Vaccine Considerations for State and Local Governments

An overview of the major changes impacting state and local governments as vaccine efforts accelerate around the country.

Since the November 2020 Guidehouse Insight publication “COVID-19 Vaccine Deployment: Are State and Local Governments Prepared?” vaccine efforts have accelerated around the country, with some good news and some stumbling blocks. In this February 2021 vaccine update, we provide an overview of the major changes impacting state and local governments.

Changes to the Federal Funding Landscape

In November 2020, state and local governments were working to determine Federal Emergency Management Agency-Public Assistance (FEMA-PA) eligibility of vaccine-related costs, and it was unclear what vaccine-specific funding would be available in the Consolidated Appropriations Act, 2021, (CAA). We now have significantly more information about available funding for vaccine programs. The largest change is that President Biden’s January 21st Memorandum revises FEMA-PA guidance to both prioritize and fully fund vaccine costs expensed after January 21. This change eliminates the need for applicants to cover the 25% local cost share required for most FEMA emergency disaster funding. In addition to this FEMA change, new vaccine funding to state governments, appropriated by the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA) and the CAA, was released by the CDC to states. With different eligibility rules for different funding sources, state and local governments will need to carefully consider which funding sources to use for each vaccine-related expense. This strategy is particularly important for smaller states, as the PPPHCEA and the CAA funding did not include a state minimum, resulting in awards to smaller states that may fall short of the need.

FEMA Funding

FEMA has released new guidance that outlines the vaccine-related work and costs eligible for FEMA-PA funding. These eligible costs will assist state and local governments (and other eligible applicants) with the distribution, transportation, storage, and administration of COVID-19 vaccines. Eligible costs include, but are not limited to:

  • Personal protective equipment.
  • Other equipment, and supplies required for storing, handling, distributing/transporting, and administering COVID-19 vaccines.
  • Facility support costs, including leasing space for storage and/or administration of vaccines, utilities, maintenance, and security.
  • Medical and support staff not paid for by another funding source.
  • Information technology systems and support.
  • Communications to disseminate public information regarding vaccinations.
  • Training and technical assistance for vaccine distribution and administration.

All these costs will be covered at 100% federal cost share—no local 25% cost share will be required. Additionally, FEMA will provide reimbursement to states, local, tribal, and territorial governments for the use of their National Guard to support vaccination distribution and administration at a 100% cost share until September 30, 2021. A breakdown of all eligible costs can be found in Section 4 of the COVID-19 Pandemic: Vaccination Planning FAQ.

FEMA is moving forward quickly to obligate vaccination money, allowing state and local governments to move forward without cash flow concerns. FEMA is obligating vaccination projects within days of receipt. State and local governments will then be able to “draw down” federal funds associated with these obligations as they incur the costs. State and local governments are strongly advised, however, to carefully track and maintain the required FEMA-compliant documentation, as this will be critical at closeout. Guidehouse continues to suggest that an embedded FEMA specialist involved in each step of the process will allow a state to draw down federal FEMA funding with fully compliant and complete documentation much earlier than normal and with less risk of de-obligation.

CDC Vaccine Funding

The Centers for Disease Control and Prevention (CDC) has provided, through the existing Immunizations and Vaccines for Children and Epidemiology and Laboratory Capacity cooperative agreements, vaccine funding to states. As of February 1, 2021, the CDC had not released specific guidance on the allowed uses of this funding. Congressional appropriations language may allow the CDC to define allowed uses broadly or more narrowly; in the case that this funding has broad allowed uses, Guidehouse suggests that states work to maximize FEMA vaccine funding for all FEMA-eligible vaccine expenses, saving the CDC money for non-FEMA eligible uses.

Supply Chain Updates

State and local governments are dependent on the federal government for COVID-19 vaccine doses. On January 21, 2021, the Biden administration released the National Strategy for the COVID-19 Response and Pandemic Preparedness outlining the new administration’s plan to manage the COVID-19 public health emergency. Included in that strategy was a commitment to increasing the number of doses and “kit materials” by:

  • Leveraging the Defense Production Act.
  • Deploying onsite support to monitor contract manufacturing operations.
  • Purchasing additional FDA-authorized vaccines to be delivered as quickly as possible.

