A new analysis from the CDC this week confirmed what we have been hearing anecdotally from health systems for several weeks—as the coronavirus lockdown took hold, there was a precipitous drop in visits to hospital emergency departments. According to the study, visits were down by 42 percent in the month of April compared to the previous year, and despite a rebound in May, were still 26 percent lower than a year ago. Visits in the Northeast dropped the most, as did those among women, and children under 14.
Although visits for minor ailments and symptoms declined the most, even more disconcerting was the drop in visits for chest pain, echoing the concern we’ve heard in many parts of the country that many patients may have suffered minor heart attacks without being treated, or may have waited to be seen until significant damage had been done.
As non-emergent visits have begun to return to many facilities, we continue to hear that emergency department and urgent care volume remains relatively low.
Survey data indicate that patients are fearful of becoming infected with coronavirus if they visit healthcare facilities—especially, it seems, ones where they’ll be forced to wait.
While many providers are investing in messaging campaigns to assure patients it’s safe to return, this nightmarish first-person account by one healthcare insider provides a useful cautionary tale.
Visiting a surgeon for a pre-op consult, she found the experience of visiting a COVID-era hospital downright dystopian. Simply touting safety precautions by itself won’t make patients more comfortable—they’ll need to see and feel that measures are in place to make time spent in a care setting as efficient and reassuring as possible. Otherwise, like the insider in question, they’ll take their business elsewhere. There’s work to be done.
After months of lock down, hospitals are eager to get patients back for routine care and elective procedures.
An executive at a Palm Beach hospital stands between a box of surgical masks and a Purell dispenser.
“We understand you haven’t been inside our hospitals for some time,” she says to the camera. The executive is delivering her line for a promotional video intended to get people back to hospitals after almost three months of avoiding the place at all costs.
Moments later, the film crew records her chatting with a vascular surgeon in an idled operating room, who soothingly reassures that a hospital is the cleanest place to be outside your home. “The hospital is safer than the grocery store,” the doctor says.
The video published on YouTube in mid-May is part of a marketing campaign by Tenet Healthcare, which operates 65 hospitals and about 250 ambulatory surgery centers. It’s one attempt to solve a problem the entire health-care industry faces: Most patients vanished when Covid-19 swept the country.
Billions in Losses
Much of routine health care came to a halt in March as hospitals cleared space for an expected wave of Covid-19 patients and authorities ordered a halt to surgeries and other procedures that could be postponed. The decline in volume has clobbered hospital finances, with the industry estimating it is losing $50 billion a month.
Emergency visits dropped by 42% in four weeks in April compared to the same period last year, the Centers for Disease Control reported June 3. The number of U.S. patients getting hospital care dropped by more than half in late March and early April compared to 2019, according to data from Strata Decision Technology, which provides software to hospitals.
Some of that rebounded modestly in May as distancing rules eased, but hospital volume is nowhere near pre-Covid levels. With the pandemic ongoing and many states still confirming hundreds of new cases daily, patients are hesitating to rush back to hospitals.
“The main thing that really is a gating factor at this point is patient comfort,” Tenet President and Chief Operating Officer Saumya Sutaria said at a recent virtual conference with investors. Tenet declined interview requests.
Free Masks
To counter the public’s fears, hospitals publicize what they’re doing to keep patients safe. They’re handing out masks at the door and spacing out chairs in waiting rooms. They’re steering Covid-19 patients to dedicated sites and testing staff regularly.
Hospitals need to show patients that their facilities are safe. At Catholic hospital chain Trinity Health, that includes moving patients through “Covid-free” zones with separate doors, elevators and waiting areas.
“We can put all of the outreach and marketing in place, but it’s only as effective as the people who execute those strategies,” said Julie Spencer Washington, Trinity’s chief marketing and communications officer.
The question for the entire industry is how quickly patients come back. The answer will depend on a constellation of related variables, including how reluctant people are to resume care, and the course of the pandemic. Future surges could force hospitals to shut down regular care again — and spook patients further.
Hospitals and doctors are going to have to do as much as they can as fast as they can until they can’t anymore,” said Lisa Bielamowicz, co-founder of consultancy Gist Healthcare.
Many patients, on the other hand, are in no rush. “They’re waiting and watching rather than pulling the trigger and going to see the doctor like they would have in the past,” Bielamowicz said.
The calculation for the health-care industry is different than for many other service businesses resuming operations. A hospital procedure or even a check-up is more intimate than a meal out.
