New Hampshire is scrambling to find enough staffed hospital beds to handle the current surge in COVID-19 patients. Suddenly, politicians on the left and the right are deeply concerned about the low number of hospital beds in the state. Which is kind of maddening because they’re the ones who created the shortage in the first place.

For decades, state laws have severely restricted the state’s hospital capacity. They still do. 

Before 2016, New Hampshire was one of many states with a Certificate of Need (CON) law that essentially required businesses to prove that a large medical equipment or facility investment was needed before it could be approved by the state. That law suppressed investment in new facilities and services. 

In 2016, the CON law was repealed, but it was replaced with laws that created additional restrictions on hospital capacity. Senate Bill 481, passed that year, added three major requirements into state law that restrict hospital competition. 

1. RSA 151:2-g mandates that every hospital “shall operate an emergency department offering emergency services to all individuals regardless of ability to pay 24 hours every day, 7 days a week.” This law prohibits the creation of any competing hospital services that don’t also include a 24/7 emergency room. Conveniently, this law “shall not apply to any hospital licensed and operating prior to July 1, 2016, which does not operate an emergency department.” Incumbent hospitals are protected from this anti-competitive law. 
2. RSA 151:4-a prohibits the establishment of any “ambulatory surgical center, emergency medical care center, hospital, birthing center, drop-in or walk-in care center, dialysis center, or special health care service” within 15 miles of an existing critical access hospital if the new facility “will have a material adverse impact” on the incumbent hospital. That is, if it would hurt the hospital’s business, it is prohibited from state licensure. A 15-mile radius might sound small, but it equals 706.9 square miles. 
3. RSA 151:2-f mandates that every hospital, infirmary, “outpatient rehabilitation clinic, ambulatory surgical center, hospice, emergency medical care center, drop-in or walk-in care center, dialysis center, birthing center, or other entity where health care associated with illness, injury, deformity, infirmity, or other physical disability is provided” accept all forms of payment. This law mandates that medical facilities accept Medicare, Medicaid and private insurance — which means that it bans any facility designed to cut costs by accepting only cash payment. This inflates the cost of services and eliminates competition. 

In addition, RSA 151:2 VI (a.) imposes a moratorium on new beds for nursing and rehab facilities. It states that “there shall be no increase in licensed capacity of, any nursing home, skilled nursing facility, intermediate care facility, or rehabilitation facility, including rehabilitation hospitals and facilities offering comprehensive rehabilitation services.”

State laws ensure that it is much easier for incumbent hospitals and other medical facilities to expand than for new competitors to enter the New Hampshire market. The results are exactly what one would expect. 

Since 1980, New Hampshire’s population has increased by 49.6%. But in that time, only one new acute care hospital, Parkland Medical Center in Derry, has been built, Greg Moore, state director of Americans for Prosperity-NH has pointed out.

The current COVID-induced crunch on hospital capacity has many causes. The media have reported, accurately, that a surge in patients combined with a staffing shortage has put severe strain on the system. 

But that system entered the COVID-19 pandemic with a capacity already artificially constrained by anti-competitive state laws. Going forward, politicians who insist that New Hampshire needs to improve its hospital bed capacity can start by removing unnecessary barriers that make it extremely difficult for new competitors to enter the New Hampshire market. 

Since the beginning of February, unvaccinated individuals have accounted for 99% of New Hampshire’s COVID-19 cases and 98% of deaths, according to state data. The numbers indicate how extremely effective vaccines have been at fighting COVID-19 in the state.

From February 1 through June 23, the state recorded 33,703 COVID-19 cases, according to the state’s Joint Information Center, part of its Emergency Operations Center. Of those, only 349 involved people who had been fully vaccinated. That’s 1.03% of the total.

During the same period, 236 people have died from COVID-19. Only five of those were fully vaccinated. That’s 2.1% of the total.

Only 15 fully vaccinated individuals have been hospitalized for COVID-19 in New Hampshire,  according to the Joint Information Center.

Because of the way the state tracks hospitalizations, an exact percentage breakdown for hospitalized patients is not possible. The state records whether a patient was hospitalized at the time the case was reported to the state, but not whether hospitalization was required later. However, the state does track how many vaccinated people have required hospitalization for COVID-19 at any point. That number has totaled only 15. 

