Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic continues to have a significant impact on communities throughout the United States and around the world. The federal response to this crisis has included multiple waves of supplemental appropriations for various agencies, programs, and accounts to help prevent, prepare for, and respond to the pandemic.

Within the Department of Health and Human Services (HHS), eight agencies and two offices are designated components of the U.S. Public Health Service (PHS).¹ Some of these agencies and offices—such as the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA)—have played a major role in the federal public health response to the COVID-19 pandemic. Others have played a role in providing community health support services, for example, the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

PHS agencies are primarily funded by annual discretionary appropriations. As such, many of these agencies have received additional supplemental discretionary appropriations for pandemic-related activities. In addition, one-time appropriations have been made to the Public Health and Social Services Emergency Fund (PHSSEF) account, which funds emergency preparedness and response activities and is often used for one-time and pass-through funding to address health emergencies. As part of the federal response to the pandemic, PHSSEF appropriations have been made to fund activities such as purchasing medical products and supplies (e.g., vaccines and syringes) and supporting health care providers. Some of these activities are carried out by the Office of the Assistant Secretary for Preparedness and Response (ASPR, a PHS component). PHSSEF appropriations also include a number of transfers to PHS agencies as directed in the response measures.

This report summarizes coronavirus supplemental funding for the public health service agencies and to the PHSSEF in the 116^th Congress. It also includes resources for tracking spending. Funding has been provided across five supplemental appropriations measures:

• First Measure: Division A of the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (P.L. 116-123), enacted on March 6, 2020.
• Second Measure: Division A of the Families First Coronavirus Response Act (FFCRA, P.L. 116-127), enacted on March 18, 2020.
• Third Measure: Division B of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act, P.L. 116-136), enacted on March 27, 2020.²
• Fourth Measure: Division B, of the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA, P.L. 116-139), enacted on April 24, 2020.
• Fifth Measure: Division M of Consolidated Appropriations Act, 2021 (P.L. 116-260), enacted on December 27, 2020.

This report provides an overview of each of the PHS agencies as well as the PHSSEF. The funding tables (Table 1 and Table 2) display supplemental funding as appropriated to these accounts across the measures. In addition, this report provides an overview of resources for tracking spending; however, it does not provide a comprehensive overview of allocations, outlays, and awards because available funding data are incomplete.

Understanding PHS COVID-19 Supplemental Appropriations

The above appropriations measures provided additional budgetary resources to PHS accounts to address the pandemic. In these measures, discretionary funding was appropriated to PHS accounts pursuant to an "emergency requirement" and directed to be used for various pandemic-related activities.³ Additionally, the measures directed that certain amounts of appropriations funding be transferred from one account to another. In several instances, these transfers were directed as "not less than" or "not more than" a certain amount.

In addition, the measures included several authorities that allow the HHS Secretary to transfer certain funds between certain accounts, as specified in each measure. This transfer authority is in addition to the directed transfers specified in the laws.

The first measure broadly allowed for HHS to transfer funds among accounts at CDC, NIH, and PHSSEF. The third measure allowed for transfers among accounts at CDC, PHSSEF, the Administration for Children and Families (ACF), the Administration for Community Living (ACL), and NIH. The fourth measure allowed for transfers among accounts at CDC, NIH, PHSSEF, and FDA, but limited the amounts available for such transfers (e.g., it excluded from this authority $75 billion provided to the PHSSEF for the "Provider Relief Fund"). The fifth measure allowed for transfers among accounts at CDC, NIH, SAMHSA, ACF, and PHSSEF, but again limited the amounts available for such transfers (e.g., it excluded from this authority $22.4 billion provided to the PHSSEF for COVID-19 testing, contact tracing, surveillance, containment, and mitigation). The acts require HHS to notify the House and the Senate appropriations committees 10 days in advance of such transfers. Unless otherwise noted, the budgetary figures in this report do not reflect transfers between accounts pursuant to these authorities.

Moreover, in several instances, one agency administers a program funded by appropriations that were made to another agency's or office's account. This report acknowledges some such instances, but does not comprehensively reflect allocations, transfers, and spending of agency appropriations below the level of detail specified in the supplemental appropriations measures.

Several of the other divisions in the above measures include either regular discretionary appropriations to these agencies' accounts or mandatory appropriations to support ongoing programs and operations. These regular, annual funds are not reflected in this report because they were not appropriated specifically to address the pandemic. However, this report does include the mandatory appropriations for the HRSA Health Centers program that were provided in Division A of the third measure, because these funds were specifically directed as supplemental awards for pandemic-related activities at HRSA-funded health centers.

PHS Agency and PHSSEF Appropriations: A Snapshot

Across the five measures, a total of $305.6 billion was provided to the PHS agencies and PHSSEF. Much of this funding is available for multiple years or until expended. These measures include the following amounts by PHS agency (as appropriated to agency accounts):

• CDC, the federal government's lead public health agency, received a total of $15.3 billion.
• The Agency for Toxic Substances and Disease Registry (ATSDR), which is headed by the CDC director and investigates the public health impact of exposure to hazardous substances, received a total of $12.5 million.
• FDA, which regulates medical products such as vaccines, treatments, and tests, received a total of $196 million.
• HRSA, which funds programs and systems that provide health care services to the uninsured and medically underserved, received a total of $1.3 billion.
• The Indian Health Service (IHS), which supports a health care delivery system for American Indians and Alaska Natives, received a total of $1.1 billion.
• The National Institutes of Health (NIH), the nation's lead medical and health research agency, received a total of $3.0 billion.
• SAMHSA, which funds mental health and substance abuse prevention and treatment services, received a total of $4.7 billion.

The PHSSEF received a total of $280 billion for a broad set of purposes, including funding directed as transfers to the above agencies. This funding was, in large part, provided for four main purposes:

• Medical Countermeasures and Surge Capacity (approximately $53.4 billion), including the development, manufacture, and purchase of medical countermeasures such as tests, treatments, vaccines, and other medical supplies, as well as for activities related to supporting a surge in demand for health care (e.g., health care workforce supports, distribution of medical supplies, and alternative care sites).
• COVID-19 Testing for the Uninsured ($1 billion), provided in the second measure. Accounting for a transfer in the fourth measure of not more than $1 billion of the amount for COVID-19 Testing, Surveillance, Contact Tracing, Containment and Mitigation (last bullet below), a total of not more than $2 billion has been provided for this fund.
• Provider Relief Fund ($178 billion) to reimburse eligible health care providers for health care-related expenses or lost revenues attributable to the pandemic.
• COVID-19 Testing, Surveillance, Contact Tracing, Containment and Mitigation ($47.4 billion). Much of this funding has been awarded as grants to states and other jurisdictions by CDC, while other amounts have been transferred to other PHS agencies or used for related purposes, such as purchasing testing-related supplies, or transferred to the uninsured fund listed above.

Some of the funded activities are carried out by ASPR, particularly BARDA for medical countermeasure development and procurement. Some PHSSEF funding has since been transferred from PHSSEF and is administered by other agencies (though these transfers were not explicitly directed in the laws).

