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Positioning America’s Public Health System for the Next Pandemic

The COVID-19 pandemic has made clear that the nation’s safety, health, and economic prosperity are dependent on a robust public health system. Federal public health agencies and state and local public health departments have long been severely underfunded. They have lacked the workforce and modern data systems to support surveillance, contact tracing, testing, guidance on mitigation measures, administration of vaccines, and clear communication that is needed to stop infectious diseases from spreading across the country. In the beginning of the current pandemic, the federal government did not provide effective testing kits or clear and timely guidance to states, localities, tribes, and territories on COVID-19 mitigation measures, resulting in a delayed and fragmented national response. In addition, many Americans have chronic underlying health conditions such as obesity and heart disease, leaving them more likely to develop severe illness from the virus that causes COVID-19. Public health agencies and departments lack the resources to support prevention programs that might have reduced the prevalence of these conditions. Further, there are long-standing racial and socioeconomic inequities with respect to health and health care access.

Had these shortcomings not existed, the United States death toll might have been smaller. It is also true that if vaccine development had been delayed further, the death toll would have been higher. As of the end of May 2021, the U.S. has the highest mortality numbers in the world, with more than 592,000 deaths from COVID-19.1 Communities of color disproportionately represent these deaths. Tens of thousands more Americans are living with the persistent and debilitating symptoms from COVID-19, including brain fog, headaches, and shortness of breath.

Halfway into 2021, the United States is on better footing. There has been a whole-of-government response to the pandemic along with clearer federal guidance issued to public health departments. Congress has appropriated additional resources to the public health sector, which is engaged in a historic national vaccination effort. As of the end of May, more than half of adults received at least one dose of a COVID-19 vaccine and deaths are at the lowest level in 11 months. The economy is recovering, and Americans are expecting a return to a more normal life.

But even as the pandemic is easing, the United States must prepare for possible additional waves of disease from this pandemic, potentially caused by new virus variants, as well as plan for future public health emergencies. The nation remains vulnerable to myriad threats, including from another dangerous infectious disease, a widespread natural disaster, or a potential bioterrorist attack, each of which could impact almost every sector of the economy, disrupt social connections, and have significant long-lasting health impacts. Equipping the public health system with an adequate and prepared workforce, data systems, and medical countermeasures will enable the country to better withstand not only a pandemic, but any number of other public health emergencies.

Shoring up the system will take years of consistent effort by public health officials and policymakers. In the past 20 years, the nation has responded to every public health crisis with temporary funding measures that have not provided state and local public health departments with the people and the information technology tools needed to build enduring programs which address Americans’ poor health and adequately prepare for a future emergency. This moment must be different. There is heightened appreciation for the critical role of public health. A May 2021 survey from the Harvard Opinion Research Program and the Robert Wood Johnson Foundation found that over 70% of adults “favor substantially increasing federal spending on improving the nation’s public health programs,” and the same proportion believe public health agency activities are very or extremely important to the nation’s health.2

Since August 2020, the Bipartisan Policy Center’s Future of Health Care Initiative leaders have been developing and supporting recommendations to improve the resilience of the nation’s health care and public health systems to address the threat of COVID-19 and beyond. In January 2021, the Future of Health Care leaders released a report outlining high-priority immediate actions that the administration and Congress should take in combating COVID-19. In this report, the leaders have developed additional recommendations to ensure that the public health system, specifically, not only continues to respond to COVID-19, but that it is well-prepared to respond to and mitigate the consequences of a future pandemic.

Our recommendations focus on three areas: 1) creating clarity and accountability in federal leadership and operations during a pandemic; 2) improving public health information technology and data systems; and 3) committing the United States to more and consistent funding of public health to prepare for inevitable public health crises.

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There are 10 overarching recommendations in this report:

  1. Clarify and strengthen federal operational roles and responsibilities during a federal response to a pandemic.

    To improve the nation’s federal response to emergency events such as a pandemic, the White House and Congress should clearly define roles, responsibilities, and authorities for all relevant governmental entities. Because only the White House has the authority to direct federal departments to work with one another and coordinate their efforts, the president should appoint a White House Deputy National Security Advisor for Pandemic and Biothreats Preparedness to provide leadership to prepare and respond to national public health emergencies and conduct joint pandemic planning efforts including exercises to refine roles and responsibilities. White House leadership and coordination of agency preparedness should be supplemented by congressional evaluations of roles and responsibilities to ensure federal entities have the necessary authorities and resources to execute emergency pandemic response efforts.

