Axes of alienation: applying an intersectional

T he COVID-19 outbreak has claimed more than 100,000 American lives, but evidence shows the disease has cut an especially wide swath of serious illness and death through African American communities in the United States. It is not entirely clear why, but healthcare experts say that complex, deeply rooted socioeconomic issues and healthcare inequities are the most probable explanation. Any number of statistics reveal that COVID-19 has disproportionately a� ected African Americans. � e COVID-19 database maintained by Johns Hopkins University shows that although African Americans represent only about 13% of the population in states reporting racial and ethnic infor- mation, they account for about 34% of total COVID-19 deaths in those states. COVID-19 data from cities, states and health systems paint the same picture. In Chicago, 50% of cases and nearly 70% of deaths as of mid-April were black individuals, although African Americans comprise 30% of the city’s population. In Louisiana, roughly 70% of those who have died of COVID-19 are African American, yet African Americans make up only 32.2% of the state’s population. � e disproportion is similar in Michigan: 33% of the COVID-19 cases and 40% of COVID-19-related deaths have been among African Americans, but African Americans comprise only 14% of the state’s population. Researchers at Sutter Health, an integrated delivery system in California, reported in Health A� airs in late May that among the system’s 1,052 con� rmed COVID-19 cases, African Americans who tested positive for COVID-19 were twice as likely to be hospitalized as white people who tested positive (52.5% versus 25.7%) and, once admitted, were more likely to be transferred to the ICU (24.6% versus 10.7%). However, when they looked at the 51 COVID-19-related deaths, they didn’t see a racial imbalance. An analysis by researchers from Epic, the electronic health record company, con- veys the same basic message. Using their access to data on 23 million patients from 27 health systems in 16 di� erent states, the Epic researchers found that African American patients accounted for 27% of COVID-19 hospitalizations and 22% of the deaths although they made up 12% of the sample population. Other minority groups have also been hit harder by COVID-19 than the gener- al population, data show. In California, Latinos make up about 39% of the popu- lation but they accounted for 55% of the COVID-19 cases (34,809 of 63,505) in the California Department of Public Health’s Health and healthcare inequities are the most likely explanation for the disproportionate effect. Deadly and Revealing: 34% About 13% of the population is African American in states reporting racial and ethnic information. African Americans account for of the COVID-19 deaths in those states. � e Toll � at COVID-19 Has Taken on the African American Community BY KAREN APPOLD Managed Healthcare Executive.com MANAGED HEALTHCARE EXECUTIVE ❚ JUNE 2020 5 Special Report MHE0620_005-007_Special Report.indd 5MHE0620_005-007_Special Report.indd 5 6/12/20 10:55 AM6/12/20 10:55 AM ethnic group data. � e proportion of deaths, 38% (1,329 of 3,504), however, was in line with the popu- lation proportion. In Arizona, 17% of the COVID-19 cases and 12% of the deaths were Native Americans, although they make up only about 5% of the population. FOCUSING ON COMORBIDITIES An unknown biological or genetic factor could explain the dispropor- tionate e� ect that COVID-19 has had on the African American commu- nity. But using race as biological or genetic category is hugely problem- atic and has been rejected by many researchers. Socioeconomic and healthcare inequities are a better explanation. For generations, racist policies and program segregated African Americans into poor urban areas with limited access to educa- tion, employment opportunities, housing and healthcare services. One result is that African Americans are more likely to hold lower-paying jobs that require them to attend work in person rather than remotely and rely on public transporta- tion, both of which make exposure to the virus more likely. People of color are more likely to work in lower-wage industries such as restaurants and hotels, notes Doug Wirth, president and CEO of Amida Care, a not-for-pro� t Medic- aid special needs health plan in New York City. Stay-at-home and social distancing rules shut many of those business down. If they don’t bounce back, African Americans workers will be disproportionately a� ected. It’s also well documented that people in communities of color are far more likely to su� er from chronic diseases such as diabetes, asthma, obesity, hypertension, and heart dis- ease that put people at higher risk for COVID-19, Wirth observes. When the Epic researchers looked at patients with no comorbidities, African Ameri- cans were still overrepresented among COVID-19 cases and deaths but not by as much as in the population with comorbidities. � e Epic study and others have