by Andrew Cuomo
MAY 10 | 2,273 NEW CASES | 7,262 HOSPITALIZED | 207 DEATHS
“I wish I could be with you, but I can’t be because I love you.”
MOTHER’S DAY DURING COVID WAS a particularly lonely time for families. Afraid to hug or even be in the same space as a loved one who was elderly or in a vulnerable population meant over two months of unnatural solitude. We were saying “I love you” to one another by staying away, but the long, lonely days of isolation caused depression and angst.
The most painful aspect of the COVID crisis has been its devastating effect on our elderly in nursing homes. The first COVID case in the United States that really caught people’s attention was the nursing home near Seattle, Washington. Ever since, nursing homes across the nation have suffered tremendous hardship and loss; as of this writing, more than 41 percent of this nation’s COVID deaths have happened in nursing homes.
Understanding the threat, on March 13, we were taking every precaution that we could think of. Even before New York had a single COVID death, we banned visitors from going into nursing homes for fear that they might be transmitting the virus, and we required PPE, temperature checks, and cohorting of residents with COVID. Despite this, as was the case in every state in this nation, New York’s nursing homes were not spared from COVID’s wrath.
By early spring, Republicans needed an offense to distract from the narrative of their botched federal response—and they needed it badly. So they decided to attack Democratic governors and blame them for nursing home deaths. On April 25, conservative columnist Michael Goodwin published a piece in Rupert Murdoch’s New York Post aimed at New York with the headline: “State Lacked Common Sense in Nursing Homes Coronavirus Approach.” It was an orchestrated strategy and a Fox News drumbeat. It wasn’t just me—Phil Murphy in New Jersey, Gretchen Whitmer in Michigan, Gavin Newsom in California, and Tom Wolf in Pennsylvania were all in the Republican crosshairs on nursing homes. As the states with the most deaths were Democratic states, the Trump forces saw us as an easy target. Moreover, their entire COVID strategy was political: This was a Democratic state problem mishandled by Democratic governors.
The entire episode was truly despicable. Imagine having lost a loved one in a nursing home. You are already questioning yourself about whether you should have removed them and then you hear their life was lost because of a government blunder. I have talked to many people who have lost loved ones in nursing homes, and I could see the agony on their faces and hear it in their voices. It’s not so much that they were looking to blame anyone, they just needed to know what happened.
Unfortunately, although I tried, I never successfully communicated the facts on this situation. The Trump forces had a simple line: “Thousands died in nursing homes.” It was true. But they needed to add a conspiracy, which was that they died because of a bad state policy that “mandated and directed” that the nursing homes accept COVID-positive people, and these COVID-positive people were the cause of the spread of the disease in the nursing homes.
It was a lie.
New York State never demanded or directed that any nursing home accept a COVID-positive patient. The Federal Centers for Medicare & Medicaid Services guidance was that a nursing home should continue to accept patients from hospitals where COVID-19 was present, and not discriminate against a COVID-positive person. The state followed the guidance, stating that nursing homes should not reject a patient “solely on the basis” of COVID status. It also applied to hospitals. We couldn’t have a situation in which elderly patients who had been treated in hospitals ended up on the street because their nursing homes refused to take them back. Nor could we have a situation in which hospitals refused to take a COVID-positive person.
The context here is very important. Early on in the crisis, our main fear was that the hospitals would be overwhelmed, and collapse. All health professionals agreed that if that situation developed, we would need to free up hospital beds for people with critical needs. As it turned out, our successful efforts to reduce the viral transmission rate and create additional beds meant we were never in that dire situation. The state always had additional beds available all across the state. Therefore, the critics’ premise that we “forced” nursing homes to take COVID-positive people is patently false and illogical because we always had alternative available beds throughout the state. We never “needed” nursing home beds.
Also, the critics misstate the law and policy. No law or policy would have ever required a nursing home to take any COVID-positive person. The policy was that nursing homes couldn’t discriminate, not that they had to accept. That makes all the difference in the world. In fact, in New York law, it is clear that a nursing home can “only accept” a patient that it is prepared and equipped to treat given the needs of the other patients in its facility.
The law clearly states that while nursing homes cannot discriminate, they also cannot accept any patient that they cannot properly care for—in this instance, that specifically meant nursing homes had to be able to separate residents into cohorts of positive, negative, and unknown and needed separate staffing teams to deal with COVID-positive residents and nonpositive residents. They had an obligation to keep the other residents safe from the virus. If they couldn’t do that, then they could not accept a COVID-positive person and they were legally obligated to decline that person’s admission. In fact, many nursing homes in New York did just that, opting not to accept COVID patients. Factor into this the reality that nursing homes get paid for every person they treat, so they have financial issues. The law therefore dictates that every nursing home must have the capacity to effectively treat every patient as a safeguard to financial interest.
