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COVID-19 and Health — What to Watch in 2022

As 2022 begins, the omicron variant is proof that the pandemic is still far from over and remains politicized. More than 90 percent of Democratic adults have received at least one vaccination, compared with 60 percent of Republicans.

man getting tested for the novel coronavirus
Editor’s note: Each January, Governing produces its annual Issues to Watch, a detailed look at the legislative activities that will keep states busy for the next 12 months. We have decided to break down the report into a series of articles that tie together related issues. You can find our “Biggest Issues to Watch in 2022,” in its entirety here.


That the disease carries the year of its birth in its very name presents a frustrating reminder of how long the COVID-19 pandemic has dragged on. Last year opened with optimism, with vaccines starting to roll out, holding out the apparent promise of a return to normal life. That promise proved short-lived. As 2022 begins, the omicron variant is proof that the pandemic is still far from over.

Offices that hoped to have workers return in person in the new year have delayed opening fully yet again. Just before Christmas, several of the nation’s most prestigious universities, including Harvard and Stanford, announced that they’re moving classes back online for at least the start of spring semester. The University of Illinois delayed its start by one week, while the University of Virginia announced that faculty and students would be required to have booster shots to return to campus. K-12 schools, at least in some jurisdictions, have also returned to remote learning — while a well-publicized standoff in Chicago that led to temporary school closures — but that is something the vast majority of districts are determined to avoid.

Closures offer a strong sense of deja vu, but they are not the rule. The public and political will for strict lockdowns is now part of the past. Even many Democratic governors have lost their appetite for measures such as mask mandates. After two years, people aren’t reacting well to an “ongoing environment of fear,” Colorado Gov. Jared Polis said in December. “You can’t, at the end of the day, force people to do something they don’t want to do,” he said. “Public health doesn’t get to tell people what they want to wear. It’s just not their job.”

The mask and vaccine mandates that are in place continue to face challenges in court. Republican attorneys general are still battling the Biden administration’s requirements for vaccinations or frequent testing for most workers, in a challenge that reached the Supreme Court. “Let me be clear — I will never force you to get the vaccine,” Mississippi Gov. Tate Reeves tweeted in November. “Why? Because you can be trusted to make good and responsible decisions.”

More than 90 percent of Democratic adults have received at least one coronavirus vaccination, compared with 60 percent of Republicans. Only elderly Republicans are as likely as the youngest Democrats to be vaccinated. In Texas — where President Biden carried just 22 of the 254 counties in 2020 — 17 of the 20 counties with the highest vaccination rates all voted for the Democrat. This divergence has led to a sizable partisan gap in death rates, one likely to worsen as the omicron variant spreads and infects millions more. “In 2021, we started to see more of a divergence, and 2022 is potentially going to be even worse, unless we can pull it back from the intense politics,” says Joshua Sharfstein, vice dean of the Bloomberg School of Public Health at Johns Hopkins University.

Even as omicron cases spike, there is some good news. Late last year, the federal Food and Drug Administration approved the use of two anti-viral pills. One, manufactured by Pfizer, reduced the risk of hospitalization in clinical trials of infected patients by 88 percent. Increasing supply to meet the enormous demand will be a big task, but finally treatments are available that should make a real difference.

All of this means that the pandemic continues to present challenges to state and local governments — running vaccination clinics, supplying at-home test kits, sending the National Guard in to help in strapped hospitals. Some states are planning to send additional stimulus checks to residents whose economic fortunes remain crimped.

Public health officials continue to maintain that the tried-and-true methods of avoiding disease — vaccination, distancing, hand hygiene, avoiding indoor crowds, masks — offer the best hope for individuals to evade omicron. They’re unhappy that about a dozen states placed curbs during the pandemic on the authority of health departments, particularly at the local level. They hope, perhaps optimistically, that lawmakers can be persuaded to strengthen local authority, while also helping to build up public health infrastructure for the longer term that will allow them to address future emergencies more capably.

In the meantime, there are plenty of other public health concerns that have received inadequate attention during the pandemic, including suicide and mental health issues, particularly among young people. Substance abuse has increased, notably abuse of opioids and alcohol. “We have undervaccinated children,” says Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. “We didn’t have that before the pandemic, but we have it now. We don’t want the pandemic to be a cause for us having to deal with a lot of measles outbreaks, or other outbreaks.”

— Alan Greenblatt
One elderly woman sitting in a wheelchair and one sitting in a folding chair talking on the phone while looking at a large pill bottle.
(David Kidd/Governing)


Heading into 2022, COVID-19 continues to perpetuate a public health crisis that seems never ending. The ongoing pandemic will continue to dominate public health policies this year and is expected to exacerbate issues concerning mental health and health equity. The state and local public health workforce will remain strained as COVID-19 continues to cut into the number of available workers needed to provide health services to a weary public.

The result? This year, health-care costs will continue to rise and consume an ever-greater share of state budgets, accounting for about a third of total expenditures, and are expected to overtake state spending on all other categories within the next 50 years, according to a study by the Government Accountability Office.

Geography can be a major factor in a person’s health in the U.S. The physical environment, access to local care, cost of insurance and food insecurity are just a few of the factors that can determine quality of life and longevity. In many cases, these problems require solutions beyond the purview of health departments alone. When it comes to health policy and outcomes, not all states are created equal.

Massachusetts is a top state for health insurance coverage and child immunization, with just 3 percent of the population uninsured. With an uninsured rate of 18 percent, Texas has one of the lowest rates of health insurance coverage. Georgia ranks near the bottom for percent of uninsured as well as child immunization rate. There is also wide disparity in the cost of monthly premiums among the states, some of which can be explained by differences in geography and whether or not an area is served by only one health-care system. Medicaid expansion continues to be a factor in state spending and health outcomes. Most of the 12 states that have not adopted expansion are consistently ranked near the bottom in terms of overall health care.

A significant percentage of state and local budgets are spent on factors related to health but not directly associated with health care. The Environmental Protection Agency estimates there are at least 6 million lead water lines still in service throughout the U.S. putting millions of Americans at risk. Efforts are underway in several cities to replace these lines. Illinois will replace all lead pipes over the next 50 years, including in Chicago, which has the most of any U.S. city. Air pollution is another factor in a community’s health. Pollution levels have decreased in several states, even before the pandemic. But despite decades of remediation, air pollution is on the rise in others, including California, Illinois and Nevada.

COVID-19 was the third leading cause of death in 2020, increasing the overall death rate by 17 percent and contributing to a two-year drop in life expectancy. COVID-related deaths totaled over 800,000 before the end of 2021. The disease is costing jurisdictions more than the costs associated with constant testing.

Testing protocols and resistance to vaccine mandates are disrupting health departments across the country. Local officials worry that they will lose employees to neighboring jurisdictions if vaccine mandates are imposed. Public health departments in California have had to close labs due to a staffing shortage. Experienced technicians, nurses and microbiologists across the country are leaving due to exhaustion, retirement or higher-paying jobs.

One positive outcome from the pandemic has been a broader acceptance of telemedicine. But emergency rules put in place in the early days of the pandemic are ending. States had relaxed licensing rules so that physicians could treat remote patients across borders, without the complex forms and fees normally required. At least half of the states have already begun to tighten their rules. One possible solution is the Interstate Medical Licensure Compact, a framework for participating states to streamline the process of licensure for physicians. The nearly 30 percent of rural patients without broadband, however, will still be left out.

— David Kidd
Alan Greenblatt is the editor of Governing. He can be found on Twitter at @AlanGreenblatt.
David Kidd is a photojournalist and storyteller for <i>Governing</i>. He can be reached at
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