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ASPR Cutting 19 States Out of HPP

ASPR Cutting 19 States Out of HPP

If ASPR has its way with Congress, there will only be 36 eligible awardees for Hospital Preparedness Program funding. Nineteen states will be out under a "risk-based" approach that limits awards to only those states and local jurisdictions ASPR has 'scientifically' determined have the highest risk. And before those states that appear to have avoided the axe get too giddy, know that ASPR expects you to compete with academic medical centers, state and local hospital associations... for the opportunity to administer the HPP cooperative agreement.

Yes, going forward, ASPR will use "evidence-and science-based tools to more clearly define risk." The question begs, are we talking about electoral evidence and political science, or something a bit more empirical?

Before we move on, let's take a moment to understand the divergent budget cycle and HPP funding cycle. Understanding when ASPR's proposal gets a bit confusing when terms like Continuing Resolution (CR), Fiscal Year, Budget Period, and Project Period are thrown around like Bocce Balls.

First, understand that the calendar year means nothing to the federal budget cycle, or the funding cycle for PHEP and HPP. And second, when a state has an application for the PHEP or HPP cooperative agreement approved and accepted, it does not necessarily mean the money will come.

Instead of trying to explain what I'm talking about, check out the infoGraphic below.

Federal Fiscal Year vs. ASPR HPP Budget Year

There are a few important takaways from the infoGraphic:

  • FY 2017 ends September 30, 2017. Congress' most recent budget action in May (Omnibious Budget Bill) only funds the govenment through Setember 30
  • Budget Period 1 of the 2017-2022 Project Period, starts July 1, 2017
  • States receiving the HPP coopertive agreement are only funded through September 30, unless Congress passes a budget or passes a Continuing Resolution
  • On October 1, nineteen states would lose their funding and another 12 would have their funding cut if Congress concurs with ASPR's strategy and enacts the FY 2018 budget as they've requsted

Know that Congress rarely – make that almost never – passes a budget before the close of the Fiscal Year, yet somehow the government keeps the lights on, and the grants continue to flow. How? They pass something called a Continuing Resolution (CR) that essentially says, "Hey, y'all keep doing what you're doing at the same level as last year's budget. We'll let you know when we figure this thing out."

Given history and the chaos in Washington, there will most surely be another CR, so relax – for now.

HPP On the Chopping Block?

Since the Hospital, Preparedness Program (HPP) cooperative agreement was hit with more than a $100,000,000 cut in 2014, it has held steady at $228,500,000. In recent years, there has been speculation that the program would eventually lose its funding. And concerns only grew as the new administration took over the White House in January. 

HPP Chopping Block ImageIn March, the HPP community's worst fears appeared to be realized when the President released his 'skinny budget,' America First, A Budget Blueprint to Make America Great.

Though the skinny budget is not the official budget request, it does shed light on the President's philosophies and priorities. With fewer than two pages dedicated to cost-savings reforms that cut 17.9% from the Department of Health and Human Services (HHS) budget, public health, emergency preparedness, and prevention programs were specifically called out as being duplicative.

The skinny budget, "[r]eforms key public health, emergency preparedness, and prevention programs. For example, the Budget restructures similar HHS preparedness grants to reduce overlap and administrative costs and directs resources to States with the greatest need." The CDC Public Health Emergency Preparedness Program (PHEP) also appeared to be under attack. "The Budget also reforms the Centers for Disease Control and Prevention through a new $500 million block grant to increase State flexibility and focus on the leading public health challenges specific to each State."

By the time, the Preparedness Summit in Atlanta rolled around in April, Acting Assistant Secretary, George Korch stated, based on recent meetings, that he felt the consolidation of PHEP and HPP was likely off the table.

But, just because consolidation is off the table, doesn't mean that the President would not push to drastically reduce or eliminate HPP funding all together.

Great News! HPP Budget Cut!

Yes, you read that right. A budget cut is great news. The President’s official budget request, Budget of the U.S. Government: A New Foundation For American Greatness, Fiscal Year 2018, proposes a 10% cut to HPP. And given the options, a 10% cut has a nice ring to it, right?

But, before you get too giddy, if ASPR has their way, not every state will get to play. We’ll get back to this later.

The 10% cut has its roots in the fact that the President gave federal agencies a mandate to deliver a budget request that cuts at least 10%, which would be necessary to offset a proposed 10% increase in defense spending. As the Washington Post reported in February, “President Trump will propose a federal budget that would significantly increase defense-related spending by $54 billion while cutting other federal agencies by the same amount, an administration official said.”

