GAO United States Government Accountability Office Report to Congressional Committees March 2022 COVID-19 Information on HHS's Public Education Campaign GAO-22-104724 GAO Highlights Highlights of GAO-22-104724 a report to congressional committees Why GAO Did This Study In response to the COVID-19 pandemic, HHS began a national public education campaign led by ASPA. Congressional committees and the media raised questions about the focus and timing of the campaign. There were also concerns that funds meant for CDC were used to pay for the effort. The CARES Act includes a provision for GAO to report on the federal response to the pandemic. In addition, GAO was asked to conduct a review of the award process for the COVID-19 public education campaign, as well as its source of funding. This report describes, among other issues: ASPA, FDA, and NIH's roles in executing the COVID-19 public education campaign, and how ASPA paid for the campaign awards. To conduct this work, GAO reviewed and analyzed inter-agency agreements, award files, related funding documents, and the products developed for the public education campaign; federal statutes and regulations; applicable agency guidance; and agency email communications about the campaign. GAO also interviewed relevant agency officials and contractors, and received written answers to questions regarding the funding used for the campaign. GAO provided a draft of this report to HHS for review and comment. HHS stated that it appreciated the opportunity to review the draft, and had no comments. View GAO-22-104724. For more information, contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov. CE COVID-19 Information on HHS's Public Education Campaign What GAO Found In the summer of 2020, the Office of the Assistant Secretary for Public Affairs (ASPA) within the Department of Health and Human Services (HHS) worked with procurement offices within the Food and Drug Administration (FDA) and the National Institutes of Health (NIH) to solicit proposals and make awards to two firms in support of a COVID-19 public education campaign. The primary goals of the campaign, according to award documents, were sharing information on preventing the spread of COVID-19 and increasing vaccine acceptance. ASPA officials developed and led the campaign, while FDA and NIH staff oversaw the technical aspects of the contracting process. e FDA awarded a nearly $15 million contract in September 2020 to Atlas Research, a consulting firm The award focused primarily on developing a series of public service announcements for multiple media channels. The announcements were to feature members of the entertainment industry and public health officials. e NIH made a $250 million award in September 2020 to Fors Marsh Group, a consulting firm, which then developed multiple messages for the public on vaccine development and COVID-19 prevention. Messages were designed for television, radio, print and social media channels. Fors Marsh Group also designed the campaign's theme and logo, We Can Do This (see figure). HHS's We Can Do This Web Page € © Q@_ & wecandothis.hhs.gov QeCx #2: An official website of the United States government Here's how you know v COVID-19 Public Education Campaign Source: Department of Health and Human Services (HHS). | GAO-22-104724 In October 2020, following congressional inquiries and negative press coverage about the campaign, the then-Secretary of Health and Human Services convened a group of public health officials to ensure the campaign was serving important public health purposes. FDA terminated the Atlas Research contract in November 2020, following the HHS internal review. Fors Marsh Group has continued to work on the campaign. ASPA paid for the two awards and other campaign costs with COVID-19 relief funds appropriated for the Centers for Disease Control and Prevention (CDC). Specifically, CDC and ASPA entered into a $300 million interagency agreement, initially funded with $100 million from the CARES Act and $200 million from the Paycheck Protection Program and Health Care Enhancement Act. HHS budget officials reported that the department subsequently identified a more appropriate funding source, and CDC adjusted its budget accounts to use only its CARES Act funds for the $300 million interagency agreement with ASPA. United States Government Accountability Office Contents Letter Background 5 ASPA Worked with Procurement Offices within FDA and NIH on the COVID-19 Public Education Campaign 8 ASPA Assembled Group of HHS Officials to Review Campaign Materials for Alignment with Public Health Recommendations 15 ASPA Used CDC COVID-19 Relief Funds for the Public Education Campaign 15 Agency Comments 17 Appendix | GAO Contact and Staff Acknowledgments 20 Figure Figure 1: HHS's We Can Do This COVID-19 Public Education Campaign Logo 13 Page i GAO-22-104724 HHS's COVID-19 Public Education Campaign Abbreviations ASFR ASPA CDC COVID-19 FAR FDA HHS NIH PICS Il PSA RFP Office of the Assistant Secretary for Financial Resources Office of the Assistant Secretary for Public Affairs Centers for Disease Control and Prevention Coronavirus Pandemic 2019 Federal Acquisition Regulation Food and Drug Administration Department of Health and Human Services National Institutes of Health Public Information and Communication Services II public service announcement request for proposals This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-22-104724 HHS's COVID-19 Public Education Campaign GAO U.S. GOVERNMENT ACCOUNTABILITY OFFICE 441 G St. N.W. Washington, DC 20548 March 29, 2022 Congressional Committees In the summer of 2020, the Department of Health and Human Services (HHS) initiated a $265 million public education campaign to help inform the public about preventative measures and therapeutics related to the COVID-19 pandemic.' The campaign-led by HHS's Office of the Assistant Secretary for Public