Order Code RL33579
CRS Report for Congress
Received through the CRS Web
The Public Health and Medical Response
to Disasters: Federal Authority and Funding
Updated October 10, 2006
Sarah A. Lister
Specialist in Public Health and Epidemiology
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

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The Public Health and Medical Response to Disasters:
Federal Authority and Funding
Summary
When catastrophes overwhelm the response capability of state and local
authorities, the President can provide certain assets and personnel to aid stricken
communities, and can provide funding to individuals, government and not-for-profit
entities to assist them in response and recovery. Aid is provided under the authority
of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford
Act), upon a presidential declaration of an emergency (providing a lower level of
assistance) or a major disaster (providing a higher level of assistance). The Secretary
of Health and Human Services (HHS) also has both standing and emergency
authorities to assist state and local governments, not-for-profit entities, and others in
response to public health and medical emergencies.
The flawed response to Hurricane Katrina and preparedness efforts for an
influenza (“flu”) pandemic have each raised concerns about existing federal response
mechanisms for incidents in which there are overwhelming public health and medical
needs. In addition, some concerns have been expressed about federal leadership and
delegations of responsibility for the public health and medical response to incidents,
as carried out according to the National Response Plan (NRP).
While there is precedent for presidential authority to declare an infectious
disease threat an emergency, pursuant to the Stafford Act, there is not corresponding
precedent for the authority to declare such a threat a major disaster. Many of the
needs likely to result from a flu pandemic could not be met with the types of
assistance provided pursuant to the Stafford Act, even if a major disaster declaration
applied. For example, in a severe pandemic, the healthcare system may have to
provide care for seriously ill victims who are uninsured or underinsured, or sustain
the loss of revenue if more lucrative but non-essential procedures are postponed
during a pandemic. In addition, potential adverse economic impacts of a flu
pandemic, such as losses in trade, travel and tourism, are not generally eligible for
Stafford Act assistance. In the course of the public health and medical response to
Hurricane Katrina, numerous federal aid mechanisms in addition to those in the
Stafford Act assistance were developed administratively or in statute. Some of these
mechanisms may be applicable during a flu pandemic.
This report examines: (1) the statutory authorities and coordinating mechanisms
of the President (acting through the Secretary of Homeland Security) and the
Secretary of HHS in providing routine assistance, and in providing assistance
pursuant to emergency or major disaster declarations and/or public health emergency
determinations; (2) mechanisms to assure a coordinated federal response to public
health and medical emergencies, and overlaps or gaps in agency responsibilities; and
(3) existing mechanisms and potential gaps in financing the costs of a response to
public health and medical emergencies. A listing of federal public health emergency
authorities is provided in the Appendix.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Federal Authority and Plans for Disaster Response . . . . . . . . . . . . . . . . . . . . . . . . 2
Federal Statutory Authorities for Disaster Response . . . . . . . . . . . . . . . . . . . 2
Stafford Act: Major Disaster Declaration . . . . . . . . . . . . . . . . . . . . . . . 2
Stafford Act: Emergency Declaration . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Public Health Emergency Authorities . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Intersection of Stafford Act and
Public Health Emergency Authority . . . . . . . . . . . . . . . . . . . . . . . 6
Federal Coordinating Mechanisms for Disaster Response . . . . . . . . . . . . . . 6
National Response Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
National Response to an Influenza Pandemic . . . . . . . . . . . . . . . . . . . . 7
Would the Stafford Act Apply in a Flu Pandemic? . . . . . . . . . . . . . . . . . . . . 8
NRP Emergency Support Function 8:Roles and Challenges . . . . . . . . . . . . . . . . . 9
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ESF-8 Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Unclear Federal Leadership for Certain Response Functions . . . . . . . . . . . 11
Federal Funding to Support an ESF-8 Response . . . . . . . . . . . . . . . . . . . . . . . . . 13
Funding Sources and Authorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
The Disaster Relief Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
The Public Health Emergency Fund . . . . . . . . . . . . . . . . . . . . . . . . . . 14
The Public Health and Social Services Emergency Fund . . . . . . . . . . 15
Funding the ESF-8 Response to Hurricane Katrina . . . . . . . . . . . . . . . . . . . 15
Federal Assistance for Disaster-Related Healthcare Costs . . . . . . . . . . . . . 17
Existing Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Financing Healthcare Needs Following Hurricane Katrina . . . . . . . . . 18
ESF-8 Funding Needs During a Flu Pandemic . . . . . . . . . . . . . . . . . . . . . . 20
Appendix: Federal Public Health Emergency Authorities . . . . . . . . . . . . . . . . . . 21
Broad Authority in Section 319 of the Public Health Service Act . . . . . . . 21
Other Public Health Emergency Authorities of the HHS Secretary . . . . . . 24
Additional Public Health Emergency Authorities . . . . . . . . . . . . . . . . . . . . 28
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

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The Public Health and Medical Response
to Disasters: Federal Authority and Funding
Introduction
In response to catastrophes, the President can provide certain additional assets
and personnel to aid stricken communities, and can provide funding to individuals
and to government and not-for-profit entities to assist them in response and
recovery.1 This aid is provided under the authority of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (the Stafford Act), upon a presidential
declaration of an emergency (providing a lower level of assistance) or a major
disaster (providing a higher level of assistance).2
While there is precedent for presidential authority to deem an infectious disease
threat (i.e., West Nile virus) an emergency, there is not corresponding precedent
regarding the authority to declare such a threat a major disaster. In addition, there are
some concerns about federal leadership and delegations of responsibility for the
public health and medical response to incidents, as carried out according to the
National Response Plan (NRP), Emergency Support Function 8 (ESF-8).
Many of the needs likely to result from a flu pandemic could not be met with the
types of assistance provided pursuant to the Stafford Act, even if a major disaster
declaration applied. For example, in a severe pandemic, the healthcare system may
confront the challenge of providing care for seriously ill victims who are uninsured
or underinsured, as well as the loss of revenue from more lucrative but non-essential
procedures that may be canceled as a result of the pandemic. In addition, potential
adverse economic impacts of a flu pandemic, such as losses in trade, travel and
tourism, or costs associated with changes in the demand for services, are not
generally eligible for Stafford Act assistance.
In the course of the public health and medical response to Hurricane Katrina,
numerous federal assistance mechanisms other than Stafford Act assistance were
developed administratively or in statute. Some of these mechanisms may be
1 The terms emergency and major disaster have specific meanings in the Stafford Act. To
avoid confusion, in this report the terms event, incident, and catastrophe will be used in
general reference to events, whether or not Stafford Act assistance applies. The term public
health emergency is also commonly used in both a generic manner and to describe one or
more specific authorities in law. This is discussed further in the Appendix.
2 Information on the Stafford Act is provided, in part, by Keith Bea of the Government and
Finance Division of the Congressional Research Service (CRS). For background on the
Stafford Act, see CRS Report RL33053, Federal Stafford Act Disaster Assistance:
Presidential Declarations, Eligible Activities, and Funding, by Keith Bea.

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CRS-2
applicable in response to a flu pandemic. Information regarding the overall cost of
these one-time assistance mechanisms is not publicly available, however.
This report examines (1) the statutory authorities and coordinating mechanisms
of the President (acting through the Secretary of Homeland Security) and the
Secretary of Health and Human Services (HHS) in providing routine assistance, and
in providing assistance pursuant to emergency or major disaster declarations and/or
public health emergency determinations; (2) mechanisms to assure a coordinated
federal response to public health and medical emergencies, and overlaps or gaps in
agency responsibilities; and (3) existing mechanisms and potential gaps in financing
the costs of a response to public health and medical emergencies. A listing of federal
public health emergency authorities is provided in the Appendix.
Federal Authority and Plans for Disaster Response
Federal Statutory Authorities for Disaster Response
Stafford Act: Major Disaster Declaration. A major disaster declaration
issued pursuant to the Stafford Act authorizes the President to provide a variety of
types of assistance to eligible entities.3 A major disaster declaration must meet three
tests — definition, need, and action. First, the statute defines a major disaster as
follows:
“Major disaster” means any natural catastrophe (including any hurricane,
tornado, storm, high water, winddriven water, tidal wave, tsunami, earthquake,
volcanic eruption, landslide, mudslide, snowstorm, or drought), or, regardless of
cause, any fire, flood, or explosion, in any part of the United States, which in the
determination of the President causes damage of sufficient severity and
magnitude to warrant major disaster assistance under this chapter to supplement
the efforts and available resources of States, local governments, and disaster
relief organizations in alleviating the damage, loss, hardship, or suffering caused
thereby.”4
Second, the incident must result in damages significant enough to exceed the
resources and capabilities not only of the affected local governments, but the state as
well. The requirement is set forth as follows:
All requests for a declaration by the President that a major disaster exists shall
be made by the Governor of the affected State. Such a request shall be based on
a finding that the disaster is of such severity and magnitude that effective
3 42 U.S.C. § 5170(a)-5189. For more information, see CRS Report RL33053, Federal
Stafford Act Disaster Assistance: Presidential Declarations, Eligible Activities, and
Funding, pp. 7-9, by Keith Bea.
4 42 U.S.C. § 5122(2).

