Program, http://www.phe.gov/preparedness/planning/hpp/pages/default.aspx. (Select
Cancel in the dialog box to proceed to the website.)
11
Public Health Service Act, 319C-2 [42 U.S.C. 247d3b].


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Pandemic and All-Hazards Preparedness Act, P.L. 109-417. PAHPRA is the Pandemic and All-Hazards Preparedness
Reauthorization Act of 2013, P.L. 113-5. PB is Presidents budget request.
PAHPRA authorizes the appropriation of $375 million for the HPP for each of FY2014 through FY2018. The two earlier
laws authorized the specified amounts for one fiscal year, as shown, and such sums as may be necessary for each of
several subsequent fiscal years.
The amount for FY2013 reflects sequestration as required under the Budget Control Act (BCA, P.L. 112-25).
The HPP has helped, among other things, to improve emergency communication and coordination among
hospitals, and between hospitals and health officials, facilitating such activities as tracking of evacuated
patients and available hospital beds.
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Nonetheless, the economics of the healthcare market push hospitals
toward leanness and efficiency, and away from the redundancies and reserve capacity that a health system
needs in order to surge for a mass casualty incident.
13
As with the CDC PHEP cooperative agreements,
developing performance metrics for the HPP grants has been a challenge.
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12
See for example HHS, ASPR, HPP in Action: Stories fromthe Field, http://www.phe.gov/Preparedness/planning/hpp/events/
Pages/default.aspx. (Select Cancel in the dialog box to proceed to the website.)
13
See for example GAO, National Preparedness: Improvements Needed for Measuring Awardee Performance in Meeting
Medical and Public Health Preparedness Goals, GAO-13-278, March 2013, p. 40 ff., www.gao.gov/assets/660/653259.pdf.
14
Ibid. See also Eileen Salinsky, Strong as the Weakest Link: Medical Response to a Catastrophic Event, National Health Policy
Forum, Background Paper No. 65, Washington, DC, August 8, 2008, http://www.nhpf.org/library/details.cfm/2640; and Institute
of Medicine, Medical Surge Capacity: Workshop Summary, Washington, DC, 2010, http://www.iom.edu/Reports/2010/Medical-
Surge-Capacity-Workshop-Summary.aspx.