HEALTH POLICY CENTER Disparities in Preventive Care Receipt in Washington, DC, During the Coronavirus Pandemic: A Case Study Kimá Joy Taylor, Sarah Benatar, Faith Mitchell, Jackie Liu, Clara Alvarez Caraveo January 2023 Introduction The District of Columbia, like the nation, has long experienced persistent racial, ethnic, income, and health disparities. These have been exacerbated by the coronavirus pandemic, which first took hold in mid-March 2020. At that point, Americans experienced major disruptions in the nation's critical infrastructure, social support services, and health care system. To reduce transmission of COVID-19 and ensure hospital capacity for those in need of critical care, many elective and non-COVID-related medical services were limited or shut down. In turn, 36 states suspended the provision of elective medical procedures through the end of April 2020, with some suspensions lasting into May.1 Many patients began curtailing their use of health care in response to limitations imposed by clinical facilities, due to a desire to avoid exposure to the often severe and deadly consequences of infection. While the health care impact was severe, the pandemic also had profound effects on people's everyday lives, which in turn affected overall health. Many families in the US experienced loss or instability of housing, employment, food, and education (Drake and Rudowitz 2022) along with other increased stressors and grief that also weighed on health and well-being. We have not seen another widespread suspension of medical services since May 2020; however, the emergence of novel variants of the virus has led to multiple surges in COVID-19 cases, each time resulting in significant disruptions to the labor force, supply chains, and, broadly, life in America (and abroad). These case surges have exposed and reaffirmed the structural issues that debilitate US health care infrastructure and overburden the health care workforce. Even as this paper is written in the latter half of 2022, the COVID-19 pandemic remains an ongoing issue, exacerbated by a sense of distrust in public health, expert opinion, and vaccine science. In response to COVID-19 concerns, the health care system has had to move quickly, shifting from business as usual. The system prioritized the sickest patients, postponing elective surgeries in favor of keeping beds available for COVID-19 patients. The system also rapidly changed how care is provided. In response to the virus, many health sectors drastically increased the use of telehealth services for health care and social services. In an effort to reduce spread of disease, outpatient clinics and providers cut back the number of patients allowed in waiting rooms. This, in turn, reduced the number of visits, impacting the bottom line for providers and facilities. Evidence from studies using electronic medical records indicates that ambulatory care visits declined significantly after stay-at-home orders were issued in 2020 and that these declines occurred across visits for a wide range of conditions and for preventive services, such as wellness visits, checkups, and cancer screenings (Mehrotra et al. 2021). Access to care also changed for health and social services, with an increased reliance on online access and enrollment. In care settings, the pandemic resulted in capacity constraints and shifts in care delivery. In communities, there were disparate effects, especially in communities of color. These outcomes require us to ask whether the pandemic-induced changes increased inequities in access, utilization, and quality of preventive care. Currently, it is known that during the pandemic's early years, COVID-19 disproportionately affected Black, Latinx, and Native American people in the US (Hill and Artiga 2022). Efforts to improve information about and access to vaccines has shifted this imbalance, and now white people are more likely to die from COVID-19 than Black people, often due to mistrust of vaccinations.2 This Urban Institute project sought to better understand how and whether the pandemic impacted access to and utilization of preventive health care, particularly among communities that have historically lacked access to high-quality health care services. The findings presented below are based on a series of in-depth interviews with community leaders, health care providers, insurance payers, and community advocates, as well as on focus groups composed of community members. They are part of a larger effort that has included analysis of national data on utilization along with in-depth community engagement and case studies. The work focused on two cities-Washington, D.C., and Oakland, California-to better understand how the pandemic affected (and continues to affect) access to and utilization of preventive care by residents who are more likely to experience hardship due to income, language accessibility, immigration status, structural racism, age, and more. The work was guided by the following research questions: 1. How did preventive health care use change during the pandemic? 2. Did racial and ethnic disparities in preventive care receipt widen during the pandemic? 3. Why did people delay care (closed offices, fear/safety, cost, other)? 