Equitable Recovery Strategies
Marissa Korn and Heather Howard, State Health and Value Strategies
The Coronavirus pandemic, which is infecting and killing people of color and other marginalized communities at disproportionately high rates, has magnified existing disparities driven by a highly inequitable health care system and underlying structural inequities. In the face of this staggering inequity, state and local policymakers across the country have been considering how to incorporate health equity into their response efforts. These strategies range from assembling equity-focused task forces to collecting and publishing data outlining the differential impact of COVID-19 based on race and ethnicity.
Yet state officials working to incorporate equity into their COVID-19 responses may experience new challenges and opportunities as states shift focus towards loosening social distancing policies and reopening. Policymakers must now grapple with balancing both economic and public health concerns while also considering how reopening policies will impact residents in very different ways, possibly mitigating or exacerbating preexisting disparities. The below analysis provides a survey of actions that state and local governments have taken to intentionally incorporate equity into their recovery and reopening policies.
Limiting Spread and Targeting Resources
Target resources that are needed for a safe reopening – such as testing and personal protective equipment (PPE) – to the hardest-hit communities.
New York: The state of New York is expanding access to testing for communities of color and low-income neighborhoods by establishing an initial 24 testing sites at churches in predominantly minority communities in downstate New York. These testing sites, which are accessible and trusted locations in communities that have been hardest hit, are part of broader efforts of the state to address inequities and distribute resources to those most at risk.
North Carolina: The state of North Carolina is launching an initiative that will send up to 250 Community Health Workers into underserved areas with high caseloads of COVID-19 to connect community members to medical and social support resources, which includes primary care, diagnostic testing, case management, nutrition assistance, and mental health services. Community Health Workers will collaborate with local health departments and contact tracers to connect with individuals in need of support and will leverage North Carolina’s statewide technology platform NCCARE360, which streamlines information collected in both health care and non-health care settings.
Virginia: The commonwealth of Virginia is partnering with the City of Richmond to expand access to personal protective equipment in underserved communities. This partnership, which is focused on ensuring equitable access to health care resources, will continue as the state moves through the various stages of reopening.
West Virginia: The West Virginia Department of Health and Human Services is increasing COVID-19 testing opportunities in counties with high minority populations and evidence of COVID-19 transmission. This plan, which prioritizes marginalized populations in medically underserved counties, will make testing free and available to all residents in the targeted localities.
Promote alternative sites to help individuals separate and isolate safely while recovering from COVID-19.
Rhode Island: The state of Rhode Island submitted a waiver to CMS to use Medicaid funds to provide food, housing, and mobile phone minutes for people who are housing insecure. This includes funding for temporary housing and meals for those at high risk of exposure, as well as funding for hotel/motel stays or rent during periods of quarantine and COVID-19 treatment. The state’s provision of mobile minutes is aimed at increasing access to telephonic health care.
New York City: The city of New York launched the “Take Care Initiative,” which will help New Yorkers who have tested positive for COVID-19 and are unable to safely separate in their own homes isolate by providing free hotel rooms with wrap-around services. The city will also support those who are separating at home by designating Resource Navigators, who work with community-based organizations across the city, to help New Yorkers overcome logistical issues such as accessing medicine or clean laundry.
Incorporating Equity in Planning, Outreach, and Sustainable Recovery
Assemble task forces and teams dedicated to promoting racial equity in recovery planning and decision-making processes.
Michigan: The state of Michigan established the Michigan Coronavirus Task Force on Racial Disparities, which is charged with identifying the drivers of existing racial disparities in COVID-19 outcomes and recommending policies addressing such disparities. The Task Force’s focus includes developing recommendations that support the state’s long-term economic recovery and health following the pandemic. In early May, the state released the Michigan Safe Start Plan, which utilizes public health metrics such as impacts on marginalized populations as criteria to trigger movement into consequent phases of reopening.
North Carolina: Through an executive order, the Governor of North Carolina established the Andrea Harris Social, Economic, Environmental, and Health Equity Task Force. This task force will identify best practices for North Carolina departments and agencies to eliminate health disparities, foster economic stability, and achieve environmental justice as the state recovers from the pandemic.
