President Donald Trump announced guidelines Thursday to ease economic restrictions on businesses and social distancing, but most states and counties will take a much more cautious approach out of fear that a second wave of COVID-19 cases could emerge if they act too soon.

The administration laid out a three-phase approach to easing restrictions on businesses and social distancing, according to a White House document ​​​​obtained by CQ Roll Call.

The proposed guidelines suggest easing restrictions only after a state reports a 14-day downward trend in reported COVID-19 and influenza-like symptoms; a downward trajectory in documented cases or positive tests as a percentage of all tests and a testing system is in place for health care workers; and crisis care is no longer necessary.

The first phase would allow for gyms to open with some restrictions and for hospitals to resume elective surgeries. The second phase would allow nonessential travel, schools to reopen, and bars and large venues to reopen with some restrictions.

The third phase would allow visits at senior care facilities and hospitals.

“Our team of experts now believe we can begin the next front in our war, which we are calling opening up America again,” Trump said.

Nearly 30 percent of the country has reported no new cases in the last seven days, he added.

Governors will have the final say over lifting restrictions in their states, but the White House guidelines could offer cover to governors of states with fewer cases to restart their economies in the coming weeks.

Still, local officials in Washington, D.C., New York and New Jersey this week have extended stay-at-home orders or school closures until May 15.

Trump has been itching to lift the restrictions that shut down large parts of the U.S. economy over the last month as people were instructed to stay home to avoid spreading the COVID-19 virus. He previewed the announcement Wednesday as protesters in Michigan pushed back on Democratic Gov. Gretchen Whitmer’s stay-at-home order and more Republicans urged the administration to prioritize an economic rebound.

While Trump suggested that some people in some parts of the country could start to return to some normalcy even before the administration’s guidance to limit movements lifts on May 1, most state health officials and governors are not eyeing a concrete timeline for any changes.

“We’re always pleased to have national leadership, but I think that this can’t be a national opening. That would be very disadvantageous in terms of national health. It would have to be regional and state-run,” said Rachel Levine, secretary of health at the Pennsylvania Department of Health and president-elect of the Association of State and Territorial Health Officials.

Multiple public health officials said certain milestones should be met before restrictions can be modified, pointing to increased levels of testing and contact tracing for confirmed cases, even as officials take into consideration economic and social concerns. Officials in several states are still determining which metrics to consider when planning for a resumption of activities.

“Each state is going to need to do what they do for their state, but [we’re] looking at some of these common principles and approaches that we want to take into account and the overall strategy,” said John Wiesman, secretary of health at the Washington State Department of Health. “We are identifying those measures that we want to look at that give us some indication for appropriate timing.”

Deborah Birx, the White House coronavirus response coordinator, said Wednesday that while some states like California and Washington never had a true peak and cases are plateauing, other areas where cases are rising like Providence, R.I., are concerning. The handful of states that have not seen many cases are the ones that would be more likely to reopen soon, she said.

“We do have states that have very few cases and very few new cases,” she said Wednesday. “These are the ones the president is referring to that have been silent — relatively silent — throughout this epidemic and pandemic that many of us have faced.”

Many Republicans are eager to see the economy rebound.

“The President is right: We can continue to apply maximum pressure on the coronavirus while reopening our economy safely and responsibly,” Ways and Means Committee ranking member Kevin Brady, R-Texas, said in a statement Thursday after a call with Trump and House members working on plans to reopen the country. “Not only can we — we must if we hope to prevent hurting working families and the jobless with an unnecessarily extended economic recession.”

Competing factors

Trump’s desire for the economy to rebound contradicts the health care advice from many experts.

Emory University health policy professor Kenneth Thorpe, who was a deputy assistant secretary for health policy during the Clinton administration, said it was “almost counterproductive” to pick dates to lift the restrictions keeping people at home.

“We can’t be really rigid about what those dates are,” he told CQ Roll Call.

Health experts say that to avoid a second wave of infection before a vaccine is available, the United States needs to lower the number of overall cases and then make sure that stays low.

“You need to look for a couple of weeks to see if the leveling off continues or if we have successfully flattened the curve,” said Amanda Castel, a professor of epidemiology at the George Washington University.

California is weighing six main criteria before officials will ease restrictions. The state will evaluate the ability to test and isolate those who were exposed or are positive, prevent infection in those most at risk, and handle patient surges in hospitals. Officials will also consider the ability to develop therapeutics, whether businesses and schools are able to support social distancing, and when to possibly reinstate future stay-at-home orders and other restrictions.

Ohio GOP Gov. Mike DeWine announced Thursday that the state will begin phasing in reopening some businesses on May 1, while requiring precautions to protect employees and customers. He provided few other specific details. Texas is also expected to announce its own modifications this week.

New York Democratic Gov. Andrew Cuomo on Thursday emphasized the need to ramp up contact tracing, a system where a health agency tracks down other individuals a positive patient has interacted with.

“The tracing investigators are really assembling an army that does not now exist. I spoke to the White House again this morning about it and I understand that this is a problematic area and the federal government isn’t eager to get involved with testing,” said Cuomo at a press conference. “I get that. But the plain reality here is we have to do it in partnership with the federal government.”

Meanwhile, states and cities are attempting to take on the task of contact tracing. Massachusetts is seeking to hire 1,000 people to pinpoint through contact tracing who has been infected and stop them from spreading the disease further. San Francisco hopes to trace individuals through phone interviews with patients about their contacts and follow-ups with those contacts. Maryland officials have also indicated they want to ramp up contact tracing efforts.

Richard Besser, the president and CEO of the Robert Wood Johnson Foundation and former Centers for Disease Control and Prevention acting director, said contract tracing can be done best by community members, but that the public health workforces in most places have been reduced so local organizations would need to staff up to conduct those efforts.

“Resources will need to come to states but the efforts to do contact tracing, those are state and local public health responsibilities,” he said.

A slower comeback in many places

Three separate regional coalitions — in the Northeast, Midwest and West — formed this week with the goal of making multistate decisions about when to eventually ease restrictions on businesses and stay-at-home orders.

Monica Bharel, the Massachusetts Department of Public Health commissioner, said the pandemic is still on the upswing in her state, so officials there aren’t yet ready to focus on lifting restrictions.

“When the time comes to think about reopening our economy, we have to do it strategically and safely,” she said, cautioning that the worst possible outcome would be triggering a second round of the pandemic.

Officials in other states say that while they’re not prepared to end stay-at-home orders, they are discussing how to slowly allow people to return to work and where those efforts might start.

“This is going to have to go in a slow, progressive fashion,” said Levine, the Pennsylvania health official. “We’re not going to have one grand opening of Pennsylvania where the businesses are open and everyone goes back to restaurants. We’re going to have to have a slow, iterative approach starting with counties that have been less affected.”