[Senate Hearing 117-178]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 117-178

                    EXAMINING OUR COVID	19 RESPONSE:
                  IMPROVING HEALTH EQUITY AND OUTCOMES
                    BY ADDRESSING HEALTH DISPARITIES

=======================================================================

                                 HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                                   ON

 EXAMINING OUR COVID-19 RESPONSE, FOCUSING ON IMPROVING HEALTH EQUITY 
             AND OUTCOMES BY ADDRESSING HEALTH DISPARITIES

                               __________

                             MARCH 25, 2021

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                    PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                     TOMMY TUBERVILLE, Alabama
                                     JERRY MORAN, Kansas

                     Evan T. Schatz, Staff Director
               David P. Cleary, Republican Staff Director
                  John Righter, Deputy Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        THURSDAY, MARCH 25, 2021

                                                                   Page

                           Committee Members

Murray, Hon. Patty, Chair, Committee on Health, Education, Labor, 
  and Pensions, Opening statement................................     1
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State 
  of North Carolina, Opening statement...........................     3

                               Witnesses

Wilkins, Consuelo H., MD, MSCI, Vice President for Health Equity, 
  Vanderbilt University Medical Center, Nashville, TN............     7
    Prepared statement...........................................     8
    Summary statement............................................    13
Echo-Hawk (Pawnee), Abigail, Executive Vice President, Seattle 
  Indian Health Board, Seattle, WA...............................    14
    Prepared statement...........................................    16
    Summary statement............................................    24
Mackenzie Williams, Taryn, Managing Director, Poverty to 
  Prosperity, Center for American Progress, Washington, DC.......    25
    Prepared statement...........................................    27
    Summary statement............................................    29
Woods, Gene A., President and Chief Executive Officer, Atrium 
  Health, Charlotte, NC..........................................    30
    Prepared statement...........................................    32
    Summary statement............................................    40

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.

Murray, Hon. Patty:
    COVID-19 & Achieving Health Equity, Disparities Report.......    67
Wilkins, Consuelo H:
    Equitable Pandemic Preparedness and Rapid Response: Lessons 
      from COVID-19 for Pandemic Health Equity...................   113
    ``A Systems Approach to Addressing COVID-19 Health 
      Inequities''...............................................   128

 
                    EXAMINING OUR COVID-19 RESPONSE:
                  IMPROVING HEALTH EQUITY AND OUTCOMES
                    BY ADDRESSING HEALTH DISPARITIES

                              ----------                              


                        Thursday, March 25, 2021

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:05 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Patty Murray, 
Chair of the Committee, presiding.
    Present: Senators Murray [presiding], Casey, Baldwin, 
Kaine, Hassan, Smith, Rosen, Lujan, Burr, Cassidy, Murkowski, 
Braun, and Scott.

                  OPENING STATEMENT OF SENATOR MURRAY

    The Chair. Good morning. The Senate Health, Education, 
Labor, and Pensions Committee will please come to order.
    Today we are holding a hearing on how we can address the 
health inequities that have made this pandemic so much more 
deadly for some communities than others. Ranking Member Burr 
and I will each have an opening statement, and then Senator 
Burr and I will introduce today's witnesses. After the 
witnesses give their testimony, Senators will each have 5 
minutes for a round of questions.
    Before we begin, I want to walk through the COVID-19 safety 
protocols in place. We will follow the advice of the attending 
physician and the Sergeant at Arms in conducting this hearing. 
The Committee Members are seated at least six feet apart, and 
some Senators are participating by video conference. While we 
are unable to have the hearing fully open to the public or 
media for in-person attendance, live video is available on our 
Committee website at help.senate.gov.
    If you are in need of accommodations, including closed 
captioning, you can reach out to the Committee or the Office of 
Congressional Accessibility Services.
    We are grateful to everyone, including our clerks, who have 
worked hard to get this set up and help everyone stay safe and 
healthy.
    When we talk about inequities, we are talking about the 
reality that people's health suffers because of systemic issues 
like how far they are from quality, affordable, accessible, 
culturally competent care; whether they are recruited for 
clinical trials or the health care workforce; and issues 
including social determinants of health, things like where 
people are born or live and work. The reality of health 
inequities is that how you live and even whether you live or 
die in a pandemic is impacted by your race, your income, your 
ZIP Code, your disability, your gender identity, and your 
sexual orientation, and these factors intersect in ways that 
compound injustice if you are, for example, a woman of color or 
a person with a low income and a disability. And now the COVID-
19 pandemic has deepened these inequities to a devastating 
effect and made it even more urgent we look at how we got to 
this awful point and what to do.
    Here are the facts. Native Hawaiian and Pacific Islanders 
have the highest COVID-19 infection rate. American Indian and 
Alaska Natives have the highest death and hospitalization 
rates. One of the strongest predictors of death for COVID-19 
next to age is having an intellectual disability. In the wake 
of this pandemic we have also seen an unacceptable and ugly 
uptick in hate crimes against Asian American and Pacific 
Islanders, like we saw in Georgia last week. And while the 
hospitalization rate for Black people and the rate for Latinx 
people are both around three times that for white people, and 
the death rates for each group are twice as high as that for 
white people, their vaccination rates are both half of the 
white population.
    The picture painted by the data so far is grim, and despite 
improvements, that picture is still incomplete. I secured a 
provision in law last year requiring the Centers for Disease 
Control and Prevention to provide monthly reports on COVID-19 
demographic data with information on sex, age, race, and 
ethnicity. And since the first report last May, the percentage 
of cases with complete racial data has increased from 21 to 71 
percent, and complete ethnic data has increased from 18 to 55 
percent, meaning we still have room for progress.
    Even on hospitalizations, where we've gone from having data 
on 40 percent of the cases a year ago to nearly 100 percent of 
cases now, the data fails to break out certain race and 
ethnicity data, for example, aggregating data on Asian American 
and Pacific Islander populations in a way that leaves us 
without a full vision into health inequities.
    We also still lack Federal reporting requirements for 
congregate care facilities, including for people with 
disabilities who have also been hit particularly hard by COVID-
19. And the challenge before us is to not only accurately 
collect and report the data but act on the realities we see in 
front of us and keep gathering information so we can improve 
our response.
    Which is why I'm glad we were able to make critical 
investments in the American Rescue Plan to support communities 
of color, people with disabilities, tribes, and other 
underserved communities. President Biden has also made this a 
priority by establishing his COVID-19 Health Equity Task Force 
on January 21st, and today the Administration announced a $10 
billion investment of funding from the American Rescue Plan to 
expand vaccine access and build vaccine confidence in 
underserved communities.
    The Administration also recently announced over $2 billion 
for an initiative supporting state, local, and territorial 
health departments as they address COVID-related health 
disparities; and has set up a program to distribute vaccines 
directly to 950 community health centers, which have been a 
lifeline to some of our hardest hit and hardest-to-reach 
communities during this pandemic.
    These investments, along with efforts from state and local 
governments and trusted community partners, are critical to 
making sure we get vaccines and information to communities of 
color, people with disabilities, rural communities, people with 
limited English proficiency, and people who lack access to the 
Internet, which in turn is critical to ending this pandemic for 
every community.
    Of course, while the pandemic has put a harsh spotlight on 
inequities in health care, there were problems long before the 
crisis began, and our work to end them must continue even after 
it ends, because the same injustices we are seeing play out 
with COVID have been playing out with maternal mortality, 
mental health, cancer, and many other health issues for years.
    I put out a report last year that outlined the many ways 
our health care system has failed communities of color and 
others due to entrenched bias, discrimination, ableism, and 
racism. The history is a long and painful one, and 
comprehensive action is overdue.
    Steps not only to address the inequities of this pandemic 
but also to root them out of the health care system altogether, 
like prohibiting discrimination in the health care system and 
requiring anti-racist and anti-bias training, providing support 
for people in underrepresented communities to participate in 
clinical trials, pursue a career in medical research, or become 
a health care provider, assuring everyone has quality, 
affordable health coverage, the support of strong public health 
infrastructure, and paid family sick and medical leave, those 
are a few of the recommendations I made in that report, and I 
look forward to hearing from our witnesses about these 
challenges during today's discussion on improving health 
equity.
    I really want to underscore, as I said when I first spoke 
about becoming Chair of this Committee, health equity is 
personally important to me, and I know to so many of us here 
today. We've all heard about it from people we represent. We 
know how painful and how present this injustice is across our 
states, and I believe the work on this Committee can make a 
difference. And I look forward to our discussion today and the 
work ahead.
    With that, I will turn it over to Ranking Member Senator 
Burr for his opening remarks.

                   OPENING STATEMENT OF SENATOR BURR

    Senator Burr. Thank you, Madam Chair. And I want to thank 
our witnesses for being here today to discuss ways to improve 
our pandemic response for those hit hardest by it, especially 
low-income, minority, and rural populations.
    This Committee has a long history of working together on 
health care issues that affect our seniors, our children, 
Americans with disabilities, and in supporting our hardest-to-
reach communities.
    To our witnesses, thank you. Thank you for the work you've 
done during the pandemic and for taking time away from your 
critical work to share your experiences today. On behalf of the 
Chair and I, we apologize that we may temporarily be out of the 
room because, as this hearing goes on, we'll have a series of 
four votes. But we're going to try to do it as seamlessly as we 
can, and we encourage all of the Members to please be here or 
let us know that you're not going to be here so that we can 
appropriately schedule time.
    The disproportionate impact of COVID-19 on minority 
populations, people in rural areas, and others has revealed 
cracks in our health care system that persist despite efforts 
to improve care, including through community health centers and 
the National Health Service Corps, which seek to improve care 
for underserved communities. This pandemic has given us another 
perspective on these challenges and demonstrates a need to 
redouble our work to address the underlying problems facing 
these and other affected populations. Each response requires 
the ability to identify the problems local communities will 
face, strong leadership to recognize the best solutions, and an 
ability to leverage the right approaches and technology to 
execute those changes.
    With each emergency response, we learn about the ways each 
threat affects Americans differently and have adjusted our laws 
and our plans accordingly. That's why we designed a response 
framework that is flexible: you never quite know how a new 
infectious disease or a natural disaster may impact us until 
it's on the ground and we are forced to respond. For example, 
during the last PAHPA reauthorization, Senator Casey and I 
included new advisory committees to identify the specific needs 
of our seniors and Americans with disabilities during 
emergencies. We also codified the Children's Preparedness Unit 
at CDC to improve the availability of information for health 
care providers and families during the response to a public 
health threat.
    We made changes to the PAHPA statute after the tragedies 
that occurred in Florida nursing homes in the 2017 hurricane 
season, allowing states to have better plans in place to 
protect their nursing home residents. Some states have done a 
great job of taking care of their nursing home residents during 
the COVID-19 response, and we can learn from the failures in 
New York and Pennsylvania about what not to do going forward.
    We have also made changes to the PAHPA statute to improve 
the development of countermeasures to meet the needs of 
different populations, and we've made sure we wrote it in a way 
that allowed maximum flexibility to respond to affected 
populations. During the response to swine flu, we realized that 
young children were coming into the hospital in need of 
treatment, so we worked quickly to get an emergency use 
authorization for flu antivirals, saving lives in real time. 
While we were working to treat children with swine flu, the 
science also showed us that some older Americans were less 
affected by the virus because that generation was exposed to a 
similar strain many years ago.
    In contrast, most children appear to be less likely to 
experience serious illnesses from COVID, and older adults are 
at significantly higher risk. This virus has also compounded 
existing challenges that many communities--including rural and 
racial and ethnic minorities, and low-income populations--face. 
These differences underscore the importance of maintaining 
flexibility as part of a public health response so that the 
state and local governments can most effectively reach those in 
their communities most at risk for a particular public health 
threat.
    The novel coronavirus has shown us that we cannot fully 
anticipate the ways in which a threat will affect different 
communities across the country. We have to utilize new 
technologies throughout the response to better understand just 
how the virus takes its toll and to do something about it.
    The FDA has provided greater flexibility in clinical trial 
designs, working with drug developers to enhance enrollment in 
clinical trials in ways that reach more communities by 
deploying remote technology that allows for patient monitoring 
without traveling to a major hospital. Manufacturers have 
gotten creative with targeting their trials to those who stand 
to benefit the most from a drug, with one developer creating 
mobile units to bring their COVID therapies directly to nursing 
homes as soon as they found an outbreak of the virus. Mobile 
health units have also been deployed to bring testing and 
vaccines to areas that needed countermeasures, and partnerships 
with Historically Black Colleges and Universities improved 
outreach to racial and ethnic minority populations on testing, 
participation in clinical trials, and providing information on 
vaccines and ways to prevent COVID.
    Now, as we look toward the weeks and months ahead, this 
ingenuity needs to continue. Our response efforts must leverage 
technology to improve our surveillance capabilities and inform 
our public health decisionmaking, and our policies should 
encourage the incorporation of new technology, strategies, and 
partnerships to solve problems and overcome challenges.
    I look forward to hearing from the witnesses today on their 
testimony, and I yield to the Chair.
    [The prepared statement of Senator Burr follows:]
    The Chair. Thank you very much, Senator Burr.
    We will now introduce today's witnesses, and I'm pleased to 
start by welcoming Dr. Consuelo Wilkins. Dr. Wilkins is the 
Vice President for Health Equity and Professor of Medicine at 
Vanderbilt University Medical Center, and a principal 
investigator at the Vanderbilt Miami Meharry Center of 
Excellence in Precision Medicine and Population Health, which 
aims to reduce disparities among Black and Latino communities. 
She is also recognized for her innovative work to engage 
patients and communities in health research.
    Dr. Wilkins, welcome. Thank you for joining us today.
    Next I would like to introduce Abigail Echo-Hawk. She is a 
nationally recognized leader in tribal health and health 
inequities from my home state of Washington. Ms. Echo-Hawk is 
the Executive Vice President of the Seattle Indian Health 
Board, Director of the Urban Indian Health Institute, and an 
enrolled member of the Pawnee Nation of Oklahoma.
    Welcome, Ms. Echo-Hawk. We're very glad to have you with us 
today.
    Next I would like to introduce Taryn Williams. Ms. Williams 
is the Managing Director for the Poverty to Prosperity Program 
at the Center for American Progress, specializing in disability 
issues. She previously worked at the Office of Disability 
Employment Policy at the U.S. Department of Labor, where she 
handled a variety of issues related to education, workforce 
policy, Social Security, Medicaid, civil rights, and more. And 
I should also mention she is a HELP Committee alumnus, serving 
as policy advisor when Senator Harkin was the Chair.
    Ms. Williams, welcome back. Thank you for joining us today.
    Now I will turn it over to Ranking Member Burr to introduce 
our final witness, Mr. Gene Woods.
    Senator Burr. Thank you, Madam Chair.
    Before I introduce Gene Woods, let me say to Dr. Wilkins 
that I apologize that we have stolen your provost from 
Vanderbilt to become the next president of Wake Forest 
University. I understand she is a wonderful individual, a 
biologist, I think, by profession, and we look forward to 
having her on board at the end of next month.
    Madam Chair, Gene Woods really needs no introduction. He's 
from Charlotte, North Carolina, and I'm extremely proud of the 
incredible work of Atrium Health and of North Carolina's health 
systems during the pandemic this year.
    Thank you, Gene, for taking time out of your work to be 
with us today remotely.
    Mr. Woods currently serves as President and Chief Operating 
Officer of Atrium Health and brings to the panel over 30 years 
of leadership experience in the health care sector. Atrium 
Health is a nationally leading non-profit health system with 42 
hospitals and over 1,500 care locations across four states. 
Under Gene's leadership, Atrium Health has been recognized by 
the American Hospital Association with the Equity of Care Award 
for its commitment to serving underserved communities, and by 
the Centers for Medicare and Medicaid Services as a 2020 CMS 
Health Equity Award winner for its dedication to reducing 
health disparities.
    Gene has been recognized as one of the most influential 
people in health care and as one of the top 25 minority 
executives in health care, and is one of the most admired CEOs 
and is the 2020 Person of the Year by the Charlotte Business 
Journal. He was awarded the Senior Executive of the Year Award 
by the National Association of Health Services Executives.
    Gene is a leader among his peers, having served as Chairman 
of the American Hospital Association Board of Trustees, as well 
as the Wall Street Journal CEO Council. Gene holds three 
degrees from Pennsylvania State University, including a 
bachelor's degree on health planning and administration, a 
master's degree in business administration, and a master's 
degree in health administration.
    Gene, thank you for being with us today and for the 
important work that you're doing in North Carolina. I look 
forward to your testimony.
    The Chair. Thank you.
    Again, welcome to all of our witnesses. We appreciate you 
joining us today.
    I will reiterate what Senator Burr said. We have a number 
of votes occurring today, so he and I will both be in and out. 
I would ask all of our Members if you want to ask questions, 
please let our staffs know so we can schedule everybody in a 
timely fashion.
    With that, we'll begin our testimony. Dr. Wilkins, you may 
begin with your opening statement.

