Coronavirus Diary (61): Tyler Cowen on the Nursing Home Controversy

In a much-read and much-discussed interview in The Atlantic, the economist Tyler Cowen argues that the COVID-19 crisis proves that “the regulatory state is failing us.” Here is his Exhibit A for that claim:

Friedersdorf: What are the most significant failures of America’s regulatory state as it relates to the pandemic?

Cowen: Let me give you a few examples:

  1. New York state regulations, until very recently, forced nursing homes to accept COVID-19-positive patients being discharged from hospitals. Nursing homes, especially in the northeast, have been an epicenter for COVID-19 casualties. By law, they were forced to accept more than 4,500 COVID-19-positive patients, often without proper PPE for their staff.

I don’t find this convincing. Why, exactly, does this very partial description of the issue prove that government failed? And why does Cowen regard the matter as so obvious that a summary this brief should suffice to make the case?

Yes, both New York and New Jersey regulations until recently forced nursing homes to accept COVID-19-positive patients upon discharge from hospitals. Yes, nursing homes have been an epicenter for COVID-19 casualties. Yes, these nursing homes often lacked proper PPE for staff, as well as testing, isolation, and so on. But how does this add up to a regulatory failure on the part of the relevant state governments? What exactly was the failure? And why was it a failure?

Like so many people repeating this charge, Cowen omits most of the crucial intermediate steps required to get him from the facts he cites to the judgment he makes. I’ve gone back and read as many of the posts on nursing homes on Marginal Revolution as I could in an hour or so, and basically came up with nothing more than a series of promissory notes gesturing at an argument-not-yet-made, along with promises to “hammer away” at the polemical point involved. Maybe I missed something, but I didn’t see an actual argument for any relevant conclusion. And maybe it’d be wise to come up with an argument before hammering away at a conclusion.

In particular, like so many of the people wielding the “nursing home failure” bludgeon, Cowen conspicuously fails to deal with any of the following issues:

(1) Rationale for the order. What was the rationale for the order forcing nursing homes to accept COVID-positive patients? Was it a good rationale at the time it was passed, or not? Cowen writes as though the rationale for the adoption of the order could simply be ignored (along with the text of the order itself, the explanation given in the original text, and so on). The preferred strategy, it seems, is to condemn the order without asking why or under what circumstances it was adopted. This seems like a good way to produce a libertarian talking point, but a bad way of tracking the truth.

(2) The need for expedited discharge from hospitals. The order was issued because hospitals expecting a wave of acute COVID patients wanted to discharge non-acute COVID patients as soon as they were stable, many of them elderly COVID positive patients requiring intensive follow-up care (despite being stable). Question for Cowen: were the hospitals (of New York and New Jersey) wrong to discharge the patients in question when they did (meaning, elderly non-acute COVID-positive patients needing intensive follow-up care)? How so? To say this is to say that their fears of an imminent incoming wave of COVID patients were all nonsense, hype, exaggeration, or miscalculation. True? Wouldn’t an argument to that conclusion require quite a lot of data arranged in very precise ways? If so, can Cowen cite a source?

(a) Expedited discharge option. Suppose that the hospitals were right to expect that an incoming wave was en route. Assume accordingly that non-acute patients had to be moved somehow, somewhere to make room for the expected incoming wave of patients. If so, either the non-acute patients had to be discharged on an expedited basis or not. Suppose that they were to be discharged on an expedited basis. If so, where besides nursing homes were they supposed to go? A decision to discharge a patient requires a plan for discharge, including transportation to some appropriate destination, the permission of the destination itself, and an arrangement at the receiving end to receive the patient and care for him or her. What does Cowen have in mind here? Where was all of that available except at nursing homes?

NJ: 'We Can Do Better' In Troubled Nursing Home COVID Crisis ...

Judith Persichilli, NJ State Health Commissioner (photo credit: Chris Pedotta, Gannett)

One possibility would have been to discharge patients to private homes. But this was easier said than done. Obviously, for the resident herself, the nursing home was the functional equivalent of a private home. In the case of relatives, working families might in theory take their relatives in, but had to make arrangements for the care of an elderly post-COVID patient. Some families were unable to do this (whether financially or logistically or both), and others were unwilling to do so (partly out of fear of infection, partly out of a refusal to do the job that the nursing home was being paid to do). Recall that working families had earlier demanded that schools stay open to care for young children. In the relevant respects, the convalescent elderly are just as helpless as very young children. So it’s not clear that discharge to private homes was a useful or widely available option.

Another option was to send the elderly to intermediate quarantine facilities specifically set up to house non-acute patients (including nursing homes specially designated as capable of handling COVID-positive patients). But arguably, the creation/organization etc. of such facilities was a later development in places like New York and New Jersey, and not something that could be relied on with certainty at the outset, i.e., at the time that the order was issued (March 31 in the case of New Jersey). What was to be done in the window of time before the intermediate quarantine facilities had been set up, and before anyone could be certain they would be? Where, in short, does Cowen think elderly, hospital-discharged COVID-positive patients needing intensive follow-up care were supposed to go if not nursing homes? His accusation only has merit if we treat this window of time–between the governors’ issuing of the order and the state’s ensuring that the quarantine facilities were ready to admit patients–as non-existent or unimportant, and as though it was clear that intermediate quarantine facilities were ready to accept patients immediately upon discharge from the hospitals throughout March and April. True?*

(b) Rejection of expedited-discharge option. Now suppose that hospitals had not discharged the patients in question, but had permitted (or forced or pressured) them to remain within the hospitals themselves.** Is Cowen certain that the mortality and morbidity outcomes would have been improved on this scenario in New York and New Jersey? If so, I’d be curious to know how he knows that. But if he doesn’t know, what is his complaint about what actually happened?

Again, suppose that the relevant patients had not been discharged from hospitals on an expedited basis. What does Cowen think about what would have happened–or what might reasonably have been expected to happen–to the throughput of the relevant hospitals, taking “throughput” to refer to the entire sequence, for cohorts of patients, from admission to discharge? In other words, is Cowen sure that hospital throughput would not have been adversely affected by a decision to keep elderly non-acute COVID-positive patients needing intensive follow-up care admitted to the hospitals? Can he exclude the nightmare scenario of incoming acute cases piling up in the Emergency Department, the halls, the lobbies, the parking lot, and/or the street, given the space being taken up by non-acute cases convalescing in the hospital out of a reluctance to send them to nursing homes?

(3) Admits vs. re-admits. Does Cowen regard his criticism as applying both to initial admits and to re-admits to nursing homes? In other words, is he saying that nursing homes ought to have been free both to reject new COVID-positive patients who had never been resident before at a given facility, and to reject COVID-positive patients who had previously been resident at a given facility? This latter claim implies that a person who was originally a resident of a given nursing home, was taken to the hospital (say) by ambulance in respiratory distress, and who was then stabilized and discharged from the hospital, ought to have been forcibly prevented from returning home because he or she had either tested positive or was merely thought to have been positive for COVID based, say, on clinical presentation.