An eighth PHS agency, the Agency for Healthcare Research and Quality (AHRQ) did not receive COVID-19 supplemental appropriations in any of the measures.

Report Roadmap

This report provides an overview of COVID-19 supplemental appropriations to PHS accounts in three main sections:

Agency Overviews. This section provides a high-level overview of each PHS agency and its role in the pandemic response. The discussion includes total supplemental appropriations and additional budgetary resources made available to each agency for pandemic response, accounting for both appropriations made to agency accounts and transfers to the agency directed from other accounts. The section discusses the purposes for which funds were appropriated, as well as programs administered by the agency for which funding was appropriated to another account. Finally, the section discusses PHSSEF, the largest account covered in this report, and the major categories of its appropriations.

Funding Overview. This section includes two tables of COVID-19 supplemental appropriations for PHS agencies as appropriated, with information on availability of funds. Table 1 provides a high-level summary of appropriations by agency and includes information about transfers specifically directed to another agency account. Table 2 provides a more detailed view of these appropriations, including overviews of all appropriations for accounts, programs, and specified purposes within an agency, as well as directed transfers outside of agency accounts. In at least one case, transfers are directed to "other federal agencies" without specifying the specific agency or account.

Resources to Track Spending. This section provides an overview of available resources to track spending from PHS accounts, with a discussion of data limitations and relevant caveats for interpreting these sources. The section includes both general federal spending and department and agency-specific resources.

As a general caveat, the PHS agencies are not the only agencies within the federal government that have conducted public health activities for pandemic response. The federal public health response to the COVID-19 pandemic has been "whole-of-government" and has involved departments and agencies outside of HHS, such as the Federal Emergency Management Agency (FEMA), the Department of Defense (DOD), and others. These entities and their appropriations are outside the scope of this report.

Agency Overview

Seven PHS agencies received COVID-19 supplemental appropriations across the five measures. As shown in Figure 1, CDC received the largest amount of appropriations at $15.3 billion (59.6% of all PHS agency appropriations), followed by SAMHSA ($4.7 billion; 18.3%), NIH ($3.0 billion; 11.9%), HRSA ($1.3 billion; 5.2%), IHS ($1.1 billion; 4.3%), FDA ($196.0 million; 0.8%); and ATSDR ($12.5 million; less than 1%).

Figure 1. PHS Agencies: COVID-19 Supplemental Appropriations (Dollars in millions; amounts shown as appropriated)

Source: Compiled by CRS from amounts specified in P.L. 116-123 (Division A), P.L. 116-127 (Division A), P.L. 116-136 (Division A and Division B), P.L. 116-139 (Division B), and P.L. 116-260 (Division M). Notes: These amounts reflect discretionary supplemental appropriations to agency accounts, as well as additional mandatory appropriations for pandemic response made available to HRSA. These amounts do not reflect transfers directed into and from agency accounts in the laws; therefore these amounts may differ from those in the discussion below about transfers. Other sources that track federal spending, such as USASpending,gov, may include various breakdowns and presentations of funds in these agency accounts that do not match numbers in this figure.

This section discusses agency funding accounting for directed transfers to and from the agency accounts in the laws. As such, the funding totals based on these calculations differ from Figure 1, as well as Table 1 and Table 2 in the "Funding Overview" section, as those figures and tables show funds as appropriated in each account and prior to any transfers.

Centers for Disease Control and Prevention (CDC)

As the nation's lead public health agency, CDC's mission is to "to protect America from health, safety and security threats, both foreign and in the United States."⁴ To fulfill its mission, CDC supports various activities related to a wide array of illnesses and injuries, including developing expertise and best practices in disease prevention and control; conducting and supporting public health research; supporting health education; developing laboratory capacity; and conducting surveillance (i.e., data collection), among others. A large portion of CDC's annual budget is awarded as external financial assistance (typically in the form of grants)—especially to state health departments.⁵

During the COVID-19 pandemic, CDC has played major roles in supporting the nation's public health response. The agency has produced and disseminated health information on COVID-19, conducted research, awarded funding, and provided technical assistance to public health agencies at the state, local, territorial, and tribal level (SLTT). These activities include (1) supporting surveillance, epidemiology, and contact tracing; (2) supporting laboratory testing and diagnostics development; (3) coordinating across public health agencies; (4) providing health education and guidance for a variety of stakeholders; (5) providing travel health advisories and notices; (6) supporting international public health responses to the pandemic; and (7) coordinating, setting requirements, and providing assistance for the COVID-19 vaccination program.⁶

Across four of the five supplemental appropriations measures, CDC received appropriations of nearly $15.3 billion to the CDC-Wide Activities and Program Support account, along with an additional directed transfer in the fourth measure of not less than $1 billion to CDC from PHSSEF. In addition, the fifth measure directed a transfer of $210 million from CDC to IHS. Accounting for transfers, total budgetary resources available to CDC are not less than $16.0 billion. In addition, CDC has administered grants funds for testing-related activities initially appropriated to the PHSSEF account (as explained in the text box below).

In general, appropriations to CDC have been provided for three major purposes:

Broadly Available Funding. The first and third measures made available a total of $6.5 billion to CDC "to prevent, prepare for, and respond to coronavirus," including $2.2 billion in the first measure and $4.3 billion in the third measure, with amounts set aside or transferred for the following purposes:

• Grants to state, local, territorial, tribal governments, and other tribal health organizations (SLTT agencies): Not less than $2.45 billion total, including not less than $950 million in the first measure and not less than $1.5 billion in the third measure. As specified in the laws, the funding was directed "to carry out surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities." CDC has since awarded the funding through several grant mechanisms and programs (see the text box below). The measures specify that, at a minimum, every grantee that received a Public Health and Emergency Preparedness (PHEP) grant for FY2019 must receive no less than 90% of that grant level from the first measure, and no less than 100% of that grant level from the third measure.⁷ A portion of funds in each measure is designated for tribal entities (as detailed in "Funding for Tribal Entities" section).
• Global disease detection and emergency response: Not less than $800 million total is for global disease detection and emergency response, including not less than $300 million in the first measure and not less than $500 million in the third measure.
• Public health data modernization: The third measure set aside not less than $500 million of the total appropriation to CDC for "public health data surveillance and analytics infrastructure modernization."
• Transfers to the Infectious Disease Rapid Response Reserve Fund (IDRRRF): $600 million total was directed to IDRRRF, including $300 million in the first measure and $300 million in the third measure. The IDRRRF is a reserve account for CDC used for infectious disease emergencies.⁸

Testing-Related Funding. The fourth measure directed a transfer of not less than $1 billion from PHSSEF to CDC for "surveillance, epidemiology, laboratory capacity expansion, contact tracing, public health data surveillance and analytics infrastructure modernization, disseminating information about testing, and workforce support necessary to expand and improve COVID-19 testing."

In addition, a large portion of the general testing-related funds in the PHSSEF account made available by the fourth and fifth measures has been administered as CDC grants (see the text box below).

