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Non-pharmaceutical interventions were less effective in reducing mortality in Republican counties

September 1, 2020

Topics: Quote of the Day

By Catalina Amuedo-Dorantes, Neeraj Kaushal, Ashley N. Muchow
National Bureau of Economic Research, August 2020


Using county-level data on COVID-19 mortality and infections, along with county-level information on the adoption of non-pharmaceutical interventions (NPIs) in the United States, we examine how the speed of NPI adoption affected COVID-19 mortality. Our estimates suggest that advancing the date of NPI adoption by one day lowers the COVID-19 death rate by 2.4 percent. This finding proves robust to alternative measures of NPI adoption speed, model specifications that control for testing and mobility, and across various samples: national, restricted to the Northeast region, excluding New York, and excluding the Northeast region. We also find that the adoption speed of NPIs is associated with lower infections, as well as lower non-COVID mortality, suggesting that these measures slowed contagion and the pace at which the healthcare system might have been overburdened by the pandemic. Finally, NPI adoption speed appears to have been less relevant in Republican counties, suggesting that political ideology might have compromised their efficiency.

From the Introduction

In the United States, where COVID-19 has taken a high toll in terms of infections and mortality, skepticism toward NPIs reigns high among the public and legislators. Early in the pandemic, President Trump famously criticized NPIs by remarking that “the cure cannot be worse than the problem itself.” The nation remained divided on the effectiveness of NPIs, even as the pandemic raged from March to early May 2020 in the northeast, spreading to the rest of the country thereafter. Surveys show that conservative Republicans expressed more skepticism about NPIs than liberal Democrats. State and local implementation and lifting of NPIs were often driven by political ideology. Republican-governed cities were slower in adopting NPIs, whereas cities led by Democrats were more aggressive.

Heterogeneous impacts

Studies show that attitudes towards the efficacy of NPIs have been partisan, with Republican governors and mayors being more reluctant to implement NPIs. It is also possible that residents in majority-Republican counties with NPIs in place may be less compliant with health care guidelines and recommendations. We first examine the differential impact that the speed of NPI adoption had in Republican counties—measured as those with a Republican vote share above 50 percent in the 2016 presidential election—given the role of political partisan ideology in NPI adoption. Adopting an NPI one day earlier lowers COVID-19 mortality in majority-Republican counties by approximately 2.4 percent, whereas the reduction in other counties reaches 5.4 percent. In other words, speeding up the implementation of NPIs in primarily Republican counties would lower COVID-19 mortality by half the amount it would in non-Republican counties. Why? Perhaps, NPIs are less strictly observed in Republican counties, in which case, speeding up their implementation does not have the same bite as in other counties. Note that descriptive statistics in Table 1 show that, according to our NPI speed measure, Republican counties were more likely to be early adopters, largely on account of the late outbreak of the pandemic in these counties. Thus, our findings suggest that, despite the advantage of learning from the experience of counties where the virus spread earlier, the NPIs were less effective in these counties.

A couple of studies in the United States have investigated the effect of stay-at-home orders on infections and mortality from COVID-19. Both studies find that NPIs are associated with lower infection and mortality rates. We build on this research by assessing the relevance of the adoption timing of two NPIs—safer-at-home orders and non-essential business closures—on mortality.

Summary and Conclusions

The rapid spread of the COVID-19 pandemic took the world by surprise. In the absence of a vaccine, and to halt the devastating impact of the pandemic on lives, several countries opted for the adoption of non-pharmaceutical interventions (NPIs). The United States was no different in that regard, even though the response has been more fragmented and piecemeal. Prior research has shown the effectiveness of NPIs in curtailing deaths in the United States, Europe and Asia. Our focus is on the importance of their timeliness, the mechanisms behind it, and the heterogeneity of any effectiveness depending on the political ideology and degree of vulnerability of counties.

Using county-level data on COVID-19 mortality and infections, along with county-level information on the adoption of stay-at-home orders and business closures, we examine how the adoption speed of NPIs has affected COVID-19 mortality. We find that moving up the implementation date of NPIs by one day lowers the COVID-19 death rate by 2.4 percent. The effectiveness of acting early is similar for both stay-at-home orders and business closures. An event study addresses concerns regarding the endogeneity of NPI adoption, and robustness checks show the results persist when introducing controls for testing and mobility, altering the definition of adoption speed, weighting counties by population size, and considering different geographic scopes. Finally, we confirm how the relevance of responding early stems from the ability to slow contagion, which likely prevented the overburdening of the healthcare system. We also find that NPI adoption speed has less relevance in Republican counties—a possible byproduct of skepticism and reluctance to apply or fully comply with NPIs. In contrast, NPIs appear similarly effective, and their speed of implementation equally as relevant, in counties with distinct degrees of vulnerability to the disease, as captured by an index of comorbidity and the share of residents without health insurance, unemployed, or living in poverty.

While we await anxiously a vaccine or cure, NPIs remain the main mechanism to curtail COVID-19 deaths. Gaining a better understanding of their timeliness and the importance of responding early is essential, especially in the foreseeable occurrence of additional waves.



By Don McCanne, M.D.

Two non-pharmaceutical interventions (NPIs) used during the Covid-19 pandemic – stay-at-home orders and business closures – were effective in reducing mortality during the pandemic, with effectiveness being greater with earlier implementation of the interventions. This was just as true for counties with greater vulnerability such as those with higher rates of comorbidity and with higher levels of being uninsured, unemployed, or living in poverty.

However, Republican counties were slower to implement NPIs, and the delay was followed by higher mortality rates. The differences were thought to be related to political ideology. It may be not only the delay that increased mortality, but it may also have been due to lower compliance, based both on political ideology prevalent in the community and on Republican politicians who failed to provide the leadership needed in times of a public crisis.

The lesson here should be much more broad than just that of the failures in managing the Covid-19 pandemic. Health policy science is quite advanced, and we know many ways to improve the health of the nation. An example would be implementation of a health care financing system that would ensure access to and affordability of comprehensive health care services for everyone – a single payer, improved Medicare for All. But too many politicians lay the policy science aside and grant a higher priority to anti-government political ideology.

We now have 183,000 Covid deaths in the United States, and many of them could have been prevented with more effective political leadership. If we are going to be able to enact and implement the policies that we know work to benefit the health of all of us, we are simply going to have to change the politics. It’s too late to ask the 183,000 who have died, but with the facts in hand, shouldn’t the rest of us take action?

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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