The powerful state budget managers who controlled key parts of Utah’s initial coronavirus response were skeptical about the value of medical expertise in handling the crisis and made repeated attempts to resist or subvert health officials, according to records obtained by The Salt Lake Tribune.
Springing into action soon after the virus hit Utah, the Governor’s Office of Management and Budget (GOMB) molded an economy-focused strategy that called for clamping down quickly on the disease, flooding the state with testing and swiftly returning to work.
The agency then aggressively advanced its strategy by signing massive, no-bid contracts for testing and data analysis. And its then-leader Kristen Cox sought to influence Gov. Gary Herbert, her direct supervisor, by curating the coronavirus data and research he reviewed as he made public health decisions.
Herbert’s spokeswoman said the governor leans primarily on the Utah Department of Health for information on the pandemic. Hundreds of emails show that GOMB — the agency charged with overseeing the state’s budget — was far more entangled in Utah’s coronavirus response than in simply shaping strategy around improving the economy.
The email correspondence, obtained through public records requests, also illustrates an apparent power struggle between the office and public health officials, who indicated they felt pushed out of major decisions and panicked about the state’s trajectory.
“The Governor’s Office has just gone rouge,” Alessandro Rossi, the chief infectious diseases scientist at the state lab, wrote in an email to a colleague, misspelling the word rogue.
“I just can’t take it anymore,” he wrote in another email. “Whatever topic they ask the group [of lab scientists], they end up doing what they were thinking in the first place.”
“It is out of control,” state epidemiologist Dr. Angela Dunn wrote in April, describing GOMB interference to the manager of the health department’s epidemiology bureau. “We are in danger of losing trust with ... [t]he public, which will make controlling this pandemic even harder.”
[Read more: 5 key findings from the hundreds of emails]
To Cox, who did not respond to requests to speak to The Tribune for this story, the danger was in overreliance on epidemiologists. In an email to a Utah Department of Health manager this spring, Cox wrote that her agency’s staffers were proficient in dealing with policies and grants but expressed the need for an “independent thinker” to oversee major coronavirus projects.
“Experts are important,” wrote Cox, who left GOMB in September. “But a real expert for me is somebody who can think for themselves, get results — all while using the body of knowledge they have acquired. The body of knowledge on its own does not suffice.”
GOMB staff in April celebrated Utah’s forthcoming economic reopening as a validation of its approach. And they stuck by their philosophy a few weeks later, even as epidemiologists warned that case counts were spiraling out of control.
Cox’s primary goal wasn’t to halt the spread of COVID-19, the records show. Instead, she and business consultants who worked at her right hand fought for “surgical” interventions that would protect the very highest-risk Utahns, arguing against broader-based public health restrictions that they believed would cripple the economy.
GOMB spokesman Colby Oliverson said in a statement to The Tribune that the office was “deeply appreciative and supportive of UDOH’s efforts to combat” the virus and said the conflict between the state agencies was routine.
“Most would expect differing viewpoints and ideas to be offered in efforts to solve a problem as deep, complex and far reaching as the COVID-19 pandemic,” he said. “However, as is the Utah way, decision-makers have repeatedly come together in crafting solutions to protect both lives and livelihoods throughout the pandemic.”
A high-ranking official in the Herbert administration, who talked on condition of anonymity because he was not authorized to speak, attributed the conflicts between the health department and GOMB to a tension between conventional wisdom and Cox’s willingness to challenge norms — a trait that characterized her time at the agency and led to an expansive view of its place in state government. Her resignation in September and Herbert’s exit in January could portend a return to the role laid out for it in state law.
And the state’s history of relegating public health experts to a secondary, mostly advisory role may raise questions about how the state will carry out the next, more crucial pandemic response phase: distributing and administering millions of vaccines to Utahns.
Shaping the state’s response
GOMB officials didn’t have a public-facing role in the health crisis. But emails show they were engaged in drafting the Utah Leads Together framework (a comprehensive plan to manage the coronavirus and its impacts on the state) and involved in decisions about which counties could move to a less restrictive color-coded restriction phase and when.
When cases spiked this summer, Cox asked her team to go over data “to see where we think green does and does not make sense.” She also directed a consultant to prepare information for the governor about which counties “may be ready to transition” to a different color level or need “to stay in the same color because of any data trends.”
