On January 21, 2021, President Biden issued an executive order “Ensuring an Equitable Pandemic Response and Recovery” in which he established the COVID-19 Health Equity Task Force, charged with providing specific recommendations for mitigating inequities caused or exacerbated by the pandemic, and for preventing future inequities.
According to the Centers for Disease Control and Prevention (CDC), health equity broadly defined is the opportunity for every person, regardless of social position or other socially determined circumstance, to attain full health potential. Implicit in this definition is the recognition of social factors that drive health and are fundamental to health equity. Recognizing the barriers to health equity starts with acknowledging health inequities, which are easy to identify by simply looking at measures such as length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.
What COVID-19 has so sharply put into focus is the health inequities that exist among different populations within the United States—populations based on race/ethnicity, age, and geographical location (urban or rural). Indisputable is the disproportionate impact of COVID-19 infection and mortality rates on racial and ethnic minority groups, with, for example, data showing COVID-19 mortality rates 6-fold higher and infection rates 3-fold higher in predominately Black counties compared to predominately White counties. Reasons for this include the disproportionate number of individuals within minority groups who make up the nation’s essential workers, and therefore at greater risk of exposure and death from COVID-19. Social factors are also involved, such as barriers to health care access and use, inadequate housing or transportation, poverty or less access to high-quality education, and discrimination.
COVID-19 has made it easy to see just how entwined these social determinants of health are on quality of health and health outcomes, and just how critical it is to better address inequities in health care to reduce the susceptibility of populations to and consequences of catastrophic events like a pandemic as well as reducing the burden of disease and illness further upstream through more equitable access to quality of care and prevention.
It is a tall order requiring committed action. “We need to think about bold actions with large scale interventions; [this is] not the time for pilot projects,” said Niranjan S Karnik, MD, PhD, The Cynthia Oudejans Harris, MD, professor of psychiatry, associate dean for community behavioral health, Rush Medical College, Chicago, during a COVID-19 Health Equity Task Force meeting on April 30 focusing on behavioral health, the third task force meeting held so far. [Two prior meetings focused on data and health justice, and vaccinations.]
“We know what works and we already have great evidence of interventions that can be used in this moment, and it is my contention that we need to leapfrog our changes rather than relying on the traditional evolutional way of our care system,” said Dr Karnik.
Given the enormity of health equity and issues involved, this article focuses on behavioral health to provide a more in-depth look at some of the work being done to address health equities in this area. As pointed out in an interview with Dr Karnik, behavioral health is a critical equity issue as it permeates all aspects of health care with some estimates indicating it accounts for up to 40% of health care visits (as a direct behavioral health visit, underlying somatic symptoms, or as a comorbidity with conditions such as cancer).
Addressing health equity in this area can affect health equity in other areas. In addition, tools such as telehealth and programs that make behavioral health more accessible to under-resourced and disadvantaged communities can be used for other areas of healthcare.
Bringing Care to Where it is Needed
Like many innovative approaches to difficult problems, simply looking at the problem a bit differently can suggest potential solutions often with an underlying paradigm shift. For Dr Karnik, this came from considering the success of an approach used to addressing multiple behavioral and mental health problems in other countries around the world, particularly in highly volatile situations such as in war zones. The Common Elements Treatment Approach (CETA) is a science-based approach that uses a single treatment approach to addressing mental, behavioral, and social problems together and can be implemented by professionals or lay providers. Core components of CETA include engagement/education, cognitive copying/thinking differently, behavioral activation, confronting fears and trauma memories, safety assessment and planning, substance abuse intervention, problem-solving, and anxiety management.
Using this approach, Dr Karnik and colleagues have introduced a CETA-based program into one of the most underserved neighborhoods in Chicago—North Lawndale. Partnering with an organization called I AM ABLE—which according to their website is a faith-based trauma-informed care agency providing services from birth to the end-of-life—people within the community are chosen and trained as block leaders or neighborhood leaders to identify people within their community at risk of or experiencing mental health issues. These leaders are trained in structured approaches to use for basic cognitive behavioral interventions, such as for improving sleep. The approach is meant to be a first-line intervention for people without severe illness or behavioral issues to catch mental health stressors early and prevent more severe problems by giving people the tools they need.
“This is not a replacement for good health care,” said Dr Karnik. “This is a logical extension of a health care system that should be much more broadly based, and this should be an arm or our clinical work.”
For Dr Karnik, if prevention is the goal, this is a real model to help achieve it. “We want to take prevention seriously and if we want to do that, we need solid models that do some type of intervention.”