Affairs (ASPA)-was intended to quickly share public health information on the virus with wide audiences to support the anticipated re-opening of businesses and the broader economy. At the time, COVID-19 cases were on the decline and vaccines were in development. To execute the COVID-19 public education campaign, ASPA-with assistance from procurement offices within the Food and Drug Administration (FDA) and the National Institutes of Health (NIH)-made awards to Atlas Research and Fors Marsh Group, both private sector consulting firms. The Atlas Research award was a contract for nearly $15 million, and was intended to result in an "immediate surge" (up to 6 months) of information featuring public service announcements (PSA) with discussions between celebrities and public health officials about ways for the public to stay safe during the pandemic. The original Fors Marsh Group award was a task order for just over $250 million, and supported a longer-term public education effort on various strategies to prevent the spread of COVID-19.3 Soon after the awards were made in September 2020, congressional committees raised concerns that monies appropriated to the Centers for Disease Control and Prevention (CDC) were used to fund the public education campaign, as well as questions as to the timing and intent of the campaign, given the upcoming presidential election in November 1The original award amounts for the COVID-19 public education campaign, before Modifications and additional awards, totaled $265 million. 2After a spike of about 65,000 new cases per day in late July 2020, on average, the United States had about 40,000 reported new COVID-19 cases per day in early September 2020, according to GAO analysis of data from the Centers for Disease Control and Prevention (CDC). 3A task order is an order for goods or services placed against an established contract. Page 1 GAO-22-104724 HHS's COVID-19 Public Education Campaign 2020.4 Following an internal HHS review, FDA terminated the Atlas Research contract in November 2020, while Fors Marsh Group has continued to work on the public education campaign. The CARES Act includes a provision for us to report on the federal response to the COVID-19 pandemic. Specifically, the act requires us to monitor and oversee the federal government's efforts to prepare for, respond to, and recover from the pandemic.5 We also received a request to conduct a review of HHS's COVID-19 public education campaign, including its source of funding. This report is part of our body of work in response to the CARES Act.é In this report, we describe: 1. ASPA, FDA, and NIH's roles in executing the COVID-19 public education campaign; 2. ASPA's efforts to ensure that the Fors Marsh Group campaign materials aligned with public health recommendations; and 3. how ASPA funded the COVID-19 public education campaign. To address the first objective, we reviewed documents comprising the contract files for the two COVID-19 public education campaign awards to Atlas Research and Fors Marsh Group. Specifically, we reviewed the interagency agreements between ASPA and CDC, ASPA and FDA, and ASPA and NIH, as well as the requests for proposals (RFP), submissions from bidding firms, and documentation of the selection criteria and rating process. We also reviewed products and deliverables from Atlas Research and Fors Marsh Group, including, for example, PSAs and 4See, Hearing entitled Review of Coronavirus Response Efforts, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Committee on Appropriations, U.S. Senate, September 16, 2020, webcast available online: https:/Avww.appropriations.senate.gov/hearings/review-of-coronavirus-response-efforts. Also see, Letters to the Honorable Alex M. Azar Il Secretary, Department of Health and Human Services (Sept. 10 and Oct. 28, 2020), Committee on Oversight Reform, Select Subcommittee on the Coronavirus Crisis, and Subcommittee on Economic Consumer Policy, U.S. House of Representatives, available online: https://oversight.house.gov/letters (accessed 1/6/2022). 5Pub. L. No. 116-136, § 19010, 134 Stat. 281, 579-81 (2020). 6We have regularly issued government-wide reports on the federal response to the COVID-19 pandemic. For the latest report, see GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds and Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington, D.C.: January 2022). Our next government-wide report will be issued in April 2022 and will be available on GAO's website at https:/Awww.gao.gov/coronavirus. Page 2 GAO-22-104724 HHS's COVID-19 Public Education Campaign interviews for television and radio, social media content, and related market research results. Additionally, we reviewed weekly status updates prepared by Fors Marsh Group for ASPA between December 2020 and June 2021 to understand how initial campaign messaging was developed. In addition, we reviewed the Federal Acquisition Regulation (FAR) and applicable agency guidance on acquisitions from FDA and NIH." To supplement our documentation review, we interviewed agency officials involved in developing and overseeing the campaign from ASPA, FDA, and NIH, as well as representatives from Atlas Research and Fors Marsh Group. To address our second objective, we reviewed email communications about the COVID-19 public education campaign messaging and products between ASPA and a review group made up of approximately 70 public health and public affairs officials from various HHS agencies and offices. Within the review group, we focused on the participation of three HHS agencies that we identified as having experience in establishing and assessing public health recommendations-FDA, NIH, and CDC.8 To obtain information on the frequency and nature of those agencies' interactions with ASPA and the input they provided on campaign materials, we emailed a set of questions to the officials from those agencies who served on the review group. We received responses from 18 officials-nine from CDC, five from FDA, and four from NIH which we reviewed and summarized.? Lastly, we interviewed ASPA officials as well 7The FAR is the primary regulation used by all executive agencies in their acquisition of goods and services with appropriated funds. 