On March 4th, 2020, the Texas Department of State Health Services reported the state’s first case of covid in Fort Bend County, just outside of Houston. What followed mirrored much of the national response to a fast-moving pandemic. Through a series of executive orders, Governor Greg Abbott issued lockdowns, suspended schools, set hospital capacity and mask mandates, and imposed quarantines on all interstate travelers. Within weeks, however, the state had begun reopening, and by March of the following year, all covid restrictions had been lifted. This essay examines Texas’ response to the covid-19 pandemic, the policy decisions, major actors, and outcomes for one of the nation’s most populous states.
Policy and Literature Review
Within ten days of the Fort Bend covid case, Governor Abbott invoked the Texas Disaster Act of 1975 and declared a state of disaster. The Act’s provisions suspended many of the checks and balances inherent in state and local governance, and enabled the governor to enact sweeping policy decisions (OTG, 2020). Over the course of the pandemic, Governor Abbott would issue over two dozen executive orders, enforcing everything from social distancing to inmate visitation restrictions. In fact, in March 2020 alone, the governor would legislate limits on gatherings, order full lockdowns of non-essential services, and issue mandatory quarantines for all travelers. The state also issued daily reporting requirements and expanded hospital bed capacity to accommodate a surge in cases. Mask mandates, however, would not be issued until July 2020 under executive order 29 (OTG, n.d.).
While Texas may have garnered a reputation for covid obstinance, their early policy decisions, including mask-mandates, were in-line with most other states. California, for example, implemented mask mandates in June 2020, just two weeks ahead of Texas. To the extent that controversy exists, it most likely stems from Texas’ decision to prioritize economic concerns ahead of perceived health risks. Yet Texas’ policies didn’t produce radically adverse results. For example, by the end of March 2020, Texas was averaging 370 new covid cases per day, or 0.0125 cases per 1,000 people. By the same measure, the national rate of infection stood at 0.04 cases per 1,000 people. By the time Texas reopened in March 2021, that average had increased to 0.12 cases (per 1,000) per day but still below the national average of 0.17 cases per 1,000 people per day (Google, 2022). In other words, Texas’ initial rate of infection was one third that of the broader United States and remained below the national average even after opening early. This is not necessarily due to policy, however. While Texas’ restrictions were not that different than most other states, Texas’ population is younger and significantly less dense then harder hit areas like New York. Texas also implemented an aggressive vaccination drive, vaccinating over 1 million people by mid-January 2021 (OTG, 2021). These factors at least partly explain why Texas outperformed national rates of infection, even while being home to large at-risk populations.
Policy Actions
Although Texas would become the first state to deliver over 1 million covid vaccinations, the state’s efforts were not without criticism. The Texas Tribune, for example, noted that vaccine distribution centers were most often located in the hospitals and pharmacies of white affluent neighborhoods, and raised concerns that vaccination wouldn’t be available to the state’s Black, Hispanic, and other at-risk populations (Garnham & Cai, 2021). Such concern for minority infections was echoed by the Texas Health and Human Services Commission. A 2021 report, for example, noted that Black, poor, and socioeconomically disadvantaged neighborhoods had fewer hospitals, physicians, and pharmacies per 100,000 people, than other neighborhoods (DSHS, 2021, p. 7). In a follow up study conducted the next year, the Commission found that Blacks and Hispanics were most likely to get covid and added that Hispanic ethnicity was the strongest leading indicator of covid mortality across groups (DSHSa, 2022, p. 4). Such vulnerabilities were evident in their reliance on social welfare programs as well. For example, throughout the pandemic, Black and Hispanic enrollment in the state Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) program, was higher than all other demographics (pp. 43-47). Yet the state’s vaccination efforts produced effective results and, at least partly, refute concerns stated in the media.
While Texas enlisted the National Guard to assist with testing in the early months of the pandemic (Wallace, 2020), the Department of Health and Human Services was the primary agency responsible for coordinating vaccination efforts. In fact, the DSHS was arguably the principle policy actor throughout the pandemic, second only to the governor’s office. Administration of the vaccine, however, was predominately conducted by private entities (hospitals, pharmacies, etc). The state DSHS authorized vaccinators and worked with other agencies, such as the Division for Emergency Management and the Texas Education Agency to distribute vaccines and raise public awareness. Concerns over low vaccination rates amongst at-risk communities led officials to begin holding “pop up vaccine events” in Wal-Mart parking lots and other retail locations. The purpose of the events, according to the DSHS, was to increase vaccination coverage among at-risk adults as well as drive vaccine education (DSHSb, 2021). In addition, the Texas DSHS stopped requiring proof of underlying health conditions, which had previously prevented undocumented immigrants from receiving vaccines (Chen & Jameel, 2021). The combination of robust supply, mobile vaccination sites, and decreased scrutiny resulted in broad coverage for some of Texas’ most at-risk communities. By July 2022, 68% of Hispanics reported being vaccinated, while 55% of Whites and 49% of Blacks had received at least one shot (Ndugga et al., 2022). As of 2024, only 0.054 per 1,000 Texans are hospitalized with covid compared to a national rate of 0.065 per 1,000 people (CDC, 2024). These numbers suggest Texas has maintained national parity despite a drive to reopen quickly and perceived vaccine hesitancy.
