Making Sense of the U.S. Covid-19 Pandemic Response: A Policy Regime Perspective

David P Carter & Peter J May. Administrative Theory & Praxis. Volume 42, Issue 2, 2020.

On March 26, 2020, 3 months after Chinese authorities admitted to a novel coronavirus outbreak and 10 weeks after the first infection was documented on American soil, the U.S. led the world in COVID-19 cases with an estimated 81,321 afflicted residents (McNeil, 2020). Two weeks later, the number had climbed to 690,714 cases, with 35,443 deaths attributed to the disease (CDC, 2020b). While the State Department touted the U.S. as “leading the world’s humanitarian and health assistance response to the COVID-19 pandemic” (2020), media accounts more often used terms like “muddled” and “confused” to characterize the response (see Clausing, 2020).

In many respects, the latter characterizations are not especially surprising. Arjen Boin (2009), for one, describes how such crises set off a cascade of interrelated and endogenous problems that cross geographic, functional, and temporal boundaries. The resultant uncertainty and complexity foster delays, conflicts, and finger pointing. These are especially heightened in the American federalist system during a period of hyper-partisanship. Such facts notwithstanding, credible observers find the U.S.’s apparent inability to mount a timely and robust response puzzling, given the inevitability of such a pandemic and the country’s advantaged position to address it (e.g., Yong, 2020).

In this essay, we step back to consider what it takes to bring about swift and coordinated action in pandemic response and what has impeded such a response in U.S. attempts to address COVID-19. Rather than a rigorous empirical analysis, ours is an exercise of “sense-making” (Starke, 2018)—attempting to bring conceptual order to an unpredictable and still evolving situation. We apply a policy regime perspective (May & Jochim, 2013) to reflect how, in the U.S. setting, attention to crisis risk can be mobilized and appropriate public and private actions induced. Effective policy regimes involve common goals, institutional structures that channel attention and resources in support of those goals, and mobilization of interests to support those actions. We consider how the U.S. COVID-19 response fell short in policy regime terms and how that, in turn, limits the response’s coherence, legitimacy, and (near-term) durability.

The novel coronavirus that causes COVID-19 propagated internationally with the characteristics inherent to boundary-spanning crises—a widespread and serious threat, urgency, and uncertainty—on a scale unprecedented in living memory. Such crises require swift and coordinated action that reacts nimbly to changing circumstances; “contingent coordination” in the words of Don Kettle (2003). Our take on what such a response entails builds from the policy regime perspective’s conceptualization of regime strength.

Policy regimes are governing arrangements for addressing policy problems, made up of three elements: ideas, institutional arrangements, and interests (May & Jochim, 2013). Ideas are the rationales around which policy goals are established and implementation is organized. A vivid example in the COVID-19 pandemic is the oft-cited “flatten the curve,” which combines notions of virus outbreak mitigation and healthcare capacity constraints. Institutional arrangements structure authority, information channels, and relationships, reflecting elements of institutional design (Ostrom, 1990) and implementation structures (Matland, 1995). The pandemic compelled a system-wide “whole of government” response (FEMA, 2020) that is both fragmented and decentralized, cobbling together arrangements which span disparate organizations within and across levels of government, nonprofit entities, and for-profit enterprises. Interests are the constituencies that assemble around, or in reaction to, policy efforts. For example, the response activated previously inconspicuous cross-sector emergency management and public health communities, and, as we discuss later, politically and economically aligned interests.

How Ideas, Institutions, and Interests Can Foster Robust Crisis Response

The policy regime perspective suggests that interactions between the three regime elements (ideas, institutional arrangements, and interests) help determine the relative strength of a crisis response. This relative strength, in turn, shapes what emergency and crisis management scholars typically refer to as coordination (Boin, 2009) and policy regime scholars label “coherence”—the fidelity, competency, and consistency of actions taken in pursuit of policy goals. Credible accounts describe this as lagging, insufficient, and uncoordinated in the U.S. COVID-19 response (e.g., Yong, 2020).

