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How health care inequity could make the COVID-19 crisis worse

As global warnings about COVID-19 intensify, the message is increasingly stark: If you’re sick, stay at home. A wave of cancellations and closings have tried to keep even seemingly healthy people away from big gatherings or close quarters. But if you’re one of the millions of people in the United States who don’t have paid sick leave or adequate health insurance coverage, taking time off of work while you’re sick — or seeking medical care in the first place — can feel impossible.

Trying to soldier on as normal in the middle of a global pandemic carries a different peril, however: the risk of further spreading a disease that has so far killed over 5,000 people worldwide, overwhelmed other countries’ health systems and for which there is no vaccine or cure.

On Friday, President Donald Trump declared a national emergency and announced that $50 billion would be made available to bolster efforts on the state and federal level to respond to the virus. That’s after the World Health Organization officially declared that the COVID-19 crisis meets the definition of a pandemic, which is characterized by the uncontrolled, international spread of disease.

“In effect, the more cases there are, the more risk everyone faces,” Northeastern University public health law expert Wendy Parmet said. “For that reason, we protect everyone by helping the most vulnerable people in our country stay healthy.”

By nature, respiratory viruses like COVID-19 are highly transmissible and therefore difficult to confine. Pre-existing barriers to medical care — like a lack of insurance — only exacerbate the virus’ spread, Parmet said.

Having insurance is, by and large, “the key to the [American] health care system,” University of Washington health policy expert Aaron Katz said. Those who aren’t insured can accrue overwhelming medical bills or face “outright refusal” when they do seek care.

Evidence so far suggests that the majority of people who contract COVID-19 experience relatively mild symptoms that resemble the common cold or flu. But the elderly, immunocompromised and those with underlying health conditions are more likely to experience severe, potentially lethal cases of the virus.

Katz said that those who don’t feel debilitated by their symptoms and have no paid sick time off may choose to keep working and avoid losing several days of pay, but at a potential cost to the general public.

In an Oval Office address on Wednesday, Trump announced that leaders in the health insurance industry agreed to waive co-pays for COVID-19 testing, but that agreement did not include an extension of coverage for any treatment associated with the virus.

For now, people who are presenting symptoms of COVID-19 must get a doctor’s note in order to receive a test for the virus. Those who don’t have established primary care providers can seek a physician’s advice through their local urgent care clinic or health center. The Centers for Disease Control and Prevention has advised all clinicians to work with state and local health departments to “coordinate testing through public health laboratories.”

On Wednesday, NPR reported that while these tests are fully covered under private insurance, Medicare and Medicaid, uninsured patients may be charged for the test “at whatever rate the doctor or hospital chooses.”

READ MORE: The reason U.S. COVID-19 numbers aren’t higher? Not enough tests

Weeks have gone by since the start of the outbreak in the U.S., and moves to make testing available and accessible have been slow. There have been reports of missteps in tracking and reporting cases, and the tests originally developed and distributed by the CDC were later discovered to be faulty.

Last Thursday, Vice President Mike Pence, who is leading the federal government’s response to COVID-19, acknowledged that officials did not have enough tests to meet anticipated demand in the near future. Now, some medical researchers and private companies are working to develop their own tests.

State and federal lawmakers are considering emergency legislation that addresses major questions like how to make testing accessible for more people and how to ensure that those who can’t work during this pandemic will still be able to pay their bills. But will those efforts be enough to ensure that everyone who needs care has access to it?

How community health care centers can help

The U.S. has a strong network of health centers, many of which offer services like a sliding pay scale in order to meet the needs of their community members, including those who are uninsured. Still, a notable range of factors, including income and immigration status, can significantly affect a person’s ability to access care.

Asqual Getenah is the medical director of International Community Health Services, which runs 11 clinics in the Seattle area. The majority of her patients are immigrants — more than 65 percent of visits, she said, are conducted through interpretation services — and another 10 to 20 percent are uninsured. The clinics are also open until 6:00 or 7:00 p.m. many nights of the week to give patients more scheduling flexibility.

ICHS provides a range of services, including helping connect people with health care coverage for which they may not realize they qualify. But Getenah emphasized that providers will care for patients regardless of their ability to pay.

The considerations surrounding care also must account for the reality that millions of Americans live in mixed-status families where close relatives in the same household have different immigration statuses. One in four children in the United States has at least one immigrant parent, and an estimated 5.8 million children who hold American citizenship have a non-citizen parent, who may have immigrated legally or illegally.

In February, the Supreme Court approved the Trump administration’s move to implement a “public charge” rule that disincentivizes legal immigrants from seeking public assistance like Medicaid and food stamps. The ruling has had a “chilling effect” in immigrant communities, Getenah said, where undocumented residents also may refrain from seeking medical care for fear of legal repercussion.

For those who fear it may impact them or their family members, ICHS staff can help break down the legal intricacies of the new rule.

Health centers like ICHS serve over 29 million people in more than 12,000 communities across the country and provide many of the same services, including sliding pay scales and translation services. The National Association of Community Health Centers offers a searchable list of those providers through its website.