In focusing entirely on the the force involved in the state’s adoption of its regulation, Cowen ignores the fact that the order served to prevent nursing homes from forcibly preventing the admission or re-admission of COVID positive patients. In the case of re-admits, if nursing homes had contracts to care for their own residents, the refusal to admit them was a breach of contract. In that case, the state regulation was only an act of “force” in the sense that a specific performance remedy is an act of “force.” The initiatory act of force was not the remedy offered by the state, but the breach committed by the nursing home.

But even if we set the contractual issue aside, in the case of re-admits, Cowen ignores the fact that had the state not used force, the relevant patients would have been deprived (whether forcibly or not) of the opportunity to return home, and would thereby have been rendered homeless. Whether that qualifies as “force” or not, it is surely morally relevant, and demands acknowledgement and discussion. It’s well known that as far as the rental market is concerned, evictions were put on moratorium during this time; isn’t a failure to re-admit a convalescent COVID positive patient to a nursing home a kind of eviction? And a remarkably cruel one? Would Cowen then reject the moratorium on evictions? But in that case a similar question arises: if a person can’t pay rent due to unemployment, is it fair or wise to force them out of their domicile and render them homeless in the middle of a pandemic?

(4) Inadequate PPE. Whose fault (if anyone’s) was nursing homes’ failure to have adequate PPE? Cowen writes as though the state did nothing to provide anyone with PPE. True? He doesn’t draw attention to the fact that New Jersey, at least, asked private institutions–like universities–to provide lists of PPE in their possession that could be requisitioned for emergency purposes. Is Cowen certain that these institutions were completely candid in their requisition declarations? If not, is that fact to be blamed on the state?

In the absence of detailed (“granular”) discussion of these, I see no way of understanding even the basics of the nursing home issue.*** Commentators who insist on doing so are adding little of value to public discourse, but simply helping to vilify state actors, and to indulge in problematic forms of cherry picking, hindsight bias, and motivated reasoning. The most obvious failure here is not that of state governments’ like New York or New Jersey, but of those who insist on making tendentious accusations based on insufficient evidence and argument.

I don’t doubt that there is a great deal of government failure to recount here, including regulatory failure involving nursing homes, hospitals, and other health care facilities. But one can’t credibly spin out a narrative regarding “regulatory failure” on the exiguous basis that so many libertarians have staked out. It is not credible to insist, over and over, that because the state forced nursing homes to accept COVID positive patients, and many of these patients died and infected others who died, the state (or worse, the state alone) was at fault for their deaths, or even wrong to have done what it did. There is more to the story than that, and it’s time that those who have told one part of that story ad nauseam, acknowledge that there is another part of the story to be told, one not altogether helpful to their case.


*I grant that this option was evidently available in other states, which took it, or took options like it. The question is whether it was available in New York and New Jersey. The question is: are the state governments of New York and New Jersey primarily at fault for their failure to set aside quarantine facilities for stable, elderly, COVID-positive patients requiring intensive follow up care upon expeditious discharge from hospitals? Or are some other entities primarily at fault?

**This, I take it, is what Florida did. But Florida is not New York or New Jersey. And it may be worth re-visiting the Florida case by going back and interviewing the discharge staff in Florida hospitals re what they thought about the pressure they got from the governor’s office to keep elderly patients in the hospitals against their better judgment. Were their discharge decisions voluntary under those circumstances? If force initiations are objectionable to libertarians, were those force initiations likewise objectionable?

***This very typical news item fails the test.

Thanks to Russell Browne, William Dale, Mike DeFilippo, Teresa DeFilippo, Nancy Gable, Rob Gressis, John Holt, Suleman Khawaja, William Ortiz, Robert Platt, Chris Sciabarra, and Michael Young for helpful conversation on this issue. The usual proviso applies: none of the preceding should be taken to agree with me, or to agree with one another.  

24 thoughts on “Coronavirus Diary (61): Tyler Cowen on the Nursing Home Controversy

  1. This pertains to Tyler Cowen’s example about New York state regulations that did force nursing homes to accept COVID-19-positive patients being discharged from hospitals. Here is a devil’s advocate question.

    Imagine the following:
    1. You are the owner and manager of such a nursing home.
    2. None of your residents has tested positive for the coronavirus or have been admitted to a hospital for COVID-19.
    3. A policeman and an ambulance arrive at your nursing home. The ambulance has a person, totally unknown to you, who had COVID-19, had a hospital stay, and then was discharged. The policeman demands you admit said person to your nursing home and threatens severe consequences if you don’t.

    What would be your response? What about the consequences to the current residents of your nursing home?

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    • I would reflect on the fact that the scenario was not a surprise; I had been told to prepare for it weeks before the order had been issued, and weeks before the event in your scenario had transpired (on March 6). I would reflect on the fact that as a nursing home manager/owner, I have an obligation to plan for the possibility that my patients might suffer infectious disease (a fact reflected in the law prior to COVID-19). I would then grasp why the situation was happening in the first place: given hospital throughput patterns under current circumstances, if I don’t accept patients like this, they will have nowhere to go.

      I would then ask myself how much state money I had accepted as payment for my facility over the years, and for how long. If the latter figure was sufficiently high, it would occur to me that the state has a certain say over admissions at my facility: it pays my bills. In that case, I would regard myself as being under an obligation to take the patient in, to isolate him (as I was told to do weeks ago), to give my employees PPE to deal with him, and to ask the state for help in dealing with all this. If excess mortality still took place despite my every effort, I would regard myself as entitled to immunity from legal liability, and immunity from adverse reputational consequences.

      Click to access 4-4-20%20%20Infection%20Prevention%20Assisted%20Living%20Guidance%20Memo.pdf

      https://time.com/5835228/nursing-homes-legal-immunity-coronavirus/

      I’d then tell the state to hurry up and create some quarantine facilities as fast as possible, because there’s only so long I can do this. I would tell them to consolidate the existing FEMA facilities in NJ so that at least one of them could function as a quarantine facility (rather than having several dedicated to non-COVID patients).

      If I really couldn’t handle the patient in question, I’d tell the state that from the outset, and beg it to take the patient elsewhere,offering profuse apologies, and promising to take the next one next week. Yes, that might create a bureaucratic problem for me down the road, but it would solve the immediate problem.

      What I wouldn’t do is confabulate a false narrative in which the governor is at fault for the deficiencies of my institution. Nor would I repeat misleading talking points about the state’s “lack of a sense of urgency about what was going on in nursing homes,” its “failure to prioritize,” “its failure to give us any PPE,” and so on. It would occur to me that pandemics and outbreaks happen, and are directly related to what I do for a living. I’d either find a way to take responsibility for that fact, or I’d look for another job.

      Incidentally, though it’s a relatively minor point, item (3) would never happen as described in your scenario. No one is simply going to show up in an ambulance with a police officer and demand admission of a patient out of the blue. The hospital will have called the nursing home and made the arrangements over the phone with full discharge/admissions information. The element of surprise you’ve baked into your example is implausible in two respects: the admission wouldn’t happen that way, and the owners knew that such admissions were coming.

      Finally, though I don’t know this for sure, I don’t think violation of the Health Dept’s directive is a criminal matter. It would not be enforced by a police officer, with the implications in your scenario of arrest and jail time. I think it’s a civil or regulatory matter, but I may be mistaken.

