Addressing Racial Health Disparities In The COVID-19 Pandemic: Immediate And Long-Term Policy Solutions – healthaffairs.org

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The devastating impact of COVID-19 is apparent, with nearly three million confirmed cases and more than 131,000 deaths in the US. Among those affected, communities of color bear the brunt of the pandemic. Health disparities in the COVID-19 crisis call attention to long-standing inequities that pervade the health care system and society at large.
This post will present a framework for understanding health disparities during the COVID-19 pandemic, as well as provide short-term and long-term solutions to reduce these disparities.   
The pattern of disparities during the COVID-19 crisis is analogous to the medical concept of “acute on chronic.” This refers to a long-standing medical condition that is exacerbated by an acute illness, often leading to worse outcomes than would have resulted from the acute illness alone. This is the case for COVID-19: It is a novel disease and global pandemic that has unmasked long-standing underlying health disparities.
New federal data reveals that African Americans and Latinos in the US have been three times more likely to contract COVID-19 than white residents and nearly twice as likely to die from it. Some counties with a majority of African American residents have almost six times the death rate compared to counties that are predominantly white. In some states such as Illinois, Latinos have nearly seven times the rate of COVID-19 cases compared to white people, while African Americans have the highest death rate. In California, Pacific Islanders face a death rate from COVID-19 that is 2.6 times higher than the rest of the state, while in South Dakota, the rate of COVID-19 among Asian Americans is six times what would be predicted based on their share of the population. Other minority communities are also disproportionately affected, including in New Mexico, where Native American people comprise about 11 percent of the population yet account for more than half of COVID-19 cases.
Health disparities during COVID-19 reflect two important patterns of inequity. First, minority communities have a high likelihood of contracting the virus by living in urban areas and disproportionately working in higher-risk environments. According to data from the Bureau of Labor Statistics, a greater number of African American workers are unable to work from home, compared to white workers. A study of the “Mission District” community in California showed that Latinos accounted for more than 95 percent of positive COVID-19 cases and 90 percent of individuals with positive tests were unable to work from home. Certain industries that have workers that are predominantly minorities face higher rates of COVID-19: At meatpacking plants, where the rate of COVID-19 infections is higher than the rate in 75 percent of US counties, nearly half of workers are Hispanic and a quarter are African American.
Second, racial minorities also experience higher rates of chronic medical conditions, including obesity, diabetes, and kidney disease, which are risk factors for severe illness from COVID-19. These statistics occur on a backdrop of existing disparities in outcomes: For example, African Americans have higher rates of maternal mortality and death from cancer and heart disease than any other racial and ethnic group. Individuals from underserved communities are also more likely to have undiagnosed chronic disease, compounding the acute impact of COVID-19. These inequities are tied to long-standing barriers to accessing essential resources such as food, transportation, and housing, as well as a long history of unequal treatment, discriminatory policies, and systemic racism.
COVID-19 has resulted in stopping key social programs that are community lifelines, such as schools and senior centers. Home visitation programs that have been instrumental in reducing infant mortality and lead poisoning have been put on hold. Many who have chronic conditions face additional problems of accessing care. The acute impacts of COVID-19 worsen underlying conditions in individuals and communities. Solutions must therefore focus on both aspects.
First, public health resources for COVID-19 should be targeted to minority and underserved communities. The tenets of an effective public health strategy for controlling COVID-19 are testing, contact tracing, and isolation and quarantine, with data/surveillance to inform these efforts.
Testing must be made free, widespread, available without a physician’s prescription, and targeted to communities that are most impacted by COVID-19, namely communities of color. The Families First Coronavirus Response Act, passed in March 2020, eliminated cost sharing for “COVID-19 testing-related service[s]” for those with private insurance and granted states the option to cover costs for uninsured patients; the Coronavirus Aid, Relief, and Economic Security Act expanded the range of tests covered by insurers. Still, there have been reports of patients facing hundreds of dollars in medical costs due to testing; shortages of COVID-19 tests force providers to administer multiple non-COVID-19 tests to rule out disease, raising the cost of medical bills.
