COVID-19 Shines Light on How Healthcare Is Leaving At-risk Populations Behind 

September 8, 2020
Robert Fields, MD

While we take stock of successes and failures, we are once again reminded that the US healthcare system isn’t built for everyone.

There is no shortage of examples highlighting how our healthcare system has failed – or at least could have done better – since COVID-19 took hold back in March. There are many reasons for this failure and many of them actually existed before COVID. The pandemic simply exposed the deficiencies in infrastructure, supply chain, equity and technology that we all hope will serve as lessons and guides for future strategic planning and investment.

There have been successes. Take the swift adoption of telehealth and providers’ dedication to redesigning and reconfiguring how and where they deliver care. We have seen that, when necessary, the system can be much more agile and flexible than many thought.

While we take stock of the good and bad, successes and failures, we are once again reminded – often glaringly – that the US healthcare system isn’t built for everyone. The coronavirus pandemic has exposed further gaps between the haves and have-nots, which, in a remote-centric healthcare environment, puts people’s health at risk and highlights the vast amount of work still to be done.

Exposing the problem

Gaps in infrastructure, social determinants of health, and disparities in technology were made clearly visible by COVID-19 and the nation’s response to the virus. Given the fundamental nature of these issues in determining the health of populations, systems must consider investment in these areas in order to achieve the goals they have set for themselves and for their communities.

Infrastructure gaps

According to recent reports, up to 30 million Americans still lack access to fixed broadband service at threshold speeds. Without reliable Internet, it becomes difficult for a person to take advantage of virtual access to their doctors, such as through telehealth appointments. Beyond appointments, access to reliable Internet enables better healthcare; lack of access impedes it. For example, disease management requires education, monitoring, and support. When a person can’t easily watch a video, consume educational content, or connect to an online portal in order to communicate with their healthcare team, their health is at higher risk than someone with the ability to do those things.

As providers, we know that access to information that promotes healthier outcomes, is just the beginning. So much of a person’s health is determined by external factors, like financial and housing stability.

Social determinants of health (SDOH)

SDOH are conditions in the places where people live, learn, work, and play, which affect a wide range of health risks and outcomes. Back in September, one in eight Americans lived below the poverty line, a stark reality that correlates directly to poor outcomes. But, as we are all painfully aware, COVID-19 has wreaked havoc on Americans’ finances: a staggering 1.5 million people have filed for unemployment, and the average household shortfall is nearly $1,000 each month. These numbers are incredibly troubling, given how much we know about the relationship between a person’s financial stress and outcomes – especially because it trickles down to so many other issues: Housing stability, food security, and transportation.

With the current economic crisis standing firm for the foreseeable future, the number of at-risk Americans continues to climb, as their positive outcomes decline.

Disparities in technology

Like infrastructure and SDOH, a person’s lack of access to – or inexperience with – technology can have a direct negative impact on their health. According to Pew Research, 81 percent of Americans own a smartphone, meaning nearly one-fifth of the population lacks the access to connection that these tools afford. Nearly three-quarters of U.S. adults own desktop or laptop computers, and roughly half own tablet devices. While those numbers continue to move in the right direction, there are still large gaps between the haves and have-nots.

Beyond having the tools, technology requires a level of literacy that simply does not exist across all users. When trying to ensure all patients have access to care, we are up against challenges of both access and understanding, which has a tangible negative impact on at-risk populations.

Addressing the problem

Now that COVID-19 is bringing the level of attention this problem deserves, it’s time we get to work on fixing the underlying system that created it through a combination of innovation, partnerships, and community engagement.

Prioritize innovation that equalizes

Like so many things, “access” means something different post-COVID; it means everyone needs to have some sort of device – or access to a device – that allows them to receive healthcare as well as much needed social supports such as food, personal protective equipment, health and other benefits among other services.

As we design new technologies in response to this experience, we need to prioritize things like remote monitoring that is open to everyone; chronic disease management that doesn’t center around face-to-face care; and patient engagement that mirrors consumer experiences. As we design and innovate, we need to ensure every patient – regardless of their location or socio-economic status – has access to virtual visits, and that those visits provide equal or better quality of care than in-person ones. Health systems should be working to find ways, develop tools, and design delivery models that allow care teams to monitor patients remotely. No person’s health should be compromised just because they don’t have a smartphone or reliable Internet. Communication should be a priority… and seamless. We need systems and tools that allow every patient to interact with their care team in ways that fit into their daily lives, such as text messaging.

Establish strong non-profit partnerships

Health systems should develop formal and lasting partnerships with non-profit organizations. In each community – and, in some cases on a national level – there are established organizations focused on addressing specific issues, such as food and housing insecurity. Rather than trying to design and manage a new solution on their own, health systems can look to those already doing the critical work and design ways to work together to combat the SDOH that impact whether a person will have positive outcomes or not.

Facilitate community engagement

We need to design and execute cohesive strategies for community engagement. In New York City where I live and work, you can’t simply solve problems as a delivery system looking outward; it starts at home, and requires partnerships with community organizations. Whether it’s a faith-based organization or an association board, the solution is often found within the community. As we look to ways we can improve access and outcomes, we need to start by looking to those who already have the attention of at-risk communities, and work with them to amplify, educate, and, ultimately, close the gaps.

When we look at the numbers and see the stories that highlight the large disparities for at-risk populations, it’s easy to feel overwhelmed and hopeless. But there is amplified support – driven by COVID-19 and the renewed racial justice movement following George Floyd’s death – for the philosophical discussions necessary to drive change. After all, we can’t change something if we don’t agree it needs to change. In addition, we have access to advanced – and relatively affordable – technology that allows us to design solutions that leverage those tools to not only deliver care, but increase access to it. As long as we — as a nation and health system — agree that the health of all citizens is a priority, we can use what we’ve learned from this time in history to begin to innovate with the goal of quality healthcare for every American.

Robert Fields, MD, is senior vice president and chief medical officer Population Health at Mount Sinai Health System and Inlightened Expert.