When evaluating Texas’ response to the covid pandemic, it’s important to recognize the relationship between economic, health, and social priorities. Academics Michael Kraft and Scott Furlong note that prolonged economic hardships and unemployment not only impact families, but also governments, tax revenue, and agency’s ability to provide social services (Kraft & Furlong, 2019, p. 210). This was apparent both in Governor Abbott’s decision to reopen as quickly as possible, but also in the state’s decision to extend SNAP, TANF, and Medicaid benefits throughout the pandemic. While federal assistance was available to all states, local funding was still required for each of the aforementioned programs. Such policies illustrate the balance lawmakers must strike between economic and social priorities. Economic collapse would have disproportionately impacted Black and Hispanic communities, who were more dependent on the continuation of SNAP and TANF than other groups.
As mentioned, KFF data (Ndugga et al., 2022) indicate a majority of Whites and Hispanics have been vaccinated. The Black community remained behind as of 2022 data, however. One policy approach Texas might consider is conducting outreach through members of the African American medical community. That is, work with Black doctors to engage the black community. It may also prove beneficial to offer incentives for developing pharmacies and other facilities in at-risk neighborhoods. That said, gathering quality requirements is perhaps the most important action the state could take. Texas should begin by asking Black communities about vaccine hesitancy and whether such approaches as those suggested above are relevant.
More broadly, the state could consider expanding its Medicare and Medicaid coverage. Together these programs represent some of the most at-risk individuals, from the elderly to the disabled, yet coverage quality remains an issue. Rand Corporation (Rand, n.d.) cites the fee-for-service model, common throughout the U.S. as incentivizing quantity over quality of service. In addition, such structures and the bottomless supply of cash associated with the federal government, leads to overbilling and fraud (Kraft & Furlong, 2019). One potential solution identified by Rand (n.d.), however, is the use of Accountable Care Organizations to help ensure a proper balance of quality and quantity of care. Such ACOs are proliferating across the United States and could help provide better care for Texans with at-risk conditions or long-covid.
Conclusion
In summary, Texas’ initial handling of the covid-19 pandemic was not that dissimilar from other states. Whie their push to reopen was more aggressive than other regions, it required a careful balance between economic, social, and public health concerns. In the end, Texas’ rate of infection and hospitalization were in line with national averages, suggesting that their decisions were not significantly riskier than more conservative approaches.
References
CDC. (2024). Trends in United States COVID-19 hospitalizations, deaths, emergency
department (ED) visits, and test positivity by geographic area. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#trends_currenthospitalizations_select_00
Chen, C. & Jameel, M. (2021). False barriers: The things should not prevent you from
getting a COVID vaccine. ProPublica. https://www.propublica.org/article/false-barriers-these-things-should-not-prevent-you-from-getting-a-covid-vaccine
DSHSa. (2021). Impact of COVID-19 on vulnerable populations in Texas. Texas Health
and Human Services Commission. https://www.hhs.texas.gov/sites/default/files/documents/services/health/coronavirus-covid-19/impact-covid-19-vulnerable-populations-texas.pdf
DSHSb. (2021). DSHS launches new round of pop up vaccine events. Texas Health and
Human Services. https://www.dshs.texas.gov/news-alerts/dshs-launches-new-round-pop-up-vaccine-events
DSHS. (2022). Impact of COVID-19 on vulnerable populations in Texas: Phase 2 report.
Texas Health and Human Services Commission. https://www.hhs.texas.gov/sites/default/files/documents/covid-19-impact-on-vulnerable-populations-in-texas-dec-2022.pdf
Garnham, J.P. & Cai, M. (2021). Advocates worry vaccines will be out of reach for Black
and Hispanic neighborhoods devastated by COVID-19. The Texas Tribune. https://www.texastribune.org/2021/01/09/texas-coronavirus-vaccine-racial-inequality/
Ndugga, N., Hill, L., Artiga, S., & Haldar, S. (2022). Latest data on COVID-19
vaccinations by race/ethnicity. KFF. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/
Google. (2022). COVID-19 open data repository. Google Health.
https://health.google.com/covid-19/open-data/
Kraft, M. E., & Furlong, S. R. (2019). Public Policy: Politics, Analysis, and Alternatives
(7th ed.). SAGE Publications, Inc. https://bookshelf.vitalsource.com/books/9781544374598
OTG. (n.d.). Coronavirus executive orders, funding and waiver. Office of the Texas
Governor. https://gov.texas.gov/coronavirus-executive-orders
OTG. (2020). Governor Abbott declares state of disaster in Texas due COVID-19. Office
of the Texas Governor. https://gov.texas.gov/news/post/governor-abbott-declares-state-of-disaster-in-texas-due-to-covid-19
OTG. (2021). Texas first state to administer 1 million COVID-19 vaccines. Office of the
Texas Governor. https://gov.texas.gov/news/post/texas-first-state-to-administer-1-million-covid-19-vaccines
Rand (n.d.). Paying for care: In depth. Rand Corporation.
https://www.rand.org/health-care/key-topics/paying-for-care/in-depth.html
Wallace, J. (2020). National Guard to help with mobile testing. The Houston Chronical.