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      • This is not an entirely clear-cut issue, but to some degree, I’ve clarified the issue in the last paragraph of my comment. Criminal prosecutions for violations of the allocation orders of the governor’s office are legally possible, but only with the approval of the Attorney General. In New Jersey, at least, a police officer could not unilaterally make the threat described in your scenario simply by showing up out of the blue with a patient in an ambulance.

        Click to access AG%20Directive%202020-03%20Allocation%20Policy%20FINAL.pdf

        Though not airtight, the implication of the AG’s Directive is that criminal prosecution would only be sought in cases involving the commission of a “crimea crime, actual fraud, actual malice, gross negligence or willful misconduct.” A nursing home owner who, in good faith insisted that he was unable to admit a COVID positive patient would either not be prosecuted or have a strong defense against prosecution.

        Because the state’s nursing home order took the form of a letter from the state’s health commissioner “clarifying expectations” under the governor’s Executive Order 103 (it was not itself an executive order by the governor), it’s not entirely clear to me what its legal status is, or how violations were supposed to be treated.

        Click to access HospitalDischarges_andAdmissions_toPost-AcuteCareSettings.pdf

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      • Thanks for your response. It seems you would admit the new, infected patient. Doing so would increase the risk of infecting your current patients and employees. I suspect Tyler Cowen wouldn’t want to do that if he were the hypothetical owner-manager of the nursing home situation I described. Neither would I. Anyway, I don’t believe your response undercuts the legitimacy of Cowen’s position.

        Cowen didn’t say so explicitly, but I suspect that underlying what he said in the The Atlantic article was a libertarian perspective. A principle dear to libertarians is non-initiation of force. An extended version is no use or threat of the initiation of force. This extended version is clearly violated in the scenario I created.

        I believe it’s reasonable to hold, which maybe Cowen did, that ‘use or threat of initiation of force’ implies regulatory failure. Its modus tollens is regulatory success implies ‘no use or threat of initiation of force.’

        Despite the many aspects of your response, the moral perspective in it is far from clear. If anything, I would call it amoral. Also, since there is a far from subtle anti-libertarian flavor in your blog post, I would be surprised if you were to recognize any libertarian principle as a valid argument or even relevant to the New York regulations and directives towards nursing homes.

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        • Yes, I would admit the patient even if COVID positive. I think you might profit from reading my exchange with Michael Young nearby, because I’ve covered much of the ground that your comment covers with him. But let’s step back a bit, to evaluate your claim that I haven’t succeeded in undercutting Cowen’s “position.”

          What position? As a purely logical point, I’ve claimed that Cowen has generated a conclusion–an accusation, really–without any supporting argument. I’ve asked anyone sympathetic to his position (or positions like it) to produce an argument for the intended conclusion. He hasn’t. You haven’t. Setting aside Michael Young, to whom I’ve responded at length nearby, no one has made any attempt to produce any such argument.

          So let me repeat the request. You seem very confident that the nursing home directive was not just in error, but blameworthy. Why? Neither you, nor Cowen, nor any of the critics of the directive that I’ve encountered have come up with a single credible argument that is responsive to all of the relevant facts. You’ve simply wished the facts out of existence and produced the following “argument”:

          1. The state issued a directive that required nursing homes to accept COVID positive patients, or patients presumed so.
          2. There was a great deal of mortality at these nursing homes.

          Both premises state well-established facts. But what conclusion do they entail about blameworthiness? On their own, none. You can’t generate a conclusion about blameworthiness out of premises that make no reference to blameworthiness. For people so confident about their accusations of blameworthiness, these critics sure seem reluctant to supply and defend a premise or set of premises that gets them from their premises to their conclusion.

          My hypothesis is that they’re reluctant because they can’t produce a defensible set of premises to yield the conclusion. I don’t mind being proven wrong. But they have to engage with the issue before they prove anything. You haven’t. Neither has Cowen. Neither have they. You’ve all been content to hurl accusations of “failure” without specifying who failed at what, how, when, and where. But an accusation that leaves who, what, how, when, and where blank is just a blank check for moral irresponsibility. People who make accusations should be prepared to defend them. If not, they should withdraw them. Nothing amoral about my position on that score.

          If Cowen thinks that the non-initiation of force principle underlies his judgment, I would offer the following counter-responses:

          a) I’d challenge him to give an explicit statement of the principle.
          b) I’d challenge him to produce a justification of the principle as stated.
          c) I’d ask whether the principle has the same application at the epicenter of a pandemic during the apex of a surge in acute patients that it has at other times.
          d) I’d ask him how the principle applies to nursing home re-admissions.

          In the absence of worked-out answers to these, Cowen’s argument is amply open to doubt. The fact that he holds libertarian intuitions dear is neither here nor there. That’s not going to fly in the non-libertarian rest of the world (which includes me: I’m not a libertarian).

          The moral perspective of my response rests on two basic principles. One I’ve already mentioned: anyone who makes an accusation should back it up, or if unable to do so, withdraw it.

          The other is a principle of rationality: a rational agent facing a decision should strive to take the best of the alternatives available to her with as comprehensive an understanding of the alternatives as she can manage. If the two options are

          Try to warehouse post-acute patients in hospitals to the point of wrecking the health care system’s capacity to handle an imminent influx of acute patients

          or

          Demand expedited discharge of post-acute patients from hospitals and expect nursing homes either to admit or re-admit these patients, or assert explicitly that they lack the capacity to do so,

          I would argue that rationality counsels the latter option. The less destructive option is better than the more destructive option, a fact not refuted by repeating over and over that the less destructive option involved destruction.

          The criticisms made of this directive are like complaining that a life-saving surgery involved the use of an incision; since incisions cut the skin and hurt a lot, and even cause post-surgical pain, we can ignore the fact that the surgery was life-saving, and just fixate ad nauseam on the bad effects of the incision, using those effects as the basis of a malpractice suit against the surgeon.

          But really, the focus here should be on Cowen’s (or anyone’s) positive argument for the initial accusation, not my non-specialist unemployed person’s musings about hospital throughput. I didn’t make the initial accusation; he did. I don’t get paid to study these things; he does. I don’t have a job; he does. So do the other people making this accusation. It seems to me that given the relatively meager resources at my disposal, I’ve gone a much longer way toward uncovering the truth than the critics of the nursing home directive. At some point, I think I’m owed some reciprocity–something that begins to resemble a payment in kind. So far, the NJ Department of Labor has delivered unemployment benefits to me a hell of a lot faster than any libertarian has delivered the relevant discursive payment. But I don’t mind waiting.

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          • You wrote: “You’ve simply wished the facts out of existence and produced the following “argument”:
            1. The state issued a directive that required nursing homes to accept COVID positive patients, or patients presumed so.
            2. There was a great deal of mortality at these nursing homes.”
            I did no such thing. My argument was that if I were the owner-manager of that nursing home, then I would not admit the new, infected patient because doing so would increase the chances of infecting the current residents and employees. If I were to voluntarily admit said patient and that infected my residents and employees, then I would be blameworthy. If I were to coerced to admit said patient, then whoever coerced me, directly or indirectly, would be blameworthy for infecting my residents and employees.