Vaccine-Related Funding. The fifth measure made available $8.75 billion to CDC for "activities to plan, prepare for, promote, distribute, administer, monitor, and track coronavirus vaccines to ensure broad-based distribution, access, and vaccine coverage." Of this total, at least $4.5 billion was for SLTT grants (or cooperative agreements), of which $210 million is to be transferred to the Indian Health Service (IHS) and a separate amount of not less than $300 million is for "high-risk and underserved populations, including racial and ethnic minority populations and rural communities."

The Agency for Toxic Substances and Disease Registry (ATSDR), which is headed by the CDC Director, investigates the public health impact of exposure to hazardous substances. The third measure made available $12.5 million to ATSDR, designated for two purposes:

• $7.5 million for the Geospatial Research, Analysis and Services Program "to support spatial analysis and Geographic Information System mapping of infectious disease hot spots, including cruise ships."
• $5 million to Pediatric Environmental Health Specialty Units and state health departments "to provide guidance and outreach on safe practices for disinfection for home, school, and daycare facilities."

U.S. Food and Drug Administration (FDA)

FDA regulates the safety of foods (including dietary supplements), cosmetics, and radiation-emitting products; the safety and effectiveness of medical products (e.g., drugs, biologics, and devices); and public health aspects of tobacco products.⁹

During the pandemic, FDA has engaged in premarket regulatory activities to facilitate the availability of medical products for the treatment, prevention, mitigation, and diagnosis of COVID-19, as well as postmarket activities such as monitoring of medical product safety and supply chain issues.¹⁰ With respect to its premarket work, FDA has granted approval, clearance, marketing authorization, or emergency use authorization (EUA) to COVID-19 therapeutics, vaccines, diagnostics, and other medical devices (e.g., respirators and ventilators).¹¹ FDA has issued guidance to facilitate COVID-19 vaccine development, clarifying its expectations for licensure and EUA.¹² As part of its postmarket work, the agency has monitored medical product shortages and issued policies of enforcement discretion to increase availability of certain medical products, including in vitro diagnostics (e.g., tests), hand sanitizer, surgical gowns, and face masks. To further address potential supply chain disruptions, FDA has worked with the pharmaceutical industry and federal partners to accelerate the adoption of advanced manufacturing technologies (i.e., technologies that may improve medical product quality, reduce shortages, and speed time to market).¹³

Across four of the five measures, FDA has received a total of $218 million, including $196 million to the agencies' accounts and a directed transfer from the PHSSEF to FDA of $22 million in the fourth measure. This funding was provided in two categories:

Broadly Available Funding. In the first, third, and fifth measures, funding was made available to FDA to "prevent, prepare for, and respond to coronavirus domestically and internationally." The supplemental funds were to be used for activities such as pre- and postmarket work on medical countermeasures (e.g., therapeutics, vaccines, and diagnostics), EUAs, monitoring of medical product supply chains, advanced manufacturing, and related administrative activities. In the first and third measures, amounts were not designated for specific activities.

However, the fifth measure specified that FDA was to spend the total supplemental appropriation of $55 million as follows:

• $9 million for the development of necessary medical countermeasures and vaccines,
• $30.5 million for advanced manufacturing of medical products,
• $1.5 million for the monitoring of medical product supply chains,
• $7.6 million for other public health research and response investments,
• $1.4 million for data management operation tools, and
• $5 million for after action review activities.

Testing Activities. The fourth measure provided $22 million to FDA, as a transfer from the PHSSEF account, to support activities associated with "diagnostic, serological, antigen, and other tests, and related administrative activities."

Health Resources and Services Administration (HRSA)

HRSA provides health care to individuals who are geographically isolated, economically or medically vulnerable, or both. HRSA programs target specific populations, including pregnant women and their children and individuals with HIV/AIDS. In addition, HRSA supports the health care workforce; oversees organ, bone marrow, and cord blood donation; and administers the National Vaccine Injury Compensation program. HRSA currently awards funding to more than 3,000 grantees, including community-based organizations; colleges and universities; hospitals; state, local, and tribal governments; and private entities. These funds support health services projects, such as training health care workers and providing specific health services.¹⁴

COVID-19 prevention, treatment, and response has involved a number of HRSA programs. For example, the health centers program, HRSA's largest program, provides grants to support more than 12,000 sites in underserved areas that provide primary care to disadvantaged populations regardless of their ability to pay.¹⁵ Because of their scope, health centers have been an important part of COVID-19 response.¹⁶ They have provided testing to underserved and largely minority populations. The Biden Administration has included health centers in its vaccine program beginning in February 2021 as a way of reaching underserved populations.¹⁷

The Ryan White HIV/AIDS program (Ryan White) provides HIV/AIDS health care and related health and social support services to individuals with HIV or AIDS. Individuals with HIV/AIDS may be particularly vulnerable to serious COVID-19 infections.¹⁸ Ryan White sites have undertaken prevention efforts and increased certain services (e.g., meal delivery) to facilitate program participants' ability to self-isolate to reduce their risk of infection.

During the pandemic, health care providers have increasingly used telehealth services to reduce the spread of COVID-19 and conserve health care workforce time and supplies (e.g., personal protective equipment). HRSA has made long-standing investments in increasing telehealth in rural areas, which may have less access to technology and infrastructure needed to effectively deliver telehealth, and has increased this support during the pandemic.¹⁹

HRSA received a total of $1.3 billion in COVID-19 supplemental mandatory funding for its Health Centers program in Division A of the CARES Act (P.L. 116-136). In addition, the first, third, and fourth measures directed HHS to transfer a combined total of $975 million to HRSA from PHSSEF. These transfers are estimated to increase HRSA's total budgetary resources for pandemic-related activities to nearly $2.3 billion. Moreover, HRSA administers several pandemic response programs funded by the PHSSEF account: (1) the Uninsured Fund for testing, which received funds in two of the measures, (2) the Provider Relief Fund, which received funds in three of the measures, and (3) testing programs at rural health clinics, which received funds in one of the measures. HRSA funding and programs are described in greater detail below.

Health Centers. The Health Centers program received funding in the first, third, and fourth measures. In the first and fourth measures, funding was provided as transfers from the PHSSEF account, including $100 million in the first measure and $600 million specified for testing-related activities in the fourth measure. Funding in the fourth measure was specifically made available to federally qualified health center look-alikes.²⁰ Health centers received $1.3 billion as a mandatory appropriation in the third measure to supplement existing health center grant awards. The law directed these funds specifically for supplementary awards to health centers for "the detection of SARS–CoV–2 [the virus that causes COVID-19] or the prevention, diagnosis, and treatment of COVID–19."²¹ All told, the Health Centers program has received additional budgetary resources totaling roughly $2 billion.

