50 States, 50 Plans, 50 Bad Outcomes
How the lack of a national COVID-19 strategy has led to repeated cycles of infections and death across the country
The problem with telling America’s COVID-19 story is there isn’t one.
There are 50–51 counting Washington DC — and they are all different.
It has become clear since March that the only way an organization can talk expertly about the national pandemic is with 51 contributors — one carefully tracking all the oddities of their state. They would know when death counts go up because a state starts counting probable cases and when there’s a spike in positive tests because a lab just reported six weeks of testing all at once. No one can keep track of that for every state — there’s not enough time in the day.
There’s one of me, and I’ve only got 24 hours, so I’m not going to pretend to be able to give you a comprehensive breakdown of the COVID-19 situation in every state. I’m going to do something a lot simpler — use group analysis to look for patterns.
To do this, we’re going to give each state a rating of low, medium, or high in two basic categories. The first is confirmed cases per million residents (CCPM). That ranges from over 22,500 in New York to 1,145 in Hawaii — a state that only hit four figures on July 21. For our purposes, “high” will be anything over 10,000 — that means one percent of the population has had a confirmed case. Low will be anything under 5,000.
The second statistic will be the case fatality rate (CFR). This is simply the percentage of confirmed cases who end up dying. While fewer than 1% of people with the virus will die, many of them will go untested and never become a confirmed case. At the moment, the state with the highest CFR is Connecticut at 9.0%, and the lowest is Utah at 0.7%. For this essay, “high” will be 6% and up, while “low” will be anything under 3.%.
Using those two measures, we will put each state into one of nine groups. Imagine a tic-tac-toe grid where the three rows are low, medium, and high CCPM rates, and the three columns are low, medium, and high CFRs. A state scoring low in both would be at the bottom left — Group 1 — while a state scoring at the top in both would be at the top right — Group 9.
So we end up with something like this:
Every group contains at least one state, although one includes precisely one, and two more have two each. So, starting with Group 9, let’s look at each group in turn.
High case rate, high fatality rate
Members: NY, NJ, CT, MA
This group took the worst of it in March and April. They are the only four states in the country with more than 1,000 deaths per 1 million citizens — a 0.1% death toll — and four of the five highest CFRs.
These states came the closest to having their health-care systems collapse, but have recovered exceptionally well. They all rank near the bottom of the nation in new cases and deaths, while showing no sign of a second wave.
All four have been above the national average in testing, with New York (2nd), New Jersey (7th), and Connecticut in the top 10.
High case rate, medium fatality rate
Members: RI, DC, LA, IL, MD, DE
This group was hit a little later than Group Nine, mainly peaking in late April and May, and the states were able to keep their CFR under 6%. They make up six of the next seven spots on the national list of per-capita death rates, ranging from Rhode Island’s 946 per million to Maryland’s 569.
All six are above the national average in testing — Rhode Island leads the nation at 311,089 tests per million — but they haven’t been as successful as the Group Nine states in preventing a second peak.
Rhode Island is doing reasonably well, going from a peak of 390 cases a day in late April to about 60 in late July, but the other five have seen case numbers rise in July. Delaware averaged 45 in mid-June but is now back up to 110, while Washington DC went from 195 to 32 to 75.
Illinois has larger numbers, but a similar trend. They were over 2,500 cases a day in early May, dropped under 600, then bounced back to around 1,350. Maryland was averaging 1,100 cases in mid-May, got down to a seven-day average of 338 on June 24, and is now at 835.
However, no other Group Eight state has been hit as hard by a second peak as Louisiana. New Orleans was one of the first major urban outbreaks, along with Seattle, New York City, and Detroit, so they peaked early — hitting an average of 1,578 cases on April 7. They stayed below 500 from April 21 to June 14, only to see another burst of exponential growth that has them over 2,000 cases/day.
As of July 26, Louisiana’s confirmed case rate is at 2.23% of the population, just behind New York’s 2.26% and just ahead of Arizona’s 2.22%. Louisiana and Arizona will pass New York on July 27 and battle each other for the dubious distinction of the nation’s highest rate of confirmed infections.
High case rate, low fatality rate
Members: AZ, GA, AL, IA, FL, NV, SC, CA, NE, TX, TN, AR, UT, NC, MS
This group is currently dealing with the June/July peak. They’ve built up enormous case numbers without seeing anything like the death tolls of the states that peaked in the spring. Even Louisiana, while not a member of this group, has had a much lower death rate for its second peak than it did in April and May.
Unfortunately for the nation, the reason for the drop in fatalities has become a political issue. The president and other leading Republicans have pointed to it as a sign of triumph — the disease is no longer as deadly as it was in the spring, so the affected states don’t need to go into lockdown.
That’s almost certainly the wrong approach. The lower death rate isn’t due to the coronavirus losing its lethality but to a combination of factors that don’t promise a good ending. First, every state in the country is testing at a higher level than any could approach in April or May, meaning we are getting positive tests from people with illnesses that aren’t causing hospitalizations or deaths.
