The default governance architecture for public and individual health care in the United States is federalism, the division of responsibility between federal and state governments. A public health emergency such as a pandemic typically produces swift federal actions to support affected individuals, businesses, and states. Such actions include exercising executive emergency power to disseminate supplies, enacting relief bills, and triggering agencies to facilitate financial and regulatory relief. An emergency also typically involves coordination between federal and state governments, as state and local public health officials need federal funding and guidance but also perform key functions such as isolation orders, testing, contact tracing, and vaccine dissemination. In the case of COVID-19, some of the usual patterns have been disrupted. The two major federal response bills enacted in March 2020 followed prior playbooks, offering financial assistance such as increased Medicaid funding and unemployment insurance benefits as well as novel policies such as paid leave to care for COVID-19-positive relatives. The bills largely relied on states to take up funds, implement emergency assistance, and exercise regulatory options to reach those harmed by the pandemic and its attendant recession. This approach built on states’ preexisting policies, heightening differences between states and intensifying the pandemic’s inequitable impact. This chapter evaluates the atypical federal pandemic response – which witnessed an executive branch rejecting much of the centralized responsibility necessary for addressing emergencies – and the wildly variable state response – some of which prioritized politics over health, and all of which depended on the strength of preexisting social programs – to determine the legacy of the novel coronavirus for federalism in public health emergencies.

Throughout American history, protecting states’ rights within federal health reform laws has served purposes other than the needs of the poor, such as excluding those deemed undeserving of assistance, the “able-bodied.” This chapter explores the role of federalism in health reform, paying particular attention to the importance of universality in programs meant to aid the poor, such as Medicaid. American federalism is dynamic, involving separate state negotiations with the federal government rather than the fixed dual sovereignty imagined by the Supreme Court. Such negotiations lead to variability, which in health care may lower the baseline for reform-resistant states and thus the nation as a whole. This is especially significant when the federal government attempts to improve conditions nationwide, as it did with the Affordable Care Act’s (ACA’s) universal health insurance coverage. The example of Medicaid expansion under the ACA demonstrates how state variability can improve coverage but also jeopardize it; keeping states in the picture sometimes results in restricting access to the safety net rather than strengthening it. The debates of the twentieth century about the role of government in health and who is deserving of aid are bound to repeatedly arise without fully gauging federalism’s mixed effects in health reform.