The box score on Baker’s COVID-19 response
3 hits, 3 errors, and 3 balls still in play
AS WE REACH what may be fairly termed the “end of the beginning” phase of the coronavirus outbreak in Massachusetts, with initial efforts now to reopen the state, it’s fair to take a moment to review how effective Gov. Charlie Baker and his administration have been to date in confronting the challenges of COVID-19.
It bears saying first that issues tied to the biology of the virus as well as the behavior of humans – longstanding social and economic inequities in our state and country fueling disparate impacts of COVID-19, and a failing federal government at many levels, and especially in the White House—are all factors that clearly shape and limit what any governor can do to address COVID-19 and its impacts. Baker and his administration should be judged with these realities in mind.
That said, as someone who spends a good deal of time thinking about health care and public health policy, I offer my grades here of the Baker administration. Since many people are missing baseball right now (for me, not so much —NBA basketball is more my thing), I will categorize the nine issues I consider below into three hits, three errors, and three batted balls still in play where we are waiting to see what happens.
By far, I think the this is the governor’s greatest success. Perhaps it’s made easy because we have Donald Trump to compare him to at the national level, but Charlie Baker is clearly hitting for extra bases as a leader during this pandemic crisis on a daily basis. He understands the importance of being engaged, being informed, taking on issues that are hard, reaching out to get good advice and opinions, and, to a large extent, not running away from his mistakes by blaming others. He has been ably assisted by many people in his administration, but I especially call out Health and Human Services Secretary Marylou Sudders, who has played a key role as leader of the state’s COVID-19 command center. If you dropped in to Massachusetts and observed the state response, you would have no idea what Charlie Baker’s party affiliation is—and that is precisely the kind of political leader we need right now.
2. Flattening the Curve and Avoiding Overwhelming the Hospital System
By far and away, the mantra of this first phase of the pandemic was: flatten the curve of people needing hospital care at any one time—and especially in its most intense form of ICU care with people on ventilators. The goal was to prevent our health care system from being overwhelmed, avoiding some large number of preventable deaths of hospitalized patients. Although New York City did not run out of ventilators, per se, people died there a result of an overtaxed system in which patients were not prioritized to be intubated ahead of others.
While this did not happen in our state, the Baker administration is not being awarded a hit tied to total deaths in our state—many of which could have been avoided had we shut down the Massachusetts economy even more quickly than we did, or had our nursing homes been better prepared to prevent COVID-19 spread. Rather, the governor and his administration get a hit for working with hospitals to help them ensure bed capacity, halt elective cases procedures early, and in helping to obtain ventilators and PPE for hospitals—as well as coaxing them to communicate very regularly about any need to share these resources across hospitals.
3. Reopening Plan for the Massachusetts Economy
While there are things in the Baker administration reopening plan unveiled last Monday that don’t make complete sense to me (opening houses of worship immediately), the overall plan seems pretty thoughtful and credible. Its phases seem to make sense, and it certainly seems more thoughtful than plans from most other states or the almost totally absent federal government guidance on how to reopen and stay safe at the same time. We will of course see if it accomplishes its aim to begin to revive our economy while keeping a lid on the pandemic. If we see the beginning of an upsurge in cases again, we’ll see how nimble state government is in pulling back quickly, and what will that look like—something that apparently President Trump has now said he is indifferent to.
Though I’m calling the reopening plan a hit, it’s more of a infield single than a drive to the gap, and the praise for beating a close throw at first comes with a few points of criticism. As a number of people have noted, the Reopening Advisory Board was not as inclusive as it should have been, especially missing sufficient numbers of voices of essential workers and people from the most impacted communities, as well as including an inadequate number of public health experts. Legislators were absent as well. So things like enforceable health and safety standards for workers (really a continuing issue because much of the COVID spread to date is taking place as a result of essential workers getting exposed during their employment duties) are dealt with only partially in the plan, primarily through directives aimed at staffing levels, use of disinfectants, and physical distancing on the job. Less attention in the guidelines goes to practices aimed at minimizing worker exposure, or appropriate availability and use of PPE. Perhaps even more uncertain are the enforcement questions tied to the health and safety standards that are recommended and which can vary by industry and setting. The plan seems to leave much of it up to workers to complain about an unsafe condition or risk. Reopening qualifies as a infield hit, but we better be careful about how big a lead we take off first.
