Judging How U.S. States Performed in the COVID-19 Pandemic Depends on the Metric
from Global Health Program

Judging How U.S. States Performed in the COVID-19 Pandemic Depends on the Metric

A highway sign promotes COVID-19 vaccination in May 2021 in Vancouver, Washington.
A highway sign promotes COVID-19 vaccination in May 2021 in Vancouver, Washington. Nathan Howard/Getty Images

The United States struggled with COVID-19, but some states managed to keep deaths and infections relatively low without shutting society down or ignoring the crisis.

July 13, 2023 8:13 am (EST)

A highway sign promotes COVID-19 vaccination in May 2021 in Vancouver, Washington.
A highway sign promotes COVID-19 vaccination in May 2021 in Vancouver, Washington. Nathan Howard/Getty Images
Interactive

Introduction

Pandemics are, by definition, transnational, but the battle against them is won and lost in local trenches.

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Treaties, national governments, and international institutions draw the most attention during outbreaks of viruses and other pathogens, but successful detection, containment, and mitigation of those health threats ultimately depend on the actions of local public health agencies, hospital and healthcare workers, community organizations, and citizens.

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Public Health Threats and Pandemics

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This was particularly true during the COVID-19 crisis in the United States, where states and localities had to make many of the hardest calls of the pandemic. This is in part by design. The U.S. Constitution makes states the primary engine of public health emergency response. Yet the role of local authorities became even larger when the White House opted to leave it “up to states to figure out what they want to do.” The isolation of local decision-makers in this crisis was compounded by the persistent struggle of U.S. federal agencies to provide timely data and practical, transparent guidance to states and the public. As a result, state and local authorities were left to decide how to balance protecting health in an emergency against other societal priorities such as economic productivity, educational needs, and personal liberty.

States were the essential unit of change in this pandemic. With little political appetite to bolster federal public health authorities, states are likely to retain that central role in future U.S. public health emergencies, too. Accordingly, efforts to improve U.S. performance ahead of the next pandemic should start with examining why some states did so much better than others, even according to the various metrics governors set for themselves.

This interactive presents three ways of assessing U.S. state performance in COVID-19:

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  • Health: a composite measure based on cumulative COVID-19 deaths and infections, adjusted for state-level differences in age and rates of diabetes, obesity, and other important health conditions that made COVID outcomes worse. Deaths are weighted as 75 percent of this composite measure.
  • Economy and Education: a composite measure based on changes in state gross domestic product (GDP) and employment, relative to what was expected for each pre-pandemic, and on changes in states’ fourth grade test scores between 2019 and 2022 in the National Assessment of Educational Progress. The economic measures are adjusted for the composition of economic sectors, such as tourism and agriculture, to ensure fair cross-state comparisons. GDP, employment, and test scores are equally weighted in this measure.

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COVID-19

Public Health Threats and Pandemics

Health Policy and Initiatives

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U.S. Economy

  • All-around: a combination of the health measure and the economy and education measure. Health is weighed more heavily (66 percent) in our measure given the priority on saving lives in a pandemic.

The data for this assessment covers the period from January 1, 2020, to July 31, 2022, and is drawn from our recent peer-reviewed study published in the medical journal the Lancet. A full description of our methodology, data sources, and a few necessary simplifying assumptions can be found here.

Here are a few of the lessons that can be observed from each assessment.

Health: Separate Americas

The health disparities among U.S. states in the COVID-19 pandemic were so large that to write about them is like describing the travails of different nations. For most of the pandemic, New Hampshire, Vermont, and Washington posted COVID-19 death rates comparable to those in Denmark, Germany, or Switzerland, while mortality rates from the virus in Arizona and Mississippi rival those in the world’s three worst-performing countries during that same period: Bulgaria, Peru, and Russia. Even after accounting for the relevant biological factors in this pandemic—variation in the age of state populations and in the local rates of diabetes, obesity, and other exacerbating health conditions—there is still a nearly fourfold difference between COVID-19 death rates in the best- and worst-performing U.S. states. Geographic disparities are not new to U.S. health, but the state-level differences in COVID-19 death rates are much larger than on other population-wide health measures such as average life expectancy at birth. In this pandemic, it has been as if the residents of those best- and worst-performing U.S. states reside in separate Americas.

