May 21, 2020

How reliable is the COVID-19 death count?

How reliable is the COVID-19 death count?

Plus, a podcast appearance where I discuss Tangle's growth.

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Today’s read: 10 minutes.

I examine the COVID-19 death count, a question about alienating readers, a story about “experience economies” and some Tangle-related news.

Johns Hopkins map showing the prevalence of COVID-19.

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Podcast appearance.

Yesterday, a podcast appearance I did was released on YouTube. The conversation was with Josh Brahm, the president of the Equal Rights Institute, a pro-life group that’s trying to improve the way pro-life people talk about abortion. It’s one of the most in-depth conversations I’ve ever had about Tangle, why I created it and what’s come of it so far.

Obviously, abortion is one of the most divisive issues on the planet. We don’t touch on it, but we do talk a lot about confirmation bias, speaking to people you don’t agree with, the mission of this newsletter and the results I’m seeing so far. If you want a look into my past or to hear more about Tangle, it’s a good listen. Josh was very gracious with his time and gave me a lot of space to blabber. You can check out the episode on YouTube below or click here.

Readers respond.

Yesterday’s newsletter brought in some strong reader responses. Jeff from Aston, PA, objected to the notion that governors in Florida or Georgia should be judged by their state’s death counts alone. “DeSantis allowed spring breakers to spread the disease far and wide and Kemp somehow didn't know asymptomatic people could spread COVID-19 until April, which kept him from shutting down the state sooner and saving lives,” Jeff wrote in an email to Tangle.

Libby from Durham, North Carolina was similarly skeptical, saying the state-by-state comparisons hinge on accurate data in places like Florida, where the top COVID-19 data scientist was fired. “Do we have any confidence in that?” she asked about the data being accurate. “Goodness knows the count of cases could be highly under-reported if we can't track deaths accurately.”

Today’s top story is on this very topic, so let’s dive in…

What D.C. is talking about.

The data. As local, state and federal governments try to decide whether it’s safe to reopen, many conversations have devolved into a debate over the data. Making informed decisions is crucial, but we can’t even agree on the fundamental questions of whether cases are going up or down, or whether deaths are being overcounted or undercounted.

Plenty of stories have spurred these questions. The central issue is around how deaths are counted. Federal guidance specifies that “COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to the death.” That has been interpreted by a lot of people to mean COVID-19 deaths are being assumed without a positive test or legitimate reasons.

But there’s also the struggle with data across the board. State and federal data on COVID-19 don’t match up. Somehow, the CDC actually mixed up antibody tests and COVID-19 viral tests. Some governors have been caught releasing misleading, mixed-up data. As a result, over the last few weeks, questions have poured into Tangle about whether the data on COVID-19 deaths are accurate — and the right and left have been debating the issue across social media, on TV and in the newspapers.

Public polling suggests this is playing out nationally, too. Just 32% of all Americans believe the number of Americans dying from the COVID-19 is about the same as the reported number. 44% believe the actual number is higher and 23% believe it's lower.

What the right is saying.

Generally speaking, the right has claimed the total death toll has been overcounted. Earlier this month, President Trump suggested publicly and privately that the official COVID-19 death toll may be higher than the actual one. One of the central reasons for this is that Medicare is giving hospitals a 20% bonus for their treatment of COVID-19 patients as a way to help make up the money they’re losing for canceling non-coronavirus treatment and procedures.

That, combined with the fact that numbers are being “revised upward” to include presumptive cases, would indicate there are plenty of unknown but assumed deaths included in the official count. We’ve seen this play out in real time. In late April, New York revised its death count upward by 3,700 victims, saying they were including people who never tested positive for the virus but were presumed to have it.

Scott Jensen, a Republican state senator and doctor in Minnesota, combined both these views when he told Fox News in April that the CDC’s guidelines were “ridiculous” and could be misleading the public. Jensen added that things get “awkward” when money and health care are combined, and explained that COVID-19 admissions are worth thousands of dollars. “If that COVID-19 patient goes on a ventilator, you get $39,000; three times as much,” he said. “Nobody can tell me, after 35 years in the world of medicine, that sometimes those kinds of things don’t [have] an impact on what we do.”

