As a former secretary of the Department of Health and Human Services, serving under President Obama, and a former governor of Kansas, during the George W. Bush era, Kathleen Sebelius has a unique perspective on the challenges posed by a pandemic, the urgency of coordinating a federal response, and the rightful role of states in a moment of national crisis.
In describing the Trump administration’s reaction to the coronavirus outbreak, Sebelius leans on words like “terrifying,” “head-spinning,” and “total nightmare.”
I spoke to Sebelius in April in reporting Rolling Stone’s investigation into the deadly testing failures that have defined the administration’s COVID-19 response. What follows is an edited transcript of that conversation:
Rolling Stone: I wanted to first ask you about your experience as a governor. The administration seems to be putting governors into an impossible position, asking them to take on responsibilities that belong to the federal government, even as Trump picks fights with Democratic governors.
Kathleen Sebelius: My head is spinning. The entire time I was a governor, I was a Democrat with a Republican president. I’m used to having a partisan difference with the chief executive. The response in my day was very evenhanded. And the president’s brother was one of my colleagues; Jeb Bush was governor of Florida, but nothing in terms of policy from the the White House seemed to be tilted toward Florida, much less toward Republicans and away from Democrats. It was very transparent. I find the approach of this White House to be very difficult. For policymakers to be singled out as partisans, or called out by name because the president doesn’t like you? I’ve never seen anything like that.
Beyond that, there are things that are uniquely in the purview of the federal government. And disaster response is one of them. In this case, every state needed the feds from the outset. And what has been terrifying to watch is that the federal government has refused to use the unique purchasing authority, the unique production authority, and the national logistics system that no state can mobilize. In addition to that, the White House created a framework where states competed with one another and competed with the federal government. In purchasing supplies, they were told they needed to do go out and “find it on their own,” only to have the supplies confiscated by the federal government at the point of customs. It’s beyond not not doing what is needed. The administration is creating a system of chaos and competition as opposed to collaboration. This has made the situation worse for most states.
Let’s unpack this idea. There were a couple of different roles the federal government could have played. It could have intervened and used its own purchasing power to funnel supplies to the states. Or the federal government could choose to play a traffic-cop role and help coordinate actions among the states. What you’re describing is that they abdicated both duties, leaving the states to scrap among themselves — and later to fight against belated responses by the federal government.
Yeah. I mean, there was an early warning that the feds paid no attention to. That was a missed opportunity to mobilize resources, to look at the stockpile, to make a very rapid assessment of where surge capacity was going be needed in hospitals — how many ventilators we had. Doing that from a national basis, measuring it against what was available. And again using the federal purchasing power, the federal Production Manufacturing Act, any tool that was available to say: “We are going to gather resources, we’re going to do it at the lowest possible price, and we are going to set up the system of equitable distribution.” Letting states know what that is. Having it be very transparent. And then, if the states feel like that system is not going to serve them as well as needed, then the states can try to gather their own supplies, above and beyond that. But that basic start was never done!
The New England Patriots have a plane and were able to fly to China and pick up masks. But that’s a ridiculous situation, where now a national football team has to provide a private plane for Charlie Baker as a governor [of Massachusetts]. And Charlie Baker, as the former head of the Partners Health System, I would argue knows more, supply-chain-wise, than the governor sitting in Oklahoma does. It’s this crazy situation. Charlie has shared this with a lot of people: Governor Baker had an initial purchase that was confiscated by FEMA. So this is a situation I don’t think anybody’s ever seen before.
You’ve talked about two months that were wasted by this administration. Walk me through what the administration could have been doing in that time that was lost — I think we’re talking mid-January, February into March. What were key steps that weren’t taken?
The National Security folks knew in December that something was happening and began to raise a lot of red flags about the pathogen appearing in China. Warning, warning, warning, ignored. We can go back to December. The ban on Chinese travel that happened at the end of January was somewhat effective, although there seemed to have been lots of trips before it was put on. But let’s assume that’s effective. We didn’t use the time between the travel ban and the explosion [of COVID cases] in New York City to mobilize materials, get the country ready by way of communication, lay out a policy of social distancing, begin to really put the pathway together. That is the wasted time. We didn’t expand production of equipment. We didn’t expand testing by any means. All of those are just lost opportunities.
