As the COVID-19 (novel coronavirus) pandemic unfolds, the St. Louis Regional Health Commission (RHC) advocates for the following five actions to ensure equitable access to health care for all Missourians:

1. Missouri should expand Medicaid now.

The state should immediately expand Medicaid through a State Plan Amendment, which would secure coverage for an additional 200,000 Missourians. Medicaid not only covers treatment for COVID-19, but also covers management of co-morbid conditions, like heart disease, that make people more susceptible to the virus. The need for Medicaid is growing. Before the current pandemic, 500,000 Missourians (about 11% of the population) were uninsured, but as the country faces a recession, workers are losing their employment along with their employee-sponsored health insurance.

Not only would Medicaid expansion help more Missourians gain access to critical health care services, but it would also help the state save money. A study by Washington University in St. Louis found that expansion would be revenue neutral and could create significant cost savings. Medicaid expansion is both the right and smart thing to do.

2. The federal government should open enrollment for Healthcare.gov immediately.

The federal Department of Health and Human Services (HHS) should establish an emergency special enrollment period (SEP) so the uninsured and underinsured can enroll in health coverage through the federal health insurance exchange. This SEP would allow workers with slightly higher incomes to obtain coverage and help pay their premiums. States also have a role; Missouri should widely publicize existing SEPs, like the one occurring from losing health insurance due to a layoff.

3. The federal government should increase support to community health centers.

Community health centers, including Federally Qualified Health Centers (FQHCs), constitute the backbone of our health care safety net system – providing critical primary care services to people, despite their ability to pay. The uninsured and underinsured rely on these organizations to access quality health care services, such as medical appointments, behavioral health therapy, and dental care. In fact, according to Access to Care data, approximately one-third of all patients who visit community health centers in the St. Louis region are uninsured.  

We are expecting these health centers to provide critical services to treat COVID-19, while seeing a reduction in normal patient visits. Most health centers have experienced a sharp decline in patient volume, with some health centers even reporting a 40% appointment cancelation rate. Most health centers expect a 20% decrease in patient revenue over the next several months. To survive economically, health centers are reducing hours of operation in a time when health care is desperately needed. Without increased support through a sustainable funding source, we will see our health centers scaling down services, which will affect entire communities, disproportionally impacting the uninsured and historically marginalized.

Simultaneously, health centers are preparing to serve an influx of patients with COVID-19 symptoms.  While the recently passed CARES Act provides critical financial relief for community health centers, more legislation is need to support community health centers during this pandemic. The RHC urges the federal government to grant additional funding to community health centers in additional  COVID-19 legislation. 

4. The federal government should continue to support hospitals.

Given the current public health need to end elective procedures and appointments, as well as a spike in cancellation rates due to fear of transmission of COVID-19, hospitals are feeling an increased financial burden. Furthermore, hospitals are spending more on personal protective equipment, such as facemasks, which are in short supply. The federal government must protect the lives of Americans and keep these organizations financially afloat. Immediate cash assistance, no-interest loans, Medicare reimbursement adjustments, Medicaid expansion, and financial reliefs could help hospitals survive this tumultuous time and secure access to health care for Missourians. 

COVID-19 is no longer just affecting urban centers; it is spreading into rural communities across the country. As of April 6, 2020, the coronavirus has reached more than two-thirds of the country’s rural communities, with one in 10 reporting at least one death. Rural communities tend to be older, poorer, and sicker than the rest of the country; the virus, therefore, will hit these communities particularly hard. On top of increased risk, access to health care in rural areas is limited and worsening. Rural communities rely on rural hospitals, which have been closing at a rapid rate. In the past decade, more than 120 rural hospitals have closed in the United States. Hospitals are closing at an expedited rate in states without Medicaid expansion, like Missouri. In our state, fifteen hospitals (ten rural) have closed since 2014. Geographical access to care in Missouri is confined and only getting worse in the current pandemic.

5. The federal government and the State of Missouri should center health equity and justice in the COVID-19 response.

Communities of color have been affected disproportionately by the virus due to structural racism – a system of policies and practices that produce inadequate access to health care, higher rates of co-morbid conditions, economic insecurity, and overrepresentation in essential jobs with low wages. To actively fight against this structural inequity, we first must change the way we collect data around rates of COVID-19. The St. Louis region, state, and country should disaggregate COVID-19 data by race.

Some institutions in the St. Louis region have started to look at data broken down by race. For example, maps from St. Louis City and County Departments of Public Health track the prevalence of the virus by zip code, an indicator of race in the St. Louis region. These data show a significantly higher prevalence of COVID-19 in North County, North City, and South City, areas in the St. Louis region with a majority of African American residents. Hospitals in St. Louis are also starting to disaggregate COVID-19 data by race, and the results are numbing. Washington University and BJC found that African Americans are over two times more likely to be hospitalized and transferred to the ICU, and four times more likely to end up on a ventilator. These findings show that not only are African Americans more likely to get sick, but they are also more likely to keep getting sicker, even with treatment. On April 8, 2020, The City of St. Louis also shared that all 12 COVID-19-related deaths to date were African Americans. Reporting these numbers can help lead to targeted interventions and policy change with a racial justice focus.

The state should also ensure equitable access to information and testing. A regional collaborative, including the RHC and various other public health organizations, created a communications strategy called PrepareSTL to reach marginalized communities, specifically African American neighborhoods. The information about COVID-19 will be culturally competent and accessible; we need more communications efforts like this across the State of Missouri. Less resourced communities and people of color should have access to free testing. With the financial support of the RHC and the St. Louis County Department of Health, Affinia Healthcare and CareSTL Health recently added new testing sites in North City and North County to help address this need. The RHC urges for an expansion of testing sites, particularly in African American neighborhoods in the most affected areas in St. Louis region – North City, North County, and South City – and across Missouri.

Responding to COVID-19 through a lens of health equity requires addressing social determinants of health, particularly for marginalized communities. Ensuring housing stability for those experiencing homelessness, banning utility shut offs, and creating safer conditions in jails and prisons are just a few of the calls to action for Missouri. The RHC supports Empower Missouri’s other calls to action for our state legislators.

Photo: St. Louis Business Journal

To learn more about RHC’s response to COVID-19, please visit our website: www.stlrhc.org/work/covid-19/.

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