No one should be surprised that low-income populations are being hit harder by COVID-19: How do we achieve health equity?

By Elizabeth Baca, M.D., M.P.A., specialist leader, Deloitte Consulting, LLP

Health equity has been in the spotlight during the last several months as study after study has shown that COVID-19 disproportionately impacts low-income populations and communities of color. These findings have exposed the deep roots of racism that have contributed to health inequities in communities across the country over decades…if not centuries. Why do health outcomes vary so widely by race and income? What are the underlying factors affecting health? And, most importantly, what can we do to make health more equitable?

We see these disparate outcomes for most diseases. There is often a stepwise relationship among race, income, and disease. As COVID-19 began to grip the country in March, I knew it would have a profound and disproportionate impact on low-income people and people of color. The economic impact caused by the pandemic led to a sudden loss of income for many people, which has affected housing, healthy food options, and the ability to socially distance. As my colleagues Asif Dhar and Kulleni Gebreyes noted in their recent blog, Black Americans are more than twice as likely to die from COVID-19 than white Americans.¹ Look at virtually any disease—from diabetes to heart disease to mental health issues—and you will likely see strong disparities based on race and income.

When I decided to become a pediatrician more than 15 years ago, I was drawn to the field because I saw an opportunity to help children live fuller and healthier lives. As a pediatrician working at a federally qualified health center in East Palo Alto, California, I quickly realized that low-income children and children of color were often at a significant disadvantage in terms of health. Some of the kids I saw suffered from obesity and Type 2 diabetes, high blood pressure and hypertension, depression, and other diseases typically only seen in adults…and at shockingly young ages. Between 1960 and 2005, the percentage of US children with a chronic disease nearly quadrupled.²

As a doctor, I could offer clinical guidance. For the parents of a child in danger of developing Type 2 diabetes, for example, I might urge them to buy more fruits and vegetables and encourage more exercise. But a low-income family might not have access to a grocery store, might not be able to afford healthy food options, or might live in a neighborhood where it’s not safe for their child to play outside. All of these scenarios were common among my patients and their families. For those families, my clinical guidance—although well-intentioned—could not change the underlying conditions that created the problem in the first place. I was driven to change these conditions so that all kids—and adults—could have the opportunity for a healthy life.

As a consultant, I work closely with Deloitte’s leadership and our clients to address the underlying drivers of health for health plans, government payers, and hospitals. We try to quantify the impacts of racial and economic disparities and then design proactive strategies that organizations can use to alter the trajectory. This can lead to greater health equity, better economic opportunities and productivity, and a more just and fair society. It starts by placing equity at the center and expanding from there. Our framework (see image below) outlines the foundation for this work, giving specificity to the issues and opportunities that should be addressed to achieve this broader goal.

Health equity framework:

Healthy people, communities, and planet

Where does change start? How do we move toward well-being and healthy people? It can start with recognizing that health is much broader than health care. As a former provider, I have enormous respect for clinicians and other care providers on the front lines…it is demanding work. But to truly move toward health equity, the health sector should broaden the definition of health. The first step can be recognizing that we need healthy communities—as well as a healthy planet—to truly have a supportive ecosystem.

Sustain well-being or receive care

Our health is part of a continuum—we are either healthy, or we need care (being healthy is different than not being sick). Unfortunately, low-income families and people of color tend to be less healthy than other members of the population and are more likely to have more than one chronic condition. This impacts life expectancy, quality of life, even earning potential. As we think to the future of health, earlier prevention (including addressing underlying factors so prevention is possible) should be the goal for supporting and sustaining well-being. In a 2019 blog post, my colleagues David Rabinowitz and Josh Lee outlined the drivers of health and their link to our well-being.