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            • That response ignores virtually everything I’ve said on this topic. You really are visibly wishing facts away right there on the screen. The facts that you’re repeating over and over are not all of the relevant facts. You’re ignoring several crucial, relevant facts, treating them as literally non-existent, and proceeding as though they don’t exist. But they do exist. There’s nothing more I can say to you. All I could do is repeat the facts that I’ve cited, but if you’re going to ignore them, repeating them won’t help.

              Like

  2. Friedersdorf is one of my favorite journalists and Cowen one of my favorite public intellectuals. Yay! That said, I’d give CF 8/10 and Cowen a generous 7/10 on this (for reasons unrelated to your criticism of Cowen on the nursing home failure or perhaps “failure.”

    I think Cowen assumes that the most obvious and immediate alternative to ordering the patients to or back to the nursing homes — simply keeping the patients in the hospitals — would have resulted in less death. I still find that intuitive but once you provide relevant context I lose some degree of confidence. This is still my best guess but this is not an *obvious* or *strong* point in favor of regulatory failure (or simply a bad decision here). However, the timing of events is crucial. It seems much more plausible that, at a certain point — after the prospect of an overwhelming wave had faded, after alternative care or quarantine facilities had come on line — it was a slam-dunk to rescind the order. And that it was not rescinded at that time. What you have to say here does not speak directly to that.

    Also, as you allude to, the relevant alternative might include doing whatever it takes to set up additional, basic quarantine and care facilities (tents in parking lots, hotel rooms, college dorms, etc.) as well as not ordering the patients into or back into the nursing homes (thus lessening the risk that the hospitals get overrun). And now, though the issue gets more complicated as the relevant alternatives do, we are speaking quite directly to the kind of flexibility that bureaucracies and bureaucratic mindsets (both public and private) often do not have. This speaks as much to making possible alternatives viable as it does to choosing well from alternatives. The standing alternatives here were, at least initially or at the point that the order was issued, awful — downright unacceptable. The need was to create better alternatives. I think the capacity to do so — no mean feat in the context of bureaucracy — is what would have been most valuable (at least when the order was initially given).

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    • I’d intended to send this to Cowen, but if someone would like to do that for me, I’d be much obliged. I already sent my other post to Marc Siegel, who was taking the same Cowen-esque line on Tucker Carlson’s show:

      http://doctorsiegel.com/

      Haven’t heard back yet, but let’s see. But let me respond to your points.

      I think Cowen assumes that the most obvious and immediate alternative to ordering the patients to or back to the nursing homes — simply keeping the patients in the hospitals — would have resulted in less death.

      He may be assuming that, but if so, he’s doubly wrong.

      First of all, if the post-acute patients were literally taking up space needed by the incoming acute patients, then by keeping the post-acute patients admitted, you’d get mortality of the incoming acute patients.

      Second, since hospitals are not set up to care for post-acute patients, certainly not in such high numbers during a pandemic–and hospitals are, like nursing homes themselves, highly conducive to the spread of infectious disease, and very bad places to recover from illness–it’s likely that all that would have happened by keeping sub-acute patients in the hospital is that you’d replace mortality-in-nursing-homes with mortality-in-hospitals along with the added mortality of the incoming acute patients. Bear in mind that at one point, nine New Jersey hospitals were on divert status even with expeditious discharge. (“DIvert” status means that the hospital has reached capacity and can’t accept any more patients.) So the idea that you’d get a positive result if by ditching expeditious discharge and keeping those patients admitted strikes me as literally dead wrong.

      However, the timing of events is crucial. It seems much more plausible that, at a certain point — after the prospect of an overwhelming wave had faded, after alternative care or quarantine facilities had come on line — it was a slam-dunk to rescind the order. And that it was not rescinded at that time. What you have to say here does not speak directly to that.

      Yes, the timing was crucial. At most, the point you’re making here shows that the nursing home order was not rescinded “fast enough,” not that it was wrongly adopted ab initio. But I’m very skeptical of the idea that outsiders can make accurate or reliable judgments about the timing of a bureaucratic decision with any degree of confidence. In judging a decision at this level of resolution, you need super-granular evidence about micro-level decisions. I find it ironic that the Hayekians, so insistent on “local knowledge,” all seem to be claiming that they can second-guess on-ground decision-makers from locations nowhere near the action.

      If Cowen thinks he can do that, I’d invite him to set up a timeline of decisions and events that show why the failure to rescind “took too long.” Bear in mind that we’re talking about four sets of bureaucracies here–government, hospitals, nursing homes, and potential quarantine facilities. Each of them moves slowly. We have no evidence re which moved the slowest, and no external way of judging what culpable slowness amounts to. Certainly, Cowen has presented nothing of the sort.

      And of course, to note the obvious: the order was eventually rescinded. The idea that we can get a “slam dunk” judgment on when the surge was good and over strikes me as implausible in the extreme. It’s not clearly over yet. And change one variable on any slum dunk judgment, and you end up invalidating it. It’s worth remembering that states started to open up before the CDC’s recommended waiting time: the recommendation was to let two full weeks elapse of downward trends in new cases before we opened up our economies. No one did that, not even New Jersey. The nursing home order was rescinded well before two weeks of downward trends had gone by. So by one measure, you could say that the order was rescinded prematurely, i.e., before anyone was entirely sure that the surge was over. And given the marching in the streets taking place now, all bets are off as to what will happen in the next two weeks. We could get our second surge faster than we ever thought we would. There are no “slam dunk” judgments to be made here.

      Here’s an article from NJ.com from two days ago, somewhat before the George Floyd protests became nationwide:

      https://www.nj.com/coronavirus/2020/05/silence-descends-on-nj-hospitals-but-the-threat-of-a-coronavirus-resurgence-looms.html

      Sobering, as I see it.

      Also, as you allude to, the relevant alternative might include doing whatever it takes to set up additional, basic quarantine and care facilities (tents in parking lots, hotel rooms, college dorms, etc.) as well as not ordering the patients into or back into the nursing homes (thus lessening the risk that the hospitals get overrun).

      Hotel rooms and college dorms, yes. But tents in parking lots will not work (not for the purpose at hand). You can’t put an elderly post-COVID patient in a tent in April weather in New Jersey and expect him or her to survive. You might as well put her on an ice floe and push her out to sea.

      On hotels and dorm rooms, how do we know that it was the state that dragged its heels rather than the hotels and universities? FEMA set up field hospitals across New Jersey, but those facilities were not allowed to accept COVID positive patients. That wasn’t the fault of our state government. That dumb Navy ship Comfort sat in New York Harbor for I forget how long, precipitated a fight with the New York authorities, was then promised by Trump to New Jersey, but eventually sailed away without doing shit for anyone around here. That’s a government failure, but not one that devolves on the governors of New York or New Jersey.

      Finally, if the problem is the bureaucratic mentality common to both private and public sectors, one can’t say, with Cowen, that the underlying explanation here is regulatory failure (in a sense of “regulatory” that implies state regulation and that alone).

