Dollars for disaster readiness, bioterrorism tricky to spend

OIG audits find unspent money and trigger calls for more oversight. States respond that problems result from growing pains.

By Victoria Stagg Elliott — Posted Jan. 2, 2006

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Victor Freeman, MD, an internist and past president of the Medical Society of the District of Columbia, is frustrated with the local efforts regarding bioterrorism and disaster preparedness. He knows that physicians are a key element of any such response plan, but the local public health department has proven so difficult to work with that he and other MSDC members have considered disbanding their emergency preparedness committee.

"We're quite disappointed, almost to the point of being demoralized," said Dr. Freeman.

His frustration results from an emerging reality that, despite increased federal support for shoring up public health readiness, this money has not always been easy to spend.

According to a series of eight reports issued in the past year by the Dept. of Health and Human Services Office of Inspector General, a significant portion of the billions of dollars directed to the public health system since the 2001 terrorist attacks was unspent as of August 2004.

More OIG reports analyzing how states used money from the Centers for Disease Control and Prevention and from the Health Resources and Services Administration for disease surveillance, laboratory capacity, and upgrades to hospitals' disaster response ability are expected in the coming months.

For now, though, what is clear is that each state along with the District of Columbia has its own unique set of issues in utilizing these newfound riches and most feel the hurdles faced thus far are a result of the difficulties that come with rapid growth. CDC preparedness funding, for example, was $40 million in 1999 but jumped to $982 million in 2002.

"The OIG is looking at a very new program, and it certainly takes some time to get a new program up and running," said Georges Benjamin, MD, executive director of the American Public Health Assn. "And there have been some barriers to being able to spend these dollars."

This circumstance has meant that, although the money to rebuild the public health infrastructure has been much welcomed, it hasn't always been easy to rapidly determine how to use it. One report found that, as of August 2004, Massachusetts had failed to utilize 65% of the money it received from HRSA, but this was blamed on efforts to establish a coordinated regional system. Much of this money was expected to be spent by the end of 2005.

According to two of the reports, as of August 2004, 48% of CDC funds in the District of Columbia had not been spent; just over 46% of HRSA money hadn't been used either. These cash balances were blamed on the District's complex bureaucracy that is linked to the federal budget.

"Spending money in D.C. is really tough," said Dr. Benjamin, who was the District's health officer from 1990 to 1991. "It's a challenge being in the nation's capital, and it's a little different planning process. There are regional issues to consider, and there's a complexity that doesn't exist in other places."

Work-force issues

For many jurisdictions, it also hasn't been easy to hire staff to spend this money. Public health departments in states with budget problems have been strapped by hiring freezes. Those that have been allowed to hire new staff have found that it isn't always easy to find the right people, particularly when most public health departments are unable to provide salaries that can compete with the private sector. Additionally, public health advocates have long expressed concerns about work-force availability, with lab staff and epidemiologists being in particularly short supply.

"We are in many cases cannibalizing ourselves by hiring good people from other public health areas," said Steve Cline, DDS, MPH, chief of epidemiology at the North Carolina Dept. of Health and Human Services and the principal investigator for CDC and HRSA grants in his state. "There's a lot of turnover. It's a real problem."

Public health officials also say that leftover money is not necessarily a sign that they don't know what to do with it. It may be a sign of efficiency.

In North Carolina, the OIG found that the state had either spent or committed all of its bioterrorism budget for 2004, though that may not be the case for 2005, when the budget included money for laboratory information management and electronic disease reporting systems. Both cost less than expected.

Officials are also unconcerned that they may lose the money they have been given. So far both the CDC and HRSA have allowed states to carry forward leftover money, and most state officials intend to spend the money, if they haven't already.

"In the end we have not lost any money. It's about when it gets spent, and we have spent more of the total available each year," said Steve Wagner, MPH, assistant chief for preparedness at the Ohio Dept. of Health. The OIG found that, as of the end of August 2004, 15% of Ohio's HRSA and CDC funds were still unspent.

Officials say, however, that spending has become easier as programs mature. There is also great variability from state to state, and overall states have spent just over 87% of the money allocated, according to a survey by the Assn. of State and Territorial Health Officials.

"This is a young program, but we see big improvements in how states spend this money," said Alison Johnson, director of the CDC's Division of State and Local Readiness.

The biggest concern of public health advocates, though, is that any evidence of unspent funds may be interpreted as a sign that the resources are not needed. Both CDC and HRSA faced cuts in the proposed 2006 federal budget, which was still being finalized in Congress at press time.

"Because a state has not spent what was allotted is not a reason to not continue to fund states for this kind of work," said James J. James, MD, DrPH, MHA, director of the American Medical Association's Center for Disaster Preparedness and Emergency Response.

Back to top


Low marks are given for being ready

The public health system has improved its ability to respond to naturally occurring and deliberately initiated disasters but still does not have adequate infrastructure to respond to a serious incident, according to the third annual report on the topic issued last month by Trust for America's Health, a Washington, D.C.-based public health advocacy organization.

"The health community has worked tirelessly since 9/11 to make improvements, but serious vulnerabilities still remain," said TFAH Executive Director Shelley A. Hearne, DrPH. "While there is no way to be 100% prepared, there are still basic achievable levels ... we have yet to meet."

The report gave the federal government a D-plus for its overall preparedness efforts but a C-plus for the Strategic National Stockpile.

At the state level, the report found that nearly half of states do not use national standards to track disease outbreak information. Only one quarter had sufficient bioterrorism laboratory response capabilities. And only two states had plans to encourage physicians and health care workers to continue to provide care during a crisis.

The organization is calling for a single official within the Dept. of Health and Human Services to be responsible for disaster preparedness efforts. TFAH is also seeking development of standardized performance measures to assess readiness and consideration of the general public as a significant partner in the planning process.

Back to top

External links

Office of Inspector General audit reports on Centers for Disease Control and Prevention funding (link)

OIG audit reports on Health Resources and Services Administration funding (link)

AMA's Center for Public Health Preparedness and Disaster Response (link)

"Ready or Not? Protecting the Public's Health from Disease, Disasters and Bioterrorism 2005," Trust for America's Health report (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn