In the aftermath of the presidential election, the US has its last best chance to reset the fight against the coronavirus. The first true test is vaccine distribution.
Text by authors Selin Zalma, Rich Davey, Marin Gjaja, Daniel Acosta | BCG
A successful vaccination playbook will depend on close coordination and communication between the federal government and the states. Without a strong federal˗state partnership, we will repeat the mistakes and messiness that marked the distribution of test kits and personal protective equipment (PPE) early in the crisis.
Federal and state governments have different strengths. By virtue of its borrowing and purchasing power, the federal government excels at funding and procurement. Its expertise and broad perspective also position the federal government to establish evidence-based national standards and offer tailored regulatory relief. The states’ strength derives from local knowledge and service delivery. They clearly see the reality in the field that can be fuzzy to federal officials.
The incoming Biden administration can get this balance, coordination, and communication right. But only if it acts decisively and immediately with a well-executed rollout of vaccines. This is not an impossible dream.
This federal˗state handshake works best—as it did during the Great Recession—when both sides play to their strengths. Then-President Barack Obama actively involved the nation’s governors in the execution of the American Recovery and Reinvestment Act of 2009 and put his vice president, Joe Biden, in charge of the overall effort. This hand-and-glove approach allowed states to quickly direct significant federal resources to infrastructure, education, health, and renewable energy and put millions of Americans to work.
Restoring the federal-state relationship
When roles and responsibilities are unclear, an effective response is impossible. One telling example: in April, Maryland’s governor, Larry Hogan, hid 500,000 testing kits procured from South Korea after the governor of Massachusetts said that the federal government had seized 3 million N95 masks purchased by his state. “We weren’t going to let Washington stop us from helping Marylanders,” Hogan wrote in the Washington Post. But, as the Post later reported, those tests turned out to be flawed, a sober reminder that the federal government is best suited to certain roles, such as centralized purchasing of mission-critical supplies.
Conflicts between states and the federal government are not new in US history. But in times of emergency, those differences have been put aside in the national interest. We are at one of those moments. By restoring the federal˗state partnership in the following five key areas, we can protect lives and livelihoods:
- Economic support
- Protective equipment and drug supply
- Testing and tracing
- Vaccines and therapeutics
- Research agenda and guidelines
Despite the many mishaps along the way, the US is still in a position to win the fight against the coronavirus. Operation Warp Speed, the federal government’s $10 billion-plus vaccine development initiative, has supported both the Moderna and Pfizer vaccines, which will likely be the first ones authorized for emergency use. The bipartisan $3 trillion economic package delivered early in the pandemic provided relief to individuals, state and local governments, and businesses, including hospitals on the frontline. These are roles that only the federal government can play by virtue of its financial resources, borrowing capacity, and regulatory authority.
But the federal government can do more than simply supply money. States have struggled to spend their allocations under the federal CARES Act, the primary stimulus package, because of confusion over what is allowed and what to do. For example, without a coherent national testing strategy and guidance, states are still sitting on federal funding devoted to this critical activity.
Protective equipment and drug supply
The demand for PPE, medical equipment, and other supplies has increased exponentially during the pandemic. The federal government did help expand manufacturing under the Defense Production Act. However, it did not adequately explain its strategy or clearly lay out what the states could expect from the federal government, leaving them scrambling for supplies in the early days. Supply strategy and execution are better today than in the spring, but there are still gaps.
It’s not too late to get this right and improve overall supply chain resiliency. The federal government has the analytical firepower and relationships with manufacturers and distributors that can help it work with the states to better match supply and demand—based on need, equity, and forecasting—and fix bottlenecks in the supply chain. It should also use its purchasing power to support the states rather than compete with them. States can advocate for their needs using common demand forecasting tools. They would retain their power to allocate supplies where they are needed most within the state.
Testing and tracing
Testing and tracing strategy has been delegated to the states, and to a degree this makes sense. States are better at identifying areas where the spread of infection is likely rising and reaching out to marginalized and high-risk communities. But the lack of national guidance and a national testing strategy has resulted in a hodgepodge of state and local policies not necessarily based on sound science and socioeconomic considerations. For example, there is varying acceptance of rapid tests and differing views on their best uses. As a result, numerous facilities have reported that equipment and tests are sitting on shelves—a waste of resources at a time when every test matters.
