The coronavirus outbreak first erupted in the United States in Washington state, and while New York has become the American epicenter of the pandemic, there are Covid-19 cases in all 50 states.

The pathogen is spreading across the country, along with positive tests and death counts. Getting control over the outbreak depends on each state’s ability to engineer an effective response to slow the virus down and eventually contain it. What plans for physical distancing are put in the place — and how well are they followed? Can the state health system survive an influx of infected patients?

“Each region has its own socio-cultural reasons that contribute to the rate of spread and its own approach to dealing with that rate of spread,” says Carl Bergstrom, a professor of biology at the University of Washington who has been modeling infectious disease outbreaks for 20 years.

At first, the coronavirus was most concentrated in urban centers, primarily New York City and its surrounding suburbs. It could flourish in those places because they are densely packed with people, exposing them to a stealthy virus that takes several days for symptoms to show up. Metro centers all over the US — Detroit, New Orleans, Miami, and many more — have continued to see increases in coronavirus cases.

At the same time, the US is still almost certainly undertesting in other parts of the country. To give one example, Connecticut has done about twice as many tests per capita as Texas. Yet both states have roughly the same number of positive test results, despite the latter testing far fewer people per capita. Such a high positive test rate suggests that the real number of cases may be much larger than the official count.

As of May 11, New York has the most confirmed cases (about 335,000) and it has also conducted the second most tests per million people (about 60,000), having been recently surpassed by Rhode Island.

Here’s how states, territories, and Washington, DC, compare based on the number of confirmed cases and deaths, and the number of people tested, according to data from the COVID Tracking Project. Using the latest available Census Bureau numbers, we also calculated the number of tests per million people in a population, to give a better sense of a state’s efforts in tracking the disease.

(Note: We have updated the chart to display “tests conducted” instead of “people tested” because some states are reporting a raw count of the number of tests performed, which may include multiple tests for the same person.)

State health systems have different capacities to handle the surge of Covid-19 cases. Some started the crisis with higher uninsured rates, particularly in the South, because they have refused to expand Medicaid through the Affordable Care Act. Now, millions of workers are newly unemployed as the coronavirus economic crisis sets in, suddenly uninsured during a public health emergency. Some states have younger and healthier populations; others are older. Certain states have more hospital beds per capita than their neighbors, and funding for public health differs considerably among states.

“One thing that always strikes me about the American system is effectively there are, like, 51 American systems,” Ellen Nolte, professor of health services and systems research at the London School of Hygiene and Tropical Medicine, told Vox last year.

The coronavirus pandemic has presented an unprecedented challenge for states

New York, Washington, and California were forced early on to take measures to curtail the Covid-19 outbreak, and some states quickly followed their lead. Others were reluctant to impose strict distancing guidelines, worried about the imposition on daily life and especially businesses.

New York Gov. Andrew Cuomo moved to expand hospital capacity in his state; he also waived out-of-pocket costs for health insurance, and the state put out a call for retired doctors to volunteer their services to avert a hospital staffing shortfall. New York set up “containment zones” to contain local hot spots, where all the area schools were closed, and religious gatherings and other large gatherings were halted. The state has also radically reorganized its hospitals into effectively one statewide system, in the hopes of better managing staff, supplies, and patients. However, New York, like many other states, initially hesitated to put out “stay at home” guidance, before instituting that policy on March 22.

Washington Gov. Jay Inslee quickly ordered the state’s schools to close until the last week of April after the Everett nursing home outbreak. He also appeared uneasy about issuing a statewide “stay at home” order, though he’s since done so. California Gov. Gavin Newsom was the first governor to issue such an order (after several major metropolitan areas in his state had taken that step), and he helped convince some of the big tech companies in his state to donate much-needed protective masks for medical staff.

Other governors adopted more lax attitudes toward the crisis, at least initially. Oklahoma Gov. Kevin Stitt tweeted out (and then deleted) a picture of him and his family eating at a restaurant even though other states were starting to shut down nonessential businesses. Florida Gov. Ron DeSantis at first shrugged off calls to issue a stay-at-home order after pictures of college-age beachgoers in his state stirred up fears they would become vectors for spreading a virus that is generally milder for young people. On April 1, he changed his mind and finally issued a statewide stay-at-home order.

By late April, more than 40 states had issued stay-at-home orders, but some have now begun to relax those social distancing measures. Georgia, South Carolina, and Tennessee have initiated a phased reopening plan, as Vox’s Katelyn Burns reported. Florida is doing the same. Other states, such as Washington, are expected to be more cautious as they unwind restrictions that public health experts credit with stemming the spread of Covid-19.

Hospitals are relying on states to increase the health system’s capacity of hospital beds, ICUs, and ventilators, as well as the personnel to staff them. States, in turn, will need support from the federal government, as their tax revenue takes a hit in the economic downturn. The stimulus bill passed by Congress provides money to hospitals as well as funding for states, although experts say much more is needed.

The relationship between the states and the White House has been a fickle one in the crisis. President Donald Trump has insinuated states should treat his administration kindly in order to win more federal support. Governors have contradicted Trump over his speculation in mid-March that Americans could return to normal life soon; he has somewhat backed off such claims. And many states say that they are still not getting enough supplies from the federal government to make up for expected shortfalls.

States are depending on federal aid to increase testing capacity, too, so they can actually trace the outbreak. New York so far is testing people at the highest rate of any state, while there are other states with a growing number of cases (like Texas and Georgia) where the testing rates still remain low.

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