PAHPA's Not Sick, It's Dead

The Pandemic and the All-Hazards Preparedness Act (PAHPA) is dead. Some believe that it's gravely ill, maybe on a ventilator. Not true; it's dead. But there is hope because it was a witnessed arrest, CPR is in progress, and the defibrillator is charged. Clear!

Author's Note: Since the Center for Disease Control and Prevention (CDC) was created in 1946, its authority is tied to many sections of the Public Health Services Act. Though the Public Health Emergency Preparedness Program (PHEP) appears to be hit by PAHPA's expiration, the broader impact on the Division of State and Local Readiness (DSLR) is unclear. Therefore, this article focuses on ASPR and its programs.

But if PAHPA's dead, how is the U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response (ASPR) still operating? And how is the Hospital Preparedness Program (HPP) reimbursing expenses submitted by states receiving the HPP Cooperative Agreement (CA)? And what does the mean for Health Care Coalitions (HCCs)?

As we'll learn, it's all about timing, and the clock is ticking on HCCs.

Resuscitation?

So here we are, PAHPA reauthorization has failed; it's expired, they say. Others like to say it's on life support. That's untrue; it's dead. Effective October 1, there's no pulse or breathing, but there is hope because it was a witnessed arrest. CPR is in progress; the monitor shows V-Fib, not asystole, and the defibrillator is charged.

Technically, we're not talking about reauthorization anymore. Reauthorization is more like having a myocardial infarction but making it to the cath lab and having the clot removed before going into cardiac arrest. PAHPA has coded, and we're praying for resuscitation.

It's an alarming period for the healthcare emergency management community. We've endured massive funding cuts, a move away from direct facility funding, new emergency preparedness regulations?from the?Centers for Medicare & Medicaid Services, and requirements that redirected much funding to hiring full-time?HCC?employees.

Still, few had PAHPA's death on their radar. And many remain in denial, believing a few zaps with 360 jouls will spark the program to life. Hopefully, the deniers are correct. But in the wake of the highly politicized COVID-19 response and Congress' newfound appreciation for fiscal discipline, the possibility of PHAPA's funeral is real.

And PHAPA is likely only the first domino to fall across the portfolio of federally funded emergency management programs. But that's a story for another day.

If?Elisabeth Kübler-Ross'?Five Stages of Grieving?are on-target, today's denialism will soon bleed to anger, then bargaining, depression, and finally, acceptance. Let's be clear: there's one absolute in all of this: neither denial, depression, nor acceptance will resuscitate PAHPA. Those are post-funeral strategies.

So, stakeholders that appreciate the family business must stop waiting for the funeral; get angry and start bargaining (lobbying).?

As professional colleague Andrew Pickett pointed out here on LinkedIn in September, more attention needs to be paid to the plight of PAHPA. Andy's plea was from a position of deep knowledge of Congress' temperature. He's the Director of the Bureau of Emergency Preparedness and Response at the Pennsylvania Department of Health and the outgoing chair of the?Association of State and Territorial Health Officials?Directors of Public Health Preparedness Peer Network.

Despite Andy's long professional history and credibility, his plea – and my attempt to amplify it – seemed to fall on deaf ears.?Maybe denial is locked in, or simply ignorance is bliss. It could be that the death will be acknowledged when the money stops flowing from the HPP CA.

It's beyond time to get angry.

Peel the Onion

But go in knowing that successful resuscitation is only the first step, and the definition of success means different things to different stakeholders. The return of a pulse and spontaneous circulation may initially bring relief and celebration, but will there be quality of life going forward?

Even with resuscitation, depending on what the new law holds, ASPR and HPP may differ significantly from today.

As we work the code, we must educate and advocate for a meaningful law that does not decimate needed authorities. And since?authorization?does not guarantee?appropriations, we must build stamina for the unending annual funding battles.

You see, this onion has three layers to peel. The first two reoccur every five years and, until now, were frictionless. The third layer must be peeled annually, and it has been anything but. There's no rest for the weary. So be ready to fight or pack your parachute. You are in, or you are out.

