If a flu pandemic breaks out, who should be first in line for treatment? Researchers have long known that another nasty bug, like the one that killed tens of millions of people around the world in 1918, could emerge again. Vaccines to stop the spread would be limited, and treatment facilities would be overwhelmed.
So who ought to get shots and medical care first? Doctors, nurses and other first responders, one might argue. That makes sense. Perhaps a high priority ought to be given as well to workers needed to keep the economy running, such as grocery store employees and truck drivers. A recent Johns Hopkins University study suggested that the secondary effects of a pandemic -- food shortages, banking failures and transportation breakdowns -- could hurt more than the disease itself. But the trickiest question of all might be a more subtle one: Who in government gets to decide which Americans are "essential" enough to be given first dibs on strained medical care?
In a curious way, all this relates to the larger questions about federalism that have occupied the past several years of public debate. With 9/11, Katrina and the financial meltdown, public officials have puzzled over where to set the tripwire for federal government intervention. The de facto result has been a steady, perhaps irreversible flow of power to Washington.
To be sure, state and local governments have seized the upper hand in important areas. The feds have largely abandoned environmental initiative to the states, and California has become a global leader in the management of climate change. State Medicaid waivers have significantly expanded that program's coverage.
But fundamental changes are afoot in the basic architecture of federalism. On issues dealing with risk -- government's role in making sure big things don't cause hurt -- the federal government has steadily been exercising a stronger role.
Consider 9/11. In its aftermath, Congress concluded that disaster response ought to be housed in one central place in government. After some initial doubts, the Bush administration came to champion the idea of just such a response system under the Department of Homeland Security umbrella.
Then there was Katrina. The near-total breakdown of civil order in New Orleans taught federal officials that they always need to be ready to move when big problems swamp local authorities. Few government officials were covered in glory during the first days after the storm submerged the city, but federal officials are still quietly complaining that they reaped most of the blame for the failures of state and local officials. Politics aside, many have concluded that they have to be faster on the trigger when big dangers loom. That's why the feds played a much bigger role in pushing the evacuation of New Orleans for hurricanes Gustav and Ike.
In the federal response to the financial meltdown, the states have largely been left on the sidelines. That's ironic, of course, because banks have long been able to choose whether to be chartered by a state or by the federal government. Bankers always liked the dual option, but reformers wanted a more streamlined system. In March, Treasury Secretary Henry Paulson proposed a blueprint with the feds firmly in control of a centralized financial regulation system. He said the current arrangement "fosters duplicative requirements which can allow important regulatory matters to fall through the cracks." Those cracks already have turned out to be enormous chasms.
As the Obama administration sets up shop, it will face a system of disaster planning and relief vastly different from the one George W. Bush inherited in 2001. Citizens are increasingly calling on government to prevent bad things from happening, and to ride in to help when they do. That increasingly leads to calls for quick action from Washington.
We've crossed an important frontier: Dramatic events have reset the tripwire for federal involvement. If a pandemic breaks out, state and local governments will be on the front lines of response. But the feds will likely make the call on who deserves to get care first.