COVID-19: Current and Future Federal Preparedness Requires Fixes to Improve Health Data and Address Improper Payments
Although hospitalizations and deaths associated with COVID-19 have recently decreased, the pandemic continues to challenge U.S. response and recovery efforts. The federal response continues to focus on vaccinations, testing, and treatment.
As of March 2022, we have made 279 recommendations to improve the federal response, such as collecting data on long-term COVID-19 effects. Agencies have fully or partially addressed 39% of our recommendations.
In this report, we make a suggestion for Congress to consider and 15 new recommendations to address payment oversight, data collection, critical manufacturing and supply chain issues, and more.
What GAO Found
By late March 2022, daily COVID-19 cases in the U.S. had fallen substantially since the Omicron-related peak in January 2022. Though COVID-19-associated hospitalizations and deaths have also decreased, the effects of the Omicron variant—and the rising prevalence of its new BA.2 sublineage—underscore enduring challenges and the importance of a continued, agile federal response.
This response has included a focus on COVID-19 vaccinations. As of March 26, 2022, about 70 percent of the eligible U.S. population had been fully vaccinated. According to the Centers for Disease Control and Prevention (CDC), getting vaccinated and staying up to date with vaccines—including a booster dose—is the best way to protect against COVID-19. Data show that vaccinated adults experienced lower COVID-19-associated hospitalization rates (see figure).
Age-Adjusted Rates of COVID-19-Associated Hospitalizations by Vaccination Status in Adults Aged 18 Years and Older, Oct. 2021–Feb. 2022
Since June 2020, GAO has made 279 total recommendations for improving federal pandemic operations. These recommendations include improvements in such areas as publicly reporting COVID-19 nursing home vaccination data and targeting vaccine outreach to veterans. Agencies have fully or partially addressed 39 percent of these recommendations as of March 2022, fully addressing 22 percent (61 recommendations) and partially addressing another 17 percent (48 recommendations). Fully addressing GAO’s recommendations will enhance federal COVID-19 pandemic response and recovery efforts, and help prepare for future public health emergencies.
In this report, GAO makes 15 new recommendations and raises one matter for congressional consideration in the areas of COVID-19 payment oversight, public health data collection, and critical manufacturing, among others.
Payment Integrity: COVID-19 Spending
The Payment Integrity Information Act of 2019 defines improper payments as any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. Improper payments are a pervasive and growing problem in regular programs across the federal government. They also have been a significant concern in pandemic spending, especially among the largest programs such as unemployment insurance.
Under guidance from the Office of Management and Budget (OMB), agencies are to complete a risk assessment to determine a new program’s susceptibility to significant improper payments after the first 12 months of program operations and, if susceptible, develop corrective actions and report on improper payments the following fiscal year. This means that improper payment information for new COVID-19 programs may not be reported until November 2022. By that time, agencies may have disbursed most or even all COVID-19 funds before assessing risk or developing corrective actions to address potential improper payment issues.
GAO therefore suggested in its November 2020 report that Congress consider in any future legislation appropriating COVID-19 relief funds designating all executive agency programs and activities making more than $100 million in payments from COVID-19 relief funds as “susceptible to significant improper payment.”
GAO continues to believe that expeditiously estimating and reporting improper payments and developing corrective actions to reduce such payments is critical to agency accountability, particularly for new programs that receive large outlays in a given year. GAO reiterates the November 2020 matter, as well as a matter GAO made in a March 2022 testimony suggesting that Congress consider amending the Payment Integrity Information Act of 2019 to designate all new executive agency programs—such as those created specifically to respond to the COVID-19 pandemic—making more than $100 million annually in payments as “susceptible to significant improper payments” for their initial years of operation.
GAO also recommends that OMB require agencies to certify the reliability of submitted improper payment data. OMB neither agreed nor disagreed with this recommendation.
FEMA’s COVID-19 Funeral Assistance and Public Assistance Program
As of February 28, 2022, the Federal Emergency Management Agency (FEMA) had received and was processing more than 444,000 applications for funeral assistance since April 2021—when it began accepting applications—and awarded more than $1.92 billion for more than 296,000 approved applications. (See figure for obligations made for COVID-19 Funeral Assistance from May 10, 2021, through February 22, 2022.)
Cumulative Obligations for FEMA Funeral Assistance over Time, May 10, 2021–Feb. 22, 2022
However, GAO identified several gaps in FEMA’s internal controls meant to prevent improper or potentially fraudulent payments, such as cases in which these controls did not prevent duplicate applications for funeral assistance or assistance issued to ineligible recipients. For example, GAO identified 374 deceased individuals that were listed on more than one award-receiving application; in total, these applications received about $4.8 million in assistance. Without adequate controls in place, COVID-19 Funeral Assistance is at risk of improper payments and potential fraud.
