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Why America’s public health system can’t withstand Trump

The Trump administration has still not fulfilled its duties for public health — and has actively undermined it.

President Donald Trump sits behind the Oval Office desk with his arms crossed.
President Donald Trump talks to reporters while hosting Republican congressional leaders and members of his Cabinet in the Oval Office on July 20.
Doug Mills-Pool/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Rather than engineer a robust federal response to the coronavirus, President Donald Trump has instead tried to exploit the decentralized nature of the US public health system to abdicate all responsibility for the virus’s toll on America’s health and economy.

The New York Times delved deep over the weekend on the decision by the Trump administration to delegate as much responsibility for the Covid-19 response (and, by proxy, blame) as possible from the federal government to the states:

Their ultimate goal was to shift responsibility for leading the fight against the pandemic from the White House to the states. They referred to this as “state authority handoff,” and it was at the heart of what would become at once a catastrophic policy blunder and an attempt to escape blame for a crisis that had engulfed the country — perhaps one of the greatest failures of presidential leadership in generations.

As a rule, state and local governments do occupy the front lines in the response to any public health emergency. They work with their hospital systems to create enough capacity, they employ the staff members who do the work of contact tracing, they set up mobile testing sites, etc. and so forth.

“Different infectious diseases will affect different communities in different ways, and ultimately you want to have responses that address the specific needs of affected communities,” Angela Rasmussen, a virologist at Columbia University, told me.

“But there’s delegation of local issues to local leaders,” she continued, “and then there is dereliction of duty to provide any leadership at all.”

The federal government must play a critical role in providing resources and coordinating amongst states during a public health crisis. The CDC collects and publishes data on outbreaks, the FDA approves vaccines and treatments, the NIH directs and funds scientific research. The feds can allocate supplies, issue guidance for states and cities to follow, and provide money for state and local health departments to perform their vital duties.

What we are seeing from the Trump White House is zero interest in performing any of those roles. As early as April, according to the Times report, the administration was trying to figure out how to shirk its responsibilities, on the false belief that they had already done enough and the pandemic was starting to subside. Now cases, hospitalizations and deaths are rising again and the US has not built up the capacity to contain the virus — by testing and contact tracing — that other countries successfully have.

“We are witnessing what happens in the absence of a coherent federal leadership that puts public health first,” Rasmussen said. “The federal government has failed to provide leadership on virtually all of these points.”

That was the near-unanimous consensus of the public health experts I spoke with on Monday. The coronavirus doesn’t respect state borders and therefore stopping it requires a national response. But Trump has failed in delivering one.

Yes, America’s public health system is designed to place states and local governments in charge of the first level of defense against a deadly virus. But the Trump administration has still not fulfilled its own duties under such a system and, in fact, has hampered the US response because of its delinquency.

“From Day One, the Trump White House has delegated coronavirus response largely to the state and local jurisdictions. That’s an unprecedented decision in a national emergency of this kind,” says David Harvey, executive director of the National Coalition of STD Directors, whose members oversee contact tracing programs. “We need federal leadership, federal plans, a federal coordinating body. We’ve not seen that from this administration.”

The sidelining of the CDC is an indisputable fact at this point; the agency was barred for months from holding its own briefings and its guidelines have either been delayed or watered down over political concerns. The FDA has a mixed record in approving tests and treatments: Some are approved too quickly, others too slowly, experts say. And when the Trump administration is not outright blocking its government scientists from speaking to the press or issuing the guidance that state and local governments depend on, White House officials or the president himself have been blatantly undermining the public’s trust in their authority.

The Trump administration has not only neglected its responsibilities but broken from long-standing precedents in ways that have added to a confused national response. Last week, for example, the Trump administration asked hospitals to stop reporting their data to the CDC, as they have always done, and start sending it to the Department of Health and Human Services instead.

Earlier in the crisis, the administration was reluctant to deploy the strategic national stockpile for critical supplies like masks and ventilators. White House adviser Jared Kushner even said the stockpile was not meant for states, as it historically has been understood to be. Instead, the states found themselves competing against each other for scarce supplies during an emergency.

“In this response, the notion that it’s up to states and local government to figure it out was quite inconsistent with not only past practice but what the past federal protocols were,” John Auerbach, now the president of Trust for America’s Health and previously a top public health official at the state and federal level, told me. “You just can’t change the rules in the middle of an emergency. It’s just too disruptive.”

And now, the administration is reportedly trying to block Congress from allocating more money for testing and contact tracing — once again giving up on what is supposed to be one of its primary functions, providing funding in a public health emergency.

“It is mind-boggling that there is a debate about whether there needs to be more money,” Harvey says. “It’s a no-brainer, we need these funds.”

Trump didn’t set up this system of governance. It goes back to the founding and the 10th Amendment. America’s problems with properly prioritizing public health precede him by decades as well; a recent New York Times magazine feature explored that long history.

According to Trust for America’s Health, the funding for the CDC has been effectively flat for the last decade. State and local health agencies had to cut more than 50,000 jobs in the Great Recession, and most of those jobs have not been filled since. America’s chronic inability to invest in public health exacerbated the obesity and diabetes epidemics. That shortsightedness made the US more vulnerable to Covid-19, which is particularly hard on people with those chronic conditions.

And a decentralized system does not mean a country is fated to struggle in responding to the coronavirus. Other countries with federalist structures have contained their outbreaks much better than the US has.

“The reason a national plan and federal emergency authorities are needed in the time of a public health crisis is precisely to be able to contain outbreaks that do not respect borders (state or local) and cannot be addressed on a piecemeal basis, by localities,” Jennifer Kates at the Kaiser Family Foundation, told me. “Other federalized nations (Australia, Canada, Germany) have figured out how to do this.”

Rather, it has been the debilitating combination of these two variables — a decentralized health system and an intransigent national government — that has helped make the United States the epicenter of the worst pandemic in a generation.

“The national response strategy is a hodgepodge of half-measures that appear to be characterized by cronyism and political considerations over public health,” Rasmussen said. “President Trump’s guiding principle in public health policy making appears to be magical thinking.”

But despite these efforts, the American public appears to be holding the president accountable for his inaction in a pandemic that has left more than 140,000 Americans dead. Approval of Trump’s response to Covid-19 fell from more than 50 percent in March to less than 40 percent now, according to the Washington Post.

There is some bitter irony in those numbers: A pandemic response strategy founded in shifting the blame and wishing the virus away has now left Trump as a historically weak incumbent just a few short months before Election Day. And that failure came at a deep cost to Americans, one that is still being paid today.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.