PCDC recently submitted testimony to the New York State legislature for its Joint Senate and Assembly Public Hearing on Exploring Solutions to the Disproportionate Impact of COVID-19 on Minority Communities to recommend an increased focus on primary care in the State’s efforts to address COVID-19 health disparities. Blacks and Hispanics are dying at drastically higher rates from COVID-19 than their white counterparts. PCDC believes that primary care should play a fundamental role in COVID-19 relief and response in order to eliminate disparities and achieve health equity.
The testimony highlighted recent research findings from PCDC indicating that primary care access is lower in many areas with high COVID-19 rates. Many of the same neighborhoods with high rates of COVID-19 infections and poor primary care access are low-income neighborhoods of color and experience higher rates of chronic diseases that are best managed by primary care providers. PCDC offered ten targeted policy recommendations to the State to protect the primary care infrastructure, increase access, and further us on the path toward improving the health of minority communities who are most impacted.
Read the full testimony below.
The Primary Care Development Corporation (PCDC) appreciates the opportunity to provide recommendations for New York State’s approach to mitigating the disproportionately adverse impacts of COVID-19 on minority communities. PCDC is a nonprofit organization and Community Development Financial Institution (CDFI) dedicated to building equity and excellence in primary care. We provide capital financing and capacity building services throughout New York State and across the country. Our mission is to create healthier and more equitable communities by building, expanding, and strengthening the national primary care infrastructure.
PCDC’s History of Impact and Service
Since our founding in 1993, PCDC has worked with over 950 health care sites in the Empire State, including seven DSRIP (Delivery System Reform Incentive Payment) Performing Provider Systems (PPS) in all corners of the state. Thanks in part to the New York State Legislature, we have financed and enhanced health care facilities and practices in more than 92% of New York’s Senate Districts (58 of 63) and 86% of Assembly Districts (129 of 150) to increase and improve the delivery of primary care and other vital health services for millions of New Yorkers. Our legacy includes the financing of key regional health providers such as Hometown Health Centers (Schenectady), HRHCare Community Health (Poughkeepsie and Monticello), Community Health Center of Buffalo (Buffalo), Hudson Headwaters (Fort Edward), and Callen-Lorde (New York City). In just the last five years, PCDC arranged nearly $75 million in affordable and flexible financing to expand access to primary care across New York.
Nationally, we have improved primary care access by leveraging more than $1.2 billion to finance over 130 primary care projects, the majority in the Empire State. Our strategic community investments have built the capacity to provide nearly 4 million medical visits annually, created or preserved more than 15,000 jobs in low-income communities, and transformed 1.8 million square feet of space into fully functioning primary care practices. Through our capacity building programs, PCDC has trained and coached more than 9,000 health workers to deliver superior patient-centered care. We have also assisted more than 800 primary care practices to achieve Patient Centered Medical Home recognition, impacting care for more than 5 million patients nationwide.
Health Disparities and Lack of Access to Quality Primary Care in Minority Communities
COVID-19 has scourged communities of color across the country, and this phenomenon has been felt acutely here in New York State. The age-adjusted rate of fatality of COVID-19 cases per 100,000 people is 24.9, while that rate for Asian ethnicities is nearly double (55.4) and triple for Hispanics and blacks (91.3 and 102.9, respectively). The same can be said of non-fatal cases of the virus in New York City, where black and Latino populations experience a rate nearly double that of their white counterparts. More than 75 percent of essential and front-line workers in New York City are people of color, which makes them particularly vulnerable to contracting the virus. We must respond forcefully and immediately to this challenge and primary care should play a fundamental role in this response.
The drastically disparate impact that COVID-19 is having on minority communities comes as no surprise – these same communities consistently face a reality that is starkly different from their white counterparts. Historic discriminatory policies such as redlining have left these communities deeply underinvested and under-resourced, which have manifested in a lack of access to quality primary care, among other essential community services. Systematic denial of resources and opportunities to communities of color at the state and federal levels has resulted in the vast health and economic inequities we are seeing today. Community development financial institutions such as PCDC have worked tirelessly for decades to reverse the effects of discriminatory public policies to revitalize underserved communities through capital investment.
Communities of color are also suffering disproportionate financial consequences because of the pandemic. According to a survey conducted by the CUNY School of Public Health, black New York residents are twice as likely to lose health insurance coverage as their white counterparts, Hispanics are more likely to lose their jobs, and immigrant communities experience heightened hardship compared to those with citizen status.
