A Shot in the Arm for Decentralization

When facing dangers blind, the best strategy to remain nimble is to have no single plan at all. Faced with the COVID-19 epidemic for which there was no existing vaccine and no evident treatment, the Trump Administration responded with Operation Warp Speed, a system of federal funding and federal purchase guarantees that enabled a number of major drug manufacturers to ramp up and produce hundreds of millions of doses even before their putative vaccines had been developed and tested. 

The Trump Administration laid out and executed a national plan that got vaccines tested, approved, made, and distributed with unprecedented speed and efficiency. But it is one thing to have the vaccines stacked in cold storage in your city, and another to get them into people’s arms. Here, in the tradition of all of its predecessors, the Trump Administration relied on the states, which have the primary responsibility for public health emergencies, to make and carry out their own injection plans.

Some critics think that the absence of a single national injection plan has slowed U.S. vaccination rates. Certainly, some states, especially Trumpier states like West Virginia, South Dakota, and Florida, have managed to get a lot more of their allocated vaccine into the most vulnerable than others, like New York, Washington, and California, where vaccine injections have been slowed by disputes about equity, priority, and political and bureaucratic power games.

The critics assume, without evidence, that a national injection plan and organization would have achieved the utilization rates of the best states rather than those of the worst. While counterfactuals are hard to prove, we can gain some enlightenment by looking at what other countries have done.

The country with the highest rate of COVID-19 vaccination so far is Israel. The Israeli government considered having the Army carry out mass vaccination. Yet despite a population less than 1/30th of the United States, Israel quickly and wisely discarded that plan in favor of a division of labor: the government ordered vaccine doses from Pfizer, and then handed them over to the four competing health maintenance organizations. Each HMO developed and executed its own plan to stick its own patients, all the way from four separate freezer warehouses at the airport, through their separate appointment and patient management systems, to their local clinics.

Despite what might look like irrational duplication and failure to implement a single plan to the central planning fetishists (who, unfortunately, we will always have with us), the result for Israel has been the best uptake of COVID-19 vaccines in the world. Israel is on schedule to complete vaccination of all adults by the end of March 2021, when some richer countries will not even have begun.

Israel, unlike the United States, has universal access to health care through the four competing HMOs. Yet some countries that have universal health care and modern electronic record keeping, such as Canada, Britain, France, and Spain, are doing worse than the United States (as a whole) at vaccine rollout and much worse than Israel.

As this pandemic shows, a nationalized system—as opposed to a competitive and decentralized health care system—is the worst choice of all. The difference between a government monopoly of health care providers through national or provincial health systems (as in Canada, Britain, France, and Spain) and competition (in Israel and the United States) outweighs the difference between universal and non-universal health care.

The Trump critics would have preferred imposing a single vaccine rollout plan on all the states, and the Biden Administration may yet try to formulate and carry out such a plan. This has the political advantage that nobody would have U.S. comparative data to criticize the planners, as Uncle Joe bans all approaches alternative to their own.

Federalism matters most, as the relative successes and failures in the campaign of the needle show, when it is important to get things right. When success and failure start to emerge, national leaders should encourage, shame, and at the limit constrain the laggards to emulate the speedy or yield to those willing to put tribalism aside and learn from best practices. Federalism and other forms of competitive decentralization allow the organizations that stumble to learn, if they choose, from those that roll out better. Competitive decentralization allows individuals to reward success and punish failure by exiting the failed organizations and entering the successful ones.

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About Linda Frances James

Linda Frances James is a pseudonym for an academic analyst of science policy.

Photo: Paul Hennessy/NurPhoto via Getty Images