Many COVID policies and practices exacerbated longstanding health disparities. Here’s how we can change that going forward.
Since Omicron first appeared here in December 2021, the United States has had a 63 percent higher COVID death rate than other high-income nations. We also continue to experience deep disparities by race and ethnicity for risk of infection, hospitalization, and death from COVID. Even though federal agencies issued guidelines on how to stay safe, it was our local and state responses that explain many of the differences in health outcomes.We turned to researchers working with Systems for Action, Policies for Action, and Evidence for Action, all signature research programs of the Robert Wood Johnson Foundation, to find evidence-based answers within policies, practices, and data to help explain these disparities. The questions included: Which responses worked best during the pandemic for our population as a whole and for communities at greatest risk? And how can we respond to future large-scale national emergencies in ways that better protect the health of vulnerable people and communities?
Here are three important lessons that emerged:
1. Pandemic Response Policies Must Protect People at Greatest Risk
While rapid policy responses to COVID (from physical distancing to temporary paid leave) were meant to protect the general public, many of these policies left out groups most vulnerable to the health and economic consequences of COVID-19. For instance, the federal Families First Coronavirus Response Act excluded some 60 million workers, including health care providers and first responders who could not stay at home or practice measures such as physical distancing.
Safety net programs like paid leave weren't accessible to many gig workers and part-time employees—even after evidence showed that lower-income workers were more likely to get COVID. When vaccines became available, the government prioritized groups by age rather than by risk, bypassing many people in essential industries who continued going to work to keep the nation running while risking exposure to coronavirus.
Julia Raifman is a researcher at Boston University School of Public Health who helped develop a database to track state implementation of health and social policies in response to COVID. She notes: “It’s been really striking to track these policies because we see there are several that leave out the lowest income, informal sector workers again and again: minimum wage policies, unemployment insurance policies, paid leave policies, and health insurance. We need to ensure that social support policies reach people who have part-time jobs or work as independent contractors, who are most likely to need support to avoid food and housing insecurity. We also need policies like an OSHA (Occupational Safety and Health Administration) emergency temporary standard that reaches all workers.”
2. Policymakers Should Take Steps to Expand and Protect Insurance Coverage Through Medicaid Expansion and Other Measures
In what proved to be the most significant test of the U.S. health insurance system since the implementation of the Affordable Care Act, the pandemic and associated recession affected insurance coverage, making it harder for those with low incomes to access healthcare. Rapid-response research found that the presence of Medicaid expansion was associated with protective effects on coverage for Black and Latinx populations during the rise in the uninsured rate.
“Medicaid has tremendous potential to protect people from economic shocks,” said study author Aditi Bhanja who is a research advisor at the Women’s Refugee Commission. “While our study covered just four states, the data suggests that extending safety net benefits is beneficial to individuals and communities. As we are bound to encounter future emergencies, it is important that we rapidly assess how well our system can support the most vulnerable among us.”
3. Partnerships that Improve Care for People with Complex Needs Are Especially Important During a Pandemic
People living with complex medical, behavioral health, and social needs require an integrated approach to care. One study in progress is evaluating the effectiveness of California’s Whole Person Care (WPC) initiative that coordinates services for people receiving Medi-Cal. These pilots use diverse care coordination teams to help reduce silos, improve the value of care, and increase access to care—ultimately helping improve the health and well-being of people participating in the program.During the COVID-19 pandemic, partnerships formed through WPC held strong. “Many of the staff in WPC programs were public health workers who were reassigned to deal with urgent COVID response activities,” said evaluator Nadereh Pourat of the UCLA Center for Health Policy Research. “Still, they were able to use their experience and connections to provide important benefits to people in the program, like helping people experiencing homelessness to be housed quickly because they were already enrolled in the program. Building partnerships between county health agencies, other agencies, and community providers and organizations [now] means that you don’t have to begin from scratch in public health emergencies.”
How Policy Can Support Healthy Equity In the Future
This evidence suggests better policies and policy implementation can improve health. The COVID-19 pandemic has demonstrated that this is an important moment to reset policies that scale up and support the tools that are most effective in controlling the spread of COVID and to prioritize protections for people who have been left behind by many pandemic-era policy decisions.We know what works: more inclusive social policies that prioritize disproportionately impacted communities, including racial and ethnic groups as well as essential workers. We must extend benefits and expand safety net programs like Medicaid, especially for those facing health disparities. We must continue to build partnerships among sectors, agencies, programs, community groups, policymakers, and stakeholders, both to benefit public health efforts currently underway and to better prepare us for future public health emergencies.
A treasure trove of rapid-response COVID-era policy research exists—let's rely on this evidence to address health inequities during the pandemic and after it ends.The COVID-19 pandemic revealed how racism has shaped the life course of Black and Brown communities.
LISTEN to my discussion with Dr. Alonzo Plough about his new book, Necessary Conversations, which examines racism as a barrier to health equity and offers strategies to build a healthier, more equitable future.
About the Author
Jacquelynn Orr is a former program officer with RWJF's Research-Evaluation-and-Learning team.