What is federal COVID relief money for anyway?

As the daily news headlines detailing the spread of bird flu grow, so does Dr. Leonard Mermel’s anxiety.

An infectious disease expert who works as medical director for Lifespan’s Department of Epidemiology and Infection Control, Mermel fears what the outbreak of H5N1 avian influenza now detected in cows, skunks, and even one confirmed human case, in the United States could mean. Human-to-human transmission, not yet confirmed, would be far worse than what was experienced during the COVID-19 pandemic.

“The mortality rate of that virus in humans is as high as 30%,” Mermel, who also serves as a professor of medicine at Brown University, said in a recent interview. “That’s 10 times more deadly than SARS-CoV-2 [the name for virus causing COVID-19]. We want public health authorities to be ready.”

Yet the federal relief aid set aside for Rhode Island state agencies to handle public health emergencies, including the COVID-19 response, has barely been touched. And now, Gov. Dan McKee wants to repurpose more than half of that leftover funding to other, non-health-related projects like the Interstate-195 Washington Bridge rebuild and the state’s unemployment insurance trust fund.

Funds must be obligated by Dec. 31 of this year, and spent by the end of 2026, according to the U.S. Department of Treasury.

The Pandemic Recovery Office, a subset of the Rhode Island Department of Administration (DOA), identified several buckets of COVID-19 federal funds as “at risk of significantly underspending,” based on lack of use so far. With the December deadline to obligate funds looming, state officials recommended giving back $40 million in unspent State Fiscal Recovery Funds (SFRF) to the state for other projects, according to a January report by the Pandemic Recovery Office  

The funds, part of Rhode Island’s $1.1 billion share of American Rescue Plan Act aid, were originally earmarked to pay for COVID-19 testing, vaccines, contact tracing and other public health measures. 

“The state has not experienced a surge in cases great enough to require their use,” Derek Gomes, a spokesperson for DOA, said in an email on Friday.

Not so fast, Mermel countered.

Between the prospect of an even deadlier public health crisis of avian flu in humans, and the inevitable surge in COVID-19 cases as the virus continues to mutate, he wants the state to hang on to federal funds for health emergency preparation and response. 

“We don’t know what’s next on the horizon,” Mermel said. “We need to have a robust public health system to identify, manage and stymie transmission.”

Indeed, staffing shortages and a scarcity of testing centers and vaccines in the initial COVID-19 outbreak showed the state’s lack of preparation.

Dr. Michael Fine, former state health director who serves as chief health strategist for the cities of Central Falls and Pawtucket, recalled begging the federal government for money to set up testing centers in hard-hit communities when COVID-19 first hit Rhode Island.

By the time federal aid became available, and state leaders developed a plan to spend it, approved alongside the state’s fiscal 2023 budget, the sense of urgency surrounding the COVID crisis had subsided.

The state health department reported 9,120 COVID-19 total cases in June 2022, when the state’s long-term spending plan for federal pandemic aid was approved. At that time, there were 30.6 hospital admissions and 8.8 deaths per 100,000 residents. Cases, hospitalizations and deaths reported to the state have continued to decline, with 408 total cases, and five hospitalizations and less than one death per 100,000 residents in April 2024.

At its peak in January 2022, state health officials reported more than 101,000 cases with a hospitalization and death rates of 181 and 30.4, respectively, per 100,000 residents.

McKee’s original pandemic spending plan, approved in fiscal 2023, included $186.9 million for the state’s COVID-19 response through fiscal 2025. This was separate from money given to hospitals, nursing homes and community health centers.

A year later, as part of the fiscal 2024 budget, $110 million was moved to other projects. The remaining $73 million was split between the Department of Administration ($41.8 million) and the Department of Health ($34.9 million). None of the DOA money has been spent, while the health department has used $13.4 million of its COVID-related funding as of March 2024, according to data with the Pandemic Recovery Office.

McKee in his initial fiscal 2025 budget proposal unveiled in January, proposed shifting $20 million from the DOA’s COVID aid to other projects, including plugging budget deficits within the Rhode Island Department of Corrections and Rhode Island Public Transit Agency. On April 22, McKee proposed a budget amendment essentially draining the remaining DOA COVID money, leaving just $1.8 million for fiscal 2025.

