14 April 2023

COVID-19 by State

The US spends more on health care than any other country and, in 2020, based on data collected prior to the pandemic, it was ranked best prepared of 195 nations for a pandemic. Yet the US had the highest number of recorded COVID-19 deaths and one of the highest per capita fatality rates globally.

Residents protest coronavirus stay-at-home orders in 5 states, 19Apr2020 (from abcnews.go.com/US/residents-protest-coronavirus-stay-home-orders-states/story?id=70233220).

Welcome back. Expanding on the pandemic’s overall outcome in the US, a recent study examined why the pandemic didn’t impact US states equally.

The comprehensive analysis addressed five key policy questions: (1) the role of social, racial and economic inequities; (2) whether states with greater health care and public health capacity performed better; (3) the influence of politics on the results; (4) whether states that imposed more policy mandates and sustained them longer did better; and (5) whether there were trade-offs between a state having fewer cumulative SARS-CoV-2 infections and total COVID-19 deaths and better economic and educational outcomes.

The observational and modelling study was conducted by nearly 60 researchers, most of whose primary affiliation was with either the Institute for Health Metrics and Evaluation at the University of Washington, or the Council on Foreign Relations in Washington, DC. Other affiliations included Drexel, Harvard, Pittsburgh, Toronto, Washington and Yale universities.

Study Approach
The researchers broke out data by state
from public databases, 1 Jan 2020 to 31 July 2022. To facilitate comparison of states' successes in mitigating the effects of COVID-19, they standardized infection rates for population density and death rates for age and prevalence of major comorbidities.

Cumulative standardized COVID-19 infection rate per 10,000 people by state, 1Jan2020-15Dec2021 (from fig.1, www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00461-0/fulltext). 
They statistically related these health outcomes to pre-pandemic state characteristics (e.g., educational attainment, health spending per capita), policies adopted by states during the pandemic (e.g., mask mandates, business closures), and population-level behavioral responses (e.g., vaccine coverage).

Going further, they explored potential mechanisms connecting state-level factors to individual-level behaviors. This included quantifying reductions in state GDP, employment, and student test scores to identify associated policy and behavioral responses and assess trade-offs with COVID-19 outcomes.

Selected Findings
Standardized cumulative COVID-19 death rates over the study period varied across the US (national rate 372 deaths per 100,000 population). The lowest rates were in Hawaii (147 deaths per 100,000) and New Hampshire (215 per 100,000), the highest in Arizona (581 per 100,000) and Washington, DC (526 per 100,000). 

Cumulative standardized COVID-19 death rate per 100,000 people by state, 1Jan2020-31July2022 (from fig.1, www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00461-0/fulltext).

A lower poverty rate and more years of education were associated with lower SARS-CoV-2 infection and Covid-19 death rates; states with larger percentages of non-Hispanic Black or Hispanic were associated with higher cumulative death rates.

Access to quality health care was associated with fewer deaths and infections, but higher public health spending and more public health personnel per capita were not.

Partisan politics played a nuanced role in state-level outcomes. The state governor’s political affiliation was not associated with infection or death rates, but worse outcomes were associated with the proportion of a state's voters who voted for the 2020 Republican presidential candidate.

State governments' uses of protective mandates were associated with lower infection rates but not death rates, which were impacted by many other factors. Mask use and higher vaccination rates were associated with lower infection and death rates.

State GDP and student reading test scores were not associated with state COVID-19 policy responses, infection rates or death rates.

Employment had a statistically significant relationship with restaurant closures and greater infections and deaths. On average, states with a 1% increase in employment rate were associated with 1,574 additional infections per 10,000 population.

Several policy mandates and protective behaviors were associated with lower fourth-grade math test scores, but the study did not find a link to state-level estimates of school closures.

Wrap Up
While I’ve tried to capture study highlights, there’s much more in the report.

The researchers make clear that COVID-19 magnified the polarized, persistent inequities that exist across US society. States that mitigated those inequalities, deployed science-based interventions, and promoted their adoption across society were able to minimize COVID-19 death rates. Overall, these findings could contribute to the design and targeting of clinical and policy interventions to facilitate better health outcomes in future crises.

Thanks for stopping by.

Study of COVID-19 policies and behaviors across US states in The Lancet journal: www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00461-0/fulltext
Article on study on EurekAlert! website: www.eurekalert.org/news-releases/983582

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