The Health of Nations: Give Me Liberty or Give Me Death

By Matthew S. Berge

We are over two years into the COVID-19 pandemic, with highly-transmissible variants like Omicron; seemingly, no end is in sight. Experts agree that COVID-19 is probably a new seasonal illness rather than a temporary plague; this is becoming part of the social mores of contemporary American society. However, fragmentation is a tenet of American federalism, presenting an antithetical threat to the federal government’s duty to promote the public's “general welfare” by suppressing the federal government’s ability to manage the pandemic effectively.

Public Health in America has become politicized, and resistance to public health protocols witnessed throughout the COVID-19 pandemic poses long-term risks for future crises. America's unpreparedness to deal with pandemics may be greater now than 2020. States resist federal guidance, banning mandates altogether. Many of these state-level policies are hypocritical. These futile attempts to safeguard citizens’ individual “liberties” is itself government overreach because localities lose autonomy, making this most hypocritical.

Anti-Public Health policies prevent self-governance putting America’s “general Welfare” at significant risk, creating further fragmentation in an already fragmented system—allowing an emergent tyranny of the minority. The majority can favor mask mandates while unable to enact/enforce such mandates. Similar issues apply to the amalgam of states across America, where pandemic protocols are decentralized, varying from state to state. State and local governments have passed myopic laws limiting the power of public health officials to enforce/implement public health policy. Limiting public health agency powers effectively shrinks the public health system, creating difficulties for identifying future variants or other infectious diseases in general. The long-term effects remain unclear. This topic requires critical monitoring, as disaster is unnatural but inevitable under a dysfunctionally-fragmented system.

Early on, national health systems responded differently to COVID-19, presenting examples of how to respond to the crisis. In those days of uncertainty, the U.S. could become the next Italy or South Korea. Italy saw a fragmented-federal response that led to hospitals “overwhelmed with patients” by early March; on the other end was South Korea, where “the national government took strong action with aggressive testing” in their success in “flatten[ing] the curve.” The U.S. took a decentralized approach, as Trump avoided defining a clear role for the federal government, holding, in a letter to Senator Chuck Schumer, that “the Federal Government is merely a back-up for state governments.”

The existing literature on how differing federations across the globe handled the pandemic indicates that fragmented federalism presents a significant hurdle in ensuring universal compliance with public health guidance throughout states/localities. A “large scale review” of European Union (EU) public health policies found that the EU “regulatory state” hindered the EU’s ability to “formulate a health policy…focuse[d] on health” because health policy in the EU “is legally, politically, and financially [weak].” The fragmented federalist structure of the EU has limited ability to enact “health and social policy initiatives,” posing a long-term threat to sustainability.

Let's compare the U.S. to another dysfunctionally-fragmented nation, the Republic of India. India practices Centripetal Federalism, a political system modeled on “power-sharing” often found in “multi-segmental [and], especially multi-ethnic countries.” The underlying motive of centripetalism is to “foster cooperation” through an “integrative institutional framework,” providing a voice for marginalized groups. Choutagunta holds India's “centripetal federalism…has become dysfunctional;” subsequently, “state and local governments” cannot adequately “deal with public health problems.”

Dysfunctional federalism is omnipresent in the U.S., perhaps even more so than in India. In the early days of the pandemic lockdown, states sought guidance/aid from a federal government, lacking “a national strategy on what was clearly a national problem.” Fragmentation is a feature, not a bug, of American federalism. Resistance to national public health guidance caused reckless policy initiatives antithetical to public health. The Kansas state legislature was “alarmed by the persistence and power of public health orders,” reacting with new laws that “limited…contact tracing” gave politicians power over health decisions and allowed those "aggrieved" by mask mandates, closures, or limits on public gatherings to “sue the agencies” enacting/enforcing them.

The New York Times found that "100 new laws have passed” limiting or stripping “power from…public health officials” and a “staggering exodus” in the field as they felt “exhausted and demoralized” due to “abuse and threats." About 130 of 300 public health departments said they lacked enough personnel for contact tracing. A troubling revelation as contact tracing is vital to stop the spread of highly infectious pathogens. Additionally, “hundreds more [policies were] under consideration” to limit the power of public health agencies. Responsibility and control over public health shifted to politicians, with an increased ability to “undo health decisions,” including “flu vaccination campaigns…[or]…quarantine protocols,” rather than public health officials who've dedicated their careers to public service.