Additional Support for Existing HRSA Programs. The third measure included a transfer of $275 million from the PHSSEF to HRSA to support three agency programs:

• $90 million to supplement grants awarded as part of the Ryan White HIV/AIDS program to support pandemic response,
• $5 million transfer to "improve the capacity of poison control centers to respond to increased calls," and
• $180 million for telehealth and rural health activities, of which not less than $15 million was reserved for Indian Tribes (ITs), Tribal Organizations (TOs), Urban Indian health organizations (UIOs), and health service providers to tribes. These funds were provided to support small rural hospitals in their pandemic response and were awarded to telehealth resource centers to provide technical assistance to rural areas to aid with pandemic response.²²

New Funds that HRSA Administers. The various measures created two new funding streams, from PHSSEF funds, to support health care providers in responding to the pandemic:

• The Uninsured Fund: The Uninsured Fund, which was created to pay for health care expenses of the uninsured during the pandemic, received a total of not more than $2 billion to pay for costs associated with testing the uninsured. The second measure appropriated $1 billion to the PHSSEF to reimburse providers for uninsured testing. Though no administering agency was specified, the language in the second measure stated that reimbursements were to be made in "in coordination with the Assistant Secretary for Preparedness and Response and the Administrator of the Centers for Medicare & Medicaid Services." HHS elected to have HRSA administer these funds as part of the Uninsured Fund.²³ Uninsured testing subsequently received an additional not more than $1 billion transfer in the fourth measure.
• Provider Relief Fund: The Provider Relief Fund (PRF), which was created to reimburse health care providers for lost revenues and increased expenses during the pandemic, received a total of $178 billion across three measures. The third measure provided the PHSSEF with $100 billion "to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus." This fund was later termed the Provider Relief Fund and is administered by HRSA, though the third measure did not use this term, nor did it specify an administering agency for the fund.²⁴ Subsequent measures increased PRF to a total of $178 billion—with $75 billion provided in the fourth measure and $3 billion provided in the fifth measure. The Trump Administration elected to use an unspecified amount of the third measure appropriation to reimburse providers for uninsured treatment, which is administered in conjunction with the appropriation for uninsured testing as the Uninsured Fund. This fund was subsequently expanded to enable reimbursement of costs for vaccination services for the uninsured and underinsured.²⁵

In addition to these larger funds, HRSA administers the $225 million transferred from the PHSSEF in the fourth measure for testing at rural health clinics (RHCs)—small outpatient clinics located in rural areas. As directed in the law, funds are to be awarded through grants or other mechanisms "for building or construction of temporary structures, leasing of properties, and retrofitting facilities as necessary to support COVID–19 testing." Although RHCs are similar to health centers, a dedicated grant program for RHCs did not exist prior to the pandemic. As such, unlike health centers, where grants can be supplemented, RHCs required a new funding process to receive funds—a process that was undertaken by HRSA.²⁶ The law did not specify which agency is to administer these funds.

Indian Health Service (IHS)

The Indian Health Service (IHS) provides health care to American Indian and Alaska Native populations. Such health care is provided either directly, by providing funds for Indian Tribes (ITs) or Tribal Organizations (TOs) to operate health care facilities, or by providing grants to Urban Indian Health Organizations (UIOs) to provide care to American Indians and Alaska Natives in urban areas.²⁷ IHS generally provides services free of charge to approximately 2.6 million eligible American Indians and Alaska Natives in 37 states.²⁸ More than two-thirds of IHS facilities are operated by ITs/TOs through contracts or compacts authorized under the Indian Self-Determination and Education Assistance Act (ISDEAA, P.L. 93-638). ITs/TOs generally contract or compact for services that IHS would have otherwise provided by entering into a funding agreement that delineates the services funded under the agreement.

Funding has been provided to IHS for COVID-19 pandemic response, in part, because of the agency's role as a direct health care provider. In that role, the agency directly supports testing, treatment, and vaccination services for its service population, which has been disproportionally affected by the pandemic. A number of IHS areas, including the Navajo area, experienced early and sustained outbreaks of COVID-19 infections. Data show high COVID-19 mortality rates among American Indians and Alaska Natives.²⁹ IHS, like other health systems, experienced increased demand for intensive COVID-19 related services, while seeing declining revenue from cancelled or delayed routine and elective care.³⁰ In addition to providing health services related to COVID-19, IHS supports certain public health and health education activities (similar to those of CDC).

Across four of the five measures, IHS received $1.1 billion in supplemental appropriations to the agency accounts and a total of not less than $1.8 billion in directed transfers and set-asides either (1) to agency accounts or (2) to be allocated at the discretion of the IHS Director in other accounts. In total, accounting for transfers and set-asides, budgetary resources of at least $2.8 billion have been made available either to IHS accounts or at the direction of the IHS Director. In addition, a total of not less than $320 million has been reserved for tribal entities (i.e., ITs/TO/UIOs) from funds that were appropriated to other HHS accounts but were not specifically directed to IHS.

Funding has been provided to IHS in three categories: (1) funding for testing, (2) funding for health services and infrastructure, and (3) funding for vaccines. In addition, funds have been provided to tribal entities (i.e., ITs/TO/UIOs), but not specifically to IHS, for public health activities and telehealth and behavioral health.

Funding for Testing. IHS received funding for testing-related activities in the second, fourth, and fifth measures. In the second measure, $64 million was provided directly to IHS for COVID-19 testing, test administration, and related items and services.³¹ In the fourth measure, of the not less than $11 billion in that measure set aside for SLTT grants for testing-related activities, not less than $750 million was provided in the PHSSEF account to be allocated in consultation with the IHS director. The law did not specify that these funds be transferred to IHS; however, HHS eventually did so.³² The fifth measure directed that $790 million be transferred to IHS from the PHSSEF for testing, contact tracing, surveillance, and containment, among other purposes. The law specified that funds were to be allocated, at the discretion of the IHS Director, to IT/TOs through ISDEAA contracts and compacts, and to UIOs through grants or contracts. In total, IHS has been provided not less than $1.6 billion for testing-related purposes.

Funding for Health Services and Infrastructure. The third measure appropriated $1.032 billion to the IHS Indian Health Services account. Specifically, funds were provided to

respond to coronavirus, domestically or internationally, including for public health support, electronic health record modernization, telehealth and other information technology upgrades, Purchased/Referred Care, Catastrophic Health Emergency Fund, Urban Indian Organizations, Tribal Epidemiology Centers, Community Health Representatives, and other activities to protect the safety of patients and staff.

Purchased/Referred Care and the Catastrophic Health Emergency Fund are both mechanisms used to pay for care provided to beneficiaries at non-IHS facilities. Tribal Epidemiology Centers (TEC) and Community Health Representatives perform public health activities for the IHS system. TECs conduct surveillance and epidemiology activities for IHS service areas. Community Health Representatives are generally paraprofessionals involved in activities such as health education and disease prevention. Further, the law specified that not less than $450 million was for ITs/TOs to supplement their existing ISDEAA contracts and compacts, and that not more than $125 million was for the Indian Health Facilities account and to be allocated at the discretion of the IHS Director.³³ The Indian Health Facilities account is used for facility and equipment-related expenses.

Funding for Vaccine Distribution. In the fifth measure, CDC was directed to transfer $210 million to IHS "for activities to plan, prepare for, promote, distribute, administer, monitor, and track coronavirus vaccines to ensure broad-based distribution, access, and vaccine coverage." The law specified that these funds were to be allocated at the discretion of the IHS Director, to IT/TOs through ISDEAA contracts and compacts, and to UIOs through grants or contracts.

