MILWAUKEE (SPECTRUM NEWS) — It’s become a common idea during the pandemic: COVID-19 does not affect all communities equally. As the coronavirus has torn through the U.S. and the world, low-income areas have been hit hard by higher infection rates and by more severe infections as pre-existing conditions exacerbate effects of the disease. This impacts many essential workers who haven’t been able to stay safer at home.
To compound these issues, low-income communities also disproportionately lack access to intensive care options, according to recent research from the University of Pennsylvania Perelman School of Medicine.
“Disparities of health and healthcare are certainly not a new thing,” says Genevieve Kanter, the study’s lead author and an assistant professor of medicine, medical ethics, and health policy. “The big concern was that these low-income populations would be hit multiple times.”
The study, published this month in the journal Health Affairs, looked at data based on hospital service areas — clusters of ZIP codes with at least one hospital. They found that many American communities had no ICU beds, and that access often corresponded with income: Around half of all areas with median incomes under $35,000 had zero ICU beds, compared to just 3% of areas with median incomes over $90,000. These disparities were especially wide in rural areas of the country.
Those national trends mostly held up in Wisconsin as well. No Wisconsin communities fell into the lowest income bracket, but about 44% of areas with a median income of $35,000 to $54,999 lacked ICU beds, the researchers found. In comparison, 26% of areas with income levels of $55,000 to $89,999 lacked ICU beds.
The one Wisconsin community with a median income of $90,000 or higher — Oconomowoc — fell in the highest range of ICU bed availability.
According to a database of Medicare information compiled by Kaiser Health News, 34 of Wisconsin’s counties — nearly half of them — don’t have a single ICU bed. And in many counties that do have some beds available, the number is limited: Jefferson County, for example, has a ratio of 4,577 older residents per ICU bed.
“The most surprising thing was really how many communities did not have any access,” Kanter says. “There will always be to some extent, unfortunately, some level of disparity, but I think what surprised me was the degree of the disparity, especially in a country like the U.S., which has a lot of resources.”
ICU beds aren’t the only measure of critical care options, says Kathryn Miller, rural hospitals and clinics program manager with the Wisconsin Office of Rural Health.
She points out that Wisconsin has a strong network of critical access hospitals, which are designed to fill in the gaps and provide short-term care to residents in rural areas. Though they may not be included in ICU counts, these locations still provide emergency care, and have transfer protocols in place to send patients to other hospitals if necessary. A 2017 analysis by the Office of Rural Health found that 99% of Wisconsinites lived within a 30-minute drive of some form of emergency care.
“If you're looking at a critical care case like COVID, trauma, or major heart attack or stroke events, they may very well present at a critical access hospital and then get transferred,” Miller says. “So, it's not that counties don't have resources. They all have resources for some kind of immediate care.”
Having intensive care options available is important even in non-pandemic times. But in the midst of COVID-19, when thousands of Wisconsinites have been hospitalized with a disease that can quickly turn life-threatening, the issue has come to the forefront.
A study in JAMA Internal Medicine last month found that coronavirus patients were more likely to survive if they were admitted to hospitals with a greater number of ICU beds. Things like ventilators, 24/7 monitoring, and controlled airflow are vital resources for those struggling with an intense respiratory disease like COVID-19, Kanter says.
“In terms of actual impact, I think if patients are seriously ill from COVID-19 and they don't have access to these technologies, we're really meaning the difference between life and death,” Kanter says.
Over recent months, Wisconsin has increased its ventilator supply by almost 70%. Today, the state has around 2,000 ventilators on hand, with 342 currently in use, the DHS reports. Especially with the ramp-up of COVID-19, Miller says many hospitals are likely equipped with ventilators or other support for critically ill patients, even if they don’t have full ICUs.
Cooperation between counties, hospitals, and health providers can also help ensure critical care access, Kanter says.
In St. Croix County, at the western edge of Wisconsin, health partnerships cross county and even state borders, says public health administrator Kelli Engen. The county shares health systems with its neighbors in Pierce County and in Minnesota’s Twin Cities, she says.
As of Wednesday afternoon, the county had 12 residents hospitalized with COVID-19, three of whom were being treated outside of county lines, according to health department data. And even though that St. Croix County has no ICU beds, according to the Medicare data, it was ranked as the healthiest county in Wisconsin this year by the Robert Wood Johnson Foundation.
“We are definitely in a better situation than some,” Engen says.
Compared to other states, Engen says Wisconsin’s public health model gives a lot of control to local health authorities instead of leaving it up to the state level. Miller says there’s a history of collaboration between different agencies to support rural hospitals.
“We're all in this to help hospitals together, not to compete,” Miller says.
Still, for many rural and low-income residents, getting access to critical care isn’t easy. As Engen says, “barriers to access come in a variety of different shapes and sizes.” In addition to shortages of nearby ICU beds, these hurdles could include lack of health insurance or scarce educational resources in languages besides English.
Kanter says she hopes the research helps guide policy to support these vulnerable populations across the country, especially as a pandemic that started out affecting wealthy “jetsetters” now seems poised to keep taking its toll on poor and rural residents.
“Our main goal was to help policymakers focus on these communities in rural areas, low-income areas, to direct resources to these communities,” she says. “As you see the wave of infections headed towards rural areas, they'll also be experiencing the greatest demand.”