When a Medicaid Card Isn’t Enough

tradeoffs.org/2022/05/17/medicaid-physician-access/

A certain segment of the health policy world spends a lot of time trying to get more states to expand Medicaid and reduce underinsurance.

But are we doing enough to make sure care is accessible once people enroll? One issue is access to physicians, who are less likely to treat patients on Medicaid than Medicare or private insurance because Medicaid payment rates are lower.

A new paper in Health Affairs by Avital Ludomirsky and colleagues looked at how well the networks of physicians supposedly participating in Medicaid reflect access to care. The researchers used claims data and provider directories from Medicaid managed care plans (the private insurers that most states contract with to run their Medicaid programs) in Kansas, Louisiana, Michigan and Tennessee from 2015 and 2017 to assess how the delivery of care to Medicaid patients was distributed among participating doctors. Their results were striking:

  • One-quarter of primary care physicians provided 86% of the care; one-quarter of specialists provided 75%.
  • One-third of both types of physicians saw fewer than 10 Medicaid patients per year, hardly contributing any “access” at all.
  • There was only one psychiatrist for every 8,834 Medicaid enrollees after excluding those seeing fewer than 10 Medicaid patients per year. This is especially concerning given that the COVID-19 pandemic has worsened mental health in the U.S., particularly among children

The authors note that their study only covers primary care and mental health providers in four states, so it is not necessarily generalizable to other states or specialties. But these results are still concerning.   

States have so-called network adequacy standards for their Medicaid managed care plans that are supposed to make sure there are enough providers. These standards typically rely on either a radius (a certain number of providers for a geographic area) or ratio (number of providers per enrollee), but the authors’ findings show these methods fall short if they are based on directories alone.

The authors specifically recommend states use claims-based assessments like the ones in the study and “secret shopper” programs — like this recently published one from Maryland by Abigail Burman and Simon Haeder — to better evaluate whether plans are offering adequate access to physicians. We absolutely need people to have coverage, but it needs to be more than just a card in their wallet.

Credit monitoring companies are removing most medical debt from consumer credit reports

Spurred by the Consumer Financial Protection Bureau’s investigation into how credit companies report medical debt, TransUnion, Equifax, and Experian—the country’s three largest credit bureaus, who keep records on 200M Americans—are revising how they report medical debt.

As a result, the companies could eliminate up to 70 percent of medical debt from consumers’ credit reports. Starting in July, medical debts paid after going to collections will no longer appear on credit reports, and unpaid debts won’t be added until a year after being sent to collections (instead of six months, per current policy). And beginning in 2023, medical debts of less than $500 will also be excluded from credit reports altogether.

The Gist:The poorest and sickest patients have been disproportionately saddled with the highest levels of medical debt. In 2017, 19 percent of US households carried medical debt, including many with private insurance. 

While these changes will help mitigate the impact of medical debt for some, they aren’t a fix to the larger underlying problem of rising healthcare costs and access to adequate health insurance coverage. 

The growing burden of mental health on emergency departments

https://mailchi.mp/9d9ee6d7ceae/the-weekly-gist-october-22-2021?e=d1e747d2d8

The stress, disruption, isolation, and lives lost during the pandemic have exacerbated longstanding challenges in access to mental healthcare. In the graphic above, we highlight how COVID has impacted the state of mental health across generations. 

Younger Americans are faring much worse. This week, the nation’s leading pediatric professional societies declared a national mental health emergency for children and adolescents, and nearly half of “Generation Z” reports that their mental health has worsened during COVID. 

Mental health-related emergency department (ED) visits increased in 2020 across all age groups, with the steepest rise among adolescents. Because of a national shortage of inpatient psychiatric beds, patients with mental health needs are increasingly being “boarded” in the ED—even as nearly two-thirds of EDs lack psychiatric services to adequately manage patients in crisis.

Case in point: research on behavioral health access in Massachusetts shows one in every four ED beds is now occupied by a patient awaiting psychiatric evaluation. ED boarding of patients in mental health crisis not only delays necessary care, but leads to throughput backups in hospitals, and increases caregiver stress and burnout. 

