A couple of weeks ago, states from coast to coast were racing to find personal protective equipment and ventilators so their hospitals would be ready for Covid-19. “It was at the height of what seemed like the Hunger Games, everybody out there fighting for their life, people buying orders out from under you,” says David Postman, chief of staff to Washington governor Jay Inslee.
Then a phone call between staffers for the governors of Washington and California sparked what would become a new alliance. It made sense they’d start talking. King County in Washington had the first reported case of the novel coronavirus in the US; in California, the San Francisco Bay Area had the first reported community transmission of the disease. Local governments in both places were early and aggressive in instituting social distancing and stay-at-home measures.
“And then they were having a problem with nursing homes, and we obviously had a big problem with nursing homes,” Postman says. “So we put our teams together. We also connected our testing task forces together.” Like the rest of the nation, the two states—as well as Oregon, in between them—were trying to figure out plans for reentry into the economy.
A similar alliance was forming on the other side of the continent, a multistate council made up of representatives from New York, New Jersey, Connecticut, Pennsylvania, Rhode Island, Delaware, and Massachusetts, also aiming to figure out how to get local economies moving again without risking whatever progress they’d made against infection and death rates that may not have even plateaued yet.
After President Trump threatened to order states to end their shelter-in-place policies (something he doesn’t have the authority to do), Trump said in a press conference on Tuesday that he’d allow states to go their own way. That’s no more confusing than anything else coming from the White House. “We don’t have a national strategy at this point,” Postman says. “We think that the public, they don’t have unlimited patience for these shutdowns. The day will come when they start to push back. I think it’ll help people if they can understand our thinking. We’re not just sitting here waiting for a vaccine.”
Alliances among states aren’t, by themselves, unusual. The Northeast and the West have similar compacts regarding carbon emissions, and in the Northeast, states are intimately linked by geography and economics. Connecticut, New Jersey, and New York have political borders, but residents frequently cross them for work and recreation—or they used to, in the Before Times. And that nexus has been the center of the virus’s spread in the US to date. “If one state opens up— whatever that means—in a way that the other states are not ready to do, it could cause a catastrophe,” says Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University. “The virus doesn’t pay a toll on the George Washington Bridge.”
Still, though, it’s hard not to notice that the state alliances are all formed by Democratic governors, pushing back against authoritarian rhetoric from the White House while simultaneously asking for federal aid. (Federally stockpiled equipment did start arriving in some states, though generally not in the quantities governors asked for, and the US Army Corps of Engineers has helped build emergency hospital facilities).
Blue-state governors have also been quicker, relatively speaking, to put stay-at-home orders in place and determine whether and which businesses should close, rather than let the businesses decide for themselves. (And cell phone data suggests that people who live in redder states aren’t staying home as much, though that might be as much a function of density and resources as it is of politics.)
“I don’t know that it’s entirely a partisan story, but it does happen that the red states have been the ones that are cutting public health budgets and in general have the philosophy that the government’s job is to stay out of the way,” says David Jones, a professor of health policy at Boston University who studies how states implement public health regulations. “This is just a hypothesis that I don’t have a real way to test, but states with schools of public health, with people who are graduating with master’s of public health degrees or DrPHs—there’s just something in the air.”
California certainly qualifies. It has world-class public health schools up and down the state, and a budget and population that support a large public health infrastructure. In laying out the strategy that California (and likely the other states in the Western States Pact, and perhaps beyond) will follow at a Tuesday press conference, Governor Gavin Newsom included as a prerequisite a large system for tracking contacts of infected people and then isolating them when necessary. That’ll need perhaps tens of thousands of workers.
“For those that think that sounds challenging, it is and it’s not,” Newsom said. “We have tracing in the state of California, because of the scale of our health care system, that predates this current crisis.”
Every plan for easing social distance calls for a similar corps of contact tracers, public health workers—often volunteers. They’ll be expensive, and they’ll have to act across city and state borders. The federal government doesn’t seem to be building any such national system. Regional alliances might help solve all those problems.
By the time of that press conference, Newsom had already announced that California had cut a $1 billion deal with a Chinese manufacturer of personal protective equipment for 200 million masks—N95s and surgical. The state’s task force on testing was a week old, with a mandate to test up to 50,000 people a day by the end of the summer, with new blood tests for antibodies to Covid-19 in people who’ve recovered alongside the snot-and-spit tests for people with current infections.
