South Seattle Neighborcare Response to COVID-19 Exposes Health Care Inequities

by Alexa Peters

In South Seattle, those who are uninsured, face housing instability, or are undocumented immigrants have few places to turn other than sliding-scale neighborhood clinics like Neighborcare. With South End locations in Columbia City, Rainier Beach, and Georgetown, Neighborcare typically provides vital medical, dental and behavioral care to South King County residents as well as those who have been pushed out by gentrification and come to the clinic from as far away as Kent and Tukwila.

"Across Neighborcare, about 70% of our patients have household incomes at 200% federal poverty level or lower. And at our Rainier Beach clinic, nearly 87% of our patients have household incomes at 200% of federal poverty level or lower," said Neighborcare's Communications Director Mary Schilder.

Amid the COVID-19 pandemic, which has now claimed the lives of 189 (as of this writing) Washington residents, community clinics like Neighborcare and healthcare advocates fight for the state's most vulnerable amidst overwhelm, underfunding, and inequity.

South Seattle residents have the "lowest rates of health insurance and annual dental visits" and many "unmet medical needs due to cost," according to the 2018/2019 King County Community Health Needs Assessment. They are also at higher risk for conditions like diabetes and heart disease that may make them more vulnerable to poorer outcomes like COVID-19.

"Diabetes diminishes your ability to fight infection and heart disease [and] just puts a lot more demand on the body because your heart has to work harder," said Dr. Valentina Warren, a family practice doctor for Neighborcare in Rainier Beach.

Up until the pandemic, Neighborcare focused exclusively on providing access to preventative care to South Seattle and prided themselves on being a safe place for community gathering and education—all on a shoestring budget. But as the seriousness of novel coronavirus takes hold, Neighborcare has had to pivot dramatically to react to the pandemic.

Like most other clinics and hospitals in the country, they're being inundated with patients while working with limited amounts of personal protective equipment (PPE). For that reason, they have moved away from in-person visits to limit exposure and are instead utilizing telehealth since the Federal government relaxed regulations.

Neighborcare has also begun to treat those with COVID-19 symptoms outside in the parking lot, so as not to expose other patients, and has set up a pilot outdoor testing site at their Rainier Beach clinic for current patients who've already spoken with a provider over the phone. If all goes well, they hope to install more outdoor COVID testing at additional locations.

Though they are adapting quickly, Neighborcare's Schilder says that switching their entire model has been "challenging" to both staff, who are trained for specialized care, and for patients, who are used to feeling welcome inside clinics for all of their complex needs. Dr. Warner said that switching the community clinic model feels "confusing" right now.

"A lot of the people who are the highest risk for COVID-19 are the ones really needing to be seen for routine visits, like blood sugar, blood pressure, heart failure—you really have to see those people in person to do appropriate medical care," said Dr. Warner.

Things are similarly challenging for other clinics around the South Seattle area. According to Dr. Deepa Yerram, practice lead for Zoom+Care's Seattle market including the Southcenter clinic, they are seeing large numbers of patients in an effort to mitigate overwhelmed emergency rooms. To do this they have also had to start seeing all "non-urgent" patients using telehealth, video, and their chat application, which allows patients to speak directly with providers. Yerram is optimistic about the reach of their technology when it comes to keeping up treatment for their patients at high-risk for COVID-19.

"If we're unable to provide [in-person] care long-term, then yes, [I'd be concerned for these high-risk patients.] But we can do almost everything over phone and video that we do at a normal appointment," said Dr. Yerram. "If labs are needed, we can do it at our neighborhood clinics. Given the scenario this is the best way we've figured to go forward and provide care to those in the high-risk group."

Along with worries for their patients, Schilder says Neighborcare is facing an "unprecedented financial impact" because traditionally, they weren't able to bill telehealth appointments and they've lost a major source of revenue by suspending routine dental visits to create more resources for the COVID-19 response. This could have long-lasting economic impact for these vital hubs: The Washington Association for Community Health told NPR that the cutback in dental care alone could lead to a $250 million shortfall for the state's community health center system, and many clinics are already cutting back staff hours.

That said, Washington State Health Care Authority did recently approve that community health centers will receive a comparable payment for Medicaid visits by phone as compared to in-person visits. This may help mitigate financial strain, Schilder said.