STATEMENT OF CONSUELO H. WILKINS, MD, MSCI, VICE PRESIDENT FOR 
HEALTH EQUITY, VANDERBILT UNIVERSITY MEDICAL CENTER, NASHVILLE, 
                               TN

    Dr. Wilkins. Thank you, Chairwoman Murray, Ranking Member 
Burr, and distinguished Members of the Committee. My name is 
Dr. Consuelo Wilkins. I am a physician, clinical researcher, 
and Vice President for Health Equity at Vanderbilt University 
Medical Center.
    Since March 2020 I have been deeply entrenched in managing 
COVID-19 operations, as well as COVID-19 research. As part of 
our COVID work streams at Vanderbilt, I've led the health 
equity work, and part of our goals is reducing disparities and 
increasing access to care.
    At Vanderbilt, we performed more than 185,000 COVID-19 
tests. We've cared for more than 3,400 hospitalized patients 
with COVID-19. And most recently, we vaccinated more than 
115,000 doses of vaccine.
    It has been harrowing to witness the devastating impacts of 
COVID-19 on marginalized and minoritized communities across the 
Nation. These are the very communities I've spent the last 21 
years striving to improve the lives of.
    As you know and has already been described, across the 
United States individuals who identify as African American, 
American Indian, Hispanic and Latino have been extremely 
impacted by this disease, bearing the burden of deaths and 
hospitalizations. Additionally, individuals who speak languages 
other than English, individuals who are unhoused, and people 
living in rural communities have been disproportionately 
impacted by COVID-19. And now, with three vaccines already 
available and the United States leading the way, these 
populations are being vaccinated at less than half the rate of 
other Americans.
    To address these COVID-19 inequities, I offer three 
critical areas we should prioritize as a country.
    First, the data. At Vanderbilt, we have disaggregated data 
by race, ethnicity, language, and ZIP Code. By doing so, we 
found the most striking disparities occurred in individuals who 
speak languages other than English, specifically those who 
speak Spanish and Arabic. We also found that the ZIP Code with 
the highest number of COVID-19 cases is one where African 
Americans are more likely to live, where individuals are 
actually more likely to be employed but have a per capita 
income of much less. This represents essential workers and 
individuals who are striving to take care of their families but 
cannot work from home. They live in households with more 
people, so there's more crowding. They're more likely to take 
public transportation, so they're at increased risk of the 
disease.
    Unfortunately, as Chairwoman Murray already pointed out, 
we're still lagging behind with collecting data on race and 
ethnicity. That alone, those strides we've made, won't be 
enough. We need better data. We need data that's detailed for 
ethnicity. We need social demographic data, social determinants 
of health data if we're truly going to actually develop 
strategies that are specific to the communities we intend to 
improve the lives of.
    That can't happen without funding. The reason that we're 
not actually collecting this data is we don't have people who 
are dedicated to it, who know how to do it in a meaningful, 
socially and culturally appropriate way. So that is necessary 
to move to the next stage.
    Second, we must invest in community-driven solutions. While 
I'm extremely proud of the work we've done at Vanderbilt, I am 
keenly aware that we are not able to address these health 
inequities alone. In Nashville, we are grateful that Meharry 
Medical College, an historically Black academic health center, 
has led city-wide COVID-19 testing and is now vaccinating 
individuals in the most vulnerable communities.
    Community health centers like Matthew Walker are 
vaccinating individuals in the most disadvantaged neighborhoods 
in Nashville. Salom Health has worked closely with our metro 
Nashville health department to offer community health workers 
who are bilingual and bicultural to do contact tracing and 
assist individuals with access to care.
    To be successful, we must prioritize trust. We have to 
invest in community organizations who are trusted and 
trustworthy, and they must be given the opportunity to lead 
with decisions that reflect the perceptions, the needs, and the 
preferences of the individuals that they represent.
    I'm grateful to hear that additional funding is being made 
available to these communities, but I fear it is not enough. 
They need to be able to provide transportation, resources to 
register for vaccinations, and develop long-term solutions.
    Finally, we must prepare for the long haul of COVID-19. As 
the early data indicate, more than a third of individuals will 
experience long-term consequences. The very populations who 
have been disproportionately impacted will suffer. They need 
care, we need research, and, of course, long term we need 
solutions that will address the underlying structural racism, 
inadequate public health infrastructure, and lack of health 
care.
    Thank you.
    [The prepared statement of Dr. Wilkins follows:]
               prepared statement of consuelo h. wilkins
    Chairwoman Murray, Ranking Member Burr, and Members of the 
Committee:

    My name is Dr. Consuelo H. Wilkins. I am a physician, clinical 
researcher, professor, and Vice President for Health Equity at 
Vanderbilt University Medical Center (VUMC). I am board certified in 
both Internal Medicine and Geriatric Medicine and practice on the 
inpatient geriatrics service. I lead a portfolio of research awards 
focused on health equity, health disparities, and clinical trial 
recruitment and am one of the Principal Investigators of our Clinical 
and Translational Science Award (CTSA) supported by the National 
Institutes of Health.

    Thank you for hosting this hearing ``Examining Our COVID-19 
Response: Improving Health Equity and Outcomes by Addressing Health 
Disparities''. COVID-19 health inequities have become intractable and I 
appreciate the invitation to share about the challenges VUMC faced 
addressing these inequities in addition to the lessons our team has 
learned implementing a systems approach to COVID-19 health equity. My 
testimony is based on my expertise in medicine, clinical research, 
community engagement and health equity, as well as my experience during 
the past year as member of the VUMC COVID-19 Command Center and COVID-
19 Mass Vaccination Executive Team.

    I will first provide background and contextual information related 
to COVID-19 inequities then share recommendations in three areas:

          1. Key data needed to drive more equitable decisions in the 
        COVID-19 response

          2. Community-driven solutions to COVID-19 inequities

          3. Preparing for COVID-19 long-haul

    My testimony will draw from two publications I co-authored: 
``Equitable Pandemic Preparedness and Rapid Response: Lessons from 
COVID-19 for Pandemic Health Equity'' and ``A Systems Approach to 
Addressing COVID-19 Health Inequities''. Both papers have been 
submitted to the Committee for inclusion in the record of the hearing.
                    Overview of COVID-19 Inequities
    Inequities in the burden of COVID -19 have been uncovered among 
marginalized populations across the world and have been particularly 
striking among African American, Indigenous, American Indian, Hispanic 
and Latino populations in the United States. These groups are 3-4 times 
more likely to be hospitalized and 2-2. times more likely to die from 
COVID-19 3. Individuals with limited English proficiency, people who 
are unhoused, and those living in rural communities have also been 
disproportionately impacted by COVID.

    With three COVID-19 vaccines now available, the United States is 
leading the world--vaccinating more than 2 million people each day. 
Unfortunately, the populations suffering the greatest burden of the 
COVID-19 pandemic are not fully benefiting from the tremendous 
scientific advancements in vaccine development. As of March 22, 2021, 
nearly 83 million Americans have received at least one dose 
administered of a COVID-19 vaccine and nearly 24 million are fully 
vaccinated. Of fully vaccinated persons with race/ethnicity data 
available, 7.4 percent are Hispanic/Latino, 7 percent are Black, and 4 
percent Asian, which is substantially lower than their representation 
in the U.S. population (18.5 percent, 13.4 percent, and 5.9 percent, 
respectively). These lower vaccination rates are particularly 
concerning in light of the higher rates of COVID-19 hospitalizations 
and deaths among Black and Hispanic/Latino populations. Conversely, 
White Americans are being vaccinated at a higher percentage (68.9 
percent) than their representation in national demographics (60.1 
percent).
                    Etiology of COVID-19 Inequities
    Although COVID-19 inequities are acute, they reflect long-standing 
disparities in health that many communities, clinicians, public health 
practitioners, and researchers have striven to address, often with too 
few resources. The causes of COVID-19 inequities are multifold and 
involve differences in exposure, susceptibility, testing, and 
treatment. Groups socially disadvantaged because of race, ethnicity, 
social position, and/or economic status have greater exposure to COVID-
19 because of jobs that prevent work from home, dependence on childcare 
outside the home, reliance on public transportation, and household 
size. Poverty and experiences with discrimination and racism lead to 
chronic psychosocial stress, causing prolonged secretion of stress 
hormones, which has profound physiological impacts. These changes lead 
to increased susceptibility both acutely, through impaired immune 
response to the virus, and chronically, through predisposition to 
diabetes, obesity, and cardiovascular disease, which are linked to 
worse COVID-19 outcomes. Marginalized groups are less likely to have a 
primary care provider, medical home, or regular access to care and may 
have limited access to COVID-19 testing, treatment, and vaccination.
       Lessons from a Systems Approach to COVID-19 Health Equity
    At Vanderbilt University Medical Center (VUMC), we have tested more 
than 185,000 people, admitted more than 3,400 people COVID-19, and 
administered more than 100,000 doses of COVID vaccines. At VUMC, we are 
utilizing a systems approach that emphasizes interdependence and 
interaction across the health system and community to address the 
complex drivers of COVID-19 inequities and rapidly respond to data 
trends in real time. As part of our COVID-19 Command Center, we created 
a health equity workstream to prevent, identify, and address COVID--
related inequities. (The Command Center refers to the team that 
coordinates the health system's response to an emergency or disaster, 
as well as the designated work space for those involved.) We identified 
five initial areas of concentration: four COVID-19--specific areas 
focused on prevention, testing, treatment, and clinical research; and 
the fifth area, telehealth, which, although not specific to COVID-19, 
is increasingly used because of the pandemic and could lead to 
inequities in access to care. By integrating health equity into our 
health system's COVID-19 operations, it is a priority, not an isolated 
stream of work. This approach has allowed us to identify and work to 
mitigate inequities in real time as our response to the pandemic has 
evolved. Our key lessons so far are:

          1. Executive leaders should clearly state that achieving 
        health equity is a priority and allocate resources, including 
        people, to do this important work; in the case of Vanderbilt 
        University Medical Center, institutional funds totaling more 
        than $1.5 million annually were committed to the Office of 
        Health Equity prior to COVID-19, facilitating our ability to 
        pivot and rapidly respond;

          2. Health equity--related goals and programs should be 
        integrated into the health system's organizational readiness 
        and response with clear expectations for accountability and 
        action;

          3. Race, ethnicity and language data must be available in 
        real time, and new processes may be needed to collect and 
        aggregate data;

          4. The COVID-19 Command Center includes a wide range of 
        clinical, administrative, and operations leaders, some of whom 
        have limited knowledge of health equity; this exposure could 
        facilitate culture change and innovative ways of advancing 
        health equity in the long term--an example of a learning health 
        system; and

          5. Hospitals and health systems must work closely with public 
        health departments and trusted organizations that are closely 
        connected to communities.
   Ongoing Challenges and Recommendations to Advance COVID-19 Health 
                                 Equity
    Key Data Needed To Drive Decisions

    The importance of race, ethnicity, and language (REAL) data to 
understanding COVID--19 cannot be overstated. Without these data, we 
are unable to disaggregate data to identify disparities in COVID-19 
testing, care, vaccination, and outcomes. Even when race, ethnicity, 
and language are available, these are insufficient for mitigating 
health inequities, which also requires data on social determinants of 
health.

    At VUMC, we created visualization dashboards for all patients 
tested for COVID--19 that can be filtered by race, ethnicity, primary 
language, and ZIP Code, which can be linked to community-level 
socioeconomic data and social vulnerability indices. For example, the 
ZIP Code with largest number of COVID-19 cases at VUMC is 37013 (Figure 
1, outlined in green). Compared with the Nashville metropolitan area, 
37013 is home to twice as many people who are Black/African American or 
Hispanic/Latino and three times more people who speak languages other 
than English at home. Despite a higher percentage of adults in this ZIP 
Code being employed, per capita income is 24 percent less than the 
Nashville metropolitan. We used this data to inform our communications 
strategies including the development and compilation of materials in 
Spanish and Arabic and to connect with trusted organizations serving 
communities in this ZIP Code to leverage and amplify the impact of 
communications efforts.



    Unfortunately, race and ethnicity are missing in data reported by 
the CDC in 46 percent of COVID-19 cases, 24 percent of deaths due to 
COVID-19, and 47 percent of COVID-19 vaccinations. Although the CDC's 
recommended reporting documentation9 includes fields for primary 
language and use of an interpreter, the CDC does not include primary 
language in its COVID Data Tracker or COVID-Net Hospitalization Data 
Tracker. Some local and state departments of health are reporting 
language data, however, there may still be a high proportion of 
missing/unknown data. For example, the Washington State Health 
Department reported 60.6 percent of unknown language data for confirmed 
or probable COVID-19 cases from 03/01/2020--03/13/202110. Several 
cities and states have mandated the collection of language data 
including California, Massachusetts, Michigan, North Carolina, Oregon, 
and New York City.

    Recommendations:

          1. Require capture of self-reported sociodemographic data 
        including race, ethnicity and preferred language in ways that 
        allow for the valid, non-stigmatizing collection of potentially 
        sensitive personal information.

          2. Capture individual and/or macrolevel data on the social 
        determinants of health geocoded to home addresses when 
        possible, at units of geography that correspond to meaningful, 
        locally defined neighborhoods (i.e., census block).

          3. Allow for data sharing across those sectors (health care, 
        public health, social services, etc.) while protecting 
        individuals' information.
     Community-Driven Solutions are Needed to Advance Health Equity
    One-size-fits-all approaches are unlikely to address the striking 
disparities evident in COVID-19. Many racial and ethnic minorities, 
individuals with limited English proficiency, and people living in 
rural communities face unique sociocultural and economic barriers to 
COVID-19 testing, care, and vaccination. Interventions most likely to 
be successful in receiving health equity are often embedded in the 
community and are built on trusting relationships, which are developed 
over time. Without well-established, mutually beneficial relationships, 
it is difficult to effectively mobilize resources and partner with 
trusted community organizations.

    Many community organizations are well positioned to lead or work 
closely with health systems and public health agencies to implement 
effective strategies to mitigate COVID-19. Trusted community 
organizations and leaders can develop and disseminate messaging about 
COVID-19 testing and vaccination that is relevant to socially 
vulnerable communities and recognizes the varying socioeconomic needs 
and differing levels of trust of health systems and government. 
Organizations already serving these communities can be sites for 
testing, distribution of PPE, multi-lingual communications, and 
vaccinations. Community organizations have the potential to address 
vaccine readiness and support/provide care for individuals experiencing 
long-term sequelae of COVID-19.
                            Recommendations:
        1. Fund trusted organizations within communities experiencing 
        inequities to be COVID--19 resource centers--providing access 
        to testing, educational information, access to vaccinations. 
        Include funds to support transportation to sites, child care, 
        operating evenings and weekends, interpreters, tailored 
        messaging, resources in multiple languages, and training for 
        peer educators and vaccinators.

        2. Create community-based surveillance programs that leverage 
        community assets and use community health workers to collect 
        surveillance data, share risk-reduction information, support 
        care for individuals with COVID-19, and serve as access point 
        for healthcare. Efforts to support utilization of community 
        health workers specifically for COVID-19 should be considered, 
        however, long-term strategies for reimbursement of community 
        health worker models are also needed.

        3. Provide additional funding to safety net providers in 
        recognition of the differential needs of safety net providers 
        who disproportionately care for populations experiencing COVID-
        19 inequities and typically have fewer resources at baseline.
                    Preparing for COVID-19 Long-Haul
    Early data indicate as many as a third of people with COVID-19 will 
experience long--term symptoms due to the disease. The full extent of 
the disease is yet unknown, however, given the disproportionate impact 
of COVID-19 on specific groups, we should expect these groups to also 
be burdened by the long-term sequelae. To date, people who have 
survived COVID-19's acute symptoms are experiencing extreme fatigue, 
shortness of breath, short-term memory loss, tinnitus, and 
hypersensitivity to light. For some individuals, these symptoms are 
debilitating, and with no known treatment, quite distressing.

    The potential long-term consequences of COVID-19 bring additional 
concerns for populations disproportionately burdened by the disease. 
These groups are less likely to have a primary care provider, medical 
home, or regular access to care. Although many states now have Long-
COVID clinics, individuals without routine access to care may not be 
referred. Additionally, these clinics are likely to be located in large 
cities and difficult to access for rural populations.
                            Recommendations:
          1. Provide long-term follow-up care and monitoring for people 
        diagnosed with COVID-19 including free care for those without 
        health insurance

          2. Make care available to individuals who experienced COVID-
        19 symptoms who may not have been tested.

          3. Provide specific research funding to understand and 
        address the long-term physical and mental health consequences 
        of COVID-19 in populations disproportionately impacted.
                               Conclusion
    Communities of color and other marginalized populations--those 
living in or near poverty, people who are unhoused, those living in 
rural communities, etc.--have limited to no resources or access to 
information address their communities' increased vulnerability to 
COVID-19. Importantly, the inequities emerging in the COVID-19 pandemic 
are not due to race or social class. Rather, they are the result of 
structural racism and social inequalities embedded within the economic, 
political, education, health care, criminal justice and other systems 
and social structures in the U.S. Understanding the fundamental causes 
of COVID-19 health inequities requires appreciating that the more 
proximate causes--higher rates of serious medical conditions, living in 
crowded housing, inability to work from home, etc.--are themselves the 
result of social inequalities produced by social systems reinforced 
through policy. We must act now to mitigate the immediate and long-term 
consequences of COVID--19 on populations already burdened by health 
inequities.
                                 ______
                                 
               [summary statement of consuelo h. wilkins]
    Consuelo H. Wilkins, MD, MSCI is a physician, clinical researcher, 
professor, and Vice President for Health Equity at Vanderbilt 
University Medical Center (VUMC) in Nashville, TN. Board certified in 
both Internal Medicine and Geriatric Medicine, Dr. Wilkins also leads a 
portfolio of research awards focused on health equity, health 
disparities, and clinical trial recruitment. She is a member of VUMC's 
COVID-19 Command Center and Mass Vaccination Executive Team.

    In her testimony, Dr. Wilkins will offer observations about health 
inequities exacerbated by COVID-19 and lessons learned at VUMC with 
respect to a systems approach to addressing health equity. Marginalized 
groups across the U.S. are experiencing a higher burden of COVID-19. 
African American, American Indian, Hispanic and Latino populations are 
3-4 times more likely to be hospitalized and 2-2.5 times more likely to 
die from COVID-19. Individuals with limited English proficiency, people 
who are unhoused, and those living in rural communities have also been 
disproportionately impacted by COVID-19. To address these COVID-19 
inequities, Dr. Wilkins recommends the following:

    To address these COVID-19 inequities, I recommend the following:

          1. Increase capture and use of key sociodemographic data 
        needed to drive strategies. Race and ethnicity data are missing 
        in 46 percent of COVID-19 cases and 47 percent of vaccinations 
        (CDC). Without this data, we are unable to fully understand the 
        extent of COVID-19 inequities or develop specific approaches to 
        mitigate. Primary language and social determinants data are 
        also essential to effectively addressing inequities.

            -Require collection of self-reported sociodemographic data 
        including race, ethnicity and preferred language--Capture 
        individual and/or macrolevel data on social determinants of 
        health geocoded to home addresses, at units that correspond to 
        defined neighborhoods (i.e., census block).--Allow data sharing 
        across health care, public health, social services, sectors

          2. Invest in community-driven solutions. One-size-fits-all 
        approaches will not address the striking disparities evident in 
        COVID-19. Solutions must be built on the specific needs, 
        perceptions, and assets of communities. Trusted organizations 
        embedded in communities must help drive solutions.

            -Fund trusted organizations within communities experiencing 
        inequities to be COVID-19 resource centers--providing access to 
        testing, risk prevention, and vaccinations.

            -Create and fund community-based programs that leverage 
        community assets such as community health workers to collect 
        surveillance data, share risk-reduction information, support 
        care for individuals with COVID-19, and serve as access point 
        for care.

            -Provide additional funding to community safety net 
        providers who disproportionately care for these populations

          3. Prepare for COVID-19 long-haul. Early data indicate as 
        many as a third of people with COVID-19 will experience long-
        term symptoms due to the disease. The full extent of the 
        disease is yet unknown, however, given the disproportionate 
        impact of COVID-19 on specific groups, we should expect these 
        groups to also be burdened by the long-term sequelae.

            -Provide follow-up care/monitoring for people diagnosed 
        with COVID-19 including free care for those without health 
        insurance--Make care available to individuals who experienced 
        COVID-19 symptoms but not tested

            -Fund research specifically to address long-term physical 
        and mental health inequities
                                 ______
                                 
    The Chair. Thank you, Dr. Wilkins.
    We will turn to Ms. Echo-Hawk.

    STATEMENT OF ABIGAIL ECHO-HAWK (PAWNEE), EXECUTIVE VICE 
      PRESIDENT, SEATTLE INDIAN HEALTH BOARD, SEATTLE, WA

    Ms. Echo-Hawk. Thank you so much, Madam Chair and Ranking 
Member, and distinguished Members of the Committee. My name is 
Abigail Echo-Hawk. I am a citizen of the Pawnee Nation of 
Oklahoma, and I currently serve as the Director of the Urban 
Indian Health Institute, one of 12 tribal epidemiology centers 
located across the country. In addition, I serve as the 
Executive Vice President of the Seattle Indian Health Board, 
which is a federally qualified health center and Indian health 
care provider in Seattle, Washington.
    I want to start my testimony with a story. Seattle was the 
epicenter of COVID-19 in February 2020. We soon became overrun 
by folks who were looking for COVID testing and were 
experiencing symptoms and had been infected with COVID-19. We 
quickly ran short of PPE. We sent out requests to our state, 
our Federal, and our county partners. Soon we received a box at 
our clinic, and the CEO and myself opened up that box expecting 
to see gowns, masks, and the PPE that our providers needed. 
Instead, what we found was a box of body bags. We had been sent 
a box of body bags instead of the PPE that we had requested.
    While this was a very literal example of Indian health care 
funding and the way we have been treated in the United States 
that has created the health disparities that currently exist 
for my people, it is also a metaphor for the way many tribal 
nations experience getting resources for the COVID-19 response 
early in the pandemic.
    As a result of this, what we find is that Native people are 
3.5 times more likely to be infected with COVID-19, and we are 
also more likely to die. As the co-author of those papers which 
were released by the CDC, what I was most disturbed by was not 
just those rates but with the fact that we were only able to do 
analysis on 23 states in the Nation because they were the only 
ones that had at least 70 percent of the race and ethnicity 
data that allowed us to do the science to establish what was 
happening in our communities, and we know as a result of that 
gross underreporting of race and ethnicity in COVID-19 cases 
that is not a true reflection of what's happening in our 
communities. The death rates, the hospitalization rates are 
much, much higher.
    As a result of the crumbling infrastructure of public 
health surveillance systems, we currently do not have the 
ability for both the states and the CDC to properly report 
COVID-19 data, which now includes vaccinations. Recently my 
organization released a report titled ``Data Genocide,'' 
detailing how American Indians and Alaska Natives were being 
eliminated in the data across the Nation by grading states in 
four categories on how they reported the data and how it was 
reported to the CDC. What we found was appalling.
    More than 50 percent of the states in the Nation received a 
C or below, and the Nation as a whole received a D+. I may not 
have graduated high school with that grade. And unfortunately, 
it is deeply impacting our ability to serve our communities. It 
is essential for us to begin to properly fund the surveillance 
systems across the United States from the local, tribal, all 
the way to the Federal level in order to make the change that 
we need to get the information so policymakers like yourselves 
can actually make data-driven decisions, and scientists like me 
are actually able to do good science, because right now with 
the system that we have, I can't do that.
    As part of that, as we reflect on the under-enrollment of 
minority populations into both the clinical trials on testing, 
on COVID-19 treatment and vaccines, we have seen the impact of 
not having the numbers that we need of minority populations 
enrolled in those trials despite the best efforts of the NIH. 
And unfortunately in the Native community, we've actually seen 
that in the last few weeks reflected in an attack on vaccines 
that use the lack of clinical trial data to try to warn Native 
people to not take certain vaccines. So it's actually being 
used as a weapon against us by the fact that we haven't been 
enrolled in those clinical trials.
    We need further concentration on the proper enrollment in 
clinical trials that also, in working with tribal nations, 
ensures that they are working to preserve and uphold tribal 
sovereignty.
    COVID-19 is impacting most of our essential services beyond 
the everyday services we do for those who are coming in for 
testing, for treatment, and getting vaccinated. In fact, at the 
Seattle Indian Health Board, we have seen a 13 percent decrease 
in our prenatal care. One of our programs in Great Falls, 
Montana has seen a 40 percent decrease in their substance abuse 
programs as a result of their people not being able to access 
telehealth as a result, again, of the lack of broadband 
Internet access, phone access, the things that are needed for 
telehealth. And while the expansion of telehealth has been 
absolutely essential, we cannot forget those rural populations 
who do not have the same access to broadband Internet, and also 
those who are socioeconomically disadvantaged and don't have 
access to phones.
    However, despite all of these obstacles, what we have seen 
is Indian Country, our tribal communities, both urban and 
rural, have done what nobody else in the Nation has done, and 
that is we have been more successful at vaccinating our 
population than anywhere else. In fact, the Black Feet Nation 
in Montana has a 95 percent vaccination rate of their 
reservation. Ninety-five percent puts them at herd immunity 
numbers if the rest of the United States could simply catch up. 
In fact, the Seattle Indian Health Board has vaccinated 100 
percent of our elders.
    There are lessons learned, and as part of that the 
investment that initially came through the CARES Act and now is 
coming through the American Rescue Plan have provided the 
resources, essential resources we need and assisted us in 
having some of the highest vaccination rates in the country. In 
fact, there are lessons learned that the rest of the country 
should be looking toward tribal nations so that we can as a 
nation address the devastating impact in this community and 
concentrate on serving those most desperately in need.
    Thank you.
    [The prepared statement of Ms. Echo-Hawk follows:]
                prepared statement of abigail echo-hawk
    Members of the Health, Education, Labor, and Pensions (HELP) 
Committee, my name is Abigail Echo-Hawk, and I am an enrolled citizen 
of the Pawnee Nation of Oklahoma, currently living in an urban Indian 
community in Seattle, Washington. I am the Executive Vice President of 
the Seattle Indian Health Board and Director (SIHB) of the Urban Indian 
Health Institute (UIHI), a tribal epidemiology center, where I oversee 
our policy, research, data, and evaluation initiatives.

    I am an American Indian health researcher with more than 20 years 
of experience in both academic and non-profit settings, and am part of 
numerous local, state, and Federal efforts to support and American 
Indian and Alaska Native communities in research, including serving on 
the Tribal Collaborations Workgroup for the National Institutes of 
Health All of Us precision medicine initiative. I am co-author to four 
groundbreaking research studies on sexual violence and Missing and 
Murdered Indigenous Women and Girls (MMIWG) where I have called 
national attention to the institutional barriers in data collection, 
reporting, and analysis of demographic data that perpetuate violence 
against American Indian and Alaska Native people. Most recently, I was 
a committee member for the National Academies of Sciences, Engineering, 
and Medicine: Framework for Equitable Allocation of COVID-19 Vaccine. 
As the only representative from the Native community, I worked to 
ensure the needs of our Indian Healthcare System and tribal and urban 
Indian communities were appropriately included in the framework that is 
informing states and policymakers nationwide.

    For over 5 years, I have worked to address institutional barriers 
to public health surveillance data experienced by Tribal Epidemiology 
Centers. During the COVID-19 pandemic, this advocacy has been amplified 
through the collective power of the We Must Count Coalition--a group of 
health and racial equity and civil rights organizations. Together we 
are calling for the uniform collection and release of COVID-19 testing, 
cases, health outcomes, and mortality rates using data disaggregated by 
race, ethnicity, primary language, gender, disability status, and 
socioeconomic status. However, the crumbling public health data 
infrastructure nationwide is inhibiting our ability to reach these 
goals as evidenced by UIHI's recently released report, Data Genocide.

    These experiences guide my statement today that is directed at the 
government's failure to appropriately address the COVID-19 health 
disparities raging within our communities--including American Indian 
and Alaska Native, Black, Hawaiian and Pacific Islanders, Hispanic/
Latinx, and Asian American communities.
    Data, Evaluation, and Research by and for Indigenous Communities
    UIHI is an Indian Health Service (IHS)-funded Tribal Epidemiology 
Center, providing services to more than 62 urban Indian organizations 
who provide culturally attuned health and social services in areas that 
represent approximately 1.5 million American Indian and Alaska Native 
living in urban settings nationwide. UIHI recognizes research, data, 
and evaluation as an integral part of informed decisionmaking for not 
only our American Indian and Alaska Native community, but also our 
policy and funding partners. We assist our communities in making data-
driven decisions, conducting research and evaluation, collecting and 
analyze data, and providing disease surveillance to improve the health 
and well-being of our entire American Indian and Alaska Native 
community. UIHI's mission is to advocate for, provide, and ensure 
culturally appropriate, high quality, and accessible data for American 
Indian and Alaska Native public health organizations that provide 
culturally attuned care to American Indian and Alaska Natives living 
off tribal lands in urban settings. Recognizing the migratory patterns 
of our population as they move between urban and rural locations, we 
also serve tribal nations and tribally based organizations.

    Tribal Epidemiology Centers are IHS division-funded organizations 
who serve the Indian healthcare system compromised of IHS Direct, 
Tribal 638, and Urban Indian Health Programs by managing public health 
information systems, investigating diseases of concern, managing 
disease prevention and control programs, responding to public health 
emergencies, and coordinating these activities with other public health 
authorities. There are currently 12 Tribal Epidemiology Centers 
nationwide with the mission to improve the health status of American 
Indian and Alaska Natives through identification and understanding of 
health risks and inequities, strengthening public health capacity, and 
assisting in disease prevention and control. UIHI is unique in that it 
serves the urban American Indian and Alaska Native population 
nationally, while sister Tribal Epidemiology Centers service regional 
IHS areas including Alaska, Albuquerque, Bemidji, Billings, California, 
Great Plains, Nashville, Navajo, Oklahoma, Phoenix, and Portland.

    In response to the COVID-19 pandemic, UIHI has mobilized to create 
COVID-19 fact sheets, reports, and online resources for tribes, tribal 
organizations, and urban Indian organizations. This includes conducting 
original research to guide the creation of culturally attuned public 
health messaging. In late January of this year UIHI released the first, 
and to date, the only national survey on vaccine hesitancy in Native 
communities. Since August 2020, UIHI and other Tribal Epidemiology 
Centers co-authored two COVID-19 studies on American Indian and Alaska 
Native people in partnership with the Centers for Disease Control and 
Prevention (CDC). These Morbidity and Mortality Weekly Report (MMWR) 
revealed American Indian and Alaska Native communities experience 
disproportionate morbidity and mortality due to the COVID-19 pandemic, 
with the rate of new infections and death among American Indian and 
Alaska Native people are estimated to be 3.5 and 1.8 times that of non-
Hispanic Whites, respectively. \1\
---------------------------------------------------------------------------
    \1\  Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality 
Among American Indian and Alaska Native Persons--14 States, January-
June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(49):1853-1856. 
doi:10.15585/mmwr.mm6949a3.
---------------------------------------------------------------------------
    However, the MMWR report on COVID-19 infections notes the authors 
were only able to include 23 states in the analysis, as they were the 
only states that had collected at least 70 percent or more of race and 
ethnicity data, \2\ highlighting the need for Tribal Epidemiology 
Centers to advise and improve data collection and reporting practices 
of American Indian and Alaska Native data by Federal, state, and local 
agencies.
---------------------------------------------------------------------------
    \2\  Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among 
American Indian and Alaska Native Persons--23 States, January 31-July 
3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(34):1166-1169. 
doi:10.15585/mmwr.mm6934e1
---------------------------------------------------------------------------
    As healthcare and public health organization on the forefront of 
serving urban Indian communities, we are alarmed by the on-going data 
genocide that continues to perpetuate negative COVID-19 outcomes among 
American Indian and Alaska Native people by eliminating them in the 
data.
              Disproportionate Impact to Indigenous People
    As Director of a national Tribal Epidemiology Center, UIHI's 
service population represents approximately 71 percent of the 5.2 
million American Indian and Alaska peoples (alone or in combination) in 
this country. In this work, I am often asked to speak on the pervasive 
health disparities experienced by American Indian and Alaska Native 
people. What I must continue to remind people, is that these 
disproportionate outcomes are a direct result of centuries of chronic 
underfunding of trust and treaty obligations, particularly chronic 
underfunding of our health care, public health systems, and 
infrastructure have long impacted access to medical care, education, 
housing, clean water, healthy foods, and traditional medicines among 
Indigenous communities.

    It is clear that the disproportionate impact that COVID-19 is 
having on Native communities is not an accident. It is the product of 
systems of inequities that have created and perpetuated rampant health 
disparities for Native people.
                Disparities Across Communities of Color
    The Color of Coronavirus project by APM Research Labs provides 
weekly updates on COVID-19 mortality by race and ethnicity. According 
to the APM Research Lab, as of March 5, 2021, the past 4 weeks have 
yielded the highest number of new deaths since the start of the COVID-
19 pandemic for all racial groups except Black and Pacific Islander 
Americans, for whom it is the second most deadly stretch. \3\ As our 
Nation continues to roll out vaccination programs, it is more important 
than ever to accurately collect, report, and analyze race and ethnicity 
data. These data are essential to understanding racial equity impacts 
and developing equitable strategies for vaccine distribution. The 
following statistics reveal the devastating impacts of COVID-19 among 
Black, Indigenous and people of color (BIPOC) communities. As of March 
5, 2021:
---------------------------------------------------------------------------
    \3\  APM Research Lab. The Color of Coronavirus: COVID-19 Deaths by 
Race and Ethnicity in the U.S. February 4, 2021. Retrieved from: 
https://www.apmresearchlab.org/covid/deaths-by-race.

          Indigenous Americans had the highest actual COVID-19 
        mortality rates nationwide. While the CDC reports a mortality 
        rate of American Indians and Alaska Natives 1.8 times higher 
        than the non-Hispanic Whites, reports by the APM Research Lab 
        suggest is it closer to 2.2 times higher than White Americans. 
        \4\ Data from APM also notes they were unable to gather data 
        from all states due to the lack of data reported by them, and 
        rates are not calculated for those identified as ``Other'' 
        race. Indian Country has had at least 5,477 Indigenous 
        Americans lose their lives to COVID-19,4 but we know this 
        number is a massive undercount due to the missing and 
        inconsistent data collected by health care providers and 
        governments nationwide; and
---------------------------------------------------------------------------
    \4\  Painter EM, Ussery, EN, Patal A, et al. Demographic 
Characteristics of Persons Vaccinated During the First Month of the 
COVID-19 Vaccination Program--United States, December 14, 2020-January 
14, 2021. MMWR Morb Mortal Wkly Rep 2021; 70;174-177. DOI: http://
dx.doi.org/10.15585/mmwr.mm7005e1

          73,236 Black Americans have lost their lives to 
        COVID-19 and Black Americans have the second-highest mortality 
        rate of all groups, behind Indigenous people and are 2 times 
---------------------------------------------------------------------------
        more likely to have died compared to Whites.; and

          nationwide, Pacific Islanders are 2.6 times more 
        likely to have died as Whites. Since March 5, 2021, the Pacific 
        Islander community has had at least 830 community members lose 
        their lives to COVID-19.4 However, we know these are not exact 
        numbers. Arizona, Connecticut, Delaware, Michigan, New Mexico, 
        North Carolina, Virginia, and Wisconsin report deaths for 
        Asians and Pacific Islanders jointly. Without disaggregated 
        data, the true impacts to the Pacific Islander community 
        continue to be undercounted; and

          89,071 Latinos have lost their lives to COVID-19 and 
        Latinos are 2.4 times more likely to have died as Whites from 
        COVID-19; and

          Over 17,747 Asian Americans are known to have lost 
        their lives to COVID-19. Nationwide, Asian Americans have 
        experienced 3.6 percent deaths by race, while they represent 
        5.6 percent of the population.

    As devastating as these data are, we know they are an undercount of 
the true impact COVID-19 is having in our communities of color. The 
gaps in this mortality data are a stark reminder that our Nation's 
inability to accurately collect, report, and analyze race and ethnicity 
data that directly contributes to health inequity and erasure. Today, 
Native people--and communities of color--are fighting to address the 
COVID-19 pandemic and are demanding equitable solutions and equitable 
distribution of the vaccine to communities most impacted.
                        A National Data Failure
    On February 15, UIHI released a national report card, titled Data 
Genocide, analyzing the current status of collecting and reporting 
state COVID-19 surveillance data on American Indians and Alaska 
Natives. This analysis reviews state and national data reported on 
American Indian and Alaska Native people including percent of confirmed 
cases with complete race and ethnicity information.

    The report revealed more than half the states in the Nation 
received a C grade or below with a total of 13 states receiving a F. 
The five states in the Nation that ranked the worst in collecting and 
reporting racial demographic data are Texas (50th), New York (49th), 
Maryland (48th), West Virginia (47th), and Delaware (45th). The 
national average was a grade of D plus. Overall, states are doing a 
poor job of tracking and reporting racial demographic COVID-19 data for 
American Indians and Alaska Natives and other people of color. A recent 
study by the CDC, found that current data on vaccinations is missing 48 
percent of race/ethnicity data.

    It is not possible for policymakers to make data-driven decisions 
on COVID-19 with incomplete data. States must be held accountable to 
improving their data practices if we are to ever achieve data-driven 
decisionmaking for allocation of resources to end this pandemic.
                  Gaps in the Indian Healthcare System
    Due to chronic underfunding of trust and treaty obligations, the 
Indian healthcare system is only resourced to serve a fraction of 
American Indian and Alaska Native people. Across the Nation, Indian 
Health Care Providers are seeing an influx of IHS beneficiaries 
visiting tribal and urban Indian clinics seeking the COVID-19 vaccine 
and other healthcare services. We welcome our relatives into culturally 
attuned care--many for the first time. Yet, our Indian healthcare 
system is in need of additional resources and support to appropriately 
serve our community.

    The California based Indian Health Center of Santa Clara Valley, 
along with Urban Indian Health Programs nationwide, report rising cost 
including increased personnel and sanitation costs of serving the 
growing number of relatives seeking care. Many programs are holding 
vaccination clinics along with mass vaccination sites. A mass 
vaccination sites requires 25-30 people to be effective, which requires 
diverting staff from their normal duties and hiring temporary staff 
which can be cost prohibitive. Urban Indian Health Programs that do not 
provide direct clinical care, such as Lifelines of Boston and 
Baltimore, have found themselves struggling to find partners to host 
vaccination clinics for their American Indian and Alaska Native 
clients. The urban Indian provider in Great Falls, Montana has seen an 
influx of patients who tried to access the vaccine elsewhere and 
despite being eligible under the state distribution guidelines were 
told ``go to the Indian clinic.'' Indian Health Care Providers are 
making decisions every day on what services to prioritize recognizing 
that with the scarce funding and resources, they will not be able to 
provide all the services our community needs.

    This is not a new issue for the Indian healthcare system. In a 2009 
report to Congress, IHS identified 17 urban areas that would benefit 
from and Urban Indian Health Program. \5\ In 2017, UIHI expanded their 
service population to reach 62 urban Indian organizations nationwide. 
Among the 17 IHS-identified cities with high American Indian and Alaska 
Native populations, many have strong local support and active efforts 
to develop health care programs for urban Natives. The report also 
recommended increasing funding to grantees for satellite 
expansionsites, new partnerships with community health centers, and 
identifying local providers to serve the needs of urban Native people. 
We know that the current health needs of urban Natives are not being 
met, despite the mounting evidence that increased Urban Indian Health 
Program facilities would benefit the health status of American Indian 
and Alaska Native nationwide.
---------------------------------------------------------------------------
    \5\  U.S. Department of Health and Human Services Indian Health 
Service. New Needs Assessment of the Urban Indian Health Program and 
the Communities it Serves. Accessed March 2021. Retrieved from:https://
www.ihs.gov/sites/urban/themes/responsive2017/display--objects/
documents/ReportToCongressUrbanNeedsAssessment.pdf.
---------------------------------------------------------------------------
    Tribal partners are also calling out the concern for our urban 
dwelling relatives who do not have access to the Indian healthcare 
system. In February 2021, the National Indian Health Board passed 
Resolution 21-01 \6\ requesting the Department of Health of Human 
Services and IHS to implement COVID-19 vaccination clinics in the 
Washington, DC. Metropolitan Area and prioritize American Indian and 
Alaska Native people in the 17 cities identified in the 2009 IHS 
report. This call for an equitable distribution model that prioritizes 
high-risk communities should be reproduced throughout local health 
jurisdictions to support Indigenous, Black, and communities of color 
who disproportionately experience negative impacts of COVID-19.
---------------------------------------------------------------------------
    \6\  National Indian Health Board Resolution 21-01: Promoting and 
Prioritizing AI/Ans in the DC Metropolitan Area for the COVID-19 
Vaccine. February 2021. National Indian Health Board. Retrieved from: 
https://www.nihb.org/docs/03012021/21-01--NIHB percent20Resolution 
percent20Prioritizing percent20Vaccines percent20for percent20AIANs 
percent20in percent20DC.pdf.
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    In addition to addressing gaps in provider access, Indian Health 
Care Providers are in need of additional vaccine access. As the Biden 
Administration has implemented its initiative to distribute the vaccine 
directly through Community Health Centers, we have seen only a fraction 
of Indian Health Care Providers represented. Of the 250 Community 
Health Centers invited thus far, ten were Urban Indian Health Programs 
and 16 were Tribal health programs. It is urgent to supply more Indian 
Health Care Providers and Community Health Centers with additional 
access to the vaccine. As seen in Alaska, who represents 11 of the 16 
tribal facilities receiving vaccines through this initiative, 
additional access to the vaccine has amplified the success of Alaska 
Native health providers to reach their priority groups. Currently, 28 
percent of Alaskan residents have received a first dose of the 
vaccine--higher than the national average. Alaska is now encouraging 
other states to do the same: invest in protecting our most impacted 
communities, enlist entrusted members of the communities to educate, 
and adapt to the health care needs of local residents.
                  Impacts to Maternal and Child Health
    As our Nation moves toward addressing COVID-19, we must 
simultaneously work toward improving healthcare systems impacted by 
COVID-19. COVID-19 has also disrupted routine care in the healthcare 
system for child immunizations. \7\ In Washington State, the Department 
of Health (DOH) reported a drop in immunization rates among children 
during the COVID-19 pandemic, as well as a drop in vaccines ordered by 
providers. During the pandemic, DOH reported that thus far, 30 percent 
fewer vaccines were given in 2020, compared to the year before. \8\
---------------------------------------------------------------------------
    \7\  Sanoli JM, Lindley MC, DeSilva MC, et al. Effects of the 
COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and 
Administration--United States, 2020. MMWR Morb Mortality Wkly Rep 2020; 
69:591-593. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2.
    \8\  Washington State Department of Health. May 2020. Drop in 
vaccination leaves children vulnerable to other diseases. Accessed 
March 2021. Retrieved from: https://www.doh.wa.gov/Newsroom/Articles/
ID/1161/Drop-in-vaccination-leaves-children-vulnerable-to-other-
diseases.
---------------------------------------------------------------------------
    At SIHB, we have seen a 13 percent drop in our relatives seeking 
prenatal care and a 38 percent decrease in relatives seeking pediatric 
immunizations. We are hearing similar stories across the Nation as 
birthing people express fears related to exposing themselves and their 
child to COVID-19. Responding to this crisis requires safe environments 
to be created such as dedicated pediatric clinics that are family 
friendly and COVID-19 safe. However, with already over-stressed 
systems, many clinics do not have the resources needed to rapidly adapt 
and respond without impacting other essential programs. There needs to 
be additional support efforts to stabilize prenatal and child 
immunization healthcare systems among Native communities who most 
impacted by maternal and infant health disparities.
 Increase in Domestic Violence, Gender Based Violence and Missing and 
                  Murdered Indigenous Women and Girls
    Studies have shown one in three Native women will experience 
violence in their lifetime, a much higher rate as compared to the 
general population. In a soon to be released survey, UIHI assessed the 
impact of COVID-19 on Native female identifying sexual assault 
survivors. We found that 20 percent of the respondents were 
experiencing an increased lack of physical safety due primarily to 
domestic violence. Another national study found, 40 percent of rape 
crisis centers have seen an increase in demand for services since 
COVID-19, with over 534 of these organizations requesting $100 million 
in emergency stimulus funding to provide support and emergency 
assistance to survivors. \9\ These finding echo what many advocates 
have been sharing, that there is a national increase in violence as 
COVID-19 continues to increase stress on every American. For those 
unable to leave, they are now quarantine with their abusers increasing 
the likelihood of more violence. This violence impacts the entire 
family and children who are not yet in school, are now experiencing 
violence they would normally escape while attending in person 
schooling.
---------------------------------------------------------------------------
    \9\  National Alliance to End Sexual Violence. April 6, 2020. 
Responding to COVID-19: Rape Crisis Center & Survivor Needs. Retrieved 
from: https://documentcloud.adobe.com/link/
track'uri=urn:aaid:scds:US:1d3534ee-960e-4f94-96dd-8196d2017c90--
pageNum=1.

    In UIHI's groundbreaking report on Missing and Murdered Indigenous 
Women and Girls, we found that there is an ongoing crisis. And now we 
are seeing the crisis increase as rates of violence go up nationwide. 
Over the course of the pandemic there have been horrific murders and 
numerous Indigenous women and girls who have gone missing. One leading 
organization reports they have seen a spike in requests for assistance 
to find missing people and increased need for support services to 
families of murder victims. Many of these essential support services 
are provided by county, tribal, and non-profit organizations with 
support from Violence Against Women Act (VAWA) funds. These funds have 
allowed these providers to continue and expand essential services to 
victims of violence while allowing for culturally specific services for 
tribes and Native organizations. In UIHI's recent survey of sexual 
assault survivors, 90 percent asked for culturally specific services 
citing their struggles with non-Indigenous methodologies for healing 
highlighting the need for continuing to allocate funds for culturally 
attuned programs and services.
                 National Institutes of Health Research
    The National Institutes of Health (NIH) has been working to quickly 
roll out research initiatives to address and understand the 
disproportionate impacts of COVID-19. However, we continue to see under 
enrollment of Native people in clinical trials for COVID-19 vaccines 
and treatments nationwide. This lack of diversity in the clinical 
trials continues to increase hesitancy and has been used by anti-
vaccination advocates to push misinformation into Native communities. 
Recently UIHI responded swiftly to misinformation targeting Native 
people nationwide that was misinterpreting clinical trial data that was 
resulting in increased vaccine hesitancy. The impact of lack of Native 
people in the clinical trials is having, and will continue to have, 
tangible impacts.

    Current NIH initiatives also are often not inclusive of urban 
Indian populations, despite 71 percent of all Native people living in 
urban settings. We do not advocate for taking away funding for tribally 
based research, instead we urge the NIH to increase funding overall 
with dedicated funds for research on health disparities for urban 
Indian populations.
                 The Expense of Not Leading with Equity
    In July, the average cost for COVID-19 inpatient care ranged 
$51,000-$78,000 depending on age, with younger people paying the most. 
\10\ In 2020, it is expected that COVID-19 related hospitalizations 
cost will range from $9.6 billion to $16.9 billion with Medicare 
expected to pay $3.5 billion to $6.2 billion. \11\ As the mounting 
costs of preventing, preparing, and responding to COVID-19 totals, we 
must look to equity as the fastest solution to ending this pandemic.
---------------------------------------------------------------------------
    \10\  Mallory Hackett. November 5, 2020. Average cost of hospital 
care for COVID-19 ranges from $51,000 to $78,000 based on age. 
Healthcare Finance. Accessed 2021. Retrieved from: https://
www.healthcarefinancenews.com/news/average-cost-hospital-care-covid-19-
ranges-51000-78000-based-age--:text=In percent20July percent2C 
percent20the percent20report percent20'showed,23 percent20to 
percent2030 percent20age percent20bracket.
    \11\  Sloan, Chirs., Markware, Nathan., Young, Joanna., Frieder, 
Miryam., Grady, Lance., Rosacker, Neil., Vidulich.. June 19, 2020. 
COVID-19 Hospitalizations Projected to Cost up to $17 B in US in 2020. 
Avalere. Accessed 2021. Retrieved from: https://avalere.com/insights/
covid-19-hospitalizations-projected-to-cost-up-to-17b-in-us-in-2020

    With over a year of devastating economic impacts to individuals, 
industries, and governments, the vaccine has been a sign of hope for 
many. Yet, inequity in vaccine distribution threatens to increase costs 
and slow our national recovery. While many policymakers are committed 
to mass vaccination in short time periods, it is becoming increasingly 
clear that our most resourced community members are among the first to 
---------------------------------------------------------------------------
access the vaccine.

    According to the CDC, in December 2020, the Moderna and Pfizer 
vaccines were distributed to health care personnel and long-term 
facility residents. However, available demographic data shows of people 
vaccinated, 63 percent were women, 55 percent were 50 and older, and 60 
percent were non-Hispanic White while 39 percent of those vaccinated 
were represented racial and ethnic minorities.4 Of the racial and 
ethnic minorities vaccinated, 11 percent were Hispanic/Latino, 5 
percent were Black, .3 percent were Pacific Islander, and 2 percent 
were American Indian and Alaska Native. However, of the data collected 
on individuals vaccinated, race/ethnicity was unknown or not reported 
for 48 percent or people. This first report of vaccine distribution 
reveals vaccine distribution is inequitable and not going to our most 
marginalized communities most impacted by COVID-19. Vaccination 
programs must plan for distribution to priority groups at highest risk 
for infection, hospitalization, and mortality.

    We will not end this pandemic by vaccinating the privileged masses 
that can afford to shelter in place. The Seattle Indian Health Board 
recently had an incidence, where well-resourced people showed up at our 
clinic because they had the privilege of language access, technology 
access, and transportation access. They were capable of social 
distancing, capable of accessing healthcare systems, and could wait to 
access the vaccine through their primary care provider, but they 
didn't. They swarmed our urban Indian clinic and demanded access to the 
vaccine. However, we did not comply with their demands. Instead we 
continue to prioritize those most at risk for morbidity and mortality 
as we apply an equitable approach to vaccine access. We must be 
prioritizing people more likely to work in high risk settings, living 
in congregate and multi-generational settings, experiencing high rates 
of co-morbidities that increase COVID-19 risk and associated healthcare 
costs, and at risk for mortality. Leading with equity in our national 
vaccine distribution strategy is essential to reducing the number of 
hospitalizations, inpatient length of stay in hospitals, and associated 
costs to the healthcare system. Vaccine distribution can't just be 
about how many arms we inject, it has to be an equity-based decision 
that acknowledges it's about whose arm receives the injection.
      Centering Communities Most Impacted Drives Equitable Success
    Despite our Nation's on-going challenges with data, tribal and 
urban Indian communities continue to demonstrate that culturally 
attuned and community-driven approaches are essential to reaching our 
most impacted communities. As our Nation moves toward addressing data 
challenges, we must simultaneously resource and amplify the work of our 
trusted messengers and community organizations. To take a lesson from 
Indigenous communities, we must ensure trusted messengers are included 
in the creation and distribution of COVID-19 vaccine programs and 
outreach.

    Throughout the pandemic, UIHI has disseminated culturally attuned 
through fact sheets, reports, and a COVID-19 Vaccine Poster series to 
address vaccine hesitancy in the Native community. A recent study from 
the UIHI, and to date the only national study conducted, reinforced 
what we already knew. Seventy-four percent of American Indian and 
Alaska Native people surveyed were willing to get vaccinated because of 
their cultural responsibility to protect Elders and next generation. 
These are the teachings the Elders instilled in us--our responsibility 
is to our community. This Indigenous knowledge is also a public health 
understanding that can increase adherence to COVID-19 safety measures, 
including masking, social distancing and vaccinations.

    In December 2020, SIHB was the first organization in Washington to 
receive a shipment of the Moderna vaccine \12\ and since has vaccinated 
over 3,900 people in our community. In phase one, we vaccinated our 
health care providers and partners organizations that serve the local 
urban Native community. We are now in Phase 2, where we vaccinate 
American Indian and Alaska Native Elders and all people age 50 and 
older. Our vaccination plan is a model for a community-centered 
approach where we value those who are on the frontlines of addressing 
the pandemic, protecting our culture keepers, and ensure our 
intergenerational households are safe.
---------------------------------------------------------------------------
    \12\  Sandi Doughton. December 21, 2020. Moderna Vaccine Arrives in 
Seattle, with more coming later this week. The Seattle Times. Accessed 
2021. Retrieved from: https://www.seattletimes.com/subscribe/signup-
offers/'pw=redirect&subsource=paywall&return=https://
www.seattletimes.com/seattle-news/health/moderna-vaccine-arrives-in-
seattle-with-more-coming-later-this-week/.

    As an Indian Health Care Provider, we have been able to exercise 
sovereignty alongside our tribal partners in the Indian Healthcare 
System to respond to the needs of our community. While other vaccine 
distributors were forced to adhere to strict guidance from state and 
local governments, we have demonstrated that culturally attuned and 
community-driven approaches have meaningful impact. However, this 
provision of care has come with significant costs that are not covered 
by the Federal reimbursement for the vaccine. Urban Indian and tribal 
programs providing vaccines have experienced an influx of American 
Indian and Alaska Native people nationwide who are not normally 
patients of record at our facilities. While we welcome all our 
relatives, including IHS beneficiaries, the chronic underfunding of our 
Indian healthcare system is again becoming evident. To adequately reach 
the American Indian and Alaska Native population in our current system, 
our state and local health jurisdictions must prioritize American 
Indian and Alaska Native people who experience higher rates of co-
---------------------------------------------------------------------------
morbidities that worsen the impacts of COVID-19.

    Tribal and urban Indian communities continue to demonstrate a 
culturally attuned and community-driven vaccine distribution model is 
essential to reaching our most impacted communities. In Washington 
State, Muckleshoot Indian Tribe, Lummi Nation, Suquamish Tribe, and 
Seattle Indian Health Board have demonstrated our commitment to 
ensuring Native elders and healthcare providers are fully vaccinated 
and are now moving toward vaccinating teachers to support the re-
opening of schools. \13\1 Nationally, the Blackfeet Nation has 
vaccinated 95 percent of eligible residents. \14\ Navajo Nation, who 
was impacted heavily by COVID-19 is now reporting 70 percent of its 
citizens are vaccinated administering over 120,000 doses to its 
community members. \15\, \16\ Cherokee Nation has recently opened its 
COVID-19 vaccine distribution to its 14-county area for both Native and 
non-Native residents. \17\ The Bay Mills Indian Community in Michigan 
has vaccinated over 1,300 adult tribal members who live in their 
service region, \18\ and remote villages in Alaska are reporting 
vaccination rates of 50-60 percent of adult village occupants. \19\ 
Indian Country is proving the exercise of our sovereignty rights create 
equitable vaccine distribution that is attainable and successful for 
the benefit of our service population and surrounding communities.
---------------------------------------------------------------------------
    \13\  Hellmann, Melissa. February 2021. How a Native American 
COVID-19 vaccine rollout is a model for community-centered approaches. 
Seattle Times. Retrieved from: https://www.seattletimes.com/seattle-
news/health/we-take-it-for-our-community-how-a-native-american-survey-
and-vaccine-rollout-models-a-community-centered-approach/.
    \14\  Franz, Justin. March 2021. Blackfeet Tribe reopens border 
with Glacier. Montana Free Press. Retrieved from: https://
montanafreepress.org/2021/03/17/blackfeet-tribe-reopens-border-with-
glacier/.
    \15\  Healy, Jack. March 2021. Plenty of Vaccines, but Not Enough 
Arms: A Warning Sign in Cherokee Nation. New York Times. Retrieved 
from: https://www.nytimes.com/2021/03/16/us/vaccines-covid-cherokee-
native-americans.html.
    \16\  Newton, Creede. February 2021. Navajo Nation forecasts 
`community immunity': 120,000 jabs given. Aljazeera. Retrieved from: 
ttps://www.aljazeera.com/news/2021/2/26/navajo-nation-sees-community-
immunitycoming-120k-jabs-given.
    \17\  Tulsa World. March 2021. Cherokee Nation opens vaccine to 
public living in 14-county area. Retrieved from https://tulsaworld.com/
news/local/cherokee-nation-opens-vaccine-to-public-living-in-14-county-
area/article--63891098-8124-11eb-a6bd-c3f6eeb8bd94.html.
    \18\  Steeno, Paul. February 2021. Bay Mills: Nearly 700 community 
members have received one dose of COVID vaccine. Up North Live ABC. 
Retrieved from: https://upnorthlive.com/news/local/bay-mills-nearly-
700-community-members-have-received-one-dose-of-covid-vaccine.
    \19\  Andrew, Scott. March 2021. Rural Alaska is getting COVID-19 
vaccinations right. Here's what the rest of the US can learn. CNN. 
Retrieved from: https://www.cnn.com/2021/03/09/us/alaska-covid0919-
vaccine-success-trnd/index.html.

    We are encouraged by the allocation of $6.1 billion in COVID-19 
resources authorized under the American Rescue Plan Act of 2021 to IHS. 
It will be necessary for IHS to make short-and long-term plans for 
these dollars, however this cannot be seen as a one-time investment. 
Since its inception, the IHS has suffered from chronic underfunding and 
systematic issues that have resulted in poor health outcomes for Native 
people. It will take continued financial support and systematic change 
across the Federal agencies if we are ever to see the health care 
system required under the Federal Governments treaty and trust 
---------------------------------------------------------------------------
responsibility.

    Nationwide, we must demand more accurate racial and ethnic 
demographic data collection, reporting, and analysis. We must identify 
gaps in service delivery and ensure the health disparities experienced 
by our Indigenous communities do not worsen as our healthcare systems 
adapt and respond to COVID-19. We must resource and amplify the work of 
our most impacted communities and trusted messengers. We must lead with 
racial equity to reach low-income, communities of color, and those most 
impacted by the virus. We cannot end the pandemic or re-stabilize our 
healthcare systems impacted by COVID-19 without equitable distribution 
of resources that advance health equity.
                                 ______
                                 
                [summary statement of abigail echo-hawk]
    As Executive Vice President of the Seattle Indian Health Board and 
Director of the Urban Indian Health Institute (UIHI), my testimony 
highlights the successes of Indigenous communities, continued 
challenges in health services and data, and recommendations to advance 
health equity.
                    Indigenous Resilience in Action
    Tribal and urban Indian communities continue to demonstrate that 
culturally attuned and community-driven approaches are essential to 
leading an equitable response to COVID-19. We are modeling a community-
centered approach while exercising our sovereignty rights as tribal 
people to advance equity among our service population and surrounding 
communities. For example,

          The Blackfeet Nation has vaccinated 95 percent of 
        eligible residents; \1\
---------------------------------------------------------------------------
    \1\  Franz, Justin. March 2021. Blackfeet Tribe reopens border with 
Glacier. Montana Free Press. Retrieved from: https://
montanafreepress.org/2021/03/17/blackfeet-tribe-reopens-border-with-
glacier/.

          Navajo Nation has vaccinated 70 percent of citizens 
        and administered over 120,000 doses; \2\, \3\ and
---------------------------------------------------------------------------
    \2\  Healy, Jack. March 2021. Plenty of Vaccines, but Not Enough 
Arms: A Warning Sign in Cherokee Nation. New York Times. Retrieved 
from: https://www.nytimes.com/2021/03/16/us/vaccines-covid-cherokee-
native-americans.html.
    \3\  Newton, Creede. February 2021. Navajo Nation forecasts 
`community immunity': 120,000 jabs given. Aljazeera. Retrieved from: 
https://www.aljazeera.com/news/2021/2/26/navajo-nation-sees-community-
immunitycoming-120k-jabs-given.

