When President Biden announced in January that he would make Wisconsin's top health official his No. 2 at the Department of Health and Human Services, the state seemed like a poor model for the nation's most crucial public health priority: fighting the pandemic.
Wisconsin had just come through a surge more intense than New York City's, and it ranked near the bottom of states in bringing a first dose of vaccine to its residents. Only about a third of doses sent to the state had been administered. The grim numbers galvanized Republicans in Wisconsin to take aim at a familiar target, state health secretary-designate Andrea Palm, whom they had refused to confirm since 2019, denying her symbolic authority even as the coronavirus gripped the state.
Her elevation to Biden's team provided an opportunity to nationalize their campaign against Democratic-led pandemic policies.
"It is unfortunate that the cabinet official in charge of Governor Tony Evers' disastrous covid-19 vaccine rollout … is exporting her incompetence to the Biden administration," Duey Stroebel, a Republican state senator, wrote on Facebook.
Two months later, Wisconsin is among the states leading the immunization race. It maintains one of the fastest rates of vaccination, having administered 90 percent of doses delivered as of Saturday. It has found success especially in convincing residents to complete the two-dose series recommended for shots developed by Pfizer-BioNTech and Moderna. And it has not seen the kind of disparities between urban and rural communities plaguing other states.
Wisconsin offers lessons for the nation that go beyond its approach to coronavirus vaccinations. The state also shows how expertise can win out in spite of partisanship — a lesson Palm, a veteran of the Obama administration, will likely carry with her back to Washington. If confirmed by the Senate, she will help steer federal health policy during a period of intense polarization. Unlike in Wisconsin, however, Democrats have legislative majorities, at least for now.
The experience in Wisconsin — where Republicans went to court to try to limit Palm's power, alleging she had "laid claim to a suite of czar-like powers" — represents a "deepening of what she saw at HHS," said Kathleen Sebelius, who served as the nation's health secretary during the Obama administration and relied on Palm as her chief of staff.
The two women worked together to address problems implementing the administration's sweeping Affordable Care Act, a challenge heightened by the refusal of congressional Republicans to consider any legislative fixes, Sebelius said. "You learn how to operate outside a process that is totally locked into opposition by using administrative tools," including issuing new rules and regulations, she added. "That experience in Wisconsin only further amplified [Palm's] creativity when you look at the strategies to get things done."
Democrats plan to highlight that experience in advancing her nomination as deputy health secretary as soon as this month. The irony is that Palm was plucked by the president-elect before her department had vaccination numbers to tout.
"She wasn't here to see the fruits of the department's efforts," said Stephanie Harrison, chief executive of the Wisconsin Primary Health Care Association, which represents the state's community health centers.
'No wrong door' for vaccine
The turnaround of Wisconsin's immunization drive has left state Republicans noticeably quiet, a contrast with their year-long war against their Democratic governor's response to the pandemic, which culminated Wednesday in the Wisconsin Supreme Court's invalidation of Evers' mask mandate. The GOP-led legislature that threatened for months to fire Palm by calling up her still-pending nomination and quickly voting her down has gone silent on her record.
Stroebel did not respond to requests for comment about whether he still viewed the rollout as disastrous and Palm as incompetent. Patrick Testin, the Republican chairman of the state senate's health committee, showered praise on Palm's replacement, saying she was able to cut through "bureaucratic red tape" hindering the state's early efforts.
But interviews with state and county officials, medical providers and other health-care leaders suggest the more meticulous measures governing the parceling out of vaccine — and put into place under Palm's leadership — caused initial delays but are now bearing fruit.
The state adhered more rigidly than did others to a tiering system that steered shots to the most vulnerable. This caused frustration as other states threw open the floodgates, but now 63 percent of people 65 and older are fully vaccinated, compared to 55 percent nationwide. "Early on it looked like maybe we had been too elegant with the categories," said Azita Hamedani, the chair of emergency medicine at UW Health who led the state's prioritization committee.
Gradually, more flexibility was introduced. When leaders in Milwaukee identified stark racial disparities in the city's vaccinations, they won state approval to open up eligibility to anyone 16 and over in 10 Zip codes, said Kirsten Johnson, the city's health commissioner.
"Within a week and a half, we had put 6,000 doses into those communities," Johnson said. "The state did a really good job of messaging to everyone that if they're sending us doses, we need to get them into arms — and if we don't, they're going to send them to someone else."
The state focused from the outset on activating a large number of public and private health-care providers, rather than relying on locations that could handle a high volume of shots. This compounded initial uncertainty about supply, but now residents have more options about where to seek out immunizations.
The aim has been to "create a system where there's no wrong door for vaccine," said Julie Willems Van Dijk, the No. 2 at Wisconsin's health department. The state isn't relying on mega sites, she said in an interview. The most shots any clinic is delivering a day, she said, is about 2,000.