Rep. Mark Baisley, Republican state legislator in Colorado, levied similar accusations, asking prosecutors to charge Colorado’s top public health official for illegally falsifying death records to inflate COVID-19 death tolls. Baisley says members of the Colorado Department of Public Health and Environment overruled attending physicians’ cause of death in nursing homes and ruled the cause of death was COVID-19 if a patient tested positive, regardless of whether it was the primary or official cause of death or not. A revised Colorado COVID-19 death count consequently went from 1,150 to 878.

Stories on the fringes of the right have also ramped up questions. Project Veritas’s James O’Keefe released interview clips with New York funeral directors who speculated that city officials were “looking for federal funding” and putting more COVID-19 deaths on the certificates then were accurate. None of the funeral directors claimed inside information but instead conceded they were speculating based on their experience.

What the left is saying.

Many on the left also don’t trust the data — but in the opposite direction. Liberals have been saying that COVID-19 death counts are actually underreported because so many people are likely dying at home or dying before their test results come back. The left has pointed to experts, like epidemiologists and health care officials, who say the delay in widespread testing has also left the count lower than it should be.

One of the main reasons the left believes true counts are too low is that there are thousands and thousands of unexplained “excess” deaths all across the U.S. and in New York. For example, New York state has had a huge surge in deaths above the usual rate for this time of year. The New York Times collected data suggesting there are three times as many excess deaths as there are COVID-19 deaths. In other words: assume for a moment that, on average, 10 people die in New York every year in March. This year, 40 people have died in March, meaning there were 30 “excess deaths.” 10 of those 30 excess deaths have been diagnosed COVID-19 deaths, leaving 20 excess deaths that are still unexplained — and many epidemiologists are assuming they’re COVID-19 related.

The polling and statistical outfit FiveThirtyEight took a similar stance, leading with an anecdotal story about a man who almost certainly died of COVID-19 but wasn’t counted in the official death toll. The reporters there explain that because testing was so inaccessible in the early days of the pandemic, and because so many people with underlying conditions die quickly of the virus before getting to a hospital, there were likely thousands of uncounted COVID-19 deaths.

While local Republican representatives say there’s an overcount, local Democratic leaders like New York City councilmember Mark Levine have taken the opposite stance repeatedly in public. He is backed by Mayor Bill de Blasio, Gov. Andrew Cuomo and other Democrats across the U.S. who insist that — if anything — the counts are still too low.

My take.

Tracking down this answer has been one of the most complicated and difficult pieces of research I’ve ever done for Tangle. I’ve been down the rabbit hole of how we count deaths in America and it is a dark, bizarre, morbid and complicated place to be. But I’ve come out on the other end with more clarity on this than I had before.

First, it’s not a conspiracy theory that states and hospitals are getting financial incentives to inflate their COVID-19 deaths. Yes, Medicare is funding hospitals with COVID-19 patients. And yes, there are plenty of perfectly reasonable assumptions we can make about humans and incentives to come to the conclusion that hospitals would inflate those counts to get more money.

But there’s also no evidence of them acting on those incentives. Even Jensen, the doctor and state representative who initially sparked this theory on Fox News, has since clarified that he doesn’t think hospitals are committing fraud — he just meant it was possible.

The closest we’ve come to hard evidence for that sort of thing is the case in Colorado, where public health officials allegedly revised the way seven nursing home deaths were counted according to the attending physician. That’s pretty small-time stuff, and it’s still nothing more than an accusation. Even the funeral directors in New York were not working off of any firsthand knowledge, but instead were making presumptions based on what they knew about how the incentives worked and the huge ramp-up in deaths they were seeing. The huge upward revision in New York death counts from April was actually pretty well-justified.

