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How American-Style Federalism Is Hazardous to Our Health

The U.S. could have done much better in battling COVID-19, preventing hundreds of thousands of deaths. But its decentralized system of governance failed to rise to the challenge.

Hospital workers move bodies of deceased patients to a nearby refrigerator truck that is serving as a temporary morgue outside of Wyckoff Heights Medical Center in Brooklyn, N.Y., on April 4, 2020.
Lev Radin/Shutterstock
Now that widespread vaccinations have begun to ease the terror of COVID-19, it’s time to look back for the lessons learned. Underneath the headlines is an important question: Did Americans suffer more than necessary because of the nation’s system of federalism?

The answer, sadly, is yes: Federalism as practiced in the United States has been dangerous to our health. The coronavirus death rate in the United States ranks fifth among the world’s largest nations, behind Italy and the United Kingdom but far ahead of France, Sweden, Chile, Austria, South Africa and Russia.

The U.S. went into the pandemic with a public health system and national public health agencies that were the envy of much of the world. The virus hit America’s shores with fair warning, so there was the opportunity to be prepared. And as the pandemic progressed, many of the nastiest coronavirus variants struck this country later than in other nations, so we had the chance to learn from others’ experiences. But the virus savaged the country and undermined the sterling global reputation of the nation’s public health system.

Back in March 2020, Dr. Anthony Fauci said he expected that the pandemic could kill 100,000 to 200,000 Americans, numbers that seemed mind-boggling at the time. More than a year later, the number is closing in on 600,000. The Lancet, the British medical journal, published an analysis this past February concluding that 40 percent of the deaths were preventable if the U.S. had followed the same course as other major industrialized nations. Andrew Atkeson, a UCLA economist, argued that American fatalities could have been held to fewer than 300,000 with better testing, masking and social distancing. Even the Trump administration’s coronavirus coordinator, Dr. Deborah Birx, concluded that hundreds of thousands of deaths could have been prevented.

So it’s impossible to escape the conclusion that America could have done much better in battling COVID-19. A bigger debate is whether federalism, American style, was especially to blame.

Among federal systems resembling our own, in which powers are divided between levels of government, the fatality rate was higher in Brazil, but the U.S. ranked second, higher than Mexico, Germany, Switzerland and Australia. The U.S. death rate has been almost three times higher than Canada’s.

It would be a reasonable guess that, because of the divided authority, federal systems would struggle more with COVID-19 than unified systems, those in which central governments call most of the shots. But that guess doesn’t pan out. Unitary systems like those of the United Kingdom, France, Israel and Denmark didn’t perform significantly differently in the pandemic. Nor did more centralized federal systems, like India’s and Brazil’s, perform better than more decentralized ones, like Switzerland and the U.S.

Americans suffered more from COVID-19 because its decentralized system of federalism simply failed to rise to the challenge. Rather than asserting authority from Washington, President Donald Trump chose to deflect action to the states. State leadership varied wildly, from states like Florida and Texas, whose governors had to be dragged into masking and social distancing and who fought against local shutdowns, to states like Washington and Oregon, which became national leaders after the early weeks of the virus exacted a terrible toll. A look around the globe reveals that the most successful nations were those with a strong national hand steering policy, with an equally strong engagement of local governments in partnership toward a national policy.

COVID-19 affected every part of the U.S., but it did not affect all parts equally. It proved six times more deadly in New Jersey, New York and Massachusetts than in Alaska, Vermont and Hawaii. As with so many other policy issues, Americans’ odds of dying from COVID-19 depended mightily on where they lived. Rhode Island’s death rate is similar to Arizona’s, and Maryland’s is almost identical to Kentucky’s. In between, Delaware is almost identical to Kansas. There isn’t a red state/blue state pattern to the data.
Death rates from COVID-19 per 100,000 people as of May 21, 2021

But the variations do frame a big puzzle. Did the Trump administration’s aggressive efforts to push the big decisions to the states make the crisis worse, forcing so many states to reinvent the wheel over and over again, wasting valuable time and causing more Americans to suffer? Or did it help the country’s overall response because at least some states were able to break away from the others and put more aggressive pandemic-battling policies into place, which also helped protect them from the national government’s inaction?

There’s no doubt that some states and communities used that flexibility to enormous advantage. One of the cities initially hit hardest, Seattle, over time became a national model. In fact, if every local government and every state had followed its lead, the death toll would have been cut in half and 300,000 Americans would be alive today.

That’s a powerful case for the argument posed by Justice Louis Brandeis, who saw the states as laboratories of democracy. But, more generally, the states did not prove very good labs in dealing with the pandemic. In writing about the reaction of his own government in Switzerland, Danny Buerkli, co-founder of a government reform lab, made a powerful point that applies even more to the U.S.: There was, he wrote, “lots of experimentation” but “very little learning.” In the U.S., there simply wasn’t any mechanism for collecting nationally what the states and their cities were learning, and that handicapped the American response. In fact, one of the most profound American breakdowns was the failure even to recognize that this was an essential question in desperate need of a solid answer. And that, in turn, weakened the national hand on the COVID-19 steering wheel and the ability of the states to act as true laboratories.

These same challenges are now flowing into the campaign to vaccinate Americans, where huge differences are emerging yet again. There are major income, class and racial differences in who is getting vaccinated, but there are other big socio-economic drivers as well: States with a higher percentage of uninsured residents have a lower rate of vaccination. The higher the share of residents with good Internet access, the higher the rate of vaccination. Both these indicators reflect problems of access to health care in general, the vaccination signup process in particular and wider inequities in health care across the country.

That’s the most basic problem with the American response to COVID-19. The country has massive inequities, which COVID-19 helped demonstrate and which the pandemic, in turn, accelerated. Federalism has turned out to be dangerous to your health, most of all because it’s helped widen the gap between the health haves and have-nots in American society.

The only way to narrow this national gap is national action in close partnership with the states. We’re now further from that than ever. That not only threatens the broader effort to reduce inequality in the U.S. but also sets us up for a fall, yet again, when the next pandemic inevitably emerges.

Governing's opinion columns reflect the views of their authors and not necessarily those of Governing's editors or management.
Donald F. Kettl is a professor emeritus and the former dean of the School of Public Policy at the University of Maryland, College Park. He can be reached at or on Twitter at @DonKettl.
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