Abstract
The United States takes a federalist approach to pandemic responses while the bulk of pandemic powers sits at the state level. Thus, comprehensive accounts of how state health officials managed the crisis and how the federal government affected those efforts are needed to better understand the governmental response to the COVID-19 pandemic. This article reports the results of semistructured interviews with 29 state-level policy actors from 16 US states. Interviewees discussed multiple aspects of the US federal COVID-19 response that affected the response in their states, including communications with the public, intergovernmental communications, and federal actions regarding various aspects of health service preparedness including emergency funding, procurement, testing capacity, vaccine development and distribution, and data systems. This research enriches the discussion about US pandemic preparedness and response, and indicates that alignment of public communications across government levels, enhanced intergovernmental communication, inclusion of rural perspectives, and federal investment in and sustainment of health service preparedness are key factors that can improve future US pandemic responses.
Introduction
A
The federalist framework is celebrated for allowing policy adaptation to regional variances, but it contrasts with the unified, collaborative approach required for effective pandemic management.11,12 Comparative studies of federal systems in countries such as Australia, Canada, Germany, and the United States examine this dynamic.13,14 These studies highlight the inferiority of the US pandemic response compared with counterparts, attributing the shortfall to factors beyond federalism. Specifically, they critique the delayed and disjointed approach of the United States and its lack of national leadership.
The Centers for Disease Control and Prevention (CDC), the Council on Foreign Relations, the Covid Crisis Group, and the House Select Subcommittee on the Coronavirus Crisis (HSCC) published COVID-19 after-action reports that also concluded the lack of a strong national response—replete with inadequate support for health services, lack of national leadership, and missteps by federal actors in pandemic communication—hindered the US response.15-18 Together, these comparative studies and after-action reports suggest that although US federalism provides a structured framework of governance during a pandemic crisis, the specific actions taken within this framework contributed both to effective and less effective outcomes in pandemic management and mitigation.
This article focuses on the US federal COVID-19 response from the perspective of state-level actors. We report the results of qualitative interviews with 29 state-level policy actors from 16 states and characterize these findings within a broader discussion of federalist government structures. The research presented here offers a novel, nuanced analysis of federal actions and how state-level policy actors felt those actions affected state-level responses. Consequently, this study contributes to an improved comprehension of how effective pandemic mitigation opportunities afforded by the US federalist structure can be preserved and less effective elements can be avoided to strengthen preparedness for future pandemics.
Methods
Participant recruitment occurred from February to December 2022. Recruitment and interviews occurred in 2 phases. First, state government officials and others involved in the state-level response were identified through outreach to governor’s offices, snowball sampling, and internet searches for 9 states selected for their geographic and political diversity. This led to interviews with 25 interviews with 26 individuals across 6 states (2 interviews each contained 2 interviewees, and 1 interviewee was interviewed twice). Second, contact information for state epidemiologists from 32 states was identified using internet searches of both official government websites and secondary sources; the state epidemiologists were then emailed a recruitment email. This led to interviews with 12 individuals across 11 states (11 state epidemiologists and 1 additional health department official trained as an epidemiologist). Some interviewees were still serving in their role at the time of the interview, whereas others were not.
The interview guide was refined through several rounds based on input from experts in semistructured interviews and state government. It initially covered a range of topics, including state policymaking, policymaker management of multiple policy objectives, ethics guidance, and public communications. The first 24 interviews did not include a specific question about the federal government’s COVID-19 response. However, the topic was mentioned spontaneously by 16 interview participants across these 24 interviews. The subsequent 12 interviews included a specific question on the support provided by the federal government in the early and later stages of the pandemic, and the topic was discussed by all 13 interviewees. In total, our analysis includes only the 29 interview participants from 16 states who discussed the federal COVID-19 response, either spontaneously or in response to a question from the interviewer, across 28 interviews (see Table 1). Of the 16 states, 9 had Democratic governors at the beginning of the pandemic, while 7 had Republican governors. Ten of the 29 interviewees came from states with Democratic governors, and 19 came from states with Republican governors. To maintain confidentiality, identifying information about participants’ states or details of service are not included. Several interviewees asked us to refer to them using a general title such as “state government official,” whereas other interviewees are referred to by their specific job titles. Interviews were conducted via videoconference and transcribed verbatim using transcription software or a transcription service, except for 1 instance where an interviewee did not grant recording permission and notes were taken instead. Interviews ranged from 36 minutes to 1 hour and 34 minutes and were conducted by multiple research team members. The Johns Hopkins Bloomberg School of Public Health Institutional Review Board approved all procedures.
