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The tragic deaths last year of dozens of military veterans who were under state care ought to be a scar on the conscience of the Commonwealth. More than a year later, fixing the way the state cares for sick and elderly veterans remains a moral obligation. Yet adoption of crucial long-term reform is still a hope versus a reality.

In May, a special committee formed by the Massachusetts Legislature released a report on its investigation into the COVID-19 outbreak at the Holyoke Soldiers’ Home that resulted in the deaths of at least 76 veterans. As the committee cochairs, state Representative Linda Dean Campbell and state Senator Michael Rush, wrote for the Globe, their investigation revealed “the underlying governance failures that created a perfect storm for the preventable tragedy that occurred at the facility.”

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“Preventable” means those veterans did not have to die. It’s true that COVID-19 tore through many nursing homes and elderly facilities around the country last year, but some studies suggest that more well-run homes were able to limit infection and deaths. So now the question is: Will the Holyoke report and the legislation filed in its wake trigger substantive change? If not, the committee’s hard work is just another useless gathering of information and data.

The “governance failures” were also well documented in a Globe Spotlight report. Bennett Walsh, a superintendent with political connections and no long-term care experience or health care expertise, was put in charge of the facility, with sign-off from Governor Charlie Baker. Walsh kept the job long after his management deficiencies were known by Health and Human Services Secretary Marylou Sudders. The foggy chain of command between the facility, a local board of trustees, and the Baker administration preceded the COVID-19 crisis and greatly hindered response to it. No one in government paid much attention to who was accountable for what until veterans started to die. That’s what has to change.

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A sweeping reform bill filed last month lays out a path to do that. It sets up a process of more streamlined and centralized governance of the Soldiers’ Homes in Holyoke and Chelsea, with more state oversight; a professional process for the selection and firing of people in key leadership positions; and increased inspections and mandatory staffing requirements. The local boards of trustees that currently oversee the Holyoke and Chelsea homes would be replaced. A centralized state board would be created, with appointees required to have expertise in financial oversight, health care administration, and veteran needs. Local input and support will remain in the form of stewardship councils.

The proposed legislation would create a cabinet-level position: secretary of veterans affairs. It would also set up a clear chain of command — from the superintendent of a facility, to an executive director of veterans homes and housing, to the secretary of veterans affairs, to the governor.

Under the reform bill, all future superintendents must be licensed nursing home administrators. Candidates for the job would be reviewed by the secretary of veterans affairs, the secretary of health and human services, and the executive director of veterans homes and housing. The governor would have final say to appoint or remove a superintendent.

The reform bill calls for, at a minimum, the staffing standard certified by the Centers for Medicare and Medicaid Services. Other requirements: a full-time ombudsman and full-time infection control and emergency preparedness specialist.

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Those are just a few highlights of a reform package that deserves support from House Speaker Ronald Mariano and Senate President Karen Spilka. In it lies the potential for real, substantive change. Let’s hope that quest doesn’t devolve into a power struggle over bureaucratic turf. Let’s hope this doesn’t become a battle between Boston and Western Massachusetts. Let’s hope that instead of vying for influence, different veterans groups work together. These Soldiers’ Homes belong to Massachusetts. The people who run them should be professionals, committed to hiring other professionals.

Since COVID-19 swept through the Holyoke facility, there have been some changes. Walsh is gone, and he and former medical director David Clinton face criminal neglect charges. Some staffing problems have been addressed. But on paper, the chain of command remains the same: muddled. Last May, the Idaho veterans home administrator chosen to serve as the new superintendent decided not to take the job. He cited family reasons for his decision. But the politics of what it would take to fix this mess could also deter the best people from considering the position.

Lawmakers and the governor owe it to the veterans of Massachusetts — and especially to those who died of COVID-19 at the Soldiers’ Home in Holyoke — to get it right.


Editorials represent the views of the Boston Globe Editorial Board. Follow us on Twitter at @GlobeOpinion.