Fixing COVID-19–Based Disparities Requires Addressing All SDOHs, Not Just Health Care Access

It’s no surprise that COVID-19–based disparities have negatively affected the most vulnerable communities in the United States, especially low-income populations. It’s also no surprise that the poorest Americans tend to be a part of Black, Latino, and/or Indigenous communities.¹

However, what the pandemic has revealed is the extent to which reforms are needed; not just in how the United States approaches health care, but in how it approaches all aspects of life.

According to the APM Research Lab’s 2020 Coronavirus Review, 17.0% of US deaths related to COVID-19 were among Black individuals, despite them only accounting for 12.4% of the total population.² Overall, the review found that Indigenous, Black, and Latino Americans were at least 2.7 times more likely to die of COVID-19 than were White Americans in 2020.

These numbers were even more drastic in areas with the highest case numbers, such as in California, where 54.0% of all deaths were among Black or Latino individuals compared with the 30% of deaths attributed to White individuals, and New York, where Black and Latino individuals accounted for 49.0% of deaths and White individuals made up 39.0%.

Death rates among Indigenous people are often even more difficult to summarize, as data for Native populations are often disaggregated into multiple groups, such as Alaskan Native, Native American, and Pacific Islander. Additionally, many Latino individuals have Indigenous ancestry but are often categorized separately, and many Black individuals have Latino heritage, making it difficult to realize the true extent of how non-White communities have been affected by the pandemic.

“This issue of aggregation vs disaggregation is a real one, in terms of thinking about how do we best serve populations….We need to do a better job of identifying the infrastructure that will help us in the United States have a true public health focus…and that will allow us to reach communities to meet their needs,” said Karen Winkfield, MD, PhD, executive director of the Meharry-Vanderbilt Alliance, a strategic partnership focused on improving health equity at Vanderbilt University Medical Center, in an interview with The American Journal of Managed Care^®.

How Can Addressing SDOHs Help?

Long-standing systemic disparities that negatively impact non-White communities seep into most aspects of society, including income inequality, housing crises, lack of generational wealth, lack of access to reliable transportation, access to comprehensive education, food insecurity, and more. These social determinants of health (SDOHs) can have a significant impact on people’s general health, well-being, and quality of life, especially during public health crises like the COVID-19 pandemic.³

“Individuals have [always] needed housing, transportation, job support, and income support. I think what COVID-19 has done is shine a light on how vast and how quickly those needs can grow for all of us. We saw COVID-19 become something that the entire population was at risk for. But the social pieces have definitely taken more of a toll on historically underserved populations,” said Kelly Binder, chief solutions officer at Unite Us, a technology company that builds coordinated care networks to connect health care providers with social service providers, in another interview with The American Journal of Managed Care^®.

Additionally, many non-White communities have greater risks of being uninsured, having low income, and being unhoused. They also are at higher risk of having multiple comorbidities, such as diabetes, cardiovascular disease, and kidney disease, all of which impact Black individuals disproportionally compared with White individuals and are considered risk factors for COVID-19 complications.⁴ Winkfield mentioned the growing need to consider the intersectionality of COVID-19 risk factors related to SDOHs with race, ethnicity, and other aspects of identity.

“All of these issues when it comes to solutions, when it comes to addressing how we can improve care, are important….So, because there are some communities that have been so disenfranchised, individuals who are from the LGBTQ+ community, Black individuals, or individuals who may not have English as their primary language, may find themselves being more highly represented in poverty states. Poverty status [is] one of the greatest predictors of health status….These are all things that are important to consider, because that's what's going to help drive the solutions,” she said.

Government and Community Efforts

According to Binder, one of the biggest actions taken by the federal government in 2020 was the passage of the Coronavirus Aid, Relief, and Economic Security Act, also known as the CARES Act.⁵ The CARES Act was a $2.2 trillion economic stimulus package that helped US residents with rental and mortgage assistance during the pandemic and provided loans for small businesses to keep them from laying off their employees or closing down.

On a state level, some state governments, including North Carolina and Oregon, utilized Medicaid waivers allowed by Section 1115 of the Social Security Act under the authority of the secretary of HHS.⁶ These waivers give states added flexibility to implement new initiatives intended to improve their Medicaid programs.

