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

Wisconsin’s Response to the Coronavirus: The August Update (2020)

Thomas R. Oliver and Ajay K. Sethi
Department of Population Health Sciences
University of Wisconsin School of Medicine and Public Health

The Current Scope of the Pandemic

The United States is seemingly unique among advanced industrial countries for its mismanagement of the SARS-CoV-2 pandemic.  Six months into the crisis, the U.S. continues to report confirmed infections (now 5 million) and deaths (now over 160,000) from COVID-19 at rates that greatly exceed those of all other countries except for Brazil and India.  While the original devastation in New York and the northeastern U.S. more generally has been stanched and brought nearly to a standstill, the rest of the country, including rural areas, has seen a summer-long surge of cases and over 1,000 Americans are once again dying each day from COVID-19 infections.

Thus, the current state and trajectory of the pandemic in Wisconsin must be characterized in relative terms.  By U.S. standards, Wisconsin is a relative success.  As of August 8, Wisconsin has confirmed 64,268 COVID-19 infections, 4,980 hospitalizations, and 1,008 deaths.  On a per capita basis, the state currently ranks 28th out of 50 states in COVID-19 infections and 36th in COVID-19 related deaths.  By international standards, Wisconsin has mixed outcomes to date with a relatively high rate of infections (1,086 per 100,000) but low rate of hospitalizations (101 per 100,000) and deaths (17 per 100,000).

The state is presently averaging about 850 new cases per day, more than 2.5 times the rate in early May.  As in much of the U.S., transmission of COVID-19 has shifted to younger individuals with 20-39 year olds now representing 42% of confirmed cases to date in Wisconsin with most cases stemming from gatherings in homes, restaurants, and bars.  The recent surge in infections has taxed contact tracers and there have been long delays in test results.

Contested Policies in a Polarized Political Environment

Wisconsin is operating in a far less restrictive environment than in the early phase of the pandemic.  On May 13, the state Supreme Court struck down Governor Tony Evers’ extension of the statewide stay-at-home order originally issued in March.  Milwaukee County, Dane County and a few other jurisdictions adopted their own stay-at-home orders and plans for gradual reopening but most local governments chose not to adopt stay-at-home orders or quickly reversed them.  Since mid-May, all municipalities and counties have proceeded, whether rapidly or gradually, to reopen businesses and allow larger gatherings while relying on a mixture of guidance from local health departments, the Wisconsin Economic Development Corporation, and private sector leaders.

Throughout the summer, the public health crisis has intersected with social upheaval and political mobilization focused on racial and social justice.  Black Lives Matter protests erupted and still continue across the U.S. (and internationally) following the killing of George Floyd, a black American man, by a white police officer in Minneapolis, Minnesota in late May.  Few cases of COVID-19 have been traced to participation in protests, however.  The outdoor environment, widespread mask use, and physical distancing while protesting are believed to have mitigated transmission.

Responding to the recent surge of COVID-19 infections, hospitalizations, and deaths, Governor Evers issued a new emergency order on July 30 that included a statewide requirement to wear face coverings in all public indoor spaces.  Republican leaders, who successfully challenged the governor’s extended stay-at-home order and statewide plan for reopening, may convene the state legislature to overturn the new mandate.  They have consistently aligned with President Trump and most Republican office holders nationally in resisting nearly all governmental restrictions in response to the pandemic.

The Damaging Consequences of COVID-19 and an Uncertain Future

Unlike countries that prevented a major outbreak or suffered a serious outbreak but then suppressed COVID-19, the U.S. is still in the throes of the pandemic and could see trends get even worse in the absence of renewed mitigation efforts or an effective and widely administered vaccine.  The ongoing shock to the American economy is unprecedented.  Despite a recent uptick in job growth, over 16.3 million Americans are officially unemployed, up from 2.1 million in mid-March.  Weekly unemployment claims in Wisconsin still exceed 200,000, nearly five times the number in mid-March.  Due to the widespread loss of jobs and employment-based health insurance, enrollment in BadgerCare, Wisconsin’s public insurance program for low-income residents has expanded by more than 100,000 since February.

Congress and the president are currently deadlocked on providing new federal assistance for unemployed workers and households, small businesses, and state and local governments hit hard by the combination of increased budget outlays and reduced tax revenues.  As the end of summer draws near, Americans face another hard choice: If they reopen schools for the upcoming academic year, they risk uncontrolled spread of the virus and harm to teachers, staff, students and family members; yet if they attempt to implement distance-based teaching, they risk less-effective educational outcomes, more stress for students and families, exacerbating disparities, and loss of extra-curricular activities that complement formal courses and strengthen a sense of community.

Not surprisingly, decisions on reopening schools have joined stay-at-home orders, closure of nonessential businesses, mask wearing, and other topics as lightning rods for political controversy.  The distinctive American model of federalism in operation throughout the pandemic is also in evidence here.  School reopening is in some places a state-level decision, but in Wisconsin where partisan politics is a barrier to coordinated planning and policy, 421 local school districts will each have to make a series of choices, implement a plan, and live with the consequences.

Wisconsin’s Response to the Coronavirus Pandemic – Update (May 2020)

Thomas R. Oliver and Ajay K. Sethi
School of Medicine and Public Health, University of Wisconsin—Madison

The Current Scope of the Pandemic

Wisconsin has “flattened the curve” of the COVID-19 pandemic better than most places in the U.S., which has by far the most confirmed cases and deaths of any country in the world. As of May 7, Wisconsin has confirmed 9,215 COVID-19 infections, 1,732 hospitalizations, and 374 deaths.  On a per capita basis, the state currently ranks 32nd out of 50 states in official COVID-19 infections and 31st in COVID-19 related deaths.  The relative success here is largely due to a series of difficult decisions made in March by Governor Tony Evers and the Wisconsin Department of Health Services to close schools, many workplaces, and public facilities and to limit nonessential travel and large social gatherings. 

The relative success to date is not, however, an unequivocal success or assurance of future success.  In the first month after the governor’s stay at home order took effect on March 25, daily new confirmed COVID-19 cases and deaths initially stabilized and showed signs of decline.  More recently, both of these indicators have been increasing.  The increases are due to several factors, including expanded testing outside of health care facilities, outbreaks in long-term care facilities and industrial workplaces, and waning adherence to physical distancing guidelines.  The growth and geographic spread of the pandemic—cases are now reported in 68 of 72 counties in Wisconsin—complicate response efforts here and in the neighboring states of Iowa and Minnesota.  The pandemic has also exacerbated existing health and social inequalities as African Americans, Hispanics, and senior citizens in residential care have suffered disproportionate numbers of COVID-19 infections and deaths.

Expanding Capacity for COVID-19 Testing and Tracing

Over the past month, both COVID-19 testing capacity and daily testing have roughly tripled.  The state now has 51 public and private labs capable of processing nearly 14,000 tests per day, more than the state’s official goal of 12,000 per day.  The actual number of tests each day, however, has just this week reached 4,000—still only a third of the state’s goal.  Shortages in testing supplies have plagued Wisconsin and much of the U.S., which has yet to provide national support to expand testing to needed levels to contain the spread of the virus.  The state and local health departments have relied on current employees and volunteers to perform contact tracing, but the state is now hiring additional workers to expand capacity as political leaders prepare to reopen more businesses and public facilities.

An Unstable Economic and Political Environment Compounds the Risks of COVID-19

As the public health crisis has deepened, so has the economic crisis.  Since mid-March, 511,577 Wisconsin residents filed unemployment claims and official unemployment stands at about 16%, higher than any previous recorded rate.  Government officials acknowledge the reported numbers are substantial underestimates of lost jobs and hourly wages.  Enrollment in BadgerCare, the state’s health insurance programs for low-income adults and children, increased by 39,031 in April and there will likely be a much larger surge in future official reports.

The economic distress has resulted in pressure to ease the “lockdown” set in place in mid-March and a rapid series of political decisions and challenges.  In a brief moment of bipartisan cooperation, Republican leaders in the state legislature worked with the governor, a Democrat, to enact legislation on April 15 that allows Wisconsin to tap into more than $2 billion in federal stimulus funds, including roughly $300 million in additional Medicaid funding and increased unemployment benefits.

