Abstract

Excerpted From: Shavonnie R. Carthens, Covid-19 and Access to Healthcare at the Crossing of Race, Poverty, and Rurality, 38 Journal of Law and Health 145 (October 31, 2024) (226 Footnotes) (Full Document)

Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data.

On January 20, 2020 the Centers for Disease Control and Prevention (“CDC”) reported the first confirmed case of the 2019 Novel Coronavirus (acute respiratory syndrome coronavirus 2(SARS-CoV-2)) in the United States. On March 11, 2020, the World Health Organization (“WHO”) declared the COVID-19 outbreak a Pandemic. The next day, on March 12, 2020, a community in New Rochelle, New York, was declared to be a “containment area.” On March 16, 2020, a “shelter in place” order was issued for six counties in the San Francisco Bay Area. States and local governments began to follow suit - closing schools, limiting grocery store occupancy, and preparing health systems to deal with quarantine and treatment measures. Many of us were glued to television screens and dealing with massive anxiety about the possibility of transmission, death rates, and the health of ourselves, our families, and friends.

We have learned many lessons from this life-changing event - from communicable disease awareness to healthcare access, and health inequities - the possibility of a pandemic still looms in our collective consciousness. Of the many lessons we learned during this event is an appreciation for the fact that although the COVID-19 Pandemic was a shared experience, distinct differences exist among U.S. residents around risk management and resilience depending upon where they were situated across geographic, racial, and economic strata. This post-Pandemic era affords us with a unique opportunity to assess lessons learned from these different experiences and evaluate the role that access to healthcare plays in one's ability to manage the COVID-19 virus, with specific attention given to the reality that a lack of access to healthcare drives health inequities. What many marginalized groups have always experienced, regarding healthcare access in America, was put on full display during the pandemic, with many groups enduring unequal health-related, economic, and social burdens. For example, individuals from poor, rural, and minority backgrounds were disproportionately impacted by the virus. As socio-economic status, race, gender, comorbidities, geographic location, and other factors have long impacted health outcomes, so these factors also impacted one's ability to positively navigate the pandemic and rebound in its aftermath. For example, in a study of urban-rural differences in South Carolina, researchers found that case rates and mortality rates were positively correlated with pre-existing social vulnerabilities. Rural communities experienced compounding disparity factors such as limited health care, fewer testing sites, transportation deficits, and cultural perceptions of health.

Healthcare access challenges experienced by minorities in rural communities did not have their genesis in the pandemic. A closer look at rural, impoverished, and minority communities, reveals a history of inequities related to health and specifically the importance of healthcare access. Approximately one in five Americans live in rural America. Individuals in rural communities have historically experienced poorer health than those living in urban areas. Though a smaller swath of the rural landscape, there is also a growing minority population in rural America. There are approximately 3.5 million non-Hispanic Black people living in rural America, who faced worse health outcomes than their white rural counterparts during the COVID-19 pandemic. Early in the pandemic the daily increase in the COVID-19 mortality rate was significantly higher in rural counties with the highest percent Black and percent Hispanic populations.

To get to the heart of why Black residents have a history of health struggles, that both pre-date and extend beyond the COVID-19 pandemic, policy makers must be concerned with a wide range of health inequity data points from both academic and community-based research. From a health status perspective, some of these communities experienced poor health based on not only their proximity to healthcare services but also due to a history of racism and medical mistrust, environmental hazards, a lack of health literacy, and history that are unique to this community. As a result, it is important to continually engage in the process of evaluating how we collectively understand healthcare access as a socio-legal concept. Policymakers must take this broader look to address future public health emergencies. The need to consider the future, in terms of our ability to rebound from these events, is particularly important for Black, impoverished, rural communities that are most immediately and detrimentally impacted- those for whom collective resilience was lacking from the outset. Policymakers must be receptive of this complexity and understand that healthcare access remedies, in practice, may vary depending upon the convergency of different inequity markers.

This article introduces the concept of “Healthcare Access+,” which addresses critical omissions in pandemic-era and current discussion of healthcare access, markedly the erasure of Black experiences in conversations that center rurality; and allows for more robust legal and policy responses that target healthcare access in a manner that is inclusive of rural Black communities. This article argues: (1) that the COVID-19 public health crisis highlighted important omissions in public health discussions of healthcare access and health equity, notably that traditional ways of defining healthcare access falls short of capturing the lived experiences of Black, impoverished people, living in rural communities; and (2) that law and policy responses targeting healthcare access, must expand the definition of “access “to include ““Healthcare Access+” factors that uncover additional touchpoints important for developing policy that acknowledges health disparities that hinder the ability of some residents to survive public health crises, an d rebound in their aftermath.

Part I provides an overview of the health outcomes and disparities present in rural American pre-COVID-19 pandemic. Part II then offers a survey of outcomes of inequities experienced by rural communities during the pandemic, specifically using COVID-19 outcomes to illustrate how the differences in healthcare access and outcomes among the general rural population often diverge from the experiences of Black rural residents during the pandemic. Part III critiques legal and policy solutions geared toward addressing healthcare access inequities and gaps in legal responses during the COVID-19 pandemic, along with limitations on those actions. Part IV identifies “Healthcare Access+” factors that contributed to the heighted inequities experienced by rural Black people during the pandemic and which should be considered as precursors to policymaking aimed at combating public health crises. This section argues that acknowledging “Healthcare Access+” enables law and policy to respond more effectively to healthcare access concerns among Black residents in rural America.

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Much public health discourse on the COVID-19 pandemic focuses on the health of the general population impacted, however similar emphasis should be placed on groups that were particularly vulnerable to negative health impacts, beginning even prior to the outbreak. The question of how to improve access to healthcare for these populations must be addressed prior to the next national or world-wide health crisis emerges. Indeed, it is time for policymakers to devise solutions that are not only important for the many, but also important for the statistical few. We cannot afford to ignore the reality that recovery from contagious disease crises is not the same for all: everyone is not similarly situated, particularly those in rural communities. Yet, we must also come to grips with the fact that “rural health” does not fully capture the experiences of rural Black populations.

By combining an accounting of contemporary and historical race discrimination, structural health inequities, rural public health outcomes, and COVID-19 infections and death, my Healthcare Access+ concept allows us to not only better understand and predict the effect of future public health emergencies, but to also deploy law and policy in ways that best respond to the potential health challenges experienced by marginalized communities. Healthcare Access+ factors, like racism, rurality, poverty, history, lifestyle challenges, and environmental vulnerability effectively captures the experience of Black rural communities in America and thus should guide legal and policy solutions aimed at addressing the complex problem of reduced healthcare access for some of our most vulnerable U.S. residents.

Assistant Professor of Law, University of Kentucky, J. David Rosenberg College of Law.