Don Wood, an official with the Strategic National Stockpile, shown in 2009 awaiting a shipment of medical supplies during the H1N1 outbreak. (Francisco Kjolseth/AP)

On Feb. 5, with fewer than a dozen confirmed novel coronavirus cases in the United States but tens of thousands around the globe, a shouting match broke out in the White House Situation Room between Health and Human Services Secretary Alex Azar and an Office of Management and Budget official, according to three people aware of the outburst.

Azar had asked OMB that morning for $2 billion to buy respirator masks and other supplies for a depleted federal stockpile of emergency medical equipment, according to individuals familiar with the request, who spoke on the condition of anonymity about internal discussions.

The previously unreported argument turned on the request and on the budget official’s accusation that Azar had improperly lobbied Capitol Hill for money for the repository, which Azar denied, the individuals said.

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The $2 billion request from HHS was cut to $500 million when the White House eventually sent Congress a supplemental budget request weeks later. White House budget officials now say the relief package enacted Friday secured $16 billion for the Strategic National Stockpile, more money than HHS had asked for.

The dispute over funding highlights tensions over a repository straining under demands from state officials. States desperate for materials from the stockpile are encountering a beleaguered system beset by years of underfunding, changing lines of authority, confusion over the allocation of supplies and a lack of transparency from the administration, according to interviews with state and federal officials and public health experts.

The stockpile holds masks, drugs, ventilators and other items in secret sites around the country. It has become a source of growing frustration for many state and hospital officials who are having trouble buying — or even locating — crucial equipment on their own to cope with the illness battering the nation.

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Despite its name, it was never intended for an emergency that spans the entire nation.

“The response contains enough for multiple emergencies,” said Richard Besser, a former acting director of the Centers for Disease Control and Prevention. Now president of the Robert Wood Johnson Foundation, he previously led the CDC’s Coordinating Office for Terrorism Preparedness and Emergency Response that oversaw the stockpile during Hurricane Katrina. “Multiple does not mean 50 states plus territories and, within every state, every locality.”

The federal cache has been overwhelmed by urgent requests for masks, respirators, goggles, gloves and gowns in the two months since the first U.S. case of covid-19 was confirmed. Many state officials say they do not understand the standards that determine how much they will receive.

Anecdotally, there are wide differences, and they do not appear to follow discernible political or geographic lines. Democratic-leaning Massachusetts, which has had a serious outbreak in Boston, has received 17 percent of the protective gear it requested, according to state leaders. Maine requested a half-million N95 specialized protective masks and received 25,558 — about 5 percent of what it sought. The shipment delivered to Colorado — 49,000 N95 masks, 115,000 surgical masks and other supplies — would be “enough for only one full day of statewide operations,” Rep. Scott R. Tipton (R-Colo.) told the White House in a letter several days ago.

The Federal Emergency Management Agency inherited control of the stockpile barely a week ago from HHS. Lizzie Litzow, a FEMA spokeswoman, acknowledged the agency maintains a spreadsheet tracking each state’s request and shipments. Litzow declined repeated requests to release the details, saying the numbers are in flux.

Florida has been an exception in its dealings with the stockpile: The state submitted a request on March 11 for 430,000 surgical masks, 180,000 N95 respirators, 82,000 face shields and 238,000 gloves, among other supplies — and received a shipment with everything three days later, according to figures from the state’s Division of Emergency Management. It received an identical shipment on March 23, according to the division, and is awaiting a third.
“The governor has spoken to the president daily, and the entire congressional delegation has been working as one for the betterment of the state of Florida,” said Jared Moskowitz, the emergency management division’s director. “We are leaving no stone unturned.”
President Trump repeatedly has warned states not to complain about how much they are receiving, including Friday during a White House briefing, where he advised Vice President Pence not to call governors who are critical of the administration’s response. “I want them to be appreciative,” he said.

At briefings, Trump and Pence routinely say material is being purchased for the stockpile, supplies are being shipped out and manufacturers under federal contract are ramping up supplies. On Thursday, Pence said the stockpile had shipped 9 million N95 masks and 20 million surgical masks, as well as “millions” of gloves, gowns and face shields.

But Trump and Pence also urge states to buy supplies on their own. During the March 19 briefing, Trump said governors “are supposed to be doing a lot of this work. . . . You know, we’re not a shipping clerk.”