          Remote Alaska villages are reporting vaccination 
        rates of 50-60 percent of adult occupants. \4\
---------------------------------------------------------------------------
    \4\  Andrew, Scott. March 2021. Rural Alaska is getting COVID-19 
vaccinations right. Here's what the rest of the US can learn. CNN. 
Retrieved from: https://www.cnn.com/2021/03/09/us/alaska-covid-19-
vaccine-success-trnd/index.html.
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                    Worsening of Health Disparities
    Data shows Native communities experience disproportionate morbidity 
and mortality due to the COVID-19.1,2 We are also seeing other health 
disparities worsen as a result of disruptions to our healthcare systems 
including concerning trends in domestic violence, child immunization, 
and prenatal outcomes and services. Recent data reveal:

          20 percent of respondents in a UIHI study experienced 
        an increase in lack of physical safety due to domestic violence 
        and 40 percent of rape crisis centers have seen demand for 
        services increase; \5\ and
---------------------------------------------------------------------------
    \5\  National Alliance to End Sexual Violence. April 6, 2020. 
Responding to COVID-19: Rape Crisis Center & Survivor Needs. Retrieved 
from: https://documentcloud.adobe.com/link/
track'uri=urn:aaid:scds:US:1d3534ee-60e-4f94-96dd-8196d2017c90-
pageNum=1.

          Decreases in accessing clinic services, SIHB has seen 
        a 13 percent drop in patients seeking prenatal care and a 38 
        percent decrease in pediatric immunizations.
     Advancing Equity through Community Health Center Partnerships
    Community Health Clinics (CHCs) have struggled to gain access to 
the vaccine. As culturally attuned and community-based healthcare 
providers, CHCs are trusted messengers in our most impacted 
communities. With additional and continuous funding to respond to and 
recover from COVID-19, CHCs are best positioned to help overcome health 
disparities.
               Advancing Equity through Data Improvements
    UIHI has drawn national attention to the data challenges 
experienced by Tribal Epidemiology Centers. Most recently, UIHI 
released Data Genocide, a report card on states revealing our national 
failure to collect quality data and the impacts of decades of chronic 
underfunding of public health infrastructure. There continues to be 
institutional barriers to making significant progress of data 
improvements with Health and Human Service (HHS) agencies. Ultimately, 
it is not possible for policymakers to make data-driven decisions on 
COVID-19 with the current data available for people of color.

          A CDC study, \6\ found that 48 percent of race/
        ethnicity data in missing in COVID-19 vaccination data; and
---------------------------------------------------------------------------
    \6\  Painter EM, Ussery, EN, Patal A, et al. Demographic 
Characteristics of Persons Vaccinated During the First Month of the 
COVID-19 Vaccination Program--United States, December 14, 2020-January 
14, 2021. MMWR Morb Mortal Wkly Rep 2021; 70;174-177. DOI: http://
dx.doi.org/10.15585/mmwr.mm7005e1

          UIHI found that the national average among states 
        COVID-19 surveillance data on Natives is a D-.
                            Recommendations
          Continue to invest in the Indian healthcare system 
        including public health and healthcare infrastructure, maternal 
        and child health, gender-based violence services, research, and 
        CHCs;

          Leverage oversight authority to ensure HHS compliance 
        with data sharing requirements; and

          Increase the supply of COVID-19 vaccines directly to 
        CHCs and Indian Health Care Providers.
                                 ______
                                 
    The Chair. Thank you, Ms. Echo-Hawk.

    We'll turn to Ms. Williams.

   STATEMENT OF TARYN MACKENZIE WILLIAMS, MANAGING DIRECTOR, 
     POVERTY TO PROSPERITY, CENTER FOR AMERICAN PROGRESS, 
                         WASHINGTON, DC

    Ms. Williams. Good morning. Thank you to Chairwoman Murray, 
Ranking Member Burr, and Members of the Committee for having me 
here today. I'm Taryn Williams, Managing Director of the 
Poverty to Prosperity Program and Disability Justice Initiative 
at the Center for American Progress. I testify today not only 
as someone who has spent more than a decade in disability 
policy but also as a Black woman who lives with multiple 
chronic conditions, and as someone who has seen and personally 
felt the devastating impact of this pandemic on communities of 
color and people with disabilities.
    In addition to the disparate data presented on racial and 
ethnic communities, there are stark disparities for the 
disability community. The CDC reported that all people seemed 
to be at higher risk of severe illness from COVID-19 if they 
have serious underlying chronic medical conditions. As of 
February 11th, among the states reporting data, there were 
111,000 cases and over 6,500 deaths, resulting in a fatality 
rate of 5.9 percent for people with disabilities. Even more 
startling, a cross-sectional study revealed that having an 
intellectual disability was the strongest independent risk 
factor measured for presenting with a COVID-19 diagnosis and 
the strongest independent risk factor other than age for COVID-
19 mortality.
    In order to ensure a comprehensive response to the 
pandemic, it is incumbent upon us to understand the factors 
that shape this crisis. The 1999 Supreme Court case, Olmstead 
v. Lois Curtis, confirmed that people with disabilities have 
the right to receive care within an integrated community or 
home setting. Yet, preserving access to resources in home-and 
community-based services has been an ongoing challenge. Absent 
this critical funding, people with disabilities are compelled 
to live in congregate settings and, as we've seen, these 
settings can be deadly.
    Equally critical in this moment is an ongoing fight for 
equal protection under the law, particularly in medical 
settings. In the past year the disability community has feared 
and fought to prevent health care providers from withholding or 
withdrawing life-sustaining treatment on the basis of arbitrary 
standards about quality of life. We know that calculations made 
in these critical moments are at great risk to be colored by 
bias and stereotypes or, in short, ableism, the ongoing 
devaluing of the lives of people with disabilities that gives 
rise to discrimination and the belief that disabled lives are 
not worth saving.
    In addition to ableism, we must discuss racism and the ways 
that it contributes to disparate outcomes during the pandemic 
in these communities, particularly those that have been ravaged 
by COVID-19. We see the ways in which poverty and its 
correlates--low wages, inadequate means, lack of affordable 
housing, and a lack of affordable health care--have been 
inextricably linked to higher rates of infection and mortality 
from COVID-19. Our society has codified a two-tier economic 
system that overwhelmingly excludes Black and brown workers, 
women, and people with disabilities from opportunities to earn 
competitive wages and have their basic needs met.
    With this history, it is no wonder that we have observed 
some of the worst outcomes of COVID-19 among these communities. 
We cannot begin to understand or come up with improved policy 
without comprehensive data, not only on fatalities but also on 
infection and COVID-19 long haulers. Indeed, a measurable 
improvement in the equitable response to the pandemic can only 
occur when we have ongoing collection and reporting of all 
COVID-19-related data by race, ethnicity, socioeconomic 
factors, and disability.
    As U.S. efforts to vaccinate our communities continue to 
scale up, we need to take steps to ensure a more equitable 
rollout of the COVID-19 vaccines. This includes taking steps to 
ensure that communities of color and people with disabilities 
are prioritized in vaccination efforts. It is imperative that 
people receiving care can remain in their homes and communities 
rather than being admitted to crowded, unsafe congregate 
settings. We are pleased to see the addition of dedicated 
funding to HCBS in the American Rescue Plan. We applaud 
Representative Dingell and Senators Brown, Casey, and Hassan 
for their release of a discussion draft of the HCBS Access Act, 
and we know it is key to ensuring that states have what they 
need to keep people with disabilities in their homes.
    My colleagues at CAP have noted that while the coronavirus 
crisis has led to significant job loss, it has not been as 
severe of an increase in uninsurance as predicted earlier in 
the pandemic. I would note that ongoing support of the ACA and 
its role in expanding access to health care is critical. 
Equally important is support for Medicaid expansion. One way 
that members can act is to continue to expand coverage and 
further incentivize state Medicaid expansion.
    To guarantee equitable recovery, we urge Congress to 
address the low wages that keep people in poverty. An increased 
minimum wage, basic worker protections like the right to form a 
union or receive overtime pay, coupled with access to paid 
family and medical leave stand to benefit the marginalized 
communities that have been most impacted by this crisis.
    It may not be possible to avert another pandemic. However, 
it is certainly within our power to ensure that the next one 
doesn't devastate individuals, families, and communities to the 
extent that we've seen in the last year.
    Thank you.
    [The prepared statement of Ms. Williams follows:]
             prepared statement of taryn mackenzie williams
    Good Morning. Thank you to Chair Murray, Ranking Member Burr, and 
Members of the Committee, for inviting me to speak today.

    I testify today not only as someone who has spent more than a 
decade in disability policy but also as a Black woman who lives with 
multiple chronic conditions. And, as someone who has seen and 
personally felt the devastating impacts of the pandemic on communities 
of color and people with disabilities.
                      The Magnitude of the Crisis
    First, I will note where we are today.

    According to the Centers for Disease Control and Prevention (CDC), 
as of March 22, 2021, 539,517 people in the U.S. have died from COVID-
19. Nationwide, as of March 12, Black people have died at 1.9 times the 
rate of white people. \1\ Hispanics and Latinos are 3.1 times more 
likely to be hospitalized from COVID-19 and 2.3 times more likely to 
die from COVID-19. \2\ And, from January to June 2020, American Indians 
and Alaska Natives were 3--5 times more likely to be diagnosed with the 
disease than non-Hispanic whites and their mortality rate was almost 
twice as high. \3\
---------------------------------------------------------------------------
    \1\  Centers for Disease Control and Prevention. Risk for COVID-19 
Infection, Hospitalization, and Death By Race/Ethnicity. 03/12/21
    \2\  Ibid.
    \3\  Talha Burki. ``COVID-19 Among American Indians and Alaska 
Natives.'' The Lancet: Infectious Diseases. March 2021.

    The stark disparities are also apparent for the disability 
---------------------------------------------------------------------------
community.

    The CDC reported that all people seem to be at higher risk of 
severe illness from COVID--19 if they have serious underlying chronic 
medical conditions. As of February 11th among states reporting data, 
there were 111,000 cases and over 6,500 deaths, resulting in a fatality 
rate of 5.9 percent for people with disabilities. \4\ Even more 
startling, a cross-sectional study of nearly 65 million patients 
revealed that having an intellectual disability was the strongest 
independent risk factor measured for presenting with a COVID-19 
diagnosis and the strongest independent risk factor other than age for 
COVID--19 mortality. \5\
---------------------------------------------------------------------------
    \4\  MaryBeth Musumeci and Priya Chidambaram. ``COVID-19 Vaccine 
Access for People with Disabilities'' KFF: March 01, 2021
    \5\  Shaun Heasley. ``Intellectual Disability Among Greatest COVID-
19 Risk Factors, Study Finds.'' Disability Scoop. March 10, 2021
---------------------------------------------------------------------------
                  Factors that Exacerbated the Crisis
    In order to ensure a comprehensive response to the pandemic, it is 
incumbent upon us to understand the factors that have shaped this 
crisis.
                        People with Disabilities
    The 1999 Supreme Court case Olmstead v. L.C. confirmed that people 
with disabilities have the right to receive care within an integrated 
community or home setting. \6\ Yet preserving access to resources and 
home and community based services (HCBS) has been an ongoing challenge. 
Absent this critical funding, people with disabilities are compelled to 
live in settings such as nursing homes, group homes, or institutions. 
And, as we have seen, these settings can be deadly.
---------------------------------------------------------------------------
    \6\  About Olmstead. Retrieved on March 22, 2021 from: https://
www.ada.gov/olmstead/olmstead--about.htm

    Equally critical in this moment is the ongoing fight for equal 
protection under the law, particularly in medical settings. In the past 
year, the disability community has feared and fought to prevent health 
care providers from withholding or withdrawing life-sustaining 
treatment on the basis of arbitrary standards about quality of life. 
\7\ We know that calculations made in these critical moments are at 
great risk to be colored by bias and stereotypes. In short, they are 
subject to ableism. The ongoing devaluing of the lives of people with 
disabilities that gives rise to discrimination, and the belief--
entrenched within our policies and systems--that disabled lives are not 
worth saving.
---------------------------------------------------------------------------
    \7\  Joseph Shapiro. ``People with Disabilities Fear Pandemic Will 
Worsen Medical Biases.'' NPR: Morning Edition. April 15, 2020
---------------------------------------------------------------------------
                      Racial and Ethnic Minorities
    In addition to ableism, we must discuss racism and the ways it 
contributes to disparate outcomes during the pandemic. As noted, COVID-
19 has ravaged communities of color, which includes people with 
disabilities. In these communities, we see the ways in which poverty 
and its correlates: low wages, inadequate leave, lack of affordable 
housing, and a lack of affordable healthcare have been inextricably 
linked to higher rates of infection and mortality from COVID-19. \8\
---------------------------------------------------------------------------
    \8\  Molly Kinder and Martha Ross. ``Reopening America: Low-wage 
workers have suffered badly from COVID-19 so policymakers should focus 
on equity.'' Brookings Institution. June 23, 2020.

    Far from coincidental, the relationship between racial and ethnic 
minorities, low wages and the results: inadequate housing, healthcare, 
and poorer health outcomes is by design. Our society has codified a 
two-tiered economic system that overwhelmingly excludes Black and Brown 
workers, women, and people with disabilities from opportunities to earn 
competitive wages and have their basic needs met. With this history, it 
is no wonder that we have observed some of the worst outcomes of COVID-
19 among these communities.
             Steps Forward for Improved Equity and Outcomes
    Data Collection

    We cannot begin to understand or come up with improved policy 
without comprehensive data not only on fatalities, but also on 
infection and COVID-19 long haulers. Indeed, a measurable improvement 
in the equitable response of the pandemic can only occur with ongoing 
collection and reporting of all COVID-19-related data by race, 
ethnicity, socioeconomic factors and disability. Many states do not 
publish vaccine data that includes race and ethnicity and--a year into 
the pandemic--no comprehensive data exist detailing the full extent of 
the pandemic on people with disabilities throughout the U.S.
                       Equitable Vaccine Roll-Out
    As the U.S.'s efforts to vaccinate our communities continue to 
scale-up, we need to take steps to ensure a more equitable rollout of 
the COVID-19 vaccines. The distribution of vaccines should take into 
account the disproportionate impacts that the pandemic has had on 
marginalized communities. \9\ This includes taking steps to ensure that 
communities of color and people with disabilities are prioritized in 
vaccination efforts.
---------------------------------------------------------------------------
    \9\  Jamila Taylor. ``The Path Toward Equity in COVID-19 
Vaccination.'' The Century Foundation. March 15, 2021.
---------------------------------------------------------------------------
            Investment in Home and Community Based Services
    It is imperative that people receiving care can remain in their 
homes and communities, rather than be admitted to crowded, unsafe 
congregate care settings--particularly during an ongoing pandemic and 
as we move into the future. We were pleased to see the addition of 
dedicated funding to HCBS in the American Rescue Plan (ARP), we applaud 
Representative Dingell and Senators Brown, Casey, and Hassan for their 
release of a discussion draft of the HCBS Access Act and look forward 
to working with Congress to ensure that states have the resources they 
need to enable people with disabilities and older adults to live in 
their communities. \10\ \11\
---------------------------------------------------------------------------
    \10\  American Rescue Plan of 2021. Retrieved from Congress.gov on 
March 23, 2021. https://www.Congress.gov/bill/117th-congress/house-
bill/1319/text
    \11\  Michelle Diament. ``Waiting Lists May Be Eliminated for 
Disability Services Provided by Medicaid.'' Disability Scoop. March 22, 
2021
---------------------------------------------------------------------------
                  Investment in Affordable Healthcare
    My colleagues at CAP have noted that while the coronavirus crisis 
has led to significant job loss in the United States, it has not been 
as severe of an increase in un-insurance as predicted earlier in the 
pandemic. \12\ This is in part because the programs established by the 
Affordable Care Act (ACA) are robust, helping those who lost their jobs 
in the past year secure new sources of coverage. Ongoing support of the 
ACA and its role in expanding access to healthcare in the US is 
critical.
---------------------------------------------------------------------------
    \12\  Emily Gee and Thomas Waldrop. ``Policies to Improve Health 
Insurance Coverage as America Recovers From COVID-19'' Center for 
American Progress. March 11, 2021
---------------------------------------------------------------------------
                           Medicaid Expansion
    Equally important is support for Medicaid expansion. \13\ One way 
that Congress can act to expand coverage is to further incentivize 
state Medicaid expansion. States that have yet to expand Medicaid under 
the ACA have left millions of people--whose incomes are below the 
Federal poverty level--without access to either Medicaid coverage or 
financial assistance toward marketplace coverage. \14\
---------------------------------------------------------------------------
    \13\  Ibid.
    \14\  Ibid.
---------------------------------------------------------------------------
            Increased Wages and Access to Affordable Housing
    To guarantee an equitable recovery, we urge Congress to address the 
low wages that keep people in poverty. An increased minimum wage, basic 
worker protections like the rights to form a union and receive overtime 
pay coupled with access to paid family and medical leave stand to 
benefit the marginalized communities that have been most impacted by 
this crisis. In addition to wages, it is critical that we continue to 
provide support for individuals who are housing insecure. The ARP's 
investments in assistance for renters, landlords and individuals who 
are at risk for homelessness is an important first step toward 
addressing a key risk factor for poor health outcomes. \15\
---------------------------------------------------------------------------
    \15\  American Rescue Plan of 2021. Retrieved from Congress.gov on 
March 23, 2021. https://www.Congress.gov/bill/117th-congress/house-
bill/1319/text
---------------------------------------------------------------------------
                               Conclusion
    It may not be possible to avert another pandemic. However, it is 
certainly within our power to ensure that the next one doesn't 
devastate individuals, families and communities to the extent that we 
have seen in the last year. In the coming months, we should work hard 
to identify what went wrong, take action, and be undeterred in our 
effort to commit the investments necessary to guarantee a better 
future.
                                 ______
                                 
            [summary statement of taryn mackenzie williams]
    This testimony will explore the magnitude of the COVID-19 crisis; 
factors that have exacerbated the crisis; and proposed steps that 
Members of Congress can take to address the needs of the communities 
most impacted by the pandemic. It will begin with an overview of the 
available data from the CDC describing the disparate impacts of the 
pandemic on communities of color and people with disabilities. Next, it 
will address how congregate settings and ongoing discrimination in 
medical settings has detrimentally impacted people with disabilities. 
It will also explore how low wages, inadequate leave, and lack of 
affordable housing and healthcare have affected COVID-19 rates in 
communities of color. In the final sections, proposed recommendations 
will be discussed.
                      The Magnitude of the Crisis
    Where we are today:

          CDC Data on the Disparate Impacts of COVID-19 on 
        Communities of Color

          CDC Data on the Disparate Impacts of COVID-19 on the 
        Disability Community
                  Factors that Exacerbated the Crisis
    In order to ensure a comprehensive response to the pandemic, it is 
incumbent upon us to understand the factors that have shaped this 
crisis.

    People with Disabilities

          Lack of Access to Home and Community Based Services

          Ongoing Discrimination in Medical Settings

    People of Color

          Low Wages

          Inadequate Paid Family and Medical Leave

          Lack of Affordable Healthcare and Housing
             Steps Forward for Improved Equity and Outcomes
    It is imperative that lawmakers take into consideration the needs 
of the communities most impacted by the COVID-19 crisis. Critical next 
steps include:

          Invest in Robust Data Collection

          Commitment to Equitable Vaccine Roll-out;

          Investment in Home and Community Based Services

          Investment in Affordable Healthcare

          Continued Incentivization of Medicaid Expansion

          Increasing Wages and Access to Affordable Housing
                                 ______
                                 
    The Chair. Thank you very much.
    We will turn to Mr. Woods.

