Butler SM. Four COVID-19 Lessons for Achieving Health Equity. JAMA Health Forum. Published online November 5, 2020. doi:10.1001/jamahealthforum.2020.1370
The coronavirus disease 2019 (COVID-19) pandemic has underscored the deep inequities in our health care system. The disproportionately high levels of COVID-19 cases, hospitalizations, and deaths among non-White racial groups reflect poorer underlying health, housing, and job conditions among these minority groups, as well as an inequitable distribution of health resources and persistent gaps in insurance coverage.
The basic disparities in coverage and resource allocations obviously need to be addressed to achieve a more equitable health system in the US. But COVID-19 also has provided many other lessons about our health system that need to be taken to heart. Even with a rebalancing of spending, it is essential to respond to such lessons to create a more equitable and effective system. Consider just 4.
The COVID-19 pandemic has made it very clear that for households in underserved communities and for those least connected to health resources, it is critical to take services to people rather than always expecting people to travel to obtain them. That is why it is so important to decentralize care by building up the infrastructure of health services within underresourced communities. One component of this would be to expand the network of community health centers that serve people in their own neighborhoods. It is also important to expand opportunities for health services to be delivered within the local institutions that people frequent, not just in shopping centers but also by such steps as creating miniclinics within housing complexes and expanding the role of school-based clinics.
Public health officials have faced serious challenges in encouraging good health practices and timely care during the pandemic. Poor communication and distrust between physicians and patients are factors and, for health care encounters generally, they lead to poorer health outcomes. The suspicion among Black individuals regarding a COVID-19 vaccine has deep historical roots. But more generally, insensitive or awkward interracial communication in health care is an impediment that disproportionately affects Black individuals and other minorities, and appears connected to differences in such areas as pain management and perhaps even birth outcomes.
There are strategies for improving trust and effective communication. Teaching better communication skills to physicians and nurses is one strategy. But another technique is to use intermediaries essentially as cultural translators. City Health Works in New York City, for instance, has a team of community “health coaches” who build trust and better communication between health professionals and patients. Some local institutions could also play this role. Barbershops, for instance, have a unique social role in the Black community, and some barbers have been recruited and trained to engage their clients in conversation about men’s physical and mental health and link them to necessary care.
Infections introduced into nursing homes by caregiving staff appears to be an important element in the COVID-19 perfect storm that engulfed these facilities. The characteristics of the caregiving workforce increased the risk of virus transmission. A high proportion of caregivers, for example, are themselves at high risk. They work multiple jobs and often take public transportation to work, and almost half live close to the poverty level or below. The health and socioeconomic conditions of the staff at most nursing homes and in home-based caregiving systems are a microcosm of the gaps and weaknesses in the health system.
COVID-19 drew attention to the caregiver workforce and has reinforced the importance of improving the conditions and skills of professional caregivers for the benefit of residents as well as the staff. One needed step is to increase Medicaid and other payments to make possible improved pay levels and to attract staff with higher skills. Another is to revamp the training and regulation of caregivers, which varies widely among the states in both scope and intensity. It will be impossible for the US to have effective care for older adults without these and other reforms for the workforce.
For millions of families, the COVID-19 shock of losing employment has been compounded by the temporary or permanent loss of health insurance. The profound weakness and inequities of insurance linked to the workplace has become very evident thanks to the economic effect of COVID-19. This unique feature of the US system, encouraged by the tax-free status of the part of compensation allocated to health insurance, did help over many decades to expand coverage among working families in the US. But for those who do not work for employers offering insurance or are only loosely connected to the full-time workforce—such as part-time workers, seasonal, and retail workers as well as workers in the gig economy—employment-based insurance is rare. And even when employer-sponsored insurance is offered, their share of the cost for buying family coverage for themselves and their dependents is prohibitive for many workers. It is not surprising, then, that the rate of uninsurance is highest among groups, such as Black and Latino individuals, whose employment often does not provide affordable employer-sponsored insurance.
The COVID-19 experience should spur a long-overdue reassessment of employer-sponsored insurance for working families. The Affordable Care Act exchange plans and subsidies were a major step forward and created a more affordable and available alternative for millions of families. But current law prevents workers with the offer of employer-sponsored insurance that meets federal requirements from choosing a subsidized Affordable Care Act alternative, even if that alternative is much more affordable. At the very least, that firewall needs to be removed as presidential candidate Joe Biden proposed. If tax benefits and subsidies generally were unconnected to the place of work, the double whammy of a lost job and lost health coverage would end.
COVID-19 has taught us many lessons about public health and the transmission of disease. It has also shed a stronger light on the deficiencies and inequities in the US health system. As efforts to combat the spread and effect of COVID-19 continue, it will be important to also address the many lessons it has taught lawmakers about these fundamental weaknesses of the system.
Corresponding Author: Stuart M. Butler, PhD, Brookings Institution, 1775 Massachusetts Ave NW, Washington, DC 20036 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Butler reported being an unpaid board member of a Federally Qualified Health Centers community health center in the Washington, DC area. No other disclosures were reported.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Stuart M. Butler, PhD Stuart M. Butler, PhD, is a Senior Fellow in Economic Studies at the Brookings Institution in Washington, DC. Previously, he served as Director of the Center for Policy Innovation at the Heritage Foundation in Washington, DC, where he focused on developing...