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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
December 21, 2020
State Health Policy Leadership COVID-19
Christopher F. Koller, President Read Bio
Back to President’s Blog: The View from Here
“We felt abandoned.”
It was March of 2020. The scope of the COVID-19 pandemic was becoming clear and state officials were scrambling. For personal protective equipment. For testing supplies. For guidance and a plan. Not only did federal officials have no answers, they seemed little interested in finding them, according to several senior state health and human services leaders I have spoken to. “It was clear; we were on our own,” one told me.
This was not how federalism was supposed to work. This was not the vaunted state–federal partnership that apportions authority and resources in ways that honor local values and control while maintaining national consistency for essential affairs. As a result, issues of science became matters of politics, communities struggled to agree even on basic facts, and the toll of the pandemic in lives disrupted, suffering, and death has been much greater than it should have been.
The election of a new President, however, provides a chance to reset the state–federal relationship. Leaders set the tone, and President-elect Biden has an opportunity to encourage state and federal leaders to work together on the challenge of COVID-19 vaccine distribution and administration, as well as of improving the persistently dismal performance of our health care system.
Three principles, often lacking in 2020, ought to guide this federalism reset.
First, wise leadership is needed at the state and federal level. Unable to delegate responsibility or print money like their federal colleagues, governors consistently make hard decisions and reconcile conflicting priorities. During the pandemic, their constituents have looked to them for information, competence, and reassurance. Some governors have responded with more courage and wisdom than others, but the job is demanding – and not for the faint of heart.
Usually, the governors, in turn, look to federal leaders in Washington — especially in the administration — for the same traits of wise leadership. For the last four years, these characteristics have largely been lacking. A White House focused on a personal and political agenda berated the states to “innovate” and take responsibility, and cabinet officials were obliged to follow suit. States have largely been “on their own.”
The impact of this lack of leadership extends beyond a state’s government to all residents, and its effects are significant. Frustrated state legislators — Republican and Democrat — tell me of fruitless local conversations where people, lacking authoritative information on the pandemic from federal leaders, can’t even agree on current realities.
Second, the judicious use of federal authority is essential to a healthy federalism. The appropriate amount of health policy flexibility for states is a matter of interpretation, not a bright line. As a nominee, President-elect Biden continually faced red-meat questions about federal mask mandates and lockdowns. States, for their part, regularly petition federal officials for permission to depart from federal Medicaid requirements and still receive federal funding.
These policy decisions require judgement calls by federal officials. As the party of limited government, Republicans champion flexibility for states — the “laboratories of innovation,” they say, quoting Justice Louis Brandeis. When it comes to Medicaid waivers, Democrats often want to have it both ways. They decry state efforts to take up the Trump administration’s concept of “community engagement” requirements, but now hope states can strike out boldly to develop public option health insurance products.
For federalism to function well, federal officials must use their authority thoughtfully. You can’t swap Ted Cruz and Bernie Sanders: Vermont’s civic culture really is different from Texas’s, and residents of both states like it that way. On the other hand, officials can’t duck their responsibility to enforce federal law, and a thousand flowers will bring a lot of weeds.
This judicious use of authority might emerge not as mandates but as federal guidance and standards — sorely lacking in the pandemic — which local officials can use as a reference when advancing politically challenging initiatives. At other times state and local officials need “a heavy,” an external authority they can blame to limit options or make the difficult call.
Finally, resetting federalism depends on reliable communications between the federal and state governments. The states and the federal government are in a relationship, and the key to a functioning relationship, any marriage therapist will tell you, is regular and direct communication.
Governors exhausted by the pandemic don’t expect to get everything they want in their exasperating dealings with the federal government, but a Biden administration can quickly change the tone with states, a former state and federal official told me, by simply listening to the governors and treating them with respect.
Similarly, the declaration of a public health emergency during the pandemic and the subsequent release of certain emergency funds and approval of Medicaid waivers to relax coverage and administrative requirements is acknowledged to have unfolded reasonably smoothly, without the drama and conflict seen in other parts of the pandemic response. This is due in part to successful efforts to maintain these decisions as administrative rather than political determinations, but also because state and federal Medicaid officials were in regular contact before the pandemic and have maintained those communications. Like the old Holiday Inn commercials, in federalism “the best surprise is no surprise.”
By contrast, relationships between the Centers for Disease Control and Prevention and state departments of health have been severely disrupted during the pandemic, as federal authority and regular communication mechanisms were usurped by political leadership.
A federalism reset with the incoming Biden administration need not be challenging, but is vital to restoring some trust in the public sector. Wise leadership, judicious use of authority, and trustworthy communications will go a long way to making state officials — and the people they serve — feel supported, not abandoned.
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