Image of woman visiting her grandmother in isolation during a coronavirus pandemic

The United States has the largest economy, spends more on healthcare than any other nation, and — prior to the COVID-19 pandemic — was ranked as best prepared for a pandemic in the Global Health Security Index. The country, however, maintains the highest number of recorded COVID-19 deaths and one of the highest per capita fatality rates from COVID-19 globally.

But the pandemic did not affect all U.S. states equally, according to the results of a newly published observational analysis in The Lancet.

Between Jan. 1, 2020, and July 31, 2022, cumulative COVID-19 death rates varied widely across the U.S. States with higher poverty, lower rates of educational attainment, less access to quality healthcare and lower levels of interpersonal trust experienced disproportionately higher rates of SARS-CoV-2 infections and COVID-19 deaths.

The researchers found a four-fold variation in standardized COVID-19 death rates (adjusted for age and comorbidities) across states, with death rates lowest in Hawaii, New Hampshire and Maine and highest in Arizona, Washington, DC, and New Mexico.

In addition, COVID-19 exploited and compounded existing local racial inequities, health disparities and partisan politics, they said, resulting in a disproportionate burden of COVID-19 on communities of color and in states that voted heavily Republican in the 2020 presidential election.

“The tragic human toll of the COVID-19 pandemic in the USA challenged conventional assessments of pandemic preparedness and exposed existing vulnerabilities in our societal fabric that were not identical across states,” said co-lead author Emma Castro, a researcher at the Institute of Health Metrics and Evaluation. “Even after accounting for age and underlying illnesses, we observed a nearly four-fold difference in COVID-19 death rates across states, suggesting that the country as a whole could have performed much better. Examining how specific states fared and identifying commonalities of states that performed well offers important insights about how we can and must respond better to this and future pandemic threats.”