Number of Interviewees in States, by 2020 Governor Party Affiliation
Data analysis proceeded following the approach of Miles et al. 19 First, we developed an initial codebook of 126 codes for the first cycle of coding. These codes were selected based on the research questions, interview guide, and interview transcripts. The codebook was validated using interrater reliability, whereby a research team member coded 5 interview transcripts and then later recoded the same 5 transcripts after at least a week had passed. To measure interrater reliability between 2 research team members, we used the unweighted Cohen’s kappa based on character, which was 0.82 and in the target range. One researcher then analyzed the coded data based on actions taken by the federal government during the COVID-19 response, and coded the data for sentiment as negative, positive, and mixed (see Table 2).
Interviewee Views of Topic Areas Discussed
Results
Twenty-nine interviewees from 16 states discussed aspects of the US federal government’s COVID-19 response that affected their state-level response. Some of these observations focused on communication between the federal government and the public and between the federal government and the states. Interviewees also discussed application of federal policies in rural areas, emergency funding and procurement, COVID-19 testing, vaccine development and distribution, and data systems (Table 2). Interviewees mostly expressed negative views about the federal government’s actions; this is true for interviewees who discussed the federal government spontaneously and for those who were asked a neutrally worded question about the support they received from the federal government.
Communication Between the Federal Government and the Public
Eight interviewees from 6 states criticized 1 or more aspects of the federal government’s communication with the public during the pandemic. These criticisms were directed toward presidents Donald Trump and Joe Biden, and other federal actors.
Criticisms of Presidential Communications With the Public
One state government official criticized President Biden’s rhetoric on vaccinations, saying that Biden’s remarks “made my job harder.” Specifically, this interviewee felt that Biden’s “name calling” and the “unhelpful” comments he directed toward unvaccinated individuals created unnecessary public anger and hindered vaccination rates in their state. The interviewee added that successful vaccine messaging “couldn’t be heavy handed or strong armed. It had to be a selling job” (29-P).
Six interviewees from 5 states, 4 of whom were from states that had a Republican governor at the beginning of the pandemic, conveyed unprompted dissatisfaction with President Trump’s approach to public communication. They stated that Trump failed to show strong leadership, politicized the pandemic, discredited scientific information, and served as an “avenue for misinformation” (27-P).
According to the respondents, Trump’s public communication negatively impacted the COVID-19 response in their states. One state government official (20-M) felt compelled to act as a “myth-busting operation.” A state epidemiologist shared that Trump’s approach forced state leaders to reestablish their public credibility and the credibility of public health as an institution. They believed that Trump’s communication style contributed to demonstrations and personal attacks on health officials.
I’m mainly talking about Trump and his politicization of this—the name calling, discrediting science and experts, doing that very publicly, and making faux pas [such as] you should take bleach [as a coronavirus treatment]. Public health was constantly discredited. We constantly had to say what the facts and the truth [were], and what our observations were. We had personal attacks on us. For example, someone was saying that I had people in my basement that wouldn’t get vaccinated, and that I was holding them prisoner. (12-K)
Interviewees indicated that communications by Trump and Biden hindered their ability to effectively respond to the pandemic by stoking anger and mistrust among the public. Trump received more criticism for causing confusion, diminishing the public’s trust in health authorities, and increasing the workload of those responding to the pandemic.
Criticism of Other Federal Actors’ Communications With the Public
Five interviewees from 5 states also criticized communications with the public by other federal actors. While these interviewees understood that public communications during the pandemic were extremely difficult, they believed that clarity and forthright acknowledgment were necessary aspects of successful communications and that federal actors did not always meet these standards. The following 2 quotes are indicative of their views.
I’m just going to say this. [The federal government] did a really poor job with messaging. […] I think the federal government should have done a much better job of admitting to the knowns and the unknowns. Because when things changed, it wouldn’t have been a shocker. When you say something with confidence and authority as truth with a capital T and then it changes, that really impacts your credibility. (15-L)
You all have heard as much as I have from the national media and everybody on down from CDC not recommending masks. You can imagine the constant churn and challenge in that area as science evolved […] Even the CDC was really poor on [public communication]. There were all sorts of confusion, even from Anthony Fauci, in the early stages around the importance of masks. The Surgeon General was nowhere to be seen. (13-L)
Three interviewees were also critical of federal actors ability to effectively communicate pandemic-related scientific uncertainty, and 7 were critical of the lack of clarity of communication regarding pandemic mitigation measures. On both topics, these interviewees felt that communication missteps complicated matters at the state level by reducing credibility and creating conflicting information.
