Health Letter, October 2020
By Michael T. Abrams, M.P.H., Ph.D.
The COVID-19 pandemic is disproportionately hurting and killing ethnic minorities in the U.S. Just how bad is this state of affairs? To what extent are these disparities directly related to COVID as opposed to long-standing, systemic social problems? This essay addresses these questions with facts from before and after the emergence of COVID-19.
Data from the Centers for Disease Control and Prevention (CDC)
A report published in the CDC’s Morbidity and Mortality Weekly Report (MMWR) on July 17 demonstrated that Black and Latinx people have been killed by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the virus that causes COVID-19) at much higher proportions than white people. From mid-February to mid-May, there were 83,000 confirmed COVID-19 deaths in the U.S. The CDC reviewed data on over 52,000 of those deaths and found the following racial/ethnic makeup: 40% white, 21% Black and 14% Latinx. These numbers strongly contrast the general population figures of 60% white alone, not Latinx; 13% Black or African American alone; and 19% Latinx of all races. Additional reporting to the CDC designed to assess more complete information revealed even more pronounced disparities among over 10,600 people who died from COVID-19 from February 12 to April 24, with white, Black and Latinx people composing 35%, 25% and 24% of those deaths, respectively.
The above analyses from the CDC demonstrate that in the U.S., dark skin especially and Latinx origin more subtly correspond with increased risk of death from COVID-19. Data reported to the CDC further demonstrate an additional indicator of disparity — minority groups compose an even higher percentage of deaths among those under the age of 65 years: white people 18%, Black people 30% and Latinx people 34%. The authors of the MMWR report speculated that “one potential contributing factor is higher percentages of Hispanic and nonwhite persons engaged in occupations…or essential activities that preclude physical distancing.”
A more recent MMWR report published on August 21 analyzed the racial and ethnic makeup of people diagnosed with COVID-19 in county-level COVID-19 “hotspots” that appeared from June 5 to June 18. Hotspot counties were principally defined as those with over 100 new cases in the last week and three- to seven-day increases exceeding 60%. Among more than 3,100 U.S. counties, the CDC identified 205 hotspots (across 33 states), and of those, 79 (across 22 states) had race/ethnicity data in over 50% of reported COVID-19 cases. Disparities in one or more underrepresented racial/ethnic groups were evident in 96% of the 79 counties, and disparities specific to Black or Latinx populations were evident in at least 86% of those jurisdictions. A disparity was defined as either a 5% or greater difference between the proportion of COVID-19 cases and the proportion of the population for a particular racial/ethnic group in the county (for example, 25% of the COVID-19 cases in a county were in Black people, but only 20% of the county population was Black) or a ratio of these proportions of at least 1.5 (for example, 6% of the COVID-19 cases in a county were in Black people, but only 4% of the county population was Black; 6%/4% would be a ratio of 1.5). The researchers concluded that these results demonstrate “disproportionate incidence of COVID-19 among communities of color, as has been shown by other studies.” The disparities were attributed to many factors, including economic and social realities that make physical distancing difficult at home and work.
Investment disparities between hospitals
Not assessed by the CDC were differences in medical resources available to minorities in the U.S. One study published in July in the International Journal of Health Services found that in recent years (2013-2017) Black- and Latinx-serving hospitals have markedly lower capital assets (land, buildings, equipment) than other hospitals that predominantly serve white populations.
Using cost reports and survey data from the American Hospital Association for the nation’s 4,400 Medicare-serving hospitals across the U.S., the study authors split hospitals into three distinct groups: the top 10% serving the most Black people (by percentage), the top 10% serving the most Latinx people, and all others. The other hospitals had significantly more assets per patient-day than the highest Black- and Latinx-serving facilities — $8,325, $5,172 and $5,763, respectively. Moreover, even after adjusting for differences in hospital size, geographic region, teaching status and for-profit versus not-for-profit ownership, this research found that the average bed in an Black or Latinx hospitals was tied to accumulated assets in 2017 that were approximately $215,000 lower than a similar bed in other hospitals.
This study further showed that hospitals serving the highest proportion of patients of color were less likely than other hospitals to offer 19 of 27 capital-intensive services such as certain advanced diagnostic imaging or surgical procedures. As examples, the hospitals serving primarily people of color were 45% less likely to offer positron emission tomography, 56% less likely to offer robotic surgery and 63% less likely to offer cardiac rehabilitation services, even when these comparative analyses were adjusted for hospital size, ownership type, teaching status, region and urban/rural location.
Further statistical analysis found that income/wealth and illness severity differences between hospitals did not explain the observed differences in hospital assets, thereby adding support that race/ethnicity was a singular factor in that regard. Overall these analyses reveal substantial race/ethnic disparities in the current U.S. hospital health care system. This is despite the explicit hospital desegregation aims of the 1964 Civil Rights Act. Moreover, several studies have demonstrated higher death rates related to the care of people of color that range from low-birth-weight infants to adults suffering from heart attacks or other trauma.