For procedures that require in-patient rehab stints for recovery, the havoc Covid-19 has brought to nursing homes adds another layer of concern. “Those places seem like deathtraps now, so it’s much harder to bring back those patients because you need to find an alternative way for them to rehab,” Bielamowicz said.
And the biggest consumers of health care are the elderly and the chronically ill, the very people Covid-19 most threatens. “From personal discussions with my patients, the older and more co-morbidities that any individual has, the more nervous they are about returning,” said Shauna Gulley, chief clinical officer at Centura Health, which has hospitals in Colorado and Kansas.
Patients with serious ongoing needs like cancer treatment or emergencies like heart attacks and strokes have continued to get care. And many medical problems resolve on their own. The decline in those visits – for a migraine headache, for example – reduces providers’ revenue but may not harm patients in the long-term.
While people often go to the emergency room for needs better treated in other settings, now the concern is the opposite: That true medical emergencies will be neglected.
Ascension, the nation’s largest Catholic hospital chain, has purchased billboards that say “Don’t delay ER care.” On hospital websites and social media posts, Tenet facilities reminded patients that “Emergencies Can’t wait. We’re Open & Safe.”
Deferred Care
Doctors fear that some patients will defer needed care too long, allowing progressive conditions to deteriorate. Clinicians at Maimonides Medical Center in Brooklyn, New York, have seen patients arrive sicker because they didn’t come earlier, said Ken Gibbs, the hospital’s CEO.
“There are unmet needs, I think that’s clear,” he said. “And I think the data on that will emerge, but it will take time.”
Maimonides treated 471 Covid patients at the peak on April 9, Gibbs said, and still had about 100 in late May. The hospital has applied for a waiver from New York State to resume elective surgeries, which are still on hold in New York City.
Some hospitals are preparing for a lasting dent in their revenue. For years, health economists have pointed to waste in the health-care system, with the estimated cost of unnecessary treatments in the hundreds of billions of dollars. Covid-19 may demonstrate that patients are willing to forego some of that care or opt for more conservative treatment.
People who had delayed back surgeries, for example, may now decide that doing physical therapy at home is good enough, said Marvin O’Quinn, president and chief operating officer at CommonSpirit Health, a large Catholic hospital system.
“We’ve all talked about too much intervention in health care in the past,” he said. “I think we’ll see a new normal in terms of what patients want to do and what doctors want to do, and we will have to adjust to that.”
“Superspreader facilities”—nursing homes, correctional facilities, and meatpacking plants—have become major COVID hotspots across the US. Many counties are dealing with a large outbreak in one type of tightly-packed facility or another.
Case in point: the outbreak at Cook County Jail in Chicago, which now accounts for a whopping 15.7 percent of all COVID cases in the state of Illinois. Some places, like Colorado’s Weld County, are managing outbreaks across all three types of superspreader facilities.
The graphic above highlights the nearly 260 counties that we’ve termed “triple-threat counties”: those which have all three types of superspreader facilities. The counties are mapped using our Gist Healthcare COVID-19 Risk Factor Index, which identifies particularly vulnerable populations using chronic disease, demographic, and acute care access variables.
The top 10 “triple-threat counties” by risk index score are all in more rural areas of the country with limited acute care access and more vulnerable populations—places where a COVID outbreak is likely to be particularly devastating. Seven of the 10 have a high percentage of African-American or Hispanic/Latino residents, groups with a an outsized burden of COVID-19 illness and death.These risk factors are intersectional; for example, food processing plants employ twice as many Hispanic workers as the national average, and a disproportionate share of long-term care workers are black.
[Click here for more information and interactive data from our analysis of the risk impact of these superspreader facilities.]
Centers for Disease Control and Prevention (CDC) Director Robert Redfield told Congress on Thursday that the country needs between 30,000 and 100,000 people working on contact tracing in order to help contain the next wave of the coronavirus.
The estimate shows the daunting challenge of hiring an army of people to interview those infected with coronavirus to identify who they have been in contact with so that those people can quarantine and help prevent the spread of the virus.
“I’ve estimated between 30 and 100,000” contact tracers are needed,” Redfield told the House Appropriations Committee during a hearing Thursday. He acknowledged the figure is “sizable,” though it is actually less than the 300,000 people former CDC director Tom Frieden has estimated the U.S. will need.
He said it is crucial to get the contact tracing system in place by September to try to keep the virus in check ahead of an expected surge in the fall and winter. That could help prevent the type of blunt stay-at-home orders that the U.S. had to implement this spring after missing the window to contain the virus earlier this year.