Funding for Tribal Entities

As discussed elsewhere in this report, some of the measures directed that funding in certain accounts (e.g., CDC, SAMHSA) be made available to tribal entities (ITs, TOs, UIOs, and health service providers to tribes); however, the measures did not specify that these funds be transferred to IHS.

Funding for Public Health Activities. Several CDC appropriations have been directed to tribal entities in the first and third measures. The first and third measure required that not less than $40 million and not less than $125 million, respectively, in CDC funds for SLTT grants be made available to ITs/TOs, UIOs, and health providers to Indian Tribes for "surveillance, epidemiology, laboratory capacity, and other preparedness and response activities." CDC awarded much of this funding using new noncompetitive grant mechanisms to tribal nations, consortia, and organizations, as well as through some of its existing grant relationships with regional tribal organizations.³⁴ As noted above, some of the funds provided directly to the Indian Health Services account in the third measure were to be used for public health activities conducted by IHS.

Funding for Telehealth and Behavioral Health. The third and fifth measures included set-aside funding for tribal entities in both HRSA and SAMHSA appropriations. For HRSA, the third measure specified that of the amount transferred from PHSSEF to HRSA's Office of Rural Health for telehealth and rural health activities, not less than $15 million was to be allocated to ITs/TOs, UIOS, or health service providers to tribes. These funds were subsequently provided to facilitate the ability of ITs/TOs to provide telehealth to their service populations. ³⁵ In addition, SAMHSA appropriations included set-asides for tribal entities for behavioral health activities in two of the measures, specifically not less than $15 million in the third measure and not less than $125 million in the fifth measure. As directed in the measures, these appropriations were to be allocated to ITs/TOs/UIOS and to behavioral health service providers to tribes.

National Institutes of Health (NIH)

NIH is the nation's lead medical and health agency. It supports much of the basic biomedical research in the United States and some development of new medical products. NIH is made up of 27 institutes and centers (ICs) and the Office of the Director (OD). Of the ICs, 24 ICs and OD support research programs; each IC has broad responsibilities to support research, scientific training, information dissemination and health and medical science as related to its respective mission. In general, about 80% of NIH's budget supports extramural research through grants, contracts, and other awards to research institutions (e.g., universities, medical centers) and 10% supports intramural research at NIH-operated laboratories and facilities.³⁶ During the pandemic, NIH has supported scientific research on the virus and disease, as well as the development of vaccines, therapeutics, and diagnostics. NIH has also published and maintained treatment guidelines and other health information.

Across four of the five measures, NIH received a total of $3.0 billion to NIH IC accounts along with directed transfers from the PHSSEF account to NIH accounts totaling not less than $1.8 billion. Accounting for transfers, NIH is to receive a total of at least $4.8 billion. This funding was primarily provided in three categories:

Broadly Available Funding. In the first and third measure, funding was made available to several NIH IC accounts "to prevent, prepare for and respond to coronavirus, domestically and internationally." Uses of the funds would be governed by the mission and authority of the ICs receiving funds. For example, the National Institute of Allergy and Infectious Diseases (NIAID) supports research, training, and information dissemination related to "allergic and immunologic diseases and disorders and infectious diseases, including tropical diseases."³⁷ The National Heart, Lung, and Blood Institute (NHLBI) supports research, training, and information dissemination related to "heart, blood vessel, lung, and blood diseases."³⁸ NIH IC accounts that received broadly available funds and their totals include the following:

• NIAID: $1.5 billion, including $836 million in the first measure and $706 million in the third measure. Some transfers or set-asides were directed for specific purposes in the NIAID appropriations. The first measure directed a transfer of not less than $10 million to the National Institute of Environmental Health Sciences (NIEHS) for "worker-based training to prevent and reduce exposure of hospital employees, emergency first responders, and other workers who are at risk of exposure to coronavirus through their work duties." The third measure set aside not less than $156 million of the total for "the study of, construction of, demolition of, renovation of, and acquisition of equipment for, vaccine and infectious diseases research facilities of or used by NIH, including the acquisition of real property."
• NHLBI: $103.4 million in the third measure.
• National Institute of Biomedical Imaging and Bioengineering (NIBIB): $60 million in the third measure.
• National Library of Medicine (NLM): $10 million in the third measure.
• National Center for Advancing Translational Sciences (NCATS): $36 million in the third measure.
• Office of the Director (OD): $30 million in the third measure.

Diagnostic Testing Research and Development (R&D). In the fourth and fifth measure, NIH received funding for specific purposes related to diagnostic test R&D. This funding was directed to NIH as "not less than" transfers from the PHSSEF account in the fourth measure, and directly to the OD account in the fifth measure. These amounts include the following:

• National Cancer Institute (NCI): Transfer of not less than $306 million from PHSSEF to NCI "to develop, validate, improve, and implement serological testing and associated technologies."
• NIBIB: Transfer of not less than $500 million from PHSSEF to NIBIB "to accelerate research, development, and implementation of point of care and other rapid testing related to coronavirus."
• OD: Transfer of not less than $1 billion from PHSSEF to OD "to develop, validate, improve, and implement testing and associated technologies; to accelerate research, development, and implementation of point of care and other rapid testing; and for partnerships with governmental and non-governmental entities." In the fifth measure, not less than $100 million of the $1.25 billion total provided to the OD account is for "the Rapid Acceleration of Diagnostics."

NIH's Rapid Acceleration of Diagnostics (RADx) initiative is a prize competition for diagnostics development. As communicated to CRS, the $1.5 billion total for NIBIB and OD in the fourth measure was used to support RADx initially, with additional funds in the fifth measure as specified above.³⁹

Long-Term Studies of COVID-19. The fifth measure directed $1.15 billion of the total $1.25 billion provided to the OD account "for research and clinical trials related to long-term studies of COVID-19." The fifth measure also allows the total $1.25 billion appropriation to OD to be transferred to other IC accounts (in addition to other HHS transfer authorities in the law).

Substance Abuse and Mental Health Services Administration (SAMHSA)

SAMHSA is the federal agency primarily responsible for supporting community-based mental health and substance abuse treatment and prevention services. SAMHSA provides federal funding to states, local communities, and private entities by administering block grants and other formula and discretionary grants. Some grants allow broad uses of funds, whereas others target specific behavioral health issues or populations. Through such grants, SAMHSA supports activities that include education and training, prevention programs, early intervention activities, treatment services, and technical assistance. SAMHSA does not provide mental health or substance abuse treatment. Rather, the agency supports states' efforts in providing community-based behavioral health services. In addition, SAMHSA conducts surveillance and data collection of national behavioral health issues, provides statistical and analytic support to grantees, and administers other agency-wide initiatives.