      I am the last to dispute that government regulation plays a significant role in explaining what went wrong. What I object to is Cowen’s pat inference and rhetorical strategy: people died in nursing homes; therefore the order forcing nursing homes to accept COVID-positive patients is the culprit; let’s hammer on that over and over so that we can create a useful libertarian talking point that drowns out all other considerations. He may not be saying the latter, but the latter is the predictable effect of what he is saying, and how he’s saying it. And not just him.

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  3. I appreciate your better grasp of relevant possibilities and evidence but I don’t think you present nearly enough and good enough to make for a conclusive argument for withholding or disbelief (of the proposition that additional nursing-home-mortality is greater than the additional hospital-mortality would have been). We are at loggerheads defending clashing intuitive epistemic attitudes. Here is my best shot for rationally moving you: the average still-contagious person *actually* being placed in a not-medically-professional congregate setting (full of the most vulnerable people) most likely would result in more deaths from the disease than that average person *possibly* contributing to hospital overload and hence death due to inadequate care among existing and incoming patients (not all of whom are among the most vulnerable). I’m curious what your best, clear shot here is. I worry that you have thrown a bunch of good, relevant flak up in the air, but flak that is neither strong enough to require me to move off my belief nor comprehensive and strong enough to get close to a gold-standard case (for that we would need solid inference from relevant statistical, scientific studies of good quality). I’d be curious what an expert on both nursing home and hospital disease spread would think. The well-informed, unbiased intuitive judgment of such an authority is something that I might take to the bank (and trust more than my own intuitive judgment) absent a gold-standard case.

    It is rather strange that I am arguing against the agnostic position here. Maybe, despite my intentions/pretenses, I want to have opinions on everything (that I don’t know myself to be utterly, hopelessly ignorant about)! In any case, somehow, you’ve gotten me interested in defending a proposition that I initially barely cared enough about to have an opinion regarding. And interested — moreso — in the individual and social epistemology of these kinds of disputes.

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    • Well, let me step back a bit.

      First, it’s Cowen who’s making the positive claim here: the New York (and by implication New Jersey) decision were, on his view, significant regulatory failures. My claim is that he hasn’t met the burden of proof for making that claim, at least in anything that I’ve read, and certainly not in the statement he gave The Atlantic. I’ve sent the post to him, and got acknowledgement, so he may respond. But my framing issue is not that I have an airtight contrary case, but that he has presented no case, and needs to. So far, I think that claim stands.

      Second, suppose we take your claim at face value. If so, it is currently undecidable whether or not (2a) was the right option to take, i.e., whether or not hospitals should have engaged in expedited discharge. But if it currently undecidable whether (2a) was the right decision to take, it cannot be currently decidable that it was the wrong decision to take. A fortiori, it can’t be decided that it was the wrong decision to take in real time. So our being at loggerheads doesn’t help Cowen.

      But I also think you’re understating the argument for (2a).

      We are at loggerheads defending clashing intuitive epistemic attitudes. Here is my best shot for rationally moving you: the average still-contagious person *actually* being placed in a not-medically-professional congregate setting (full of the most vulnerable people) most likely would result in more deaths from the disease than that average person *possibly* contributing to hospital overload and hence death due to inadequate care among existing and incoming patients (not all of whom are among the most vulnerable). I’m curious what your best, clear shot here is.

      The plausibility of your argument, I think, turns on the vagueness of the phrase “not-medically-professional-congregate setting.” I think it also turns on slightly misunderstanding my argument.

      Consider the situation from the hospital’s end. The hospital is expecting a very large influx of acute COVID patients. I don’t think it’s legitimate to think of this incoming cohort as being on a spectrum of greater or lesser vulnerability with any other cohort. There is no sense, ex ante, in which you can regard the incoming influx as consisting of people of “average” vulnerability as compared with the greater vulnerability of any other cohort.

      For one thing, you don’t know anything about the demographics of the incoming cohort. For another, in both New York and New Jersey, there was triage at the level of 911 calls. So anyone being brought to the ER by ambulance was someone deemed so urgent an emergency that they could not stay home; they had to be brought in on an emergent basis. There is no clear sense in which people were of merely “average” vulnerability. To be transportable was ipso facto to be of the highest vulnerability. And such people were inundating the hospitals, and threatened to do so indefinitely. That’s why nine hospitals in north Jersey were put on “divert” status on one given day, and several were in divert status day after day.

      Here’s a map of NJ with hospitals superimposed on it.

      Click to access HospitalListandMap.pdf

      Blot out nine hospitals in the northeastern quadrant of the state and the problem becomes apparent. If you have nine hospitals out of commission, and an incoming wave of acute COVID patients, you are looking at imminent disaster.

      Suppose we are in Bloomfield, my old town. I call 911 from my old apartment there in respiratory distress. Bloomfield EMS shows up and deems me high priority. Now suppose that not just one but several of the hospitals I might usually go are on divert status. So the crew has to get me to an open hospital. Note that they have only one bite at the apple here. They can’t shop around, taking me from hospital to hospital. If they take me to St Barnabas, 7 or 8 miles away, that is my destination, full stop. They can’t drive there, see that things aren’t so good, then pick a new hospital, and drive there. Every minute of delay is a minute that increases the probability of death.

      Now they get to St Barnabas. Even in its expanded state, the hospital only has so many beds, so many acute care beds, so many infectious disease control facilities, so many doctors, so many nurses, so many doctors with the right training, so many nurses with the right training. And of course, we are not talking about one ambulance arriving as a one-off. We are talking about a constant stream of ambulances converging on the hospital one after another, including those diverted away from other area hospitals. If incoming patients cannot be brought in and given acute care, they will die. They certainly can’t pile up in the part of the hospital that is not an acute care facility.

      The relevant point is broader: if you don’t have efficient throughput for these patients, you will compromise their care and they’ll die. In other words, if you have no efficient mechanism to get them from their house to the front door of the hospital, and from there to the ER, and from there to the ICU–if there are significant blockages on the way–you are likely looking at mortality. It isn’t enough to deposit the patient at the front door. She has to be moving through the hospital in the right way and at the right times to the right places with the right people staffing those places all along the way. It’s a delicate operation.

      Now suppose that you have a cohort of stabilized post-acute patients–not just one, but a bunch–just hanging around in the hospital for lack of anywhere to send them. It seems to me that you’re imagining that these post-acute patients can in effect be warehoused by the hospital in a medically safe fashion. They absolutely cannot. First of all, they have to be moved out of acute care to admit the incoming acute care influx. They also have to be moved out of the parts of the hospital that are most stringently disease controlled. And they have to be moved into the parts where personnel are best trained. (Recall that all staff physicians were brought in to the hospitals regardless of specialty, meaning that totally unprepared doctors and nurses were having to deal with acute COVID patients, or post acute ones, having little clue how that was done.)