“We really have to get this built and we have to get it built between now and September,” Redfield said.
Redfield said his agency has met with all 50 states to discuss hiring contact tracers and is pleased that some states have already started to do so. New York City, for example, has hired 1,700 contact tracers.
He said the CDC Foundation is working to hire personnel to augment state efforts and the CDC has distributed funding to states provided by Congress for the purpose. He added he hopes AmeriCorps is a source of additional staff.
“It is fundamental that we have a fully operational contact tracing workforce that every single case, every single cluster, can do comprehensive contact tracing within 24 to 36 hours, 48 hours at the latest, get it completed, get it isolated, so that we can stay in containment mode as we get into the fall and winter of 2020,” he said.
The American Red Cross said its blood supply levels have been cut in half as social-distancing and stay-at-home orders have caused fewer people to donate, The New York Times reported.
Across the country, collection drives at offices, schools and churches have been canceled to comply with stay-at-home orders.
For a while, the drop in donations weren’t critical because supply and demand fell at the same time, as hospitals canceled most elective surgeries and far fewer people were getting injured in car crashes and other accidents.
But now that hospitals are resuming elective surgeries and many people are leaving the house more often, the number of donations has not increased, according to the Times.
Chris Hrouda, president of biomedical services for the American Red Cross, which collects about 40 percent of the country’s blood donations, told the Times that there’s been a “staggering” drop in blood supply. The Red Cross usually has enough blood to meet the country’s needs for five days; it currently has less than two days’ worth.
On May 31, the Red Cross had to stop sending hospitals their full blood orders and could fill only 75 percent of them, Mr. Hrouda told the Times. He said that if donations don’t increase in the next week or two, the Red Cross will have to start filling just half of hospitals’ requested blood orders.
“It puts hospitals and doctors in the precarious position of deciding who gets blood,” Mr. Hrouda told the Times.
Hospitals are performing even more surgeries than before the pandemic to get through backlogs of operations.
Brian Gannon, chief executive of the Gulf Coast Regional Blood Center in Texas, said he told about 100 hospitals that get blood from his center to slow down their elective procedures, according to the Times.
Factors such as how many patients would need ICU treatment, average length of stay and fatality risk are straining hospital resources.
When it became evident that the COVID-19 pandemic would spread across the U.S., lawmakers, scientists and healthcare leaders sought to predict what the financial and operational impact on hospitals would be. In those early days, policymakers relied on data from China, where the pandemic originated.
Now, with the benefit of time, the early predictions seriously underestimated the coronavirus’ impacts. University of California Berkeley and Kaiser Permanente researchers have determined that certain factors — such as how many patients would need treatment in intensive care units, average length of stay and fatality risk — are much worse than previously anticipated, and put a much greater strain on hospital resources.
WHAT’S THE IMPACT
Looking primarily at California and Washington, data showed the incidents of COVID-19-related hospital ICU admissions totaled between 15.6 and 23.3 patients per 100,000 in northern and southern California, respectively, and 14.7 per 100,000 in Washington. This incidence increased with age, hitting 74 per 100,000 people in northern California, 90.4 per 100,000 in southern California, and 46.7 per 100,000 in Washington for those ages 80 and older. These numbers peaked in late March and early April.
Those numbers are greater than the initial forecast, especially when factoring in the virus itself. Modeling estimates based on Chinese data suggested that about 30% of coronavirus patients would require ICU care, but in the U.S., the probability of ICU admissions was 40.7%. Male patients are more likely to be admitted to the ICU than females, and also are more likely to die.
Length of stay was also higher than had been predicted. By April 9, the median length of stay was 9.3 days for survivors and 12.7 days for non-survivors. Among patients receiving intensive care, the median stay was 10.5 days, although some patients stayed in the ICU for roughly a month.
Long durations of hospital stay, in particular among non-survivors, indicates the potential for substantial healthcare burden associated with the management of patients with severe COVID-19 — including the need for ventilators, personal protective equipment including N95 masks, more ICU beds and the cancellation of elective surgeries.
The considerable length of stay among COVID patients suggests that unmitigated transmission of the virus could threaten hospital capacity as it has in hotspots such as New York and Italy. Social distancing measures have acted as a stop-gap in reducing transmission and protecting health systems, but the authors said hospitals would do well to ensure capacity in the coming months in a manner that’s responsive to changes in social distancing measures.
