Page 1 GAO-13-477R CDC Awards

United States Government Accountability Office

Washington, DC 20548

April 30, 2013

Congressional Requesters

Subject: Centers for Disease Control and Prevention: Lobbying Policies and 

Monitoring for Program to Reduce Obesity and Tobacco Use

According to the Centers for Disease Control and Prevention (CDC), obesity-related 

medical expenses in the U.S. were an estimated $147 billion in 2008, and tobacco 

use costs the nation $96 billion in medical expenses each year. To help reduce 

obesity and tobacco use, two leading causes of chronic disease, CDC established 

the Communities Putting Prevention to Work (CPPW) program using funds 

appropriated to the Department of Health and Human Services (HHS) by the 

American Recovery and Reinvestment Act of 2009 (Recovery Act).1 With this 

funding, CDC awarded a total of approximately $522.3 million in cooperative 

agreements to state and local health departments in fiscal year 2010 throughout the 

country to address issues related to obesity and nutrition, and support tobacco usecessation efforts.2 CDC made additional awards totaling approximately $36.9 million 

using funds appropriated by the Patient Protection and Affordable Care Act 

(PPACA), enacted in 2010, and transferred to an account specifically for the CPPW 

program.3 All CPPW awards were made during fiscal year 2010, and, according to 

CDC officials, all CPPW award recipients will have completed their work by 

September 2013; CDC has no plans to continue the CPPW program.

 

1

Pub. L. No. 111-5, Div. A, Tit. VIII, 123 Stat. 115, 172. The Recovery Act directed that $650 million 

be used to carry out evidence-based clinical and community-based prevention and wellness 

strategies authorized by the Public Health Service Act, as determined by the Secretary of Health and 

Human Services, that deliver specific, measurable health outcomes that address chronic disease 

rates. Pub. L. No. 111-5, 123 Stat. 180. These funds were available for obligation through fiscal year 

2010. See Pub. L. No. 111-5, §1603, 123 Stat. 302.

2

Health departments could receive awards to address obesity and nutrition or tobacco use, or receive 

multiple awards to address both issues. As the primary recipients of these awards, health 

departments had the ability to provide funding to other organizations, which are referred to as 

subrecipients.

3

See Pub. L. No. 111-148, §§ 4002(b) and (c), 10401(b),124 Stat. 119, 541, 974. PPACA established 

in HHS and appropriated specified amounts each year to the Prevention and Public Health Fund 

(PPHF) to provide for expanded and sustained national investment in prevention and public health 

programs to improve health and help restrain the rate of growth in private- and public-sector health 

care costs. PPACA appropriated $500 million to this fund for fiscal year 2010, of which HHS 

transferred a portion to CDC to fund additional CPPW awards. See GAO, Prevention and Public 

Health Fund: Activities Funded in Fiscal Years 2010 and 2011, GAO-12-788 (Washington, D.C.: 

Sept. 13, 2012).
Page 2 GAO-13-477R CDC Awards

CDC has administered and provided oversight of the CPPW program, which 

includes the monitoring of award recipients. CDC required recipients to use their 

CPPW funds to support efforts to improve nutrition, increase physical activity, or 

reduce tobacco use and exposure to secondhand smoke. In addition, CDC 

suggested possible strategies for achieving these results, such as working to 

establish smoke-free zones or to implement zoning changes that promote physical 

activity. CDC policy prohibited CPPW award recipients from using funds for specific 

types of activities, including lobbying, which generally meant certain activities 

designed to influence action in regard to a particular piece of pending legislation. 

You asked that we review CDC policies on lobbying and CPPW award recipients’ 

activities. We are providing information on several issues about CDC policy on 

lobbying as it pertained to CPPW award recipients.

To obtain the information we present here, we reviewed documents provided by 

CDC, including the written policy on lobbying that pertained to CPPW award 

recipients; CPPW award notices, which were the written agreements between the 

CDC and recipients; documentation generated by CDC staff during the monitoring of 

CPPW recipients; and CDC site visit reports. We interviewed CDC officials regarding 

the lobbying policy that applied to CPPW award recipients; the types of activities 

agency staff would define as violations of this policy; how CDC educated CPPW 

award recipients about this policy; how CDC monitored CPPW recipients to detect 

potential violations of this policy; and the steps CDC took in the event that it 

suspected a CPPW recipient was in violation of it. Our results are limited to the 

280 CPPW cooperative agreements, all of which were made in fiscal year 2010.

We conducted this performance audit from August 2012 to April 2013 in accordance 

with generally accepted government auditing standards. These 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.