8Other HHS agencies that were part of the review group included: Administration for Children and Families, Administration for Community Living, Agency for Healthcare Research and Quality, Centers for Medicare & Medicaid Services, Departmental Appeals Board, Health Resources and Services Administration, Indian Health Service, and the Substance Abuse and Mental Health Services Administration. The review group also include the following HHS offices: Assistant Secretary for Health, Assistant Secretary for Planning and Evaluation, Assistant Secretary for Preparedness and Response, General Counsel, Global Affairs, Office of the Secretary, Inspector General, Intergovernmental and External Affairs, Medicare Hearings and Appeals, and the National Coordinator for Health Information Technology. 8Initially we emailed four additional officials from these agencies, however we determined they had moved to other positions within HHS and therefore were not serving on the review group at the time of our work. Page 3 GAO-22-104724 HHS's COVID-19 Public Education Campaign as representatives from Fors Marsh Group to gain their perspectives on these collaborative efforts. 1° To address the third objective, we analyzed the interagency agreements-which describe the relevant statutory authorities-as well as funding and account information. In addition, we interviewed officials or received written responses from ASPA, CDC, FDA, and NIH, as well as from HHS's Office of the Assistant Secretary for Financial Resources (ASFR), to understand how funding decisions were made.11 We analyzed the information gathered to identify the amounts appropriated, the accounts to which the appropriations were made, and the amounts obligated. We also analyzed contract invoices to determine amounts expended. We focused our efforts on the performance period for the Atlas Research contract (6 months) and the first Fors Marsh Group task order (15 months).12 As such, our analysis covers activities for the public education campaign from September 2020 through November 2021. We conducted this performance audit from January 2021 to March 2022 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. 10Assessing the effectiveness of the public education campaign was outside the scope of our review. 11ASFR is the office that oversees HHS's activities related to budget, financial management, and grants and acquisition management. 12The first Fors Marsh Group task order was modified in August 2021 to extend the performance period-originally 12 months-by 3 months. Fors Marsh Group was awarded two additional task orders to continue work on the public education campaign. These task orders were outside the scope of our review. Page 4 GAO-22-104724 HHS's COVID-19 Public Education Campaign Background Federal Contracting and Interagency Agreements Federal statutes and regulations permit agencies to procure goods and services from each other. For example, the Economy Act authorizes an agency to order goods or services from another agency.'3 The agency in need of the goods or services is the "requesting" agency, and the agency providing the purchased goods or services is the "servicing" agency. The requesting and servicing agencies develop interagency agreements to establish the terms and conditions of the work to be done by each. The requesting agency may reach an agreement with the servicing agency to pay for the purchased goods or services in advance or upon provision of the goods or services. '4 The servicing agency may need to procure the requested goods or services by awarding a contract or placing an order against an existing contract. New contracts and orders are generally overseen by a servicing agency contracting officer who has the authority to enter into, administer, or terminate contracts and make related determinations and findings. In addition, contracts may also have at least one contracting officer's representative, a requesting agency official, who provides day-to-day oversight of the contractor's performance and work products. 15 To procure goods or services through contracts or other acquisition vehicles such as task orders, federal agencies may proceed through the following four phases: 13The Economy Act allows agencies to order goods or services from another agency if (1) amounts are available; (2) the requesting agency decides the order is in the government's best interest; (3) the servicing agency is able to provide or procure the ordered goods or services; and (4) the requesting agency decides the order cannot be provided by contract as conveniently or cheaply by a commercial enterprise. See 31 U.S.C. § 1535. See also FAR § 17.502-2. 14When agencies enter into an interagency agreement under the Economy Act, the requesting agency obligates funds for the goods or services to be performed, and depending on the agreement, either makes a payment before or after the work is performed. The servicing agency records the receipt of these funds as offsetting collections. 15The contracting officer's representative is an individual, including a contracting officer's technical representative, designated and authorized in writing by the contracting officer to perform specific technical or administrative functions. Page 5 GAO-22-104724 HHS's COVID-19 Public Education Campaign Pre-Solicitation. Federal agencies define the requirements-or needs-of the award, conduct market research to assess available goods and services, and develop an acquisition plan and an RFP, which describes the government's requirements, anticipated terms and conditions of the award, and other pertinent information. Solicitation. Agencies seek firms to perform work by issuing an RFP. The solicitation may be limited to a defined set of firms, or to a single firm, depending on the needs of the contract or task order. 