Two weeks after the polls closed in this year’s Ohio primary, two U.S. Postal Service employees showed up in the office of Diane Noonan, the director of elections in Butler County. The workers carried a tray of 317 unopened ballots that had been sitting in a Postal Service warehouse since the day before the election.

The ballots would have counted if they had been delivered on time. Now, there was no way to legally count them. The next day, another ballot that had been postmarked in time to be counted arrived with no explanation. In Geauga County, officials found 26 such ballots; Lucas County saw 13.

Many election administrators in Ohio had already lost patience with the Postal Service. During Ohio’s April 28 primary, mail delivery had been so slow that the secretary of state publicly warned voters and called for the Postal Service to add staff. As they counted votes, Noonan and her team checked in with the service every day until the deadline. “We said, ‘Listen this is the last day,’” she recalled. “‘If we get ballots after this, they’re not going to be counted.’ They assured us.”

The Postal Service’s official excuse for misplacing the Butler County ballots was an “unintentional missort.” That response satisfied neither Ohio’s secretary of state nor Noonan. “We got an explanation that really wasn’t an explanation,” Noonan said. “It’s all in their hands. That’s what’s scary.”

The missing ballots in Ohio were just one sign of a larger problem. Frequently attacked by President Donald Trump and his supporters, the beleaguered Postal Service is under tremendous pressure to ensure that an unprecedented number of Americans can vote by mail in November, avoiding the potential health risk of in-person polling places during the coronavirus outbreak. The disarray Tuesday in the Georgia primary, in which voting machines malfunctioned and people waited in line for hours to cast their ballots, underscores the potential value of voting by mail.

With online retailers like Amazon cutting into its packaging revenue, the Postal Service has been losing both money and its former centrality in American culture. By running a national election smoothly, it could rebuff its critics and regain some of its prominence. But in the primaries, voters and election officials have been confronting the new reality of the Postal Service: delivery times slowed by years of budget cuts and plant closures. There have already been significant delays and mistakes in delivering ballots in Indiana, New Jersey, Maryland, Ohio, Wisconsin, Pennsylvania and Washington, D.C.

The Postal Service has not hit its own goals for on-time delivery of any type of first-class mail in five years. Last year, the agency delivered only 80.88% of its three- to five-day single-piece first-class mailings on time, missing its goal by 14.37 percentage points. Performance on that type of first-class mail — which is how some absentee ballots are sent — has been declining for the better part of a decade.

“In the last five years it’s gotten really bad,” said a former Postal Service executive, who requested anonymity because he still works in the mailing industry. He added that election officials still may not know enough about how the agency operates. “There’s a huge gap in understanding of how mail is sorted and how that could affect vote by mail ballots.”

Complicating the Postal Service’s task is that many states are building large vote by mail systems on the fly. In 2018, 26 states and Washington, D.C. had vote by mail rates under 10%, according to the Brennan Center for Justice. States that don’t regularly send ballots to voters may keep inaccurate voter address lists, leaving overburdened postal workers to deliver ballots to the wrong places.

Many states have failed to adjust their ballot deadlines to accommodate slower delivery. More than half of states allow voters to request an absentee ballot seven or fewer days before an election. Though some jurisdictions let voters submit ballots in designated drop-off boxes, those who wait too long to request or mail back their ballots could see their votes arrive too late to count.

There are other deadlines that can be affected by mail delivery problems. Many states use “received by” deadlines tied to when local election offices receive a ballot. This year, as mail delays have mounted, some states have had to extend these deadlines. Other states stipulate a date by which a mail ballot must be postmarked. Controversies over missing or illegible postmarks marred Wisconsin’s primary this year, and House Democrats tried to include national standards on ballot postmarking in one of the stimulus packages.

In the general election, even mail delays in line with the Postal Service’s historical performance could affect hundreds of thousands or perhaps millions of votes. According to a report from the Postal Service’s Office of Inspector General, 95.6% of election mail nationally was delivered on time during the 2018 election, just below the agency’s target of 96%. But the seven lowest-performing mail processing centers that the report examined, including facilities in swing states Florida, Ohio and Wisconsin, delivered an average of 84.2% of election mail on time. Six of those seven low-performing facilities failed to reassign staff to handle increased election mail volume.

To be sure, the Postal Service’s operations are still massive: Last year, the agency delivered a total of 143 billion pieces of mail. Election experts believe that the Postal Service has the capacity to handle a national election conducted primarily through the mail — but only if it coordinates closely with state election officials and if voters cooperate by sending their ballots early.