The poor social and economic outcomes experienced by minority communities perpetuate poor health outcomes. A black woman is 69 percent more likely to die from coronary artery disease than her white counterpart. She is 352 percent more likely to die from hypertension. In New York City, she is as much as 12 times more likely to die from pregnancy- and childbirth-related causes. And now she can add COVID-19 to her list of clinical risks more threatening to her than to the white woman across town. The biological “weathering” effects of high-effort coping from a lifetime of societal oppression and discrimination has once again revealed itself – this time by way of COVID-19.
Build and Strengthen Primary Care Infrastructure for Health Equity
As the need to address the poor social conditions that disproportionately impact the health of minority communities becomes increasingly self-evident in the midst of this crisis, we must remember access to primary care is a social determinant of health, as recognized by the WHO, CDC, and the federal Healthy People initiative framework. Financial, geographic, transportation, and physical barriers have created and furthered health disparities across the State. PCDC’s New York State Primary Care Profile (2018) found a correlation between lack of access to primary care and worse health status. These disparities in COVID-19 outcomes reflect the pervasive and persistent racial and economic inequalities in health status as well as the importance of primary care access and addressing the social determinants of health as a top priority for governments and health care organizations.
The link between primary care access and health status was highlighted yet again in PCDC’s most recent research using New York City-wide data on COVID-19 incidence. These findings, while unsurprising, are alarming and warrant heightened attention and swift action: primary care access is lower in many areas with high COVID-19 rates. A Steinway, Queens neighborhood has the highest COVID-19 case rate in the city – 6.4 times the rate in the East Village of Manhattan – and there are 79.1 times more primary care providers (PCPs) per 10,000 residents in East Village than in Steinway. Many of the same neighborhoods with high rates of COVID-19 infections and poor primary care access are low-income neighborhoods of color and experience higher rates of chronic disease.
These are not just numbers. The confluence of disease burden, limited access to care, and socioeconomic status will widen health inequities without rapid and targeted community-level investment and intervention. Further, the poor health outcomes these communities are experiencing will necessarily drain the health system of its resources, prolonging the recovery from this crisis and perpetuating the lack of access that so many residents are feeling.
As New York begins to reboot and reopen, we must prepare for what some experts are calling the “second pandemic.” For the past several months, people with chronic diseases have gone without critical screenings, vaccinations, and medications because of reduced primary care capacity, social distancing guidelines, and the associated public fear. While demand for primary care will likely soon increase, the pandemic has devastated the healthcare sector, reducing jobs by 1.4 million in April, and dropping primary care visit rates by nearly 60 percent. Those primary care providers who are paid on a fee-for-service basis have had to scale back operating hours or close their doors completely due to a drastic lapse in revenue. And, while telehealth visits are an option for some, more than half of PCPs report being reimbursed less or not at all for virtual visits. Coupled with technologic challenges of seeing low-income patients through telehealth, the lack of chronic disease management and disproportionate rates of COVID-19 will worsen health outcomes and increase mortality in many neighborhoods across New York.
The State has the responsibility to view this as a moment of reckoning. We can no longer stand by and continue to accept the disproportionate suffering and death of black and brown New Yorkers – we must respond in a way that demonstrates the value of human life. We should allow this crisis to redefine how we think about advancing health equity. While we recognize that primary care alone is insufficient to solve the structural inequities that are built into the many systems we interact with throughout our lifetime, it can certainly be a vehicle to accelerate us on the path toward that goal. The role of primary care in achieving health equity has evolved over time, but the declaration made by the WHO at the 1978 Assembly in Alma Ata remains true: “[Primary care] forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community.”
With this in mind, PCDC offers the following recommendations:
- Promote and encourage utilization of primary care.
Many individuals in minority communities with disproportionate rates of chronic disease have delayed or foregone their care during the pandemic, putting them at high risk for COVID-19 complications as well as long-term health effects resulting from lack of care management. Racial health disparities will only widen in the coming months as we face the possibility of a “second pandemic” resulting from deferred care without management and treatment of chronic disease by primary care providers.
To incentivize primary care utilization, the State should reduce or eliminate patient cost-sharing, including co-pays, deductibles, and premiums for primary care for the foreseeable future. At a time when loss of income is high, many individuals do not have disposable funds to allocate towards cost-sharing for health care services. The State should encourage individuals to seek care regardless of an individual’s ability to pay. By reducing cost-sharing, minority populations who have been forced to forgo chronic disease management due to an inability to pay would be able to return to vital care.
