30 Issues: The Disparate Impact of COVID-19

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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Later this hour, we will meet the Democratic and Republican candidates for the open congressional seat on Long Island, the one that Congressman Peter King, a Republican, is retiring from after 28 years in Congress. We will talk to Republican Andrew Garbarino and Democrat Jackie Gordon coming up later this hour.

Right now, we continue with our 30 Issues in 30 Days election series. Issue 28, How to fight disparate impact, and who gets sick from COVID. As the pandemic continues to sweep across the country. The New York Times reports this morning that 26 states are at or near record numbers for new infections and more than 500,000 cases have been announced just in the past week. Not a single state is seeing a sustained decline in numbers at this time.

One thing has become abundantly clear since the beginning of this in March, as many of you certainly know, communities of color are bearing the brunt of the pandemic, largely due to longstanding health inequities that have resulted in not only an increased risk for infection and severe illness, but also death from COVID-19 and other structural things that just have led to more exposure.

Joining me now to talk about how to fight the disparate impact on who gets sick, who gets treatment, and who dies from COVID-19, and how the two parties approach it differently is Dr. Mary Bassett, director of the FXB Center for Health and Human Rights at Harvard, as well as professor at the Harvard School of Public Health. As some of you may remember, she was the first New York City health commissioner under Mayor de Blasio. Hi, Dr. Bassett. Welcome back to WNYC.

Dr. Mary Bassett: It's a pleasure. Thanks, Brian.

Brian: Let's further break down some of these numbers. According to a Senate committee report from earlier this month, "Black people are dying from COVID-19 at 3.4 times the rate of white people when adjusted for age." That's a quote from the report and that COVID-19 accounts for one in five deaths among Latinos. Rising to not just an epidemic in the country and a pandemic in the world, but a major cause of death proportionately among Latinos in the United States.

Additionally, American Indian or Alaska native patients "are hospitalized at more than four times the rate of white people." According to the analysis undertaken by Democrats on the Senate Committee on Health, Education, Labor, and Pensions, known as HELP, we got those stats. From your research and expertise, why are the numbers continuing to go up for communities of color?

Mary: They're going up particularly for Latino communities and indigenous communities and remain excessively high among African Americans. With a group here at Harvard, we looked at the national data from the CDC and found adjusting for age because that's important. Obviously, your risk of dying goes up with age. If you compare a bunch of old people to a bunch of young people and their mortality rates are the same, that's not a good comparison. Adjusting for age, we found African Americans with 3.6 times higher, more likely to die of COVID.

You framed it well. The first thing, since I'm in public health, I like to talk about is the risk of exposure. That is almost certainly a principal driver of these disparities. Although people focus a lot on what we call co-morbidities, the higher rates of diabetes, heart disease, and so on in communities of color, the kinds of excess risk that we're seeing, particularly among younger people are just too high to be explained by anything other than differences in exposure.

For example, for Blacks, between the ages of 35 and 44, there is a nine-fold, that's 900%, higher risk of dying of COVID. That's the fact that people are in low wage essential jobs, they don't have paid sick leave, they don't have health insurance, they don't make a living wage, and they may work multiple jobs. They live in crowded housing because of the housing affordability crisis. They travel to work and are continuing to work. All of those are driving higher rates and people can take personal actions. It's a good idea to wear a mask, wash your hands, keep your distance but to address exposure, we really need policy remedies.

Then, of course, when you don't have good health generally reflected by our crisis and healthcare access and the crisis in delivering high-quality primary care, you're more likely not to be in good shape at the time that you get COVID and that makes you more likely to die. Dying of COVID is a combination of getting it. Then when you get it, getting it severely so that you are more likely to die of it and people of color are at risk all down that chain.

Brian: Also having access to healthcare. One of the policy items that President Trump signed a few months ago, that he said was to keep patients from having to pay for testing and treatment, was exactly that on paper. His administration is letting "Hospitals bill the government directly for coronavirus testing and treatment for the uninsured, instead of charging patients." That's how it was described in Business Insider. Have you looked at how much--

Mary: It's not working. [chuckles]

Brian: If not, why not?

Mary: I think you journalists have done a better job possibly than public health researchers at showing the continued confusion about whether you're going to pay and when you're going to pay. Of course, if you have symptoms which are fairly non-specific flu symptoms, you don't have COVID written on your head, people don't know whether or not they're going to have COVID when they go to the hospital. Then if they don't, who's going to pay for that? Anybody knows you go to a hospital, you got a bunch of tests. This idea that you can carve out one condition and subsidize its care is really not the way our human bodies work. Anyway, you were going to ask me a question, sorry.

