Leveraging federal dollars for COVID-19 response: Part 2

Full transcript below: 

Marko: Hello. This is Marko Bourne with ICF, Senior Vice President of Special Projects and Initiatives. Thank you for joining us again today for a podcast in regards to COVID-19 and the nation's response and recovery from this event as it continues. Several weeks ago, we did a podcast that was based on the initial understanding of the federal funding that's available for state and local governments and individuals, including HHS funds from the Department of Health and Human Services, and the various sub-components of that organization. The Housing and Urban Development funding that is available through the Community Development Block Grant programs and the latest version of that, the CDBG-CV funding. And then, finally, the FEMA side of the equation--where all 50 states have been declared for COVID-19 under the Public Assistance Program--especially for things like emergency protective measures, equipment, and those kind of services. That funding podcast was based on information that was available at the time, much of which is still very much in play and accurate.

But what we wanted to do was take on a Part Two. We're now several weeks into the event, almost bordering on a couple of months since the initial declarations were made. Our clients at the state and local level and, of course, our federal friends, have all been working through the myriad of issues that come up with regards to the response, the protective measures, the recovery operations from COVID-19. While we continue, in many places, to shelter in place, still practice social distancing, and deal with a number of issues surrounding the response and recovery that are going to get further complicated as we move into the summer months with potential hurricanes, tropical storms, and other natural hazards that work in conjunction with COVID-19 ongoing response and recovery, and the potential for a second wave.

I wanted to start it off today bringing back our three experts on the federal funding that's available, Meghan Treber, who leads our practice in the Department of Health and Human Services and specifically ASPR and the work we do there and at CDC—she’s a longtime emergency manager public health official. Also, Kelly Price. Kelly, leads our housing and urban development work for HUD itself--doing the training, and programs, and support efforts that allows state and local governments to understand the uses of CBDG dollars and the HUD programs that are available to them. And then, finally, Marty Altman. Marty is a longtime public assistance and FEMA response and recovery expert who handles many of our interactions with our state and local clients on how they receive, utilize, and understand the rules around federal funding for disaster relief--whether that comes from FEMA or other sources. Thank you, all three of you, for being here today. Appreciate it. And let's just jump right in. Meghan, from a health perspective, we are now at May 27th. What is the latest on the condition of the COVID response and what is HHS thinking about in terms of where we stand right now--and where we may go over the coming weeks?

The current situation

Meghan: Sure. Thanks, Marko. So, as of May 27th, we have over 1.6 million cases and more than 97,000 deaths in the United States , as Marko mentioned, in just a few short months, from a virus that we didn't know about six months ago. And we have all altered our lives, our businesses, and specifically--from my perspective--the way that we conduct healthcare, and even the way that we do emergency management to try to contain this virus. Scientists across the world are working on treatments and a vaccine, but there's still no sure treatment. And we are many, many, many months--maybe years--away from a vaccine that will be available to the entire population. Social distancing, disease mitigation, and preparedness for the next wave is now our new normal.

So, also as it is now May, on top of COVID-19, we are also entering a season of increased natural disasters, which will compound the COVID-19 situation. We've already had one named Atlantic Hurricane, and I think there's another one brewing. We've had a series of earthquakes in Nevada over the past couple of weekends in some other states. We've had severe flooding in Michigan, and unexpected winter storm in the Northeast, tornadoes in the Midwest, and we're coming into wildfire season. So, we need to prepare now for the reality of concurrent disasters and understand the best options available to protect residents and effectively respond and recover. That's really where the various federal state and local agencies are thinking. They're looking at this sort of transition out of the first wave of disease, although, in all reality, there are still many communities that have not experienced their peak yet. We are not done with the first wave of this pandemic. There might even be a second peak before we hit a full second wave. So, we need to just be careful with the term ‘recovery.’ This isn't your normal recovery where the event ends, and you can start to rebuild and resume either normal or new normal operations. This is the kind of event that is ongoing, long-acting, and continuous. So, there are shorter phases of recovery and it's just a new normal.

Marko: Meghan, certainly a lot of changes and lessons are being learned as we go here. As the funding that HHS has put in place, from their perspective of the equation, especially around health resources, Medicare coverage issues, all of the laboratory work, all of the hospital preparedness, what are they doing now and how is that kind of evolved over the course of the last couple of months from our original discussion?

HHS changes in the last few weeks

Meghan: Sure. Since the last time we talked, there have been some clarifications and a couple of additional cooperative agreements that have been issued from HHS and a few new programs. HHS, through ASPR--the Assistant Secretary for Preparedness and Response--and the CDC have several existing programs, the Hospital Preparedness Program and the Public Health Emergency Preparedness Program are used in preparedness for the healthcare system and the public health system to respond to emergencies. During times of emergency, there are augmented and new programs under those existing structures.