There’s also the complicating factor of underlying health issues. The vast majority of Americans dying from COVID-19 also suffer from things like diabetes, obesity, previous lung or heart conditions and so on. That means their death certificate will include hedging language like “probable COVID-19” death or will simply have multiple causes of death, as most certificates do. All of this stuff is even further complicated by the CDC method for counting, which includes a fast count (quickly released estimates based on incoming state data and various factors) and a slow count (a more accurate and verified death total that is a few weeks or even a month behind the real total). People have been confusing the two on a regular basis and sometimes interpreting them as the CDC not knowing what it's doing.

The most compelling evidence I saw were the various, state-level studies showing the huge jump in excess deaths in places like New Jersey and New York. But even that comes with a caveat: yes, far more people than usual are dying in those places. But how many of the deaths were unrelated to COVID-19 infections and instead because of an overwhelmed hospital? Or a patient staying home for fear of going to a hospital? Or some other extraneous factor where someone who wasn’t sick with COVID-19 died because of the circumstances the virus created?

It’s all complicated and sticky and difficult to parse. Who died with COVID-19 versus who died because of COVID-19? Who died because of a COVID-19 infection versus who died because COVID-19 is overwhelming certain hospitals and they couldn’t get care? But I do have a conclusion.

The idea that COVID-19 deaths are being inflated is based on two major assumptions. One is that healthcare workers, coroners and attending physicians nationally are committing fraud. They’re listing COVID-19 as the cause of death without a positive test and without indicators (like symptoms) to reasonably assume the person was infected. And they’re doing it to increase their hospitals’ funding all across the country.

The second is that the fraud those physicians are committing is greater than the total number of uncounted COVID-19 deaths that happened both in the first few weeks of the pandemic, before testing was widespread, and perhaps continue to happen as we ramp testing up. The fraud needs to be more than the grand total of both those deaths and the people who died at home before getting to a hospital.

Both of those assumptions, to me, seem nuts. I just don’t think the fraud hospitals are being accused of is that widespread and I certainly don’t think the number of people who died without positive tests or without getting to a hospital is small. The excess death numbers statewide seem to show that. Ultimately, it looks to me as if  — at the very least — the death counts are just about accurate and all of the complicating factors make it a wash. Just as likely is that we are undercounting the totals, and as the weeks go by and the “slow,” more accurate counts catch up, we’ll see the death toll steadily rise, too.


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Quick hits.

  1. A new study says federal and state governments could have saved 36,000 people’s lives if they began imposing social distancing measures one week earlier than they did.
  2. Several southern states began seeing a jump in coronavirus cases, and experts are trying to figure out whether it’s because of expanded testing or a sudden increase in the spread of COVID-19.
  3. Nearly 10,000 Michiganders’ homes were destroyed by a “500-year flood” that overwhelmed two dams.
  4. The Atlantic is laying off 20% of its staff this week as the already fragile media industry continues to be crushed by the global coronavirus pandemic.
  5. Elizabeth Warren appears to be moderating her stances in an effort to sell herself as a potential Vice Presidential pick for Joe Biden.

Your questions, answered.

Reminder: reader questions are one of my favorite parts of Tangle. If you have something you want to see in the newsletter, simply reply to this email and write in. I’ll try to get to it as soon as I can.

Q: You recently mentioned your awareness that you had a good deal of readership from Trump supporters and you feared alienation, angering or driving them away because of your inability to find metrics that showed justification for the Trump administration's saying they were doing a good job with the COVID response. While I appreciate the candor here, how do you feel that your awareness of this dynamic shapes your content? Does it ever make you wait for a better justification before you take a stance on certain issues or affect where you pull your source material from?

— Addison, Asheboro, NC

Tangle: This is a great question, and one of the biggest challenges of being anybody who has a public profile and shares their opinions on things. There’s an old saying in journalism that if you’re pissing people off on both sides of an issue, you’re doing something right. My editor at my college paper told me that the first time I was inundated with mail for a column I published in the school paper.

Frankly, I think it has an impact on how I frame my responses in the “My take” section but rarely has an impact on the conclusions I come to. First, the readership of Tangle — based on the polling data I have — is still a majority to the left. About half of my readers self-identify as Democrats. The other half is made up of conservatives and independents. So if the dynamic was going to play out this way, I think it would work in the opposite direction.