So, it appears that the proposed cut to HPP, although in their budget request, is not of ASPR’s making – they had their hand forced. Maybe not!

Per the Public Health and Social Services Emergency Fund: Justification of Estimates for Appropriations Committee, ASPR's FY 2018 budget request for HPP shows a decrease of $26,869,000 below the FY 2017 Annualized Continuing Resolution level. Under the proposal the HPP budget would decrease from $254,071,000 to $227,201,000.

Note that the total HPP budget includes not only the HPP cooperative agreement, which ultimately feeds healthcare coalitions, but also ASPR’s administrative cost to run the program, including their online academic research platform, the Technical Resources Assistance Center and Information Exchange (TRACIE). Of the total $227,201,000 HPP budget, $204,500,000 is for cooperative agreements, which is $24,000,000 below FY 2017 funding.

So, we’ll take the 10% hit and let ASPR off the hook, right? Well, “not so fast my friend," as Lee Corso likes to say on ESPN College Game Day.

You see, interestingly, ASPR’s request for the office is $110,072,000 more than their FY 2017 budget. So much for the 10% being applied across the board. I mean, could they not have found somewhere else in the office to cut the $24,000,000, if they actually had to make the cut at all? Heck, maybe they could have simply requested a $134,073,000 increase in their budget instead of $110,072,000? What's a few million dollars among friends, right?

••• FY 2017 FY 2017 (CR) FY 2018 Request +/-
ASPR Budget $1,498,999,000 $1,467,824,000 $1,577,896,000 +11%
HPP Budget $254,555,000 $254,071,000 227,201,000 -9%
HPP Cooperative Agreement $228,500,000 $228,500,000 $204,500,000 -9%

And one more thing, ASPR states in their budget request, Public Health and Social Services Emergency Fund: Justification of Estimates for Appropriations Committee, that "[t]he Hospital Preparedness Program (HPP) is critical to the local, state and regional health care preparedness and response efforts. HPP enables the health care system to save lives during emergencies that exceed the day-to-day capacity of the health and emergency response systems."

Great sounding stuff. But based on their budget priorities, you'd think ASPR leadership believes they don't need much from the local, state and regional health care preparedness and response system. Heck, they must have a 3,000 mile long screwdriver that can fix any problem anywhere in the Country.

For the record, despite ASPR’s 11% budget increase, HHS’ total FY 2018 budget request is roughly 17% less than their FY 2017 budget. So they had a bit of wiggle room.

HPP 4.0: Sunday Bloody Sunday

Now, I doubt Congress will pass the FY 2018 budget on a Sunday, as they tend to head home on Thursdays for long weekends. But, if they drink ASPR's Kool Aid, no matter the day of the week, it will feel like Sunday Bloody Sunday to those punched in the nose. A new risk-based funding formula that boots 19 states and 7 freely associated states/insular areas out of HPP, cuts funding to another 14 states, and opens competition for the funding opportunity with nonprofit entities for those left in the game. 

Wow! And to think, some states were angry with Dr. David Marcozzi when the then Director of the National Healthcare Preparedness Program (NHPP) turned the HPP ship to healthcare coalitions in 2012. Marcozzi received strong push back even though he gently nudged the rudder to give everyone time to adjust to the new world order. Marcozzi's three-year stint at the White House  as the Director of All-Hazards Medical Preparedness Policy for the National Security Council gave him keen insight as to how far executive branch agencies can push the envelope with Congress. Not to mention how resistant the federal bureaucracy and state awardees are when it comes to rapid paradigm shifts.

HPP Awardee Cuts

In hindsight, maybe Marcozzi could have pushed the rudder a bit harder. Simply put, too many states took advantage of the soft rudder approach to interpret the cooperative agreement in a manner that supported their definition of a healthcare coalition. And now, five-years later, we are readying to kick off a new five-year project period with too many laggards on complete reboots.

Heading into FY 2018, there is no doubt that ASPR needed to jerk the rudder a little harder to avoid the rocks. But, holy, uhhh… Wow! Melissa Harvey, NHPP Director, must have found the biggest dude in the office to put a flying drop kick on it. In normal times, a paradigm shift this drastic would never make it to paper, but these are not normal times in D.C. Sure, ASPR's free market, risk-based strategy – with a touch of sledge hammer accountability – speaks nicely to the White House, but will it play in Congress? I'm not so sure about that. 

So, what does ASPR have planned? Let’s use their words, as they leave little ambiguity.

The following are excerpts from pages 59-61 of ASPR’s budget document, Public Health and Social Services Emergency Fund: Justification of Estimates for Appropriations Committee. It is laid out under the three core tenets of HPP 4.0.

