[Senate Hearing 117-178]
[From the U.S. Government Publishing Office]
S. Hrg. 117-178
EXAMINING OUR COVID 19 RESPONSE:
IMPROVING HEALTH EQUITY AND OUTCOMES
BY ADDRESSING HEALTH DISPARITIES
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING OUR COVID-19 RESPONSE, FOCUSING ON IMPROVING HEALTH EQUITY
AND OUTCOMES BY ADDRESSING HEALTH DISPARITIES
__________
MARCH 25, 2021
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Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
46-758 PDF WASHINGTON : 2022
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
C O N T E N T S
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STATEMENTS
THURSDAY, MARCH 25, 2021
Page
Committee Members
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
and Pensions, Opening statement................................ 1
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State
of North Carolina, Opening statement........................... 3
Witnesses
Wilkins, Consuelo H., MD, MSCI, Vice President for Health Equity,
Vanderbilt University Medical Center, Nashville, TN............ 7
Prepared statement........................................... 8
Summary statement............................................ 13
Echo-Hawk (Pawnee), Abigail, Executive Vice President, Seattle
Indian Health Board, Seattle, WA............................... 14
Prepared statement........................................... 16
Summary statement............................................ 24
Mackenzie Williams, Taryn, Managing Director, Poverty to
Prosperity, Center for American Progress, Washington, DC....... 25
Prepared statement........................................... 27
Summary statement............................................ 29
Woods, Gene A., President and Chief Executive Officer, Atrium
Health, Charlotte, NC.......................................... 30
Prepared statement........................................... 32
Summary statement............................................ 40
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
Murray, Hon. Patty:
COVID-19 & Achieving Health Equity, Disparities Report....... 67
Wilkins, Consuelo H:
Equitable Pandemic Preparedness and Rapid Response: Lessons
from COVID-19 for Pandemic Health Equity................... 113
``A Systems Approach to Addressing COVID-19 Health
Inequities''............................................... 128
EXAMINING OUR COVID-19 RESPONSE:
IMPROVING HEALTH EQUITY AND OUTCOMES
BY ADDRESSING HEALTH DISPARITIES
----------
Thursday, March 25, 2021
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:05 a.m., in
room 430, Dirksen Senate Office Building, Hon. Patty Murray,
Chair of the Committee, presiding.
Present: Senators Murray [presiding], Casey, Baldwin,
Kaine, Hassan, Smith, Rosen, Lujan, Burr, Cassidy, Murkowski,
Braun, and Scott.
OPENING STATEMENT OF SENATOR MURRAY
The Chair. Good morning. The Senate Health, Education,
Labor, and Pensions Committee will please come to order.
Today we are holding a hearing on how we can address the
health inequities that have made this pandemic so much more
deadly for some communities than others. Ranking Member Burr
and I will each have an opening statement, and then Senator
Burr and I will introduce today's witnesses. After the
witnesses give their testimony, Senators will each have 5
minutes for a round of questions.
Before we begin, I want to walk through the COVID-19 safety
protocols in place. We will follow the advice of the attending
physician and the Sergeant at Arms in conducting this hearing.
The Committee Members are seated at least six feet apart, and
some Senators are participating by video conference. While we
are unable to have the hearing fully open to the public or
media for in-person attendance, live video is available on our
Committee website at help.senate.gov.
If you are in need of accommodations, including closed
captioning, you can reach out to the Committee or the Office of
Congressional Accessibility Services.
We are grateful to everyone, including our clerks, who have
worked hard to get this set up and help everyone stay safe and
healthy.
When we talk about inequities, we are talking about the
reality that people's health suffers because of systemic issues
like how far they are from quality, affordable, accessible,
culturally competent care; whether they are recruited for
clinical trials or the health care workforce; and issues
including social determinants of health, things like where
people are born or live and work. The reality of health
inequities is that how you live and even whether you live or
die in a pandemic is impacted by your race, your income, your
ZIP Code, your disability, your gender identity, and your
sexual orientation, and these factors intersect in ways that
compound injustice if you are, for example, a woman of color or
a person with a low income and a disability. And now the COVID-
19 pandemic has deepened these inequities to a devastating
effect and made it even more urgent we look at how we got to
this awful point and what to do.
Here are the facts. Native Hawaiian and Pacific Islanders
have the highest COVID-19 infection rate. American Indian and
Alaska Natives have the highest death and hospitalization
rates. One of the strongest predictors of death for COVID-19
next to age is having an intellectual disability. In the wake
of this pandemic we have also seen an unacceptable and ugly
uptick in hate crimes against Asian American and Pacific
Islanders, like we saw in Georgia last week. And while the
hospitalization rate for Black people and the rate for Latinx
people are both around three times that for white people, and
the death rates for each group are twice as high as that for
white people, their vaccination rates are both half of the
white population.
The picture painted by the data so far is grim, and despite
improvements, that picture is still incomplete. I secured a
provision in law last year requiring the Centers for Disease
Control and Prevention to provide monthly reports on COVID-19
demographic data with information on sex, age, race, and
ethnicity. And since the first report last May, the percentage
of cases with complete racial data has increased from 21 to 71
percent, and complete ethnic data has increased from 18 to 55
percent, meaning we still have room for progress.
Even on hospitalizations, where we've gone from having data
on 40 percent of the cases a year ago to nearly 100 percent of
cases now, the data fails to break out certain race and
ethnicity data, for example, aggregating data on Asian American
and Pacific Islander populations in a way that leaves us
without a full vision into health inequities.
We also still lack Federal reporting requirements for
congregate care facilities, including for people with
disabilities who have also been hit particularly hard by COVID-
19. And the challenge before us is to not only accurately
collect and report the data but act on the realities we see in
front of us and keep gathering information so we can improve
our response.
Which is why I'm glad we were able to make critical
investments in the American Rescue Plan to support communities
of color, people with disabilities, tribes, and other
underserved communities. President Biden has also made this a
priority by establishing his COVID-19 Health Equity Task Force
on January 21st, and today the Administration announced a $10
billion investment of funding from the American Rescue Plan to
expand vaccine access and build vaccine confidence in
underserved communities.
The Administration also recently announced over $2 billion
for an initiative supporting state, local, and territorial
health departments as they address COVID-related health
disparities; and has set up a program to distribute vaccines
directly to 950 community health centers, which have been a
lifeline to some of our hardest hit and hardest-to-reach
communities during this pandemic.
These investments, along with efforts from state and local
governments and trusted community partners, are critical to
making sure we get vaccines and information to communities of
color, people with disabilities, rural communities, people with
limited English proficiency, and people who lack access to the
Internet, which in turn is critical to ending this pandemic for
every community.
Of course, while the pandemic has put a harsh spotlight on
inequities in health care, there were problems long before the
crisis began, and our work to end them must continue even after
it ends, because the same injustices we are seeing play out
with COVID have been playing out with maternal mortality,
mental health, cancer, and many other health issues for years.
I put out a report last year that outlined the many ways
our health care system has failed communities of color and
others due to entrenched bias, discrimination, ableism, and
racism. The history is a long and painful one, and
comprehensive action is overdue.
Steps not only to address the inequities of this pandemic
but also to root them out of the health care system altogether,
like prohibiting discrimination in the health care system and
requiring anti-racist and anti-bias training, providing support
for people in underrepresented communities to participate in
clinical trials, pursue a career in medical research, or become
a health care provider, assuring everyone has quality,
affordable health coverage, the support of strong public health
infrastructure, and paid family sick and medical leave, those
are a few of the recommendations I made in that report, and I
look forward to hearing from our witnesses about these
challenges during today's discussion on improving health
equity.
I really want to underscore, as I said when I first spoke
about becoming Chair of this Committee, health equity is
personally important to me, and I know to so many of us here
today. We've all heard about it from people we represent. We
know how painful and how present this injustice is across our
states, and I believe the work on this Committee can make a
difference. And I look forward to our discussion today and the
work ahead.
With that, I will turn it over to Ranking Member Senator
Burr for his opening remarks.
OPENING STATEMENT OF SENATOR BURR
Senator Burr. Thank you, Madam Chair. And I want to thank
our witnesses for being here today to discuss ways to improve
our pandemic response for those hit hardest by it, especially
low-income, minority, and rural populations.
This Committee has a long history of working together on
health care issues that affect our seniors, our children,
Americans with disabilities, and in supporting our hardest-to-
reach communities.
To our witnesses, thank you. Thank you for the work you've
done during the pandemic and for taking time away from your
critical work to share your experiences today. On behalf of the
Chair and I, we apologize that we may temporarily be out of the
room because, as this hearing goes on, we'll have a series of
four votes. But we're going to try to do it as seamlessly as we
can, and we encourage all of the Members to please be here or
let us know that you're not going to be here so that we can
appropriately schedule time.
The disproportionate impact of COVID-19 on minority
populations, people in rural areas, and others has revealed
cracks in our health care system that persist despite efforts
to improve care, including through community health centers and
the National Health Service Corps, which seek to improve care
for underserved communities. This pandemic has given us another
perspective on these challenges and demonstrates a need to
redouble our work to address the underlying problems facing
these and other affected populations. Each response requires
the ability to identify the problems local communities will
face, strong leadership to recognize the best solutions, and an
ability to leverage the right approaches and technology to
execute those changes.
With each emergency response, we learn about the ways each
threat affects Americans differently and have adjusted our laws
and our plans accordingly. That's why we designed a response
framework that is flexible: you never quite know how a new
infectious disease or a natural disaster may impact us until
it's on the ground and we are forced to respond. For example,
during the last PAHPA reauthorization, Senator Casey and I
included new advisory committees to identify the specific needs
of our seniors and Americans with disabilities during
emergencies. We also codified the Children's Preparedness Unit
at CDC to improve the availability of information for health
care providers and families during the response to a public
health threat.
We made changes to the PAHPA statute after the tragedies
that occurred in Florida nursing homes in the 2017 hurricane
season, allowing states to have better plans in place to
protect their nursing home residents. Some states have done a
great job of taking care of their nursing home residents during
the COVID-19 response, and we can learn from the failures in
New York and Pennsylvania about what not to do going forward.
We have also made changes to the PAHPA statute to improve
the development of countermeasures to meet the needs of
different populations, and we've made sure we wrote it in a way
that allowed maximum flexibility to respond to affected
populations. During the response to swine flu, we realized that
young children were coming into the hospital in need of
treatment, so we worked quickly to get an emergency use
authorization for flu antivirals, saving lives in real time.
While we were working to treat children with swine flu, the
science also showed us that some older Americans were less
affected by the virus because that generation was exposed to a
similar strain many years ago.
In contrast, most children appear to be less likely to
experience serious illnesses from COVID, and older adults are
at significantly higher risk. This virus has also compounded
existing challenges that many communities--including rural and
racial and ethnic minorities, and low-income populations--face.
These differences underscore the importance of maintaining
flexibility as part of a public health response so that the
state and local governments can most effectively reach those in
their communities most at risk for a particular public health
threat.
The novel coronavirus has shown us that we cannot fully
anticipate the ways in which a threat will affect different
communities across the country. We have to utilize new
technologies throughout the response to better understand just
how the virus takes its toll and to do something about it.
The FDA has provided greater flexibility in clinical trial
designs, working with drug developers to enhance enrollment in
clinical trials in ways that reach more communities by
deploying remote technology that allows for patient monitoring
without traveling to a major hospital. Manufacturers have
gotten creative with targeting their trials to those who stand
to benefit the most from a drug, with one developer creating
mobile units to bring their COVID therapies directly to nursing
homes as soon as they found an outbreak of the virus. Mobile
health units have also been deployed to bring testing and
vaccines to areas that needed countermeasures, and partnerships
with Historically Black Colleges and Universities improved
outreach to racial and ethnic minority populations on testing,
participation in clinical trials, and providing information on
vaccines and ways to prevent COVID.
Now, as we look toward the weeks and months ahead, this
ingenuity needs to continue. Our response efforts must leverage
technology to improve our surveillance capabilities and inform
our public health decisionmaking, and our policies should
encourage the incorporation of new technology, strategies, and
partnerships to solve problems and overcome challenges.
I look forward to hearing from the witnesses today on their
testimony, and I yield to the Chair.
[The prepared statement of Senator Burr follows:]
The Chair. Thank you very much, Senator Burr.
We will now introduce today's witnesses, and I'm pleased to
start by welcoming Dr. Consuelo Wilkins. Dr. Wilkins is the
Vice President for Health Equity and Professor of Medicine at
Vanderbilt University Medical Center, and a principal
investigator at the Vanderbilt Miami Meharry Center of
Excellence in Precision Medicine and Population Health, which
aims to reduce disparities among Black and Latino communities.
She is also recognized for her innovative work to engage
patients and communities in health research.
Dr. Wilkins, welcome. Thank you for joining us today.
Next I would like to introduce Abigail Echo-Hawk. She is a
nationally recognized leader in tribal health and health
inequities from my home state of Washington. Ms. Echo-Hawk is
the Executive Vice President of the Seattle Indian Health
Board, Director of the Urban Indian Health Institute, and an
enrolled member of the Pawnee Nation of Oklahoma.
Welcome, Ms. Echo-Hawk. We're very glad to have you with us
today.
Next I would like to introduce Taryn Williams. Ms. Williams
is the Managing Director for the Poverty to Prosperity Program
at the Center for American Progress, specializing in disability
issues. She previously worked at the Office of Disability
Employment Policy at the U.S. Department of Labor, where she
handled a variety of issues related to education, workforce
policy, Social Security, Medicaid, civil rights, and more. And
I should also mention she is a HELP Committee alumnus, serving
as policy advisor when Senator Harkin was the Chair.
Ms. Williams, welcome back. Thank you for joining us today.
Now I will turn it over to Ranking Member Burr to introduce
our final witness, Mr. Gene Woods.
Senator Burr. Thank you, Madam Chair.
Before I introduce Gene Woods, let me say to Dr. Wilkins
that I apologize that we have stolen your provost from
Vanderbilt to become the next president of Wake Forest
University. I understand she is a wonderful individual, a
biologist, I think, by profession, and we look forward to
having her on board at the end of next month.
Madam Chair, Gene Woods really needs no introduction. He's
from Charlotte, North Carolina, and I'm extremely proud of the
incredible work of Atrium Health and of North Carolina's health
systems during the pandemic this year.
Thank you, Gene, for taking time out of your work to be
with us today remotely.
Mr. Woods currently serves as President and Chief Operating
Officer of Atrium Health and brings to the panel over 30 years
of leadership experience in the health care sector. Atrium
Health is a nationally leading non-profit health system with 42
hospitals and over 1,500 care locations across four states.
Under Gene's leadership, Atrium Health has been recognized by
the American Hospital Association with the Equity of Care Award
for its commitment to serving underserved communities, and by
the Centers for Medicare and Medicaid Services as a 2020 CMS
Health Equity Award winner for its dedication to reducing
health disparities.
Gene has been recognized as one of the most influential
people in health care and as one of the top 25 minority
executives in health care, and is one of the most admired CEOs
and is the 2020 Person of the Year by the Charlotte Business
Journal. He was awarded the Senior Executive of the Year Award
by the National Association of Health Services Executives.
Gene is a leader among his peers, having served as Chairman
of the American Hospital Association Board of Trustees, as well
as the Wall Street Journal CEO Council. Gene holds three
degrees from Pennsylvania State University, including a
bachelor's degree on health planning and administration, a
master's degree in business administration, and a master's
degree in health administration.
Gene, thank you for being with us today and for the
important work that you're doing in North Carolina. I look
forward to your testimony.
The Chair. Thank you.
Again, welcome to all of our witnesses. We appreciate you
joining us today.
I will reiterate what Senator Burr said. We have a number
of votes occurring today, so he and I will both be in and out.
I would ask all of our Members if you want to ask questions,
please let our staffs know so we can schedule everybody in a
timely fashion.
With that, we'll begin our testimony. Dr. Wilkins, you may
begin with your opening statement.
STATEMENT OF CONSUELO H. WILKINS, MD, MSCI, VICE PRESIDENT FOR
HEALTH EQUITY, VANDERBILT UNIVERSITY MEDICAL CENTER, NASHVILLE,
TN
Dr. Wilkins. Thank you, Chairwoman Murray, Ranking Member
Burr, and distinguished Members of the Committee. My name is
Dr. Consuelo Wilkins. I am a physician, clinical researcher,
and Vice President for Health Equity at Vanderbilt University
Medical Center.
Since March 2020 I have been deeply entrenched in managing
COVID-19 operations, as well as COVID-19 research. As part of
our COVID work streams at Vanderbilt, I've led the health
equity work, and part of our goals is reducing disparities and
increasing access to care.
At Vanderbilt, we performed more than 185,000 COVID-19
tests. We've cared for more than 3,400 hospitalized patients
with COVID-19. And most recently, we vaccinated more than
115,000 doses of vaccine.
It has been harrowing to witness the devastating impacts of
COVID-19 on marginalized and minoritized communities across the
Nation. These are the very communities I've spent the last 21
years striving to improve the lives of.
As you know and has already been described, across the
United States individuals who identify as African American,
American Indian, Hispanic and Latino have been extremely
impacted by this disease, bearing the burden of deaths and
hospitalizations. Additionally, individuals who speak languages
other than English, individuals who are unhoused, and people
living in rural communities have been disproportionately
impacted by COVID-19. And now, with three vaccines already
available and the United States leading the way, these
populations are being vaccinated at less than half the rate of
other Americans.
To address these COVID-19 inequities, I offer three
critical areas we should prioritize as a country.
First, the data. At Vanderbilt, we have disaggregated data
by race, ethnicity, language, and ZIP Code. By doing so, we
found the most striking disparities occurred in individuals who
speak languages other than English, specifically those who
speak Spanish and Arabic. We also found that the ZIP Code with
the highest number of COVID-19 cases is one where African
Americans are more likely to live, where individuals are
actually more likely to be employed but have a per capita
income of much less. This represents essential workers and
individuals who are striving to take care of their families but
cannot work from home. They live in households with more
people, so there's more crowding. They're more likely to take
public transportation, so they're at increased risk of the
disease.
Unfortunately, as Chairwoman Murray already pointed out,
we're still lagging behind with collecting data on race and
ethnicity. That alone, those strides we've made, won't be
enough. We need better data. We need data that's detailed for
ethnicity. We need social demographic data, social determinants
of health data if we're truly going to actually develop
strategies that are specific to the communities we intend to
improve the lives of.
That can't happen without funding. The reason that we're
not actually collecting this data is we don't have people who
are dedicated to it, who know how to do it in a meaningful,
socially and culturally appropriate way. So that is necessary
to move to the next stage.
Second, we must invest in community-driven solutions. While
I'm extremely proud of the work we've done at Vanderbilt, I am
keenly aware that we are not able to address these health
inequities alone. In Nashville, we are grateful that Meharry
Medical College, an historically Black academic health center,
has led city-wide COVID-19 testing and is now vaccinating
individuals in the most vulnerable communities.
Community health centers like Matthew Walker are
vaccinating individuals in the most disadvantaged neighborhoods
in Nashville. Salom Health has worked closely with our metro
Nashville health department to offer community health workers
who are bilingual and bicultural to do contact tracing and
assist individuals with access to care.
To be successful, we must prioritize trust. We have to
invest in community organizations who are trusted and
trustworthy, and they must be given the opportunity to lead
with decisions that reflect the perceptions, the needs, and the
preferences of the individuals that they represent.
I'm grateful to hear that additional funding is being made
available to these communities, but I fear it is not enough.
They need to be able to provide transportation, resources to
register for vaccinations, and develop long-term solutions.
Finally, we must prepare for the long haul of COVID-19. As
the early data indicate, more than a third of individuals will
experience long-term consequences. The very populations who
have been disproportionately impacted will suffer. They need
care, we need research, and, of course, long term we need
solutions that will address the underlying structural racism,
inadequate public health infrastructure, and lack of health
care.
Thank you.
[The prepared statement of Dr. Wilkins follows:]
prepared statement of consuelo h. wilkins
Chairwoman Murray, Ranking Member Burr, and Members of the
Committee:
My name is Dr. Consuelo H. Wilkins. I am a physician, clinical
researcher, professor, and Vice President for Health Equity at
Vanderbilt University Medical Center (VUMC). I am board certified in
both Internal Medicine and Geriatric Medicine and practice on the
inpatient geriatrics service. I lead a portfolio of research awards
focused on health equity, health disparities, and clinical trial
recruitment and am one of the Principal Investigators of our Clinical
and Translational Science Award (CTSA) supported by the National
Institutes of Health.
Thank you for hosting this hearing ``Examining Our COVID-19
Response: Improving Health Equity and Outcomes by Addressing Health
Disparities''. COVID-19 health inequities have become intractable and I
appreciate the invitation to share about the challenges VUMC faced
addressing these inequities in addition to the lessons our team has
learned implementing a systems approach to COVID-19 health equity. My
testimony is based on my expertise in medicine, clinical research,
community engagement and health equity, as well as my experience during
the past year as member of the VUMC COVID-19 Command Center and COVID-
19 Mass Vaccination Executive Team.
I will first provide background and contextual information related
to COVID-19 inequities then share recommendations in three areas:
1. Key data needed to drive more equitable decisions in the
COVID-19 response
2. Community-driven solutions to COVID-19 inequities
3. Preparing for COVID-19 long-haul
My testimony will draw from two publications I co-authored:
``Equitable Pandemic Preparedness and Rapid Response: Lessons from
COVID-19 for Pandemic Health Equity'' and ``A Systems Approach to
Addressing COVID-19 Health Inequities''. Both papers have been
submitted to the Committee for inclusion in the record of the hearing.
Overview of COVID-19 Inequities
Inequities in the burden of COVID -19 have been uncovered among
marginalized populations across the world and have been particularly
striking among African American, Indigenous, American Indian, Hispanic
and Latino populations in the United States. These groups are 3-4 times
more likely to be hospitalized and 2-2. times more likely to die from
COVID-19 3. Individuals with limited English proficiency, people who
are unhoused, and those living in rural communities have also been
disproportionately impacted by COVID.
With three COVID-19 vaccines now available, the United States is
leading the world--vaccinating more than 2 million people each day.
Unfortunately, the populations suffering the greatest burden of the
COVID-19 pandemic are not fully benefiting from the tremendous
scientific advancements in vaccine development. As of March 22, 2021,
nearly 83 million Americans have received at least one dose
administered of a COVID-19 vaccine and nearly 24 million are fully
vaccinated. Of fully vaccinated persons with race/ethnicity data
available, 7.4 percent are Hispanic/Latino, 7 percent are Black, and 4
percent Asian, which is substantially lower than their representation
in the U.S. population (18.5 percent, 13.4 percent, and 5.9 percent,
respectively). These lower vaccination rates are particularly
concerning in light of the higher rates of COVID-19 hospitalizations
and deaths among Black and Hispanic/Latino populations. Conversely,
White Americans are being vaccinated at a higher percentage (68.9
percent) than their representation in national demographics (60.1
percent).
Etiology of COVID-19 Inequities
Although COVID-19 inequities are acute, they reflect long-standing
disparities in health that many communities, clinicians, public health
practitioners, and researchers have striven to address, often with too
few resources. The causes of COVID-19 inequities are multifold and
involve differences in exposure, susceptibility, testing, and
treatment. Groups socially disadvantaged because of race, ethnicity,
social position, and/or economic status have greater exposure to COVID-
19 because of jobs that prevent work from home, dependence on childcare
outside the home, reliance on public transportation, and household
size. Poverty and experiences with discrimination and racism lead to
chronic psychosocial stress, causing prolonged secretion of stress
hormones, which has profound physiological impacts. These changes lead
to increased susceptibility both acutely, through impaired immune
response to the virus, and chronically, through predisposition to
diabetes, obesity, and cardiovascular disease, which are linked to
worse COVID-19 outcomes. Marginalized groups are less likely to have a
primary care provider, medical home, or regular access to care and may
have limited access to COVID-19 testing, treatment, and vaccination.
