Unsanitized and Unfair: How COVID-19 Bailout Funds Refuel Inequity in the U.S. Health Care System

Context: The CARES Act of 2020 allocated provider relief funds to hospitals and other providers. We investigate whether these funds were distributed in a way that responded fairly to COVID-19-related medical and financial need. The U.S. health care system is bifurcated into the “haves” and “have nots.” The health care safety net hospitals, which were already financially weak, cared for the bulk of COVID-19 cases. In contrast, the “have” hospitals suffered financially because their most profitable procedures are elective and were postponed during the COVID-19 outbreak. Methods: To obtain relief fund data for each hospital in the U.S., we start with data from HHS posted on the CDC website. We use RAND Hospital Data to analyze how fund distributions are associated with hospital characteristics. Findings: Our analysis reveals that the “have” hospitals with the most days of cash on hand received more funding per bed than hospitals with fewer than 50 days of cash on hand (the “have nots”). Conclusions: Despite extreme racial inequities, which COVID-19 exposed early on in the pandemic, the federal government rewards those hospitals that cater to the most privileged in the U.S., leaving hospitals that predominantly serve low-income people of color with less.

How the Trump Administration’s Pandemic Health Care Response Failed Racial Health Equity: Case Studies of Structural Racism and a Call for Equity Mindfulness in Federal Health Policymaking

Context: The racial health equity implications of the Trump administration’s response to the COVID-19 pandemic. Methods: We focus on four key health care policy decisions made by the administration in response to the public health emergency: rejecting a special Marketplace enrollment period; failing to use its full powers to enhance state Medicaid emergency options; refusing to suspend the public charge rule; and failing to target provider relief funds to providers serving the uninsured. Findings: In each case, the administration’s policy choices intensified, rather than mitigated, structural racism and racial health inequality. Its choices had a disproportionate adverse impact on minority populations and patients who are more likely to depend on public programs, be poor, experience pandemic-related job loss, lack insurance, rely on health care safety net providers, and be exposed to public charge sanctions. Conclusions: Ending structural racism in health care and promoting racial health care equity demands an equity-mindful approach to the pursuit of policies that enhance—rather than undermine—health care accessibility and effectiveness and resources for the poorest communities and the providers that serve them.

Health Equity and the Allocation of COVID-19 Provider Relief Funds

When the COVID-19 pandemic landed in the United States, and particularly once cases began to grow substantially in March, the entire health care system suffered, but the safety net was exceptionally hard hit. The “health care safety net,” an ill-defined term that encompasses public and some nonprofit hospitals that take care of the poor and uninsured, was on the front lines of taking care of the bulk of individuals who had contracted COVID-19. These hospitals tended to suffer from a lack of adequate supplies and relatively low reimbursement in a system that was already financially weak. (Am J Public Health. Published online ahead of print February 4, 2021: e1–e4. https://doi.org/10.2105/AJPH.2020.306127 )

Case Study—Acting (and Funding) Locally: How One Virginia Foundation Is Changing the Way It Supports Communities

This chapter presents a case study based on the experience of the Northern Virginia Health Foundation (NVHF). The NVHF was created twelve years ago and was created to improve the health and health care of the residents of Northern Virginia, with a particular emphasis on those of low income and the uninsured. The chapter shows how despite being a small foundation, over the years, NVHF has made significant investments in the health care safety net. However, despite this, low-income residents in the area continue to face considerable challenges. The chapter makes some general conclusions based on this experience: cross-sector collaboration is difficult and, in many instances, expensive. But the return on investment is potentially strong. The direction should be creative and focused.