As of November 2020, the United States leads the world in confirmed coronavirus disease 2019 (COVID-19) cases and deaths . Over the past 10 months, the United States has experienced three peaks in new cases, with the most recent spike in November setting new records . Inaction and the lack of a scientifically informed, unified response have contributed to the sustained spread of COVID-19 in the United States . This paper describes major events and findings from the domestic response to COVID-19 from January to November 2020, including on preventing transmission, COVID-19 testing and contact tracing, ensuring sufficient physical infrastructure and healthcare workforce, paying for services, and governance . We further reflect on the public health response to-date and analyse the link between key policy decisions (e.g . closing, reopening) and COVID-19 cases in three states that are representative of the broader regions that have experienced spikes in cases . Finally, as we approach the winter months and undergo a change in national leadership, we highlight some considerations for the ongoing COVID-19 response and the broader United States healthcare system . These findings describe why the United States has failed to contain COVID-19 effectively to-date and can serve as a reference in the continued response to COVID-19 and future pandemics.