4. How were community members' health-related social needs (e.g., housing and access to food) affected by COVID? How did these circumstances affect the need for and receipt of care? 5. How could/should health care policies and practices change to address these unmet needs and support equitable access to preventive care? 2 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC Methods Our project was reviewed and approved by the Urban Institute's Institutional Review Board, which is an administrative body established to protect the rights and welfare of human research subjects recruited to participate in research activities conducted under the auspices of the institution with which it is affiliated. In an effort to identify DC patients' access to preventive care during the first year of the pandemic, the qualitative research design consisted of three components: creation of a Community Advisory Board (CAB), interviews with key stakeholders, and focus groups with patients and providers, beginning in the summer of 2021 and running through the fall of 2022. We recruited a diverse set of individuals who represented a combination of community and systems perspectives from both Oakland, California, and Washington, DC, to serve on a CAB. As an integral component of our project, we relied on the CAB to help us understand the experiences, challenges, and barriers its members and their clients have endured, both currently and prior to COVID-19. The CAB informed the research questions that guided this project, the interpretation of both qualitative and quantitative findings, and the proposed strategies developed. The team conducted key stakeholder interviews to better understand how communities responded to the impacts of COVID-19. In partnership with the CAB, we created robust and diverse interview lists consisting of physical and behavioral health providers (particularly those who serve the uninsured and Medicaid populations), social service providers, day care providers, and others on the front line of client care. The team conducted one-hour virtual stakeholder interviews to identify both barriers and creative solutions to providing access to preventive and other health and social services during the early part of the pandemic. Interviews occurred during the summer of 2021 when vaccines were first widely available and the Delta variant was emerging. Overall, the DC team interviewed eight stakeholders. Interview findings were analyzed by the team in partnership with the CAB and helped prioritize preventive care areas and populations for the focus groups. The team conducted two virtual focus groups. One focus group involved clients many of whom had unstable housing, and another met with staff of organizations providing care to clients from historically excluded populations. The team created and the CAB reviewed the focus group interview guide, which allowed for consistency across focus groups and sought to identify barriers and/or incentives to preventive care services. We then compiled all information, looking for both site-specific and cross-cutting findings about ways in which COVID-19 affected access to preventive services. From these findings, and in partnership with the CAB, the research team sought to identify local, state, and federal recommendations to improve equitable access to preventive services in the future, with or without a pandemic. DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC 3 Findings Prior to the COVID-19 pandemic, structural barriers disproportionately affected low-income residents' care-seeking behavior and utilization of preventive care services. CAB members, interviewees, and focus group members attested to the prevalence of racial, ethnic, and other inequities in access to and outcomes for high-quality health and social services; the pandemic exacerbated and illuminated these longstanding inequities. Previous social supports were altered or not available during the early days of the pandemic, leaving many people to focus on seeking new jobs, receiving employment, accessing food, and avoiding eviction. These basic needs against a backdrop of critical illnesses from COVID-19 interfered with an individual or systems-level focus on preventive care. The health care system was also forced to change, at times deprioritizing and/or changing health offerings in order to care for the sickest and protect staff. Health care providers and systems faced unprecedented financial pressures, as they needed to reduce operations while unexpectedly having to fund protective equipment and telehealth infrastructure and to cover staff needs. Health care systems were forced to rapidly innovate in order to engage and serve patients and their families during a deadly disease outbreak. People with whom we talked identified areas of concern, opportunity, and space for future innovation. Below, we present our findings from key informant interviews and focus groups with providers and recipients that pertain to institutional, provider practice, and individual factors that presented challenges and opportunities for clients seeking preventive care and other health and social services. Patients' Social Needs The health care system promotes preventive care to improve health, avert poor future outcomes, and save money. However, COVID-19 caused massive disruptions in the lives of patients and families. Clients lost employment, affecting their ability to pay for rent, food, child care, and other basic needs. As a result, often these necessities took priority over securing preventive services. Below we discuss the disparities and struggles in obtaining these social services and basic needs as detailed in interviews and focus groups. Housing rose to the top of the needs list in every interview. Before the pandemic, many people in Washington, DC, were already unstably housed. The pandemic only worsened this problem, and, but for the eviction moratorium, many more people would have been made homeless. Housing instability also intersected with caregivers' concerns. Caregivers had additional stress because schools were conducting virtual classes in instances where some children did not have access to the hardware or bandwidth to engage. Simultaneously, caregivers were often working or looking for work and unable to provide necessary oversight in helping students understand and finish school tasks. Housing instability or lack of housing compounded these issues. 