At HHS ASPR, there are four cooperative agreements that are available for COVID-19, specifically. One that goes to the existing 62 states, territories, and directly funded cities to help to enhance some staffing costs, equipment costs, but nothing to cover direct patient care costs. None of these cooperative agreements that I'm talking about can be used to cover direct patient care costs. There is an additional HHS ASPR cooperative agreement, that is being issued, or has been issued, to hospital associations in all 50 states, plus D.C. and Puerto Rico. Same concept of funding through the hospital associations and directly to hospitals and other healthcare facilities. This provides funding for equipment purchases, and some staff augmentation, and a few other items.

One cooperative agreement that goes to the NETEC, the National Emerging and Special Pathogens Training and Exercise Center. And then a final one that goes to the 10 regional Ebola treatment centers that were established as hubs for highly infectious disease management. At CDC, there are three cooperative agreements. One is the crisis response cooperative agreement, one is the epidemiology and lab capacity for COVID-19 cooperative agreement, and another is a tribal cooperative agreement--all issued to help augment public health emergency preparedness activities. The operations of your local or state health department helping to augment and cover those operations and epidemiology activities, so contact tracing, and quarantine, and isolation costs, and staffing costs for geological activities, and testing laboratory capacity. That is generally what those CDC efforts will cover. And then there are two other opportunities that we didn't really talk about in the last podcast because we were looking for some clarity and some guidance about what those were going to look like. The first is sort of regular routine reimbursement through the Centers for Medicare and Medicaid Services.

For facilities already enrolled as participating providers in Medicare and Medicaid, they can, and should, bill according to their normal procedures for any care given to one of their enrolled patients for COVID-19 services. Those are completely valid and reasonable costs that CMS will reimburse. Finally, the Health Resources and Services Administration, or HRSA, is administering a brand-new program for COVID-19, the COVID-19 Uninsured Program. It's funded through all three COVID-19 related congressional appropriations, and it is designed to provide funding or reimbursement for healthcare providers--for uninsured patients diagnosed with COVID-19--as a payer of last resort. So, if there's no insurance to bill--there's no Medicare, Medicaid to bill--a healthcare provider can apply for this program for reimbursement of treating a COVID-19 patient.

Marko: Excellent. Definite change from last time, and I'm certain that most of the medical facilities will welcome that. Because, obviously, the ability to pay for the service is critical, not only to providing it but also for those facilities to be able to continue to operate. And with regards to the reimbursement process, there are certain costs that--under the multiple entities able to provide it from the federal government, in terms of dollar reimbursement for certain costs--can actually be covered by more than one federal program. Is it possible for eligible entities, like, you know, state locals or hospitals or others to have costs covered by more than one of the federal programs?

Meghan: Absolutely. And in fact, it's pretty common to have emergency activities covered by more than one entity. As long as it as an eligible expense, you are an eligible applicant for whichever program you're looking at. And the costs are not being duplicated. You can have multiple programs cover similar or same eligible expenses. So, if something costs $100,000 and it is an eligible expense--and one entity can provide cost either in advance or reimbursement for, say, $50,000--you could still seek reimbursement for the remaining $50k from another source. You could also say in the case of an alternate care site, which is an area that I've been focusing a lot of my time on. An alternate care site is a structure of opportunity established to provide care outside of a hospital. So, you could have multiple costs and multiple covered expenses within that one structure or within that one project. And a different program is covering a cost for something different. Say one program covers the cost of beds, equipment, and PPE. Another program covers the cost of some staffing, overhead staffing--you know, indirect staffing. And another program perhaps covers the cost for the actual structure, the actual facility itself.

That is all eligible, that is all covered, that is all allowable. And then in the end, once you’re operational--if it is turned over and managed by a healthcare facility--you could build CMS for those Medicare patients, and you could build a COVID-19 Uninsured Program for the non-insured patients. So it's really a matter of talking with your state and local representatives--and for state and local reps, talking with your FEMA and your HHS, regional emergency coordinators and regional administrators--to figure out in advance what your best bet is and what your best options are. Marty is going to be talking about this, he always talks about this. You need to be able to accurately account for your costs and eligible expenses, and know exactly which program is covering which dollar. It's why meticulous accounting and record-keeping is so important for reimbursement right from the start.