The impact on community health clinics and other factors have raised some concern that racial and economic disparities in healthcare will dictate access to quality, preventative COVID-19 care in this emergency.

Robert Jones is a fourth-year medical student at the University of Washington with a dual degree in public health and epidemiology. For the last two years of his program, and up until two weeks ago, Jones has been learning medical specialities by working with patients from all walks of life in hospitals and clinics. In terms of minorities and people of color during the pandemic, Jones says he has some concerns.

"I'm concerned because I'm a black male and there are very few of us in medicine, and although I was a student, I still was a representative voice of the care for that community. [And] especially in uncharted territory like this, decisions that get handed down are often informed by status quo models in existence," said Jones.

Before the pandemic, and even as a medical student who couldn't prescribe, Jones said he would often share what he knew about the experience of being a person of color with care teams in order to give minority patients access to the best-possible care. Jones asserts that this lens is extremely important right now, and he's not sure it will be provided.

"What I would often be able to do is comment on how other communities experience their day and their interaction with the system," Jones said."In this case, getting to the pharmacy to get their medications, getting internet connectivity to be able to have the [virtual] patient encounters, getting to the walk-in clinic that you set up in a new area that's not along their bus route, or even now, putting them in a situation where they have to be on a bus."

Additionally, Kelly Powers, a healthcare advocate who works with Healthcare for All Washington said that this recent Buzzfeed article, about a group of Virginia doctors who fear African Americans aren't getting fair access to COVID-19 testing, got her wondering whether COVID-19 tests are being distributed fairly in Washington State.

"The article said there is no counting being done among race lines for testing, to figure out who's getting tests. That's not something they're asking about or recording on the public health side. We don't know if the testing is being equitably distributed," Powers said.

Washington DOH does ask about race on their surveillance data collection form, but that form is only used if someone tests positive, says their public information officer Jamie Nixon. Regarding if inequities are being considered as tests are dolled out, Nixon referred me to those who are conducting testing—clinicians and facilities.

Currently, COVID-19 tests in Washington are provided based on providers' recommendations. According to a form sent along by Seattle Public Health to providers in the city, the main diagnostics local providers are using are fever, cough or shortness of breath in the past 14 days.

But, as the Buzzfeed article reports, "doctors have to rely on a lot of diagnostics that can be quite subjective to decide whether someone should get a test or not… rather than measurable objective factors" and this makes the whole process of testing "more vulnerable to the implicit biases that every patient and medical professional carr[ies] around with them."

For her part, Dr. Warner thinks economic inequalities experienced by minorities, the unstably housed, and undocumented immigrants, are just as, if not more, concerning than potential testing inequities.

"Once there's a treatment, issues of class, race, and inequality will be super glaring [in respect to access to tests]," said Warner. "But, what's more important [right now] is that people have access to safe housing and food because they're sick. They shouldn't be in overcrowded housing, which is happening more because of gentrification."

As Warner said, a lack of safe, adequate housing may speed transmission. And, though Seattle has put a moratorium on evictions during this time, Warner says she believes this "piecemeal approach" is not adequate.

"In South Seattle [economic relief] is really needed. Because, you know, we're pressing on it more and more, there are a lot of people who are borderline homeless, you know what I mean? People are crowded, more than they've ever been," Warner said.

Additionally, Northwest Health Law Advocates, a group that lobbies for consumers in the health sector, expressed their concern for immigrants during this time because they are more likely to be uninsured and low-income, and are subject to Trump-era policies such as increased immigration enforcement, which prevents some immigrants from venturing out to seek care at their neighborhood clinics.

This is an area that is particularly close to Eric Gonzalez, Legislative Director at ACLU of Washington and son of immigrant field workers in Wenatchee. Raised on Medicaid, and well-aware of its necessity for families like his, he fought last year to have the program extended to cover children until age 26. It didn't pass, but he still contends that better fundamental coverage like expanded Medicaid—for everyone—is a key takeaway from this pandemic.

"I think we know that people should have healthcare and I don't believe that immigration status should be what determines a person's ability to get healthcare. I think there should be options regardless of whether or not you're employed," said Gonzalez. "I think going forward we need to really think about prioritizing foundational public health, instead of reacting to it."

Alexa Peters is a Seattle based journalist

Featured image by Alex Garland