The Joint Information Center sets February 1 as the approximate date by which Granite Staters began to become fully vaccinated. 

A University of New Hampshire poll released Thursday reports that 25% of Granite Staters say they probably or definitely will not get the vaccine. 

Among that group, 56% say they don’t believe it will be effective at stopping them from getting COVID. 

The state data show that, contrary to this view, the vaccines are highly effective at reducing the risk of infection, serious illness and death from the coronavirus. 

The state figures also are similar to national data released last week. An Associated Press analysis of COVID-19 data from May found that 99.2% of COVID-19 deaths in the United States were among unvaccinated people. 

The difference between the 99% and 98% rates for New Hampshire cases and deaths, respectively, is not statistically significant, Beth Daly, chief of the state Bureau of Infectious Disease Control, said. (Dr. Daly’s comment was received after press time and was added to this story after publication.)

“The numbers are not really statistically different because you are comparing a small number (236) to a larger one (33,703).

“This is an issue of small numbers when you compare a denominator of tens of thousands to a denominator of just a few hundred. The confidence interval of 5 divided by 236 is from <1% to 5%, so the 1% observed in the calculation of 349 divided by 33,703 is not statistically nor meaningfully different from the proportion of deaths.

“To say it another way,  the proportion of vaccine breakthrough infections is statistically the same/no different from the proportion of vaccine breakthrough deaths. They are also not substantively different.”

 

In late April, New Hampshire was No. 1 in the nation in the percentage of distributed vaccines administered. Nearing mid-May, the state has dropped to 24th (80%). 

As those who were most eager to get vaccinated have done so, the number of people signing up for their first dose has fallen sharply. Though Becker’s Hospital Review reports that 59% of the population has received at least one dose as of May 14, only 35% has been fully vaccinated. 

This slowdown in vaccine demand creates a public health concern because it threatens to prolong the spread of the pandemic.

The state has been encouraging people to get vaccinated for months. It has initiated a public awareness campaign with the message that getting vaccinated protects you and others. This has been the standard public messaging for COVID-19 vaccination campaigns. But recent research suggests that it’s not very effective at convincing those who remain reluctant to get vaccinated.

A recent YouGov poll found that 63% of Americans who do not plan to get vaccinated think it’s safe to gather indoors with other unvaccinated people without wearing a mask. A campaign that focuses on telling people they and their loved ones will be safer if vaccinated won’t resonate with unvaccinated people who already think they’re safe.  

Shift to incentives and a positive message

A better vaccination campaign would offer a combination of fun incentives and positive messages. 

A UCLA study found that people respond to cash and lifestyle incentives. Offering between $25-$100 raised people’s willingness to get the vaccine by between 13-19%. Cash was more effective with Democrats than Republicans.

Telling people that they won’t have to wear a mask after they get vaccinated also was effective at changing minds. For all respondents, the percentage who said they were more likely to get a vaccine rose by 13 points, from 50% to 63%. For Republicans, the gain was 18 points, from 35% to 53%.

That’s one reason the CDC’s newly announced guidance that vaccinated people don’t have to wear masks is so important. Requiring people to continue masking in public after vaccination undermines the government’s message that vaccination will make them safer and bring a return to pre-pandemic life. 

This confusing messaging is prevalent in New Hampshire. Dover, which has a public mask mandate, tells residents that they must continue masking after getting vaccinated. 

Its guidance reads: 

“WILL I BE ABLE TO STOP WEARING A MASK AND SOCIAL DISTANCING IF I GET THE VACCINE?

“No.”

Portsmouth and Nashua are among the New Hampshire municipalities that continue to mandate mask-wearing in public, including outdoors, which undercuts the state’s vaccine messaging. 

Instead of communicating the depressing, negative message that vaccination offers no escape from mask mandates and other government controls, government ought to be sending a message of hope and joy while offering people fun incentives to get the shot.  

Yes, the caveat is that businesses, local governments and other organizations might continue to require masks indoors for the time being. But governments aren’t effectively communicating that this should be a temporary, transitional practice rather than a permanent one.

A few jurisdictions, however, have tried creative, incentive-based initiatives to encourage vaccination, and the results are encouraging.

An Erie County, N.Y., program that offered free local craft beer and a pint glass to those who showed up to get vaccinated at a local brewery resulted in more vaccinations in one day than all of the county’s first-dose clinics for the previous week, The Buffalo News reported. 