These large interstate differences cannot be explained by politics, urbanization, and community mitigation measures alone. The leading states in this composite health measure tilt Democratic, but the Lancet study found no relationship between the political affiliation of state governors and the number of deaths that state suffered in the pandemic. The top ten in this composite measure for health are a mix of rural and urban states. Policy mandates, such as stay-at-home orders, business closures, and mask mandates, worked synergistically to reduce infections, but do not on their own explain the large state variance in COVID-19 deaths. COVID-19 vaccine mandates and coverage rates, however, were strongly associated with fewer deaths and infections.

New Hampshire ranks second on our composite health measure during the pandemic, but it is middle of the pack on other population health measures (such as life expectancy). It also falls in the bottom half nationally on mandate propensity, a summary measure of a state’s overall use of COVID-19 policy mandates, such as business and school closures, mask mandates, and gathering restrictions.

So, what else mattered in the Granite state? Social, economic, and racial disparities, and the measures that the state took to address those disparities and to protect vulnerable populations, played a central role.

New Hampshire distinguished itself during the pandemic by being more aggressive in protecting vulnerable populations and in addressing its social and economic disparities. Its early vaccine allocation strategy departed from federal guidelines in prioritizing the medically vulnerable and other disproportionately affected populations, including marginalized racial and ethnic groups, the homeless, the medically homebound, and others experiencing transportation or language barriers to vaccination. The state deployed a fleet of mobile vax vans and hosted mass vaccination sites to reach more politically conservative populations, such as at the New Hampshire Motor Speedway. It undertook measures to expedite access to testing and therapeutics in nursing homes and promote telehealth for rural settings, and worked with the private sector to promote more statewide sharing of essential medical supplies and load balancing at hospitals.

A Boston Medical Center child life specialist tends to a baby in a pediatrics tent.
A Boston Medical Center child life specialist tends to a baby in a pediatrics tent in 2020. Boston Medical Center pediatricians created a mobile clinic due to concerns of transferring COVID-19 in hospital buildings. Erin Clark/The Boston Globe via Getty Images

Like some other top-performing states, New Hampshire also benefited from already low levels of social, economic, and racial disparities. It has the nation’s lowest poverty rate, high levels of average educational attainment, excellent access to quality health care, and low rates of uninsured residents. New Hampshire also reports the nation’s highest levels of interpersonal trust—the trust that people have in one another—which makes it easier to mobilize against a pandemic. New Hampshire is one of the least diverse states in the country, which matters because a key legacy of this pandemic was the degree to which individuals identifying as Black, Hispanic, and American Indian and Alaska Natives disproportionately suffered. Essential workers are drawn disproportionately from those groups and are more likely to live in multigenerational households, where SARS-CoV-2 spreads more easily. Long-standing and systemic discrimination and socioeconomic disadvantages in accessing health-care services, including vaccination, clearly contributed in many other states as well.

Finally, the proximity of New Hampshire to early hard-hit states could have also played a role. Many top health performers were neighboring states that were all struck early in the pandemic, such as Massachusetts, New Jersey, and New York. Those searing examples could have motivated citizens and policymakers in New Hampshire and other top-performing states to adopt protective behaviors and take COVID-19 seriously. A similar phenomenon occurred with nations and territories near China.

The False Trade-Off Between Health and the Economy

The dominant perception is that the pandemic presented states with a choice of protecting public health or protecting their economies and preserving in-person schooling, with Democratic governors favoring the former (lives) and Republican governors prioritizing the latter (personal freedoms and the economy). For the most part, however, this perception does not correspond with the story told by our data.

Nearly all states, Republican and Democratic alike, instituted protective health mandates (such as gathering restrictions, mask mandates, and closures of bars, restaurants, and gyms) during the pandemic. Most states had such mandates in place between March 2020 and June 2020. The biggest difference between the use of mandates among states occurred in November 2020 with the emergence of the Delta variant. At this point, more Democratic-leaning states than Republic-leaning states reinstituted protective health mandates. Almost no states employed protective health measures after July 2021.

Overall, there is no association between these differences in states’ use of health mandates and changes in GDP or employment. The only exception is restaurant closures, which were associated with fewer jobs in our analysis.

