COVID-19 And Health Disparities: Insights From Key Informant Interviews


Editor’s Note

This post is part of a Health Affairs Blog short series, “Higher Health Care Value Post COVID-19.” The series examines opportunities to create a research and policy agenda using the changes wrought by COVID-19 to help create a better health care system in its aftermath. The posts in the series were completed with support for the authors from the Research Consortium for Health Care Value Assessment, a partnership between Altarum and VBID Health, through a grant from the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA extended complete independence to Altarum to select researchers and specific topics. Health Affairs retained review and editing rights.

For almost 40 years, James Mahoney, MD, was a front-line pulmonary and critical care physician at Brooklyn’s University Hospital. He worked tirelessly treating COVID-19 patients in his safety-net institution. He was a heroic figure to many colleagues.

In April, Mahoney became infected with COVID-19, requiring care in his hospital’s underresourced intensive care unit (ICU). His condition worsened. As the New York Times reported:

“In a desperate effort to save his life, his colleagues loaded him onto an ambulance and rushed him to Tisch Hospital, a wealthier institution with a sophisticated blood oxygenation machine that University Hospital did not possess.

“Five colleagues, a kind of honor guard, followed the ambulance as it rode from Brooklyn to Manhattan. They escorted him to the hospital and were with him, at his bedside, when he died.”

More than 220,000 Americans have died from COVID-19; more than six million have been infected. No part of the US has been fully spared, but the burdens are unequally distributed. At every point, from initial infection to intensive care, COVID-19 exposed disparities by race/ethnicity and immigration status, by income and wealth. The pandemic exposed disparities in preexisting disease vulnerability, in the effectiveness of public health efforts, and in the availability and intensity of medical care.  

This post draws upon key informant interviews with physicians, nursing and medical leaders, epidemiologists and health services researchers, and policy scholars to explore causes of these disparities and to examine proposed solutions. No single measure can eliminate COVID-19 disparities. Many, however, can help.

Epidemiological Disparities

American Indian, Alaska Native, and Black individuals are five times more likely, and Latinx individuals four times more likely, to be hospitalized for COVID-19 than are non-Hispanic Whites. Segregation also matters, with predominantly-Black counties experiencing higher COVID-19 death rates. Low-income Americans are more likely to experience comorbidities, including diabetes and cardiovascular disease, that render COVID-19 more burdensome and lethal.

Immigrants represent 15 percent of the US labor force; one-third of these workers are undocumented. Almost three-quarters of undocumented immigrants work in essential, often people-facing, roles. Many immigrants face additional risks because they reside in crowded households.

Disparities In The Intensity And Proficiency Of Medical Care

COVID-19 also exposes disparities within the health care delivery system.

Roughly 40 percent of COVID-19 deaths in the US, at least 77,000, have occurred in nursing homes and long-term care facilities. More than 760 nursing home staff members have died, making this one of the most dangerous occupations in the US.

Prevalent COVID-19 infection within surrounding communities produced the first wave of deaths inside long-term care facilities—a pattern that produced substantially higher death rates among African American patients. Right now, facilities that are less Medicaid-dependent with higher-quality ratings are less likely to report shortages of staff or protective equipment, suggesting that we will see widening COVID-19 disparities within the long-term care population and among the staff who serve them (R. Tamara Konetzka interview; David Grabowski interview).

Disparities also arise in the proficiency and intensity of COVID-19 care. Critically ill COVID-19 patients admitted to hospitals with fewer than 50 ICU beds were markedly more likely to die (odds ratio=3.28) than were patients admitted to larger hospitals. The frequency of prone positioning—a key evidence-based therapy for COVID-19 patients at risk from Acute Respiratory Distress Syndrome (ARDS)—ranged from almost 5 percent at one hospital to nearly 80 percent at another. Such disparities align with other social and economic cleavages. Forty-nine percent of the lowest-income communities do not have any ICU beds, compared to just 3 percent of the highest-income communities.

Measures That Can Help

The failures and successes of our national COVID-19 response underscore the need for a nationally coordinated, administratively capable, emergency response and public health system at every level of government. This system must be anchored in clear federal guidance and politically durable funding for disease prevention, focused on effective testing, physical isolation, and evidence-based treatment.

Contact Tracing That Addresses Social Determinants

Many clinicians, policy makers, and citizens initially hoped that traditional contact tracing could contain or slow the US COVID-19 pandemic. These hopes were dashed. This failure partly arises from the speed and efficiency with which COVID-19 spreads. Yet, this is not the whole story. Other nations faced and contained the same biological-epidemiological process. Testing delays and limited organizational infrastructure and capacity hindered public health efforts. Such failures revealed a weak infrastructure, ill-prepared for crisis.