Emails show the office and its contractors from the business group Goldratt Consulting were also heavily involved in working on the Healthy Together app with Twenty, the company that created the contact tracing tool that now works more as a symptom checker and portal for test results. And they worked with TestUtah, a coronavirus testing outfit that was scrutinized for the reliability of its tests.
Cox saw both testing and the app as ways to increase public confidence, ease uncertainty and get the economy back up and running, according to email correspondence.
But even as those operating TestUtah claimed the program was being guided by health department advice, UDOH staff repeatedly complained that the companies were unresponsive to them.
“We have zero control over and limited visibility on TestUtah.com processes and procedures,” Dunn wrote in April. “We were just alerted today that they had approximately 40 positives that they had not sent to public health, some over two weeks old. We have brought these issues up with TestUtah.com representatives. ... However, no action has been taken. We continuously hear that TestUtah.com gets their direction from GOMB.
“l am very concerned that the TestUtah.com actions are harming the public’s health. .... Please know that this is not coming out of UDOH.”
By May, GOMB was producing weekly reports Cox said would “help provide insight and possible policy direction for managing the Covid 19 risk.” She directed that the first of these be shared with members of the commission, the medical panel, the governor and the House speaker.
Cox also focused her staff’s attention in the early months of the outbreak and into the summer on researching the mortality rate of the coronavirus, particularly as it compared to the flu — even as one staffer pushed back, saying “data wise they are apples and oranges” and that COVID is “definitely more concerning.” (GOMB says this never-published analysis sought to address “the incorrect assumption that COVID-19 was no worse than the flu.”)
Lehnardt, the governor’s spokesperson, said GOMB played a “minor role” in providing him with statistical updates.
Emails show, though, that officials from GOMB were involved not only in major projects but also at times in filtering the coronavirus data to which Herbert had access. At one point, Cox discouraged Herbert’s top aides from putting stock in COVID-19 modeling produced by outside experts and said outright that she wanted state officials to lean solely on research findings presented by her agency and UDOH as they made policy decisions.
In early April, Cox said she wanted a special dashboard made for the governor and directed her team to build him one with four data points that would help measure the state’s success in dealing with the coronavirus. The next day, a Goldratt consultant directed the staff to change a graphic on new hospitalization projections because it did not “look governor friendly.”
Lehnardt said Herbert is “quick at processing data and information, so basically any piece of research is ‘governor friendly.’”
GOMB staffers not only worked to streamline information to the governor, unified command and the legislative commission, emails reveal, but also were responsible at some points for developing Herbert’s “talking points.”
A May 6 email shows a GOMB staffer’s points on the coronavirus response emphasized that the state was doing “an excellent job at containing the virus,” as evidenced by its low death rate and high testing numbers. During a news conference the next day, many of Herbert’s remarks mirrored those provided to him the day before.
GOMB said that because the governor’s “time is extremely valuable and scarce,” it delivered coronavirus information to him in “the clearest and most concise manner possible so he could make timely, well-informed decisions.”
Economic and social harms of a shutdown
About an hour before midnight one day in April, Cox poured her philosophy about COVID-19 into an email and asked GOMB staff and Goldratt consultants to burnish the “brain dump” into a LinkedIn post.
The piece, she said, should argue that amid the worst global pandemic in a century, leaders and policymakers should beware of leaning too heavily on infectious disease experts.
“We do need the medical establishment — they are part of the solution. But relying on them exclusively has put our country into a serious and avoidable crisis,” Cox wrote. “Our state would be in serious trouble if we relied only on their input.”
GOMB staff and Goldratt contractors aimed to strike a balance between protecting Utahns from COVID-19 and the economic and social harms associated with a shutdown. That could even mean allowing COVID-19 to spread, at times. As long as hospitals still had space and the disease growth rate was manageable, the volume of infections was “less relevant” to decision-makers, Cox wrote in April.
State public health experts, though, cautioned that letting the disease move through the wider community would put vulnerable people at greater risk.
“[T]he idea that we can protect at risk populations while allowing for increased transmission is something I have tried to advise against from a public health standpoint,” Keegan McCaffrey, a state epidemiologist, wrote in a June email to a GOMB staffer.
In support of a hyper-focused COVID-19 strategy and efforts to identify the people most endangered by the virus, GOMB and Goldratt consultants also pressed for access to the state health department’s epidemiological data.