The National Healthcare Quality and Disparities Report
Since 2003, the Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services, has issued annual National Healthcare Quality and Disparities Reports (QDRs). Annual QDRs are mandated by Congress and offers a comprehensive overview of health care access and quality issues with particular focus on the experiences of racial and socioeconomic subgroups that compose the U.S. population.
The most recent QDR is based on the nation’s broad health care situation through 2018 and was published in 2019. This report prominently features health care disparities between white populations and Black and Latinx populations. It noted that uninsured rates in 2018 were 9% for white people, 15% for Black people and 27% for Latinx people. The especially high rate for the Latinx population may be related to immigration status among migrant workers and their families, who may be reluctant to enroll, or be barred from participating, in Medicaid or other available public health insurance programs.
The QDR draws from more than 250 quality measures of the U.S. health care system. A review of these measures from recent years offers both a static (snapshot) and a dynamic (changes over time) national scorecard of racial/ethnic disparities. The QDR published in 2019 shows aggregate disparities for Black and Latinx populations compared with white populations across at least 167 quality measures corresponding to the most recent data available from 2013 through 2017. Among Black people, 40% of the totality of these measures were worse than those experienced by white people while only 15% are better compared to white people (the remaining 45% were similar between white and Black people). Latinx quality measures were less disparate from those of white people but still inferior. Compared with white people, 35% of Latinx quality indicators were worse, and only 23% were better. Accordingly, the overall gap in quality measures between Black and white people is 25% (40% minus 15%) and between Latinx and white people is 8% (35% minus 23%). Moreover, trending data extending backwards in time for each measure considered shows that most of the disparities observed for Black and Latinx people were evident in the year 2000.
The largest disparities for Black and Latinx people are further revealing and thus described briefly in this and the next paragraph. In 2015, the rates of new cases of HIV infection per 100,000 persons aged 13 or over were six for white people and 53 (more than eight times higher) for Black people. Likewise, HIV-related death rates in 2016 were one and seven per 100,000 persons in white and Black people, respectively. In 2016, the rates of hospital admissions for asthma (the most common chronic lung condition) per 100,000 children (age 2-17 years) were 46 for white people and 221 for Black people.
For Latinx people, the rate of new HIV cases per 100,000 persons in 2015 was also substantial at 23, nearly four times higher than the rate for white people. Another measure that was especially disparate in Latinx people was the prevalence of end-stage kidney disease due to diabetes in 2016, which was 30 per 100,000 persons, compared with just 12 per 100,000 for white people. Finally, QDR data revealed that 22% of Latinx people go without a usual source of medical care because of limited financial or health insurance resources, more than double the percentage for white people.
Thus, national and comprehensive measures from the two decades preceding the COVID-19 pandemic show that Black and Latinx health care quality lagged well behind that experienced by white people.
The National Equality Index
The National Urban League is a civil rights advocacy organization founded in 1910. In 1976, it created the “State of Black America” report. An important component of these now annual reports is the calculation of a disparity index based on a quantitative compilation of measures spanning the five areas of economics, health, education, social justice and civic engagement issues. It yields a single number from 0 to 100 that can be interpreted as the percentage of the U.S. “pie” a group achieves compared with that which would represent equity with U.S. whites.
The equality index calculations in 2020 showed that, overall, Black Americans lag substantially in four out of five areas reviewed except for civic engagement and that those lags were 16% or more. Latinx Americans overall showed similar equity lags of at least 23%, except for a single slight advantage in health over white Americans. This advantage in health was surprising, but is likely explained by two facts: 1) this report is based on pre-COVID-19 data and 2) the health measures assessed are not as comprehensive as those used for the AHRQ QDR report. Whatever the case, the Urban League Equality Index showed substantial patterns of racial/ethnic disparities. Regarding the cause of these disparities, the Urban League 2020 report is unequivocal:
Our reporting reveals the common denominator in the alarming and disproportionate ratio of Black people left gasping for air in emergency rooms and at the hands (and knees) of law enforcement: centuries of systemic racism.
COVID-19-related health care data sadly support the charge that Black and Latinx people are disproportionately hurt and killed by infectious diseases. Other health care data show more generally that even well before the onset of the COVID-19 pandemic, people of color regularly experienced restricted access to insurance and well-equipped hospitals. Comprehensive appraisals of Black and Latinx societal standing show measurable and marked lags between such minorities and non-Latinx white people. These realities all point to systemic discrimination as a substantial barrier against improvement of the U.S. health care system. Absent improvements in these health indicators, which sometimes signify life and death differences, Americans of all racial and ethnic backgrounds should continue to protest.