THE LARGER TREND
These challenges have placed a financial burden on hospitals that can’t be overstated. In fact, a Kaufman Hall report looking at April hospital financial performance showed that steep volume and revenue declines drove margin performance so low that it broke records.
Despite $50 billion in funding allocated through the CARES Act, operating EBITDA margins fell to -19%. They fell 174%, or 2,791 basis points, compared to the same period last year, and 118% compared to March. This shows a steady and dramatic decline, as EBITDA margins were as high as 6.5% in April.
Relatively few Americans say they have been diagnosed with COVID-19 or tested positive for coronavirus antibodies, but many more believe they may have been infected or say they personally know someone who has been diagnosed.
Only 2% of U.S. adults say they have been officially diagnosed with COVID-19 by a health care provider, according to a new Pew Research Center survey. And 2% say they have taken a blood test that showed they have COVID-19 antibodies, an indication that they previously had the coronavirus. But many more Americans (14%) say they are “pretty sure” they had COVID-19, despite not getting an official diagnosis. And nearly four-in-ten (38%) say they’ve taken their temperature to check if they might have the disease.
Although few Americans have been diagnosed with COVID-19 themselves, many more say they know someone with a positive diagnosis. More than one-in-four U.S. adults (28%) say they personally know someone who has been diagnosed by a health care provider as having COVID-19. A smaller share of Americans (20%) say they know someone who has been hospitalized or who has died as a result of having the coronavirus.
Some groups are more likely than others to report personal experiences with COVID-19. For instance, black adults are the most likely to personally know someone who has been hospitalized or died as a result of the disease. One-third of black Americans (34%) know someone who has been hospitalized or died, compared with 19% of Hispanics and 18% of white adults. Black Americans (32%) are also slightly more likely than Hispanic adults (26%) to know someone diagnosed with COVID-19. Public health studies have found black Americans are disproportionately dying or requiring hospitalization as a result of the coronavirus.
Areas in the northeastern United States have recorded some of the highest rates of coronavirus cases and fatalities, and this is reflected in the Center’s survey. About four-in-ten adults living in the Northeast (42%) say they personally know someone diagnosed with COVID-19, significantly more than among adults living in any other region. People living in the Northeast (31%) are also the most likely to know someone who has been hospitalized or died as a result of the disease.
One aspect of personal risk for exposure to the coronavirus is whether someone is employed in a setting where they must have frequent contact with other people, such as at a grocery store, hospital or construction site. Given the potential for the spread of the coronavirus within households, risk to individuals is also higher if other members of the household are employed in similar settings. Among people who are currently employed full-time, 35% are working in a job with frequent public contact. Among those working part-time, almost half work (48%) in such a setting. For those living in a household with other adults, 35% report that at least one of those individuals is working in a job that requires frequent contact with other people.
Taken together, nearly four-in-ten Americans (38%) have this type of exposure – either currently working in a job that requires contact with others, living in a household with others whose jobs require contact, or both.
Hispanics (at 48%) are more likely than either blacks (38%) or whites (35%) to have this type of personal or household exposure. An earlier Center analysis of government data found Hispanic adults were slightly more likely to work in service-sector jobs that require customer interaction, and that are at higher risk of layoffs as a result of the virus. In fact, the current Center survey found Hispanics were among the most likely to have experienced pay cuts or job losses due to the coronavirus outbreak.
Interpersonal exposure in the workplace is also more widespread among younger adults. And there is a 10 percentage point difference between upper- and lower-income Americans in exposure, with lower-income adults more likely to work in situations where they have to interact with the public, or to live with people who do.
Health experts warn that COVID-19 is particularly dangerous to people who have underlying medical conditions. In the survey, one-third of adults say they have such a condition. Among this group, nearly six-in-ten (58%) say that the coronavirus outbreak is a major threat to their personal health. Among those who do not report having an underlying medical condition, just 28% see the outbreak as a major threat to their health. Americans who have an underlying health condition are also more likely than those who do not to say they’ve taken their temperature to check if they might have COVID-19 (47% vs. 33% of those without a health condition).
Self-reports of an underlying health condition vary greatly by age. Among those ages 18 to 29, just 16% say they have a condition; this rises steadily with age to 56% among those 65 and older. Whites are a little more likely than blacks and Hispanics to report having a health condition, but both blacks (at 54%) and Hispanics (52%) are far more likely than whites (32%) to say that the coronavirus outbreak is “a major threat” to their health.