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CRS-3
response is beyond the capabilities of the State and the affected local
governments and that Federal assistance is necessary.5
Third, the state must implement its authorities, dedicate sufficient resources, and
commit to meet its share of the costs, as follows:
As part of such request, and as a prerequisite to major disaster assistance under
this chapter, the Governor shall take appropriate response action under State law
and direct execution of the State’s emergency plan. The Governor shall furnish
information on the nature and amount of State and local resources which have
been or will be committed to alleviating the results of the disaster, and shall
certify that, for the current disaster, State and local government obligations and
expenditures (of which State commitments must be a significant proportion) will
comply with all applicable cost-sharing requirements of this chapter. Based on
the request of a Governor under this section, the President may declare under this
chapter that a major disaster or emergency exists.6
Stafford Act: Emergency Declaration. By comparison with a major
disaster declaration, considerably less assistance is authorized under an emergency
declaration.7 However, the Stafford Act gives the President considerably broader
discretion in issuing an emergency declaration. First, the definition of “emergency”
does not include the specific causal events listed in the definition of “major disaster.”
The President instead may determine whether circumstances are sufficiently dire for
the affected state to call for an emergency declaration. Also, of importance to the
issue of an influenza pandemic or other mass health threat, the protection of public
health is to be considered by the President, as seen in the following:
“Emergency” means any occasion or instance for which, in the determination of
the President, Federal assistance is needed to supplement State and local efforts
and capabilities to save lives and to protect property and public health and safety,
or to lessen or avert the threat of a catastrophe in any part of the United States.8
The statutory provisions concerning the procedures by which an emergency
declaration will be considered by the President, like those for a major disaster, also
contain requirements pertaining to need and action. However, as is the case with the
definition of “emergency,” the procedures section provides for a wider degree of
discretion on the part of the President. While governors requesting assistance must
take required actions, they do not have to identify that state and local resources have
been committed. Governors must, however, identify the type and extent of federal
aid required. The President also has discretion to act in the absence of a
gubernatorial request if the emergency creates a condition that primarily or solely
5 42 U.S.C. § 5170.
6 Ibid.
7 42 U.S.C. § 5192-5193. For more information, see CRS Report RL33053, Federal
Stafford Act Disaster Assistance: Presidential Declarations, Eligible Activities, and
Funding, p. 9, by Keith Bea.
8 42 U.S.C. § 5122(1).

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CRS-4
constitutes a federal responsibility. The Stafford Act procedure for an emergency
declaration follows:
(a) Request and declaration. All requests for a declaration by the President that
an emergency exists shall be made by the Governor of the affected State. Such
a request shall be based on a finding that the situation is of such severity and
magnitude that effective response is beyond the capabilities of the State and the
affected local governments and that Federal assistance is necessary. As a part of
such request, and as a prerequisite to emergency assistance under this chapter,
the Governor shall take appropriate action under State law and direct execution
of the State’s emergency plan. The Governor shall furnish information
describing the State and local efforts and resources which have been or will be
used to alleviate the emergency, and will define the type and extent of Federal
aid required. Based upon such Governor’s request, the President may declare
that an emergency exists.
(b) Certain emergencies involving Federal primary responsibility. The President
may exercise any authority vested in him by Section 5192 of this Title or Section
5193 of this Title with respect to an emergency when he determines that an
emergency exists for which the primary responsibility for response rests with the
United States because the emergency involves a subject area for which, under the
Constitution or laws of the United States, the United States exercises exclusive
or preeminent responsibility and authority. In determining whether or not such
an emergency exists, the President shall consult the Governor of any affected
State, if practicable. The President’s determination may be made without regard
to subsection (a) of this section.9
The emergency declaration authority in the Stafford Act has previously been
used by a President to respond to a public health threat. In the fall of 2000, President
Clinton issued two emergency declarations for New York and New Jersey to help the
states contain the threatened spread of the West Nile virus.10
Public Health Emergency Authorities. Section 319 of the Public Health
Service Act grants the Secretary of HHS broad authority to determine that a public
health emergency exists. Pursuant to such a determination, the Secretary may waive
certain administrative requirements, provide additional forms of assistance, and take
certain other actions to expand federal aid to state and local governments, not-for-
profit entities, and others. The Secretary’s statutory authority to determine a public
health emergency is as follows:
If the Secretary determines, after consultation with such public health officials
as may be necessary, that — (1) a disease or disorder presents a public health
emergency; or (2) a public health emergency, including significant outbreaks of
infectious diseases or bioterrorist attacks, otherwise exists, the Secretary may
take such action as may be appropriate to respond to the public health
9 42 U.S.C. § 5191. Examples of emergencies involving Federal primary responsibility
include the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, and
the 2001 attack on the Pentagon, both federally owned facilities.
10 For background, see Federal Emergency Management Agency (FEMA) notices at
[http://www.fema.gov/news/disasters.fema?year=2000#em].

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CRS-5
emergency, including making grants, providing awards for expenses, and
entering into contracts and conducting and supporting investigations into the
cause, treatment, or prevention of a disease or disorder as described in
paragraphs (1) and (2).11
The Secretary has a variety of additional authorities to provide assistance. Some of
these authorities require a concurrent determination of public health emergency
pursuant to the Section 319 authority above, some require a concurrent Stafford Act
declaration, and some are independent of any other authority. A listing of various
federal public health emergency authorities is provided in the Appendix.
The emergency authorities of the Secretary of HHS are not strictly comparable
to authorities in the Stafford Act. Stafford Act major disaster assistance is intended
to assist states and individuals with needs that exceed the scope of assistance
routinely provided by federal agencies, and is often triggered by large-scale damage
to public and private infrastructure. In contrast, the response to public health
emergencies, such as infectious disease outbreaks, involves technical assistance for
epidemiologic and laboratory investigation, workforce assistance, the provision of
special drugs or tests, and a variety of other extensions of routine program activities.
The Secretary of HHS can provide a considerable degree of assistance to states,
upon their request, without the restrictions of cause or the requirement to demonstrate
need as with the Stafford Act. For example, simply upon the request of a State
Health Official, and without the involvement of the President, the Centers for Disease
Control and Prevention (CDC) can provide financial and technical assistance to states
for outbreak investigation and disease control activities. These activities are carried
out under the Secretary’s general authority to assist states, pursuant to Section 311
of the Public Health Service Act.12 Public health emergency determinations have
been made considerably less often than have disaster or emergency declarations
pursuant to the Stafford Act. The Secretary of HHS has determined that a public
health emergency exists on only three occasions since 2000: (1) nationwide, in
response to the terrorist attacks on September 11, 2001; (2) in several states affected
by Hurricane Katrina in August and September 2005; and (3) in several states
affected by Hurricane Rita in September 2005.13 The rarity of public health
emergency declarations may reflect the wide latitude that may be exercised by the
Secretary of HHS through standing authority. Compared to authorities in the
Stafford Act, the Secretary of HHS appears to have considerably more discretion in
dedicating federal resources, whether he has determined there to be a public health
emergency or not.
11 42 U.S.C. § 247d(a), as amended in P.L. 106-505, the Public Health Improvement Act.
12 42 U.S.C. § 243c.
13 More information regarding these determinations is available in CRS Report RL33096,
2005 Gulf Coast Hurricanes: The Public Health and Medical Response, by Sarah A. Lister.
The 2001 determination applied to the September 11 attacks and not to the subsequent
anthrax attack (66 Federal Register 54998, Oct. 31, 2001). Stafford major disaster and
emergency declarations may be found on FEMA’s website at [http://www.fema.gov/
hazard/index.shtm].

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Intersection of Stafford Act and Public Health Emergency Authority.
Disaster and emergency authorities pursuant to the Stafford Act are generally
independent of public health emergency authorities. Only one provision in current
law — allowing for the waiver of a number of HHS statutory, regulatory and program
requirements — requires simultaneous Stafford Act and public health emergency
declarations. (See “Waiver of certain requirements” in the Appendix for more
information.) However, when all three types of declarations are issued as a result of
a specific incident, as they were following Hurricane Katrina, it poses a greater
challenge for officials in understanding the altered scope of their response
authorities.14
Federal Coordinating Mechanisms for Disaster Response
National Response Plan. Pursuant to congressional mandate, the
Department of Homeland Security (DHS) released the National Response Plan
(NRP) in December 2004 to establish a comprehensive framework for the
coordination of federal resources under specified emergency conditions.15 The NRP,
which is under the overall coordination of the Secretary of Homeland Security, and
delegated to the Federal Emergency Management Agency (FEMA), sets forth the
responsibilities and roles of federal agencies, identifies tasks to be undertaken by
specified federal officials, and includes annexes that provide detail on support
resources and mechanisms that are integral to the Plan’s implementation. The Plan
is to be invoked after the President issues a major disaster or emergency declaration
under authority of the Stafford Act.
In addition to emergencies that result in Stafford Act declarations, federal
officials implement the NRP during domestic incidents that, among other factors,
satisfy any one of four criteria set out by President Bush in Homeland Security
Presidential Directive (HSPD) - 5.16 These include:
! a federal agency, under its own authority, requests DHS assistance;
14 For example, for Hurricane Katrina, Louisiana received an emergency declaration on Aug.
27, 2006, prior to landfall, which was superceded by a major disaster declaration on Aug.
29, 2006, the day of landfall. The Secretary of HHS also determined that a public health
emergency existed in Louisiana, effective Aug. 29, 2006. To further complicate matters, at
least two types of assistance to Louisiana citizens — Medicaid and Crisis Counseling
Program grants — were based on their evacuation status from Stafford major disaster areas,
and were available to them in host areas (including other states), some of which did not
themselves have major disaster declarations.
15 6 U.S.C. § 312(6). See Department of Homeland Security, National Response Plan,
December 2004, hereafter called the NRP, at [http://www.dhs.gov/interweb/assetlibrary/
NRP_FullText.pdf]. The NRP superseded the Federal Response Plan that had been used
since 1992. See also CRS Report RL32803, The National Preparedness System: Issues in
the 109th Congress, by Keith Bea.
16 White House, “Homeland Security Presidential Directive/HSPD-5, Subject: Management
of Domestic Incidents,” Feb. 28, 2003, at [http://www.whitehouse.gov/news/releases/
2003/02/20030228-9.html].

