Public Health, Federalism, and Fragmentation
Alan Greenblatt at Governing:
To some extent, public health has been a victim of its own success. Over the past century, the focus of American health care has shifted from public health — which is concerned with infectious diseases and the overall well-being of the community — to treating individuals. Nearly all the health policy energy is devoted to debating questions about how many individuals should be covered and who should pay the bill.
As a result, public health is always a low priority, until it’s the highest possible priority. Public health is lucky to receive a penny or two out of every dollar spent on health care. Before the novel coronavirus struck, funding had been cut in half over the past decade for both public health emergency preparedness and response programs at the federal Centers for Disease Control and Prevention (CDC) and the federal hospital preparedness program.
Throughout American history, public health has been fragmented, with first local governments and later states playing a more active role than the federal government. After nearly every modern epidemic, panels of experts have called for Washington to play a more robust role. Those recommendations typically go nowhere.
The problem during the coronavirus crisis is not so much that the federal government hasn’t taken full charge, says John Auerbach, president of the Trust for America’s Health, a nonprofit that advocates for public health. There’s always been a “division of labor” between the levels of government in responding to public health emergencies. The problem is communication between those levels.
Typically, the federal government takes the lead role in setting the medical and scientific strategy, leaving its plans largely to states and localities to carry out, each offering consistent messages. Federal, state and local responses were well-coordinated following the Sept. 11, 2001, terrorist attacks, Hurricane Katrina, the H1N1 virus, Ebola and Zika, Auerbach says.
In response to COVID-19, however, the CDC has been virtually sidelined. Its daily briefings were canceled back in March. More recently, the White House vetoed a set of detailed guidelines that the CDC prepared for states, localities and businesses to follow in opening back up. In prior crises, you didn't have states competing against each other for resources.
