Will America’s public health reckoning ever come?

WASHINGTON — After 9/11, Congress created an entirely new government agency to address the threat of terrorism, and Americans are still taking off their shoes in airports more than 20 years later.

After a pandemic that killed more than 1 million people in the United States alone, very little about the federal government has changed at all, and it may not for a long time.

Virtually everyone generally agrees some kind of transformative public health reform is needed — Republicans, Democrats, and the public health agencies themselves. But they disagree on how to go about changes. It doesn’t help that Congress couldn’t agree on putting together a commission to examine the pandemic response.

“With a faceless virus, we sort of shrug our shoulders and are much slower to move,” said Alex Tabarrok, a scholar at George Mason University’s Mercatus Center.

There are still some outside scholars, experts, and organizations working to compile ideas if a moment of reckoning ever does come. Congress is facing a deadline next year to reauthorize the Pandemic and All Hazards Preparedness Act, which could be an opportunity for some action.

Some early think tank efforts at building momentum for reforms have sputtered out, but others are still working to find ideas and compromise, including some right-leaning think tanks, states, and big private foundations. Public health reform could also see renewed attention as Republicans ramp up their oversight of the Biden administration’s response, now that they control the House.

Whether Congress takes public health reform seriously could determine whether America can break out of the boom and bust cycle of funding preparedness efforts, and shape the field for the crises to come. But many reform advocates think an overhaul of the United States’ public health system may be years away, if it happens at all.

“It’s less of a sprint and more of a marathon. Hopefully, a half marathon,” said Jeffrey Levi, a professor at George Washington University’s school of public health.

The efforts so far to address the failures of America’s public health infrastructure during the Covid-19 pandemic have been piecemeal and sparsely funded.

Lawmakers did pass some modest changes as part of a pandemic preparedness package in December, including requiring Senate confirmation of future directors of the Centers for Disease Control and Prevention; creating a new, unfunded pandemic mission control office at the White House; creating new emergency hiring authorities; maintaining domestic manufacturing capacity; and requiring a modernization of public health data infrastructure. But there are also a whole lot of filler policies, ones that will require Congress or the federal health and oversight agencies to convene new committees or write new reports.

The process also laid bare the difficulties in pursuing more comprehensive reform. Congress stripped out a provision that would have created a bipartisan commission to examine the federal response to the pandemic, and to identify gaps and make recommendations for future action.

In the absence of a congressional review, the CDC initiated its own review of the agency’s structure, which resulted in an initiative launched in August with four fairly vague goals: to change how the agency shares data, to improve communication and timeliness, to break down silos, and to list new capabilities that would be helpful for emergency response.

The CDC did not respond to a STAT request to interview Mary Wakefield, a nurse and former Health Resources and Services Administration chief who is leading the effort.

Though CDC director Rochelle Walensky is hoping to make changes at the agency, there are limits to how much the CDC can do on its own. For example, the CDC needs Congress to give it the authority to demand data from states.

Some conservative critics say the CDC’s review of its past performance doesn’t go far enough, and would have been better handled by an independent entity. The agency’s structural review was conducted by three CDC officials.

“I don’t know… that having your fellow federal bureaucrat do a review of your performance is exactly impartial,” said Brian Miller, a fellow at the American Enterprise Institute.

Some groups of outside experts have convened with high hopes of making blueprints for reform, but they have largely fizzled out so far.

The Commonwealth Fund convened a short-term commission to study how America could develop an integrated national public health system, spearheaded by former FDA Commissioner Peggy Hamburg. But within three months, after the group issued a single report, it disbanded.

“The report has been useful, and it was never intended to be the end-all, be-all. It is a starting point about what a national public health system needed to look like,” Hamburg said.

The suggestions the panel came up with for lawmakers included creating a position at the Department of Health and Human Services to oversee public health, instituting sustainable and predictable funding for public health agencies tied to a basic set of capabilities, and investing in public health data.

Hamburg has pushed the ideas with members of Congress and Biden administration staff, including at the CDC, she said, but they were largely left out of Congress’ last legislation on the issue.

A long-running commission at the Center for Strategic & International Studies has met a similar fate. The group, called the Commission on Strengthening America’s Health Security, issued a prescient report in November 2019 calling for an end to the “cycle of crisis and complacency” that has plagued health preparedness.

The commission sought input from lawmakers, Biden administration officials, public health experts, and pharmaceutical companies, and published several papers on policy ideas. The proposals included bringing the Department of Defense to the table on health threats, creating a pandemic preparedness fund, and ensuring access to Covid-19 therapeutics. Other ideas included promoting private-public partnerships, ensuring sustainable, long-term funding, and treating health security like national security.

