Assessing Underlying State Conditions and Ramp-Up Challenges for the COVID-19 Response

An unprecedented pandemic has exploded within the U.S. COVID-19 has now reached all 50 states and is disrupting life in large urban areas including Seattle, the Bay Area, and New York City.

The rapid spread of a virus with an undefined risk of death has forced state and local governments and health systems to act urgently to mitigate the spread and respond to an increasing number of infected Americans. The speed of transmission threatens to strain health system capacity and presents a clear and present risk to health care workers. Mounting hospitalizations and intensive care needs appear to involve adults of all ages.

The U.S. health system is decentralized, with states playing a central role in the organization of health care and public health infrastructure. A range of resources and legislative decisions, as well as different demographics, can lead to divergent outcomes across states. Where Americans live is a strong predictor of the care available to them and their expected health outcomes.

Faced with this pandemic, states are quickly coming to terms with their ability to handle the current level of COVID-19 cases and the resources they may need if the outbreak surges and places a pronounced demand on capacity.

To understand the capacity in each state and to help inform decisions of federal and state policymakers in the coming weeks, we aggregated a set of state-level data indicators related to:

• clinical risk factors of the state’s adult population
• state health system capacity and resources, under both current and “surge” scenarios
• insurance coverage and cost-related access barriers for adults.

We present these measures in the following tables, with additional information and context.

Health Risk Factors

While adults of all ages are being hospitalized as a result of COVID-19, certain age groups are at higher risk of mortality. Using data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), we estimate the percentage of adults within each category:

• adults 65 years and older
• adults with certain underlying chronic health conditions, such as heart disease, lung disease, diabetes, and severe obesity; several of these conditions disproportionately impact racial and ethnic minorities.

An estimated 108 million adults (43% of the U.S. adult population) may be at elevated clinical risk because of their age or having a chronic illness. Within states, the percentage at elevated clinical risk ranges from a high of 53 percent in West Virginia down to 36 percent in Utah. Several states have a disproportionately high percentage of elderly who also have chronic conditions, including Kentucky, Mississippi, and West Virginia.

These estimates provide a preliminary measure of the states that may be more likely to experience resource shortages and increased mortality rates. Additionally, in the table we include the number of adults experiencing homelessness in each state as reported by the U.S. Department of Housing and Urban Development. This vulnerable population has significant underlying chronic conditions and transmission risk and could quickly contribute to capacity challenges in urban areas like New York City that are already struggling to contain the spread of the virus that causes COVID-19.

System Capacity to Meet COVID-19 Needs

Based on their population size, density, and government spending, states (and certain regions within states) vary in their capacity to respond to the pandemic. The speed of transmission of the COVID-19 virus within communities and the substantial proportion of people who may require hospital care within a week of infection could produce sudden demand for health facilities and specialized equipment that can overwhelm local systems.

Many states are engaged in contingency planning to cope with potential shortages of hospital beds and ventilators, similar to the challenges faced in other countries. A recent analysis by the Harvard Global Health Institute highlights significant potential shortages in hospital beds across the U.S. depending on the extent of the outbreak.

To understand how capacity issues will affect response, we gathered key indicators to provide a snapshot of current health resources and infrastructure within each state. We also provide preliminary estimates of health care worker capacity available to respond to “surge” scenarios as COVID-19 cases increase.

Using data from several sources, we report state measures of:

• hospital beds per 1,000 adult population
• ICU beds per 1,000 adult population
• physicians and advanced clinical practitioners per 100,000 population
• full-feature mechanical ventilators per 100,000 population
• public health funding by states per capita.

Health care worker capacity can be defined in different ways. We developed two scenarios: current status and a surge situation. For this analysis, we excluded pediatricians and pediatric service capacity. 