Seconds Count Survey Highlights New research shows fear of COVID-19 is stopping people from seeking care during medical emergencies, like heart attacks or strokes.
As States start to re-open, more than one-third of Americans (36 percent) consider going to the hospital to be one of the riskiest behaviors to take part in compared to going to a hair salon (27 percent) or going to the beach (16 percent)
61 percent of respondents think they are either somewhat likely or very likely to acquire COVID-19 in a hospital
Half of respondents are more afraid of contracting COVID-19 than experiencing a heart attack or stroke
Nearly 60 percent of respondents are more afraid of a family member or loved one contracting COVID-19 than experiencing a heart attack or stroke
When asked which are you more afraid of, contracting COVID-19, experiencing a heart attack or experiencing a stroke – twice as many people over the age of 60 are more afraid of contracting COVID-19 (52 percent) than they are of experiencing a heart attack (23 percent) or stroke (25 percent)
President Trump said Friday the U.S. would halt its funding of the World Health Organization and pull out of the agency, accusing it of protecting China as the coronavirus pandemic took off. The move has alarmed health experts, who say the decision will undermine efforts to improve the health of people around the world.
In an address in the Rose Garden, Trump said the WHO had not made reforms that he said would have helped the global health agency stop the coronavirus from spreading around the world.
“We will be today terminating our relationship with the World Health Organization and redirecting those funds to other worldwide and deserving urgent global public health needs,” Trump said. “The world needs answers from China on the virus.”
It’s not immediately clear whether the president can fully withdraw U.S. funding for the WHO without an act of Congress, which typically controls all federal government spending. Democratic lawmakers have argued that doing so would be illegal, and House Speaker Nancy Pelosi threatened last month that such a move would be “swiftly challenged.”
The United States has provided roughly 15% of the WHO’s total funding over its current two-year budget period.
The WHO has repeatedly said it was committed to a review of its response, but after the pandemic had ebbed. Last month, Robert Redfield, the director of the Centers for Disease Control and Prevention, also said the “postmortem” on the pandemic should wait until the emergency was over.
As the Trump administration’s response to pandemic has come under greater scrutiny, with testing problems and a lack of coordination in deploying necessary supplies, Trump has sought to cast further blame on China and the WHO for failing to snuff out the spread when the virus was centered in China.
During his remarks, Trump alleged, without evidence, that China pressured WHO to mislead the world about the virus. Experts say that if the U.S. leaves the WHO, the influence of China will only grow.
“The world is now suffering as a result of the malfeasance of the Chinese government,” Trump said. “China’s coverup of the Wuhan virus allowed the disease to spread all over the world, instigating a global pandemic that has cost more than 100,000 American lives, and over a million lives worldwide.” (That last claim is not true; globally, there have been about 360,000 confirmed deaths from Covid-19, the disease caused by the coronavirus.)
When Trump earlier this month threatened to yank U.S. funding in a letter, Tedros Adhanom Ghebreyesus, the WHO director-general, would only say during a media briefing that the agency was reviewing it. But he and other officials stressed that the agency had a small budget — about $2.3 billion every year — relative to the impact the agency had and what it was expected to do.
Mike Ryan, head of the WHO’s emergencies program, said the U.S. funding provided the largest proportion of that program’s budget.
“So my concerns today are both for our program and … working on how we improve our funding base for WHO’s core budget,” Ryan said. “Replacing those life-saving funds for front-line health services to some of the most difficult places in the world — we’ll obviously have to work with other partners to ensure those funds can still flow. So this is going to have major implications for delivering essential health services to some of the most vulnerable people in the world and we trust that other donors will if necessary step in to fill that gap.”
But a Vox analysis suggests that most states haven’t made the preparations needed to contain future waves of the pandemic — putting themselves at risk for a rise in Covid-19 cases and deaths should they continue to reopen.
Experts told me states need three things to be ready to reopen.State leaders, from the governor to the legislature to health departments, need to ensure the SARS-CoV-2 virus is no longer spreading unabated. They need the testing capacity to track and isolate the sick and their contacts. And they need the hospital capacity to handle a potential surge in Covid-19 cases.
More specifically, states should meet at least five basic criteria. They should see a two-week drop in coronavirus cases, indicating that the virus is actually abating. They should have fewer than four daily new cases per 100,000 people per day — to show that cases aren’t just dropping, but also below dangerous levels. They need at least 150 new tests per 100,000 people per day, letting them quickly track and contain outbreaks. They need an overall positive rate for tests below 5 percent — another critical indicator for testing capacity. And states should have more than 40 percent of their ICU beds free to actually treat an influx of people stricken with Covid-19 should it be necessary.