found that the association between diabetes and hypertension and COVID-19 is especially pro- nounced. Among adults, ages 19 to 64, 29.5% of African Americans hospital- ized for COVID-19 had diabetes and hypertension compared with 15.7% of the whites hospitalized for disease, according to the Epic data. In the population, ages 65 and older, 36.7% of African Americans hospitalized for COVID-19 had diabetes and hyperten- sion, compared to 22.5% of whites. Limited access to healthcare of any kind — and perhaps especially to high-quality care — increases the chances that those chronic diseases are poorly managed, and that in- creases the COVID-19 mortality rate, notes Renee P. Bullock-Palmer, M.D., director of noninvasive cardiac im- aging and director of the Women’s Heart Center, Deborah Heart and Lung Center, in New Jersey. Many factors play into healthcare access, especially insurance coverage. Although the uninsured rate among African Americans decreased because of Medicaid expansion and the ACA exchange plans, blacks were still 1.5 times more likely to be uninsured than whites during the 2010-2018 time period, according to the Kaiser Family Foundation (KFF). � e foundation’s numbers suggest that the rate of African Americans covered by health insurance is slipping. Even if they have insurance coverage through an employer, workers in low-paying jobs may be enrolled in less-than-stellar plans. “Limited insurance may impact a worker’s access to a large network of healthcare providers to tend to their healthcare needs,” says Bullock-Palmer. Work schedules or jobs without paid time o� can be obstacles to visiting a doctor. � e Sutter researchers said their previ- ous research showed that African Americans are more likely to seek care later in the course of a disease and in acute-care settings, and that same pattern may explain the higher COVID-19 hospitalization rate among African Americans. Andrea Polonijo, Ph.D., M.P.H., a medical sociologist and health dis- parities researcher at the University of California, Riverside, has seen COVID-19 healthcare resources be- ing disproportionately distributed to wealthier and predominantly white neighborhoods, making it di� cult for many African Americans to access testing and treatment. When African Americans do access care, healthcare professionals tend to take them less seriously, research has shown. SOCIAL DETERMINANTS AND COVID-19 Since mid-March, social distanc- ing (and wearing face masks) have been the main public health tactics for preventing the transmission of SARS-CoV-2, the virus that causes COVID-19. But for many African Americans, the tactics are di� cult to put into practice. � ey have jobs in essential businesses that put BULLOCK-PALMER MANAGED HEALTHCARE EXECUTIVE ❚ JUNE 2020 Managed Healthcare Executive.com6 Special Report Deadly and Revealing “While the data is shocking, it is not surprising that the coronavirus is impacting people of color. Such health disparities have existed for years and are now in plain view for the world to see.” —DOUG WIRTH, PRESIDENT AND CEO OF AMIDA CARE MHE0620_005-007_Special Report.indd 6MHE0620_005-007_Special Report.indd 6 6/12/20 10:55 AM6/12/20 10:55 AM them on the front lines, notes Bull- ock-Palmer, so they can’t work from the relative safety of a home o� ce. Over the past several years, healthcare providers and payers have turned their attention to the social determinants of health (SDOH) — the in� uence that housing, nutrition, personal safety and other factors have on people’s health outside of tradition- al medical care. � e toll that COVID-19 is taking on African Americans is more evidence of the power of SDOH, and the need to address them to a� ect health outcomes, say many observ- ers — although with COVID-19 the list of SDOH has grown longer. Public transportation is an exam- ple: “[It] poses an increased risk of contracting the virus, because many of these essential workers have to take buses or subways to work,” says Bullock-Palmer. A large body of research shows that poor housing is associated with chronic diseases ranging from con- ditions ranging from heart disease to obesity to anxiety. And crowded living conditions could be a factor in COVID-19 transmission. “It is much harder to self-isolate to protect other family members and neighbors in close proximity,” observes Christopher Chen, M.D., CEO of ChenMed, a privately held company in Miami that operates about 70 primary care practices around the country. IMPLICATIONS FOR HEALTHCARE FACILITIES Hospitals in low-income neighbor- hoods were overwhelmed and expe- rienced the most severe equipment shortages as the COVID-19 outbreak grew larger, says Amida Care’s Wirth. Community health centers had to adapt quickly. Telemedicine visits were up but overall visits were down, leading to declines in revenue throughout the healthcare sector. Many hospitals and federally quali� ed health centers depend on volume for revenue in fee-for- service arrangements. “With social distancing orders in place, there