Marko: That's a great point. And actually when we do talk about the FEMA funding a little bit later in the podcast, I definitely want to bring you back in because there's an interesting dynamic that gets played out in terms of federal dollars being used for reimbursement for certain protective equipment, and that is a lot of state and local governments won't need to know. Well, we'll tease that for now and we'll get back to that one in a moment. Now, obviously, we're in the midst of response and, in some cases, recovery, but still response in large measure. As we look to the future, preparedness actions, future wave of COVID, whether it is this fall or winter, is there funding still available now for preparedness actions to get ahead of that challenge moving forward?

Medical reimbursement funding to come

Meghan: Absolutely. The funding that was issued from HHS--the cooperative agreement funding--is absolutely still available. It was pushed out and it is still intended for use for either, depending on how you want to look at it. Either preparedness or mitigation actions, for current activities, and in preparation for a next wave or a new peak. So that is also available. CMS and HRSA funding for the COVID uninsured, those are reimbursements for actual patient care. So, while that funding is still available, it is not money that's available to you before you treat a patient. You would need to treat that patient, document your cost, and then reimburse like you would to any insurance company. Much of the work that we're doing now--like pre-purchasing, PPE, building alternate care capacity--those are all still available options. And definitely, jurisdictions are being encouraged to do that and keep those preparedness and mitigation actions in place, or keep them warm, so that all the work that we do now can be used later. Things like the Javits Center or other alternate care sites that have been established. We're not looking to turn those off and shut them down, just keep them warm so that they can be used in the future.

Marko: That's good to know, Meghan. Thank you. We'll be back to you here in a moment. I'd like to bring in Kelly Price for a few minutes here. We mentioned in an earlier podcast that, normally, folks don't necessarily immediately think of Housing and Urban Development as a funding source for disasters. But for, quite frankly, a couple of decades now, HUD, through the Community Development Block Grant programs, have provided resources to state and local governments through the CBDG program for disaster relief. They've recently received a significant amount of money over the last couple of years for future mitigation efforts nationwide, and most recently, have received additional dollars through the CARES Act for COVID-19 activities. As we look at the HUD programs, what are those resources that are available from HUD for COVID-19 and who's eligible for that?

Available uses for HUD funding

Kelly: Sure, great question. And you're right that HUD--while the name may not indicate disaster recovery in this type of more challenging kind of recovery-- has always played an important role. Given that they kind of cover the gamut from public housing and assisted housing, all the way through all sorts of community development, energy efficiency, and environmental type issues. And so, CDBG is often the program that Congress turns to, to put funding into recovery efforts--whether that be for natural disasters, or, in this case, economic disaster. And there's one precedent for this back during the sort of Great Recession, as we call it, of the housing market collapse called the Neighborhood Stabilization Program. And that was also CDBG funding.

So, there are a number of programs that have sort of branched off the tree of Community Development, and the latest one is the CDBG-CV. HUD was allocated a total of $12 billion in funding in the CARES Act. And that funding went to different programs. Some for housing authorities, for relief around rents and things like that, some significant amount of money actually to homelessness-related programs and prevention of homelessness through the Emergency Shelter Grant Program--which ICF also does a good deal of work around. And then the other big pot was CDBG-CV, and that was allocated $5 billion total. Since our last podcast, we're now at $3 billion of that now being allocated, and that sort of happened in two tranches, if you will--that's the term we use in the CGDR world. But that happened with $2 billion allocated based on the FY 2020 methodology that's typically used for regular CDBG.

And HUD got that money and those announcements out fairly quickly. That $2 billion was allocated to both states and entitlement jurisdictions. And entitlement jurisdictions are cities and counties of a certain size and that meet certain other criteria that's based in the regulations of the statute. Since we last met, $1 billion has additionally been allocated. That funding was announced on May 11. And the difference there is that how that was determined, and HUD put out a notice on that, but how that was determined was based less so on the typical CUG methodology, and more so this time based on the impact of COVID in the different states. And Congress laid out a number of those criteria for HUD in the CARES Act, and then HUD, you know, had to expand upon those and collect the data, and they've published a two-page document that's available on the HUD website to explain that methodology. The difference with this funding also is that it went to states and insular areas only. Entitlement jurisdictions--cities and counties that received some of that $2 billion--did not receive anything under this $1 billion allocation. Those states could choose to spend it in those areas should that need arise.

So far, $3 billion. The remaining $2 billion dollars, HUD is saying, will be allocated on a rolling basis. They actually have until 2022 to obligate that money. And the criteria around allocating that additional $2 billion is based more on the data that we previously discussed, that is still being collected and the impact of this still being determined around the instances of COVID and that sort of thing. I think we'll see that sort of roll out later, based on overall impact of COVID and certain hard-hit areas in the country. So, there's $3 billion out there to utilize at this point in time.