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! state and local governments overwhelmed by an emergency request
federal aid not only through Stafford Act declarations but also
through “catastrophic incidents” that, whether caused by natural or
human actions, result in “extraordinary” mass casualties or
disruptions of functions that might threaten national security;
! more than one federal agency is involved in incident response; and,
! the President directs the Secretary of DHS to assume management
of an incident.17
National Response to an Influenza Pandemic. In addition to the NRP,
which guides a coordinated federal response to a variety of catastrophes, key federal
planning documents specific for an influenza pandemic include:
! The National Strategy for Pandemic Influenza, November 2005:
outlines general responsibilities of individuals, industry, state and
local governments, and the federal government in preparing for and
responding to a pandemic.18
! The HHS Pandemic Influenza Plan, November 2005: provides
guidance to national, state and local policy makers and health
departments, outlining key roles and responsibilities during a
pandemic and specifying preparedness needs and opportunities.
This plan emphasizes specific preparedness efforts in the public
health and healthcare sectors.19
! Department of Defense Influenza Pandemic Preparation and
Response Health Policy Guidance, January 2006: provides policy
and instructions for Department of Defense (DOD) military assets
regarding influenza pandemic preparedness and response, with the
goal of maintaining operational effectiveness by minimizing death,
disease and lost duty time of military members.20
17 Modifications to the NRP were issued by DHS on May 25, 2006, that replaced the phrase
“Incidents of National Significance” with more general, and undefined terms such as
“incident,” “actual or potential domestic incidents,” or “domestic incident management.”
The impact of such a change might be significant, as the criteria for invoking the NRP might
change from situations not envisioned to be “Incidents of National Significance.” See DHS,
Notice of Change to the National Response Plan, May 25, 2006, at [http://www.dhs.gov/
dhspublic/display?theme=15&content=4269].
18 White House Homeland Security Council, National Strategy for Pandemic Influenza, Nov.
1, 2005, at [http://www.whitehouse.gov/homeland/nspi.pdf].
19 Department of Health and Human Services, HHS Pandemic Influenza Plan, November
2005, at [http://www.hhs.gov/pandemicflu/plan/pdf/HHSPandemicInfluenzaPlan.pdf].
20 Assistant Secretary of Defense for Health Affairs William Winkenwerder, Jr.,
“Department of Defense Influenza Pandemic Preparation and Response Health Policy
Guidance,” memorandum to the Joint Services, Jan. 25, 2006, at [http://www.vaccines.mil/
documents/ 886PandemicFluPolicy.pdf]. The guidance assumes that DOD: (1) will support
the HHS in pandemic response by conducting medical and laboratory surveillance and
diagnostic testing through DOD assets; (2) may, under applicable authorities, assist civil
authorities by providing logistical and medical support; and (3) may, upon a civilian request,
(continued...)

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CRS-8
! National Strategy for Pandemic Influenza, Implementation Plan,
May 2006: assigns more than 300 preparedness and response tasks
to departments and agencies across the federal government; includes
measures of progress and timelines for implementation; provides
initial guidance for state, local, and tribal entities, businesses,
schools and universities, communities, and non-governmental
organizations on the development of institutional plans; provides
initial preparedness guidance for individuals and families.21
Would the Stafford Act Apply in a Flu Pandemic?
Each of the pandemic influenza plans listed earlier is written with the premise
that the NRP could be triggered by a flu pandemic, thereby guiding a coordinated
federal response to problems within the health sector and other affected sectors
through routine, non-emergency, federal assistance mechanisms.22 According to the
Pandemic Implementation Plan, the Secretary of Homeland Security may declare a
pandemic an Incident of National Significance early in the event, perhaps while
foreign countries were affected, but before the disease had reached the United
States.23 Given that emergency declarations pursuant to the Stafford Act were made
in response to West Nile virus in 2000, there is precedent for a presidential
emergency declaration in response to an infectious disease threat. The matter of
presidential authority to declare a major disaster (providing a higher level of federal
assistance) in response to an infectious disease threat generally, and a flu pandemic
specifically, is less clear. FEMA has in the past, in the context of the national
TOPOFF exercises, interpreted biological disasters as ineligible for major disaster
assistance pursuant to the Stafford Act.24 However, the Administration view is that
20 (...continued)
respond immediately to save lives, mitigate human suffering, minimize property damage,
or restore essential operations and services.
21 Homeland Security Council, National Strategy for Pandemic Influenza: Implementation
Plan, May 2006, hereafter called the Pandemic Implementation Plan, at [http://www.
whitehouse.gov/homeland/pandemic-influenza-implementation.html].
22 The NRP Biological Incident Annex notes that “Actions described in this annex take place
with or without a presidential Stafford Act declaration or a public health emergency
declaration” by the Secretary of HHS. See NRP, Biological Incident Annex, p. BIO-1.
While this annex addresses intentional bioterrorism events, it also addresses naturally
occurring biological threats, and explicitly mentions pandemic influenza. In contrast, the
NRP Catastrophic Incident Annex does not explicitly mention pandemic influenza. While
this annex is designed to address disasters with “extraordinary levels of mass casualties”
such as could occur with a pandemic, it is also explicitly focused on “no-notice or
short-notice incidents of catastrophic magnitude,” a definition that would not likely apply
to an influenza pandemic. See NRP, Catastrophic Incident Annex, p. CAT-1, and DHS,
Notice of Change to the National Response Plan, May 25, 2006, pp. 9-10, at
[http://www.dhs.gov/dhspublic/display?theme=15&content=4269].
23 Pandemic Implementation Plan, p. 37.
24 See DHS, Office of the Inspector General, A Review of the Top Officials 3 Exercise,
Office of Inspections and Special Reviews, OIG-06-07, November 2005, p. 30, at
(continued...)

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the President’s authority to declare a major disaster pursuant to the Stafford Act
could be applied to an influenza pandemic.25
NRP Emergency Support Function 8:
Roles and Challenges
Overview
Hurricane Katrina demonstrated the scope of public health and medical
activities needed in response to a large-scale catastrophe. A successful public health
response — which involves the monitoring and assurance of the safety of food and
water, prevention of injury, control of infectious diseases, and a host of other
activities — is carried out by a variety of entities, primarily government and not-for-
profit agencies. A successful medical response is perhaps more challenging,
requiring the coordination of several elements, which are variously based in federal,
state or local authority, or in the private sector. These elements are (1) patients, who
may be inaccessible and require rescue or medical evacuation; (2) a treatment facility,
which may be an existing hospital or a field tent with cots; (3) a competent healthcare
workforce; (4) appropriate non-perishable medical supplies; (5) appropriate drugs,
vaccines, tests and other perishable medical supplies; (6) a system of medical
records; and (7) a healthcare financing mechanism. A flu pandemic would not likely
impose the mass dislocations and destruction of healthcare infrastructure seen
following Hurricane Katrina. But, as a pandemic would affect all areas of the nation
simultaneously, responders could not necessarily count on the state-to-state mutual
aid that was critical to the hurricane response.
According to the NRP, the Secretary of HHS is tasked with coordinating
Emergency Support Function 8 (ESF-8), the public health and medical response to
incidents.26 The 15 ESFs in the NRP are coordinating mechanisms, not funding
mechanisms. The response to an influenza pandemic is likely to be primarily an
ESF-8 response, in which public health and medical needs could be substantial. Less
onerous burdens might be expected on other ESFs such as transportation, public
works and energy, compared to those imposed following hurricanes and other
weather-related disasters. Nonetheless, planners note that a severe pandemic could
still constitute a multi-sector incident. Staffing shortages and supply chain
24 (...continued)
[http://www.dhs.gov/interweb/assetlibrary/OIG_06-07_Nov05.pdf].
25 Pandemic Implementation Plan, Appendix C, “Authorities and References,” p. 212.
26 NRP, Annex ESF#8, at [http://www.dhs.gov/interweb/assetlibrary/NRP_FullText.pdf].
See also HHS, “HHS Maintains Lead Federal Role for Emergency Public Health and
Medical Response,” press release, Jan. 6, 2005. Many ESF-8 responsibilities and activities
are delegated to the Assistant Secretary for Public Health Emergency Preparedness. See
HHS, Office of the Secretary, Office of Public Health Emergency Preparedness, “Statement
of Organization, Functions, and Delegations of Authority,” 71 Federal Register 38403, July
6, 2006.