In order to deliver the needed change to protect Americans from disasters that impact people’s health, ASPR proposes to ameliorate gaps and streamline HPP as part of its FY 2018 budget request. The innovations and improvements outlined below will drive strategic advancements in health care delivery system readiness and leverage private sector ideas and best practices to enhance government efficiency and accountability: 

Define the Target Market

Focus HPP’s investments in states and jurisdictions facing the greatest risk… HPP intends to create a lean, effective program by targeting federal funding to those states and jurisdictions at greatest risk. HPP has incorporated risk into its funding distribution formula since FY 2014. However, in FY 2018, HPP proposes to improve its risk determination by using evidence-and science-based tools to more clearly define risk, as well as limit awards to only those states and jurisdictions with the highest risk….

…Better targeting this risk must be part of the program moving forward. New for FY 2018, HPP proposes to improve the natural disaster risk score calculation used for the funding formula distribution by introducing more advanced methodologies and a historical hazard incidence to better understand the consequence of these disasters on people’s health…

 …Using these two risk scores and population for its FY 2018 funding formula distribution, HPP proposes to limit awards to only those states and jurisdictions with the highest risk. Inevitably, this means that there will be some states that see increases based on this new calculation of risk, some see major decreases, and still other awardees will no longer receive HPP cooperative agreement funding in FY 2018 (see state-by-state funding table for more information)…

With these two risk scores for its FY 2018 funding formula distribution, HPP proposes to award funds to states and jurisdictions with the highest overall risk score; therefore, not all current awardees will receive funds in FY 2018. 

Innovate through Competition

Competition breeds excellence and innovation. Injecting competition to determine HPP’s awardees will permit HHS to finance the best ideas to improve the nation’s health security.

For FY 2018, ASPR proposes to allow for state-and jurisdiction-level competition for HPP funds by allowing state and directly-funded cities governmental public health departments, academic medical centers, and state and local hospital associations to apply to serve as the awardee for their jurisdiction. Under this proposal, each funded state, directly-funded city, or territory will still only receive one award; however, this proposal will create competition within each state or jurisdiction for the award. This proposal will allow HPP to fund those entities that present the most innovative approaches to health care delivery system readiness.

Additionally, many of the current public health department awardees subcontract their HPP award to a state hospital association or other health care entity to carry out health care preparedness and response activities. In doing so, the public health department takes an average of 21% of the HPP award off the top for direct costs (i.e. personnel, fringe, and travel), in addition to indirect costs, for overseeing their award and subcontracts.

A second benefit to introducing competition is the potential it has to address the misalignment between HPP’s health care mission and its current awardees’ public health mission. Many of HPP’s governmental public health department awardees work well with their private sector health care delivery system counterparts to enhance preparedness and response, while others struggle to work collaboratively with the private health care system that they also regulate.

Accelerate Results through Accountability

Excellent performance should be rewarded and poor performance corrected. Government programs must be agile to identify, address, and resolve problems to remain good stewards of American tax dollars.

In FY 2018, HPP proposes to use its resources as smartly as possible by answering the questions: what works, for whom, and under what conditions; are awardees implementing programs at the state and jurisdiction level effectively; and how can HPP improve health care system preparedness and response nationwide to produce better results?

 …HPP has the authority to withhold funding from awardees for failure to achieve certain programmatic benchmarks and performance metrics in the immediately succeeding fiscal year following a failure. However, the drafting of the authority does not allow HPP to operationalize this authority simply due to the timing of end of year performance data collection and the distribution of subsequent awards. To address this, HPP proposes to: 

  • Provide technical assistance to low performing awardees to take corrective actions; 
  • Allow funds to be withhold up two years following a failure, and; 
  • Increase the percentage of funds that may be withheld from 10 to 20 percent for each initial failure with an additional 10 percent for each continued failure in subsequent years. 

HPP will re-compete the funding withheld from any entity that fails to achieve performance benchmarks and will give preference to alternative entities within the states or jurisdictions where the failures occur to ensure that funding is still targeting those areas at greatest risk. Additionally, HPP proposes to re-compete the funding withheld among existing awardees. 

Through these proposals, HPP will strive to take the readiness of the U.S. health care delivery system from acceptable to world class.

 

Oh yes, they said it – "HPP will strive to take the readiness of the U.S. health care delivery system from acceptable to world class."  Now, I'm not going to debate what "acceptable" means or how they measured it, but it is a bit irritating that they have chosen to leave 19 states – and the people who live in them – behind; that they feel it is honorable to tell the people of Oregon, Arizona, and Wisconsin that they get to enjoy "acceptable" healthcare system readiness, while their neighbors are valuable enough to have "world class."