16 Selection. A panel evaluates and rates submitted proposals, and, based on that review, selects an awardee. Post-award. After an award is made, agencies monitor the contract- providing direction and oversight of contract activities and deliverables (e.g., work products). HHS Agencies and Offices That Executed the COVID- 19 Public Education Campaign Awards Three HHS agencies and offices were involved in the process to award the contract to Atlas Research and the task order to Fors Marsh Group, to support HHS's COVID-19 public education campaign. ASPA. ASPA serves as the principal counsel on public affairs to the Secretary of Health and Human Services and provides centralized leadership and guidance for public affairs activities within HHS's staff and operating divisions and regional offices. In addition, ASPA conducts national public affairs programs; manages HHS's digital communications; and leads the planning, development, and implementation of emergency incident communications strategies and activities for HHS. The Assistant Secretary for Public Affairs reports directly to the Secretary of Health and Human Services. FDA, Office of Acquisition & Grants Services. Within FDA, the Office of Acquisition & Grants Services awards contracts and grants and enters into interagency agreements on behalf of FDA. For purposes of this report, we refer to the Office of Acquisition & Grants Services as FDA. NIH, Office of Logistics and Acquisitions Operations. NIH's Office of Logistics and Acquisition Operations administers the Public Information and Communication Services II (PICS II) program, which awards contracts that provide communication goods and support services to NIH institutes and centers-as well as other HHS 16Federal agencies procuring goods and services are generally required to do so using full and open competition, with certain limited exceptions. See 41 U.S.C. §§ 3301 and 3304. See also FAR §§ 6.101 and 6.301. Page 6 GAO-22-104724 HHS's COVID-19 Public Education Campaign agencies and offices.'7 Currently, 10 firms participate in the PICS II program. Other HHS agencies and offices can use the PICS II program by entering into an interagency agreement with NIH. For purposes of this report, we will refer to the Office of Logistics and Acquisition Operations as NIH. Changing Nature of the COVID-19 Public Education Campaign ASPA designed the COVID-19 public education campaign to roll out rapidly to share critical public health information on COVID-19 across wide audiences. Initial campaign-related documents stated that educating the public on ways to prevent further spread of the virus supported the goal of re-opening businesses and the broader economy. Over the course of the pandemic, ASPA's public education campaign evolved to respond to changing circumstances. Contract documents noted that ASPA expected the campaign to evolve based on new and emerging information on the pandemic. For example, initial solicitation documents- for both the Atlas Research and Fors Marsh Group awards-included goals of defeating despair and inspiring hope, sharing best practices for businesses to operate in the new normal, and instilling confidence to return to work and restart the economy. However, after those documents were signed in September 2020, the United States experienced a spike in cases.18 HHS officials confirmed that ultimately, issues related to the economy and a return to work were not included in the public education campaign. Additionally, initial contract documents described the campaign approach as coordinating public outreach efforts around prevention and treatment of the seasonal flu and COVID-19. In winter 2020, campaign efforts included paid advertisements on social media and YouTube highlighting CDC's seasonal flu vaccine messaging as well as preventative steps for stopping the spread of COVID-19. Then, when FDA authorized the first vaccines for emergency use in December 2020, the focus of the campaign shifted to the new COVID-19 vaccines and away from the seasonal flu. HHS officials confirmed that the primary goals of the campaign were to educate the 17Requirements under the PICS II program are fulfilled through the award of task orders, which are awarded under indefinite-delivery, indefinite-quantity contracts. An indefinite- delivery, indefinite-quantity contract may be awarded to one or more contractors when the exact quantities and timing for goods or services are not known at the time of the award. 18As discussed earlier, the number of cases began increasing again in September 2020 and continued to do so into 2021. For example, between December 31, 2020, and January 13, 2021, new reported COVID-19 cases averaged about 225,000 per day-over 7 and 3 times higher than the surges the nation experienced during the spring and summer of 2020, respectively. Page 7 GAO-22-104724 HHS's COVID-19 Public Education Campaign ASPA Worked with Procurement Offices within FDA and NIH on the COVID-19 Public Education Campaign public about COVID-19 prevention and increase COVID-19 vaccine acceptance. Our review of contract documents shows that ASPA officials developed and led the public education campaign, while FDA and NIH procurement officials oversaw the technical aspects of the contracting process. HHS officials told us ASPA led the campaign because, at the time, HHS needed a whole of government response, and ASPA could bring agencies together to do so. Below, we describe the roles ASPA, FDA and NIH played in awarding and executing the Atlas Research contract and the Fors Marsh Group task order Atlas Research Contract In August 2020, ASPA and FDA entered into an