These metrics line up with experts’ recommendations, as well as the various policy plans put out by both independent groups and government officials to deal with the coronavirus.
Meeting these metrics doesn’t mean that a state is ready to reopen its economy — a process that describes a wide range of local and state actions. And failing them doesn’t mean a state is in immediate danger of a coronavirus outbreak if it starts to reopen; with Covid-19, there’s always an element of luck and other factors.
But with these metrics, states can gauge if they have repressed the coronavirus while building the capacity to contain future outbreaks should they come. In other words, the benchmarks show how ready states are for the next phase of the fight.
So far, most states are not there. As of May 27, just three states — Alaska, Kentucky, and New York — met four or five of the goals, which demonstrates strong progress. Thirty states hit two or three of the benchmarks. The other 17, along with Washington, DC, achieved zero or one.
Even the states that have made the most progress aren’t necessarily ready to safely reopen. There’s a big difference between Alaska — which has not suffered from a high number of coronavirus cases — and New York, and no expert would say that all of New York is ready to get back to normal.
Nor do the metrics cover everything that states should do before they can reopen. They don’t show, for example, if states have the capacity to do contact tracing, in which people who came into contact with someone who’s sick with Covid-19 are tracked down by “disease detectives” and quarantined. Contact tracing is key to containing an epidemic, but states don’t track how many contact tracers they’ve hired in a standardized, readily available way.
They also don’t have ready data for health care workers’ access to personal protective equipment, such as masks and gloves — a critical measure of the health care system’s readiness that is difficult to track.
But the map gives an idea of how much progress states have made toward containing the coronavirus and keeping it contained.
States will have to follow these kinds of metrics as they reopen. If the numbers — especially coronavirus cases — go in the wrong direction again, experts said governments should be ready to bring back restrictions. If states move too quickly to reopen or respond too slowly to a turn for the worse, they could see a renewed surge in Covid-19 cases.
“Planning for reclosing is part of planning for reopening,” Mark McClellan, a health policy expert at Duke, told me. “There will be outbreaks, and there will be needs for pauses and going back — hopefully not too much if we do this carefully.”
So this will be a work in progress, at least until we get a Covid-19 vaccine or the pandemic otherwise ends, whether by natural or human means. But the metrics can at least help give states an idea of how far along they are in finally starting to open back up.
Goal 1: A sustained two-week drop in coronavirus cases
What’s the goal? A 10 percent drop in daily new coronavirus cases compared to two weeks ago and a 5 percent drop in cases compared to one week ago, based on data from the New York Times.
Which states meet the goal? Colorado, Connecticut, Delaware, Hawaii, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Missouri, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, and Texas — 17 states in all. Washington, DC, did as well.
Why is this important? Guidance from the White House and several independent groups emphasize that states need to see coronavirus cases drop consistently over two weeks before they can say they’re ready to begin reopening. After all, nothing shows you’re out of an outbreak like a sustained reduction in infections.
“The first and foremost [metric] is you want to have a continued decrease in cases,” Saskia Popescu, an infectious disease epidemiologist, told me. “It’s a huge piece.”
A simple reduction in cases compared to two weeks prior isn’t enough; it has to be a significant drop, and it has to be sustained over the two weeks. So for Vox’s map, states need at least a 10 percent drop in daily new cases compared to two weeks prior and at least a 5 percent drop compared to one week prior.
Reported cases can be a reflection of testing capacity: More testing will pick up more cases, and less testing will pick up fewer. So it’s important that the decrease occur while testing is either growing or already sufficient. And since states have recently boosted their testing abilities, increases in Covid-19 cases can also reflect improvements in testing.
Even after meeting this benchmark, continued caution is warranted. If a state meets the goal of a reduction in cases compared to one and two weeks ago but cases seemed to go up in recent days, then perhaps it’s not time to reopen just yet. “You have to use common sense,” Cyrus Shahpar, a director at the public health policy group Resolve to Save Lives, told me.
For states with small outbreaks, this goal is infeasible. Montana has seen around one to two new Covid-19 cases a day for several weeks. Getting that down to zero would be nice, but the current level of daily new cases isn’t a big threat to the whole state. That’s one reason Vox’s map lets states meet four or five of the five goals — in case they miss one goal that doesn’t make sense for them but hit others.
