Tracey Brown Offers Insights on COVID-19, Diabetes, and Health Care Disparities

Widespread testing targeted at the most vulnerable communities at risk of suffering complications from the coronavirus disease 2019 (COVID-19) is imperative to successfully managing this pandemic, said Tracey Brown, chief executive officer of the American Diabetes Association. In an interview with The American Journal of Managed Care^® (AJMC^®), Brown discusses how social determinants of health and underlying conditions, such as diabetes, contribute to racial and economic disparities in health care, recently brought into focus by the COVID-19 pandemic.

Transcript:

AJMC^®: Hello, I'm Gianna Melillo. Today, The American Journal of Managed Care is pleased to welcome Tracey Brown, Chief Executive Officer of the American Diabetes Association. Hi, Tracy. Thank you so much for joining us today.

Brown: Hi, thank you for having me.

AJMC^®: Can you start off by introducing yourself and tell us a little bit about your work?

Brown: Yes. I'm Tracey Brown. I am the CEO of the American Diabetes Association. Our mission revolves around preventing and curing diabetes and helping all those who are living with diabetes thrive while living with the disease.

AJMC^®: Early data have shown that of the individuals hospitalized in New York City for COVID-19, diabetes was among the most commonly reported comorbidities. Of the patients who passed away, those with diabetes were more likely to have received invasive mechanical ventilation or care in the ICU compared with those who did not have diabetes. What would you say is the most important step the government and individuals can take to keep those with diabetes healthy during this pandemic?

Brown: Those numbers that you review are quite troubling. I think that there are a number of things that we all can do. First and foremost, those that are living with diabetes are doing everything in their power to manage their diabetes, which means managing their blood sugar level, managing what they eat, their exercise, their sleep, their stress level, which during these times is a thing in and of itself. Then secondarily, the best thing that we can do against COVID-19, as someone living with diabetes, is avoid and prevent getting infected with COVID-19. And that sounds simplistic, but we really do need to follow all of the guidelines. If you are able to stay home, stay home. Make sure that you are washing your hands, make sure that you are staying away from touching your face and your eyes and all of those things, social distancing. Those are all the things that we actually need to make sure that we are doing just to avoid contracting the disease.

AJMC^®: Would you say there's a particular step that the government should be taking at this point other than enforcing social distancing?

Brown: As I think about this COVID-19 pandemic and the impact that it is having on all Americans, and the troubling data that you talked about as it relates to people living with diabetes, and the outcomes, including death, with people living with diabetes, there's just a couple of things that we have been really advocating or using our voice for. We know the number of people who have lost their jobs or been furloughed during this pandemic. One of the things that we would like to have happen and we're going to continue to push for is continuity of coverage. There's all kinds of data out there that says, obviously, when people lose their job, the majority of them also lose their health insurance. When you lose your health insurance, there are all kinds of studies that show people without health insurance have poor health outcomes. The last thing that you want to do, for people living with diabetes, or any underlying condition, is not get the medical care and attention that you need to manage your chronic disease. So that's one thing. Two, we already know for people living with diabetes that the cost that a person living with diabetes is about 2.3 times the medical costs of someone without diabetes. There is a financial burden that goes along with this. One of the other things that we are pushing very hard for right now is zero co-pays for insulin and any other prescription drug that a person living with diabetes would need. Then the third thing, the numbers continue to rise with COVID-19. In fact, today, the numbers surpassed 1 million in terms of cases and more than 50,000 deaths. Testing is critical right now with so many people walking around that are asymptomatic. One of the things that we need to make sure that we are doing is enough testing. Not just enough, but in the communities and the places where that testing needs to happen. Now more than ever, we need to make sure that the tests that we have are getting into the communities where the people are impacted the most. Those would be just 3 things that I would outline.

AJMC^®: The federal government currently is not collecting or publishing national racial or demographic data of COVID-19 deaths. However, data from states and cities show that Black individuals are regularly overrepresented compared to their share of the population. As of April 18, states with the highest disparities include Mississippi, Louisiana, South Carolina and Georgia. Can you explain some of the factors that put Black Americans at particular risk for suffering from COVID-19?

Brown: I will say, for African Americans and all people of color, actually, there are multiple factors. One we talked about, the fact that those who have diabetes or any other underlying conditions will have poor outcomes or a higher likelihood of having poor outcomes if they contract COVID-19. When you look at these minority populations, these people of color, groups of people of color, you will start to see that they do have underlying conditions. In some cases more than one underlying condition. That is a factor in and of itself. Then when you look at some of the other social determinants of health, or these environmental factors, where you're looking at where people live and whether they have access to food, many of these communities are in food deserts, whether they have access to the proper health care; whether they have transportation. I mean, you go on and on with these things. All of those things are factors that lead to not only higher percentages of unmanaged diabetes, but this in and of itself, as the risk of when these folks actually contract the disease, it puts them at a higher risk of complications and/or dying from COVID-19. This is not a new issue. There has been lots of data published around all of these social determinants of health, or access issues, or systematic barriers, whatever word you want to put around it. But one of the most telling pieces of data is that 76% of people below the poverty line are people of color. That fact and then all of those other factors compound living in this COVID-19 pandemic world right now.

