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DIVERSITY ISSUES Healthcare
Healthcare
The coronavirus pandemic has sickened and killed Americans of all races and ethnicities, but it has been felt more in African American and Latino communities.
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Center for Disease Control figures show that as of September 28, 2020, blacks are 18.3% of the reported cases and 20.9% of the deaths,1 even though they are only 13.4% of the US population. Hispanics are 29.2% of the reported cases and 16.6% of the deaths, although they are 18.4% of the population.2 In Ohio, Blacks are 20% of the cases and 18% of the deaths3 even though they are 14.1% of the population.4
Reasons given by the CDC for these disparities include5: • More health conditions that render minorities vulnerable; • More vulnerable employment with more exposure to the virus, less protective equipment, and less ability to work from a safer home environment; • Less separation from others in their housing and neighborhoods; • Less access to the health care industry. Here facilities have been torn down in minority neighborhoods and new ones built in suburban areas; • And a major underlying reason is discrimination in health care, housing, education, criminal justice, and finance, with the associated trauma that results.6
Many have recognized that this health care disparity is not a peculiarity of the pandemic, but an aggravation of the inequality in health care throughout the society as a whole. As a result, Governors including Ohio’s Governor DeWine, as well as cities like Dayton and counties like Montgomery have declared racism to be a public health crisis.7
The Ohio COVID 19 Minority Health Strike Force Blueprint states “Research estimates that health is shaped by several modifiable factors, including health care or clinical care (20%); health behaviors (30%); and a person’s social, economic, and physical environment (50%). These factors are often referred to as the “social determinants” or “social drivers” of health. Differences in access to, and the allocation of, resources across the modifiable factors that shape health result in inequities, such as housing segregation, poverty, living in high-density neighborhoods, attending high-poverty schools, and incarceration. Health behaviors are also shaped by the environments in which a person lives, including the inequities they face. Racism, other forms of discrimination, and the inequities they create are well documented as drivers of health disparities and poor overall health and well-being in communities of color.”8
For example, medical personnel assume that blacks feel pain less than whites and are less likely to prescribe pain medication.9
Who gets health care depends on who can pay for it. America’s health care payment system differs from that of other industrialized countries, in ways that are more costly and less effective in outcomes.10 Much is a result of history, and political differences over whether healthcare is a public concern or a personal responsibility.
Employer based health insurance developed in the US during the wage controls of World War II. Later Blue Cross Blue Shield became the dominant private insurer but it was challenged by competing insurers whose business model was insuring the healthy, not insuring the sick, denying claims, and creating an expensive infrastructure to do this.
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ENDNOTES:
1 https://covid.cdc.gov/covid-datatracker/#demographics 2 https://www.census.gov/quickfacts/fact/table/US/
PST045219 3 https://coronavirus.ohio.gov/wps/portal/gov/covid-19/ dashboards/key-metrics/cases 4 Blacks are 13.1% of Ohio population, Hispanics are 4%.https://www.census.gov/quickfacts/OH 5 https://www.cdc.gov/coronavirus/2019-ncov/ community/health-equity/race-ethnicity.html 6 While some have suggested that participation in handwashing, masks and social distancing may be factors, this may more reflect biased expectations than actual data. Certainly the most publicized resistance to masks and social distancing have been among whites. 7https://www.daytondailynews.com/local/coronavirus105426-total-cases-3755-deaths-reported-in-ohio/
KCWMSAKU5RBO5OP7WDTHQNTQDY/ ; https://www.greaterohio.org/blog/2020/7/16/ communities-across-the-state-declare-racism-as-apublic-health-crisis-the-state-considers-it 8https://coronavirus.ohio.gov/static/MHSF/MHSF-
Blueprint.pdf at p. 6 9https://slate.com/technology/2013/06/racial-empathygap-people-dont-perceive-pain-in-other-races.html 10The U.S. spends more on health care as a share of the economy — nearly twice as much as the average OECD country — yet has the lowest life expectancy among the 11 nations. The U.S. has the highest chronic disease burden and an obesity rate that is two times higher than the OECD average.
Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths. https://www.commonwealthfund.org/publications/ issue-briefs/2020/jan/us-health-care-globalperspective-2019
DIVERSITY ISSUES: Healthcare continued from page 10
On the government side Medicare for the elderly and disabled and Medicaid for the poor were created during the 1960s war on poverty. Medicare was originally opposed by the American Medical Association but became a major source of income to Health Care providers, and its payment standards are a major influence in health care pricing. Over time Medicaid changes included small expansions of coverage, and the introduction of “managed care” to control costs.
Later, global competition and the weakening of labor union power lead to deindustrialization and the loss of high paying jobs with adequate health care benefits. Paying for care became more difficult, particularly for those like minorities who were mostly on the lower end of the income scale.
As medical services expanded, pricing became more dependent on bargaining between big provider groups and big insurers, sometimes with lack of coverage while contracts were being renegotiated. This resulted in large gaps between what the uninsured were charged and what was provided through insurance. Those with “pre-existing conditions” would have their needs uncovered, and many were a health problem away from bankruptcy and financial ruin.
This generated political pressure for health care reform, which tangled with increasing partisan differences and the realities of political campaign finance. The Affordable Care Act, enacted under President Obama, preserves the roles of insurers and market competition. Its main provisions preserved Medicare for the elderly and disabled, expanded Medicaid to much higher incomes than previously, and created a structure of “marketplaces” where subsidized and regulated insurance policies were to be affordable. Everyone was required to buy insurance, and most popularly, young adults were covered under their parents’ policies. There were also a large number of mandates and experiments. Court challenges allowed states to refuse to expand Medicaid, which a number did, but Chief Justice Robert’s deciding vote preserved the law as a whole. Opposition to the ACA intensified during President Trump’s administration, so the ACA has never really had a period of stability to test how it works.
Complexities in the system create barriers for patients, providers, insurers and program administrators, and many people, including minorities, still are not covered. Recertifications, disputes over surprise “out of network” billings, changes in eligibility, complex dispute resolution systems and other issues cause difficulty. Financial incentives to serve those whose coverage pays the most show up in the minority health statistics.
Also disparities in the social determinants of health, rooted in historical discriminations of the past, continue to challenge us. Many of these result from ways that various laws are worded, interpreted and enforced.
What changes will a recognition that America’s racial inequalities are a public health emergency mean? Whatever consequences there are in interpreting old laws, passing new ones and more funding for government programs may be less significant than America’s willingness to undo its past, give up its express and implicit biases, and recognize that health, like coronavirus, does not care about human race, ethnicity and historical differences. Can legal professionals who are experts in solving problems, work with doctors and legislators to help devise a less complex system that works for everyone? The pandemic proves that everyone is better off if everyone is healthy, and no one deserves to be denied health.