A strong regime fosters coherence by advancing a shared sense of purpose, establishing (or activating) institutional arrangements that effectively direct action toward relevant goals, and engaging a supportive constituency (May & Jochim, 2013, p. 432). Policy ideas serve as the integrative “glue” that coalesces policy action around a plan of action. Political commitment to strong rationales ensures that responsible parties are aligned on shared goals and the means necessary to achieve them. Compelling ideas thus enable the “common operational procedure” that Boin (2009) suggests proves elusive in the bewildering pace, ambiguity, and complexity of crisis contexts. Boin further points out that leadership is crucial when it comes to identifying and committing to policy ideas in crisis response, as it typically falls to leaders to “offer a convincing rationale…which generates public and political support for their crisis management efforts” (2009, p. 373).

Effective institutional arrangements facilitate (rather than frustrate) the implementation of policy means in pursuit of shared goals. In crisis contexts, this calls on institutional flexibility which enables administrators to forgo standard procedures to improvise (sometimes outside of the rules) to adapt and respond to rapidly changing circumstances (Boin, 2009). In fragmented authority structures, this requires institutional mechanisms, either formal or informal, that foster understanding and mitigate conflict across jurisdictional and organizational barriers (Kettle, 2003). In decentralized administrative contexts, it requires institutional linkages across levels of government and between disparate organizations, to channel necessary information, expertise, and resources (Milward & Provan, 2000).

Interest support provides the energy behind a regime and the ability to overcome the criticisms of detractors. Such support is important for both operational and political reasons. Operationally, interest support can help marshal necessary resources and secure citizen cooperation (Van Meter & Van Horn, 1975). Politically, support is important in reinforcing decision makers’ commitments to response goals and measures (Kamradt-Scott & McInnes, 2012). As with any policy action, pandemic responses distribute benefits and burdens, engendering the backing of some constituents and opposition from others. Thus, while mounting a response requires rapid mobilization of emergency and healthcare interests, sustaining response efforts requires continuous support from policy makers and affected parties.

How Failing to Effectively Leverage Ideas, Institutions, and Interests Handicapped the Covid-19 Response

Our review of contemporaneous reporting reveals profound limitations when considering the U.S. COVID-19 epidemic response’s ideas, institutional arrangements, and interests. The response has lacked critical political commitment to a clear or consistent response rationale. It has failed to adapt existing institutions to the rapidly evolving threat, to harmonize differences both across and within the federalist authority structure, and to induce the changes needed to align market institutions with response needs. And, while the response has mobilized a considerable public health and healthcare infrastructure, efforts have been hampered by conflict among political interests and opposition from economic ones.

Response Ideas: Muddled Goals and Deficient Political Commitment

The U.S. response was handicapped early by an inability or unwillingness to acknowledge the novel coronavirus threat and articulate a clear vision for addressing it. In policy regime terms, the Trump administration failed to put forth and commit to a clear response idea. Public health experts were well aware of the actions required to address the COVID-19 outbreak when the U.S. announced its first case on January 21. It called for rapid deployment of measures to track and curtail the virus’ spread; what public health professionals refer to as “containment” (Parodi & Liu, 2020). Instead of committing earnestly to containment goals and measures, the administration evaded them by positioning the problem as a foreign one (the “China virus”; Vazquez & Klein, 2020). Amid testing blunders (discussed below) the administration largely limited its containment measures to those consistent with the “America first” doctrine that had guided Trump’s presidency to that point, beginning with a January 31 travel restriction barring entry to foreign nationals who had visited China.

The limited, politicized notions of COVID-19 as a foreign problem let pass a crucial opportunity to foster a shared sense of crisis and need for immediate action across subnational levels. That opportunity was closed by late February when the administration arguably came around to fuller recognition of the COVID-19 threat with assignment of Vice President Mike Pence to lead the federal COVID-19 task force. In early March, multiple COVID-19 cases were found among U.S. residents without travel histories in areas where the disease was documented, signaling that within-community transmission had been occurring outside of hospital containment zones. To public health professionals, the implication was clear: containment of the coronavirus was no longer a viable option—the response was now an effort in “mitigation” (Parodi & Liu, 2020).