4 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC The closure of government agencies also deeply affected low-income populations' access to social services. Some of the most marginalized, such as those who were unstably housed and those returning home from prison, lacked basic documents (such as driver's licenses) needed to apply for benefits; agency closures barred the ability to get duplicates. At times, participants did not know about available public services; informants noted that some clients lost housing because they were unaware of eviction protection. Some focus group participants, particularly those who were unhoused, expressed frustration with the closure or limited operating hours of public and social services providing hot meals, toilets, showers, and more. Closures affected clients' ability to access basic needs such as a place to use the bathroom, receive social assistance, or have a meal. These participants also found that complying with pandemic precautions, such as mask-wearing, was difficult as they couldn't obtain supplies themselves. One participant even noted that they had to use someone else's discarded mask to enter facilities. About a month and a half into the pandemic I finally just picked up a mask off of the floor and wore that. I wanted to have a mask on because it was the appropriate thing to do, but I couldn't find one for that month and a half; nobody gave one to me and thought that I needed one. I picked one off the floor because then at least I'd have one to wear. -Focus group participant At the onset of the pandemic, many community-based health and social service agencies were forced to rethink their business models. During the forced lockdowns, many of the agencies closed for a time and, in partnership with staff and clients, developed a new strategy for prioritizing and providing care in line with COVID-19 precautions and client needs. Because of longstanding histories of client engagement and deep client relationships, these organizations were able to transition and address clients' needs more effectively than some of the larger governmental interventions, which often struggled to achieve the stated goal, such as issuing unemployment checks (Roll and Grinstein-Weiss 2020). Staff who were used to providing culturally and linguistically effective low-barrier care also noted that their case rates increased because government core service agencies, such as the Department of Motor Vehicles, were closed. These community-based organizations accepted the overflow clientele and adjusted strategies and care plans accordingly. Many interviewees felt that the engagement of staff and clients allowed centers to build trust and prioritize needs in ways that ultimately brought people back to their agencies when they started to reopen. DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC 5 I did notice an increase in the case management workload, because we're a low-barrier case management clinic. So, a lot of the higher-need patients have other core service agencies to meet their needs because our position here is limited. So, with them [the service agencies] being closed, a lot of their clients were coming in to seek services that weren't in our realm. But, because we understood they needed this, we readjusted to implement certain strategies to meet their needs without compromising our workload. I think it worked pretty well if you ask me. -Case manager Many clinics and service agencies recognized that clients were not going to engage in health services without their basic needs being met, so they repurposed money to provide support. One institution noted that they helped parents buy diapers, formula, and other caregiving items that were usually provided by other agencies. Social realities and needs were paramount for many people, and preventive care was simply not viewed as a priority. Barriers to Accessing Preventive Care On a structural level, clients noted that transportation barriers affected access to clinics. Even when the clinics reopened, clients still struggled with access as public transportation reduced operations. As one key stakeholder said, "You have to travel to all these places. There is public transportation in DC, but you know that comes with its challenges. You could use ride-sharing options, which, you know, depending on traffic, that might affect your ability to get to an appointment on time. Also, it can become . . . cost prohibitive." Key informants noted fear as a factor in avoiding care. Many patients already faced increased risk of disease at their places of employment or from other interactions and feared additional risk; clinics and hospitals were seen as key vectors of spread. People feared going to a clinic