Federalism Is Killing Us

Deference to state governments has severely undermined public health efforts during the pandemic and deepened geographic inequality in the United States.

(Getty Images)

The Trump administration’s response to the COVID-19 pandemic set new standards for incompetence, defiance of basic science and public health precautions, and petty politicization of the smallest policy details. The Lancet Commission on Public Policy and Health in the Trump Era, released last month, details the “health-damaging policies and pronouncements” of the Trump era and their long-term effects.

Yet as the commission is careful to point out, the administration’s failures marked a difference in degree, not in kind. Deep inequities in health provision, underinvestment in public health, and indifference to the punishing inequality hardwired into our economy and our social policies all preceded Trump and—without bold action—will certainly outlast him.

An important part of this longer history is federalism: the abdication of national responsibility for basic social policy standards to state governments. Wishfully characterized as a way of nurturing “laboratories of democracy” attuned to local needs and values, welfare state federalism is in fact a chronic source of inequity and unequal protection. Its roots lie in the New Deal’s concessions to Jim Crow; the New Deal welfare state, as the NAACP’s Charles Hamilton Houston noted at the time, was a “sieve with the holes just big enough for the majority of Negroes to fall through.” Today, local discretion is still motivated and animated by racial exclusion and exploitation.

Health provision and health risks have long been shaped by state and regional policy choices. Because we rely on job-based health provision, occupational segregation and state labor market policies determine who can access healthcare. And state right-to-work laws block workers from the job-based benefits that unions collectively bargain for their members. It’s little surprise that Southern states with large African-American populations crowd the bottom of the state rankings on both rates of union membership and rates of employer-provided health insurance.

Such disparities would be less troubling if public programs filled in the gaps. Instead, they widen them. From its passage in 1965, Medicaid has “fragmented democracy” and social citizenship by allowing states to set the terms of eligibility and the scope of benefits. This jurisdictional inequity was hardened by the Supreme Court’s decision in National Federation of Independent Business v. Sebelius to make state participation in the Affordable Care Act’s Medicaid expansion optional. Eight of the twelve states that have not expanded Medicaid are in the Deep South, and more than half of the non-elderly adults left uncovered are black or Hispanic.

Deference to state governments—many without the capacity or the willingness to make meaningful investments in public goods and services—also has significant effects on the broader social determinants of health, on everything from school funding and segregation to economic inequality and environmental risk. For all these reasons, disparity in health outcomes across the states are as deep and profound as those found in cross-national comparisons.

COVID-19 and the Trump administration’s staggering negligence put federalism and its dangers on stark display. The temporary generosity of the CARES Act’s unemployment programs was a concession to both the gravity of the jobs crisis and to the inability of state unemployment insurance systems to process (let alone fund) the avalanche of claims. The anemic paid leave provisions of the Families First Act, by the same token, testified to the rank inefficiency and unfairness of delegating such basic social protections to private whim and state-by-state policy innovation. To fulfill the Centers for Disease Control’s national moratorium on evictions, states and local housing programs—even those funded with federal dollars—offer a bewildering patchwork of relief.

In the absence of meaningful federal leadership, many states crafted public health policies on the fly—inventing or reinventing their own definitions of essential businesses and social distancing, their own metrics for school closings, and their own “gating criteria” for re-opening state economies. Such decisions have been tethered as much to political or fiscal pressures as they have to actual public health guidelines.

This fragmentation of social citizenship has slowed and distorted the vaccination program as well. At the national level, “Operation Warp Speed” galvanized the development and production of COVID-19 vaccines. But delegating the administration of the vaccine to the states was like throwing them in the air and hoping they landed, needle first, in the arms of those who needed them the most.

The CDC’s Advisory Committee on Immunization Practices set basic criteria related to occupation, age, and risk. At least on paper, state plans have largely followed suit. But states immediately started tinkering with the guidelines—shoehorning new groups (first-responders, teachers, seniors) into the “1A” category set aside for healthcare workers and long-term care facilities, playing with age thresholds, and adopting idiosyncratic definitions of things like “congregate settings” or “frontline workers.” States “are increasingly diverging from CDC guidance and from each other,” as a Kaiser Family Foundation summary of state plans concluded, “suggesting that access to COVID-19 vaccines in these first months of the U.S. vaccine campaign may depend a great deal on where one lives.”

In many states, access to the vaccine is further shaped by local delegation. The nation’s roughly 3,000 counties form the basic units of our public health system, but they vary widely in population and political capacity. The early weeks of the rollout were peppered with reports of counties getting more or less than their share of the vaccine, of those with more doses than they could use, and of those who viewed the sub-state distribution as a political reward or punishment. Missouri’s Republican Governor Mike Parson used the state’s nine highway patrol regions to organize vaccine distribution—a scheme that sharply disadvantaged large urban settings like Kansas City and St. Louis. Through mid-February, African Americans in Missouri accounted for 12 percent of the state’s COVID-19 cases and 14 percent of deaths, but only 6 percent of vaccinations.

Such disparities—from state to state and within states—are compounded by uneven technical and administrative capacity. State and local public health agencies are chronically underfunded and most, as one review concluded, “are struggling with even the most basic requirements of mass immunization, including scheduling and keeping track of who’s been vaccinated.” All of this has led to a scramble for private vendors to manage the call centers, the data entry, the scheduling, and the vaccinations themselves. It is a telling commentary on the state of American social provision that in some places the task of immunizing the population and putting the virus behind us rests largely with CVS and Walgreens.

Federalism is killing us. Even the fiercest advocates of small and fragmented government concede that local jurisdictions cannot respond effectively to public health crises; that federated authority at best leaves us “rich, free, and prone to infection.” The “rich” and “free” parts of this formulation are suspect as well. The way that federalism distributes resources and risks ensures inequality and uneven citizenship. This is evident in the segregationist logic that animated our system of social provision at its origins. And it is evident in the dismal disparities that are the defining feature of our response to the coronavirus.

Colin Gordon is a professor of history at the University of Iowa. He is the author of, most recently, Growing Apart: A Political History of American Inequality and Citizen Brown: Race, Democracy, and Inequality in the St. Louis Suburbs.