Rationing is here!

I just heard a discussion on NPR about the fact that New Mexico’s governor yesterday said the state had readied a plan for hospital bed rationing and might have to put it into effect soon if admissions rise. The person commenting on the report said that, since hospital ICUs are essentially full in a lot of states, rationing might soon come to a hospital and state near you.

I have news for this person: Rationing is here. As this story in WaPo by Dr. Ashish Jha pointed out on Monday, the hospitalization rate for Covid patients is dropping across the country, and that’s bad news. Of course, this might sound counter intuitive. We’ve all been told that an increase or decrease in positive test numbers (i.e. cases) leads in one week to a similar increase or decrease in hospitalizations. And 2-3 weeks after hospitalizations increase or decrease, deaths follow suit. So why isn’t it good news that hospitalizations are dropping?

For one thing, new cases aren’t dropping at all. A week ago, they were growing at 8.9%, so hospitalizations should be increasing at that amount now – they shouldn’t be decreasing. But they are.

Dr. Jha points out that through most of the fall, one day’s new cases reliably led to a 3.5% increase in hospitalizations a week later. However, that relationship broke down in early November: The number of hospitalizations started falling short of the expected number based on new cases a week previously. This isn’t because new cases were lower, since the seven-day average of new cases has been growing since mid-September. That rate has more than doubled in that time. Hospitalizations should have been growing faster in November, not more slowly.

Of course, there’s a simple explanation for this: Hospitals reached close to their capacity by early November. Since then, they’ve been informally rationing care. What else can they do? How are they doing this? They’re not following any formal program (as the one being readied in New Mexico, and undoubtedly in other states as well). Rather, they’re simply not admitting more patients than they can handle. Here’s what Dr. Jha assumes is happening:

The decision whether to admit a patient depends on two things: clinical judgment and bed availability. Critically ill patients will always be admitted. But as hospitals start to fill up, less sick patients — younger covid patients, or those whose oxygen levels haven’t yet sunk critically low — get sent home. These patients would be safer in a hospital bed, but there isn’t one available for them anymore. And this doesn’t just happen to covid patients. People who show up at the hospital with heart failure, wound infections and other ailments will be asked to manage their conditions at home, as doctors keep the remaining beds only for the very sickest patients.

In effect, covid-19 is leading to a rationing of care. 

So there’s good news and bad news. The good news is it’s unlikely that the hospitals will fill up and people will be dying as they wait outside the emergency room – as happened in New York in April. The bad news is a lot of people who would be better off in the hospital are being sent home, with the hope that if their condition worsens and they definitely need hospitalization, they’ll be able to get to the hospital in time – and that they won’t be shunted to an adjacent state since all of the hospitals in the patient’s state are full.

However, there may soon be another informal type of rationing, which happened in New York City during the worst of their crisis: EMTs, knowing that their hospital needs every possible bed, are going to triage patients at home – based not on whether the person is sick enough to need to be admitted, but on the EMT’s personal judgment (remember, they’re not doctors and certainly aren’t paid to make these decisions) of whether the person can be saved in the hospital. If the EMT thinks they’re likely to die, there’s no point in bringing them to the hospital, where they’ll take up a bed and a lot of doctors’ and nurses’ time for a day or two before they pass away. It’s better to leave them at home to die.

So we’re living in a world of rationing now (and some of us are dying in it). As if to emphasize that point, yesterday for the first time ever, we passed 3,000 deaths – i.e. more than on 9/11. And we’re just getting going, too.

The numbers

These numbers are updated every day, based on reported US Covid-19 deaths the day before (taken from the Worldometers.info site, where I’ve been getting my numbers all along). The projections are based on yesterday’s 7-day rate of increase in total Covid-19 deaths, which was 5.9%.

Month	Deaths reported during month	Avg. deaths per day during month	Deaths as percentage of previous month’s
Month of March	4,058	131
Month of April	59,812	1,994	1,474%
Month of May	42,327	1,365	71%
Month of June	23,925	798	57%
Month of July	26,649	860	111%
Month of August	30,970	999	116%
Month of Sept.	22,809	760	75%
Month of Oct.	24,332	785	107%
Month of Nov.	38,293	1,276	157%
Month of Dec.	81,926	2,643	214%
Total March-Dec.	356,291	1,161

Red = projected numbers

I. Total deaths

Total US deaths as of yesterday: 293,496

Deaths yesterday: 3,011

Percent increase in total deaths in the last seven days: 5.9% (This number is used to project deaths in the table above. There is a 7-day cycle in the reported deaths numbers, caused by lack of reporting over the weekends from closed state offices. So this is the only reliable indicator of a trend in deaths, not the one-day percent increase, which mainly reflects where we are in the 7-day cycle).

II. Total reported cases

Total US reported cases: 15,594,534

Increase in reported cases since previous day: 210,944

Percent increase in reported cases in the last seven days: 11.4%  

III. Deaths as a percentage of closed cases so far in the US:

Total Recoveries in US as of yesterday: 9,088,387

Total Deaths as of yesterday: 294,496

Deaths so far as percentage of closed cases (=deaths + recoveries): 3.1%

For a discussion of what this number means – and why it’s so important – see this post. Short answer: If this percentage declines, that’s good. It’s been steadily declining since a high of 41% at the end of March.

IV. 7-day average of test positive rate for US: 11.4%

For comparison, the previous peak for this rate was 7.8% in late July, although the peak in early April was 22%. The rate got down to 4.0% in early October but has been climbing since then. This is published by Johns Hopkins.

I would love to hear any comments or questions you have on this post. Drop me an email at tom@tomalrich.com.