States Take Charge of Public Health Amid Federal Uncertainty

In a recent meeting of the Centers for Disease Control and Prevention‘s (CDC) Advisory Committee on Immunization Practices (ACIP), confusion reigned as members grappled with the implications of their decisions regarding childhood vaccinations. The committee initially rejected a combined measles, mumps, rubella, and chickenpox vaccine for toddlers, only to reverse their stance on funding just a day later. This back-and-forth highlights a growing trend: states are increasingly stepping in to fill the void left by federal public health agencies.

The Role of State Health Coalitions

In response to perceived federal inaction, states like California, Oregon, Washington, and Hawaii have formed the West Coast Health Alliance. This coalition aims to provide unified recommendations on vaccines for COVID-19, influenza, and respiratory syncytial virus (RSV), going beyond the guidance offered by ACIP. Oregon’s state health director, Sejal Hathi, emphasized that “public health should never be a patchwork of politics,” indicating a desire for a more cohesive approach to health policy.

California’s health director, Erica Pan, echoed this sentiment, stating that the coalition seeks to “demonstrate unity around science and values” while minimizing public confusion. The alliance is also exploring coordinated lab testing, data sharing, and group purchasing, all aimed at restoring trust in science and empowering individuals to protect their families without unnecessary barriers.

In the Northeast, a similar initiative has emerged with the formation of the Northeast Public Health Collaborative, which includes New York and its neighboring states. New York Governor Kathy Hochul described this coalition as a necessary response to what she perceives as a retreat from scientific guidance at the federal level. “Every resident will have access to the COVID vaccine, no exceptions,” she asserted, highlighting the coalition’s commitment to equitable healthcare access.

Filling the Federal Void

The emergence of these state coalitions reflects a broader sentiment among health officials that federal agencies are failing to provide the necessary leadership in public health. Connecticut’s health commissioner, Manisha Juthani, noted, “Infectious diseases don’t respect borders,” underscoring the need for coordinated action among states to protect their residents.

Acting New York City health commissioner Michelle Morse stated, “We can’t just sit by while federal agencies are hollowed out,” emphasizing the importance of local action in the face of federal inaction. This sentiment is echoed by other state leaders who view their coalitions as a necessary response to a vacuum left by Washington, D.C.

James McDonald, New York’s state health commissioner, lamented that “emerging from a pandemic, we would be embracing public health, but the federal government was heading in the opposite direction.” Massachusetts health commissioner Robbie Goldstein added that the federal government has historically been a unifying force in public health, a role that seems to be diminishing.

The Legal Landscape of Public Health

The legal framework governing public health in the United States has long favored state authority. Wendy Parmet, a law professor at Northeastern University, pointed out that states have mandated vaccinations since the 1800s. While federal agencies can approve vaccines and fund programs, they lack the authority to enforce mandates except in specific circumstances, such as for federal employees.

This decentralized approach to public health has led to a patchwork of policies across states. For instance, Florida, under Surgeon General Joseph Ladapo, is moving to eliminate childhood vaccine requirements altogether, a move that could reignite historical debates over state vaccine mandates, such as those stemming from the landmark Supreme Court case Jacobson v. Massachusetts in 1905.

Public health experts warn that this divergence in state policies could lead to confusion and inefficiencies. Larry Gostin, a law professor at Georgetown University, cautioned that “this risks confusion, inefficiency, and ultimately lives.” The potential for a fragmented public health response is particularly concerning in a time when coordinated action is crucial.

Historical Context and Future Implications

The current state-by-state approach to public health is not without precedent. In the 1800s, local health boards took the initiative to combat cholera through sanitation measures when federal authority was lacking. Similarly, during the polio epidemic of the 1950s, states organized mass vaccination clinics, but disparities in uptake persisted until federal funding helped to level the playing field.

The COVID-19 pandemic further illustrated the limitations of federal power in public health. Deborah Birx, who served as the White House response coordinator, noted the challenges of persuading governors to adopt tailored responses rather than relying solely on federal guidelines. “I was trying to get them to tailor responses to their populations,” she recalled, highlighting the complexities of public health governance in a federal system.

Supreme Court Justice Louis Brandeis famously referred to states as “laboratories of democracy,” where innovative policies could be tested without risking national consequences. However, the spread of infectious diseases does not adhere to state boundaries, complicating this notion. A virus that begins in one state can quickly cross borders, underscoring the need for a more unified approach to public health.

Conclusion

As states increasingly take the reins in public health policy, the implications for the future are significant. The formation of coalitions like the West Coast Health Alliance and the Northeast Public Health Collaborative reflects a growing recognition that local action is essential in the face of federal uncertainty. However, this decentralized approach also raises concerns about confusion and inefficiency, as states experiment with varying policies.

The historical context of public health governance in the United States suggests that while states have the authority to act independently, a coordinated national strategy is crucial for effectively managing public health crises. As the landscape continues to evolve, the balance between state and federal authority will be a critical factor in shaping the future of public health in America.