State officials say the advice is unrealistic.

“Allowing the free market to determine availability and pricing is not the way we should be dealing with this national crisis at this time,” said Virginia Gov. Ralph Northam (D). “This is why we need a nationally led response.”

Leaders in the District, Maryland and Virginia say their requests for aid from the stockpile have come up short. They have been competing with their counterparts to try to buy gear on the open market.

“The federal government has the keys to the front door,” said Nirav Shah, Maine’s state health officer and director of its own Center for Disease Control and Prevention. He said the state has been scouring the country and overseas for companies that can supply protective masks. The stockpile, he said, is a critical “leg of the stool.”

Hospital industry executives agree.

“There is no [protective gear] to be bought on the private market through vendors,” said Kevin Donovan, president of Lakes Regional HealthCare, which has two hospitals in central New Hampshire. “We order but don’t have any money to pay for it,” because companies manufacturing masks and other emergency gear are demanding cash payments on delivery. Donovan said his hospitals, like others, are low on cash because they have canceled the elective procedures that are their moneymakers.

“Unless we start getting material from the national stockpile,” Donovan said, “I don’t know where we are going to get it.”

Stocking the stockpile

Severe organizational and financial challenges left the national stockpile unprepared when the novel coronavirus arrived in the United States.

The stockpile program was created at the end of the 1990s in response to terrorist events. The original goal was to be prepared for chemical, biological, radiological and nuclear threats. The reserve, for example, was stocked with nerve agent antidotes, stored and maintained at more than 1,300 locations around the country, where they could be accessed quickly.

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In the decades since, its mission has widened to include responses to natural disasters and infectious disease threats.

Even with its expanded mission and supplies, the stockpile’s “original design and its current funding do not support responding to a nationwide pandemic disease of this severity,” said Greg Burel, who was the stockpile’s director for a dozen years before he retired in January.

The last time it was deployed on a national basis was during the 2009 H1N1 influenza pandemic, when the stockpile distributed 85 million N95 respirators, along with millions of other masks, gowns and gloves. Afterward, trade groups and public health agencies called for the stock of masks to be replenished, but the supplies were not significantly restored, according to health-care industry and public health experts.

Face masks in national stockpile have not been substantially replenished since 2009

Officials at the CDC, which previously oversaw the stockpile, focused their annual budget of roughly $600 million over the past decade purchasing lifesaving drugs and equipment for bioterror and other attacks, rather than equipment vital in a viral pandemic.

In late 2018, the Trump administration transferred responsibility for managing the stockpile from the CDC to a different part of HHS — a controversial move resisted by the CDC that placed the stockpile under the assistant secretary for preparedness and response (ASPR). According to current and former state and federal officials, the handover was bumpy.

The CDC still oversees clinical guidance to state health departments responding to public health threats, including infectious diseases. But the stockpile’s resources are now under ASPR.

“The transition has been difficult because the left hand is not talking to the right hand,” said one state health official with more than a decade of experience in emergency preparedness, who spoke on the condition of anonymity because he needs to maintain relations with ASPR.

HHS officials have sparred for more than a year with White House budget officials over money to buy more stockpile supplies.

In February 2019, the White House was planning for a presidential executive order on preparing for a potential flu pandemic. HHS requested a more than $11 billion investment over 10 years for ASPR, including $2.7 billion for “treatment and control,” according to a document read by a Washington Post reporter that said some of those funds would go toward “better protective devices, manufactured faster.”

But the executive order issued by Trump in September 2019 did not include that money.

In late January, Azar began telling OMB about the need for a supplemental budget request for stockpile supplies — and was rebuffed at a time when the White House did not yet acknowledge any supplemental money would be needed, according to several individuals familiar with the situation who spoke anonymously to discuss internal conversations.

Then came the Feb. 5 argument.

The White House official said that beyond the $500 million, money was reprogrammed within HHS that significantly boosted funds for the stockpile.

The White House official also said that, before the massive relief bill that Trump signed Friday, OMB had urged HHS to ask for more money for the emergency medical supplies.

An OMB spokesperson said Saturday, “Funding has never been a constraint on agency action in coronavirus response. . . . The president has made it clear that the federal government will throw everything we have at this.”