SAMHSA has continued to support community-based behavioral health treatment and prevention services throughout the COVID-19 pandemic. Circumstances surrounding the pandemic—including lifestyle changes instituted to prevent spread of the virus—appear to have negatively affected the mental health of many Americans.⁴⁰ Studies show elevated levels of emotional distress, anxiety, depression, substance use, and drug-related overdoses in 2020 compared with the same time period in previous years.⁴¹ On account of these increases, CDC reported that "support systems to mitigate mental health consequences as the pandemic evolves will continue to be urgently needed."⁴² In addition, physical distancing measures and temporary stay-at-home orders associated with the pandemic have required changes to service delivery for mental health and substance use treatment. Many behavioral health service providers have increased their use of telehealth modalities to deliver treatment.⁴³ Still, limits on face-to-face service provision and other economic consequences of the pandemic have led to clinic closures and other reductions to treatment service capacity.⁴⁴ Emergency financial support for behavioral health activities provided in two of the supplemental COVID-19 funding measures may address the high demand for mental health and substance use disorder treatment services and decreased capacity in the system.

SAMHSA received a total of $4.7 billion in supplemental appropriations in the third ($425 million) and fifth ($4.25 billion) measures. Funding was designated for specific purposes as follows (organized by size of appropriation):

Block Grant Programs. Of the total $4.25 billion in the fifth measure, $1.65 billion was designated for each of SAMHSA's two main block grants: the Substance Abuse Prevention and Treatment Block Grant (SABG) and the Community Mental Health Services Block Grant (MHBG)—SAMHSA's two largest grant programs. Both block grant programs distribute funds to states (including the District of Columbia and territories) according to a statutory formula.⁴⁵ The states, in turn, distribute funds to local government entities and nonprofit organizations for behavioral health-related treatment and prevention activities in accordance with a required state plan. The law maintained a 20% set-aside for prevention-related activities.

Certified Community Behavioral Health Clinic (CCBHC) Expansion Grant Program. A total of not less than $850 million was made available to the Certified Community Behavioral Health Clinic (CCBHC) Expansion grant program. The third measure included not less than $250 million of the total appropriation for SAMHSA, and the fifth measure included not less than $600 million.

Emergency Substance Abuse or Mental Health Needs. A total of not less than $340 million was made available for emergency substance abuse or mental health needs, including not less than $100 million in the third measure and not less than $240 million in the fifth measure. These funds provide crisis intervention services, mental and substance use disorder treatment, and other related recovery supports for children and adults affected by the COVID-19 pandemic.⁵⁰ SAMHSA gave states significant flexibility in how they use these funds to support behavioral health-related activities.

Suicide Prevention. A total of not less than $100 million was provided for suicide prevention, including not less than $50 million in the third measure and not less than $50 million in the fifth measure.

Project AWARE. Of the total amount in the fifth measure, $50 million was directed to SAMHSA's Project AWARE program, which supports school-based mental health training and referral services in elementary and secondary education.

National Child Traumatic Stress Network. Of the total funding amount in the fifth measure, $10 million was designated for the National Child Traumatic Stress Network, which was established to improve behavioral health services for children exposed to traumatic events. Grant funding supports development and promotion of effective community practices, mostly through information and trainings by a network of centers.

Office of the Secretary

Under the HHS Office of the Secretary (OS), the PHSSEF account is often used for one-time or short-term funding, such as emergency supplemental appropriations. PHSSEF receives annual appropriations for the routine operations of several HHS offices, including the Office of the HHS Assistant Secretary for Preparedness and Response (ASPR), the lead office at HHS for health emergency preparedness and response strategy and coordination and a component of the Public Health Service.

Public Health and Social Services Emergency Fund

PHSSEF received about $280 billion in supplemental funding across the five measures. These funds may support various activities, including health care surge capacity and the development and purchase of medical countermeasures (including vaccines), as well as provider reimbursement through the Provider Relief Fund and Uninsured Fund. In general, PHSSEF supplemental funding has been provided for certain activities and programs as shown in Figure 2.

Figure 2. PHSSEF: Major Categories of COVID-19 Supplemental Appropriations Dollars in millions; amounts shown as appropriated. All transfers and set-asides are not shown.

Sources: Compiled by CRS from amounts specified in P.L. 116-123 (Title III, Division A), P.L. 116-127 (Title V, Division A), P.L. 116-136 (Title VIII, Division B), P.L. 116-139 (Title I, Division B), and P.L. 116-260 (Division M). Notes: These amounts reflect discretionary supplemental appropriations to PHSSEF. They do not reflect directed transfers out of PHSSEF to other agency accounts or set-aside amounts within the account. PHSSEF appropriations include many transfer and set-aside amounts as detailed below and in the tables in the next section. Other sources that track federal spending, such as USASpending,gov, may include various breakdowns and presentations of funds in these agency accounts that do not match numbers in this figure. *Additionally, a total of not more than $1 billion of funding for "COVID-19 Testing, Surveillance, and Contact Tracing" in the fourth measure was set aside for Testing for the Uninsured.

PHSSEF appropriations include four major categories:

Medical Countermeasures and Surge Capacity. The first, third, and fifth measures each provided funding to support (1) the development, manufacturing, and, in some cases, federal purchase of COVID-19 medical countermeasures (e.g., diagnostic tests, treatments, vaccines, and medical supplies), and (2) other response activities, such as for health care workforce and surge capacity (e.g., health care workforce supports, distribution of medical supplies, and alternative care sites). In total, approximately $53.4 billion (prior to transfers) has been provided for these activities. The measures specify that some of these funds are to be transferred elsewhere (e.g., to other federal agencies for the care of persons under federal quarantine) or reserved for specific purposes or activities (e.g., provided to grantees of the Hospital Preparedness Program). In addition, all three measures allow for optional transfers to the Covered Countermeasures Process Fund, which funds the Countermeasures Injury Compensation Program (CICP).⁵¹ Activities funded by the $53.4 billion may be carried out by various ASPR components, especially the Biomedical Advanced Research and Development Authority (BARDA) for countermeasure development and procurement.⁵² Two major set-aside categories are described below.

• BARDA: Under ASPR, BARDA specifically supports the development of medical countermeasures for health emergencies, such as emerging infectious diseases and other threats (i.e., chemical, biological, radiological, and nuclear threat agents). A total of not less than $24.2 billion has been set aside for BARDA in the third, fourth, and fifth measures. This includes
• $23.2 billion of the total for Medical Countermeasures and Surge Capacity in the third and fifth measures, including not less than $3.5 billion in the third measure and $19.7 billion in the fifth measure. Funding in the third measure was designated for "necessary expenses of manufacturing, production, and purchase ... of vaccines, therapeutics, diagnostics, and small molecule active pharmaceutical ingredients, including the development, translation, and demonstration at scale of innovations in manufacturing platforms." Funding in the fifth measure was designated for "necessary expenses of manufacturing, production, and purchase ... of vaccines, therapeutics, and ancillary supplies."
• An additional set-aside of not less than $1 billion was directed to BARDA in the fourth measure from the total for "COVID-19 Testing, Surveillance, Contact Tracing, Containment, and Mitigation" in that measure. This transfer was directed for "necessary expenses of advanced research, development, manufacturing, production, and purchase of diagnostic, serologic, or other COVID–19 tests or related supplies, and other activities related to COVID–19 testing."
• Strategic National Stockpile (SNS), under ASPR, provides select medicines and medical supplies during public health emergencies that overwhelm local availability. PHSSEF funding in the first, third, fourth (of the total $25 billion for COVID-19 Testing, Contact Tracing and Surveillance), and fifth measures can be used for SNS supply purchases. The third and fifth measures limit the amount that can be allocated to SNS from those appropriations and specify that a total of not more than $19.25 billion may be allocated for the SNS from the total appropriations for Medical Countermeasures and Surge Capacity in those laws, including not more than $16 billion in the third measure and not more than $3.25 billion in the fifth measure.

