CDC may cut TB funds for big cities in new cooperative agreement plans

States may be given power to approve cities’ applications for funds

On Feb. 24, members of the National Tuberculosis Controllers Association (NTCA) will meet in Chicago to study their collective financial futures. At the top of the agenda is the unveiling of new priorities by which cooperative agreement funds will be divvied up next year when grants from the Centers for Disease Control and Prevention (CDC) are "re-competed." That will start in fall 2000, when TB programs must submit new applications for funding. Also at stake is the future of separate funding agreements the CDC maintains with several big cities.

CDC will convene TB controllers from the 50 states, the nine big cities that receive their own funds (with the District of Columbia making 10), plus the seven territories. Working closely with representatives of the NTCA, CDC officials have struggled during past months to come up with a fair method to apportion the smaller funding pie, says Walter Paige, executive directive of the Atlanta-based NTCA. A decision to discontinue the practice of using "carry-over" funding means there will be less new money to go around, so competition for available money will be keener than ever.

Does separate funding encourage double-dipping’?

One question the CDC is expected to address is whether separate funding for some big cities will be trimmed or eliminated. Since 1993, at the height of the national upsurge in TB cases, a handful of cities has received separate funding. In the years that followed, case rates in many of those cities have come back down. Critics have argued that continuing to provide separate big-city funding needlessly pits cities against states and has led some cities to misspend their funds. In addition — from the standpoint of some states in which no cities get their own money — the practice of funding big cities separately amounts to "double-dipping."

"My guess is that CDC will wind up still funding at least some of the cities," says Bruce Davidson, MD, MPH, outgoing president of the NTCA. "There’s still discussion going on about how that could be optimally handled." One proposed solution has been to give states the power to review, and perhaps to approve, big cities’ applications for cooperative funds, Davidson adds.

The CDC "has been working really closely with us," says Carol J. Pozsik, RN, MPH, director of the Division of TB Control in South Carolina and incoming president of the NTCA. "They want to make sure they’re being fair and equitable to the little guy as well as the big guy. That’s what we’re all interested in — that we don’t lose what we’ve got."

When money is re-competed, applicants will find the bar has been raised a notch higher when it comes to accountability, with a renewed emphasis on outcomes, Paige notes.

Dilemmas without easy answers

Along with the city-vs.-state conflict, CDC officials have had to wrestle with other issues that don’t offer easy solutions, Paige says. For example, which programs should get more money — those with big caseloads or those that have worked efficiently to reduce their caseloads? "You want to direct money toward places where there’s a problem, but you don’t want to penalize places that have done a good job," he says.

A similar dilemma is what to do with programs that have developed a good relationship with their political jurisdictions and are getting funds from them. If they’ve worked hard to win support from state legislatures, they shouldn’t be penalized; at the same time, programs that don’t benefit from extra largesse from state coffers need a helping hand, Paige says.

One likely solution will be to set up two "pots" of funding, he suggests. From the larger pot will come money for top-priority activities, including case-finding, treatment, and investigation of close contacts to cases. The second, smaller pot would be reserved for activities of secondary importance, such as programs aimed at screening targeted populations; to qualify, programs would need to show they’d done a good job on top- priority activities.

There’s talk of establishing separate categories of funding for cities and states as well. Such a system might help states without big cities that qualify for separate funds feel less slighted, Paige adds.

Last month, this year’s slate of new officers was installed at the TB controllers’ organization. Sue C. Etkind, RN, MS, director of the TB control program in Massachusetts, was elected vice-president. Denise Ingman, TB program coordinator in Montana, was chosen secretary, and John Bernardo, MD, TB controller in Boston, was elected treasurer.

After the NTCA concludes its meeting, the North American chapter of the International Union Against Tuberculosis and Lung Disease will hold its annual conference, which will last through February 27.