Reflecting upon the challenges our nation faces in responding to the disproportionate impact of the coronavirus on racial and ethnic minorities and the poor, I think back to a moment when a single person changed my perspective.
Alan Levine (Courtesy)
More than 15 years ago, I was deputy chief of staff to Florida Gov. Jeb Bush. We met a young man named Idelio, who had disabilities that threatened his health. He was excited about a new business he had started on his own, and was proud to be a taxpayer. His success was made possible by a liberation of sorts — the closure of state institutions for people with disabilities and the investment of resources to provide support tailored to their individual needs so they could work, live, pray and play in their communities rather than languishing in institutions.
From Idelio’s experience, and through my faith, I believe we are all created equal, but not the same. I’ve observed that one-size-fits-all institutional approaches to human issues fail to respect our differences and can lead to damaging results. The coronavirus pandemic exposes, yet again, such results, as it has disproportionately impacted racial and ethnic minorities, and those families living in poverty.
As the chairman and chief executive officer of Ballad Health, a health system with 21 hospitals serving rural communities in east Tennessee and southwest Virginia, I lead a team that routinely serves families disproportionally impacted by these systemic gaps. Poverty creates a gap that may be difficult for most to see, but has been painfully revealed during the pandemic. People living in poverty, suffering from chronic conditions like obesity, heart disease and diabetes, are particularly more at risk for serious illness or death from COVID-19.
Even before the pandemic, our communities were tailoring our efforts to meet the needs of our region, the Appalachian Highlands. We formed an Accountable Care Community, facilitated by Ballad Health, comprised of more than 260 organizations — churches, businesses, schools, law enforcement and government — to identify and close the gaps created by poverty.
Called the “Strong Starts Initiative,” our goal is to create partnerships throughout the region to ensure every pregnant woman receives proper access to care, and an assessment of opportunity for her child. The Accountable Care Community will offer support related to literacy, access to preventive health care, or even basic parenting support. The goal? To ensure every child is kindergarten ready by the time they are 5 years old. If successful, we believe we will see a massive improvement in third-grade reading proficiency, which leads to more 18 year-olds being prepared for college or careers — a certain remedy to reduce poverty.
Our region is among the best places to work and raise a family. But, like so much of rural America, we face economic challenges. The median family income is roughly half the national median and communities are still recovering from the devastating economic impact of the loss of the coal industry.
These economic disparities lead to social determinants of health that manifest in important ways — creating real gaps for different populations. In a region geographically the size of New Hampshire, it is often difficult to ensure access to important services like mental health care, primary health care and dental care. When these services are not available, this further exacerbates chronic health issues such as diabetes, behavioral conditions, cardiovascular disease and obesity. And the evidence shows individuals with those health issues who then get COVID-19 face a higher risk of becoming seriously ill or dying from the virus.
The economic challenges in rural communities were stressing health care systems before the pandemic. More than 120 rural hospitals have closed in the last 10 years, with four times that many at risk of financial failure. Only 17% of inpatient care at Ballad Health is provided to people with commercial health insurance. The rest of the patients are relying on Medicare, Medicaid or charity care. Yet we are fortunate that our hospitals are demonstrably high in quality, with U.S. News & World Report citing our hospitals as among the highest performing.
So if you get sick and can get to us, we provide great care. Unfortunately, we have a large number of residents with acute conditions due to the disparities related to social determinants, so our hospitalization rates were well above the national averages before the pandemic.
Now the coronavirus has created even more challenges in low-income communities where families often lack access to routine health care and have pre-existing conditions.
Access to testing for the virus is a challenge for families who don’t have the means to travel long distances. That’s why Ballad Health established more than 20 mobile testing sites throughout the region. But our ability to test relies heavily upon the availability of supplies and the capacity of national laboratories. The national supply chain simply was not prepared to meet the demand.
Now we are facing a major surge in coronavirus cases. A month ago, our hospitals had less than five inpatients with COVID-19. Today, we have more than 100 — among them some of our own team members who are fighting for their lives. We have closed services at some hospitals and redeployed staff to our COVID units in our tertiary hospitals.
During the pandemic, we have also seen a frightening reduction in the number of people who seek health care when they have needed it because they fear being exposed to the virus. For instance, emergency department visits related to chest pain declined by as much as 50%. We do not believe the number of people with chest pain declined by this much, but the number of people seeking help certainly has.
In response, we began an aggressive campaign to remind people they can be safe at home, but also safe with us. We created more telemedicine options, so people could seek urgent care without leaving their home. To a large degree, this is working, with our telemedicine visits rising from just over 2,000 from July through February to more than 28,000 from March through June. We ensured this access was available through computer technology or by telephone.
Our region has adapted to this virus because we already had recognized there are disparities between populations. The U.S. Centers for Medicare and Medicaid Services recognized this when in 2015 they awarded Ballad Health with a major grant to administer an Accountable Health Community in southwest Virginia. This grant has enabled Ballad Health to identify patients who suffer from the effects of these determinants, and to provide supports to patients who need them and want them.
Another issue we all face, particularly during the pandemic, is one of trust. Lower-income populations often feel institutions and health care systems have let them down over time. So when these same systems attempt to help, it takes continued effort and understanding to build the necessary trust. These issues have taken decades to build, and it will take an ongoing commitment and proven results to build and sustain the trust necessary to truly change the trajectory.
This year, Ballad Health was named by Forbes Magazine as the 29th best employer in America for Diversity. Our efforts began from within — ensuring an organization devoted to the idea that each of us, different as we may be, add up to a powerful team that has the empathy and ingenuity to become a part of the solution. We choose to be a health improvement organization that acknowledges the contributions of poverty to poor health.
The coronavirus pandemic has further exposed the connection between poverty and poor health, and it has increased the urgency for health care institutions and the broader community to acknowledge that connection and address the root causes together.
I saw how this approach changed the life of a young man named Idelio. And it gave us both joy.
Alan Levine is chairman and chief executive officer of Ballad Health. He served as deputy chief of staff to the governor of Florida, as Florida’s secretary of Health Care Administration and as secretary of health for the State of Louisiana. Levine is a member of the Florida Board of Governors, overseeing Florida’s 12 public universities. He chaired the health care transitions for Florida Govs. Jeb Bush, Rick Scott and Ron DeSantis, and also is an appointee of the governor of Tennessee to the Tennessee Charter School Commission.
This is part of a series funded by a grant from the Rita Allen Foundation to report and present stories about the disproportionate impact of the virus on people of color, Americans living in poverty and other vulnerable groups.
