Multi-state alliances on public health to pursue policies independent of the federal government.
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Fifteen states formed a new nonpartisan public health network last month called the Governors Public Health Alliance. Its stated goal is to “improve public health efforts that help protect Americans from disease and injury.” The group seeks to be a “coordinating hub” for state leaders to share data and develop complementary guidance on issues such as helping to align immunization recommendations across member states. This marks a return to more state control over public health. On one hand, this implies less consistency in policy across the nation. On the other hand, the variation permitted by federalism allows for more flexible and tailored approaches.
Governors from California, Washington, Massachusetts, New York, Oregon, Connecticut, Rhode Island, Delaware, Maryland, New Jersey, Colorado, Illinois, and North Carolina have signed on to the Governors Public Health Alliance. Member states have made recommendations for the influenza, COVID-19, and respiratory syncytial virus vaccines.
This initiative builds on the existing efforts of the West Coast Health Alliance, a coalition of western governors who opposed certain positions taken by the Secretary of Health and Human Services, Robert F. Kennedy Jr., including the overhaul of the Centers for Disease Control and Prevention and its advisory panel, the Advisory Committee on Immunization Practices. Kennedy has reshaped ACIP’s membership, dismissed CDC leadership, and cast doubt on the reliability of the federal immunization schedule.
Furthermore, the Trump administration has pursued deep cuts in staffing and research throughout HHS and raised spurious associations, particularly around autism and pharmaceuticals such as vaccines and acetaminophen. President Trump used a White House autism event to question acetaminophen safety and to suggest altered vaccination schedules. The moves at the national level put states in a position in which they must decide for themselves how to maintain vaccine access when federal guidance is no longer consistent with what medical professional societies recommend.
According to KFF, a total of 26 states—23 of them led by Democratic governors—have already announced or implemented vaccine policy changes in response to federal shifts in policy. Thirteen states have required insurance coverage of COVID-19 vaccines for all who want them, and four states—California, Illinois, Maryland, and Massachusetts—have mandated coverage of other vaccines, too.
Historical Context Of Decentralized Public Health
KFF says this “marks a new phase for public health in the U.S.” However, long before federal agencies such as the Food and Drug Administration and CDC were formed, in 1906 and 1946, respectively, local authorities were in charge of most public health efforts throughout the country.
In the United States, responsibility for public health has traditionally primarily been carried out at the state or local level. The U.S. has a federal system, which means that decision-making authority is constitutionally shared by the national and state governments. Accordingly, the history of public health in the U.S. is marked by the efforts of states and local authorities to protect the health of their inhabitants.
“America’s first statesman of the public health,” Lemuel Shattuck, founded a system for collecting vital population statistics in Massachusetts. He also authored the influential “Report on the Sanitary Condition of Massachusetts,” which highlighted sanitary reform and the need for a safe water supply. In his census of Boston, Shattuck wrote, “it behooves the city authorities to seek out and remove every removable cause of disease and death.”
A decade and a half later, the Metropolitan Board of Health was established in 1866 in New York City as the first modern public health authority in America. It became a model for other major cities due to its innovative approach and effectiveness in addressing the dire health conditions that stemmed in part from poor sanitation, filthy streets, inadequate ventilation in dwellings, and factors and “toxic” air. Cholera, tuberculosis, smallpox, and pneumonia were rampant.
Eventually, antibiotics and later childhood vaccines ushered in a golden era for public health nationally which helped lead to the establishment of centralized public health agencies. Still, as we saw during the COVID-19 pandemic, most actual authority to implement preventive measures or tackle disease outbreaks remains with the states.
And now that national public health authority appears to be eroding, we’re seeing a revival of enhanced state autonomy, sometimes in the form of coalitions of states banding together to counter what they view as detrimental policy emanating from Washington DC.
While decentralized approaches to public health have clear drawbacks related to lack of consistency, in a country as vast as the U.S., there are distinct advantages to a federalist system. States are closer to the people they serve, in both a literal and figurative sense. They’re more attuned to local circumstances and preferences. Supreme Court Justice Louis D. Brandeis famously said in 1932 that states can serve as “laboratories” of democracy, but also policy experiments.