Meanwhile a nationwide plan for ending social distancing, drafted by officials from the Centers for Disease Control and Prevention and the Federal Emergency Management Agency, looks likely to include many of the same provisions as Newsom’s plan for the state, including contact tracing, testing, isolation facilities, and new design ideas for facilities like schools and restaurants. But the CDC/FEMA plan is still just a draft.
It’s not an accident that Newsom often refers to California as a nation-state. It’s a cliché that states are “laboratories for democracy” in a federalist union, but the cliché might be even truer for powerhouse regions. Those three Western states don’t have the same kind of intimate live-work relationships that the smaller northeastern ones do, but Postman points out they do comprise something like the fifth largest economy in the world. They acted in concert on climate change when a Republican Congress wouldn’t, and did the same in an attempt to preserve net neutrality. “We in the West have a tradition of operating at the subnational level and have found it necessary when Washington doesn’t move,” Postman says.
A public-health alliance of the states that have had the most success in dealing with a global pandemic, though, has special significance. “I think a lot of people would be surprised how much interfacing and cooperation there is regionally, between states,” says Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officers, a national nonprofit that represents state-level public health agencies. “It makes sense. If one state tries to do something restrictive and the surrounding states don’t, everyone just drives across the border. The more effective and progressive state health officials, that’s what makes them good—they bounce things off each other and learn from each other.”
In other words, as Covid-19 became a bigger and bigger national problem, a back channel of public health bureaucrats started working on this problem before the federal politicians got to it. In California, cooperation among a few county public health officials led by Santa Clara County Public Health Officer Sara Cody issued the first shelter-in-place orders, providing cover to mayors like San Francisco’s London Breed and perhaps saving hundreds or thousands of lives. When the first case hit Washington, the state’s secretary of health, John Wiesman, called Plescia. “This was on a Saturday morning, and he said, ‘I want you to convene a call on Sunday,’” Plescia recalls. He needed to get the other state health leaders on board. “I think we had 30 or 40 of them on there, for something that got called at the last minute.”
Absent a strong national response to Covid-19, it’ll be regional efforts that take on national significance. For one thing, states take cues from each other on public health measures—anti-tobacco laws, soda taxes, age limits for driver’s licenses and legal drinking, and so on. California has long had an informal authority in the public policy world owing to its size and its sometimes too-Californian willingness to experiment.
That’s especially important as some states and state lawmakers try to break quarantine early. Senator Ted Cruz of Texas told a local TV news channel that it was already time for people in his state “to get back to work.” Republicans in Michigan touted a protest at the state capitol against statewide social distancing rules. (People protested from inside their cars.) Pennsylvania state lawmakers are agitating for the same—despite Pennsylvania’s membership in the northeastern coalition.
Political agreements and public-private partnerships are important, but they’re just the top layer of how these coalitions might work. “There’s the formal governance structures, but the informal networks within state policymaking are pretty strong. There are conferences that bring together insurance commissioners, Medicaid directors, public health folks.
It’s kind of like a conversation that rotates through hotel ballrooms,” Jones says. “All this is happening as the same time as an internal shift in the field of public health, with is trying to reenvision the field and what it means to work in a local public health department, so the job is more than just immunizations and putting up flyers about condoms.”
Public health workers are stretching, operating with the knowledge that to really improve people’s health quality and access to care, they have to work on education, transportation, food insecurity, jobs—the entire economy. If poor people are disproportionately affected by health issues, then one way to treat them is to work on poverty itself. “They’re rethinking health as being the people and place that brings together everything the public sector can do,” Jones says.
Past multistate coalitions have tended to be impermanent. The ones that self-assemble after regional disasters like hurricanes or earthquakes usually disassemble when the disaster is over. An attempt to put together a multistate regional health care exchange under the Affordable Care Act collapsed under its own bureaucratic weight.
But this time? During a nationwide crisis likely to persist for years, absent strong guidance or support from Washington, DC? They might form a new kind of mesoscale federalism, organizing subsets of states with aligned interests on issues of regional concern that still fall below the level of federal control.
“The interesting question is, how much does what happens now carry forward beyond the acute phase of the crisis? How much of it is just dealing with a crisis versus creating precedent or new norms?” Jones asks. “I don’t know the answer to that question.” Like so much of what’s happening around the world right now, these regional alliances are something new, laying down rails and ties barely ahead of a locomotive that’s already steaming down the track.