Still, the two-week reduction in cases is the most cited by experts and proposals to ease social distancing.
Goal 2: A low number of daily new Covid-19 cases
What’s the goal? Fewer than four daily new coronavirus cases per 100,000 people per day, based on data from the New York Times and Census Bureau.
Which states meet the goal? Alaska, Florida, Hawaii, Idaho, Kentucky, Maine, Michigan, Missouri, Montana, Oklahoma, Oregon, South Carolina, Texas, Vermont, Washington, West Virginia, and Wyoming — 17 states.
Why is this important? One of the best ways to know you’re getting away from a disease outbreak is to no longer see a high number of daily new infections. While there’s no universally accepted number, experts said that four daily new coronavirus cases per 100,000 people is a decent ceiling.
“If I go from one to two to three [coronavirus cases a day], it’s different than going from 1,000 to 2,000 to 3,000, even though the percent difference is the same,” Shahpar said. “That’s why you have to take into account the overall level, too.”
This number can balance out the shortcomings in other metrics on this list. For example, New York — which has suffered the worst coronavirus outbreak in the country — has seen its reported daily new coronavirus cases drop for weeks, meeting the goal of a sustained drop in cases. But since that’s coming down from a huge high, even a month of sustained decreases may not be enough. New York has to make sure it falls below a threshold of new cases, too.
At the same time, if your state is now below four daily new cases per 100,000 but it’s seen a recent uptick in cases, that’s a reason for caution. New York, after all, saw just a handful of confirmed coronavirus cases before an exponential explosion of the disease took the state to thousands of new cases a day.
But if your state is below the threshold, it’s in a pretty solid place relative to most other states.
Which states meet the goal? Alaska, Connecticut, Delaware, Georgia, Illinois, Louisiana, Nevada, New Jersey, New Mexico, New York, North Dakota, and Rhode Island — for a total of 12 states.
Why is this important? Since the beginning of the coronavirus pandemic, experts have argued that the US needs the capacity for about 500,000 Covid-19 tests a day. Controlling for population, that adds up to about 150 new tests per 100,000 people per day.
Testing is crucial to getting the coronavirus outbreak under control. When paired withcontact tracing, testing lets officials track the scale of the outbreak, isolate the sick, quarantine those the sick came into contact with, and deploy community-wide efforts as necessary. Testing and tracing are how other countries, like South Korea and Germany, have managed to control their outbreaks and started to reopen their economies.
The idea, experts said, is to have enough surveillance to detect embers before they turn into full wildfires.
“States should be shoring up their testing capacity not just for what it looks like right now while everyone’s in their homes, but as people start to move more,” Jen Kates, the director of global health and HIV policy at the Kaiser Family Foundation, told me. “As people start doing more movement, you’ll have to test more, because people are going to come into contact with each other more.”
This goal is supposed to be for diagnostic tests, not antibody tests. Diagnostic tests gauge whether a person has the virus in their system and is, therefore, sick right at the moment of the test. Antibody tests check if someone ever developed antibodies to the virus to see if they had ever been sick in the past. Since diagnostic tests give a more recent gauge of the level of infection, they’re seen as much more reliable for evaluating the current state of the Covid-19 outbreak in a state.
But some states have included antibody tests in their overall counts. Experts said states shouldn’t do this. But since the data they report and the Covid Tracking Project collects is the best testing data we have, it’s hard to tease out how much antibody tests are skewing the total.
In particular, Georgia’s data suggested it met the goal of 150 daily tests per 100,000 people, but the state only started separating antibody tests from its total after the data was collected. Without the antibody tests, Georgia very likely wouldn’t meet the goal.
Some states’ numbers, like Missouri’s, also may appear significantly worse than they should due to recent efforts to decouple diagnostic testing data from antibody testing data, which can temporarily warp the overall test count.
“The virus isn’t going to care whether they were manipulating the numbers or not in order to look more favorable; it’s going to continue to spread,” Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, told me. “It’s better to really understand what’s going on and report that accurately.”
For states honestly reporting these numbers, though, they’re a critical measure of their ability to detect, control, and contain coronavirus outbreaks.
Goal 4: A low test-positive rate
What’s the goal? Below 5 percent of coronavirus tests coming back positive over the past week, based on data from the Covid Tracking Project.
Which states meet the goal? Alaska, California, Florida, Georgia, Hawaii, Kentucky, Louisiana, Maine, Michigan, Montana, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, West Virginia, and Wyoming — for a total of 23 states.