or hospital they did not know or trust for a mammogram or colonoscopy. Clinics worked hard to convince current patients that it was safe to come back, but they are still not sure how many new or intermittent clients were lost. Fear also arose as a profound concern when talking about testing and COVID-19 vaccinations. One informant noted that their clinic's clients were always left out and overlooked for vaccine interventions and programs. Then, when the vaccine came out there were two reactions. First, the sudden interest in engaging these patients and getting them vaccinated made them wonder if there were ulterior motives involved. Second, once the vaccine was released, it became hard to obtain as people from other parts of the city, who did not look like the clinic's clients, rushed in to get vaccinated. To avoid this second problem, most of the clinics and agencies worked diligently to recalibrate and ensure that local 6 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC community members were prioritized after this initial groundswell in vaccination demand. Sites serving unhoused people noted that loss to follow-up was already an issue pre-pandemic, but that pandemic conditions exacerbated these long-standing issues. Financing As organizations reassured clients and staff, many were facing early financial challenges. Clinics and service providers lost revenue because of lockdowns, and subsequent slow reopening limited in-person visits. Lower patient volume meant lower income for organizations that were already operating on a limited-to-no-profit footing. In addition, organizations had to purchase items such as personal protection equipment for staff (and clients); new, more effective cleaning supplies; and other safety equipment. The rapid turn to virtual service provision required purchases of computers, tablets, and client phones. Rarely did grant funding cover all of these expenses. Finally, most service providers also tried to help clients with some of their other basic human needs such as food, clothing, transportation, and more, again resulting in financial difficulties. Lost revenue and additional expenses left many organizations financially fragile. While reassuring staff they were not going under, they had to rethink staffing models. Staff were also facing their own COVID-19 challenges; not only were they frontline people at risk of catching and spreading a deadly disease to family members, but they also had personal issues with finances, child care, virtual education, broadband, and more. Unfortunately, some staff died from COVID-19, which naturally increased fear among some others. Organizations created solutions so staff could work effectively in a remote capacity. Health centers tried to provide social and financial support for staff; one clinic noted that they paid everyone their full salary even as absences and part-time shifts were accepted. The compassionate response to staff at the health centers we interviewed engendered loyalty, and few staff left in the acute period. In response to financial struggles, many foundations allowed organizations to repurpose current grants and apply for additional funding to meet new technology and other needs. Some clinics created partnerships with telecom companies to cover client phones and/or minutes. Foundation funding allowed most centers to purchase organizational computers, tablets, software, and-at times-client hardware to support telehealth services. Every partner we interviewed noted that foundations' flexibility was of paramount importance in reaching and serving patients. Government funding was often more restricted and slower to be made available, so organizations appreciated those funders who allowed them to use their judgment on how best to expend money in service to their desired equitable outcome goals. One downside was that too often this relief came with additional-often duplicative and onerous-reporting requirements that interviewees hoped could be streamlined in the event of future emergencies. Practice Changes at Health Care Agencies Adopting telehealth was imperative during the pandemic; organizations had to pivot to seeing most or all patients using video or phone connections. As reported to us, clients had a mixed reaction to this DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC 7 change. Some were happy to receive health and social supports without having to arrange child care, risk exposure, and/or find transportation to and from appointments. Others were less accepting because they missed the in-person contact. Providers, too, seemed to have some ambivalence, because most had not trained to provide high-quality telehealth services. Additionally, several providers noted having to negotiate with certain patients who were adamant about not coming in for in-person visits. One focus group participant said: It's pretty functional for what it's worth. I didn't mind it at all because it saves you a trip, the money that you didn't have to get here, the energy, the resources. It saves you some time and effort that you could actually discuss what was possibly happening. And if you needed to come in, on an as needed basis, they allowed you to. It worked for me. Another focus group participant shared a different view: Online, it was so bad. . . . I tried to go online so many times, and if you don't know about that computer, you can miss out on a lot of benefits. They had a lot of benefits online about COVID, but