Lessons from a Systems Approach to COVID-19 Health Equity
At Vanderbilt University Medical Center (VUMC), we have tested more
than 185,000 people, admitted more than 3,400 people COVID-19, and
administered more than 100,000 doses of COVID vaccines. At VUMC, we are
utilizing a systems approach that emphasizes interdependence and
interaction across the health system and community to address the
complex drivers of COVID-19 inequities and rapidly respond to data
trends in real time. As part of our COVID-19 Command Center, we created
a health equity workstream to prevent, identify, and address COVID--
related inequities. (The Command Center refers to the team that
coordinates the health system's response to an emergency or disaster,
as well as the designated work space for those involved.) We identified
five initial areas of concentration: four COVID-19--specific areas
focused on prevention, testing, treatment, and clinical research; and
the fifth area, telehealth, which, although not specific to COVID-19,
is increasingly used because of the pandemic and could lead to
inequities in access to care. By integrating health equity into our
health system's COVID-19 operations, it is a priority, not an isolated
stream of work. This approach has allowed us to identify and work to
mitigate inequities in real time as our response to the pandemic has
evolved. Our key lessons so far are:
1. Executive leaders should clearly state that achieving
health equity is a priority and allocate resources, including
people, to do this important work; in the case of Vanderbilt
University Medical Center, institutional funds totaling more
than $1.5 million annually were committed to the Office of
Health Equity prior to COVID-19, facilitating our ability to
pivot and rapidly respond;
2. Health equity--related goals and programs should be
integrated into the health system's organizational readiness
and response with clear expectations for accountability and
action;
3. Race, ethnicity and language data must be available in
real time, and new processes may be needed to collect and
aggregate data;
4. The COVID-19 Command Center includes a wide range of
clinical, administrative, and operations leaders, some of whom
have limited knowledge of health equity; this exposure could
facilitate culture change and innovative ways of advancing
health equity in the long term--an example of a learning health
system; and
5. Hospitals and health systems must work closely with public
health departments and trusted organizations that are closely
connected to communities.
Ongoing Challenges and Recommendations to Advance COVID-19 Health
Equity
Key Data Needed To Drive Decisions
The importance of race, ethnicity, and language (REAL) data to
understanding COVID--19 cannot be overstated. Without these data, we
are unable to disaggregate data to identify disparities in COVID-19
testing, care, vaccination, and outcomes. Even when race, ethnicity,
and language are available, these are insufficient for mitigating
health inequities, which also requires data on social determinants of
health.
At VUMC, we created visualization dashboards for all patients
tested for COVID--19 that can be filtered by race, ethnicity, primary
language, and ZIP Code, which can be linked to community-level
socioeconomic data and social vulnerability indices. For example, the
ZIP Code with largest number of COVID-19 cases at VUMC is 37013 (Figure
1, outlined in green). Compared with the Nashville metropolitan area,
37013 is home to twice as many people who are Black/African American or
Hispanic/Latino and three times more people who speak languages other
than English at home. Despite a higher percentage of adults in this ZIP
Code being employed, per capita income is 24 percent less than the
Nashville metropolitan. We used this data to inform our communications
strategies including the development and compilation of materials in
Spanish and Arabic and to connect with trusted organizations serving
communities in this ZIP Code to leverage and amplify the impact of
communications efforts.
Unfortunately, race and ethnicity are missing in data reported by
the CDC in 46 percent of COVID-19 cases, 24 percent of deaths due to
COVID-19, and 47 percent of COVID-19 vaccinations. Although the CDC's
recommended reporting documentation9 includes fields for primary
language and use of an interpreter, the CDC does not include primary
language in its COVID Data Tracker or COVID-Net Hospitalization Data
Tracker. Some local and state departments of health are reporting
language data, however, there may still be a high proportion of
missing/unknown data. For example, the Washington State Health
Department reported 60.6 percent of unknown language data for confirmed
or probable COVID-19 cases from 03/01/2020--03/13/202110. Several
cities and states have mandated the collection of language data
including California, Massachusetts, Michigan, North Carolina, Oregon,
and New York City.
Recommendations:
1. Require capture of self-reported sociodemographic data
including race, ethnicity and preferred language in ways that
allow for the valid, non-stigmatizing collection of potentially
sensitive personal information.
2. Capture individual and/or macrolevel data on the social
determinants of health geocoded to home addresses when
possible, at units of geography that correspond to meaningful,
locally defined neighborhoods (i.e., census block).
3. Allow for data sharing across those sectors (health care,
public health, social services, etc.) while protecting
individuals' information.
Community-Driven Solutions are Needed to Advance Health Equity
One-size-fits-all approaches are unlikely to address the striking
disparities evident in COVID-19. Many racial and ethnic minorities,
individuals with limited English proficiency, and people living in
rural communities face unique sociocultural and economic barriers to
COVID-19 testing, care, and vaccination. Interventions most likely to
be successful in receiving health equity are often embedded in the
community and are built on trusting relationships, which are developed
over time. Without well-established, mutually beneficial relationships,
it is difficult to effectively mobilize resources and partner with
trusted community organizations.
Many community organizations are well positioned to lead or work
closely with health systems and public health agencies to implement
effective strategies to mitigate COVID-19. Trusted community
organizations and leaders can develop and disseminate messaging about
COVID-19 testing and vaccination that is relevant to socially
vulnerable communities and recognizes the varying socioeconomic needs
and differing levels of trust of health systems and government.
Organizations already serving these communities can be sites for
testing, distribution of PPE, multi-lingual communications, and
vaccinations. Community organizations have the potential to address
vaccine readiness and support/provide care for individuals experiencing
long-term sequelae of COVID-19.
Recommendations:
1. Fund trusted organizations within communities experiencing
inequities to be COVID--19 resource centers--providing access
to testing, educational information, access to vaccinations.
Include funds to support transportation to sites, child care,
operating evenings and weekends, interpreters, tailored
messaging, resources in multiple languages, and training for
peer educators and vaccinators.
2. Create community-based surveillance programs that leverage
community assets and use community health workers to collect
surveillance data, share risk-reduction information, support
care for individuals with COVID-19, and serve as access point
for healthcare. Efforts to support utilization of community
health workers specifically for COVID-19 should be considered,
however, long-term strategies for reimbursement of community
health worker models are also needed.
3. Provide additional funding to safety net providers in
recognition of the differential needs of safety net providers
who disproportionately care for populations experiencing COVID-
19 inequities and typically have fewer resources at baseline.
Preparing for COVID-19 Long-Haul
Early data indicate as many as a third of people with COVID-19 will
experience long--term symptoms due to the disease. The full extent of
the disease is yet unknown, however, given the disproportionate impact
of COVID-19 on specific groups, we should expect these groups to also
be burdened by the long-term sequelae. To date, people who have
survived COVID-19's acute symptoms are experiencing extreme fatigue,
shortness of breath, short-term memory loss, tinnitus, and
hypersensitivity to light. For some individuals, these symptoms are
debilitating, and with no known treatment, quite distressing.
The potential long-term consequences of COVID-19 bring additional
concerns for populations disproportionately burdened by the disease.
These groups are less likely to have a primary care provider, medical
home, or regular access to care. Although many states now have Long-
COVID clinics, individuals without routine access to care may not be
referred. Additionally, these clinics are likely to be located in large
cities and difficult to access for rural populations.
Recommendations:
1. Provide long-term follow-up care and monitoring for people
diagnosed with COVID-19 including free care for those without
health insurance
2. Make care available to individuals who experienced COVID-
19 symptoms who may not have been tested.
3. Provide specific research funding to understand and
address the long-term physical and mental health consequences
of COVID-19 in populations disproportionately impacted.
Conclusion
Communities of color and other marginalized populations--those
living in or near poverty, people who are unhoused, those living in
rural communities, etc.--have limited to no resources or access to
information address their communities' increased vulnerability to
COVID-19. Importantly, the inequities emerging in the COVID-19 pandemic
are not due to race or social class. Rather, they are the result of
structural racism and social inequalities embedded within the economic,
political, education, health care, criminal justice and other systems
and social structures in the U.S. Understanding the fundamental causes
of COVID-19 health inequities requires appreciating that the more
proximate causes--higher rates of serious medical conditions, living in
crowded housing, inability to work from home, etc.--are themselves the
result of social inequalities produced by social systems reinforced
through policy. We must act now to mitigate the immediate and long-term
consequences of COVID--19 on populations already burdened by health
inequities.
______
[summary statement of consuelo h. wilkins]
Consuelo H. Wilkins, MD, MSCI is a physician, clinical researcher,
professor, and Vice President for Health Equity at Vanderbilt
University Medical Center (VUMC) in Nashville, TN. Board certified in
both Internal Medicine and Geriatric Medicine, Dr. Wilkins also leads a
portfolio of research awards focused on health equity, health
disparities, and clinical trial recruitment. She is a member of VUMC's
COVID-19 Command Center and Mass Vaccination Executive Team.
In her testimony, Dr. Wilkins will offer observations about health
inequities exacerbated by COVID-19 and lessons learned at VUMC with
respect to a systems approach to addressing health equity. Marginalized
groups across the U.S. are experiencing a higher burden of COVID-19.
African American, American Indian, Hispanic and Latino populations are
3-4 times more likely to be hospitalized and 2-2.5 times more likely to
die from COVID-19. Individuals with limited English proficiency, people
who are unhoused, and those living in rural communities have also been
disproportionately impacted by COVID-19. To address these COVID-19
inequities, Dr. Wilkins recommends the following:
To address these COVID-19 inequities, I recommend the following:
1. Increase capture and use of key sociodemographic data
needed to drive strategies. Race and ethnicity data are missing
in 46 percent of COVID-19 cases and 47 percent of vaccinations
(CDC). Without this data, we are unable to fully understand the
extent of COVID-19 inequities or develop specific approaches to
mitigate. Primary language and social determinants data are
also essential to effectively addressing inequities.
-Require collection of self-reported sociodemographic data
including race, ethnicity and preferred language--Capture
individual and/or macrolevel data on social determinants of
health geocoded to home addresses, at units that correspond to
defined neighborhoods (i.e., census block).--Allow data sharing
across health care, public health, social services, sectors
2. Invest in community-driven solutions. One-size-fits-all
approaches will not address the striking disparities evident in
COVID-19. Solutions must be built on the specific needs,
perceptions, and assets of communities. Trusted organizations
embedded in communities must help drive solutions.
-Fund trusted organizations within communities experiencing
inequities to be COVID-19 resource centers--providing access to
testing, risk prevention, and vaccinations.
-Create and fund community-based programs that leverage
community assets such as community health workers to collect
surveillance data, share risk-reduction information, support
care for individuals with COVID-19, and serve as access point
for care.
-Provide additional funding to community safety net
providers who disproportionately care for these populations
3. Prepare for COVID-19 long-haul. Early data indicate as
many as a third of people with COVID-19 will experience long-
term symptoms due to the disease. The full extent of the
disease is yet unknown, however, given the disproportionate
impact of COVID-19 on specific groups, we should expect these
groups to also be burdened by the long-term sequelae.
-Provide follow-up care/monitoring for people diagnosed
with COVID-19 including free care for those without health
insurance--Make care available to individuals who experienced
COVID-19 symptoms but not tested
-Fund research specifically to address long-term physical
and mental health inequities
______
The Chair. Thank you, Dr. Wilkins.
We will turn to Ms. Echo-Hawk.
STATEMENT OF ABIGAIL ECHO-HAWK (PAWNEE), EXECUTIVE VICE
PRESIDENT, SEATTLE INDIAN HEALTH BOARD, SEATTLE, WA
Ms. Echo-Hawk. Thank you so much, Madam Chair and Ranking
Member, and distinguished Members of the Committee. My name is
Abigail Echo-Hawk. I am a citizen of the Pawnee Nation of
Oklahoma, and I currently serve as the Director of the Urban
Indian Health Institute, one of 12 tribal epidemiology centers
located across the country. In addition, I serve as the
Executive Vice President of the Seattle Indian Health Board,
which is a federally qualified health center and Indian health
care provider in Seattle, Washington.
I want to start my testimony with a story. Seattle was the
epicenter of COVID-19 in February 2020. We soon became overrun
by folks who were looking for COVID testing and were
experiencing symptoms and had been infected with COVID-19. We
quickly ran short of PPE. We sent out requests to our state,
our Federal, and our county partners. Soon we received a box at
our clinic, and the CEO and myself opened up that box expecting
to see gowns, masks, and the PPE that our providers needed.
Instead, what we found was a box of body bags. We had been sent
a box of body bags instead of the PPE that we had requested.
While this was a very literal example of Indian health care
funding and the way we have been treated in the United States
that has created the health disparities that currently exist
for my people, it is also a metaphor for the way many tribal
nations experience getting resources for the COVID-19 response
early in the pandemic.
As a result of this, what we find is that Native people are
3.5 times more likely to be infected with COVID-19, and we are
also more likely to die. As the co-author of those papers which
were released by the CDC, what I was most disturbed by was not
just those rates but with the fact that we were only able to do
analysis on 23 states in the Nation because they were the only
ones that had at least 70 percent of the race and ethnicity
data that allowed us to do the science to establish what was
happening in our communities, and we know as a result of that
gross underreporting of race and ethnicity in COVID-19 cases
that is not a true reflection of what's happening in our
communities. The death rates, the hospitalization rates are
much, much higher.
As a result of the crumbling infrastructure of public
health surveillance systems, we currently do not have the
ability for both the states and the CDC to properly report
COVID-19 data, which now includes vaccinations. Recently my
organization released a report titled ``Data Genocide,''
detailing how American Indians and Alaska Natives were being
eliminated in the data across the Nation by grading states in
four categories on how they reported the data and how it was
reported to the CDC. What we found was appalling.
More than 50 percent of the states in the Nation received a
C or below, and the Nation as a whole received a D+. I may not
have graduated high school with that grade. And unfortunately,
it is deeply impacting our ability to serve our communities. It
is essential for us to begin to properly fund the surveillance
systems across the United States from the local, tribal, all
the way to the Federal level in order to make the change that
we need to get the information so policymakers like yourselves
can actually make data-driven decisions, and scientists like me
are actually able to do good science, because right now with
the system that we have, I can't do that.
As part of that, as we reflect on the under-enrollment of
minority populations into both the clinical trials on testing,
on COVID-19 treatment and vaccines, we have seen the impact of
not having the numbers that we need of minority populations
enrolled in those trials despite the best efforts of the NIH.
And unfortunately in the Native community, we've actually seen
that in the last few weeks reflected in an attack on vaccines
that use the lack of clinical trial data to try to warn Native
people to not take certain vaccines. So it's actually being
used as a weapon against us by the fact that we haven't been
enrolled in those clinical trials.
We need further concentration on the proper enrollment in
clinical trials that also, in working with tribal nations,
ensures that they are working to preserve and uphold tribal
sovereignty.
COVID-19 is impacting most of our essential services beyond
the everyday services we do for those who are coming in for
testing, for treatment, and getting vaccinated. In fact, at the
Seattle Indian Health Board, we have seen a 13 percent decrease
in our prenatal care. One of our programs in Great Falls,
Montana has seen a 40 percent decrease in their substance abuse
programs as a result of their people not being able to access
telehealth as a result, again, of the lack of broadband
Internet access, phone access, the things that are needed for
telehealth. And while the expansion of telehealth has been
absolutely essential, we cannot forget those rural populations
who do not have the same access to broadband Internet, and also
those who are socioeconomically disadvantaged and don't have
access to phones.
However, despite all of these obstacles, what we have seen
is Indian Country, our tribal communities, both urban and
rural, have done what nobody else in the Nation has done, and
that is we have been more successful at vaccinating our
population than anywhere else. In fact, the Black Feet Nation
in Montana has a 95 percent vaccination rate of their
reservation. Ninety-five percent puts them at herd immunity
numbers if the rest of the United States could simply catch up.
In fact, the Seattle Indian Health Board has vaccinated 100
percent of our elders.
There are lessons learned, and as part of that the
investment that initially came through the CARES Act and now is
coming through the American Rescue Plan have provided the
resources, essential resources we need and assisted us in
having some of the highest vaccination rates in the country. In
fact, there are lessons learned that the rest of the country
should be looking toward tribal nations so that we can as a
nation address the devastating impact in this community and
concentrate on serving those most desperately in need.
Thank you.
[The prepared statement of Ms. Echo-Hawk follows:]
prepared statement of abigail echo-hawk
Members of the Health, Education, Labor, and Pensions (HELP)
Committee, my name is Abigail Echo-Hawk, and I am an enrolled citizen
of the Pawnee Nation of Oklahoma, currently living in an urban Indian
community in Seattle, Washington. I am the Executive Vice President of
the Seattle Indian Health Board and Director (SIHB) of the Urban Indian
Health Institute (UIHI), a tribal epidemiology center, where I oversee
our policy, research, data, and evaluation initiatives.
I am an American Indian health researcher with more than 20 years
of experience in both academic and non-profit settings, and am part of
numerous local, state, and Federal efforts to support and American
Indian and Alaska Native communities in research, including serving on
the Tribal Collaborations Workgroup for the National Institutes of
Health All of Us precision medicine initiative. I am co-author to four
groundbreaking research studies on sexual violence and Missing and
Murdered Indigenous Women and Girls (MMIWG) where I have called
national attention to the institutional barriers in data collection,
reporting, and analysis of demographic data that perpetuate violence
against American Indian and Alaska Native people. Most recently, I was
a committee member for the National Academies of Sciences, Engineering,
and Medicine: Framework for Equitable Allocation of COVID-19 Vaccine.
As the only representative from the Native community, I worked to
ensure the needs of our Indian Healthcare System and tribal and urban
Indian communities were appropriately included in the framework that is
informing states and policymakers nationwide.
For over 5 years, I have worked to address institutional barriers
to public health surveillance data experienced by Tribal Epidemiology
Centers. During the COVID-19 pandemic, this advocacy has been amplified
through the collective power of the We Must Count Coalition--a group of
health and racial equity and civil rights organizations. Together we
are calling for the uniform collection and release of COVID-19 testing,
cases, health outcomes, and mortality rates using data disaggregated by
race, ethnicity, primary language, gender, disability status, and
socioeconomic status. However, the crumbling public health data
infrastructure nationwide is inhibiting our ability to reach these
goals as evidenced by UIHI's recently released report, Data Genocide.
These experiences guide my statement today that is directed at the
government's failure to appropriately address the COVID-19 health
disparities raging within our communities--including American Indian
and Alaska Native, Black, Hawaiian and Pacific Islanders, Hispanic/
Latinx, and Asian American communities.
Data, Evaluation, and Research by and for Indigenous Communities
UIHI is an Indian Health Service (IHS)-funded Tribal Epidemiology
Center, providing services to more than 62 urban Indian organizations
who provide culturally attuned health and social services in areas that
represent approximately 1.5 million American Indian and Alaska Native
living in urban settings nationwide. UIHI recognizes research, data,
and evaluation as an integral part of informed decisionmaking for not
only our American Indian and Alaska Native community, but also our
policy and funding partners. We assist our communities in making data-
driven decisions, conducting research and evaluation, collecting and
analyze data, and providing disease surveillance to improve the health
and well-being of our entire American Indian and Alaska Native
community. UIHI's mission is to advocate for, provide, and ensure
culturally appropriate, high quality, and accessible data for American
Indian and Alaska Native public health organizations that provide
culturally attuned care to American Indian and Alaska Natives living
off tribal lands in urban settings. Recognizing the migratory patterns
of our population as they move between urban and rural locations, we
also serve tribal nations and tribally based organizations.
Tribal Epidemiology Centers are IHS division-funded organizations
who serve the Indian healthcare system compromised of IHS Direct,
Tribal 638, and Urban Indian Health Programs by managing public health
information systems, investigating diseases of concern, managing
disease prevention and control programs, responding to public health
emergencies, and coordinating these activities with other public health
authorities. There are currently 12 Tribal Epidemiology Centers
nationwide with the mission to improve the health status of American
Indian and Alaska Natives through identification and understanding of
health risks and inequities, strengthening public health capacity, and
assisting in disease prevention and control. UIHI is unique in that it
serves the urban American Indian and Alaska Native population
nationally, while sister Tribal Epidemiology Centers service regional
IHS areas including Alaska, Albuquerque, Bemidji, Billings, California,
Great Plains, Nashville, Navajo, Oklahoma, Phoenix, and Portland.
In response to the COVID-19 pandemic, UIHI has mobilized to create
COVID-19 fact sheets, reports, and online resources for tribes, tribal
organizations, and urban Indian organizations. This includes conducting
original research to guide the creation of culturally attuned public
health messaging. In late January of this year UIHI released the first,
and to date, the only national survey on vaccine hesitancy in Native
communities. Since August 2020, UIHI and other Tribal Epidemiology
Centers co-authored two COVID-19 studies on American Indian and Alaska
Native people in partnership with the Centers for Disease Control and
Prevention (CDC). These Morbidity and Mortality Weekly Report (MMWR)
revealed American Indian and Alaska Native communities experience
disproportionate morbidity and mortality due to the COVID-19 pandemic,
with the rate of new infections and death among American Indian and
Alaska Native people are estimated to be 3.5 and 1.8 times that of non-
Hispanic Whites, respectively. \1\
---------------------------------------------------------------------------
\1\ Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality
Among American Indian and Alaska Native Persons--14 States, January-
June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(49):1853-1856.
doi:10.15585/mmwr.mm6949a3.
---------------------------------------------------------------------------
However, the MMWR report on COVID-19 infections notes the authors
were only able to include 23 states in the analysis, as they were the
only states that had collected at least 70 percent or more of race and
ethnicity data, \2\ highlighting the need for Tribal Epidemiology
Centers to advise and improve data collection and reporting practices
of American Indian and Alaska Native data by Federal, state, and local
agencies.
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\2\ Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among
American Indian and Alaska Native Persons--23 States, January 31-July
3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(34):1166-1169.
doi:10.15585/mmwr.mm6934e1
---------------------------------------------------------------------------
As healthcare and public health organization on the forefront of
serving urban Indian communities, we are alarmed by the on-going data
genocide that continues to perpetuate negative COVID-19 outcomes among
American Indian and Alaska Native people by eliminating them in the
data.
Disproportionate Impact to Indigenous People
As Director of a national Tribal Epidemiology Center, UIHI's
service population represents approximately 71 percent of the 5.2
million American Indian and Alaska peoples (alone or in combination) in
this country. In this work, I am often asked to speak on the pervasive
health disparities experienced by American Indian and Alaska Native
people. What I must continue to remind people, is that these
disproportionate outcomes are a direct result of centuries of chronic
underfunding of trust and treaty obligations, particularly chronic
underfunding of our health care, public health systems, and
infrastructure have long impacted access to medical care, education,
housing, clean water, healthy foods, and traditional medicines among
Indigenous communities.
It is clear that the disproportionate impact that COVID-19 is
having on Native communities is not an accident. It is the product of
systems of inequities that have created and perpetuated rampant health
disparities for Native people.