New Jersey is partnering with the Brewers Guild of New Jersey to provide a free beer for anyone who gets vaccinated in May. 

Ohio is giving away $1 million each to five newly vaccinated people via a lottery, plus college scholarships to five students. 

Alabama is holding a mass vaccination event at the Talladega Superspeedway and letting people do two laps around the speedway (behind a pace car) after getting their shots. 

There is good evidence that unvaccinated people respond more to incentives such as free cash and beer — and the lifting of mask requirements — than to New Hampshire’s current messaging. The state could produce better results by changing its vaccine marketing as soon as possible to do the following:

1. Partner with willing craft breweries, wineries, distilleries, restaurants, etc. to offer freebies in exchange for getting a vaccine. Businesses hard hit by the pandemic — such as movie theaters and restaurants — might make good partners. The state is receiving another $1.5 billion in federal COVID relief funds. Using some of that money to boost the state’s vaccination rate by partnering with local businesses to offer beer, coffee, doughnuts or movie tickets to reluctant residents would be a cost-effective investment in speeding the end of the pandemic. 

2. Start communicating to people that mask-wearing and other restrictions, at least in public spaces and especially outdoors, can end when enough people get vaccinated. The confusing messaging on masking is suppressing interest in vaccination. A clear, positive message, effectively communicated, can help to reverse that. 

The state has both a public-health and an economic interest in bringing the vaccination rate up to the highest possible level. Giveaways and better messaging won’t convince everyone to get a vaccine, but there is evidence that they can produce a large enough change on the margins to make a significant difference. Available evidence suggests that this would be more effective than the standard messaging being used by New Hampshire and most other states. 

On Monday, March 29, New Hampshire became the first New England state to make at least half its population eligible for a COVID vaccine, according to an estimate by the Josiah Bartlett Center for Public Policy. Two days later, on the last day of March, it became the first New England state to make at least two-thirds of its population vaccine eligible.

In March, New Hampshire and Connecticut quickly accelerated their vaccine eligibility, trading places for the most rapid expansion. Connecticut made approximately 45.7% of its population eligible on March 19 when it allowed sign-ups for people aged 45 and older. New Hampshire opened registration for residents aged 40 and older 10 days later, then opened registrations for ages 30 and older on March 31. 

Since state vaccination programs began, they typically have been ranked by the percentage of their population that has been fully vaccinated. Another method is to measure the percentage for whom a vaccine is available. Both measures have problems, and both offer useful insights into a state’s vaccine rollout. 

The biggest problem with judging a state by the percentage of its population fully vaccinated is that state governments don’t mandate vaccination; their responsibility is to make vaccines available. 

Another problem is that a sizable, though declining, level of vaccine reluctance persists, particularly in more rural and Republican-leaning states, some data suggest. 

Measuring a state government’s success by the percentage of the population that got the vaccine is to give credit or lay blame in part for factors that are beyond the state bureaucracy’s control.

Judging states by the percentage of the population that has access to a vaccine could be a better measure of the state government’s distribution program. However, this measure also is affected by public behavior and demographics. 

If large portions of the earliest eligible groups decline vaccination because they are skeptical or fearful of the vaccine, that can make more doses available more quickly for later groups. If a state’s population is heavily skewed toward one end of the age spectrum, that will also affect the percentage eligible. 

New Hampshire’s median age is 42.9, almost two years higher than Connecticut’s (41). That gives New Hampshire an edge over Connecticut on this metric. But Maine’s median age is 44.7. Vermont’s is the same as New Hampshire’s (42.9). Rhode Island and Massachusetts are the youngest New England states, with median ages of 39.9 and 39.5, respectively. 

Another potential complication is that declaring eligibility is not the same as making the vaccine available. States can open sign-ups, but those are good only if the system is granting quick and easy access to appointments where vaccines are available.

Ultimately, states are responsible for creating a functioning distribution system that provides residents with the opportunity to obtain a vaccine. Once that system is functioning efficiently and effectively, states can encourage vaccination, but they do not conscript people into the vaccination program. 

That being the case, looking at the percentage of the population that has access to the vaccine can be a useful way of assessing a state’s competence in getting doses to people who want them. At this core task, New Hampshire has done extremely well. Sign-ups have proven relatively easy, wait times are not long, and vaccines are readily available for those who want them.