Political polarization and mistrust of government deepened the failure. COVID-19 disproportionately impacts immigrant communities, including undocumented and mixed-status households, who have distinctive reasons to distrust public health authorities and contact tracing efforts. African American and Latinx communities were also disproportionately impacted by COVID-19; this disproportionate impact is linked to poverty, crowded housing, and other social determinants. Many low-income workers are ineligible for unemployment insurance or are uninsured. Although people can obtain free testing and some free COVID-19-related care, many avoid medical care, fearing its financial burdens. Many avoid testing, in part due to practical logistical barriers, in part due to fears regarding the implications of a positive result. Without social insurance protections, many continue to work even when they experience symptoms of COVID-19.

Aligning Clinical Excellence With Community Benefit

Emerging research and key informant interviews underscore both the necessity and the limitations of marquee medical providers as leaders in COVID-19 care. Such institutions often moved more swiftly than federal or state governments. Marquee medical centers created toolkits and trainings for federally qualified health centers to expand testing, distributed personal protective equipment, and used online training systems such as ECHO to disseminate evidence-based practice guidelines (Brenda Battle interview). But this approach has proven less successful in addressing the most serious care disparities, which arise from differences in resources and incentives, rather than differences in expertise.

Consider barriers to proning in ARDS care. The survival benefits of prone positioning of COVID-19 ICU patients became quickly apparent; they exceed those associated with advanced medications that receive greater attention (William Parker interview). COVID-19 ARDS patients appear to experience similar physiological challenges to those experienced by other ARDS patients. Viewed in this light, site-disparities in COVID mortality are what one would predict based upon prior research, which documented significantly lower ARDS fatality rates at high-volume hospitals. Proning requires specific training, well-practiced standard operating procedures, and low patient-staff ratios.

Early in the pandemic, policy makers and ethicists feared that mechanical ventilator shortages would produce serious disparities. In practice, hospital staffing shortages were the greater obstacle. As one informant emphasized, “It’s not just the machine” (William Parker interview). “[T]hat’s a necessary condition, but it’s by no means sufficient to provide excellent ARDS care. Where that comes from is from having awesome ICU nurses and this team of doctors and respiratory therapists and the whole infrastructure.”

Researchers have long identified survival benefits of regionalization, whereby ARDS patients could be transferred to well-equipped hospitals that perform a high annual volume of mechanical ventilation. That volume-outcome relationship is well-known to clinicians—and in broad outline to patients, too. One physician noted her COVID-19 patients’ reluctance to call 911, for fear that they would be taken to the nearest community hospital rather than her academic medical center (Monica Peek interview).

Transportation and other logistical barriers can hinder ARDS regionalization. Yet, within densely populated areas most affected by COVID-19, organizational barriers and incentives, identified by Jeremy Kahn and colleagues long before COVID-19, proved more pressing.

Referring hospitals and physicians fear loss of revenue and autonomy. One hospital CEO was admirably candid, telling Chicago Public Radio that he tried to meet every patient’s needs because the hospital would lose money if patients left for other facilities. Organizational morale and prestige may also play some role.

Well-resourced hospitals face similarly tepid incentives to accept such transfers, particularly when uninsured or Medicaid COVID-19 patients displace privately insured patients:

“Obviously, you can bill…. But this negative spillover [impacts the other services and procedures] the hospital can do, which are even more lucrative. That’s a huge financial incentive to do as little as possible.”

In this way, submarket Medicaid reimbursement doubly undermines ICU care. Medicaid-dependent hospitals lack funding to support facilities and staff. Hospitals with greater resources are correspondingly hesitant to fill this gap by accepting transfers of Medicaid patients. Long-term federal commitment to provide Medicare rather than Medicaid reimbursement rates—at minimum during public health emergencies—would reduce these barriers.

Such evidence suggests the need for policy reforms that promote appropriate transfers and ensure proper staffing and equipment at safety-net providers. The Coronavirus Aid, Relief, and Economic Security (CARES) Act designated $175 billion for COVID-19 response and for health care organizations that experienced COVID-19-related expenses and lost revenue. Its provider relief fund sought to protect and expand access to ICU services. Statistical analyses indicate that CARES Act funding, whose formulas strongly reflect hospitals’ pre-COVID-19 revenue streams, was not well-targeted to the communities with the highest disease burden or the institutions in greatest financial need.