Nevada: In a letter to the state’s Patient Protection Commission, the Governor of Nevada requested that the Commission develop long-term policy recommendations that address COVID-19 and broader health equity concerns. This includes strengthening the state’s social safety nets for marginalized groups most impacted by COVID-19, as well as examining how data collection can enhance the state’s ability to assess the health needs of its population through a lens of health disparities and health equity.
Ohio: The state of Ohio formed the Minority Health Strike Force, which will work with state leadership to address the virus’ disproportionate impact on people of color across the state. The task force is comprised of four subcommittees: Health Care, Education and Outreach, Data and Research, and Resources. The Ohio Department of Health has also created a new position that will work directly with local communities on their specific long-term health needs and Ohio’s response to COVID-19. They will also be responsible for collecting data to inform best practices and for helping to ensure the implementation of the Minority Health Strike Force’s short-term and long-term recommendations.
Virginia: The commonwealth of Virginia formed a Health Equity Work Group that is intentionally embedded into the state’s Uniform Command center addressing COVID-19. The 50-member Work Group, which acts as a cabinet-level mechanism and reports to the Health Equity Leadership Taskforce, is comprised of representatives from state agencies as well as advocacy and stakeholder groups, community members, and faith leaders. Both the Work Group and the Taskforce meet on a regular basis and work to apply a health equity lens to each phase of the state’s response, ranging from preparedness to mitigation to recovery.
Incorporate equity metrics into the benchmarks used to determine progress and reopening decisions.
California: Effective October 6, California instituted a new health equity metric which will be used (along with other metrics) to determine a county’s reopening tier. This metric measures COVID testing positivity rate in the county’s most disadvantaged neighborhoods, as defined as being in the lowest quartile of the Healthy Places Index census tracts. These neighborhoods cannot significantly lag behind the county’s overall county test positivity rate. In order to advance to the next less restrictive reopening tier, depending on the county’s size, it will need to meet the health equity metric and/or demonstrate targeted investments to eliminate disparities in levels of transmission. The targeted investments can include spending on augmenting testing, disease investigation, contact tracing, isolation/quarantine support, and education and outreach efforts for workers. Counties will need to submit their plan by October 15 to the California Department of Public Health.
Rhode Island: Rhode Island’s recovery plan – Reopening Rhode Island – incorporates equity into its gating requirement goals, including a provision that the state ensures that all communities have access to testing, particularly communities who have been disproportionately impacted. As the state works to address COVID-19 and consider reopening plans, Governor Raimondo has also assembled an Equity Council comprised of state officials, advocacy partners, and health experts.
Washington: The Washington State Department of Health’s reopening plan, Safe Start Washington, relies on distinct data-driven categories to determine the state’s readiness for safely reopening. One of the categories is the ability to protect high-risk populations, which relies on demographic data that includes race/ethnicity data on cases, hospitalizations, and deaths.
Chicago: The city of Chicago’s reopening plan monitors cases over time by zip code, age, sex, race, and ethnicity to determine movement into different phases. This data will also be used to direct resources where they are most needed as the city focuses on recovery.
Los Angeles: The city of Los Angeles’ reopening plan, Keeping Los Angeles Safe, incorporates testing rates by poverty levels and race/ethnicity into its Effectiveness Indicators, which guide future decisions about loosening or tightening social distancing restrictions.
Build trust in outreach through targeted messaging and by collaborating with local media outlets and trusted community partners.
Ohio: The Ohio COVID-19 Minority Health Strike Force, which released their interim report in May, focuses its recommendations on developing partnerships with impacted community members and organizations. Following the May report, the Strike Force announced a drive-up/walk-up testing initiative partnering with the Ohio Association of Community Health Centers and the Ohio National Guard. These sites will collaborate with local community-based organizations such as community centers, faith-based groups, and food pantries. The Strike Force also recommended the hiring of public health workers who reflect the makeup of their own community to expand exposure notification capacity.