The federal response appears to have gotten tangled in red tape, and set back by infighting. You’re a former HHS secretary; I’m particularly interested in your perspective on the importance of getting CDC and FDA to work together after the botched testing rollout, and why private testing was so late to the game. As I understand it, when HHS Secretary Alex Azar declared a public-health emergency, it had a paradoxical effect of taking a lot of private laboratory capacity offline because they were hit with extra FDA regulation at a time when they needed to be moving quickly. You managed these agencies. What needed to happen to make them actually work for the public?
I don’t know what exactly happened with the CDC test. Starting with the CDC test makes perfectly good sense. They are the gold standard in public health. In my time, within two weeks of knowing what H1N1 looked like, CDC had that test ready — millions of test kits to push out to the states and around the world. So my experience with CDC was very different.
What exactly happens with the initial failure? I don’t know. But it does seem to be a real problem that we didn’t immediately pivot to the World Health Organization test, which we know was working very well. We could have purchased a lot of those and pushed them out. We could have, at that point, opened up the private-lab capacity and pushed that out. I mean, we knew what that [test] looked like, and we knew that the CDC tests were not ready. And we didn’t do any of that.
Under the HHS umbrella, there are 11 operating agencies. FDA is one of them. The CDC is another; they’re both under the same framework of the department. And I can guarantee you that not only can the secretary get their attention, but the White House has a unique way to get agencies’ attention: by making it very clear that a challenge is urgent and they want a solution — and [to call a meeting with] everybody at the table with that solution within 24 hours. It can happen. All this finger-pointing disappears, miraculously, if you have clarity at the top. When you have a sense of urgency, that this is the absolute, number-one priority, and the president wants this to happen, it will happen.
I heard Dr. Robert Redfield — the CDC director — testify to Congress that the WHO test somehow would have needed to have been submitted to the FDA for regulatory approval. He gave a red-tape reason why the feds couldn’t deploy that test.
The sense of urgency has to come from the top, or people default to, “There’s a rule that says we can’t.” That’s what’s happening. I used say, “Doing nothing is not an acceptable answer. Here’s where I want to go.” It’s miraculous. If you start with that approach, lawyers and others quickly find you can go around [the obstacles]. But at a time of confusion, or a time of a lack of guidance, or if you’re getting very mixed messages — which I think was absolutely going on — the default position is do nothing, to stand behind the regs, and say, “We can’t move.”
One of the more terrifying interviews I have heard in the whole episode so far was a back-and-forth with the president and a reporter in March [at CDC headquarters]. He was talking about whether or not the passengers should be allowed to get off a cruise ship. I went back and looked at it two or three times, because I was thinking I must have misheard the president. He kept saying, “I don’t want them off the ship, because if they get off the ship my numbers will go up. It isn’t my fault. I don’t want my numbers to go up. I want my numbers to stay where they are. We have good numbers.”
And for the first time I thought, “Oh, dear God, this situation with testing is intentional.” We don’t want there to be a lot of tests, we’re slow-walking tests, because the only thing that’s going to happen with testing is the numbers, of course, are going to go up. You will find more cases. You will find the asymptomatic cases. And I remember thinking: “I don’t like to be a conspiracy theorist, but there really may be a reason that we seem to be fumbling on these tests. And it might be that the president is still believing this will go away on its own. And that the more testing we do, the more cases we’ll confirm. He doesn’t want a lot of cases. So let’s just wait it out.”
One of the things that we’ve learned about this president is that he doesn’t actually have to give a corrupt order like “I don’t want more tests,” but he has a way of letting things be known, like his former consigliere Michael Cohen testified …
I mean, he’d just said to everybody at a room in the CDC that the tests are perfect. And that anybody that wants a test can have one. Both of which are blatantly not true. And then went on to say, later when he’s outside, “I don’t want the numbers to go up.” There couldn’t be a clearer signal.
