Who Controls U.S. Public Health—the Feds or the States?

The U.S. government’s approach to public health seems certain to change when the second Trump administration begins on January 20, 2025. But what powers do states have to determine and take action on their own public health priorities?

It’s complicated. States have been responsible for public health since 1791, when the Constitution’s 10th amendment granted states any powers not specifically assigned to the federal government. Today, states run vaccination programs, provide health care for the poor, supervise water and food safety, provide health education and emergency preparedness, and more.

“The president can’t force someone to take a vaccine or force a state to stop fluoridating the water supply,” says Lawrence Gostin, a public health law expert at Georgetown University. Nor can the president deny a state the right to require vaccinations or fluoridation. 

But the president, pending Senate approval, appoints leaders of HHS, NIH, CDC, FDA, and other agencies. This gives the executive branch immense influence over state and local governments’ public health efforts. All told, the federal government “provides a range of guidance, guardrails, and standardizations,” said Georges Benjamin, head of the American Public Health Association. “And it plays an enormous role in funding.”

Funding gives the federal government significant leverage. “State and local public health agencies have independence and can operate without undue interference from the Trump administration,” said Gostin. But he noted, “HHS could cut funds to state public health departments, which would constrain the scope and vibrancy of their programs and activities.” And the administration could set conditions on the money it does provide.

However, power in public health is constantly evolving. For example, the Supreme Court’s 2022 Dobbs v. Jackson Women’s Health Organization decision accorded individual states the power to determine the right to abortion. It would take an act of Congress to make abortion access a federal decision, and Trump has said he wouldn’t ask for a total ban. But the incoming administration can still limit abortions in the states. More than half the abortions in the U.S. today are medication abortions, and the new FDA commissioner could prohibit people from using telehealth appointments to get abortion medications or remove approval for their use to end pregnancies. The U.S. Postal Service could reactivate the 1873 Comstock Act that banned sending anything intended to be used for abortion, including medications, through the mail. 

Possible changes to U.S. vaccination policies have been getting much of the post-election attention because of the president-elect’s planned appointments of vaccine skeptics Robert F. Kennedy Jr. to lead HHS, and physician and former U.S. Rep. Dave Weldon, MD, to run the CDC. Kennedy would have the power to appoint experts to the CDC committee that makes recommendations for what vaccines should be given to whom and at what age. He could also limit or divert research funding at the CDC as well as the NIH. The CDC heavily supports state and local vaccination programs with money expressly directed by Congress. Those would be harder to cut because, as the nonprofit research and news organization KFF noted in a recent issue brief, “Major HHS offices and programs are mandated by law and funded through Congressional appropriations.”   

Another example of federal leverage over states: While the states run the Medicaid public health insurance program for people with low or no income, the federal government provides much of the money—on average, 70%, though there is wide variability from state to state. The U.S. government also sets strict guidelines for how the money can be spent. During the first Trump administration, nearly a dozen states received permission to institute work requirements to qualify for Medicaid. Most plans were never implemented. Arkansas had one that ended by court order after 10 months. Georgia has its own program for a subset of low-income people, but few Georgians have applied, and it is costing the state more than if it accepted federal help. The New York Times and other news outlets have reported that Trump’s transition team have been discussing a national work requirement for Medicaid recipients—and require all states to institute it. 

States can counterpunch against federal requirements with lawsuits. KFF recently cited several suits brought by states against federal government requirements on abortion counseling and privacy protection. In another area, states are challenging federal requirements to include immigrants in state health plans. 

The federal government can “gum up the works” of state public health programs, said APHA’s Benjamin. “But it’s not going to happen overnight.” It will take some time for the new administration’s plans to become clear. Appointments need to be formally made; the Senate must confirm them unless Trump carries out his threat to make recess appointments and is not stopped by the courts. Congress and the president will have to agree on a new federal budget, which could either happen before the current Congress ends, or sometime in the spring. And states or interest groups might challenge public health plans in court. 

In the meantime, some public health advocates are saying say that a change in the conversation around public health and careful nonpartisanship could help. During a November 13 webinar on post-election prospects for public health hosted by the Association of Schools and Programs in Public Health, Politico reporter Megan Messerly described how that has already worked at the state level. 

Messerly took a deep dive into how conservative Indiana, which historically has spent less than many other states on public health, dramatically upped its spending on public health last year. Careful messaging by advocates lobbying legislators, the business community and county officials led to the change. They talked about state investments that would lead to things like healthy babies and clean water, and avoided trigger terms like systemic racism, gun control, and climate change, and even “public health.” The legislature responded with grants of $225 million to counties over two years. 

Another panel member, Ali Khan, dean of the University of Nebraska College of Public Health, related a similar story about how a safe syringe program for substance users won the approval of the Republican-majority Nebraska legislature with careful lobbying. But his story did not bode so well for the ability of states to adopt progressive public health policies. The state’s GOP Gov. Jim Pillen vetoed the legislation. Still, Khan remains optimistic. “If you have the right set of conversations with the right set of words, you can help people understand how important public health is,” he said. 

Others like Gostin are more pessimistic. “The federal government has enormous capacity for doing great damage to public health, and to science itself,” he said. 

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