Future policies can correct these formulaic defects, raise Medicaid reimbursements, and take greater account of community disease burden (Amitabh Chandra interview). These may also include more effective incentives and oversight to enforce (among both receiving and referring hospitals) more frequent transfers when this would reduce mortality. Marquee medical centers now receiving substantial tax subsidies and public insurance payments may also require greater regulation to ensure that they accept more transfers.

Expanded, Politically Durable Public Health Funding

COVID-19 also underscores the need for more expansive and politically durable public health funding (Eric Patashnik interview; Gregg Gonsalves interview). The federal government now stands ready to spend trillions of dollars to address the economic and public health impact of COVID-19. States and the federal government are frantically purchasing millions of gloves and masks, hiring contact tracers, trying to stand up a competent public health response. But why was the US so unprepared for a deadly pandemic (and indeed had cut related public health funding) when the broad outline of this threat was anticipated by Bill Gates, Barack Obama, George W. Bush, and others?

By some estimates, aggressive COVID-19 case finding, contact tracing, and supported physical isolation costs $74 billion over 12 to 18 months. Although six times the Centers for Disease Control and Prevention’s annual budget, that’s a single week’s expenditure in our $4 trillion health care economy.

To reliably finance such efforts, the US must change its basic financing structures of public health. As described elsewhere, the federal government leaves states and localities to foot the majority of our public health care bill. A state-federal matching formula similar to Medicaid would provide greater incentives for states to do more.

Sustainable funding requires public officials to address more effectively political and cultural polarization. Surveys indicate large partisan differences in mask-wearing and other protective behaviors, as well as in respondents’ overall assessment of the severity of COVID-19 as a national challenge. The public health community sometimes displays poor cultural competence in crossing this divide, in part because of the community’s own limited viewpoint diversity (Jonathan Caulkins interview). Models exist for such efforts, including suicide prevention efforts promoted by hunting and shooting organizations. Expanded harm reduction models could also play a role in reducing risks experienced in a variety of activities, ranging from outdoor protests, to the resumption of economic activity, to the provision of social opportunities in college dorms (Jonathan Caulkins interview, Gregg Gonsalves interview).

A sustainable funding model requires a geographically and ideologically diverse national coalition that will defend public health investments once the immediate emergency has passed (Eric Patashnik interview). The Affordable Care Act (ACA) provides a chastening example. The ACA included supports for worthy ventures in health care outcomes research and in the prevention and public health fund. Many of the specific activities traditionally enjoyed bipartisan support, or at least had no particular political valence. Such bipartisan support largely evaporated once these provisions were identified as a partisan adversary’s centerpiece policy achievement.

The 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act provides a valuable model. Its nearly unanimous passage allows both parties to identify with and defend its provisions in a partisan environment. Key provisions of the SUPPORT Act are thus less vulnerable to particular elections. Whichever presidential candidate wins this November would be wise to politically distinguish COVID-19 and public health measures from more polarized measures such as a proposed public option. Traditionally less-partisan agencies such as the National Institutes of Health and the Food and Drug Administration offer another valuable model.

A durable public health structure would combine such investments with concerted efforts to address social determinants that promote disease spread. Although traditional contact tracing has proven disappointing, promising alternative models combine contact tracing with financial assistance to help people physically distance. An expanded community health workforce is another key element of this structure. Community health workers can fill critical needs. Mobilizing this workforce can also expand employment opportunities in a critical time for workers who may not have college or advanced degrees.

As individuals and communities see community health workers (CHWs) as a resource to meet basic needs, they become allies to promote protective behaviors and public health efforts. Right now, these workers can connect residents to health coverage, housing, and cash assistance to facilitate physical distancing. Using accessible technologies, CHWs can help seniors and individuals with disabilities maintain social connections. Such activities also provide employment opportunities for young adults (and others) eager to help vulnerable members of their own communities. Once today’s threat has passed, CHWs can pursue other public health and social service activities to strengthen communities—maintaining relationship and engagement, and providing a trained strategic reserve workforce available for emergency response.

Public health also requires sustained investment in the social work profession and workforce. Building relationship and engagement with vulnerable people, communities, and groups, helping people gain access to basic resources and reduce personal risks—these are core tasks of the social work profession, shamefully underused and underresourced during the COVID-19 pandemic.

Social workers and CHWs are especially needed to address language and cultural barriers in accessing services. Both can also assist in addressing key behavioral health issues (including likely increases in substance use disorders) associated with physical distancing and COVID-19.

We can’t turn back the clock to undo our missteps in addressing COVID-19; nor can we undo decades of public health infrastructure neglect. We can still learn from the tragedy and build on our best responses. We owe that to 221,000 fellow Americans (and counting), whose lives were so tragically, and often so needlessly, lost this year.

Laisser un commentaire