Why is this important? The positive or positivity rate, which tracks how many tests come back positive for Covid-19, is another way to measure testing capacity.
Generally, a higher positive rate suggests there’s not enough testing happening. An area with adequate testing should be testing lots and lots of people, many of whom don’t have the disease or don’t show severe symptoms. The positive testing rate in South Korea, for example, is below 2 percent. High positive rates indicate only people with obvious symptoms are getting tested, so there’s not quite enough testing to match the scope of an outbreak.
The positive rate data is subject to the same limitations as the overall testing data from the Covid Tracking Project. So if a state includes antibody tests in its test count, it could skew the positive rate to look better than it is. States only risk hurting themselves if they do this.
Which states meet the goal? Alaska, Arizona, Arkansas, California, Connecticut, Delaware, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Minnesota, Missouri, Montana, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Utah, Vermont, Virginia, Washington, Wisconsin, and Wyoming — for a total of 30 states.
Why is this important? If a pandemic hits, the health care system needs to be ready to treat the most severe cases and potentially save lives. That’s the key goal of “flattening the curve” and “raising the line,” in which social distancing helps reduce the spread of the disease so the health care system can maintain and grow its capacity to treat an influx of Covid-19 patients.
“There’s this idea that in six weeks we can open more things,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me. “But the virus is still there. It’s all about making sure that the case count isn’t too immense for our hospital system to deal with.”
The aim is to avoid the nightmare scenario that Italy went through when it had more Covid-19 cases than its health care system could handle, leading to hospitals turning away even dangerously ill patients.
To gauge this, experts recommended looking at ICU capacity, with states aiming to have less than 60 percent occupancy in their ICUs.
A big limitation in the metric: It’s based on data collected by the Centers for Disease Control and Prevention of only some hospitals in each state. So it might not be fully representative of hospital capacity throughout an entire state. But it’s the best current data available, and it suggests that the majority of states meet that standard.
That’s extremely good news. It shows that America really has flattened the curve, at least for now. But it’s done that so far through extreme social distancing. If the next step is to keep the curve flattened while easing restrictions, that will require meeting the other metrics on this list.
Hitting the benchmarks is the beginning, not the end
Vox’s map is just one way of tracking success against the coronavirus. Other groups have come up with their own measures, including Covid Act Now, Covid Exit Strategy, and Test and Trace. Vox’s model uses more up-to-date data than some of these other examples, while focusing not just on the state of the pandemic but states’ readiness to contain Covid-19 outbreaks in the future.
Very few states hit all the marks recommended by experts. But even those that do shouldn’t consider the pandemic over. They should continue to improve — for example, getting the positive rate below even 1 percent, as in New Zealand — and look at even more granular metrics, such as at the city or county level.
Meeting the benchmarks, however, indicates a state is better equipped to contain future coronavirus outbreaks as it eases previous restrictions.
Experts emphasized that states have to keep hitting all these goals week after week and day after day — Covid-19 cases must remain low, testing ability needs to stay high, and hospital capacity should be good enough for an influx of patients — until the pandemic is truly over, whether thanks to a vaccine or other means. Otherwise, a future wave of coronavirus cases, as seen in past pandemics, could kill many more people.
“You need to have all the metrics met,” Popescu said. “This needs to be a very incremental, slow process to ensure success.”
And if the numbers do start trending in the wrong direction, states should be ready to shut down at least some parts of the economy again. Maybe not as much as before, as we learn which places are truly at risk of increasing spread. But experts caution that future shutdowns will likely be necessary to some extent.
“I do worry we’re going to see surges of cases and hot spots,” Watson said. “We do need to keep pushing on building those capacities. … Otherwise, we’re just rolling the dice on the spread of the virus. It’s better if we have more control of the spread.”
That’s another reason these metrics, along with broader coronavirus surveillance, are so important: They not only help show how far along states are in dealing with their current Covid-19 outbreaks, but will help track progress to stop and prevent future crises as well.
/cdn.vox-cdn.com/uploads/chorus_image/image/66858616/GettyImages_1220891781.0.jpg)
:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/20005583/coronavirus_reopen_map.png)
:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/20007678/coronavirus_cases_map.png)
:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/20005708/coronavirus_cases_per_capita_map.png)
:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/20005705/coronavirus_test_map.png)
:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/20005702/coronavirus_positive_rate_map.png)
:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/20005695/coronavirus_icu_maps.png)
HENRY KOTULA 
