This op-ed argues that prioritizing patients based on who is most likely to benefit, the most commonly used approach to rationing scarce resources, inherently disadvantages groups who already experience worse health due to historical and structural factors.

Rationing crucial resources such as ventilators may be necessary in response to a public health crisis, and most guidance explicitly provides that factors such as race, ethnicity, gender, insurance status, perceived social worth, immigration status, and similar factors should not be considered in allocation decisions. However, the author argues that the most commonly accepted model for allocating these resources fairly – favoring patients most likely to benefit and/or patients most likely to live the longest – fails to account for existing structural factors reflected in disproportionate health burdens in some communities, particularly African-Americans.

The author cites the connection between health status and place, lingering distrust of the health system due to past abuses and continuing discrimination, and inequitable access to health insurance and care, among other historical and structural factors, as playing a significant role in creating differences in health status that reflect factors outside an individual’s control and inequitably distributed among communities. To make allocation decisions truly fair, the author argues that additional measures are required, such as adjusting or weighting triage scores to avoid penalizing patients for health factors influenced by race, ethnicity, income, or insurance status. The author argues that this is especially critical for hospitals in regions where disadvantaged groups are a minority of the population but account for a majority of COVID-19 cases, a pattern that has been reflected in several areas of the US to date.