COVID-19 in Europe and North America

Policy Responses and Multi-Level Governance

Veronique Molinari, Pierre-Alexandre Beylier

• Publisher: De Gruyter Oldenbourg
• Year: 2022
• ISBN:
  9783110745160
• Edition: 1
• Topic: History
• Subtopic: Modern History
• Index: History

Have the countries' internal boundaries played a role in the response to the Covid-19 epidemic? What does the coronavirus crisis tell us about the sometimes strained relationship between national and regional/federal governments? This collective loock at the short- and medium term impact of the COVID-19 crisis on relations between central and regional governments.

Part 1: Federal Systems in Europe and North America

1 American Public Health Federalism and the Response to the COVID-19 Pandemic

Nicole Huberfeld

Sarah H. Gordon

David K. Jones

Note: We dedicate this chapter to David K. Jones, our dear friend and coauthor who suffered an untimely death on September 11, 2021. We co-authored the article but completed revisions after his passing, honoring the thoughtfulness and precision he brought to all of our multidisciplinary projects. David cared deeply about health equity and social justice, and this work carries the imprint of his recent research in a particularly disadvantaged place, the Mississippi Delta. David’s research in the Delta on the health inequities experienced by Black and other historically oppressed populations provides an important backdrop for understanding the ways in which the novel coronavirus pandemic exacerbated challenges faced by poor people of color in the U.S. More broadly, David’s scholarship considered how U.S. federalist structures shape health inequities and can impact the objectives of public health. This chapter serves as a testament to David’s commitment to these studies.

Introduction

For the first year of the SARS-CoV-2 pandemic, the United States had the dubious distinction of being the global frontrunner in infection and mortality rates.¹ By January of 2021, COVID-19 became the number one cause of death in the U.S., with more Americans dying of COVID than World War II, the Vietnam War, and the Korean War combined. Many commentators blamed leadership failures for the lack of a coordinated response.² However, fundamental features of the American public health system complicated the launch of an effective and expedient response to the pandemic, interacting with both short and long-term leadership failures to result in more than 33 million COVID-19 infections and over 589,000 excess deaths by May of 2021.³ One key feature is federalism, the governance structure common to public health laws that divides responsibility for given policies between federal and state governments.

Federalism has commonly cited benefits such as tailoring of policies to local populations and experimenting through the smaller “laboratories of democracy” of states and localities. But the weaknesses of public health federalism came into sharp focus in the face of a global infectious disease outbreak. Federalism significantly increases the need for coordination between government officials and necessitates dependable leadership, increasing complexity and variability by relying on 51 governments rather than one and increasing risk by creating more room for error.

Leadership and federalism were intertwined in the U.S. response to the novel coronavirus pandemic. Federal laws rely on both federal and state participation in implementation of national goals in a public health emergency. The federal government can issue guidance and direct funding, but day-to-day public health measures are operationalized by over 2,000 state and local health departments. If each official does not play their role at every level, relief efforts can fail to materialize or generate inequitable responses across states and localities. In addition, emergency response builds on historical policy choices that created vulnerabilities in the public health system, such that preexisting health and economic conditions were intensified by a public health emergency. During the novel coronavirus pandemic, a disproportionately high number of infections and deaths occurred within the populations of Black, Hispanic, indigenous, and other people of color.⁴ The communities hit hardest by novel coronavirus also faced exacerbation of existing income, housing, education, and other inequities, reflecting in part that health is a function of location.

This chapter briefly provides an overview of the American public health emergency framework and highlights key leadership challenges that occurred at federal and state levels throughout the first year of the pandemic. Then the chapter examines decentralized responsibility in American social programs and states’ prior policy choices to understand how long-term choices affected short-term emergency response. Finally, the chapter explores long-term ramifications and solutions to the governance difficulties the pandemic has highlighted.

Public Health Emergency Authority

An emergency or other disaster prompts federal executive and legislative actions, especially when a multi-state or nationwide event is involved. A declaration of a public health emergency (PHE) triggers both presidential power unique to a crisis and coordinated action between the President, Congress, federal agencies, states, and localities. Each governmental player must participate with precision, engaging in certain actions in a specific order and at the right moment to address an emergency effectively.

Federal Actions

A patchwork of long-standing federal laws provides the President, Congress, and federal agencies with authority for federal emergency response, which are often enhanced by “relief bills” that Congress may enact to deliver short-term economic and other aid to people and states harmed by an emergency. Most federal legislative action involves indirect action through providing guidance and money to assist state and local efforts. Most direct actions occur at the state or local level, yet, federal response is necessary to emergency and disaster response.

In March 2020, Congress enacted two major relief bills, the Coronavirus Aid, Relief and Economic Security Act (CARES Act)⁵ and the Family First Coronavirus Response Act (Families First Act).⁶ These laws offered loans to businesses, increased federal funding to states for Medicaid, and enhanced unemployment insurance benefits. Another, smaller relief bill passed in December 2020 offered a variety of economic boosts such as stimulus checks, rent relief, enhanced unemployment benefits, education funding, aid to small businesses, and vaccine funding.⁷

In an emergency, many people become eligible for Medicaid, a program that provides public health insurance to low-income people, including those who lose their jobs. The program is governed by federal law but is funded by both the federal and state governments. The state portion of Medicaid costs is related to the state economy, ranging from about 46 % in wealthier states like California and New York to about 15 % in Mississippi.⁸ At the same moment that state tax revenue declines and states often need to cut budgets, Medicaid enrollment spikes; so, Congress often increases its share of Medicaid funding during emergencies and disasters. The health and economic emergency brought on by the pandemic led Congress to include enhanced federal Medicaid funding to states in the CARES Act and the Families First Act, but these relief bills also required state “maintenance of effort” so enrollment could not be decreased or eligibility cut while states accept the extra money.

During a PHE, multiple federal agencies have distinct responsibilities, an approach that can work with strong leadership and good communication but risks a fragmented response even in the best of circumstances. The Public Health Service Act of 1944 authorizes direct action by the Secretary of the Department of Health and Human Services (HHS) to prevent the entry and spread of communicable diseases from foreign countries and between states.⁹ The Centers for Disease Control and Prevention (CDC), a sub-agency of HHS, is authorized to detain, examine, and release individuals crossin...

Table of contents

• Title Page
• Copyright
• Contents
• COVID-19 in Europe and North America Policy Responses and Multi-Level Governance
• Part 1: Federal Systems in Europe and North America
• Part 2: Regionalism: the Cases of Spain and Italy
• Part 3: Devolution in a Post-Brexit (dis‐)United Kingdom
• Conclusion: The European Union
• List of contributors