Sponsored by the CareQuest Institute for Oral Health and the Milbank Memorial Fund Primary Care in the COVID-19 Pandemic Improving access to high-quality primary care, accelerating transitions to alternative forms of care delivery, and addressing health disparities EDITED BY Sanjay Basu, MD, PhD, Director of Research | Jessica L. Alpert, Case Writer Russell S. Phillips, MD, Center Director, William Applebaum Professor of Medicine; Professor of Global Health and Social Medicine | Harvard Medical School Center for Primary Care The Harvard Medical School Center for Primary Care is strengthening health care by supporting primary health care systems, teams, and leaders. The Center’s mission is to foster a dynamic community in and around Harvard Medical School to promote and support primary care resilience, equity and antiracism, and healthcare value with a goal of improving global health and well-being. The Center collaborates with partners at Harvard and in the broader community in advocacy and leadership training, and advances the ability of primary care practices to survive and thrive by researching and disseminating knowledge about how to build capacity for practice resil- ience, health care equity and high-value care through best practices and innovation. Finally, the Center studies how access to care is being preserved or improved given current and emerging challenges to health care, what aspects of practice challenges and responses are opportunities for accelerating transitions from traditional care to alternative care strategies such as virtual care, and how to identify the care strategies that can best address health disparities heightened by the COVID-19 pandemic. CareQuest Institute for Oral Health is a national nonprofit championing a more equitable future where every person can reach their full potential through excellent health. CareQuest Institute does this through their work in grantmaking, research, health improvement programs, policy and advocacy and education as well as their leader- ship in dental benefits, care delivery and innovation advancements. CareQuest Institute collaborates with thought leaders, health care providers, patients and local, state and federal stakeholders, to accelerate oral health care transformation and create a system designed for everyone. To learn more, visit carequest.org. The Milbank Memorial Fund is an endowed operating foundation that works to improve population health by connecting leaders and decision makers with the best available evidence and experience. It does this work by: identifying, informing, and inspiring current and future state health policy leaders to enhance their effectiveness; working with state health policy decision makers on issues they identify as important to population health, particu- larly in areas related to primary care, aging, and total costs of care; and publishing high-quality, evidence-based publications and The Milbank Quarterly, a peer-reviewed journal of population health and health policy. Primary Care in the COVID-19 Pandemic Improving access to high-quality primary care, accelerating transitions to alternative forms of care delivery, and addressing health disparities Edited by: Sanjay Basu, MD, PhD, Director of Research Jessica L. Alpert, Case Writer Russell S. Phillips, MD, Center Director William Applebaum Professor of Medicine; Professor of Global Health and Social Medicine Harvard Medical School Center for Primary Care Sponsored by the CareQuest Institute for Oral Health and the Milbank Memorial Fund Contents INTRODUCTION . 1 SECTION 1: CHALLENGES OF COVID-19 TO PRIMARY CARE ACCESS AND QUALITY . 5 Chronic Care Management During the COVID-19 Pandemic . 7 Addressing COVID-19 Proactively Through Primary Care in England’s National Health Service . .23 What We Can Learn from European Experiences of Primary Care Under COVID-19 . 31. COVID-19 and Primary Care for Incarcerated People Released to the Community . .41 The Asia Pacific Experience of Primary Health Care in the COVID-19 Pandemic . 53. Reproductive Health: Equity and Innovation During the COVID-19 Pandemic . 69 COVID-19 and Oral Health . 83 Addressing Food Insecurity Among At-Risk Older Adults . 97 SECTION 2: PRACTICE TRANSITIONS: PAYMENTS AND DELIVERY . 107 Payer Actions and Primary Care in the Wake of COVID-19: Will Primary Care Be There When We Need It? . 109 Financial Challenges for Primary Care Under COVID-19 . 123 Financial Consolidation of Primary Care Practices During and After COVID-19 . 137 Public Health Centers in Japan’s COVID-19 Response and Recovery . 155 Community Health Workers in the COVID-19 Response and Continuation of Primary Health Care . 163 Solutions to Oral Health Inequities . 179 SECTION 3: STRATEGIES TO ADVANCE PRIMARY CARE EQUITY . 