Marko: It's certainly a tremendous amount of money and have a number of great uses. What are some of the things that the CDBG-CV grantees and their partners can actually use the funding for?

Kelly: Yeah, that's a great question because one reason that CDBG is this tree that these recovery programs end up being funded through, in terms of the basis of the statute and the regulation, is because it does have a lot of flexibility. It goes to states and entitlement jurisdictions. So, it covers the gamut of rural areas and cities. And it also has, in the statute, over 20-some eligible activities. And those are...they're broad buckets of things that grantees can use the funding for in their communities. It ranges from affordable housing-- rehab and different projects like that--revitalization projects, economic development, infrastructure, and services, and everything in between. Those are just some of the broad groupings.

Because of the nature of COVID and, as we pointed out earlier, this sort of challenging, ongoing up and down of what will be this recovery. From what we understand--in talking to a number of grantees, and our clients, and the associations, and some of the HUD folks--there are three main areas where grantees seem to be coalescing around utilizing the CARES Act funding. These make sense if you think about the impact of this. One is the services. One of the things in the CARES Act that came out automatically was elimination of a cap that's normally on the CDBG funds that limits how much money grantees can use for public services. Normally, it’s a 15% cap. That is gone, so they can utilize a significant amount of money on different services. And the HUD regulations provide examples of the types of services, but they're not limited to those things. As long as they can show it's a new or a quantifiable increase in a service that wasn't provided before, which I think we all would argue.

We're in a new era of something we haven't anticipated or dealt with before of this magnitude, and it qualifies. It further needs to serve low to moderate-income people or low to moderate-income areas. And there's different ways that that's determined and there's a lot of guidance on that. So, a number of services, we've heard everything from supplementing food banks and Meals on Wheels programs, because of the need for food for folks who are unemployed or are struggling with underemployment. Medical services and things like that are being funded. And even some job retraining and other employment and counseling services to help folks who are struggling with being evicted or mortgage foreclosure. So that's a common area.

And, Marko, related to that, one of the really key areas that grantees are honing in on is that CDBG can be used in limited circumstances for emergency assistance to households--low and moderate-income households--to help them for up to three months with their rent payments, or mortgage payments, or utility payments. So that they do not lose their home and are not living in a home without those key utilities. Again, right now, that's limited to three months maximum. But a number of grantees and associations are lobbying for, and I use the term ‘lobbying’ broadly, a change to that in the upcoming guidance from HUD. They're hoping for that to be extended to 6 to 12 months because this thing is dragging on longer than any of us thought.

Rental assistance is a particular area of importance. Many grantees are trying to find a way to partner with housing authorities or local nonprofits to get that money out to households who desperately need it. And then the third most common area we're hearing about and helping some clients with is around business assistance. So, while there was the Paycheck Protection Program, SBA loans, and some other programs in some places, it seems to not still be enough. And there are a number of very small businesses and others who struggled to try to participate in those other programs, and maybe there wasn't sufficient funding or time for them to get in on that. So CDBG sort of oftentimes fills the hole, and we see this in the disaster recovery program as well.

A number of grantees in a couple of states, literally, that we're working with right now are putting together small business loan programs or small business grant programs--and even some to micro-businesses--which are defined in the regulations as very small businesses owned by low-income persons. And they're trying to stand up those programs fairly quickly, to figure out the underwriting and the qualifications around those programs. But I'm hoping that will help... with restaurants and other service-related industries, and other small businesses that may not have been able to access the other federal funding that's been available so far. There are many other activities as well, but those are sort of the key ones that seemed to hit directly at the most needed areas that we're seeing right now.

Marko: Well, it also seems to me, Kelly, that the programs that we've been talking about here that you've mentioned, in many ways, they're somewhat unique to CDBG-CV. But they actually cover aspects of disaster relief, which folks have a preconception of because of the way it's handled in natural disasters--such as if it was a hurricane, a tornado--and you needed rental assistance. It was about getting you a place to stay and that rent being covered or that assistance being covered. But in this case, you haven't lost your home, necessarily. You just don't have the income in order to necessarily pay the rent or pay the mortgage. And this is helping to provide some relief for that, which is kind of a twist on the whole thing, but incredibly more valuable in a lot of ways.

The potential follow-on crises

Kelly: Right. And there's an economic domino effect of that, too. They can't pay the rent, that affects the small landlords and even the larger real estate companies. If the mortgage crisis hits us again, that causes all sorts of ripple effects in the national economy. And then, we're even hearing from some states that their utility companies--primarily in rural areas--are really struggling because they just don't have the cash flow that some of the larger, multi-state utilities have, to go without businesses and households paying their bills. And so, they're struggling to try to make CDBG work with that. Also health services and how they can intertwine into the health services world, which is something that CDBG grantees aren't as familiar with. And would have to forge new partnerships, but the funding can be used to support some of those health services--testing, outreach, and that sort of thing--particularly to low-income and minority communities.