Preventing and managing chronic conditions is what primary care is set up to do best. Primary care is often the first point of contact with the health care system and can prevent, identify, and treat illnesses as well as promote wellness. Primary care physicians build trusted relationships with patients over time which allows them to deliver care in a culturally competent manner, taking into consideration the social and cultural factors that impact their health. This is especially true in underserved minority communities where community-based primary care providers can provide a trusted source of support in a system that has historically left vulnerable patients behind. The State must use all available government channels to reduce barriers to utilization by minority communities of primary care, during the COVID-19 pandemic and beyond.
- Implement prospective payments to providers across all payers.
This crisis has laid bare the fact that the fee-for-service (FFS) payment model is not sustainable for primary care providers in the face of a public health emergency. FFS models do not protect essential providers from financial threats and sets them up for failure during emergencies. The sustained and drastic decline in patient visit revenue has left primary care providers financially drained and has threatened their long-term sustainability to operate after the COVID-19 pandemic subsides.
The State has worked tirelessly over the last several years to advance payment structures based in value. This is more crucial now than ever before. New York State must move to implement prospective payments to providers across all payers. This fundamental change will provide immediate economic relief to primary care practices to enable them to re-open successfully and continue to give crucial care. Prospective payments will also sustain primary care providers in the face of a potential second or continued outbreak of COVID-19.
- Call for the next round of federal aid to include designated funds for primary care providers.
Primary care practices are suffering severe economic loss due to the sudden and sustained reduction of patient volume. Primary care practices have been forced to lay off or furlough employees to prevent shutting down completely. This is not sustainable. Primary care practices need immediate relief, or we risk losing many practices permanently thus putting patient lives at risk.
The federal stimulus bills to date have provided relief funds for hospitals and healthcare providers on the frontlines fighting the coronavirus. However, we cannot assume that the federal assistance thus far has reached primary care providers who need it as trickledown reimbursement rarely makes it to the target. In this crisis, many of the emergency payments have been tied to previous Medicare reimbursement- a metric that leaves out the providers who see Medicaid patients, which covers the most vulnerable New Yorkers. Instead, funds must be specifically designated for the purpose of protecting primary care, particularly in poor and minority communities. Allocating federal aid directly to primary care practices can ensure they survive the sudden and significant loss of revenue resulting from deferred patient care and can continue providing essential services. Primary care practices have struggled with the rapid transition to virtual services, with many starting from scratch in the face of this crisis. Robust telehealth is crucially important as primary care providers continue to fight the current pandemic but will also be necessary in preparing for a second wave of infections and care delivery in the future. Primary care providers can use these direct funds to improve their telehealth technology and capacity to give care remotely, improving care delivery and management of chronic illnesses.
- Create a State capital fund to deploy to underserved communities to enhance existing health facilities and increase access.
We are heartened to see that the HEROES Act recently passed by the US House of Representatives includes a $1B appropriation to the CDFI Fund (the Fund) for a rapid emergency grant program, and an additional $2B to the Fund, of which $800 million would be set aside for minority-owned lenders to support minority-owned businesses and their communities.
While the designated funds in the HEROES Act is a step in the right direction, this financial lifeline will be insufficient to revitalize many of these communities in a meaningful way. To fix this, New York State should follow suit and create a state capital fund to deploy to underserved communities to enhance existing health facilities and increase access. This increased aid will ensure that minority communities decimated from this pandemic are uplifted, enabling them to continue to expand and operate health facilities and other essential community services in low-income communities. This will help to facilitate sustained access to primary care for vulnerable populations who need it the most. The creation of this fund would demonstrate to minority communities that the State has a vested interest in not simply returning to the status quo, but in helping them to achieve the financial success they have been so often been denied in the past.
- Invest in primary care – in the short and long term.
There is near universal consensus that consistent primary care is crucially important to preventing chronic illnesses and creating healthy, thriving communities. Evidence shows that an increase of just one primary care provider per 10,000 people can generate 5.5 percent fewer hospital visits, 11 percent fewer emergency department visits, and 7 percent fewer surgeries. However, primary care has historically been undervalued and underinvested. It is estimated that as little as 5-7 percent of U.S. health care costs go toward primary care. The lack of investment into primary care has led to significant consequences for the health of Americans, including mounting rates of chronic disease and vulnerability to threats such as COVID-19. This is particularly true in low-income and minority communities, where access to a primary care provider remains a challenge.
The pathway to recovery from COVID-19 is through increased investments in primary care in order to strengthen the system’s ability to keep us healthy. To date, nine states have acted to rebalance their health care systems through regulatory or legislative means to define, measure, and increase primary care investment. New York is not one of them. New York State must join the national conversation and take action to increase the proportion of health care dollars going towards primary care. Effective investment supports more than just traditional primary care; it covers integrated behavioral and public health, care coordination, care transitions, and efforts to address social determinants of health. New York can increase primary care access and quality of care in underserved communities and can work towards incentivizing primary care within delivery system reform models, leaving a lasting impact on the health and well-being of minority communities across the state.