1. Nursing Homes and the COVID Fire
While the virus’s toll in nursing homes has been a disaster across the country, we are one of the states experiencing this issue most intensely, with more than 60 percent of COVID-19 deaths occurring in these facilities. A key indicator of the challenge is how nursing home deaths from COVID-19 are causing a reversal of the overall reported women-to-men death ratio in our state as compared to other states and internationally, a pattern I noted in late April. Many of the structural causes explaining why nursing homes are being hit so hard are tied directly to the economics of how we pay for long term care, and the lack of resources committed to this care over many years. This net underinvestment leads to insufficient staffing and infection control procedures in nursing homes. The problem is compounded by the social inequities of paying non-livable wages to front line caregivers—whose personal circumstances also increase the probability of their having multiple jobs in other skilled nursing facilities and/or residing in COVID hotspot communities. Add to this PPE inadequacy in nursing homes that was the norm until recent weeks, some slowness in closing homes to visitors, and the result was a powder keg ready to explode with COVID infection and a death trap for many old and chronically ill residents.
Gov. Baker made an error here not only because of the severe mismanagement of the state-run veterans home in Holyoke, but because the administration was slow to respond to this crisis overall. I worry that as people have died at nursing homes and others have perhaps survived with at least some short-term immunity, as we fill these homes again, the same problem will reoccur. Perhaps not if adequate PPE and regular testing (virus and antibody) become more the norm, along with some ability to segregate COVID-infected from non-infected residents, but it will remain difficult. Even though Baker has announced additional resources and a requirement of testing of all residents, I’m not sure what one-time testing for the virus accomplishes—especially if you don’t have antibody testing results on the home overall to know what proportion of people are still susceptible.
2. Failure to Decarcerate Jails and Prisons
Gov. Baker seems to have ignored the pleas of those arguing that many people in jails and prisons—whatever their offenses—were not sentenced to be exposed to an infectious agent which can kill. As the Task Force on Coronavirus and Equity in Massachusetts has noted, and a group of 12 “doctors for decarceration” wrote recently in CommonWealth, about 30 percent of those incarcerated in Massachusetts are over age 50 and people overall in prisons tend to have higher rates of chronic diseases that predispose to complications of COVID-19 infection. House Bill 4652 would allow those incarcerated who pose no immediate public safety threat by their release and are at high risk for life-threatening complications from COVID-19 to be decarcerated. Thus far, Gov. Baker seems to want to stay away from the issue—and I think that is a mistake.
3. Critical Standards of Care and Inequities
I appreciate that when the Baker administration first released its “Crisis Standards of Care,” to help hospitals prioritize who should receive life-sustaining medical supplies and services in the event of shortages, they thought these guidelines were fair from a societal perspective. The standards were explicit in saying that factors like “race, disability, gender, …ethnicity, ability to pay, socioeconomic status, perceived self worth” were “not to be considered by healthcare providers making allocation decisions.” The problem was that estimated lower survivability scores – the basis for allocating scarce resources under the guidance — are closely correlated with many of these same variables. Thus, it seemed very likely that guidelines would have exactly the sort of disparate impact on various populations that the standards sought to avoid. A public outcry caused the administration to issue new guidelines decoupling longer-term survivability because of chronic disease conditions to the prioritization score for receiving life-sustaining treatment. Nonetheless, the entire process left a feeling for many that the Baker administration folks were removed from the on-the-ground implications of what they were doing. I am awarding an error for this initial failure to appreciate how the initially designed standards missed the mark and could have led to insidious forms of discrimination and a worsening of inequities.
