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COVID-19 and Health Disparities in the United States Version: June 16, 2020

The COVID-19 pandemic has resulted in more than 2.1 million cases and more than 116,127 deaths in the United States as of June 16.i While the pandemic has touched every community in our country, it has revealed the striking socioeconomic and healthcare inequities in the U.S. that disproportionately impact African Americans, Latinx and Native Americans in addition to underserved communities such as individuals in correctional facilities, rural and immigrant populations, people with disabilities and individuals experiencing homelessness.

The Infectious Diseases Society of America and its HIV Medicine Association represent more than 12,000 infectious diseases and HIV physicians and other health care providers, public health practitioners and scientists committed to ending the health disparities that have historically impacted the lives of black and brown and other underserved Americans and that have been exacerbated by COVID-19. Uniform racial and ethnic data for COVID-19 cases and outcomes continue to be limited but below are some of the available statistics:

• In the 40 states reporting deaths by race and ethnicity, the mortality rate for African Americans is 2.4 times as high as the rate for Whites.ii Another analysis found that Latinx individuals are more than 2 times likely to die than Whites.iii

• According to CDC’s COVIDView, Non-Hispanic Black and Non-Hispanic American Indian/Alaska Native populations have a hospitalization rate approximately 4.5 times that of non-Hispanic Whites, while Hispanic/Latinos have a rate approximately 3.5 times that of Non-Hispanic Whites.iv

• Data points for Native Americans nationwide are limited but the Navajo Nation and Hopi Reservation have reported one of the highest per capita case rates in the U.S. of over 2,500 per 100,000 people.v

While the African American, Latinx and Native American communities face unique challenges, these three specific populations share the following:

• Are disproportionately impacted by structural racism and socioeconomic factors.vivii

• Are more likely to be uninsured,viii

• Experience higher rates of pre-existing and underlying health conditions,ix and Are more likely to be low wage frontline workers.x

While more limited data analysis is available on COVID-19 in rural populations, analysis by the Kaiser Family Foundation in May 2020 found that non-metro areas were experiencing faster growth rates in cases and death rates.xi Underserved populations in rural areas also have high rates of pre-existing and underlying conditions and work in low wage jobs without the ability to work remotely. In addition, the healthcare infrastructure in rural communities is ill equipped to respond to the pandemic due to rural hospital closures and a lack of Medicaid expansion in states with large rural areas.xii

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According to the CDC, “people with disabilities may not be inherently at higher risk for COVID-19, but some people with disabilities may be at higher risk if they have underlying chronic conditions. Adults with disabilities are three times more likely than adults without disabilities to have heart disease, strokes, diabetes, or cancer.”xiii Additionally, people with disabilities may find wearing masks, self- isolation, and hand-washing challenging without assistance from personal attendants that may not be accessible because of social distancing measures or staffing shortages. Further, treatment guidelines in some states may explicitly or implicitly deny or limit COVID-19 treatment to people with disabilities.xiv This policy brief and the companion series that will include a brief addressing each population individually, highlight issues contributing to the health disparities related to COVID-19 specific to each of these unique and vulnerable communities, as well as policy recommendations for addressing them. CALL TO ACTION Policy interventions are urgently needed to improve health outcomes and mitigate the impact of COVID- 19 on African American, Latinx, Native American and other higher risk communities. General policy recommendations are summarized below but are detailed in the separate policy briefs developed for each specific population. Improve Access to Healthcare Coverage and Healthcare Services The uninsured rate among African Americans is 1.5 times higher than White Americans and among the Latinx community is 2.5 times higher than White Americans. The uninsured rate among Native Americans and Alaskan Natives is the highest of any group at more than 21%.xv Rural populations also have higher uninsured rates (12.3%) than mostly urban areas (10.1%).xvi The Medicaid program is a lifeline for low income individuals and individuals with chronic conditions. To help address disparities and prevent the erosion of Medicaid eligibility and services during this national health crisis, Congress should:

• Offer incentives for the 14 states that have not expanded Medicaid to do so.

