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As Covid-19 continues to strain the country’s hospital system, new research exposes a striking gap in access to ICU care from one community to the next.

The study, published Monday in Health Affairs, examined an area’s median household income compared to the number of ICU beds per 10,000 residents over 50 years old — the age cohort at greatest risk for Covid-19 hospitalization. Nearly half of the communities with a median income under $35,000 had no ICU beds at all in their ZIP code cluster, compared to only 3% of communities with a median income over $90,000.


The authors warn that the staggering scarcity of critical care services in low-income populations can exacerbate existing disparities seen in deaths due to Covid-19. Many low-income individuals are already at increased risk of infection because they are less likely to be able to work from home and may face more challenges in quarantining.

“What we find is that this low income population is going to be doubly or triply hit,” said Genevieve Kanter, an assistant professor at the University of Pennsylvania Perelman School of Medicine and the first author of the study.

“Not only will there be higher infection rates, and worse outcomes due to underlying conditions, but also — once you get to the hospital — worse availability of the kind of care that you need,” she added.


In the earliest days after Covid-19 arrived in the U.S., confirmed cases were in people who had traveled to other parts of the world. But Kanter and her colleagues knew that if the virus were to start spreading locally, it might take a disproportionate toll on certain communities.

“What we saw coming down the pike was that eventually it was going to start hitting low-income populations,” she said.

The researchers wanted to prepare for that inevitability by taking formal stock of resources in those low-income areas. Gathering that data, they hoped, would arm policymakers with the information needed to protect the most vulnerable.

health affairs icu beds
Health Affairs Health Affairs

Now, with evidence of the disparities in ICU access, Kanter and her co-authors are urging state governments to step in and impose a patient transfer system to evenly distribute Covid-19 care among hospitals.

Another proposal: expand critical care capacity in low-income areas by temporarily outfitting procedural areas and other inpatient units with ICU beds, procured with emergency funds. The authors also suggested reconsidering the standard practice of transporting all patients to their nearest hospital, instead distributing those who are relatively stable to further locations with greater capacity.

“I do hope very much that people in state legislatures are paying attention to this,” said Nancy Beaulieu, a researcher in health care policy at Harvard Medical School who was not involved in the study.

The paper also found that this class-based disparity was far starker in rural areas than urban areas, a finding Beaulieu said was particularly notable.

“That’s a really important distinction because the health care delivery systems are very different in these areas. And the policy options for addressing disparities in these two types of areas are also likely to be quite different,” she said.

Beaulieu said researchers need to launch further studies into other disparities that affect low-income populations, such as a lack of access to specialists and fragmented coordination between speciality and primary care providers.

“Now that we have the attention on this issue, I think it’s very important to keep working at it and really come up with some actionable steps that we can take to improve the delivery systems,” she said.

  • I am not surprised. The lack of intensive care units in rural areas is to be expected. These types of units are primarily found in midsize to large cities. There are political and socioeconomic reasons for this. Perhaps it is time to stop forcing people to move away from rural areas for work. If internet access was more easily available and more workers could telecommute from anywhere it could decrease the excessive concentration of population we are currently seeing in cities. This move could rehabilitate rural communities, provide more affordable housing for the homeless living in cities in need, and support the development of bigger healthcare centers to serve these communities. It would also decrease the cloud of pollution hanging over a lot of cities. Sadly we are stuck with two political parties that are not interested in actual solutions but rather in keeping people concentrated in large urban communities with growing inequalities. We need a third more practical option.

  • The info in this article underlines what the rest of the world already knows, and certainly sees in Covid times : health care in the US caters to those with deeper pockets, and makes second class citizens of those with lesser means. And this is the nation that proclaimes itself to be “the best country in the world”? What a sad joke.

  • no surprise. it is expensive to have a patient in the ICU so if there is no reimbursement, there will not be an ICU. another reason we need medicare for all. I was at a medical meeting when another doctor told the hospital administrator that the longer the patients lived, the more money the hospital lost on the ICU patient–so they should make sure that the ICU physicians weren’t very good and the patients died quickly. this doctor was a surgeon, no surprise.

  • If the study had included predominate insurance provider, perhaps Medicaid,
    it would be clear why no provision of very costly services were found.Medicaid pays providers approximately 80% of costs so money is lost on all Medicaid patients.

    • First author of the study here. We actually did include, in our statistical model, % Medicaid and % Medicare beneficiaries (also race), and the income – ICU bed relationship still holds, accounting for these factors. Also, a lot of communities with zero ICU beds were in states that didn’t expand Medicaid.

      You do raise two important points — that Medicaid does not pay on parity with other insurers and that hospitals that locate in low-income areas do not have the resources or the incentive to provide/invest in expensive high-tech care. In either case, in the presence of COVID-19, there will be serious human cost to these disparities.

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