But as the health agency worried about sharing the sensitive medical and demographic information, GOMB reluctantly settled for greater access to UDOH analyses and a partnership with a state epidemiologist.
“For now, I compromised on the data sharing agreement because they’ll continue to stall it with vague excuses and red tape as long as there is no trust between us,” Rachel Stone, GOMB’s chief data officer, wrote in a May email. “I think this is a win-win to reduce lag times and build trust, and probably the best we can get right now.”
With earlier data the health agency had provided, GOMB created a risk hierarchy that had only one subset — people over age 45 with kidney disease — in an “extreme risk” category and placed many older people with underlying health problems into a “moderate” classification.
State epidemiologists said they couldn’t endorse publishing this initial analysis, explaining that it would be “misleading” to call someone with cardiovascular disease medium risk.
Members of Cox’s team amended their analysis following feedback from health experts. But records show they kept pushing their larger point.
When a state epidemiologist in June reported that nearly half of Utah’s adults meet the definition of high risk, a GOMB staffer wrote that the information didn’t “comport” with hospitalization rates and again suggested looking at risk “more granularly.” A Goldratt consultant later said in response to the analysis that “we cannot have almost 50% of the population be high risk and no way to focus inside that group.”
‘Save face for Kris’
Along with its focus on the state’s fiscal health, the Governor’s Office of Management and Budget is tasked with making “statewide operational improvements.” As such, leaders in the office pushed for changes within the Utah Department of Health.
In a late-night email sent in early April, Cox said she expected Rich Saunders, now the interim executive director of the Utah Department of Health, and Jeff Burton, a retired general who was involved in the early days of the state’s coronavirus response, would provide leadership on testing, contact tracing and compliance with new state guidelines. But she also expressed concern that there weren’t “the right people in place right now” to support those leaders.
The next month, Cox said she was worried about the department’s data and asked about using coronavirus funds to get its “system in shape.” One of GOMB’s projects was to “improve overall DOH performance” for the long term.
Within the health department, staffers complained that the flurry of GOMB initiatives — including TestUtah and the Healthy Together app — were creating extra work for public health workers as they were scrambling to respond to the pandemic.
Barely a month after Utah’s first coronavirus case, the health department’s information technology director, George McEwan, reported that about 880 staff hours had gone into the GOMB projects. Whenever it looked like tech staff could return to regular health department work, McEwan wrote, “I’m blindsided by a new vendor contract and GOMB staff telling us whatever the vendor needs is a critical priority and needs to be done immediately.”
Despite the labor and millions in public funds that poured into the GOMB-led efforts, health department staff complained those projects were slow to accomplish even modest public health goals like Spanish-language outreach. And health workers suggested they felt pressured to make an outward show of support for the initiatives — even ones they thought seemed half-baked at rollout or were dogged by controversy later.
“I am incredibly uncomfortable with this since these are not UDOH products and there have been a lot of issues with them,” wrote epidemiologist Kylie Sage. But she added that publicizing them was “non-negotiable because Kris Cox put a lot of work into them and they are state products.”
GOMB over the summer relinquished control over its major COVID-19 contracts, but health department officials in emails appeared to indicate that pacifying Cox was one of their goals.
“[Saunders] is working to bring all of this GOMB nonsense under UDOH and is moving all of the contracts to us … for better or for worse,” Dunn wrote to another UDOH staffer. “I asked if we could cancel contracts, and he said no. We have to save face for Kris and make these ideas useful.”
The governor’s office and health department leadership were also behind Healthy Together and TestUtah, and GOMB denied pressuring other agencies to promote them.
“Employees at all levels of state government are often asked to execute their department’s and the administration’s initiatives,” Oliverson, a GOMB spokesman, said in a statement. “Because of this multi-agency support, agencies were asked to promote Healthy Together and TestUtah.”
Other emails obtained by The Tribune document GOMB’s attempts to reach inside the health agency itself, at one point trying to influence contact tracing protocols by deploying a consultant to “edit and add to” the state’s script, to the frustration of health officials.
“GOMB ... can provide input on the contact tracing process, but ultimately it is a public health activity and they need to defer,” Dunn said. “This is wasting time when we need to be moving quickly in an efficient and effective manner.”
Dunn and GOMB also tangled over testing policies, with Cox insisting that people should be able to access COVID-19 tests on demand, the emails show.