Public health experts likely understood the shift to mitigation as a reorientation to the revised goals of slowing virus transmission and protecting those most vulnerable to COVID-19 (CDC, 2020a). In the overall response, however, it amounted to compounded ideas. For example, although the Trump administration eventually made halting moves closer to mitigation means and goals, it continued to pursue containment with a March 11 travel ban on foreign travelers from 25 European countries. By mid-March, Trump portrayed the administration as (retroactively) committed to a broader, comprehensive goal: “We’re using the full power of the federal government to defeat the virus, and that’s what we’ve been doing” (as cited in Stevens & Tan, 2020). All of this, in regime terms, amounted to muddling response goals with varied top-level commitment.

Meanwhile, “flattening the curve” gained momentum in some areas. Based on the notion that citizens can keep infection rates from overwhelming the health care system by decreasing their virus exposure through limited social interactions, the idea offered a more tractable interpretation of mitigation that sets forth actionable roles for all in combatting COVID-19. The idea was most readily embraced in states and regions first to adopt mitigation policies, such as San Francisco (the first U.S. city to impose a stay-at-home mandate) and California (the first state with a state-wide stay-at-home order), and others hardest hit by the virus (e.g., Washington state and New York). Such varied subnational commitment to “flattening the curve” and halting support from above shows how fragmented idea uptake led to a mosaic of mitigation measures, such as social distancing guidelines, travel limitations, and virus testing.

Competition among ideas and related virus rhetoric throughout this period impeded the response’s ability to galvanize attention and action in the way that might be found in a stronger regime. While “flatten the curve” became a common refrain among some, it competes with the alternative framing of virus response as a “war” which must be won (Bennett & Berenson, 2020). Perhaps more importantly, virus mitigation (including the idea of “flattening the curve”) is increasingly placed in tension with “opening the economy” through relaxed mitigation restrictions, such as stay-at-home orders. Despite arguments that extreme mitigation efforts offer the most favorable economic outcomes in the long run (e.g., Jacobson & Chang, 2020), the intensifying ideational tug of war between” flattening the curve” and “opening the economy” playing out among competing interests holds serious implications for the COVID-19 response’s durability—a point we return to later in this commentary.

Response Institutions: A Mosaic of Asynchronous, Fragmented, and Incongruous Arrangements

Just as the early weeks of the U.S. COVID-19 response were handicapped by ideational resistance and lagging commitment in the federal political sphere, they were afflicted with dysfunctional institutional dynamics among administrative ones within and across multiple levels of government. These dynamics undermined the type of “institutional cohesion” that can effectively channel attention, resources, information, and organizational relationships in support of regime goals (May & Jochim, 2013, p. 435). Four limitations are most apparent: institutional silos; red tape and regulatory hurdles; fragmented authority among national and state levels; and the “hollowing out” of healthcare institutions.

While political officials directed their ire in late January at China, public health officials at the Department of Health and Human Services (HHS) mounted concerted (if delayed) containment efforts. The first critical step was to develop and deploy tests with which to track and respond to virus spread. It is impossible to say with certainty why the U.S. failed at this seemingly straightforward task. President Trump’s inability to grasp the situation’s seriousness and subsequent evasion of responsibility surely had an impact. John Bolton’s 2018 disbanding of the National Security Council’s Directorate for Global Health Security and Biodefense, known more widely as the “pandemic preparedness unit,” likely also played a role (Lopez, 2020). These factors notwithstanding, it is clear that early and swift COVID-19 testing fell victim, to some extent, to institutional barriers and bureaucratic silos.

Delays began when officials chose to forgo a test developed by the World Health Organization but were dramatically compounded when technical blunders at the Centers for Disease Control and Prevention (CDC) rendered their test unusable for weeks (Lopez, 2020). Meanwhile, nonprofit and private testing ran into regulatory hurdles. For example, when the first case of COVID-19 landed in Washington state, a team of infectious disease researchers was in the middle of a study of Puget Sound residents displaying flu symptoms. Lacking only permission to repurpose collected samples, they encountered regulatory obstacles, ultimately to be shut down by officials enforcing Medicare rules (Fink and Baker 2020). Similarly, COVID-19 tests sat undeployed at dozens of university and for-profit labs, awaiting approval through the Food and Drug Administration’s (FDA) emergency use authorization process. As testing needs became evermore dire, coordination between the directors of the CDC, FDA, and HHS Secretary Alex Azar reportedly deteriorated amidst suspicion and blame avoidance, further impeding the already beleaguered test rollout (Shear et al., 2020).