   STATEMENT OF GENE A. WOODS, PRESIDENT AND CHIEF EXECUTIVE 
             OFFICER, ATRIUM HEALTH, CHARLOTTE, NC

    Mr. Woods. Senator Burr, first let me begin by saying thank 
you for that kind introduction and for being a friend to Atrium 
Health and for being a true champion for the communities that 
we serve throughout North Carolina.
    Chairwoman Murray and Members of the Committee, my name is 
Gene Woods, and I'm the President and CEO of Atrium Health, and 
it's an honor to be with you here today.
    Let me just first start by saying that in my 30 years in 
leadership positions in the health care field, this past year 
has been unequivocally the most challenging. But it's also been 
a year where my 70,000 teammates and I have never felt more 
connected to our purpose, because when you're on the front 
lines battling a pandemic to save lives every single day, one's 
purpose becomes brilliantly clear.
    As one of the very few CEOs of color leading one of the 
largest academic health systems in the country, I was 
profoundly distressed to see Black and brown people die 
disproportionately of COVID. It was extremely personal for me. 
They could have been members of my own family.
    COVID has beamed a blinding spotlight on the racial 
inequities that have existed for too long in this country. 
However, it fueled my passion and that of my entire 
organization to adopt a not-on-our-watch stance. We wanted to 
look back on these extraordinarily trying days and say that the 
very best of who we were showed up, and I couldn't be more 
proud of the Atrium Health heroes that I get the chance to work 
with every single day.
    When the first patient showed up with COVID in our 
community, we leveraged the full breadth of our capabilities 
and our talents to rethink every single thing that we did, 
everything. The silver lining is that the key learnings from 
battling COVID present new opportunities to fundamentally 
change and improve health care in America post-pandemic. That 
can be good for the national budget, it can be good for 
business, and above all it can be better for our patients and 
our communities.
    For example, early in the pandemic we used our analytical 
capabilities to geographically pinpoint hotspots down to the 
specific ZIP Code where there were disparities in testing and 
treatment. And working with local pastors and community 
leaders, we deployed our roving medical units well beyond our 
hospital walls, deep into the community, in church parking 
lots, on the grounds of the local YMCA, and even on 
construction sites.
    In a matter of weeks, we completely eliminated all testing 
disparities that existed through the Charlotte region. Doing so 
reinforced the fact that data is only noise until we collect 
it, analyze it, and then very quickly put it into use, because 
as General Patton once famously said, ``A good plan executed 
now is better than a perfect plan next week.''
    We also learned that health systems alone cannot create a 
healthier America. This pandemic proved that we need the whole 
community--businesses, government, and citizens alike--working 
together to create real solutions. For example, early in the 
pandemic we built a public-private coalition that ultimately 
delivered 2.6 million free masks across our community, with a 
specific focus on the most vulnerable. And in January, together 
with Honeywell, Tepper Sports and Entertainment, Charlotte 
Motor Speedway and others, we hosted among the country's 
largest and most successful vaccination events. In fact, we had 
a shot in arms every 4 seconds and published our learnings in a 
booklet titled ``A Leader's Guide to Safer, Faster, and More 
Equitable Community Vaccination Events.''
    Through these partnerships we demonstrated that we can be 
both pro-business and pro-health. In fact, as the Chair of the 
Board of the Richmond Federal Reserve, I am acutely aware that 
both of those are inextricably connected. And as the veterans 
on my team remind me, both are required for national security.
    We also used technology in new ways to reach patients 
across a very broad geography. For example, we launched the new 
Atrium Hospital to Home Program and equipped people's bedrooms 
with the most sophisticated monitoring equipment, and then used 
our medics to administer needed interventions, including 
Remdesivir, in the home.
    Today we have cared for several thousand patients who would 
have otherwise been in the hospital with over 50,000 patients 
experiencing symptoms, thereby preserving critical bed 
capacity. And this is just a glimpse of what the future of 
health care can look like.
    Finally, I'd like to say that we have arrived at many 
battled-tested beliefs from our experience this year. For one, 
there are deep disparities in both rural and urban communities 
to solve for. In fact, the major components of health equity 
can be similar whether you're a poor African American mother in 
New York, an Hispanic farmer in Texas, or even a white farmer 
in rural North Carolina.
    Let me conclude by saying this. It took us less than a 
decade to put Neil Armstrong on the moon, and doing so required 
tremendous collaboration and ingenuity that showed the world 
who we were as Americans at our very best. I believe we can 
apply the same collaboration and ingenuity in these times to 
eliminate health care disparities by 2030, whether in urban or 
rural communities, if we take this moment to collectively say, 
``Not On Our Watch.''
    Thank you for the opportunity to share our experiences and 
learnings from this past year on the front lines of battling 
this pandemic.
    [The prepared statement of Mr. Woods follows:]
                  prepared statement of gene a. woods
    Chair Murray, Ranking Member Burr and Members of the U.S. Senate 
Committee on Health, Education, Labor, and Pensions.

    My name is Gene Woods and I am the president and chief executive 
officer for Atrium Health, one of the most comprehensive and highly 
integrated, not-for-profit healthcare systems in the Nation. With 
nearly 30 years of healthcare experience, I joined Atrium Health in 
April 2016, having overseen non-profit and for-profit managed 
hospitals, academic and community-based delivery systems and rural and 
urban facilities, as well as serving as the previous chair of the 
American Hospital Association (AHA). As a multi-racial healthcare 
executive, I am most passionate about protecting and expanding access 
and coverage to all Americans, connecting with our communities to 
advance positive health outcomes and achieving equity of care by 
eliminating health disparities.

    It is now my great honor to present my written testimony to the 
U.S. Senate Full Committee on Health, Education, Labor, and Pensions on 
behalf of our 70,000 Atrium Health teammates, detailing some of the 
many successes we have achieved and lessons we have learned during this 
unprecedented pandemic period, including the disproportionate effect 
COVID-19 has had on communities of color and its impact on pre-existing 
health disparities.
                           Our Past & Present
    It's quite remarkable to think back to our humble beginnings in 
1940 when a group of ambitious, young clinicians, not being satisfied 
with the services available to the public, relentlessly lobbied for a 
new hospital to better meet the needs of the community. Over time, we 
have evolved from these simple roots, understanding that our 
responsibilities are becoming less about what happens inside our 
hospitals and more about what happens in our communities; less about 
what our clinicians are telling our patients and more about what 
patients are telling us. In fact, it is less about healthcare and more 
about health. Today, we're proud to be known as one of the nation's 
leading health organizations. Our mission to improve health, elevate 
hope and advance healing--FOR ALL is forever bound to our rich 
heritage.

    When it comes to keeping populations healthy, we know that our 
responsibilities do not begin or end at the hospital door. This 
important work starts well before a person becomes a patient, 
particularly within vulnerable ZIP Codes and census tracts--areas that 
do not have enough access to health services or fresh foods and where 
the rates of diabetes and heart disease are above the national average. 
So, we're bringing people and organizations together in new ways and 
collaborating on what matters most.

    With 42 hospitals and 1,500 care locations across the Carolinas, 
Georgia and Virginia (welcoming Wake Forest Baptist Health and Wake 
Forest School of Medicine into our family this past year), we serve a 
population of 7.8 million. We are also the largest provider of 
community benefit (i.e., the value we give back to our community in 
uncompensated care, medical education, cash and in-kind contributions, 
community-building activities, etc.) in North Carolina. And with world-
class service lines in Cancer, Children's, Heart & Vascular, 
Neuroscience, Musculoskeletal and Surgery & Transplant, we are 
recognized by our patients and industry experts to be among the very 
best, demonstrating that healthcare can be both exceptional and 
compassionate at the same time.
                        Our Awards & Recognition
    Atrium Health has also been recognized as one of the Best Employers 
for Diversity, for new grads and for Women by Forbes; No. 1 on the list 
of Best Places to Work for Women & Diverse Managers by DiversityMBA; 
one of the 150 Top Places to Work in Healthcare by Becker's Healthcare; 
and the No. 1 military-friendly employer in the country. In addition, 
our organization has been recognized by U.S. News & World Report, 
Leapfrog Group and the American Nurses Credentialing Center as among 
the very best in the Nation and honored by the American Hospital 
Association with the Equity of Care Award and one of its first-ever 
Quest for Quality honors.

    Most recently, Atrium Health was recognized by the Centers for 
Medicare & Medicaid Services (CMS) as a 2020 CMS Health Equity Award 
recipient for its dedication to health equity by reducing disparities, 
enabling communities to achieve the highest level of health. Atrium 
Health is one of only two organizations to win this prestigious award 
in 2020 and is the only non-profit healthcare system in the Nation to 
be recognized by CMS in this manner.
                              Introduction
    Eighty years ago, our organization rose from the ashes of the Great 
Depression as Charlotte Memorial Hospital. It was a time when 
institutions of every kind were struggling economically, and our 
country was being further strained by war. And while born in the midst 
of uncertainty, through all the twists and turns in our storied 
history, we have become stronger in the face of each new challenge.

    Fast forward to today--facing the challenges brought by the novel 
coronavirus, COVID-19--our resolute perseverance and passion to help 
others have never shined brighter. From within our care facilities to 
the makeshift offices now set up within their homes, every single 
member of our Atrium Health family is playing a unique role in 
protecting the health and safety of our patients, loved ones, friends 
and neighbors throughout this pandemic. Working together, during some 
of the longest and hardest days, our teammates are bringing health, 
hope and healing--FOR ALL front and center in new and remarkable ways, 
demonstrating undeniable courage and dedication.

    As a recognized leader in diversity, inclusion and health equity, 
we have also witnessed and responded to the disproportionate effect 
COVID-19 has had on communities of color. A spotlight has been shone on 
the structural social and health inequities that exist, and we are 
asking ourselves the question--what does the next iteration of FOR ALL 
look like and how can we play a role in eliminating health disparities 
completely?

    Within the following sections I will detail the work Atrium Health 
has done throughout the pandemic to address health disparities and 
inequities. I will also share recommendations we humbly present to this 
Committee that can better inform action beyond the Southeast region and 
eliminate health disparities across the entire United States.
              Out of the Box Thinking--Data Infrastructure
    When the first COVID-19 cases appeared in our region in early March 
2020, Atrium Health invested in our data infrastructure and built our 
own COVID-19 Electronic Dashboard. The Dashboard is updated every 2 
hours and provides a variety of analytics including COVID-19 positive 
cases and mortality, all stratified by race, ethnicity, age and test 
location.

    In order to evolve our data-driven operations, we also created a 
sophisticated COVID-19 GIS (Geographic Information System) Map that 
linked data on COVID-19 geographical spread, hot spots, and testing 
density to population density, median income, higher poverty ZIP Codes, 
the concentration of Blacks or Hispanics all to help our teams gain 
granular insights on health disparities. To drive successful 
operations, we knew that partnerships, access, and mobility were 
critical, so we added layers to this map that included location of 
churches, schools, certain businesses and bus routes. In health 
disparities, we often talk about ZIP Codes. But our experts knew that 
social vulnerability indices (SVI) are far more local. Accordingly we 
developed features within our GIS map to analyze the home addresses of 
patients tested on specific testing days and mobile locations to assess 
the neighborhood footprint and geographical reach of our marketing 
outreach and grassroots communications efforts.

    By the end of March 2020, our data clearly showed there were gaps 
in testing for communities of color and that the majority of tests 
among the Black population were taking place in the Emergency 
Department. We quickly formed a Multi-Disciplinary COVID-Disparities 
Task Force that developed and implemented an aggressive set of 
initiatives to mitigate these disparities.
                            Minority Testing
    To address the testing disparity among underserved and minority 
communities, we launched our nationally leading, innovative testing 
model, integrating actionable GIS data with our mobile medical units. 
With our GIS data, our mobile units target COVID-19 hotspots in 
underserved neighborhoods and break down barriers to screening and 
testing for COVID-19 in low-income communities of color by:

          Reducing administrative barriers; no appointment or payment 
        barriers

          Establishing trust; partners in media, churches, other 
        organizations

          Increasing access to care; telemedicine, mobile care

    With these efforts, by April 20, 2020--less than a month after the 
start of the initiative--Atrium Health closed the gap in testing for 
the Black population in our area. By May 4, 2020, the gap in testing 
had been closed for Hispanics as well.

    To date, the mobile units focused on underserved communities have 
tested close to 30,000 community members. And of the patients tested by 
the mobile units, 24 percent are Black/African American and 41 percent 
are Hispanic/Latino. In addition, our mobile unit have partnered with 
over 60 community host sites, including a variety of churches and 
organizations that serve large African American and Hispanic 
populations.
                           ``Para Tu Salud''
    In May 2020, we also convened a Hispanic COVID-19 Response 
Roundtable that included many key stakeholders from the Hispanic and 
Latino community. The goal was to hear from the community about gaps in 
the COVID-19 response and to get feedback about how to communicate 
messages and conduct additional community outreach to the Hispanic and 
Latino community related to the pandemic more effectively.

    The result of this meeting, as well as some smaller community 
discussions, was the launch of our new initiative, ``Para Tu Salud''--
simply translated to ``For Your Health''--to further educate and inform 
Hispanic communities on how to stay safe and healthy relative to COVID-
19. Since the launch of this initiative, we have deployed several 
communications tactics to target Hispanic and Latino populations. This 
includes developing educational materials for social media; creating 
videos in Spanish featuring Atrium leadership and physicians; and 
partnering with local Hispanic news outlets and community leaders and 
influencers.
                 Atrium Health Hospital at Home Program
    Though we continue to see COVID patients in our care facilities, we 
have also been embracing virtual care like never before. So much so 
that Atrium Health is leading the country with our efforts. Our new 
telehealth program, Atrium Health Hospital at Home, opened on March 20, 
2020 and is enabling us to care for hundreds of patients at a time from 
the comfort of their homes.

    Atrium Health Hospital at Home provides hospital-level care to 
patients who would otherwise require inpatient hospitalization. 
Principal components of this model of care include telephonic 
assessment and monitoring by a registered nurse, as well as daily 
provider virtual visits and in-home care provided by community 
paramedics for the most acutely ill. To date, Atrium Health Hospital at 
Home has cared for over 3,000 COVID-19 patients who would have 
otherwise been in the hospital. In addition, the COVID-19 Virtual 
Observation Unit has cared for nearly 54,000 patients experiencing mild 
symptoms not requiring hospitalization. Along with the significant 
impact on improved clinical outcomes, the virtual hospital has also 
created additional inpatient bed capacity, resulting in less PPE use 
and helping limit the community spread of the virus. Patient feedback 
has been overwhelmingly positive as they report feeling less fearful 
and alone throughout their illness.

    This program also has tremendous potential for impacting access to 
care in rural America. When used at scale, this model prevents the need 
to stand up costly field hospitals in times of crisis while also 
advancing a new model of more routine care. It is critical that CMS 
continue to invest in this type of program to build resilience for 
future crises--from hurricanes to pandemics--and introduce another 
level of value into traditional healthcare. To evolve telemedicine 
capabilities we also recommend:

          Establishing a payment structure the supports the technology 
        and reasonable efficiencies

          Modernization of credentialing and licensing requirements

          Multi-state licensure

          Broadband expansion and novel access rules for health care 
        purposes, such unlimited data as waiving data plans for 
        unlimited data and high-speed access under specific conditions.

          Callout: Senate HELP Committee Member Senator Tim Scott (R-
        SC) is commended for the introduction of S. 368 ``The 
        Telehealth Modernization Act'' which would empower the HHS 
        Secretary to leverage telehealth beyond the public health 
        emergency, as clinically appropriate.
               Partnerships: Two Million Mask Initiative
    At a June 26, 2020 Statehouse news conference, North Carolina 
Governor Roy Cooper issued a statewide requirement for citizens to wear 
masks while in public in order to slow the spread of COVID-19. 
Alongside Governor Cooper and Secretary of the North Carolina 
Department of Health and Human Services Dr. Mandy Cohen, Atrium Health 
proudly announced our leadership of private-public partnership with the 
state's largest businesses and organizations--including Bank of 
America, Blue Cross Blue Shield of North Carolina, The Carolina 
Panthers, Honeywell, Lowe's, Red Ventures and Wells Fargo--to 
distribute one million face masks across the region. This partnership 
is a great example of how health professionals, working in concert with 
businesses, can improve well-being.

    Our initial emphasis has been providing masks to our underserved 
communities through our deep, existing relationships with Hispanic, 
Black, elderly, millennial and faith communities. In the days following 
our initial announcement, Mecklenburg County--where Charlotte is 
located--joined our effort, pledging an additional one million masks 
and bumping our supply to two million masks for the region. By 
partnering with the private sector, we were able to improve our data 
analytics, access an entirely new group social media influencers to 
build trust, create a series of hyper-focused targeting and 
distribution operations, and innovate at the speed of the pandemic.

    The impact was dramatic. At the state level, we saw total COVID 
cases drop 21 percent and the percent positive rate drop 10 percent 
(from 7.7 percent to 6.9 percent) starting 2 weeks after the mandate. 
However, in Mecklenburg County, over the first 10 weeks of the Million 
Mask Initiative we observed a decrease in total daily positive test 
rates by over 60 percent. Critically, we noticed significant decreases 
in hospitalizations.

    This shows correlation, it does not prove causation. That said, the 
initiative was the leading factor in helping Mecklenburg County over 
perform and get control of COVID-19. The teams spanning the business, 
sports, health, government and non-profit communities got masks in 
people's hands and the message that ``Masks Save Lives'' had impact. As 
of March 1, we have surpassed our goal and distributed nearly 2.6 
million masks, all while modeling and encouraging COVID-19 safety and 
best practices while we wait for herd immunity.
             Partnerships Part 2: Mass Vaccination Playbook
    In January, North Carolina needed to quickly build the capacity to 
vaccinate with zero vaccine waste. On Jan. 14, 2021, Atrium Health, 
Honeywell, Tepper Sports & Entertainment (The Carolina Panthers) and 
Charlotte Motor Speedway (NASCAR) announced a unique public-private 
initiative with a bold goal of administering 1 million doses of the 
vaccine by July 4, 2021. With support from North Carolina Governor Roy 
Cooper, the North Carolina Department of Health and Human Services and 
local governments, our organizations collaborated to administer 
vaccinations, provide logistics and operations support, and offer 
venues for an efficient and safe initiative. These mass vaccination 
events brought together each organization's unique strengths in 
logistics, healthcare and technology to vaccinate as many eligible 
community members as quickly as possible. The public-private initiative 
organized the first mass vaccination event at Charlotte Motor Speedway 
from January 21 to 24, with second doses February 11 to 14. After these 
successful events, the team developed a plan for future vaccination 
events that can accommodate an estimated 30,000 vehicles. With multiple 
people in each vehicle, the vaccination capacity could be significantly 
higher.

    The second event was held at Bank of America Stadium from January 
26 to 29, with second doses February 26 to 28. These highly efficient 
mass events safely vaccinated a diverse group of more than 36,000 
people with scalability at a rate of nearly 1,500 vaccinations per hour 
with average total vaccination times of less than 30 minutes. With each 
event, we get better and more efficient. In fact, last week we 
partnered with American Airlines and the Charlotte Douglas 
International Airport to vaccinate nearly 5,100 transportation workers, 
44 percent of whom were minorities.

