Why State-Run Vaccine Delivery Could Be Bumpy

4 minute read

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We are about to take Supreme Court Justice Louis Brandeis’ assertion from 1932 that states are the laboratories of democracy to its extreme interpretation. States are now simply the labs.

As freight planes and armored trucks deposited the much-awaited COVID-19 vaccination vials to health care centers, the focus turned away from the multinational corporations’ trials and toward the local paths of delivery. Washington decided that when it came to vaccine distribution, each state knew best, and bowed out of a one-size-fits-all federal prescription for immunization policy. So diffusive is the control that some states even had their own safety reviews of the vaccine — a step widely seen as unnecessary and potentially dangerous to the credibility of the federal reviews.

If the stakes weren’t so high, it would be a prime moment for government nerds to opine on the merits of federalism and states’ rights. On one hand, if the whole point of a whole-of-government push to find a vaccine was to marshal resources for record-speed discovery, the splintered delivery of this incredible scientific breakthrough may yield plenty of speed bumps. On the other, small-government conservatives regularly preach that states know their populations better than Washington, and that local leadership is more responsive to parochial needs.

But those same forces are why such a localized approach could get messy. While Dr. Anthony Fauci doesn’t give a hoot about lobbying or protests, elected state officials do. Which means each and every state is open to implementing a system that minimizes friction, maximizes goodwill and perhaps incorporates science when it is convenient. Uber, for example, is lobbying states to treat its drivers as essential workers and giving them earlier access to the vaccine. The divide between the elderly and the essential illustrates a gap between who has stronger clout in state capitals. Even members of Congress — who are working in a office complex that is a super-spreader — are debating whether they should avail themselves of priority access to the shots.

To be sure, federal recommendations, like prioritizing delivery for health care workers and high-risk populations, were taken into account in state capitals and their health departments. But the decision on how to administer these vaccines is largely on the states, which filed preliminary plans with the Centers for Disease Control and Prevention. Those plans are imperfect at best. Less than a third of the states included any estimates in those plans for how many providers would be in the vaccination chain, only a quarter had plans in place to make sure the vaccines reach under-served populations and only half of the states had a vaccination registration system ready to track doses, according to a Kaiser Family Foundation review of the ever-evolving playbooks.

The disparity is incredible. Some states, like Pennsylvania and Minnesota, released just a few pages of summary of their plans to vaccinate residents. New Jersey’s plan is 182 pages. Wyoming’s is 33.

This isn’t to say that states won’t get this right. Brandeis marveled at states’ abilities to create policy without significant risk to the rest of the country. States already carry the burden of law enforcement, unemployment insurance and public education. They can do big things when they have to get them done. At the same time, states can try out new idea systems and ideas that end up working, or not, for the country as a whole. For instance, Massachusetts’ health care law under then-Gov. Mitt Romney, a Republican, gave us the framework that would become the Affordable Care Act, passed by a Democratic Congress and known more commonly as Obamacare. Another example would be Vermont’s experiment with Medicare for All which proved so financially burdensome that the liberal state scrapped it.

But it’s one thing to test the viability of mandated health coverage. It’s another to actually get into the business of direct delivery of health care itself to each and every resident. Brandeis’ observation about states being laboratories for democracy sounds honorable when it comes to tax policy but may prove to be folly when it comes to serving a lifeline to a country hobbled by a pandemic. After all, America doesn’t fight its foreign wars with each state leading its own military unit. But it is about to wage a domestic campaign against a virus with dozens of distinct battleplans.

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Write to Philip Elliott at philip.elliott@time.com