AJMC^®: As you mentioned, to some extent, individuals in the health care industry were already aware of these social determinants of health and these economic disparities and racial disparities when it comes to poor health outcomes. Now that this issue is kind of taking center stage with the pandemic, what changes do you hope for going forward in, say, the post-pandemic world?

Brown: This isn't new information, what the COVID-19 pandemic is doing is shining a light on it. What I'm hopeful for is that this becomes a wake up call. This becomes a wake up call for America. When you're in these kinds of crisis situations, I believe it's in crisis situations that you actually see humanity rise up and come together to actually solve problems. That's what I'm actually hoping for: less talk and more solving of these issues. That's why things like driving zero co-pay on insulin and prescription, that's why things like getting testing into the communities that need it most, are very important. That's why pushing for continuity of coverage is so important, particularly when you talk about people living with diabetes. One out of 2 people in this country are living with diabetes or pre-diabetes. That means everybody knows somebody. So this is an American issue. We all need to come together and do better, and we can when we work together, when we use our voice to drive the needed change. That's actually what I'm hoping comes out of this unbelievable crisis that we find ourselves in: is that together, we understand that we have to do better and and we can.

AJMC^®: Some states in the southern part of the United States are really bearing the brunt of this when it comes to disparities, and several of these southern states including Georgia, South Carolina, and I think Tennessee, have already begun reopening their economies, loosening social distancing guidelines. What are your thoughts on these states' actions?

Brown: Again, this is a very complicated issue. I tend to listen to the authorities on this, Dr. Tony Fauci, the CDC, and look at the data. Here's what we know: the number of cases continue to rise. We have yet to start to flatten the curve. In this case where the numbers are continuing to rise, we also know that you need testing. We need a lot more testing to be happening on a daily basis so that people can understand who actually has COVID-19 and who doesn't. I mean, we know again, a number of people are walking around asymptomatic and not showing the size. As the numbers continue to rise we have to test. Then the third area which we know takes a long time is the vaccinations. As states are grappling with beginning to open up, which, listen from an economy standpoint, I get it. I think we have to be smart, all of the authoritative sources are telling us, if we don't do this right we will have new spikes, more cases, and thus elongating the impact of COVID-19. So I think this has to happen extremely carefully, and you've got to let the data guide you. Right now, we need more testing, more testing, more testing, more testing. And again, I would make sure that that testing is going to the folks that are disproportionately at risk or affected. The limited data that I have been seeing, with the limited tests that are out there today, it is not getting to the communities and the people who need it most.

AJMC^®: Implicit bias has permeated the health care industry. One study in 2018 found that African American patients are often under treated for pain compared to white patients. The same study found that marginalized populations such as the homeless or people of color, are more likely to be seen as criminal or violent in emergency situations, more likely to be presumed to be non-compliant with their medications. Do you feel that distrust of the medical community among African Americans may inhibit some patients from seeking care or trusting that they can get the care that they need?

Brown: So many layers to that question. This unconscious bias and implicit bias has existed forever, right? It is a very real thing across every industry, not just the healthcare industry. I think the best thing that can be done is for people to be aware that unconscious bias is actually real. I think that's the first thing. The second thing is, if you understand that it is real, then you can actually start to change your own bias and your own behaviors. What I think is more important than ever is we will never get to a better place with unconscious and implicit bias, unless and until we actually all start to come together as a people and start to listen and understand perspective, perspective from someone who actually doesn't look like you. I think when we can all start listening more and talking less, that's when you're actually going to start to see this country pivot and change. That's overall what I think about unconscious and implicit bias. My thing is, in this crisis and pandemic situation that we find ourselves in right now, with so many Americans suffering and so many Americans dying, that I would hope that everyone would put aside any difference that they may have experienced at any time in the past, and just do the right thing around saving lives.

AJMC^®: Do you have any final thoughts you'd like to share?

Brown: I would just say, I'm very passionate about everyone using this as a wake up call and actually coming together to do something. I'm going to put out there once again, that we can all raise our voice to drive change. Let's all come together around the 3 issues, getting testing into the communities that need it. Continuity of health insurance; when people are losing their jobs, living with diabetes, making sure that they get continuity of coverage. Then trying to reduce some of the financial burden and make sure that people get zero co-pay for their insulin and prescription drugs. Then I'll say for the people who are actually living with diabetes, as I have been living with diabetes for 16 years myself, we can thrive through this, this crisis, and any other. There are a set of resources. If you go to Diabetes.org, there's a set of resources there. We have a COVID-19 hub especially for people living with diabetes to understand what resources are out there and what help is out there. If you need insulin, I implore people do not ration insulin. Do not skip your doses. Go to InsulinHelp.org, another site that we set up with all of the patient assistant programs for people to get that insulin. Then the final thing that I want to do is just encourage all of us who are living with diabetes: control what we can control. Don't give up. Keep fighting, keep living, keep thriving.

AJMC^®: Thank you so much, Tracy. It's really been a pleasure. Thanks for taking the time.

Brown: Thank you for having me.