The challenges and opportunities of the U.S. federal system’s institutionally fragmented authority are readily apparent as states and municipalities have taken up mitigation efforts. Similar to past crises (Lester & Krejci, 2007; Maestas, Atkeson, Croom, & Bryant, 2008), power struggles and blame games have at times plagued federal-state relationships. Furthermore, a patchwork of policies, from voluntary social distancing to mandatory stay-at-home orders, have emerged across states and localities—with some areas refusing to impose even voluntary restrictions. Such institutional inconsistencies invite spillover effects, as weak policies in one area threaten counterparts with stronger ones. Even stringent measures (e.g., those with noncompliance penalties) are institutionally weak, relying largely on normative social pressures to encourage compliance. At the same time, some observers have noted increased leadership by, and coordination among, state leaders. As expressed by Kansas governor Laura Kelly: “There is a lot of chatter amongst governors…We’ve just started texting and calling each other as we look to [ask] ‘Why did you do this? What was the thought process behind this?’” (as cited in Strauss, 2020).

Decentralization and the “hollowing out” (Milward & Provan, 2000) of U.S. governing institutions have created yet further institutional challenges—particularly when it comes to treating infected patients. Although state and local political officials wield most of the decision-making authority in mitigation efforts, implementation of those decisions falls to public health professionals working in tandem with the nongovernmental elements of local healthcare infrastructures. Reliance on nonprofit and for-profit partners has left state and local administrators mostly indirect mechanisms with which to encourage coordination; for example, devising credible repayment commitments to encourage hospitals to cancel elective procedures, thereby forgoing associated revenue, to create additional capacity for treatment of COVID-19-infected patients (O’Donnell, 2020).

Exacerbating this “hollowing out,” the front-line of the U.S. pandemic response depends on an institutional arrangement built to generate revenue by optimizing resources and minimizing slack. As a result, U.S. healthcare infrastructure lacks sufficient capacity to treat the impending swell of COVID-19 patients (Barbaro, 2020). A cost-savings imperative and “certificate of need” regulations have severely limited the number of available hospital beds, which is increasingly eclipsed by demand as infection rates climb. Nationwide shortages of ventilators (vital equipment in treating respiratory illnesses associated with COVID-19) have driven state agencies to the private market, where they compete with one another and the Federal Emergency Management Agency (FEMA) for a finite and increasingly expensive supply. Similarly, absent rapid or reliable distribution from a depleting national stockpile, governors, municipal officials, and hospital administrators rely on private markets for respirators, 70% of which are made overseas (Simonite, 2020).

Each of the preceding is reflective of long-term challenges and trends in the American administrative state that, in combination, clearly create shaky response footing. The administration’s presumed solution—the aforementioned appointment of Mike Pence to head the COVID-19 task force—represents a classic example of attempting to impose institutional cohesion absent a well-defined goal and in the face of underlying bureaucratic conflicts. Past examples, from the original Office of Homeland Security (Wise, 2002) to the War on Poverty (see Wilson, 1989, pp. 268-274), suggest the promise of such imposed coordination is limited. From a policy regime perspective, stronger institutional footing is based on common purpose and meaningful linkages among relevant implementing authorities at all levels—perhaps the hardest part of a regime to craft, made much harder when goals are changing, and underlying interests are in conflict, as discussed in the next section.

Response Interests: The Drive of Mobilized Support and the Inertia of Competing Interests

A policy regime’s governing capacity comes down, to a considerable degree, to the extent that a regime effectively mobilizes relevant interest support while minimizing opposition (May & Jochim, 2013, p. 436). The COVID-19 pandemic and the U.S. response to it have activated a range of interests, with varying impacts on response activities. Supporting interests have sought to push through the inertia of weak ideational commitment, institutional challenges, and opposition, while interest conflicts and resistance to response measures threaten to undermine response efforts.