GAO recommends that the FEMA Administrator take action to identify the causes of the gaps in internal control in COVID-19 Funeral Assistance and design and implement additional control activities, where needed, to prevent and detect improper payments and potential fraud.
GAO recommends that the FEMA Administrator address deficiencies in the COVID-19 Funeral Assistance data by updating data records as data are verified, and adding data fields where necessary, to ensure that consistent and accurate data are available for monitoring of potential fraud trends and identifying control deficiencies. The Department of Homeland Security (DHS) agreed with both recommendations.
COVID-19 Surveillance
CDC could be better positioned to lead and coordinate the national efforts to detect and monitor COVID-19 by including in the agency’s existing surveillance approach specific objectives for how it will achieve its goals and a description of how it will assess progress toward meeting them.
CDC’s COVID-19 surveillance approach outlines goals and activities for what the agency wants to achieve, but it does not detail how it will achieve its stated goals or how it will measure its progress—two components of an effective strategy GAO has noted in its past work. By including specific objectives that detail how CDC’s actions will allow it to meet its goals and describing measures to assess its progress towards reaching its goals, CDC could better ensure it is able to effectively monitor COVID-19 nationwide.
GAO recommends that the Director of CDC, in coordination with state, tribal, local, and territorial jurisdictions and public health partner organizations, ensure the agency builds upon its existing COVID-19 surveillance approach by detailing specific objectives for how it will achieve its COVID-19 surveillance goals and describing how it will assess progress toward meeting them. HHS agreed with our recommendation.
Public Health Data Collection and Standardization
CDC has made progress in modernizing the U.S. public health data collection and surveillance infrastructure through its Data Modernization Initiative, which aims to improve data collection and sharing, strengthen data reporting and analytics, and advance surveillance of future public health threats, among other goals.
However, CDC’s strategic implementation plan for the Data Modernization Initiative does not articulate the specific actions, time frames, and allocation of roles and responsibilities needed to achieve its objectives. In addition, CDC has not fully developed plans for how it will allocate certain funds for data modernization. Without more specific, actionable plans, CDC may not be able to gauge its progress on the initiative or achieve key results in a timely manner. In addition, such lack of progress to implement enhanced surveillance systems could affect the quality and timeliness of data needed to respond to future public health emergencies.
GAO recommends that the Director of CDC define specific action steps and time frames for the agency’s data modernization efforts. HHS agreed with this recommendation.
Critical Manufacturing Sector
The pandemic has impacted the Critical Manufacturing Sector by causing worker shortages, delays in shipments of goods, and increased cybersecurity vulnerability in critical infrastructure systems and assets. The Cybersecurity and Infrastructure Security Agency (CISA)—in its role as the lead federal agency for coordinating security and resilience efforts with the Critical Manufacturing Sector on behalf of DHS—took steps to respond to the pandemic’s impacts in the sector. For example, CISA developed voluntary guidance to help jurisdictions and critical infrastructure owners and operators identify essential work functions and ensure that the workers who performed those functions could continue to access their workplaces when restrictions, such as stay-at-home orders, were in place in their communities.
Members of the Critical Manufacturing Sector have identified a lessons-learned analysis as a high-priority need, and CISA has collected some information on the impact of the pandemic in the sector that could be leveraged in a lessons-learned analysis. However, as of February 2022, CISA had not finalized a plan for developing the analysis.
GAO recommends that the Director of CISA assess and document lessons learned from the COVID-19 pandemic’s impacts on the Critical Manufacturing Sector. DHS agreed with this recommendation and stated it plans to issue a lessons-learned report by December 2022.
Advance Child Tax Credit and Economic Impact Payments
During 2021, the Internal Revenue Service (IRS) and the Department of Treasury issued advance payments of the child tax credit (CTC) and a third round of Economic Impact Payments (EIP 3) to eligible individuals, totaling over $500 billion. Both payments could have had implications for individuals as they filed their 2021 taxes.
Information on Advance Child Tax Credit Payments, July 2021–Dec. 2021, as of April 6, 2022
To help individuals file accurate 2021 tax returns during the 2022 filing season, Treasury and IRS took several steps to reach out to individuals that received the advance CTC payments and EIP 3. However, Treasury and IRS missed opportunities to collaborate on these outreach efforts.