On April 16, Governor Evers extended his “Safer at Home” order and many of its restrictions until May 26 and closed schools for the remainder of the academic year; but new orders allowed reopening of state parks, golf courses, and businesses able to safely conduct curbside pickups.  On April 20, the governor announced his “Badger Bounce Back” plan that closely follows federal guidelines announced earlier that week by the White House and Centers for Disease Control.  Those guidelines specify that states should only proceed to the first phase of reopening after reported COVID-19 symptoms and confirmed cases have declined for two weeks and there is adequate hospital capacity to handle any surge in patients requiring intensive care.  Even then, the federal guidelines argue vulnerable individuals should remain at home, and only facilities that can assure physical distancing should resume operation.

The new executive orders were hotly contested as intense partisanship resumed.  As in other states, Wisconsin saw protesters violating stay at home and physical distancing orders in events that appeared to combine genuine grass roots frustration with artificial “Astroturf” organizing.  On April 21, Republicans petitioned the Wisconsin Supreme Court to overturn the new orders issued by the governor and Department of Health Services.  That case is still pending.  In the meantime, the White House has disavowed its own guidelines for “Opening Up America Again” and the president is urging governors to abandon precautionary measures and expedite a return to normal social and economic activities even as his own advisors predict tens of thousands more deaths.

Within Wisconsin and across the U.S., state and local officials are going their own way, often at odds with each other in the absence of consistent and coordinated support from the federal government.  The disarray and unstable conditions create immense uncertainty as to the future course of the COVID-19 pandemic, the pace of recovery, and the scale of social and economic losses in its wake.

Wisconsin’s Response to the coronavirus pandemic – Original post (April 2020)

Thomas R. Oliver and Ajay K. Sethi
School of Medicine and Public Health, University of Wisconsin—Madison

The Current Scope of the Pandemic
Wisconsin is a medium size state with 5.8 million people in the upper Midwest region of the United States.  Its location in the middle of the country provided a brief but important period of protection from the COVID-19 pandemic, which initially hit hardest on the West Coast and the northeastern U.S.

The first COVID-19 infection in Wisconsin was confirmed on February 5 in a traveler from China.  The second confirmed case came over a month later on March 9, followed by a small number of positive tests that accelerated in number and geographic spread.  As of April 6, Wisconsin has reported 2,440 positive tests and 26,574 negative tests, 668 hospitalizations, and 77 deaths attributed to COVID-19 (https://www.dhs.wisconsin.gov/covid-19/data.htm).  At this time, other states in the U.S. have between 41,090 (New Jersey) and 183 (Alaska) confirmed cases, save for the catastrophic situation in New York with 131,239 cases.  So far, the outbreak in Wisconsin is heavily concentrated in urban and suburban areas in the southeastern part of the state but cases are now reported in 57 of 72 counties throughout the state.

Measures to Slow the Spread of COVID-19
The moderate rate of growth in COVID-19 cases and deaths to date is likely due to a series of preventive measures that were relatively early and aggressive compared to other states and the U.S. federal government.  On March 12, the day after WHO declared a global pandemic, Governor Tony Evers declared a public health emergency in Wisconsin.  The next day, the state health department ordered that all public and private schools be closed by March 18.  On March 20, another executive order banned public or private “mass gatherings” of 10 or more people; required meetings or gatherings of fewer than 10 people follow federal CDC guidelines on social distancing; closed restaurants and bars except for delivery or take-out orders; closed hair salons, spas and other personal care services; and prohibited evictions from rental housing or the shutoff of water, gas, phone, and electricity for overdue bills.  Governor Evers issued a stay at home order effective March 25 to April 24 that banned all non-essential travel and mandated all non-essential businesses and services be closed.  This order came less than a week after the first such orders were issued in California, New York, and Illinois.

Efforts to limit the further spread of COVID-19 have spilled over into a chaotic American election cycle.  At the last minute, Governor Evers, a Democrat, ordered a postponement of the statewide election scheduled for April 7 until June 9, following the current ban on mass gatherings and action already taken in several other states.  That order was appealed by Republicans to the Wisconsin Supreme Court—with a Republican-appointed majority—which ruled the election should go on as originally scheduled.  In addition, the Democratic national convention to nominate the party’s candidates for President and Vice President has been rescheduled from mid-July to mid-August.  The convention will take place in Wisconsin’s largest city, Milwaukee, which currently has a majority of the confirmed COVID-19 cases in the state.

