States form “health alliances”. Can they make a difference to public health policy?

The recent emergence of several interstate health alliances marks a new phase for public health in the United States. These alliances include two that formed last month: the West Coast Health Alliance announced on September 3 and the Northeast Public Health Collaborative announced on September 18, and another announced this week by fifteen governors called the Governors Public Health Alliance, whose membership overlaps with the regional alliances. Until now, these alliances have included only Democratic-led states, and the common thread among all three is a broad rejection of the Trump administration’s approach to public health and the policies of the Department of Health and Human Services (HHS) led by its current secretary, Robert F. Kennedy, Jr.

So far this year, the administration has cut HHS staff by more than 20,000 people (the Centers for Disease Control and Prevention, CDC, losing about 3,000 workers, or a quarter of its staff), sought to cut funding for state and local health departments, implemented new, more restrictive recommendations for some vaccines, and questioned long-standing science and public health guidance. Many state health leaders, particularly those led by Democrats, have criticized these changes, with the new alliances a manifestation of that backlash. While the federal government is responsible for issuing guidance and making recommendations that can influence public health across the country, it is the states that have the ultimate authority to decide whether and where to follow that guidance.

Given this, the effects of forming these alliances generally fall into two main areas. One is practical: Although each state will continue to determine its own public health policies, alliances can foster communication and cooperation and allow for the sharing of resources when needed, without necessarily reporting directly to the federal government. For example, the West Coast Health Alliance aims to help align vaccination recommendations among member states, while the Governors Public Health Alliance seeks to be a “coordinating hub” for state leaders to share data and develop complementary public health guidance, among other activities. This could prove useful for states that no longer trust public health recommendations from the CDC or other federal agencies. This could make it easier to communicate with the public by providing a more unified message across states rather than having each state go its own way. The other effect that these alliances can have is more symbolic and political in the Wild: States unite to highly visibly criticize the Trump administration’s public health approach and policies.

Even before these alliances were announced, many states had already begun taking steps to decouple their policies from the federal government (especially regarding vaccines). So far this year, for example, 26 states have implemented policies to ensure pharmacists can administer COVID-19 vaccines on a large scale and without a prescription, despite changes – real and anticipated – in federal recommendations coming from the Trump administration. A smaller number of people have moved to require state-regulated health insurers to cover state-recommended vaccines for free, even if they are no longer recommended by the federal government.

While it may be unusual for groups of states to come together to develop their own public health recommendations, independent of federal guidelines, it is not entirely unprecedented. During the early months of the COVID-19 pandemic (under the first Trump administration), groups of Western and Northeastern states established coalitions to coordinate responses and share supplies and know-how among states in the face of what they perceived as federal inaction. Later, Republican-led states united to oppose some of the COVID-19 policies imposed by President Biden.

It remains to be seen whether other alliances will form or whether new alliances will develop. Ultimately, however, perhaps the most important consequence of their formation is to further cement what is a growing partisan divide in public health, reflected in both public opinion and state politics, and which is likely to lead to increasingly divergent public health policies and access across the country and uncertainty about the future of the federal-state relationship on key public health issues.