The National Association of Community Health Centers chief medical officer Ron Yee said that about 23 percent of health center patients nationwide are uninsured, and 91 percent are low-income. Those patients may also suffer from housing insecurity — about 1.4 million people in the United States experience homelessness each year — or chronic diseases like asthma, diabetes or obesity. Such conditions can compromise the immune system, leaving patients at greater risk of catching viruses like COVID-19.

Most community health care centers offer transportation assistance, translation services and comprehensive care that includes pharmacies and 24 hour telehealth services. Some also have facilities on school campuses, which gives parents the opportunity to make sure their children are seen by medical professionals without having to take the time off from work to attend those appointments.

These centers aim to mirror the communities they serve: Fifty-one percent or more of the board members must be patients at the centers that they represent. That community engagement, Yee said, allows providers to deliver linguistically and culturally appropriate care to their patients.

All of those efforts help community health centers form trusting relationships with their patients, which Yee emphasized becomes “critically important” when policies like the public charge rule are put into effect, or when infectious disease outbreaks like COVID-19 occur.

“When something happens in the community, [patients] come to the health center to, first of all, ask questions, but also to receive care with people that they trust already,” Yee said.

Why public health efforts are key to mitigating outbreaks

Katz agreed that medical outreach efforts like the ones carried out at community health centers are critical, but argues that the U.S. has been underfunding public health for “decades.” The unfortunate nature of those efforts, he said, is that they’re invisible when they’re working — in other words, a functioning public health infrastructure is designed to mitigate crises before they spiral out of control.

“In many places around the country, the fiscal austerity that many state and local governments have been living under has eroded that infrastructure,” Katz said.

State and local governments have emergency preparedness plans that are designed to respond to infectious diseases like COVID-19. What those plans look like differ from community to community. In cities, where there’s a wealth of densely populated public spaces for viruses to spread, urban health systems could get overwhelmed if they need to treat — or isolate — thousands of patients, Katz noted.

But urban areas typically have more health care resources compared to rural areas, where patients may have to travel long distances to access care in a hospital setting, and shortages of primary care physicians are more likely. Lack of transportation to reach care can also be a major obstacle for residents, but community health centers — nearly half of which are located in rural communities — do help fill part of that gap.

Surge capacity, or a medical establishment’s ability to handle a large number of patients, is also a concern in rural areas, said Brock Slabach of the National Rural Health Association. And it could become an even more pressing issue if a large number of patients require complex care like ventilator assistance to treat their cases. He noted that because the rise of novel coronavirus happened in the thick of flu season, some hospitals are already “at or near capacity in terms of their beds.”

“How are we going to be able to handle the surge of patients that need complex care if these rural hospitals have no place to transfer those patients that need more tertiary services?” Slabach said.

Still, Slabach is “confident” that rural hospitals will be able to meet the needs of their patients in the event of a potential COVID-19 outbreak. He emphasized the importance of strong social networks in many rural communities, and noted that faith-based organizations are often central to caring for community members.

READ MORE: Your guide to understanding COVID-19

States that have expanded their Medicaid programs and have seen a marked increase in their number of insured residents, are “much better positioned” to respond to an outbreak like COVID-19. That’s in part, Yee explained, because more people in those states have a better understanding of the health care system and how to access it.

A number of largely rural states — including Texas, Wyoming, South Dakota, Wisconsin and a block of Southern states — have opted not to expand their Medicaid programs. Around 19 percent of rural residents and 16 percent of urban residents are uninsured, and rural residents tend to stay uninsured for longer periods of time than their urban counterparts.

On March 2, Wendy Parmet and several hundred other public health and legal experts signed an open letter addressed to Vice President Pence, who is spearheading the federal response to COVID-19, and other government officials tasked with managing the growing outbreak.

The letter emphasizes that a successful response to the virus must “protect the health and human rights of everyone in the United States” while ensuring that the burdens of response measures “do not fall unfairly on people in society who are vulnerable because of their economic, social or health status.”

A range of policy measures could be taken to help ease that burden. More and more state and local governments have passed or considered legislation that would require employers to provide paid sick leave or create publicly financed programs that offer those benefits, said University of California-Berkeley health policy expert William Dow, who did not sign the open letter. Variants of those policies, he noted, are already in place in “most other wealthy countries around the world.”

A government response that compensates infected people who will endure serious financial hardship for taking time off of work to self-isolate is one step that Parmet advocates. Another is making immigration status irrelevant to public health considerations. She said she’d like to see clear messaging from entities like Immigration and Customs Enforcement, the Department of Homeland Security and the White House itself assuring that there will be no consequences for immigrants, regardless of their legal status, who cooperate with, or seek the aid of, public health officials.

State governments ― particularly those that offer health care for non-citizens ― also have a role to play, Parmet noted, when it comes to making sure that residents who may fear retribution under the federal public charge rule are aware of potential state-based coverage options.

“We have to recognize that in an infectious outbreak, everyone’s fate depends on the well-being of the most vulnerable,” Parmet said. “This is not a time for tribalism. This is not a time for division.”

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