• Further increase the federal matching rate for state Medicaid programs to prevent eligibility and coverage restrictions due to increased demands and strains on state budgets.xvii

• Authorize a national special enrollment period for Affordable Care Act plans.

• Increase funding for safety-net providers, including community health centers and safety-net hospitals including rural hospitals, which are playing a critical role in COVID-19 testing, care and treatment for the African American and Latinx communitiesxviii and other high risk populations and communities.

Ensure the Collection of COVID-19 Data by Race, Ethnicity, and Disability by Zip Code High quality data on COVID-19 are essential to identify and address disparities and to evaluate and refine our responses. States should collect and publicly report data in a uniform, rigorous manner. Data on race, ethnicity, and disability by zip code and institutional and community settings are critical to understand and track how specific populations and communities are being impacted by COVID-19 and to target response efforts. Health department reporting must be uniform across states and include race, ethnicity, and disability by zip code for every COVID-19 case. The reporting of serology or antibody testing must be separate from

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PCR or diagnostic testing and should include the number of tests performed as well as the positivity rate. Uniform reporting that includes race, ethnicity, and disability also should be required for hospitalizations and deaths due to COVID-19. Information regarding testing, cases, and deaths in institutional and community settings is important for collecting and reporting accurate data on people with disabilities.xix Provide Access to Affordable, COVID-19 Testing, Prevention, Care and Treatment As part of a national COVID-19 testing strategy for COVID-19, testing and contact tracing should be ramped up in the communities impacted by COVID-19 and should be easily accessible within the community including at walk up testing sites. Safety-net hospitals including those in rural areas should be prioritized for treatments and clinical trials as they become available. Ensure the availability of masks, hand sanitizer and enhanced educational outreach for communities and populations at higher risk for COVID-19. Protections should be in place to ensure that COVID-19 diagnostics, vaccines, and treatment are affordable, available and accessible in all communities with a focus on communities that have disproportionately been impacted by COVID-19. The programs created by Congress to support testing, care and treatment for individuals who are uninsured, including the HRSA COVID-19 Reimbursement programxx and the CARES Act Provider Relief fund should be sustained to ensure that individuals have access to the healthcare services they need regardless of their ability to pay. Protect Frontline Workers Certain racial and ethnic populations, including African Americans, Latinx and Native Americans, are overrepresented in the lower wage frontline workforce that includes positions in home-health care, grocery stores and food service, public service, transportation, and in the meat packing industry.xxi Due to the limited ability to social distance in these positions and increased exposure to the public, these essential workers are at heightened risk for COVID-19. With federal support, we urge companies that employ frontline workers be required to provide appropriate personal protective equipment and access to COVID-19 testing at no charge to employees in addition to providing paid emergency and sick leave and up to three months of paid family leave. Subsidized childcare also should be available to frontline line workers. Address Social and Economic Determinants of Health Significant structural changes are needed to address the social and economic determinants of health that are disproportionately harming the well-being of African American, Latinx and Native American communities in addition to other higher risk communities, including rural populations. Over the long- term, systemic changes are needed to promote economic stability, healthy neighborhoods, education, food security and access to culturally competent healthcare in addition to ending structural racism throughout these systems.xxii In the short-term, the following should be considered:

• Increase funding for the Federal Communications Commission’s Lifeline program to support unlimited minutes and Internet access for low income individuals and families to stay connected

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to health care and educational programs.xxiii This is particularly important in sustaining telehealth access in communities with limited access to healthcare and transportation to healthcare facilities.

• Provide a 15% increase in the Supplemental Nutrition Assistance Program maximum benefit level to provide additional resources to low income household to purchase food.xxiv

• Continue the moratorium on evictions for failure to pay rent.

