The Case For Investment In Mobile Health Care Solutions To Reduce Health Inequities from Health Affairs

By Keren Hendel

Editor’s Note

This article won the AcademyHealth Disparities Interest Group’s student essay contest. Students were asked to write an editorial on any health disparities topic of their choice, with a focus on the specific causes or consequences of disparities and/or solutions with the most potential to reduce disparities. The article was edited by Health Affairs Forefront in conjunction with the author.

The roots of health disparities are complex, well-studied, and rooted in history and contemporary structural racism, discrimination, and various socioeconomic factors. In the US, COVID-19 testing, treatment, and vaccinations have largely been implemented within existing health service infrastructure and networks. These networks include major health systems, large pharmacies, and hospitals; however, these networks often systemically exclude Black, Latinx, and American Indian communities, among others. This approach predictably led to the disparities in COVID-19 testing, cases, and deaths. According to the Centers for Disease Control and Prevention, Latinx individuals are about twice as likely to get COVID-19, about 3.0 times more likely to be hospitalized due to COVID-19, and 2.3 times more likely to die due to COVID-19.

In Durham, North Carolina, which I call home, these numbers were even more stark. In October 2020, more than 55 percent of COVID-19 cases and about 82 percent of COVID-19 deaths in Durham county were people who identified as Hispanic, Latino, or Latinx, a group that represents only 14 percent of Durham’s population. Today, about 70 percent of Durham’s Latinx population is vaccinated with at least one dose, higher than the percentage of the non-Hispanic population (64 percent). This is due in large part to the efforts of groups such as LATIN-19, which advocated for community-based, community-informed COVID-19 efforts in North Carolina. Efforts to boost equity in COVID-19 vaccinations, along with the country’s reckoning regarding racial justice, provide an opportunity to improve access to health care for the Latinx community.

One way to do this is through innovative mobile care delivery. In North Carolina, for example, the Department of Health and Human Services originally expanded testing and vaccination efforts by enlisting the help of Optum, a national health organization, to run pop-up testing sites, generally open on weekdays between 9 a.m. and 5 p.m. These mobile delivery efforts made a big impact, but they missed families without a car, essential workers unable to take time off work during business hours, people whose predominant language is not English, and children who receive their basic necessities at school. Recognizing these shortcomings, the state also enlisted the help of federally qualified health centers (FQHCs) and Black-owned providers to host mobile or pop-up events in coordination with community-based organizations. The FQHCs and Black-owned providers were already embedded within communities and were able to work with community-based organizations to increase effective outreach to those at highest risk. Furthermore, they were used to providing care in Spanish and providing services outside of regular business hours.

Health systems and universities throughout the country have developed mobile COVID-19 testing vans to reach communities with limited access to traditional health care institutions. UNC Health invested in a mobile unit to serve Raleigh, North Carolina, while Michigan’s Department of Health and Human Services, Wayne State, and Wayne Health partnered to use their mobile unit to improve equity in COVID-19 testing and access to public health services in Flint, Lansing, Grand Rapids, and Muskegon, Michigan.

A mobile van providing health care is not radical. In the United States, we have a preconceived notion that health care is provided in a doctor’s office with a speckled tile floor and white walls filled with detailed anatomical diagrams. We imagine a blue examination table with itchy white paper and folders on the wall with pamphlets, likely only in English, about “healthy habits.” But health care is already provided in so many other ways. Whether it is in an ambulance, at a school health clinic, or via telehealth platforms, we have the infrastructure to innovate outside of hospital wings and urgent care clinics. Mobile health care was effective in the HIV and SARS epidemics, and it is being used effectively in many states to reduce access gaps to reach COVID-19 testing and vaccinations.

Research has shown that mobile health units are adept at addressing both medical and social determinants of health, acting as a link between community and clinical settings and cost-effectively improving outcomes for historically marginalized communities. Several studies have showed their efficacy among diverse Latinx populations. The Women’s Health Van in Northern California and the MOMmobile medical van in Miami-Dade county increased access to prenatal care, primarily for Spanish speakers and uninsured immigrants. SALUD Family Health Centers implemented a mobile screening and care delivery program three evenings per week to reach Mexican immigrant population in northern Colorado that lacked access to health care. Data from SALUD showed the mobile unit represented the first visit with a US provider for about 63 percent of individuals.

While these efforts demonstrate the potential for success, mobile health interventions remain underinvested in the US. In discussions with health system leaders, they highlighted liability issues, staffing, upfront investment, and insufficient payment as the main barriers to investing in mobile delivery options. To expand mobile delivery and ensure the longevity of existing mobile solutions, policy makers, health systems, and payers need to work together to develop alternative payment models and liability solutions that ensure sufficient provider compensation and safety, funding for ongoing maintenance costs, and investments in community relationship building.

Policy makers could create incentives to increase investment in mobile health solutions in many ways. For example, they could increase payments for specific preventative services if they are provided at a mobile site. Or, they could fund initial pilots and evaluations in areas with high needs and low investment, which are often areas with higher concentrations of people from historically marginalized populations.

Health systems can work with payers and other intermediaries to acquire funding upfront to invest in mobile solutions through an add-on or per-member-per-month payment, while supporting accountability through equity-focused measures and outcomes. Health systems can also create incentives for providers to practice in mobile vans or use new mobile technologies through offering trainings and ensuring adequate payment and sufficient staffing. Combined with community relationship building and sufficient legal support, these strategies could help overcome the existing barriers to mobile health solutions.

We cannot continue to use the same health infrastructure and expect different results. COVID-19 has directed national attention to health inequities; this affords an opportunity to invest in mobile health delivery to reach populations missed by our current system. While mobile units require upfront investment, they are a cost-effective method to improve outcomes, especially among historically marginalized communities that experience systemic exclusion.

Author’s Note

Keren Hendel is a Margolis Scholar at the Duke Margolis Center for Health Policy and a recipient of the Winston Health Policy Scholarship.

Read, “The Case For Investment In Mobile Health Care Solutions To Reduce Health Inequities” from Health Affairs