    I would like to submit our ``Leader's Guide to Safer Faster and 
More Equitable Community Vaccination Events'' for the record. In this 
playbook, we offer several best practices to get ``shots in arms'' 
quickly, efficiently and safely. While each event and venue are unique 
and require some adaptation, this guide is intended to lay out the 
high-level elements of planning, preparing, and executing a mass 
vaccination event.

    Key Statistics:

          During our mass vaccination events we were able to give a 
        shot in the arm every 4 seconds.

          To date (3/22/21), Atrium Health has administered nearly 
        350,000 vaccines. o 21 percent of whom are people of color with 
        a goal of reaching the overall state population rate despite 
        age and workforce regulatory limitations.
                         Vaccination Hesitancy
    When the first FDA-approved COVID-19 vaccine became available in 
December 2020, Atrium Health became the first health system in North 
Carolina to administer the vaccine to our teammates. A Vaccine 
Hesitancy Taskforce was established to address vaccine hesitancy among 
teammates and community members. The taskforce uses a multi-pronged 
approach grounded in data to create innovative processes that remove 
barriers to getting the vaccine and create culturally sensitive 
education and communications to address myths and misconceptions in 
minority communities about the COVID-19 vaccine. Our community efforts 
are grassroots in nature, working with community partners to co-create 
collateral that is bilingual, culturally responsive and health 
literate. The taskforce also uses real-time data through a COVID-19 
Vaccine Demographics Electronic Dashboard, which provides a variety of 
analytics updated every 6 hours, stratified by race/ethnicity, age, and 
vaccine location. In addition, the taskforce applies a data-informed 
decision approach to prioritize vaccine distribution in communities 
with the greatest need.

    Atrium Health also created ``Community Immunity for All,'' a new 
collaborative to vaccinate underserved communities and those most 
disproportionately affected by the coronavirus disease. The goals of 
``Community Immunity For All'' are:

          Acknowledge the history of health injustice in communities of 
        color

          Listen to and collaborate with partner organizations

          Educate and support individuals in making informed decisions 
        to best protect their health and well-being

          Increase the vaccination rate in underserved communities and 
        communities of color

    Through the efforts of Community Immunity for All, African American 
and Hispanic teammates (employees at Atrium Health) acceptance or 
uptake rate of scheduling their first appointment increased 24 percent 
in the first 6 weeks of our efforts, exceeding our goal of a 20 percent 
increase.

    In addition, to address the vaccine disparity among underserved and 
minority communities, Atrium Health has expanded its nationally leading 
innovative mobile COVID-19 testing model to vaccine distribution. 
Specifically, we have deployed our mobile medical units to target 
underserved neighborhoods and breaks down barriers to obtaining a 
vaccine in low-income communities of color by:

          Not requiring an appointment

          Holding vaccination locations trusted by underserved 
        communities such as churches and community service 
        organizations.

          Leveraging grassroots communications channels such as church 
        emails and phone calls to inform community members of site 
        locations and dates and times and preserve capacity for the 
        underserved community

          Staffing the units with interpreters

          Making it clear that Atrium Health will not share an 
        individual's immigration status and that the organization will 
        not report if a patient is undocumented.

          Educating community members that the vaccine is provided at 
        no cost to them

          Offering alternate operational hours on certain days to 
        accommodate essential workers

    To date (03/17/21), the mobile units focused on underserved 
communities have vaccinated over 9,000 community members at over 20 
events at 23 community host sites, including a variety of churches and 
organizations that serve large African American and Hispanic 
populations. People of color represent 75 percent of those vaccinated 
to date at these units. Specifically, Blacks comprise 54 percent and 
Hispanics comprise 9 percent of community members vaccinated in the 
roving unit model to date. Atrium Health has scaled its roving unit 
vaccination capacity to offer 10 sites a week (including both testing 
and vaccinations). Future plans include adding two additional mobile 
units for a total of 20 sites a week.
                 Social Impact and Rural/Urban Strategy
    It is without question that the COVID pandemic has forced a re-
examination of every aspect of how we deliver care; and going forward, 
we would assert that we all have an opportunity to completely re-
examine how we can create greater social impact and eliminate the 
inequities we see, once and for all. In fact, our country is depending 
on us to do just that. As we know, social determinants of health (SDOH) 
are environmental conditions--like socioeconomic status, quality of 
education, access to job opportunities, income, transportation, access 
to technology and social norms--that affect a person's quality of life 
and health outcomes.

          Callout: The ``Black Maternal Health Momnibus Act of 2021'' 
        S. 346 represents a comprehensive set of policies to help 
        mitigate inequities from birth. I want to acknowledge HELP 
        Committee Members Senator Tim Kaine (D-VA), Senator Bob Casey 
        (D-PA), and Senator Tammy Baldwin (D-WI) for their support.

    We know that non-clinical, community services are crucial and 
impact health outcomes, such as mortality, morbidity and healthcare 
costs, by as much as 80 percent, indicating that clinical care impacts 
less than 20 percent of health outcomes. That's why, this past year, 
Atrium Health developed a Social Impact Strategy to follow our mission 
to improve health, elevate hope and advance healing FOR ALL to support 
patients and communities affected by the health inequity crisis facing 
our Nation. Led by our Enterprise Board (through the Health Equity and 
Social Impact Committee), our social impact strategy will ultimately 
become a center piece of our entire corporate strategy. Our strategy is 
built upon four pain pillars:

          Equity in Social Determinants of Health

          Equity in Acute Social Needs

          Equity in Quality and Outcomes

          Equity in Access

    As you heard at the March 9 hearing, ``An Update from the Front 
Lines,'' our teammates also need support. So, we made a commitment to 
start first with our own by piloting our social impact strategy 
internally to bring best practices to scale in the community. We 
initiated:

          Teammate Well-Being Surveys: Survey tracked food, housing, 
        utilities, internet, mental health, career development; 
        Expanded proactive, ongoing outreach to lower-income teammates 
        with resource information and support

          Career Development Center Expansion: Committed to growing 
        teammates and promote economic mobility in our community; Hope 
        to grow our reach by 5x (from 100 to 500+)

          Teammate Meal Kit Pilot Program: Offering easy affordable 
        family options to our low-income teammates; Pilot launched 
        January 2021; 2 meals per week, each meal feeds 4 people

          Housing Opportunity Promoting Equity (H.O.P.E) Program: In 
        2021, 50 teammates will be placed in affordable housing; 
        Program targeted to teammates with household income of 31-80 
        percent of the area median income.

    Since 2018, Atrium Health has also embraced ``Leveraging Integrated 
Networks in Communities'' (LINC) as a means of connecting patients to 
social services. By leveraging local expertise and technology, people 
are connected to food, housing, child development, job training, and 
transportation supports. Atrium Health relies on Aunt Bertha, a growing 
multi-state social care referral platform. This interoperable resource 
not only helps our teammates connect people to resources, but it also 
provides Atrium Health with real-time data on needs, patterns and 
utilization of services in the communities we serve.

    Since we adopted the platform in 2018, we have connected more than 
14,000 people to services in N.C., S.C., and G.A. More importantly, 
however, we were able to see the impact the pandemic, the economy, and 
distance learning had on families in our region. For example, we saw a 
drop in utilization (down to 200 connections in March 2020) when 
hospitals and the community went into lock down, and then a tremendous 
spike (more than 700 connections in August 2020) when schools did not 
reopen for in-person learning.

          Callout: Legislation introduced by Sen. Dan Sullivan (R-AK) 
        and Senate HELP Committee Member Sen. Chris Murphy (D-CT), S. 
        509 the ``Leveraging Integrated Networks in Communities (LINC) 
        to Address Social Needs Act'' aims to assist states in building 
        statewide or regional collaborations--like Aunt Bertha--to 
        better coordinate health care and services.
                  ``Teammates First'' During COVID-19
    Since the onset of COVID-19, it is important to note that Atrium 
Health has been committed to a ``Teammate First'' strategy to support 
our teammates, leaders, physicians and providers as they work to 
fulfill our mission each and every day. We recognize that in order to 
care FOR ALL, we also must care for each other as well. In doing so, by 
the end of 2020, we invested more than $179.7 million to patient safety 
and teammate well-being. Ways in which we continue to support our 
teammates throughout COVID include:

          Safety--Ensuring our teammates have access to testing and 
        proper PPEs, while moving as many teammates as possible 
        (9,000+), as quickly and effectively as possible, to a remote 
        work environment.

          Communication--Providing daily, often more than daily, 
        updates from our Emergency Operations Center. Focusing on 
        consistent and open lines of communication. Implemented texting 
        technologies to enhance screening of teammates for COVID-19

          Stress and Burnout--Convening workgroups to quickly and 
        effectively provide opportunities to support our teammates 
        through the challenging times of reduced hours, testing and 
        screening for COVID-19, back-to-school issues, etc.--and 
        keeping in mind that our leaders face the same challenges and 
        need support too.

          Engagement and Productivity--Re-energizing the conversations 
        and opportunities around engagement and productivity to fit the 
        times and support teammates, without losing sight of our 
        commitment to our patients. Providing tools and resources for 
        growth and development--whether in a remote or on-campus 
        environment.

          Flexibility--Adapted for parents with remote learning and 
        back-to-school support. Leaders provided flexibility as much as 
        possible without compromising the needs of the business and 
        safety of patients.

          Supporting Teammates--Used partnerships, for example with the 
        YMCA, to offer childcare at no cost. Employee hardship fund 
        established to provide financial support to teammates facing 
        financial challenges.

          Onboarding--Shifting to virtual, rather than in-person 
        onboarding, while keeping new teammates excited and engaged to 
        join our team. Streamlining processes and adapting flexible 
        policies to expedite health screenings and background checks.

          Cross training--Providing training and education to equip 
        staff with the knowledge and competencies needed to adapt in a 
        rapidly changing environment.

          Talent pool--Expanded talent pools to include students, 
        paramedics/military vets to support staffing surge demands. 
        Includes hiring 90-day, clinical temporary workers in support 
        of surge.

          Finances--In 2020, launched the Atrium Health Caregiver 
        Heroes Teammate Emergency Care Fund to support teammates 
        suffering catastrophic events, including extreme hardship 
        through COVID-19.

    Following the death of George Floyd last year, our already stressed 
teammates faced the additional pressure of social injustices. We 
respond with a sense of urgency, but also with a voice of compassion, 
credibility, and call to action through activities that engaged and 
supported our 70,000 teammates--in particular our teammates of color--
in healing during a time of emotional unrest. Atrium Health's 
comprehensive work in the social justice space for our teammates now 
totals more than 300 hours of programming, has attracted over 13,000 
teammates, and supported over 1,000 Atrium Health leaders.

    This included initiatives like Courageous Conversations to engage 
teammates. Working alongside our diverse Black men's and women's System 
Resource Groups (SRG's), our Office of Diversity and Inclusion hosted a 
system-wide Courageous Conversations 3-part virtual series allowing 
teammates to share their personal stories, perspectives, and emotions, 
in a safe space and to begin the healing process. The second part of 
the virtual series was open to all teammates and focused on the 
experiences of Black/African American men and women personally, and at 
work. Total attendance was over 1,700 teammates. Through these programs 
not only were our teammates able to speak their truth, but they also 
found comfort, support and hope in their Atrium Health family.

    As a system, we also provided mental health, emotional support and 
resources for teammates through our Racial Justice Toolkit: a curated 
collection of resources for teammates and community members to explore 
racial justice, improve cultural competence and start productive 
conversations about race. Our resources have also been referenced by 
local and national partners and organizations. In addition, we provided 
training and informative material for leaders to engage with their 
teams. For instance, in June 2020, our Office of Diversity & Inclusion 
held a series of enterprise-wide leader-only education sessions about 
racial justice to support leaders in understanding how to support 
teammates through the emotion curve, strategies for connecting and 
initiating conversations, mitigating unconscious bias, working through 
scenarios and best practices for leading during unprecedented, 
unpredictable times.
             Recruitment & Retention of Diversity Teammates
    In 2019, a study showed that firms owned by women and minorities 
managed just 1.3 percent of assets in the $69 trillion asset management 
industry. However, the study found that the performance of minority 
owned funds was overrepresented in the top quartile of performance.

    At Atrium Health, we believe we could do more to ensure that its 
investment decisionmaking processes promoted equity and inclusivity. As 
part of our own self-assessed, we determined that, while we had made 
some progress in diverse manager selection, our portfolios were 
underrepresented by Black-owned investment management firms. So, over 
the past several months, we (1) re-evaluated our manager search 
processes; (2) met with Black-owned investment firms to learn about 
their history, processes, and performance; (3) engaged in significant 
discussions about diversity with industry colleagues and our board, (4) 
and; most importantly, took action.

    We recently committed over $320 million to Black-owned investment 
funds bringing our total investment in women and minority-owned 
investment management firms to 12 percent of our assets. And we are not 
done. We will continue to bring a fresh diversity lens to our 
investment manager selection and increase our allocation. This is just 
one example of our commitment to diversity. We have and will continue 
to incorporate the same rigor and accountability into other areas of 
our organization for the good of our institution and the patients that 
we serve.

    In addition to investing in diversity, Atrium Health also signed 
the Parity Pledge, which pledges that we will interview at least one 
woman and one person of color for all executive positions. We are also 
participants in the AHA Equity of Care pledge. With these pledges, we 
have overhauled our executive search and selection policy to ensure a 
fair, open and equitable search and selection processes for all 
executive positions. Our Diversity and Inclusion team has also 
developed a DEI scorecard and business review process that proactively 
identifies diversity gaps and works collaboratively with our senior 
leaders to address these gaps. With this, in 2020, 122 leaders of color 
were promoted (supervisors and above) at Atrium Health. As a system 
caring FOR ALL, being made up of and representing ALL is equally 
important to delivering health equity and equality to our communities.
                                Closing
    The COVID-19 pandemic has come at a great cost to the world. We 
should view this reality as an investment that allows us to emerge 
stronger. Through unity and collaboration, government and industry are 
capable of great things. This has been, and still is, a core tenet of 
American exceptionalism. Much like when NASA was formed and the power 
of partnership through technology landed Neil Armstrong on the moon, 
the possibilities of caring for and leading better lives--especially in 
the realm of health equity--are endless. Atrium Health's experiences 
this past year proves just that, whereby the value of bringing together 
the resources of government and industry have greatly supported the 
well-being of our population. So much so that, much like President Joe 
Biden's ``Cancer Moonshot Initiative,'' we firmly believe a health 
equity moonshot is also not out of reach. Therefore, based on the work 
we have done this past year, we recommend a platform built on:

          A. Coverage: Continue access beyond the Public Health 
        Emergency by closing coverage gaps with a combination of 
        innovative government-based and private models.

          B. Standardize Data Sets: Enable real-time analytics through 
        full interoperability. Through international cooperation 
        worldwide standards for data collection can be established.

          C. Real-Time Care and Interventions: Build the national 
        infrastructure needed to make broadband available to every 
        rural and urban community in the country. It is critical to 
        education, health and the economy.

          D. Sustained Well-being: By using technology to support well-
        being, our brothers and sisters in rural and urban communities 
        will lead healthier, more productive lives.

    On behalf of Atrium Health, I would like to thank the Committee for 
this opportunity to share our observations and what we learned this 
last year. While COVID-19 and the public health emergency we have faced 
may fade over time, the health inequities the pandemic uncovered will 
persist if we don't take this moment to come together around an 
ambitious goal. The country, and indeed the world, is ready for a 
health equity moonshot.
                                 ______
                                 
                  [summary statement of gene a. woods]
                          About Atrium Health
    Founded in 1940 as a hospital to better meet the needs of the 
community. Our mission to improve health, elevate hope and advance 
healing--FOR ALL. With 42 hospitals and 1,500 care locations across the 
Carolinas, Georgia and Virginia (welcoming Wake Forest Baptist Health 
and Wake Forest School of Medicine into our family this past year), we 
serve a population of 7.8 million. Most recently, Atrium Health was 
recognized by the Centers for Medicare & Medicaid Services (CMS) as a 
2020 CMS Health Equity Award recipient for its dedication to health 
equity by reducing disparities
              Out of the Box Thinking--Data Infrastructure
    When the first COVID-19 cases appeared in our region in early March 
2020, Atrium Health invested in our data infrastructure and built our 
own COVID-19 Electronic Dashboard--updated every 2 hours with COVID-19 
analytics: cases and mortality, all stratified by race, ethnicity, age 
and test location. Using GIS data, mobile units target COVID-19 
hotspots in underserved neighborhoods and break down barriers to 
screening and testing for COVID-19 by:

          Reducing administrative barriers; (no appointment or 
        payment need)

          Establishing trust; partners in media, churches, 
        other organizations

          Increasing access to care; telemedicine, mobile care

    With these efforts, by April 20, 2020--less than a month after the 
start of the initiative--Atrium Health closed the gap in testing for 
the Black population in our area. By May 4, 2020, the gap in testing 
had been closed for Hispanics as well.
                 Atrium Health Hospital at Home Program
    Tremendous potential for impacting access to care in rural America. 
When used at scale, this model prevents the need to stand up costly 
field hospitals in times of crisis while also advancing a new model of 
more routine care. It is critical that CMS continue to invest in this 
type of program to build resilience for future crises--from hurricanes 
to pandemics--and introduce another level of value into traditional 
healthcare. We recommend:

          Establishing a payment structure, the supports the 
        technology and reasonable efficiencies

          Modernization of credentialing and licensing 
        requirements

          Multi-state licensure

          Broadband expansion and novel access rules for health 
        care purposes, such unlimited data as waiving data plans for 
        unlimited data and high-speed access under specific conditions.

    Support S. 368 ``The Telehealth Modernization Act''
               Partnerships: Two Million Mask Initiative
    Atrium Health and the state's largest businesses and 
organizations--including Bank of America, Blue Cross Blue Shield of 
North Carolina, The Carolina Panthers, Honeywell, Lowe's, Red Ventures 
and Wells Fargo--committed to distribute one million face masks across 
the region.

    At the state level, we saw total COVID cases drop 21 percent and 
the percent positive rate drop 10 percent (from 7.7 percent to 6.9 
percent) starting 2 weeks after the mandate. However, in Mecklenburg 
County, over the first 10 weeks of the Million Mask Initiative we 
observed a decrease in total daily positive test rates by over 60 
percent. Critically, we noticed significant decreases in 
hospitalizations. This shows correlation, it does not prove causation. 
That said, the initiative was the leading factor in helping Mecklenburg 
County over perform and get control of COVID-19.
             Partnerships Part 2: Mass Vaccination Playbook
    Atrium Health, Honeywell, Tepper Sports & Entertainment (The 
Carolina Panthers) and Charlotte Motor Speedway (NASCAR) announced a 
bold goal of administering 1 million doses of the vaccine by July 4, 
2021. See: ``Leader's Guide to Safer Faster and More Equitable 
Community Vaccination Events''

    Key Statistics:

          During our mass vaccination events we were able to 
        give a shot in the arm every 4 seconds.