Disparities Across Communities of Color
The Color of Coronavirus project by APM Research Labs provides
weekly updates on COVID-19 mortality by race and ethnicity. According
to the APM Research Lab, as of March 5, 2021, the past 4 weeks have
yielded the highest number of new deaths since the start of the COVID-
19 pandemic for all racial groups except Black and Pacific Islander
Americans, for whom it is the second most deadly stretch. \3\ As our
Nation continues to roll out vaccination programs, it is more important
than ever to accurately collect, report, and analyze race and ethnicity
data. These data are essential to understanding racial equity impacts
and developing equitable strategies for vaccine distribution. The
following statistics reveal the devastating impacts of COVID-19 among
Black, Indigenous and people of color (BIPOC) communities. As of March
5, 2021:
---------------------------------------------------------------------------
\3\ APM Research Lab. The Color of Coronavirus: COVID-19 Deaths by
Race and Ethnicity in the U.S. February 4, 2021. Retrieved from:
https://www.apmresearchlab.org/covid/deaths-by-race.
Indigenous Americans had the highest actual COVID-19
mortality rates nationwide. While the CDC reports a mortality
rate of American Indians and Alaska Natives 1.8 times higher
than the non-Hispanic Whites, reports by the APM Research Lab
suggest is it closer to 2.2 times higher than White Americans.
\4\ Data from APM also notes they were unable to gather data
from all states due to the lack of data reported by them, and
rates are not calculated for those identified as ``Other''
race. Indian Country has had at least 5,477 Indigenous
Americans lose their lives to COVID-19,4 but we know this
number is a massive undercount due to the missing and
inconsistent data collected by health care providers and
governments nationwide; and
---------------------------------------------------------------------------
\4\ Painter EM, Ussery, EN, Patal A, et al. Demographic
Characteristics of Persons Vaccinated During the First Month of the
COVID-19 Vaccination Program--United States, December 14, 2020-January
14, 2021. MMWR Morb Mortal Wkly Rep 2021; 70;174-177. DOI: http://
dx.doi.org/10.15585/mmwr.mm7005e1
73,236 Black Americans have lost their lives to
COVID-19 and Black Americans have the second-highest mortality
rate of all groups, behind Indigenous people and are 2 times
---------------------------------------------------------------------------
more likely to have died compared to Whites.; and
nationwide, Pacific Islanders are 2.6 times more
likely to have died as Whites. Since March 5, 2021, the Pacific
Islander community has had at least 830 community members lose
their lives to COVID-19.4 However, we know these are not exact
numbers. Arizona, Connecticut, Delaware, Michigan, New Mexico,
North Carolina, Virginia, and Wisconsin report deaths for
Asians and Pacific Islanders jointly. Without disaggregated
data, the true impacts to the Pacific Islander community
continue to be undercounted; and
89,071 Latinos have lost their lives to COVID-19 and
Latinos are 2.4 times more likely to have died as Whites from
COVID-19; and
Over 17,747 Asian Americans are known to have lost
their lives to COVID-19. Nationwide, Asian Americans have
experienced 3.6 percent deaths by race, while they represent
5.6 percent of the population.
As devastating as these data are, we know they are an undercount of
the true impact COVID-19 is having in our communities of color. The
gaps in this mortality data are a stark reminder that our Nation's
inability to accurately collect, report, and analyze race and ethnicity
data that directly contributes to health inequity and erasure. Today,
Native people--and communities of color--are fighting to address the
COVID-19 pandemic and are demanding equitable solutions and equitable
distribution of the vaccine to communities most impacted.
A National Data Failure
On February 15, UIHI released a national report card, titled Data
Genocide, analyzing the current status of collecting and reporting
state COVID-19 surveillance data on American Indians and Alaska
Natives. This analysis reviews state and national data reported on
American Indian and Alaska Native people including percent of confirmed
cases with complete race and ethnicity information.
The report revealed more than half the states in the Nation
received a C grade or below with a total of 13 states receiving a F.
The five states in the Nation that ranked the worst in collecting and
reporting racial demographic data are Texas (50th), New York (49th),
Maryland (48th), West Virginia (47th), and Delaware (45th). The
national average was a grade of D plus. Overall, states are doing a
poor job of tracking and reporting racial demographic COVID-19 data for
American Indians and Alaska Natives and other people of color. A recent
study by the CDC, found that current data on vaccinations is missing 48
percent of race/ethnicity data.
It is not possible for policymakers to make data-driven decisions
on COVID-19 with incomplete data. States must be held accountable to
improving their data practices if we are to ever achieve data-driven
decisionmaking for allocation of resources to end this pandemic.
Gaps in the Indian Healthcare System
Due to chronic underfunding of trust and treaty obligations, the
Indian healthcare system is only resourced to serve a fraction of
American Indian and Alaska Native people. Across the Nation, Indian
Health Care Providers are seeing an influx of IHS beneficiaries
visiting tribal and urban Indian clinics seeking the COVID-19 vaccine
and other healthcare services. We welcome our relatives into culturally
attuned care--many for the first time. Yet, our Indian healthcare
system is in need of additional resources and support to appropriately
serve our community.
The California based Indian Health Center of Santa Clara Valley,
along with Urban Indian Health Programs nationwide, report rising cost
including increased personnel and sanitation costs of serving the
growing number of relatives seeking care. Many programs are holding
vaccination clinics along with mass vaccination sites. A mass
vaccination sites requires 25-30 people to be effective, which requires
diverting staff from their normal duties and hiring temporary staff
which can be cost prohibitive. Urban Indian Health Programs that do not
provide direct clinical care, such as Lifelines of Boston and
Baltimore, have found themselves struggling to find partners to host
vaccination clinics for their American Indian and Alaska Native
clients. The urban Indian provider in Great Falls, Montana has seen an
influx of patients who tried to access the vaccine elsewhere and
despite being eligible under the state distribution guidelines were
told ``go to the Indian clinic.'' Indian Health Care Providers are
making decisions every day on what services to prioritize recognizing
that with the scarce funding and resources, they will not be able to
provide all the services our community needs.
This is not a new issue for the Indian healthcare system. In a 2009
report to Congress, IHS identified 17 urban areas that would benefit
from and Urban Indian Health Program. \5\ In 2017, UIHI expanded their
service population to reach 62 urban Indian organizations nationwide.
Among the 17 IHS-identified cities with high American Indian and Alaska
Native populations, many have strong local support and active efforts
to develop health care programs for urban Natives. The report also
recommended increasing funding to grantees for satellite
expansionsites, new partnerships with community health centers, and
identifying local providers to serve the needs of urban Native people.
We know that the current health needs of urban Natives are not being
met, despite the mounting evidence that increased Urban Indian Health
Program facilities would benefit the health status of American Indian
and Alaska Native nationwide.
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\5\ U.S. Department of Health and Human Services Indian Health
Service. New Needs Assessment of the Urban Indian Health Program and
the Communities it Serves. Accessed March 2021. Retrieved from:https://
www.ihs.gov/sites/urban/themes/responsive2017/display--objects/
documents/ReportToCongressUrbanNeedsAssessment.pdf.
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Tribal partners are also calling out the concern for our urban
dwelling relatives who do not have access to the Indian healthcare
system. In February 2021, the National Indian Health Board passed
Resolution 21-01 \6\ requesting the Department of Health of Human
Services and IHS to implement COVID-19 vaccination clinics in the
Washington, DC. Metropolitan Area and prioritize American Indian and
Alaska Native people in the 17 cities identified in the 2009 IHS
report. This call for an equitable distribution model that prioritizes
high-risk communities should be reproduced throughout local health
jurisdictions to support Indigenous, Black, and communities of color
who disproportionately experience negative impacts of COVID-19.
---------------------------------------------------------------------------
\6\ National Indian Health Board Resolution 21-01: Promoting and
Prioritizing AI/Ans in the DC Metropolitan Area for the COVID-19
Vaccine. February 2021. National Indian Health Board. Retrieved from:
https://www.nihb.org/docs/03012021/21-01--NIHB percent20Resolution
percent20Prioritizing percent20Vaccines percent20for percent20AIANs
percent20in percent20DC.pdf.
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In addition to addressing gaps in provider access, Indian Health
Care Providers are in need of additional vaccine access. As the Biden
Administration has implemented its initiative to distribute the vaccine
directly through Community Health Centers, we have seen only a fraction
of Indian Health Care Providers represented. Of the 250 Community
Health Centers invited thus far, ten were Urban Indian Health Programs
and 16 were Tribal health programs. It is urgent to supply more Indian
Health Care Providers and Community Health Centers with additional
access to the vaccine. As seen in Alaska, who represents 11 of the 16
tribal facilities receiving vaccines through this initiative,
additional access to the vaccine has amplified the success of Alaska
Native health providers to reach their priority groups. Currently, 28
percent of Alaskan residents have received a first dose of the
vaccine--higher than the national average. Alaska is now encouraging
other states to do the same: invest in protecting our most impacted
communities, enlist entrusted members of the communities to educate,
and adapt to the health care needs of local residents.
Impacts to Maternal and Child Health
As our Nation moves toward addressing COVID-19, we must
simultaneously work toward improving healthcare systems impacted by
COVID-19. COVID-19 has also disrupted routine care in the healthcare
system for child immunizations. \7\ In Washington State, the Department
of Health (DOH) reported a drop in immunization rates among children
during the COVID-19 pandemic, as well as a drop in vaccines ordered by
providers. During the pandemic, DOH reported that thus far, 30 percent
fewer vaccines were given in 2020, compared to the year before. \8\
---------------------------------------------------------------------------
\7\ Sanoli JM, Lindley MC, DeSilva MC, et al. Effects of the
COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and
Administration--United States, 2020. MMWR Morb Mortality Wkly Rep 2020;
69:591-593. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2.
\8\ Washington State Department of Health. May 2020. Drop in
vaccination leaves children vulnerable to other diseases. Accessed
March 2021. Retrieved from: https://www.doh.wa.gov/Newsroom/Articles/
ID/1161/Drop-in-vaccination-leaves-children-vulnerable-to-other-
diseases.
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At SIHB, we have seen a 13 percent drop in our relatives seeking
prenatal care and a 38 percent decrease in relatives seeking pediatric
immunizations. We are hearing similar stories across the Nation as
birthing people express fears related to exposing themselves and their
child to COVID-19. Responding to this crisis requires safe environments
to be created such as dedicated pediatric clinics that are family
friendly and COVID-19 safe. However, with already over-stressed
systems, many clinics do not have the resources needed to rapidly adapt
and respond without impacting other essential programs. There needs to
be additional support efforts to stabilize prenatal and child
immunization healthcare systems among Native communities who most
impacted by maternal and infant health disparities.
Increase in Domestic Violence, Gender Based Violence and Missing and
Murdered Indigenous Women and Girls
Studies have shown one in three Native women will experience
violence in their lifetime, a much higher rate as compared to the
general population. In a soon to be released survey, UIHI assessed the
impact of COVID-19 on Native female identifying sexual assault
survivors. We found that 20 percent of the respondents were
experiencing an increased lack of physical safety due primarily to
domestic violence. Another national study found, 40 percent of rape
crisis centers have seen an increase in demand for services since
COVID-19, with over 534 of these organizations requesting $100 million
in emergency stimulus funding to provide support and emergency
assistance to survivors. \9\ These finding echo what many advocates
have been sharing, that there is a national increase in violence as
COVID-19 continues to increase stress on every American. For those
unable to leave, they are now quarantine with their abusers increasing
the likelihood of more violence. This violence impacts the entire
family and children who are not yet in school, are now experiencing
violence they would normally escape while attending in person
schooling.
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\9\ National Alliance to End Sexual Violence. April 6, 2020.
Responding to COVID-19: Rape Crisis Center & Survivor Needs. Retrieved
from: https://documentcloud.adobe.com/link/
track'uri=urn:aaid:scds:US:1d3534ee-960e-4f94-96dd-8196d2017c90--
pageNum=1.
In UIHI's groundbreaking report on Missing and Murdered Indigenous
Women and Girls, we found that there is an ongoing crisis. And now we
are seeing the crisis increase as rates of violence go up nationwide.
Over the course of the pandemic there have been horrific murders and
numerous Indigenous women and girls who have gone missing. One leading
organization reports they have seen a spike in requests for assistance
to find missing people and increased need for support services to
families of murder victims. Many of these essential support services
are provided by county, tribal, and non-profit organizations with
support from Violence Against Women Act (VAWA) funds. These funds have
allowed these providers to continue and expand essential services to
victims of violence while allowing for culturally specific services for
tribes and Native organizations. In UIHI's recent survey of sexual
assault survivors, 90 percent asked for culturally specific services
citing their struggles with non-Indigenous methodologies for healing
highlighting the need for continuing to allocate funds for culturally
attuned programs and services.
National Institutes of Health Research
The National Institutes of Health (NIH) has been working to quickly
roll out research initiatives to address and understand the
disproportionate impacts of COVID-19. However, we continue to see under
enrollment of Native people in clinical trials for COVID-19 vaccines
and treatments nationwide. This lack of diversity in the clinical
trials continues to increase hesitancy and has been used by anti-
vaccination advocates to push misinformation into Native communities.
Recently UIHI responded swiftly to misinformation targeting Native
people nationwide that was misinterpreting clinical trial data that was
resulting in increased vaccine hesitancy. The impact of lack of Native
people in the clinical trials is having, and will continue to have,
tangible impacts.
Current NIH initiatives also are often not inclusive of urban
Indian populations, despite 71 percent of all Native people living in
urban settings. We do not advocate for taking away funding for tribally
based research, instead we urge the NIH to increase funding overall
with dedicated funds for research on health disparities for urban
Indian populations.
The Expense of Not Leading with Equity
In July, the average cost for COVID-19 inpatient care ranged
$51,000-$78,000 depending on age, with younger people paying the most.
\10\ In 2020, it is expected that COVID-19 related hospitalizations
cost will range from $9.6 billion to $16.9 billion with Medicare
expected to pay $3.5 billion to $6.2 billion. \11\ As the mounting
costs of preventing, preparing, and responding to COVID-19 totals, we
must look to equity as the fastest solution to ending this pandemic.
---------------------------------------------------------------------------
\10\ Mallory Hackett. November 5, 2020. Average cost of hospital
care for COVID-19 ranges from $51,000 to $78,000 based on age.
Healthcare Finance. Accessed 2021. Retrieved from: https://
www.healthcarefinancenews.com/news/average-cost-hospital-care-covid-19-
ranges-51000-78000-based-age--:text=In percent20July percent2C
percent20the percent20report percent20'showed,23 percent20to
percent2030 percent20age percent20bracket.
\11\ Sloan, Chirs., Markware, Nathan., Young, Joanna., Frieder,
Miryam., Grady, Lance., Rosacker, Neil., Vidulich.. June 19, 2020.
COVID-19 Hospitalizations Projected to Cost up to $17 B in US in 2020.
Avalere. Accessed 2021. Retrieved from: https://avalere.com/insights/
covid-19-hospitalizations-projected-to-cost-up-to-17b-in-us-in-2020
With over a year of devastating economic impacts to individuals,
industries, and governments, the vaccine has been a sign of hope for
many. Yet, inequity in vaccine distribution threatens to increase costs
and slow our national recovery. While many policymakers are committed
to mass vaccination in short time periods, it is becoming increasingly
clear that our most resourced community members are among the first to
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access the vaccine.
According to the CDC, in December 2020, the Moderna and Pfizer
vaccines were distributed to health care personnel and long-term
facility residents. However, available demographic data shows of people
vaccinated, 63 percent were women, 55 percent were 50 and older, and 60
percent were non-Hispanic White while 39 percent of those vaccinated
were represented racial and ethnic minorities.4 Of the racial and
ethnic minorities vaccinated, 11 percent were Hispanic/Latino, 5
percent were Black, .3 percent were Pacific Islander, and 2 percent
were American Indian and Alaska Native. However, of the data collected
on individuals vaccinated, race/ethnicity was unknown or not reported
for 48 percent or people. This first report of vaccine distribution
reveals vaccine distribution is inequitable and not going to our most
marginalized communities most impacted by COVID-19. Vaccination
programs must plan for distribution to priority groups at highest risk
for infection, hospitalization, and mortality.
We will not end this pandemic by vaccinating the privileged masses
that can afford to shelter in place. The Seattle Indian Health Board
recently had an incidence, where well-resourced people showed up at our
clinic because they had the privilege of language access, technology
access, and transportation access. They were capable of social
distancing, capable of accessing healthcare systems, and could wait to
access the vaccine through their primary care provider, but they
didn't. They swarmed our urban Indian clinic and demanded access to the
vaccine. However, we did not comply with their demands. Instead we
continue to prioritize those most at risk for morbidity and mortality
as we apply an equitable approach to vaccine access. We must be
prioritizing people more likely to work in high risk settings, living
in congregate and multi-generational settings, experiencing high rates
of co-morbidities that increase COVID-19 risk and associated healthcare
costs, and at risk for mortality. Leading with equity in our national
vaccine distribution strategy is essential to reducing the number of
hospitalizations, inpatient length of stay in hospitals, and associated
costs to the healthcare system. Vaccine distribution can't just be
about how many arms we inject, it has to be an equity-based decision
that acknowledges it's about whose arm receives the injection.
Centering Communities Most Impacted Drives Equitable Success
Despite our Nation's on-going challenges with data, tribal and
urban Indian communities continue to demonstrate that culturally
attuned and community-driven approaches are essential to reaching our
most impacted communities. As our Nation moves toward addressing data
challenges, we must simultaneously resource and amplify the work of our
trusted messengers and community organizations. To take a lesson from
Indigenous communities, we must ensure trusted messengers are included
in the creation and distribution of COVID-19 vaccine programs and
outreach.
Throughout the pandemic, UIHI has disseminated culturally attuned
through fact sheets, reports, and a COVID-19 Vaccine Poster series to
address vaccine hesitancy in the Native community. A recent study from
the UIHI, and to date the only national study conducted, reinforced
what we already knew. Seventy-four percent of American Indian and
Alaska Native people surveyed were willing to get vaccinated because of
their cultural responsibility to protect Elders and next generation.
These are the teachings the Elders instilled in us--our responsibility
is to our community. This Indigenous knowledge is also a public health
understanding that can increase adherence to COVID-19 safety measures,
including masking, social distancing and vaccinations.
In December 2020, SIHB was the first organization in Washington to
receive a shipment of the Moderna vaccine \12\ and since has vaccinated
over 3,900 people in our community. In phase one, we vaccinated our
health care providers and partners organizations that serve the local
urban Native community. We are now in Phase 2, where we vaccinate
American Indian and Alaska Native Elders and all people age 50 and
older. Our vaccination plan is a model for a community-centered
approach where we value those who are on the frontlines of addressing
the pandemic, protecting our culture keepers, and ensure our
intergenerational households are safe.
---------------------------------------------------------------------------
\12\ Sandi Doughton. December 21, 2020. Moderna Vaccine Arrives in
Seattle, with more coming later this week. The Seattle Times. Accessed
2021. Retrieved from: https://www.seattletimes.com/subscribe/signup-
offers/'pw=redirect&subsource=paywall&return=https://
www.seattletimes.com/seattle-news/health/moderna-vaccine-arrives-in-
seattle-with-more-coming-later-this-week/.
As an Indian Health Care Provider, we have been able to exercise
sovereignty alongside our tribal partners in the Indian Healthcare
System to respond to the needs of our community. While other vaccine
distributors were forced to adhere to strict guidance from state and
local governments, we have demonstrated that culturally attuned and
community-driven approaches have meaningful impact. However, this
provision of care has come with significant costs that are not covered
by the Federal reimbursement for the vaccine. Urban Indian and tribal
programs providing vaccines have experienced an influx of American
Indian and Alaska Native people nationwide who are not normally
patients of record at our facilities. While we welcome all our
relatives, including IHS beneficiaries, the chronic underfunding of our
Indian healthcare system is again becoming evident. To adequately reach
the American Indian and Alaska Native population in our current system,
our state and local health jurisdictions must prioritize American
Indian and Alaska Native people who experience higher rates of co-
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morbidities that worsen the impacts of COVID-19.
Tribal and urban Indian communities continue to demonstrate a
culturally attuned and community-driven vaccine distribution model is
essential to reaching our most impacted communities. In Washington
State, Muckleshoot Indian Tribe, Lummi Nation, Suquamish Tribe, and
Seattle Indian Health Board have demonstrated our commitment to
ensuring Native elders and healthcare providers are fully vaccinated
and are now moving toward vaccinating teachers to support the re-
opening of schools. \13\1 Nationally, the Blackfeet Nation has
vaccinated 95 percent of eligible residents. \14\ Navajo Nation, who
was impacted heavily by COVID-19 is now reporting 70 percent of its
citizens are vaccinated administering over 120,000 doses to its
community members. \15\, \16\ Cherokee Nation has recently opened its
COVID-19 vaccine distribution to its 14-county area for both Native and
non-Native residents. \17\ The Bay Mills Indian Community in Michigan
has vaccinated over 1,300 adult tribal members who live in their
service region, \18\ and remote villages in Alaska are reporting
vaccination rates of 50-60 percent of adult village occupants. \19\
Indian Country is proving the exercise of our sovereignty rights create
equitable vaccine distribution that is attainable and successful for
the benefit of our service population and surrounding communities.
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\13\ Hellmann, Melissa. February 2021. How a Native American
COVID-19 vaccine rollout is a model for community-centered approaches.
Seattle Times. Retrieved from: https://www.seattletimes.com/seattle-
news/health/we-take-it-for-our-community-how-a-native-american-survey-
and-vaccine-rollout-models-a-community-centered-approach/.
\14\ Franz, Justin. March 2021. Blackfeet Tribe reopens border
with Glacier. Montana Free Press. Retrieved from: https://
montanafreepress.org/2021/03/17/blackfeet-tribe-reopens-border-with-
glacier/.
\15\ Healy, Jack. March 2021. Plenty of Vaccines, but Not Enough
Arms: A Warning Sign in Cherokee Nation. New York Times. Retrieved
from: https://www.nytimes.com/2021/03/16/us/vaccines-covid-cherokee-
native-americans.html.
\16\ Newton, Creede. February 2021. Navajo Nation forecasts
`community immunity': 120,000 jabs given. Aljazeera. Retrieved from:
ttps://www.aljazeera.com/news/2021/2/26/navajo-nation-sees-community-
immunitycoming-120k-jabs-given.
\17\ Tulsa World. March 2021. Cherokee Nation opens vaccine to
public living in 14-county area. Retrieved from https://tulsaworld.com/
news/local/cherokee-nation-opens-vaccine-to-public-living-in-14-county-
area/article--63891098-8124-11eb-a6bd-c3f6eeb8bd94.html.
\18\ Steeno, Paul. February 2021. Bay Mills: Nearly 700 community
members have received one dose of COVID vaccine. Up North Live ABC.
Retrieved from: https://upnorthlive.com/news/local/bay-mills-nearly-
700-community-members-have-received-one-dose-of-covid-vaccine.
\19\ Andrew, Scott. March 2021. Rural Alaska is getting COVID-19
vaccinations right. Here's what the rest of the US can learn. CNN.
Retrieved from: https://www.cnn.com/2021/03/09/us/alaska-covid0919-
vaccine-success-trnd/index.html.
We are encouraged by the allocation of $6.1 billion in COVID-19
resources authorized under the American Rescue Plan Act of 2021 to IHS.
It will be necessary for IHS to make short-and long-term plans for
these dollars, however this cannot be seen as a one-time investment.
Since its inception, the IHS has suffered from chronic underfunding and
systematic issues that have resulted in poor health outcomes for Native
people. It will take continued financial support and systematic change
across the Federal agencies if we are ever to see the health care
system required under the Federal Governments treaty and trust
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responsibility.