In developing information on the CDC’s CPPW program, we addressed the following 

questions:

1. What CDC policies on lobbying applied to the recipients of CPPW awards, 

which were made in fiscal year 2010?

All CPPW awards were made subject to the provisions in CDC policy 

memo AR-12, which is CDC’s policy restricting the use of federal funds 

for lobbying purposes. See enclosure I for the version of AR-12 that 

was in effect at the time that CPPW awards were made.4

 

4

Unless otherwise noted, all references to AR-12 in this report are to the version that was in effect 

prior to December 2011, which is reprinted in enc. I. According to CDC officials, this version of AR-12 

applied to CPPW awards because they were made in fiscal year 2010. In 2012, CDC amended and 

expanded AR-12, 

According to 

AR-12, lobbying would be considered “[a]ny activity designed to 

influence action in regard to a particular piece of pending legislation” 

http://www.cdc.gov/od/pgo/funding/grants/additional_req.shtm (accessed 

September 12, 2012).
Page 3 GAO-13-477R CDC Awards

and would include efforts directed at inducing members of the public to 

contact their elected representatives at the federal, state, or local 

levels to urge support of, or opposition to, pending legislative 

proposals. Among other things, the policy specifically prohibited the 

use of funds for publicity or propaganda purposes, for the preparation, 

distribution, or use of any kit, pamphlet, booklet, publication, radio, 

television, or video presentation designed to support or defeat 

legislation pending before Congress or any state or local legislature, 

except in presentation to the Congress or any state or local legislature 

itself. This prohibition contained an exception for normal and 

recognized executive-legislative relationships, which could include 

presentations to legislative branch officials. The policy also recognized 

that funding could be used under certain circumstances to provide 

information to the legislative branch in order to foster implementation of 

prevention strategies to promote public health and to engage in activity 

to enhance prevention, such as the collection, analysis, and 

dissemination of data and conducting community outreach services. 

According to CDC officials, AR-12 applied to both primary CPPW 

recipients and their subrecipients.5

2. What types of activities would CDC have considered to be a violation of the 

lobbying policy that applied to the use of CPPW awards by recipients?

According to CDC officials, subject to certain exceptions, activities that 

would have constituted a violation of AR-12 included: communicating

directly in support of or opposition to specific legislation pending before 

Congress or a state or local legislature (direct lobbying); expressly 

encouraging the public or other entities to contact their elected 

representatives to ask them to support or oppose specific legislation

pending before Congress or a state or local legislature (grassroots 

lobbying); and selectively presenting materials relating to the adoption 

of specific legislation to a narrow audience, such as only to the 

supporters of the legislation. For example, according to CDC officials, 

the policy would not have allowed CPPW award recipients to use CDC 

funds to produce and distribute a pamphlet that expressly encouraged 

the public to contact their elected representatives to urge their support 

of, or opposition to, pending legislation. However, CDC officials told us 

that CPPW recipients would have been permitted to present 

information directly to elected representatives in order to educate them 

about a public health issue unconnected to pending specific legislation. 

According to CDC officials, the exception for normal and recognized 

executive–legislative relationships pertained to interaction between 

executive and legislative branches of government at the state and local 

level. For example, a state health department may interact with the 

state legislature to provide factual information related to a public health 

topic.

 

5

Subrecipients are other organizations to which primary recipients can provide CPPW funding.
Page 4 GAO-13-477R CDC Awards

3. How did CDC inform CPPW award recipients of the lobbying policy that 

applied to them?

CDC used funding opportunity announcements (FOA) and meetings with 

CPPW award recipients to educate them on AR-12. Each CPPW FOA to 

which applicants responded contained a reference to AR-12. In addition, 

officials stated that each notice of award issued to awardees contained a 

summary of AR-12 and a reference to the full version of the policy, which 

was available on CDC’s website. CDC officials told us that they reminded 

recipients about the requirements of AR-12 during required training 

sessions and other meetings. For example, during a mandatory kick-off 

meeting attended by all recipients, CDC officials reported that officials and 

recipients discussed the restriction on using CPPW funds for lobbying 

activities. In addition, CDC officials told us that they discussed AR-12 and 

its restrictions on other occasions with recipients, including sometimes 

during discussions regarding the recipients’ budgets.6

4. How did CDC monitor CPPW award recipients to detect potential violations of 

CDC lobbying policy that applied to them?

