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Two months into the coronavirus disease 2019 (COVID-19) pandemic, more than 1.7 million individuals in the US have been infected and more than 100 000 have died. This tragedy has affected people of all walks of life, but the burdens of morbidity and mortality have not been borne equally. As data have accumulated from across the nation, a disturbing, and not surprising, pattern has emerged: cases, hospitalizations, and deaths have disproportionally affected communities of color.1,2
A Crisis Within a Crisis
Burdened by a legacy of discrimination and systemic inequality, African Americans, who represent 13% of the US population, account for 26% of COVID-19 cases,3 31% of hospitalizations,4 and 23% of deaths,5 according to the Centers for Disease Control and Prevention (CDC). This translates to a mortality rate for African American individuals that is 2.4 times the rate for white individuals, with rates of 54.6 vs 22.7 deaths per 100 000, respectively, based on data from 39 states and the District of Columbia.6 However, complete data on these differences remain elusive. Nationwide, 50% of COVID-19 cases reported to the CDC lack the patient’s racial or ethnic information.3
Legislation to Date
Despite the challenges and data shortcomings, the need for immediate and decisive action is clear. Yet the response in the US so far has been shamefully inadequate.
To date, the US Congress has passed 4 pandemic response measures. The first law (Coronavirus Preparedness and Response Supplemental Appropriations Act, Public Law 116-123) did not address racial disparities at all. The second law (Families First Coronavirus Response Act, Public Law 116-127) attempts to provide basic supports (nutrition assistance) and economic stability (unemployment benefits, sick leave) to all individuals in the US. Given its uniform approach to assistance, the law is unlikely to narrow health disparities.
The third and most comprehensive law (Coronavirus Aid, Relief, and Economic Security [CARES] Act, Public Law 116-136) attempted to address the spiraling economic fallout of the pandemic through financial aid to individuals and businesses. Yet equitable access to these benefits for minority individuals (who are less likely to have filed a tax return) and minority-owned businesses (that are less likely to have a bank account) remains uncertain.7,8
In terms of health care, the CARES Act allocated $100 billion for health care organizations and clinicians for pandemic response and lost revenues. The fair distribution of these resources remains a matter of debate. Only a small portion of these funds have gone specifically toward hospitals with high numbers of patients with COVID-19 ($12 billion) or those treating high numbers of low-income and uninsured patients (based on disproportionate share hospital payments, $2 billion).
The fourth law (Paycheck Protection Program and Health Care Enhancement Act, Public Law 116-139) addressed COVID-19 racial disparities directly. The law mandates that the US Department of Health and Human Services explicitly report COVID-19 testing, hospitalization, and mortality data by race/ethnicity, and most importantly, develop a “strategic testing plan” that “address[es] disparities in all communities.” Yet the law does not address how to improve data quality or provide funding to respond to documented disparities.
A Legislative Road Map
Every individual in the US deserves equal access to prevention, testing, and treatment of COVID-19 regardless of their race or ethnicity. But most important, the US must take this opportunity to address its deep scars of racial inequality.
As Congress negotiates the next COVID-19 legislative package, health equity must be a cornerstone of the US pandemic response. The differences in morbidity and mortality between white people and people of color justifies this approach. First and foremost, the frequency and quality of data on race related to COVID-19 must be improved. Without additional data it will be impossible to fully understand the effects of the pandemic on communities of color or ensure that prevention and treatment interventions reach those most in need.
The Equitable Data Collection and Disclosure on COVID-19 Act (HR 6585) requires the CDC to issue daily updates on COVID-19 testing, hospitalizations, ICU stays, outcomes, and deaths by race and provides funding for data modernization and quality improvement nationally and locally.
In addition, increased accountability is necessary. The COVID-19 Racial and Ethnic Disparities Task Force Act of 2020 (HR 6763/S 3721) would create a task force consisting of key federal agency leadership, clinicians, health disparities experts, and community-based organizations that would provide weekly medical supply allocation recommendations to FEMA (the Federal Emergency Management Agency) during the emergency period and assist with oversight of the influence of the federal response on health equity. After the pandemic, this task force would be institutionalized to act as a watchdog for emerging racial disparities in future pandemics.
Communities of color must also be empowered to address the pandemic. The Community Solutions for COVID-19 Act (HR 7077) would provide targeted grant funding, totaling $1.5 billion over 3 years, to community-based organizations responding to the pandemic, allowing interventions to be directly informed by the communities most affected.
The US House of Representatives recently passed its preferred version of the next coronavirus relief package entitled the Health and Economic Recovery Omnibus Emergency Solutions Act (HEROES) of 2020 (HR 6800). The bill includes many high-priority areas for communities of color such as free testing and treatment for COVID-19 for all individuals (including those without health insurance); equitable access to COVID-19 testing; further racial data collection and modernization efforts; aid for health centers and clinicians caring for vulnerable populations by increasing disproportionate share hospital payments; funding for health disparities research; increased health insurance access and coverage; improved multilingual, culturally appropriate, and community-led public awareness campaigns; and aid for community health centers. Whether these provisions become law depends on ongoing negotiations with the Senate.
Addressing the legacy of health inequalities in the US will necessitate radical reform of the health care system and society. Action is required on multiple fronts, including health care access, medical workforce diversity, bias training, minority community engagement, research prioritizing the needs of communities of color, and a comprehensive strategy targeting the social determinants of health.9
Rising to action, the Congressional Black Caucus, Congressional Hispanic Caucus, and Congressional Asian Pacific American Caucus recently introduced the Health Equity and Accountability Act (HEAA) of 2020 (HR 6637). HEAA provides a comprehensive policy framework along with funding to close health gaps for individuals facing barriers to care due to race, immigration status, sex, age, ability, geographic location, sexual orientation, gender identity, and English proficiency. In doing so, HEAA aims to ensure that communities cannot only withstand the next pandemic, but promote safe and healthy lives for all US residents at all times.
At this time of crisis and heightened disparities, neither the medical community nor Congress can afford to be color-blind. Although death certificates do not allow “racism,” “discrimination,” or “poverty” to be listed as the cause of death, physicians have long known that these factors contribute to patients’ chronic diseases, premature deaths, and unequal health outcomes. Documenting “COVID-19” (or “myocardial infarction” during typical times) on a death certificate only scratches the surface of the cause of death for many patients.
The character of the US will be revealed by how it responds to the health disparities that the pandemic has so painfully exposed. The COVID-19 crisis therefore offers a difficult but important opportunity to redesign the US health care system, laws, and society to meet the needs of its most vulnerable groups. Accordingly, health professionals must reach out to local, state, and federal leaders to express strong support for long overdue societal, legal, and health system reforms that patients of all backgrounds need and deserve.
Corresponding Author: Marisa K. Dowling, MD, MPP, Health Policy Fellow, Department of Emergency Medicine, The George Washington University, 2120 L St, NW, Ste 450, Washington, DC 20037 (email@example.com).
Published Online: June 4, 2020. doi:10.1001/jama.2020.10531
Conflict of Interest Disclosures: None reported.
Additional Information: Statistics are updated as of May 29, 2020. The acts passed by the 116th Congress and proposed legislation are available at Congress.gov.
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Dowling MK, Kelly RL. Policy Solutions for Reversing the Color-blind Public Health Response to COVID-19 in the US. JAMA. Published online June 04, 2020. doi:10.1001/jama.2020.10531
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