Nationwide, we must demand more accurate racial and ethnic
demographic data collection, reporting, and analysis. We must identify
gaps in service delivery and ensure the health disparities experienced
by our Indigenous communities do not worsen as our healthcare systems
adapt and respond to COVID-19. We must resource and amplify the work of
our most impacted communities and trusted messengers. We must lead with
racial equity to reach low-income, communities of color, and those most
impacted by the virus. We cannot end the pandemic or re-stabilize our
healthcare systems impacted by COVID-19 without equitable distribution
of resources that advance health equity.
______
[summary statement of abigail echo-hawk]
As Executive Vice President of the Seattle Indian Health Board and
Director of the Urban Indian Health Institute (UIHI), my testimony
highlights the successes of Indigenous communities, continued
challenges in health services and data, and recommendations to advance
health equity.
Indigenous Resilience in Action
Tribal and urban Indian communities continue to demonstrate that
culturally attuned and community-driven approaches are essential to
leading an equitable response to COVID-19. We are modeling a community-
centered approach while exercising our sovereignty rights as tribal
people to advance equity among our service population and surrounding
communities. For example,
The Blackfeet Nation has vaccinated 95 percent of
eligible residents; \1\
---------------------------------------------------------------------------
\1\ Franz, Justin. March 2021. Blackfeet Tribe reopens border with
Glacier. Montana Free Press. Retrieved from: https://
montanafreepress.org/2021/03/17/blackfeet-tribe-reopens-border-with-
glacier/.
Navajo Nation has vaccinated 70 percent of citizens
and administered over 120,000 doses; \2\, \3\ and
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\2\ Healy, Jack. March 2021. Plenty of Vaccines, but Not Enough
Arms: A Warning Sign in Cherokee Nation. New York Times. Retrieved
from: https://www.nytimes.com/2021/03/16/us/vaccines-covid-cherokee-
native-americans.html.
\3\ Newton, Creede. February 2021. Navajo Nation forecasts
`community immunity': 120,000 jabs given. Aljazeera. Retrieved from:
https://www.aljazeera.com/news/2021/2/26/navajo-nation-sees-community-
immunitycoming-120k-jabs-given.
Remote Alaska villages are reporting vaccination
rates of 50-60 percent of adult occupants. \4\
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\4\ Andrew, Scott. March 2021. Rural Alaska is getting COVID-19
vaccinations right. Here's what the rest of the US can learn. CNN.
Retrieved from: https://www.cnn.com/2021/03/09/us/alaska-covid-19-
vaccine-success-trnd/index.html.
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Worsening of Health Disparities
Data shows Native communities experience disproportionate morbidity
and mortality due to the COVID-19.1,2 We are also seeing other health
disparities worsen as a result of disruptions to our healthcare systems
including concerning trends in domestic violence, child immunization,
and prenatal outcomes and services. Recent data reveal:
20 percent of respondents in a UIHI study experienced
an increase in lack of physical safety due to domestic violence
and 40 percent of rape crisis centers have seen demand for
services increase; \5\ and
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\5\ National Alliance to End Sexual Violence. April 6, 2020.
Responding to COVID-19: Rape Crisis Center & Survivor Needs. Retrieved
from: https://documentcloud.adobe.com/link/
track'uri=urn:aaid:scds:US:1d3534ee-60e-4f94-96dd-8196d2017c90-
pageNum=1.
Decreases in accessing clinic services, SIHB has seen
a 13 percent drop in patients seeking prenatal care and a 38
percent decrease in pediatric immunizations.
Advancing Equity through Community Health Center Partnerships
Community Health Clinics (CHCs) have struggled to gain access to
the vaccine. As culturally attuned and community-based healthcare
providers, CHCs are trusted messengers in our most impacted
communities. With additional and continuous funding to respond to and
recover from COVID-19, CHCs are best positioned to help overcome health
disparities.
Advancing Equity through Data Improvements
UIHI has drawn national attention to the data challenges
experienced by Tribal Epidemiology Centers. Most recently, UIHI
released Data Genocide, a report card on states revealing our national
failure to collect quality data and the impacts of decades of chronic
underfunding of public health infrastructure. There continues to be
institutional barriers to making significant progress of data
improvements with Health and Human Service (HHS) agencies. Ultimately,
it is not possible for policymakers to make data-driven decisions on
COVID-19 with the current data available for people of color.
A CDC study, \6\ found that 48 percent of race/
ethnicity data in missing in COVID-19 vaccination data; and
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\6\ Painter EM, Ussery, EN, Patal A, et al. Demographic
Characteristics of Persons Vaccinated During the First Month of the
COVID-19 Vaccination Program--United States, December 14, 2020-January
14, 2021. MMWR Morb Mortal Wkly Rep 2021; 70;174-177. DOI: http://
dx.doi.org/10.15585/mmwr.mm7005e1
UIHI found that the national average among states
COVID-19 surveillance data on Natives is a D-.
Recommendations
Continue to invest in the Indian healthcare system
including public health and healthcare infrastructure, maternal
and child health, gender-based violence services, research, and
CHCs;
Leverage oversight authority to ensure HHS compliance
with data sharing requirements; and
Increase the supply of COVID-19 vaccines directly to
CHCs and Indian Health Care Providers.
______
The Chair. Thank you, Ms. Echo-Hawk.
We'll turn to Ms. Williams.
STATEMENT OF TARYN MACKENZIE WILLIAMS, MANAGING DIRECTOR,
POVERTY TO PROSPERITY, CENTER FOR AMERICAN PROGRESS,
WASHINGTON, DC
Ms. Williams. Good morning. Thank you to Chairwoman Murray,
Ranking Member Burr, and Members of the Committee for having me
here today. I'm Taryn Williams, Managing Director of the
Poverty to Prosperity Program and Disability Justice Initiative
at the Center for American Progress. I testify today not only
as someone who has spent more than a decade in disability
policy but also as a Black woman who lives with multiple
chronic conditions, and as someone who has seen and personally
felt the devastating impact of this pandemic on communities of
color and people with disabilities.
In addition to the disparate data presented on racial and
ethnic communities, there are stark disparities for the
disability community. The CDC reported that all people seemed
to be at higher risk of severe illness from COVID-19 if they
have serious underlying chronic medical conditions. As of
February 11th, among the states reporting data, there were
111,000 cases and over 6,500 deaths, resulting in a fatality
rate of 5.9 percent for people with disabilities. Even more
startling, a cross-sectional study revealed that having an
intellectual disability was the strongest independent risk
factor measured for presenting with a COVID-19 diagnosis and
the strongest independent risk factor other than age for COVID-
19 mortality.
In order to ensure a comprehensive response to the
pandemic, it is incumbent upon us to understand the factors
that shape this crisis. The 1999 Supreme Court case, Olmstead
v. Lois Curtis, confirmed that people with disabilities have
the right to receive care within an integrated community or
home setting. Yet, preserving access to resources in home-and
community-based services has been an ongoing challenge. Absent
this critical funding, people with disabilities are compelled
to live in congregate settings and, as we've seen, these
settings can be deadly.
Equally critical in this moment is an ongoing fight for
equal protection under the law, particularly in medical
settings. In the past year the disability community has feared
and fought to prevent health care providers from withholding or
withdrawing life-sustaining treatment on the basis of arbitrary
standards about quality of life. We know that calculations made
in these critical moments are at great risk to be colored by
bias and stereotypes or, in short, ableism, the ongoing
devaluing of the lives of people with disabilities that gives
rise to discrimination and the belief that disabled lives are
not worth saving.
In addition to ableism, we must discuss racism and the ways
that it contributes to disparate outcomes during the pandemic
in these communities, particularly those that have been ravaged
by COVID-19. We see the ways in which poverty and its
correlates--low wages, inadequate means, lack of affordable
housing, and a lack of affordable health care--have been
inextricably linked to higher rates of infection and mortality
from COVID-19. Our society has codified a two-tier economic
system that overwhelmingly excludes Black and brown workers,
women, and people with disabilities from opportunities to earn
competitive wages and have their basic needs met.
With this history, it is no wonder that we have observed
some of the worst outcomes of COVID-19 among these communities.
We cannot begin to understand or come up with improved policy
without comprehensive data, not only on fatalities but also on
infection and COVID-19 long haulers. Indeed, a measurable
improvement in the equitable response to the pandemic can only
occur when we have ongoing collection and reporting of all
COVID-19-related data by race, ethnicity, socioeconomic
factors, and disability.
As U.S. efforts to vaccinate our communities continue to
scale up, we need to take steps to ensure a more equitable
rollout of the COVID-19 vaccines. This includes taking steps to
ensure that communities of color and people with disabilities
are prioritized in vaccination efforts. It is imperative that
people receiving care can remain in their homes and communities
rather than being admitted to crowded, unsafe congregate
settings. We are pleased to see the addition of dedicated
funding to HCBS in the American Rescue Plan. We applaud
Representative Dingell and Senators Brown, Casey, and Hassan
for their release of a discussion draft of the HCBS Access Act,
and we know it is key to ensuring that states have what they
need to keep people with disabilities in their homes.
My colleagues at CAP have noted that while the coronavirus
crisis has led to significant job loss, it has not been as
severe of an increase in uninsurance as predicted earlier in
the pandemic. I would note that ongoing support of the ACA and
its role in expanding access to health care is critical.
Equally important is support for Medicaid expansion. One way
that members can act is to continue to expand coverage and
further incentivize state Medicaid expansion.
To guarantee equitable recovery, we urge Congress to
address the low wages that keep people in poverty. An increased
minimum wage, basic worker protections like the right to form a
union or receive overtime pay, coupled with access to paid
family and medical leave stand to benefit the marginalized
communities that have been most impacted by this crisis.
It may not be possible to avert another pandemic. However,
it is certainly within our power to ensure that the next one
doesn't devastate individuals, families, and communities to the
extent that we've seen in the last year.
Thank you.
[The prepared statement of Ms. Williams follows:]
prepared statement of taryn mackenzie williams
Good Morning. Thank you to Chair Murray, Ranking Member Burr, and
Members of the Committee, for inviting me to speak today.
I testify today not only as someone who has spent more than a
decade in disability policy but also as a Black woman who lives with
multiple chronic conditions. And, as someone who has seen and
personally felt the devastating impacts of the pandemic on communities
of color and people with disabilities.
The Magnitude of the Crisis
First, I will note where we are today.
According to the Centers for Disease Control and Prevention (CDC),
as of March 22, 2021, 539,517 people in the U.S. have died from COVID-
19. Nationwide, as of March 12, Black people have died at 1.9 times the
rate of white people. \1\ Hispanics and Latinos are 3.1 times more
likely to be hospitalized from COVID-19 and 2.3 times more likely to
die from COVID-19. \2\ And, from January to June 2020, American Indians
and Alaska Natives were 3--5 times more likely to be diagnosed with the
disease than non-Hispanic whites and their mortality rate was almost
twice as high. \3\
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\1\ Centers for Disease Control and Prevention. Risk for COVID-19
Infection, Hospitalization, and Death By Race/Ethnicity. 03/12/21
\2\ Ibid.
\3\ Talha Burki. ``COVID-19 Among American Indians and Alaska
Natives.'' The Lancet: Infectious Diseases. March 2021.
The stark disparities are also apparent for the disability
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community.
The CDC reported that all people seem to be at higher risk of
severe illness from COVID--19 if they have serious underlying chronic
medical conditions. As of February 11th among states reporting data,
there were 111,000 cases and over 6,500 deaths, resulting in a fatality
rate of 5.9 percent for people with disabilities. \4\ Even more
startling, a cross-sectional study of nearly 65 million patients
revealed that having an intellectual disability was the strongest
independent risk factor measured for presenting with a COVID-19
diagnosis and the strongest independent risk factor other than age for
COVID--19 mortality. \5\
---------------------------------------------------------------------------
\4\ MaryBeth Musumeci and Priya Chidambaram. ``COVID-19 Vaccine
Access for People with Disabilities'' KFF: March 01, 2021
\5\ Shaun Heasley. ``Intellectual Disability Among Greatest COVID-
19 Risk Factors, Study Finds.'' Disability Scoop. March 10, 2021
---------------------------------------------------------------------------
Factors that Exacerbated the Crisis
In order to ensure a comprehensive response to the pandemic, it is
incumbent upon us to understand the factors that have shaped this
crisis.
People with Disabilities
The 1999 Supreme Court case Olmstead v. L.C. confirmed that people
with disabilities have the right to receive care within an integrated
community or home setting. \6\ Yet preserving access to resources and
home and community based services (HCBS) has been an ongoing challenge.
Absent this critical funding, people with disabilities are compelled to
live in settings such as nursing homes, group homes, or institutions.
And, as we have seen, these settings can be deadly.
---------------------------------------------------------------------------
\6\ About Olmstead. Retrieved on March 22, 2021 from: https://
www.ada.gov/olmstead/olmstead--about.htm
Equally critical in this moment is the ongoing fight for equal
protection under the law, particularly in medical settings. In the past
year, the disability community has feared and fought to prevent health
care providers from withholding or withdrawing life-sustaining
treatment on the basis of arbitrary standards about quality of life.
\7\ We know that calculations made in these critical moments are at
great risk to be colored by bias and stereotypes. In short, they are
subject to ableism. The ongoing devaluing of the lives of people with
disabilities that gives rise to discrimination, and the belief--
entrenched within our policies and systems--that disabled lives are not
worth saving.
---------------------------------------------------------------------------
\7\ Joseph Shapiro. ``People with Disabilities Fear Pandemic Will
Worsen Medical Biases.'' NPR: Morning Edition. April 15, 2020
---------------------------------------------------------------------------
Racial and Ethnic Minorities
In addition to ableism, we must discuss racism and the ways it
contributes to disparate outcomes during the pandemic. As noted, COVID-
19 has ravaged communities of color, which includes people with
disabilities. In these communities, we see the ways in which poverty
and its correlates: low wages, inadequate leave, lack of affordable
housing, and a lack of affordable healthcare have been inextricably
linked to higher rates of infection and mortality from COVID-19. \8\
---------------------------------------------------------------------------
\8\ Molly Kinder and Martha Ross. ``Reopening America: Low-wage
workers have suffered badly from COVID-19 so policymakers should focus
on equity.'' Brookings Institution. June 23, 2020.
Far from coincidental, the relationship between racial and ethnic
minorities, low wages and the results: inadequate housing, healthcare,
and poorer health outcomes is by design. Our society has codified a
two-tiered economic system that overwhelmingly excludes Black and Brown
workers, women, and people with disabilities from opportunities to earn
competitive wages and have their basic needs met. With this history, it
is no wonder that we have observed some of the worst outcomes of COVID-
19 among these communities.
Steps Forward for Improved Equity and Outcomes
Data Collection
We cannot begin to understand or come up with improved policy
without comprehensive data not only on fatalities, but also on
infection and COVID-19 long haulers. Indeed, a measurable improvement
in the equitable response of the pandemic can only occur with ongoing
collection and reporting of all COVID-19-related data by race,
ethnicity, socioeconomic factors and disability. Many states do not
publish vaccine data that includes race and ethnicity and--a year into
the pandemic--no comprehensive data exist detailing the full extent of
the pandemic on people with disabilities throughout the U.S.
Equitable Vaccine Roll-Out
As the U.S.'s efforts to vaccinate our communities continue to
scale-up, we need to take steps to ensure a more equitable rollout of
the COVID-19 vaccines. The distribution of vaccines should take into
account the disproportionate impacts that the pandemic has had on
marginalized communities. \9\ This includes taking steps to ensure that
communities of color and people with disabilities are prioritized in
vaccination efforts.
---------------------------------------------------------------------------
\9\ Jamila Taylor. ``The Path Toward Equity in COVID-19
Vaccination.'' The Century Foundation. March 15, 2021.
---------------------------------------------------------------------------
Investment in Home and Community Based Services
It is imperative that people receiving care can remain in their
homes and communities, rather than be admitted to crowded, unsafe
congregate care settings--particularly during an ongoing pandemic and
as we move into the future. We were pleased to see the addition of
dedicated funding to HCBS in the American Rescue Plan (ARP), we applaud
Representative Dingell and Senators Brown, Casey, and Hassan for their
release of a discussion draft of the HCBS Access Act and look forward
to working with Congress to ensure that states have the resources they
need to enable people with disabilities and older adults to live in
their communities. \10\ \11\
---------------------------------------------------------------------------
\10\ American Rescue Plan of 2021. Retrieved from Congress.gov on
March 23, 2021. https://www.Congress.gov/bill/117th-congress/house-
bill/1319/text
\11\ Michelle Diament. ``Waiting Lists May Be Eliminated for
Disability Services Provided by Medicaid.'' Disability Scoop. March 22,
2021
---------------------------------------------------------------------------
Investment in Affordable Healthcare
My colleagues at CAP have noted that while the coronavirus crisis
has led to significant job loss in the United States, it has not been
as severe of an increase in un-insurance as predicted earlier in the
pandemic. \12\ This is in part because the programs established by the
Affordable Care Act (ACA) are robust, helping those who lost their jobs
in the past year secure new sources of coverage. Ongoing support of the
ACA and its role in expanding access to healthcare in the US is
critical.
---------------------------------------------------------------------------
\12\ Emily Gee and Thomas Waldrop. ``Policies to Improve Health
Insurance Coverage as America Recovers From COVID-19'' Center for
American Progress. March 11, 2021
---------------------------------------------------------------------------
Medicaid Expansion
Equally important is support for Medicaid expansion. \13\ One way
that Congress can act to expand coverage is to further incentivize
state Medicaid expansion. States that have yet to expand Medicaid under
the ACA have left millions of people--whose incomes are below the
Federal poverty level--without access to either Medicaid coverage or
financial assistance toward marketplace coverage. \14\
---------------------------------------------------------------------------
\13\ Ibid.
\14\ Ibid.
---------------------------------------------------------------------------
Increased Wages and Access to Affordable Housing
To guarantee an equitable recovery, we urge Congress to address the
low wages that keep people in poverty. An increased minimum wage, basic
worker protections like the rights to form a union and receive overtime
pay coupled with access to paid family and medical leave stand to
benefit the marginalized communities that have been most impacted by
this crisis. In addition to wages, it is critical that we continue to
provide support for individuals who are housing insecure. The ARP's
investments in assistance for renters, landlords and individuals who
are at risk for homelessness is an important first step toward
addressing a key risk factor for poor health outcomes. \15\
---------------------------------------------------------------------------
\15\ American Rescue Plan of 2021. Retrieved from Congress.gov on
March 23, 2021. https://www.Congress.gov/bill/117th-congress/house-
bill/1319/text
---------------------------------------------------------------------------
Conclusion
It may not be possible to avert another pandemic. However, it is
certainly within our power to ensure that the next one doesn't
devastate individuals, families and communities to the extent that we
have seen in the last year. In the coming months, we should work hard
to identify what went wrong, take action, and be undeterred in our
effort to commit the investments necessary to guarantee a better
future.
______
[summary statement of taryn mackenzie williams]
This testimony will explore the magnitude of the COVID-19 crisis;
factors that have exacerbated the crisis; and proposed steps that
Members of Congress can take to address the needs of the communities
most impacted by the pandemic. It will begin with an overview of the
available data from the CDC describing the disparate impacts of the
pandemic on communities of color and people with disabilities. Next, it
will address how congregate settings and ongoing discrimination in
medical settings has detrimentally impacted people with disabilities.
It will also explore how low wages, inadequate leave, and lack of
affordable housing and healthcare have affected COVID-19 rates in
communities of color. In the final sections, proposed recommendations
will be discussed.
The Magnitude of the Crisis
Where we are today:
CDC Data on the Disparate Impacts of COVID-19 on
Communities of Color
CDC Data on the Disparate Impacts of COVID-19 on the
Disability Community
Factors that Exacerbated the Crisis
In order to ensure a comprehensive response to the pandemic, it is
incumbent upon us to understand the factors that have shaped this
crisis.
People with Disabilities
Lack of Access to Home and Community Based Services
Ongoing Discrimination in Medical Settings
People of Color
Low Wages
Inadequate Paid Family and Medical Leave
Lack of Affordable Healthcare and Housing
Steps Forward for Improved Equity and Outcomes
It is imperative that lawmakers take into consideration the needs
of the communities most impacted by the COVID-19 crisis. Critical next
steps include:
Invest in Robust Data Collection
Commitment to Equitable Vaccine Roll-out;
Investment in Home and Community Based Services
Investment in Affordable Healthcare
Continued Incentivization of Medicaid Expansion
Increasing Wages and Access to Affordable Housing
______
The Chair. Thank you very much.
We will turn to Mr. Woods.
STATEMENT OF GENE A. WOODS, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, ATRIUM HEALTH, CHARLOTTE, NC
Mr. Woods. Senator Burr, first let me begin by saying thank
you for that kind introduction and for being a friend to Atrium
Health and for being a true champion for the communities that
we serve throughout North Carolina.
Chairwoman Murray and Members of the Committee, my name is
Gene Woods, and I'm the President and CEO of Atrium Health, and
it's an honor to be with you here today.
Let me just first start by saying that in my 30 years in
leadership positions in the health care field, this past year
has been unequivocally the most challenging. But it's also been
a year where my 70,000 teammates and I have never felt more
connected to our purpose, because when you're on the front
lines battling a pandemic to save lives every single day, one's
purpose becomes brilliantly clear.
As one of the very few CEOs of color leading one of the
largest academic health systems in the country, I was
profoundly distressed to see Black and brown people die
disproportionately of COVID. It was extremely personal for me.
They could have been members of my own family.
COVID has beamed a blinding spotlight on the racial
inequities that have existed for too long in this country.
However, it fueled my passion and that of my entire
organization to adopt a not-on-our-watch stance. We wanted to
look back on these extraordinarily trying days and say that the
very best of who we were showed up, and I couldn't be more
proud of the Atrium Health heroes that I get the chance to work
with every single day.
When the first patient showed up with COVID in our
community, we leveraged the full breadth of our capabilities
and our talents to rethink every single thing that we did,
everything. The silver lining is that the key learnings from
battling COVID present new opportunities to fundamentally
change and improve health care in America post-pandemic. That
can be good for the national budget, it can be good for
business, and above all it can be better for our patients and
our communities.
For example, early in the pandemic we used our analytical
capabilities to geographically pinpoint hotspots down to the
specific ZIP Code where there were disparities in testing and
treatment. And working with local pastors and community
leaders, we deployed our roving medical units well beyond our
hospital walls, deep into the community, in church parking
lots, on the grounds of the local YMCA, and even on
construction sites.
In a matter of weeks, we completely eliminated all testing
disparities that existed through the Charlotte region. Doing so
reinforced the fact that data is only noise until we collect
it, analyze it, and then very quickly put it into use, because
as General Patton once famously said, ``A good plan executed
now is better than a perfect plan next week.''
We also learned that health systems alone cannot create a
healthier America. This pandemic proved that we need the whole
community--businesses, government, and citizens alike--working
together to create real solutions. For example, early in the
pandemic we built a public-private coalition that ultimately
delivered 2.6 million free masks across our community, with a
specific focus on the most vulnerable. And in January, together
with Honeywell, Tepper Sports and Entertainment, Charlotte
Motor Speedway and others, we hosted among the country's
largest and most successful vaccination events. In fact, we had
a shot in arms every 4 seconds and published our learnings in a
booklet titled ``A Leader's Guide to Safer, Faster, and More
Equitable Community Vaccination Events.''
Through these partnerships we demonstrated that we can be
both pro-business and pro-health. In fact, as the Chair of the
Board of the Richmond Federal Reserve, I am acutely aware that
both of those are inextricably connected. And as the veterans
on my team remind me, both are required for national security.
We also used technology in new ways to reach patients
across a very broad geography. For example, we launched the new
Atrium Hospital to Home Program and equipped people's bedrooms
with the most sophisticated monitoring equipment, and then used
our medics to administer needed interventions, including
Remdesivir, in the home.
