Research Corner: Masks, Flint and Primary Care

JULY 2, 2020

“Surgical Face Mask” by NurseTogether is licensed under CC BY-SA 4.0

In this new segment, the Research Corner, physician and economist Bapu Jena discusses a pair of interesting new health policy research papers with implications for COVID-19, primary care and more. 

Listen to the full episode below or scroll down for the transcript and more information.

Click here for more of our coronavirus coverage.

Dan Gorenstein: Hey, it’s Dan. I want to welcome you to a new nook in the Tradeoffs universe.

We’re calling this segment the Research Corner. It’s a chance for us to catch you up on some of health policy’s newest, most interesting studies, and what they mean for all of us. Today, our occasional co-host Harvard economist and physician Bapu Jena joins us in a new role…as the pod-fessor. Yeah, the pod-fessor.

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

Bapu Jena

Bapu Jena, MD, PhD, Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School

DG: Bapu, how are you?

Bapu Jena: Doing good, Dan. Thanks for asking.

DG: Nice to hear your voice again, sir.

So look, you have brought in a couple papers for us to talk about. The first one is about masks.

PBS NewsHour: The debate over wearing face masks is creating a sharp divide among some Americans

ABC News: This morning face mask controversy after this outburst caught on camera in a Los Angeles grocery store.

NY Gov. Andrew Cuomo: Governors who said, “We don’t need to do this. Masks don’t work. Now they’re doing a 180.

DG: At the highest level, Bapu what’s the question the researchers are asking?

BJ: This a paper that was published just a couple of weeks ago in Health Affairs. And at a high level, what they’re basically trying to do is understand whether a state level mandate to wear masks is effective in reducing the growth in cases of COVID 19. That’s the take home question of the paper.

DG: During the study’s time frame, 15 states plus Washington D.C. passed public mask mandates.

Requiring that everyone everywhere in the state wear masks, though the researchers couldn’t actually confirm what percent of people complied.

BJ: They basically compare states that had mask mandates to states that didn’t. And it’s an important question to ask because we’re trying to figure out what will help social distancing, new medicines, closing schools. Which are the things that we’re doing are going to be effective. The things that are effective, we should do more of. The things that are not effective, we obviously shouldn’t do.

DG: And so what did they find? How effective are these mask mandates?

BJ: So, you know, what they find, actually, is that if you look in almost immediately after a state enacts a mandate, there is a reduction in COVID 19 case growth.

DG: Bapu accepts the paper’s main finding: mask mandates slow the spread of COVID cases.

But he says the paper’s other finding…an attempt at estimating the exact number of cases that mandates have prevented…is much trickier business.

BJ: Do I think that the number is between two hundred and five thousand, as the authors estimate? I think that’s a much harder question to answer.

DG: With so many policies and behaviors changing at the same time…school closures, office shut-downs, social distancing…Bapu says it’s hard to tease out precisely how many cases each individual action prevented.

BJ: And that raises the question in my mind is, are we really picking up the effect of this ban? Are we picking up other things that states may have been doing around the same time? And that’s always the challenge with these kinds of studies is was it the effect of this policy or were there other policies or other actions that individuals were privately taking that are timed around the same period that were causing these effects?

DG: Has this study changed how you as a researcher, as a scientist, as a husband and father, think about masks?

BJ: I think it has a little bit. I mean, had this study not been published, would I stop wearing masks? The answer is no. But I don’t know that I would feel comfortable saying that the state has to mandate people to wear the masks. And the number of deaths that are going to be averted here, it’s potentially large. And so that, in my mind, means that policymakers have to take this seriously and probably to act on it.

DG: So Bapu, that’s the mask paper that you brought in. You also have another paper that has nothing to do with COVID about Flint and the aftermath of the lead crisis in people’s water. What’s this paper all about?

Sfx: dripping water

BJ: Let me give you the backdrop here. It happened in September of 2015 in Flint, Michigan, where they discovered large amounts of lead in the water.

CNN: The trouble began two years ago when the state decided to switch Flint from Detroit’s drinking water to a new system.

BJ: And what happened as a result was this huge public crisis, and effort to get people tested for lead.

PBS News Hour: Children in Flint now have double, and in some cases triple the amount of lead in their blood and a federal emergency was declared last weekend.

DG: That public health disaster prompted lots of parents in Flint to take their kids to their PCPs, that’s their primary care providers, for lead testing.

Doctors’ visits that parents in other cities were not being prompted to make.

And that gave this study’s authors a unique chance to test one of health care’s age-old questions.

Does more primary care access actually produce better health outcomes at lower costs?

BJ: It’s an idea a lot of people talk about. Very difficult to study. And the reason why is because we can’t randomize patients to have PCPs and to not have PCPs and then study what is the impact of having an PCP.

DG: But this Flint crisis created what’s known as a natural experiment…a silver lining to random, sometimes terrible events…that let you study things you couldn’t otherwise.

And that’s exactly what these researchers did.

BJ: They find two things. One is that lead testing and access to primary care went up immediately after the crisis. Second thing is they find that emergency room visits for primary-care-treatable conditions, those visits fell by about 8%.