Further, the federal government has committed to supporting the creation of as many venues as needed to increase access and accelerate vaccinations. According to the plan, this includes, but is not limited to, federally run community vaccination centers, in places like stadiums and conference centers, federally-supported state and locally-operated vaccination sites, pharmacies and retail stores, federal facilities like Veterans Affairs hospitals, community health centers, rural health clinics, critical access hospitals, physician offices, health systems, urgent care centers, and mobile and onsite occupational clinics. It’s not currently clear whether these federally run clinics will use vaccine doses that would otherwise go to state-run vaccine distribution efforts, or if they will be in addition to the state’s allocated vaccine doses.

Integrated Project Management

Efforts to accelerate vaccine administration are happening at the federal, state, and local/regional levels. While this across-the-board effort is critical to a fast and effective rollout of the vaccine, it also poses significant coordination and integration challenges. With many different entities all driving toward the same goal, integrated master project plans and schedules are critical to a successful response. Statewide views of vaccine programs aren’t truly statewide if they don’t include federal efforts at veterans’ facilities, military bases, the federal pharmacy program, and National Guard sites.

Further, most states rely heavily on their regional and local public health “boots on the ground” to share approaches and lessons learned, thus bringing appropriate and equitable approaches to each locality. States are well-served to bring these local public health jurisdictions together, facilitating the sharing of innovative approaches and lessons learned across local entities and forming a continuous and iterative improvement process that optimizes local knowledge for vaccine implementation.

Technology Solutions

Vaccine management—from inventory management, to waitlists, to appointment scheduling, to outcomes monitoring—is a challenge that cannot be efficiently and effectively managed with Excel spreadsheets and static webforms. With millions of people to vaccinate in our communities—state and local governments have faced challenges in managing and matching supply and demand, and need a technology solution that can be quickly deployed and easy to use. There is an existing nationwide solution available through the CDC that has gained limited traction in states, and many states/local governments are implementing their own solutions—funded by the 100% FEMA funding discussed earlier. State and local governments should consider launching a technology solution that meets the needs of different users: the vaccine recipient, the vaccine administrator, the vaccine site administrator, and the state and local government official.

Equity and Vaccine Acceptance Considerations

Although limited doses are available, the country is already seeing anecdotal evidence of equity issues in vaccine distribution. Simply placing vaccine clinics in communities of color will often not be enough to promote vaccine equity. Strategic community engagement and outreach will be critical to ensure equitable access and vaccine uptake. State and local governments should update their vaccination plans, describing how they will deliver vaccines to residents in the highest-risk and high-vulnerability areas using the CDC’s Social Vulnerability Index or a comparable metric. Some considerations that Guidehouse suggests as states seek to drive vaccine acceptance in hard-hit communities:

  • Public education and outreach should offer both digital and nondigital communication tools in all relevant languages and formats, and, wherever possible, share information graphically rather than in narrative form to dispel misinformation.
  • Vaccination websites must be user-friendly for non-tech savvy individuals (such as seniors) and administering entities should offer alternative sign-up services for populations without web access.
  • Engagement efforts must work to restore public confidence and should focus on communities hit hardest by disinformation campaigns working with trusted state, local, and community-based organizations, and trusted healthcare providers.
  • Leaders and decision-makers should leverage targeted data analytics to identify high-risk and underserved populations—mainly in working-class communities, rural areas, and communities of color—and should center these issues to ensure equitable access.
  • Messages should be delivered by trusted community members, in various languages, across multiple modes of communication.

Conclusion

With the change of administration at the federal level, the passing of the Consolidated Appropriations Act, and the increased availability of the vaccine, the landscape for state and local governments has evolved significantly since November 2020. However, the global COVID-19 pandemic remains a massive challenge for states and cities. Since the arrival of COVID-19, Guidehouse has assembled a team of experts and insights from public health, clinical medicine, disaster preparedness, supply chain resilience, economic development, and other areas to help our communities and people thrive. We stand ready to help state and local governments navigate the complexities of the largest vaccination effort in history.

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