As the Biden administration asks Congress for additional federal dollars to fight infectious diseases, it faces a conundrum: pandemic fatigue.

The White House has asked for $22.4 billion for COVID-19 and $4.5 billion for monkeypox as part of the upcoming short-term government funding bill, but its prospects are unclear, with Republicans reluctant to support yet another infusion of new public health funding.

While nearly 400 Americans are still dying of COVID-19 every day, hospitalization and case rates are down. Life has largely returned to normal. So it’s harder to make the case for even more pandemic money.

Republicans have largely soured on pulling more pandemic funds from the coffers, and many lawmakers said they’d need to see an immediate need for monkeypox funds before distributing them. GOP lawmakers want the administration to work with existing dollars before asking for more.

“It isn’t a question of authority; you have the authority. It isn’t a question of money; you have been given astonishing amounts of money,” Senate Health, Education, Labor and Pensions ranking member Richard M. Burr, R-N.C., told top administration public health officials during a hearing Wednesday, noting the series of pandemic funding bills that Congress has passed since the pandemic began in March 2020.

But the Biden administration argues it needs more or else case numbers could rebound. The government is running out of money for COVID-19 tests and shots just as the nation heads into the winter — a season in which COVID-19 cases are expected to rise, with the possibility of new variants emerging.

As of Sept. 2, Americans can no longer order free at-home rapid tests from the federal government, and the Department of Health and Human Services has announced that it will run out of federal dollars to purchase and distribute COVID-19 vaccines as early as January 2023.

The monkeypox outbreak faces similar funding issues. 

Sexual health clinics, which have largely been on the front lines of the outbreak, are struggling to meet the needs of patients. A public education campaign combined with the release of vaccines has helped slow case rates in the United States, but public health experts warn the future of the monkeypox outbreak could go one of two directions at this point — and much of that depends on how much money Congress allocates. 

“Firefighters are not expected to fight fire without water, nor are members of the military expected to fight wars without weapons. Yet, for the past three months, we have been on the frontlines pleading with officials for the support our network so desperately needs,” David Harvey, executive director of the National Coalition of STD Directors, said in a statement. 

Republican reluctance

Government funding runs out at the end of September, and congressional leadership appears to be eying a short-term spending bill lasting until mid-December.

Republican leadership, including Senate Minority Leader Mitch McConnell, R-Ky., and Minority Whip John Thune, R-S.D., have not shown any inclination to approve more public health funding, with Thune telling reporters last week that Republicans had “zero” interest in additional such funding.

Many other Republicans feel similarly.

“The administration is showing absolutely no restraint when it comes to spending money. So let’s look at the total package and try to understand, like, is this really needed,” Sen. Bill Cassidy, R-La., said when asked whether he’d support more pandemic funds in the upcoming spending bills. 

“If it’s a priority for COVID, and I don’t know if it is or not, we would do it. I don’t see the priority that’s imminent at the moment,” said Senate Appropriations ranking member Richard C. Shelby, R-Ala.

This attitude is irking the White House, where COVID-19 response coordinator Ashish Jha warns that it is more expensive to respond to an outbreak in real time than to be prepared.

“Let me be clear: If we get another surge, Congress likely at that point will step up. It will cost the American taxpayer twice as much and will be less effective,” Jha told reporters last week. 

‘History repeating itself’

The federal government is set to commercialize COVID-19 vaccines in January 2023 unless Congress appropriates more funds. This will hit uninsured individuals especially hard and could make booster shots prohibitively expensive for many. 

Commercializing tests could potentially lead to vaccine shortages next time there is a surge, said Jen Kates, senior vice president and director of global health and HIV policy for the Kaiser Family Foundation. Once the federal government stops buying vaccines in bulk, vaccine makers do not have a guaranteed market and may slow production or storage of materials, which could be an issue if a new variant emerges.

To cover a round of boosters for the 20 million uninsured individuals in the United States would cost roughly $1.5 billion, Brent Ewig, chief policy and government relations officer at the Association of Immunization Managers, explained. 

“It’s potentially history repeating itself. Whether it was first SARS or Zika, or H1N1 back in 2009, the history of public health funding is this predictable feast-famine,” Ewig said. 

But a COVID-19 winter wave may be mild in the absence of a new variant, according to recent projections from the COVID-19 Scenario Modeling Hub.

The new omicron boosters arrived just in time. Boosters are projected to prevent 24 million cases, more than 100,000 hospitalizations and more than 9,700 deaths, Centers for Disease Control and Prevention vaccine advisers predicted at their meeting earlier this month.

If a new variant causes a resurgence, it would most likely be near the end of the year, the modeling hub found. 

“We as a country have to move from a pandemic phase to a post-pandemic phase. But I think the biggest challenge is that transition point, that transition period. How long is that period going to be? And how well managed is it going to be? If it’s approached more like a cliff, as opposed to a rolling hill, we could be in real trouble,” Kates said.

A new public health problem

As the public health apparatus faces both monkeypox and COVID-19, it’s bracing for a winter without much help from the federal government. Experts worry that without more funds to continue prevention and vaccination efforts, both viruses could rebound. 

Harvey, of the National Coalition of STD Directors, said sexual health clinics say they need no less than $500 million to deal with the ongoing outbreak. Since monkeypox often first presents in the genital region, many individuals head to sexual health clinics as a first stop when dealing with monkeypox, and these federally funded clinics are not equipped to deal with the avalanche of testing and treatment requests.

At least one clinic reported seeing a tripling in average weekly visits without any extra funds.

White House monkeypox response coordinator Bob Fenton told reporters that the administration needs Congress to appropriate more money to replenish the monkeypox vaccine supply. The Biden administration drew on orthopoxvirus vaccines from the Strategic National Stockpile to combat monkeypox at the outset. 

But now that vaccine makers are set to make more shots, Fenton warned it’s important to have the funds not only to re-up supply for this outbreak but also to make sure the Strategic National Stockpile is well stocked for future disasters. 

The administration also says it needs funds to continue researching updated testing and treatments. For example, on Sept. 7, the Food and Drug Administration granted Quest Diagnostics emergency authorization for its lab-based monkeypox PCR test.

Meanwhile, monkeypox cases are slowing slightly. In July, the CDC estimated that it took eight days for cases to double nationwide, but by mid-August, the doubling rate was 25 days, White House spokesperson Karine Jean-Pierre recently told reporters.

Still, the CDC has tallied about 22,000 cases in the United States, and that number is seen as a likely undercount.

“There has been documented behavior change over the past couple of months that is helping to reduce infections, together with vaccines,” Harvey said of monkeypox. “But the jury is still out on where we’re headed here.”