Federal–State Intergovernmental Communication
Interviewees discussed several aspects of intergovernmental communications. Their remarks focused on meetings between the White House and state officials and their interactions with the CDC. Quotes from the following 2 sections show that meetings between the White House and the states were supported, and that interviewees felt that the CDC was a valuable, albeit flawed, partner. However, the CDC's tendency to release new guidance at inopportune times and with little notice was a strongly negative and enduring theme among several interviewees who felt that it hindered their efforts to coordinate with state and local partners.
White House Meetings
Five interviewees from 2 states commented on meetings with the White House under the Trump and Biden administrations. They portrayed these briefings, attended by federal officials, governors, and staff, as somewhat positive and informative without further elaboration.
Communications Between the States and the CDC
The CDC played a critical role in information handling. For example, a state epidemiologist from a smaller state relied on information from the CDC because it had “a lot more people doing research and policy” (7-F). The interviewee recalled posting links to CDC.gov on state websites to bolster the state’s information sharing and communication capacity.
Three state epidemiologists from 3 states praised the CDC’s frequency of communication with their states through calls and webinars. In contrast, another state epidemiologist expressed that while the CDC curated and shared scientific information, it “wasn’t always timely enough” (2-B).
A state epidemiologist also expressed frustration with the CDC’s approach to communicating policy and guidance while also stressing the important role played by the CDC.
From a policy level, particularly in the previous [Trump] administration, there was a lot of opacity, and sometimes frustrations with the types of guidance that were coming out. […] What gets lost in that is that the CDC still was, and remained throughout the entire time, a key resource for state health partners. (5-D)
Lack of Warning Before the Release of CDC Guidance
Five state epidemiologists from 5 states expressed frustration that the CDC did not give states adequate notice ahead of the release of new guidance, also noting that the CDC often released guidance on Friday afternoons. This resulted in states having inadequate time to prepare and was seen as diminishing the states’ ability to coordinate their responses with state and local partners.
They dropped a bomb on us, generally on a Friday afternoon, of some big policy change. That sucks. We replicated that at our level, dropping bombs on our partners, because we had to get all our ducks in a row. (5-D)
Three state epidemiologists from 3 states noted that states needed advance notice of CDC guidance changes because states tried, when possible, to align state policy with CDC guidance. These interviewees felt that not aligning with CDC guidance would cause confusion among the public.
Criticisms of Federal Policy Applicability to Rural Areas
Three interviewees from 2 rural states highlighted their criticisms of what an interviewee called “one size fits all” (29-P) policies, which they believed failed to account for social and geographical factors in their states.
There was very little consideration for the middle part of the country [and/or] for rural states […] In my opinion, the federal government, from a political standpoint, was trying to go one size fits all. In my mind, that’s where it broke trust with everybody. (29-P)
A governor’s chief of staff gave the example of masking guidance, expressing the view that it was not appropriate for sparsely populated areas.
We were given edicts from the coasts, particularly from Washington, DC, that were not terribly relevant. […W]ith respect, [wearing a mask outside] is just a ridiculous notion for folks that are sometimes miles away from their closest non-family counterpart. (28-P)
The quotes show that interviewees perceived a lack of coherence between federal policies and the rural state context. They also felt that exclusion from policymaking processes lowered levels of trust between rural residents and the federal government.
Federal Health Service Support Actions
In addition to communication and policy guidance, the federal government’s tangible actions in the areas of emergency funding, procurement, coronavirus testing, and vaccination capacities directly affected individual state responses. These quotes demonstrate how the complex interplay between states and the federal government is intensified when all levels of government rush to respond to a national emergency that imperiled lives and livelihoods.
Emergency Funding
Eight state epidemiologists from 8 states praised the federal government’s provision of emergency funding to increase public health capacity, although 6 of them also reported that their states were not equipped to manage such a large influx of funding. One state epidemiologist characterized the funding situation as “boom or bust” (7-F) when discussing the difficulty of managing such a situation.
Emergency Procurement
One state epidemiologist (11-J) recalled that there “just wasn’t enough PPE [personal protective equipment] or ventilators […] in the early months,” and a chief of staff noted that their state had difficulty procuring lifesaving equipment when bidding against much larger states and that their governor encouraged the federal government to address that problem.
[The governor] went out early saying you’ve got to put in the Defense Production Act in place, either to begin to manufacture these things in the United States or to federalize buying power, so that you don’t have states competing against one another for the same equipment. (28-P)
COVID-19 Testing
Five interviewees from 4 states described early failures by the federal government to bolster the states’ abilities to conduct testing. One senior advisor to a governor noted, “we were on our own from a testing perspective” (17-M).