A Postal Service spokeswoman said in a statement that it employs “a robust and proven process to ensure proper handling of all Election Mail, including ballots. This includes close coordination and partnerships with election officials at the local, county, and state levels. As we anticipate that many voters may choose to use the mail to participate in the upcoming elections due to the impacts of the COVID-19 pandemic, we are conducting and will continue to proactively conduct outreach with state and local election officials and Secretaries of State so that they can make informed decisions and educate the public about what they can expect when using the mail to vote.”

She emphasized that most first-class mail “is delivered within 2-5 days, consistent with our delivery standards.”

Still, the USPS acknowledges that it needs more time to deliver ballots than is contemplated in election rules. “To account for delivery standards and to allow for contingencies (e.g., weather issues or unforeseen events), voters should mail their return ballots at least 1 week prior to the due date established by state law,” the USPS warned on May 29. “If a state law requires completed ballots to be received by election officials by a specified date (such as Election Day) in order to be counted, voters should be aware of the possibility that completed ballots mailed less than a week before that date may not, in fact, arrive by the state’s deadline.”

It’s unclear how many voters follow this advice or even know about it. “Any voter who thinks that they’re going to want to vote by mail should really be putting in their application as soon as possible and not leaving it up to chance,” said Tammy Patrick, a senior adviser to the Democracy Fund and a former Arizona election official.

For years, Patrick and other experts have warned election officials about the need to adjust operations and deadlines to account for a slower, more cash-strapped Postal Service. But these changes have been spotty, and some states and counties are simply not prepared.

Patrick has called for states to modernize vote by mail systems and implement best practices like intelligent bar codes on the outside of ballot envelopes for tracking them, which the Postal Service also recommends. “I’ve been saying that same thing for five years,” she said.

Eight days before Ohio’s primary, Sarita Montgomery, the Postal Service’s head of election mail for northern Ohio, sent election officials a frank warning about the state’s ballot deadlines, according to an email obtained by ProPublica. Ohio gave voters until noon on Saturday, April 25, three days before the election, to request an absentee ballot. Ballots had to be postmarked by April 27. Those rules, Montgomery suggested, meant that some voters could be disenfranchised. “There is a strong likelihood that the timing for mailing out ballots may not allow adequate time for voters to receive the ballot and return it by mail in time to meet the state’s postmark deadline,” she wrote.

The warning came as no surprise to Aaron Ockerman, executive director of the Ohio Association of Election Officials. Ockerman said his members reported “outrageous” mail delays during the primary, and his organization has been urging state officials for years to change ballot deadlines to allow for longer mail times.

“I have paraded this in front of just about anybody in the world who will listen, and said, ‘We have got to fix this,’” Ockerman said. “It’s just not fair to a voter to set this false expectation that if you wait until the last minute and request a ballot that you’re actually going to get it and legally be able to cast it under Ohio law.”

When the iconoclastic Cosmo Kramer tried to cancel his mail in a 1997 “Seinfeld” episode, his friend Newman, a postal worker, was scandalized but confessed: “All right, it’s true. Of course nobody needs mail.”
The joke rings hollow now as the Postal Service may be needed to deliver tens of millions of mail-in ballots despite being in turmoil on two fronts: politics and the pandemic. The Postal Service is a favorite target of Trump, who in April called the agency a “joke,” though he later tweeted that he would never let the Postal Service fail. By statute, the Postal Service is supposed to be an independent agency, with spending and operations overseen by its board of governors. With scant evidence, Trump has attacked vote by mail as “corrupt” and “fraudulent,” even as he and at least one member of his staff have voted by mail.

In April, the Postal Service alerted members of Congress that it could run out of money by September, requested a $75 billion bailout and projected a 30% decline in revenue because of the coronavirus outbreak. Trump has said that he won’t agree to a Postal Service bailout unless the agency raises prices for packages. The Postal Service has begun discussing a $10 billion loan from the Department of Treasury, the terms of which, The Washington Post reported, could give Treasury Secretary Steven Mnuchin unprecedented say over postal operations. It’s unclear if the Postal Service will still need the loan, because online shopping has picked up, although other revenue categories are down.