interagency agreement under the Economy Act for the award of an "immediate surge" contract, which was awarded in September 2020. However, FDA terminated this contract in November 2020 after an HHS internal review. Pre-solicitation. According to officials we spoke with, ASPA-the requesting agency-defined the requirements (or needs) of the award, conducted market research and developed the statement of work. Officials from FDA-the servicing agency-were the contracting officers for the award, overseeing the regulatory and technical aspects of the process. According to HHS officials, the Office of the Assistant Secretary for Administration typically handles acquisitions for ASPA, and FDA officials told us it was atypical for FDA to provide contracting assistance to an HHS office or agency outside of FDA. However, ASPA worked with FDA to execute the contract awarded to Atlas Research because, in August 2020, FDA had the capacity and staff to execute a contract rapidly, according to officials from ASPA and ASFR. Solicitation. In August 2020, FDA oversaw and issued the RFP, which defined the goals, scope, and expected deliverables for the award. The award had a primary deliverable-a series of PSAs on COVID-19 prevention strategies featuring members of the entertainment industry and public health officials, along with the purchase of advertising space and time for the PSAs to air on multiple media platforms. The award also had specific requirements for disseminating information on the prevention and treatment of COVID-19 as rapidly as possible. Page 8 GAO-22-104724 HHS's COVID-19 Public Education Campaign According to FDA officials, ASPA initially wanted to execute a sole source contract with Atlas Research.1® However, at the suggestion of FDA officials, ASPA agreed that FDA should solicit proposals from an additional firm. According to the market research memo prepared by FDA, Atlas Research and one additional firm had the qualifications to perform under the expedited delivery requirements, including access to and knowledge of the national media landscape. Ultimately, the two identified firms prepared and submitted proposals for the award, including items such as a projected budget and timeline for deliverables. During the solicitation process, an ASPA official asked FDA staff to provide the two bidding firms the names of three companies to consider as potential subcontractors-to help perform the requirements should they be selected for the award, according to FDA officials. FDA officials stated that the three firms were suggested as potential subcontractors because they had the capacity to start the work immediately upon award, including rapid access to PSA production services. An FDA official told us that they emailed the two bidding firms the information about the three potential subcontractors during the solicitation period, as requested by the ASPA official. Atlas Research representatives and FDA officials said it was unusual for firms to be suggested as potential subcontractors during the solicitation phase.2° Atlas Research included the three suggested firms as potential subcontractors in its proposal, while the other bidding firm did not. Evaluation and award. Prior to making the award, in August 2020 a panel comprised of two ASPA officials and one FDA official evaluated and rated the submitted proposals from the two bidding firms for the award. Then, based on the scores from the reviews, the panel selected the awardee. The contracting officers from FDA reviewed the respective evaluations to ensure the rationale for the award was in line with federal 19A sole source contract is a contract for the purchase of supplies or services that is awarded after soliciting and negotiating with only one source. In March 2020, HHS issued a class justification and approval for all HHS acquisition offices to use procedures other than full and open competition, in order for HHS agencies and offices to have adequate flexibility to respond to the COVID-19 pandemic. 20in the course of our work, we became aware of a potential pre-existing business relationship between an ASPA official involved in the public education campaign and one of the suggested subcontractors. We have referred this matter to the Offices of Inspector General at HHS and the Department of Justice for action they deem appropriate. Page 9 GAO-22-104724 HHS's COVID-19 Public Education Campaign contracting standards. In September 2020, FDA awarded a contract to Atlas Research for nearly $15 million. Post-award. After the award was made to Atlas Research, the contracting officer's representative (an ASPA official) monitored the contract by providing day-to-day oversight of the contractor's performance and deliverables (e.g., work products, required status updates), according to Atlas Research and an ASPA official. Atlas Research developed a list of over 250 potential celebrity participants. Our review of contractor documents found the list included information on the celebrities' political affiliations or related public statements, any arrests, and identified the demographic groups the celebrities would most effectively reach. Atlas Research representatives said these elements were based on vetting one of the subcontractors had conducted for similar clients. In addition, they said the final selection of celebrities to participate in the campaign was based on which audience was being targeted, not on political support or affiliation.2' Under the Atlas Research contract, three members of the entertainment industry filmed PSAs that featured conversations with public health officials.22 We reviewed footage filmed for the PSAs and found that they contained information on topics such as preventative measures to combat COVID-19 (e.g., hand washing, mask wearing, social distancing), participation in COVID-19 vaccine clinical trials, and encouraging the public to receive the flu shot. Following congressional inquiries and media reports questioning the timing and content of the public education campaign in September 2020, the then-Secretary of Health and Human Services convened a review of both the Atlas Research and Fors Marsh Group awards in October 21According to Atlas Research documents we reviewed, targeted audiences included, for example, Black Americans, the Latinx community, Asian Americans, women, faith-based communities, and the elderly. 