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disruptions could affect the continuity of services, and possibly the integrity of
infrastructure, in the transportation, public works and energy sectors, among others.
The Secretary of HHS is responsible for coordinating the following activities
under ESF-8, and may request assistance from 14 designated support agencies and
the American Red Cross as needed:
! Assessment of public health and medical needs;
! Health surveillance;
! Medical care personnel;
! Health and medical equipment and supplies;
! Patient evacuation;
! Patient care;
! Safety and security of human drugs, biologics, and medical devices,
veterinary drugs, and other HHS-regulated products;
! Blood and blood products;
! Food safety and security;
! Agriculture safety and security (principally with regard to food-
producing animals and animal feeds and drugs);
! Worker health and safety;
! All-hazard public health and medical consultation, technical
assistance and support;
! Behavioral health care;
! Public health and medical information;
! Vector control (e.g., control of disease-carrying insects and rodents);
! Potable water, wastewater and solid waste disposal;
! Victim identification and mortuary services; and
! Protection of animal health (principally with regard to HHS-
regulated animal feeds and drugs).
HHS does not bear primary responsibility for mass care, which is the
coordination of non-medical services such as shelter, feeding, emergency first aid,
and efforts to reunite displaced family members. Mass care is the responsibility of
DHS and is carried out by the FEMA and the American Red Cross according to ESF-
6. HHS is also not responsible for urban search and rescue, which is also the
responsibility of DHS and FEMA pursuant to ESF-9. Furthermore, HHS may depend
on numerous other agencies to carry out certain of their ESF activities (e.g., public
safety, road clearing and power restoration) before some ESF-8 activities can
commence.
ESF-8 Leadership
Some have questioned whether the NRP clearly defines federal ESF-8
leadership, or whether the respective roles of the Secretaries of Homeland Security
and Health and Human Services could conflict during a response. Some, including
congressional investigators, felt this conflict was in evidence during the response to

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CRS-11
Hurricane Katrina.27 Others are concerned that the respective roles are insufficiently
clear to guide a coordinated response to a flu pandemic. Several pending bills in the
109th Congress propose to clarify federal responsibilities for ESF-8 response. These
include H.R. 5438 (reported in House) and S. 3678 (reported in Senate), which
provide that HHS shall lead the federal public health and medical response to
incidents, and H.R. 4632 (introduced in the House) and H.R. 5814 (reported in the
House), which would delegate certain ESF-8 preparedness and response functions to
the Chief Medical Officer in DHS. There has been particular concern about the
clarity of authority with respect to the deployment of two federal response assets, the
National Disaster Medical System (NDMS, discussed further below), and the
Strategic National Stockpile (SNS) of drugs and medical supplies, which would
likely be deployed in response to a flu pandemic. Under current law, both the
Secretary of Homeland Security and the Secretary of HHS have authority to deploy
the SNS, as well as certain joint authorities regarding procurement.28
Unclear Federal Leadership for Certain Response Functions
In the response to Hurricane Katrina, it became apparent that federal
responsibility to coordinate certain support activities was not clear in the existing
ESF assignments in the NRP. Some of these problems are discussed below.
It is not essential that an ESF lead agency have direct control of all of the federal
assets needed for the relevant response. The NRP, in fact, assumes that federal
agencies retain control over their assets and that NRP mechanisms ensure that
resource delivery from multiple federal agencies is coordinated. However, there has
been considerable discussion regarding whether ESF-8 can function effectively when
one of its key assets, the National Disaster Medical System (NDMS), is based at
FEMA rather than at HHS. (NDMS consists of a number of medical response teams
that can deploy to a scene rapidly and set up field operations that are self-sustaining
for up to 72 hours, until additional federal support arrives.29) Congressional and
White House investigators each found that NDMS deployments in response to
Hurricane Katrina were made by FEMA without the involvement of personnel at
HHS, undermining the intent of the NRP and the ability of HHS to coordinate the
overall ESF-8 response effectively.30 In FY2007 appropriations for DHS (P.L. 109-
27 See U.S. Senate, Committee on Homeland Security and Governmental Affairs, Hurricane
Katrina: A Nation Still Unprepared, chap. 24, p. 28ff, May 2006, online at
[http://hsgac.senate.gov/], hereafter called A Nation Still Unprepared; and the White House,
The Federal Response to Hurricane Katrina: Lessons Learned, p. 47, Feb. 2006, at
[http://www.whitehouse.gov/reports/katrina-lessons-learned/], hereafter called Lessons
Learned.
28 The authority of the Secretary of DHS to deploy the SNS is codified at 6 U.S.C. § 312.
The authority of the Secretary of HHS to deploy the SNS is codified at 42 U.S.C. § 247d-6b,
as are certain procurement authorities provided jointly to the two secretaries.
29 Additional information about NDMS is available in CRS Report RL33096: 2005 Gulf
Coast Hurricanes: The Public Health and Medical Response, by Sarah A. Lister.
30 See U.S. House of Representatives, A Failure of Initiative: The Final Report of the Select
Bipartisan Committee to Investigate the Preparation for and Response to Hurricane
(continued...)

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CRS-12
295, signed October 4, 2006), Congress transferred NDMS to HHS, effective January
1, 2007. The transfer was supported by the Administration.31 (NDMS was originally
transferred from HHS to DHS in P.L. 107-296, the Homeland Security Act, effective
in 2003.)
(The role of NDMS in a flu pandemic is a matter of some discussion as well.
As a pandemic would be a near-simultaneous national incident, the value of a mobile
medical force is less apparent than it would be in a localized event. Some planners
have suggested that NDMS personnel should remain within their home communities.
The Pandemic Implementation Plan envisions the strategic use of NDMS teams,
when available, to support a variety of federally coordinated disease-control
activities.)
The NRP does not clearly delegate responsibility for the retrieval of human
remains in mass fatality events. HHS is responsible for the ESF-8 function of
coordinating federal assistance to identify victims and determine causes of death.
NDMS Disaster Mortuary Assistance Teams (DMORTs) comprise medical
examiners, pathologists, dental technicians and other medical personnel. These
teams are not skilled in the safe retrieval of remains from hazardous sites such as
waterways or collapsed buildings. Other responders, including Urban Search and
Rescue teams and the Coast Guard, are trained to work safely in such dangerous
conditions, but their mission is to rescue the living, not recover the dead.32 The
matter of mass fatality management is of considerable concern to pandemic planners,
and this gap could be problematic during such a disaster.
The NRP does not clearly delegate federal responsibility for the well-being of
pets during disasters.33 It is well established that some people are reluctant to
abandon their pets and will remain at home during an evacuation order if they cannot
take pets with them: therefore, the absence of coordinated mechanisms to assure the
safety of pets in disasters may jeopardize human safety as well.34 Several states (e.g.,
30 (...continued)
Katrina, p. 297, Feb. 2006, at [http://katrina.house.gov/], hereafter called A Failure of
Initiative; A Nation Still Unprepared, chap. 24, p. 29; and Lessons Learned, p. 47.
31 Office of Management and Budget, “Statement of Administration Policy: H.R. 5441 —
Department of Homeland Security Appropriations Bill, FY2007,” Senate version, July 12,
2006, p. 2, at [http://www.whitehouse.gov/omb/legislative/sap/109-2/hr5441sap-s.pdf].
32 Further discussion of the difficulties in coordinating body retrieval following Hurricane
Katrina is available in A Failure of Initiative, p. 299.
33 A search of the NRP for the terms “pets” and “companion animals” yields references only
to FDA’s responsibilities to assure the safety of animal drugs, and USDA’s responsibilities
to control animal diseases affecting livestock and to advise on decontamination procedures
for pets exposed to radioactive material. See also, R. Scott Nolen and Allison Rezendes,
“Summit Works Toward National Animal Disaster Plan,” Journal of the American
Veterinary Medical Association, news article, June 15, 2006, at [http://www.avma.org/
onlnews/javma/jun06/060615a.asp].
34 See DHS: “Nationwide Plan Review, Phase 2 Report,” June 16, 2006, p. 53, at
[http://www.dhs.gov/interweb/assetlibrary/Prep_NationwidePlanReview.pdf]; and
(continued...)

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CRS-13
Florida, Louisiana, and Texas) have incorporated pet-friendly shelters or other
arrangements in their disaster plans, to address this concern. In FY2007
appropriations for DHS (P.L. 109-295, signed October 4, 2006), Congress included
a provision requiring the department, in approving standards for state and local
emergency plans, to account for the needs of individuals with household pets and
service animals before, during, and following a major disaster or emergency. The act
does not, however, address the broader matter of federal leadership for the needs of
pets in disasters.
Finally, as was evident in the response to Hurricane Katrina, the distinction
between ESF-6 (mass care) and ESF-8 (public health and medical) may be blurred,
such as when evacuees in Red Cross shelters required medical care, when large
numbers of hospital patients evacuated to ESF-8 field hospitals required food and
water, or when crisis counseling services were required to address victims’ mental
health needs. This problem is likely amenable to an administrative solution, and is
being considered by FEMA, HHS and the American Red Cross in their reviews of
the hurricane response and their ongoing preparedness activities.
Federal Funding to Support an ESF-8 Response
Hurricane Katrina represented the greatest test of ESF-8 since the creation of the
Department of Homeland Security and the publication of the NRP. A variety of
public health and medical activities were undertaken in the hurricane response. The
costs of these activities were borne by agencies at the federal, state and local levels,
not-for-profit groups, businesses, healthcare providers, insurers, families, and
individuals. Private insurance covered some of the property damage, healthcare and
other costs resulting from the disaster. Congress provided additional assistance
through emergency appropriations to cover expanded federal agency activities and
a portion of uninsured healthcare costs. Some other costs, such as the costs of
rebuilding the devastated healthcare infrastructure in New Orleans, have not been
fully met at this time, either through existing assistance mechanisms or mechanisms
developed since the storm.35 The response to Hurricane Katrina, and ongoing
pandemic preparedness efforts, each offer a glimpse of the complexity and adequacy
of existing mechanisms to fund the costs of an ESF-8 response.
Funding Sources and Authorities
The Disaster Relief Fund. Activities undertaken under authority of the
Stafford Act are funded through appropriations to the Disaster Relief Fund (DRF),
administered by FEMA. Federal assistance supported by the DRF is used by states,
34 (...continued)
“Ready.gov,” preparedness information for pet owners, at [http://www.ready.gov/america/
getakit/pets.html].
35 See HHS, “Louisiana Health Care System Focus of Redesign,” press release, July 17,
2006; and Bruce Alpert, “GAO Says Hospitals not Worth Salvaging,” Times-Picayune, Mar.
30, 2006.