FY 2018 (2017-2018) Proposed HPP Funding 

State FY 2018 (CR) FY 2018 (Request) +/-$
Alabama $3,316,320 $4,478,616 +$1,162,296
Alaska $951,914 $1,219,930 +$268,016
American Samoa $278,422 $0 -$278,422
Arizona $3,930,938 $0 -$3,930,938
Arkansas $2,002,932 $2,585,053 +$582,121
California $23,397,482 $20,175,928 -$3,221,554
Chicago $2,736,056 $2,048,099 -$687,957
Colorado $3,119,392 $0 -$3,119,392
Connecticut  $2,330,641 $0 -$2,330,641
Delaware $1,049,193 $0 -$1,049,193
Florida $11,882,752 $12,767,567 +$944,815
Georgia $5,973,258 $6,732,448 +$759,190
Guam $374,754 $0 -$374,754
Hawaii $1,261,124 $0 -$1,261,124
Idaho $1,247,694 $0 -$1,247,694
Illinois $8,772,659 $7,990,729 -$781,930
Indiana $3,934,926 $4,735,094 +$800,168
Iowa $2,130,401 $2,616,125 +$485,724
Kansas $2,117,146 $2,342,757 +$231,611
Kentucky $2,759,985 $3,970,833 +$1,210,848
Los Angeles County $9,263,958 $6,729,769 $-2,534,189
Louisiana $2,895,985 $4,412,533 +$1,516,548
Maine $1,065,567 $1,512,008 +$446,441
Marshall Islands $268,005 $0 -$268,005
Maryland $4,864,700 $4,240,380 -$624,320
Massachusetts $4,315,709 $3,684,602 -$631,107
Michigan $6,157,587 $4,221,454 -$1,936,133
Micronesia $276,806 $0 -$276,806
Minnesotta $3,518,356 $2,217,950 -$801,406
Mississippi $2,176,032 $2,861,356 +$2,685,324
Missouri $3,676,990 $5,186,585 +$1,509,595
Montana $920,601 $0 -$920,601
N. Mariana Islands $270,356 $0 -$270,356
Nebraska $1,373,309 $0 -$1,373,309
Nevada $1,911,347 $0 -$1,911,347
New Hampshire $1,089,878 $0 -$1,089,878
New Jersey $5,633,732 $5,186,585 -$535,388
New Mexico $1,527,031 $0 -$1,527,031
New York $9,639,512 $16,693,113 +$7,053,601
New York City $8,033,288 $13,455,551 +$5,514,224
North Carolina $5,908,241 $7,562,187 +$1,449,686
North Dakota $879,429 $0 -$879,429
Ohio $7,450,278 $6,202,189 -$248,089
Oklahoma $2,602,493 $2,758,110 +$155,617
Oregon $2,577,424 $0 -$2,577,424
Palau $255,373 $0 -$255,373
Pennsylvania $8,093,898 $7,851,839 -$242,059
Puerto Rico $2,576,010 $2,854,070 +$278,060
Rhode Island $940,547 $0 -$940,547
South Carolina $3,117,650 $3,929,521 +$811,871
South Dakota $848,108 $1,128,320 +$280,212
Tennessee $4,040,788 $3,659,664 -$381,124
Texas $16,176,634 $15,435,244 -$741,390
Utah $2,271,467 $0 -$2,271,467
Vermont $780,333 $0 -$780,333
Virgin Islands $305,611 $0 -$305,611
Virginia $6,075,317 $6,743,291 +$667,974
Washington $4,279,234 $0 -$4,279,234
Washington, DC $944,353 $1,814,895 +$870,542
West Virginia $1,405,606 $1,578,846 +$173,240
Wisconsin $3,634,631 $0 -$3,634,631
Wyoming $837,538 $0 -$837,538
Total $228,500,000 $204,500,000 -$24,000,000

So, why did ASPR propose this? Who's behind it? Can it survive Congress? I'll dig into these and more questions soon. Stay tuned to bParati.com to keep up as the story evolves. Subscribe to our eNews below.

One last thing. Please do not yell at the ASPR Field Project Officers (FPOs). This stuff is way above their pay grade. Heck, pray for them. Why would ASPR need 10 FPOs if 19 states have been thrown overboard?

 

Karl Schmitt, MPA

Karl Schmitt, MPA


Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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Karl Schmitt, Passionate Founder & CEO, bParati

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