Since March 2020, more than $400 billion has been appropriated for the domestic Coronavirus Disease 2019 (COVID-19) public health response to Department of Health and Human Services (HHS) agencies, mostly as emergency-designated supplemental discretionary appropriations.¹ Much of this funding is available for multiple years or until expended. HHS has allocated funding for vaccines, therapeutics, tests, and health care supports, among other activities.² In 2022, Congress has considered additional supplemental appropriations for HHS to support continued COVID-19 response activities. In addition, with the recent public health emergency declared for the monkeypox outbreak, more recent legislative and Biden Administration proposals would provide supplemental appropriations for other emerging diseases in addition to COVID-19.³ This report summarizes the President's requests for additional funding, selected congressional proposals in response, and selected policy considerations. COVID-19 supplemental funding for HHS was not included with the FY2023 continuing resolution package enacted in late September 2022 (H.R. 6833).

President's March 2022 Request, Subsequent Proposals, and Related Developments

March Request

On March 2, 2022, the White House submitted an FY2022 supplemental appropriations request of $22.5 billion for HHS and other agencies to support ongoing COVID-19 response efforts.⁴ The HHS portion of the request would provide $18.3 billion, as summarized in Table 1. According to the request, much of the funding would support procurement of oral antivirals, monoclonal antibodies, booster and pediatric vaccines, and rapid and lab-based tests. The funding would also support preparedness for new variants, including research and development for "pan-COVID" next-generation vaccines and surveillance of new variants.⁵ In addition, the Centers for Disease Control and Prevention (CDC) would allocate $750 million for global COVID-19 vaccine assistance (in addition to Department of State, Foreign Operations, and Related Programs appropriations for global assistance).

Selected Congressional Proposals and Related Developments

COVID-19 supplemental appropriations were included in an early version of the FY2022 omnibus appropriations package (see Rules Committee print in Table 1).⁶ However, these appropriations were ultimately excluded from the enacted Consolidated Appropriations Act, 2022 (H.R. 2471; P.L. 117-103, March 15, 2022), reportedly after some Members objected to rescinding certain previously appropriated funding in the American Rescue Plan Act (P.L. 117-2) to offset the proposed supplemental COVID-19 appropriations.⁷

On April 4, 2022, a group of Senators announced a bipartisan agreement on COVID-19 supplemental funding.⁸ However, on April 5, 2022, the Senate voted not to invoke cloture on the motion to proceed to consider the proposal (using H.R. 4373 as the legislative vehicle).⁹ No subsequent action has occurred as of the date of this report. Several Senators reportedly voted against cloture because they sought an agreement on amendments that would be considered to the bill.¹⁰

On June 8, 2022, the Administration reportedly repurposed $10 billion in existing funding, originally allocated for testing and other purposes, to purchase vaccines and therapeutics.¹¹

As the FY2023 appropriations cycle has progressed, congressional debate has continued over potential supplemental COVID-19 funding. COVID-19 supplemental appropriations were not included in the bill reported on July 5, 2022 by the House Labor, HHS, Education and Related Agencies (LHHS) Appropriations Subcommittee.¹² The Senate Appropriations Committee Chair released draft FY2023 appropriations bills on July 28, 2022.¹³ The LHHS draft bill includes a title with $16 billion in HHS FY2022 emergency-designated supplemental appropriations for COVID-19 or "any disease with potential for creating a pandemic."¹⁴ According to a press release from Senate Appropriations Committee leaders, proposed funding is for the "the next phase of the COVID-19 pandemic and to address other emerging diseases that pose a significant threat to public health."¹⁵

Table 1 compares appropriations amounts across the proposals, and Table 2 summarizes and compares key provisions.

September Request Update

On September 2, 2022, the Biden Administration announced an updated proposal for COVID-19 supplemental funding packaged with its FY2023 continuing resolution request.¹⁶ COVID-19 supplemental funding for HHS was not included with the FY2023 continuing resolution package enacted in late September 2022 (H.R. 6833).

The request would provide $18.4 billion for HHS, all provided to the Public Health and Social Services Emergency Fund (PHSSEF) account and available until September 30, 2026. The requested statutory text for the appropriation includes no set-asides; funding would be available for a broad set of purposes, including for research, development, manufacturing, production, purchase, distribution, promotion, monitoring, tracking, and administration of vaccines, therapeutics, diagnostics, and other medical supplies, as shown in Table 1. Additionally, provisions accompanying the appropriation would further allow funds to be used for myriad purposes, such as payments for testing, purchases for the Strategic National Stockpile, grants to federal community health centers, and grants to state, local, territorial, and tribal governments and other community organizations, as shown in Table 2. (The request would also provide a separate $3.9 billion appropriation to HHS for the monkeypox public health emergency. This aspect of the proposal is not included in the tables below because this report focuses on COVID-19 funding.)