  2. Incentivize states to participate in a coordinated response to national public health threats.

    The patchwork of state responses to COVID-19 raises salient concerns about barriers to a coordinated national response during public health emergencies. States and localities have the flexibility to appropriately tailor public health activities to their community needs. However, it is still vital for states and localities to follow federal evidence-based guidelines for disease mitigation during a pandemic. Congress and the executive branch should create incentives to encourage states and localities to follow these guidelines and best practices. These incentives could involve additional financial resources beyond core funding, such as providing supplemental public health funds, to enhance a state’s pandemic response.

  3. Establish a National Board on Pandemic Preparedness to provide oversight and ensure the United States is equipped to respond to future public health threat.

    There is no congressionally chartered oversight mechanism for evaluating the state of America’s pandemic preparedness system, which is reliant on the capacity, capabilities, and coordination of federal, state, and local agencies. This lack of oversight leaves the nation vulnerable to a suboptimal response to public health emergencies and future pandemics. To ensure the United States is equipped to respond, Congress should create an independent National Board on Pandemic Preparedness that will establish a set of metrics and benchmarks for evaluation of federal and state pandemic preparedness capacity and capability; gauge how the nation is faring against these metrics; and develop an annual report to Congress on the state of pandemic preparedness with specific recommendations. The Board will be supported by independent career staff in a new Office of Pandemic Preparedness located in the executive branch.

  4. Establish federal data collection and reporting standards to improve consistent collection of core public health data across data systems, with a prioritized focus on race and ethnicity data.

    The Office of the National Coordinator for Health Information Technology (ONC) recently established a Public Health Data Systems Task Force that should consider defining a “core public health dataset,” developing additional standards for data collection, and developing a plan for implementing those standards, including linking them to funding mechanisms. Core public health data should include information for public health surveillance and response, such as demographic information, electronic laboratory data, travel health data, genomic sequencing data, and electronic vital records data. The health disparities in the COVID-19 pandemic have revealed the urgent need to set standards around race, ethnicity, and other demographic data, and should be treated as a priority. To ensure accountability, Congress should require the Department of Health and Human Services (HHS) to submit a report on current streams of funding, activities, and program requirements related to data collection and standardization.

  5. Improve data sharing and interoperability by establishing integrated platforms for detection and surveillance of public health threats, clarifying privacy standards during public health emergencies, and encouraging data exchange between clinical and public health organizations.

    The U.S. public health system relies on an outdated, patchwork data system that does not allow data to flow freely between public health, clinical and other entities. To improve early detection of public health threats, the CDC should establish an integrated infectious disease surveillance system that would strengthen surveillance efforts currently conducted by multiple data systems and agencies. This system could be modeled like the CDC’s existing influenza surveillance system and be expanded to detect other novel pathogens. To improve situational awareness during public health emergencies, Congress should direct the HHS secretary to ask the National Academy of Medicine (NAM) to propose a design for a national interoperable data platform to improve access to health data and other relevant data needs during ongoing public health emergencies. Considering the volume and type of data sharing required during public health emergencies, patient privacy and security must be prioritized. Finally, as the United States updates electronic health record (EHR) standards, a priority should be made to include public health data, and to facilitate data sharing between health systems and public health officials.

  6. Build upon data collection and sharing efforts during COVID-19 to strengthen vaccination data systems for use during future infectious disease pandemics.

    The CDC recently issued guidance that fully vaccinated individuals can resume certain activities, but—despite demand from private businesses—there is not currently a reliable system in place to identify who has been fully vaccinated. Several private companies are working on platforms that an individual could use to digitally access their vaccination information. The federal government has a key role to play in promoting the development of a vaccination credential system by ensuring that credentials protect privacy and are synchronized, secure, and high quality. In addition, HHS should build on technology it is using to collect states’ COVID-19 immunization tracking data to inform national response efforts and improve interoperability between states and enhance states’ collection of demographic data, such as race and ethnicity.

