in Coronavirus, Governor Cuomo, New York, New York City, Trump Administration, Upstate New York

COVID-19: The Harsh Tradeoffs

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COVID-19 created a series of dilemmas for policymakers at the state and federal levels.  Actions that would reduce the frequency of infection involved measures that would limit personal interactions, causing the loss of jobs, while reopening the economy proved to result in higher levels of infection, hospitalizations and deaths.

But, the difficult policy choices were not limited to the jobs/infection tradeoff, but involved uncertainties about the effectiveness of control measures, difficulties in projecting the demands that the disease would create on healthcare workers and facilities and policy alternatives that at times offered no good alternatives. State and local leaders were forced to make uncoordinated, wasteful scrambles for badly needed supplies that were exacerbated by a federal government that was unwilling to make strong market interventions.

Not surprisingly, leaders at the federal and state level have been criticized for the decisions that they made during the crisis.  At the federal level, the President engaged in denial through the course of the pandemic and provided messaging that was inconsistent with the epidemiological experts.  He engaged in partisan attacks on state leaders and others, diverting attention from controlling the pandemic.  His administration did nothing to control price gouging and the negative effects of competition in a market where the demand for medical provisions far exceeded the supply.   The administration was slow to invoke its powers to force manufacturers to produce equipment and supplies that were difficult to find.

At the state level, leaders scrambled to respond to the quickly emerging threat.  In New York, although Governor Cuomo was among the first to impose an economic shutdown, there is evidence that the virus’s severe impact on the New York metropolitan area could have been substantially ameliorated had he acted sooner.  The Governor sought regionally consistent policies and imposed a phaseout of nonessential business activities over a seven-day period beginning on March 16th, 2020 with restaurants, bars, and movie theaters.

Lack of Testing Obscured COVID’s Spread

When the state began the shutdown, it had 1,431 total confirmed cases, with 369 positive tests on March 16th.    But, because very little testing was being done at the time, the low number of observed cases was a mirage.  The Institute for Health Metrics and Evaluation, at the University of Washington, offers a model that estimates that the total number of cases in the state was 492,000 on March 16th, with 82,800 new infections on that date, and was climbing rapidly.  By March 23rd, when the shutdown went into full effect,  the Institute estimates that there were almost 1.3 million total cases in the state.  The number of estimated cases grew by 1.5 times during the week-long phase-in of the state’s shutdown.

The more recent IHME model estimates that New York already was seeing 2,000 new cases per day before the first case was detected in the state on March 1st.  By that date, the model estimates that the state had 15,000 total infections.   By March 7th, the total had reached 60,000.  Testing data totaled 88 positive cases.  By March 14th, the number was 335,000.  Testing data showed 784 total cases.  Because very little testing was available, state leaders took their first control action on March 10th, believing that the infection was a primary threat in a one-mile zone around New Rochelle, attempting to contain it by closing schools, houses of worship and banning large gatherings.  Later data shows that infections were certainly far more widespread by then.

The chart above shows the different trends that resulted from the lag in testing.  While testing results showed relatively few infections, with continued increases in new infections throughout March, the estimates generated by the IHME model show that infections had reached very high numbers – peaking at more than 120,000 in a single day – beginning in early March.  New infections began to decrease quickly after Governor Cuomo instituted restrictions on business activities and group meetings.  Because of limited testing, infections appeared to be increasing even after later data from ICMI showed a decline after the implementation of control measures.

Although epidemiologists had warned that there were certainly more infections than testing had shown when the state recorded its first cases at the beginning of March, there was a perceptual gap between the available data and the actual spread.  Because cases were growing exponentially during the first weeks of March, the delay in imposing controls resulted in more cases of COVID than would have occurred had action been taken more quickly.

Impact on Hospitalizations

The rapid growth of cases that hit New York State had a severe impact on health care personnel and facilities.  While the nation currently has many more patients hospitalized than it did in March and April, the impact of the pandemic was concentrated in the northeast – particularly in the New York metropolitan area – in the Spring. About one-third of all hospitalizations in the nation were in New York State when they hit their peak at 18,825 in the state in mid-April.  The New York metropolitan area had by far the largest early outbreak of COVID in the state, with about 85% of all cases statewide.

There are currently far more COVID patients in the hospital throughout the United States than in the Spring.  As of November 27th, the COVID Tracking Project reported 89,834 patients, compared with 59,773 on April 21st. The current outbreak is far more widespread – infection levels are rising almost everywhere.  Reports show that hospitals, health facilities and health personnel are stressed by the COVID patient load in a number of locations.  But, the impact of the pandemic on the capacity of the healthcare system remains lower than it was in the Spring in New York and New Jersey.