      There is a clear trade-off here. The greater the acute care influx, the greater the demands on hospital resources. The greater the post-acute care cohort warehoused in the hospital, the greater the demands on those same resources. But “post acute” doesn’t mean that you can store these patients away, leave them alone in some corner of the hospital, and get a positive clinical prognosis. They require care, and the care they require is not care of a kind hospitals are set up to give. Just the reverse. Once these patients are out of acute care settings, the level of attention they get diminishes. Once they’re out of disease control settings, the likelihood of community spread increases. In this respect, the greater the pressure on the hospital, the greater the post-acute patients are in a situation identical to a nursing home–within the physical confines of the hospital. And there are physical limits to those confines. But the relevant point is that we shouldn’t think of “hospital” as though “being in a hospital” were some sort of magical thing such that by your presence in one, your clinical outcome is improved.

      Exactly the reverse is the case. Hospitals are a great place to go if you have an acute problem. but they are a terrible place to recover from anything. You get no sleep. The possibility of infection is high. No one is caring for you most of the day. You have no interactions with human beings most of the day. Etc. etc. It’s a long list. And people tend to forget that what makes the elderly a “vulnerable population” is that they need care–a special kind of care, the kind specialized in by nursing homes, not hospitals. The idea of warehousing post-acute COVID patients in a hospital requires turning that part of the hospital into a nursing home. The whole reason we have nursing homes is to avoid that very predicament. But if we had done it, what happened in the nursing homes would simply have happened in the hospitals. Nothing about being a post-acute patient in a hospital changes that, if the same hospital is under pressure to receive a large tranche of incoming acute patients.

      But that artificial way of describing things makes it too simple. It makes it seem as though it was physically possible to segregate whole floors of the hospital as “Hospital Nursing Home for Post-Acute Patients,” and leave “the rest” for “Incoming Acute COVID Cases.” It wasn’t. This is simply not physically possible. It’s not what hospitals do, and it wasn’t part of the original planning process. There’s a division of labor here, and to turn hospitals into nursing homes violates that division of labor.

      One background fact worth mentioning is that the duration of post-acute care for COVID patients is disproportionately long–weeks in length. So if you warehouse these patients in a hospital, you are talking about holding them for weeks and weeks. That means they are using up hospital resources for weeks, when the hospital is (precisely) not set up to care for patients of that description.

      The nightmare scenario is that you’ve tried (ineffectually) to turn large parts of your hospital into a nursing home (each cohort staying there for weeks!) while ambulances are coming in, not just from the immediately surrounding area, but from every area where the hospitals were on divert status. What that would entail is three simultaneous disasters with ripple effects:

      1. Incoming patients would be jammed at the front end of the hospital, from the lobby into the parking lot, into the street, waiting in ambulances while suffering respiratory distress or arrest.
      2. Post-acute patients would be languishing in parts of the hospital without intensive post-acute care of the sort available in a nursing home. Others of these post-acute patients would be taking up resources needed by the incoming patients (hence the jam described in [1]).
      3. Effectively, the whole hospital would be rendered ineffective, and put off-line on divert status, pushing the burden to the next hospital.

      But geographically, there is not much room for manuever here. Once ten or twelve hospitals are on divert, every 911 call requires long-distance transport. Even under lockdown, that is not that easy in New Jersey. But if we had had ordinary rush hour traffic on the streets (which is what so many anti-lockdown libertarians have insisted on), the ambulances would just become four-wheeled morgues. Even apart from that, the situation as a whole entails the wholesale shut-down of hospital care in the region. During a pandemic!

      That’s my best shot. I’m not an expert, but I have worked in hospitals, and have been around them much of my life. I also come from a medical family and have lots of friends in various different parts of the health care system, so I’ve had the opportunity to have conversations about hospital throughput for awhile.

      Your account treats the incoming patient surge as merely “possible.” It wasn’t merely possible; it was an actuality. It treats incoming patients as being of “average” vulnerability. That couldn’t be assumed. It treats hospitals as more clinically appropriate to treating post-acute patients than nursing homes. They aren’t. And I don’t think it appreciates the dynamic involved in (1)-(3) above. I described it in the case of just one hospital. But now imagine multiplying it across hospitals in a whole region, like north Jersey. It’s a recipe for destroying the health care system as such, the very thing we were trying to avoid.

      I admit that what happened in the nursing homes was horrific, but my point is: the other alternative was the scenario I was describing. That was not purely hypothetical. I think it’s unfortunate that the sheer danger of the situation we faced in NY/NJ has not been appreciated. We didn’t really dodge a bullet so much as get hit by it about a second after we put on a bullet proof vest. Many hospitals really were overwhelmed. Some were on the verge. And the concept of “overwhelm” itself needs unpacking. It’s not merely a quantitative concept involving beds and vents but the sheer trauma inflicted on staff, from EMS to nursing homes, and everywhere in between.

      So I remain unmoved. If I’m right, Persichilli’s order was intended to stave off the nightmare scenario I’ve just described. It’s easy (cheap, I think) to fixate on the adverse consequences of that order without dwelling long and hard on what it was there to avoid. If that had come to pass, the outcome would have dwarfed the tragedy at the nursing homes. At a bare minimum, anyone who wants to make Cowen’s accusation has to deal with that possibility and rebut it before making the accusation. No one on the libertarian side has done that. They are making accusations of negligence while practicing a form of intellectual negligence. Hence the tone of my post. That needs to stop. We can’t sacrifice complex truths to some talking point. We need the whole truth, nothing less.

      Liked by 1 person

      • My best guess is still that the decision/order was wrong (because the discharge option yields certain exposure for lots of high-risk people, more so than the most likely hospital-overload scenarios, which I assume would involve shipping folks to new hospitals as the existing became overloaded). But my level of confidence in this belief is pretty low. However, we are in agreement that the obviously-wrong-decision media narrative (and obvious-failure-of-the-regulatory-state libertarian narrative) is false. And that’s really the most relevant point with regard to public debate and perception.

        If Cowen wants to push the idea that, in any given arena, we need to confine ourselves to necessary regulation that promotes rather than cuts off the justice and efficiency of using market mechanisms to produce and distribute goods, coming up with better cases than this one is necessary. I think he often does. But, at least for many values of X, that the CDC does a bad job of X might be due to bone-headed beast-starving or it might be due to regulatory capture and associated misplaced priorities (or insert some other familiar pro-market or libertarian point). I do think that Cowen often believes that lack of funding for vital-function X is due to things like regulatory capture, not due to libertarian beast-starving (as evidenced by rising budgets for the relevant agency)…

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        • I can only speak to your first paragraph; I don’t have anything useful to say about the second.

          My best guess is still that the decision/order was wrong (because the discharge option yields certain exposure for lots of high-risk people, more so than the most likely hospital-overload scenarios, which I assume would involve shipping folks to new hospitals as the existing became overloaded). But my level of confidence in this belief is pretty low. However, we are in agreement that the obviously-wrong-decision media narrative (and obvious-failure-of-the-regulatory-state libertarian narrative) is false. And that’s really the most relevant point with regard to public debate and perception.

          I think you’re still ignoring too many facts. First, the discharge option does not yield “certain exposure.” It only yields high levels of exposure in the case of nursing homes that have failed to prepare for a discharge order of which they had weeks of advance notice, and regarding which they were, in principle, allowed to bow out. In the case of nursing homes that engaged in the necessary preparations, it yields low exposure, and it offers intensive care not available in a hospital.