COVID-19 Testing for the Uninsured. The second measure included $1 billion to provide reimbursements for COVID-19 testing and related services for persons who are uninsured. In addition, the fourth measure specified that up to $1 billion of the amounts appropriated for broader COVID-19 testing purposes (discussed below) may be used to cover the costs of testing for the uninsured.⁵³ (See the "Health Resources and Services Administration " section for details about HRSA's administration of this program.)

Provider Relief Fund (PRF). The third, fourth, and fifth measures each provided funding for a "Provider Relief Fund" to assist health care providers and facilities affected by the COVID-19 pandemic.⁵⁴ These funds are intended to reimburse eligible health care providers for health care-related expenses or lost revenues attributable to the pandemic. The measures define eligible providers broadly as any that provide "diagnoses, testing, or care for individuals with possible or actual cases of COVID-19." In total, $178 billion has been appropriated for the PRF.⁵⁵ (See the "Health Resources and Services Administration " section for more details about HRSA's administration of this program.)

COVID-19 Testing, Surveillance, Contact Tracing, Containment, and Mitigation. As specified in the bullets below, the fourth and fifth measures provided $47.4 billion to augment national capacity for COVID-19 containment, including expanded testing capacity and workforce and technical capacity for disease surveillance and contact tracing.

• The fourth measure provided $25 billion total and directed HHS to reserve some of these funds for specific purposes. For example, not less than $11 billion is for states, localities, territories, tribes, tribal organizations, urban Indian health organizations, and health service providers to tribes. Of this total for SLTT grantees, not less than $2 billion was to be allocated according to the formula that applied to the PHEP cooperative agreement in 2019,⁵⁶ and $4.25 billion must be allocated according to a formula that is based on the relative number of COVID-19 cases. In addition, the law specified that certain amounts of these funds are to be transferred to other agencies and accounts (e.g., $22 million is to be transferred to the FDA to support activities related to diagnostic, serological, antigen, and other tests). See Table 2 for a detailed accounting of all transfers and set-asides.
• The fifth measure provided a total of $22.4 billion and directed that funds shall be for states, localities, territories, and tribal entities, and that funding may be awarded as grants or cooperative agreements. Of the total, $790 million was designated to be transferred to IHS, and a separate amount of not less than $2.5 billion is for "strategies for improving testing capabilities and other purposes ... in high-risk and underserved populations, including racial and ethnic minority populations and rural communities as well as identifying best practices for states and public health officials to use for contact tracing in high-risk and underserved populations, including racial and ethnic minority populations and rural communities." The funding, except for the transfer to IHS, is to be awarded according to the formula that applied to the PHEP cooperative agreement in FY2020.

CDC has administered several grant awards using these appropriations (as described in the text box in the "Centers for Disease Control and Prevention (CDC)" section).

In addition to the activities specified above, PHSSEF appropriations in the first, third, and fourth measures called for some portion of the funds to be transferred to other agencies or accounts for particular activities. For instance, some PHSSEF funds are to be transferred to HRSA for health centers, rural health, the Ryan White HIV/AIDS program, and health care systems.⁵⁷ (See the "Health Resources and Services Administration (HRSA)" section for more details.)

Funding Overview

The following tables provide overviews of COVID-19 supplemental appropriations for PHS agencies as appropriated.

• Table 1 provides a high-level summary of appropriations by agency and includes information about transfers specifically directed to another agency account. It also provides information on the period of availability for these funds, listed as a specified date when they are no longer available for obligation (i.e., "expire"), or that they are "no year" funds (i.e., available until expended).
• Table 2 provides a more detailed view of these appropriations, including overviews of all appropriations for accounts, programs, and specified purposes within an agency, as well as directed transfers outside of agency accounts. It also provides information on the availability of the funds for obligation, as above.

The tables present accounts in the order in which they appear in the five appropriations laws. Transfers are listed in their account of origin, not the receiving account. In at least one case, transfers are directed to "other federal agencies" without specifying the agency or account. Several of these transfers are directed as "not less than" (NLT) or "not more than" (NMT).

Resources for Tracking PHS Spending

This section provides an overview of federal resources to track Public Health Service spending from COVID-19 supplemental legislation. For further information on tracking COVID-19 spending government-wide, see CRS Report R46491, Resources for Tracking Federal COVID-19 Spending.

USAspending.gov

USAspending.gov⁵⁸ provides information on federal awards, including grants, contracts, loans, and other assistance. USAspending.gov has a dedicated page for tracking spending from COVID-19 supplemental measures (COVID-19 Spending, https://www.usaspending.gov/disaster/covid-19). There is also an advanced search page (https://www.usaspending.gov/search) with the search option "Disaster Emergency Funding Code," to limit results by COVID-19 supplemental funding law.⁵⁹ For the COVID-19 supplemental funding, USAspending.gov provides data on obligations (amount promised) and outlays (amount paid out). Typically, USAspending.gov provides only obligations data.

Caveats to the data presented in USAspending.gov are outlined on the "Known Data Limitations" page (https://www.usaspending.gov/data/data-limitations.pdf).⁶⁰

Pandemic Response Accountability Committee

The Pandemic Response Accountability Committee (PRAC) website provides visualizations of COVID-19 supplemental appropriations funding data on the "Track the Money" page (https://www.pandemicoversight.gov/track-the-money). This site uses data from USAspending.gov. The "Funding Charts & Graphs" page (https://www.pandemicoversight.gov/track-the-money/funding-charts-graphs) shows payments from the Provider Relief Fund, and "Pandemic Response Funding" shows spending by agency, geography, and program ("assistance listing") in interactive charts, graphs, and tables.

HHS TAGGS

The HHS Tracking Accountability in Government Grants System (HHS TAGGS) has a dedicated page for COVID-19 funding (https://taggs.hhs.gov/Coronavirus). This page provides details on HHS grant awards under COVID supplemental measures. Awards can be filtered by HHS operating division (e.g., CDC), program, date, recipient, city, state, and supplemental appropriations law.

Separate tables show data on attested payments⁶¹ made under the Provider Relief Fund (https://taggs.hhs.gov/Coronavirus/Providers), Rural Health Clinic (RHC) COVID-19 Testing Fund (https://taggs.hhs.gov/Coronavirus/RuralHealthClinics), and the Uninsured Relief Fund (https://taggs.hhs.gov/Coronavirus/Uninsured).