22ASPA officials approved the three members of the entertainment industry-one actor and two musicians popular in faith communities-who were filmed for the PSAs. Public health officials included in the PSAs were the Director of NIH's National Institute of Allergy and Infectious Diseases; the then-Assistant Secretary for Health; and the then-Surgeon General. Page 10 GAO-22-104724 HHS's COVID-19 Public Education Campaign 2020.23 The review was led by ASPA officials and included other public health and communications experts within HHS, including, for example, the then-Surgeon General, the Director of NIH's National Institute of Allergy and Infectious Diseases, the then-Director of NIH's Office of Communications and Public Liaison, and the Deputy Assistant Secretary for Minority Health in the Office of Minority Health. According to the meeting report we reviewed from the review group, the purpose of the review was to ensure the work of the public education campaign served critical public health purposes (i.e., provide concrete actions-masking, hand washing-for the public to take to protect themselves against infection as well as further spread of the virus). HHS officials said the review group decided to terminate the Atlas Research contract because it relied solely on members of the entertainment industry to promote COVID-19 messages to the public and did not involve traditional, evidence-based communication. According to HHS officials, the goal of the shift in direction for the campaign was to improve the potential for, and increase the speed of, the adoption of COVID-19 risk-reduction behaviors and acceptance of COVID-19 vaccines among the public. FDA terminated the Atlas Research contract in November 2020, and before any PSAs developed by Atlas Research aired. When FDA terminated the contract, Atlas Research had expended about $2.5 million of the $15 million contract based on the work it had completed, our review of contract files shows. According to HHS officials, the approximately $12.5 million in unexpended monies were deobligated in July 2021, and, as of December 2021, had not been obligated for another use. Fors Marsh Group Task Order In August 2020, ASPA and NIH entered into an interagency agreement under the Economy Act for the award of a task order through NIH's PICS Il program.24 Pre-solicitation. According to officials we interviewed, ASPA-the requesting agency-developed the statement of work and wrote the task order RFP. Officials from NlH-the servicing agency-were the 23See, for example, Letters to the Honorable Alex M. Azar II Secretary, Department of Health and Human Services (Sept. 10 and Oct. 28, 2020), Committee on Oversight Reform, Select Subcommittee on the Coronavirus Crisis, and Subcommittee on Economic Consumer Policy, U.S. House of Representatives. For media reports, see, e.g., "HHS Bids $250 Million Contract Meant to 'Defeat Despair and Inspire Hope' on Coronavirus," Politico (Aug. 31, 2020). 24As noted above, NIH's PICS II program offers communications and outreach support to NIH institutes and centers-as well as other HHS agencies and offices. Page 11 GAO-22-104724 HHS's COVID-19 Public Education Campaign contracting officers for the award, reviewed materials submitted by ASPA and oversaw the technical aspects of the pre-solicitation process. In mid-July 2020, NIH oversaw and issued a request for information to the 10 firms participating in the PICS II program. The request invited the firms to submit capability statements demonstrating their ability to provide the services described in the request for information. Three firms prepared and submitted capability statements. NIH and ASPA reviewed the three submissions and concluded that the firms could fulfill the requirements for the task order. NIH officials told us the process for awarding the task order was generally typical for the PICS II program, however, due to the high dollar amount- $250 million-an official with the highest levels of experience and training served as the contracting officer to oversee execution of the task order, per NIH policy.25 It is common for NIH institutes and centers, as well as other HHS agencies and offices, to use the PICS II program for media, communication, information dissemination, and technology services that cannot be fulfilled in-house. Solicitation. In late July 2020, NIH issued a task order RFP to all PICS II contractors. Three firms put forward proposals for the task order. The proposals included items such as a projected budget, a timeline for deliverables, a proposed approach, and a summary of relevant past experience. Evaluation and award. In August 2020, a panel comprised of two ASPA officials and one FDA official evaluated and rated the three submitted proposals.26 Then, based on the scores from the reviews, the panel recommended the awardee. NIH officials told us the contracting officer from NIH reviewed the evaluations to ensure the rationale for the award was in line with federal contracting standards. In September 2020, NIH awarded a task order to Fors Marsh Group for just over $250 million. Post-award. After the award was made, the contracting officer's representative (an ASPA official) monitored Fors Marsh Group's progress 25According to NIH policy, the contract oversight process takes the procurement level (i.e., the dollar amount of the award) into account when designating an official to serve as the contracting officer. 