Relatedly, the communications plans and strategies IRS developed for several programs, including the advance CTC and EIP, do not include metrics for assessing the usefulness and accessibility of these outreach efforts. Such metrics would inform management of these efforts and help focus resources on what works. Without sufficient, relevant, timely, and comparable data on its outreach efforts, IRS is missing information it could use to develop performance metrics and to assess which aspects of their communications and outreach strategy were effective in reaching different audiences.
GAO is making three recommendations for Treasury and IRS to enhance communication and outreach efforts concerning the refundable tax credit. These recommendations focus on improving collaboration between the agencies and within IRS and on using data to assess the effectiveness of their efforts. Treasury and IRS neither agreed nor disagreed with the recommendations.
This report contains additional recommendations related to the Single Audit Compliance Supplement, the Capital Projects Fund, the Homeowner Assistance Fund, and Public Health Industrial Base Expansion. For example, GAO recommends that the Assistant Secretary for Preparedness and Response within HHS conduct a workforce assessment of its Innovation and Industrial Base Expansion Program Office to determine the critical skills and competencies needed to support and sustain the office, and develop corresponding workforce strategies to address those needs. HHS agreed with this recommendation.
Why GAO Did This Study
By the end of March 2022, the U.S. had about 80 million reported cases of COVID-19 and over 980,000 reported deaths, according to CDC. The country also experiences lingering economic repercussions related to the pandemic, including rising inflation and ongoing supply chain disruptions.
As of February 28, 2022 (the most recent date for which data were available), the federal government had obligated $4.2 trillion and expended $3.6 trillion for pandemic relief. These amounts reflect 91 and 79 percent, respectively, of the total amount of COVID-19 relief funds provided by the CARES Act and five other relief laws.
The CARES Act includes a provision for GAO to report on its ongoing monitoring and oversight efforts related to the COVID-19 pandemic. This report—GAO’s 10th comprehensive report—examines the federal government’s continued efforts to respond to, and recover from, the COVID-19 pandemic. In addition, GAO’s March 17, 2022 testimony included 10 new legislative suggestions to enhance the transparency and accountability of federal spending, which we reiterate here.
GAO reviewed federal data and documents and interviewed federal and state officials and other stakeholders.
Recommendations
GAO is making 15 new recommendations for agencies and one matter for consideration by Congress that are detailed in this Highlights and in the report.
Matter for Congressional Consideration
| Matter | Status | Comments |
|---|---|---|
| Congress should consider providing the Department of Health and Human Services the authority to require states to report the data necessary for the Secretary to estimate and report on improper payments for the Temporary Assistance for Needy Families program in accordance with 31 U.S.C. § 3352. See the Payment Integrity: COVID-19 Spending enclosure. | No new legislation has been enacted as of January 2023 which would provide the Department of Health and Human Services the authority to require states to report the data necessary for the Secretary to estimate and report on improper payments for the Temporary Assistance for Needy Families program. |
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Office of Management and Budget | The Director of the Office of Management and Budget should require agencies to certify the reliability of data submitted to PaymentAccuracy.gov. See the Payment Integrity: COVID-19 Spending enclosure. (Recommendation 1) |
The Office of Management and Budget (OMB) neither agreed nor disagreed with this recommendation. On August 26, 2022, OMB stated that it was planning on adding a new certification requirement for agency submissions to paymentaccuracy.gov, consistent with this GAO recommendation. In September 2022, OMB updated its fiscal year 2022 Payment integrity Annual Data Call Instructions. In this updated document, OMB instructs agencies on how to submit their annual data calls for PaymentAccuracy.gov and directs agencies to certify with their submission that the information provided "is complete and reliable and that the submission has been reviewed and approved by appropriate Agency senior leadership, e.g., the Chief Financial Officer or equivalent." We believe that OMB has addressed our recommendation. Therefore, we are closing this recommendation as implemented.
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| Federal Emergency Management Agency | The Federal Emergency Management Agency Administrator should take action to identify the causes of the gaps in internal control in COVID-19 Funeral Assistance and design and implement additional control activities, where needed, to prevent and detect improper payments and potential fraud. See FEMA's COVID-19 Funeral Assistance and Public Assistance Program enclosure. (Recommendation 2) |
FEMA will provide the update within the 180-day letter timeline (due to Congress and GAO by 10/23/22).