Though no state’s distribution system has been flawless, New Hampshire’s has managed to avoid major failures while providing relatively easy and effective access for eligible groups. 

By basing eligibility primarily on age, followed by vulnerability, the state has prioritized high-risk individuals while maintaining an uncomplicated sign-up system. 

Connecticut designed and maintained a similar priority system, based primarily on age and vulnerability. Both states have stuck with these systems amid criticism from some that race, ethnicity and income should be weighed more heavily. 

At the close of the first quarter of 2021, Connecticut and New Hampshire led New England in making vaccines rapidly available for most of the population. Other New England states have lagged weeks behind.

Connecticut’s vaccine eligibility remained at age 45 and older until April 1, when it became the first New England state to offer vaccines to all residents ages 16 and older.

New Hampshire ended March with vaccine appointments available to anyone 30 or older, with its schedule set to open vaccine sign-ups for ages 16+ on April 2, just one day after Connecticut.

Every other New England state is scheduled to expand eligibility to ages 16+ more than two weeks later, on April 19. 

Using U.S. Census data, the Josiah Bartlett Center for Public Policy estimated the percentage of each New England state’s population that was eligible for a COVID vaccine on March 31, the end of the first quarter of 2021. Based on the age groups that were being offered vaccines on that date, New Hampshire was in the lead, with 67% of its population eligible, followed by Connecticut at 45.7%, Vermont at 42%, Maine and Rhode Island at 25%, and Massachusetts at 23%.

In addition to prioritized age groups, states have made first responders and other “essential” workers eligible for vaccines. We used only age groups to estimate the vaccine-eligible percentage of the population because we did not have good data for dividing these workers by age.

Adding essential workers without adjusting for age would boost each state’s figures by a few percentage points, but adding those numbers without knowing the workers’ ages would double count many, if not most, of them, particularly in Connecticut and New Hampshire. 

Discrepancy between eligibility and vaccination rates

Becker’s Hospital Review ranks states by the percentage of the population that’s been fully vaccinated. On March 31, the New England states ranked by that metric were:

Rhode Island 20.7%

Connecticut 20.5%

Maine 19.31%

Massachusetts 18.5%

Vermont 18.4%

New Hampshire 17.1%

Why would New Hampshire rank first in New England in eligibility but last in vaccinations?

A likely reason is that a relatively high percentage of the population has reported being reluctant to get the vaccine. 

The most recent U.S. Census Bureau Household Pulse survey for late March found that 57.5% of Granite Staters who have not yet been vaccinated say they will do so. That is the 15th highest rate in the country. Yet it puts New Hampshire below every other New England state.

Looking into the survey’s data tables shows that 15% of Granite Staters said they definitely or probably would not get the vaccine. That is below the national average of 17.2%, but it’s the highest percentage in New England. Rhode Island is next at 14.3%, followed by Maine at 13.2%, Connecticut at 10%, and Massachusetts and Vermont tied at 7.4%.

Although New Hampshire has rapidly expanded eligibility, making the vaccine available to more than two-thirds of the population by the end of March, a relatively high portion of the state’s population, relative to the rest of New England, is reluctant to be vaccinated.

The importance of persuasion

And that brings us to a point the Josiah Bartlett Center made last year about the importance of building trust for public health measures. Regarding business closures and mask mandates, we cautioned that mandates and restrictions can backfire if they cut against public opinion. They can cause resistance, making it harder, rather than easier, to achieve public health goals. The first step in pursuing public health goals during a pandemic is to explain to the public why changes in behavior are needed.

In a democratic republic, persuasion is the primary political currency. Where people pride themselves in being free to live their own lives on their own terms, government dictates can backfire, causing resistance and making it harder to achieve desired goals. This is true in public health as in all other areas of public policy.

New Hampshire has done its job on the distribution end, making the vaccines widely available and easy to obtain. To get the vaccination numbers up, the state next should devote additional resources to persuading Granite Staters to get vaccinated. 

Mass vaccination is the path out of the pandemic. Though the state has made this point, the federal government’s conflicting messages have caused confusion and delay. A more energetic and high-profile state campaign to encourage vaccination would help bring up our vaccination rates and move us more rapidly back to normal, or as close to normal as we can get.