you had to stay online to get on those services, because you couldn't go down there to get anything. Moving to telehealth was often not easy. Many clinics tried different telehealth platforms until settling on one or two that were deemed easiest for clients and staff. Several providers emphasized the need to rely on low-barrier telehealth services that made accessing appointments easy and straightforward. One provider utilized a telehealth service that emails or texts the patient a link to the appointment, giving them an easy, one-click step to seeing their provider. Others noted staff spent an enormous amount of nonreimbursable time teaching clients how to use the new modalities. Ultimately, many clinics relied on providing care telephonically. While many policy-related discussions reference video appointments, key informants we interviewed said their clients preferred phone calls for myriad reasons including ease of use, lack of broadband access, and lack of technology allowing for easy video use. Sites did note drawbacks to telehealth, including more difficulty lining up translation services, particularly for non-Spanish-speaking patients. When bilingual people were seen in person, it was easy to have the translator enter the exam room. With telehealth, more scheduling and capacity for teleservices were required. If a patient was late or needed to reschedule, the translator might have a conflicting, scheduled commitment with some other provider. Some providers felt that behavioral health services were easier to provide over the phone, as patients were more comfortable in their home environments. Additionally, behavioral health providers highlighted that telehealth granted them a new perspective when seeing patients, as they were able to focus only on their face. Conversely, these providers also noted that telehealth prevented them from noticing subtle changes in a patient's nonverbal communication that would clue them in to their mental state, such as a shaking leg or tense body posture. One behavioral health provider shared the following: A lot of the time, they're comfortable in their own environment, and don't prefer to come out. One of the barriers of them not being seen in person is the things they don't always relay that we're not able to pick up on, which we can't observe on the phone. We'd need to see their movements and their presentation in person. The remote services are helpful in some instances, but when clients are in crisis, it's not as helpful. 8 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC Providers treating medical needs wanted to see patients with physical ailments in person so they could look at the mole or other manifestations. In addition, many preventive-care measures require in- person visits and testing. These were inevitably harder to deliver when telehealth was the default option for care. Operationally, many health care providers found that they could not rely on telehealth entirely. Providers serving those who are unhoused found that relying completely on telehealth overwhelmed the front-desk staff, who had the job of setting up each walk-in appointment with the needed telehealth equipment to see a provider. To reduce the workload of front-desk staff and accommodate those recipients who struggled with technology, these providers switched to a hybrid schedule. For recipients who did not have personal access to telehealth equipment, a "telehealth room" was offered where clients could take appointments and speak with providers. Some providers found that this switch to a hybrid model granted them a more holistic understanding of their patients due to the reduction in walk- in visits and maintenance of a stable, longitudinal case load. This allowed them to better connect patients to services that they fundamentally needed. It was almost like I had the same [consistent] case load during the pandemic. I would see the same 10 clients instead of 50 walk-ins a month, which allowed me to dig deeper and identify what supports they needed/didn't have, and to create a plan to achieve whatever goals they had. -Case manager Telehealth was the most-discussed COVID-related change, but not the only one. In response to the pandemic, clinics had to reduce the number and types of visits. Agencies had to sharply reduce the number of patients seen to comport with safety and social-distancing rules. When seeing the most- vulnerable patients, clinics sought to ensure they had mitigated the risk of COVID-19 exposure. Because of these exposure mitigation efforts, most clinics no longer could see their usual large volume of walk-ins. Regulating the volume of people in the building meant clinics had to require appointments. While this may seem better for preventive care, walk-in visits are often valuable for bringing people up to date on shots and other preventive measures. In addition, clients also have varied schedules, may be unstably housed, or have other reasons why they need more flexible scheduling, and this was eliminated with the acute practice changes. As soon as possible, most sites sought to reinstate walk-ins and continued to provide as many preventive services as possible to both walk-in and appointment patients. Changes in staffing patterns required by social distancing and staff realities at home also impacted the number of patients that could be seen on site. Ultimately, these staffing changes affected access not just to health care but also to other social