Making government work, and work for all.

The response to the SARS-CoV-2 (COVID-19) pandemic has highlighted both strengths and weaknesses in the USA’s ability to respond to novel global infectious disease threats and, undoubtedly, will be the subject of much study and discussion for many years to come.

Some of the nation’s greatest challenges in responding to the COVID-19 crisis have resulted from disparate alignment of public health and other interventions across the federal, state, and local levels of government. Clearly, different states and local jurisdictions came to different conclusions when balancing the risks associated with COVID-19 infection with the impact of infection risk reduction interventions on other dimensions of health, society, and family life (e.g., economic disruption, religious practices, and school attendance). This variety of responses by government jurisdictions in imposing restrictions, or not, on commerce and on the movement and behaviors of individuals provides a unique opportunity to examine federalism in response to a national crisis generally, as well as the impacts of these public health and other interventions specifically. At the time of this writing, it is not entirely clear to what degree more restrictive efforts resulted in better health and other outcomes.

The variety of political and policy decisions also have raised questions of law, authority, policy, program implementation and coordination, and resource allocation, among other things. These questions have been clearly and repeatedly observed throughout the course of the pandemic by the demonstrable tensions and conflicts between elected officials at different levels of government, as well as between appointed and elected officials at all levels of government. Understanding where the crisis response appeared to go well and where uncertainties about law, authority and other matters impaired an effective crisis response is important because – as recent history has made clear – additional and potentially more serious global infectious disease threats will again confront us in the years ahead.

With the goal of better understanding the strengths and vulnerabilities in the intergovernmental response to the pandemic, the National Academy of Public Administration convened the Working Group on the Intergovernmental Dimensions of the COVID-19 Pandemic (Working Group or WG). The Working Group plans to describe the intergovernmental response for selected key response domains, or issues, and develop actionable recommendations that may facilitate the nation’s response to the next pandemic. At present, the Working Group is focusing on writing case reports about the four topical domains of: (1) COVID-19 Testing, (2) infection risk reduction Non-Pharmaceutical Interventions (NPIs), (3) COVID-19 Vaccine Distribution, and (4) Cross-Cutting and Over-Arching Issues.

The Working Group is co-chaired by NAPA Fellows Dr. Kenneth W. Kizer and Professor Rich Callahan, with 13 additional NAPA Fellows and three other experts having strong practitioner, program, and academic experience at the local (city or county), state, and federal levels. Five of the WG members have experience as state health directors (for five different states and the District of Columbia) and three have experience with local city or county health departments; several members have experience with multiple different federal agencies, including oversight of the National Disaster Medical System; and others have strong research and academic expertise, including five current or former deans of university graduate programs in public health and public administration.

The Working Group will focus on issues that have emerged in the response to the pandemic through the lens of how problems of policy and intergovernmental functioning affected health and delivery of healthcare services, the acquisition and allocation of supplies and personal protective equipment, local business activities and economies, and other areas. Each of the four case reports will be written by overlapping ‘issue teams’ that will describe: what was the problem that needed to be addressed in the domain being examined; what were the facts of what happened; where were there demonstrable response vulnerabilities and what were the strengths and weaknesses in the response; what actions could be taken to improve the response next time; and whether the desired improvement requires changes in law, authorities, policy, program design or implementation, or some combination of these things.    

For each of four issue teams, some of the key intergovernmental challenges that are being explored are briefly highlighted below.

The Testing Issue Team is considering limitations in public health agencies and intergovernmental relations that prevented rapid scale-up of testing, including lab capacity and contact tracing, and what were the consequences of unclear and/or delayed guidance from the federal government. This issue team is developing a timeline of key events considering the federal and state actions, including the question of what do states do in the absence of federal direction.

