Tucker Doherty, Victoria Guida, Bianca Quilantan and Gabrielle Wanneh
For this story, reporters interviewed a wide range of health researchers, public officials and academic experts to ask them which states were standouts in their management of the pandemic. What we heard repeatedly were lessons culled from a handful of states that others could follow.
We’ve distilled their insights into three categories that represent the greatest challenges states are facing: fighting the virus, managing the economic fallout and reopening schools.
FIGHTING THE VIRUS
Leading the way in the rural Northeast
Few states have a record as unblemished as Vermont.
The odds could have been stacked against the state. The virus arrived in Vermont during the first wave sweeping the country. It shares borders with some of the hardest-hit states and has the third-oldest population in the country.
But Vermont swiftly flattened its initial wave and has since gone weeks at a time without any new confirmed infections. Fewer than 60 people have died, giving the state the second-fewest deaths per capita behind Alaska, which has seen surging caseloads in recent weeks. If the country as a whole had the same per capita death rate as Vermont, the nationwide death toll would be 30,000 instead of more than 215,000.
“This should be the model for the country, how you’ve done it,” Anthony Fauci, the nation’s top infectious disease expert, said during a briefing with state leaders in September. “Notwithstanding that this is a small state, it should be the model of how you get to such a low test positivity that you can actually start opening up the economy in a safe and prudent way.”
While health experts say the state has likely benefited from its rural geography, other sparsely populated areas of the country that let their guard down were overwhelmed by the virus this spring and summer. That sense of complacency never took hold in Vermont, where a moderate Republican governor and a Democratic-led Legislature helped defuse partisan tensions that hampered the response elsewhere.
“Any state that’s going to succeed against Covid has got to have the compliance of the population, because every single thing you do is telling people to alter their personal behavior,” Mark Levine, Vermont’s health commissioner, said in an interview.
— Vermont reopened slowly. The lockdown it put in place in late March is still gradually being lifted, restaurants and bars are still limited to 50 percent indoor capacity and even outdoor gatherings are still subject to a 150-person limit.
— Local governments have authority to set their own stricter rules. Burlington, the state’s most populous city, reduced its outdoor gathering limit to 25 in late August when college students began returning to nearby campuses.
— The state is also strict about visitors, requiring a two-week quarantine for people arriving from places with higher infection rates. And it invested early in testing and contact tracing and implemented a state-wide mask mandate early on.
“They took action early, they let science lead, and they were consistent but willing to pivot when the science told them new strategies were needed,” said Trish Riley, executive director of the National Academy for State Health Policy.
For Levine, the state health commissioner, there’s no secret to the state’s success.
“We opened very, very gradually,” Levine said. “There’s been this line in the sand in the Southern states, that you either reopen the economy or you do the public health work to defeat the virus. We’ve shown you can do all of that, you just have to do it right.”
Vermont’s experience has some similarities to Alaska, another predominantly rural state that until recent weeks kept the virus at bay through one of the country’s most proactive testing regimes and a strictly enforced quarantine requirement for travelers. But unlike Alaska, Vermont is just a few hours’ drive from New York City, the outbreak’s early epicenter, and that makes its performance even more noteworthy.
Seattle’s urban success story
Washington state shows larger urban centers can mount an effective defense against the virus with rapid coordination and an early focus on vulnerable populations.
“Washington was the tip of the spear,” Riley said. “They were the first and had to make decisions really fast.”
The state in late January reported the nation’s first case of Covid-19, and the pathogen’s tear through a Seattle-area nursing home was the first indication of how thoroughly the facilities would soon be devastated nationwide. But the state quickly got its act together.
— Gov. Jay Inslee, a Democrat, from early on allowed health experts rather than politicians to lead public messaging and guide the state’s response. The state’s coordinated response compared favorably to New York’s, which was initially beset by infighting and mixed public health messages. Nearly nine months since Washington’s first confirmed coronavirus case, the state’s per capita death toll is less than one sixth of New York’s.
“Washington state had a tricky early introduction to the pandemic, which it got under control. It came back again, but the increased number of cases we see now largely reflect improved testing since the spring,” said Bill Hanage, professor of epidemiology at Harvard University.
— The state’s success stems from extensive data sharing, which helped health officials better target their response measures once state restrictions and business closures during the initial lockdown were eased. That meant a better view into where the virus was still lurking and knowing where to direct critical resources like testing, protective equipment and hospital surge capacity.
“They really do a good job having eyes on the whole community. It helps them fine-tune and adapt their interventions,” said Cyrus Shahpar, a former medical epidemiologist for the CDC who now leads tracking of state responses on outbreak tracker Covid Exit Strategy.
