COVID-19 and Access to Care: The Need for Health Reform in Durham and North Carolina

                                           By Sravya Durbha, MBA, Rachel Holtzman, and Chuck Matula, JD

Access to health care is one of the most acute problems of our time. Here in Durham, a 2018 study found that 70% of residents noted access to health care and health insurance as a top health issue–and Black and Latinx Durhamites are two and seven times more likely than white residents to be uninsured, respectively. Across our state,COVID-19is only decreasing access to care. From March 15 to April 25, nearly 340,000 North Carolinians lost their jobs, leading to record numbers of newly uninsured, low-income people who will fall into the Medicaid gap and struggle to access care. In fact, because of increased patient volume nationwide due to COVID-19, 15 million adults in the U.S.have been denied care for themselves or a family member –and denial rates are four times higher for low-income adults (incomes at or below $40,000) than their peers. As students of health policy, we have learned that our U.S. health care system needs meaningful reform –we spend too much, for too few people, with poorly aligned incentives that encourage low-quality and low-value services –but we now see it in a new light. The coronavirus pandemic is exacerbating deeply unequal access to care in a time when we most need it.

Federal efforts to expand COVID-19 testing options for insured patients are important but not sufficient. The Families First Act and the CARES Act require private carriers to cover 100% of the cost of coronavirus testing (including diagnostic and antibody tests). However, affordable testing for the uninsured remains limited. A coronavirus test can cost up to $229, which may represent nearly a quarter of one’s monthly income for North Carolinians in the Medicaid gap. Even for insured patients, providers can charge for coronavirus tests by billing patients directly rather than billing insurers, which could negotiate discounted fees for their members. This doesn’t touch on the hefty medical bills patients might face if they do fall sick. A recent report estimated that an uninsured person hospitalized for coronavirus can expect to pay more than $73,000 in medical bills, and another found that14% of people with a likely case of COVID-19 will avoid care due to cost. The federal government must ensure COVID-19 testing and treatment is affordable for everyone, including people with and without insurance.

Recent federal policy increases access to telehealth for some but not all people. Understanding the important role of telehealth during the pandemic, the HHS Office of the Inspector General is allowing providers to reduce or waive cost-sharing for telehealth services used byMedicare patients. However, factors such as lack of adequate access to broadband, lack of insurance coverage, and homelessness hinder meaningful access to telehealth for some(see Boisvert, Durbha, and Nguyen and Brown and Xie reflections). Research confirms that underserved populations, such as uninsured and low-income people, use telehealth services less than their peers. This is no surprise in places like Durham, where the majority of Durham Housing Authority public housing units do not provide WiFi to their residents. Even with recent CMS guidance to expand and standardize Medicaid reimbursement for telehealth, more work is needed to ensure that underserved populations have the internet connectivity and devices necessary to utilize telehealth. Federal and state governments must align incentives and resources to this end.

The federal government must also invest in the home and community-based services workforce. As more patients become hospitalized due to COVID-19, acute care settings will become increasingly overwhelmed. While portions of the Cares Act’s $175B in relief funds are allocated to Medicare facilities, providers in rural areas, and providers in low-income areas, simply providing funds to existing facilities and providers is not enough. Many rural, low-income, or other health professional shortage areas do not have enough of an existing health care workforce to take advantage of these funds. Investments in building a more robust home and community-based services workforce –especially for vulnerable populations like the elderly and immunocompromised –is vital to ensure that people can receive care in the communities where they live.

Because of the remaining needs for access to care, Durham community-based organizations are stepping up to fill in the gaps. A few of the many examples include Project Access of Durham County, Senior Pharmassist, and Lincoln Community Health Center. In addition to its regular work connecting uninsured patients to specialty care, Project Access of Durham County is part of a coalition working to ensure prevention, identification, and medical care for COVID-19 cases among Durhamites experiencing homelessness. Meanwhile, Senior PharmAssist staff received free masks from Covering the Triangle, typed up instructions for how to wear them, and then brought the masks and instructions to the Forest at Duke to be shipped out to each of their 1,400 members so they could safely leave their homes. (Talk about a team effort!) Further, Lincoln has created a walk-up or drive-through testing site for suspected COVID-19 patients, most of whom are uninsured and pay for care on a sliding scale. These and other safety net providers around Durham are ensuring that vulnerable communities have access to the services they need.

But community and federal efforts cannot succeed alone; the North Carolina General Assembly must expand Medicaid to support North Carolinians through this crisis. Citizens in news outlets from Asheville to Burlington to Greensboro to Robeson have pleaded for state legislators to expand Medicaid in the face of the pandemic.Harvard researchers have explained how Medicaid expansion will provide needed support for health care systems and state budgets, and noted the harmful effects that 1115 waivers like the “Healthy Adult Opportunity” initiative would have in these times. Meanwhile, the NC Justice Center has noted that manyNorth Carolinians in the Medicaid gap are service workers --the very people we rely on for child care, groceries, and health care during the pandemic. NCChild has shown that Medicaid coverage is important for the financial security of NC families during the pandemic, and prior research by AAP tells us that the children of parents with insurance are more likely to receive necessary pediatric care. Meanwhile, experts such as Duke professor Don Taylor and attorneys at the National Health Law Program and the Charlotte Center for Legal Advocacy have long since made the case for how Medicaid Expansion would benefit our health and economy in NC–which are needed more than ever right now.We must expand Medicaid to ensure that North Carolinians can access the care they need for us all to weather this storm together.

This reflection was authored by some of the 2019-2020 Duke University Margolis Scholars as part of a five-part series reflecting on the disparate impacts of the COVID-19 pandemic on the health of the Durham community. Each of the five reflection pieces centers around one of the five top health priorities in Durham, identified by the community in the 2017 Durham County Community Health Assessment. For more information, visit https://healthydurham.org/.