Access to inpatient treatment is most challenged for children and adolescents, as well as “med-psych” patients, who also have significant physical health needs that must be managed. New solutions have emerged during the pandemic: burgeoning telemedicine platforms don’t just increase access to outpatient therapy, they also enable psychiatrists to evaluate emergency patients virtually.

In the long term, a three-part approach is needed—new virtual solutions, expanded inpatient capacity, and greater community resources to address the social needs that often accompany a behavioral health diagnosis.

Democrats’ moral Medicaid dilemma

Democrats’ push to extend health coverage to millions of very low-income people in red states has a lot working against it: It’s expensive, it’s complicated, it may invite legal challenges, and few national Democrats stand to gain politically from it.

Yes, but: The policy is being framed as a test not only of Democrats’ commitment to universal health coverage, but also their commitment to racial equity.

The big picture: Democrats are still figuring out how much money they have to spend in their massive social policy legislation, but there’s already intense competition among policies — including between health care measures.

  • Progressives are adamant about expanding Medicare to cover dental, vision and hearing benefits. But a handful of prominent Democrats are making the case that closing the Medicaid coverage gap is equally, if not more, important.
  • The gap exists in 12 Republican-controlled states that have refused to accept the Affordable Care Act’s Medicaid expansion, the majority of which are in the South.

What they’re saying: Closing the coverage gap is “very, very important to people of color. The majority of Black people in this country still live in the South,” said Rep. Jim Clyburn, one of the leading proponents of the measure.

  • More than 2 million adults are in the coverage gap, and 60% of them are people of color, according to the Center on Budget and Policy Priorities.
  • “What is the life expectancy of Black people compared to white people? I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people,” Clyburn added. “If we took care of Medicaid, maybe Black people would live longer.”

Between the lines: In terms of raw politics, it’s pretty easy to see why many Democrats would prioritize Medicare expansion over closing the Medicaid gap: Seniors live in every district and state in the U.S.

  • Only three Democratic senators represent non-expansion states, and in 2020, only ine of the 41 battleground House seats identified by Ballotpedia were in non-expansion states.

Yes, but: Sens. Jon Ossoff and Raphael Warnock, both from Georgia, are the reason that Democrats are able to consider their social policy legislation at all. Warnock is up for re-election next year.

  • “This is about people in this country, and I wish we’d stop this red state and blue state stuff,” Clyburn said. “Warnock and Ossoff won a runoff that nobody gave them a chance to win by promising they would close this gap.”

The catch: States that have already expanded Medicaid are covering a small portion of those costs themselves, and may question the fairness full federal funding for the holdout states.

  • That could create an incentive for existing expansion states to drop the ACA’s Medicaid expansion and pick up the new program instead. And any effort Congress makes to stop them could invite legal challenges.
  • “The case law in this domain is a bit of a moving target, and as we’ve seen over the past decade, there’s an awful lot of litigation over things pertaining to health reform,” said Nick Bagley, a professor at the University of Michigan Law School.

The bottom line: Like Democrats’ other proposed health policies, filling the coverage gap could cost hundreds of billions of dollars.

  • But “if your goals are relieving health care cost burdens or expanding access to care, then it’s hard to do better on a dollar-for-dollar basis than buying coverage for uninsured people below the poverty line,” said Brookings’ Matt Fiedler.

What we’re watching: “I don’t see Medicaid as being on the radar of some of my friends in the caucus who seem to feel it’s more important to do Medicare,” Clyburn said. “I’m trying to get Medicaid on their agenda.”

  • “I’m tired of my party perpetuating … inequity,” he added. “Treating people according to their needs is what breaks the cycle.”

Why the US healthcare system ranks last among 11 wealthy countries

U.S. Health Care Ranks Last Among Wealthy Countries | Commonwealth Fund

The performance of the U.S. healthcare system ranked last among 11 high-income countries, according to a report released Aug. 4 by the Commonwealth Fund.