services. Few facilities offered just one service; most were an DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC 9 amalgam of health, social, employment, and/or transportation services and more. With the lockdown, many of the nonurgent health supports closed or became ambulatory. For instance, one agency that provided daily food began dropping it off at clients' houses, although this often limited their services because they could not always find their clientele. Health Care Needs For the first three to six months, access to COVID-19 care, testing, services, and then vaccine took priority over everything else. At times, this change in priorities required redeployment of staff from usual duties that may have included preventive care education, testing, and engagement. For example, sites that previously offered diabetes management courses focused instead during the pandemic on COVID-19 prevention courses. Similarly, lab work was often geared toward the testing needs of the community. However, even as there was a laser focus on COVID-19, every site mentioned experiencing an increased demand for mental health services. Mental health services, often stigmatized and ignored pre-pandemic, were mentioned by every interviewee as something needed and accepted during the pandemic. One interviewee felt that discussing mental health in terms of increased anxiety and pandemic-induced stress made it easier for patients to reach out and ask for support. Even some of the mental health providers struggled to meet patient need because of an overall shortage of staff before and during the pandemic. Several patient participants noted an increase in mental health distress but a decrease in mental health offerings due to shutdowns and limited operating hours. But the recognition of the ongoing need has been one area where interviewees agreed that telehealth could really play an important access role. Patient participants noted that their distress largely had to do with a feeling of stagnation, frustration, and alienation over lack of job opportunities, stable housing, and basic needs during the height of the pandemic. A focus group participant described the following: If you had a goal, you couldn't reach it anymore because things are shut down. We're living in an unknown, what's happening? What's going to happen? We don't know what to do, which way to turn. Our lives have been interrupted, and who knows when we will be whole again? If I could do something about it, I would and did. But some things you just couldn't do anything because things would be shut down, and it affected me. We're still feeling the effects of this pandemic. Every interviewee noted the significant shift away from preventive care during the pandemic. One of the federally qualified health centers with whom we talked had detailed statistics that demonstrated a considerable decrease in initial preventive care screening for diabetes, breast cancer, immunizations, and more. Another site pointed out that there were major delays in scheduling these preventive care screenings, with wait times of as much as half a year. There's a delay in getting cancer screening tests, not so much on our end. I guess our problems are twofold. Some people weren't coming in for fear of the pandemic, which seems 10 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC to be waning a bit, so that was one issue. But if they came in for preventative care, it would take several months (for example, a colonoscopy) to get them on the schedule. And I'm sure that's a complex issue influenced by personnel issues and a multitude of factors. But I definitely think it's worrisome that it takes so long to get people in for mammograms and colonoscopies and things like that. -Health care provider But informants also noted that secondary prevention suffered as well. When people returned to care, their diabetes and hypertension were no longer controlled and caused harmful sequelae. Others felt that people were going to have higher-stage cancer diagnoses because of missed screenings. Most clinics were trying desperately to catch up, recommending preventive measures to all who entered. But they admitted that they had lost many clients to changes in employment and insurance, eviction, and other negative pandemic consequences. As a result, there were many patients who were still not receiving preventive care. Ongoing Considerations and Lessons Learned From the outset of the pandemic, governments and organizations diligently worked to overcome barriers for all patients and, once data demonstrated inequities, began to promote work to eliminate them. However, overall access to and outcomes from culturally and linguistically effective preventive services seemed to decrease. COVID-19 led to some innovations and demonstrated that the health care system can change, when necessary, but lack of consistent disaggregated data made it more difficult to know which innovations most successfully reduced inequities. Drawing from this conclusion, we have arrived at the following recommendations: 1. Support providers and services that have a long history of working in partnership with clients on how they develop, implement, and deliver services. During the pandemic these organizations already had the infrastructure in place to listen and respond to patient needs. Often the larger, well-funded providers received money even as they were turning patients away. 2. Provide more flexible funding to support providers and organizations in responding to each client's unique and urgent needs. Flexible funding can allow for staff redeployment, rapid purchase of electronic infrastructure, rapid purchase of protective equipment, but also on the client level can help with individual transportation, food, and other social needs that may improve the individual's access to and engagement in preventive services. 