Last month, Louis DeJoy, a North Carolina businessman and longtime Republican donor who has given more than $1 million to Trump’s campaigns, was named postmaster general, stoking concerns that the agency was being politicized. DeJoy, who said upon his appointment that he looked forward to “working with the supporters of the Postal Service in Congress and the administration” to ensure that it remains “an integral part” of the federal government, did not respond to emailed questions.

Robert M. Duncan, chair of the board of governors and former chair of the Republican National Committee, said in a May 6 statement that the board “appreciated Louis’ depth of knowledge on the important issues facing the Postal Service and his desire to work with all of our stakeholders on preserving and protecting this essential institution.”

DeJoy’s appointment has coincided with departures of key administrators. Ronald Stroman, the deputy postmaster, and the lead coordinator on election mail, announced that he was resigning as of June 1. And David Williams, a Trump-appointed Democrat on the Postal Service’s board of governors, stepped down, reportedly angry with the Treasury Department for intervening in Postal Service affairs. Williams and Stroman did not respond to requests for comment.

Postal worker unions, for their part, say they’re sure that they can handle this year’s election mail, provided there’s proper planning and they are given enough staffing. Still, the pandemic has put a strain on many postal workers’ lives and on mail operations. More than 3,000 of the nation’s 600,000 postal workers have tested positive for COVID-19, 67 have died of the virus and 5,800 workers are under quarantine, according to the American Postal Workers Union. Even before the pandemic, the Postal Service relied on many postal workers regularly working overtime to get mail delivered.

Four workers in the union’s Detroit chapter have died of COVID-19. As mail volume has increased during the pandemic, local President Keith Combs said, his chapter has seen workers fall sick or miss work to care for loved ones. “The union office that I represent sits right in the middle of the worst ZIP code here in Detroit for the coronavirus. It has caused a big issue with the mail flow,” Combs said.

Detroit’s problems affected Ohio’s election mail delivery. Because of the wave of plant consolidation, mail for some northwestern Ohio municipalities, like Toledo, is sorted in Detroit. As Ohio’s mail delays mounted in the week before the primary, the secretary of state, Frank LaRose, a Republican, successfully lobbied to get mail sorted in-state.

John Dyce, president of the Ohio Association of Letter Carriers, worries that his organization’s reputation will be hurt by factors outside members’ control, such as election laws that don’t allow enough time for delivery. “We take great pride in what we do. We do feel we get unfairly blamed for it,” Dyce said. Years of cutbacks and a 2006 law requiring the Postal Service to prefund its retirement benefits, Dyce said, have put the agency in an untenable financial position: “Whenever you’re doing things like that, there’s the possibility for delays,” he said.

On April 8, one day after Wisconsin’s primary, a Postal Service official found 1,600 ballots headed for Appleton and Oshkosh in an area plant, according to a May report by the Wisconsin Election Commission. Those ballots never reached voters.

The report was critical of the Postal Service’s response: “Written inquiries to the USPS did not produce any specific information about these ballots,” the commission said. It said that its staff had been unable to learn any more, and that Wisconsin’s two U.S. senators have asked the Postal Service’s inspector general to investigate.

In Fox Point, Wisconsin, outside Milwaukee, election officials were baffled that ballots were mailed to voters only to be returned to the village by the Postal Service without an explanation. “People would ask us, ‘Where’s my ballot?’” said Scott Botcher, the village’s manager. “And I’d say, ‘Well, we mailed it.’”

Botcher’s office delivered the ballots by hand to the local post office each day. Still, 100 to 150 ballots per day were sent back to his offices in the week before the election. On Election Day, Fox Point village offices received a tray with 175 such ballots. It’s unclear how many Fox Point voters were disenfranchised, Botcher said, as residents who did not receive their ballots could still have voted in person.

He remains perplexed. “We still don’t know why it happened,” he said. “I just want to know so it doesn’t happen again and I can get my taxpayers their ballots.”

New Jersey held municipal elections on May 12 entirely by mail. There were reports of mail delays and problems in several cities including Paterson, where a City Council race was decided by just one vote. At least 300 ballots for the Paterson race, left in a mailbox in a nearby town, had to be discarded because of suspicions that they had been illegally bundled together. Mayor Andre Sayegh said that authorities are investigating possible ballot harvesting, which occurs when a political operative collects and submits large numbers of absentee ballots. New Jersey prohibits bundling by individuals of more than three ballots.

“Something nefarious has happened because I don’t know how anyone can explain 300 ballots appearing in a neighboring town,” Sayegh said.