26The same panel of three officials reviewed the proposals submitted for the contract awarded to Atlas Research. Page 12 GAO-22-104724 HHS's COVID-19 Public Education Campaign on the task order by providing oversight of the contractor's performance and deliverables (e.g., work products, required status reports), according to officials we interviewed. The HHS review group-convened in October 2020-also assessed Fors Marsh Group's work, and concluded that the task order should continue. Fors Marsh Group activities in support of the COVID-19 public education campaign included the development of multiple messages for the public, to be distributed through different media platforms (television, radio, print, and digital). In addition, Fors Marsh Group secured placements for these messages in both paid and earned media; and conducted market research to apply to campaign products.2" Fors Marsh Group also designed the campaign's theme and logo, We Can Do This (see fig. 1). Figure 1: HHS's We Can Do This COVID-19 Public Education Campaign Logo Source: Department of Health and Human Services (HHS) and Fors Marsh Group. | GAO-22-104724 27Paid media efforts include outreach for which an entity must pay a fee (e.g., buying airtime on the radio). The campaign also included earned-or unpaid-media, which is content shared at no cost. Page 13 GAO-22-104724 HHS's COVID-19 Public Education Campaign Total expenditures for the task order-from September 2020 through November 2021-were nearly $295 million, according to invoices Fors Marsh Group submitted to NIH.28 Invoices indicated that Fors Marsh Group spent the majority (nearly 80 percent) of funds on media efforts, such as: e PSAs in television, radio, print, out-of-home (i.e., billboards), and digital (i.e., social media) formats. e Interviews and outreach featuring HHS spokespeople and trusted messengers-targeting media outlets that reach individuals who were disproportionately affected by the COVID-19 pandemic (e.g., specific racial and ethnic groups). e Social media engagement across official HHS platforms. e Engagement in conferences, seminars, expert panels, and webinars on topics such as vaccine development and COVID-19 prevention. e Campaign efforts also included sub-campaigns, such as: e Slow the Spread, which provided information about how to combat COVID-19 and flu; and e Building Vaccine Confidence, which used public education to help build vaccine confidence in people who were hesitant about COVID- 19 vaccines. In July 2021, NIH awarded Fors Marsh Group a new $150 million task order to continue work on the campaign from August 2021 through January 2022. 28The costs above the original award amount of $250 million were covered by a modification approved on June 16, 2021, that raised the task order ceiling by $50 million. Page 14 GAO-22-104724 HHS's COVID-19 Public Education Campaign ASPA Assembled Group of HHS Officials to Review Campaign Materials for Alignment with Public Health Recommendations ASPA Used CDC COVID-19 Relief Funds for the Public Education Campaign In November 2020, following the HHS review of the public education campaign and the termination of the Atlas Research contract, ASPA assembled a group of approximately 70 federal officials from across HHS agencies to obtain their review of and input on COVID-19 public education campaign materials developed by Fors Marsh Group. Many group members were health communications or public affairs officials, according to documentation we reviewed. An ASPA official told us they provided the members with campaign materials for review and input before approving them for use. While our review of award documents did not find specific requirements that campaign materials be aligned with public health recommendations, the statement of work NIH issued noted that awardees should develop their messaging approach with the guidance of scientific expertise and HHS leadership. Similarly, HHS officials said it is standard HHS practice to have relevant professionals from across the department review any education materials being provided to the public. According to the review group members we contacted from CDC, FDA, and NIH, they were asked to provide a review of, and input into, proposed campaign materials, such as talking points and scripts for videos and radio ads. Additionally, some members said that ASPA asked them to review materials to ensure the content aligned with any updates to public health guidance (e.g., changes to indoor masking guidance). Many members we contacted said they communicated with ASPA officials at least weekly. In addition, many members said they provided input on some aspect of the campaign-either directly or through subject matter experts. According to documentation provided by ASFR, ASPA used COVID-19 relief funds appropriated for CDC to pay for the public education campaign, including both the Atlas Research and Fors Marsh Group awards. Specifically, in July 2020, CDC entered into an interagency agreement under the Economy Act with ASPA to procure $300 million of services for the COVID-19 public education campaign. According to the interagency agreement, the funds were to support the development and implementation of PSAs-$100 million for flu-related messaging, and $200 million for COVID-19-related messaging. The interagency agreement stated that the estimated cost-$300 million-was based on public education initiatives of similar size and scope-national, with multiple audiences and multiple communication channels-such as the FDA youth tobacco use prevention campaign. The two original awards for the public education campaign, before modifications, totaled Page 15 GAO-22-104724 HHS's COVID-19 Public Education Campaign approximately $265 million. According to ASFR, ASPA used almost all of the remaining $35 million for additional funding for the initial Fors Marsh