Support for mitigation efforts is most easily witnessed in the nationwide cadre of public health professionals that has marshaled to the response, from National Institute of Allergy and Infectious Diseases director Dr. Anthony Fauci to healthcare professionals and hospital personnel. Civic efforts have further attempted to step up in the wake of response deficiencies. For example, the Bronx Documentary Center (a nonprofit gallery) posted hundreds of self-printed posters and flyers to inform public housing residents of how to reduce COVID-19 spread, Utah tech companies committed to a public-private initiative to overcome testing shortages in the state, and small businesses and everyday residents all over the country have rallied in attempts to address critical resource shortages, such as making and distributing hand sanitizer and face masks. Many entities, from community associations to celebrities, have taken to social media to encourage compliance with stay-at-home mandates.

The common interest among practitioners, including researchers, hospitals, and the medical profession, in confronting a public health crisis offers a potentially forceful focusing of attention across all levels of government and the private and nonprofit sectors. Yet, gaining traction on coronavirus spread has been challenging and many healthcare systems across the country are stretched beyond their capacities—begging the question of how public health interest support has been so impaired. Much of the answer may be found in the incredible challenges imposed by testing deficiencies and resource shortages, such as those in critical protective equipment and treatment devices. Apart from the countervailing economic and political forces (discussed below), public health support has obviously been hampered by the inability to get sufficient resources to the right places at the right times. From a public health perspective, this is not a problem of regime mobilization, but one of effective implementation.

The importance of resource deficiencies notwithstanding, the response has been repeatedly frustrated by clashing political interests. Likely reflecting the hyper-partisan times coupled with the President’s political-transaction governing approach, federal-state relationships have been plagued by power struggles and blame games. More than in any prior crisis, the pattern of conflict seemed to break along partisan lines. For example, more than a few observers point out that governors politically aligned with the President have been quicker to receive aid, while several Democratic governors are the target of public insults (Nicholas, 2020; van Wagtendonk, 2020). The impact of partisan political interests plays out beyond federal-state relations. Both reporters (McCarthy, 2020) and scholars (Adolph, Amano, Bang-Jensen, Fullman, & Wilkerson, 2020) note a pattern to the timing of state stay-at-home measures: even accounting for differences in infection rates, Democrat governors have tended to move faster to impose restrictions than Republican ones.

Although such political divides may be in part ideological, they are also likely driven by the strongest opposition to mitigation efforts: economic interests. The COVID-19 pandemic is more than a public health crisis; among other things, it triggered a disastrous economic one. Social distancing guidelines and stay-at-home policies abruptly froze entire sectors of economic activity across the U.S. and worldwide, with near immediate consequences. A staggering 3.3 million U.S. residents filed for unemployment in the third week of March, only to be superseded by 6.8 million the following week, and 6.6 million in the first week of April. Estimates put the April jobless rate at around 13% (Wolfers, 2020) and future projections are as high as 32% (Davidson, 2020). Considering such massive economic impacts, resistance to coronavirus curtailment measures has begun to grow, calling into question the sustainability of mitigation measures.

Pandemic Response Feedback: Implications for Response Coherence, Legitimacy, and (Near-Term) Durability

The policy regime perspective provides an additional lens for thinking about what all this means for governing (May & Jochim, 2013): how policy regimes—in this case the COVID-19 response regime—engender feedback among affected interests. Feedback can be either direct, such as public objections or pronouncements of support, or indirect, reflected in compliance or noncompliance with guidelines or directives. The nature and extent of such feedback are “mediated by the perceptions of the core ideas behind the policies, the experience with the institutions that deliver the policies, and the images put forth by the interests that support or oppose the policies” (May & Jochim, 2013, p. 430). At issue is whether a given policy regime advances a coherent set of ideas (or not), entails an approach that is perceived as legitimate (or not), and is durable or fleeting.