Belleville, New Jersey, Mayor Michael Melham, a proponent of voting by mail, implored state officials to offer in-person voting options, to no avail. Belleville routinely sees problems with mail delivery, Melham said. “I’m a mayor,” he said. “Last November, I attempted to vote by mail and I never got my ballot.”

This year, Melham said, about a third of Belleville’s ballots came in after Election Night, but in time to count. Melham took to Twitter to point out a tub of ballots that the Postal Service had apparently left in the lobby of an apartment building. “The problems in the post office have been systemic for years,” Melham said. “I do think that they’re overwhelmed. I don’t think they’re capable any more of simply delivering mail. I just don’t think that they can do it.”

Ahead of Pennsylvania’s June 2 primary, Montgomery County election officials warned voters that “mail delivery times are slower than normal” and filed an emergency petition in a state court to extend the absentee ballot deadlines by one week. A judge denied the petition, but after Black Lives Matter protests gained steam across the country, and other counties asked for more time to process ballots, Pennsylvania’s Democratic governor, Tom Wolf, extended the deadline for receipt of ballots in Montgomery and five other counties.

In Maryland, state officials blamed a mailing vendor for ballot delivery problems and the vendor blamed the state. In Washington, D.C., election officials received so many complaints of missing ballots that officials allowed voters to send in ballots via email.

In Indiana’s Marion County, home to Indianapolis, it took two weeks for many voters to get their ballots in the mail ahead of the June 2 primary, according to the county clerk’s office. In a May 28 letter to Indiana’s secretary of state, Marion County Clerk Myla Eldridge warned that a flood of absentee ballots and mail delays could mean mass disenfranchisement: “In short, this could mean that thousands of ballots will remain uncounted despite the best efforts of both the Marion County Election Board and the voters themselves — even while state and county officials have strongly encouraged voters to vote by mail,” she wrote.

Russell Hollis, the office’s deputy director, said, “We are worried that if a voter puts a ballot in the mail, we won’t see it by Election Day.” Eldridge, a Democrat, asked the state’s Republican secretary of state to extend the deadline to receive ballots, but he was denied.

During the week of the election, the Marion County staff were still hearing from voters that they hadn’t received ballots. It took the office six days to count all of the absentee ballots, and the office is still certifying the results.

Election experts say that successful vote by mail systems depend on building good working relationships with the Postal Service. These relationships are reflected in a complicated system of logistics, communication and safeguards that can take years to set up. In states with large vote by mail operations — Colorado, Hawaii, Oregon, Utah and Washington run all-mail elections — the protections include last-minute election-night sweeps of Postal Service facilities to search for ballots.

Colorado election officials, working with a group of local and national mailing vendors, closely track ballot delivery times and take steps to move some mail faster. When deadlines get closer, vendors who help with ballot logistics will ask the Postal Service for clearance to send ballots using faster and more expensive classes of mail. “The whole system has to work together to increase the speed of the ballot,” said Judd Choate, Colorado’s director of elections.

On every election night since 2013, a lawyer and a staffer from Colorado’s election offices, along with a local Postal Service manager, have scoured the Denver General Mail Facility, which sorts 10 million pieces of mail per day. They arrive at 6 p.m., one hour before the state’s voting deadline. The team checks in with Postal Service managers who oversee various distribution points throughout the state to ensure all ballots are located. Any ballots that are found are hand-stamped, time-coded and then sent back to county election offices to be counted.

Similar sweeps are carried out at other postal facilities across the state. Colorado officials say the extra scrutiny works: In Colorado’s presidential primary this year, the Denver sweep found over 1,000 ballots that may not otherwise have been counted.

But many states and counties that don’t have large vote by mail systems have yet to implement these mail facility sweeps.

Choate said he’s not worried about the Postal Service’s ability to handle mail-in ballots this year. “We’ve had a number of conversations nationally, and we’ve also held meetings locally,” he said in late May. “I’ve been on the phone as recently as last week talking to local USPS officials, and I’ve asked the question straight out: Are you delayed in any way? They say that they’re not, and they have statistics to show it. That’s not a current worry that we have.”

The prediction from New York Gov. Andrew Cuomo was grim.

In late March, as the number of COVID-19 cases was growing exponentially in the state, Cuomo said New York hospitals might need twice as many beds as they normally have. Otherwise there could be no space to treat patients seriously ill with the new coronavirus.