FEMA takes on the stockpile

In mid-March, Trump declared the coronavirus outbreak a national emergency. As a result, control of the stockpile shifted again — from HHS to FEMA.

Since then, FEMA’s administrator, Peter Gaynor, has been asked frequently how many supplies have been shipped to states and how allocation decisions are being made.

To a question about masks from ABC News on March 22, Gaynor replied, “Well, I mean, there’s hundreds of, thousands of, millions of things that we’re shipping from the stockpile. I mean, I can’t give you the details about what every single state, of what every single city’s doing.”

State officials and federal lawmakers are demanding to know.

“We don’t know how the federal government is making those decisions,” said Casey Katims, the federal liaison for Washington state, the site of the nation’s first confirmed case on Jan. 21 and of an early deadly cluster at a nursing home.

Since the state made the first of several requests — 233,000 respirators and 200,000 surgical masks — the supplies have been arriving piecemeal and without any explanation of the numbers. The state is now awaiting more, including a plea for 1,000 ventilators, and has been told 500 are en route, Katims said.

The Minnesota congressional delegation wrote on March 22 to Azar, also perplexed: “How is HHS determining which states receive certain medical supplies? When will Minnesota receive the full order of medical supplies that state officials have requested?”

The next day, the chairman of the House Committee on Homeland Security, Rep. Bennie Thompson (D-Miss.), sent a letter to HHS and the Department of Homeland Security, which oversees FEMA. The letter demanded to know the stockpile’s inventory of protective gear and ventilators, how much has been distributed, how the allocations are being made and how much is on order from manufacturers.

Explanations of the decision-making process have been inconsistent.

Gaynor told the homeland security committee during a conference call, according to Thompson’s letter, that states would be receiving protective gear based on each state’s population and that state needs would be factored in. The letter did not provide further detail.

While the stockpile was still under HHS as the virus began spreading in the United States, the department for the first time used a formula, according to individuals familiar with the system. Under that formula, 25 percent of a state’s requests were fulfilled based on its population and 25 percent on its number of covid-19 cases. The remaining supplies were held back so the stockpile would not be depleted.

These individuals said that, even before FEMA took over, the formula had changed again to put more emphasis on need.

Asked to explain the current process, a statement from FEMA on Wednesday said, “The allocation process of PPE (personal protective equipment) to states is now focused on meeting future demand models where patient levels are expected to strain state and local medical conditions in coming weeks.” Asked which models FEMA is relying on, Litzow said Thursday, “future modeling is mostly based off of data from HHS and CDC that is continually updated as more information about this emerging disease becomes available.”

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For the coronavirus outbreak, California has asked for 20 million N95 respirators — more than the stockpile’s entire inventory, estimated at about 12 million.

California has received 358,381 N95 masks and about 1 million surgical masks and face shields, according to the governor’s office. The state is now scouting the global market. Gov. Gavin Newsom (D) has noted that California is in a better position because its size gives it purchasing leverage.

California officials said they welcomed FEMA’s involvement because they already had a strong working relationship with the agency after months of fighting the state’s catastrophic wildfires.

Minnesota’s manager of public health emergency preparedness, Deborah Radi, said FEMA has been clearer about stockpile deliveries than HHS. She said her state’s first shipment from the stockpile had arrived one night at 1 a.m., when the state’s warehouse to receive it was closed. When FEMA handled a more recent delivery of protective gear, she said, it alerted the state about a delay and then again when the truck was one hour away.

States continue to press their cases with federal officials. They point out the severity of the outbreak in their state, or the vulnerability of their population. As of mid-March, West Virginia had not reported a confirmed case, but it has one of the nation’s oldest populations. It received an initial shipment of slightly more than 1 percent of its request for 160,000 masks — 2,220 N95s.

Trump’s warnings for states not to complain have not subdued Illinois Gov. J.B. Pritzker (D), who has been particularly outspoken during the crisis. Illinois has received 10 percent of the N95s and surgical masks it has requested from the stockpile.

“I will continue to pound the table to get the federal government to acquire the supplies our states so critically need and allocate them accordingly,” Pritzker tweeted on Tuesday. “Lives depend upon it.”

Aaron C. Davis, Alice Crites, Gregory S. Schneider, Ovetta Wiggins, Darran Simon, Emma Brown and Jeff Stein contributed to this report.

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