The Vaccine Issues Team is focusing on key vaccine distribution vulnerabilities, health equity, and variations in rates and in designations of eligibility, as well as technological issues regarding scheduling appointments. The team is considering recommendations regarding the roles of federal, state, and local government in creating guidance on vaccine delivery and implementation of vaccination administration methods for hard-to-reach populations, vaccination priorities during periods of limited supply, and funding for vaccine distribution.

The NPI Issues Team is reviewing the alignment of federal, state, and local guidance on masks and social distancing, as well as the relations between states and counties regarding authorities and pre-emption issues, especially in regard to the overt tensions and conflicts between appointed public health and elected officials that have been repeatedly observed during the pandemic. The team will also consider how having more targeted data (e.g., through greater testing and contact tracing) may have affected the economic impacts of the pandemic.

The Cross Cutting and Over-Arching Issues Team is considering, among other things, the merits of centralized versus decentralized response systems, how to balance the relative values of health and economic impacts, the challenges presented by a lack of consistent standards across levels of government, and how to effectively mobilize and use disbursed public authority. This Issue Team will likely develop several pieces, including the lessons learned from decisions made (e.g., Medicare and Medicaid waivers for telehealth payments, use of authorities triggered by declaration of a National Public Health Emergency).

Overall, the response to the COVID-19 pandemic offers a focused lens through which we can examine how well our intergovernmental public health and human service systems and our decentralized and distributed governance structure protected and provided for the general welfare of the populace. In brief, the COVID-19 pandemic provides an unprecedented opportunity to examine ‘federalism in action.’

The COVID-19 Intergovernmental Working Group members include:

  1. Kenneth W. Kizer, MD, MPH, Co-Chair – Chief Health Care Transformation Officer and Senior Executive Vice President, Atlas Research
  2. Rich Callahan, DPA, Co-Chair – Professor, Master of Public Health Program, University of San Francisco
  3. Michelle Alletto, MPA – Chief Program and Services Officer, Texas Health and Human Services Commission
  4. Jia Ahmed, MD, MPH – Research Associate, Johns Hopkins Bloomberg School of Public Health
  5. Maria Aristigueta, DPA – Dean, Joseph R. Biden, Jr. School of Public Policy and Administration, University of Delaware
  6. John J. Bartrum – Chief Executive Officer of Brightstar Innovations Group and USAF Brig Gen, Mobilization Assistant to the Air Force Surgeon General
  7. Georges Benjamin, MD – Executive Director, American Public Health Association
  8. Jonathan Freedman, MSPH – Vice President, Health Management Associates
  9. Susan Gooden, PhD – Dean and Professor, Public Administration and Policy, Wilder School of Government and Public Affairs, Virginia Commonwealth University
  10. Marc Holzer, PhD – Professor, Suffolk University
  11. John Kirlin, PhD – Distinguished Professor of Public Policy and Founding Director, Public Policy Programs, McGeorge School of Law, University of the Pacific
  12. Lauren Larson, MPP – State Budget Director, Office of State Planning and Budgeting, State of Colorado Governor’s Office
  13. Gene Migliaccio, DrPH – Associate Dean and Professor, Milken Institute, School of Public Health, George Washington University.
  14. Stephanie P. Newbold, PhD – Associate Professor, School of Public Affairs & Administration, Rutgers University-Newark
  15. Rear Admiral (retired) Deborah Parham Hopson – The MayaTech Corporation
  16. Courtney Phillips, PhD – Secretary, Louisiana Department of Health
  17. Josh Sharfstein, MD, MPH – Professor and Vice Dean, Bloomberg School of Public Health, Johns Hopkins University
  18. Vikki Wachino, MPP – Principal, Viaduct Consulting, LLC

Kenneth W. Kizer, MD, MPH, is the Chief Health Care Transformation Officer and Senior Executive Vice President at Atlas Research. Rich Callahan, DPA, is a Professor in the Master of Public Health Program at the University of San Francisco. They are both Fellows of the Academy and Co-Chairs of the Working Group on the Intergovernmental Dimensions of the COVID-19 Pandemic.