The commission had its last meeting in December, and is rebooting this year, its leader said.

“We are transitioning, and broadening the remit for next three years because we need to incorporate a more global dimension. Health security is not just a U.S. issue,” said Julie Gerberding, co-chair of the commission and CEO of the Foundation for the National Institutes of Health.

In the absence of decisive federal action, some states and philanthropies are exploring how they can make change on their own terms.

Indiana, a solidly red state with historically lackluster investment in public health, is actively pursuing public health reform at the direction of its Republican governor this upcoming legislative session. Gov. Eric Holcomb convened a commission of former lawmakers, public health officials, and hospital groups.

Last week, Holcomb listed public health development as one of top five priorities for the next legislative session. The commission made 32 recommendations for action, and suggested a $240 million annual increase in public health funding. It’s unclear how much of that could actually make it through the legislative process, but state lawmakers are considering the plan.

“They really are surfacing in Indiana their needs. Here’s the data we need, here are the investments we need, to build credibility not just within public health, but with a broader group of people,” said Hemi Tewarson, the executive director of the National Academy of State Health Policy.

Three other states, Arkansas, Michigan, and Rhode Island, are joining Indiana in a learning group run by NASHP to collaborate as state officials incorporate lessons from the pandemic into their public health infrastructure. That effort is supported by the Commonwealth Fund.

Prominent foundations are also exploring how best to support the public health system. A group of nine private foundations including the Robert Wood Johnson Foundation, the Commonwealth Fund, and the California Endowment, are part of the Funders Forum on Accountable Health at George Washington University, which has discussed the issue.

Levi, of George Washington University, said the group is exploring how best to leverage its expertise and prior investments to help public health departments build out their long-term capacity with cash infusions from Covid-19 relief funds. If the money is spent well and accounted for, Levi said, there’s a chance that the data could make a case for more investments in the future.

But there’s no guarantee that a day for comprehensive health reform will come.

“Everything I’m doing right now is based on that hope. I would be lying if I didn’t say the moment is slipping away,” Levi said.

Republicans, with newly minted control of the House of Representatives, have some appetite for their own vision of public health reform, but they haven’t coalesced around any specific policies yet.

House Republicans in particular will now be handling some oversight of federal science agencies, including the National Institutes of Health and the CDC. Senate health committee ranking member Bill Cassidy (R-Fla.) has also been interested in examining the agency’s remote work policies.

Eventually, the revelations could form a basis for legislative action.

“We need to actually take action to solve problems. Oversight is important, but the function of oversight is to set us up to solve problems from there,” said Miller, a physician and a fellow at the American Enterprise Institute.

Miller and several other right-leaning policy wonks are laying the groundwork for what conservative changes to public health reform could look like. Some of them involve delegating more authority to state and local health departments, and calling for CDC to be focused more on infectious disease threats than other issues like climate change.

Miller cited the agency’s rollout of a new unit called the Center for Forecasting and Outbreak Analytics to predict future disease outbreaks as an example of his belief that the agency has gotten away from its core responsibilities.

“Isn’t that your core job from 1946? Guys, why are you celebrating that? You should be embarrassed,” Miller said.

Andrew Keyes, a former Republican Study Committee policy staffer who now works at Paragon Health Institute, said he’s working in a similar vein on developing concrete policy frameworks to address the distrust of public health agencies that has emerged in the Republican voting base.

“We know there’s this frustration, and there’s distrust. What kind of reforms can we do to build back that trust?” Keyes said.

One opportunity for the 118th Congress to address public health issues is the reauthorization of the Pandemic and All Hazards Preparedness Act, which expires at the end of September. Lawmakers could choose to tack on related reforms, but the policy would have to be bipartisan to pass both the House and the Senate.

Even if this Congress doesn’t take up public health reform in earnest, the issue is likely to be present on the campaign trail ahead of the 2024 presidential election.

Florida Gov. Ron DeSantis, who’s widely expected to run for the Republican nomination, has already made federal public health agencies a rhetorical punching bag. DeSantis last month proposed creating his own “public health integrity committee” to independently review public health agencies’ recommendations.

“CDC will say these things and then people will think because they’re saying it we have to do it,” DeSantis said. “So other governors and I have talked about the need to have a panel of experts who can counteract nonsense when it’s coming out of these institutions.”

Besides outright antagonism, proponents of public health reform of all shapes and sizes will also have to overcome a powerful force in a reactive institution like Congress: apathy.

“The urge to turn to normal is incredibly strong, and just to kind of put it in the rearview mirror. That that is what we really are pushing back against,” said Joshua Sharfstein, the vice dean for public health practice and community engagement at Johns Hopkins University’s school of public health.