“The presence of those waivers and pushes towards funding social care are definite ways that the government is trying to address [health disparities]. And what we want to see is that done at scale, where it's not time limited or only specific to certain states. If it's able to be done consistently at scale, it could be a systemic solution to addressing and acknowledging that social needs are a part of someone's health,” expressed Binder.

Local efforts aimed at providing vulnerable populations with added assistance have also expanded during the pandemic to address disparities. Winkfield mentioned efforts taken by a surgeon in Pennsylvania to bolster COVID-19 vaccine and testing capabilities for alienated communities and similar efforts that the Meharry Medical Colleges campus where she works in Tennessee had taken.

Winkfield also emphasized the Community Engagement Alliance (CEAL) Against COVID-19 Disparities developed by the National Institutes of Health, which provides information on vaccines, clinical trials, community efforts, and tools and resources for communities that have been hit the hardest by COVID-19.⁷

“There are 20 of them all around the country that are really focused on building community partnerships and serving the communities to understand what some of the barriers are to making sure that traditionally excluded communities have access to clinical trials related to the COVID-19 vaccines, treatments, and the long-term effects of COVID-19….We want to make sure that every community has access to it….I think the work that's going to come out of that group is going to be really important,” she noted.

Overcoming Vaccine Hesitancy

Furthermore, hesitancy around vaccines against COVID-19 is rampant across the country. As of February 19, 2022, 64.7% of the entire US population is fully vaccinated, meaning that they have received either 2 doses of an FDA-approved messenger RNA vaccine or 1 dose of the Johnson & Johnson vaccine.⁸ Additionally, only 28.0% of the population has received at least 1 booster dose.

According to a review from August 2021 published in Brain, Behavior & Immunity – Health, the vaccine hesitancy rates among African Americans and Hispanic Americans were significantly greater than that in the general US population (41.6% vs 30.2% vs 26.3%, respectively).⁹ The authors cited several major reasons for this difference, including:

• Sociodemographic characteristics (eg, income, education, household size)
• Medical mistrust and history of racial discrimination in health care spaces
• Exposure to myths and misinformation about vaccine safety and efficacy
• Perceived risk of getting infected with COVID-19, beliefs about vaccines, and past vaccine compliance
• Concerns about the safety, efficacy, and adverse effects of the COVID-19 vaccines

The authors of the review also suggested a number of community efforts that address SDOHs to help health care providers overcome vaccine hesitancy that may exist among underserved communities, such as:

1. Understanding that mistrust stems from historical injustices and experiences of discrimination in African American and Hispanic American populations
2. Ensuring collective employment of local role models, faith leaders, and social networks to deliver reliable and authentic information about vaccines
3. Implementing community and place-based approaches to ensure equitable access to COVID-19 vaccines and eliminating vaccine barriers (eg, transportation, registration, digital divide, rurality, lack of healthcare facilities)

Binder echoed some of these ideas, saying that more needs to be done to scale up community efforts to boost vaccination rates among underserved populations.

“The more we can make that a consistent part of the conversation, the more we can sit down to figure this out. I even say that at Unite Us….Sometimes, it's really important to say, ‘Well, do we have everyone here whose perspective, feedback, or expertise we need?’ And I think that us doing that in the community to solve any problem or to form any strategy that we need is a really important piece of the equation,” she said.

Another study published in January 2022 in JAMA Network Open found that Black Americans have become more receptive to COVID-19 vaccines between December 2020 and June 2021 at a greater rate compared with White Americans.¹⁰ Although this is encouraging and suggestive that worries regarding the safety and efficacy of vaccines have dissipated to some degree among Black Americans, rates of vaccination are still considerably lower in this population compared with White Americans, suggesting other systemic barriers are preventing access to vaccines.

The authors cited findings from Kaiser Family Foundation surveys that 55.0% of Black respondents said that they were very or somewhat concerned about missing work if the vaccine made them sick. Additionally, 37.0% of Black individuals were worried about having to pay for a vaccine compared with 24.0% of White individuals, and 23.0% of Black people voiced concerns about taking time off work to get vaccinated compared with 16.0% of White individuals. About 17.0% of Black individuals vs 9.0% of White individuals reported being worried about having transportation to a vaccination site.