That sounds like the exact opposite of what you were talking about earlier. Instead of moving fast and cutting through red tape to get these tests working, it was direction from the top to stay the course and keep the numbers down? What other moments have left you, as a former governor or HHS secretary, shaking your head, where you couldn’t quite believe what was happening?
Wow. Every day. Every day. We’re again at a pivotal moment. I found it terrifying that the president on a Monday [April 13] said, “I have ultimate authority” to order reopening. “I have to order what needs to happen. I will lay it out. It’s only my authority.” Again, totally wrong. I don’t know what Constitution he is reading or quoting. That is not the way our system of government works. But that was his announcement, only to end up the next day, with what could only generously be called an abdication of that: “States are on their own.” And then offering … it’s being generous to call them “guidelines,” and they’re certainly not a policy. Certainly not any commitment by the federal government to be responsible for a level of testing, or the contact tracing, or for making sure they’re prepared, or, “We will provide the resources and we will make sure that things are distributed equitably. This is the role that we will play at the federal level.”
So I think we’re going to see a whole mishmash of [reopening] policies begin to roll out, some of which could be very, very dangerous for the people who live in those states and for those of us who need to travel to or come in contact with people in those states.
Since the previous Great Recession, state and local public-health agencies have been hollowed out. People who were let go in 2008, 2009 were not hired back. So we are going into this contact-tracing effort without the army that will be needed. What could the federal government be doing right now in that regard? Funding guarantees?
Public-health funding at the state level is always underfunded. There is no real constituency that’s coming to the statehouse — unlike, education or prisons or highways, there’s nobody who shows up to say, “We should be doing it.” Not only did they lose a lot of revenue in ‘08 and ‘09, but budgets which were never very robust to begin with haven’t been rebuilt. And this administration has systematically also reduced the budget. The funding of the CDC, they have fewer resources.
We have a very good model of how you do contact tracing — public-health epidemiologists have done this for decades with HIV, sometimes in low-income neighborhoods for prenatal care. We know how to do it, but it takes trained employees. It takes money to put a data system together that’s effective and easy to use. And right now, particularly with the tax deadlines having been pushed out, with the states losing money, and payroll taxes falling fast, state revenues are really hurting. So not only did public-health agencies not have the money going into this, but overall budgets at the state and city levels have really been hollowed out.
So look: States all work on balanced budgets. By constitution, you can’t run a deficit at a state level; it’s illegal. The feds clearly run big deficits all the time. So they are the only ones who could fund this kind of new expenditure. That’s going to be absolutely essential to give consumers confidence that if they go into the store or are going to a restaurant they won’t be putting themselves or their family in jeopardy.
Help us look over the horizon here. How do we not let the slow start keep us trapped in a state of constantly playing catch up?
We’re in the early days of this episode. I would just put on your radar screen the fact that we absolutely have to have a plan of what happens between now, the middle of April 2020, and when we finish a national vaccination campaign. The federal role has to be funding, guidance, communication, logistics. The PPE, the equipment, the ventilator fight was just precursor. Wait till we get to a vaccine or to treatment. If everybody’s on their own to try and figure this out, we will have a total nightmare.
Only the federal government can buy enough of a vaccine or can set up the logistics. I mean, we’re not going to have 330 million doses of vaccine being produced simultaneously on day one. It will come in gradually. Who goes to the front of the line? How does it get distributed? Who is gonna do the vaccinations? We’ve got a bunch of really major issues facing us, and so far I don’t think they’ve done very well with the challenges that we’ve had.
I’m hopeful that this will change, or that maybe governors will just put together their own national system and ignore what’s happening in the White House. But right now people are very confused, and that doesn’t help when you’re terrified for your health and you’re terrified about your job. That puts Americans in a very difficult situation going forward.
Did I just hear you say that state governors could invent a shadow national government, to go around Trump?
I was being somewhat facetious, but that is what is happening, at least regionally, when governors are banding together and saying, “We’re going figure out on the West Coast how we’re going to reopen government.” The Northeast said the same. There’s now a coalition from the Midwest governors. They’re going to put together guidance and policies because the feds haven’t done that. The president and his administration haven’t done that. It doesn’t exist.