By Phil Galewitz and Lauren Weber and Sam Whitehead, Kaiser Health News

The Biden administration in March 2021 announced it was investing $2.25 billion to address covid health disparities, the largest federal funding initiative designed specifically to help underserved communities hardest hit by the virus.

Two months later, the Centers for Disease Control and Prevention awarded grants to every state health department and 58 large city and county health agencies. The money is intended to help limit the spread of covid-19 among those most at risk in rural areas and within racial and ethnic minority groups, as well as improve their health. The CDC initially said the grant had to be spent by May 2023 but earlier this year told states they could apply to extend that time.

A year later — with covid having killed 1 million people in the U.S. since the start of the pandemic and hospitalizing millions more — little of the money has been used, according to a KHN review of about a dozen state and county agencies’ grants. While some states and localities have allocated large portions of the CDC money for projects, they still have spent only a small proportion.

Missouri’s health department has not spent any of its $35.6 million. Wisconsin, Illinois, and Idaho — whose state health departments each received between $27 million and $31 million — have used less than 5% of their grant money.

Pennsylvania’s health department has used about 6% of its nearly $27.7 million grant.

California’s health department has spent just over 10% of its $32.5 million funding.

The public health agencies give a litany of reasons for that: They need time to hire people. They blame their state’s long budget process. They say it takes time to work with nonprofit organizations to set up programs or for them to put the money to use. They’re already tapping other federal dollars to fight covid disparities.

Mounting unspent covid relief dollars is one of the key reasons Republicans in Congress oppose Democrats’ efforts to appropriate billions more federal dollars for managing the pandemic.

The slow disbursement also highlights the ripple effects of years of neglect for public health systems and the boom-bust cycle of legislative funding. “They are investments that overwhelm a system that has been starved for so long,” said Dr. Usama Bilal, an assistant professor of epidemiology and biostatistics at Drexel University in Philadelphia.

Dr. Kirsten Bibbins-Domingo, chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, added that it is difficult for public health systems lacking resources and fighting a pandemic to establish ties to local nonprofits so quickly.

“The pandemic shone a light on these big health disparities, but they also shone a light on the fact that [public health systems] don’t have the structures in place to partner directly with communities,” she said.

The funding is meant to reduce the pandemic’s disproportionate effect on minorities. When adjusting for the age differences across racial and ethnic groups, Black, Hispanic, and Native American communities experienced higher rates of covid hospitalizations and deaths compared with white people. Such adjustments are necessary, researchers say, as communities of color tend to be younger.

Despite the need to address these issues, the Riverside County health department in California has spent about $700,000 of its $23.4 million grant, which is separate from the state health department’s funds.

“Public health has been historically underfunded, and all of a sudden this is way more money than we ever get,” said Wendy Hetherington, public health program chief with the agency. “It's great that we got this funding because it's necessary, but we are struggling in trying to spend it.”

Part of the problem was that county health officials had to wait six months for local government approval to spend it. Then, she said, she faced delays negotiating contracts with area nonprofits.

Stan Veuger, a senior fellow at the conservative American Enterprise Institute, echoed Republican lawmakers’ concerns, saying the slow rollout of these grants shows that Congress sent more pandemic relief than state and local governments needed since their tax revenue rebounded much quicker than many expected.

“It raises questions about why this separate grant program was set up,” he said.

Rachel Greszler, a senior research fellow at the Heritage Foundation who has argued against Congress funding new covid relief, said the slow spending also shows how states need time to absorb an influx in revenue and develop programs, especially when governments are facing labor shortages and supply chain issues.

The CDC has said the money could be used to aid in preventing the spread of the covid virus, improve data collection, expand health services related to covid, and address social and economic issues that have hampered many minority communities from receiving appropriate care during the pandemic.

CDC officials are working with groups on the implementation of the grant, said spokesperson Jade Fulce.

Because the term “health disparities” encompasses challenges facing all types of population groups, the money can be applied to almost anything that affects health.

The Illinois Department of Public Health received $28.9 million and has spent $138,000, according to spokesperson Mike Claffey. The state plans to spend some of the money on American Sign Language translation for covid materials, outreach to those in jail, mobile health units for rural areas, and the hiring of community health workers.

"The goal was to design programs that build up the health care infrastructure and address these historic inequities in a significant way and meaningful way," Claffey said.

Florida’s Health Department plans to use $236,000 of its nearly $35 million grant on newborn hearing screenings after covid-related closures led to a decline in timely checks, said spokesperson Jeremy Redfern.

The Miami-Dade County Health Department has spent $4 million of its $28 million CDC grant. It’s giving money to local nonprofit groups to deal with food insecurity and language barriers. Like other jurisdictions, the county noted it has awarded funding that groups haven’t spent yet, including $100,000 to improve literacy among its large Haitian community. Saradjine Batrony said she hopes to help between 60 and 100 people starting in May with that grant.

“The language barrier is what prevented people from getting vaccinated,” said Batrony, who was a researcher at the University of Miami before starting her own company last year focused on translating health documents into Haitian Creole.

Almost $4.6 million of Pennsylvania’s CDC grant went to the state Office of Rural Health, which last fall was planning to give money to 20 counties. As of May 5, it hadn’t funded any of them.

“In the last couple months, we have encountered issues with county leaders losing momentum and interest in covid-19 work,” said Rachel Foster, rural covid-19 program manager for the agency based at Penn State University. “In rural Pennsylvania, cases are low, interest in vaccines has waned, and rural residents largely feel the pandemic is over.”

Some counties and states say they were addressing health inequity issues before the CDC disparity money.

Philadelphia’s $8.3 million grant followed several CDC awards that also dealt with issues affecting underserved communities, said spokesperson Matthew Rankin. Philadelphia has spent about $147,000 of the disparities grant.

The University of Florida health system in Jacksonville was awarded $1.25 million last July from Duval County to expand services to communities disproportionately affected by covid. But as of early May, the university had not yet received the money, said spokesperson Dan Leveton. “We’re not concerned because we have other covid funding we’re using for now and will use the CDC’s funding when it comes through,” he said.

Mississippi received $48.4 million, the single-largest award to any state health agency from the grant. So far, the agency has spent $8.2 million, said spokesperson Liz Sharlot, although it has already used other federal relief dollars to address covid health disparities.

While states figure out how to spend the money, health experts worry about the consequences politically and to the communities that need help.

“The money is terribly needed, but we need to consider that these health departments have long been overburdened and they don’t really have enough people to handle it,” said Drexel’s Bilal.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.