Today we have cared for several thousand patients who would
have otherwise been in the hospital with over 50,000 patients
experiencing symptoms, thereby preserving critical bed
capacity. And this is just a glimpse of what the future of
health care can look like.
Finally, I'd like to say that we have arrived at many
battled-tested beliefs from our experience this year. For one,
there are deep disparities in both rural and urban communities
to solve for. In fact, the major components of health equity
can be similar whether you're a poor African American mother in
New York, an Hispanic farmer in Texas, or even a white farmer
in rural North Carolina.
Let me conclude by saying this. It took us less than a
decade to put Neil Armstrong on the moon, and doing so required
tremendous collaboration and ingenuity that showed the world
who we were as Americans at our very best. I believe we can
apply the same collaboration and ingenuity in these times to
eliminate health care disparities by 2030, whether in urban or
rural communities, if we take this moment to collectively say,
``Not On Our Watch.''
Thank you for the opportunity to share our experiences and
learnings from this past year on the front lines of battling
this pandemic.
[The prepared statement of Mr. Woods follows:]
prepared statement of gene a. woods
Chair Murray, Ranking Member Burr and Members of the U.S. Senate
Committee on Health, Education, Labor, and Pensions.
My name is Gene Woods and I am the president and chief executive
officer for Atrium Health, one of the most comprehensive and highly
integrated, not-for-profit healthcare systems in the Nation. With
nearly 30 years of healthcare experience, I joined Atrium Health in
April 2016, having overseen non-profit and for-profit managed
hospitals, academic and community-based delivery systems and rural and
urban facilities, as well as serving as the previous chair of the
American Hospital Association (AHA). As a multi-racial healthcare
executive, I am most passionate about protecting and expanding access
and coverage to all Americans, connecting with our communities to
advance positive health outcomes and achieving equity of care by
eliminating health disparities.
It is now my great honor to present my written testimony to the
U.S. Senate Full Committee on Health, Education, Labor, and Pensions on
behalf of our 70,000 Atrium Health teammates, detailing some of the
many successes we have achieved and lessons we have learned during this
unprecedented pandemic period, including the disproportionate effect
COVID-19 has had on communities of color and its impact on pre-existing
health disparities.
Our Past & Present
It's quite remarkable to think back to our humble beginnings in
1940 when a group of ambitious, young clinicians, not being satisfied
with the services available to the public, relentlessly lobbied for a
new hospital to better meet the needs of the community. Over time, we
have evolved from these simple roots, understanding that our
responsibilities are becoming less about what happens inside our
hospitals and more about what happens in our communities; less about
what our clinicians are telling our patients and more about what
patients are telling us. In fact, it is less about healthcare and more
about health. Today, we're proud to be known as one of the nation's
leading health organizations. Our mission to improve health, elevate
hope and advance healing--FOR ALL is forever bound to our rich
heritage.
When it comes to keeping populations healthy, we know that our
responsibilities do not begin or end at the hospital door. This
important work starts well before a person becomes a patient,
particularly within vulnerable ZIP Codes and census tracts--areas that
do not have enough access to health services or fresh foods and where
the rates of diabetes and heart disease are above the national average.
So, we're bringing people and organizations together in new ways and
collaborating on what matters most.
With 42 hospitals and 1,500 care locations across the Carolinas,
Georgia and Virginia (welcoming Wake Forest Baptist Health and Wake
Forest School of Medicine into our family this past year), we serve a
population of 7.8 million. We are also the largest provider of
community benefit (i.e., the value we give back to our community in
uncompensated care, medical education, cash and in-kind contributions,
community-building activities, etc.) in North Carolina. And with world-
class service lines in Cancer, Children's, Heart & Vascular,
Neuroscience, Musculoskeletal and Surgery & Transplant, we are
recognized by our patients and industry experts to be among the very
best, demonstrating that healthcare can be both exceptional and
compassionate at the same time.
Our Awards & Recognition
Atrium Health has also been recognized as one of the Best Employers
for Diversity, for new grads and for Women by Forbes; No. 1 on the list
of Best Places to Work for Women & Diverse Managers by DiversityMBA;
one of the 150 Top Places to Work in Healthcare by Becker's Healthcare;
and the No. 1 military-friendly employer in the country. In addition,
our organization has been recognized by U.S. News & World Report,
Leapfrog Group and the American Nurses Credentialing Center as among
the very best in the Nation and honored by the American Hospital
Association with the Equity of Care Award and one of its first-ever
Quest for Quality honors.
Most recently, Atrium Health was recognized by the Centers for
Medicare & Medicaid Services (CMS) as a 2020 CMS Health Equity Award
recipient for its dedication to health equity by reducing disparities,
enabling communities to achieve the highest level of health. Atrium
Health is one of only two organizations to win this prestigious award
in 2020 and is the only non-profit healthcare system in the Nation to
be recognized by CMS in this manner.
Introduction
Eighty years ago, our organization rose from the ashes of the Great
Depression as Charlotte Memorial Hospital. It was a time when
institutions of every kind were struggling economically, and our
country was being further strained by war. And while born in the midst
of uncertainty, through all the twists and turns in our storied
history, we have become stronger in the face of each new challenge.
Fast forward to today--facing the challenges brought by the novel
coronavirus, COVID-19--our resolute perseverance and passion to help
others have never shined brighter. From within our care facilities to
the makeshift offices now set up within their homes, every single
member of our Atrium Health family is playing a unique role in
protecting the health and safety of our patients, loved ones, friends
and neighbors throughout this pandemic. Working together, during some
of the longest and hardest days, our teammates are bringing health,
hope and healing--FOR ALL front and center in new and remarkable ways,
demonstrating undeniable courage and dedication.
As a recognized leader in diversity, inclusion and health equity,
we have also witnessed and responded to the disproportionate effect
COVID-19 has had on communities of color. A spotlight has been shone on
the structural social and health inequities that exist, and we are
asking ourselves the question--what does the next iteration of FOR ALL
look like and how can we play a role in eliminating health disparities
completely?
Within the following sections I will detail the work Atrium Health
has done throughout the pandemic to address health disparities and
inequities. I will also share recommendations we humbly present to this
Committee that can better inform action beyond the Southeast region and
eliminate health disparities across the entire United States.
Out of the Box Thinking--Data Infrastructure
When the first COVID-19 cases appeared in our region in early March
2020, Atrium Health invested in our data infrastructure and built our
own COVID-19 Electronic Dashboard. The Dashboard is updated every 2
hours and provides a variety of analytics including COVID-19 positive
cases and mortality, all stratified by race, ethnicity, age and test
location.
In order to evolve our data-driven operations, we also created a
sophisticated COVID-19 GIS (Geographic Information System) Map that
linked data on COVID-19 geographical spread, hot spots, and testing
density to population density, median income, higher poverty ZIP Codes,
the concentration of Blacks or Hispanics all to help our teams gain
granular insights on health disparities. To drive successful
operations, we knew that partnerships, access, and mobility were
critical, so we added layers to this map that included location of
churches, schools, certain businesses and bus routes. In health
disparities, we often talk about ZIP Codes. But our experts knew that
social vulnerability indices (SVI) are far more local. Accordingly we
developed features within our GIS map to analyze the home addresses of
patients tested on specific testing days and mobile locations to assess
the neighborhood footprint and geographical reach of our marketing
outreach and grassroots communications efforts.
By the end of March 2020, our data clearly showed there were gaps
in testing for communities of color and that the majority of tests
among the Black population were taking place in the Emergency
Department. We quickly formed a Multi-Disciplinary COVID-Disparities
Task Force that developed and implemented an aggressive set of
initiatives to mitigate these disparities.
Minority Testing
To address the testing disparity among underserved and minority
communities, we launched our nationally leading, innovative testing
model, integrating actionable GIS data with our mobile medical units.
With our GIS data, our mobile units target COVID-19 hotspots in
underserved neighborhoods and break down barriers to screening and
testing for COVID-19 in low-income communities of color by:
Reducing administrative barriers; no appointment or payment
barriers
Establishing trust; partners in media, churches, other
organizations
Increasing access to care; telemedicine, mobile care
With these efforts, by April 20, 2020--less than a month after the
start of the initiative--Atrium Health closed the gap in testing for
the Black population in our area. By May 4, 2020, the gap in testing
had been closed for Hispanics as well.
To date, the mobile units focused on underserved communities have
tested close to 30,000 community members. And of the patients tested by
the mobile units, 24 percent are Black/African American and 41 percent
are Hispanic/Latino. In addition, our mobile unit have partnered with
over 60 community host sites, including a variety of churches and
organizations that serve large African American and Hispanic
populations.
``Para Tu Salud''
In May 2020, we also convened a Hispanic COVID-19 Response
Roundtable that included many key stakeholders from the Hispanic and
Latino community. The goal was to hear from the community about gaps in
the COVID-19 response and to get feedback about how to communicate
messages and conduct additional community outreach to the Hispanic and
Latino community related to the pandemic more effectively.
The result of this meeting, as well as some smaller community
discussions, was the launch of our new initiative, ``Para Tu Salud''--
simply translated to ``For Your Health''--to further educate and inform
Hispanic communities on how to stay safe and healthy relative to COVID-
19. Since the launch of this initiative, we have deployed several
communications tactics to target Hispanic and Latino populations. This
includes developing educational materials for social media; creating
videos in Spanish featuring Atrium leadership and physicians; and
partnering with local Hispanic news outlets and community leaders and
influencers.
Atrium Health Hospital at Home Program
Though we continue to see COVID patients in our care facilities, we
have also been embracing virtual care like never before. So much so
that Atrium Health is leading the country with our efforts. Our new
telehealth program, Atrium Health Hospital at Home, opened on March 20,
2020 and is enabling us to care for hundreds of patients at a time from
the comfort of their homes.
Atrium Health Hospital at Home provides hospital-level care to
patients who would otherwise require inpatient hospitalization.
Principal components of this model of care include telephonic
assessment and monitoring by a registered nurse, as well as daily
provider virtual visits and in-home care provided by community
paramedics for the most acutely ill. To date, Atrium Health Hospital at
Home has cared for over 3,000 COVID-19 patients who would have
otherwise been in the hospital. In addition, the COVID-19 Virtual
Observation Unit has cared for nearly 54,000 patients experiencing mild
symptoms not requiring hospitalization. Along with the significant
impact on improved clinical outcomes, the virtual hospital has also
created additional inpatient bed capacity, resulting in less PPE use
and helping limit the community spread of the virus. Patient feedback
has been overwhelmingly positive as they report feeling less fearful
and alone throughout their illness.
This program also has tremendous potential for impacting access to
care in rural America. When used at scale, this model prevents the need
to stand up costly field hospitals in times of crisis while also
advancing a new model of more routine care. It is critical that CMS
continue to invest in this type of program to build resilience for
future crises--from hurricanes to pandemics--and introduce another
level of value into traditional healthcare. To evolve telemedicine
capabilities we also recommend:
Establishing a payment structure the supports the technology
and reasonable efficiencies
Modernization of credentialing and licensing requirements
Multi-state licensure
Broadband expansion and novel access rules for health care
purposes, such unlimited data as waiving data plans for
unlimited data and high-speed access under specific conditions.
Callout: Senate HELP Committee Member Senator Tim Scott (R-
SC) is commended for the introduction of S. 368 ``The
Telehealth Modernization Act'' which would empower the HHS
Secretary to leverage telehealth beyond the public health
emergency, as clinically appropriate.
Partnerships: Two Million Mask Initiative
At a June 26, 2020 Statehouse news conference, North Carolina
Governor Roy Cooper issued a statewide requirement for citizens to wear
masks while in public in order to slow the spread of COVID-19.
Alongside Governor Cooper and Secretary of the North Carolina
Department of Health and Human Services Dr. Mandy Cohen, Atrium Health
proudly announced our leadership of private-public partnership with the
state's largest businesses and organizations--including Bank of
America, Blue Cross Blue Shield of North Carolina, The Carolina
Panthers, Honeywell, Lowe's, Red Ventures and Wells Fargo--to
distribute one million face masks across the region. This partnership
is a great example of how health professionals, working in concert with
businesses, can improve well-being.
Our initial emphasis has been providing masks to our underserved
communities through our deep, existing relationships with Hispanic,
Black, elderly, millennial and faith communities. In the days following
our initial announcement, Mecklenburg County--where Charlotte is
located--joined our effort, pledging an additional one million masks
and bumping our supply to two million masks for the region. By
partnering with the private sector, we were able to improve our data
analytics, access an entirely new group social media influencers to
build trust, create a series of hyper-focused targeting and
distribution operations, and innovate at the speed of the pandemic.
The impact was dramatic. At the state level, we saw total COVID
cases drop 21 percent and the percent positive rate drop 10 percent
(from 7.7 percent to 6.9 percent) starting 2 weeks after the mandate.
However, in Mecklenburg County, over the first 10 weeks of the Million
Mask Initiative we observed a decrease in total daily positive test
rates by over 60 percent. Critically, we noticed significant decreases
in hospitalizations.
This shows correlation, it does not prove causation. That said, the
initiative was the leading factor in helping Mecklenburg County over
perform and get control of COVID-19. The teams spanning the business,
sports, health, government and non-profit communities got masks in
people's hands and the message that ``Masks Save Lives'' had impact. As
of March 1, we have surpassed our goal and distributed nearly 2.6
million masks, all while modeling and encouraging COVID-19 safety and
best practices while we wait for herd immunity.
Partnerships Part 2: Mass Vaccination Playbook
In January, North Carolina needed to quickly build the capacity to
vaccinate with zero vaccine waste. On Jan. 14, 2021, Atrium Health,
Honeywell, Tepper Sports & Entertainment (The Carolina Panthers) and
Charlotte Motor Speedway (NASCAR) announced a unique public-private
initiative with a bold goal of administering 1 million doses of the
vaccine by July 4, 2021. With support from North Carolina Governor Roy
Cooper, the North Carolina Department of Health and Human Services and
local governments, our organizations collaborated to administer
vaccinations, provide logistics and operations support, and offer
venues for an efficient and safe initiative. These mass vaccination
events brought together each organization's unique strengths in
logistics, healthcare and technology to vaccinate as many eligible
community members as quickly as possible. The public-private initiative
organized the first mass vaccination event at Charlotte Motor Speedway
from January 21 to 24, with second doses February 11 to 14. After these
successful events, the team developed a plan for future vaccination
events that can accommodate an estimated 30,000 vehicles. With multiple
people in each vehicle, the vaccination capacity could be significantly
higher.
The second event was held at Bank of America Stadium from January
26 to 29, with second doses February 26 to 28. These highly efficient
mass events safely vaccinated a diverse group of more than 36,000
people with scalability at a rate of nearly 1,500 vaccinations per hour
with average total vaccination times of less than 30 minutes. With each
event, we get better and more efficient. In fact, last week we
partnered with American Airlines and the Charlotte Douglas
International Airport to vaccinate nearly 5,100 transportation workers,
44 percent of whom were minorities.
I would like to submit our ``Leader's Guide to Safer Faster and
More Equitable Community Vaccination Events'' for the record. In this
playbook, we offer several best practices to get ``shots in arms''
quickly, efficiently and safely. While each event and venue are unique
and require some adaptation, this guide is intended to lay out the
high-level elements of planning, preparing, and executing a mass
vaccination event.
Key Statistics:
During our mass vaccination events we were able to give a
shot in the arm every 4 seconds.
To date (3/22/21), Atrium Health has administered nearly
350,000 vaccines. o 21 percent of whom are people of color with
a goal of reaching the overall state population rate despite
age and workforce regulatory limitations.
Vaccination Hesitancy
When the first FDA-approved COVID-19 vaccine became available in
December 2020, Atrium Health became the first health system in North
Carolina to administer the vaccine to our teammates. A Vaccine
Hesitancy Taskforce was established to address vaccine hesitancy among
teammates and community members. The taskforce uses a multi-pronged
approach grounded in data to create innovative processes that remove
barriers to getting the vaccine and create culturally sensitive
education and communications to address myths and misconceptions in
minority communities about the COVID-19 vaccine. Our community efforts
are grassroots in nature, working with community partners to co-create
collateral that is bilingual, culturally responsive and health
literate. The taskforce also uses real-time data through a COVID-19
Vaccine Demographics Electronic Dashboard, which provides a variety of
analytics updated every 6 hours, stratified by race/ethnicity, age, and
vaccine location. In addition, the taskforce applies a data-informed
decision approach to prioritize vaccine distribution in communities
with the greatest need.
Atrium Health also created ``Community Immunity for All,'' a new
collaborative to vaccinate underserved communities and those most
disproportionately affected by the coronavirus disease. The goals of
``Community Immunity For All'' are:
Acknowledge the history of health injustice in communities of
color
Listen to and collaborate with partner organizations
Educate and support individuals in making informed decisions
to best protect their health and well-being
Increase the vaccination rate in underserved communities and
communities of color
Through the efforts of Community Immunity for All, African American
and Hispanic teammates (employees at Atrium Health) acceptance or
uptake rate of scheduling their first appointment increased 24 percent
in the first 6 weeks of our efforts, exceeding our goal of a 20 percent
increase.
In addition, to address the vaccine disparity among underserved and
minority communities, Atrium Health has expanded its nationally leading
innovative mobile COVID-19 testing model to vaccine distribution.
Specifically, we have deployed our mobile medical units to target
underserved neighborhoods and breaks down barriers to obtaining a
vaccine in low-income communities of color by:
Not requiring an appointment
Holding vaccination locations trusted by underserved
communities such as churches and community service
organizations.
Leveraging grassroots communications channels such as church
emails and phone calls to inform community members of site
locations and dates and times and preserve capacity for the
underserved community
Staffing the units with interpreters
Making it clear that Atrium Health will not share an
individual's immigration status and that the organization will
not report if a patient is undocumented.
Educating community members that the vaccine is provided at
no cost to them
Offering alternate operational hours on certain days to
accommodate essential workers
To date (03/17/21), the mobile units focused on underserved
communities have vaccinated over 9,000 community members at over 20
events at 23 community host sites, including a variety of churches and
organizations that serve large African American and Hispanic
populations. People of color represent 75 percent of those vaccinated
to date at these units. Specifically, Blacks comprise 54 percent and
Hispanics comprise 9 percent of community members vaccinated in the
roving unit model to date. Atrium Health has scaled its roving unit
vaccination capacity to offer 10 sites a week (including both testing
and vaccinations). Future plans include adding two additional mobile
units for a total of 20 sites a week.
Social Impact and Rural/Urban Strategy
It is without question that the COVID pandemic has forced a re-
examination of every aspect of how we deliver care; and going forward,
we would assert that we all have an opportunity to completely re-
examine how we can create greater social impact and eliminate the
inequities we see, once and for all. In fact, our country is depending
on us to do just that. As we know, social determinants of health (SDOH)
are environmental conditions--like socioeconomic status, quality of
education, access to job opportunities, income, transportation, access
to technology and social norms--that affect a person's quality of life
and health outcomes.
Callout: The ``Black Maternal Health Momnibus Act of 2021''
S. 346 represents a comprehensive set of policies to help
mitigate inequities from birth. I want to acknowledge HELP
Committee Members Senator Tim Kaine (D-VA), Senator Bob Casey
(D-PA), and Senator Tammy Baldwin (D-WI) for their support.
We know that non-clinical, community services are crucial and
impact health outcomes, such as mortality, morbidity and healthcare
costs, by as much as 80 percent, indicating that clinical care impacts
less than 20 percent of health outcomes. That's why, this past year,
Atrium Health developed a Social Impact Strategy to follow our mission
to improve health, elevate hope and advance healing FOR ALL to support
patients and communities affected by the health inequity crisis facing
our Nation. Led by our Enterprise Board (through the Health Equity and
Social Impact Committee), our social impact strategy will ultimately
become a center piece of our entire corporate strategy. Our strategy is
built upon four pain pillars:
Equity in Social Determinants of Health
Equity in Acute Social Needs
Equity in Quality and Outcomes
Equity in Access
As you heard at the March 9 hearing, ``An Update from the Front
Lines,'' our teammates also need support. So, we made a commitment to
start first with our own by piloting our social impact strategy
internally to bring best practices to scale in the community. We
initiated:
Teammate Well-Being Surveys: Survey tracked food, housing,
utilities, internet, mental health, career development;
Expanded proactive, ongoing outreach to lower-income teammates
with resource information and support
Career Development Center Expansion: Committed to growing
teammates and promote economic mobility in our community; Hope
to grow our reach by 5x (from 100 to 500+)
Teammate Meal Kit Pilot Program: Offering easy affordable
family options to our low-income teammates; Pilot launched
January 2021; 2 meals per week, each meal feeds 4 people
Housing Opportunity Promoting Equity (H.O.P.E) Program: In
2021, 50 teammates will be placed in affordable housing;
Program targeted to teammates with household income of 31-80
percent of the area median income.
Since 2018, Atrium Health has also embraced ``Leveraging Integrated
Networks in Communities'' (LINC) as a means of connecting patients to
social services. By leveraging local expertise and technology, people
are connected to food, housing, child development, job training, and
transportation supports. Atrium Health relies on Aunt Bertha, a growing
multi-state social care referral platform. This interoperable resource
not only helps our teammates connect people to resources, but it also
provides Atrium Health with real-time data on needs, patterns and
utilization of services in the communities we serve.
Since we adopted the platform in 2018, we have connected more than
14,000 people to services in N.C., S.C., and G.A. More importantly,
however, we were able to see the impact the pandemic, the economy, and
distance learning had on families in our region. For example, we saw a
drop in utilization (down to 200 connections in March 2020) when
hospitals and the community went into lock down, and then a tremendous
spike (more than 700 connections in August 2020) when schools did not
reopen for in-person learning.
Callout: Legislation introduced by Sen. Dan Sullivan (R-AK)
and Senate HELP Committee Member Sen. Chris Murphy (D-CT), S.
509 the ``Leveraging Integrated Networks in Communities (LINC)
to Address Social Needs Act'' aims to assist states in building
statewide or regional collaborations--like Aunt Bertha--to
better coordinate health care and services.
``Teammates First'' During COVID-19
Since the onset of COVID-19, it is important to note that Atrium
Health has been committed to a ``Teammate First'' strategy to support
our teammates, leaders, physicians and providers as they work to
fulfill our mission each and every day. We recognize that in order to
care FOR ALL, we also must care for each other as well. In doing so, by
the end of 2020, we invested more than $179.7 million to patient safety
and teammate well-being. Ways in which we continue to support our
teammates throughout COVID include:
Safety--Ensuring our teammates have access to testing and
proper PPEs, while moving as many teammates as possible
(9,000+), as quickly and effectively as possible, to a remote
work environment.
Communication--Providing daily, often more than daily,
updates from our Emergency Operations Center. Focusing on
consistent and open lines of communication. Implemented texting
technologies to enhance screening of teammates for COVID-19
Stress and Burnout--Convening workgroups to quickly and
effectively provide opportunities to support our teammates
through the challenging times of reduced hours, testing and
screening for COVID-19, back-to-school issues, etc.--and
keeping in mind that our leaders face the same challenges and
need support too.
Engagement and Productivity--Re-energizing the conversations
and opportunities around engagement and productivity to fit the
times and support teammates, without losing sight of our
commitment to our patients. Providing tools and resources for
growth and development--whether in a remote or on-campus
environment.
Flexibility--Adapted for parents with remote learning and
back-to-school support. Leaders provided flexibility as much as
possible without compromising the needs of the business and
safety of patients.
Supporting Teammates--Used partnerships, for example with the
YMCA, to offer childcare at no cost. Employee hardship fund
established to provide financial support to teammates facing
financial challenges.