Brian: I think you answered the question that I was going to ask. Since racial disparities also exist in health insurance and economics in general, how much did those executive orders alleviate the racial disparities in COVID outcomes? You were just describing the limitations of that. Now, Vice President Biden and other Democrats have brought up the fact that if the Affordable Care Act is struck down by the newly constituted Supreme Court, it could complicate treatment for COVID-19 and add to disparities even further. Let's take a listen to Vice President Biden during the last debate.

Joe Biden: The deal is that it's going to wipe out pre-existing conditions. By the way, the 200,000 people that have died on his watch, how many of those have survived? Over 7 million people that contracted COVID. What does it mean for them going forward, if you strike down the Affordable Care Act?

Brian: I think your last answer, Dr. Bassett, actually indicates that even striking down the Affordable Care Act or that even the protections currently afforded by the Affordable Care Act don't diminish the racial disparities entirely. Do they diminish them some in a way that striking it down would be a threat to increase disparate outcomes from COVID-19?

Mary: The answer to your multi-part question is yes. The Affordable Care Act still left millions of people uninsured and because insurance is tied to having a job, the numbers of people who are uninsured because they've lost their jobs has risen during the COVID pandemic, but there's no doubt that the Affordable Care Act narrowed the racial disparities in healthcare coverage.

The Latino population has been disadvantaged probably in part because of concerns about public charge. Because a key way the Affordable Care Act has worked has been to expand Medicaid and also concern, the fact that people who lack documentation weren't eligible to even purchase health insurance on the exchanges if they were undocumented. There's no doubt that the gaps in health insurance coverage were narrowed under The Affordable Care Act, and that dismantling those expansions, including the expansions in Medicaid coverage, would be extremely destructive. We really need to do better in the Affordable Care Act, but to strike it down, would unquestionably be measured in the loss of life.

Brian: Listeners, we can take a few phone calls if you have questions for Dr. Mary Bassett, the former New York City health commissioner, now in a position at Harvard on the confluence of health and human rights. If you have any stories, or comments, or questions on racial disparities in COVID-19 exposure and outcomes. Or, even suggestions for how to minimize those in the short run, like right away, as this new wave sweeps across the country, (646)-435-7280. Issue 28, racial disparities in COVID, 30 issues, in 30 days, pre-election series, I'm going to talk a little bit more about the two campaigns.

In May, Biden came out with his "Lift Every Voice" plan, which addresses the racial disparity in COVID-19-related deaths and hospitalizations. In this way, the data we've seen so far, suggests that African Americans are dying from COVID-19 at a higher rate than whites. Long-standing systemic inequalities are contributing to this disparity, including the fact that African Americans are more likely to be uninsured, and to live in communities where they're exposed to high levels of air pollution. Air pollution is another underlying factor.

In July, the Secretary of the Department of Health and Human Services, Alex Azar, and Surgeon General of the United States, Jerome Adams, published a letter on the Health and Human Services website. That outlined some of the measures that the Trump administration has taken to address the racial disparity. They state that all COVID-19-case reporting must now include race, ethnicity, age, and zip code data to help with intervention. In addition, they claim testing is offered at more than 90% of the 1,300 plus federally-supported community health centers.

There's some language from each side. What do you think is most important in terms of policy right away in the short run? We're not going to cure literally hundreds of year old underlying conditions for racial health disparities in the United States before this pandemic passes, so what can we do immediately?

Mary: We ought to have paid sick leave, and people-- Some of these things really can be done quite quickly. The problem here is simply political will. Additionally, we need to fix access to healthcare delivery, so that people get tested and know their status, if they're infected. It is expanded, we know that more people are getting tested, but there continue to be many barriers because of the uncertainty of what things will cost. I just have to go back to the fact that we're paying a price for the abandonment of the notion of decent work, of worker protections, of people not only having paid sick leave, but having protections at work.

They can make mask mandate. There's been resistance to this very simple measure with the bizarre result that mask-wearing has become a political statement. There have been health commissioners in other cities, not New York, it would not be in New York, I believe, who face death threats, over recommending that people wear cloth masks. Those are things that could be done right away, but I do think we have to keep our eyes on the fact that we need some big changes. That's why it's so important that everybody vote, [chuckles] if I may say.

Brian: Bijan in Brooklyn, you're on WNYC with Dr. Mary Bassett. Hi, Bijan

Bijan: Hi, Dr. Bassett. First, I just like to say thank you. Your work has inspired me over the years. Three years ago, at 31, I decided to go back to school to try and become a doctor and I just got into medical school. Thank you for your inspiration. The question that I have for you is, what role or what responsibility does the medical community have in the current condition? The whole idea that we have this insurance conglomerate and people can't get into to see doctors, that only exists by having doctors that acquiesce to that condition.