Imagine instead if the federal government created common standards for testing and a common means of reporting test results to a strengthened and reinvigorated national data platform. This transparency would allow the federal government to equitably distribute the right type of tests for the right purposes, based on the needs of individual states, and to foster a sense of shared responsibility for ensuring that outbreaks are monitored and quickly controlled.
The standards could lay out the principles governing the best uses of rapid tests and of the more accurate molecular PCR tests, as well as testing turnaround times, sentinel testing, and when to rely on techniques such as pooling. The national data platform would also allow sharing of best practices and successes in such critical areas as keeping K-12 schools open and safe. And it would give local communities the benefit of national expertise regarding contact-tracing effectiveness, quarantine adherence levels, and other control measures.
With national testing and tracing guidelines and principles firmly in place, state officials could spend their limited time and resources on execution, distributing test kits where they are needed most, supporting the expansion of testing for all citizens, and monitoring specific populations such as schoolchildren.
Finally, the US could create reserve laboratory and test inventory capacity to support states that are experiencing surges. This approach could also apply to contact tracing through the creation of a national corps of tracers who—supported by robust technology and tools—could be dispatched, virtually, to states in need.
Vaccines and Therapeutics
The interplay between states and the federal government has been understandably minimal in vaccine development to date. Deployment is another story. States will be necessary partners.
The US Department of Defense is using its vast logistical capabilities to support distribution and administration, but it will take more than an army to ensure success. We require a massive, unified mobilization, analogous to a wartime effort, in which states, health care professionals, public-health leaders, businesses, and civil society all pull together in the same direction. It would be a national tragedy if safe and effective medicines are developed but not fully deployed because of logistical and financial hurdles or public mistrust.
As an early step, the federal government should provide guidance, following the recommendations of independent bodies such as the Advisory Committee on Immunization Practices and the National Academy of Medicine, on the populations that should receive early doses and the framework for prioritization within those groups. It should clarify the roles of the federal government, the states, and providers in tracking patients and ensuring that they receive their second vaccine dose. Finally, the federal government should work closely with governors, health departments, and providers to support them with financial and logistical assistance and regulatory relief. If the federal government assumes responsibility for activities such as running clinical call centers or broad public-health campaigns, we can avoid the need for all 50 states to reinvent the wheel.
The states will ultimately be responsible for following federal guidelines and administering vaccines through on-the-ground programs. State and local governments will also play leading roles in local messaging and outreach, especially to marginalized communities where mistrust of government is often highest. This communication should be local, targeted, and tailored.
Research and guidelines
We have never had a modern-day epidemic with the economic consequences of the novel coronavirus. There needs to be coordinated, national guidance on local responses to infection conditions. Restrictions should be reduced or increased based on public-health factors such as local infection rates and health system capacity and optimized for both health and economic outcomes.
Imagine if the federal government coordinated and synthesized governmental and academic research to build a comprehensive and accessible research library focused on the epidemiological and economic threats posed by the novel coronavirus. Where knowledge gaps emerged, the government could fund targeted and accelerated research. Ultimately, the government could translate that research into robust guidelines that fully balance medical, economic, and social risks and rewards.
For example, the federal government could create a county-by-county scorecard on metrics such as rates of infection, mortality, and hospitalization. Jurisdictions would feed their data into the national data platform and be publicly assigned a red, yellow, or green color code reflecting their economic and epidemiological health. The federal government could also establish national guidelines on business openings, communal activities, mask wearing, and interstate travel according to each jurisdiction’s infection rate.
States should of course have the final say in most of what happens within their borders, but they would benefit from the expertise and resources of the federal government in guiding them. This approach would leave most of the decisions that affect the daily lives of the general public to state and local officials. It would also inject accountability, transparency, and scrutiny into vital decisions that often have not received the public input that they deserve. In this scenario, the federal government could also put the weight of its expertise behind best health care practices, including mental health.
The test around the corner
Vaccine distribution and administration will be among the new administration’s first tests. Can it put together a thoughtful, coordinated, and well-communicated rollout—one that gets vaccines to those most in need, especially those who are vulnerable because of their health status or susceptibility to exposure? In the early days of the pandemic, the elderly and members of marginalized communities were let down by their governments. We have a chance to restore the status of the US as a nation that leads in the face of adversity, works with states to unlock the amplifying power of partnership, and is prepared for future public-health crises. It is an opportunity to unite a divided country against a common foe.