That approach drew on the department's strategy of maximizing the number of vaccinators, a laborious process that taxed the state's resources right as it was emerging from a deadly fall and winter virus surge. The method, Willems Van Dijk said, was bolstered by recommendations from an expert committee advising the state on issues of scarcity.
"What they said was, 'Do a peanut butter spread. Don't decide this provider is more important than this provider when you go to allocate vaccine. Give some to everybody, and that will increase access,' " she recalled. "That was a very wise decision."
These factors make Wisconsin well-prepared for the next phase of its immunization campaign, as the challenge of insufficient supply gives way to issues of access and vaccine hesitancy, said Jonathan Temte, associate dean for public health and community engagement at the University of Wisconsin School of Medicine and Public Health. That's because a robust network of small and midsized providers allows tailored outreach to vulnerable or resistant groups.
These are also central dilemmas in Washington, where federal health officials have spent months worrying as much about demand as about supply. The state's vaccination efforts have drawn interest from Congress and health associations. Stephanie Schauer, the head of the Wisconsin Immunization Program, participated in a March 23 virtual briefing for congressional staff, including those working with senior members of the House and Senate's appropriations health subcommittees. Wisconsin was chosen to participate because of the state's recent success in rolling out vaccines, according to Claire Hannan, who leads the Association of Immunization Managers and organized the session.
To Palm's proponents, that suggests Biden chose wisely.
"We were lucky to have her for the time we had her," said Jon Erpenbach, a Democratic state senator who has championed efforts to expand health insurance coverage in the state. "I'm not shocked at all the Biden administration wants her."
'We have got to fix this'
Palm is likely to face the Senate Finance Committee for a hearing on her nomination this month, according to a committee aide, and Senate Democrats are pointing to Wisconsin's vaccine numbers to build a drumbeat of support for her confirmation.
"Andrea really set us up for success in Wisconsin as a national leader getting people vaccinated quickly, and I give her a tremendous amount of credit for where we are today," said Sen. Tammy Baldwin (D-Wis.).
The executives of five large employers in Wisconsin, including the health software company Epic, backed her confirmation in an April 1 letter to Finance Committee leaders obtained by The Washington Post. They said she partnered effectively with the private sector and "led with facts, strength, and transparency."
Palm did not respond to a request for comment. If confirmed, Sebelius said, she would be a natural partner to HHS Secretary Xavier Becerra — a longtime veteran of the Hill who has limited health-policy experience and is new to HHS.
"She knows every piece of the department," said Sebelius, enumerating Palm's prior roles as a counselor specializing in public health, an adviser to the secretary and also chief of staff. "I can't imagine a more helpful training ground to be deputy secretary — and now that she's led a state health department, she comes with such intimate knowledge from that perspective, too."
Bill Corr, who served as HHS deputy secretary under Sebelius, said Palm's experience with Wisconsin's GOP-led legislature shows she can navigate Washington's policy fights.
"The fact that she's had so much opposition, and she's still managed to organize and deliver so much in Wisconsin says legions about her leadership ability and addressing the public's needs, and not getting caught in the political games," Corr said.
People involved in the state's vaccination drive said it is difficult to assess how much credit for Wisconsin's vaccination numbers accrue to Palm.
County health officials said they had little direct interaction with her during the planning for vaccine rollout, a matter handled mostly by Willems Van Dijk and the department's immunization specialists. "Most of us didn't know her very well," said Doug Gieryn, the top health official in Winnebago County.
"Andrea supervised her, but I think Julie Willems is the one who really deserves a great deal of the credit," said Tommy Thompson, a former Republican governor of Wisconsin who now leads the University of Wisconsin System.
But health-care leaders said Palm, who has served in her role since January 2019, deserves credit for assembling a skilled team with more intimate knowledge of the state's public health system.
"She was new to the state, and she was brought in not to fight a pandemic, but to try to find a solution to Medicaid expansion issues," said Tim Size, executive director of the Rural Wisconsin Health Cooperative, a collaborative of rural hospitals and health systems.
Republican lawmakers in control of the legislature quashed that effort in 2019, despite broad public support for expansion of health services for poor and working class residents. The decision made Wisconsin one of just 12 states — and one of only three with Democratic governors — not to have expanded the insurance program, hardly a welcome distinction for the state health secretary.
The sluggish start to the state's vaccination campaign was nothing to crow about, either.
Those were dark days, health officials acknowledged, but Palm kept them from despairing. Her message in December, according to her deputy, was, "We don't have a choice here. This is lifesaving vaccine."
She told department staff, "It's too bad it's the holidays, and it's too bad that we are all exhausted from a surge that has been going on, but we have got to fix this and move it forward," according to Willems Van Dijk.