Testing must also be made easily accessible in the community, through expansion of testing sites beyond clinics to places of worship, community centers, and public housing complexes. Testing has already begun at churches in states such as New York, Alabama, West Virginia, and Maryland, although reports show that hundreds are being turned away due to insufficient tests, staff, personal protective equipment, and lab capacity.
The federal government should also make it a priority to acquire accurate tests with a very low false positive rate and the ability to produce rapid results. Tests that do not give a result for 24 hours have limited utility to prevent disease transmission. Lengthy waits for test results lead to a significant lag in data, preventing the ability to adjust public health guidance based on the actual spread and severity of disease at a single point in time.
Contact tracing is underway including through direct outreach and mobile applications, although the number of contact tracers still lags behind projected workforce requirements. As efforts ramp up to recruit, train, and deploy contact tracers, there must be recognition that effective contact tracing depends on community trust. Mistrust of medical institutions and authorities among communities of color is related to a historical legacy of mistreatment and discrimination, such as during the Tuskegee experiment, and extends to policies such as the Trump administration’s public charge rule. Every effort should be made to recruit contact tracers from the communities they serve and to deploy contact tracers based on community need. Using trusted contact tracers can also help to overcome language barriers that interfere with effective outreach to non-English-speaking people. This community engagement will also serve as an opportunity for employment in communities hardest hit by the economic impacts of COVID-19.
The Centers for Disease Control and Prevention (CDC) recommends quarantine for 14 days from the last day of exposure to the virus and isolation for at least 10 days after illness onset and 3 days after recovery. Isolation/quarantine is impossible to achieve for individuals who live in close quarters or shared housing arrangements. One analysis found that in California, 18.4 percent of Latino families live in overcrowded housing compared to 2.4 percent of white households; the same study found that home overcrowding is correlated with a higher death rate from COVID-19. The federal government should allocate funds to establish or repurpose facilities that can be used free of charge for isolation/quarantine; empty hotels and dormitories can serve as temporary housing for individuals who are unable to find a place in which to isolate. Funding should also be directed to reduce the financial impact of isolation/quarantine: A bipartisan proposal calls for $45 billion with a significant portion dedicated to funding a stipend—in an amount analogous to federal jury duty—for voluntary self-isolation. For those who will choose to remain at home, support can be given by way of grocery and medication delivery assistance programs to encourage isolation within the home.  
There is one critical metric still needed: demographic data for testing. Leading medical and public health groups have called for the release of available racial demographic data about infection rates, hospitalizations, and mortality from COVID-19. One pilot study found that African American patients were six times less likely to receive COVID-19 testing than white patients. Experts have also argued that the initial COVID-19 testing criteria, which was based on travel and exposure to positive-testing patients, favored testing for affluent, white patients. Data on testing for different demographics will provide information about measures in our control to prevent the spread of disease in the first place.
Public health experts generally agree that the number of tests performed is considered to be sufficient when the positive rate falls below 10 percent. This testing data should be broken down by race and ZIP code. That way, if a community sees a positive COVID-19 rate of 10 percent but African Americans are still testing positive at a rate of 20 percent, it will be clear that African Americans are undertested compared to other groups. Similarly, neighborhood data would allow for better targeting of tests and resources to specific areas.
The Trump administration’s recent announcement that it will require demographic data during COVID-19 testing is a step in the right direction. These data can be compiled in the form of a dashboard that is updated in real time and coordinated by the CDC with data uploaded by state and local officials. Creating a central source for this data provides important information and ensures transparency and accountability that are needed to ensure that communities most in need are receiving the resources they require. Federal funding can be tied to the availability of these data, adding a strong incentive for compliance.
Second, public health authorities such as the CDC should establish clear, directive guidelines to protect workers and ensure that they are enforced. Local public health officials rely on the unambiguous guidance of the CDC. The CDC held informative daily briefings at the beginning of the COVID-19 crisis, but it has since been stopped. Subsequent guidance from the CDC was delayed, and the language used in the guidelines was not specific, directive, and clear.