Onboarding--Shifting to virtual, rather than in-person
onboarding, while keeping new teammates excited and engaged to
join our team. Streamlining processes and adapting flexible
policies to expedite health screenings and background checks.
Cross training--Providing training and education to equip
staff with the knowledge and competencies needed to adapt in a
rapidly changing environment.
Talent pool--Expanded talent pools to include students,
paramedics/military vets to support staffing surge demands.
Includes hiring 90-day, clinical temporary workers in support
of surge.
Finances--In 2020, launched the Atrium Health Caregiver
Heroes Teammate Emergency Care Fund to support teammates
suffering catastrophic events, including extreme hardship
through COVID-19.
Following the death of George Floyd last year, our already stressed
teammates faced the additional pressure of social injustices. We
respond with a sense of urgency, but also with a voice of compassion,
credibility, and call to action through activities that engaged and
supported our 70,000 teammates--in particular our teammates of color--
in healing during a time of emotional unrest. Atrium Health's
comprehensive work in the social justice space for our teammates now
totals more than 300 hours of programming, has attracted over 13,000
teammates, and supported over 1,000 Atrium Health leaders.
This included initiatives like Courageous Conversations to engage
teammates. Working alongside our diverse Black men's and women's System
Resource Groups (SRG's), our Office of Diversity and Inclusion hosted a
system-wide Courageous Conversations 3-part virtual series allowing
teammates to share their personal stories, perspectives, and emotions,
in a safe space and to begin the healing process. The second part of
the virtual series was open to all teammates and focused on the
experiences of Black/African American men and women personally, and at
work. Total attendance was over 1,700 teammates. Through these programs
not only were our teammates able to speak their truth, but they also
found comfort, support and hope in their Atrium Health family.
As a system, we also provided mental health, emotional support and
resources for teammates through our Racial Justice Toolkit: a curated
collection of resources for teammates and community members to explore
racial justice, improve cultural competence and start productive
conversations about race. Our resources have also been referenced by
local and national partners and organizations. In addition, we provided
training and informative material for leaders to engage with their
teams. For instance, in June 2020, our Office of Diversity & Inclusion
held a series of enterprise-wide leader-only education sessions about
racial justice to support leaders in understanding how to support
teammates through the emotion curve, strategies for connecting and
initiating conversations, mitigating unconscious bias, working through
scenarios and best practices for leading during unprecedented,
unpredictable times.
Recruitment & Retention of Diversity Teammates
In 2019, a study showed that firms owned by women and minorities
managed just 1.3 percent of assets in the $69 trillion asset management
industry. However, the study found that the performance of minority
owned funds was overrepresented in the top quartile of performance.
At Atrium Health, we believe we could do more to ensure that its
investment decisionmaking processes promoted equity and inclusivity. As
part of our own self-assessed, we determined that, while we had made
some progress in diverse manager selection, our portfolios were
underrepresented by Black-owned investment management firms. So, over
the past several months, we (1) re-evaluated our manager search
processes; (2) met with Black-owned investment firms to learn about
their history, processes, and performance; (3) engaged in significant
discussions about diversity with industry colleagues and our board, (4)
and; most importantly, took action.
We recently committed over $320 million to Black-owned investment
funds bringing our total investment in women and minority-owned
investment management firms to 12 percent of our assets. And we are not
done. We will continue to bring a fresh diversity lens to our
investment manager selection and increase our allocation. This is just
one example of our commitment to diversity. We have and will continue
to incorporate the same rigor and accountability into other areas of
our organization for the good of our institution and the patients that
we serve.
In addition to investing in diversity, Atrium Health also signed
the Parity Pledge, which pledges that we will interview at least one
woman and one person of color for all executive positions. We are also
participants in the AHA Equity of Care pledge. With these pledges, we
have overhauled our executive search and selection policy to ensure a
fair, open and equitable search and selection processes for all
executive positions. Our Diversity and Inclusion team has also
developed a DEI scorecard and business review process that proactively
identifies diversity gaps and works collaboratively with our senior
leaders to address these gaps. With this, in 2020, 122 leaders of color
were promoted (supervisors and above) at Atrium Health. As a system
caring FOR ALL, being made up of and representing ALL is equally
important to delivering health equity and equality to our communities.
Closing
The COVID-19 pandemic has come at a great cost to the world. We
should view this reality as an investment that allows us to emerge
stronger. Through unity and collaboration, government and industry are
capable of great things. This has been, and still is, a core tenet of
American exceptionalism. Much like when NASA was formed and the power
of partnership through technology landed Neil Armstrong on the moon,
the possibilities of caring for and leading better lives--especially in
the realm of health equity--are endless. Atrium Health's experiences
this past year proves just that, whereby the value of bringing together
the resources of government and industry have greatly supported the
well-being of our population. So much so that, much like President Joe
Biden's ``Cancer Moonshot Initiative,'' we firmly believe a health
equity moonshot is also not out of reach. Therefore, based on the work
we have done this past year, we recommend a platform built on:
A. Coverage: Continue access beyond the Public Health
Emergency by closing coverage gaps with a combination of
innovative government-based and private models.
B. Standardize Data Sets: Enable real-time analytics through
full interoperability. Through international cooperation
worldwide standards for data collection can be established.
C. Real-Time Care and Interventions: Build the national
infrastructure needed to make broadband available to every
rural and urban community in the country. It is critical to
education, health and the economy.
D. Sustained Well-being: By using technology to support well-
being, our brothers and sisters in rural and urban communities
will lead healthier, more productive lives.
On behalf of Atrium Health, I would like to thank the Committee for
this opportunity to share our observations and what we learned this
last year. While COVID-19 and the public health emergency we have faced
may fade over time, the health inequities the pandemic uncovered will
persist if we don't take this moment to come together around an
ambitious goal. The country, and indeed the world, is ready for a
health equity moonshot.
______
[summary statement of gene a. woods]
About Atrium Health
Founded in 1940 as a hospital to better meet the needs of the
community. Our mission to improve health, elevate hope and advance
healing--FOR ALL. With 42 hospitals and 1,500 care locations across the
Carolinas, Georgia and Virginia (welcoming Wake Forest Baptist Health
and Wake Forest School of Medicine into our family this past year), we
serve a population of 7.8 million. Most recently, Atrium Health was
recognized by the Centers for Medicare & Medicaid Services (CMS) as a
2020 CMS Health Equity Award recipient for its dedication to health
equity by reducing disparities
Out of the Box Thinking--Data Infrastructure
When the first COVID-19 cases appeared in our region in early March
2020, Atrium Health invested in our data infrastructure and built our
own COVID-19 Electronic Dashboard--updated every 2 hours with COVID-19
analytics: cases and mortality, all stratified by race, ethnicity, age
and test location. Using GIS data, mobile units target COVID-19
hotspots in underserved neighborhoods and break down barriers to
screening and testing for COVID-19 by:
Reducing administrative barriers; (no appointment or
payment need)
Establishing trust; partners in media, churches,
other organizations
Increasing access to care; telemedicine, mobile care
With these efforts, by April 20, 2020--less than a month after the
start of the initiative--Atrium Health closed the gap in testing for
the Black population in our area. By May 4, 2020, the gap in testing
had been closed for Hispanics as well.
Atrium Health Hospital at Home Program
Tremendous potential for impacting access to care in rural America.
When used at scale, this model prevents the need to stand up costly
field hospitals in times of crisis while also advancing a new model of
more routine care. It is critical that CMS continue to invest in this
type of program to build resilience for future crises--from hurricanes
to pandemics--and introduce another level of value into traditional
healthcare. We recommend:
Establishing a payment structure, the supports the
technology and reasonable efficiencies
Modernization of credentialing and licensing
requirements
Multi-state licensure
Broadband expansion and novel access rules for health
care purposes, such unlimited data as waiving data plans for
unlimited data and high-speed access under specific conditions.
Support S. 368 ``The Telehealth Modernization Act''
Partnerships: Two Million Mask Initiative
Atrium Health and the state's largest businesses and
organizations--including Bank of America, Blue Cross Blue Shield of
North Carolina, The Carolina Panthers, Honeywell, Lowe's, Red Ventures
and Wells Fargo--committed to distribute one million face masks across
the region.
At the state level, we saw total COVID cases drop 21 percent and
the percent positive rate drop 10 percent (from 7.7 percent to 6.9
percent) starting 2 weeks after the mandate. However, in Mecklenburg
County, over the first 10 weeks of the Million Mask Initiative we
observed a decrease in total daily positive test rates by over 60
percent. Critically, we noticed significant decreases in
hospitalizations. This shows correlation, it does not prove causation.
That said, the initiative was the leading factor in helping Mecklenburg
County over perform and get control of COVID-19.
Partnerships Part 2: Mass Vaccination Playbook
Atrium Health, Honeywell, Tepper Sports & Entertainment (The
Carolina Panthers) and Charlotte Motor Speedway (NASCAR) announced a
bold goal of administering 1 million doses of the vaccine by July 4,
2021. See: ``Leader's Guide to Safer Faster and More Equitable
Community Vaccination Events''
Key Statistics:
During our mass vaccination events we were able to
give a shot in the arm every 4 seconds.
Atrium Health has administered nearly 350,000
vaccines, 21 percent of whom are people of color.
Vaccination Hesitancy
Taskforce was established to address vaccine hesitancy among
teammates and community members. Uses Dashboard to track progress. The
Taskforce uses analytics to prioritize vaccine distribution in
communities with the greatest need.
Social Impact and Rural/Urban Strategy
Support the ``Black Maternal Health Momnibus Act of 2021'' S. 346
Support S. 509 the ``Leveraging Integrated Networks in Communities
(LINC) to Address Social Needs Act''
``Teammates First'' During COVID-19
Social equity starts with our own team members.
Closing
We recommend a ``Moonshot'' platform built on Coverage, Standardize
Data Sets, Real-Time Care and Interventions, to Sustained Well-being.
______
The Chair. Thank you very much to all of our witnesses for
really excellent testimony.
We will now begin our rounds of 5-minute questions for our
witnesses. I ask my colleagues to please keep track of your
clock and stay within those 5 minutes.
COVID-19 has really exacerbated underlying health
inequities and been especially deadly for our communities of
color, including Black, Latino, Asian American and Pacific
Islander communities, tribal populations, people with
disabilities, people living in rural areas, and low-income
families. We have struggled to get tests and therapeutics and
vaccines to those communities even as they have been the
hardest hit. And we saw a troubling lack of diversity in COVID-
19 vaccine trials, perpetuating an historic trend.
As vaccine rollout continues and we work to end this
pandemic, we have to ensure that vaccines and reliable
information about them are getting to the populations who are
most at risk. I want to ask Ms. Williams and Dr. Wilkins both,
how can we make sure COVID-19 vaccines are available in our
most impacted communities and that people are actually willing
and able to get vaccinated?
Ms. Williams, I'll start with you, and then we'll turn to
Dr. Wilkins.
Ms. Williams.
Ms. Williams. Great. Thank you for that question. And I
appreciate it because in late 2020, national surveys found that
Black and Latino respondents were less likely than white
respondents to say that they planned to get a vaccine, but
surveys done in the past month have begun to suggest that gap
has diminished, or at least started to disappear.
There's been a perception that Black Americans are more
hesitant than whites to receive a COVID-19 vaccine, but roughly
equal proportions of Black and White respondents in a recent
poll said they planned to get vaccinated.
I don't want to understate the amount of vaccine hesitancy
or the lack of trust that still exists in our communities, but
what I do want to emphasize is our need to prioritize equity in
the vaccine rollout. If they have access to it, we are starting
to see in those data that we know Black and Latino communities
will seek it out.
This requires accessible and equitable systems that help to
bridge the technological divide. For example, we know there are
people in communities who don't have access to broadband.
Further, we need to ensure that they are accessible systems.
The technology used in some portals may not be accessible to
screen readers used by individuals who are visually impaired or
blind. There is also an economic divide. I consider myself
fluent in technology, and I have paid leave, and yet I've
struggled to navigate my own system for accessing a vaccine
here in Washington, DC.
I would note that as we think about prioritizing these
communities in the vaccine rollout, we must make sure that we
have accessible transportation, that we address the lack of
broadband access, and that we're making the information about
vaccines available in plain language and multiple languages to
ensure that communities of color and individuals with
disabilities will have access to information about the
vaccines.
The Chair. Thank you.
Dr. Wilkins.
Dr. Wilkins. Yes. Thank you, Chairwoman Murray. I would
echo the emphasis on making sure that we understand that
availability of vaccines is more than--there's more to access
than availability. There are several steps: transportation,
being able to register, get to a site where vaccines are. So
getting to where we can actually offer and administer vaccines
where people live, work, play and pray.
Taking vaccines out to communities is really important, and
I think we need to increase the opportunities for others to be
trained in vaccinations, nurses who are leading health
ministries. Individuals who can be trained to give onsite
vaccinations will be very important.
I will say as far as information, we have to also shift
away from the terminology of ``vaccine hesitancy,'' because
that is putting the blame on the individuals for not being
ready to be vaccinated. We need to understand that individuals
have questions. They want to know the data. They want to know
if people like them were included in studies. And we need to
take the time to explain that to them. That is one of the
strategies that we used at Vanderbilt, especially early on for
our employees, our environmental services workers, food and
nutrition, workers who were more likely to be minority. We did
onsite town hall meetings to answer their questions. We made
sure that information was available in multiple languages, and
we also have gone back to them multiple times to allow them the
opportunity to become ready.
The Chair. Thank you very much, and good point. I
appreciate that.
We are starting a series of votes. I am going to turn the
gavel over to Senator Burr. I will go vote and be back as soon
as I can and let him go vote. So again, to all of our Members
who are going to be doing this dance here for a bit, thank you.
Senator Burr.
Senator Burr. Thank you, Chair.
Dr. Wilkins, you have conducted a tremendous amount of
research on the recruiting and retaining of minority
populations to participate in clinical trials. How can lessons
from that work be applied to increase access and administration
of COVID-19 vaccines in the minority populations?
Dr. Wilkins. Thank you for acknowledging that. We certainly
at Vanderbilt have led a national recruitment innovation
center, and we also have a mass online course available to
support individuals becoming trained and better prepared to
enroll racial and ethnic minorities into clinical research.
I think a key thing that we've learned as part of the
COVID-19 research is that we have to understand the kinds of
studies we're doing, when we need to enroll individuals, and
where we can do that. So if we're going to actually do testing
onsite and require individuals to be enrolled in trials in the
short term, we need to understand what their needs are as far
as, again, transportation, access to information, linkages to
health care. All of those things are necessary if we're going
to actually enable individuals to participate in research.
Those are the things that we can do also for vaccinations.
As others have testified, being able to leverage systems and
technology during COVID-19 has also been very helpful. So we've
been doing remote trial monitoring. The ability to connect
individuals to trials and studies and information digitally has
certainly substantially increased, but not everyone has those
opportunities. So we need to be able to support people who
might not have access to the digital tools, as well as high-
speed Internet.
Senator Burr. Great. Thank you for that.
Gene, welcome. Always good to talk to you. I have to admit,
after Dr. Wilkins' comments and some of the things that you--
the challenges you had in Charlotte and how you overcame them,
there were many times early on in this pandemic I thought we
made a huge mistake by not turning over vaccinations to Chick-
fil-A, because Chick-fil-A changed their system overnight and
processed people through, and if you look at the outside of it,
it looks totally different than it did at the beginning of
this. And as we went back to statute, we found out that we
provided everybody within health care the same degree of
flexibility that Chick-fil-A displayed in their process.
Gene, you were able to take advantage of some of that. How
did Atrium successfully change the way it used its data systems
and patient information during the pandemic response to
determine where and how people were getting COVID?
Mr. Woods. Thank you for the question, Senator. I mean, if
I step back, we changed just about everything that we did, and
we were changing it on a 12-hour or 24-hour cycle.
One of the things I highlighted in my opening testimony is
that we have this geo-mapping capability, and it's updated
every 2 hours. So we know exactly to the neighborhood what the
income disparities are, where testing was occurring, what were
the mortality rates. So that enabled us to really take these
roving vans, and if we found that in a particular neighborhood
there were disparities, we would work with the pastors and the
community leaders there, and we were very targeted in our
ability to then use that data, mirror that data with our
ability to deliver care.
As was mentioned before, it's really about getting outside
of our walls. We knew that there were transportation issues,
there were Internet access issues, and people couldn't come to
us. So if you think about our vans, our medical roving vans,
they're like a hospital room on wheels. So we would go into
these communities.
But what we found also, Senator, is that it wasn't just
about solving for testing. We have a gentleman that I remember
named Samuel. He came to us and was waiting for his test
results. Well, the staff found out, where was he going to sleep
that night? He didn't know. So we had to arrange for temporary
housing that evening. A nurse realized that he didn't have many
clothes, and his shoes had holes in them. So she called her
husband to bring clothes in, and we got him food as well.
What we realized is that it was about mirroring this data
capability with our ability to reach deeper into the
communities, but also in a holistic way. It wasn't just about
COVID. We have a bunch of other needs that exist in the
community.
Senator Burr. Gene, thank you. It strikes me in hearing and
seeing some of the things you did in Charlotte that the
historical precedent didn't apply to COVID. Historically we
relied on public health departments to determine the geo-
location of the spread of a disease. In this case you and maybe
Vanderbilt took the responsibility to look at it and to
identify it yourself in real time, versus with delayed data
that might be coming in. I'm sure it was not cheap, but the
mobilization that you made in Charlotte to overcome the
challenges that you identified, transportation and other
issues, this is unusual for a hospital system to get outside of
its walls, but the flexibility existed because the need was
there.
I thank all of our witnesses today.
Senator Casey.
Senator Casey. I want to thank Ranking Member Burr, and I
want to thank our witnesses today for giving us the benefit of
your expertise and your experience.
I'll start with Taryn Williams with a question that relates
to individuals with disabilities. I especially appreciate your
ongoing and significant advocacy on behalf of people with
disabilities, continuing with your testimony today. I know that
in your testimony today you indicated that individuals with
disabilities have been disproportionately impacted by the
COVID-19 pandemic, and that's a certainty.
For example, these individuals may be both at higher risk
of contracting the virus due to underlying conditions, but also
at the same time face challenges in taking preventive measures
and also having to experience disruption to their essential
health services. And now that we're in the rollout of the
vaccine--vaccines, plural, I should say--we're hearing about
barriers to accessing the vaccines for people with intellectual
and developmental disabilities.
We know that the CDC guidance on prioritization recognizes
that people with Down Syndrome should receive priority in
getting the vaccine, but people with other types of
developmental disabilities or intellectual disabilities, such
as Prader-Willi Syndrome or autism, and who are also greatly at
risk, these individuals are not included, not included, among
the groups to be prioritized.
My question is simple but important. Given your
professional background and your personal experience, what
guidance do you think the CDC should provide states regarding
prioritization of vaccinations of people with both
developmental and intellectual disabilities?
Ms. Williams. Thank you for that question. I would note
that there are a number of researchers, and we've observed in
our advocacy efforts the ongoing challenges and barriers that
people with disabilities are experiencing as they attempt to
access the vaccinations in their state.
Few state vaccination plans explicitly mention people with
disabilities other than stating people with high-risk medical
conditions, and we know that prioritizing certain high-risk
medical conditions may include some people with disabilities,
but it may not include all of them.
It is our belief that we need to urge the CDC to release
updated guidance that explicitly names the need for people with
disabilities and those higher-risk underlying medical
conditions, that they should be prioritized in the rollout of
vaccines. Absent that critical guidance from the CDC, we will
continue to see our community lag behind in the vaccination
rates.
Senator Casey. Ms. Williams, thanks very much for your
answer.
Moving next to Dr. Wilkins for a question about so-called
long haulers, you made reference to those Americans in your
testimony. We have focused today on the fact that people of
color are overrepresented among those who have been adversely
impacted by the disease, and at the same time, in addition to
being overrepresented, also face barriers to access to care.
You made specific recommendations in your testimony to address
the needs of these COVID long haulers, and I'd ask maybe one or
two questions in my remaining time.
How should we ensure access to care for these individuals,
No. 1? And No. 2, is it about access to comprehensive health
insurance, whether through Medicaid or the marketplaces, or is
it about access to specific clinics dedicated to treating
people with so-called long COVID?
Dr. Wilkins. Thank you, Senator. I think the answer is
perhaps both. I believe that, from my standpoint as a physician
and a clinical researcher, I think it's most important that
people have access to care. The symptoms that we have
identified so far--extreme fatigue, shortness of breath, a
ringing in the ears, short-term memory loss--we have no idea
how long these are going to occur or what other long-term
sequelae people are going to experience.
We do need to have systems in place for people to access
care in a meaningful way, and when I say access, I mean in a
local area. So sometimes that means specific clinics, safety
net providers. Individuals in rural communities who don't have
access might need to use telehealth. We need to be thoughtful
in that approach, and I don't think a one-size-fits-all
approach is going to work, but we have to be really thoughtful
and we have to remove any financial barriers to accessing that
care.
Senator Casey. Doctor, thank you.
My question period is done, but I do want to say to Mr.
Woods, I will get him a question in writing. After getting
three degrees from Penn State, I don't know how we let you get
away to Ranking Member Burr's state, but we'll get you back.
Thank you.
Senator Burr. Senator Kaine.
Senator Kaine. Thank you, Ranking Member Burr and Chair
Murray, for doing this important hearing.
I think I'd like to ask a question about public health
data. Dr. Wilkins, you had a good bit about that in your
testimony. And then maybe a little bit about long COVID and
about mental health, all in the equity space.
It seems to me that one of the important kinds of lessons
from this pandemic is our public health data systems are
inadequate, and we really haven't been able to share
information between local, state, and Federal agencies in the
way that we should.
Now, the good news is I introduced a bill a couple of years
ago with Johnny Isaacson from Georgia. The CDC is very much an
item of passion for him, to invest more in our public health
data infrastructure, and in the act that we just passed there's
a $500 million investment to do just that. I want to thank
Senator Isaacson--maybe he's watching or somebody can tell
him--and bipartisan colleagues who supported it.
I think data helps us understand inequities. If we're not
measuring well, we don't have a full grasp on who is being
affected by a pandemic, who might be affected by the long-term
consequences, and even getting the data about who is being
vaccinated and where inequities are in that space becomes much
more difficult if we don't have good metrics and data systems.
Dr. Wilkins, if you could just share your advice to the
Committee as we grapple with trying to buildup a robust public
health data infrastructure in the United States.
Dr. Wilkins. Thank you, Senator Kaine. I think the issue is
not just data in public health. It's data in health care and
health systems, social services as well. We are not collecting
the types of data that we need, nor are we collecting it in
complete enough ways. So there's missing data, and it's not
detailed enough.
I do think this is a great opportunity COVID has brought to
light, the need for all of these sectors to come together and
identify really a core set of data elements that we should all
be capturing and finding ways to share that. So race,
ethnicity, detailed ethnicity needs to be captured in ways that
people actually identify.
As was already brought up today, when we talk about people
who are Asian or who are of African descent, we're talking
about entire continents of people with very different
ethnicities and backgrounds, and languages spoken at home, and
cultures. So if we're going to actually develop individualized
or customized approaches, we need to have that data.
We also need to be able to link it to community-level data,
to geo-coded data at a meaningful neighborhood level so that we
can actually bring in information about food deserts or food
swamps, where are community health centers or access to other
health systems. We need to be able to bring that all into a
single space and share it across different sectors.
Senator Kaine. I think the equity discussion around
vaccines has been a really good one to kind of demonstrate to
people the difference between equality, which we should always
desire, and equity, which we should certainly aspire to.