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CRS-14
localities, and certain non-profit organizations to provide mass feeding and shelter,
restore damaged or destroyed facilities, clear debris, and aid individuals and families
with uninsured needs, among other activities. Federal agencies that receive mission
assignments from DHS and provide assistance pursuant to the NRP are also
reimbursed through funds appropriated to the DRF. The DRF is a no-year account
in which appropriated funds remain available until expended. Supplemental
appropriations legislation is generally required each fiscal year to replenish the DRF
to meet the urgent needs of particularly catastrophic disasters.36
The Public Health Emergency Fund. In 1983, Congress established
authority for a no-year public health emergency fund to be available to the HHS
Secretary.37 In 2000, Congress reauthorized the fund, clarifying that it could only be
used when the Secretary had made a determination of a public health emergency
pursuant to 42 U.S.C. § 247d(a), as follows:
(1) In general. There is established in the Treasury a fund to be designated as the
“Public Health Emergency Fund” to be made available to the Secretary without
fiscal year limitation to carry out subsection (a) only if a public health emergency
has been declared by the Secretary under such subsection. There is authorized to
be appropriated to the Fund such sums as may be necessary.
(2) Report. Not later than 90 days after the end of each fiscal year, the Secretary
shall prepare and submit to the Committee on Health, Education, Labor, and
Pensions and the Committee on Appropriations of the Senate and the Committee
on Commerce and the Committee on Appropriations of the House of
Representatives a report describing — (A) the expenditures made from the
Public Health Emergency Fund in such fiscal year; and (B) each public health
emergency for which the expenditures were made and the activities undertaken
with respect to each emergency which was conducted or supported by
expenditures from the Fund.38
Prior to 2000, the fund was authorized for annual appropriations sufficient to
have a balance of $45 million in the fund at the beginning of each fiscal year.
Despite this prior authorization of annual appropriations, the fund received
appropriations only in response to a few public health threats (e.g., the emergence of
hantavirus in the Southwest in 1993-1994), but did not receive an appropriation for
its intended use as a reserve fund for unanticipated events. The fund has not received
an appropriation since it was explicitly linked to the public health emergency
authority in 42 U.S.C. § 247d(a) in 2000. As a consequence, the fund was not
utilized during three public health emergency determinations made subsequently: (1)
nationwide, in response to the terrorist attacks on September 11, 2001; (2) in several
states affected by Hurricane Katrina in August and September 2005; and (3) in
several states affected by Hurricane Rita in September 2005.39
36 For more information, see CRS Report RL33053, Federal Stafford Act Disaster
Assistance: Presidential Declarations, Eligible Activities, and Funding, by Keith Bea.
37 P.L. 98-49.
38 42 U.S.C. § 247d(b), as amended by P.L. 106-505.
39 More information regarding these determinations is available in CRS Report RL33096,
(continued...)

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CRS-15
In 2002, Congress reauthorized the National Disaster Medical System (NDMS)
in language suggesting that the emergency fund could be used to support NDMS
activities, as follows:
... For the purpose of providing for the Assistant Secretary for Public Health
Emergency Preparedness and the operations of the National Disaster Medical
System, other than purposes for which amounts in the Public Health Emergency
Fund under Section 319 are available, there are authorized to be appropriated
such sums as may be necessary for each of the fiscal years 2002 through 2006.40
The Public Health and Social Services Emergency Fund. The Public
Health and Social Services Emergency Fund (PHSSEF) is an account at HHS that has
been used to provide annual or emergency supplemental appropriations for one-time
or short-term public health activities in a variety of agencies and offices. Providing
funding to the PHSSEF, which does not have an explicit authority in law, separates
these amounts from an agency’s annual “base” funding. Recent activities funded
through the PHSSEF include preparedness activities for a flu pandemic, one-time
purchases for the Strategic National Stockpile (SNS), and funding for state public
health and hospital preparedness. Amounts appropriated to the PHSSEF may or may
not be designated as emergency spending. Because the PHSSEF has been used only
to fund certain planned activities, it is not a reserve fund for unanticipated events.
In FY2006, Congress appropriated certain amounts that had previously been
provided through the PHSSEF directly to the various agencies overseeing the
programs. These included funding for the SNS and grants for upgrading state and
local public health capacity, amounts now appropriated in CDC’s “Terrorism and
Public Health Preparedness” budget line,41 and state grants for hospital preparedness,
now appropriated in the budget line for bioterrorism programs of the Health
Resources and Services Administration (HRSA).42
Funding the ESF-8 Response to Hurricane Katrina
In response to the widespread destruction caused by Hurricane Katrina, the 109th
Congress enacted two FY2005 emergency supplemental appropriations bills (P.L.
109-61 and P.L. 109-62), which together provided $62.3 billion for emergency
response and recovery needs. The FY2006 appropriations legislation for the
Department of Defense (P.L. 109-148) reallocated $23.4 billion in funds appropriated
in the two emergency supplemental statutes, and an additional amount from a
government-wide rescission, primarily to pay for the restoration of damaged federal
facilities. In June 2006, Congress provided an additional $6 billion to the DRF in
39 (...continued)
2005 Gulf Coast Hurricanes: The Public Health and Medical Response, by Sarah A. Lister.
40 42 U.S.C. § 300hh-11, as amended by P.L. 107-188.
41 More information on CDC’s budget is available at [http://www.cdc.gov/fmo/
fmofybudget.htm].
42 More information on HRSA’s budget is available in the FY2007 budget justification at
[http://www.hrsa.gov/about/budgetjustification07/].

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CRS-16
P.L. 109-234, Emergency Supplemental Appropriations Act for Defense, the Global
War on Terror, and Hurricane Recovery, 2006.43
A portion of supplemental appropriations to the DRF supported federal ESF-8
response activities. FEMA reports expenditures for mission assignments to both
HHS and separately to CDC (an agency within HHS) for the responses to Hurricanes
Katrina, Rita and Wilma.44 A number of HHS agencies in addition to CDC were
involved in the response to the hurricanes, and their activities, when requested by
FEMA, were presumably reimbursed through the DRF.45
There were likely other HHS activities carried out in response to the hurricanes
that would not fall within the scope of activities reimbursable by the DRF. For
example, on September 16, 2005, CDC issued guidance to state grantees permitting
them to redirect funds from a number of grant programs to their hurricane relief
efforts as needed.46 According to CDC, funds could be used for alternate activities
within the state, or to support state-to-state mutual aid pursuant to the Emergency
Management Assistance Compact (EMAC).47 States were permitted to redirect funds
from the following federal grant programs: infectious diseases (including
immunization, sexually transmitted disease prevention, tuberculosis, West Nile virus,
hepatitis, HIV, emerging infections and laboratory programs); environmental health;
injury prevention; and, terrorism and emergency preparedness. CDC noted at the
time that “No supplemental appropriations have been provided to CDC for Katrina
relief, so any existing CDC funds used for relief will reduce the overall amount
available to work non-relief grant issues.”48 HRSA also advised state grantees that
some redirection of funds provided by the National Bioterrorism Hospital
43 For more information, see CRS Report RS22239, Emergency Supplemental
Appropriations for Hurricane Katrina Relief, by Keith Bea; and CRS Report RL33298,
FY2006 Supplemental Appropriations: Iraq and Other International Activities; Additional
Hurricane Katrina Relief, coordinated by Paul M. Irwin and Larry Nowels.
44 See, for example, DHS, FEMA, “Weekly Disaster Relief Fund (DRF) Report,”
Congressional Weekly Report, July 12, 2006, at [http://appropriations.house.gov/_files/
HurricaneKatrinaLink.htm].
45 For information regarding the activities of HHS agencies in response to the 2005
hurricanes, see CRS Report RL33096, 2005 Gulf Coast Hurricanes: The Public Health and
Medical Response, by Sarah A. Lister; and HHS, Centers for Medicare and Medicaid
Services (CMS), “Summary of Federal Payments Available for Providing Health Care
Services to Hurricane Evacuees and Rebuilding Health Care Infrastructure,” Jan. 25, 2006,
at [http://www.hhs.gov/katrina/#hhs].
46 CDC, letter from William P. Nichols, Director, CDC Procurement and Grants Office, to
CDC directors and grants management personnel, regarding “Treatment of Grants under
Emergency Conditions due to Hurricane Katrina,” Sept. 16, 2005, hereafter referred to as
the Nichols letter, at [http://www.bt.cdc.gov/disasters/ hurricanes/katrina/pdf/grantuse.pdf].
47 The Emergency Management Assistance Compact is a congressionally approved interstate
mutual aid agreement that provides a legal structure by which states affected by a
catastrophe may request emergency assistance from other states. For more information, see
CRS Report RS21227, The Emergency Management Assistance Compact (EMAC): An
Overview, by Keith Bea.
48 Nichols letter.