“We have 53,000 hospital beds available,” Cuomo, a Democrat, said at a briefing on March 22. “Right now, the curve suggests we could need 110,000 hospital beds, and that is an obvious problem and that’s what we’re dealing with.”

The governor required all hospitals to submit plans to increase their capacity by at least 50%, with a goal of doubling their bed count. Hospitals converted operating rooms into intensive care units, and at least one replaced the seats in a large auditorium with beds. The state worked with the federal government to open field hospitals around New York City, including a large one at the Jacob K. Javits Convention Center.

But when New York hit its peak in early April, fewer than 19,000 people were hospitalized with COVID-19. Some hospitals ran out of beds and were forced to transfer patients elsewhere. Other hospitals had to care for patients in rooms that had never been used for that purpose before. Supplies, medications and staff ran low. And, as The Wall Street Journal reported on Thursday, many New York hospitals were ill prepared and made a number of serious missteps.

All told, more than 30,000 New York state residents have died of COVID-19. It’s a toll worse than any scourge in recent memory and way worse than the flu, but, overall, the health care system didn’t run out of beds.

“All of those models were based on assumptions, then we were smacked in the face with reality,” said Robyn Gershon, a clinical professor of epidemiology at the NYU School of Global Public Health, who was not involved in the models New York used. “We were working without situational awareness, which is a tenet in disaster preparedness and response. We simply did not have that.”

Cuomo’s office did not return emails seeking comment, but at a press briefing on April 10, the governor defended the models and those who created them. “In fairness to the experts, nobody has been here before. Nobody. So everyone is trying to figure it out the best they can,” he said. “Second, the big variable was, what policies do you put in place? And the bigger variable was, does anybody listen to the policies you put in place?”

So, why were the projections so wrong? And how can political leaders and hospitals learn from the experience in the event there is a second wave of the coronavirus this year? Doctors, hospital officials and public health experts shared their perspectives.

The Models Overstated How Many People Would Need Hospital Care

The models used to calculate the number of people who would need hospitalization were based on assumptions that didn’t prove out.

Early data from the U.S. Centers for Disease Control and Prevention suggested that for every person who died of COVID-19, more than 11 would be hospitalized. But that ratio was far too high and decreased markedly over time, said Dr. Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington. IHME’s earliest models on hospitalizations were based on that CDC data and predicted that many states would quickly run out of hospital beds.

A subsequent model, released in early April, assumed about seven hospitalizations per death, reducing the predicted surge. Currently, Murray said, the ratio is about four hospital admissions per death.

“Initially what was happening and probably what we saw in the CDC data is doctors were admitting anybody they thought had COVID,” Murray said. “With time they started admitting only very sick people who needed oxygen or more aggressive care like mechanical ventilation.”

A model created by the Harvard Global Health Institute made a different assumption that also turned out to be too high. Data from Wuhan, China, suggested that about 20% of those known to be infected with COVID-19 were hospitalized. Harvard’s model, which ProPublica used to build a data visualization, assumed a hospitalization rate in the United States of 19% for those under 65 who were infected and 28.5% for those older than 65.

But in the U.S., that percentage proved much too high. Official hospitalization rates vary dramatically among states, from as low as 6% to more than 20%, according to data gathered from states by The COVID Tracking Project. (States with higher rates may not have an accurate tally of those infected because testing was so limited in the early weeks of the pandemic.) As testing increases and doctors learn how to treat coronavirus patients out of the hospital, the average hospitalization rate continues to drop.

New York state’s testing showed that by mid-April, approximately 20% of the adult population in New York City had antibodies to COVID-19. Given the number hospitalized in the city and adjusting for the time needed for the body to produce antibodies, this means that the city’s hospitalization rate was closer to 2%, said Dr. Nathaniel Hupert, an associate professor at Weill Cornell Medicine and co-director of the Cornell Institute for Disease and Disaster Preparedness.

Dr. Ashish Jha, director of the Harvard Global Health Institute, and his team also assumed that between 20% and 60% of the population would be infected with COVID-19 over six to 18 months. That was before stay-at-home orders took effect nationwide, which slowed the virus’s spread. Outside of New York City, a far lower percentage of the population has been infected. Granted, we’re not even six months into the pandemic.

