COVID-19 Disparities Drive New Public Health Thinking

September 2020

The time for action is long overdue. More than 700,000 people in the United States have lost their life to the COVID-19 pandemic. It will take years to realize fully the immensity of this loss of life but many of the current signs point towards rethinking our systems. As we near the two-year mark, our public health system, economy, and community strength have suffered far-reaching devastation.

Though the loss of life has affected people across all demographics, there is considerable evidence of its particular attack on vulnerable populations. At the infancy stage of the virus, health officials especially cautioned individuals with compromised health conditions of the higher risk. However as the virus continued to spread, we have seen a disparate vulnerability to certain sectors of our communities.

Many social factors including environment, income level and race influence COVID-19 outcomes. Dense urban environments where more people are interacting also increases the potential for transmission. People experiencing food insecurity or lack of access to nutrient rich foods often have lower immune response levels and thus increased susceptibility to health risks. Further, the rate of infection across our country is three times higher in predominantly black counties than in predominantly white counties, and the mortality rate is six times higher.1 Although blacks make up 30% of the total Chicago population, more than 50% of COVID-19-19 cases and almost 70% of COVID-19 fatalities are disproportionately within the black population.1

These social inequalities including access to health services, quality housing and economic advancement – widely known as social determinants of health (SDOH) – play a factor in the contraction and more importantly, ability to cope with the virus. Essentially, the starting line is not the same for everyone leaving some at greater risk of becoming severely ill and/or dying.

How did we get here?

At first glance, this may be surprising for the U.S., as the world’s wealthiest country that boasts the most advanced biomedical research infrastructure and world-class healthcare institutions. However, much of the problem is due to inequalities in economic opportunity and unfortunately very little focus has been given to mending this divide when addressing public health.2 Of the primary drivers of health (genetics, behavior, healthcare, and social/environmental factors), nearly all of the attention has been given to improving healthcare systems. While there have been some successful public campaigns to influence individual behavior, such as quitting smoking and seat belt use, the social/environmental factors, or “social determinants of health,” have largely been ignored by the US healthcare delivery system.

When considering the weight of these drivers (excluding genetics), it can be argued that social/environmental factors have the largest influence. Often, one’s economic and social conditions directly or indirectly determine their access to healthcare and influence their personal wellness behaviors. For example, a neighborhood with low access to healthy food or parks with recreational facilities may deter a healthy lifestyle. Also, some neighborhoods are located close to sources of pollution, such as highways, waste dumps, or factories that can cause long term health impacts. In other words, these foundational factors represent the root drivers of health. Hospitals and the broader healthcare system mostly focus on the reactionary “band aid” solutions, such promoting profitable elective procedures to wealthier and therefore healthier people to compensate for the costly but low quality care to the uninsured through their emergency departments. In the end, we are stuck with a system of healthcare that does not work for either group.

Since 2014, life expectancy in the U.S. has been trending downward. This recent decline and the devastating impact of COVID-19 reveals we have traveled down the road of reactionary healthcare as far as possible. Now, the shift back to the source of health, holistic wellness that stems from addressing social, economic, and environmental conditions must happen. In addition to poor health outcomes, the economics of today’s healthcare system has begun to break apart. With little or no incentive for avoiding expensive hospitalizations, therapies, pharmaceuticals and/or technologies, total healthcare spending in the United States mushroomed from $147 per person in 1960 to over $11,800 per person today. Even when adjusting for inflation, the average American today pays nearly ten times more on healthcare services than a generation ago.3 Even with trillions of dollars flowing within the healthcare delivery system, urban safety net hospitals and small rural hospitals struggle to operate financially and risk closure. Therefore, change is necessary to address unsustainable increases in cost, greater disparities among populations, and poorer health status compared to other developed countries.

What can we do moving forward?

There is some promising news indicating that healthcare leaders are paying more attention to addressing social determinants of health in local communities. A recent report from the Healthcare Intelligence Network4 indicates that 88% of health systems are currently considering social determinants of health (e.g., employment status, housing, food security, home environment, transportation options) when seeking to impact target populations. They view this as a strategic imperative due to the linkages among SDOH and physical and mental health outcomes. By the end of 2020, 40% of the US health systems and commercial payers will utilize “social determinant” data of some type in making risk assessments, patient outreach, and business decisions.5 Clearly the U.S. healthcare delivery system, however damaged, is paying attention to the need for effective actions to address community health and related economic disparities.

Healthcare leaders are shifting their strategies to achieve the economic benefits that come from managing social determinants of health. By first addressing the root causes of disease, healthcare systems can lower emergency visits, reduce readmission rates, and achieve higher quality outcome scores. All of which are important as government and private payers continue to drastically lower reimbursement and penalize hospitals, physicians and other healthcare providers for poor quality care and readmissions.

Setting the course

The answers to our community health challenges are within reach. Acknowledging and tackling the underlying factors that contribute to the disproportionate demographic outcomes will pave the way to better public health. Putting focus on whole-person care, engaging patients in their health and strengthening community services will drive improved outcomes for both individuals and the organizations serving them. This will also require community leaders to rethink the planning and design of our communities.

Change is happening. Key community players are embracing innovative approaches and the strategies necessary to create a more equitable starting point. Through community transformation initiatives, Tripp Umbach is partnering with forward thinking organizations to identify solutions and create long-term viability of healthcare systems, economic development and community strength.

View Endnotes

  1. COVID-19-19 and African Americans, JAMA. 2020
  2. America the Unhealthy: Inequality kills, Knowable Magazine (June 23, 2020), https://www.knowablemagazine.org/article/health-disease/2020/america-unhealthy-inequality-kills
  3. Poverty and the Myths of Health Care Reform, Johns Hopkins University Press (2016).
  4. Healthcare Intelligence Network, www.hin.com
  5. Top 8 Predictions That Will Disrupt Healthcare in 2020, Forbes (Dec 4, 2019), https://www.forbes.com/sites/reenitadas/2019/12/04/top-8-predictions-that-will-disrupt-healthcare-in-2020/#313bb5b57f1e

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Paul Umbach

Founder and President

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