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CRS-17
Preparedness Program was also permissible to support the hurricane response.49
Information regarding the overall amount of funds that may have been redirected by
HHS agencies to support Hurricane Katrina response activities, and, for those
expenditures that were not reimbursable by the DRF, whether there were alternate
mechanisms to “backfill” the accounts, is not publicly available.
Federal Assistance for Disaster-Related Healthcare Costs
Existing Mechanisms. Several federal assistance mechanisms are available
to cover the costs of healthcare services that are rendered during, or required as a
result of, a catastrophe. Examples include:
! Services provided by the National Disaster Medical System (NDMS)
or other federalized employees while carrying out mission
assignments requested by FEMA may be reimbursed by the DRF,
though efforts are made to seek reimbursement from patients’
insurers when possible. This assistance may be provided under both
major disaster and emergency declarations that involve the provision
of health and safety measures and the reduction of threats to public
health and safety.50
! The FEMA Individuals and Households Program (IHP) provides
cash assistance that may be used for uninsured medical expenses.
Recipients might have to use the funds to meet other needs
concurrently, such as rent and other costs of living. The amount
available is the same for an individual or a household, and is capped
in statute, with an adjustment based on the Consumer Price Index.51
The maximum amount available for Hurricane Katrina relief was
$26,200,52 and the current ceiling is $27,200.53
! The Stafford Act authorizes the President, pursuant to a major
disaster declaration, to provide financial assistance to state and
qualified tribal mental health agencies for professional counseling
services, or training of disaster workers, to relieve disaster victims’
mental health problems caused or aggravated by the disaster or its
aftermath. The Substance Abuse and Mental Health Services
Administration (SAMHSA) in HHS administers the Crisis
49 See notice posted by the Association of State and Territorial Health Officials at
[http://www.astho.org/templates/display_pub.php?pub_id=1681&admin=1].
50 42 U.S.C. § 5170b (major disaster) and 42 U.S.C. § 5192 (emergency).
51 42 U.S.C. § 5174(h).
52 For more information on the FEMA Individuals and Households Program, see DHS,
Office of Inspector General, “A Performance Review of FEMA’s Disaster Management
Activities in Response to Hurricane Katrina,” OIG-06-32, Appendix B, pp. 149 ff., March
2006, at [http://www.dhs.gov/interweb/assetlibrary/OIG_06-32_Mar06.pdf].
53 70 C.F.R. 58735.

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CRS-18
Counseling Assistance and Training Program (CCP). Financing for
this assistance is drawn from the DRF.54
! Certain medications and supplies may be provided to patients from
pre-paid stockpiles for which reimbursement is not expected.
Examples may include supplies used in Red Cross first aid stations
or distributed to states from the CDC’s Strategic National Stockpile.
! Public Health Service agencies in HHS may provide support to
states and other entities through existing non-emergency
mechanisms to assist in managing surges in healthcare needs for
specific populations. In some cases, agencies have received
supplemental appropriations to support these activities. Examples
include SAMHSA Emergency Response Grants (SERG) to states,
territories, and federally recognized tribal authorities for crisis
mental health and substance abuse services,55 and expanded federal
support, including personnel, for health centers in disaster-affected
areas.56
These programs provide a patchwork of coverage that in some cases fails to
optimally match services with need (e.g., the Crisis Counseling Program), or in other
cases fails to meet the magnitude of need (e.g., the FEMA individual assistance
program). In any case, these programs are not generally coordinated with each other
at the federal level, though programs that support state activities to finance or deliver
healthcare services may be coordinated at that level.
Financing Healthcare Needs Following Hurricane Katrina. Hurricane
Katrina was one of the worst natural disasters in the nation’s history, and the largest
mass casualty incident in recent memory. Many of Katrina’s victims were dislocated
to different states, separated from their documentation of health insurance, or both.
Others lost employer-based health insurance due to the destruction or closure of
businesses. In many cases, care was rendered without definitive financing
mechanisms, while federal, state and private entities worked to retrofit these
mechanisms in the disaster’s aftermath.
In response to Hurricane Katrina, HHS expanded a number of existing programs
to assist state and local agencies, healthcare providers and the storms’ victims with
54 42 U.S.C. § 5183. For more information, see CRS Report RS22292, Hurricanes Katrina
and Rita: Addressing the Victims’ Mental Health and Substance Abuse Treatment Needs,
by Erin D. Williams.
55 Ibid.
56 Health centers provide healthcare services regardless of ability to pay. For more
information, see HRSA, Bureau of Primary Health Care, Health Center Program, at
[http://bphc.hrsa.gov/chc/]; and Hurricane Relief and Recovery, at [http://www.hrsa.gov/
katrina/].

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CRS-19
a variety of health and public health needs.57 Information regarding the overall cost
of these expansions is not publicly available.
In 2002, Congress gave the Secretary of HHS authority to waive certain
administrative requirements for provider participation in Medicare, Medicaid and the
State Children’s Health Insurance Program (SCHIP) when there has been both a
Stafford Act declaration by the President and a determination of public health
emergency by the Secretary of HHS.58 This authority was exercised in a number of
affected and host states following Hurricane Katrina. While this authority may
improve access to healthcare services in affected areas, it does not directly address
the financing of services.
A significant challenge following Hurricane Katrina involved setting up or re-
establishing healthcare financing mechanisms for displaced individuals. Ultimately,
the Medicaid program became the mechanism by which affected and host states
financed certain healthcare costs that were not compensated through other public or
private insurance sources. After several months of debate over a number of
proposals, Congress provided authority and funding to cover, for certain states
through January 31, 2006, the Medicaid and SCHIP matching requirements for
individuals enrolled in these programs, and the total cost of uncompensated care for
the uninsured, for eligible individuals who had been displaced from declared major
disaster areas.59 Congress provided up to $2 billion for these activities. This was in
addition to $100 million earlier provided in supplemental appropriations to NDMS
to cover expenses related to the response to Hurricane Katrina.60 Through an
interagency agreement, most of the $100 million was transferred from FEMA to the
HHS Centers for Medicare and Medicaid Services (CMS), which is also
administering the $2 billion amount.61
57 HHS, Centers for Medicare and Medicaid Services (CMS), “Summary of Federal
Payments Available for Providing Health Care Services to Hurricane Evacuees and
Rebuilding Health Care Infrastructure,” Jan. 25, 2006, at [http://www.hhs.gov/katrina/#hhs].
58 42 U.S.C. § 1320b-5, enacted in P.L. 107-188.
59 Section 6201 of P.L. 109-171, the Deficit Reduction Act of 2005, enacted Feb. 8, 2006.
This arrangement was designated for those states covered under a Medicaid and SCHIP
waiver developed specifically for Hurricane Katrina relief. For more information, see CRS
Report RL33083: Hurricane Katrina: Medicaid Issues, by Evelyne P. Baumrucker, April
Grady, Jean Hearne, Elicia J. Herz, Richard Rimkunas, Julie Stone, and Karen Tritz. FEMA
had previously determined, regarding a Medicaid waiver proposed by New York state in
response to the terror attack of Sept. 11, 2001, that the DRF may not be used to reimburse
a state for a federal matching requirement. FEMA cited its grant regulations at 44 CFR §
13.24(b)(1), which say that “Except as provided by Federal statute, a cost sharing or
matching requirement may not be met by costs borne by another Federal grant.” (Letter
from Joseph F. Picciano, Acting Regional Director, FEMA Region II, to Edward F. Jacoby,
Jr., Director, New York State Emergency Management Office, Jan. 13, 2003.)
60 P.L. 109-62, Second Emergency Supplemental Appropriations Act to Meet Immediate
Needs Arising From the Consequences of Hurricane Katrina, 2005, Sept. 8, 2005, 119 Stat.
1991.
61 HHS, Centers for Medicare and Medicaid Services, Justification of Estimates for
(continued...)

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CRS-20
ESF-8 Funding Needs During a Flu Pandemic
While a severe flu pandemic may constitute a national catastrophe, requiring a
robust ESF-8 public health and medical response, the types of funding needs may not
be readily addressed through existing assistance mechanisms pursuant to the Stafford
Act (to the extent that they apply), and could outstrip existing government and
private resources. While the need for public health and medical services could be
considerable, extensive damage to public or private infrastructure is not anticipated.
Costs associated with workforce surge capacity (e.g., overtime pay) and consumption
of certain supplies (e.g., for public health laboratory tests) could increase
substantially. Presuming a surge of patients in the healthcare system, non-urgent
procedures could be postponed for weeks or months at a time. This has raised
questions regarding whether there would be shifts in overall revenue to providers for
services rendered during a pandemic, and how such shifts could affect providers and
insurers. Finally, the cost of providing healthcare services during a pandemic, when
almost 46 million Americans lack health insurance, is of concern to many.
Americans’ concerns about equity and fairness tend to be heightened during
catastrophes. Also, some are concerned that disease control efforts could suffer if
some subgroups of the population were unwilling, because of their uninsured status
or for other reasons, to seek care or otherwise interact with disease control authorities
during a pandemic.
As previously noted, following Hurricane Katrina, Congress provided $2.1 billion
to states to cover the states’ usual share of Medicaid and SCHIP costs for storm
victims for a defined time period, and the cost of uncompensated care for the
uninsured. This federal assistance mechanism required legislative action and took
nearly six months to enact, in the absence of a pre-existing mechanism to provide
such federal assistance. Whether this could serve as a model for federal assistance
during a flu pandemic is unclear. An important element of the discussion regarding
the Katrina assistance was the desire to help both states that had been directly
affected, and states that had assumed fiscal liability by accepting evacuees. While
the element of victim displacement would not likely be seen during a pandemic,
Congress may nonetheless debate the merits of expanding federal assistance for
healthcare costs during a flu pandemic, and the model developed following Hurricane
Katrina may serve as a useful starting point for discussion.
61 (...continued)
Appropriations Committees, FY2007, p. 192.