3. Align required data collection to help with understanding effects of service-provider investments while reducing burden. It was difficult for providers who were overwhelmed and at DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC 11 risk to collect different evaluation data for the myriad of funders. It also made it harder for them to analyze and use findings. Funders could work to align metrics and help agencies collect the data that will demonstrate achievement of goals. 4. Conduct additional research to assess which telehealth services are most effective and for whom, with an eye toward understanding whether telehealth is equally effective for all populations and care needs. Notes 1 Jordan Grushkin, John Tilton, and Kenneth Yood, "Elective and Non-Essential Medical Procedures: States React to Federal Recommendations and the Opening Up America Again Guidelines," Sheppard Mullin, April 23, 2020, https://www.sheppardhealthlaw.com/2020/04/articles/coronavirus/reopening-guidance-elective-non- essential-medical-procedures/. 2 Akilah Johnson and Dan Keating, "Whites Now More Likely to Die from Covid Than Blacks: Why the Pandemic Shifted," Washington Post, October 19, 2022, https://www.washingtonpost.com/health/2022/10/19/covid- deaths-us-race/. References Drake, Patrick, and Robin Rudowitz. 2022. "Tracking Social Determinants of Health during the COVID-19 Pandemic." San Francisco: Kaiser Family Foundation. Hill, Latoya, and Samantha Artiga, 2022. "COVID-19 Cases and Deaths by Race/Ethnicity: Current Data and Changes Over Time." San Francisco: Kaiser Family Foundation. Mehrotra, Ateev, Michael E. Chernew, David Linetsky, Hilary Hatch, David M. Cutler, and Eric C. Schneider. 2021. "The Impact of COVID-19 on Outpatient Visits in 2020: Visits Remained Stable, Despite a Late Surge in Cases." New York: Commonwealth Fund. Roll, Stephen, and Michal Grinstein-Weiss. 2020. Did CARES Act Benefits Reach Vulnerable Americans? Evidence from a National Survey. Washington, DC: Brookings Institution. About the Authors Kimá Joy Taylor is the founder of Anka Consulting, a health care consulting firm, and a nonresident fellow at the Urban Institute. Taylor collaborates with Urban Institute researchers on a number of topics, including analyses of racial disparities in screening and treatment practices for parents with substance use disorder, management of neonatal abstinence syndrome at hospitals in California, and prevention and early detection of mental and behavioral health problems among adolescents and young adults. Sarah Benatar is a principal research associate in the Health Policy Center at the Urban Institute. Her research investigates how public policies affect vulnerable populations' health outcomes, access to care, use of services, and enrollment in coverage programs, with a particular focus on maternal and child health. 12 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC Faith Mitchell is an Institute fellow at the Urban Institute working with the Center on Nonprofits and Philanthropy and the Health Policy Center. She is also developing Urban's American Transformation project, which will look at the implications-and possibilities-of this country's racial and ethnic evolution. Over several decades, her career has bridged research, practice, and social and health policy. Jackie Liu is a qualitative research assistant in the Health Policy Center at the Urban Institute. She assists in research concerning the impact public policies have on health care access and outcomes, with a particular focus on marginalized communities. Her past research has focused on revising liver transplant policies depending on smoking status, analyzing the impact of women's empowerment on maternal and child health, and untangling how providers are complicit in medicalized fatphobia. Clara Alvarez Caraveo is a research analyst studying the effects of Medicaid expansion as a result of the Affordable Care Act on maternal health and coverage trends among vulnerable populations. She uses quantitative analysis to understand underlying trends in health and health insurance coverage to inform policy recommendations. DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC 13 Acknowledgments This brief was funded by the Merck Foundation. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. This report greatly benefitted from feedback from DaQuan Lawrence and Sarah Coquillat, as well as from the comments, suggestions and questions that resulted from discussions with members of our community advisory board. This report also benefited from the editorial assistance of Rachel Kenney, Gordon Swift, and Lauren Lastowka. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people's lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance 500 L'Enfant Plaza SW fairness and enhance the well-being of people and places. Washington, DC 20024 Copyright © January 2023. Urban Institute. Permission is granted for www.urban.org reproduction of this file, with attribution to the Urban Institute. 14 DISPARITIES IN PREVENTIVE CARE RECEIPT IN WASHINGTON, DC