CDC officials told us that they used reviews of the proposed budgets of 

CPPW award recipients to identify any planned activity that could violate 

AR-12. CDC officials explained that before a recipient began work funded 

by CDC, officials from CDC’s Procurement and Grants Office (PGO), the 

assigned CDC project officer, and the recipient met to review each line 

item of a recipient’s budget. Officials said that during these meetings, they 

would determine whether the proposed activities were allowable under the 

CPPW program. CDC officials stated that this process would have 

identified any planned activity that appeared inconsistent with AR-12. For 

example, officials reported that during the review of activities proposed by 

several recipients, they disapproved some activities, such as a proposal to 

promote state legislation to ban indoor smoking, as well as a proposal to 

engage in a public health campaign to support the passage of a law to ban 

smoking in public places.

CDC officials told us that CDC project officers conducted regular 

monitoring phone calls with each award recipient, during which they 

discussed ongoing CPPW activities, including milestones specific to each 

award. Project officers also conducted at least one annual site visit to 

each primary award recipient where they met with the recipient, reviewed 

 

6

The HHS Office of the Inspector General (OIG) issued an early alert in June 2012, noting a lack of 

clear guidance from CDC to CPPW award recipients concerning lobbying policy. In the early alert, 

OIG advised that CDC, among other things, provide additional training of CDC staff working with 

CPPW award recipients about antilobbying provisions, and provide additional guidance to award 

recipients on how to avoid violating these provisions. See Daniel R. Levinson, OIG, HHS, 

memorandum to Thomas R. Frieden, M.D., M.P.H., CDC, (June 29, 2012). In its response to the 

OIG’s early alert, CDC reported that it is taking steps to implement each of the actions noted by the 

OIG. See Thomas R. Frieden, M.D., M.P.H., CDC, memorandum to Daniel R. Levinson, OIG, HHS

(July 26, 2012). The OIG is also conducting additional work generally related to this topic pertaining to 

HHS-wide awards made in fiscal years 2011 and 2012, and therefore does not anticipate the 

inclusion of CPPW awards in this work.
Page 5 GAO-13-477R CDC Awards

award documentation, provided any necessary technical assistance, and 

reviewed progress related to award-specific milestones.7 According to 

CDC officials, these monitoring activities were intended, in part, to identify 

unallowable activities, such as violations of CDC lobbying policy in AR-12. 

Finally, CDC officials stated that each recipient is required to complete a 

final report summarizing the work done under its CPPW cooperative 

agreement, which is reviewed by CDC officials.8

CDC officials reported that the project officers overseeing CPPW awards 

were trained to be cognizant of any CPPW-funded activities that could be 

in violation of AR-12. According to CDC staff, lobbying information was 

shared during meetings with CDC staff. For example, during a May 2010 

CDC staff meeting, project officers and other CDC officials specifically 

discussed AR-12 and the steps project officers should take if they 

suspected a violation of this policy. Project officers also engaged in case 

review exercises to practice identifying issues, such as lobbying, among 

CPPW award recipients.

5. What procedures did CDC have in place to investigate CPPW award 

recipients suspected of violating the CDC lobbying policy?

According to CDC officials, at the time of the CPPW awards, if a project 

officer identified information that indicated a CPPW award recipient was 

conducting activities that violated AR-12, the project officer would 

implement a risk-mitigation plan, which was established for CPPW to

address any potentially unallowable activity performed by a recipient. 

Under this plan, CDC would contact the recipient by telephone to request 

additional information and ask that the activity cease immediately until 

further information could be gathered by CDC. The project officer would 

then investigate the activity to gather additional information. This 

information would then be presented and reviewed at a risk mitigation 

meeting. According to CDC’s risk mitigation plan, risk mitigation meetings 

typically included the director of the CPPW program and the project 

officer, as well as other CDC staff. If this group determined that no 

violation of AR-12 occurred, a note would be made in the file and no 

further action would be taken beyond regular monitoring of the recipient. 

However, if it was determined that a potential violation occurred, written 

findings and recommendations would be prepared by the CPPW program 

and the case elevated to the Recovery Act Coordination (RAC) Unit and 

 

7

CDC officials stated that some recipients received two site visits in a year, depending on the needs 

of the recipients and availability of CDC travel funds. In addition, officials stated that during site visits 

to these primary recipients, project officers would also typically meet with selected sub-recipients 

based, in part, on the needs of the sub-recipient and availability of time and travel funds.