To compare the performance of the healthcare systems in 11 high-income countries, the Commonwealth Fund analyzed 71 performance measures across five domains: access to care, care process, administrative efficiency, equity and patient outcomes.

Despite spending far more of its gross domestic product on healthcare than the other nations included in the report, the U.S. ranked last overall, as well as last for access to care, administrative efficiency, equity and patient outcomes. However, the U.S. ranked second on measures of care process, trailing only New Zealand.

Norway, the Netherlands and Australia had the best healthcare system performance, according to the report. In all seven iterations of the study conducted by the Commonwealth Fund since 2004, the U.S. has ranked last. It is the only country included in the study that does not provide its citizens with universal health insurance coverage.

Four features separate the top performing countries from the U.S., according to the report: universal health insurance coverage and removal of cost barriers; investment in primary care systems to ensure equitable healthcare access; reduction of administrative burdens that divert time and spending from health improvement efforts; and investment in social services, particularly for children and working-age adults.

Medicare shrinks racial disparities

Medicare helps to reduce racial and ethnic disparities and close gaps in insurance coverage, a new study in JAMA Network shows.

Why it matters: This raises the possibility that expanding the program could further reduce health disparities — a timely idea, as Senate Democrats debate lowering the Medicare eligibility age and broadening its benefits, Axios’ Marisa Fernandez reports.

What they found: Medicare access at age 65 sharply reduced the share of Black and Hispanic people reporting poor health and poor access to care, but not mortality, the study notes.

  • Respondents were “significantly more likely” to be insured immediately after age 65 compared to before turning 65, and coverage increased more for Black and Hispanic adults than white adults.
  • Medicare eligibility alone doesn’t completely eliminate disparities among the elderly, suggesting other social determinants of health need to be addressed.

State of play: Senate Democrats have signaled that they’ll attempt to expand Medicare to include dental, hearing and vision coverage in the coming months.

  • Although lowering the Medicare eligibility age from 65 to 60 wasn’t included in their original proposal, Axios has reported it’s still possible that the measure gets included.

A mounting specialist access crisis

https://mailchi.mp/b5daf4456328/the-weekly-gist-july-23-2021?e=d1e747d2d8

Types of Doctors: Some Common Physician Specialties

We’ve been hearing a growing number of stories from patients about difficulties scheduling appointments for specialist consults.

A friend’s 8-year-old son experienced a new-onset seizure and was told that the earliest she could schedule a new patient appointment with a pediatric neurologist at the local children’s hospital was the end of November. Concerned about a five-month wait time after the scary episode, she asked what she should do in the meantime: “They told me if I want him to be seen sooner, bring him to the ED at the hospital if it happens again.”

A colleague shared his frustration after his PCP advised him to see a gastroenterologist. Calling six practices on the recommended referral list, the earliest appointment he could find was nine weeks out; the scheduler at one practice noted that with everyone now scheduling colonoscopies and other procedures postponed during the pandemic, they are busier than they’ve been in years. Recent conversations with medical group leaders confirm a specialist access crunch. 

Patients who delayed care last year are reemerging, and ones who were seen by telemedicine now want to come in person. “We are booked solid in almost every specialty, with wait times double what they were before COVID,” one medical group president shared. The spike in demand is compounded by staffing challenges: “I pray every day that another one of our nurses doesn’t quit, because it will take us months to replace them.”

Doctors and hospitals are now seeing a rise in acuity—cancers diagnosed at a more advanced stage, chronic disease patients presenting with more severe complications—due to care delayed by the pandemic. If patients can’t schedule needed appointments and procedures, this spike in severity could be prolonged, or even made worse. 

For medical groups who can find ways to open additional access, it’s also an opportunity to capture new business and engender greater patient loyalty.

Dollar General: Rural America’s new health hub?

Dollar Stores and food deserts: The latest struggle between Main Street and  corporate America - CBS News

Dollar General hired its first CMO and plans to become a destination for affordable healthcare offerings.  

The retail giant will bring an increased assortment of medical, dental and health aids to its shelves as part of its first major jump into the healthcare industry, according to a July 7 news release.