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| Federal Emergency Management Agency | The Federal Emergency Management Agency Administrator should address deficiencies in the COVID-19 Funeral Assistance data by updating data records as data are verified, and adding data fields where necessary, to ensure that consistent and accurate data are available for monitoring of potential fraud trends and identifying control deficiencies. See FEMA's COVID-19 Funeral Assistance and Public Assistance Program enclosure. (Recommendation 3) |
FEMA will provide the update within the 180-day letter timeline (due to Congress and GAO by 10/23/22).
|
| Department of Education | The Secretary of Education should document policies and procedures for providing information to the Office of Management and Budget to better enable it to annually update the Compliance Supplement that include steps for (1) establishing management's expectations of staff competence for key roles (e.g., relevant knowledge, skills and abilities) and providing ongoing training, and (2) agency officials proactively involving internal stakeholders (e.g., the inspector general, general counsel and chief financial officer) and external stakeholders (e.g., the audit community) when developing audit procedures, prior to submitting drafts to the Office of Management and Budget, in order to ensure the guidance meets users' needs. See the Single Audit Compliance Supplement enclosure. (Recommendation 4) |
The Department of Education agreed with this recommendation. In September 2022, Education provided additional documentation of their policies and procedures. We will review these documents to determine whether the recommendation has been fully addressed.
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| Department of Health and Human Services | The Secretary of Health and Human Services should document policies and procedures for providing information to the Office of Management and Budget to better enable it to annually update the Compliance Supplement, that include steps for (1) establishing management's expectations of staff competence for key roles (e.g., relevant knowledge, skills and abilities) and providing ongoing training, and (2) agency officials proactively involving internal stakeholders (e.g., the inspector general, general counsel and chief financial officer) and external stakeholders (e.g., the audit community) when developing audit procedures, prior to submitting drafts to the Office of Management and Budget, in order to ensure the guidance meets users' needs. See the Single Audit Compliance Supplement enclosure. (Recommendation 5) |
As of September 2022, HHS did not provide additional information.
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| Department of the Treasury | The Secretary of the Treasury should document policies and procedures for providing information to the Office of Management and Budget to better enable it to annually update the Compliance Supplement, that include steps for (1) establishing management's expectations of staff competence for key roles (e.g., relevant knowledge, skills and abilities) and providing ongoing training, and (2) agency officials proactively involving internal stakeholders (e.g., the inspector general, general counsel and chief financial officer) and external stakeholders (e.g., the audit community) when developing audit procedures, prior to submitting drafts to the Office of Management and Budget, in order to ensure the guidance meets users' needs. See the Single Audit Compliance Supplement enclosure. (Recommendation 6) |
As of September 2022, Treasury did not provide additional information.
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| Department of the Treasury | The Secretary of the Treasury should document a comprehensive plan that includes timely and sufficient policies and procedures for monitoring recipients of the CPF to provide assurance that funds are being used in compliance with laws, regulations, agency guidance, and award terms and conditions, including ensuring that funds are being used for allowable purposes. See the Capital Projects Fund enclosure . (Recommendation 7) |
Treasury agreed with the recommendation. As of September 2022, Treasury had taken steps to address this recommendation by issuing several documents detailing internal controls over monitoring recipients of CPF awards, including the Office of Recovery Program's (ORP's) Awards Management Policy. Treasury also issued Compliance Testing Procedures for its programs including CPF, and stated that ORP's Recipient Monitoring team will be developing a compliance matrix, business rule inventory, and analytics scenarios for Capital Projects funds, which Treasury anticipates will be in place when monitoring begins. In addition, Treasury stated that ORP issued its Compliance and Reporting Guidance for CPF recipients including states, territories and freely associated states in August 2022, and was drafting but had not completed similar guidance for tribal government recipients. Treasury has not yet developed a recipient monitoring approach to address the provision of services or activities funded under CPF that could extend up to 5 years beyond December 31, 2026, an issue GAO noted in our April 2022 CPF report. We will continue to monitor the actions Treasury takes in response to our recommendation.
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| Department of the Treasury | The Secretary of the Treasury should develop and implement written procedures to monitor Homeowner Assistance Fund participants' programs and uses of funds for compliance with program requirements and improper payments. See the Homeowner Assistance Fund enclosure. (Recommendation 8) |
In September 2022, Treasury told us its Office of Recovery Programs had finalized policies and procedures for award management and compliance testing that applied to all recovery programs administered by the office, including the Homeowner Assistance Fund. Treasury shared these policies and procedures, which described an overall framework for award management and compliance testing but lacked procedures that were specific to the fund. According to Treasury, the agency is still working to develop and implement such procedures but did not provide an expected completion date.
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| Centers for Disease Control and Prevention | The Director of the Centers for Disease Control and Prevention should define specific action steps and time frames for the agency's data modernization efforts. See the Public Health Data Collection and Standardization enclosure. (Recommendation 9) |
As of September 2022, HHS did not provide an update.
