This article offers a roadmap to improving coordination between the states and federal COVID-19 response.

Under the U.S. Constitutional structure, public health governance largely occurs at the state and local, rather than the federal, level, resulting in a “patchwork response to epidemics.” Variations in how states and localities respond, and limited and inconsistent responsiveness of the federal government in its support and coordination roles, have caused confusion and exposed weaknesses in the national response to an infectious disease that is “highly transmissible, crosses borders efficiently, and threatens our national infrastructure and economy.”

Furthermore, management of the crisis through governors and presidential use of executive and emergency powers leave the system with few ways to correct poor decisions or hold officials accountable in the midst of the crisis for falling short in their response.

How can a more unified, effective, evidence-based response be mounted by the Federal government without upending the structure of our system? Drs. Rebecca Haffajee and Michelle Mello guidance includes:

• “convene governors and state directors of public health and exhort them to reach consensus on a coordinated set of community mitigation interventions and a timeline. Unified decision making would ensure that all governors have access to the best available evidence, provide political cover for those under pressure to minimize disruptions to their local economy, and replace competition among states for scarce medical resources with a sensible allocation framework.”
• Congress can use its spending power to get states to adopt a “uniform playbook” of response measures, conditioning future funding on adherence to a set of best practices;
• Congressional use of interstate commerce powers to slow the virus’ spread;
• Continue to use Federal emergency declarations to clear regulatory barriers to rapid, equitable response, get needed equipment and services manufactured and shipped out, and “prevent the virus’s spread in federal facilities, including immigration-detention centers and correctional facilities.”