Ending Racial Inequality in Health — Now
Disproportionate COVID-19 death rates among Black and Latino communities confirm systemic disparities in patient care. Here’s what needs to happen to close the gaps for good.
Perhaps the cruelest pandemic paradox: Across the U.S., people of color — who are disproportionately more likely to contract and suffer more severe illness from COVID-19 — are also getting vaccinated at lower rates than white people, early data suggests.
A February 2021 Kaiser Family Foundation (KFF) analysis that looked at published vaccination statistics from 23 states found that people of color are getting significantly smaller shares of vaccinations, compared with their share of the population.
The vaccination inequity echoes much of the past year, as the virus has revealed deeply embedded inequities in the country’s health care system — and the overwhelming need to develop a real path forward.
The numbers paint a clear picture of the tremendous toll COVID-19 has taken on people of color: Black people are 1.4 times more likely to contract the coronavirus and 2.8 times more likely to die from it than their white counterparts, according to data reported in November 2020 from the Centers for Disease Control and Prevention (CDC).
Addressing COVID-19 Head-On
Dr. Lavdena Orr, market chief medical officer at AmeriHealth Caritas District of Columbia, elaborates on her team’s response to the coronavirus.
When it became clear that COVID-19 was going to be a true health emergency, what did you do to help protect members?
We reviewed all of our high-risk enrollees so that we could do special outreach to them. I was involved in identifying the list of chronic conditions considered high-risk based on CDC guidelines. Having done that, we were able to implement a program whereby all of those enrollees with asthma, congestive heart failure, transplants and other chronic conditions or who were immunocompromised were contacted individually by our outreach associates to find out how they were doing and educate them about our services available to support them during the public health emergency.
What did those outreach efforts look like?
We were able to make sure they all received masks and hand sanitizer, we set up meal delivery should they need it and we ensured that they had transportation, especially for our enrollees who receive dialysis. We worked very quickly to ensure that we could do all we could to close the gaps in their access to the social determinants of health and reduce any disparities that would result from that.
As the health care world thinks through long-term solutions, how might Medicaid play a role in closing the gap in COVID-19 outcomes?
I believe Medicaid has played a significant role in the solution by ensuring practitioners can practice telehealth and be reimbursed. Otherwise, doctors aren’t able to interface with patients who are afraid to go outside or don’t have access to transportation to make it to appointments. Our efforts were population health focused, because we were able to identify the enrollees with chronic conditions and have a plan to reach them, while understanding what their needs were and how to address them.
We also identified ways to address vaccination inequity and hesitancy. For example, to facilitate access to the vaccine for communities disproportionately affected by COVID-19 in Greater Philadelphia, we equipped our Wellness and Opportunity Center, as well as our headquarters, to serve as vaccination sites with education about the COVID-19 vaccines for anyone in the surrounding communities, which have significant numbers of low-income residents. This is not only helping to close a health equity gap, but also to strengthen our community partnerships, which are even more essential during the pandemic.
Latinos were 1.7 times more likely to contact the virus and 2.8 times more likely to die from it than whites. A deeper dive into the numbers reveals an even more bleak story, according to the CDC. People of color are dying of COVID-19 at younger ages than white patients. Nonwhite people accounted for 40% of deaths under 65, though they make up just 23% of those under 65 nationally, the CDC reported in July. For health experts, the disparity is stark—but not surprising. “Many of us saw it coming, and we weren’t surprised to see these inequities in COVID-19, because we see the exact same pattern across countless other diseases, illnesses and injuries in this country,” says Dr. Malika Fair, senior director of health equity partnerships and programs at the Association of American Medical Colleges and associate clinical professor of emergency medicine at the George Washington University School of Medicine and Health Sciences.
People of color experience higher rates of chronic medical conditions, including obesity, diabetes and kidney disease — all shown to be risk factors for severe illness from COVID-19. These chronic conditions are tied to social risk factors, such as housing insecurity, food insecurity, and lower quality and attainment of education, which lead to higher-risk service-related jobs, says Dr. Fair.
“Then you have to take it another level and look at systemic racism in our country that we, probably for the first time this summer, acknowledged en masse, both in our country and also in the medical community. We’re seeing a recognition that systemic racism has led to the inequities in COVID-19, but also the inequities in countless other diseases and illnesses in our nation.”
The most recent edition of the National Healthcare Quality and Disparities Report published in 2018, for example, reported that Black patients, Native Americans and Alaska Natives, and Native Hawaiians/Pacific Islanders received worse care than whites for about 40% of quality measures.
“COVID has helped people better understand the role that racism plays in health care access, health conditions and also health coverage as well.”