Interviewees unsurprisingly indicated that lack of testing support at the onset of the pandemic was seen as a barrier to a successful response at the state level. However, as the pandemic continued, a state epidemiologist (6-E) noted that the federal government “leveraged existing mechanisms” to support testing capacities at the state level, which was seen as beneficial.
COVID-19 Vaccinations
Three interviewees from 3 states praised the federal government’s actions on vaccine development. “We had all these different companies and the government knocking down the walls to be able to get something to market quickly” (29-P). Three interviewees from 3 states praised the CDC vaccine prioritization scheme that states were able to adapt to their own needs. Relatedly, a state epidemiologist and a COVID-19 work group member from the same state praised the CDC’s Advisory Committee on Immunization Practices, a standing group of experts that created vaccine allocation guidelines, as a “very successful model” (13-L) of a transparent process allowing public comment and input. Three interviewees from 3 states praised the vaccine allocation guidelines, which states were able to adapt to their own needs.
Two interviewees from separate states were critical of the federal government’s role in vaccine distribution. One health official felt that concentrating vaccine distribution in 2 retail pharmacy chains was inadequate for their state. “We ended up with huge swaths of the state that just really didn’t have access to the vaccine” (28-P). A government official felt that the use of multidose vials of vaccine were inadequate.
You cannot take a 10 to 12 dose vial and then say, “Everyone, line up.” There may be 3 people [at a vaccination site] that need the vaccine. So, what do you do [with] that balancing of waste, and how to equitably do that? [It] was very, very difficult. (29-P)
Two other interviewees from different states expressed frustration toward vaccine data management systems. One government official said that the CDC’s data tracking capacities were inadequate, with “a lot of discrepancies between the [CDC and state] reporting systems” (29-P). A senior advisor to a governor in another state noted that “on the IT side […] we were on our own” (17-M). Both interviewees felt that data systems hampered the state’s early vaccine effort, and that more federal support for information technology would have been useful.
Discussion
This study offers an account of how state-level actors viewed the influence of federal actions on state-level COVID-19 responses. Interview data highlights the complex relationship between states and the federal government and outlines the impacts that state-level policy actors felt federal actions had on responses in their states. Our findings underscore how the US federalist structure presents opportunities and challenges in pandemic management.
Public Communications Across Government Levels
Pandemic communication between the federal government and the public was a recurring theme. Interviewees, mostly from states with Republican governors, expressed deep dissatisfaction with President Trump’s public communication during the pandemic. Their critiques closely echo the Council on Foreign Relations, Covid Crisis Group, and HSCC, which found that Trump’s communications were inconsistent, unclear, and politicized.16-18 The HSCC also concluded that misinformation emanating from the Trump administration was a major issue that cost lives during the COVID-19 pandemic. 18 Although most of the critiques of presidential communications we heard from state actors were leveled at Trump, 1 interviewee expressed disapproval of Biden’s approach to vaccine messaging.
Multiple interviewees criticized communications from other federal entities, including the CDC. Specifically, they argued that these communications were inconsistent and failed to adequately address what was unknown about COVID-19 and mitigation measures and what was thought to be known.
Respondents also addressed the complexities of public communications coming from multiple sources including state and local officials and the federal government. Under the right conditions, public communications coming from various sources could be beneficial; for example, Barua et al 20 suggested that encouraging the public to crosscheck information across the World Health Organization and CDC may help to counter misinformation. Findings from our study show that this potentially beneficial strategy should also extend to state communications. The CDC has worked over years to build its capacity for public communication. Its communications efforts were reviewed and revamped in the wake of the 9/11 and Anthrax attacks that occurred in 2001. 21 In 2020, a large majority of the public (81%) reported high trust in COVID-19 information from the CDC. 22 A similar percentage of the public (76%) held high trust for COVID-19 information from state health departments. The roles and responsibilities of US presidents during crisis situations have increased in importance for decades. 23 The president holds a special ability to quickly communicate information, guidelines, and recommendations to the entire nation at once and at any time. It is possible that if these various sources of communication to the public had been able to coordinate their messages more effectively, public confidence and understanding may have been higher. Our findings highlight how this level of coordination did not occur, and how that complicated the state-level response.