Dunn resisted unrestricted asymptomatic testing, given the frequency of false negatives for people without signs of illness. But TestUtah, the multimillion-dollar COVID-19 testing program launched in partnership with GOMB, continued to refer asymptomatic people to testing for weeks after health officials asked them to stop.
In a late May email, Cox implied that financial considerations were motivating traditional health institutions to push back on asymptomatic testing, writing that “they only get reimbursed from insurance if the person has symptoms.” (The chief medical operations officer at University of Utah Health said insurance has generally covered testing regardless of symptoms and attributed his system’s early reservations about asymptomatic testing to a shortage of staffing and resources.)
The state’s head of testing, on the other hand, said in a separate email thread that GOMB’s alternative, TestUtah, appeared to have taxpayers covering thousands of coronavirus tests for which insurance should pay.
“This arrangement is a terrible deal for the state and won’t allow us to take advantage of the fact that these tests are covered 100% by insurance, Medicaid, and even for the uninsured,” wrote Nate Checketts, a deputy health department director. “We need to require that TestUtah collect insurance information so the state can bill these tests appropriately later.”
Today, the Utah Department of Health’s testing coronavirus strategy “supports targeted testing of asymptomatic individuals,” a department spokesman said, an approach that has “changed throughout the response to the pandemic, especially as we have learned more about asymptomatic spread of the virus.”
A ‘very different’ approach
The GOMB emails obtained by The Tribune run through late June — as COVID-19 was pummeling the state with record numbers of infections and a state epidemiologist shared that he had “not been this worried since mid-March, when we were first seeing this pandemic pick up speed.”
This summertime surge is small in comparison with the eruption of COVID-19 in Utah in the fall, when the state emerged as one of the worst hot spots in the nation and hospitals opened overflow wings and warned they were on the brink of rationing care to patients.
Cox left her state post in September, and — according to the high-ranking Herbert administration official who spoke on the condition of anonymity — stayed on longer than previously planned to help the state through the pandemic after resigning voluntarily. She has since signed on as an instructor at the University of Utah David Eccles School of Business and has promoted her consulting services.
Former Rep. Sophia DiCaro was picked by Lt. Gov. Spencer Cox, the incoming governor, to lead GOMB after his January inauguration. She said she hasn’t mapped out her vision for the agency yet but will “definitely have some things that I would like to enhance or do differently.” And though she’s not sure how GOMB will fit into the next phase of the COVID-19 response — which will include vaccine distribution — she said she looks forward to building strong relationships with the health department.
A review completed by the governor-elect’s transition team acknowledges GOMB initiatives during the Herbert administration have “caused some frustration and friction” and suggested that the agency’s future leaders try to stay “in tune with employees in the trenches and leaders on the front line.” Meanwhile, a similar review of the health department uncovered “significant morale challenges” among the agency staff because of political conflicts and heavy workload related to COVID-19.
Over the summer, the Governor’s Office of Management and Budget handed off many of the biggest COVID-19 contracts, including those for TestUtah and the Healthy Together app, to the state health department for supervision. It hasn’t announced any major coronavirus initiative in months.
GOMB has also returned in recent weeks to its primary role and focus: “helping craft and maintain the State budget,” the governor’s office said in a statement. Its involvement in the pandemic response now is tracking federal Coronavirus Aid, Relief and Economic Security (CARES) Act spending.
But the friction between health experts and Utah officials continued, playing out as Herbert tried to avoid mandating masks across the state and denied physicians’ pleas for more restrictions on public gathering places like bars, gyms and theaters. Caught between political pressures and an urgent need to contain the disease, Herbert in November issued and then rescinded a ban on social gatherings.
Meanwhile, Kristen Cox has highlighted her approach to COVID-19 on the website advertising her consulting services, portraying the pandemic as a management and logistics puzzle.
“It struck me, early on, that we all seemed to be passengers, listening to our epidemiologist ‘tour guides’ tell us how quickly we were all going to get infected,” Cox wrote. “We were talking about where the virus was going to take us, not where we wanted to be 60-or-90 days out. So, I suggested we take a very different, very aggressive approach to our COVID-19 response, here in Utah.”
Today, Utah continues to report high case counts as part of a fall spike that has extended into the winter. And more than 1,300 Utahns have died from the virus as of Sunday.
From an economic perspective, the state is poised to emerge strong from the pandemic, with one of the lowest unemployment rates in the nation and enough new revenue to add hundreds of millions to the public school budget this year.