We Will Win the COVID Battle, But Will We Win the War Against Healthcare Inequities?

COVID-19 is a global pandemic, but it also represents a battle in the war against disparities in healthcare for older adults. The effects of COVID-19 have been devastating, particularly among populations and communities disproportionately and negatively impacted by social determinants of health (SDOH). These disparities exist in not only who is getting sick, but also why some are at higher risk, such as older adults and communities of color. Both populations struggle with chronic conditions and are at an increased risk for severe illness and longer hospitalizations, compared to the general population. 

COVID-19 has highlighted our health system’s shortfalls, but it has also galvanized policymakers into action to achieve meaningful change. This momentum must be maintained to create solutions that will improve older adults’ long-term health, while decreasing medical utilization and cost—such as ensuring access to proper nutrition, reliable transportation and telehealth. Thoughtful policy recommendations must address underlying community-level factors that promote social and health disparities. 

Ensure Access to Quality Food

A key to eliminating disparities among older adults is ensuring access to food. Approximately 10 million older Americans do not have access to a regular source of nutrition and one in two are malnourished. While community nutrition programs exist, many older adults were already on waiting lists for these services prior to the pandemic, as the Government Accountability Office found. This number dramatically increased with the COVID-19 public health emergency, with a large number of older adults who previously did not require assistance suddenly finding themselves unable to safely leave their homes to acquire groceries. 

Shelter-in-place orders resulted in strains on systems that provided home-delivered meals as congregate meal sites closed. A number of combined efforts and changes to these programs have been implemented to address the need to stay at home during the pandemic that greatly improved access. These efforts should remain in place as the country begins to reopen. 

Additionally, the United States Department of Agriculture expanded its online pilot program of the Supplemental Nutrition Assistance Program, to allow beneficiaries to purchase groceries online. We must ensure that these programs continue to support diverse communities of older adults, by:

  • Providing alternative ways to order groceries for delivery given the digital divide between older adults and younger age cohorts, disproportionately affecting people of color.
  • Offering culturally appropriate meals and nutrition education. By 2030, the older adult population will be more racially and ethnically diverse. Providing these foods and education enhances the quality of life and health outcomes of older adults.
  • Ensuring, and funding, nutrition programs for communities of color. According to the CDC, older Americans of color are more likely to suffer from chronic health conditions such as hypertension, diabetes and obesity. Access to nutritious meals is critical to the management of all of these health conditions.

Provide Reliable Transportation

Lack of reliable transportation creates a significant barrier to healthcare access for older adults. Despite the efforts of transportation services, many older adults remain isolated due to insufficient transportation systems. Additionally, millions of older adults rely on transportation to remain a part of their communities—via grocery shopping, attending religious services and trips to senior centers. 

In 2011, there were approximately 8.4 million older adults who depended upon someone else for transportation. Demand for transportation services, including public transportation, declined sharply as shelter-in-place orders were implemented. It remains unclear to what extent these services will be reestablished once states reopen. This time presents an opportunity to revise current transportation structures to better meet the needs of older adults aging in place in their communities, including:

  • Require the Centers for Medicare & Medicaid Services to create a permanent transportation benefit for Medicare and Medicaid beneficiaries. Transportation benefit options are available in some Medicare Advantage plans, but not all, and some states are provided a waiver that makes transportation an optional benefit under Medicaid. A permanent transportation benefit, and the elimination of state waivers, would allow low-income older adults to access necessary medical appointments and remain in their community, while reducing expenditures through a reduction of emergency room visits and use of ambulance services.
  • Congress should increase the funding authorized for transportation programs in the Older Americans Act under Title III B. Flexibilities in allowable use of funds should be developed to better coordinate efforts across programs providing transportation and delivery services for older adults living in the community. 

Encourage and Reimburse for Telehealth Services

Telehealth has been shown to be invaluable during this crisis, especially now that health systems are encouraging its use and insurance companies are providing reimbursement. Telehealth provides convenient and safe care, but it remains unclear if it is effective for all patients and providers. Technology infrastructure varies widely across urban and rural environments, and access is fragmented further by socioeconomic status, education and digital literacy. It is estimated that one in four patients may not have the skills or resources available to use telehealth services, and while 73 percent of older adults report they use the Internet, many are unable to fill out online forms, send emails or understand basic tech terminology. 

As the use of telehealth becomes more commonplace, health systems must ensure that all patients have access to appropriate technology and understand how to use it. Telehealth training, demonstration and practice will be critical to patient acceptance. Policy suggestions include:  

  • Encourage the development of telehealth capabilities and patient training.
  • Work with community industries to increase access to Internet-enabled devices.
  • Ensure parity of payment for telephone and video encounters, through Medicaid, Medicare and private payers.

The fight against COVID-19 not only shed a light on weaknesses in community structures that support health, but also added cracks to its already inadequate foundation. To win the COVID-19 battle we must be committed to addressing health inequities. Access to proper nutrition, transportation and telehealth services are vital to improving the lives of older adults in their communities. 

Researchers and policymakers must be mindful to include diverse voices in the conversation as future policy recommendations and solutions are developed for the aging population. Moving forward, there must be a commitment to include at-risk populations in the discussions of how to solve these complex issues.

Thomas Eagen, PhD, MPH, Marie C. Gualtieri, PhD, and Ivorie Stanley, MD, MPH, are all residential 2019–2020 Health and Aging Policy fellows in Washington, DC. Luming Li, MD, is an assistant professor at Yale University School of Medicine, Department of Psychiatry, placed with the National Institutes of Mental Health in Bethesda, Md. Lisa O’Neill, DBH, MPH, is the associate director of research and education at the University of Arizona Center on Aging, in Tucson, Ariz. 

All authors are 2019–2020 Health and Aging Policy Fellows. 

This article is part of a series to appear in Generations Now and Generations Today, by the 2019¬2020 Health and Aging Policy Fellows.