Marko: That's great to know. Kelly, we'll bring you back here in just a few minutes as we think about the future. What I want to do is bring Marty Altman in. Obviously, the FEMA Public Assistance Program is well known to many. Certainly, many state and local governments are well aware of the provision of recovery dollars that are available to those governments for a number of measures. And then under COVID, every state is eligible for emergency protective measures. And in many cases, some additional program benefits from the Public Assistance Program because of COVID-19, and there are multiple funding sources which most communities deal with on a lesser scale. But now are having to understand multiple programs and how they intersect. In working with our clients, you've seen them ask questions about how they maximize their recovery while avoiding a duplication of benefits. How do they go about doing that and what are they asking you to help them with? How are they addressing that challenge of this, the maximizing of these resources?

Plans for the inevitable return to the workplace

Marty: That's a good question, Marko. And as Meghan and Kelly were speaking on the programs that they have oversight on, how the complexity of the different funding sources are together, one of the biggest questions that we're getting is, "How do I keep track of all this? How can I maximize every funding source that's made available?" Meghan spoke a little bit of it when she was speaking about, you know, certain programs will pay for certain things. So what they're asking us is, "What kind of tracking mechanisms do you have in place?” Or “how can you guide us in order to make sure with all these funding buckets--the one that we're taking the maximum on each funding sources--and it's not coming into the duplication of benefits?" Because that's the key thing. And FEMA is the last resort. They've always been the last resort.

So, what we're doing is looking at a governmental entity and taking every funding source that's made available to them. Not everybody has the same funding sources, but some are pretty close to the same funding sources. And we're explaining it to them. You've got to understand what is covered by each and every one of those funding sources. Then, as Meghan also mentioned previously, the key thing is you got to document everything and be able to support whatever you're going to ask for reimbursement for. Without that documentation, you're not even going to be able to maximize your funding sources or know what bucket it goes into.

So, we're working with our clients, and applicants, and sub-applicants, and just saying, "Here's what you have, what have you expended?" And we'll just start putting it into buckets and see where you can maximize. ”Say this funding source is going to be able to take $100,000, and--just as Meghan says--it may cost you $200,000. Where can the rest of it go?” I call it going backwards, down to the final funding source, which is FEMA. And so they're looking for that expertise to understand because they're afraid that one is they're going to end up having a duplication and one of these agencies are going to come back and say, "We want our money back." Because that's always a big thing. Or, if they get audited, and they find out things are crossing over each and every funding source.

So, that's a critical thing. And it really is going to replay even a harder time. I tell people now, we're in the hurricane season, as you mentioned, and we had two named storms already. And then we had several tornado incidents and flooding incidents--this is coming into play. So not only do you have to worry about what funding sources for the COVID-19 response has been, but now you've got to be able to keep it segregated from the new event that you may be faced with. Because you can't overlap those causes either. That's one key question they're asking us, how to track these humongous funding resources that's out there.

Marko: When the funding's available, especially when we look at activities that CDC and HHS are recommending with regards to government facilities--never mind the security of businesses and all the rest of it--but really understanding how certain activities have to happen to comply with guidance from the CDC over retrofitting facilities. There are a number of options that state and local governments can take. And what funding is available for helping meet those federal guidelines from CDC for retrofitting facilities so that, quite frankly, government workers can get back into the workplace?

Marty: Well, currently, FEMA has not come out with their guidance on how they're going to handle that. So, everybody's still waiting. And that's a big question. Because even this morning and several phone calls, it says, "Has FEMA come out and say, 'How and what is eligible for retrofitting our facilities to bring our folks back into work?'" You know, we're talking about eligible sub-recipients and even some recipients itself. They're exposed to the same thing. I look at the State of Louisiana and they're starting to bring their people back and they're having issues already. They got to look at different alternatives on how they can keep workflow moving, as well as working off-site, remotely. And all that is still going on.

But everybody's waiting and saying, "Who's going to help us to fund retrofitting our facilities? Because it is a cost that is strictly related to this incident and this disaster." So, we're still waiting on answers. And just as we've mentioned many a times, this is a very complex disaster. It's unprecedented. And it's changing every day, to what's going to be coming out. Who's going to pay for what? I know everything in FEMA's world is we have to adhere to what HHS says and CDC says. They are the primary agency to manage a pandemic, and FEMA's taken nearly off and everything reverts back to them. So, again, back to the multiple funding sources. Determining what CDC will pay for, what HHS will pay for, and then what FEMA will pay for, and everybody is just waiting for the FEMA piece right now.