- Protect Medicaid.
The Legislature must reject any proposed cuts to Medicaid for the foreseeable future. As the State grapples with the economic devastation resulting from COVID-19, it runs the risk of cutting spending where it is needed most. A public health crisis is not an appropriate time to make drastic changes and rollbacks to the safety net. The impact of proposed cuts will reach an increasing number New Yorkers as so many people, many of whom are minorities, have lost their jobs and will rely on the Medicaid program to receive their care. In New York, half of all Medicaid enrollees are black or Hispanic. Reducing Medicaid funding and services will further exacerbate the disparities in access that have been illuminated by this crisis.
- Require reporting of COVID-19 surveillance data by race and ethnicity.
In order to make decisions on how best to combat the impact on minority communities, the State should move to require COVID-19 surveillance data by race ethnicity. The risk of misunderstanding or misinterpreting the disparate impact this virus has had on communities of color would result in further marginalization and the continuation of the unacceptable precedent where the plight of these communities is consistently ignored. Surveillance data collected by demographic characteristics, namely race and ethnicity, will allow for more direct and efficient allocation of resources to those communities most affected. The dearth of racially informed data on New York’s COVID-19 crisis disallows a response that is equitable.
- Promote community-based population health initiatives aimed at increasing cultural competence in provider settings.
The importance of cultural competence in health equity cannot be overstated. Patients benefit from care delivered according to their social and cultural needs. Culturally competent care aims to achieve health equity by reducing disparities that exist in the health system through care delivery that adheres to racial, cultural and social differences in the patient population. There are many examples of culturally competent care already being integrated into New York’s health system through its many community health centers, independent physician practices, and other primary care settings.
A move to increase the prevalence of culturally competent care in the primary care system would improve outcomes and quality of care through better communication and increased trust. Evidence shows that patients are more satisfied when seeing a provider of their same race. The State should promote the creation of incentive programs for medical and nursing students of minority racial backgrounds to pursue primary care. Further, the State should increase funding for programs like the Patient-Centered Medical Home (PCMH) model which utilizes a team-based approach to primary care and often includes community health workers (CHWs) as members of the care team who are traditionally from the communities they serve. Additionally, the State should require state-regulated public and private insurers to create educational training programs to be disseminated to all health providers. Insurers should offer a financial incentive to all contracted providers who take part in this educational program to reward participation.
- Extend health coverage to all New Yorkers regardless of immigration status.
New York State Medicaid coverage for undocumented immigrants is limited to emergency services only. This is problematic during a public health crisis when visiting the emergency room is discouraged without consulting with a healthcare provider first, and when many see the emergency room as a place at high risk for COVID-19 transmission. In addition, some undocumented immigrants have reported being reluctant to seek care during this crisis due to fears stemming from the federal Public Charge Rule. Fear of care can lead to a multitude of downstream effects including more severe consequences of COVID-19.
The State needs to commit to combating this problem and encourage immigrant communities to seek care. To do this, New York should extend low-cost coverage through the Essential Plan to all residents regardless of immigration status. Increased coverage for immigrant populations will help to reduce health disparities by encouraging management of chronic and acute illnesses and providing earlier access to testing for coronavirus if necessary.
- Reduce regulatory barriers to Article 28, 31, 32, and 16 state-licensed facilities.
This pandemic has shown that both the federal and State governments can move quickly to waive existing regulatory requirements that can serve as operational barriers – as has been done with telehealth. The State should move quickly to fully modernize physical plant requirements, satellite clinics, telemedicine regulations, and those governing the integration of physical and behavioral health across agencies, including the DOH, OMH, OASAS, and OPWDD. Lack of primary care access in poor and minority communities has as much to do with the byzantine regulatory framework of the New York State licensure system as it has to do with reimbursement practices. This has been promised by the Administration for many years; now is the time to move swiftly and decisively.
Thank you for your consideration of these recommendations. Primary care is the foundation of the health care system and a cornerstone of healthy, thriving communities. Without a strengthened focus on primary care in New York’s response to COVID-19, we cannot make progress toward achieving health equity and improving the health of minority communities who are most impacted.
Louise Cohen, Chief Executive Officer
Patrick Kwan, Senior Director of Advocacy and Communications
Primary Care Development Corporation
45 Broadway, 5th Floor, New York, NY 10006