How Kentucky became a surprising leader in flattening the curve on COVID-19

As states in the US South and Midwest see their coronavirus infection rates grow, the rate remains notably low in a state with some of the worst health outcomes nationally. Kentucky Gov. Andy Beshear has drawn bipartisan praise for navigating the outbreak in a calm and decisive manner, including declaring a state of emergency in early March that gave local officials time to help residents as well as school, health and other officials protect and plan against the global pandemic. 

And his calm, fact-based daily news briefings, which have drawn comparisons to President Franklin Roosevelt's famous fireside chats, have earned Beshear a new status as a sex symbol on social media.

On Tuesday, Kentucky officials reported the state's fourth death due to COVID-19, the respiratory illness caused by the coronavirus, and said the state's total number of confirmed infections had reached 163. Despite officials' repeated admonitions against social gatherings, some in the state still don't take the risk seriously. At least one of the latest infections -- that of an adult in their 20s -- originated at a "coronavirus party." 

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In comparison, neighboring Indiana had reported 365 confirmed cases and 12 deaths by Monday. Tennessee, which has 2.3 million more residents than Kentucky, had 517 confirmed cases and one death as of Sunday.

"We've seen states take very different approaches," Beshear, 42, said in a briefing on Sunday. "We have already done a whole lot of what other states are doing in one major -- and sometimes it seems scary -- order." 

Asked this week whether his administration has seen positive results from its efforts, Beshear said it was still early. "We are in the midst of it, and I believe we are taking aggressive and important steps that are, and will, save people's lives. But it will be really hard to know exactly how we have done until we are further through it and have more data," he told reporters. "Our numbers aren't necessarily jumping as fast as some other ones are."

As of last week, state public health leaders reported that about 7% of COVID-19 tests conducted in Kentucky had come back positive. The state's junior senator, Rand Paul, also disclosed that he tested positive for the virus, becoming the first member of the Senate to receive such a diagnosis. As reported by local CBS affiliate WYMT, Kentucky is faring average among surrounding states, with a lower percentage than Indiana's 20% and Tennessee's 27% positive-test rate. Kentucky's 7% is, however, higher than rates in West Virginia and Missouri, which have fewer cases and have done less testing. It's also higher than the rate in Virginia, which has double the number of cases and substantially more tests completed. 

Beshear's battle to "flatten the curve," or slow the spread of the coronavirus, has been charted in his daily press briefings, where he routinely appears with Kentucky Public Health Commissioner Steven Stack and American Sign Language interpreter Virginia Moore. Beshear's calm, methodical explanations of the state's efforts to combat the spread, always accompanied by repeated reassurances in the face of panic, have received praise across social media. 

More telling is the praise the Democratic governor has received from conservative Republicans in the state. 

Republican Robert Stivers, president of the Kentucky state Senate, said earlier this month that the Beshear administration's "consistent updates on the state of public health" have helped "efforts to ensure our public health groups are prepared for this situation."

Although both the Kentucky House and Senate had been considering measures to restrict executive branch power in the weeks prior to Beshear's COVID-19 response, Republican David Osborne, Kentucky's speaker of the house, more recently pledged to aid Beshear's efforts. He told the Courier Journal newspaper that he thinks the governor has the "authority he needs to take action, but we are prepared to step in with additional support if necessary."

Other influential Republican voices have also chimed in with support, including former Kentucky House Speaker Jeff Hoover, who tweeted that Beshear "has done a masterful job leading us in this unprecedented public health crisis. Proud of him (and for this state). I shudder to think what could have been."

Following a conversation with Beshear, US Senate Majority Leader Mitch McConnell called on US Health and Human Services Secretary Alex Azar to back the governor's efforts to obtain supplies, according to a Tuesday press release.

"I urge you to work with Kentucky Governor Andy Beshear as his administration requests additional PPE and test kits from your department," McConnell said.

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The strategy 

By March 4, Kentucky's central lab in the capital city of Frankfort had the ability to run 1,000 tests. Though Tennessee Gov. Bill Lee waited until March 12 to declare a state of emergency, Beshear set Kentucky's wheels in motion sooner, declaring a state of emergency on March 6. Within days, Beshear issued an order to waive co-pays, deductibles and coronavirus testing fees for about 433,000 privately-insured Kentuckians. 

For those without private health insurance, much of the groundwork was set by Beshear's father, former Gov. Steve Beshear, who served from 2007 to 2015. That work was reaffirmed by the younger Beshear on taking office in December. Unseating Republican incumbent Gov. Matt Bevin, the younger Beshear swiftly made good on his campaign promise to halt Bevin's widely unpopular efforts to revoke the state's expanded Medicaid coverage for about 480,000 residents. 

The same Medicaid expansion, authorized by the Affordable Care Act, was enacted by the former Gov. Beshear. Kentucky covers about 1.3 million people through Medicaid. About 600,000 of them are children.

The grandson of a preacher, the younger Beshear is open about his faith and quickly called on religious communities to cease weekly gatherings. By March 10, Beshear had cracked down on price gouging through an executive order and directed that all nursing homes and long-term care facilities, with narrow exceptions, be closed to visitors. Two days later, he asked public and private schools to begin shutting down, allowing flexibility to individual districts, which quickly implemented lunch-delivery programs for students. Then child care centers were closed. 

