Resource Allocation and Social Inequities

This article by Schmidt, Roberts & Eneanya critiques the use of facially neutral (or “colorblind”) criteria for the allocation of scarce resources such as ventilators. Such neutral frameworks are designed to maximize utility, typically lives saved and/or life-years saved, and frequently rely on points-based systems based on specific measures such as Sequential Organ Failure Assessment (SOFA) scores. However, despite the apparent objectivity of such methods, they may fail to promote health equity.

Existing structural disadvantages and disproportionate COVID-19 morbidity and mortality experienced by communities of color and particularly Black communities create a situation in which these communities are likely to be unfairly penalized by such allocation systems. Among other examples, the use of creatinine as the primary measure of kidney function as part of SOFA scores may systematically disadvantage Black persons, who have higher average creatinine levels due to higher prevalence of comorbidities affected by various social inequities. In addition, COVID-19 morbidity and mortality has been markedly higher for this population, meaning that such persons would be more likely to be affected by the disease and also more likely to be denied allocations of scarce treatment resources.

The authors outline 6 possible policy options designed to improve scarce resource allocation frameworks to better promote health equity and racial justice, including improving diversity in decision processes and decision-making bodies, adjusting or replacing certain organ function measures (e.g., creatinine), using alternative measures, adopting equity weighting procedures, or eliminating use of SOFA scores in allocation frameworks.

This AJPH article by Peek et al. presents an action plan for mitigating COVID-19 disparities with a focus on addressing impacts on African American communities. Data continue to show a disproportionately high burden of COVID-19 on communities of color and particularly African American communities. Counties with higher proportions of African American populations have higher numbers of COVID-19 cases and deaths, due in part to more crowded living conditions, higher unemployment, lower health insurance rates, and higher chronic disease burdens, which in turn reflect the extensive effects of structural racism and persistent residential segregation. Individual risk factors impacted by economic and sociopolitical burdens of racism also affect COVID-19 morbidity and mortality through inequities in education, employment, income, incarceration, health care access, chronic stress, and other pathways.

Recommendations in the action plan include:

1. Requiring collection of race/ethnicity data in COVID-19 reporting to allow better tracking of disease burden in different communities and inform just allocation of critical resources and infrastructure.
2. Utilizing risk- and place-based strategies to decrease COVID-19 exposure, including ensuring protections for essential workers, working with community-based organizations to disseminate resources, preventing conflict between community policing practices and public health efforts, and protecting persons in congregant and densely populated settings.
3. Utilizing risk- and place-based strategies to increase COVID-19 testing, including supporting drive-through or walk-up testing at federally qualified health centers and other community-level care settings, implementing universal screening in high-prevalence areas, supporting community health worker and other professional and volunteer involvement to reach marginalized populations, and improving sharing of testing resources from larger medical centers to community-based clinics and hospitals.
4. Repurposing ambulatory staff and infrastructure for COVID-19 prevention, support, and monitoring, including providing high-risk patients with enhanced telehealth monitoring, education, social risks screening, and supplies to help manage chronic disease and mitigate risk.
5. Safely isolating and supporting COVID-19 patients from high-risk living conditions, including collaboration between health care organizations, housing agencies, hotels and other housing facilities, food banks and distribution services, mental and behavioral health services, and other social service agencies.
6. Implementing city- and statewide plans to share resources and patients across hospital systems, including protocols to assign scarce resources to ensure fair distribution based on need, using statewide crisis care standards to reduce interhospital variability and promote dissemination of best practice updates, sharing of various resources with less-resourced hospitals to maximize patient and employee safety and health, and committing all hospitals to providing comprehensive care to COVID-19 patients regardless of ability to pay and to transferring patients across health systems to align patient volume and acuity with hospital capacity.
7. Allocating scarce medical resources to reduce racial inequities, including consideration of allocation methodologies that have been validated in minority populations and/or prioritize persons from marginalized populations, seeking to avoid pitfalls of existing priority scoring approaches that may disproportionately penalize African Americans due to inaccurate prediction of life span and inequitable distribution of chronic disease burden.