The facts totally defeated the Republican claim. Interestingly, this was not even a New York–specific issue. Quite the opposite. New York was number forty-six out of fifty in the nation when it came to percentage of deaths in nursing homes. There were only four states with a lower percentage of nursing home deaths, and New York had a much worse situation to manage. But this was all politics. No one wanted to hear the facts.
In early July, the New York State Department of Health did a full review of nursing homes in the state, and what it showed was that the virus came into nursing homes as the workforce got infected—mainly through asymptomatic spread. Twenty thousand nursing home workers were COVID-positive in March and April, and who knows how many there might have been who were COVID-positive in January and February, before we were doing testing. In the geographic regions where the infection rate was higher, more staff got infected and brought the virus into facilities. It is also possible that visits early on from family and friends brought the virus into facilities before they were banned. The rate of infection and deaths in nursing homes correlated with that of the broader regional community—a phenomenon that played out in every single state across the country and in nations around the world.
On May 10, as soon as we had the capacity, we mandated testing twice a week for staff of nursing homes. Any infected staff were identified and not allowed into the facility. The nursing home operators were very unhappy with the regulation, but I wanted to make sure we did everything we could. Ironically, the same Republican politicians who seized on the order not to discriminate against COVID patients were also the loudest critics of the staff testing mandate.
Political attacks aside, the situation in nursing homes has kept me up at night from the beginning. I have spoken with governors across the country, international and medical experts, nursing home operators, and family who lost loved ones. I am continually thinking it through because in my mind we are always preparing for the next time, and I believe there will be a next time. I wonder what we could have done differently and can do differently in the future.
Here is the conundrum. The virus was here earlier than we knew and therefore was spreading among the nursing home workers before we were aware. There is nothing New York could have done about that. I don’t know eve
n today that New York can do anything besides push the federal government to build an effective CDC and global alert system. The federal government was also wrong about asymptomatic spread. Again, all New York can do is push for a competent federal health agency. But even once we knew that the virus was here and the nursing home workforce was probably getting infected, what could we do? The ideal scenario would be to test every nursing home employee before they go to work every day. But there are 158,000 nursing home employees. New York did not have enough testing capacity, even at our height, when we were doing 70,000 daily tests, to accomplish this feat. A more modest goal would be to test workers once a week. Even this was not achievable when COVID first came to New York, because the statewide testing capacity was only about five thousand per week, and again, there were 158,000 nursing home workers. Once our testing capacity increased, we mandated testing every nursing home worker once a week. We would do that again in the future. However, even this is imperfect. Some workers can get infected and bring in the virus between weekly tests. It could slow the number of infected people entering nursing homes, but it wouldn’t prevent the virus from entering entirely.
We also could have stopped family visitation earlier. Again, we didn’t know the virus had come to New York, or that there was asymptomatic spread. We stopped visitation on March 13. But even going forward, if at the first sign of a virus we stop all family visitation, that would be a harsh, dual-edged sword. I hear many recriminations about stopping people in nursing homes from having visits from their loved ones.
Theoretically, we could test all visitors and workers daily going into nursing homes. Again, theoretically, that could be applied to hospitals, group homes, and so on. But that would require a testing capacity that as of this writing is impossible to achieve. It would require serious federal participation.
The ideal scenario would be to hermetically seal off nursing homes. The closest model to this was done by a nursing home in France, where some workers volunteered to live in the facility and not go back to their own homes. They essentially quarantined in the facility. This is extraordinary: staff living in the facility for months and not seeing their families. This would have to be combined with no outside visitors. Theoretically, it would be the safest procedure but I don’t know that it is practical or replicable on a large scale. Legally, I could not force 158,000 workers to stay on site. If that is what we need in the future, we would need to be clear and hire workers willing to do that. We should then also consider that for hospitals, group homes, et cetera. It would be ideal but virtually impossible to implement.
I believe we need the best federal health experts to review international data and determine a national nursing home and congregate facility protocol to be implemented at the first sign of an outbreak. The key would be large-scale testing capacity, which only the federal government could provide.
Wisdom comes back to the same point: We control what we can, but we must accept that we cannot control everything.
As of this writing, six months after everything New York experienced, COVID is now devastating nursing homes in Florida, where nursing home patients and staff account for approximately 45 percent of all deaths in the state. To explain the increase in deaths, Governor DeSantis’s secretary of the Agency for Health Care Administration (AHCA) said, “Infected, asymptomatic health workers themselves are carrying the virus and transmitting to their own patients.” (That is what happened in New York five months ago without the notice Florida had.) On July 15, the AHCA issued Emergency Rule 59AER20-6, allowing nursing homes with healthy residents to accept COVID-positive patients. Following the order, it was reported that “many long-term care facilities throughout Florida quietly, quickly, and deliberately began bringing COVID-19-positive patients into places where healthy residents live.” COVID patients are being transferred from hospitals into Florida nursing homes with the express blessing of the DeSantis administration. Florida was having the problem we prepared for but which we avoided. Their hospitals were over capacity, and they had no choice but to send seniors back to nursing homes. They did not reduce the viral transmission rate the way New York State did, nor did they build the alternative additional beds we did. For New York, it was a worst-case-scenario plan that never materialized. For Florida, it was reality. Unsurprisingly, neither Donald Trump nor Fox News maligns Republican governor DeSantis for actually doing what they incorrectly accused New York of doing.