Underlying factors 

Technologies

Technology, which has always had an impact on health, is expanding at an exponential rate and is leading to regular breakthroughs. But systemic racism and socioeconomic barriers can make it difficult for everyone to access that technology to sustain or improve health and well-being. While technology can make it easier for people to connect to clinicians and care teams, the best and most advanced technologies are useless for someone without access. Someone who doesn’t have a computer or broadband internet, for example, likely won’t be able to participate in a virtual-health visit. It’s the same with distance learning. Children who don’t have access to a computer or the internet are now at a significant disadvantage. However, intentional and thoughtful applications of technology offer the potential for breakthroughs to decrease these disparate impacts.

Cultures

Cultural constructs—including how we think about and value diversity and how we foster a sense of inclusion—can have an impact on heath and health outcomes. Some studies have shown that cultural issues can negatively impact the health of current generations, but also might affect the genetic make-up of future generations. Health care strategies—from how providers communicate with patients to what providers suggest as treatment—should be grounded in the cultural experience of the patient to be effective.

History

Past policies can cast a long shadow, even when not tied directly to health. For instance, in the 1930s, the federal government marked out “risky” neighborhoods for federally backed mortgages. This tactic allowed banks to deny mortgages to people based on geography rather than on an individual’s credit worthiness. This policy, known as redlining, often kept Black Americans in urban areas from being able to obtain financing to buy homes or to renovate properties. Along with making it difficult to accumulate wealth, redlining also limited access to health care in those communities.³ Health outcomes and life expectancy still map to the geographic boundaries established generations ago. These policies could be modified to have the opposite impact—and to support health.

The drivers of health

Up to 80% of health outcomes are affected by social, economic, and environmental factors. These drivers of health (also known as social determinants of health) include physical environment, food, infrastructure, economy, wealth, employment, education, social connections, and safety. There is extensive evidence that these factors all have an impact on health. I had the honor of working on the Communities in Action: Pathways to Health Equity report with the National Academies of Sciences, Engineering, and Medicine, which provided an extensive review of this evidence.⁴

Consider these factors:

• Environmental exposure: Black and Hispanic communities are exposed to 60% excess pollution vs. what they produce in daily activities. White communities, by contrast, experience 17% less pollution than what is caused by their emissions.⁵
• Economic impacts: More than 60% of Hispanic and 44% of Black households have experienced a job or wage loss due to COVID-19, compared to 38% of white households.⁶
• Disease risk: Low-income American adults are more than twice as likely to have a stroke. They also have higher rates of heart disease, diabetes, stroke, and other chronic disorders compared to wealthier Americans.⁷
• Social factors: About 40% of homeless individuals reported a history of domestic violence or partner abuse; this was true of 58% who identified as LGBTQ in King County, Washington.⁸ These stark differences all contribute to health outcomes.

Tackling these drivers of health can start with a deep analysis of the policies and practices that either contribute to or enable movement within each dimension of the social, environmental, and economic factors that contribute to inequities. It isn’t enough to address just one dimension, and it is equally important to recognize that there are actions that can be force multipliers. The framework (above) can enable a thoughtful development of specific actions and commitments that can be vital for moving us all closer to a future of health in which all of us can attain our best health and reach our fullest potential.

Endnotes

^{1. COVID-19 is affecting Black, Indigenous, Latinx, and other people of color the most, The COVID Tracking Project at the Atlantic}

^{2. Racial/ethnic disparities in chronic diseases of youths and access to health care in the US, BioMed Research International, September 23, 2013}

^{3. Redlining was banned 50 years ago. It’s still hurting minorities today, Washington Post, March 28, 2018}

^{4. Communities in action: Pathways to health equity, National Academies of Sciences, Engineering, and Medicine, January 11, 2017}

^{5. Inequity in consumption of goods and services adds to racial–ethnic disparities in air pollution exposure, National Academy of Sciences, March 26, 2019}

^{6. Racial economic inequality data, Inequality.org}

^{7. How are income and wealth linked to health and longevity?, Urban Institute, April 2015}

^{8. Community Health Needs Assessment, Highline Medical Center, 2019}

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