          Second, you can’t ship COVID patients around in the way you’re imagining. If you have a large influx of acute (meaning emergency) patients coming in by ambulance, you then have a shortage of ambulances and paramedic personnel. You can’t have them driving from county to county looking to off-load patients.

          You get only one bite at the apple in the emergency COVID transportation business: you get the 911 call, suit up, rush to the patient’s location, make a quick determination as to whether the patient’s situation demands transportation to the ER, find an available ER (one), go to precisely that location, then return to base, decontaminate the squad, and do it again. There are no second chances. You can’t show up at hospital A, see a long line, call hospital B, ask them about the wait time, drive there, find out the wait time’s changed, change plans for hospital C. The patient will have died 20 minutes ago.

          An ambulance is little more than a glorified van with lights, siren, and radio. It has no pharmacy and no advanced life-saving equipment on board. Plus, it’s moving–possibly the worst conceivable environment for emergency medical care. At best, they can do some very simple procedures that buy time until they reach a nearby ER. They certainly cannot do what you’re imagining–transport the patient in acute respiratory distress to a faraway hospital (faraway in emergency medical terms), then discover it’s overloaded, and drive to the next in search of availability. That just pushes the hospital overload onto the emergency medical service, which is probably even worse than just leaving the patients in the basement of the hospital and checking in on them when you get a chance.

          I think there are really two relevant issues here, one an implication of the one you mention. Yes, the media narrative is wrong; we agree there. But the reason why it’s wrong is that those writing the narrative have not asked or answered detailed logistical questions about throughput in emergency medicine.

          To do that, you have to sit there and work it through, step by painstaking step. The case begins with a call to 911. The dispatcher relays the call to the next available ambulance–assuming there is one. (And if there isn’t, it’s a different story.) The crew has to suit up. The ambulance has to drive to the scene. They have to evaluate the patient. Etc.

          This is a tedious description of the first 10 minutes of a case that may be weeks or months in duration. At every step, you have to plot chronology against practical and clinical considerations. Even if you do that as a mere armchair exercise as a total amateur, you realize that the very tedium of the exercise teaches you that no simple answers will fly. There are so many variables involved that it’s overwhelming to work things out even from the comfort of an armchair with all the time in the world.

          But once you do work things out from an armchair, you then have to re-imagine the whole scenario from the first-person perspective of the relevant agents, speeded up so that it matches what they would have experienced in real time. And then you have to imagine decisions taking place at various different levels, involving different people with different experiences, knowledge, roles in the division of labor, etc. And I’m abstracting from the psychological effects of what it’s like to have to make these decisions.

          My deepest objection to the critics of the nursing home directive is that they haven’t done that. And my response to them is: either do it (as I have); or find a short-cut that works; or drop the matter. But don’t wave your hands at a set of decisions whose granular features you haven’t bothered to understand even at an amateur level (like mine), then pass moralized judgment on the front-line actors. Part of standing to judge, I think, is the knowledge that if you switched places with the person you’re judging, you could have done better. But if you don’t even know what had to be done, you couldn’t possibly engage in that role-reversal. That’s the bedrock assumption about moral judgment that I’d like to see more widely adopted, and that I think is missing here.

          Liked by 1 person

          • Here’s a simpler way of putting my point. Persichilli et al had to choose where in the health care system the stress most urgently had to be alleviated–the front end or the back? Meaning, the parts closest to the beginning of the case, or the parts nearer to its conclusion? They decided to do what they could to alleviate stress at the front end, and let the back end take care of itself. So their emphasis was on EMS and hospitals, not nursing homes.

            But the rationale here should be transparent. They prioritized the front end over the back because the front end is where most of the stress already is. The time pressures, the clinical pressures, the resource pressures, are all most urgent at the front end, not the back–precisely because it is the front end. EMS and emergency/ICU workers were receiving patients early in the process when things were a matter of life and death. Nursing homes were receiving patients later when they were post-acute. There was much less pressure on the back end precisely because it was so far down the line.

            Suppose I’m 70 years old and live alone. If I call 911 in respiratory distress at 3:30 on June 2, the EMS will arrive at 3:35. I will be at the hospital by maybe 4. Crucial decisions will be made between 4 and 5. Etc. But I won’t be discharged for awhile. Whenever that is, the time scale is much slower than minutes or hours. So if one end has to be prioritized over the other (and given the resource situation, it did), the decision to prioritize the front end over the back makes perfect sense. If the front end isn’t in place, you lose the game within the first day. If the back end isn’t in place, you get a bad outcome, but one that might in principle have been averted between the first day and the nth day. The question is: whose responsibility was it to avert the worst outcomes? My claim is: not obviously the state’s; or at the very least, not exclusively the state’s. So we can’t invoke “regulatory failure” and call it a day.

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            • I’ve posted at PoT many times about the “front end” of acute care during the surge, but here’s one more item that gives the sense of it. I think it drives home (so to speak) the sheer impossibility of pushing more of the critical care burden onto EMS during a surge. It can’t be done.

              This video is about EMS in New York City, but the issue was not appreciably different in New Jersey. NYC is more crowded than most of New Jersey, but the distances are longer in NJ. And in any case, taken as a whole, northeastern New Jersey probably has a population density on par with New York City taken as a whole (meaning all five boroughs, including Staten Island). I’ve basically been treating New York City and northeastern New Jersey as interchangeable for purposes of this discussion.

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              • Ugh, you can’t see the video in the preceding comment, but if you click the “T” for “Times,” it should come through. If not, it’s in today’s New York Times, called “Bye, Mommy, I Love You: Medics and Coronavirus Patients Make Hard Decisions.”

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          • I agree with most of that. I’d chew on all of this some more if I had time/desire and maybe, at the end of it, change my as-yet unchanged best guess (but, really, who cares what my best guess is, given that I’m not fully informed about the relevant facts?). I would love to see two people, both with deep knowledge of the relevant medical and elder-care systems but of differing opinion on the discharge-decision, debate the topic. It would also be nice to see Cowen respond to you, though I think this would mostly address the question of whether the discharge decision was obviously wrong and, on this point, I think Cowen would do well to simply concede (at least if my framing of his regulatory-state-failure point is correct). Perhaps he would make similar, but more plausible, claims about regulatory failure at later junctures (i.e., failure to lift the order sooner) or about regulatory failure leading to the shitty initial choice situation (e.g., not prioritizing rapidly-available provision of quarantine facilities, bureaucracies not be nimble enough to see this need and meet it). But these are different points in any overall case for an effective regulatory state that does not over-regulate or succumb to any of the failures that libertarians have harped on for years.

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            • I raised the issue with several people, two of whom had extensive hands-on knowledge of elder care. One basically agreed and the other basically disagreed with my take.

              I haven’t commented on the larger issue of bureaucratic inefficiency, e.g., at the CDC, because it’s way beyond my pay grade. I don’t claim to understand that. But here is a segment on local health departments, again, in New Jersey. The criticisms I’ve seen of the CDC don’t speak to the issues discussed here. It surely is a failure of some kind that we haven’t had contact tracers in place at the local level well before COVID struck. What’s unclear is whose failure it is. I never heard a word about contact tracing from the legislators now grandstanding about nursing homes. Nor was contact tracing a regular topic of discussion in libertarian circles (or any other).

              https://www.njtvonline.org/news/video/local-health-departments-strapped/

              On the other hand, this seems an underplayed success story.