Second is the assumption I’m making about my readers. I’m selling Tangle as a place to come and have your views challenged, to hear the “full story,” to hear from the “other side,” to get a more balanced look at the day’s big news. So, naturally, I’m assuming that the people reading Tangle — whether they’re Trump supporters, far-left progressives, independents, never-Trump Republicans or Blue Dog Democrats — are here because they’re open-minded. They have intellectual rigor. They can handle reading something they don’t like. And, in fact, they want to read things that they may not get in their normal news consumption. That’s the great thing about my readers.

So, how does it shape my content? I actually talk about this a bit on the podcast appearance in the top of today’s newsletter, but I think there is one specific way it works: I write thinking about whether my readers who have the views I’m trying to represent would feel like I’m being “fair.” So, for instance, if I’m putting together or responding to the right’s position on the day’s story, I think about how my readers who share that view are going to look at it.

If they’re going to read it and think, “I’m on the right and that’s not at all how I feel,” then there might be a problem. In other words: I’m not going to cherry-pick the worst arguments from Trump supporters or liberals because I know I have readers who are Trump supporters and liberals who will lose trust in me if they see their views being inaccurately represented.

In that sense, I think the dynamic plays out really positively. Naturally, it does impact my “source material,” since I intentionally go where I think my readers are going for news. I want to know what you’re reading or watching on TV or hearing on talk radio while simultaneously wanting to present new views and perspectives and arguments to you that you haven’t seen.

All in all, I write knowing that my job isn’t to make my readers agree with me or make them happy. I write knowing that the people who subscribe to and read Tangle are here because they want to better understand politics, better understand arguments they don’t agree with and have a chance to engage with an accountable and transparent news source. In that sense, I think knowing that I could alienate certain parts of my readership on any given day doesn’t change what I write so much as it forces me to be more thorough and careful while representing various views.

A story that matters.

The loss of the “experience economy” is taking its toll on Americans financially and psychologically. The COVID-19 pandemic has led to the cancellation of sporting events, music festivals, nightclubs and other large group gatherings that have become staples of social hangouts and tourist economies. Arts, entertainment, recreation, accommodations and food services account for nearly $1.6 trillion in GDP and are up 60% from a decade prior. Now, they’re being crushed. Along with them is the loss of gatherings with friends, family and strangers — or, as The New York Times recently put it: “how we make meaningful memories and define ourselves.” Americans treasure these crowded, messy, germ-filled pastimes and our economies and psyches are suffering without them. Click.


  • 83%. The estimated percentage of COVID-19 deaths that would have been avoided had the national lockdown began on March 1st.
  • 83%. The percentage of Americans who said they had worn a mask or other face-covering in the last seven days in a poll taken this week.
  • 27%. The percentage of Americans who said they had worn a mask or other face-covering in the last seven days in a poll taken on April 1st.
  • 67%. The percentage of Americans who say Donald Trump should wear a mask when in public, according to a new Quinnipiac poll.
  • 38%. The percentage of Republicans who say Donald Trump should wear a mask when in public, according to a Quinnipiac poll.
  • 2.4 million. The number of jobless claims filed in the last week.
  • 1,555,537. The total number of confirmed COVID-19 cases in the United States, as of 11 a.m. EST.
  • 5,027,732. The total number of confirmed COVID-19 cases across the globe, as of 11 a.m. EST.

Have a nice day.

An Alaskan man who lives on the remote island of Gustavus is making weekly, 14-hour boat trips to Costco to feed his town. Toshua Parker owns the Icy Strait Wholesale store on the island, the only grocery store for some 450 residents. But COVID-19 has restrained Alaska’s ferries, and the ferry that used to bring the town its food supply is no longer stopping in Gustavus. Instead, Parker and his staff are using a 96-foot-long converted military landing aircraft on weekly trips to Juneau, stocking up at Costco and then turning around to bring the food home to the residents. It’s a very, very Alaska story. Click.

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