Marko: Well, has there been any guidance from FEMA on reimbursement for putting up temporary facilities?

Marty: They've come out back with non-congregate sheltering facilities that they will pay for and reimburse for. And if they have to put a temporary facility up in making sure there's no duplication of benefits, FEMA will reimburse them for temporary facilities, to put up testing facilities and treatment facilities, depending on what isn't being reimbursed from the other agencies. Again, FEMA is the last resort.

Marko: I would like to also bring Meghan into the discussion on, at this point, again, too. I think from a medical care cost standpoint, there are some costs that FEMA will pay for, that, you know, the alternate care sites, you know, equipping them, staffing them, etc., and the associated costs. But there are some interesting things for both FEMA Public Assistance will cover certain costs to manage response through a joint agreement with HHS. But PPE was personal protective equipment purchased by the state and locals in order to support their efforts. FEMA will pay for it, HHS will pay for it, but there are nuances to this. And if you could share how the two work together, and as state and locals think about how they want to utilize the funding from other source. How do they handle that in this particular case for PPE?

Meghan: Right. So, I'll answer that question first. And then I think I'll come back and talk a little bit about the conversation you were just having with Marty. But with regards to PPE, PPE can be purchased using funding given to states and other recipients from HHS and from CDC. All of those cooperative agreements do have PPE purchasing as an allowable expense. So, you can choose to use your cooperative agreement funding to purchase PPE. You can also submit an unmet need request or a request for assistance from the state to the federal government to request PPE purchase--and replenishment through that traditional unmet needs request process. And there is an agreement between HHS and FEMA to purchase that equipment and provide it to the states, if that mission assignment is accepted, at 100% cost share--so at no cost to the state. There are a number of options, again, sort of the same advice I gave before. When you're looking at making those kinds of purchases--or you have that kind of need--your best first approach is to talk to your FEMA regional administrator and your HHS regional emergency coordinator. Look at your budget, look at your options, and figure out what is most and easiest available for you.

And then going back to what you guys were just talking about a second ago--in terms of the sort of structures of opportunity and the temporary facilities--FEMA will pay for some of the construction and build out a new site, just like some of the cooperative agreements will cover some of those costs. FEMA will also pay for emergency medical care. So they will cover the costs of initial assessment, diagnosis, treatment--basically all of the kind of care that you would receive in an emergency department, up and to the point where a patient is determined to be admitted to a hospital or discharged. And that's only if they are the payer of last resort. So, a healthcare provider needs to bill insurance first--they need to bill Medicare and Medicaid first--and they should tap into the COVID-19 Uninsured Program first. And if not, they can look into FEMA for providing that bit through the limited costs for medical care.

Where to find funding for personal protection equipment

Marko: That's a great point. And I also want to re-emphasize one of the other points you made that is very interesting. Because if the PPE is purchased through the federal government--in other words, the federal government is the purchaser--the federal government is providing it, that 100% cost-share comes into play. I would suspect, however--and please, both of you, correct me if I'm wrong--that should the state or local governments make those purchases on their own, it would be subject to the normal cost share for that program.

Meghan: If they purchased it using FEMA PA funding as opposed to submitting it as a direct request, possibly. But this sort of special arrangement has been made, so that there would be no cost to the states if you go through FEMA as an unmet need. So, in terms of a reimbursement, Marty, I would defer to you on that. But I don't think that's encouraged because I think that if FEMA is going to be involved in it, they want it to be a federal purchase.

Marty: Yeah, Meghan, you're 100% correct. You know, again, just mentioned earlier, FEMA is the last resort. But the problem you have in the earlier days is the equipment that was purchased in the early stages of this pandemic, there is cost associated with that. And they would be subject to the federal cost share, which is right now, currently, it's 75/25 for what they have. But states are going to encourage the sub-recipients to follow through the mission assignment they have for those needs, through the unmet needs that the communities need. So, to answer your question, yeah, there would be a cost share when anything was submitted. It's not that if you submit something--and this is what the sub-recipients need to understand-- and you go to send it in for a reimbursement, it will get reimbursed but that cost-share will be 75/25. But it's highly advisable to go through the state to get the PPE equipment.