DG: And is that a good thing, staying out of the E.D? Why is this an important finding?

BJ: So staying out the E.D. is a good thing if you don’t need to be in the E.D. Of course, if you need to be in the emergency department, then you absolutely should go. I think  what the study shows is a good thing is it adds some meat, some data, to this idea that physicians have long discussed and thought about, which is that primary care isn’t just about cancer screening. It’s not only about wellness visits…but it can be something more. It can be something that helps prevent expensive care use like hospital care or emergency care. That’s an attractive idea, an idea that a lot of doctors and other health care professionals have thought about but have been unable to rigorously show.

DG: So, Bapu, emergency room use spending went down, but overall, what did the authors find when it came to total spending?

BJ: So what they actually found here was that there is a statistically significant increase in Medicaid spending. And I presume the reason why is because office visits went up, ED visits went down, but they didn’t go down by enough so that in aggregate, money was saved. Now, that is not to say that that’s necessarily a bad thing.

Remember, Dan, this study is about kids. And, you know, one of the things that we know kids need to have is vaccines. And what the study showed was that getting kids access to primary care did lead to an increase in subsequent vaccination rates, and suggested that the primary care that these kids are now getting was delivering some benefits.

DG: So you see this result. And on first blush, you’re excited like, “Alright ED, use went down! That’s fantastic.” But then you look at total spending. Spending goes up and there’s a temptation to be like, “Oh, this isn’t good. This is actually bad.” But actually, it seems like this is sort of sufficiently murky. What’s the take home for you?

BJ: It does raise this idea that, alright. If there are certain types of primary care that actually do reduce health care spending. What if we could figure out what those types of care were? Who were the types of patients who benefited? That would be an interesting insight to have, because it would suggest that those are the types of patients who we might double down on in terms of establishing access to primary care.

DG: So it’s interesting, Bapu, the Flint crisis…gave researchers a rare chance to study what happens when people seek out more care.

But with COVID…it’s the opposite natural experiment, right? With lots of folks skipping or delaying their care.

And the question would seem to be: what’s the impact of that going to be?

BJ: The opposite natural experiment is exactly right, and I suspect that we are going to see a lot of studies in the upcoming months or years that look at whether or not delays in care have had impacts on outcomes. What we know for sure is that during this period, spending on those conditions is going to be going down. We know that because people aren’t seeing the doctor. What we don’t know is how much worse, if at all, outcomes are going to be, and what the increase in costs associated with that delayed treatment is going to be. And I think this would be a great natural experiment to try to unpack what are those areas where we need to be doing more? And where are those areas where we can get away with doing less?

DG: Bapu, it sounds like you’ve got to get busy. Gotta start researching this question.

BJ: I’ve got to start researching this question. You’re absolutely right.

DG: What are you doing? Why are you talking to us? Get out of here.

BJ: I’ll see you later.

DG: Great talking to you as always, Bapu. It’s always a pleasure to talk to you. Thank you so much.

BJ: Thank you so much. Appreciate it.

DG: Today’s papers were by Shooshan Danagoulian, Daniel Grossman and David Slusky who wrote the NBER working paper on Flint. And Wei Lyu and George Wehby who published on mask mandates in Health Affairs.

Links to both papers are on our website

I’m Dan Gorenstein, this is Tradeoffs.

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Episode Resources

Articles Discussed in the Episode:

Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US (Wei Lyu and George L. Wehby; Health Affairs; 6/16/2020)

Office Visits Preventing Emergency Room Visits: Evidence From the Flint Water Switch (Shooshan Danagoulian, Daniel S. Grossman and David Slusky; 5/1/2020)

Related Research and Reporting on Masks and COVID-19:

These are the states requiring people to wear masks when out in public (Allen Kim, Scottie Andrew and James Froio; CNN; 6/30/2020)

Still Confused About Masks? Here’s the Science Behind How Face Masks Prevent Coronavirus (Nina Bai; UCSF; 6/26/2020)

Respiratory virus shedding in exhaled breath and efficacy of face masks (Nancy Leung, et al; Nature Medicine; 4/3/2020)

Related Research on Primary Care and Emergency Care Utilization:

Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases (Sayeh Nikpay, et al; Annals of Emergency Medicine; 6/19/2017)

Medicaid Increases Emergency-Department Use: Evidence from Oregon’s Health Insurance Experiment (Sarah Taubman, Heidi Allen, Bill Wright, Katherine Baicker and Amy Finkelstein; Science; 1/2/2014)

The Medical Home, Access to Care, and Insurance: A Review of Evidence (Barbara Starfield and Leiyu Shi; Pediatrics; 5/1/2004)

Episode Credits


Bapu Jena, MD, PhD, Ruth L. Newhouse Associate Professor of Health Care Policy, Harvard Medical School; Associate Professor of Medicine, Massachusetts General Hospital

The Tradeoffs theme song was composed by Ty Citerman, with additional music from Blue Dot Sessions.

This episode was produced by Sabrina Emms and Leslie Walker. It was mixed by Ryan Levi.

Additional thanks to:

The Tradeoffs Advisory Board…and our stellar staff!