An additional funding summary provided by the Biden Administration broke down the $18.4 billion in COVID-19 supplemental funding requested for HHS as follows:¹⁷

• $7.1 billion to procure additional vaccines and therapeutics, purchase equipment for the Strategic National Stockpile, cover vaccination costs for the uninsured and underinsured, and improve access to treatment for people with Long COVID;
• $2 billion to continue testing programs, including by supporting free community testing at pharmacies, sustaining testing capacity, and distributing free tests to households;
• $8 billion for R&D for new vaccines and therapeutics; and
• $1.3 billion to support ongoing Phase 3 clinical trials for adult and pediatric vaccines, and for variant surveillance.

Selected Considerations

Public Availability of Data on COVID-19 Public Health Spending

Throughout the pandemic, real-time publicly available information on COVID-19 public health spending by appropriated purpose has been limited—due in part to how Congress and the President appropriated the funding. Much of the COVID-19 relief public health appropriations were made available for broad and flexible purposes.¹⁸ Further, a large portion of COVID-19 relief funding was appropriated to the PHSSEF account, including funding for the Provider Relief Fund, testing, vaccines, and therapeutics, among other purposes.¹⁹ The laws that provided COVID-19 relief funding also included transfer authorities that have allowed HHS to shift funds between accounts.²⁰ Providing emergency appropriations to the PHSSEF account under the Office of the Secretary, in addition to transfer authorities, has allowed HHS some flexibility to allocate funds to meet emerging needs. At the same time, this practice has diminished public transparency regarding how much funding has been spent for what purpose. Official federal spending trackers such as USASpending.gov track spending by agency and account. When several different appropriations are provided to an account, or when funds are shifted between accounts, it is challenging for observers to assess what amount of the appropriations have been spent for specific purposes as appropriated.

The Government Accountability Office has separately published detailed tables on HHS COVID-19 funding by agency and activity (e.g., vaccines, testing) in its quarterly CARES Act reports, but these tables are not current—they reflect data from several months earlier.²¹ Though not official, media organizations have published what are reportedly more detailed White House documents on COVID-19 spending transmitted to Congress.²²

It is unclear whether current congressional proposals would improve publicly available information. Such proposals would continue the practice of providing all of the supplemental appropriations to the PHSSEF account. Although the proposals would require regular reports to congressional committees, it is unclear if the reports would be made publicly available. Congress could also propose long-term solutions to better track HHS public health emergency spending and require that spending data be made publicly available in useful categories and formats for analysis.

Policy Considerations

In determining whether and how much funding to appropriate toward the public health response to COVID-19 and other threats, Congress may consider the following issues:

• Supply availability and demand: Data regarding ordered and administered COVID-19 therapeutics and vaccines do not indicate a supply shortage relative to demand, but this situation may not continue.²³ For the current bivalent COVID-19 vaccine booster campaign, program operational guidance notes that the Administration has purchased enough doses "to ensure a robust and complete national booster vaccination campaign through the fall and early winter."²⁴ One survey shows that, as of September 2022, about one-third of adults have already received or intend to get the booster as soon as possible. The rest are waiting, do not intend to get a booster, or are ineligible.²⁵ Public education and awareness, however, could affect demand.²⁶ Separately, several COVID-19 therapeutic products are in late-stage clinical trials and may become available for purchase later this year.²⁷ Further, the Biden Administration specifically highlighted a goal to maintain testing capacity for future surges in a blog post on the September 2022 request for additional funding.²⁸
• Variants: The evolution of SARS-CoV-2 is unknown, which adds uncertainty to any supply needs projection. Some currently available vaccines, therapeutics and tests might be ineffective against future variants.²⁹ Some of the proposed funding in the FY2022 supplemental appropriations proposals would fund pan-COVID vaccine research, which is already supported by the Department of Defense and NIH.³⁰
• Commercialization: To date, the federal government has purchased much of the U.S. COVID-19 vaccine and therapeutics supply. Congress could consider whether and when to stop appropriating specific funds for federal purchase and distribution, and therefore transition COVID-19 products to routine health care financing systems. On August 30, 2022, the Administration for Strategic Preparedness and Response (ASPR) announced plans to commercialize COVID-19 products, with vaccines and therapeutics transitioning to the commercial market by early 2023. According to the announcement, the commercialization plans were "accelerated" given the lack of additional funding from Congress. The announcement also states that additional funding would assist with winding down federal procurement and distribution programs.³¹
• Monkeypox outbreak: The public health emergency for monkeypox raises new questions as supplemental appropriations are considered. As noted, the July 28 proposal from the Senate Appropriations Committee Chair would provide funding that would be available for both COVID-19 and other emerging threats. In contrast, in September 2022, the Biden Administration has requested separate funding for COVID-19 and monkeypox response respectively. As another consideration, many states and other jurisdictions have remaining funding balances on COVID-19-specific public health grants that they received from the prior relief laws.³² Congress could consider legislative changes to expand the possible uses of existing grant funds to other threats.