From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

New Jersey’s response to the coronavirus pandemic – Update (May 2020)

Tsung-Mei Cheng, Princeton University

Current Status

On March 21, when New Jersey had 90 confirmed Covid-19 cases and 11 deaths, Governor Phil Murphy ordered a state-wide stay-at-home order exempting only essential workers. Seven weeks later, with more than 97% of the US population under lockdown, New Jersey officials reported that, on May 7, New Jersey had 133,635 Covid-19 cases and 8,891 deaths, prompting Governor Murphy to announce that: “We are still in the midst of a public health emergency.”

Many of the deaths remain concentrated in the northeastern part of the state, which is in close proximity to the densely populated New York City.

A hopeful sign, however, is that New Jersey is seeing a continued leveling of daily counts of cases and deaths. Current Covid-related hospitalizations represents a 40% drop from its peak seen in mid-April.

In terms of New Jersey’s health care system capacity to meet the once rapidly-rising demand for care of Covid patients, Mark Levine, President of the Medical Society of New Jersey, said this in his May 5 op ed. in the Star Ledger: “Our healthcare system has met the surge.”

Re-Opening New Jersey

As in most other states in the United Sates, the lockdown has had catastrophic economic consequences in the state. Health care professional are also worried about the severe impact of the crisis on the mental health of Americans. New Jersey is among the more than 40 states that are either making preparations for reopening or now reopening, albeit with restrictions.

Two core federal criteria for preparedness for states to reopen are, first, downward trajectory of documented cases over a 14-day period, and second, testing and contact tracing capacities. NJ has met the first criterion. Testing and contact tracing, however, have proven to be more problematic.

New Jersey does not yet have the infrastructure for population-wide testing or contact tracing. On May 6, Governor Murphy extended his public health emergency declaration for 30 days. On May 8, Governor Murphy added two more testing sites to the existing group of 122 sites in the state of 9 million to test asymptomatic people: frontline health workers, first responders, nursing home residents, New Jersey residents in close contact with Covid-19 patients. The governor will announce a contact tracing structure for New Jersey the week of May 11.

New Jersey is part of a consortium of seven Northeastern states — New York, Connecticut, Pennsylvania,, Delaware, Rhode Island, and Massachusetts – to coordinate the reopening of the economy.

In the meantime, New Jersey’s state parks, golf courses, and county parks reopened May 2.

Challenges

One serious concern New Jerseyians who have health insurance face is the potential steep price they will pay in lives and health lost as a result not of Covid-related illnesses, but from cancellations of “elective” medical interventions that are nevertheless necessary and time is of the essence; for example, cancer surgeries, stents for blocked heart arteries, etc. Each year 18,000 New Jerseysians die of heart disease. What will be the mortality from coronary heart disease in New Jersey in 2020?

Levine, in the same op ed., sounded the alarm thus: “Those suffering from non-Covid illnesses will create a second wave of patients in NJ …” If we have learned anything about COVID-19, it is that it feasts on those with underlying chronic conditions. We must not create a population of vulnerable individuals by leaving their chronic conditions unmanaged.” Levine’s warning applies to the entire US as many Americans have one or more chronic conditions – heart disease, cancer, chronic lung disease, stroke, Alzheimer’s disease, diabetes, chronic kidney disease: 6 in 10 American adults have a chronic disease, and 4 in 10 have two or more.

The situation is likely to be far worse if one took into consideration two additional facts: first, many insured New Jerseyians, and insured Americans overall for that matter, stopped accessing needed care by not going to health care facilities out of fear of contracting Covid-19. Second, many uninsured Americans, including the newly-uninsured who lost their jobs because of the Covid-19 crisis, do not seek care out of concern that they cannot afford the cost of care.

According to an April 28 Associated Press article citing a Gallup-West Poll, “nearly 1 in 10 adults say cost would keep them from seeking help if they thought they were infected… A significantly higher number, 14%, would avoid seeking treatment because of pocketbook worries if they had fever and a dry cough, two widely publicized symptoms of Covid-19.”

Access barriers to needed medical care because of affordability concerns is a uniquely American phenomenon, one caused by the US employer-based health insurance system. Many critics of this system, including the late Princeton economist Uwe Reinhardt, have long advocated replacing the employer-based health insurance system with an individual-based system.

The United States must address, sooner rather than later, the problem of cost and access, which plagues tens of millions of Americans. The US must change from its current health care system, which is based fundamentally on the ability to pay, to one based on healthcare needs, like the health systems in every rich nation and economy in the world.

New Jersey’s response to the coronavirus pandemic – Original post (April 2020)

Tsung-Mei Cheng
Princeton University

As of April 6, 2020, there were a total of 337,278 confirmed Covid-19 cases and 9,637 deaths in the United States. New Jersey, the 11^th largest state by population (8.9 million, or 2.7% of US population), accounted for 37,505 confirmed cases (11.1% of total) and 917 deaths (9.5% of total), making it one of the states in the United States with the heaviest Covid-19 burden to date. Geographically, New Jersey is adjacent to the highly dense New York City (population 8.7 million), the epicenter of the crisis. Many New Yorkers reside in New Jersey and commute daily to work in the Big Apple. Not surprisingly, New Jersey communities surrounding New York City are seeing far higher numbers of cases and deaths than the rest of the state.