Instead, McKee pitched spending the money for housing and homelessness initiatives, state transportation projects including the state share of the cost to rebuild the Washington Bridge and bolstering the unemployment insurance trust fund, among others, according to a separate budget amendment memo submitted the same day,

Sen. Sam Zurier, a Providence Democrat, wasn’t sold. 

“I just question whether this is the right time to take $20 million out of our COVID program and use it for the bridge,” Zurier said during a State House hearing April 23 on the health department budget.

His comments came seconds after state health officials shared updated vaccination rates during the same Senate Committee on Finance hearing, showing that 18% of Rhode Islanders have received the latest COVID-19 vaccine. 

Seema Dixit, the deputy director for RIDOH, blamed the seemingly low participation on vaccine fatigue, noting that Rhode Island is on-par with regional and national averages. As of April 19, 14% of children and 22.8% of adults nationwide had received the latest COVID vaccine, according to the Centers for Disease Control and Prevention.

Zurier was not satisfied.

“That means five out of six people are not getting this vaccine,” he said during the Senate Finance Committee hearing, noting that the health department’s own budget presentation acknowledges the risk of potential COVID-19 surges in the future.

In a later interview with Rhode Island Current, Zurier elaborated.

“The primary responsibility for that money is to give us resilience against this pandemic and future ones,” he said. “I just want to make sure we’re doing everything we can before we give that money up.”

Public health funding wish list

Dixit seemed skeptical that more education and outreach could get more Rhode Islanders to roll up their sleeves for the latest COVID-19 shot. But other public health experts offered up a wealth of ways to spend the federal aid on public health preparation and care.

Among the top prescriptions: strengthen the state’s primary care workforce, which has suffered from shortages even before the COVID-19 pandemic came to town.

“We know there is a critical shortage of primary care doctors, and those are one of the most trusted sources for encouraging vaccinations in underserved communities,” said Chris Gadbois, CEO of nonprofit Carelink Inc. and past board president of the Rhode Island Public Health Association. 

A bevy of bills up for consideration at the Rhode Island State House seek to tackle the primary care shortage. Among them: proposals to start a scholarship program to incentivize medical and nursing students to stay in the state, and increase the number of clinical training sites where primary care professionals can hone their skills. The combined $3.5 million funding required in fiscal 2025 for both initiatives was initially proposed to come from state general revenue.

But perhaps that would be a better use of pandemic aid than a bridge, which while crucial, has little to do with the aftermath of the crisis that spurred the funding, Zurier said.

The D.C.-based the Center on Budget and Policy Priorities in a January 2023 report specifically named state transportation projects and unemployment insurance trust funds as examples of spending of federal pandemic aid that don’t actually address the health and human impacts of the crisis.

Federal guidelines allow states to spend their American Rescue Plan Act relief on replacing lost revenue, in addition to programs that address the health, economic and human service gaps created by the pandemic. But just because they can, doesn’t mean they should, said Whitney Tucker, director of the center’s state fiscal policy research

Some of these initiatives like a bridge or unemployment trust fund fall outside the spirit of what the funding was intended for,” Tucker said. “I am not saying there aren’t urgent needs there, but they are not needs that should be funded from this money.”

The revised spending plan for Rhode Island’s pandemic aid, adopted in the fiscal 2024 budget, allocates $600 million — over half of its total $1.1 billion windfall — to negative economic economics. Revenue recovery accounts for another $371 million of allocated funds as of July 1, 2023, equal to one-third of total aid. Meanwhile, the $120.6 million allocated for public health represents just under 11% of the federal funding.

McKee’s office deferred questions for comment to the state health department.

Joseph Wendelken, a health department spokesperson, offered an emailed response in which he highlighted the $32.2 million still available in the proposed fiscal 2025 budget for COVID-19 prevention and control. 

“Combined with other non-SFRF funding sources, we have the resources we need to effectively do work related to COVID-19 prevention and control,” Wendelken said.

The health department anticipates spending the entire $32 million on COVID-related surge needs, technical assistance, data and analytics and communications in fiscal 2025, according to Wendelken. A separate allocation in the proposed fiscal 2025 budget, funded through a restricted receipt account from fees to health insurers, would pay for COVID-19 vaccines.