COVID-19's politicization carries into the midterms. I worry candidates with radical anti-public health policy positions may bring their agenda to Washington, potentially passing legislation limiting public health officials' powers. Remember, in the summer of 2020, Trump “ordered hospitals to bypass" CDC reporting COVID-19 information; instead, data went directly to agencies in Washington. Health officials worried data would be “politicized or withheld from the public,” only a month earlier, Trump claimed, “if you don't test, you don't have any cases;” insisting U.S. case rates were elevated because we test more, making us “show more cases” than other countries who “don't talk about it.”

Myopic disbursement of pandemic emergency funds is concerning. The federal government funneled “billions of dollars” supporting state/local public health initiatives through legislation like the CARES Act or the more recent American Rescue Plan. Funds were reactionarily utilized, addressing immediate needs rather than “hiring permanent staff" for long-term sustainability. Before the pandemic, most public health departments surveyed worried about "decreasing or flat" funding.

Decreased health spending correlates to political polarization; this trend began after Republicans controlled Congress. Obamacare “authorized $18.75 billion” to the new “Prevention and Public Health Fund”(PPHF). In 2012, Congress “passed multiple bills…to cut and redirect money,” funding legislation unrelated to public health and calling for “$2 billion per year” for PPHF; nevertheless, funding hasn't surpassed $1 billion since 2012. Funding cuts began once the Republicans controlled the House of Representatives. These cuts were politically motivated, as Obamacare passed along partisan lines. Republicans spent years trying to repeal Obamacare, ultimately costing them the 2018 mid-terms when Democrats took control of the House for the first time since 2010—campaigning on healthcare reform initiatives, like Medicare-for-All, while Republicans pushed repeal and replace rhetoric without a replacement plan.

Once the threat was real, funding poured in like an open faucet through the CARES Act, allocating “$175 billion” to the “Provider Relief Fund” (PRF). A Washington Post investigative article unveiled for-profit nursing homes previously accused of “Medicare fraud” were granted “hundreds of millions” in aid without "strings attached,” a windfall of PRF cash. Future legislators must consider protecting public health a constitutional duty because healthcare is necessary for the “general welfare” of citizens.

These revelations are alarming, as the U.S. was unprepared in 2020, and while we may know more about this disease/pandemic, we remain grossly unprepared for the next. American federalism's dysfunctionally-fragmented nature is antithetical to public health. Protecting public health is the federal government's responsibility; the U.S. Constitution states, “Congress shall…provide for the…general Welfare.” Unfortunately, public health became hyper-politicized, with public officials stoking resistance for political gain.

Trump publicly called the virus a “hoax” created by the opposition party while privately calling the virus “a plague” that “rips you apart.” Trump left pandemic mitigation up to state governments, adhering to the tenets of federalism, by granting greater autonomy to states. Florida rejected guidance from the very start of the pandemic. Governor DeSantis signed numerous bills, calling this “the strongest pro-freedom, anti-mandate action taken by any state;” the hypocrisy of Florida’s pandemic response is most troubling.

Florida went beyond blocking federal mandates. School districts cannot have "mask policies.” Parents may sue schools for “violating” state law even if the majority favors masks in schools. Averting a tyranny of the majority is deemed a vital aspect of a republican system instead of direct democracy; however, these anti-public health initiatives allow for a tyranny of the minority and potentially fatal consequences.

Federalism's inherent fragmentation is inconducive to public health, especially during a pandemic when cooperation ought to be prioritized. In addition, the United States is a unique case, as the right to healthcare is not a right provided by the welfare state, unlike our European counterparts. In contrast, some states “recently enacted public option-style laws.” This system allows for better control of public health at the state-level. Ostensibly, states that resist public health protocols will likely see a rise in public health crises. An inevitable result of myopic, reactionary anti-public health policies that effectively create barriers for public health officials to fulfill their role efficiently.

Ultimately, “liberty” in healthcare can only be realized if healthcare is a guaranteed right, like in other Western democracies. Liberty is granted by removing the burden of for-profit healthcare from the equation, a seemingly impossible task in the American economic and political system. Nevertheless, I advocate for such liberty for all Americans. America's societal health outcomes are much worse than in countries where healthcare is a right. Give us this liberty or, else you shall continue to, give us death.