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Appendix:
Federal Public Health Emergency Authorities62
Broad Authority in Section 319
of the Public Health Service Act
In 2000, in P.L. 106-505, the Public Health Improvement Act, Congress gave the
Secretary of HHS63 broad authority to determine that a public health emergency64
exists, as follows:
! “If the Secretary determines, after consultation with such public
health officials as may be necessary, that — (1) a disease or disorder
presents a public health emergency; or (2) a public health
emergency, including significant outbreaks of infectious diseases or
bioterrorist attacks, otherwise exists, the Secretary may take such
action as may be appropriate to respond to the public health
emergency, including making grants, providing awards for expenses,
and entering into contracts and conducting and supporting
investigations into the cause, treatment, or prevention of a disease or
disorder as described in paragraphs (1) and (2).”65
This authority, found in Section 319 of the Public Health Service Act (PHSA) and
codified at 42 U.S.C. § 247d, is the basis for much, but not all of, the Secretary’s
authority to waive or streamline administrative requirements and certain statutory
requirements, and to take certain other actions, when needed, to prepare for or
respond to non-routine threats to public health.
Also in P.L. 106-505, Congress reauthorized a no-year public health emergency
fund to be available to the HHS Secretary during a public health emergency
determined pursuant to the authority above, as follows:
! “There is established in the Treasury a fund to be designated as the
‘Public Health Emergency Fund’ to be made available to the
Secretary without fiscal year limitation to carry out subsection (a)
only if a public health emergency has been declared by the Secretary
under such subsection. There is authorized to be appropriated to the
Fund such sums as may be necessary. ... Not later than 90 days after
the end of each fiscal year, the Secretary shall prepare and submit to
62 Kathleen S. Swendiman, legislative attorney in the American Law Division of CRS,
contributed to this section.
63 In this appendix, unless otherwise stated, “the Secretary” refers to the Secretary of HHS.
64 Federal statute contains numerous authorities relating to instances of public health
emergency. In some cases the term is defined, such as for the HHS Secretary’s key
emergency authority in Section 319 of the Public Health Service Act, though definitions
vary. In other cases the term is not defined, or does not refer explicitly to related authorities.
65 42 U.S.C. § 247d, as amended by P.L. 106-505, the Public Health Improvement Act.

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the Committee on Health, Education, Labor, and Pensions and the
Committee on Appropriations of the Senate and the Committee on
Commerce and the Committee on Appropriations of the House of
Representatives a report describing — (A) the expenditures made
from the Public Health Emergency Fund in such fiscal year; and (B)
each public health emergency for which the expenditures were made
and the activities undertaken with respect to each emergency which
was conducted or supported by expenditures from the Fund.”66
Subsequently, Congress expanded or clarified the Section 319 emergency
authority, as follows:
! Duration of emergency, notification of Congress: “Any such
determination of a public health emergency terminates upon the
Secretary declaring that the emergency no longer exists, or upon the
expiration of the 90-day period beginning on the date on which the
determination is made by the Secretary, whichever occurs first.
Determinations that terminate under the preceding sentence may be
renewed by the Secretary (on the basis of the same or additional
facts), and the preceding sentence applies to each such renewal. Not
later than 48 hours after making a determination under this
subsection of a public health emergency (including a renewal), the
Secretary shall submit to the Congress written notification of the
determination.”67
! Data submittal and reporting deadlines: “In any case in which the
Secretary determines that, wholly or partially as a result of a public
health emergency that has been determined pursuant to subsection
(a), individuals or public or private entities are unable to comply
with deadlines for the submission to the Secretary of data or reports
required under any law administered by the Secretary, the Secretary
may, notwithstanding any other provision of law, grant such
extensions of such deadlines as the circumstances reasonably
require, and may waive, wholly or partially, any sanctions otherwise
applicable to such failure to comply. Before or promptly after
granting such an extension or waiver, the Secretary shall notify the
Congress of such action and publish in the Federal Register a notice
of the extension or waiver.”68
! Requirement for notification: During the period in which the
Secretary of HHS has determined the existence of a public health
emergency under 42 U.S.C. § 247d, the Secretary “shall keep
relevant agencies, including the Department of Homeland Security,
66 42 U.S.C. § 247d, as amended by P.L. 106-505. This fund has not received a recent
appropriation.
67 42 U.S.C. § 247d, as amended by P.L. 107-188, the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002.
68 Ibid.

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the Department of Justice, and the Federal Bureau of Investigation,
fully and currently informed.”69
! Emergency use of countermeasures: The Secretary may declare an
emergency justifying expedited use of certain medical
countermeasures on the basis of: (1) a determination by the Secretary
of Homeland Security that there is a domestic emergency, or a
significant potential for a domestic emergency; or (2) on the basis of
a determination by the Secretary of Defense that there is a military
emergency, or a significant potential for a military emergency; or (3)
on the basis of a “determination by the Secretary of a public health
emergency under Section 247d of Title 42 that affects, or has a
significant potential to affect, national security, and that involves a
specified biological, chemical, radiological, or nuclear agent or
agents, or a specified disease or condition that may be attributable to
such agent or agents.”70 This provision in the Federal Food, Drug
and Cosmetic Act is referred to as the Emergency Use Authorization.
! Waiver of certain requirements: In order to assure “that sufficient
health care items and services are available to meet the needs of
individuals in ... (an emergency, and) ... that health care providers
... that furnish such items and services in good faith, but that are
unable to comply with one or more requirements ... may be
reimbursed for such items and services and exempted from sanctions
for such noncompliance, absent any determination of fraud or
abuse,” the Secretary may modify or waive certain statutory or
regulatory requirements following a determination of public health
emergency pursuant to 42 U.S.C. § 247d and an emergency or
disaster declaration by the President pursuant to the National
Emergencies Act (50 U.S.C. § 1601) or the Stafford Act (42 U.S.C.
§ 5121 et seq.).71 Requirements that may be waived or modified
pursuant to this section include (1) conditions of participation and
certain other requirements in the Medicare, Medicaid and SCHIP
programs;72 (2) federal requirements for state licensure of health
professionals; (3) certain provisions of the Emergency Medical
Treatment and Active Labor Act of 1985 (EMTALA); (4) certain
sanctions prohibiting physician self-referral (so-called “Stark”
provisions); (5) modification, but not waiver, of deadlines and
timetables for performance of required activities; (6) limitations on
certain payments for health care items and services furnished to
individuals enrolled in a Medicare + Choice plan; and (7) sanctions
and penalties that arise from noncompliance with certain patient
69 6 U.S.C. § 467, authorized in P.L. 107-296, the Homeland Security Act of 2002.
70 21 U.S.C. § 360bbb-3, authorized in P.L. 108-276, the Project BioShield Act of 2004.
71 42 U.S.C. § 1320b-5, as amended by P.L. 107-188 and P.L. 108-276.
72 For more information on the use of these waivers following Hurricane Katrina, see CRS
Report RL33083, Hurricane Katrina: Medicaid Issues, by Evelyne P. Baumrucker, April
Grady, Jean Hearne, Elicia J. Herz, Richard Rimkunas, Julie Stone, and Karen Tritz.

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privacy requirements of the Health Insurance Portability and
Accountability Act of 1996.
! Alternate Medicare drug reimbursement method: In situations
where a public health emergency has been determined to exist under
42 U.S.C. § 247d, and “there is a documented inability to access
drugs and biologicals,” the Secretary may, under certain
circumstances, use an alternative methodology for determining
payments of certain drugs under the Medicare program.73
Pursuant to the authority in Section 319, the Secretary of HHS has determined
that a public health emergency exists on three occasions: (1) nationwide, in response
to the terrorist attacks on September 11, 2001; (2) in several states affected by
Hurricane Katrina in August and September, 2005; and (3) in several states affected
by Hurricane Rita in September, 2005.74
Other Public Health Emergency Authorities
of the HHS Secretary
The following is a list of statutory authorities or requirements of the Secretary or
others within HHS to take certain additional actions during public health emergencies
that are not explicitly defined or linked to an emergency determination pursuant to
Section 319 authority. In some cases these actions flow from federal emergency or
major disaster declarations pursuant to the Stafford Act. In other cases reference is
made to a situation of public health emergency, but such emergency is not defined.
! Assistance to states: Pursuant to Section 311 of the Public Health
Service Act, the Secretary of HHS has broad authority to assist state
and local governments in their disease control efforts, upon their
request, as follows: “The Secretary may, at the request of the
appropriate State or local authority, extend temporary (not in excess
of six months) assistance to States or localities in meeting health
emergencies of such a nature as to warrant Federal assistance. The
Secretary may require such reimbursement of the United States for
assistance provided under this paragraph as he may determine to be
reasonable under the circumstances. Any reimbursement so paid
shall be credited to the applicable appropriation for the Service for
the year in which such reimbursement is received.”75 The term
“health emergencies” is not defined in this context, but this authority
underpins a variety of unanticipated activities which are undertaken
each year such as CDC’s deployment of Epidemic Intelligence
Service officers to assist states affected by an ongoing mumps
outbreak.
73 42 U.S.C. § 1395w-3a(e), authorized in P.L. 108-173, the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003.
74 More information regarding these determinations is available in CRS Report RL33096,
2005 Gulf Coast Hurricanes: The Public Health and Medical Response, by Sarah A. Lister.
75 42 U.S.C. § 243c.