• Increase the availability of housing assistance and temporary housing for individuals experiencing homeless and those living in shared housing with a large or extended family to quarantine.

i Johns Hopkins University. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE). Online at: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Accessed June 16, 2020. ii APM Research Lab. The Color of Coronavirus: Covid-19 Deaths By Race and Ethnicity in the U.S. Online at: https://www.apmresearchlab.org/covid/deaths-by-race. Accessed June 8, 2020. iii Gross CP, et al. Racial and Ethnic Disparities in Population Level Covid-19 Mortality. medRxiv. doi: https://doi.org/10.1101/2020.05.07.20094250. iv Centers for Disease Control and Prevention. COVIDView. Ma 23, 2020. Online at: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/pdf/covidview-05-29-2020.pdf. Accessed June 3, 2020. v Statista. Navajo Nation Hit Hard by COVID-19. June 3, 2020. Online at: https://www.statista.com/chart/21691/native-americans-covid-impact/. Accessed June 9, 2020. vi Artiga S. Health Disparities are a Symptom of Broader Social and Economic Inequities. Kaiser Family Foundation. June 1, 2020. Online at: https://www.kff.org/coronavirus-policy-watch/health-disparities-symptom-broader- social-economic-inequities/. Accessed June 9, 2020. vii Bailey ZD, Krieger N, Z Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389: 1453–63. viii Artiga, S., et al. Changes in Health Coverage by Race and Ethnicity since the ACA, 2010-2018. Kaiser Family Foundation. March 5, 2020. ix Artiga S, Garfield R, Orgera K. Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19. Kaiser Family Foundation. April 7, 2020. Online at: https://www.kff.org/coronavirus-covid-19/issue- brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Accessed June 9, 2020. x Blau FD, Koebe J, Meyerhofer PA. Essential and Frontline Workers in the COVID-19 Crisis. Econofact. April 30, 2020. Online at: https://econofact.org/essential-and-frontline-workers-in-the-covid-19-crisis. Accessed June 9, 2020. xi KFF. COVID-19 in Metropolitan and Non-Metropolitan Counties. May 21, 2020. xii National Health Law Program. The COVID-19 Pandemic Will Cause Deep cuts to Rural America. May 20, 2020. https://healthlaw.org/the-covid-19-pandemic-will-cause-deep-cuts-to-rural-america/. xiii https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-disabilities.html xiv http://www.c-c-d.org/fichiers/COVID-disability-data-collection-letter-2020-4-27.pdf xv IBID. Artiga, S., et al. xvi United States Census Bureau. Health Insurance in Rural America. April 2019. https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.html. xvii Musumeci, MB. Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19. KFF. May 4, 2020. Online at: https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new- increase-in-federal-medicaid-matching-funds-for-covid-19/. Accessed June 9, 2020.

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xviii Corallo B, Tolbert J. Impact of Coronavirus on Community Health Centers. KFF. May 20, 2020. Online at: https://www.kff.org/coronavirus-covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/. June 9, 2020. xix http://www.c-c-d.org/fichiers/COVID-disability-data-collection-letter-2020-4-27.pdf xxHealth Resources and Services Administration. COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured. Online at: https://www.hrsa.gov/CovidUninsuredClaim#:~:text=For%20dates%20of%20service%20or,with%20a%20COVID%2 D19%20diagnosis.&text=Specimen%20collection%2C%20diagnostic%20and%20antibody%20testing. Accessed June 8, 2020. xxi IBID. Blau FD, Koebe J, Meyerhofer PA. xxii IBID. Artiga S. June 1, 2020. xxiii FCC. Lifeline Program for Low-Income Consumers. Online at:https://www.fcc.gov/general/lifeline-program-low- income-consumers. Accessed June 3, 2020. xxiv Center on Budget and Policy Priorities. April 29, 2020. Available at: https://www.cbpp.org/research/poverty- and-inequality/boost-the-safety-net-to-help-people-with-fewest-resources-pay-for