Access and Equity
The pandemic may not have told us anything new, but it does make the inherent inequalities all the more difficult to ignore and add urgency to the search for potential solutions.
“COVID has helped people better understand the role that racism plays in health care access, health conditions and also health coverage as well,” says Jamila Taylor, PhD, director of health care reform and senior fellow at the Century Foundation, an independent think tank.
A March 2020 report by Rubix Life Sciences, a biotech R&D firm, analyzed medical claims data across seven states and found that Black patients presenting with COVID-like symptoms were less likely to receive referrals for the then-hard-to-access COVID test than white patients with similar symptoms. “It’s important that we, as a medical community, take a hard look at these data and ask if we’re delivering differences in our care to our patients,” says Dr. Fair, regarding the Rubix report. “If we can’t fix that, then we’re not going to fix differences in morbidity and mortality in COVID-19.”
Broader access to health care is a necessary first step, says Dr. Taylor. “We saw millions of Americans lose their jobs because of COVID-19, and, as a result, they also lost their employer-sponsored health insurance.”
The expansion of Medicaid is one option. A Kaiser Family Foundation review of 65 studies published between 2014 (when coverage provisions of the Affordable Care Act went into effect) and July 2020 found Medicaid expansion didn’t eliminate but helped narrow racial disparities in health coverage. And some of the studies showed that Medicaid expansion was associated with narrowed disparities in health outcomes for Black and Latino patients, particularly in regard to maternal and infant health.
If states that haven’t yet expanded Medicaid were to do so, at least 4 million additional uninsured adults would become eligible for Medicaid coverage — nearly 60% of them people of color, according to the Center on Budget and Policy Priorities. Greater access means better outcomes. A study published in JAMA found significant reductions in mortality from end-stage renal disease in expansion states compared to non-expansion ones, with the largest drop in Black patients. A 2020 study in Women’s Health Issues found Medicaid expansion lowered maternal deaths among Blacks by 16 per 100,000 live births and resulted in six fewer maternal deaths per 100,000 live births for Latinas.
“We believe it is not sufficient for medicine to be nonracist, which is why the AMA is committed to pushing for a shift in thinking.”
“If we think about Medicaid expansion and the impact that it’s had on addressing disparities in access to health care, it really is an important lever for advancing health equity,” says Dr. Laurie Zephyrin, vice president of health care delivery system reform at The Commonwealth Fund and a clinical assistant professor of obstetrics and gynecology at NYU School of Medicine.
Broader health care access — combined with publicly reported, real-time data that shows population race, ethnicity, gender, language and disability — would allow public health officials “to really understand who could potentially be the hardest hit by the pandemic and invest in resources to prioritize those hardest hit,” she says. Medicaid expansion alone won’t erase inequity, but “we’d be in a better place to help mitigate where people are at highest risk due to lack of access to health care.”
The Seat Belt Model
COVID-19 has proven to be a powerful call to action to finally address inequities. The American Medical Association explicitly acknowledged racism as a public health threat in November and proposed a series of actions, including shifts in education, research and policy to ameliorate the health effects of bias. “The AMA is dedicated to dismantling racist and discriminatory policies and practices across all of health care, and that includes the way we define race in medicine,” said AMA board member Dr. Michael Suk. “We believe it is not sufficient for medicine to be nonracist, which is why the AMA is committed to pushing for a shift in thinking from race as a biological risk factor to a deeper understanding of racism as a determinant of health.”
Some of the methods for addressing racial inequity in health care aren’t all that novel, says Dr. Lavdena Orr, market chief medical officer for AmeriHealth Caritas District of Columbia. Just look at nationwide efforts to convince people to wear seat belts or stop smoking, she says.
“These proven national agendas have dramatically reduced deaths,” she says. But they required intense collaboration across government, health care and community leaders. A national initiative to end health care inequity would likewise have to address not only bias in health care but also the racist systems that underscore that bias.
Shot in the Dark
Improving vaccination equity relies first on tracking and benchmarking the current state — an impossible task without robust data. But when it comes to the COVID-19 vaccine, inconsistencies abound, the KFF analysis shows.
For instance, not all states have thus far published vaccination data. Of those that have, the data is often incomplete. In some instances, up to half of a state’s total vaccination records list “unknown race” or “other.” States also vary in whether individuals can identify as multiple races or whether Hispanic ethnicity is included as a racial category.
The data lapses and inconsistencies are so pervasive that many public health experts have argued that it’s all but impossible to gauge the full scope of the inequity. That opacity further frustrates efforts to distribute limited vaccine supplies in an equitable manner.