The current capacity scenario assumes the health care workforce as it is currently configured. For simplicity, we categorize providers based on whether they will provide care in one of two roles: 1) triage and clinical management of ambulatory adults or 2) hospital and ICU care.  Ambulatory providers in the community will test and triage patients, treating those who can receive care in the community and referring those in need of hospital or intensive care. We include in the triage and clinical management group active primary care physicians and internal medicine-related specialists. We include in the hospital and ICU group active hospital-based physicians familiar with admitting and managing patients in inpatient settings. Surgeons are also included in this group. Finally, nurse practitioners (NPs) and physician assistants (PAs) are included as a separate category. We recognize that clinicians may be called to different roles depending on the local situation. Our results approximate capacity at the outset of the pandemic. 

In addition, we calculate capacity under a surge scenario in which physicians who currently report serving in research, teaching, or administrative roles move into patient care to meet patient demand. This group does not include retired clinicians, although some states are preparing to mobilize retired clinicians and others to assist with the response. Within the table, this additional surge capacity is captured for each state in a separate column.

Depending on the underlying risk factors within a state’s population and the transmission path of the COVID-19 virus, states with lower current or surge capacity may be at higher risk of shortages and need additional federal and state assistance. For example, Nevada and Texas report lower capacity as measured by facilities, clinician capacity, and state public health funding.

Coverage and Access

There are currently 30 million people who lack health insurance coverage nationwide and an additional 44 million who underinsured — meaning they have unaffordable deductibles and cost-sharing. This leaves the U.S. in a particularly vulnerable position relative to other countries that have universal, comprehensive coverage. Moreover, coverage rates vary widely across states, leaving some at an even greater disadvantage. In addition, there is considerable variation in out-of-pocket cost exposure because of increasing deductibles for private health coverage, including employer plans, which especially impact lower- and middle-income families.

Inadequate health coverage is a challenge not faced by other countries. A new poll by NBC News and the Commonwealth Fund found that nearly seven of 10 adults said that cost would be an important factor in people’s decisions to seek COVID-19-related care. Reflecting the high out-of-pocket deductibles that people face in private coverage, the survey found no significant difference between insured and uninsured adults for this question.

States with a higher percentage of residents who are uninsured or underinsured may face a greater challenge in mitigating the spread of the virus if those individuals are less likely to seek care when infected, which could lead to potentially higher mortality rates and poorer outcomes. For those who are insured, new legislation requires private plans to cover the cost of tests and care associated with the visits, and a growing number of states are imposing similar changes in their own insurance markets. In addition, the federal legislation allows states to cover tests for people who are uninsured or enrolled in non-ACA-compliant plans through Medicaid. But these provisions are just for testing, not the costs of care for COVID-19.

In the table below, we report:

• the uninsured rate for adults ages 19 to 64
• if a state has expanded Medicaid eligibility under the Affordable Care Act (ACA)
• percentage of adults ages 18 to 64 and 65 and older who reported skipping needed care because of cost
• average deductible for an employer-sponsored insurance (ESI) health plan within the state.

Unsurprisingly, state trends can vary widely. Maryland, for example, reports an adult uninsured rate (8%) well below the national average, along with below-average cost-related access problems and ESI deductibles. Texas, on the other hand, has the nation’s highest uninsured rate (24%).

What Lies Ahead

Our findings demonstrate that some states are potentially better positioned to respond to COVID-19 than others. For example, some have a higher percentage of at-risk adults combined with lower rates of insurance coverage and below-average hospital bed and clinician capacity. Others may have a lower percentage of the population at risk, but more limited ability to scale up medical capacity in the case of a surge in COVID-19 cases. States like Nevada, Texas, Arizona, and Georgia report variable population risk alongside less capacity, lower insurance coverage, and cost-related access problems — meaning they may face a heightened challenge.

These data are not a forecast. We selected measures among potentially dozens of relevant indicators that can affect the response to COVID-19. In addition, the pattern of viral spread will be affected by factors outside the control of health care systems, including policy decisions by state and federal leaders around social distancing and other mitigation tactics. But these tables, which will be updated as data become available, offer a preliminary and early warning of the differential challenges and risks that may affect states in the weeks ahead. They also may help identify vulnerable states where targeted federal support will be critical.