In October, the heads of fifteen primarily liberal-leaning states and territories founded the Governors Public Health Alliance (GPHA), a self-described nonpartisan state-level public health coalition. The press release by California Governor Gavin Newsom was a bit more direct: “As extremists try to weaponize the [Centers for Disease Control and Prevention] and spread misinformation, we’re stepping up to coordinate across states, protect communities, and ensure decisions are driven by data, facts, and the health of the American people.” The Wall Street Journal also offered its own take: “Blue States Are Setting Up a Shadow Public-Health Alliance to Counter RFK Jr.”
Policy-focused, multistate coalitions are not new: Subnational networks, compacts, and platforms—including those that stretch across national borders and continents—have been on the rise in the past two decades. Nor are these groupings necessarily partisan. But GPHA doesn’t fit neatly into any of these molds, and it may be best understood as an alternative government structure—one that signifies a profound shift in the federalist landscape of public health governance.
One starting point is to consider its defining qualities, nascent though the effort is, in the context of other subnational coalitions. The most natural sphere for subnational coalitions is shared geographic features or natural resources. Regional collaborations—within countries or across borders—dominate subnational networks and coalitions. The Colorado River Compact, for example, involves seven U.S. states working collectively to manage the river’s water resources. This partnership, which dates to the 1920s, addresses water allocation amid climate change, focusing on drought planning, conservation strategies, and legal compliance.
Subnational and transnational networks and coalitions have increasingly been at the vanguard of climate action. For instance, California has actively participated in international climate compacts, asserting its commitment to environmental standards and carbon reduction targets. In some cases, the state is stepping up to fill the void left by the federal government. California Governor Gavin Newsome told the Los Angeles Times he’s “absolutely” standing in for the United States at this week’s COP30 climate policy conference, which U.S. President Donald Trump is not attending.
Other efforts have been aligned with, even in support of, policy positions advanced by the U.S. government. California is a member of the Under2 Coalition, which emphasizes limiting global warming to 2 degrees Celsius—a target emphasized in the Paris Agreement, to which the United States was a signatory. And the 2023 bilateral memorandum of understanding between California and Australia, with its focus on clean energy, technologies, and transportation, fit neatly with wider U.S. policies at the time. California, along with other Western states such as Oregon and Washington, has also developed carbon trading agreements with Canadian provinces such as British Columbia and Quebec. These agreements are structured under the Western Climate Initiative, which aims to reduce greenhouse gas emissions through a market-based cap-and-trade system.
Beyond compacts and collaborations, subnational action can occur when the state, county, or community is seen as the most appropriate level at which to structure or administer an initiative. In the United States, subnational action has a profound and enduring influence in the realm of health policy. A prime example is the Affordable Care Act (ACA): Under the ACA, states were granted the discretion to decide whether to establish their own health insurance exchanges or to rely on the federal marketplace. They also were tasked with determining the extent of Medicaid expansion to cover additional low-income individuals.
California’s own healthcare approach is another unique model of federalism. The state delegates substantial autonomy to its fifty-eight counties, each operating distinct systems for financing and delivering public healthcare services. Some counties, for instance, contract with private hospitals for Medicaid service provision, while others run their own public hospital systems.
Additionally, subnational action in health policy extends to public health management. Take the early months of the COVID-19 pandemic: States implemented diverse masking mandates and varied in directives concerning the closure of schools and businesses, reflecting tailored responses based on regional epidemiological data and policy priorities. This decentralized approach underscored how dramatically states can differ in their applications of health policy. A top adviser to the GPHA emphasized that the coalition’s effort is part of a “broader ‘realignment’ in health policy that is seeing states take on a larger role in addressing challenges like maternal and child health, with governors seeking guidance about how health care systems and public health systems can best work together.”
A decent amount of evidence suggests, though, that the GPHA might be best understood not within the context of conventional subnational networks, coalitions, or actions, but instead as an alternative government structure—perhaps temporary and based on political conditions. The GPHA is, after all, not rooted on any specific shared concrete geographic interest, as with the Colorado River Compact. The states participating in this alliance are either states that have solid majorities of Democrats or that have governors who are Democrats. The GHPA is not a domain, such as the Affordable Care Act, where the federal government created a structure to give states flexibility to design their own programs. It’s also not like climate-focused subnational compacts, which are primarily pushing beyond the federal government in terms of policy innovation.
In the GPHA’s case, Health and Human Services Secretary Robert Kennedy Jr. has taken several actions that the participating states interpret as undermining the nation’s public health infrastructure. Notably, he has made major staffing cuts at federal public health agencies and advocated for diminished funding for federal agencies that oversee disease prevention, health promotion, and emergency preparedness programs. Additionally, Kennedy has sought to roll back immunization requirements and restrict vaccine mandates, weakening vaccination efforts crucial for herd immunity. He has also promoted decentralizing decisionmaking by shifting responsibilities from federal agencies to states, thereby potentially creating disparities in health responses. These actions collectively may impact the capacity of the national public health system to coordinate effective responses during crises like pandemics that generally do not stay within state borders. And while pushing responsibility to the states, Kennedy has not advocated for additional funding to improve state-level public health infrastructure.
The creation of the GPHA, if best understood as an alternative government structure, signifies a profound shift in the federalist landscape of public health governance. As a coalition of state governors operating semi-autonomously from federal agencies, the alliance embodies a decentralized approach that could challenge traditional federal oversight, allowing states to craft more tailored, region-specific health policies. This parallel structure may undermine federal authority, potentially leading to disparities in public health standards and responses across states, and complicating nationwide efforts to manage public health crises. It also suggests states’—particularly California’s—evolving role as regional leaders and innovators in shaping health policy, asserting a form of sovereignty that emphasizes state independence within the federalist system.
Going forward, California’s leadership in this alliance highlights its strategic ambition to influence national and global health policy by championing localized, collaborative approaches. These moves could potentially position the state as a de facto policymaker in public health, especially in the face of national partisan dynamics and federal inconsistency. And given that public health is both a local and transnational issue, whether that leadership takes on an even broader scope may be crucial for the public health of millions of people.