The CDC should resume daily briefings to keep the public and local and state authorities apprised of latest guidance. For example, with states reopening, employees are told to return to work. What standards must be met prior to going back to work? What specific criteria must be met in different types of workplaces, such as office environments versus meat-packing plants? People should not just be “encouraged” to maintain social distance. Masks should not be worn, “if appropriate.” They should be required. The CDC should issue clear statements such as: If the following 15 criteria cannot be met, then reopening is not safe and employees should not be allowed back in these spaces. The Occupational Health and Safety Administration should then enforce these rules, as should local and state regulatory entities. If not, it is people of color and those who already face systemic disparities who will suffer the most.
Some may argue that directives should not come from the federal government and that local officials who know communities the best should put out this guidance. No local official has the time nor the workforce capacity to wade through thousands of scientific studies. The CDC is the leading expert in synthesizing scientific information into actionable guidelines. Local public health leaders depend on the CDC to develop evidence-based guidelines that can be tailored and explained by local officials in the local context of their communities. Quite the opposite of constraining, federal guidelines empower local officials to do their work.
Third, the federal government should ensure that all patients who need medical care related to COVID-19 have access to it. The prohibitive cost of treatment for many Americans has been well-described: An analysis by FAIR Health found that insured patients who are hospitalized with COVID-19 can expect to pay up to nearly $75,000, while uninsured patients can pay an estimated average of more than $70,000 for a six-day hospital stay; communities with the highest rates of uninsurance, namely American Indian/Alaskan Native, Hispanic, and African American patients, bear the burden of these costs. The high out-of-pocket costs of COVID-19 care are compounded by loss of employment, which is the source of health insurance for about half of Americans. Research by Gallup points to the practical impacts of these financial barriers, with one in seven people in the US stating that they would avoid seeking treatment for symptoms of COVID-19 due to cost.
Health care to treat COVID-19 and related illnesses must be fully covered. Such coverage can be achieved through expanding Medicaid, approving state Medicaid waivers to expand eligibility and coverage, and having open enrollment in state exchanges, especially to assist those whose insurance is tied to employment. There must also be paid sick leave, as well as facilities and mechanisms to properly isolate/quarantine as mentioned above.
We cannot discount the role of long-term recovery: Many individuals who become sick from COVID-19 may take months or even longer to recover. Already, many insurance companies and employers have adjusted health insurance plans to ensure coverage of COVID-19 care. For example, Aetna waived cost sharing for inpatient admissions at in-network facilities for treatment of COVID-19 or complications of the disease during a certain time frame, and Blue Cross and Blue Shield companies similarly waived cost sharing for COVID-19 treatment through the end of May. Given that health care needs of patients will extend into the coming months, particularly as new cases emerge, these waivers should be extended accordingly.
While the above measures are critical to reducing the burden of COVID-19 disease in communities most vulnerable to COVID-19, they are not sufficient to reduce racial disparities in the long run. Longer-term, systemic solutions are therefore critical.
First, policy makers and health care authorities should prepare for the next surge. In March 2020, the US faced an unconscionable situation: Hospitals ran out of personal protective equipment (PPE) and were forced to put frontline clinicians in harm’s way without equipment as basic as masks. The country also came to the brink of running out of ventilators and other critical equipment; medical providers in New York City described having to “split” ventilators between patients and make heart-wrenching decisions about who to ventilate. States were forced to bid against each other for these and other critical supplies, such as swabs and reagents for tests. There are a number of reasons why the US was not prepared the first time around. We know what is needed now, and we know that a second surge will almost certainly happen, especially with the convergence of COVID-19 with the flu season.
The federal government must develop and implement a national, coordinated effort to secure needed supplies and create a plan for procurement and distribution. PPE should not only be available to frontline hospital workers but also to others who must interface with many people every day, such as grocery cashiers, bus drivers, and nursing home attendants. Hospitals need to prepare for the second surge, and local and state policy makers must gird for this too. Lack of action will affect everyone, but in particular those in our society who are the most vulnerable, many who already face the brunt of existing health disparities.
