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Health and healthcare inequities are the most likely explanation for the disproportionate effect.
The 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 affected African Americans. The 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 information, 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. The 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 Affairs in late May that among the system’s 1,052 confirmed 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, conveys the same basic message. Using their access to data on 23 million patients from 27 health systems in 16 different 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 general population, data show. In California, Latinos make up about 39% of the population but they accounted for 55% of the COVID-19 cases (34,809 of 63,505) in the California Department of Public Health’s ethnic group data. The proportion of deaths, 38% (1,329 of 3,504), however, was in line with the population 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 disproportionate effect that COVID-19 has had on the African American community. But using race as biological or genetic category is hugely problematic 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 education, 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 transportation, 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-profit Medicaid 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 affected.
It’s also well documented that people in communities of color are far more likely to suffer from chronic diseases such as diabetes, asthma, obesity, hypertension, and heart disease that put people at higher risk for COVID-19, Wirth observes. When the Epic researchers looked at patients with no comorbidities, African Americans were still overrepresented among COVID-19 cases and deaths but not by as much as in the population with comorbidities. The Epic study and others have found that the association between diabetes and hypertension and COVID-19 is especially pronounced. Among adults, ages 19 to 64, 29.5% of African Americans hospitalized 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 hypertension, 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 increases the COVID-19 mortality rate, notes Renee P. Bullock-Palmer, M.D., director of noninvasive cardiac imaging 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).
The 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 off can be obstacles to visiting a doctor. The Sutter researchers said their previous 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 disparities researcher at the University of California, Riverside, has seen COVID-19 healthcare resources being disproportionately distributed to wealthier and predominantly white neighborhoods, making it difficult 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 distancing (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 difficult to put into practice. They have jobs in essential businesses that put them on the front lines, notes Bullock-Palmer, so they can’t work from the relative safety of a home office.
Over the past several years, healthcare providers and payers have turned their attention to the social determinants of health (SDOH) - the influence that housing, nutrition, personal safety and other factors have on people’s health outside of traditional medical care. The toll that COVID-19 is taking on African Americans is more evidence of the power of SDOH, and the need to address them to affect health outcomes, say many observers - although with COVID-19 the list of SDOH has grown longer. Public transportation is an example: “[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 conditions 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 neighborhoods were overwhelmed and experienced 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 qualified health centers depend on volume for revenue in fee-for-service arrangements. “With social distancing orders in place, there has been a marked decrease in volume at healthcare organizations,” Chen says. “Combined with increases in coronavirus infections, a decreased patient volume has resulted in significant revenue loss. Many healthcare facilities have resorted to salary cuts, hiring
freezes and unpaid furloughs. Federal dollars have helped but have not nearly made up the difference.”
Effects on payers
Many states are bracing for large budget shortfalls because of the economic downturn from COVID-19. Meanwhile, because of job losses, the number of Americans eligible for Medicaid coverage is expected to increase. A KFF projection estimated that 17 million more Americans may be enrolled in Medicaid next year. Chen describes COVID-19 as a “perfect storm to create a spike in demand for Medicaid coverage.”
It is difficult to know exactly how COVID-19 will affect the insurance coverage among African Americans. African Americans make up just over 13.4% of the country’s population; in 2018, roughly 20% of nonelderly Americans covered by Medicaid were African Americans, according to KFF figures. But many of the states that haven’t expanded Medicaid have large African American populations, including Mississippi (36%), Georgia (29%), and Alabama (26%). A surge in unemployment among African Americans in those states may not increase Medicaid enrollment as much as the number of those who are uninsured.
More than lifestyle choices
COVID-19 has brought to light several issues regarding African Americans’ health and healthcare. “First and foremost, COVID-19 has revealed the impact of centuries of inequality and racism that make up the African American experience as well as that of other people of color in the United States,” says Melva Thompson-Robinson, Dr.PH., a professor at the University of Nevada, Las Vegas, School of Public Health, and executive director of the university’s Center for Health Disparities Research. “Too often, lay people like to think that health disparities result from people’s lifestyle choices. But COVID-19 has highlighted differences in access to care, impact of unemployment, and lack of health insurance, as well as the impact of high housing density on health.”
Wirth says that COVID-19 is just the latest public health crisis to lay bare the statistics showing the country’s health disparities and the gap between white Americans and communities of color. “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.”
Polonijo says many steps could be taken that could also help lessen statistical inequalities in other preventable diseases. “Policies such as living wage and paid sick leave could help individuals to meet their basic needs and prevent disease transmission in the workplace,” she said. “Affordable healthcare and equitable allocation of healthcare resources could help alleviate barriers to healthcare access. Enhanced provider training in cultural competency and social determinants of health could help to improve patient/provider encounters for African Americans, as well as other marginalized populations.”
“I hope that people will continue to ask the questions to understand why the differences exist,” says Thompson-Robinson, “and then will join together to fight the good fight to address the disparities.”
Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.