8

The Single Audit Act, as amended, requires all nonfederal entities (states, local governments, and 

nonprofit organizations) that expend $500,000 or more in federal awards per year to obtain an annual 

audit in accordance with specified criteria. See 31 U.S.C. §§ 7501 et seq. Office of Management and 

Budget Circular A-133, Audit of States, Local Governments, and Non-Profit Organizations, sets forth 

standards for obtaining consistency and uniformity among federal agencies for such audits. CDC 

officials stated that they receive A-133 audit findings for primary CPPW award recipients and follow 

up on the findings to ensure that necessary action is taken.
Page 6 GAO-13-477R CDC Awards

the Associate Director for Policy within the National Center for Chronic 

Disease Prevention and Health Promotion (NCCDPHP).9

According to CDC officials, two CPPW award recipients were suspected of 

conducting activities that violated AR-12, and one of the recipients was 

found to be conducting activities that constituted lobbying under CDC’s 

AR-12 policy. In this case, a project officer identified activities that 

demonstrated CPPW-funded staff at the South Carolina Department of 

Health and Environmental Control significantly contributed to planning and 

scheduling a press event designed to influence the decision of city council 

members with regard to a smoke-free ordinance. CDC submitted a written 

request to this recipient in May of 2011 for additional information, and the 

recipient responded in writing the following month. CDC determined that 

this recipient conducted lobbying activities. In its written response, the 

recipient calculated the amount of funds spent on staff time for planning 

activities related to lobbying ($247.79) and agreed to refund this amount. 

The recipient also agreed to provide additional training to staff on lobbying 

restrictions as outlined in AR-12. CDC officials noted that the activities 

conducted by this recipient were planning activities and the planned press 

event was not held.

Cases referred 

to these entities would be discussed and reviewed at an NCCDPHP riskmitigation meeting that would include RAC members, CPPW program 

representatives, policy staff, PGO staff, and staff from HHS’s Office of the 

General Counsel. Results from this meeting would be used to determine 

whether an enforcement action was warranted.

In the other case, CDC suspected that subrecipients of the Public Health 

Institute of Metropolitan Chicago, a primary CPPW award recipient, might 

have violated AR-12 by participating in a May 2011 hearing on sugarsweetened beverages before the Illinois Senate Public Health Committee. 

CDC wrote to this primary recipient in May of 2012 and requested 

additional information about its subrecipients’ attendance at this hearing. 

The primary recipient responded in June of 2012 with additional 

information. On the basis of this information, CDC concluded that the 

activity in question had not been approved as part of the award when the 

recipient applied for funding. As a result, CDC disallowed funding related 

to this activity. Officials stated that because the activity was not approved, 

no further evaluation was undertaken to determine whether the activity 

violated AR-12.

Agency Comments

We provided a draft of this report to HHS. HHS provided technical comments that we 

incorporated, as appropriate.

 

9

Officials stated that this same process was used for all CPPW awards, including those funded 

through PPACA. Officials stated that they wanted to use the same process for all CPPW awards in 

order to maintain consistency.
Page 7 GAO-13-477R CDC Awards

– – – – – 

As agreed with your offices, unless you publicly announce the contents of this report 

earlier, we plan no further distribution until 30 days from the report date. At that time, 

we will send copies of this correspondence to the Secretary of Health and Human 

Services, appropriate congressional committees, and other interested parties. The 

report is also available at no charge on the GAO website at http://www.gao.gov. 

If you or your staff members have any questions about this report, please contact 

me at (202) 512-7114 or kohnl@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page of this 

correspondence. Other key contributors to this correspondence included Will Simerl, 

Assistant Director; George Bogart; Krister Friday; Andrea E. Richardson; and 

Jennifer Whitworth.

Linda T. Kohn

Director, Health Care

Enclosures – 1 
Page 8 GAO-13-477R CDC Awards

List of Requesters

The Honorable Orrin Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Lamar Alexander

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Tom Coburn, M.D.

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Susan Collins

Ranking Member

Special Committee on Aging

United States Senate
Enclosure I

Page 9 GAO-13-477R CDC Awards

Centers for Disease Control and Prevention (CDC) Policy on Lobbying 

Applicable to Awards Made during Fiscal Year 2010

(291075)
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