GAO Reports

GAO provides oversight of the federal response to the pandemic and COVID-19-related spending. Information on COVID-19 supplemental funding is available on the "Coronavirus Oversight" page (https://www.gao.gov/coronavirus/). The following GAO reports in particular have detailed information on PHS and COVID-19 related funding:

• COVID-19: Opportunities to Improve Federal Response and Recovery Efforts (GAO-20-625, June 25, 2020)
• COVID-19 Contracting: Observations on Federal Contracting in Response to the Pandemic (GAO-20-632, July 29, 2020)
• COVID-19: Brief Update on Initial Federal Response to the Pandemic (GAO-20-708, August 31, 2020)
• COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions (GAO-20-701, September 21, 2020)
• COVID-19: Federal Efforts Accelerate Vaccine and Therapeutic Development, but More Transparency Needed on Emergency Use Authorizations (GAO-21-207, November 17, 2020)
• COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response (GAO-21-191, November 30, 2020)
• COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity, and Other Challenges Require Focused Federal Attention (GAO-21-265, January 28, 2021)
• Operation Warp Speed: Accelerated COVID-19 Vaccine Development Status and Efforts to Address Manufacturing Challenges (GAO-21-319, February 11, 2021)
• COVID-19:Sustained Federal Action Is Crucial as Pandemic Enters Its Second Year (GAO-21-387, March 31, 2021)
• COVID-19: Efforts to Increase Vaccine Availability and Perspectives on Initial Implementation (GAO-21-443, April 14, 2021)
• COVID-19: Continued Attention Needed to Enhance Federal Preparedness, Response, Service Delivery, and Program Integrity (GAO-21-551, July 19, 2021)
• COVID-19 Contracting: Actions Needed to Enhance Transparency and Oversight of Selected Awards (GAO-21-501, July 26, 2021)

PHS Agency Websites

The following PHS agency websites have information on the distribution of COVID-19 supplemental funding:

• ASPR. BARDA's COVID-19 Medical Countermeasure Portfolio (https://www.medicalcountermeasures.gov/app/barda/coronavirus/COVID19.aspx) has information on funding awards for the development and manufacturing of COVID-19 products including diagnostics, vaccines, and therapeutics. ASPR's COVID-19 Supplemental Funding Overview (https://www.phe.gov/emergency/events/COVID19/HPP/Pages/overview.aspx) has a funding table by state for several programs supporting health care system COVID-19 response funded by the Coronavirus Preparedness and Response Supplemental Appropriations Act and the CARES Act.
• CDC. The CDC Budget website (https://www.cdc.gov/budget/index.html) provides CDC COVID-19 State, Tribal, Local, and Territorial (STLT) Funding (https://www.cdc.gov/budget/fact-sheets/covid-19/funding/index.html) with information on funding by supplemental measure, program, and topical area by jurisdiction. Additional information is available on the page "Budget Fact Sheets: Novel Coronavirus (COVID-19)" (https://www.cdc.gov/budget/fact-sheets/covid-19/index.html).
• HRSA. HRSA provides funding information on various pages for programs that received supplemental funding; for example, "Primary Health Care Coronavirus Related Grants by State Funding Report" (https://data.hrsa.gov/data/reports/datagrid?gridName=COVID19FundingReport); "Coronavirus Disease (COVID-19) Frequently Asked Questions – Federal Office of Rural Health Policy" (https://www.hrsa.gov/rural-health/coronavirus/frequently-asked-questions); "Rural Health Clinic COVID-19 Testing and Mitigation Program Funding Distribution" (https://www.hrsa.gov/coronavirus/rural-health-clinics/testing/funding); and "Ryan White HIV/AIDS Program: FY 2020 CARES Act Awards" (https://hab.hrsa.gov/coronavirus/cares-FY2020-awards). Relevant information can also be found on the HHS TAGGS pages for the Provider Relief Fund (https://taggs.hhs.gov/Coronavirus/Providers), Rural Health Clinic (RHC) COVID-19 Testing Fund (https://taggs.hhs.gov/Coronavirus/RuralHealthClinics), and the Uninsured Relief Fund (https://taggs.hhs.gov/Coronavirus/Uninsured).
• IHS. The IHS website Coronavirus (COVID-19) Resources (https://www.ihs.gov/coronavirus/resources/) provides details on funding under the section "COVID-19 Funding Guidance for Tribes, Tribal Organizations and Urban Indian Organizations," including "Guidance on Indian Health Service COVID-19 Funding Distribution for Tribes, Tribal Organizations, and Urban Indian Organizations" (https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/COVID-19_Funding_Guidance_Tribes_UrbanIndianOrganizations.pdf) and "FY 2020-2021 Coronavirus (COVID-19) and American Rescue Plan Act Funding Allocations" (https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/FY-2020-2021-COVID19-ARPA-Funding-Summary.pdf).
• NIH. NIH provides details on research projects funded by COVID-19 supplemental measures, filtered by state and congressional district on the site COVID-19 Research: Funding (https://covid19.nih.gov/funding). Also, the NIH RePORTER database (https://reporter.nih.gov/) provides details on NIH-funded projects with more detailed search capabilities. The "Advanced Projects Search" page (https://reporter.nih.gov/advanced-search) has an option to add the search filter "NIH COVID-19 Response," with choices for "NIH Regular Appropriations Funding Used for COVID-19 Research," which allows users to limit the search to COVID-19 research funded by regular NIH appropriations, COVID-19 supplemental appropriations, or specific supplemental appropriations laws.
• SAMHSA. The SAMHSA website Coronavirus (COVID-19) (https://www.samhsa.gov/coronavirus) under "SAMHSA Resources and Information" provides COVID-related grant funding details under "FY 2021 SAMHSA COVID-19 Funded Grants" (https://www.samhsa.gov/sites/default/files/covid19-programs-funded-samhsa-fy21.pdf) and "FY 2020 SAMHSA COVID-19 Funded Grants" (https://www.samhsa.gov/sites/default/files/covid19-programs-funded-samhsa.pdf).

SAM.gov Data Bank: Contract Data Reports

• Contract Data Reports (https://sam.gov/reports/awards/static) includes a "COVID-19 Report," which is a spreadsheet of COVID-19 pandemic-related federal contract awards that have been made since March 13, 2020. Note that this is a very large file. The spreadsheet may be filtered by criteria such as agency, place of performance (including state and congressional district), and Treasury Account Symbol (TAS).

Nongovernment Sources

The following sources are examples of unofficial, nongovernment sources that provide tracking and analysis of COVID-19 supplemental funding:

• COVID Money Tracker (Committee for a Responsible Budget), https://www.covidmoneytracker.org/explore-data/interactive-table
• COVID-19 Relief Spending Tracker (Project on Government Oversight), https://covidtracker.pogo.org/table-view
• Coronavirus Disease 2019 (COVID-19) (Federal Funds Information for States, FFIS), https://ffis.org/COVID-19 (by subscription only)
• Coronavirus Contracts: Tracking Federal Purchases to Fight the Coronavirus (ProPublica), https://projects.propublica.org/coronavirus-contracts/