Second, there’s a significant lag between symptom onset and deaths — as much as three weeks in some studies. The Group Nine states all had case peaks long before they hit their highest death totals, and the Group Seven states still haven’t gotten to that point.
Third, the death rates might be low, but they are increasing. Arizona’s death rate has gone from 40/day to 80/day since July 10, while Georgia’s has almost doubled in the last week.
More alarming is the rise in the nation’s three largest states — California, Texas, and Florida. California was averaging around 60 deaths in early July and is now in triple digits. Texas went from the 30s on July 6 to 150 this weekend, while Florida has gone from 48 to 125 in three weeks.
This group is also not great at testing. Tennessee (8th) is the only one in the top-10 nationally, while Utah, Nevada, and California are above the national average.
There are reasons to believe this group’s eventual fatality rates will stay below the states in Groups Eight and Nine. The enhanced testing levels allow tracking-and-tracing programs to limit outbreaks, while doctors have learned better treatment techniques from the spring-peak states. However, there is every reason to expect many more deaths from these states.
Medium case rates, high death rates
Members: MI, PA
These are both states who suffered terribly during the spring peak but only in certain areas. In Michigan, Metro Detroit would be firmly in Group Nine, but the rest of the state would drop to Group Five — medium in both case rates and death rates.
Philadelphia had a similar impact on Pennsylvania’s numbers. There were also significant outbreaks in Pittsburgh and the Cumberland Valley , but the Philadelphia metropolitan area was the main driver behind the state’s numbers.
For much of the spring and early summer, Michigan had the nation’s highest death rate among confirmed cases at nearly 10%. However, they’ve gone from a flat peak that stayed over 120 deaths/day from April 11–29 to single-digit averages since mid-July. The state reported minus-2 deaths for the weekend of July 25–26. On the 25th, they had six new deaths and reclassified eight from earlier in the pandemic as COVID-19. They also removed 16 deaths from their total after discovering the people were still alive. Zero deaths were reported on the 26th, leaving them down two for the weekend.
(Sadly, I don’t know how they discovered those 16 people.)
One significant difference between the two states; Michigan is currently 12th in the nation in tests per-capita while Pennsylvania is next to last.
Medium case rates, medium death rates
Members: IN, CO, MN, NM, OH, KY
These states dealt with the edges of the spring peak but were able to shut down before ending up with the high case numbers of Group Eight.
However, they are all trending upwards since reopening, which could make testing levels crucial. With a robust tracking-and-tracing program, states can contain outbreaks at a local level — something that is working for many of the spring-peak states.
That’s a good sign for New Mexico, which ranks fifth in the nation for per-capita tests, but Minnesota is the only other member with above-average testing levels. Colorado has the country’s lowest rate, and Ohio and Indiana are both in the bottom 10.
Medium case rates, low death rates
Members: VA, MO, WI, SD, ND, OK, KS, ID, WA
This group is a perfect demonstration of the problems of putting the states into somewhat arbitrary categories. Idaho (9,976 cases per million) and Virginia (9,908) will move into Group Seven on July 27 and are facing those challenges with below-average testing rates.
South Dakota (9,497), on the other hand, has averaged between 50 and 90 daily cases for more than two months. They are below average at testing but have shown no signs of a spike.
Other states in the category aren’t about to hit 10,000 cases per million but are on the same trajectory as the Group Seven states. North Dakota was averaging 30 cases/day a month ago and is now closing in on 120. Wisconsin, Missouri, Oklahoma, Kansas, and Washington are also facing large spikes.
North Dakota has an advantage, being 11th in the nation in testing, but the other states in the category are all below average.
Low case rate, high death rate
Low case rate, medium death rate
Members: VT, ME
The small states in northern New England all had exposure to the spring peak going on to their south, but have been able to contain outbreaks since reopening.
New Hampshire was the hardest hit of the three, with 301 deaths per million inhabitants as opposed to Vermont’s 90 and Maine’s 89. Vermont hasn’t reported a death since June 8 and only four since May 4, while all three states are averaging fewer daily cases than Hawaii.
Low case rate, low death rate
Members: OR, WV, WY, MT, AK, HI
Six lightly populated states — only Oregon has more than 2 million citizens — with lower densities than the national average. They still haven’t proven immune to the summer wave occurring all around them, though.
Oregon has gone from an average of 35 cases/day in late May to more than 300, while Wyoming (6 to 48), Montana (2 to 112), West Virginia (16 to 125), and Alaska (1 to 77) have all seen steady rises over the last two months. Even Hawaii has gone from one case a day to 38.
However, even at those elevated levels, they are still experiencing some of the lowest per-capita infection rates in the country. Hawaii is only higher than the three northern New England states, while the other states in the group are accumulating new cases at less than half the national average.
With a coherent national strategy, we could have learned enough from the spring peak to reduce the current surge. There’s still time to protect the states in Groups Four and One, but action needs to be taken immediately.