While deniers wait in the quiet room for news on the outcome of the heroic resuscitation efforts in the trauma bay, there's comfort in short-term financial security as the Fiscal Year (FY) 2024 HPP CA continues to reimburse states for authorized costs. As such, HCCs also live to fight another day.

Actually, that'd be the number of days left until September 30, 2024. Tick, tick, tick...

Knowing how ASPR and HPP seem unaffected by PAHPA's expiration comes down to understanding the lexicon, legislative process, and appropriations cycle. As I've detailed in my LinkedIn post,?Preparedness, Tomato, Tomaaato...,?words matter.

Law>Agency>Programs>Appropriations

Understanding the legal hierarchy and interrelations keeping ASPR operating requires knowing the underlying lexicon as it applies to the federal government.

• Authorization:?Legislation that can establish, continue, or modify an agency, program, or activity for a fixed or indefinite period of time.
• Appropriations:?Legislation that authorizes agencies to make payments from the federal treasury (allows agencies to spend money for authorized purposes).
• Amendment:?Legislation that changes existing law by adding, subtracting, or substituting text.
• Sunset Provision:?Text in a law that?automatically terminates an agency, a law, or a government program that fails to obtain reauthorization?within a fixed period.
• Reauthorization: Legislation that authorizes an existing law with a sunset provision to remain in effect for a period of time.
• Fiscal Year (FY):?A one-year period used by some businesses, governments, and nonprofits that ends on a date other than December 31. The FY for the U.S. government is October 1 through September 30.

After taking in the definitional foundation above, the hierarchy specific to PAHPA, ASPR, and HPP comes into focus.

1. PAHPA is a?law?enacted by Congress and signed by the President in December 2006. It is an?amendment?to the?Public Health Services Act of 1944.
2. PAHPA is ASPR's enabling legislation that?authorizes?its existence and permits the operation of its?programs?and activities.
3. HPP is a PAHPA-authorized?program?in the ASPR?Office of Health Care Readiness.
4. The HPP?funding opportunity?is a PAHPA-authorized activity offered to state health departments through a?Notice of Funding Opportunity (NOFO).
5. The HPP?Cooperative Agreement (CA)?is a contract states enter into with ASPR that formalizes their acceptance of and agreement with requirements and restrictions outlined in the NOFO.
6. PAHPA does not guarantee funding for ASPR, HPP, and the CA; funding is determined annually through the?appropriations?process on The Hill.
7. PAHPA has a?sunset provision?that requires?reauthorization?from Congress to remain in effect. Reauthorization was uncontested in 2013 and 2018, but 2023 turned into a political scrum. The sun set on PAHPA on September 30, 2023.?
8. FY 2024 funds appropriated prior to PAHPA's expiration must be closed out by September 30, 2024.

Taken all together, it seems clear that PAHPA is indeed dead. Yes, warm, but dead. As such, ASPR, HPP, and HCCs are gravely ill and, without resuscitation, should plan for hospice care in the months ahead.

For those in denial, waiting in the quiet room for news, the time is now to either get angry or parachute into a new line of work. If you love what you do, reach out to the organizations educating, advocating, lobbying to secure PAHPA's resuscitation – I mean reauthorization.

• Association of State and Territorial Health Officers (ASTHO)
• American Hospital Association (AHA)
• National Association of County and City Health Officials (NACCHO)
• American Public Health Association (APHA)
• National Governors Association (NGA)
• Big Cities Health Coalition
• Trust for America's Health
• Association of Healthcare Emergency Preparedness Professionals (AHEPP)
• Healthcare Ready
• International Association of Emergency Managers (IAEM)

FYI:?A reauthorized law may receive a new title but is generally referred to by the original title followed by ", as amended". PAHPA has followed this pattern:

• 2006: Pandemic and All-Hazards Preparedness Act (PAHPA)
• 2013:?Pandemic and All-Hazard Reauthorization Act (PAHPRA)
• 2018:?Pandemic and All-Hazards Preparedness and Advancing Innovation Act (PAHPAIA)
• 2024: Stay Tuned!

To better understand the potential fallout of PAHPA's funeral for emergency managers and public health administrators, please read Public Health; It's Not Health Care: The HCC Bridge.