Group award, as well as for other public education campaign costs, such as staffing and operational costs. According to ASFR, the monies for this interagency agreement came from appropriations for CDC under two laws: 1. The CARES Act appropriated $4.3 billion to CDC "to prevent, prepare for, and respond to coronavirus, domestically or internationally," of which CDC used $100 million to fund the interagency agreement with ASPA.29 2. The Paycheck Protection Program and Health Care Enhancement Act appropriated $25 billion to the Public Health and Social Services Emergency Fund, with a required $1 billion transfer to CDC, "for surveillance, epidemiology, laboratory capacity expansion, contact tracing, public health data surveillance and analytics infrastructure modernization, disseminating information about testing, and workforce support necessary to expand and improve COVID-19 testing."3° Of that $1 billion, CDC used $200 million to fund the interagency agreement with ASPA. Our review of the work products produced by Atlas Research and Fors Marsh Group raised questions about whether the expenditures for the public education campaign were consistent with the purposes of the appropriation in the Paycheck Protection Program and Health Care Enhancement Act.31 We asked ASFR about the use of funds appropriated by the Paycheck Protection Program and Health Care Enhancement Act for the public education campaign. In response, ASFR stated that, after further review of expenditures for the campaign, "HHS determined a more appropriate funding source was and continued to be available and has adjusted its accounts accordingly." Specifically, CDC adjusted its accounts to instead use only its CARES Act funds for the $300 million 29Pub. L. No. 116-136, div. B, tit. VIII, 134 Stat. at 554. 30Pub. L. No. 116-139, div. B, tit. |, 134 Stat. 620, 624 (2020). The Public Health and Social Services Emergency Fund is an HHS emergency fund that supports HHS's efforts to improve the nation's preparedness against naturally occurring and man-made health threats and threats to the ability of HHS to carry out such missions. 31Under the purpose statute, appropriated funds are available only for the purposes authorized by Congress. 31 U.S.C. § 1301(a). Page 16 GAO-22-104724 HHS's COVID-19 Public Education Campaign Agency Comments interagency agreement with ASPA.?2 According to ASFR, funds appropriated by the Paycheck Protection Program and Health Care Enhancement Act are no longer being used for the public education campaign since sufficient balances were available from the CARES Act to fund the interagency agreement.*3 We provided a draft of this report to HHS for review and comment. HHS stated that it appreciated the opportunity to review the draft, and had no comments. We are sending copies of this report to the appropriate congressional committees, the Secretary of Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at hitp://www.gao.gov. If you or your staff have any questions about this report, please contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in the appendix. Alyssa M. Hundrup Director, Health Care 32An agency can adjust its accounts by charging obligations and expenditures previously incurred in one account to a different account. 33In addition to the $300 million in CARES Act funds for the interagency agreement, ASPA also used appropriations provided by the American Rescue Plan Act of 2021 to fund additional work on the public education campaign performed by Fors Marsh Group. See Pub. L. No. 117-2, § 2302, 135 Stat. 4, 38-39 (appropriating funds to HHS, acting through CDC, for vaccine confidence activities, among other activities). Page 17 GAO-22-104724 HHS's COVID-19 Public Education Campaign List of Addressees The Honorable Patrick Leahy Chairman The Honorable Richard Shelby Vice Chairman Committee on Appropriations United States Senate The Honorable Ron Wyden Chairman The Honorable Mike Crapo Ranking Member Committee on Finance United States Senate The Honorable Patty Murray Chair The Honorable Richard Burr Ranking Member Committee on Health, Education, Labor, and Pensions United States Senate The Honorable Gary C. Peters Chairman The Honorable Rob Portman Ranking Member Committee on Homeland Security and Governmental Affairs United States Senate The Honorable Rosa L. DeLauro Chair The Honorable Kay Granger Ranking Member Committee on Appropriations House of Representatives The Honorable Frank Pallone, Jr. Chairman The Honorable Cathy McMorris Rodgers Republican Leader Committee on Energy and Commerce House of Representatives Page 18 GAO-22-104724 HHS's COVID-19 Public Education Campaign The Honorable Bennie G. Thompson Chairman The Honorable John Katko Ranking Member Committee on Homeland Security House of Representatives The Honorable Carolyn B. Maloney Chairwoman The Honorable James Comer Ranking Member Committee on Oversight and Reform House of Representatives The Honorable Richard Neal Chairman The Honorable Kevin Brady Republican Leader Committee on Ways and Means House of Representatives The Honorable Patty Murray Chair Subcommittee on Labor, Health and Human Services, Education and Related Agencies Committee on Appropriations United States Senate The Honorable Angus S. King, Jr. United States Senate The Honorable Jeanne Shaheen United States Senate Page 19 GAO-22-104724 HHS's COVID-19 Public Education Campaign Appendix |: GAO Contact and Staff Acknowledgments GAO Contact Alyssa M. Hundrup, (202) 512-7114, hundrupa@gao.gov Staff In addition to the contact named above, Lori Achman (Assistant Director), Kristeen McLain (Analyst in Charge), Sam Amrhein, Kaitlin Farquharson, Acknowledgments and Lillian Riehl Schultze made key contributions to this report. Other contributors to this report were Sandra George, Teague Lyons, Vikki Porter, and Miranda Riemer. 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