Bridging Preparedness: State Medication Reserves for Pandemics and Beyond

In July 2024, the U.S. Centers for Disease Control and Prevention (CDC) confirmed new human cases of H5N1 in Colorado, which brings the total to 13 since April. Unlike COVID-19, there are already several antiviral medications that can be used to prevent the spread of H5N1 among humans. Should H5N1 cases begin to escalate rapidly, having these existing medications is a significant advantage. However, it remains uncertain how states will perform if the need arises to quickly address a worsening situation. One strategy that could help improve the readiness of certain states is leveraging state-managed medication reserves.

A June 2024 Healthcare Ready study on “State-Managed Medication Stockpiling” showcases where the United States stands if another pandemic becomes a reality. This study revealed a lack of essential funding keeping states from most effectively developing their own reserves of critical medications and other resources to respond to public health emergencies. The research was prompted by growing concerns over rising drug shortage events and the potential for medication reserves to safeguard patient access to these resources in the future, especially during a crisis.

Varying Levels of Available Reserves

In the past, many states have maintained state-wide medication reserves, primarily for medical countermeasures (MCM) – products or interventions used to protect against, diagnose, treat, or mitigate the effects of a public health emergency. However, the stockpiling study found that fewer than eight states currently operate state-wide medication reserves outside of MCMs. Part of the decline in recent years is being driven by the high costs associated with the management of physical inventory and clearing expired stock.

Through interviews and a search of publicly available information, the study also found that most states are not prioritizing the development of medication reserves amid competing public health needs such as restoring their healthcare workforce. When asked about current medication stockpiling practices, 10 of the 12 state agency representatives who participated in interviews for this study specifically mentioned having reserves of Tamiflu (generically known as oseltamivir, one of several antiviral medications that can be used to treat H5N1). Those representatives cited the shelf-life extension program as one of the primary policies that enabled them to have these reserves. Other medications mentioned throughout interviews included:

• Current stockpile medications supplied or subsidized by the federal government, such as Paxlovid, Jynneos, and tecovirimat;
• General antibiotics and immunizations that participants wished to expand within current stockpiles such as naloxone, saline, and penicillin; and
• Medications desired as part of future stockpiles such as ibuprofen, gastrointestinal medications, and sedatives used in surgery (e.g., propofol).

The capacity to develop, manage, and implement strategic medication reserves varies significantly across states. Differences in public health infrastructure (e.g., the availability of hospitals and the number of healthcare professionals), social determinants (e.g., economic stability, education, and access to healthcare), and existing regional demographics (e.g., rates of chronic diseases) play essential roles in determining health outcomes after a pandemic or other major disaster. As a result, states with fewer resources and less robust infrastructure could face more significant challenges in ensuring access to necessary supplies and medications during emergencies.  In today’s deeply connected world, addressing these structural disparities is crucial to saving lives everywhere.

Should cases of H5N1 and potentially other flu cases rapidly increase, states with well-established processes and a stocked inventory of oseltamivir and other antivirals may be better equipped to quickly distribute medicines to areas in need or populations who are highly vulnerable to the impacts. This is especially critical in the absence of an emergency declaration, which is needed to activate most major federal disaster relief benefits to states. Programs like the Federal Emergency Management Agency’s Public Assistance Program, for example, provide funding for debris removal, emergency protective measures, and the repair, replacement, or restoration of disaster-damaged facilities, which are only accessible through a federal disaster declaration.

Bolstering State Preparedness Capabilities for All Hazards

While pandemics underscore the importance of traditional MCM reserves, the study also highlighted the serious threats that supply-side drug shortages pose in maintaining patient access to life-saving treatments. Interviews from the study reveal that drug shortages pose significant challenges to the healthcare system but are not always recognized as public health emergencies. This lack of clear classification often results in delayed responses and confusion over which state and federal entities should address these issues, hindering the allocation of state and federal resources to tackle drug shortages. In addition to calling on Congress to take more action on tackling drug shortages, state agencies and elected leaders are seeking solutions on their own for managing persistent disruptions to medication supplies.

The 2006 Pandemic and All-Hazards Preparedness Act (PAHPA) and its subsequent reauthorizations have been the backbone of U.S. preparedness, enabling states and major cities to build the infrastructure needed to respond to health emergencies. Programs like the Hospital Preparedness Program and CDC Public Health Emergency Preparedness Cooperative Agreements have expanded state and local recipients’ capacity to better coordinate for rapid response to crisis events – including funding some current and past state medication reserves. However, Congress’s failure to reauthorize PAHPA last September left a significant gap in the preparedness framework requiring temporary extensions in the continuing resolution. On August 1, 2024, the Senate Labor, Health and Human Services, and Education (LHHS) Appropriations Committee released its version of the FY25 LHHS appropriations bill, moving it out of committee. Although the proposed funding levels are still subject to negotiation before this fiscal year ends on September 30, 2024, the bill continues to support grants for the development of state stockpiles and other PAHPA-related provisions through September 2025.

Simply having medications in stock is not enough. Ensuring they reach those in need promptly requires sustained public health funding and authorities that support and enable multi-jurisdictional coordination before, during, and after disasters. The support for state stockpiles outlined in the recent Senate Appropriations bill is crucial to this broader strategy. By adopting a comprehensive approach that includes robust infrastructure, clear policies, and effective communication, government and elected leaders can ensure the nation’s healthcare system remains resilient and capable of managing future crises. Now is the time for federal and state collaboration to protect public health and guarantee that all Americans have access to the care they need during emergencies.