For example, in Virginia, the state had multiple ways to
sign up to get vaccinated, and they ended up combining them
into a single statewide registration that you could do online.
So when it was time for Group 1B to be able to register, what
could be more equal than that? Everyone in Group 1B can now get
online and register. But not everyone has access to devices and
can afford them. Not everyone has good broadband connectivity,
depending upon the part of the state where they live. People
who telework from home or may not have to work have a lot more
time to go on and hit Refresh over and over again like they're
trying to buy Rolling Stones concert tickets, versus somebody
who is working as a cashier at a grocery store who doesn't have
the same amount of time to try to register.
If we just have a system that's ``equal,'' like first-come,
first-serve, everybody in 1B can get online and try to sign up,
we're guaranteed to end up with outcomes that are inequitable.
And, frankly, the folks who have been hit the hardest by the
virus probably have the hardest time accessing vaccine
registration. So that's why some of the testimony of the
witnesses about outreach, going out and doing vaccinations
where people are, not waiting for everybody to come to the
central vaccination site, is really, really important. And
again, better data helps us get there.
I'll just say, because I only have 30 seconds left, that
the two issues that I've been really interested in is long
COVID and mental health, because the day that the President
says the national health emergency is over, the mental health
consequences and the long COVID consequences won't be over. And
because this has been disproportionately tough on especially
Latino and African American communities, those two issues will
be disproportionately tough on those communities, and we have
to understand it, have the data to measure it, and commit the
resources to remedy it.
Thank you. Thanks, Madam Chair.
The Chair. Thank you.
Senator Cassidy.
Senator Cassidy. Thank you.
Dr. Wilkins, has anybody--and I'm sorry if this has already
been answered. But knowing that there are different reasons why
people are not vaccinated, the relative contribution of vaccine
hesitancy, has anyone teased out to what degree that is an
issue versus, perhaps, as Senator Kaine said, not having a
phone which is connected to the Internet?
For context, I was just on a focus group that Frank Luntz
ran with white Republicans. As it turns out, certain white
Republicans are the least likely to be vaccinated, and it turns
out vaccine hesitancy is a huge aspect of that. So the whole
thing is how do you approach white Republicans who, as it turns
out, have a lower rate as that subgroup than any other
subgroup, according to Luntz.
To what degree is vaccine hesitancy playing a role there?
Dr. Wilkins. Thank you, Senator. Yes, you're correct,
Republicans, individuals who are living in rural settings, are
among the most likely to not be ready to be vaccinated. I use
readiness instead of hesitancy because I do think that we have
to make sure that we are giving the right message, that we're
sharing information----
Senator Cassidy. I get that, but I have limited time. Let
me ask you what percent, if we're just taking now people of
color, what percent of their not being vaccinated is related to
vaccine hesitancy or being an anti-vaxxer or something such as
that?
Dr. Wilkins. I don't think we know that. I don't think we
can tease it apart, either. I will say, though, that----
Senator Cassidy. But we do know historically because--I'm
sorry, I just have limited time. I do my medical practice in a
hospital for the uninsured in Louisiana and did lots of vaccine
work, and so became somewhat familiar with this data. Vaccine
hesitancy is disproportionately, at least among African
Americans--I don't know about Hispanics or Native Americans.
You're familiar with that information, that data, I'm sure.
Dr. Wilkins. Yes.
Senator Cassidy. Indeed, if you look at childhood
immunization rates, there is, even when you make them generally
available, the immunization rates among African American
children is lower than that--and it was interesting, when I did
my programs, African American boys are less likely than African
American girls, and I didn't quite know that because they have
the same African American parents, presumably. But nonetheless,
little boys still have that sense of agency. So, that said----
Dr. Wilkins. I'm not sure that we can actually project or
infer from prior vaccination information. This is a pandemic--
--
Senator Cassidy. Now, that would be important, though,
because there seems to be a lot of this undercurrent of
conversation that somehow there is discrimination taking place,
which quite likely there is. Again, as Senator Kaine said, if
you don't have access to the Internet, it's more difficult to
get on. If you're working full time, it's harder to just sit
there and let the phone roll.
But on the other hand, just like Frank Luntz did, it is
important to actually look at the relative contribution of
personal agency. ``I don't want it, I'm not going to show up
for it.''
It seems as if--let me ask you--if we look at health care
workers, is there any data among health care workers who could
receive the vaccine at work divided down by race or by
socioeconomic class, et cetera, as to the relative rate of
immunization?
Dr. Wilkins. We do know that, from our Vanderbilt
experience, that individuals who are working in the lower-wage-
earning positions, environmental services, food and nutrition,
were less likely to be vaccinated. That's across the board,
although we still did see lower vaccination rates among some of
our nurses who were younger and white women.
Senator Cassidy. Let me ask you, I presume Vanderbilt was
giving those vaccinations for free?
Dr. Wilkins. Of course.
Senator Cassidy. They could receive the vaccine at work?
Dr. Wilkins. Yes.
Senator Cassidy. I assume it was well publicized that they
could get it for free and receive it at work?
Dr. Wilkins. Yes. I will point out, though, that there are
some similar issues. Individuals who work for environmental
services and food and nutrition are not sitting at desks and
not able to actually sign up online the way that others of us
have. So we did actually have to go onsite and do in-person
town halls and support them in signing up. And we did find that
actually bringing that information did make a difference. We
did find that direct information, the opportunity for them to
ask questions and get answers and talk about these myths that
are widespread due to social media, addressing those actually
increased the uptake of the vaccine among our health care
workers.
Senator Cassidy. That's exactly what Frank Luntz found with
white Republicans. And I point that out because we fool
ourselves if we say the only reason that people are not getting
vaccinated is X, Y, and Z, without ignoring the role of
personal agency. We've got to address it. Congratulations to
Vanderbilt for addressing it, and that's where we should be
going as a society, acknowledging personal agency and then
giving the information. But I also note that it seems as if
there still was a difference even after you did all that.
Again, we have to kind of acknowledge the state of play.
With that, I yield back. And thank you, Dr. Wilkins, for
very informative answers.
The Chair. Thank you, Senator Cassidy.
I would ask any of our Members who wish to ask questions,
either remotely or in person, if you could let our staffs know
within the next several minutes so we can make sure we hold the
Committee open for you.
With that, Ms. Echo-Hawk, I want to go back to you. We have
seen alarming evidence that rates of COVID-19 infection,
hospitalization, and death are higher among American Indian,
Alaskan Native, Native Hawaiian and Pacific Islander
populations than white populations. And at the same time we
know that tribal communities and community health centers, such
as the Seattle Indian Health Board, are leading impactful
vaccination campaigns to combat COVID-19 and reduce health
inequities. These campaigns are really critical to defeating
COVID-19, but much more needs to be done to ensure vaccine
equity, and that's why I fought to make historic investments
for tribal communities in the American Rescue Plan.
Ms. Echo-Hawk, if you can share with us, as we continue to
grapple with the pandemic, how are we going to ensure tribal
communities have equitable access to and uptake of COVID-19
vaccines?
Ms. Echo-Hawk. Yes, thank you so much for that question. My
organization has done, to date, the only national survey of
American Indians' and Alaska Natives' willingness and what
questions they need answered if they have any expressed
hesitancies toward receiving the COVID vaccine. When we look at
all the national polls and other evidence, it didn't include
data related to American Indians and Alaska Natives. When we
got at that information, what we found is 75 percent of Native
people were willing and wanted to take the vaccine, and their
main reason for doing that is they saw themselves as an
individual who had a responsibility to their community, and
that is a core public health practice, that we take care of our
communities as individuals, doing that through masking, social
distancing, and other public health practices. The Native
community saw vaccinations as part of that.
Using that survey, tribal nations nationwide have
implemented incredible programs. So today here at my
organization, I've already got a line starting out at the back
of our agency waiting for vaccinations. We have people who are
going out to homeless encampments working to get to those who
are most marginalized, knowing that they may only vaccinate 15
instead of the 100 they could do at our agency.
But right now, as we think about equitable approaches, the
one thing that tribal nations have done is exert our tribal
sovereignty to define who are priority populations. So those
homeless individuals who may be 18 years old, who may be 75
years old, we know they are most at risk for hospitalization
and death, and so we are out there getting them vaccinated.
In addition, tribal nations, as a result of being able to
determine who are their priority populations outside of the
state mandates on priority populations, have done incredible
things for the communities, not just the tribal nations. But we
see ourselves as part of the communities in our states and in
this Nation as a whole.
In Oklahoma, there are tribes who will vaccinate any
resident of Oklahoma within the tribal facilities, not just
tribal members. The Seattle Indian Health Board a week ago
vaccinated public school teachers, starting with special ed
teachers, before the State of Washington did because there's a
mandate starting to get them to head back into the schools and
we recognized we needed to protect them. There are also other
tribes across the Nation doing the exact same thing. These
dollars that have been invested in our community are benefiting
our communities and are addressing our health disparities, but
they are also working to address the health disparities and the
outcomes of COVID-19 for all communities.
As we see these investments roll in and we see tribal
nations take the responsibility of serving those most in need,
we are seeing that impact all Americans, and there are so many
lessons that could be learned on how we are rolling that out
right now.
The Chair. Thank you very much.
Senator Baldwin has joined us. I will turn to her for
questions.
Senator Baldwin. Thank you so much.
This question is for Dr. Wilkins. Even before the pandemic,
women of color, particularly Black women, faced significantly
higher rates of maternal complications and deaths than white
women. Experts are concerned that maternal health inequities
will only worsen during this crisis due to the impact of COVID-
19 on communities of color.
Last month I introduced the Perinatal Workforce Act, which
would improve access to maternity care and grow and diversify
that perinatal health workforce to better address some of the
staggering maternal health inequities we face as a country.
This bill is certainly a step in the right direction, but I'm
worried about how the pandemic will only worsen this existing
crisis.
Dr. Wilkins, can you speak to two issues: one, the impact
of the pandemic on maternal health disparities; and second, why
it's important to prioritize the diversity of our health care
workforce in responding to these crises and what we can do to
mitigate the effects of the pandemic?
Dr. Wilkins. Thank you, Senator. I share your concern about
worsening disparities, especially related to maternal health.
We certainly are seeing issues related to follow-up care for
patients across the board, but certainly for individuals who
are from racial and ethnic minority groups, especially Black
women who are least likely at times to present for maternal
care, prenatal care in a timely manner.
I share those concerns, and it's probably going to worsen
due to some of the issues related to access to telehealth, the
challenges with having children at home and making sure that
they are being educated remotely, the burdens that they're
bearing, the loss of jobs. All of those things are actually
increasing the amount of stress and burden on Black women.
Those are issues that are not related, actually, to health
care delivery that are increasing their risk for maternal
mortality and morbidity.
As far as the workforce is concerned, we need more
diversity and more people of color in the health professions,
from physicians to nurses to doulas, and making sure that when
women are with child and in this environment, that they don't
feel the toxicity of the environment, that they feel welcome,
that their pain is acknowledged, that their symptoms are
considered, that they feel welcome and that they belong.
We need to ensure not just that we increase the number of
individuals who are in traditional medical roles but in non-
traditional ones like doulas and birthing experts, as well as
individuals who are supporting mothers breastfeeding.
Senator Baldwin. Thank you.
In 2019, before the pandemic, Milwaukee County, Wisconsin
declared racism a public health crisis. They were the first in
the Nation to do so. And since, others have followed suit.
Central to this declaration was a commitment to taking action,
which we saw during our response to COVID-19. From the
beginning, the city included race and ethnicity as factors in
its COVID-19 data, and as a result they were one of the first
to recognize who was being most impacted by COVID-19, the
city's Black community.
Ms. Echo-Hawk, how does the recognition of racism as a
public health crisis improve our understanding and response to
crises like the COVID-19 pandemic, and what can state and local
governments do to improve their data collection efforts?
Ms. Echo-Hawk. Yes, such a great question. Thank you. These
are absolutely integral things as we think about what it means
to declare racism as a public health crisis. We recognize, and
the research has shown us, that the impacts of racism impacted
the overall health outcomes of racial and ethnic minorities. If
we think about Milwaukee, I know there are incredibly high
rates of infant and maternal mortality in the urban Indian
community in Milwaukee, who are served by the Urban Indian
Health Program located there. That is a direct result of not
having access to transportation, access to safe and affordable
housing, walkable spaces, all of the things that create the
stress on a body that we know through the research that racism
actually impacts the stress in your body, and it impacts
whether or not you can carry a baby full term.
It's in the recognition like that you're able to take a
holistic view of health and look at what is impacting your most
vulnerable populations. In taking that into consideration,
you're able to identify policies and procedures that can allow
for ensuring you're getting the resources to the right people.
However, you can't do that without the data. So if you're
not collecting the race and ethnicity data, what happens is
these health disparities are effectively hidden and you're not
able to direct the resources to the right people to make the
right impactful changes that are needed in order to improve the
health outcomes. I would love to see every city across the
Nation declare racism a public health crisis so we can begin to
take that holistic look at health and recognize that it's
beyond just access to basic medical care. It's the holistic way
that every one of us lives, breathes, where we pray, and where
we spend time with our families. No matter where we are or what
time of the day it is, it impacts our health overall.
Senator Baldwin. Thank you.
I yield back, Madam Chair.
The Chair. Thank you very much.
Senator Scott.
Senator Scott. Without any question, the pandemic has
brought real challenges and really illuminated a lot of
disparities that we see in health care, whether those are
chronic conditions like sickle cell anemia or, if it's focused
on the pandemic, COVID-19. There's no doubt that we have to
improve the delivery system for our Nation's most vulnerable.
As we look toward solutions, not just combatting this
pandemic but also addressing disparities in the long term, it
seems clear to me that telehealth is a vital part of the new
apparatus that's necessary. Mr. Woods, you and I had a
discussion last year, if you recall, during the Aging Committee
about the importance of telemedicine, and I took your words to
heart, and we worked on bipartisan legislation called the
Telehealth Modernization Act that will help stop that Medicare
cliff from happening.
Can you talk about the importance of such legislation,
whether it's mine or others, that would help us focus attention
on making permanent the telehealth delivery system? And I thank
you for your leadership on this very important issue.
Mr. Woods. Thank you, Senator, and thanks for your
leadership on that. It's great to be able to come to do
testimony and see legislation come out of that which is fully
needed.
Before COVID, we were running about 1,300 telehealth visits
a month. That jumped up to about 130,000 in the middle of
COVID, and now it's hovering around 60,000 to 70,000. We could
not have served not just the population in general but the most
vulnerable populations without that capability. And to your
point, we're really concerned about the cliff because I don't
think we can put the genie back in the bottle in terms of how
we delivered care before. I spoke in my opening testimony about
our hospital homes. We treated 50,000 people in their home, and
it was the telehealth capability.
As we look to affordability of health care going forward,
these are the things we need to continue going forward past
this pandemic. So your bill and what it includes, including
looking at broadband access in rural communities and things of
that nature, are really critical, and we applaud that, and
we're the biggest advocate of that because we know it works as
we've gone through this pandemic.
Senator Scott. Mr. Woods, you just touched on a very
important point, that point being broadband, because if you
have telehealth available but you don't have a connection in
your home, I'm not sure how available it really is. So the
importance of us prioritizing, as part of an infrastructure
conversation and a health care conversation, the broadband
piece of the puzzle, I can't think of that as being less
important than telehealth, because if you don't have the
ability to have the connection, it just doesn't work. Am I
missing anything there?
Mr. Woods. I think you're spot on, Senator. If you think
about just a rural hospital that's hours away from a major city
that doesn't have access--for example, having physicians on
staff that understood infectious diseases was really critical.
We were able, because we have rural hospitals that are part of
our system, able to use our doctors in Charlotte, for example,
and beam into those hospitals several hours away. But that's
not available to all the communities. A hospital is one thing,
but it's not available. I think that should be a major national
priority because that's also about collecting data. We've had a
lot of conversations about data, and it's important to really
know how access is occurring in the most vulnerable
communities, rural or the urban poor.
Senator Scott. Absolutely. Thank you for that very
comprehensive answer.
My last question, and since I'm running out of time I'll
sort of abbreviate it. Clinical trial diversity is incredibly
important for us to be able to measure the effectiveness of the
drugs, whether it's the COVID-19 vaccine or any other drug, and
that is an area where I believe we need to focus more of our
attention on finding ways to diversify those who are willing to
participate in some of the trials. I'm not sure if it's
geographic location, factors like distrust based on the long
storied history as it relates to trusting the government when
it comes to vaccinations and health care.
Mr. Woods, with your experience, can you tell me what steps
providers, researchers, and other stakeholders are taking, and
what steps should policymakers like myself look at taking in
order to increase clinical trial diversity?
Mr. Woods. Yes. I mean, the fundamental issue, and I think
it's been referenced, is an issue of trust. Whether you're a
white Republican or whether you're a person of color, there are
some fundamental issues of trust that have to be addressed.
We're speaking to Latinx people in their language so that we
can explain that, for example, the Pfizer trials I think had
about 40 percent of people of color in that trial, and we have
to explain.
I think part of the things that you, Senator, and your
colleagues could do is continue to hold us accountable, but the
FDA and others accountable, that in order to approve new
treatments they have to have a certain percentage of people of
color and Native communities also as part of those trials.
Senator Scott. Excellent. Thank you very much, sir.
I know I'm out of time. Thank you, Madam Chair, for the
extra 45 seconds.
The Chair. Thank you.
Senator Rosen.
Senator Rosen. Thank you, Chair Murray and Ranking Member
Burr. This is a really important hearing, and I appreciate the
witnesses for your important work.
I want to build a little bit on what so many of my
colleagues have already been talking about, the Latino
community access. Our Latino community in Nevada has been the
hardest hit by COVID-19. Latinos make up roughly 30 percent of
our state's population, but they account for well over 36
percent of the COVID-19 cases, nearly a quarter of the deaths.
Fortunately, local partners in the community have really
stepped up in a big way to assist the city of Las Vegas, and we
recently partnered with the Mexican Consulate to host a vaccine
clinic equipped with bilingual staff to vaccinate over 250 of
our most vulnerable Latino community residents. I'm pleased
that the Governor and so many elected officials have made it
clear that COVID-19 vaccines will be free to all Nevadans who
need them.
This is building on Senator Scott's questions, and others.
Dr. Wilkins, what more should we be doing to ensure that
members of our Latino communities and all underrepresented
communities, not just in Nevada but across the country,
understand that the vaccines are safe, effective, and free? And
how do we get that public health message out there for them?
How do we do that?
Dr. Wilkins. Thank you, Senator. I think the key really is
that the actions have to be at the local level. We have to find
ways to bring in the voices of individuals from local
communities to help develop these strategies, the plans, and
the messaging. We're still talking about very heterogeneous
groups of people, and what works in one setting, system, town,
state, might not work everywhere.
You have to understand, as I'm sure you already know in
your communities, what their needs are, what their priorities
are, but also what are the community assets. I think that is
something that we often miss. We keep talking about communities
that are disinvested and deprived, but there are many assets
and resources in communities that we have not been able to
leverage, and bringing the voices of those in to tell us who
are the trusted organizations, who are the trusted community
leaders, who can actually deliver the message in a culturally
appropriate, relevant way that addresses the concerns and the
myths and the issues that are circulating, and how do we
actually get vaccines and information to places where people
already live, work, play and pray, I think that's really
important.
Of course, it has to be in languages that people speak and
understand, and there are many different dialects even of
Spanish. So understanding again what that looks like and how
the messaging, the images on the brochures and the videos, what
that should look like is very important.
Senator Rosen. Yes, I agree with you. In Las Vegas, over
180 students from our UNLB School of Public Health, they
partnered with our health district to provide culturally
competent contact tracing in 27 different languages. We have
one of the fastest growing AAPI communities in the country, our
Latino population in our state. So really working on this is
critical to improving outcomes.
I quickly want to move on to delayed care during COVID-19,
which we also know is an issue even before the pandemic,
particularly in our minority communities. They were already
experiencing unequal levels of medical care, particularly in
Nevada where there is a severe provider shortage. And now
during COVID, I've heard from providers that patients were
still afraid to come into the office to receive their cancer
treatment, preventative health care like mammograms or prostate
screenings and the like. In Nevada we already rank 47th in the
Nation in percent of women who are up to date with mammograms,
and we're 49th for people who are current with their colon
cancer screenings, and 44th for women of color who are up to
date on their cervical cancer screening.
This really has long-term consequences for families, right?
So how can we work to increase patient confidence and improve
access to basic preventative care to those who already were
marginalized and feel increased fear due to the pandemic?
Dr. Wilkins. I do think this is where we should be
leveraging community health workers, peer educators, peer
navigators, individuals who have the ability to go out into
communities, who have the time and resources and who are funded
to make calls, to make visits, to actually understand what,
beyond the fear of just going in, is preventing the individuals
from seeking care. Is it transportation needs? Is it child care
needs? What other resources do they need to actually be able to
come in for that preventative care? And also what can we
provide to them with respect to preventative care in their
homes or in their communities?
Senator Rosen. I think we can see what we might be able to
connect with them initially on telehealth and then buildup that
trust to bring them into the office for those tests, or
wherever those tests are provided, do as much as we can there.
Thank you. My time has expired.
The Chair. Thank you so much.
Senator Braun.
Senator Braun. Thank you, Madam Chair.
My question is for Mr. Woods. There have been a lot of
questions asked already about what we can glean from the whole
challenge with COVID. To me it's exposed and accentuated
several weaknesses within the system. Heading up a major health
care system, I'm going to focus more on two areas.
No. 1, why it's taken so long for the industry to embrace
technology in the full breadth of how you could lower costs,
because the biggest issue in health care today is not only
accessibility but it costs too much. I know in my own business
I was able to use certain tools that embraced technology. We
were doing telehealth for some of our employees 12, 13 years
ago. And now all of a sudden, due to COVID, it seems like it's
a revelation.
I think leading a major health care system, being a CEO of
it, tell me why it's taken so long for the industry in general,
from records to treatments and so forth, to embrace technology,
and then give me about a minute to a minute-and-a-half on that
answer, and then I've got one other question after that.
Mr. Woods. Thanks for the question, Senator. You know,
actually, at Atrium Health, we invested in telehealth
capabilities about 14 years ago. And what we asked ourselves is
where is technology going? But at the time we made that
investment, very significant infrastructure investments,
including establishing all kinds of protocols with our
physicians, there was no reimbursement for that.
I think part of the challenge, if you look historically,
especially for rural communities and things of that nature,
it's just the affordability of really investing in that
infrastructure. I think what we learned in COVID is that
because of the CARES Act and all the dollars that were allowed
to be used for telehealth, that changed pretty quickly
overnight.
I think it's a matter of really having the funding for the
infrastructure required, and there's very significant
infrastructure that's required. I think that's part of the
answer. I think we, though, at Atrium, we recognized that even
if we weren't going to be reimbursed, it was really the
direction care was going in, and we continued to make
investments in telehealth.
I think really what COVID has showed us is that this
technology has been pulled forward about 10 years, and I don't
think the industry will go back. I think going forward we've
learned that it has to be part of how we deliver care, to your
point to make care more accessible but also more affordable.
Senator Braun. I would just have one counterpoint to that.
You talk about reimbursement, the rest of the economic spectrum
as we invest in technology, we're not looking for a
reimbursement or for somebody else to offset our cost. We don't
have it. It would beg the question why, with all the wealth--in
fact, health care is 20 percent of our economy--that you need
reimbursement to invest, making yourself more efficient like
all other sectors of the economy do.