              Hunch: what’s essential to the success of the story is similar to what’s been essential to the success of Newark at avoiding rioting in the post-George Floyd environment. Whatever else may be wrong with them (plenty), New Jersey’s cities are small enough to function somewhat like Aristotelian city-states. I don’t want to exaggerate, but there is a certain degree of solidarity and communal spirit there, forged in many cases by community activist groups. And the political players go out of their way to forge ties with these groups; their political success depends on it.

              The result (I surmise) is that when the going gets really rough, the political leaders and community activists have both a strong incentive to cooperate, and a track record of cooperation to rely on. They (mostly) don’t meet immediately in a spirit of rancor or partisan adversariality. That’s the sort of environment you need to get contact tracing off the ground (as in Paterson), or to avoid riots (as in Newark). That doesn’t really fit a libertarian narrative; it fits a communitarian narrative of community-city partnership. I’m not giving my wholehearted endorsement to it, just pointing out that it has its successes, and is something to learn from.

              Liked by 2 people

              • That all makes sense. Size certainly matters — that is part of why Providence/RI (very closely analogous to a city-state, that amalgam) has done so well. As well as the sheer competence of the Raimondo (state) administration. I don’t think the community-ties part is there as much, basically because the left (I think including the community-organizing part as well as the white, educated mere-virtue-signalling part?) does not trust Raimondo (from what I can tell, this is the left’s problem not hers; she reaches out, they call her a plutocrat in Democratic clothing and their media allies treat her only a little more fairly than the national news media treats Trump). Our testing has been great (including walk-in testing centers in poorer, harder-hit communities, explicitly justified on grounds of anti-discrimination and social equality) and the contact tracing seems to be going well (the infrastructure is there — not sure how much difference it has made for us or how big a piece this is in the effectiveness of our response thus far). But the contact-tracing infrastructure was not in place beforehand. And I don’t think our situation here is as challenging as the situation in Paterson.

                Liked by 1 person

                • I still have not delivered on my promise to study Raimondo’s governing style.

                  Meanwhile, a good interview with a local epidemiologist (Montclair State University). I think she’s a little too understated about the health consequences of the protests, but note the comment at the end about contact tracing.

                  https://www.njtvonline.org/news/video/will-there-be-a-spike-in-covid-19-cases-as-the-state-reopens/

                  I may be biased about this (I’m a job seeker, after all), but I do think that under our present circumstances, you’d expect the state to be hiring contact tracers hand over fist. I may need to look harder, but that’s not the impression I get.

                  Some private bioetch companies are hiring contact tracers, but apart from the fact that they’re invading my inbox in pandemic fashion, I can’t really judge the volume, quality, etc.:

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  4. A relevant news item from today’s NJ.com:

    https://www.nj.com/coronavirus/2020/06/scathing-letter-from-health-department-insiders-says-njs-pandemic-failures-led-to-preventable-deaths.html

    The letter addresses the nursing home issue but adds nothing by way of argument or evidence.

    First relevant paragraph:

    The State OEM office then used arbitrary allocation guidelines that short-changed nursing homes and other congregate living centers, or in other words, where the most vulnerable New Jersey residents live when it comes to this virus. While testing capacity has always been limited from the outset of this pandemic due to failures at the federal level, there was clearly enough testing capacity, from the day that the first public, drive-thru testing center opened up, to instead allocate that testing capacity to the individuals most likely to die from this disease. We understand that public anxiety made it politically more favorable to offer a testing resource to the general public early on. But to completely ignore longterm care testing until late April, when at that point, tens of thousands of tests had been offered to only mildly symptomatic New Jersey residents (again, remember that one has to be well enough to drive or be in a car to get the test at these centers), is a clear failure.

    This strikes me as almost willfully confused, at least if the issue concerns expedited hospital discharges to nursing homes. The default assumption for expedited discharges was that discharged patients were COVID positive. There was therefore no need to test these patients. They had been admitted to the hospital on suspicion of having COVID, and were discharged expeditiously, not because they had become COVID negative, but because they were post-acute, hence clinically stable. In the absence of clear evidence that they were negative, the prudent assumption would be that they were positive. So there is no “clear failure” here, and the testing issue is basically a red herring. Testing of this population would have been a waste of time and resources.

    Next relevant paragraph:

    Much ado has already been made about the Commissioner’s order to make long-term care facilities take residents back from hospitals, even without negative tests. This administration’s defense has been, “well, we did require them to be able to cohort residents in order to do so!” Of course, we do know that many nursing home administrators probably did lie so that they could take residents back and charge for their stays. But allow us to offer you a reality check: very few of these nursing homes were tangibly ready to take these residents back based on the Commissioner’s criteria because the state failed to allocate enough PPE and staffing resources to them to do so. And with a former hospital CEO at its helm, the Department of Health was only focused on the acute care hospital piece of the health care system.

    This is just a series of logical fallacies masquerading as an argument.

    For one thing, it fails to note the obvious: that expedited discharges were presumed positive. It also fails to note the rationale underlying Persichilli’s order. The critics’ attempt to summarize the administration’s “defense” is therefore a strawman: the defense they cite omits the fundamental rationale for the order; it bears on a secondary issue that makes no sense unless the fundamental issue is discussed. So the discussion essentially gets the cart before the horse.

    To admit that nursing home administrators probably lied about their ability to take back COVID positive patients, or were unable to do so, suggests that the nursing homes were at fault for preventable deaths in their own facilities, not that the governor or the health commissioner were for expecting the nursing homes to take in patients they claimed to be able to care for.

    It begs the question to say that “the state failed to allocate enough PPE and staffing resources” (my emphasis) to the nursing homes. The primary obligation here devolved on the nursing homes, not the state, but the deeper point is that there was an acute shortage of both PPE and staffing resources, and the state, facing this difficulty, prioritized hospitals over long-term care facilities. This isn’t obviously culpable; when you face a shortage, you have to prioritize something over something else. Only magical thinking insists that if a prioritization must be made, it’s unacceptable for prioritization of X over Y to have the inevitable effect of giving Y lower priority than X. But that is literally what these critics are committed to saying.

    The last sentence in the passage poisons the well and fails to grapple with the underlying reality: however important long-term care facilities may be, hospitals are more fundamental to a pandemic response. So it made sense to prioritize them over long-term care facilities, given that both institutions couldn’t claim equal attention. It doesn’t follow, and isn’t true, that the state’s prioritization of hospitals over long-term care facilities entailed that it was “only focused on the acute care hospital piece of the health care system.” To prioritize X over Y is to give more attention to X than Y, not all attention to X and none to Y.

    Honestly, I’d hate to have subordinates this illogical working for me. It makes me wonder why I’m out of a job while these people have the jobs they have.

    Liked by 1 person

  5. Pingback: Cowen on Nursing Homes: A Postscript | Policy of Truth

  6. Pingback: Hayek at the Hospital: The Use of Knowledge in Hospital Discharge Decisions | Policy of Truth

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