Winkfield noted that these trends will be important for ensuring consistency regarding efforts to overcome these barriers, especially given the current recommendations for booster vaccine doses and the potential for more doses needed in the future.

“I think the booster is an important component of this….This is going to be something that we need to have continued renewed interest in….Transportation is a huge barrier to health care in the United States. So, people may or may not have cars to get to a place. There have been testing sites and vaccine sites set up in lots of different locations that have been restricted unnecessarily. And we don't have the personnel to staff all those sites. [Also,] if you're only staffing from 9 am to 12 pm, you're going to miss a lot of people. They're going to be a lot of people who won't be able to get there. So, part of it is figuring out from a community standpoint how to make sure people have access to the boosters and not just raise awareness,” she explained.

Are Things Getting Better?

Both Winkfield and Binder conveyed a positive feeling that things are getting better regarding the COVID-19 pandemic and its impact on disadvantaged communities.

“I think that we are seeing that happen day after day, the fact that we're even having this conversation and the social determinants of health are a part of it….If someone is unhoused or food insecure, how do we expect them to be living their healthiest life?...I am very hopeful that we are progressing because we’re acknowledging that things need to be done at a policy level so it can be felt throughout our country consistently for every community,” Binder expressed.

However, Winkfield expressed concerns that governments and agencies may be lifting protective regulations, such as mask mandates, capacity limits, and other measures to prevent the virus that causes COVID-19 from spreading, too quickly.

“We know that the numbers of hospitalizations have gone down despite the high number of individuals who are being diagnosed, so the vaccines are working, which is great….But remember this virus has shown itself to be very crafty, as many of them are, and it can create variants very quickly and efficiently. So, we cannot sleep on this. I don't want people to relax so much that they forget that we are still in the midst of a pandemic,” Winkfield warned.

Overall, Winkfield said that she believes that the pandemic has fostered a renewed interest in addressing systemic problems and historical failures that have negatively impacted non-White communities, giving hope that disparities related to SDOHs will be addressed.

“I do think that this is a critical moment in the United States. We have right now an opportunity to do things in a very different way. And I think that begins with acknowledging that we did things wrong in the past that have disproportionately impacted specific communities. And by acknowledging, that goes a long way….But now’s the time for us to stand together collectively, to do things differently,” Winkfield concluded.

Reference

1. Creamer J. Inequalities persist despite decline in poverty for all major race and hispanic origin groups. US Census Bureau. September 15, 2020. Accessed February 22, 2022. https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-and-hispanics-reached-historic-lows-in-2019.html
2. Egbert A, Liao K. The color of coronavirus: 2020 year in review. APM Research Lab. December 21, 2020. Accessed January 15, 2022. https://www.apmresearchlab.org/covid/deaths-2020-review
3. Social determinants of health. HHS. Accessed February 19, 2022. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
4. People with certain medical conditions. CDC. Updated February 15, 2022. Accessed February 19, 2022. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#:~:text=Having%20heart%20conditions%20such%20as,very%20sick%20from%20COVID%2D19
5. COVID-19 economic relief. US Department of the Treasury. Accessed February 19, 2022. https://home.treasury.gov/policy-issues/coronavirus
6. State waivers list. Medicaid. Accessed February 19, 2022. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html
7. NIH Community Engagement Alliance (CEAL). National Institutes of Health. Accessed February 19, 2022. https://covid19community.nih.gov/
8. Mathieu E. State-by-state data on COVID-19 vaccinations in the United States. Our World in Data. Published January 16, 2021. Updated February 19, 2022. Accessed February 21, 2022. https://ourworldindata.org/us-states-vaccinations
9. Khubchandani J, Macias Y. COVID-19 vaccination hesitancy in Hispanics and African-Americans: a review and recommendations for practice. Brain Behav Immun. 2021;15:100277. doi:10.1016/j.bbih.2021.100277
10. Padamsee TJ, Bond RM, Dixon GN. Changes in COVID-19 vaccine hesitancy among Black and White individuals in the US. JAMA Netw Open. 2022;5(1):e2144470. doi:10.1001/jamanetworkopen.2021.44470