Second, the federal government must anticipate and address the issues that will emerge as treatment and vaccines develop. If there is an effective treatment developed, how will it be equitably distributed? If a limited supply of a vaccine becomes available, how can we ensure that it is not only those who are privileged who will have access to it? Lack of thoughtful planning will inevitably lead to a situation where those who are well-connected and well-resourced can obtain scarce resources, leaving many others to go without them. The government should take early action to ensure that new vaccines or treatments for COVID-19 are affordable and accessible to all. Residents of minority communities should be encouraged to take active part in discussions about vaccine distribution so that they can advocate on behalf of their communities. As with the call for racial data on testing, the CDC should develop and oversee a system that tracks demographic data on vaccination and access to treatment to ensure that certain groups are not overlooked.
Third, the federal government should support safety-net health systems. Thousands of primary care and community-based health care organizations have suffered substantially during the COVID-19 crisis, and some may not survive in its aftermath: In states such as Connecticut, nearly three-quarters of the state’s community health center sites shut down temporarily due to COVID-19. Home visitation and other community outreach programs have also had to curtail their work; many others may not be financially sustainable either. Efforts must be made to support these community-based programs that serve as the safety net for many.
These same community health clinics and organizations, which include home visiting programs, provide essential primary care services to underserved communities that might not otherwise receive care: Nearly one in five Medicaid patients go to community health centers for care, and almost 70 percent of patients at safety-net health clinics live in poverty. Investment in community health systems will be all the more important as the number of individuals covered by Medicaid grows.
Funding local public health is a critical safety net in times of crisis. Already, local public health is chronically underfunded, with less than 3 percent of the estimated $3.6 trillion in annual health care spending directed toward public health and prevention; CDC funding for public health preparedness and response programs has been cut by half over the past decade, and public health laboratories, which manage early diagnostic testing, suffered severe budget cuts prior to the COVID-19 pandemic. This insufficient funding forces local public health officials to make impossible tradeoffs between critical, life-saving programs that serve communities in need. There is an urgent need to strengthen local public health infrastructure not only to ensure a robust response to COVID-19 and future crises but also so that those interventions do not come at the cost of health and well-being and thus further perpetuate racial disparities. Funding should also be made flexible. Local health systems must be able to swiftly adapt and respond to evolving community needs, rather than having to justify how they meet congressional spending mandates.
There must also be attention to previously marginalized areas of health care. Mental health is already a neglected area, and the need for behavioral health services can only be expected to rise with the convergence of health, economic, and societal crises; the National Alliance on Mental Illness reported a 41 percent increase in the number of calls to their hotline during the pandemic compared to the same time period in 2019. Any discussion of health care reform must regard mental health as an equivalent need to physical health. There must be funding for programs to address trauma and build resiliency. And there needs to be recognition of the fact that racism is a public health issue—indeed a public health crisis in and of itself.
Finally, resources should be targeted to address social determinants of health, with a focus on areas of greatest need. Disparities in health are inextricably linked to housing instability, food deserts, and lack of transportation access.
Any reform of the health care system must consider that 70 percent of variation in health outcomes is tied to social determinants rather than the health care that one receives. For example, there needs to be examination of affordable housing through investment in the construction and repair of potential housing options and support of policies that extend debt forgiveness and prevent eviction. Food insecurity can be addressed by expanding eligibility and granting waivers for food assistance programs such as WIC and SNAP, investing in local food banks, and incentivizing food delivery for low-income and vulnerable neighborhoods, while education should be made a priority by ensuring access to books, technology, and internet, all essential components of virtual instruction. Resources provided in the wake of the pandemic should be specifically targeted to areas of greatest need.
All of these interventions must be implemented in the context of systemic changes that recognize and address racism as a public health crisis. The ongoing uprisings following the murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many others highlight profound inequities that have persisted for years and that underlie health disparities. As the disparate outcomes from COVID-19 have shown, it is not sufficient to advance policy or strategy without an explicit focus on equity.
While the COVID-19 crisis has shone a spotlight on the structural failings of our health care system, it has also revealed the disproportionate impact of crises on the poor and communities of color. As states begin to reopen and we look ahead to the next stage of the COVID-19 pandemic, policy makers, health systems, and public health authorities should turn attention to concrete steps that can be taken to ensure that recurring patterns of health disparities do not repeat themselves.

DOI: 10.1377/hblog20200716.620294

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