Health Inequity in the Time of a Pandemic

While much of the residual implications of the COVID-19 pandemic remains unknown, incalculable, and therefore difficult to manage, one thing has come clearly into focus: health inequity.

Reports have shown that populations or individuals who were considered vulnerable or part of a marginalized group have experienced disproportionately higher infection rates of COVID-19 and worse health outcomes. In addition to higher overall infection rates, there is a current imbalance in the distribution of and access to resources in response to the pandemic, causing the already frayed threads of the precarious safety net to break.

The Health Inequities that Have Contributed

The current public health crisis has exacerbated and amplified health inequity, or the systematic differences, regarding the access individuals have to achieve optimal health, leading to unfair and avoidable differences in health outcomes. Differences in access and availability to resources are driven by structural inequities such as racism, ableism and classism. Ultimately, these structural inequities have a direct correlation with the health inequity that arises from conditions known as the social determinants of health (SDOH).

SDOH includes data points such as level of food security, level of educational attainment, income, access to care, reliable transportation and safe housing, and the composition of a person’s social support network or lack thereof. Encompassing educational attainment, income and subjective perception of social status is socioeconomic status, a consistent and reliable predictor of health outcomes, both physical and psychological.

In the spring of this year, the unemployment rate in the U.S. hit a stark 14.7% as reported by the U.S. Bureau of Labor Statistics, with particularly heavy job losses in leisure and hospitality. This economic downturn was disproportionately felt by racial minorities with higher percentages of job loss and hours cut among these groups, as well as evidence of disparities in ability to work from home. While we see the exacerbation of pre-existing social vulnerabilities, such as worsening socioeconomic status among racial minority groups, it is not a surprise that we see increased rates of COVID-19 infections in these groups, particularly among African Americans. According to data released from the Centers for Medicare and Medicaid Services, African Americans have been hospitalized four times more than white people and have contracted the virus nearly three times as often as white people.

Given the robust body of evidence that exists about the patterned relationship between structural and health inequities and the social determinants of health, this devastating and destructive circumstance seems obvious. A deeply embedded structural inequity (racism), producing further health inequity (higher rates of COVID-19 infections), through existing social determinants of health (low socioeconomic status), is the formula that we see consistently playing out throughout this public health crisis.

While structural inequities exist on a systemic level, the COVID-19 pandemic has also held a magnifying glass to the imbalances in healthcare-related resource allocation at the community level. An example of this is evident in the placement of COVID-19 testing sites on which Georges C. Benjamin, executive director of the American Public Health Association is quoted, “Inherent biases held by the people leading the response inform such things as where the testing site is located and how easy it may be to get there. These factors can play a huge role in determining who gets tested. Many of the drive-in centers have been in places inaccessible to minorities or people without a car.”

Additionally there has been an overwhelming increase in the use of telehealth services, not only for COVID-19 related care, but also for chronic disease management. While the adoption of telehealth is necessary in practicing social distancing guidelines and has proven to be a powerful and valuable health IT tool in care management, there are inequitable distributions in the ability to access and use this tool. At least one in four Americans may not have digital literacy skills or access to internet-capable digital devices to engage in video visits. These digital barriers are more pervasive amongst rural populations, racial/ethnic minority groups, those of low-socioeconomic status and older adults. Proactive efforts, as seen in this case study from Unity Health Care Inc., a Federally Qualified Health Center in Washington D.C., are necessary to ensure equity in the wide-scale implementation of valuable telehealth services.

The United States safety net system exists to catch Americans when they come into hard times. However, this “system” is less of a system and more of a patchwork of programs created on an ad-hoc basis with glaring, costly oversights and missed opportunities. Many of the people losing their jobs, and subsequently their health insurance, during this major health crisis are often the same cohort of individuals experiencing a lack of health resources and access to care, both around testing locations and telehealth services.

Practices to Promote Health Equity During the COVID-19 Pandemic

As we enter another month of the COVID-19 response, addressing these disparities and promoting equity within the U.S. healthcare system is paramount. The Institute for Diversity and Health Equity recommends five actions to promote health equity during the current pandemic including specific educational tactics that are relevant to that community and collecting SDOH-related patient data to ensure vulnerable communities are being accurately represented around COVID-19’s impact.

Jacob Reider, chief executive officer at the Alliance for Better Health, who also serves as chair of the HIMSS Social Determinants of Health Task Force, argues going a step beyond education tactics with a listen and learn model of response. Regarding how health inequity has become flagrantly transparent throughout the COVID-19 pandemic, Reider stated, “We need to listen. Really hear what folks are saying. They’re saying it louder now—but that’s because we haven’t been listening. If we really listen, then we’ll learn, and only then can we act with empathy.” Reider goes on to argue that by listening to people and showing empathy toward underserved communities and marginalized populations, then promoting equity becomes less complicated.

Continuing to collect patient SDOH-data during this time is of great importance as well. However, where we collect this information and the specifics of information we collect can make a substantial difference. The act of collecting SDOH data where an individual presents with a social issue, such as a community-based organization, as opposed to a healthcare facility, can provide more accurate data regarding the specific needs of a community.

With rapid losses in jobs and health benefits among vulnerable groups, relying on health system data to determine community needs leads to an inaccurate representation of needs and distribution of resources as many of the people lacking basic necessities will not be able to afford utilization of traditional health care services. Furthermore, in an effort to avoid disguising the full impact the virus has had on minorities, gathering data that squarely focuses on race and ethnicity can help close the data gaps that have persisted throughout the pandemic and strengthen efforts to contain the virus that has disproportionately overwhelmed minority communities.

Next Steps

Looking ahead and determining an actionable path forward, we asked members of our HIMSS SDOH Task Force to reflect on the past six months of the current pandemic and comment on how the future role of health IT tools, resources and concepts can more equitably allocate resources. A common response amongst the members included how technology can serve as both an enabler and a polarizer by cementing differences rather than bridging them. To avoid replicating existing biases in our social and healthcare systems, technology is something to be thoughtfully embraced in the effort to mitigate health inequity. Health IT applications and tools should be made available on multiple platforms with translation services offered. These tools should be interoperable and clearly outline individuals’ data use and ownership to ensure privacy and compliance. Culturally and linguistically appropriate language should be made widely available in communications, app development and available during care coordination.

Regarding telehealth, the current default for primary care delivery, proactively addressing the disparities associated with this shift and advocating for the appropriate policy changes can support sustained equitable access. These changes might include:

• Permanent expansion of low-cost or free broadband.
• Funding for equipment purchase and infrastructure improvement to expand telehealth services in less resourced health centers such as federally qualified health centers.
• Pay parity for telephone and video visits by all payers, Medicaid in particular.
• Removal of barriers such as the requirement for patient portal enrollment to engage in video visits.
• Implementation of outreach programs that assist patients in setting up a video platform application.

In terms of health coverage, it has been recommended that states facing increased demands on their Medicaid programs should streamline enrollment and expedite coverage for eligible people while minimizing workload for eligibility workers. States can expand presumptive eligibility, streamline account transfers from HealthCare.gov, increase real-time eligibility determinations, and minimize paperwork through various pathways, as noted by the Center on Budget and Policy Priorities.

As we continue our fight against the COVID-19 pandemic it is important to note that although this is a global crisis, health is local. Local input, local data and the empowerment of local leaders can identify communities that need higher levels of resources and funding, as well as identify community-level barriers to optimal health before a crisis even occurs.

Updated October 9, 2020