Public Health on Life Support
In retrospect, we were so busy celebrating the advent of coronavirus vaccines that we forgot the real challenge would be getting the vaccine into patients’ arms. Until recently, the federal government saw its role as ending with the delivery of the vaccine to the states. What the states chose to do with the vaccine once it reached their borders was largely up to them.
This led to a disjointed, state-specific system that defies generalization. In two states, you qualify for vaccination if you are a smoker. In 15 states, you qualify if you are obese.3 Are you taking immunosuppression? Then you’re in luck—if you have a solid organ transplant. Most states don’t prioritize patients with rheumatic disease, even if they are taking the same immunosuppressive drugs. Several resources have popped up to help the confused, but often these websites only narrow your search to a smaller subset of subsidiary websites.4
The real problem with leaving vaccine distribution in the hands of the states comes down to a question of resources. All of the states, with the exception of Vermont, are required by statute to have balanced budgets; 38 states prohibit carrying a deficit from one year to the next.
These balanced budgets have been achieved, in part, by hollowing out state public health services. On average, spending on public health has been reduced to just 1.5% of a state’s budget. Since 2010, spending on state health departments has fallen by 16% per capita. Three-quarters of all states spend less than $100 per person on public health. In Louisiana, it’s $32 per person.5
Why was this serious underfunding of public health across the country allowed to take place? By and large, public health in the U.S. has been a victim of its own success. You know your state has an effective public health system when you forget it exists. You breathe clean air, you drink pure water, and you go about your life in blithe ignorance of the public health officials who are working like mad behind the scenes to keep you safe.
Because we forget about the importance of public health departments to maintaining public health, state legislatures cut their funding. This is roughly analogous to cutting funding to the local fire department because no buildings have burned down recently. And now that our house is on fire, we have finally realized no one left is in the firehouse to rescue us.
State public health systems have not been able to ramp up to meet the demands of vaccinating a state because they are operating on bare-bones budgets. State governments cannot quickly reallocate funds to support their public health departments because of their balanced budget requirements; to move money to support vaccination efforts, they would have to choose to cut funding to schools, or sanitation or some other mandatory governmental function that has also been taxed by the pandemic. To do otherwise would require a degree of political bravery that state legislators largely lack. Thus, most states are stuck making do with the public health systems they had in place pre-pandemic, which in most cases, was not much.
National Vaccination Strategies
The $1.9 trillion pandemic relief package approved by Congress includes $160 billion to support a national vaccination program. These funds will enable the federal government to take the following steps:6