New York’s rate of COVID-19 hospitalizations was 97 per hundred thousand residents when it peaked in the Spring. With New Jersey, which peaked at 93 per hundred thousand residents, the state far exceeded the peak COVID hospitalization rates in other states.  South Dakota, which is the most severely affected state at present, has 69 cases per hundred thousand, followed by the District of Columbia and Massachusetts.

The heavy impact of COVID cases in New York State in the Spring was highly visible. National news reports showed overflowing hospitals and personnel that came to New York to assist overwhelmed local health care workers.  Equipment shortages were severe.

Managing the COVID-19 Pandemic

In the end, a primary goal of COVID-19 management has been to implement whatever public health measures are needed to ensure that healthcare institutions and personnel can care for the patient load that the disease imposes.  In New York’s case, the sudden early surge initially overwhelmed the system, and state leaders had to appeal for help from other states and the Federal government.

While the pause was an effective strategy, its impact was not felt immediately.  It took about a month from the beginning of the pause on business and personal activities on March 16th to see hospitalizations begin to decline.  On March 16th, New York State had 325 COVID-19 patients in hospitals.  Hospitalizations would rise to almost 19,000 in the month following the start of the pause.

During late March and early May, the Governor and other state officials could not know how high the peak in demands on hospitals and health care facilities would be.  Because the pause was a novel strategy, government leaders did now know how effective it would be or if effective, how quickly cases and hospitalizations would decline.  That uncertainty led to requests for assistance from the Federal government and other states for personnel, equipment and field hospitals.

 

The pause on business activities and personal interactions imposed by New York State was stricter and lasted longer than in most other states.  After the economy began to reopen, the state continued restrictions on high-risk activities, such as indoor dining, movie theaters and fitness facilities, while mandating mask-wearing in public settings.

Oxford University publishes a “stringency index” which measures the strictness of government responses to the COVID-19 pandemic.  New York currently ranks second in the nation on the index, trailing only New Mexico.  The data shows that the state’s rate of hospitalizations per hundred thousand residents has been substantially lower than the nation’s since July.  While hospitalization rates in New York have risen substantially since October, they remain at only half the national level.

The impact of New York’s tight restrictions can be seen in the state’s low COVID-19 daily death rate.  For November 26th, based on the seven day rolling daily average, the state’s rate was eighth lowest in the nation.  Its rate was less than half the rate for the nation as a whole.

Based on available data, New York saw 1,998 deaths from COVID-19 since June 15th, after the end of the initial surge – a rate of 10.27 deaths per million residents.  Nationally, 143,300 deaths occurred during the period, a rate of 43.7 per million.  Had New York seen deaths at the national rate, the state would have seen 8,495 deaths instead of 1,998.

Tight restrictions succeeded in bringing down cases, hospitalizations and deaths in New York, but questions remain about decisions made in the process.  Questions have been raised about the need for a statewide shutdown when infections were much lower in much of upstate New York than in the New York City metropolitan area.  The Governor has been criticized for releasing hospitalized nursing home patients who were still positive for the disease back to the nursing homes from which they came during the initial surge in the Spring.  Business owners have argued that the restrictions were too strict and lasted too long.  Church leaders objected to limits on church gatherings that were more severe than in other locations.  The decisions made by the Governor and other leaders involved significant tradeoffs between public health and limits on personal and business activities that crippled the state’s economy.

Impact of COVID-19 Related Restrictions on Employment

New York’s economy has been harder hit than the nation as a whole.  Nationally, private sector employment was 6.2% lower in October of this year than it was last year.  Overall, employment in New York State declined by 11.5%. In October, the state had 968,000 fewer private-sector jobs than it did in the same month last year.  Employment declines ranged from 7.3% in the Utica-Rome and Binghamton metropolitan areas to 12.3% in Syracuse.

The sharper declines in New York State are not a result of the particular mix of industries in the state.  Employment declines here have been larger in almost all of the major industry sectors than in the nation as a whole.  Nationally, the impact of the COVID-19 pandemic has primarily been on the leisure and hospitality industries – hotels, restaurants and amusement venues.  The impact on those industries has been severe – with 20% fewer jobs in October 2020 than in the same month in 2019.  But, the damage has been more severe here – with 34% fewer jobs compared to last year.   Because New York has imposed stricter controls on leisure and hospitality businesses than other states, employment has suffered more than elsewhere.  Because employees in these industries are relatively low paid, the impact of the employment losses has disproportionately hurt low-income workers.

Employment declines in New York have been greater in other industries as well.  Professional and business services and wholesale and retail trade in New York State have also seen relatively large employment losses, with decreases of about 10% or more, compared to losses of less than 5% nationally.