Such a model feels similar to models used to improve outcomes in resource poor areas for other chronic conditions, such as diabetes, in which community health care workers go into communities to follow patients and help them, for example, comply with treatment interventions. Such an approach has been used by the organization Partners In Health in various countries around the world to successfully address health equity within resource-poor communities. But instead of community workers hired by health care systems to go into communities, the CETA approach turns this around slightly by training community workers within a community to identify and offer first line intervention to at risk people within the community before health care services are needed. Dr Karnik said the focus on prevention and giving communities the tools to engage in selfcare is in response to the difficulties and often failures of placing medical resources within under-resourced communities and trying to get people to trust in and use clinical care.
The approach is an example of what many people think, and studies show, will work to reduce health inequities by focusing on bringing care to people where they are – both geographically as well as psychologically. Studies are showing that successful interventions are often embedded in the community and rely on trusted relationships.
Stuart M Butler, PhD, senior follow in economic studies at The Brookings Institute, recently highlighted this in a JAMA editorial in which he outlined 4 lessons learned from COVID-19, the first of which is to provide health services where people are.
“I think the biggest challenges today are really in the delivery system, and in particular how health services are provided at the point of consumption and patients are engaged,” he said. “We see so many barriers there, such as lack of localized services, a lack of recognition that you have to deal with people ‘where they are at’, and a failure to recognize that the way to actually communicate with people in a culturally or racially sensitive way is crucial to success.”
Along with citing the importance of focusing on institutions like community health clinics to better deliver health services, he underscored the need for using “intermediaries that act as links between ordinary people and the medical profession.”
What the CETA program in west Chicago and rural Illinois is engaging in is just that—using intermediaries (lay people within the community) as links to the medical profession.
Along with advancing health equity, programs like CETA can also potentially improve the economics of a community by creating job opportunities. “This community driven model of care enables people to pursue good paying health care jobs that bring good resources back into the community,” said Dr Karnik, adding that the training people receive and work they do as neighborhood workers provide the skills and exposure to professions such as social work or nursing for which they might then pursue.
Telehealth: A Bridge to Equity if Done Right
Telehealth is another tool emerging during COVID-19 that has the potential to improve health equity by improving access to care and potentially reducing cost. “We’ve seen that the cost structures of telehealth are going to reduce cost by making the health care system more efficient,” said Dr Karnik, saying that “no show” visits of telehealth is almost zero vs a “no show” rate of 30% to 40% for in-person visits.
Evidence supports the strong use of telehealth during COVID-19, and the potential for this tool to address health inequities to care. A study by Cantor and colleagues published in the American Journal of Preventive Medicine found a 20-fold increase in the incidence of telemedicine use after March 2020 with an almost 50% decline in office-based visits. Using county-level income and urbanicity data, the study also found disparities in access to and use of telehealth during COVID-19 with greater usage in higher income areas and metropolitan areas compared with poorer and rural areas.
Although access to broadband is often cited as a barrier to some communities to access telehealth, the disparities found in the study emerged after controlling for broadband. Lead author of the study, Jonathan Cantor, PhD, RAND Corporation, Santa Monica, CA, speculated that disparities in telehealth use were related to the greater resources in higher-income and metropolitan areas as well as the pre-existing disparities and utilization prior to the pandemic. The study also suggested that telemedicine use during COVID-19 initially broadened the disparities found in these populations, but that over the long run telehealth can actually reduce some of the disparities.
Lori Uscher-Pines, PhD, senior policy researcher, also with the RAND Corporation, led another study looking at telehealth use during COVID-19 among safety-net organizations in California, emphasized that telehealth can be deployed to reduce inequities in access to care by, for example, bringing providers into rural communities that lack them. Findings from her study, however, suggest that the type of telehealth visits reimbursed will be critical to the equitable use of telehealth beyond COVID-19. “If we are not careful in how telehealth is deployed, it can actually exacerbate existing inequities,” she said.
Dr Uscher-Pines found that more than 90% of telehealth visits in primary care were telephone visits, with patients interacting with their providers by telephone more than any other modality. “The study shows that health centers serving low-income populations relied on telephone visits during the early months of the pandemic to maintain access to care,” she said, suggesting that the data indicate that health centers nor patients are ready for video visits in high volume. “Given this, eliminating coverage for telephone visits could disproportionately affect underserved populations and threaten the ability of federally qualified health centers to meet patient needs,” she said.
To truly advance health equity, all patients need access to devices, broadband, and digital literacy to participate in video visits.
For Dr Karnik, addressing issues of unequal access to telehealth is critical as he sees this tool as a critical way to bring care to people where they are and scale up interventions, particularly for resource-poor communities.