COVID-19 highlights racial disparities in our health care system

In almost 60% of states for which race and ethnicity data is available on the CDC website, the distribution of COVID-19-related deaths is substantially higher among African American and Latinx communities than the groups’ distribution in the population. COVID-19 mortality rates are 2.6 times higher for African Americans than for whites in the US. The virus is uncovering the vast social determinants of health that differentially affect communities of color: higher risk of co-morbidities and prevalent health conditions such as heart disease, diabetes, asthma and hypertension, which could lead to more severe impact of COVID-19.

Communities of color also face increased health risks associated with COVID-19 related to their economic and social circumstances. They are less likely to have health insurance, which reduces their ability and willingness to seek treatment. On the other hand, African Americans with insurance are more likely to live in neighborhoods that have under-resourced clinics, emergency rooms and hospitals and therefore less equipped to take care of the community during this pandemic.

Finally, faced with the shortage of testing kits and the inherent subjectivity of COVID-19 symptoms, doctors seem to differentially administer tests among patients of different races, ordering white patients to get tested, and black patients to shelter in place and observe symptoms.

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Pathways to better care

These health care disparities are part of a long-standing problem of disparate health care access for racial and ethnical groups. The pandemic provides an opportunity to take radical action to build trust and mitigate harm. There are no simple solutions, especially given the unprecedented nature of the outbreak, but clear paths to better care can be identified.

Expanding Medicaid coverage

Expanding Medicaid coverage alone would extend coverage to over two million individuals who currently fall into the so-called coverage gap. Lack of health insurance among low-income groups represents a threat to all. Expansion of health care coverage is an urgent and a necessary step.

Testing and self-isolation policies

Current interventions fall short of catering to the needs and interests of marginalized communities. After initial failures to ramp up testing, the US has been working to increase its testing capacity. With an increasing number of labs processing an average of 250,000 verified diagnostic tests per day and policies such as the CARES Act decreasing the economic burden of getting tested, it might seem that the country is on track to provide equitable access to COVID-19 screening to all its citizens. However, barriers to access for marginalized populations prevail. 

Drive through testing centers are one example of an intervention with unintended consequences: both their design and location assume that all the patients will arrive in vehicles. Yet many citizens simply do not own a vehicle that they could use to show up at a drive-through testing center. In some states a majority of testing centers are located in areas that are either whiter, wealthier or both.

Similarly, social distancing policies and stay at home orders place a disproportionately high burden on those with unstable, low incomes and without possibilities to perform their work remotely. When these groups are additionally asked to self-isolate due to a COVID-19 risk or diagnosis, they often find themselves with no place to go. Not only must testing be affordable and accessible to marginalized communities but isolation and quarantine must be voluntary and feasible.

Transparency in data

To be able to design and execute targeted and effective interventions, it is key to set up better reporting systems and processes. Transparency about socioeconomic determinants of health in all state and federal statistics is needed. In the COVID-19 pandemic, the disease reporting form provided by the CDC does request granular data, including the cases’ race and ethnicity, but race is still reported as missing/unspecified in almost 53% of cases.

Health care experts warn that efficient data sharing will be instrumental in containing the disease in the US, potentially as important as supplying personal protective equipment to medical centers. Now that the nation is gradually opening up and easing social distancing measures despite no sign of the virus retreating, its importance is not to be underestimated. 

Under pressure, CMS announced that more granular data, with breakdown by race and ethnicity, will be published, but a recent report to Congress is woefully limited. Both during this pandemic and after it,  the CDC should commit to tracking and publishing data on race and ethnicity to avoid further deepening disparities in access to health and economic relief and ensure equitable division of resources.

Rebuilding trust

Differential treatment of patients based on race and ethnicity, different access to care and systematic bias over the years have undermined trust that communities of color have in the health care system. Working to address racial disparities in the COVID-19 outbreak can be a first step towards rebuilding it.

Health care leaders must work with community leaders and advocates that the local community trust. This is a time when health care systems need to strengthen their community-based coalitions.  The messages that the health care system is giving patients of color must be echoed by leaders in the community, or else they will be met with distrust. In parallel, it will be critical to bring testing and education directly to the most impacted communities, while addressing long-standing biases and stereotypes. Many African Americans are afraid to wear mask in public for fear of being assumed to be criminals and exposed to increased interactions with law enforcement, which can be life threatening for them.

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The global pandemic is a dark moment in US history, exposing our lack of attention to health equity in the nation. However, it can be a moment when we begin to address long-standing failures of our health care system, promote equitable access to health services and help communities of color to achieve the care that all Americans should have.

Aneta Gasiewska is an MPH/MBA candidate at Yale University. Dr. Howard P. Forman is a professor of Public Health (Health Policy) and Management at Yale University. Dr. Darin Latimore is deputy dean, chief diversity officer and associate professor of Medicine at Yale School of Medicine.