Marko: It's a great point, and I think it's important that our state and local listeners understand the differences and the nuances of that because it certainly can make a significant difference when buying... Certainly, in the case of PPE. When you're buying in such volume because of the need, that difference between 100% and 75/25 could essentially mean that 25% of state dollars or other resource dollars that could be applied elsewhere, as opposed to pay the cost share on those particular activities. And certainly, it also--in many respects--allows for at least some semblance of order in the process in terms of how supplies are purchased nationally, given the fact that the marketplace is responding to inputs from all over the place. People trying to purchase from multiple sources--and, certainly, there's buying power that's available through federal direct mission assignment that may not be available to some state localities on their own. As we look to the future--and I'll bring all three of you into this equation--Marty, what are some of the things that, from your perspective on the emergency management side, the FEMA side, we should be thinking about? Our state and local clients really should be thinking about in terms of future continuity of operations, expertise they need to start really thinking about and putting in place now, as we move through the ongoing summer events and into the fall?

Complications with continuity of operations

Marty: I think there are several things they need to look at. One, they got to look at their continuity of operations plans and making sure they are up-to-date to be able to help manage them through two incidents running at one time--with the pandemic and with whatever nature brings us in the upcoming season. But one of the things they really need to start looking at is, what are the sheltering resources they have within their own communities? Because there could be, just as Meghan said earlier on, places that haven't had a peak yet. We don't know where that's going to be as well because, as we've seen over the holiday weekend, the mass of people in certain locations. So if you're along, say, the coastlines and everything else, and all of a sudden you start getting an uptick in this pandemic, where are you going to put the people during the next event? What isolation did you have for people? Temporary lodging, high-risk populations sheltering--you know, the elderly and the healthcare workers, and also, we can't forget about the pets. A lot of people have pets today, you’ve got to have sheltering for that.

So, you really need to look at their plan, their response plan, their recovery plans, and say, "What do we need? What did we learn from the pandemic that we need to be prepared for when there's another event coming in our communities?" They can get that expertise. There are people out there who understand how to make sure continuity of operation plans are put together, there is funding for that, and it's different FEMA programs. We don't know what's going to happen with the mitigation dollars, it's going to be coming out. Taking advantage of that, through that whole process as well to improve and prepare, --or I call it hardening the infrastructure, so to speak--to prevent things from happening.

Marko: Well, that certainly is a fodder for a future podcast, and we've talked about doing one on mitigation activities that both involve FEMA mitigation funding, that is a spinoff of the Public Assistance Program. Obviously, FEMA has started the Building Resilient Infrastructure and Communities Program, BRIC, which is replacing the Pre-Disaster Mitigation Program. And that application period for state and locals is expected to begin in the fall of this year. And then, of course, there is a significant amount of prior year funding available through HUD programs and CDBG mitigation, which--in many cases--states are just beginning to put in place their plans for how they're going to utilize those funds, and how that program will move forward and dovetail into some of these others. So, Kelly, since I brought HUD up, one of the things that I think as we look forward around CBDG-CV and how HUD will use the most recent edition of funding--obviously, there are some aspects that have yet to be determined--where do you see some of the challenges that HUD will be looking at in terms of future use of those dollars?

Kelly: Sure, yeah. That's why some of the grantees haven't totally rolled out programs. That's similar to what we were saying about FEMA, waiting on this guidance. Not that they're not working very, very hard on it, but it's complicated. There are some challenges, particularly for states. The way the program is written, they have to provide the funding only in non-entitlement areas. So, they can't fund the bigger cities and counties, which is where in a lot of places that the concentration of cases has been. And they have to fund it through a unit of local government. And, that's one layer down. But those units of local governments in rural areas often don't have the sort of infrastructure or the capacity to just start up a new eviction prevention program or a business grant program. So, they're having to really think through how to get the money down to where it needs to go, knowing to know that there are these layers that they have to adhere to, at least for now.

Again, a lot of the advocacy groups are pushing HUD to waive the requirement that they have to go through local governments. And they have waived that under Disaster Recovery Funding before, so there's a precedent for that. And, again, one of the other challenges that I just mentioned in there that is true-- probably on the health side and everything else--which is this is unprecedented. So finding partners that, again, have the capacity and are ready to stand up a program, and get the funding out quickly but do so in compliance with all of the rules and requirements--particularly the sort of administrative, and financial, and reporting requirements--is tough. It can be done. But, in rural areas or cities that have been particularly hard hit, those systems are pretty taxed right now. So, they're having to think through that.

And then another area that was mentioned earlier is duplication of benefits. While disaster recovery CDBG-DR grantees are used to dealing with duplication of benefits, some of them still struggle with doing it properly. But these grantees who are getting CDBG-CV are not the same and/or have never had CDBG-DR funding. This twist of duplication of benefits is a new thing. And, hopefully, it's not super complicated for them given the type of activities that they fund. But it's still an exercise they have to go through and have that documentation in place, particularly for those businesses--as I mentioned earlier--that they might assist, to ensure that if they did, in fact, get SBA assistance or paycheck protection or something like that. That’s factored into their calculations as to how much CDBG-CV can pay it for. It's sort of a last resort funding as well. So, those are some of the challenges. Again, I think we're all hopeful that HUD is working very hard to try to minimize those as much as possible, and that some of those barriers will sort of fall away, but always a challenge.