The data lapses ... are so pervasive that ... it’s all but impossible to gauge the full scope of inequity.
Dr. Taylor worked with Vice President Kamala Harris when she was a senator on the COVID-19 Bias and Anti-Racism Training Act of 2020, introduced in July 2020 but never voted on. “Bias is the low-hanging fruit, like changing whether or not a doctor has a stereotypical view of a low-income woman and how she may be living her life that has a direct impact on her health status.”
Health care providers trained to understand bias would see that situation as controllable: With shifts in her home life or access to transportation, the patient’s situation would improve. “Whereas if we look at it in the context of racism and white supremacy, we acknowledge that regardless of a person’s income level, if they’re Black or brown, racism is going to be a part of their daily experience, and we need to look at how racism manifests in systems,” she says. “It’s why this bill is focused on bias and anti-racism because we need accountability at the individual level, but we also need to address it at the systemic level.”
The bill calls for $100 million in funding in each of the next two fiscal years. It affords the Department of Health and Human Services the ability to award grants to hospitals, community health centers and health care providers for bias and anti-racism training, with the specific goal of reducing racial and ethnic disparities in COVID-19. “We’re talking about treatments, testing, health outcomes and vaccine access,” says Dr. Taylor. And the goal is for this training to be ongoing, not a one-off course that checks a box.
Added accountability could be another potent prescription for lasting change. Hospitals and health care providers alike are already accustomed to tracking and reporting detailed metrics around their quality scores, so it wouldn’t be difficult to prioritize the reporting of any racial inequities, even at an individual provider level, says Dr. Fair.
“I routinely get data on how fast I see a patient, how quickly I discharge them,” she says. “We should make it standard across the community to provide that sort of information by race and ethnicity, because if I see a report card that I’m treating my white patients differently than my Black patients, I’m going to have to change, right?”
“If I see a report card that I’m treating my white patients differently than my black patients, I’m going to have to change, right?”
Some hospital systems have already begun this work, putting in place training and accountability measures to spur change, one department at a time. Twice a year, residents at Washington University receive a report with data on inequities in diabetes metrics based on race, gender, primary language and insurance type. The data is used to not only reveal care disparities but to spark conversations on how to correct them. At the 51-hospital system Providence St. Joseph Health, executives in September 2020 announced a $50 million investment in closing health disparities, starting with the COVID-19 care gap. Initial plans center on outreach and education, as well as increasing COVID-19 testing supplies for marginalized communities.
In October 2020, Blue Cross and Blue Shield of Illinois launched a three-year, $100 million equity pilot aimed at helping populations most at risk for contracting COVID. And Brigham Health, the world-renowned medical complex and Harvard teaching affiliate in Boston, has become a notable case study in how a next-gen data approach can help erase disparities. There, a team that spanned clinical and hospital leaders in diversity, equity and inclusion, quality improvement, and data science collaborated to create a robust data infrastructure and visual dashboards to examine racial inequities for COVID-19. Data included inpatient and intensive care unit census, deaths and discharges — all stratified into subgroups, such as race, language, insurance type and health care worker status. The team took it a step further by applying filters, which made it possible to parse the impact by intersectional identities — that is, how the virus impacted not just Blacks versus whites or men versus women, but Black women versus Black men. That greater refinement surfaced actionable insights, such as the fact that Hispanic non-English-speaking patients were dying at a greater rate from COVID-19 than those Hispanic patients who spoke English, which sparked a program to improve access to language interpreters. When the team looked at stratified data on hospital employees by demographic groups, they found frontline workers such as environmental, food services, materials management and transport employees had high rates of transmission. That finding prompted a shift to small-group sessions aimed at keep those workers connected to crisis resources, including printed handouts in five languages. More than 1,000 employees attended.
Still, for change to take root, it has to move beyond just the hospital walls. “Health care disparities are controlled by us who are practicing,” says Dr. Fair. “But in order for health disparities to be eliminated, a lot of people have to be involved.” She points to Denver Health’s partnership with the local housing authority to turn an unused office building into temporary affordable housing. As homeless patients are discharged, they will be offered the option to stay there rather than return to the shelters or streets.
“We know that housing is health, and you really can’t be healthy if you have no place to live,” she says. “It’s cheaper to invest in affordable housing and housing for the homeless than it is to have uncompensated care in the emergency department and to admit a patient for a week in your hospital.”
Driving real reform to eliminate health disparities will take nothing short of an interdisciplinary full-court press.
“We tend to think as a medical community that we can cure all, and we really can’t,” says Dr. Fair. “We have to do this in partnership with other sectors in our society and, most importantly, with our local communities.”