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During a public health crisis in the US, distancing power rests with the states

During a public health crisis in the US, distancing power rests with the states


But the federal government controls the purse strings

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NY Governor Andrew Cuomo Holds Daily Briefing At Javits Center
Photo by Eduardo Munoz Alvarez / Getty Images

At press conferences for the past week, President Donald Trump has continued to push the idea that the United States could relax the distancing measures put in place around the country to slow the COVID-19 outbreak by Easter, April 12th. “America will, again, and soon, be open for business,” he said on Monday, despite public health experts’ warnings that April 12th is far too soon and would be catastrophic.

Many governors (both Republican and Democrat) and local officials are shrugging off that suggestion. “We are going to make sure we take care of the needs of New Hampshire first,” said Chris Sununu, the Republican governor of New Hampshire. Missouri Gov. Mike Parson, also a Republican, said the same: “We’re planning this much longer than two weeks here in the state of Missouri,” he said.

During a public health crisis like this one, they are the ones who have the final say, says Ross Silverman, professor of health policy and management at Indiana University. “Public health powers are generally handled at the state level,” he says. The federal government plays a major role in resource allocation and can offer states suggestions and expertise, but state and local governments are largely responsible for on-the-ground decision-making.

“For the most part, when we have public health concerns, they arise mostly at the local and state level. The way the system is constructed really reflects that history as far as public health is concerned,” Silverman says. “It’s the same reason why drivers licenses are different — it’s from the same decentralized system.”

Legally, the states can maintain social distancing orders and business closures, even if Trump says that they shouldn’t, but that can create communication problems. “It sends really mixed messages,” Silverman says. It makes public health officials’ jobs harder when people in different types of leadership positions contradict each other, Glen Nowak, director of the Center for Health and Risk Communication at the University of Georgia, told The Verge. “It can be hard to know which point of view should be weighted more heavily and what actions and recommendations should be followed,” he said.

While states can make their own decisions about the types of public health responses they think are necessary, they’re reliant on resources and regulations from the federal government during an unprecedented crisis like the COIVD-19 pandemic. For example: states had to wait for COVID-19 tests to be approved and manufactured at the federal level. Mismanagement and errors at the Centers for Disease Control and Prevention meant they had to wait longer to receive federal tests, and Food and Drug Administration regulations meant they weren’t allowed to make their own for weeks.

The federal government also, in theory, has access to reserves of drugs and protective equipment through the Strategic National Stockpile. States do not have direct access to the stockpile. The federal government can put pressure on companies to produce things like masks, either informally or under the Defense Production Act, which lets the president require companies to take on federal contracts for certain items. It also has a far more extensive and flexible budget. “States respond to the crisis first and foremost with the resources they have,” Silverman says. “The way it’s set up to work is that the feds provide a boost, and are the backup if states run out of something.”

In this crisis, though, states have struggled to access that boost. The national stockpile is more limited than the situation requires, Trump hasn’t used the Defense Production Act to boost manufacturing of masks and ventilators, and the federal government has largely left the states to negotiate for and purchase supplies on their own.

It’s still hard to say how much state-level policies like physical distancing can steer their outbreaks and how much the federal government’s influence impacts those trajectories, Silverman says. The two levels of governance are supposed to work together, with the federal government setting the tone for the state-level response. But the decentralized public health system in the US coupled with inconsistent and slow activity at the federal level means initiatives have been patchwork.

“You can see which governors are working very closely with their health experts,” Silverman says. Some are following best practices, and some seem to be focused on other priorities.

“The tension right now is between economic and public health interests,” he says. “You would hope everyone would be on the same page, and that is to protect the health of the public. It seems like that’s become a challenge. That’s going to lead to a more difficult-to-handle outbreak.”