What to watch for in the second wave

Marko: Absolutely. Meghan, future perspectives from the healthcare side of this equation?

Meghan: Sure. I think, obviously, continuing to prepare for future waves of the pandemic because--as history and science tell us--second waves of pandemics have always been worse than the first. So, everybody is keeping their eye on that sort of horizon. And then I think it really goes for the more short-term concern over concurrent disasters over the summer, much to what Marty talked about. Sheltering is a huge concern, trying to get jurisdictions that are most likely to be hit by shelter requiring disasters. So, earthquakes, hurricanes, wildfires, floods, tornadoes--those sorts of events--to get them prepared to do non-congregate sheltering as best they can. And if you have to do congregate sheltering to attempt to do it in a reasonable way as possible to reduce the potential for infectious disease outbreaks, running concurrent operations while trying to maintain social distance.

So, just because we are opening up and coming back into the office, it doesn't mean that we're all going to stay there. The possibility certainly exists, that you could have to respond to a disaster while your community is under stay-at-home orders again. And, obviously, emergency management and first responder personnel are essential personnel, but some adherence to social distancing has to be maintained if you do not want to get your entire workforce sick. So, you do need to think through the sort of physical engineering of your emergency ops centers, of your disaster field offices, of your emergency response structure, for, say, a hurricane response, that keeps in mind that there is a highly infectious droplet spread infectious disease occurring at the same time. You have to plan for that.

I also think that there's going to be some confusion in terms of federal funding with concurrent disasters. And I do look forward to some guidance coming out in the summer that addresses this. Is the non-congregate shelter that you are forced to establish in your community because of a hurricane, is that covered by COVID-19 funding because you had to do a non-congregate shelter because of the infectious disease? Or is that covered by hurricane funding because you had to do a shelter in the first place because of the hurricane? I don't think that's clear and I don't think any of us have a good answer for that right now. It’s something that jurisdictions need to think about.

Certainly, on the jurisdictional side, just track your costs and, you know, that gets figured out. But it is something to think about. And then, I think just trying to prepare for, and be in a position to do, vaccinations. When we do get a vaccine, it isn't good enough to just have the vaccine. A countrywide vaccination campaign is a huge undertaking. You have emergency managers on the phone. Your public health counterparts are already starting to think through what this will look like. It'll look like some sort of a combination of what the community-based testing looks like--a combination of how we did vaccinations during H1N1 during a normal flu season. It's going to be a combination of efforts. But that is something that is definitely on everyone's mind because it's going to be a huge planning undertaking. You can't plan for it the day before you receive the vaccine. You have to start planning for it now, even if it's 6 months, 12 months, 18 months, or 2 years away.

Marko: I think those are great points. And I think the bottom line--for any of our state and local partners--is thinking in terms of proactive planning. Making sure that they are fully documenting all costs and not necessarily waiting for federal guidance that may, on certain aspects of it, take some time. Do the right things for your community, do the right planning in advance, make sure that you document it all. And, ultimately, as the guidance is developed on some of these longer-term issues, it'll be far easier at that point to understand which programs can pay for what at what level and in order to avoid duplication of benefits. But more importantly, maximize the resources that have been and are continuing to be made available through federal funding programs. I'd like to thank all of you for joining. I know that we have raised a number of topics and subjects with regard to funding.

Duplication of benefits is a huge challenge. ICF is preparing now a webinar on duplication of benefits to help address and understand those issues a little more in-depth. Look for announcements about that webinar in the future. We'll also be looking at posting on the ICF website in the not too distant future--as soon as this podcast loads--a funding matrix, which is looking at the federal funding programs that are available for COVID-19 and the things that they cover, and showing where some of them are complementary in terms of items that they cover. And so that it will give our state and local clients and friends an opportunity to have an initial introduction to how those programs interact and overlap.

And certainly, there is a tremendous amount of detail that can go behind that, and that will also be made available on the ICF website. icf.com/insights is where this podcast can be found, and the materials and the links to the federal agencies. To Kelly, to Meghan, to Marty, thank you very much for joining us today. Appreciate your services to the community and to the nation. And ICF looks forward in the future to doing more podcasts and more educational programming to help assist our state, local, and federal clients do the best they can for their communities. Thank you.