201 Anti-Racist Primary Care Policy in the United States . 203 Building Community-Engaged Primary Care: Returning to Our Roots . 221 Integration of Primary Care and Oral Health . 231 Telehealth Equity: Before and After COVID-19 . 245 Improving Health Communication for Primary Care Practitioners During and After COVID-19 . 257 Undocumented Immigrants in the United States in the Time of COVID-19 . 269 Migrant Worker Health and Health Care in COVID-19 . 285 CONCLUSION . 299 Introduction Jessica L. Alpert and Russell S. Phillips he COVID-19 pandemic has been a global disaster . A January 2021 report by the World Health TOrganization Independent Panel for Pandemic Preparedness and Response summarized the cascade of global missteps made during the course of the pandemic and the ways in which “we have failed in our collective capacity” to respond to the challenges posed by COVID-19 .1 In the United States, as of this writing, more than 400,000 people have died, in large part because of a failure of leadership and the lack of a national plan to confront and control the pandemic .2 Scientifically proven methods of infection control such as masking, maintaining social distance, testing, and contact tracing were politicized and questioned rather than uniformly followed .3,4 However, even if effective leadership had been in place, the United States was poorly prepared to confront such a pandemic. Public health and primary care, both essential to fighting infectious disease, are poorly funded .5 The payment structure for primary care was not optimized for tele- medicine or for supporting practices when patients stay away due to fear of infection .6,7 Personal protective equipment was not stockpiled in adequate amounts to protect caregiving physicians, nurses, and other staff, and primary care physicians suffered the greatest mortality of any physi- cian group .8,9 The Centers for Disease Control and Prevention, the usual source of leadership, scien- tific expertise, and guidance in the context of a pandemic, was sidelined and ridiculed by the lead- ership of the country .10 Unlike the United States, countries with better funding for and coordination of primary care and public health closed down their economies, mounted effective messaging and utilization of masking and social distance, and effectively implemented testing and contact-tracing programs, demonstrating that the pandemic could be controlled .11,12 As of January 2021, much of the national discourse is centered on vaccine dissemination, with a par- ticular focus on prioritization strategies for underserved and vulnerable populations disproportion- ately impacted by the pandemic . Despite the promise of vaccine availability, it is not clear whether the United States is sufficiently prepared to develop and operationalize vaccination allocation plans, leaving the potential for those at highest risk to be left behind .13 2 PRIMARY CARE IN THE COVID-19 PANDEMIC The rationale for developing this report and the proceeding chapters is to put a spotlight on (1) the ways in which countries failed or succeeded in overcoming the pandemic, (2) how primary care innovated in response to the pandemic, (3) lessons learned that might inform approaches to confronting future catastrophes, and (4) the ways in which innovation has served as a tool for driving health equity . Through these chapters we aim to address some key questions: • How was primary care adversely impacted by the COVID-19 pandemic, and in what ways did the field innovate and adapt to the situation at hand? • What is a framework for understanding the risks and opportunities posed by COVID-19 for primary care practices? • How have marginalized and vulnerable populations been disproportionally impacted in the face of the COVID-19 pandemic? • How did the social determinants of health and oppressive ideologies, including racism, ableism, and ageism, intersect and coalesce in the health inequities observed among com- munities and primary care patients? • What lessons can be distilled from international experiences with COVID-19, and how can those lessons be leveraged to catalyze systemic and structural change in the United States? The COVID-19 pandemic highlighted long-term inefficiencies and inequities in health systems globally, and societies struggled to mitigate the contagion and loss of life . The chapter authors celebrate the resilience, ingenuity, and devotion that primary care provid- ers have shown during this time of uncertainty and loss . Their writings ultimately serve as an important reminder that if systemic barriers remain unaddressed, equitable, accessible, and sustainable primary care delivery will remain an empty promise for our patients and communities . PRIMARY CARE IN THE COVID-19 PANDEMIC 3 7. Blandford A, Wesson J,