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| Centers for Disease Control and Prevention | The Director of the Centers for Disease Control and Prevention, in coordination with state, tribal, local, and territorial jurisdiction and public health organization partners, should ensure the agency builds upon its existing surveillance approach by detailing specific objectives for how it will achieve its COVID-19 surveillance goals and describing how it will assess progress toward meeting them. See the COVID-19 Surveillance enclosure. (Recommendation 10) |
The Department of Health and Human Services (HHS) agreed with our recommendation, and the Centers for Disease Control and Prevention noted that it will continue efforts to develop a document summarizing its COVID-19 surveillance goals and how it will assess progress towards meeting them. As of September, 2022, HHS had not provided an update on its efforts to implement the recommendation. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Cybersecurity and Infrastructure Security Agency | The Director of the Cybersecurity and Infrastructure Security Agency should assess and document lessons learned from the COVID-19 pandemic's impacts on the Critical Manufacturing Sector. See the Critical Manufacturing Sector enclosure. (Recommendation 11) |
CISA agreed with our recommendation and stated that in March 2022 the agency conducted a pandemic lessons-learned workshop with members of the Critical Manufacturing Sector Coordinating Council to discuss pandemic impacts on the sector and related mitigation actions. CISA officials said they planned to use input from the workshop to develop an after-action report with recommendations for addressing pandemic-related impacts to the sector. In September 2022, CISA provided the Critical Manufacturing Pandemic Planning Guide (July 2022), which, according to officials, provides suggested guidelines and best practices for the sector during a pandemic or other similar crisis. We are reviewing this planning guide and the extent to which it assesses and documents lessons learned from the COVID-19 pandemic's impacts on the Critical Manufacturing Sector.
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| Office of the Assistant Secretary for Preparedness and Response | The Assistant Secretary for Preparedness and Response within the Department of Health and Human Services should conduct a workforce assessment of its Innovation and Industrial Base Expansion Program Office to determine the critical skills and competencies needed to support and sustain the office, and develop corresponding workforce strategies to address those needs. See the Public Health Industrial Base Expansion enclosure. (Recommendation 12) |
The Administration for Strategic Preparedness and Response (ASPR) agreed with GAO's recommendation. (Note: In July 2022, the Secretary of Health and Human Services elevated ASPR to an operating division within the department. Prior to this, ASPR was known as the Office of the Assistant Secretary for Preparedness and Response). In December 2022, ASPR provided information on recent efforts taken to begin to address the recommendation. Specifically, ASPR used a third-party contractor to assess needs and related gaps in the size and composition of the agency's acquisition workforce. The assessment stated that it included staff needs of the new IBx office. However, the information reported was at a high-level, so it is unclear if the analysis included a full assessment of the needs of the IBx office or only specific duties of the office. ASPR also provided GAO with a hiring plan, which indicates that the agency plans to hire nine new full-time equivalents for the IBx office in fiscal year 2023. While ASPR's actions are a positive step forward, GAO is keeping this recommendation open until we obtain further information from the agency that outlines the critical skills and competencies needed to support the current and future needs of the IBx office specifically. Such documentation will help us determine the extent to which ASPR's hiring plans meet those needs or if further strategies need to be developed to meet those needs, as we recommended.
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| Department of the Treasury | The Secretary of the Treasury, in coordination with the Commissioner of Internal Revenue, should enhance collaboration among departmental components for refundable tax credit communication and outreach efforts by including relevant participants and clearly defining participant outcomes, roles, and responsibilities. See the Advance Child Tax Credit and Economic Impact Payments enclosure. (Recommendation 13) |
As of September 2022, Treasury did not provide additional information.
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| Internal Revenue Service | The Commissioner of Internal Revenue should enhance internal collaboration among its stakeholder outreach and education offices for refundable tax credit communications and outreach efforts by clearly establishing outcomes, roles and responsibilities, and developing resources to facilitate joint interactions and methods to document information sharing. See the Advance Child Tax Credit and Economic Impact Payments enclosure. (Recommendation 14) |
As of September 2022, IRS did not provide additional information.
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| Internal Revenue Service | The Commissioner of Internal Revenue should collect sufficient, relevant, and comparable data on the usefulness and accessibility of its communications and outreach efforts for refundable tax credits and use these data to develop performance metrics to assess the effectiveness of ongoing efforts. See the Advance Child Tax Credit and Economic Impact Payments enclosure. (Recommendation 15) |
As of September 2022, IRS did not provide additional information.
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