Health Equity in a Post-Pandemic Nation: Safety-Net Providers as a First Resort

The world has changed in countless ways over the past 21 months. As autumn arrived, COVID-19 deaths in the United States climbed to an average of more than 1900 per day for the first time since early March.¹ The pandemic's conclusion, if we can call it that, seems ever illusory with the arrival of new variants and vaccination rollout concerns. For some of us, returning to “normal” is something to look forward to; however, there are many more of us for whom “normal” was never a healthy reality. Striving for a new equitable approach to health care access will take many stakeholders and policy solutions, a cornerstone of which will require significant investment in our nation’s safety-net systems.

HOLES IN THE SAFETY NET

Medicaid, the nation’s public health insurance program covering people with low incomes and many vulnerable individuals requiring complex and costly care, is often the dominant payor to safety-net providers.² The reimbursement for services rendered to Medicaid program beneficiaries is lower (sometimes much lower) than the average commercial rate across private insurance plans. New Administrator of the Centers for Medicare and Medicaid Services (CMS) Chiquita Brooks-LaSure recently described it best:

Many of these … essential providers … have been underfunded for decades … They are the institutions people know and love, but they are not able to provide the kind of care, they are not supported at the same level, they have a different patient mix… not able to have a lot of commercial pay to cover costs.³

Medicaid represents $1 out of every $6 spent on health care in the United States, yet it is widely misunderstood and frequently hampered by underfunding and political posturing.⁴ While the federal Medicare program covers adults 65+ and the disabled regardless of income, the Medicaid program covers low-income qualified individuals of any age, is overseen by broad federal rules, and administered by states and funded jointly by the states and the federal government.² One in 5 Medicaid enrollees are elderly and persons with disabilities who qualify for both programs due to Medicare coverage limitations, making state Medicaid programs the primary payor for high-cost acute and long-term care services.²

Financial strains presented by the COVID-19 pandemic have affected the health care industry as the virus disrupted standard revenue cycles and exacerbated critical workforce and material resource availabilities while simultaneously manifesting costly new treatment expenditures. These circumstances present tremendous operational leadership challenges, but for those providers that serve a high share of Medicaid patients, the additional adversity is much greater. As noted by the Medicaid and Children's Health Insurance Program (CHIP) Payment and Access Commission, “safety net providers are particularly vulnerable because prior to the pandemic they often had low operating margins and because Medicaid patients have been disproportionately affected by COVID-19.”⁵ Studies are now demonstrating the disparity, including health and community-based services (HCBS) providers that experienced a direct care workforce contraction of 280 000 workers during the first 3 months of COVID-19.⁶ Furthermore, “state officials and HCBS provider representatives described how some HCBS agencies had trouble hiring direct care providers because the COVID-related stimulus relief and unemployment benefits were more than the Medicaid rates and what home care agencies pay direct care workers.”⁶

The divide is even present when examining safety-net provider access to pandemic federal financial support programs created by Congress in the spring of last year and distributed by the US Department of Health and Human Services (HHS). Passed in March 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) provider relief fund was “intended to help cover expenses and lost revenue attributable to COVID-19,” ultimately totaling $175 billion once supplemented by the Paycheck Protection Program and Health Care Enhancement Act.⁵ Despite experiencing by far the gravest magnitude of pandemic financial burden, those safety-net health care providers serving predominantly Medicaid populations, including HCBS and behavioral health, “appear to have been less likely to receive provider relief funding” due to a hampering number of application process complexities and program rollout confusion, according to a recent Medicaid and CHIP Payment and Access Commission analysis.⁵

CATASTROPHIC CATALYST TO HEALTH INEQUITY

Because safety-net health care systems are the primary care providers for the Medicaid population, they serve the majority of marginalized and vulnerable citizens throughout the country. According to the latest Medicaid enrollment data prepared by the Kaiser Family Foundation, more than 50% of Medicaid enrollees identify as Black, Indigenous, and People of Color. ⁷ Faced with myriad access barriers, these individuals must manage significant challenges in attaining gainful employment, housing, transportation, nutritious food, potable water, education, and social inclusion.^8,9 These disparities are borne out in the differential health and health-related outcomes for these populations, most recently demonstrated in COVID-19 data through morbidity, mortality, and vaccine access.⁸ Perhaps most notable is the magnitude of the pandemic’s impact across marginalized groups, as described by Zelner et al:

In crude and age-standardized analyses we found rates of incidence and mortality more than twice as high than for Whites for all groups except Native Americans. Blacks experienced the greatest burden of confirmed and probable COVID-19 (age-standardized incidence, 1626/100 000 population) and mortality (age-standardized mortality rate, 244/100 000). These rates reflect large disparities, as Blacks experienced age-standardized incidence and mortality rates 5.5 (95% posterior credible interval [CrI], 5.4-5.6) and 6.7 (95% CrI, 6.4-7.1) times higher than Whites, respectively. We found that the bulk of the disparity in mortality between Blacks and Whites is driven by dramatically higher rates of COVID-19 infection across all age groups, particularly among older adults, rather than age-specific variation in case-fatality rates.¹⁰

The Medicaid population COVID-19 pandemic mortality rates can be observed across all its care delivery systems, including long-term care facilities, where they have accounted for 36% of COVID-19 deaths as of January 28, 2021.⁵ The data demonstrate the urgency with which government health equity priorities must not just incorporate but be invested through the Medicaid program systems to tackle the origination of access disparity.

The Medicaid-reliant patient population has also grown, with a 13.9% increase in enrollment from February 2020 to January 2021, which was directly attributed to the COVID-19 pandemic as 9.9 million individuals sought quality and needed coverage.¹¹ Pre-pandemic enrollment trends have further demonstrated why Medicaid is a safety-net program. Economic conditions significantly impact the counter-cyclical nature of Medicaid program enrollment and eligibility; a downturn means a larger volume of low-income qualified individuals will seek health insurance coverage.⁴ COVID-19 pandemic enrollment trends data recently released by CMS have become just the latest example of this dynamic, showing a record high of more than 80 million people covered through Medicaid and CHIP.¹¹ The growth trajectory shows no sign of abating; current estimates project even higher Medicaid enrollment through 2021, with 17 million more nonelderly individuals seeking coverage.¹¹

EQUITABLE POLICY LEADERSHIP BEYOND COVID-19

According to the Centers for Disease Control and Prevention, “Health equity is achieved when every person has the opportunity to ‘attain his or her full health potential’ and no one is ‘disadvantaged from achieving this potential, because of social position or other socially determined circumstances.’”¹² It is increasingly clear that health equity must be a core tenet of both state and federal policymaking as compounding inequalities in Medicaid services support and delivery have safety-net providers and their patient populations facing a steeper climb in a post-pandemic nation.

Such a meaningful impact could be realized under the Biden administration as current CMS leadership has recognized this and the broader implications for their role as the nation’s largest health care coverage provider. Officials collectively acknowledge the status of the US health care system inequities and make clear their policy perspective is not limited to existing parameters and old narratives, even acknowledging that government-promulgated initiatives, despite their good intentions, have at times fell short or even contributed to systemic issues.¹³ With this starting point, they outline firm commitments to an innovative and refreshing Medicare and Medicaid agenda rooted in health equity and access for all.¹³ Translating these aspirations to actions will undoubtedly take time, resources, and political maneuvering, even after the COVID-19 pandemic finally abates.

REFERENCES

1. Modern Healthcare. ‘Soul-crushing’: U.S. COVID-19 Deaths are Topping 1,900 a Day. September 21, 2021. Accessed September 24, 2021. https://www.modernhealthcare.com/safety-quality/soul-crushing-us-covid-19-deaths-are-topping-1900-day?utm_source=modern-healthcare-covid-19-.

2. Rudowitz R, Garfield R, Hinton E. 10 Things to Know About Medicaid: Setting the Facts Straight. Kaiser Family Foundation. March 6, 2019. Accessed September 24, 2021. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/.

3. Health Affairs Speaker Series. Health Affairs Policy Spotlight with CMS Administrator Chiquita Brooks-LaSure. August 17, 2021. Available at: https://www.youtube.com/watch?v=1Ww1hRooCOQ

4. Rudowitz R, Williams E, Hinton E, Garfield R. Medicaid Financing: The Basics. May 7, 2021. Accessed September 24, 2021. https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.

5. Medicaid and CHIP Payment and Access Commission. COVID Relief Funding for Medicaid Providers. February 2021. Accessed September 24, 2021. https://www.macpac.gov/wp-content/uploads/2021/02/COVID-Relief-Funding-for-Medicaid-Providers.pdf.

6. Espiniza R. Would You Stay? Rethinking Direct Care Job Quality. PHI: 2020. Accessed September 24, 2021. https://phinational.org/wp-content/uploads/2020/10/Would-You-Stay-2020-PHI.pdf.

7. Corallo B, Mehta A. Analysis of Recent National Trends in Medicaid and CHIP Enrollment. September 21, 2021. Accessed September 24, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/.

8. Artiga S, Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. The Henry J. Kaiser Family Foundation. May 10, 2018. Accessed September 24, 2021. https://www.

Ms Sellers is Associate Director of Corporate Strategy, Sellers Dorsey, Philadelphia, PA. The opinions and statements expressed herein are specific to the respective author and not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.