Virginia: In an event titled, “COVID-19 and Health Equity in Virginia: You Ask, We Answer” the Virginia Department of Health and the Health Equity Task Force partnered with a local media outlet to provide information about the next phases of the recovery process and its implications for health equity. Members of the public were encouraged to submit video recordings with their questions, which culminated in a live broadcast in which experts on the Health Equity Task Force answered the public’s questions.
North Carolina: The North Carolina Department of Health and Human Services (NCDHHS) awarded grants of $100,000 each to five local organizations across the state to help address the Coronavirus’ disproportionate impact on the state’s Hispanic and Latinx communities. These five community organizations will help advance disease prevention measures by coordinating with NCDHHS on outreach and messaging related to wearing face coverings, practicing social distancing, accessing COVID-19 testing, and interfacing with contact tracers
New Jersey: The state of New Jersey has taken intentional steps to integrate equity and patient privacy into its contact tracing initiative’s public outreach and training processes. In outreach on their website and on Twitter, the state emphasized to New Jerseyans that any information collected will never be used for immigrant enforcement or public charge assessments to deny people access to health care or other public services. Additionally, the state’s contact tracing training curriculum, developed by the Rutgers School of Public Health, will focus on cultural sensitivity and bias, as well as the historical context of existing disparities.
Los Angeles: In response to high infection rates among Pacific Islanders, the L.A. County health department collaborated with community groups to create tailored, culturally relevant outreach materials that resonate with the Pacific Islander community. This includes educational graphics for social media in the Tongan, Samoan, Chamorro, and Marshallese languages, photos of Pacific Islander families wearing masks, and public service announcement videos featuring community leaders. Additionally, following community recommendations, L.A. County began publishing disaggregated COVID-19 data that no longer included Pacific Islanders in the Asian population category.
New York City: The city of New York hired over 1,700 contact tracers to join their Test & Trace Corp, surpassing the city’s hiring goals. Of the new hires, 700 are from the neighborhoods that have been the hardest hit by COVID-19. Additionally, to meet the needs of the diverse languages spoken across the city, 40 distinct languages are spoken across the Corps.
Promote an equitable and inclusive economic recovery by investing in historically marginalized communities.
California: The state’s Task Force on Business and Jobs Recovery issued an open letter urging business and civic leaders in California to explicitly address racial disparities and focus their recovery policies on equitable and sustainable solutions. These broad recommendations include supporting small businesses operated in and owned by communities of color, addressing racially disparate housing security patterns, and designing job programs for California’s diverse youth so that their employment opportunities are not permanently hindered by the recession.
North Carolina: The Governor of North Carolina signed an executive order expanding the state’s efforts to support communities of color disproportionately impacted by COVID-19. These efforts – which are focused on economic stability, environmental justice, and health equity – include directing resources to historically underutilized businesses, ensuring equitable distribution of pandemic relief funds, and supporting mass testing of migrant farm workers and food processing plant workers.
Chicago: The City of Chicago announced a $56 million two-year grant for community-based organizations (CBOs) to hire, train and support 600 people to conduct contact tracing. The Chicago COVID Contact Tracing Corps will direct 85% of the funding to small neighborhood-based organizations and will recruit and hire residents who have historically faced barriers to employment. The CBOs funded by this program will support the contact tracers not only to bolster recovery efforts while earning a living wage, but also to pursue continuing education through “Earn-as-You-Learn” opportunities. This programming, which invests in communities most impacted by COVID-19, will support contact tracers to exit the crisis with marketable skills and connections to upwardly mobile, stable employment.
This window into how states and localities are working to incorporate health equity into their recovery policies highlights a few important points. First, each approach must be tailored to meet the needs of the state or locality. The work of centering equity principles in response policies is not “one size fits all,” and should be shaped by the community members most at risk. States must also assess whether their recovery policies may be inadvertently perpetuating inequities. For instance, when scaling up contact tracing programs, states should consider if certain qualifications, such as educational requirements, are necessary or could be creating a barrier for hiring from communities most impacted.
States should also consider that any steps, no matter how small, constitute a good beginning to what will be a long journey. Just as the drivers of health inequity are far-reaching and structural in nature, many of the approaches needed to comprehensively address these disparities will require long-term investment at each level of government.