The Covid-19 pandemic has swept across our nation and robbed the lives of over 200,000 individuals in the United States, with what feels like no end in sight. Infecting our universities, workplaces, and communities at mounting rates, not even the highest level of federal leadership has been spared. It is even more heartbreaking to know that minority communities have been among the hardest hit throughout the pandemic, bearing the highest burden of job loss, infection, and death.
Covid-19 has magnified systemic health inequities that have long been perpetuated by barriers in access to care, physician bias, and financial disincentives. Many minority communities are experiencing difficulties in accessing Covid-19 testing due to unequal site distribution, lack of transportation, and limited hours of operation. Compounding matters further, minorities are more likely to work in frontline jobs considered “essential” and live in densely populated neighborhoods and residences, both of which dramatically increase the risk of infection. While CMS and payers have worked to mitigate barriers for lower income individuals (e.g., waiving cost-sharing), minorities often fall into coverage gaps with 22% still lacking coverage compared to 8% of white individuals.
Over the last eight months, the realities in health disparities have been well-publicized, leading some cities to implement stop-gap solutions through initiatives like pop-up community-based testing in underserved areas. Building on these initiatives and the momentum of our country’s racial justice reckoning, we are entering the next phase of the pandemic and face a critical decision—how will we ensure equitable distribution of a vaccine while maintaining equitable access to testing?
Learning from our mistakes: how historical vaccine distribution has exacerbated health disparities
While Covid-19 is distinct from any health crisis the country has previously faced, there are still many parallels. As such, assessing U.S. public health strategies during past crises can provide insight into what has contributed to a more or less equitable response.
The mid-1900’s polio pandemic highlighted the ubiquity of the U.S. healthcare system’s racial segregation. Leading up to this pandemic, the U.S. Public Health Service was conducting the infamous Tuskegee Study, in which Black men of Alabama were lied to, mistreated, and denied treatment. This study reinforced long-standing mistrust which, combined with the lack of public education in communities of color and a decentralized vaccine distribution effort, led to an uptick in polio cases primarily in low-income Black communities.
As for a more recent case study, the approach to vaccine distribution for the H1N1 virus differed significantly from that of the polio pandemic. The CDC initially prioritized distribution to high-risk individuals and healthcare professionals. Health authorities then leveraged targeted strategies to narrow the gap between white and minority vaccination coverage with interventions such as localized action plans, partnerships with minority-focused health organizations, and free vaccinations. However, vaccination rates among Black individuals still lagged behind, suggesting that even targeted strategies may not be sufficient for fully addressing these racial disparities.
History has shown that one of the largest challenges in vaccine distribution is convincing the public of a vaccine’s safety and efficacy. This is especially concerning as public distrust of a vaccine is higher than ever due to the politicization of healthcare, and is especially high among Black Americans. While 58% of white people surveyed indicated they would be willing to be vaccinated this year, that figure is much lower at 43% among Black Americans.
An effective strategy for supporting vaccination efforts in minority communities will require a thoughtful approach that builds upon lessons from our past.
Prioritizing vaccine distribution for vulnerable populations
To date, several policies have been introduced that consider race, socioeconomic status, and broader vulnerability in the distribution strategy of a Covid-19 vaccine. The CDC, advised by the National Academies, recently proposed a framework for equitable allocation. First, prioritize healthcare workers and first responders, followed by nursing home residents and individuals with underlying conditions. Next, prioritize teachers, childcare workers, and essential workers, with vaccines only available to the general population once supply increases sufficiently. Most notably, the framework suggests that the CDC hold back 10% of the vaccine supply for “hot spots” identified using the Social Vulnerability Index, which incorporates measures of race, poverty, and housing density among other factors.
Beyond decisions around population prioritization, there are still structural shortfalls that must be addressed to ensure equitable distribution. For example, many minority individuals have not been formally diagnosed with “high-risk” conditions, and thus would not surface as high priority vaccine candidates in population data. Even for individuals who are appropriately identified, many lack access to transportation or reside in rural areas with inaccessible vaccine distribution sites.
Strategies to narrow vaccination inequities – a playbook for payers and providers
Partnerships between payers, providers, digital health solutions, and the government will be essential in expanding awareness, deploying up-to-date health education, increasing vaccine access, and confirming dosing completion to ensure population-wide immunization.
Adopt digital solutions to expand awareness and education
Payers and providers will be critical actors for driving vaccine awareness by meeting hard-to-reach individuals through a combination of technology and human touch. By partnering with local community leaders, advocacy groups, and faith-based organizations, providers can equip on-the-ground advocates with resources about vaccine safety and availability. San Joaquin General Hospital leveraged this strategy by partnering with Verily’s Covid-19 pathfinder to guide patients to relevant information and local resources. Communication of information in multiple languages will be vital for closing the education gaps for multicultural communities of color in particular.
Reduce access barriers with creative localized approaches
Addressing access barriers will likely be an operationally challenging, but an essential step in closing care gaps. Payers can be a critical partner by leveraging existing social determinants data to uncover challenges that may inhibit vaccination and provide tailored solutions in target communities, such as providing transportation and directing members to care sites with flexible hours. BCBS of Oklahoma tackled transportation barriers by collaborating with local city governments to send vans equipped with Covid-19 testing capabilities into vulnerable communities, a strategy which can be repurposed for vaccine distribution.
Closing vaccine completion gaps through digital interventions
Lastly, as most late-stage vaccine candidates will likely require a series of doses, clear education on dosing requirements and data-driven interventions to encourage completion will be essential. Equipped with access to population data, payers and providers can leverage multi-modal communication strategies to deploy both the preferred and most effective intervention tactics. Such a strategy was previously applied in inner-city primary care practices for HPV vaccine communication and intervention, ultimately increasing completion rates of the vaccine series. Digital solutions will be a critical component for reaching populations and driving vaccine completion at scale.
While the resources that have been devoted to removing cost barriers are encouraging, this is just one piece of a broader solution. Effective strategies for supporting vulnerable populations will require more coordinated involvement from payers, providers, communities, and government agencies to holistically identify unmet needs at the local level, close access barriers, and deliver tailored education. But coordination efforts will only go so far; such strategies must be amplified by equipping consumers with information and empowering them to become stewards of their own health. At this critical juncture in the pandemic, we as a society have a moral and social responsibility to support the individuals that have historically fallen victim to systemic care gaps. It is time to finally tackle the hard problem of healthcare inequity.