Conclusions

The COVID-19 pandemic presented serious challenges to government leaders at the national, state and local levels.  While the Trump administration scored a notable success with its “warp speed” vaccine development program, the shortcomings of leadership at the national level have been well documented.  See, for example, this or this or this.  At the state level, Governor Cuomo’s performance illustrates the difficult policy choices faced by leaders, while showing some strengths and weaknesses.

Had the Governor imposed restrictions on businesses and individuals earlier, there would have been fewer hospitalizations and deaths.  But, the lack of availability of testing early in the pandemic hampered decision making.  Currently available models point to the fact that New York had significant numbers of residents infected with COVID-19 before the first case was detected here.  In March, the number of confirmed positive cases was a small fraction of the actual number as estimated by the ICMI model.

A few states acted before New York, but only by a few days.  California issued a stay at home offer on March 19th, compared with New York’s requirement that all non-essential businesses move to fully remote activities on March 23rd.   Overall, New York’s took action as early as most states, reflecting the meager availability of testing data that led to underestimates of the disease’s spread.

Critics have raised questions about the fact that from March until May, state rules directed hospitals to discharge nursing home patients in hospitals with positive COVID tests back to the hospitals from which they came.   On March 25th, 2020, the State Health Department issued the following directive, “No resident shall be denied re-admission or admission to the NH solely based on a confirmed or suspected diagnosis of COVID-19. NHs are prohibited from requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.”  Because residents of nursing homes are members of the population deemed most vulnerable to COVID and live in congregate settings, the policy was highly controversial, given the potential exposure to COVID from returning hospital patients.

Much of the argument about the issue relates to the failure of the state to release data on nursing patients who died of COVID in hospitals.  Critics point to the fact that the state’s policy, which does not mirror that of some other states, leads to underestimates of the COVID death toll among the vulnerable nursing home population.   But, from a policy perspective, the more important questions have to do with the decision making processes that led to the policy.  One question that needs to be answered is whether the decision to require nursing homes to accept COVID positive patients was made primarily because of capacity constraints at hospitals burdened by large numbers of COVID patients.  The policy directive was issued after COVID hospital populations had begun to decline.  A second question has to do with whether the state did all it could to provide alternative places to discharge COVID positive nursing home patients, recognizing that nursing home residents typically have specialized support needs.  Finally, the Administration waited until May to rescind the controversial policy, long after the crushing burden of COVID patients.  Why did the policy remain in effect long after the hospital population peaked?  A more complete discussion of the issue, by Bill Hammond of the Empire Center, may be found here.

Finally, there have been many objections to the strictness of the state’s limitations on business, religious, and personal activities.  These concerns reflect the tension between the measures used to reduce hospitalizations and infections and their impact on jobs.  There is no doubt that New York’s limits have negatively affected employment – the state’s percentage employment loss in October compared with the same month in 2019 was almost twice as great as the nation’s.  But it is also true that New York’s rate of hospitalizations is much lower than the national rate, as are its deaths.  Given the current rise in infections nationally and in New York,  responding to pleas from those who want restaurants, movie theaters, churches, and other gathering places to be freer of restrictions would create a clear likelihood of more infections and thousands more deaths.

Governor Cuomo has consistently recommended that state residents employ prudent practices to limit the spread of COVID and has backed up his public statements with policies that mandate limits on interactions. But, at times his manner has been bellicose, making overtly political statements in his briefings. Although some of the Governor’s political arguments with President Trump were designed to highlight the state’s need for more help, others, such as his statements about New York’s unwillingness to provide residents vaccines approved by the Trump administration without New York making its own evaluation sounded like petty bickering.

The Governor sometimes appears to be unwilling to consider the arguments of those who may have valid concerns.  Cuomo appeared to be unwilling to consider the views of religious leaders who believed that they were being unfairly discriminated against by being required to abide by very strict limitations on religious observances.  These unnecessary confrontations undermined the perception that the Governor is a leader whose primary interest was in protecting the state’s residents.

With effective vaccines soon to be available, the light is at the end of the pandemic tunnel.  But, we face heightened risks through the holiday season and in the Spring until a large percentage of the population acquires immunity.

The federal government is transitioning to new leadership, but the Trump administration will be in place until late January.  The administration accepted its transition responsibilities belatedly and could obstruct efforts to coordinate vaccine distribution and overall COVID management.

At the state level, Governor Cuomo has provided more consistent messaging in support of disease management but has muddied his message with overly combative stances  Additionally, when confronted by questions about his decisions, he has at times been overly defensive instead of accepting responsibility for actions that involved significant tradeoffs.  Whether the Governor will become more conciliatory with a new federal administration in place is a question.

New Yorkers and residents of the nation as a whole would benefit from more cooperative and consistent approaches from the state and federal governments.  Instead of political theatrics and defensiveness, we need leaders who acknowledge and explain the difficult tradeoffs posed by the COVID-19 pandemic.

 

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