Three things to know:

  1. In the United States, 75 percent of the population lives within five miles of one of the chain’s 17,400 stores. The chain recognizes that it’s postured to deliver care to rural communities that are traditionally underserved in the healthcare ecosystem, the release said.
  2. “At Dollar General, we are always looking for new ways to serve, and our customers have told us that they would like to see increased access to affordable healthcare products and services in their communities,” said Todd Vasos, Dollar General CEO. “Our goal is to build and enhance affordable healthcare offerings for our customers, especially in the rural communities we serve.”
  3. The chain selected Albert Wu, MD, as its first CMO and vice president. Dr. Wu will strengthen relationships with healthcare service providers to build a network for its customers. In his previous position, Dr. Wu worked at McKinsey, where he oversaw the care model for 250,000 rural patients and drove $2-5 billion in revenue.

Biden’s Broader Vision For Medicaid Could Include Inmates, Immigrants, New Mothers

https://www.npr.org/sections/health-shots/2021/06/23/1009251576/bidens-broader-vision-for-medicaid-could-include-inmates-immigrants-new-mothers

Hospitals, health care advocates launch campaign to authorize Medicaid  expansion through statewide vote

The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.

Biden’s efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration’s moves to scale back the safety-net program.

The changes could further boost Medicaid enrollment — which the pandemic has already pushed to a record 80.5 million. Some of the expansion is funded by the COVID-19 relief bill that passed in March, including coverage for new mothers.

Others who could also gain coverage under Biden are inmates and undocumented immigrants. At the same time, the administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn’t traditionally offered.

“There is a paradigm change underway,” said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.

“We’ve had discussions at the federal level in the last 90 days that are completely different from where we’ve ever been before,” Langer Jacobs said.

Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.

“They are taking very bold action,” said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting in particular the administration’s swift reversal of Trump policies. “There really isn’t a precedent.”

The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 holdout states, including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act.

And while some of the recent expansions – including for new mothers — were funded by close to $20 billion in new Medicaid funding in the COVID relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.

The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic, pushing enrollment to a record 80.5 million, including those served by the related Children’s Health Insurance Program. That’s up from 70 million before the COVID crisis began.

The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.

The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.

But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can’t make up for all the inadequacies in government housing, food and education programs.

“Focusing on the social drivers of health … is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn’t mean that Medicaid can or should be responsible for paying for all of those services,” said Matt Salo, head of the National Association of Medicaid Directors, noting that the program’s financing “is simply not capable of sustaining those investments.”

Restoring federal support

However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program’s reach.

“I think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it’s a lifeline to millions,” Biden’s new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a “backbone to our country.

The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.

In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.

The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states’ rights to run their Medicaid programs as they choose.

“Biden is reasserting a larger federal role and not deferring to states,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.

But Biden’s early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.

“It’s a breath of fresh air,” said Kim Bimestefer, head of Colorado’s Department of Health Care Policy and Financing.

Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: “To be in an environment where people are talking about expanding health care access has made an enormous difference.”

Mounting evidence shows that expanded Medicaid coverage improves enrollees’ health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.

Broadening eligibility

In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.

Biden supported a provision in the COVID relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is far higher than rates in other wealthy nations.

Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.

The COVID relief bill — which passed without Republican support — also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid’s reach.

And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.

Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered health care, such as housing.

This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.

In recent years, Medicaid officials in red and blue states — including Arizona, California, Illinois, Maryland and Washington — have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.

The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.

But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.

That has made a big difference, said Kate McEvoy, who directs Connecticut’s Medicaid program. “There was a lot of discussion in the Trump administration,” she said, “but not the capital to do it.”

Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.

Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state’s initiative.

Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.

“Covering all Californians is critical to our mission,” said Jacey Cooper, director of California’s Medicaid program, known as Medi-Cal. “We really feel like the new administration is helping us ensure that everyone has access.”

The Trump administration moved to restrict even authorized immigrants’ access to the health care safety net, including the “public charge” rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid. In March, Biden abandoned that rule.