Health Systems Planning and Capacity
The state health department is highly engaged with counties, health care facilities, and private industry as well as U.S. federal agencies as they anticipate a surge of COVID-19 cases by the middle of April.  Many elective ambulatory visits and most hospital-based procedures are being postponed in order to conserve as many of the state’s hospital beds, ICU beds, ventilators and health professionals as possible.  Other health services have been switched to telehealth visits as much as practical with federal, state, and private insurance programs offering flexibility on privacy protections and billing.  Finally, some non-health care facilities are being secured and prepared if needed for patients discharged from hospitals but needing to remain in isolation, or for health care workers who need to isolate away from households.

While there appear to be sufficient hospital beds, the existing supply of about 2,400 ICU beds and 1,200 ventilators could fall short of peak need.  With the help of bioethicists, a State Disaster Medical Advisory Committee is developing guidelines for choosing which patients get ventilators should clinically-assessed need exceed the available supply.  In the meantime, the governor is attempting to buy thousands of additional ventilators on the open market.  He has also requested large numbers of ventilators and personal protective equipment for health care workers from the U.S. national emergency stockpile.  Though some of these critical supplies have arrived, Wisconsin is in competition with other states and the national stockpile is largely depleted or diverted to states and localities that already are facing large numbers of patients requiring intensive care.  Even at this still-early stage of the pandemic, 10-14% of the hospital workforce is presently sidelined due to infection or unprotected exposure in patient care and many facilities are asking retired health care workers to return to practice.

Gaps in Health Security, Economic Security, and Governance
The health consequences of the COVID-19 pandemic cannot be separated from its severe economic consequences.  In Wisconsin, as elsewhere in the U.S., the spread of the virus and enforcement of social distancing have brought an abrupt loss of income and insurance coverage to large numbers of people.  By the end of March, 9% of Wisconsin residents responding to a poll reported having lost their job and an additional 22% reported having their work hours reduced.  In just two weeks, more than 200,000 residents filed claims for unemployment insurance.  On March 31, Governor Evers requested disaster relief from the Federal Emergency Management Agency.  The request, granted on April 4, will add federal support to the state’s efforts including financial and direct assistance to individuals and businesses, hazard mitigation, crisis counseling, and disaster supplemental nutrition services.

Wisconsin will be harder hit than many other states because of a relatively high proportion of state residents who are covered by private, employer-sponsored insurance.  Those losing coverage will have three options outside of seeking emergency care: enroll in BadgerCare, the state’s Medicaid program for low-income adults and children; buy federally subsidized private insurance coverage offered under the 2010 Affordable Care Act; or forgo insurance coverage and seek primary care services at one of the state’s federally-qualified community health centers.  These centers already serve about 30 million Americans and are receiving additional funding under federal legislation enacted in late March in response to COVID-19.  They do not provide hospital-based services, however.

There are already gaps in coverage because Wisconsin has not accepted the optional expansion of Medicaid eligibility provided by the Affordable Care Act, which would cover an additional 80,000 adults and costs the state about $1 billion annually in federal funds. Now, the state must repeal or suspend new premiums and cost-sharing recently imposed on Medicaid beneficiaries or lose a 6.2% increase in funds—$50 million per month—included in the federal legislation intended to cushion the impact of COVID-19.

Wisconsin is moving rapidly into the brave new world of COVID-19 and has yet to face its greatest challenges.  The state’s relatively strong steps, relatively early on seem to be paying off with slower growth of COVID-19 cases, hospitalizations, and mortality.  However, adherence to physical distancing varies by location and demographics.  The pandemic is exposing cracks in Wisconsin and elsewhere in the U.S. stemming from 1) a political culture rooted in individualism and distrust of authority, 2) a political system unable to mount unified responses due to horizontal and vertical divisions in governance and hyper-partisanship, and 3) a health care system with multiple and incomplete sources of eligibility, scope of coverage, funding, and regulation.

Most obviously, there are different messages from different levels of government and even within state government.  This is compounded by partisan conflict and maneuvering in the middle of election campaigns for President, Congress, and many state legislatures including Wisconsin.  Nearly every action taken by Governor Evers and his secretary of health has been challenged on libertarian or fiscal grounds by Republican leaders who control sizable majorities in the state legislature; and proposals requiring legislative action have been quashed.  As a result, even though the governor and state agencies have mobilized data and an army of experts and volunteers in health systems and state universities, actions to slow COVID-19 and protect state residents have been gradual and reactive, based on changing circumstances visible to all and on actions taken in places where the pandemic has already struck far more deadly blows.

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