March 1, 2021

Dr. Schmidt Provides Public Comment at Inaugural Biden Health Equity Task Force

Harald Schmidt, PhD, MA, Assistant Professor of Medical Ethics & Health Policy, provided a public comment at the U.S. Department of Health and Human Services' COVID Health Equity Task Force on February 26, 2021. His comments are transcribed below:

"In spring 2020, across the country, triage protocols were adopted that aimed to integrate objective data in a way that enables fair ventilator allocation. Only, in focusing on maximizing overall benefits, dominant models paid insufficient attention the distribution of benefits.

And this matters, because the way data were combined meant that historically and structurally disadvantaged populations, especially disabled and Black communities, had lower chances of getting a ventilator. Despite major guideline revisions in 2020, much of this guidance remains, some legally binding.

We are on a better incidence trajectory now but still can’t be sure that we can continue not having to ration ventilators, and guidance carries important expressive value.

So it’s welcome that the Task Force will provide recommendations on federal crisis standards of care guidance, and I will share with the Task Force six concrete suggestions colleagues and I recently published on how we can reduce inequitable consequences from reliance on widely used SOFA score data within dominant triage frameworks, along with a study showing we lack data on the views of disadvantaged populations on ventilator triage principles.

Two comments on vaccine allocation -- first on how we allocate vaccines to states. 

Former Health Secretary Alex Azar explained that allocating vaccines to states proportionate to population isfair, simple and consistent.’ Only, it’s not clear that that’s so. And that's because not all states have the same number of disadvantaged people.

Using the CDC’s Social vulnerability index at the national level, colleagues and I showed that in 16 states—half blue, half red—more than 1/4 of the population are among the nation's most disadvantaged.

So, for example in New Mexico more than 3 in 10 people are among the nationwide's most disadvantaged, but in New Hampshire, just over 1 in 10 are in this group.

Allocating by population alone therefore means that disadvantaged groups—and by extension, more disadvantaged minorities—face increased scarcity in states in which they account for a larger population share. But this is not their fault, and it is not fair. 

It would therefore be helpful if the Task Force reviewed the formula for allocating vaccines to states and thought about ways of mitigating inequitable impact, such as adjusting quotas.

Finally, colleagues and I carried out several reviews of states’ use of disadvantage indices such as the SVI. Last year, we found roughly 1/3 of states used this data tool. This year, we found 1/2 of states use such an index for four main purposes that all directly increase equitable allocation. It would be useful if the Task Force found a way of enabling states and cites still contemplating using a disadvantage index to learn from their peer leaders. There are countless ways in which we can make real progress with equitable allocation, and importantly none sacrifice equity for efficiency.    

And really finally: a data target that aligns with the recommendation in the national strategy that states should use the SVI or a similar index to describe progress towards equitable vaccine access: It would be helpful if the Task Force encouraged jurisdictions to strive for vaccine uptake in a way that there are no differences across the disadvantage index spectrum. This would help simultaneously promote public health, social, and racial justice."

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