Some Face Dire Consequences for Delaying Care During Pandemic

Mammogram

Throughout the COVID-19 pandemic, experts have been warning of the dangers of postponed health care services. In January, the American Cancer Society, the National Comprehensive Cancer Network, and 73 other organizations, including many major health care systems, issued a statement stressing the urgency of preventive care. “We urge people across the country to talk with their health care provider to resume regular primary care checkups, recommended cancer screening, and evidence-based cancer treatment (PDF) to lessen the negative impact the pandemic is having on identifying and treating people with cancer,” the groups said.

Essential Coverage

That was sound advice not everyone could follow, as ProPublica’s Duaa Eldeib reported last week in a tragic story about Teresa Ruvalcaba. The 48-year-old single mother of three worked for 22 years at a candy factory on Chicago’s West Side. During the pandemic, disaster struck. “For more than six months, the 48-year-old factory worker had tried to ignore the pain and inflammation in her chest. She was afraid of visiting a doctor during the pandemic, afraid of missing work, afraid of losing her job, her home, her ability to take care of her three children,” Eldeib reported.

“Even though her chest felt as if it was on fire, she kept working. She didn’t want to get COVID-19 at a doctor’s office or the emergency room, and she was so busy she didn’t have much time to think about her symptoms,” Eldeib wrote.

Ruvalcaba’s pandemic fears were typical of patients across the nation, surveys revealed. A 2020 CHCF poll of 2,249 California adults revealed that even when people wanted to see a doctor for an urgent health problem, one-third did not receive care. Nearly half of those surveyed didn’t receive care for their nonurgent health problems.

Nationally, more than one in three people delayed or skipped care because they were worried about exposure to Covid-19, or because their doctor limited services, according to an Urban Institute analysis of a September 2020 survey.

The toll of this disruption in care — the forgone cancer screening, the chest pain that isn’t reported — will devastate some patients and families. Ruvalcaba had to face a diagnosis with a terrible prognosis, inflammatory breast cancer. “If she would have come six months earlier, it could have been just surgery, chemo and done,” Ruvalcaba’s doctor told Eldeib. “Now she’s incurable.”

Doctors expect the delayed care “could cause worsening health conditions, delayed diagnoses and earlier deaths,” Ana Ibarra reported in CalMatters.

“Unfortunately, we know we’re going to see some tragedies related to the delays,” Wiley Fowler, an oncologist at Dignity Health in Sacramento, told Ibarra.

Consequences of Delayed Care

Public health messages early in the pandemic urged people to avoid public places, including doctor’s offices. In April, as Hayley Smith noted in a Los Angeles Times story, the US Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services “both published guidelines recommending the postponement of elective and nonurgent procedures, including ‘low-risk cancer’ screenings, amid the first wave of the pandemic.”

Patients and doctors listened. Appointments were canceled. “Nonurgent” procedures encompassing a wide array of treatments and operations, including cancer surgeries, were delayed.

Preventive cancer screenings dropped 94% over the first four months of 2020, Eldeib reported. The National Cancer Institute expects to see 10,000 preventable deaths over the next decade because of pandemic-related delays in diagnosis and treatment of breast and colorectal cancer. Screenings for these cancers, which account for about one in six cancer deaths, are routine features of preventive care.

I know I should get another check soon, but the anxiety of COVID feels like more of a priority than the anxiety of cervical cancer.

—Molly Codner, a Southern Californian who received an abnormal Pap smear last summer

In California, cancer deaths have remained roughly the same as prepandemic rates, but that stability is not expected to last. Based on the National Cancer Institute data, Ibarra calculates that an additional 1,200 Californians will die from breast and colon cancer. The National Cancer Institute estimate is conservative “because it only accounts for a six-month delay in care, and people are postponing care longer than that,” Ibarra reported.

Nationally, death rates from cancer are expected to increase in a year or two. Slow-growing cancers will remain treatable despite a delayed diagnosis, Norman Sharpless, MD, director of the National Cancer Institute, told Eldeib. Yet for conditions like Ruvalcaba’s inflammatory breast cancer, delayed care can be disastrous.