The COVID-19 pandemic coincided with substantial declines in U.S. educational performance, but those learning losses were not systematically associated with state-level primary school closures. California, a state with long school closures during the pandemic, had test-score declines similar to or smaller than those in Florida and Maine, states with low rates of school closures. Those results, however, could be well different if the analysis were performed at the district or county-level.

All that said, the vast majority of states that did well on our economic and education composite measure were led by Republican governors. Only six Democrat-led states—Illinois, Kansas, Kentucky, Rhode Island, Washington, and Wisconsin—were in the top half of states in this ranking. Those differences cannot be explained by sectoral differences in those states’ economies, such as tourism or agriculture, which were controlled for in our analysis.

The reason for those differences could be tied to population behavior and perceptions of risk differing in states along political lines. Previous analysis from the National Bureau of Economic Research found that only small a portion of the decline in economic activity during the pandemic was associated with protective policy mandates; individual choices and fear of infection played a larger role in shifting consumers away from busy in-person businesses. That result is consistent with our data, which shows that higher infection rates were associated with higher employment and better education performance. In other words, states where more people were willing to frequent in-person stores, restaurants, and schools appear to have done better on our economic and education measure. None of the states hit hard early by COVID-19 rank among the best on economic and educational performance, perhaps because that early experience shaped individual behaviors for the remainder of the pandemic. In contrast, states in which COVID-19 cases started to appear later do best on this composite measure—Alabama, Montana, and South Dakota—and the population in those states continued to exhibit high levels of mobility relative to most other U.S. states during the pandemic.

All-Around: Not All U.S. States Struggled Equally

The United States struggled in this pandemic, but not all states struggled equally. Some states managed to keep deaths and infections relatively low, even by international standards, without shutting society down or ignoring the COVID crisis. The top performers in this measure are split almost evenly between states with Democratic governors (six) and Republican governors (four). They are not confined to a single geographical region and represent a mix of urban and rural states.

Like New Hampshire, Washington has relatively low levels of poverty and high levels of educational attainment, access to quality health care, and interpersonal trust. Washington deployed protective health mandates more than nearly any other state. Yet the Evergreen State economy is also host to a large and vibrant technology sector, which was better equipped than most to shift to remote work. Washington also faced challenges in this pandemic: a politically polarized population, with liberal coastal cities and conservative rural areas around the I-5 corridor; a large Native American and Alaska Native population—a group that disproportionately suffered in other states in this pandemic—and a large unhoused population in Seattle.

In interviews, Washington state health officials credit Governor Jay Inslee’s leadership and historical investments in the state public health system for more regular access to relevant data to support decision-making; an existing infrastructure for community engagement and trusted messengers, including with tribal authorities; and the human and financial resources to support rural communities and mobile vaccination campaigns. Exceptionally strong public-private partnerships enlisted leading local companies and nonprofits, such as Amazon, Starbucks, and the Bill and Melinda Gates Foundation, to advise on test-kit logistics, mass-vaccination centers, and public-health data analysis. Collaboration with neighboring state authorities enabled state officials to adapt and innovate in the face of changing circumstances, including early adoption of wastewater surveillance to monitor changing disease patterns. Identification of the first U.S. cases of COVID-19 in Washington state illustrated the seriousness of the pandemic early to Governor Inslee, state officials, and the public.

States as the Essential Unit of Change in Pandemic Preparedness and Response

Our assessments reveal that, whether the metric is health or the economy, the most important lessons from this pandemic were not about protective policy mandates or countermeasures, but instead what COVID-19 revealed about the communities that deployed those measures. Doing better in future health crises depends on investments to mitigate the socioeconomic and racial inequalities that led to higher death rates in this and previous pandemics. Partnering with local physicians, health centers, and faith-based institutions in divided communities can help identify trusted messengers and advance public health priorities, data collection, and two-way decision-making and communication with constituents in future crises. If the United States can learn from the best-performing states in this pandemic, perhaps other states will not struggle so much when the next health emergency happens.

This interactive was made possible by a generous grant from Bloomberg Philanthropies. The statements made and views expressed are solely the responsibility of the authors. The Council on Foreign Relations takes no institutional positions on policy issues and has no affiliation with the U.S. government.

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