Two months into the COVID-19 pandemic the tragic numbers were already reflecting a painful reality. By May 2020, African American residents accounted for 47 percent of confirmed COVID-19 cases but made up 80 percent of confirmed COVID-19 deaths in the District of Columbia. Other communities of color had similar outcomes. Those of us who work in health care have seen the well-documented research and knew why this was happening: systemic racism and historical health inequities.
Nationally, the health disparities in COVID-19 infection rates by race and ethnicity also emerged very quickly in the pandemic. Over a two-month period at the onset of the pandemic, a study published by the Journal of the American Medical Association found that in all 12 states that reported COVID-19 hospitalizations by race and ethnicity, the percentage of African American hospitalizations was far greater than the percentage of the African American population in each of those 12 states. In Ohio, African Americans accounted for 31.8 percent of COVID-19 hospitalizations, while only representing 13.0 percent of the state’s population. In nearby Virginia, researchers found that Hispanic residents made up 36.2 percent of COVID-19 hospitalizations but account for 9.6 percent of the population. Over a three-month period early in the pandemic, a Centers for Disease Control and Prevention study of COVID-19 outbreaks in Utah workplaces found that Hispanic and workers from other communities of color accounted for 73 percent of COVID-19 cases, while representing only 24 percent of Utah workers.
Institutional systemic racism and health disparities are complex problems, and there is no one simple solution, but they should be addressed by entities at all levels within the health care system. The DC Health Benefit Exchange Authority (DCHBX) was established by the District of Columbia in 2013 to develop and operate the Affordable Care Act’s (ACA’s) online health insurance Marketplace for residents and small businesses in the District. DCHBX is a private-public partnership intended to foster competition and transparency in the private health insurance market, to help residents and small businesses to compare health insurance prices and benefits and to purchase affordable, quality health insurance. DC Health Link, DCHBX’s online health insurance Marketplace, was one of four state-based Marketplaces that opened for business on time on October 1, 2013. As a part of its mission, DCHBX is committed to addressing the entrenched health inequities in health care.
In the fall of 2020, the DCHBX executive board established the Social Justice and Health Disparities Working Group. The working group was composed of diverse stakeholders committed to social justice and health equity, including all health insurance companies offering coverage on DC Health Link, patient advocates, health equity experts, members from our broker community, and providers, including doctors and hospitals. They were charged with issuing recommendations in three focus areas:
- Focus Area 1: Expand access to providers and health systems for communities of color in the District of Columbia.
- Focus Area 2: Eliminate health outcome disparities for communities of color in the District.
- Focus Area 3: Ensure equitable treatment for patients of color in health care settings and in the delivery of health care services in the District.
The Social Justice and Health Disparities Working Group focused on areas under DCHBX control or influence, mindful to focus on work that would supplement and not supplant other equity efforts already underway in the District. The working group developed unanimous recommendations, which the executive board of DCHBX adopted in July 2021 and we are now working with our DC Health Link health plans to implement.
Immediate actions include:
- changing health insurance policies to eliminate cost barriers to care for conditions that disproportionally impact communities of color, starting with type 2 diabetes. In the District of Columbia, 14 percent of African American adults and 8 percent of Hispanic adults have type 2 diabetes compared to 2 percent of White adults.
- prohibiting race adjustment in estimating glomerular filtration rate (GFR)—a blood test that checks how well kidneys are functioning. A GFR test can help determine the extent of chronic kidney disease in a patient. Race-adjusted GFR score made it look like African American patients’ kidneys functioned better and delayed them getting care and getting placed on the kidney transplant list.
As a result of these priorities, during the fall of 2021 with our health plans, advocates, and experts, we at DCHBX have adopted a new plan design to eliminate cost sharing for type 2 diabetes. Starting for plan years in 2023, DCHBX standard plans will no longer have any cost sharing for physician visits, blood tests, vision and foot exams, prescription medications, and supplies—no deductibles, no copayments, and no co-insurance. Also, for the first time, DCHBX will have standard plans in our small business Marketplace. Currently, we cover approximately 100,000 people in the individual and in the small group Marketplace. Already in 2022, DC Health Link individual Marketplace standard plans have eliminated cost sharing for insulin and diabetic supplies.
For subsequent plan years, we will examine a no cost-sharing plan design for pediatric mental and behavioral health services, as well as for adult cardiovascular disease, cerebrovascular disease, mental health, and HIV, as well as cancer of the breast, prostate, colorectal, and lung/bronchus. These conditions disproportionally impact our communities of color.
Using coverage design—what a health plan covers and at what out-of-pocket cost to the patient for covered services—is one important way that ACA Marketplaces can help address health disparities. Eliminating out-of-pocket costs such as deductibles, copayments, and co-insurance removes the financial burden from patients to help them access necessary medical care. We are proud that DC Health Link is the first state-based health insurance Marketplace to change our standard plan design eliminating cost sharing to help address health disparities. By eliminating cost sharing, we eliminate a financial barrier to medical care for conditions that disproportionality impact communities of color and other populations that continue to endure systemic inequities. We have shared our experience with other state-based Marketplaces and the federal government, and we hope our experience can serve as a blueprint for addressing health disparities through changes to coverage design elsewhere.
We acknowledge that financial barriers to care are only one piece of larger health system issues and that coverage design cannot address underlying causes of deep-rooted systemic racism. In addition to new plan design, by July 2022 our health plans are working to prohibit their network providers, including labs, from using race-adjusted GFR. GFR is a blood test that helps to assess how well kidneys are functioning. For many years, additional points for race were added to the GFR score resulting in African American patients getting a higher GFR score. This higher score delayed many African Americans from getting timely care for kidney problems and resulted in delays in getting placed on the kidney transplant list. Race-adjusted GFR is just one of many examples of embedded racism that contributes to health disparities and increases the severity of illness in Black Americans.
We are also working with our DC Health Link health plans to identify and stop biases in other clinical decision support tools and algorithms. Studies show significant racial bias in health care algorithms used to identify patients who would benefit from additional health care services, negatively affecting both the provider’s medical decision making and patient outcomes. Our DC Health Link health plans are looking at clinical management algorithms that bias clinical decision making or influence access to care, quality of care, or health outcomes for racial and ethnic minorities. One example of this is unequal access to care often leads to lower health care use and therefore lower health care costs for Black patients. As a result, these lower costs lead this algorithm to erroneously conclude that Black patients are healthier than they are and require less intensive care. By July 2022, our health plans will report their findings and timelines for necessary corrections.
Changing coverage design, eliminating race-based GFR assessment, and removing biased algorithms are just some of the immediate actions we and our health plans are taking. Our planned longer-term actions include tackling biases in patient care, expanding access to diverse providers—including funding scholarships for students of color interested in STEM (science, technology, engineering, and mathematics), reexamining networks, and engaging in new and extensive data collection to further understand and address differences in available care.
The work of DCHBX to identify and dismantle systems of inequity within our influence as a state-based Marketplace is just beginning. We know that it will take a sustained and substantial commitment to these policies to achieve the goal of advancing health equity and that we must act in areas within our power to help end systemic racism. As a state-based Marketplace, we are committed to building and maintaining a health system that delivers trusted quality care, central to which is respect and value for communities of color as patients, as health professionals, and as members of the broader community.