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! National preparedness plan: “The Secretary shall further develop
and implement a coordinated strategy, building upon the core public
health capabilities established pursuant to Section 319A [42 U.S.C.
§ 247d-1], for carrying out health-related activities to prepare for and
respond effectively to bioterrorism and other public health
emergencies, including the preparation of a plan under this
section.”76
! HHS exemption from “Select Agent” regulation: The Secretary
maintains regulatory control over certain biological agents and
toxins which have the potential to pose a severe threat to public
health and safety. The Secretary may temporarily exempt a person
from the regulatory requirements of this section if “the Secretary
determines that such exemption is necessary to provide for the
timely participation of the person in a response to a domestic or
foreign public health emergency (whether determined under Section
247d(a) of this Title or otherwise).” (Emphasis added).77
! USDA exemption from “Select Agent” regulation: The Secretary,
after granting an exemption under 42 U.S.C. § 262a(g) (relating to
regulation of certain biological agents and toxins) pursuant to “a
finding that there is a public health emergency” may request the
Secretary of Agriculture to “temporarily exempt a person from the
applicability of the requirements of this section with respect to an
overlap agent or toxin, in whole or in part, to provide for the timely
participation of the person in a response to the public health
emergency.”78
! Activation of NDMS: The Secretary may activate the National
Disaster Medical System (NDMS) to “provide health services,
health-related social services, other appropriate human services, and
appropriate auxiliary services to respond to the needs of victims of
a public health emergency (whether or not determined to be a public
health emergency under Section 247d of this Title)” (emphasis
added). NDMS was subsequently transferred to the Department of
Homeland Security in P.L. 107-296, the Homeland Security Act,
without any other amendment to its authorizing language.79
! Authority for the Strategic National Stockpile: “The Secretary,
in coordination with the Secretary of Homeland Security, shall
maintain a stockpile or stockpiles of drugs, vaccines and other
biological products, medical devices, and other supplies in such
numbers, types, and amounts as are determined by the Secretary to
76 42 U.S.C. § 300hh. This provision, in Section 2801 of the PHSA, refers to Section 319A
of the PHSA.
77 42 U.S.C. § 262a, as amended by P.L. 107-188. Additional information regarding the
regulation of so-called “Select Agents” may be found at [http://www.cdc.gov/od/sap/
index.htm] and CRS Report RL31719: An Overview of the U.S. Public Health System in the
Context of Emergency Preparedness, by Sarah A. Lister.
78 7 U.S.C. § 8401, as amended by P.L. 107-188.
79 42 U.S.C. § 300hh-11, as amended by P.L. 107-188.

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be appropriate and practicable, taking into account other available
sources, to provide for the emergency health security of the United
States, including the emergency health security of children and other
vulnerable populations, in the event of a bioterrorist attack or other
public health emergency.”80
! Authority for the Emergency System for Advance Registration
of Volunteer Health Professionals (ESAR-VHP): “The Secretary
shall, ... establish and maintain a system for the advance registration
of health professionals for the purpose of verifying the credentials,
licenses, accreditations, and hospital privileges of such professionals
when, during public health emergencies, the professionals volunteer
to provide health services.” ... “The Secretary may encourage each
State to provide legal authority during a public health emergency for
health professionals authorized in another State to provide certain
health services to provide such health services in the State.”81
! Federal quarantine authority: The Secretary has the authority to
“make and enforce such regulations as in his judgment are necessary
to prevent the introduction, transmission, or spread of communicable
diseases from foreign countries into the States or possessions, or
from one State or possession into any other State or possession.”
These regulations may “provide for the apprehension and
examination of any individual reasonably believed to be infected
with a communicable disease in a qualifying stage.” The term
“qualifying stage” means that the disease is “in a communicable
stage” or is “in a precommunicable stage, if the disease would be
likely to cause a public health emergency if transmitted to other
individuals.”82
! Authority for the administration of smallpox countermeasures:
The Secretary may issue a declaration “concluding that an actual or
potential bioterrorist incident or other actual or potential public
health emergency makes advisable the administration of” certain
countermeasures against smallpox for Public Health Service
employees.83
! Liability protection for certain countermeasures: If the Secretary
“makes a determination that a disease or other health condition or
other threat to health constitutes a public health emergency, or that
there is a credible risk that the disease, condition, or threat may in
80 42 U.S.C. § 247d-6b, as amended by P.L. 108-276, the Project BioShield Act of 2004.
81 42 U.S.C. § 247d-7b. Additional information regarding the ESAR-VHP program is
available at [http://www.hrsa.gov/esarvhp/].
82 42 U.S.C. § 264. There are other sections dealing with quarantines such as 42 U.S.C. §
243, assistance to States in the enforcement of quarantine regulations and public health
plans; § 249, medical care for quarantined persons; and § 267, dealing with quarantine
stations. For more information, see CRS Report RL33201, Federal and State Quarantine
and Isolation Authority, by Kathleen S. Swendiman and Jennifer K. Elsea.
83 42 U.S.C. § 233(p). See also sections immediately following this section, including 42
U.S.C. §§ 239 et seq.

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the future constitute such an emergency, the Secretary may make a
declaration, through publication in the Federal Register,
recommending, under conditions as the Secretary may specify, the
manufacture, testing, development, distribution, administration, or
use of one of more covered countermeasures....” Liability protection
is provided for certain persons with respect to claims resulting from
the administration of covered countermeasures following a
declaration of a public health emergency under this authority.84
! Disaster relief for aging services organizations: The Assistant
Secretary for Aging, in HHS, “may provide reimbursements to any
State (or to any tribal organization receiving a grant under Title VI
[42 U.S.C. §§ 3057 et seq.]), upon application for such
reimbursement, for funds such State makes available to area
agencies on aging in such State (or funds used by such tribal
organization) for the delivery of supportive services (and related
supplies) during any major disaster declared by the President in
accordance with the Robert T. Stafford Disaster Relief and
Emergency Assistance Act.”85
! Authority to expedite research: If the Secretary “determines, after
consultation with the Director of NIH, the Commissioner of the
Food and Drug Administration, or the Director of the Centers for
Disease Control and Prevention, that a disease or disorder
constitutes a public health emergency, the Secretary, acting through
the Director of NIH,” shall expedite certain review procedures for
applications for research grants on diseases relevant to the disease or
disorder involved in the emergency and take other specified
administrative measures to assist relevant grants or contracts. (NIH
is the National Institutes of Health.)86
! Fisheries management: The Secretary of Commerce may take
certain measures relating to the national fishery management
program in case of an emergency. If the emergency is a public
health emergency, then the Secretary of HHS is to “concur” with the
“emergency regulation or interim measure promulgated” by the
Secretary of Commerce.87
! ATSDR assistance for exposure to toxic substances: The
Administrator of the Agency for Toxic Substances and Disease
Registry (ATSDR, an agency within HHS) shall, “in cases of public
health emergencies caused or believed to be caused by exposure to
84 42 U.S.C. § 247d-6d. Additional information regarding this authority is available in CRS
Report RS22327, Pandemic Flu and Medical Biodefense Countermeasure Liability
Legislation: P.L. 109-148, Division C (2005), by Henry Cohen.
85 42 U.S.C. § 3030.
86 42 U.S.C. § 289c.
87 16 U.S.C. § 1855(c).

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toxic substances, provide medical care and testing to exposed
individuals.”88
! Mosquito-borne diseases: The Secretary has enhanced budget
authority for the response to public health emergencies related to
mosquito-borne diseases as follows: “In the case of any control
programs carried out in response to a mosquito-borne disease that
constitutes a public health emergency, the authorization of
appropriations (in this provision) is in addition to applicable
authorizations of appropriations under the Public Health Security
and Bioterrorism Preparedness and Response Act of 2002.”89
Additional Public Health Emergency Authorities
The following are public health emergency authorities of individuals other than
the HHS Secretary.
! Authority of the Attending Physician to Congress: “The
Attending Physician to Congress shall have the authority and
responsibility for overseeing and coordinating the use of medical
assets in response to a bioterrorism event and other medical
contingencies or public health emergencies occurring within the
Capitol Buildings or the United States Capitol Grounds. This shall
include the authority to enact quarantine and to declare death. These
actions will be carried out in close cooperation and communication
with the Commissioner of Public Health, Chief Medical Examiner,
and other Public Health Officials of the District of Columbia
government.”90
! Crisis counseling assistance and training during a disaster: “The
President is authorized to provide professional counseling services,
including financial assistance to State or local agencies or private
mental health organizations to provide such services or training of
disaster workers, to victims of major disasters in order to relieve
mental health problems caused or aggravated by such major disaster
or its aftermath.”91 This provision in the Stafford Act is
administered by the Substance Abuse and Mental Health Services
Administration in HHS.92
! Notification during potential public health emergencies: “In
cases involving, or potentially involving, a public health emergency,
but in which no determination of an emergency by the Secretary of
88 42 U.S.C. § 9604.
89 42 U.S.C. § 247b-21.
90 2 U.S.C. § 121g, first authorized in P.L. 108-199, the Consolidated Appropriations Act,
2004.
91 42 U.S.C. § 5183, Section 416 of the Stafford Act.
92 For more information, see CRS Report RS22292: Hurricanes Katrina and Rita:
Addressing the Victims’ Mental Health and Substance Abuse Treatment Needs, by Erin D.
Williams.

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Health and Human Services under Section 319(a) of the Public
Health Service Act (42 U.S.C. 247d(a)), has been made, all relevant
agencies, including the Department of Homeland Security, the
Department of Justice, and the Federal Bureau of Investigation, shall
keep the Secretary of Health and Human Services and the Director
of the Centers for Disease Control and Prevention fully and currently
informed.”93
Methodology
The above listing of federal public health emergency authorities was developed
by reviewing the results of a search of the U.S. Code for the terms “public health
emergency,” or “health threat” or “disaster,” or for citations to the public health
emergency authority at 42 U.S.C. § 247d. Not included in the listing are references
to the suspension of certain routine activities in the event of a disaster, requirements
for disaster planning in healthcare facilities, or other provisions not directly related
to the declaration or determination of a federal public health emergency or the
activities authorized or required when such a declaration or determination is made.
93 6 U.S.C. § 467, authorized in P.L. 107-296, the Homeland Security Act of 2002.

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