By March 14, the administration's new COVID-19 hotline was receiving 2,000 calls a day. 

Without explicitly naming the directive an order to shelter in place, the Beshear administration announced the euphemistic "healthy at home" initiative on Sunday. Some 14 states have implemented similar orders. Beshear's initiative is the social-distancing policy capstone to what's been a nuanced, systematic shutdown of nonessential businesses and government services -- starting with bars and restaurants, and progressing until only grocery stores, auto mechanics, banks and medical facilities remain open. (In accordance with the bourbon-barreling state's unique food and beverage laws, liquor stores will also stay open.)

Amid the layered business closures, the governor's administration loosened the rules around unemployment insurance and established new unemployment phone lines and an application schedule following a surge. Driver's license and Real ID offices have also been closed.

The administration hasn't been alone in its actions. Kentucky Supreme Court Chief Justice John D. Minton Jr. shut down most of the state's courts until April 10, including eviction court. Though housing insecurity is expected to rise in the state, concurrent with household income drops amid job losses, by March 20 most evictions in the state had been halted. 

Hospitals are setting up temporary coronavirus facilities or "cough clinics" in Hardin County and Harrison County, the location of the first confirmed case of COVID-19 in Kentucky. As panicked shoppers empty store shelves, Kroger grocery stores in Kentucky and Southern Indiana are reserving the first operating hours exclusively for the use of residents considered at higher risk. 

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High stakes 

For Kentuckians facing a pandemic, the stakes are higher than those in many other states. Kentucky routinely ranks among the worst for resident health outcomes, particularly in rates for smoking, cancer, black lung and cardiopulmonary disease. A Kaiser Family Foundation study said that up to 46% of Kentuckians would be considered high-risk if infected by COVID-19, making the state the sixth most vulnerable in the nation. 

Kentucky has only barely recovered from a 2019 hepatitis A outbreak that killed over 50 people and sickened more than 4,400. The state's vulnerability to HIV outbreaks has made it a subject of federal focus. And by the most recent tally, Kentucky was No. 1 in the nation for fentanyl abuse, a finding consistent with the state's regular high-ranking appearances in opioid abuse studies across the nation. 

Rural and Appalachian Kentucky remain at the heart of that vulnerability, with limited health care access and a string of recently shuttered hospitals. Just a week before the Beshear administration's sweeping COVID-19 response, the Kentucky General Assembly was weighing legislation aimed at stemming the closure of rural medical facilities after lawmakers discovered that of the state's 64 hospitals (in counties of fewer than 50,000) about 14%-15% of them are ready to default. In January alone, 1,000 area jobs in eastern Kentucky were lost when a hospital in Ashland closed. 

Adding to the risk is the uncertainty over the exact capacity of both urban and rural hospitals, with Kentucky's Office of Rural Health recently requesting more information from the Kentucky Hospital Association. On Tuesday, Beshear said the state had about 18,000 hospital beds. A March ProPublica investigation into hospital capacity found that Louisville, the state's largest city, had 4,160 total hospital beds (510 in intensive care), with a 59% occupancy, potentially leaving only 1,700 beds open for incoming patients. Lexington, the state's second largest city, had 5,050 total beds (580 intensive care), leaving 2,070 beds potentially open at 59% occupancy.

Beshear has ordered all hospitals to suspend elective procedures, which could clear space for incoming COVID-19 cases as well as reduce viral spread. On Monday, Beshear told reporters his administration has considered creating "pop-up" facilities with the National Guard and has plans in place to convert hotels into hospitals, with additional beds, if needed. 

On Tuesday, Beshear told reporters at a press briefing that the state had been outbid by the Federal Emergency Management Agency in one attempt to buy medical personal protective equipment. Kentucky's struggles to obtain COVID-19 tests and medical equipment, and to implement testing statewide, reflect similar struggles faced by states elsewhere. In Kentucky's first reported case, the patient was twice denied testing. Similarly, a Lexington woman had to wait nine days before being tested. 

"The test is not yet unlimited. We want the test to be unlimited," Kentucky Public Health Commissioner Steve Stack said during a press conference. "We have voiced our concerns and our needs to the federal government to work with the partners who have the resources to make it unlimited as fast as it can."

Since testing began, Kentucky has prioritized its limited number of test kits, per CDC guidelines, to the most vulnerable patients at highest risk. That means the number of cases in the state may be far higher than charted, with transmission rates much faster. 

"We are now just seeing the escalation of this virus and to suggest that there is a short duration that we can almost promise people is not something that we should be doing," Beshear told reporters Tuesday. 

"This will not last forever. There will be a light at the end of the tunnel, even though we don't know exactly how far it is away. But as long as we have the strength and the perseverance and the resiliency, we can defeat this coronavirus on the very first try. And that's what we've got to do to protect our people."

With a vaccine potentially as far away as next year, and federal government support for medical supplies still uncertain, Kentucky's governor faces an uphill battle. But it's one in which his state appears ready to rally behind him. 

Correction, 8:04 a.m. PT: The governor of Tennessee was incorrectly identified. The governor is Bill Lee.