— Washington health authorities understood early the need to protect the elderly, identifying people living in nursing homes and assisted living communities as particularly vulnerable clusters.
When Congress gave states a 6.2 percent bump to their federal Medicaid funds in March, Washington was among a handful of states that largely used the windfall to provide targeted aid to nursing homes, helping them pay for additional staffing, equipment and hazard pay. New York was not.
Closing racial disparities in Michigan
It was apparent early that the virus was sickening a disproportionate share of minority populations, a tragic outcome that’s been fueled by a mix of socioeconomic factors, including longstanding inequities in the health care system. Compared to white Americans, Black and Hispanic Americans are nearly five times more likely to be hospitalized from the virus, and Black Americans are twice as likely to die from it, according to the CDC.
When Michigan was hit hard during the country’s initial wave in March and April, Black residents accounted for over 40 percent of Covid-19 deaths while making up just 14 percent of the population. The state in mid-April created a task force to address racial disparities in Covid-19, making it one of just a dozen similar health equity task forces across the country, and one of the few specifically focused on Covid-19, according to the National Governors Association.
“Michigan, I think, is impressive because they created that task force on racial disparities early on,” said Heather Howard, director of the State Health and Value Strategies program of the Robert Wood Johnson Foundation and the former state health commissioner in New Jersey. “And a clear focus of the task force has been incorporating equity into the long-term recovery from the pandemic.”
— The task force helped expand testing to communities of color through walk-up and pop-up sites. Mobile testing fleets were also dispatched to places easily accessible to high-need communities, like parks, and those more remote, like farms.
“The task force was ultimately charged with two jobs: The first was to decrease the disparity in the mortality rate of Covid-19 across racial and ethnic lines,” Lt. Gov. Garlin Gilchrist said in an interview. “The second charge was to connect the interventions and efforts of the racial disparities task force to our broader, longer-term systemic work to decrease racial disparities in everything that we do.”
— Vulnerable populations, including those in nursing homes, homeless shelters, and prisons have gotten extra attention for Covid containment. In May, Michigan became one of the first states to test every prisoner, doing so within 15 days. Only a few states like North Carolina followed suit with their own mass testing programs this summer.
By the fall, Michigan had dramatically narrowed Covid-19 disparities, with Black residents comprising just 8 percent of new cases and 10 percent of deaths in the last two weeks of September.
“We’ve done a lot, and the result that we’ve seen over the last couple of months is that we have flattened the disparity in the mortality rate,” Gilchrist said. “It speaks to the power of focus and prioritization.”
MANAGING THE ECONOMIC FALLOUT
Efficient and quick unemployment action in Colorado
All states have struggled in the face of an avalanche of jobless claims, which have weighed down their ability to get the money out. But Colorado has one of the best records on paying out funds quickly. It also outlined extensive guidelines to make sure workers have the ability to refuse to go back to work if they don’t think they’ll be safe. And it’s done all that while finding ways to effectively fight fraud.
Andrew Stettner, a senior fellow at progressive think tank The Century Foundation, cited Colorado’s fraud-prevention work as a success, in contrast to similar efforts in other states that just end up delaying payments to deserving individuals because of errors on their applications.
Claims “just sit in a queue for weeks, and it’s because … [many state officials] look at the unemployed as wanting to commit fraud in general,” Stettner said. “They don’t think of the unemployed as their customers who they’re trying to serve in a timely fashion.”
— The Century Foundation cites Colorado as one of just a few states with a strong directive giving workers specific reasons that they can hold off going back to their jobs, such as living with someone from a vulnerable population or not having access to child care.
— The state has successfully foiled scams, recently announcing it had prevented the payment of nearly $ 1 billion in fraudulent claims for Pandemic Unemployment Assistance, federal money intended for out-of-work freelancers, gig workers and the self-employed.
Generous help in the Midwest
Iowa began paying out Pandemic Unemployment Assistance claims within two or three weeks of the federal program’s passage, making it early out of the gate to get money into the pockets of unemployed residents. And “they were able to deliver a generous amount of aid to unemployed workers on top of the federal emergency aid,” said Ernie Tedeschi, policy economist at Evercore ISI.
— Iowa had the highest average wage replacement rate of any in the country, giving workers roughly 50 percent of lost wages.
— Neighboring Minnesota similarly has a generous replacement rate, only slightly lower than Iowa’s. The state stands out for its state-of-the-art unemployment insurance infrastructure, which has helped the state process a steady stream of applications. Some states have struggled for months to keep up with demand as weekly claims across the country stayed above a million until late August — and still remain at record levels.
In part because they don’t have the type of outdated computer systems prevalent in other states, Minnesota was able to “stay ahead of the curve of the extraordinary demand for UI in the initial part of the recession,” Tedeschi said.