Intergovernmental Communications
Interviewees commented favorably on several aspects of the federal response. Meetings convened by the White House with federal officials, governors, and their staff were viewed as informative, and states relied on the CDC to disseminate vital information, which was then posted on state websites. The CDC was also an important source of technical support. These functions are all examples of how states benefit from effective intergovernmental relations and access to federal expertise. However, interviewees also noted, sometimes strongly, the challenges they faced related to the CDC releasing guidance at inopportune times and without warning. The CDC’s recent self-reviews include the recommendation to “adopt a no surprises communication operating posture,” establish “routine delivery schedules for such information sharing,” “share proposed options with key external stakeholders,” and “establish a feedback loop to quickly assess the effectiveness of guidance implementation.” 15 Responses from interviewees suggest that they would endorse these efforts. However, the interviews suggest more specific actions for consideration. Namely, the CDC should consider releasing guidance at opportune times, as opposed to Friday afternoons. In addition, the CDC, with input from state-level policymakers, should explore the potential benefits and drawbacks of sharing drafted guidance with state officials ahead of public releases. At a minimum, the CDC should inform all states that a guidance change is pending and provide a clear time and date for its release. One way to test such a system is by conducting regular, federal–state tabletop exercises, which have been shown to highlight strengths and expose weaknesses in other disaster preparedness scenarios. 24
Rural Perspectives
Interviewees from rural states felt that their needs were overlooked and that resulting federal policies and CDC guidance were not always well suited to their needs. The HSCC noted that people in rural areas, an underserved group, faced disproportionate harm during the pandemic. 18 The HSCC and Council on Foreign Relations also call for a commitment to public health workforce development and increased healthcare capacity in rural areas.16,18 While significant, these recommendations overlook the hallmark tension between levels of government within a federalist structure when they have divergent views toward the adequacy of pandemic policies. Our results are a reminder that federalist structures allow policy adaptations sensitive to local factors including disease prevalence, population density, or geographical needs. However, inconsistent polices may lead to confusion and be perceived as unfair, and Birkland et al 25 and Rozell and Wilcox 14 raise concerns about how differing state policies might compromise public health and safety. The extent to which states should enact policies that deviate from federal recommendations, or the amount of variation federal policies should have across states during a pandemic response, remains unclear. However, findings from the interviews clearly demonstrate that the specific needs of rural states must be heard and fairly considered in the policymaking process. Downey and Myers 13 suggest that the development of intergovernmental oversight forums akin to Australian counterparts may aid in this type of intergovernmental coordination. Potential partners for moving forward might include the Commonwealth Fund Commission on a National Public Health System, Council of State and Territorial Epidemiologists, and the National Governors Association.
Federal Investment in and Sustainment of Health Service Preparedness
The federal government has the ability to fund and coordinate the health service and medical countermeasures components of a pandemic response in a way that states cannot achieve independently. As such, states stand to derive significant benefits from effective federal assistance in this area. Some interviewees expressed very favorable views toward the federal government’s role in a successful vaccine development initiative that was accomplished in record time. However, interviewees also noted that the federal government failed to effectively wield its capacity in other aspects of countermeasure and health services support, including the procurement of desperately needed emergency medical equipment, such as ventilators. They also suggested that more prompt and extensive federal support for testing and vaccine deployment infrastructure could have mitigated at least some of the damaging impacts of the pandemic. Our results underscore the importance of recommendations from the HSCC calling for more extensive investment in the strategic national stockpile 18 and add that hard-fought pathways for medical supplies such as PPE, vaccines, and testing capacity should be maintained for future response efforts.
Limitations
This study has some limitations. Recruitment was difficult, and a minority (20%) of the policy actors we contacted were interviewed. Factors including government officials' commitments to confidentiality or fears of reprisal may be to blame. Interviewees who did agree to participate may have done so because they hold strong views. Some interviewees may have also hesitated to criticize their state leaders. Despite our attempts to recruit a politically diverse sample, most interviewees worked in a state led by a Republican governor during the pandemic. Recall bias is also a concern. Future research could incorporate and evaluate more insights via surveys and combine interview data with document analysis to enhance findings.
Conclusion
Data from interviews with state-level policy actors highlight some of the challenges and opportunities that were presented by the US federalist approach to managing the COVID-19 pandemic, from the standpoint of those directly involved in state-level responses. Our research adds to the ongoing discussions of the COVID-19 pandemic response and to pandemic preparedness in the United States. The results suggest that that factors such as alignment of public communications across government levels, improvement of intergovernmental communication, inclusion of rural perspectives during policymaking, and federal investment in and sustainment of health service preparedness all stand to improve future US pandemic responses.
Footnotes
Acknowledgments
The authors are grateful for funding from the