Our account of the U.S.’s response to COVID-19 shows a range of maladies that have handicapped what policy regime literature labels coherence, and emergency and crisis management scholars more typically refer to as coordination (Boin, 2009). Top political officials first yielded the potential for a swift and coordinated response when they failed to put forth a clear vision for virus containment. They have since impeded one by not firmly committing to mitigation measures. Mitigation take-up among state and local officials is disjointed and inconsistent, made all the more complicated by the decentralized and market institutions upon which response efforts rely. While the response has mobilized support from public health, healthcare, and civic corners, it has been impeded by sparring political interests and growing opposition from economic ones. Put differently, the pandemic response reflects a feeble policy regime, reflected in inferior federal direction and an inconsistent, disorganized patchwork of state, local, and nongovernmental actions.

The repercussions of an incoherent response are more than operational (as crucial as these are): they further erode the response’s legitimacy, already undermined by credibility issues from the top. Presidential statements that the virus would only mildly impact the U.S. were exposed as invalid. Halting endorsements of virus mitigation and contradictions with public health experts, such as Dr. Fauci, undercut the seriousness and sincerity of national guidelines. The disabling effects of partisanship are evident in varied mitigation measures, public battles between the President and beleaguered governors, and the tenuous balance that state and local responses attempt to strike while conserving depleting resources. To be sure, sections of the American public, certain business interests, and the President’s political allies would disagree with many of these characterizations, but the fact remains that politization has likely impaired widespread acceptance of the response’s legitimacy.

The consequences of an incoherent response, coupled with the impacts of impaired legitimacy, have grave implications: they have allowed an already serious threat to dig in deeper, leading to a longer crisis and thousands more deaths than might otherwise be the case. In the face of a prolonged crisis, the intensity of response opposition has grown among some more vocal corners of those economically (or otherwise) afflicted, and the President’s commitment to costly coronavirus mitigation measures appears shaky. In late March, Trump floated the idea of easing federal guidelines aimed at curbing the virus’ spread by Easter (far earlier than experts recommend), two days after proclaiming in a tweet “WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF” (caps in the original; as cited in Associated Press, 2020). Although he abandoned the expedited timeline, reportedly influenced by both virus mortality projections and public polling (Baker & Haberman, 2020), the President’s wavering commitment raises concerns over the durability of the U.S. response.

The policy regime perspective cautions that even robust policy efforts are vulnerable to deterioration over time (May & Jochim, 2013). As demonstrated by policy feedback scholars (e.g., Patashnik & Zelizer, 2013) and seen in the examples above, undesirable impacts can foment interest‐based backlash that threatens to cripple the energy behind policy efforts. And, given sufficient momentum, backlash can alter the focus of political commitments in what Aaron Wildavsky (1979) refers to as a “strategic retreat on objectives.” As we have sought to demonstrate in this narrative, political commitments in the coronavirus response have proved far from strong and the response to-date far from robust.

It is clear to us that renewed commitment to mitigation goals from the Trump administration would prove a valuable (re)starting point for energizing the COVID-19 response nationwide. More fully leveraging the federal governments’ existing mechanisms for overcoming institutional barriers, such as the Defense Production Act, would also help. However, the President’s strong desire to “reopen” the economy suggests such actions are unlikely, and any proclamations to a renewed commitment would surely be received with skepticism by many due to the legitimacy concerns discussed above.

The greatest promise likely rests in state and local politicians working in tandem with public health experts, healthcare professionals, and civic partners. Subnational coordination is needed to foster greater cohesion in the current fragmented national response, including shared commitments to bring states “on the same page” regarding mitigation and the timing of economic reopening. Relevant elected officials must fully reinforce these commitments over time, with appropriate adjustments for changing circumstances. An economic reopening alliance recently announced by East Coast governors is a step in this direction, as is the analogous Western States Pact between California, Oregon, and Washington. Ultimately, whether the U.S. response gains sufficient traction to keep mortality rates to the sobering 49,000-136,000 COVID-19 deaths projected by experts (Wan & Johnson, 2020) depends on whether such efforts engender the legitimacy and cohesion necessary to sustain essential undertakings through the hardships of coming months.