Batted Balls Still in Play
1. Early Call for Contact Tracing Initiative with Partners in Health
The governor gets credit for deciding to launch a contact tracing effort with the nonprofit Partners in Health at a time when many were reluctant to even think about a public health approach to reducing COVID spread. He made Massachusetts the first state to commit to such an effort, and did so at a time when most people were only able to focus on preventing hospitals from being overwhelmed. That said, this is very much still a ball in play.
I and many others with much greater expertise have some real doubts as to exactly how effective contact tracing will be in reducing COVID spread at this stage. Why the skepticism? To begin with, there is an asymptomatic phase when people can be spreading the virus to many others that makes contract tracing more difficult and a real issue now as the economy opens back up. There are also time lags between when a person becomes sick enough to even be tested and a result comes back positive and then reported; lags between when a contract tracer first learns of the case and makes contact with that person; possible difficulty in learning the identities and then connecting with potential contacts of that case; and questions of what happens with the follow-up with contacts and the tracer’s ability to coax the exposed individual to voluntarily (some experts argue this should be mandated, like in China) quarantine and possibly get tested.
The idea behind contact tracing is sound. But with all of these steps where its effectiveness can get tripped up, we shall now see whether this effort will add real value or not in our battle against COVID-19.
2. Financial Protection of Key Health Care Providers
A lot of money, both state and federal, has been committed to help with the financial challenges confronting health care providers as a result of COVID-19. Much more of that money seems to be finding its way towards hospitals than other providers. Health centers are also getting some support, while private practices are getting the least.
My worry here is with two distinct groups.
On the institutional provider side, I worry about independent hospitals and health centers that serve significant numbers of Medicaid beneficiaries. These include the usual “have-not” institutional providers pre-COVID. Even with the initial flow of state and federal funds, they may within a few months again be behind the eight-ball.
The other group I worry about are small, primary care practices. Even if they have a broader mix of patients, including Medicare and commercially-insured patients, and even with enhanced payments for telehealth services, the cash flow from reduced fee-for-service volume may threaten a number of smaller and even mid-size independent primary care practices with economic collapse. While right now, a few months of breathing room may have been obtained with Paycheck Protection Program loans, I think a dedicated effort by the Baker administration is called for to fully understand the depth of the issue and then bring a broad group of stakeholders to the table with both ideas and some cash (the Legislature for sure, but also our commercial insurers who should strongly consider moving toward a system of capitation for primary care) to help address this problem for both the short and long term.
This ground ball is still rolling and I know that leaders in the Executive Office of Health and Human Services and Medicaid are aware of the issue. It remains to be seen whether it will be a hit.
3. A Public Transportation System That Works for People
While policy issues in this sector are generally beyond my expertise, public transportation policy in our state is integral to many aspects of how the COVID pandemic will impact our lives. At a common sense level, getting people to work or somewhere else they need to go (like a health care appointment) safely via public transportation will be critical to the economy and people’s health in this next phase of the COVID era.
Those of us on the public health side are very worried about the need for masks to be worn by both workers and riders of public transit, as well as physical distancing practices and rider limits on buses and subways. Beyond what is deemed preferable, there will of course be enforcement issues tied to all of these things. The last thing we need is a public transportation system that fails to address these issues. While we can hope that walking and biking are more fully utilized in this COVID era, the great fear is that a failed public transit system will force people to choose cars over public transit in a way that makes congestion even more unbearable than pre-COVID 19. When it comes to our transit systems in the COVID-19 era, transportation, economic, and public health issues all come together in important ways. How we handle things in the coming months will determine whether they come together in a way that advances essential goals in all of these areas or not.Dr. Paul Hattis is an associate professor at the Tufts University School of Medicine and cohost of CommonWealth’s Health or Consequences Codcast.