As the coronavirus continues to spread, all federal, state, and local hands are on deck. What are their roles and responsibilities?

March 22, 2020

The Chinese government recently boasted that its drastic measures to fight the coronavirus — including halting public transit, walling off entire cities, and isolating millions of people — successfully slowed the spread of the disease. That left many Americans wondering if similar measures are necessary, desirable, or even possible in the U.S.

Here, heavy-handed federal action is not the norm when it comes to public health. While the federal government has significant responsibilities during a disease outbreak, most of the work falls to 2,684 state and local public health departments across the country. When an outbreak hits the U.S., who does what? What are the challenges and benefits of our federal public health system?

Federal Authority
When an infectious disease becomes a threat to the U.S., federal officials are the first line of defense. They can restrict non-citizens travelers from entering the country and order citizens to undergo health screenings and quarantines. The federal government also supplies testing kits and determines how to distribute them, though it can authorize additional labs to conduct testing in an emergency.

Much of our funding for disease control flows to the states from the federal government, primarily through the Centers for Disease Control’s (CDC) Public Health Emergency Preparedness cooperative agreement. When necessary, federal emergency funding flows too. Earlier this month, Congress passed an $8 billion emergency funding bill to fight the coronavirus outbreak, of which $950 million will go to state and local health departments.

State Implementation
Where the rubber really meets the road is at the state and local level. For example, when federal officials mandate a quarantine, it’s up to state and local officials to enforce it. Monitoring people who have been exposed, tracing the contacts of those who test positive, setting rules for quarantine and isolation, and providing personnel to do the work — that’s all up to state and local officials, says Polly Price, a professor of law and global health at Emory University.

The interplay of all these entities can get murky, Price explained to The Atlantic. “The federal quarantine order for the 195 evacuees from Wuhan? That order was able to prevent them from leaving the plane they arrived in. The federal government could also order the quarantine of an entire cruise ship at one of the nation’s seaports — as Japan has done. But otherwise, federal quarantine orders have a pretty limited effect. When one of the Wuhan evacuees wanted to leave the military base in California where the group was under quarantine, a state-level quarantine order was necessary to prevent that from happening. This is because the quarantined group was no longer at a point of entry, or in an airplane, and was thus subject to the jurisdiction of the local health department where they were quarantined.”

Around the country, state and local officials are taking targeted actions to slow the spread of the coronavirus. After an outbreak in the suburb of New Rochelle, New York’s governor imposed a one-mile containment zone in which schools, houses of worship, and other gathering places are closed, but grocery stores are open and people are free to move around. On the opposite coast, Washington State’s governor ordered all schools in three hard-hit counties to close until the end of April.

State and local health departments also set their own criteria for who gets tested during an outbreak. The Oregon Health Authority, for example, said it is prioritizing testing for people who are so sick they must be hospitalized, or who have been directly exposed to someone with a confirmed case of the disease.

Benefits and Frustrations
Some experts say that our decentralized system makes confronting a public health crisis more difficult than in other wealthy nations. Jeffrey Levi, a professor at the Milken Institute of Public Health at George Washington University, says that without strong messaging from the federal government, local authorities may not mobilize quickly enough. As it is, readiness varies dramatically across the country. Different jurisdictions maintain different levels of funding and their residents have different degrees of insurance coverage. Some offer paid sick leave so workers can isolate themselves when necessary, while many do not.

Other experts say that centralization has its own problems. In China, says sociologist Robert Dingwall, local actions require approval from Beijing, slowing down the response. In the U.S., which has a culture of “local civic-mindedness,” mayors and local journalists may be able to manage things as capably and efficiently as federal officials might somewhere else.

It may be years before we can fully evaluate the U.S. response to COVID-19. One thing is sure, however: public health emergencies may not occur every year, but we must constantly prepare for them. “We can’t afford for federal decision-makers to waste time relearning old lessons when they should be innovating and acting”.

Learn More

Unhealthy Budget: The CDC budget for state and local emergency preparedness fell by a third between 2003 and 2019. While the budget has seen two small increases since then, one advocacy group says these additions were not nearly enough to make up for the earlier cuts, or to adequately prepare for public health emergencies — via Trust for America’s Health

Corporate Response: What role do corporations play in fighting an outbreak? Research shows that paying employees to stay home when they’re sick is an effective way to slow the spread of seasonal flu, and the New York Times editorial board writes that companies should offer paid sick leave if we want to effectively fight COVID-19 — via The New York Times

Disease Detectives: How do public health officials track the spread of a disease? It takes a lot of legwork, and often starts with contact tracing — asking a sick person to detail where they’ve been and who they’ve been with, then monitoring their entire circle of contacts for symptoms — via NPR

Health Care, Not Illness Care: Public health departments are on the front lines of tracking communicable diseases, but the U.S. spends only about $19 per person per year on public health activities. The bulk of our health care dollars go instead to treatment. Some experts say that investing in public health would save treatment dollars down the road — via The Washington Post

Mandatory Vaccination: If a vaccination against COVID-19 becomes available, can the federal government mandate that Americans get it? Yes and no. The Public Health Service Act appears to allow the federal government to prevent the spread of disease among states, but a provision of the law explicitly forbids regulations that supersede state law — via Health Affairs