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How States Used Their Pandemic Response to Address Health Inequities

A new study highlights innovative state-level strategies driven by data that emerged during the pandemic to address social factors undermining the well-being of too many Americans.

A homeless encampment in Los Angeles' MacArthur Park.
(Carolyn Cole/Los Angeles Times/TNS)
For the past two years, COVID-19 has assaulted the health of Americans. Some had much less to bring to this fight; pandemic aside, citizens in the lowest socioeconomic levels face two to three times greater risk of death than those in the highest.

Black mortality rates before the pandemic were substantially higher than white mortality has been during it. A University of Minnesota sociologist estimated that even if there were 400,000 excess white deaths in 2020, that would be equal to the “best mortality ever recorded among Blacks.” (Kaiser Family Foundation analysis of CDC data suggests that excess white deaths were just under 300,000 that year.)

Infectious diseases such as typhoid fever, diphtheria and measles, made more contagious and deadly by the living conditions of the poor, have been virtually eradicated in the U.S. But this has not been enough to bring about health equity. Instead, they have been replaced by disparities in rates of heart disease, cancers and other illnesses.

The stark differences in exposure, illness and death rates seen among ethnic and racial groups during the pandemic may have surprised some, says Gail C. Christopher, executive director of the National Collaborative for Health Equity. But for those with deep understanding of the power of social factors in determining health and longevity, these outcomes were “both predictable and avoidable.”

Christopher leads a commission established by the Robert Wood Johnson Foundation (RWJF) to explore how public health data systems can do a better job of capturing data regarding social determinants of health and guide investment toward health equity. “This pandemic should have helped us see how interrelated and interdependent social, economic and health policies are — we can no longer afford to ignore or politicize these matters of life and death,” she says.

The right state investments can improve population health and local economies alike, she says. A new policy brief from researchers at the Duke-Margolis Center for Health Policy at Duke University, with support from RWJF, examines how several states developed comprehensive interventions to reduce COVID-19 risks from social factors, filling gaps in a disjointed federal response.

The Kaiser Family Foundation estimates that U.S. citizens lost an additional 3.6 million potential years of life in 2020. The scale of these losses varied greatly across racial and ethnic groups.

Unmet Needs

William K. Bleser, the lead author of "Pandemic-Driven Health Policies To Address Social Needs And Health Equity" is assistant research director of health care transformation for population health, social needs and health equity at the Duke-Margolis Center. States can play a leadership role in relieving social determinants of health (SDoH) if they leverage their authority and powers, he says, but this is still a nascent field of policy.

“We don’t really know what policy interventions work best yet, but that’s where our work came in,” says Bleser. “We were trying to look at the interesting things that happened, and the early lessons from them.”

The brief highlights three strategies that states implemented during the pandemic to deal with health-related social needs. One, says Bleser, used CARES funding to create a “one-stop shop” program to address multiple pandemic-related social needs.

The COVID-19 Support Services Program in North Carolina, supported by both CARES Act and state funds, enabled four regional centers to provide transportation to medical services and to deliver food, medication and COVID-19 supplies to marginalized populations. It also helped with living expenses and child care, and took advantage of a network of community health workers to identify clients and connect them to resources.

A second approach was to identify a single social need and focus on that. Arizona Medicaid worked with service groups and housing authorities in Maricopa County to help homeless persons who tested positive for COVID-19 access medical and social services. This initiative identified more than 500 such individuals in its first six months, according to the brief.

“The third approach was a quicker but less sustainable cross-sectoral approach to jumpstart progress, where executive authority was leveraged to stand up a pandemic health equity task force,” says Bleser. Ohio established a Minority Health Strike Force in the state department of health to develop “culturally appropriate” COVID-19 notification services and improve testing access for minorities and other high-risk communities. A new position was created within the department dedicated to SDoH, including “collecting data to inform best practices.”
Yvonka Hall, executive director of the Northeast Ohio Black Health Coalition. The group conducted a statewide survey in which many Black respondents said they felt disrespected by doctors or received inferior care due to their race. The state has created a Minority Health Strike Force to address health inequities.
(Joshua Gunter/TNS)

Sustaining Progress

The public health crisis put a spotlight on circumstances that endanger the health of Americans and created an acute need to do something about them. One of the main goals of his paper, says Bleser, is to ensure that attention continues to be paid to these issues as pandemic pressures lessen. “How can we sustain this progress or continue to build new efforts that address social needs and health equity beyond the pandemic?”

“The positive impact of emergency policies that improved access to vital resources and protections must be sustained,” says Christopher.

Toward this outcome, the Duke-Margolis Center brief outlines long-term strategies including cross-sectoral collaboration, expanded health insurance coverage, value-based payment, data partnerships and engaging marginalized populations in policy design and implementation.

Policy goals should be stated explicitly, says Bleser. “If your goal is to use health policy to address social needs and promote equity, you need to state that up front and not just make it a piece of a program. It needs to be the goal; you want it there so it’s driving you.”
Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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