  7. Assess existing federal funding of pandemic preparedness and response activities for opportunities to increase coordination and efficiency and improve equity. For programs deemed highest priority to prevent, detect, and address infectious disease threats, create a permanent budget designation named Biodefense Interagency Operations outside annual 302(a) allocations, and should they be established by future legislation, outside overall budget limitations.

    Congress should form a Joint Select Committee including members representing the relevant authorizing and appropriating committees to evaluate existing federal funding, identify mission-critical investments, and produce legislative recommendations with stakeholder feedback on how interagency funding can be better coordinated and optimized. Those programs deemed mission critical would receive a Biodefense Interagency Operations (BIO) exemption, allowing them to be exempt from budget caps, including any future discretionary spending limits set after the expiration of Budget Control Act of 2011 limits in fiscal year 2021, and federal departments and agencies should be allowed to independently request the BIO exemption for their programs to ensure the country remains vigilant and primed for pandemic threats.

  8. Allocate funding to the Public Health Emergency Fund for use immediately following a Public Health Emergency declaration and use it as the primary vehicle for supplemental appropriations funding.

    To enable the federal government to rapidly deploy funding as a stopgap measure in a public health emergency until Congress can pass emergency supplemental appropriations, Congress should add funding to the Public Health Emergency Fund and consider passing future supplemental appropriations through the fund in future emergencies. When the pandemic began, there were zero dollars in the fund, requiring the HHS secretary to draw upon the transfer of funds from other executive programs to pay for emergency response, arguably adding to the initially disorganized response to COVID-19.

  9. Allocate $4.5 billion in permanent annual mandatory funding to a new Public Health Infrastructure Account to support state, local, tribal, and territorial foundational public health capabilities.

    To enable state and local health departments to develop the minimal, cross-cutting capabilities that are needed to support their delivery of public health programs, the federal government should build on investments made by the administration through the American Rescue Plan. Congressional appropriations committees would still appropriate this money annually, but the money would not be subject to Committee 302(b) allocations. The HHS secretary would award the appropriated money in grants to accredited jurisdictions based on population size, level of health disparities, level of health risk and chronic disease burden in the community, and public health governance structure to bolster foundational public health programs. Part of the funding would be tied to the set of metrics and benchmarks created by the National Board on Pandemic Preparedness for evaluation of federal, state, and local pandemic preparedness capacity and capability

  10. Reform and increase annual funding to the existing Prevention and Public Health Fund from its current level of about $900 million to $4 billion to bolster inadequately supported public health programs and meet local needs.

    Congress should direct funds from the Prevention and Public Health Fund, created under the Affordable Care Act, to state and local health departments to support public health programs, and the Preventive Health and Health Services Block Grants that gives health departments “the flexibility to solve problems
    unique to their residents, while still being held accountable for demonstrating the local, state and national impact of the investments.” Public health programs include chronic disease prevention and communicable disease control programs
    that aim to improve community health.3 Statutory language should be added to the law to prevent Congress from using the Prevention Fund to offset other activities as Congress has done since 2014. Research shows investment
    in prevention reduces long-term illnesses in a population. With a healthier population, the United States will be less vulnerable to an infectious disease outbreak, and individuals will live longer with a higher quality of life. The $7.6 billion called for in Recommendation Nos. 9 and 10 would be funded by a public health excise tax.

End Notes:

1 Johns Hopkins University & Medicine Coronavirus Resource Center, “COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University,” May 21, 2021. Available at: https://coronavirus.jhu.edu/map.html.
2 Robert Wood Johnson Foundation, “Poll: Public Supports Substantial Increase in Spending on U.S. Public Health Programs, But Has Serious Concerns About How the System Functions Now,” May 13, 2021. Available at: https://www.rwjf.org/en/library/articles-and-news/2021/05/poll-public-supports-substantial-increase-in-spending-on-uspublic-health-programs.html?cid=xrs_rss-nr
3 Public Health National Centers for Innovations, Foundational Public Health Services Factsheet, November 2018. Available at: https://phnci.org/uploads/resource-files/FPHSFactsheet-November-2018.pdf.

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