Context: The racial health equity implications of the Trump administration’s response to the COVID-19 pandemic.
Methods: We focus on four key health care policy decisions made by the administration in response to the public health emergency: rejecting a special Marketplace enrollment period; failing to use its full powers to enhance state Medicaid emergency options; refusing to suspend the public charge rule; and failing to target provider relief funds to providers serving the uninsured.
Findings: In each case, the administration’s policy choices intensified, rather than mitigated, structural racism and racial health inequality. Its choices had a disproportionate adverse impact on minority populations and patients who are more likely to depend on public programs, be poor, experience pandemic-related job loss, lack insurance, rely on health care safety net providers, and be exposed to public charge sanctions.
Conclusions: Ending structural racism in health care and promoting racial health care equity demands an equity-mindful approach to the pursuit of policies that enhance—rather than undermine—health care accessibility and effectiveness and resources for the poorest communities and the providers that serve them.
When COVID-19 began to spread in the United States, the first public health orders were to hunker down at home. But for the vulnerable people experiencing homelessness, especially those sleeping outdoors, retreating to a private dwelling was not possible. This suggests that places with greater homelessness would also have elevated COVID-19 infections. This paper examines how spatial variation in unsheltered homelessness was related to the cumulative number of cases and deaths from COVID-19. Although Continuums of Care (CoCs) with more households receiving welfare, without internet service, and more disabled residents had a higher rate of COVID-19-related cases and deaths, CoCs with more unsheltered homelessness had fewer COVID-19-related deaths. More research is needed to explain this counterintuitive result, but it may reflect the bicoastal pattern of homelessness which is higher where government intervention, community sentiment, and compliance with rules to promote the common welfare are greater. In fact, local politics and policies mattered. CoCs with more volunteering and a higher share of votes for the 2020 Democratic presidential candidate also had fewer COVID-19 cases and deaths. Yet, other policies did not matter. Having more homeless shelter beds, publicly assisted housing units, residents in group quarters, or greater use of public transportation had no independent associations with pandemic outcomes.
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