Vulnerable Low-Income Groups, Racial Disparities: Lessons India Must Learn from US Healthcare System

Coronavirus is a like Thanos' justice -- indiscriminate and randomised. It will affect any pair of lungs it can latch onto, irrespective of who they belong to, be it British Prime Minister Boris Johnson, Hollywood actors Tom Hanks and Idris Elba, or the Prince of Whales. But, as the virus travels through countries claiming several lives, causing lockdowns, disrupting economies and overwhelming healthcare systems, an alarming trend has emerged in the United States, the current hotspot of the global pandemic.

In the United States, unfortunately, several social, political and economic factors affecting generations of African Americans have augmented their risk of chronic illness and made their lungs, and immune systems vulnerable, thereby, leaving them more susceptible to coronavirus. But, apart from biological reasons, there are many existing socio-economic factors that have resulted in a disproportionate number of coronavirus positive cases among African Americans, and have caused a high number of casualties.

Another especially vulnerable community in the US at this point are the low-income groups. In the past few years, low-income groups (which also comprise of African Americans) had only just begun to show signs of progress with the rise in the minimum wage, and record low unemployment rates. However, that progress came to a crashing halt with the arrival of COVID-19, thanks to a discriminatory healthcare system.

US President Donald Trump, initially had made testing (but not treatment) for coronavirus free for Americans, which left 30 million Americans, who did not have any health insurance to fend for themselves in case they tested positive for the virus. Of course, beyond that 30 million, there is also a large group of underinsured people. As the public health organisations struggle with a lack of basic infrastructure, and doctors and nurses are forced to make the heart breaking choice of who gets a ventilator, just footing the bill for hospitalisation was a matter of big concern for a large portion of Americans, who may not have been able to afford it even if they show symptoms of the deadly virus.

However, on Friday, according to a New York Times report, Trump declared that the government will pay for the uninsured coronavirus patients from the Stimulus bill although critics were quick to point out that the money may not go to hospitals in the hardest-hit states, and just covering coronavirus still doesn't provide medical cover to 30 million people from other diseases.

As if that was not bad enough, the inherent biases of healthcare workers in the United States are beginning to show on the surface, as resources to cope with coronavirus fall deplorably short. NPR recently quoted the study of a Boston based biotech company, Rubix Life Sciences, which had reviewed several states in the US and found that doctors are less likely to advise testing to an African American, even when he or she shows signs of the disease. Already the tests are scare, but because of this inherent discrimination, many African Americans are not being detected with COVID-19 in the early stages making it hard for them to survive it.

There is no collective data from the US that show the 'disproportionate' effect of COVID-19 on African Americans, but several states have revealed their data which point toward that fact. A report shows that in Milwaukee -- which is one of the few states analysing racial breakdown in coronavirus cases -- out of the total 945 cases (till Friday morning), 81 per cent affected are blacks. And, among the 27 deaths till Friday, 26 per cent were also from the African American community. Majority of those affected are African American men.

In Cook County, out of 183 COVID-19 caused deaths, 107 were black (as of Saturday), while in Chicago, as much as 70 per cent, which is 61 out of 86 recorded deaths, were African Americans. The Washington Post also revealed data of Maryland and Virginia that showed that African Americans were affected in an inordinate way. Data released on Sunday show that in Michigan 34 per cent of the 40 per cent of deaths are American Americans. A ProPublica report also notes Detroit and Louisiana, which have relatively large African American residents, as the hotbeds for coronavirus.

The lists of data are growing with each passing day, pointing at the horrendous mistakes America has made by not reaching out to all communities, by allowing human biases to dictate who gets tested and by not providing the low-income groups with the financial support initially, which would have encouraged early testing and detection, and perhaps could have even helped in flattening the curve. There are several lessons to learn from such mistakes, especially for a country like India, with its 1.3 billion population, and it's huge religious, social, economic and cultural diversity.

One of the best things that the Indian government has done so far is that unlike the United States it has wasted no time in announcing free test and treatment for COVID-19 under Ayushman Bharat -- Pradhan Mantri Jan Arogya Yojna. Ayushman Bharat is one of the world's largest government-sponsored healthcare program covering as many as 500 million individuals and providing a cover of Rs 5 lakh per family. While that cover may be lacking if many members of a family test positive, and it still may not provide cover to a proportion of Indian poor who do not fulfil the eligibility criteria, it automatically takes into account some of the most vulnerable groups of our country like the homeless, beggars, manual scavengers, primitive tribal groups etcetera.

However, while Ayushman Bharat provides a cover to millions, it doesn't take away the fact that our hospitals are still woefully lacking in basic infrastructure, and if the situation continues to get worse, it might push the healthcare workers towards the same Sophie's choice, as their counterparts are facing in the United States.

From the onset of the pandemic, health insurance has also been a major cause of concern among middle-class Indians, as many have rushed to buy insurance, or raise the cap of existing policies. The Insurance Regulatory and Development Authority of India has recently announced the Arogya Sanjeevani Policy starting from April 1, which will provide a cover of up to Rs 5 lakhs, and will include COVID-19 treatment in it. All this seems like good news, but according to a Mint report, there are several caveats hidden in the fine print of this policy, which doesn't particularly make it a useful option.

In an article in The Mint, an insurance expert states that Aroya Sanjeevani Policy has a really low room-rent cap (2 per cent), which will raise the cost of the treatment for the patient if he/she is admitted to a private hospital as they would have to pay the excess money themselves. Apart from that, the policy also comes with a co-pay clause, which makes it is mandatory to shell out 5 per cent of the bill. Furthermore, in metro cities, five lakh may not suffice, as hospitals are expensive.

There are a few other insurance issues, which needs to be sorted immediately, if we want to avoid a US like situation. However, it isn't enough to ensure healthcare, it is also equally important to make sure from the government's side that there is no discrimination in accessing the healthcare, and no one is being targeted for their racial, ethnic or religious background.

Unfortunately, reports of such discrimination are growing with time. In March, a Muslim congregation, Tablighi Jamaat was held in Delhi's Nizamuddin area which had spiked up not only coronavirus cases, but also Islamophobia with many fake reports doing rounds on social media platforms, and Muslims being targeted for spreading the virus. However, any case of religious discrimination in the healthcare framework wasn't reported until a couple of days ago. A doctor in Rajasthan had reportedly refused to treat a pregnant woman, because of her Muslim identity, which resulted in the death of her baby. Such blatant discriminatory attitude must have consequences and should be discouraged at all cost.