GOV. CHARLIE BAKER on Monday refused to sign a bill overhauling the state’s public health system, instead returning it to the Legislature with an amendment.
The intention of the bill had been to introduce state funding and state standards into a system that has until now been controlled entirely by local governments. Baker, worried about the impact on municipal governments, proposed turning it into a local option instead – where local governments could opt in to receiving the money and abiding by the new standards but would not be required to do so.
Baker also vetoed a bill that would have allowed administrators or teachers to administer insulin to diabetic students in school. That bill would appear to be dead for this session, since the Legislature cannot override Baker’s veto without returning to formal sessions, which is highly unlikely.
The public health bill is also in a precarious position. The Legislature concluded its formal sessions for the year on August 1, which means lawmakers cannot take any action without unanimous consent. If the Legislature doesn’t accept Baker’s amendment, the bill dies. If the Legislature somehow musters enough support to send the bill back insisting on its amendment, Baker could just veto it. Any disagreement between Baker and the Legislature could easily push the issue off until the new legislative session begins in January.
The problem lawmakers are trying to address with the public health bill is that before the COVID pandemic hit, local public health departments had been entirely funded by cities and towns, which led to major disparities. Some small towns had a single public health inspector or a volunteer board, while large communities might have a public health nurse, inspector, and fully built-out department. Public health departments are responsible for a wide range of services, from inspecting restaurants, housing, and water systems to responding to disease outbreaks.
When COVID-19 required public health departments to take on an even wider range of responsibilities, like contact tracing and setting up vaccine clinics, the disparities became more evident. The state took on many of these responsibilities, paying outside vendors.
Public health advocates used the pandemic experience to push for a slate of reforms that had been recommended by a special commission on public health that released its report in 2019. Most of those reforms were included in the bill, dubbed SAPHE 2.0, which stands for Statewide Accelerated Public Health for Every Community and builds on a public health bill signed into law in 2020.
The bill would create minimum standards for public health departments, laying out how departments should act in areas like communicable disease investigation and environmental permitting. It also sets standards for workforce education and credentialing. The bill then sets up a mechanism for the state to provide funding to each community to help it meet these standards, and also sets up state programs to assist with things like training public health workers. There are financial incentives for communities that share public health services regionally. The bill creates new data collection requirements, so the Department of Public Health can better track public health trends.
This bill does not allocate any money itself but lays out how to spend the $200 million over five years that lawmakers previously appropriated to improve local public health departments.
In a statement after the bill passed, Carlene Pavlos, executive director of the Massachusetts Public Health Association, said the bill “will ensure that strong public health protections are available to all residents of our Commonwealth – regardless of race, income, or zip code.”
Baker wrote in his amendment letter to the Legislature that he strongly supports the aim of the bill “to provide high-quality coordinated and more uniform public health services across the commonwealth, supported by targeted state investments.”
But he worried that the bill requires all public health departments to comply with new state standards, regardless of whether the state provides adequate funding. Since the funding is not guaranteed, Baker worried that, over the long term, the bill will turn into an unfunded mandate on cities and towns, giving rise to funding and budgetary disputes. He said there is also nothing in the bill that would prevent a city or town from eliminating local funding for public health once they get money from the state.
Baker’s amendment would let cities and towns opt into the new standards. They would then be eligible for financial assistance from the Department of Public Health, on condition that they maintain local spending at at least the amount spent the year before opting in.
Baker also wrote that he remains concerned that revamping the funding structure for local boards of health will have only limited effectiveness if the Legislature also does not reconsider “the variety and breadth of governance structures” in local boards of health. Baker urged lawmakers to consider that issue next session.
Baker outright vetoed a separate bill that would have let school nurses designate other school personnel, like teachers, to administer insulin or give glucose tests to diabetic students. Baker wrote that the administration of insulin requires very specific dosing, and administering a glucose test requires specific knowledge to interpret the results and apply them to decisions around how much food to eat or how much insulin to administer. Insulin is a considered a high-risk medication, which means a patient can be seriously harmed by the administration of the wrong dose.
“Because of this level of complexity and the clinical assessment skills needed, allowing the delegation of insulin administration to unlicensed school personnel would create an unnecessary risk of error which could lead to serious injury or even death for a student with diabetes,” Baker wrote.