A number of factors go into disease models, including the attack rate (the percentage of the entire population that eventually becomes infected), the symptomatic rate (how many people are going to show symptoms), the hospitalization rate for different age groups, the fraction of those hospitalized that will need intensive care and how much care they will need, as well as how the disease travels through the population over time (what is known as “the shape of the epidemic curve”), Hupert said.

Before mid-March, Hupert’s best estimate of the impact of COVID-19 in New York state was that it would lead to a peak hospital occupancy of between 13,800 to 61,000 patients in both regular medical wards and intensive care. He shared his work with state officials.

David Muhlestein, chief strategy and chief research officer at Leavitt Partners, a health care consulting firm, said one takeaway from COVID-19 is that models can’t try to predict too far into the future. His firm has created its own projection tool for hospital capacity that looks ahead three weeks, which Muhlestein said is most realistic given the available data.

“If we were held to our very initial projection of what was going to happen, everybody would be very wrong in every direction,” he said.

Hospitals Proved Surprisingly Adept at Adding Beds

When calculating whether hospitals would run out of beds, experts used as their baseline the number of beds in use in each hospital, region and state. That makes sense in normal times because hospitals have to meet stringent rules before they are able to add regular beds or intensive care units.

But in the early weeks of the pandemic, state health departments waived many rules and hospitals responded by increasing their capacity, sometimes dramatically. “Just because you only have six ICU beds doesn’t mean they will only have six ICU beds next week,” Muhlestein said. “They can really ramp that up. That’s one of the things we’re learning.”

Take Northwell Health, a chain of 17 acute-care hospitals in New York. Typically, the system has 4,000 beds, not including maternity beds, neonatal intensive care unit beds and psychiatric beds. The system grew to 6,000 beds within two weeks. At its peak, on April 7, the hospitals had about 5,500 patients, of which 3,425 had COVID-19.

The system erected tents, placed patients in lobbies and conference rooms, and its largest hospital, North Shore University Hospital, removed the chairs from its 300-seat auditorium and replaced them with a unit capable of treating about 50 patients. “We were pulling out all the stops at that point,” Senior Vice President Terence Lynam said. “It was unclear if the trend was going to go the other way. We did not end up needing them all.”

Northwell went from treating 49 COVID-19 inpatients on March 16 to 3,425 on April 7. “I don’t think anybody had a clear handle on what the ceiling was going to be,” Lynam said. As of Wednesday, the system was still caring for 367 COVID-19 patients in its hospitals.

As hospitals found ways to expand, government leaders worked with the Army Corps of Engineers to build dozens of field hospitals across the country, such as the one at the Javits Center. According to an analysis of federal spending by NPR, those efforts cost at least $660 million. “But nearly four months into the pandemic, most of these facilities haven’t treated a single patient,” NPR reported. As they began to come online, stay-at-home orders started producing results, with fewer positive cases and fewer hospitalizations.

Demand for Non-COVID-19 Care Plummeted More Than Expected

Hospitals across the country canceled elective surgeries, from hip replacements to kidney transplants. That greatly reduced the number of non-COVID-19 patients they had to treat. “We generated a lot more capacity by getting rid of elective procedures than any of us thought was possible,” Harvard’s Jha said.

Northwell canceled elective surgeries on March 16, and over the span of the next week and a half, its hospitals discharged several thousand patients in anticipation of the coming surge. “In retrospect, it was a wise move,” Lynam said. “It just ballooned after that. If we had not discharged those patients in time, there would have been a severe bottleneck.”

What’s more, experts say, it’s clear that some patients with true emergencies also stayed home. A recent report from the CDC said that emergency room visits dropped by 42% in the early weeks of the pandemic. In 2019, some 2.1 million people visited ERs each week from late March to late April. This year, that dropped to 1.2 million per week. That was especially true for children, women and people who live in the Northeast.

In New York City, emergency room visits for asthma practically ceased entirely at the peak, Cornell’s Hupert said. “You wouldn’t imagine that asthma would just disappear,” he said. “Why did it go away? … Nobody has seen anything like that.”

Undoubtedly some people experienced heart attacks and strokes and didn’t go to the hospital because they were fearful of getting COVID-19. “I didn’t expect that,” Jha said. A draft research paper available on a preprint server, before it is reviewed and published in an academic journal, found that heart disease deaths in Massachusetts were unchanged in the early weeks of the pandemic compared to the same period in 2019. What that may mean is that those people died at home.