That leads to my second question. The biggest issue along
with accessibility would be affordability. I didn't disagree
with the underpinnings of the Affordable Care Act. In fact, I
think that made sense. But it turned into--a better title would
be the Unaffordable Care Act, and I think it's mostly due to
the industry. You might be a leader, a trendsetter, but in
general you have risen from just four or five decades ago when
it was 5 percent of our GDP to where it's pushing 20 percent of
our GDP.
How are you leading the way to avoid more government
involvement in telling you how to run your business, embracing
things like full transparency, transparency between hospitals
and insurance companies, so the main stakeholders out there who
pay all the bills in health care would be all the businesses
that are unrelated to health care and those of us, the CEOs
that run it who have probably been too sheepish in using our
leverage to get you to do what all the rest of us do, compete,
be transparent, get rid of the barriers to entry, and it's a
whole other question of how you start engaging the health care
consumer financially in his or her own well-being.
Mr. Woods. Senator, to clarify just one point in my former
answer, we did invest before there was reimbursement. So I want
to clarify that Atrium Health did not wait for reimbursement to
do the right thing.
Second, if you look at the transparency, we have fully
embraced transparency and complied with the law that exists
right now, and we fully continue to try to make that data more
available in a way that can be interpretable. So we agree with
that, as well.
If you look at most hospitals, for lack of a better way of
saying it, they are price takers, not price setters, right?
Medicare and Medicaid typically comprise about 70 percent to 80
percent of how we are reimbursed, and then the 20 percent is
commercial insurance, up to 30 percent. So if you look at our
margins at Atrium Health last year, it's less than 3 cents on
the dollar at the end of the year in order to reimburse our
communities. And this year with COVID, it was less than 1 cent
on the dollar that we had to reinvest in the community because
of all the expense with COVID.
I think it's a multi-factorial issue. Health systems have
to lean in, pharma has to lean in, industry has to lean in, and
we need partnership with our legislators to really deal with
the comprehensive and multi-factorial issues that surround
affordable care.
Senator Braun. Thank you. You'd better get better at it, in
my opinion, because you're losing the support of businesses and
CEOs that would like to see our health care costs go down. So
whatever is being done I don't think is going to escape the
heavier hand of government unless you get a little better at
it.
Thank you.
The Chair. Thank you.
Senator Smith.
Senator Smith. Thank you, Chair Murray and Ranking Member
Burr.
To all of our panelists, it's so great to be with you
today. I have been jumping around between votes and hearings,
like a lot of my colleagues, but I want to just start out by
saying I appreciate the conversation around the importance of
telehealth, and I appreciate very much the focus on equity in
this Committee.
I just want to note that nearly 37 percent of Black
American households, 31 percent of Hispanic American
households, and 35 percent of Americans living on tribal lands
have no access to broadband or computer access in their home.
So the opportunity that telehealth provides to improve access
to care is again not widely shared, and this is something that
we have to focus on.
Ms. Echo-Hawk, I really appreciated the statement that you
made at the beginning about the impact of these inequities and
systemic racism in tribal nations, and also the impact on urban
indigenous communities. It seems to me that in some sense with
culture we have the opposite--I mean, with COVID we have the
opposite of a virtuous circle or a healing circle. We have the
impact of COVID on top of systemic and historic trauma and
racism that has just been so compounded. And yet, I think there
are some positive lessons to be learned from this, and I wanted
to ask you about this example.
Last Friday I had the opportunity to stop by the
Minneapolis urban office of the Bois Forte of Ojibwe in
Minnesota. Now, they have already vaccinated all of the
eligible members in their tribal lands, and they are now coming
down to the city, making stops with an ambulance that they were
able to purchase with CARES Act funding, and they are doing
incredible outreach and having real impact.
My question for you is what can we learn from efforts like
the Bois Forte and others in Minnesota around the country about
why this is working to vaccinate people both in tribal land as
well as urban communities?
Ms. Echo-Hawk. Thank you so much for that question. They're
doing an absolutely incredible job in Minnesota, across the
state, and across the Nation as we look at tribal nations,
again recognizing that as a result of exercising tribal
sovereignty they have the ability to define who they vaccinate,
and that just doesn't apply to their tribal members. They can
vaccinate people within their communities, and that's what's
happening.
We were also able to get the high vaccination rates within
our community by using trusted messengers, and also having an
established health care system, the Indian health care system,
that had already identified our most vulnerable community
members. We had already established how we reached them and we
just needed the resources. So the CARES Act funds and now the
American Rescue Plan are going to be part of building forward
those resources. It really illustrates the need to have trusted
community messengers. Those are the ones the community will
say, OK, you got vaccinated, that helps me overcome the
questions I had about whether or not I should be doing that.
It also allows us to ensure that for Native people--for
example, today I sent my son off to a funeral I wasn't able to
attend, because like many other Native people I've seen extreme
numbers of deaths within my family and friend circle. We are
also working to preserve our elders and our community members,
those who, when we lose them, we've lost libraries of knowledge
systems. So we recognize that those same things exist in other
populations, which is why tribal nations have dedicated
themselves to not only serving their people but the people
around them.
Senator Smith. Thank you. That is so good. I mean, that is
a virtuous circle. It is appreciation of sovereignty. It is
getting resources so that they can execute strong plans rooted
in culture and community, and it works. I just want to note
that the American Rescue Plan, which we have just passed,
provides historic new levels of resources for tribal
communities to begin to build back from the historic under-
investment that we have made, and I have hopes for that, and I
look forward to working on that.
Ms. Echo-Hawk. If I could say one thing with that rescue
plan. As Indian Country, it has to be known that it is an
incredible investment, but it cannot be seen as a one-time
investment, because as it relates to investment in the Indian
health care system, this has to be ongoing. It's just a start,
and we look forward to working with all of you to continue that
to ensure the funding of our systems.
Senator Smith. It's such a great point. This is an issue, I
think, with much of what's in the Rescue Plan. Another example
is the child tax credit will benefit families across the
country, but we cannot be in a situation where we're reducing
child poverty by 50 percent and then have it jump back up
again. We need a systemic change in the way we're doing this,
so thank you for that.
I am out of time, but I want to just thank Ms. Williams for
your excellent discussion on what lies underneath this so-
called vaccine hesitancy in communities of color and how we can
address it, and I think it ties in directly with this
conversation we were just having right now.
The Chair. Thank you.
Senator Murkowski.
Senator Murkowski. Thank you, Madam Chair.
Thank you to all of our witnesses at this very important
hearing this morning.
Even prior to the pandemic last year, Alaska Natives have
lived in fear of disease that might come to their remote
communities. When the 1918 influenza pandemic hit Alaska, our
Alaska Native populations were significantly impacted. They
suffered one of the pandemic's worst death rates in the world
at that time. The loss of entire families, the loss of
practically entire villages resulted in generational trauma
that really carries through today. There are those who still
tell the stories of how the influenza wiped out their
communities.
During this past year, as we've looked at the disparities
in mortality rates, we found that the mortality rates of
American Indians and Alaska Native persons aged 20 to 29 years
was 10.5 times higher compared to their non-Hispanic white
counterparts. Those in the age 30 to 39 bracket had mortality
rates of 11.6 times higher. Those aged 40 to 49 were 8.3 times
higher compared to their non-Hispanic white counterparts.
The question is we've seen this; we saw it 100 years ago.
We have seen other areas where disease has come in where our
Native peoples have perhaps been some of the most vulnerable.
What investments do we need to make to close these gaps in
mortality rates, especially as we're looking to our young
people? There was a lot of focus initially, and we need to take
care of our elders, we need to take care of our seniors, but it
is also the young in our tribal communities.
It's kind of a broad question, and I will throw that out to
those of you online and here in the room.
Ms. Echo-Hawk. Thank you so much, Senator. As an individual
who was born and raised in Alaska--I'm associated with Mentasta
Village--I recognize I heard those stories. And I'm also the
co-author on the paper which you just cited those statistics.
And as I was part of writing that paper, I could hear those
stories in my head, the ones that I had heard. And it is
absolutely essential for us to recognize that these underlying
health disparities are resulting in deaths, and people are
dying every single day. And unless we begin to invest in these
community resources, and for tribal communities specifically
investing in tribal sovereignty and the rights of tribal
nations through Indian health care systems, unless we do that
to the full funding capacity which is needed, we're not going
to see this end, and I don't want to see the next pandemic
impact us in the exact same way. I don't want to have these
same stories that my grandchildren are saying. Unfortunately,
unless we continue to invest like we have done in this most
recent package, we're going to see that continue.
It also has to be community driven. We know how to serve
our communities. We know what they need, and we don't need
people coming to us because they think we have all the problems
but instead acknowledging we have the answers, and when
properly resourced, as we've seen with the high vaccination
rates, and in particular Alaska has some of the highest
vaccination rates overall, and we had Native communities there
that are 80 to 90 percent fully vaccinated as a result of the
Indian health care systems, tribal health care systems in
Alaska. When we see and have those investments, these are the
changes we can bring.
Again, it can't be a one-time fix. It needs to be an
ongoing conversation that fully funds for tribal communities
the Indian health care system and respects tribal sovereignty
and the need for economic vitality through other types of
investments to ensure that our people no longer experience
these terrible, terrible outcomes.
Senator Murkowski. Ms. Echo-Hawk, maybe you can also join
with response to this because another area that we are seeing
statistics that just are not in line with where we want to be,
the United States is the only well-resourced country with a
rising maternal mortality rate, and indigenous moms are dying
at a rate two to three times higher than non-Hispanic white
mothers nationally. We found that the maternal death rate for
Alaska Native women between 2009 and 2018 was significantly
higher than that for women of other racial or ethnic
backgrounds.
As we're looking at these statistics and the vulnerability
of our Native people in this COVID time, I think it's also
important to look at where these other health disparities lie.
For us as a nation to actually be going the wrong way with
maternal mortality is just something that in my mind is almost
unforgivable, inexcusable. And then to see again how that has
disproportionately impacted our Native women is something that
I would hope we'll have an opportunity to continue to work on.
I know that I've got some good partners on this Committee to
help me with that.
I'm out of time, Madam Chair, but I want to make sure that
these types of disparities, and again statistics that are going
in exactly the wrong way, we have an opportunity to address.
The Chair. Thank you, Senator Murkowski, and I'm delighted
you brought that up. We'll continue to work with you on that.
Critically important.
Senator Hassan.
Senator Hassan. Thank you, Madam Chair, and to our Ranking
Member. And I'll just echo what you just said and what Senator
Murkowski talked about. It's work we need to do, and I look
forward to working with our colleagues on it.
I want to thank all the witnesses for being part of this
hearing today, and I want to start with a question to you, Dr.
Wilkins. The pandemic has certainly magnified the disparities
in access to care for people of color all across the country,
not just in cities but also in rural areas, including many
places across my home state of New Hampshire. Studies show that
people of color in rural areas are less likely to have access
to primary care, and they are therefore less likely to have a
trusted medical professional in their community to rely on for
information and care during this pandemic.
We have to do more to ensure that people of color have
access to primary care, which is obviously important during
this pandemic, but it's also necessary for preventive
screenings and early diagnosis of many life-threatening medical
conditions.
Dr. Wilkins, how can we ensure that people of color who
live in rural areas have access to trusted primary care
providers?
Dr. Wilkins. Thank you, Senator. I think this is a really
important point. We saw this very early on in the pandemic,
that individuals who had symptoms and needed testing were being
told to contact their health care provider.
Senator Hassan. Right.
Dr. Wilkins. Well, if you don't have one, then who are you
contacting, and how does that work? The delays and the lack of
access due to that I think are really important.
But we don't have enough primary care providers. We need
more, and we also need to acknowledge that you don't have to be
a physician to be a primary care provider. So we need to make
sure that nurse practitioners and physician assistants also
have the opportunity to provide that preventative care, the
preventative screening, and be a front door for access to care.
Again, we have not taken full advantage of community health
workers as an access point, as people who are great
communicators and can actually link to and improve the uptake
of care that we're not seeing in so many communities.
There's been a lot of talk about telehealth, and I'll just
point out that at Vanderbilt we also saw a dramatic increase,
and I'm really proud of the great adoption of telehealth during
the pandemic. But when we disaggregate that data again by race,
ethnicity, language, and ZIP Code, the communities who are most
likely to use telehealth are wealthy and well educated. So even
though we saw some individuals in rural communities, some urban
racial and ethnic minorities using telehealth, it was not at
the same rate, and we need to be prepared for what telehealth
looks like for everyone, because it is not all the same.
Senator Hassan. We have to get connectivity to everybody,
and it has to be what they can afford.
Dr. Wilkins. I think it's beyond connectivity. People have
devices. They use their smart phones. But having to type in all
the information for insurance, and if you need an interpreter
to be on the line, connecting a third person, lots of
challenges with that. Are you in a room where you actually can
be by yourself in a crowded home and have a private health care
visit? There are lots of things that we have to consider there.
Senator Hassan. That's very helpful. Thank you very much.
Ms. Williams, I want to turn to you for a question. Earlier
this month I wrote to the Departments of Justice and Health and
Human Services pushing for improvements in vaccine access for
individuals with disabilities. I was pleased to receive a
response that highlighted plans to investigate claims of
discrimination and provide technical assistance to states and
individual vaccination sites.
However, I know that information about such resources is
often not accessible to those who need it most, and I know you
discussed this a bit in your answer to a couple of other
questions earlier. But, Ms. Williams, what further steps should
the Federal Government take to ensure that all vaccination
sites and registration portals are fully accessible for
individuals with disabilities?
Ms. Williams. I'm really glad that you've asked this
question. Something I think we need to consider, particularly
as Members of Congress look for another response bill to this
crisis, is we need to ensure that state and Federal responses
to the pandemic really account for the needs of individuals
with developmental disabilities and the needs of folks who
aren't getting equitable access to vaccines across the Nation.
As I noted in my testimony, they are some of the folks who
are most impacted by this crisis, and we actually have entities
throughout our communities, entities like state councils on
developmental disabilities, university centers on developmental
disabilities, and protection and advocacy agencies that are
able to go into institutions and ensure that folks are getting
equitable access to care and equitable access to vaccinations.
They are equipped and have, over the last year, rapidly stood
up virtual platforms that really do serve the needs and the
voices of individuals who have been impacted by this crisis.
As we think about future responses, I would ask that you
all consider including additional support activities authorized
under the Developmental Disabilities Act and the Bill of Rights
to ensure that these entities that exist across our Nation in
support of people with disabilities, that they can continue to
serve them at this moment of crisis.
Senator Hassan. Well, thank you very much.
I know, Madam Chair, I am over time. I will just say it's
also going to be important that we provide people with
disabilities the kind of information they need so they can
report violations, and that they can do that in a
straightforward way.
The other point I would make that follows up on Senator
Murkowski's point and that of Senator Baldwin and others about
the maternal health disparities we're seeing is given how big
these disparities are, and given a relative dearth of
information about the impact of vaccines on pregnant people, we
need to make sure that we are addressing those disparities and
getting vaccines to people for whom it is safe and answering
their questions about the impact on pregnancy.
Thank you.
The Chair. Thank you.
Senator Lujan.
Senator Lujan. Thank you so much, Chair Murray.
I come from a state with large Native American and Hispanic
communities. And while all communities of color have been hit
hardest by the COVID-19 pandemic, I want to ask some questions
specifically in the Native American and the Hispanic community
populations.
The racial and ethnic groups for which the CDC reports
COVID-19 health outcomes, the American Indian and Alaska Native
populations face the highest death rate. Hispanics and Latinos
are 1.3 times more likely to contract COVID-19, twice as likely
to be hospitalized, and more than three times more likely to
die from COVID-19. Data is a double-edged sword. When used
correctly it can be an invaluable tool in focusing resources
and addressing trends as they emerge. But data can also be used
to further marginalize communities through exclusion.
Ms. Echo-Hawk, yes or no? As a public health expert, are
you confident the nationally reported data accurately reflects
rates of COVID-19 infection among tribal communities?
Ms. Echo-Hawk. No, it absolutely does not, and my
organization recently released a report titled ``Data
Genocide'' that ranks every single state on their ability and
how they're reporting race and ethnicity of American Indians
and Alaska Natives, and what we found is this Nation is
failing.
Senator Lujan. I appreciate that. You anticipated my next
question, which is about over-or under-reporting, and I
appreciate your clarification. I don't know if you want to add
something about that?
Ms. Echo-Hawk. Yes, absolutely. So we know there is a
chronic under-reporting of race and ethnicity. The current data
infrastructure is not allowing for race and ethnicity to be
collected. In addition, for American Indians and Alaska
Natives, when our race and ethnicity is not collected and then
it is used for funding allocations, like what was done in the
CARES Act package, what happens is the resources don't go to
our smaller communities and do not properly reflect the needs
of our communities as a result of that data.
With the non-collection of our data, it's actually a
failing of our treaty and trust responsibilities that then
Congress is tasked with making sure that happens, and you're
not able to do that without the right data. We are seeing an
effort right now that I'm actively a part of with the Council
for State and Territorial Epidemiologists. We're working to get
funding to ensure we can build out the public health
surveillance systems nationwide to properly reflect race and
ethnicity for not only American Indians and Alaska Natives but
for all people of color, and to assure accountability of the
states to do that reporting.
Senator Lujan. Chair Murray, last Congress Senator Tina
Smith carried legislation in the Senate, I carried it in the
House to address this issue, and we look forward to working
with you and others on this specific area.
Ms. Echo-Hawk, looking beyond the pandemic, what is the
connection between improved data collection methodologies and
improved health outcomes in Native, Hispanic, and Black
communities?
Ms. Echo-Hawk. We absolutely need that data in order to
understand where to direct the proper resources. When we have
the right information, we have the ability to understand where
to go with that, and that includes not only the gaps, and I
know we like to focus on the gaps, but it also has to include
the strengths and the resiliencies. It is through those
strengths and resiliencies we identify the protective factors
that allow us to improve the health outcomes. And without all
of those together, we are not going to be able to address these
health disparities. It is going to take a concerted effort from
the states and the Federal Government to ensure that actually
happens.
Senator Lujan. Dr. Wilkins, we're now finally seeing more
awareness, at least I'd like to say that. That's my
observation. I hope the data supports it. We're getting more
support to Hispanics, Native American and Black communities in
regards to the disparities that exist with access to care. How
can we all work together to ensure that these partnerships are
real, that they grow, and that they're sustainable after COVID?
Dr. Wilkins. Thank you for the question. I do think that we
need to make sure that we continue to emphasize that the
community has assets, and they're often not recognized. So when
we build these partnerships, we often see there's the
opportunity to get vaccines out or deliver a certain message.
But the only reason that can happen is because these
communities do have assets, resources. They have trust. They
are deemed as trustworthy. And we need to invest in those
relationships long term. If there is not a commitment to a
long-term partnership, then we'll continue to have these
opportunities where we're just doing one-offs and not taking
full advantage of the resources, intellect, and people who can
actually solve these problems.
Senator Lujan. Mr. Woods, we know that patients who are
able to receive culturally competent behavioral health care
have improved outcomes. What is one lesson we should learn from
your work at Atrium Health to recruit and retain diverse health
care providers who are able to provide high-quality care to
their patients?
Mr. Woods. There are a number of factors. I mean, we do
cultural competency training every year, and you can't just do
it one time and then not continue. I think in a typical year, I
think we have 300 different languages and patients that we have
to take care of. When you're talking to somebody in their own
language, their blood pressure goes down because they feel like
they're in a place that understands them.
But I think the other thing, Senator, is we have to take a
long view here. We have to really start in Title 1 schools to
grow more physicians and clinicians that are Black and brown
that go into the pipeline. We just combined with Wake Forest
University in building a new medical school in Charlotte, and
that medical school is going to be focused on making sure that
we're reaching out to young bright minds that look like the
community they serve so that they can go back into those
communities.
Senator Lujan. Thank you, Chair Murray, for this important
hearing. I appreciate the time today.
The Chair. Thank you.
Senator Burr.
Senator Burr. Senator Murray, I've only got one question
left, but I know we've got Members who are frozen on the floor,
frozen in other committees. I know you'll do a unanimous
consent, but I encourage all the Members to ask questions,
written questions, and I would urge our witnesses to please
answer those as expeditiously as you can.
Gene, let me come to you just real quick. You talked
briefly about the public-private partnerships that Atrium had
and has ongoing. Can you expand a little bit on those and what
the difference is it's made to the health community of
Charlotte and the community herein?
Mr. Woods. Thank you, Senator. We just could not as
effectively have dealt with this pandemic without those
partnerships. When I refer to the mass vaccination events that
we did, and my good friend is the CEO of Honeywell and lives in
the neighborhood, and we took a walk and said how do we get
shots in arms faster? Honeywell has tremendous logistical
capabilities throughout the world, really. So we blended those
capabilities with the ones that we have at Atrium and really
were able to effectively, for example, pull off some of the
largest, most successful mass vaccination events. We did the
same thing for masking. We're working together.
There's a group here in Charlotte that's led by Brian
Moynihan, the CEO of Bank of America, and we're working with
business communities and the government to deal with things
like pre-K education.
I think the problems, the issues that we deal with as a
society are too big for any one sector to deal with alone. I
think it's those partnerships that actually, quite frankly,
have been strengthened in the middle of this pandemic that I'm
looking to continue to maintain well past that, because it's
only when, as I said in my testimony, when government, when
health systems and businesses and citizens work together that
we can solve these most intractable issues that we've faced for
too long.
Senator Burr. Gene, thank you for that.
I'd point out to the Chair that partnerships have been
essential not only to the delivery of vaccines, it was
essential to the development of a vaccine. Today we see Big
Pharma companies that don't have a vaccine manufacturing for
another company; that's unheard of historically. This shouldn't
be the exception. It should help to shape how we look at this
from a policy standpoint and statute, to continue to allow
flexibility out there.
The decision was made very early on, I'm sure with
objection, that we leave it up to states and Governors to
decide where the deployment of vaccines went. I still think
that was much better than us deciding in Washington here's the
location it's going to go to. When Governors chose the wrong
place, it was Vanderbilt or it was Gene Woods or it was
somebody that said to the state people we need different, we
need more, we need something that doesn't look traditional
because we're not reaching a population, and locally those
changes were made. We haven't made them everywhere in the U.S.,
but as long as we keep in mind that as we write policies the
flexibility has to be there so people can change the
architecture based upon the geographical location, based upon
the disease, based upon the target for that disease, then I
think we're going to be just fine.
I thank the Chair.
The Chair. Thank you.
In September 2020, I published a report titled ``COVID-19
and Achieving Health Equity.'' Congressional action is
necessary to address racism and inequality in the U.S. health
care system. That report outlined how the health care system
has failed communities of color due to entrenched bias,
discrimination and racism, and laid out a series of
recommendations for Congressional action, and I ask unanimous
consent to enter that report in the record.
So ordered.
[The following information can be found on pages 67 through
112 in Additional Material:]
The Chair. Thank you. That will end our hearing today, and
I'd like to thank all of our colleagues, and I'd really like to
thank all of our witnesses--Dr. Wilkins, Ms. Echo-Hawk, Ms.
Williams, and Mr. Woods--for having such a substantive
conversation on how damaging longstanding health inequities
have been, including during this COVID-19 pandemic, and what we
can do about it, and I look forward to continuing to discuss
these issues and, more importantly, to taking long overdue
action to address them.
With that, for any Senators who wish to ask additional
questions, questions for the record will be due in 10 business
days, on Thursday, April 8th, at 5 p.m.
This hearing record will remain open until then for Members
who wish to submit additional materials for the record.
With that, thank you again to all of our witnesses, and
this Committee stands adjourned.
ADDITIONAL MATERIAL
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[Whereupon, at 12:05 p.m., the hearing was adjourned.]
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