MAY 11 | 1,660 NEW CASES | 7,226 HOSPITALIZED | 161 DEATHS
“We have been smart through this, and we have to continue to be smart.”
THE BUDGET IN THE FEDERAL government is not real. The numbers don’t add up, but then again they don’t have to. The federal government can print money, so theoretically it can solve any financial issue by turning on the printing press in the basement. States don’t have a printing press; however, I do have an old Xerox copier in the basement. A state must pass a balanced budget. By July, the COVID crisis had already caused a $14 billion budget shortfall in New York because of reduced tax revenue. That was an impossible number for me to deal with. If there was ever a day that it was not top of mind for me, I was joined at the daily briefings by my budget director, Robert Mujica, who made it his business to remind me.
We had to reopen, and we had to reopen smart. While every expert talked about an economic reopening plan that included testing and a data-driven approach, no such coherent methodology existed. No state had successfully done it yet. There was no template or blueprint. I assembled my team and said that I wanted to develop the most science-based reopening plan in the country.
I wanted the reopening plan to track specific metrics like infection rate, hospital capacity, and testing and tracing rates. I wanted two specific data thresholds: first, a series of metrics that had to be met—showing the virus is under control—that would be required before a region could begin reopening; second, a series of metrics that would monitor the reopening and allow us to slow down if the virus spread began to increase.
To illustrate this approach, I made a PowerPoint slide that had gauges on a pipe, each measuring a specific metric, such as hospital capacity and infection rate, and a valve at the end to illustrate the pace of the reopening. If the gauges showed upticks in hospitalizations or infections, the valve would be tightened. And vice versa.
First, we started with the ten regions of New York State and set seven metrics that each region needed to meet before starting to reopen: (1) decline in total hospitalizations; (2) decline in deaths; (3) decline in number of new hospitalizations; (4) sufficient hospital bed capacity; (5) sufficient ICU bed capacity; (6) sufficient diagnostic testing capacity; and (7) sufficient contact tracing capacity.
Second, we set four phases to the reopening, starting with low-risk, more essential businesses and gradually moving to higher-risk, less essential businesses. Phase 1 would allow low-risk businesses within construction and manufacturing and agriculture. Phase 2 would allow some nonessential businesses including retail (but not malls) as well as outdoor dining and takeout—with strict rules in place. Phase 3 allowed for restaurants and personal care services, like hair salons, to reopen—again, with strict rules about mask wearing, testing, and social distancing. Phase 4, which we wouldn’t get to until midsummer, allowed for professional sports without fans, and, importantly, schools could reopen, but this would be a complicated and ongoing discussion in every district in the state.
Each phase would be separated by two weeks, which was the period of time needed to determine if the virus spread increased due to the increased activity, to detect such a spread, and to see if there was any effect on the hospital system. Each region would continue to need a certain number of tests to be performed on a daily and weekly basis. We recruited a team of global experts, including Dr. Michael Osterholm from the University of Minnesota and Dr. Samir Bhatt from Imperial College in the U.K., who, before giving a region the green light to move from one phase to the nex
t, would review our data and then advise whether it was safe to continue the reopening of that region of the state. Counties within each of the ten regions would work together, and regional control rooms would be responsible for coordinating hospitals, testing, contact tracing, compliance enforcement, business, education, and data collection.
I said we needed to do “a reopening book” to distribute to local governments across the state. A “book” had no specific definition, but in my office it meant more than a discussion, more than a memo, more than a twenty-page paper, and that meant it would take a lot of effort. I spent hours working on drafts with the team. The result was our NY Forward: A Guide to Reopening New York & Building Back Better. It was a 156-page book complete with charts and graphs, just like my daily PowerPoints in the briefings. We printed five hundred copies to distribute; I wanted people to be able to hold it in their hands, not just click on a link, although they could do that too.
Additionally, I insisted on posting all these metrics and the daily data online with an easily readable dashboard so that every New Yorker and local elected official could understand them and see the impact of the reopening on the virus transmission. This way, if we had to slow down the reopening, we would all be operating from the same set of facts. I would also review the data daily at the press briefing. We would announce any troublesome occurrences in the data in real time so the people of that region would know what was going on. If we all have the same information, then we are all on the same journey. Governor, mayor, local supervisor, business leaders, newspaper reporters, small business owner—if we all knew the same things at the same time, we could openly discuss all decisions before they were made. That was the ideal relationship between citizens and their government: a relationship of trust and credibility.