Report summarized by Kyle Romano, Academy Senior Research Associate 

The COVID-19 pandemic offers an unprecedented opportunity to examine federalism in action. This blog follows up on an earlier entry in Intergovernmental Matters from May 24^th, 2021: “Federalism in Action – Understanding the Intergovernmental Dimensions of the COVID-19 Response and Their Consequences,” and presents the findings and recommendations of this important work. 

The National Academy of Public Administration’s Working Group on the Intergovernmental Dimensions of the COVID-19 Pandemic (WG) was co-chaired by Academy Fellows Dr. Kenneth W. Kizer and Professor Richard Callahan, with 12 additional Academy Fellows and three other experts. Four WG members have served as state health directors (including the District of Columbia), and three have served in city or county health departments. Several members have experience with federal agencies, including the U.S. Centers for Medicare and Medicaid Services (CMS), Food and Drug Administration (FDA), and the U.S. Department of Veterans Affairs. Others provided oversight of the National Disaster Medical System and 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 report focuses on issues that have emerged in response to the pandemic, viewed through several lenses, including how intergovernmental functioning affected general health, the delivery of testing and vaccines, the acquisition and allocation of supplies and personal protective equipment, and local business activities and economies. Each ‘issue team’ independently addressed and made recommendations on four key intergovernmental challenges in Testing Response, Non-Pharmaceutical Interventions (NPIs), Vaccine Distribution, and Cross-Cutting and Over-Arching Issues: 

1. The Testing Issues Team observed that the contemporary approach to intergovernmental relations emphasizes collaboration among and across governments. This approach allows for distinct priorities for the needs of populations in different states and municipalities. Still, it comes at a cost to efficiency in a public health crisis where mandates from the national government may make implementation more uniform and efficient. The U.S. intergovernmental system presents a set of predictable challenges to crafting efficient, effective, and equitable responses to a rapidly emerging health crisis. To tackle those challenges, the WG developed recommendations that address responsibilities at each level of government. It recommended a consistent policy at the national level, with pre-crisis planning sessions to create clear expectations for testing development, deployment, data collection, and reporting requirements.  

2. The Non-Pharmaceutical Interventions Issues Team analyzed the intergovernmental responses to this public health crisis for recommendations on implementing infection risk reduction NPIs such as social distancing, use of facial masks, restrictions on in-person contacts, and reduction or limits in indoor or outdoor meetings. It found that one of the most significant challenges facing the U.S. from the onset was the lack of agreement among levels of government about the seriousness of the coronavirus. Throughout the COVID-19 pandemic, tensions and disagreements between state and local leaders arose over how to best implement NPIs. The NPI Issue Team made recommendations that would expand the tools of intergovernmental management to resolve disagreements transparently between agency experts when the external political environment shapes the public’s response to the pandemic. 

3. The Vaccine Issues Team focused on key vaccine distribution vulnerabilities, health equity, variations in rates and designations of eligibility, and technological issues regarding scheduling appointments. A decentralized and underfunded public health infrastructure eroded the Nation’s capacity to mount a rapid mass vaccination effort. Additionally, weak federal guidance led to a patchwork of unequal vaccination efforts, as states did not set consistent priorities for vaccination groups. The Vaccine Issues Team proposed recommendations to lessen the volatility in public health investments over time, establish minimum expectations for states and mechanisms to intervene when state actions are insufficient, and strengthen the Nation’s data infrastructure for vaccine appointment registration. In addition, if implemented, these recommendations would provide sustained funding for active engagement of communities of color in vaccination and other public health efforts to solicit their input on gaps in access to services and outreach strategies to build trust.  

4. The Cross-Cutting and Over-Arching Issues Team considered 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 mobilize and use disbursed public authority effectively. This Issues Team addressed the lessons learned from decisions made throughout the response process (e.g., Medicare and Medicaid waivers for telehealth payments and use of authorities triggered by the declaration of a National Public Health Emergency). It issued recommendations for improved intergovernmental responses to future pandemics, focusing on operational areas that impact a range of actions. The Issues Team derived recommendations from evidence observed in five case studies: medical care services with an emphasis on CMS, supply chains and the Strategic National Stockpile, Emergency Support Function #8 (federal assistance to supplement State, Local, Tribal, and Territorial partners), data collection for disease surveillance, and data systems to support responses to pandemics. 

Overall, the report offers varied, independent perspectives on improving the intergovernmental response to future pandemics in our decentralized and distributed governance structure. From this study, the members of the Working Group provide over 30 recommendations to improve and further evaluate the intergovernmental response to a major public health crisis. The analysis and recommendations in this report should deepen our understanding of the recent experience in intergovernmental responses to the COVID-19 pandemic and improve both our response to the ongoing pandemic and our preparation for future pandemics. 

Click here to view a recording of the April 13^th webinar discussion to learn more about the report’s findings and recommendations.

The report can be found at this link.

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. Richard Callahan, DPA, Co-Chair – Professor, Master of Public Health Program, University of San Francisco 

3. Jia Ahmad, MD, MPH – Emergency Medicine Residency, Harvard Medical School 

4. Maria Aristigueta, DPA – Dean, Joseph R. Biden, Jr. School of Public Policy and Administration, University of Delaware 

5. John J. Bartrum – Chief Executive Officer of Brightstar Innovations Group and USAF Brig Gen, Mobilization Assistant to the Air Force Surgeon General 

6. Georges Benjamin, MD – Executive Director, American Public Health Association 

7. Jonathan Freedman, MSPH – Vice President, Health Management Associates 

8. Susan Gooden, Ph.D. – Dean and Professor, Public Administration and Policy, Wilder School of Government and Public Affairs, Virginia Commonwealth University 

9. Marc Holzer, Ph.D. – Professor, Suffolk University 

10. John Kirlin, Ph.D. – Distinguished Professor of Public Policy and Founding Director, Public Policy Programs, McGeorge School of Law, University of the Pacific 

11. Lauren Larson, MPP – State Budget Director, Office of State Planning and Budgeting, State of Colorado Governor’s Office 

12. Gene Migliaccio, DrPH – Associate Dean and Professor, Milken Institute School of Public Health, George Washington University. 

13. Stephanie P. Newbold, Ph.D. – Associate Professor, School of Public Affairs & Administration, Rutgers University-Newark 

14. Rear Admiral Deborah Parham Hopson (Retired) – President, Parham Hopson & Associates, LLC 

15. Courtney Phillips, Ph.D. – Secretary, Louisiana Department of Health 

16. Josh Sharfstein, MD, MPH – Professor and Vice Dean, Bloomberg School of Public Health, Johns Hopkins University 

17. Vikki Wachino, MPP – Principal, Viaduct Consulting, LLC