The Coronavirus Attacked Every Region at a Different Pace

Some initial models forecast that COVID-19 would hit different regions in similar ways. That has not been the case. New York was hit hard early; California was not, at least initially.

In recent weeks, hospitals in Montgomery, Alabama, saw a lot of patients. Arizona’s health director has told hospitals in the state to “fully activate” their emergency plans in light of a spike in cases there. The Washington Post reported on Tuesday that hospitalizations in at least nine states have been rising since Memorial Day.

Dr. Mark Rupp, medical director of the Department of Infection Control and Epidemiology at the University of Nebraska Medical Center in Omaha, said his region hasn’t seen a tidal wave like New York. “What we’ve seen is a rising tide, a steady increase in the number of cases.” Initially that was associated with outbreaks at specific locations like meatpacking and food processing plants and to some degree long-term care facilities.

But since then, “it has just plateaued,” he said. “That has me concerned. This is a time when I feel like we should be working as hard as we can to push these numbers as low as possible.”

Rupp’s hospital has been caring for 50 to 60 COVID-19 patients on any given day. The hospital has started to perform surgeries and procedures that had been on hold because “elective cases stay elective for only so long.”

The hospital’s general medical/surgical beds are 70% to 80% filled, and its ICU beds are 80% to 90% full. “We don’t have a big cushion.”

Even in New York City, the virus hit boroughs differently. Queens and the Bronx were hard hit; Manhattan, Brooklyn and Staten Island less so. “Maybe we can’t even model a city as big as New York,” Hupert said. “Each neighborhood seemed to have a different type of outbreak.”

That needs further study but could be attributable to both social and demographic conditions and the type of jobs residents of the neighborhoods had, among other factors.

What We Can Learn From Coronavirus “Round One”

While hospitals were able to add beds more quickly than experts realized they could, some other resources were harder to come by. Masks, gowns and other personal protective equipment were tough to get. So were ventilators. Anesthesia agents and dialysis medications were in short supply. And every additional bed meant the need for more doctors, nurses and respiratory therapists.

In early February, before any cases were discovered in New York, Northwell purchased $5 million in PPE, ventilators and lab supplies just in case, Lynam said. “It turned out to be a wise move,” he said. “What’s clear is that you can never have enough.”

Northwell has spent $42 million on PPE alone. “We were going through 10,000 N95 masks a day, just a crazy amount,” he said. “One of the lessons learned is you have to stockpile the PPE. There’s got to be a better procurement process in place.”

If there’s one thing the system could have done differently, Lynam said, it’s bringing in more temporary nurses earlier. Northwell brought in 500 nurses from staffing agencies. “They came in a week later than they should have.”

Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco, agreed. “I’ve helped run services in hospitals for 25 years,” he said. “I’ve probably given two minutes of thought to the notions of supply chains and PPE. You realize that is absolutely central to your preparedness. That’s a lesson.”

Experts and hospital leaders agree that everyone can do better if another wave hits. Here’s what that entails:

• Having testing readily available, as it now is, to more quickly spot a resurgence of the virus.
• Stocking up now on PPE and other supplies. “We definitely have to stockpile PPE by the fall,” Gershon of NYU said. “We have to. … [Hospitals and health departments] have to really get those contracts nailed down now. They should have been doing this, of course, all the time, but no one expected this kind of event.”
• Being able to quickly move personnel and equipment from one hot spot to the next.
• Planning for how to care for those with other medical ailments but who are scared of contracting COVID-19. “We have to have some sort of a mechanism by which we can offer people assurance that if they come in, they won’t get sick,” Jha said. “We can’t repeat in the fall what we just did in the spring. It’s terrible for hospitals. It’s terrible for patients.”
• Providing mental health resources for front-line caregivers who have been deeply affected by their work. The intensity of the work, combined with watching patients suffer and die alone, was immensely taxing.
• Coming up with ways to allow visitors in the hospital. Wachter said the visitor bans in place at many hospitals, though well intentioned, may have backfired. “When all hell was breaking loose and we were just doing the best we could in the face of a tsunami, it was reasonable to just keep everybody out,” he said. “We didn’t fully understand how important that was for patients, how much it might be contributing to some people not coming in for care when they really should have.”

Lynam of Northwell said he’s worried about what lies ahead. “You look back on the 1918 Spanish flu and the majority of victims from that died in the second wave. … We don’t know what’s coming on the second wave. There may be some folks who say you’re paranoid, but you’ve got to be prepared for the worst.”