The COVID-19 Pandemic is Worsening Health Disparities. Emergency Physicians Can Help

By William E. Baker MD, David A. Kim MD, PhD, and Leon D. Sanchez MD, MPH on behalf of the SAEM ED Administration and Clinical Operations Committee

Though COVID-19 was initially described as a “great equalizer” to which rich and poor, young and old alike were susceptible, the pandemic’s “Though COVID-19 was initially described impact on our society has been anything but uniform. COVID-19 as a “great equalizer” to which rich and mortality is markedly higher in regions with more poverty, crowding, and poor, young and old alike were susceptible, racial segregation. In Chicago, Black residents account for 30 percent of the the pandemic’s impact on our society has population, but 70 percent of COVID-19 deaths. Nationwide, only six percent of been anything but uniform.” white patients who died from COVID-19 were younger than 60, compared to 25 percent among Latinos. Even among front-line providers, risk of COVID-19 is and minority patients make up a the height of the outbreak in New York greater among minorities. disproportionate part of the “essential City, COVID-19 mortality was as much Though medical comorbidities are more prevalent among minority and low-income patients and are risk factors for severe COVID-19, comorbidities alone do not explain the stark disparities in cases and deaths by race and socioeconomic status. Lower income workforce,” with few opportunities for social distancing or remote work. When patients fall ill with COVID-19 and seek care, minority and low-income patients are more likely to receive care in overburdened and under-resourced public and/or safety-net hospitals. At as three times higher in the understaffed and overwhelmed public system (which received a preponderance of lowincome patients), compared to wellstaffed private hospitals, which received vanishingly few transfers from the overwhelmed public system.

COVID-19 Disparities and the Emergency Department

Emergency departments (EDs) are the safety net of our health care system. Only 31 percent of 139 million annual ED visits are paid by private insurance, and many “safety net” hospitals serve primarily minority and low-income patient populations. In Boston, where less than one percent of the population is homeless, homeless patients comprised 16.4 percent of one safety net hospital’s COVID-19 census.

Emergency departments have experience handling unpredictable and variable volumes of patients, but our mechanisms for expanding capacity to meet demand can themselves exacerbate disparities. ED patients insured by Medicaid are substantially more likely than comparable privately insured patients to be assigned to temporary hallway beds when dedicated rooms are unavailable (hallway care being associated with adverse outcomes and lower patient satisfaction compared to standard ED bed care). Infection control concerns during the pandemic have curtailed the use of these provisional and inferior care spaces, but the temptation to reinstate them will inevitably recur. EDs concerned with equity would do well to eliminate hallway spaces permanently, or at the very least audit their use to avoid compounding the disadvantage of their most vulnerable patients.

American health disparities did not arise with the COVID-19 pandemic. Structural racism and economic inequality have deep roots, and cannot be solved in the ED. Yet emergency physicians, with unique experience caring for our society’s most vulnerable patients, have an important role to play not only in diagnosing and treating COVID-19 but in mitigating the disparities the pandemic has exposed. Beyond ensuring that low-income and minority patients receive equal triage and treatment, EPs can screen patients for unmet social needs and work to ensure safe dispositions for homeless and other vulnerable patients. EPs must be especially attentive to undiagnosed domestic violence, which has surged as the pandemic has forced people to spend more time at home. EDs with greater capacity and resources can lobby hospital administrators to accept appropriate and timely transfers of COVID-19 patients from overwhelmed regions and hospitals. Additionally, EDs should collect detailed data on outcomes by income and race/ethnicity, so as to measure their performance in reducing disparities and disseminate successful practices.

When the World Health Organization (WHO) first declared the global outbreak of COVID-19 a “pandemic” in March, the obvious connotation was of a uniform and ubiquitous threat. As EPs now prepare for a second wave of COVID-19 in the fall, or continue to fight the first one, we harbor no such illusions. EPs are uniquely positioned to advocate for the patients and communities that continue to bear the brunt of the pandemic’s worst effects.

ABOUT THE AUTHORS

Dr. Kim is an assistant professor of emergency medicine at Stanford University.

Dr. Baker is clinical associate professor and senior vice chair of emergency medicine, Boston University School of Medicine, Boston Medical Center.

Dr. Sanchez is vice chair for emergency department operations at Beth Israel Deaconess Medical Center and associate professor of emergency medicine at Harvard Medical School.