New Jersey’s response so far

New Jersey reported its first coronavirus case in early March. On March 9, 2020, New Jersey Governor Phil Murphy declared a State of Emergency and a Public Health Emergency across all 21 counties in the state effective immediately in an attempt to contain the spread of Covid-19. Public places where people gather in close proximity — theatres, casinos, gyms, dining facilities, etc. — were ordered closed. By mid-March, alarmed at the rapid rate of increase in confirmed cases, which had climbed 50% to 267, Governor Murphy expanded the list of closures to include schools, universities, indoor malls, and amusement centers. Murphy also ordered all 55,000 residents of the city of Hoboken to isolate at home for a week. Hoboken is a part of the New York Metropolitan area where the major transportation hub for the tristate region New York-New Jersey-Connecticut is located. Furthermore, Murphy banned gatherings of groups of 50 or more people; told all New Jersey residents to observe social distancing, only leaving their homes for essential needs like groceries and medical care; and postponed all non-urgent surgeries to free up delivery system capacity, a measure several other states have also taken.

These measures to flatten the curve notwithstanding, all projections point to a seriously worsening situation for New Jersey beginning this week (early April) through next, particularly in the urban and suburban communities around New York City.

How prepared Is New Jersey for the projected coming onslaught? Some hospitals in the state’s heavily affected areas are already running out of beds. As is the case in other states heavily affected by Covid-19, a plethora of delivery system capacity constraints will further impede New Jersey’s ability to respond: serious shortages of ventilators, personal protective equipment (PPE), and staffing are widely anticipated. Some numbers tell the severity of the ventilator shortage: two-thirds of the total inventory of ventilators (2,400) in the state are currently in use. New Jersey asked the federal government for 2,500 more to meet the anticipated exploding demand for ventilators, but received just 850 as of April 3. New Jersey Health Commissioner Judith Persichilli told Politico that “Our estimated gap … is that we need 6,000 more.”

It is also feared that temporary hospitals set up to receive non-Covid-19 patients transferred from hospitals to free up beds for Covid-19 patients will not be sufficient to meet the anticipated demand for hospital beds when the peak comes.

Rationing of care, hitherto unthinkable to Americans, is taking place before their own eyes — some physicians and medical staff are now choosing which patients to put on ventilators.

Testing for Covid-19 infection is lagging also because, once again, of supply-side capacity constraints. Limited testing kits and labs to run the tests cause long waiting times for test results, one reason why to date the state does not know how many of its residents are infected.

So far, the federal government has paid roughly 75% of the money New Jersey spent on PPE through its Federal Emergency Management Agency (FEMA). New Jersey’s private sector is also stepping up to address shortages. For example, the large private insurer Horizon Blue Cross Blue Shield and the International Longshoremen’s Association have donated needed equipment. The state is also working with China, Taiwan, and Germany to get more PPE.

Reflections on New Jersey’s response

The covid-19 crisis in New Jersey is a moving target. It is clear, seen from even the limited information presented here, that New Jersey is woefully under-prepared for the challenge, current and projected, as New Jersey anxiously awaits the worst to come.

New Jersey’s problems are, sadly, in fact part-and-parcel of the larger set of problems stemming from a confluence of several uniquely American circumstances, which has repercussions that affect the whole country. It can be said that, under the combined forces from the Covid-19 crisis and these uniquely American national circumstances, today’s America is “sailing into the perfect storm,” a metaphor the late Princeton economist and health policy scholar Uwe Reinhardt often used to describe the troubled American health care system and its consequences.

Some important uniquely American national circumstances include, but are not limited to, America’s complicated federal-state relations, which make it difficult and sometimes impossible to have a well-planned and coordinated national response to a national and global health crisis such as Covid-19. Leadership at the top has also been called into question. The Trump Administration’s closing, in 2018, of the National Security Council Directorate for Global Health Security and Biodefense left the country vulnerable to pandemic outbreaks, which in the current crisis contributed to making matters worse. National shortages of ventilators, PPE, and medical staffing have put severe strains and constraints on the delivery system. New Jersey must compete with other states, through price wars and other means, for the limited federal supply of PPE, ventilators, etc.

In this chaotic scramble to fight the pandemic, it is ironic that, to date, eight of fifty states in the US have not mandated social distancing, one of the most effective ways to contain the spread of Covid-19. President Trump steadfastly insists that social distancing is a matter of state policy.

America’s hugely complex and fragmented health care financing and delivery systems is another impediment to policy makers organizing coordinated policy responses to the crisis. For example, it took New Jersey an entire month between its first reported confirmed case and when a clear count of the number of Covid-19 patients being treated in its hospitals was made public.

Finally, despite spending more than twice the OECD average on health care as a percentage of gross domestic product — 16.9% vs. 8.8%, respectively, 2018 — America has fewer doctors, nurses, and hospital beds than many other rich OECD nations. This adds strains on an already overburdened delivery system because of Covid-19. Staffing shortages have prompted calls for volunteers to boost the supply of clinicians to care for Covid-19 patients. Many retired or non-working clinicians responded by returning to work. Medical schools moved up the graduation date for the current graduating class so they could go to the frontline immediately.

The important lesson for New Jersey, and in fact for the US, is that, the ultimate outcome of any pandemic outbreak depends to a significant degree on the response of the government and the public to the threat. Whether New Jersey has done enough, and early enough, remain open questions. Going forward, New Jersey can, however, surely look to other nation’s success stories and learn from them.

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