I don't see a lot of people in the medical community, saying, "Listen, this is a real problem to the health of my patients, that we don't have public access to health care." I was just at a doctor's office last week, and a young man in front of me, his insurance had expired, said, "Well, can I see someone today?" They said, "No, not without health insurance." I don't understand how the condition that we have with health insurance here, is at all in line with the Hippocratic Oath that every medical student has to take going into medical school. Again, thank you for your work and inspiration.

Mary: Well, thank you.

Brian: I'm going to out Bijanas a former Brian Lehrer Show intern, who, instead of pursuing a journalism career, like most of our interns do, decided to go straight and go into medicine. Congratulations on getting into med school, Bijan, that's wonderful. Dr. Bassett, how would you answer his important question?

Mary: Well, I agree. I've just recently wrote something for Nature, which is sort of the British equivalent of our magazine called Science, saying that, it's time for people in health to acknowledge that they have to speak up and engage with the political life of our country and say that things like not having universal access to health insurance is killing people, and we can't be quiet about these things.

We have seen The New England Journal of Medicine, the most prestigious medical journal in the United States, come out with a statement saying that the current administration has taken a crisis and turned it into a tragedy. That, they have manifestly demonstrated their incompetence and need to be voted out. That's The New England Journal. They've never made a statement in the presidential campaign [crosstalk]

Brian: I get it, but he's making two points, really, one is systemic, and the other was really about the individual responsibility of doctors, who, even if somebody doesn't have health insurance, at this time, and with respect to that disease, where is the Hippocratic Oath to do no harm in the rank and file medical profession? I'm curious if you see that as a problem as well.

Mary: Well, a business is a business, and people who are running doctor's offices are running businesses, so they respond to business pressures. That said, of course, I can imagine personally, and I trained in the public sector, where we never turn anyone away. New York City is lucky in having a very robust public healthcare sector, where no one will be turned away, and no one will be made to pay first. I don't know what to say about the structure of how we finance healthcare. That individual doctor is not responsible for that. That said, I can't personally imagine telling somebody who has a health problem to come back when they could pay for it.

Brian: Yes, and many doctors, of course, go above and beyond. One of the things that they sometimes do is, invite people who are uninsured to pay cash, and sometimes that's a lot less-- Sometimes people can't, obviously, but sometimes that's a lot less than they would be charging somebody with insurance, because the third party payer is going to give them a certain amount. I'm glad you remind people at least in New York City, that in the Health and Hospitals Corporation System, nobody will be turned away for inability to pay. Sam, and then--

Mary: No. They may have to pay later or work out some repayment structure but they will not be denied care. Nobody says, "Show me your insurance, and then I'll decide if I can look after you."

Brian: One more, Sam in Englewood. We've got about 30 seconds for you, Sam. Thanks for calling.

Sam: Oh boy, I got to talk fast. Hi, full disclosure, Dr. Bassett. I worked in your press office in Public Affairs and know you a little bit over the years. I want to ask you about coming vaccines. NAS has put out a framework, New Jersey just put out its framework and plan, do you think enough has been done to deal with inequities with regard to vaccine testing and then, distribution? I asked because I'm very involved with the intellectually and developmentally disabled folks and their needs.

Brian: Well, that's one of the next big policy challenges to come. Is vaccine distribution in a way that reduces rather than increases the disparity?

Mary: That's right, and there are two parts of it. One is the fact that communities of color legitimately are skeptical about being asked to go first because of the history of experimentation on communities of color. The other is whether or not an effective and safe vaccine will go first to people who can pay for it. These are two competing challenges, both the receptivity of communities that have been marginalized and the availability of the vaccine.

Personally, I think it should be focused by sectors and by possibly by neighborhoods. I don't think it should be directed to people on the basis of race. Race is functioning in ways that reflect the social consequences of race. Does disability function in those ways? It's not as though it's an inherent feature of risk. We all are looking forward to having a vaccine and how it gets distributed will be an important policy conversation to have and it's glad it started now.

Brian: Dr. Mary Bassett, director of the FXB center for health and human rights at Harvard, as well as a professor at the School of Public Health there, former New York City health commissioner. Thank you so much for helping us through Issue 28 in our pre-election series 30 issues in 30 days, disparities in COVID exposure, and outcomes. Thanks, Dr. Bassett.

Mary: Thanks. Thanks for having me.

Brian: Tomorrow Issue 29, COVID relief bill and the difference between the two parties on what should come next.

 

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