SummaryThe COVID-19 pandemic has revealed several weaknesses in our country’s web of safety net programs. Although the virus may not discriminate, it may exacerbate existing health inequities driven by social determinants of health (SDOH).
Research suggests that SDOH drive approximately 50% of health outcomes, making it essential to evaluate the relationship between the COVID-19 outbreak and SDOH. Avalere assessed 3 major SDOH domains: socioeconomic status, healthcare access, and food security to determine the potential implications of the COVID-19 outbreak for vulnerable populations.
Socioeconomic status measures an individual’s or family’s economic and social position in relation to others. According to the World Health Organization, higher income and social status are linked to better health outcomes. Lack of financial resources complicated by COVID-19 is disproportionately impacting communities with lower social economic status, potentially compromising healthcare access and food and housing security. Projections from the US Private Sector Job Quality Index Team estimate that over 37 million US jobs are vulnerable to layoffs in the short term (in fact, 30 million Americans filed claims for unemployment in just the last 6 weeks), with hourly wage workers in the restaurant and service industry most affected. Non-white populations and Americans with lower education levels constitute most of the workforce in high-risk industries like restaurants, hospitality, and retail. With a lack of savings, this vulnerable population will require frequent visits to shop for food, putting them at greater risk of infection.
In addition to declining economic prospects due to impacts of the outbreak, the quality of housing is also a major factor that may exacerbate how the outbreak will impact poor communities disproportionately. As with socioeconomic status overall, inadequate housing is an issue that disproportionately impacts non-white populations. Many lower income communities that disproportionately comprise racial/ethnic minority groups are located in urban areas with a larger proportion of families living in substandard and poor quality housing. They may share enclosed spaces with multiple dwellers, limiting the efficacy of self-quarantine and increasing susceptibility to infection. Furthermore, loss of wages puts individuals at risk of not being able to pay rent or mortgages and place undue economic stress on families who struggle to meet these obligations. These economic stressors have been shown to have longer-term impacts on mental health and are likely predictors of chronic diseases such as hypertension, diabetes, and cardiovascular disease.
Healthcare access issues in the US are both a matter of affordability and physical access to providers that are mainly driven by health insurance coverage, which is not universal in the US. We are uniquely positioned in the developed world with a combination of 2 deficits, having neither a universal healthcare system nor a consistent social safety net that comprehensively meets the need of the more than 38 million who live under the federal poverty threshold ($25,700 for a family of 4). Specifically, in terms of the uninsured, lack of insurance coverage was already on the rise, but with the impacts of COVID-19 on employment, millions of Americans will likely be impacted and be losing whatever coverage they did have, a topic Avalere recently discussed during its webinar, “Evolving COVID-19 Impacts on Health Insurance Enrollment.” Considerable impacts on already economically insecure Americans are happening at a time that most families’ access to health insurance is based on securing employment-sponsored coverage. There was already data demonstrating that patients in these precarious economic situations withhold visits to clinics and hospitals in order to avoid the burden of healthcare costs. Ultimately, the COVID-19 outbreak will only exacerbate the problem.
The US Department of Agriculture (USDA) defines food insecurity as a “lack of consistent access to enough food for an active, healthy life.” According to a USDA food security report, 37 million Americans experience food insecurity, including 11 million children. This pandemic expands the food insecure population, including those dependent on food pantries, as many food banks across the country are strained or closing due to lack of volunteers. Furthermore, most low-income children also rely on free or subsidized school meals, so school closures in more vulnerable communities pose a nutritional risk for these families.
Ongoing Solutions and Recommendations
The federal government passed a $2 trillion coronavirus stimulus bill with provisions for direct payments to individuals ($1,200 for those making up to $75,000 a year), suspension of student loan payments for 6 months, expansion of unemployment insurance, protection against foreclosure and evictions, and a $500 billion low-cost lending program. Independent contractors and part-time workers like those who work in the gig economy will be eligible to receive expanded unemployment insurance support as well.
The earlier Families First Coronavirus Response Act provided paid sick leave for workers, although millions who work for large corporations with over 500 employers are not covered. It also allows for free coronavirus testing for all. HHS will use some of the funds from Coronavirus Aid, Relief and Economic Security (CARES) Act to pay hospitals for care of the COVID-19 patients who are uninsured.
State-level governments have been considering and sometimes passing protective measures to reduce the potential wave of evictions. Many families will likely be unable to meet rent or mortgage obligations with stay-at-home orders impacting working communities’ ability to continue earning income.
Across issues of healthcare access, the most impacted patients are those who are uninsured or underinsured. For those with insurance, the CDC recommended using telehealth to help triage and direct patients to the appropriate point of care given their symptoms and condition. Groups like the Center for Connected Health Policy have produced a resource highlighting telehealth policies and initiatives To support those patients who are uninsured, the current administration has suggested using $100 billion in funds made available by the CARES Act to pay healthcare facilities directly. Reimbursement will be made for COVID-19 testing and treatment with COVID-19 as the primary diagnosis. These payments would be provided by the HHS through the Health Resources and Services Administration. Reimbursement through this pool for testing and treatment is available for the uninsured but only covers testing for people with alternative plans (Short-Term Limited Duration Insurance and Fixed Indemnity Insurance).
This is an important population to target. The Kaiser Family Foundation estimated that anywhere between 670,000 and 2 million uninsured Americans may end up hospitalized across the country but acknowledges that these estimates are highly uncertain. Stakeholders will need to consider the impacts of economic losses on communities, many of whom may have had limited healthcare coverage but now will not have any. Policymakers could evaluate options to expand Medicaid eligibility through existing mechanisms or potentially a new temporary program to help formerly and newly uninsured access necessary care.
The first of the 2 bills approved by Congress provides about $1 billion for food security programs with the aim of helping individuals and families who may struggle to get access to meals during this pandemic, including people who rely on the Supplemental Nutrition Assistance Program and food banks and the 22 million children who rely on school lunch programs. However, major private and not-for-profit organizations are expanding their charity efforts to compensate for what is likely going to be become a food insecurity crisis exacerbated by COVID-19. Feeding America, the nation’s largest domestic hunger-relief organization, has established a COVID-19 response fund to help food banks across the country during this pandemic. City governments in areas significantly impacted by the COVID-19 outbreak have also implemented food delivery initiatives for all their city residents to ensure nutrition is made available to those at high-risk of food insecurity. Food pantries, meal kitchens and community organizations are changing their approach to food service by opting for drive-through or delivery services but will likely require more state and federal funding to remain viable for a long period of time. Additionally, local education authorities are being permitted to leverage approaches from the USDA’s summer feeding programs, and the USDA has also released national waivers for mealtime and congregant meal setting requirements. These developments have allowed schools to adopt innovative approaches to providing meals and to practice appropriate social distancing.
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