Women, People of Color Disproportionately Affected

For women across Southern California, appointments have been delayed, exams canceled, and screenings postponed during the pandemic, Smith reported in the Los Angeles Times. “Some are voluntarily opting out for fear of encountering the virus,” Smith wrote, “while others have had their appointments canceled by health care providers rerouting resources to COVID-19 patients.”

Before Pap smears became part of routine American health care, cervical cancer was one of the deadliest cancers for women. Today, as many as 93% of cervical cancer cases are preventable, according to the CDC, and screenings are a crucial component of preventive care. Yet during the first phase of California’s stay-at-home orders, cervical cancer screenings dropped 80% among the 1.5 million women in Kaiser Permanente’s regional network, Smith wrote.

The effects of the pandemic shutdown extended beyond delayed Pap smears. Women who spoke to Smith said that “mammograms, fertility treatments and even pain prevention procedures have been waylaid by the pandemic.”

Sometimes, obstacles other than the pandemic are continuing to interfere with access to care. One woman had an appointment delayed and then lost her job and her health insurance, Smith reported.

“Molly Codner, 30, has needed a checkup ever since she received an abnormal Pap smear last summer,” Smith wrote, “but like many Southern Californians, the trauma of the last year still weighs heavily on her mind: Nearly a dozen people she knows have had COVID-19.” Codner told Smith that “I know I should get another check soon, but the anxiety of COVID feels like more of a priority than the anxiety of cervical cancer.”

People who face disparities in treatment and care are most likely to be hard hit by pandemic delays. That includes Black people, who were already more likely to die from cancer than any other racial group. Cancer also is the leading cause of death among Latinx people. Breast cancer is the most common cancer diagnosis for Latinx women. Overall, more Americans die of heart disease.

Black adults are more likely than White or Latinx adults to delay or forgo care, according to researchers from the Urban Institute.

Telehealth Solved Access Issues for Some, Not All

Telehealth was a boon for patients during the pandemic year. Yet, as Ibarra notes, “there’s only so much that doctors and nurses can do through a screen.” Dental visits, mammograms, and annual wellness checks were also put on hold by the pandemic.

Unequal access is another challenge for telehealth. The benefits of the telehealth boom were not shared equally, according to a statewide survey conducted last month by the University of Southern California and the California Emerging Technology Fund.

Latinx, Asian, and Black respondents did not use telehealth as often as White respondents. USC researchers attribute these differences to “disparities in income, education and access to any kind of health care.”

Researchers at the Urban Institute report similar findings: “Black and Latinx adults were more likely than White adults to report having wanted a telehealth visit but not receiving one since the pandemic began, and that difficulties getting a telehealth visit were also more common among adults who were in poorer health or had chronic health conditions.”

After controlling for socioeconomic factors and health status, patients with limited English were half as likely to use telehealth compared to fluent English-speaking patients, the Urban Institute said. “Much work remains to ensure all patients have equitable access to remote care during and after the pandemic,” the researchers wrote.

Whether telehealth is conducted by video or phone may be crucial to ensuring access to care. A study of telehealth use at Federally Qualified Health Centers in California in 2020 found that “more primary care visits among health centers in the study occurred via audio-only visits (49%) than in-person (48%) or via video (3%). Audio-only visits comprised more than 90% of all telemedicine visits.”

“For many Californians with low incomes, the ability to connect with a doctor or their care team by phone or video is much more than a convenience,” Chris Perrone, director of CHCF’s Improving Access team, explained on The CHCF Blog. “It’s really the difference between canceling a visit because the barriers are too great or getting the timely care that they or their child needs.”

Pandemic Health Effects Will Outlast COVID-19

Public health efforts might need to focus on two goals at the same time as the US recovers from the pandemic: increasing vaccine uptake to keep COVID-19 in check and proactively managing the fallout from delayed care.

“As we focus on recovery, we have to ensure that we get vaccinated,” Efrain Talamantes, a primary care physician in East Los Angeles, told Ibarra. “But also that we have a concerted effort to manage the chronic diseases that haven’t received the attention required to avoid complications.”