          Atrium Health has administered nearly 350,000 
        vaccines, 21 percent of whom are people of color.
                         Vaccination Hesitancy
    Taskforce was established to address vaccine hesitancy among 
teammates and community members. Uses Dashboard to track progress. The 
Taskforce uses analytics to prioritize vaccine distribution in 
communities with the greatest need.
                 Social Impact and Rural/Urban Strategy
    Support the ``Black Maternal Health Momnibus Act of 2021'' S. 346

    Support S. 509 the ``Leveraging Integrated Networks in Communities 
(LINC) to Address Social Needs Act''
                  ``Teammates First'' During COVID-19
    Social equity starts with our own team members.
                                Closing
    We recommend a ``Moonshot'' platform built on Coverage, Standardize 
Data Sets, Real-Time Care and Interventions, to Sustained Well-being.
                                 ______
                                 
    The Chair. Thank you very much to all of our witnesses for 
really excellent testimony.
    We will now begin our rounds of 5-minute questions for our 
witnesses. I ask my colleagues to please keep track of your 
clock and stay within those 5 minutes.
    COVID-19 has really exacerbated underlying health 
inequities and been especially deadly for our communities of 
color, including Black, Latino, Asian American and Pacific 
Islander communities, tribal populations, people with 
disabilities, people living in rural areas, and low-income 
families. We have struggled to get tests and therapeutics and 
vaccines to those communities even as they have been the 
hardest hit. And we saw a troubling lack of diversity in COVID-
19 vaccine trials, perpetuating an historic trend.
    As vaccine rollout continues and we work to end this 
pandemic, we have to ensure that vaccines and reliable 
information about them are getting to the populations who are 
most at risk. I want to ask Ms. Williams and Dr. Wilkins both, 
how can we make sure COVID-19 vaccines are available in our 
most impacted communities and that people are actually willing 
and able to get vaccinated?
    Ms. Williams, I'll start with you, and then we'll turn to 
Dr. Wilkins.
    Ms. Williams.
    Ms. Williams. Great. Thank you for that question. And I 
appreciate it because in late 2020, national surveys found that 
Black and Latino respondents were less likely than white 
respondents to say that they planned to get a vaccine, but 
surveys done in the past month have begun to suggest that gap 
has diminished, or at least started to disappear.
    There's been a perception that Black Americans are more 
hesitant than whites to receive a COVID-19 vaccine, but roughly 
equal proportions of Black and White respondents in a recent 
poll said they planned to get vaccinated.
    I don't want to understate the amount of vaccine hesitancy 
or the lack of trust that still exists in our communities, but 
what I do want to emphasize is our need to prioritize equity in 
the vaccine rollout. If they have access to it, we are starting 
to see in those data that we know Black and Latino communities 
will seek it out.
    This requires accessible and equitable systems that help to 
bridge the technological divide. For example, we know there are 
people in communities who don't have access to broadband. 
Further, we need to ensure that they are accessible systems. 
The technology used in some portals may not be accessible to 
screen readers used by individuals who are visually impaired or 
blind. There is also an economic divide. I consider myself 
fluent in technology, and I have paid leave, and yet I've 
struggled to navigate my own system for accessing a vaccine 
here in Washington, DC.
    I would note that as we think about prioritizing these 
communities in the vaccine rollout, we must make sure that we 
have accessible transportation, that we address the lack of 
broadband access, and that we're making the information about 
vaccines available in plain language and multiple languages to 
ensure that communities of color and individuals with 
disabilities will have access to information about the 
vaccines.
    The Chair. Thank you.
    Dr. Wilkins.
    Dr. Wilkins. Yes. Thank you, Chairwoman Murray. I would 
echo the emphasis on making sure that we understand that 
availability of vaccines is more than--there's more to access 
than availability. There are several steps: transportation, 
being able to register, get to a site where vaccines are. So 
getting to where we can actually offer and administer vaccines 
where people live, work, play and pray.
    Taking vaccines out to communities is really important, and 
I think we need to increase the opportunities for others to be 
trained in vaccinations, nurses who are leading health 
ministries. Individuals who can be trained to give onsite 
vaccinations will be very important.
    I will say as far as information, we have to also shift 
away from the terminology of ``vaccine hesitancy,'' because 
that is putting the blame on the individuals for not being 
ready to be vaccinated. We need to understand that individuals 
have questions. They want to know the data. They want to know 
if people like them were included in studies. And we need to 
take the time to explain that to them. That is one of the 
strategies that we used at Vanderbilt, especially early on for 
our employees, our environmental services workers, food and 
nutrition, workers who were more likely to be minority. We did 
onsite town hall meetings to answer their questions. We made 
sure that information was available in multiple languages, and 
we also have gone back to them multiple times to allow them the 
opportunity to become ready.
    The Chair. Thank you very much, and good point. I 
appreciate that.
    We are starting a series of votes. I am going to turn the 
gavel over to Senator Burr. I will go vote and be back as soon 
as I can and let him go vote. So again, to all of our Members 
who are going to be doing this dance here for a bit, thank you.
    Senator Burr.
    Senator Burr. Thank you, Chair.
    Dr. Wilkins, you have conducted a tremendous amount of 
research on the recruiting and retaining of minority 
populations to participate in clinical trials. How can lessons 
from that work be applied to increase access and administration 
of COVID-19 vaccines in the minority populations?
    Dr. Wilkins. Thank you for acknowledging that. We certainly 
at Vanderbilt have led a national recruitment innovation 
center, and we also have a mass online course available to 
support individuals becoming trained and better prepared to 
enroll racial and ethnic minorities into clinical research.
    I think a key thing that we've learned as part of the 
COVID-19 research is that we have to understand the kinds of 
studies we're doing, when we need to enroll individuals, and 
where we can do that. So if we're going to actually do testing 
onsite and require individuals to be enrolled in trials in the 
short term, we need to understand what their needs are as far 
as, again, transportation, access to information, linkages to 
health care. All of those things are necessary if we're going 
to actually enable individuals to participate in research.
    Those are the things that we can do also for vaccinations. 
As others have testified, being able to leverage systems and 
technology during COVID-19 has also been very helpful. So we've 
been doing remote trial monitoring. The ability to connect 
individuals to trials and studies and information digitally has 
certainly substantially increased, but not everyone has those 
opportunities. So we need to be able to support people who 
might not have access to the digital tools, as well as high-
speed Internet.
    Senator Burr. Great. Thank you for that.
    Gene, welcome. Always good to talk to you. I have to admit, 
after Dr. Wilkins' comments and some of the things that you--
the challenges you had in Charlotte and how you overcame them, 
there were many times early on in this pandemic I thought we 
made a huge mistake by not turning over vaccinations to Chick-
fil-A, because Chick-fil-A changed their system overnight and 
processed people through, and if you look at the outside of it, 
it looks totally different than it did at the beginning of 
this. And as we went back to statute, we found out that we 
provided everybody within health care the same degree of 
flexibility that Chick-fil-A displayed in their process.
    Gene, you were able to take advantage of some of that. How 
did Atrium successfully change the way it used its data systems 
and patient information during the pandemic response to 
determine where and how people were getting COVID?
    Mr. Woods. Thank you for the question, Senator. I mean, if 
I step back, we changed just about everything that we did, and 
we were changing it on a 12-hour or 24-hour cycle.
    One of the things I highlighted in my opening testimony is 
that we have this geo-mapping capability, and it's updated 
every 2 hours. So we know exactly to the neighborhood what the 
income disparities are, where testing was occurring, what were 
the mortality rates. So that enabled us to really take these 
roving vans, and if we found that in a particular neighborhood 
there were disparities, we would work with the pastors and the 
community leaders there, and we were very targeted in our 
ability to then use that data, mirror that data with our 
ability to deliver care.
    As was mentioned before, it's really about getting outside 
of our walls. We knew that there were transportation issues, 
there were Internet access issues, and people couldn't come to 
us. So if you think about our vans, our medical roving vans, 
they're like a hospital room on wheels. So we would go into 
these communities.
    But what we found also, Senator, is that it wasn't just 
about solving for testing. We have a gentleman that I remember 
named Samuel. He came to us and was waiting for his test 
results. Well, the staff found out, where was he going to sleep 
that night? He didn't know. So we had to arrange for temporary 
housing that evening. A nurse realized that he didn't have many 
clothes, and his shoes had holes in them. So she called her 
husband to bring clothes in, and we got him food as well.
    What we realized is that it was about mirroring this data 
capability with our ability to reach deeper into the 
communities, but also in a holistic way. It wasn't just about 
COVID. We have a bunch of other needs that exist in the 
community.
    Senator Burr. Gene, thank you. It strikes me in hearing and 
seeing some of the things you did in Charlotte that the 
historical precedent didn't apply to COVID. Historically we 
relied on public health departments to determine the geo-
location of the spread of a disease. In this case you and maybe 
Vanderbilt took the responsibility to look at it and to 
identify it yourself in real time, versus with delayed data 
that might be coming in. I'm sure it was not cheap, but the 
mobilization that you made in Charlotte to overcome the 
challenges that you identified, transportation and other 
issues, this is unusual for a hospital system to get outside of 
its walls, but the flexibility existed because the need was 
there.
    I thank all of our witnesses today.
    Senator Casey.
    Senator Casey. I want to thank Ranking Member Burr, and I 
want to thank our witnesses today for giving us the benefit of 
your expertise and your experience.
    I'll start with Taryn Williams with a question that relates 
to individuals with disabilities. I especially appreciate your 
ongoing and significant advocacy on behalf of people with 
disabilities, continuing with your testimony today. I know that 
in your testimony today you indicated that individuals with 
disabilities have been disproportionately impacted by the 
COVID-19 pandemic, and that's a certainty.
    For example, these individuals may be both at higher risk 
of contracting the virus due to underlying conditions, but also 
at the same time face challenges in taking preventive measures 
and also having to experience disruption to their essential 
health services. And now that we're in the rollout of the 
vaccine--vaccines, plural, I should say--we're hearing about 
barriers to accessing the vaccines for people with intellectual 
and developmental disabilities.
    We know that the CDC guidance on prioritization recognizes 
that people with Down Syndrome should receive priority in 
getting the vaccine, but people with other types of 
developmental disabilities or intellectual disabilities, such 
as Prader-Willi Syndrome or autism, and who are also greatly at 
risk, these individuals are not included, not included, among 
the groups to be prioritized.
    My question is simple but important. Given your 
professional background and your personal experience, what 
guidance do you think the CDC should provide states regarding 
prioritization of vaccinations of people with both 
developmental and intellectual disabilities?
    Ms. Williams. Thank you for that question. I would note 
that there are a number of researchers, and we've observed in 
our advocacy efforts the ongoing challenges and barriers that 
people with disabilities are experiencing as they attempt to 
access the vaccinations in their state.
    Few state vaccination plans explicitly mention people with 
disabilities other than stating people with high-risk medical 
conditions, and we know that prioritizing certain high-risk 
medical conditions may include some people with disabilities, 
but it may not include all of them.
    It is our belief that we need to urge the CDC to release 
updated guidance that explicitly names the need for people with 
disabilities and those higher-risk underlying medical 
conditions, that they should be prioritized in the rollout of 
vaccines. Absent that critical guidance from the CDC, we will 
continue to see our community lag behind in the vaccination 
rates.
    Senator Casey. Ms. Williams, thanks very much for your 
answer.
    Moving next to Dr. Wilkins for a question about so-called 
long haulers, you made reference to those Americans in your 
testimony. We have focused today on the fact that people of 
color are overrepresented among those who have been adversely 
impacted by the disease, and at the same time, in addition to 
being overrepresented, also face barriers to access to care. 
You made specific recommendations in your testimony to address 
the needs of these COVID long haulers, and I'd ask maybe one or 
two questions in my remaining time.
    How should we ensure access to care for these individuals, 
No. 1? And No. 2, is it about access to comprehensive health 
insurance, whether through Medicaid or the marketplaces, or is 
it about access to specific clinics dedicated to treating 
people with so-called long COVID?
    Dr. Wilkins. Thank you, Senator. I think the answer is 
perhaps both. I believe that, from my standpoint as a physician 
and a clinical researcher, I think it's most important that 
people have access to care. The symptoms that we have 
identified so far--extreme fatigue, shortness of breath, a 
ringing in the ears, short-term memory loss--we have no idea 
how long these are going to occur or what other long-term 
sequelae people are going to experience.
    We do need to have systems in place for people to access 
care in a meaningful way, and when I say access, I mean in a 
local area. So sometimes that means specific clinics, safety 
net providers. Individuals in rural communities who don't have 
access might need to use telehealth. We need to be thoughtful 
in that approach, and I don't think a one-size-fits-all 
approach is going to work, but we have to be really thoughtful 
and we have to remove any financial barriers to accessing that 
care.
    Senator Casey. Doctor, thank you.
    My question period is done, but I do want to say to Mr. 
Woods, I will get him a question in writing. After getting 
three degrees from Penn State, I don't know how we let you get 
away to Ranking Member Burr's state, but we'll get you back. 
Thank you.
    Senator Burr. Senator Kaine.
    Senator Kaine. Thank you, Ranking Member Burr and Chair 
Murray, for doing this important hearing.
    I think I'd like to ask a question about public health 
data. Dr. Wilkins, you had a good bit about that in your 
testimony. And then maybe a little bit about long COVID and 
about mental health, all in the equity space.
    It seems to me that one of the important kinds of lessons 
from this pandemic is our public health data systems are 
inadequate, and we really haven't been able to share 
information between local, state, and Federal agencies in the 
way that we should.
    Now, the good news is I introduced a bill a couple of years 
ago with Johnny Isaacson from Georgia. The CDC is very much an 
item of passion for him, to invest more in our public health 
data infrastructure, and in the act that we just passed there's 
a $500 million investment to do just that. I want to thank 
Senator Isaacson--maybe he's watching or somebody can tell 
him--and bipartisan colleagues who supported it.
    I think data helps us understand inequities. If we're not 
measuring well, we don't have a full grasp on who is being 
affected by a pandemic, who might be affected by the long-term 
consequences, and even getting the data about who is being 
vaccinated and where inequities are in that space becomes much 
more difficult if we don't have good metrics and data systems.
    Dr. Wilkins, if you could just share your advice to the 
Committee as we grapple with trying to buildup a robust public 
health data infrastructure in the United States.
    Dr. Wilkins. Thank you, Senator Kaine. I think the issue is 
not just data in public health. It's data in health care and 
health systems, social services as well. We are not collecting 
the types of data that we need, nor are we collecting it in 
complete enough ways. So there's missing data, and it's not 
detailed enough.
    I do think this is a great opportunity COVID has brought to 
light, the need for all of these sectors to come together and 
identify really a core set of data elements that we should all 
be capturing and finding ways to share that. So race, 
ethnicity, detailed ethnicity needs to be captured in ways that 
people actually identify.
    As was already brought up today, when we talk about people 
who are Asian or who are of African descent, we're talking 
about entire continents of people with very different 
ethnicities and backgrounds, and languages spoken at home, and 
cultures. So if we're going to actually develop individualized 
or customized approaches, we need to have that data.
    We also need to be able to link it to community-level data, 
to geo-coded data at a meaningful neighborhood level so that we 
can actually bring in information about food deserts or food 
swamps, where are community health centers or access to other 
health systems. We need to be able to bring that all into a 
single space and share it across different sectors.
    Senator Kaine. I think the equity discussion around 
vaccines has been a really good one to kind of demonstrate to 
people the difference between equality, which we should always 
desire, and equity, which we should certainly aspire to.
    For example, in Virginia, the state had multiple ways to 
sign up to get vaccinated, and they ended up combining them 
into a single statewide registration that you could do online. 
So when it was time for Group 1B to be able to register, what 
could be more equal than that? Everyone in Group 1B can now get 
online and register. But not everyone has access to devices and 
can afford them. Not everyone has good broadband connectivity, 
depending upon the part of the state where they live. People 
who telework from home or may not have to work have a lot more 
time to go on and hit Refresh over and over again like they're 
trying to buy Rolling Stones concert tickets, versus somebody 
who is working as a cashier at a grocery store who doesn't have 
the same amount of time to try to register.
    If we just have a system that's ``equal,'' like first-come, 
first-serve, everybody in 1B can get online and try to sign up, 
we're guaranteed to end up with outcomes that are inequitable. 
And, frankly, the folks who have been hit the hardest by the 
virus probably have the hardest time accessing vaccine 
registration. So that's why some of the testimony of the 
witnesses about outreach, going out and doing vaccinations 
where people are, not waiting for everybody to come to the 
central vaccination site, is really, really important. And 
again, better data helps us get there.
    I'll just say, because I only have 30 seconds left, that 
the two issues that I've been really interested in is long 
COVID and mental health, because the day that the President 
says the national health emergency is over, the mental health 
consequences and the long COVID consequences won't be over. And 
because this has been disproportionately tough on especially 
Latino and African American communities, those two issues will 
be disproportionately tough on those communities, and we have 
to understand it, have the data to measure it, and commit the 
resources to remedy it.
    Thank you. Thanks, Madam Chair.
    The Chair. Thank you.
    Senator Cassidy.
    Senator Cassidy. Thank you.
    Dr. Wilkins, has anybody--and I'm sorry if this has already 
been answered. But knowing that there are different reasons why 
people are not vaccinated, the relative contribution of vaccine 
hesitancy, has anyone teased out to what degree that is an 
issue versus, perhaps, as Senator Kaine said, not having a 
phone which is connected to the Internet?
    For context, I was just on a focus group that Frank Luntz 
ran with white Republicans. As it turns out, certain white 
Republicans are the least likely to be vaccinated, and it turns 
out vaccine hesitancy is a huge aspect of that. So the whole 
thing is how do you approach white Republicans who, as it turns 
out, have a lower rate as that subgroup than any other 
subgroup, according to Luntz.
    To what degree is vaccine hesitancy playing a role there?
    Dr. Wilkins. Thank you, Senator. Yes, you're correct, 
Republicans, individuals who are living in rural settings, are 
among the most likely to not be ready to be vaccinated. I use 
readiness instead of hesitancy because I do think that we have 
to make sure that we are giving the right message, that we're 
sharing information----
    Senator Cassidy. I get that, but I have limited time. Let 
me ask you what percent, if we're just taking now people of 
color, what percent of their not being vaccinated is related to 
vaccine hesitancy or being an anti-vaxxer or something such as 
that?
    Dr. Wilkins. I don't think we know that. I don't think we 
can tease it apart, either. I will say, though, that----
    Senator Cassidy. But we do know historically because--I'm 
sorry, I just have limited time. I do my medical practice in a 
hospital for the uninsured in Louisiana and did lots of vaccine 
work, and so became somewhat familiar with this data. Vaccine 
hesitancy is disproportionately, at least among African 
Americans--I don't know about Hispanics or Native Americans. 
You're familiar with that information, that data, I'm sure.
    Dr. Wilkins. Yes.
    Senator Cassidy. Indeed, if you look at childhood 
immunization rates, there is, even when you make them generally 
available, the immunization rates among African American 
children is lower than that--and it was interesting, when I did 
my programs, African American boys are less likely than African 
American girls, and I didn't quite know that because they have 
the same African American parents, presumably. But nonetheless, 
little boys still have that sense of agency. So, that said----
    Dr. Wilkins. I'm not sure that we can actually project or 
infer from prior vaccination information. This is a pandemic--
--
    Senator Cassidy. Now, that would be important, though, 
because there seems to be a lot of this undercurrent of 
conversation that somehow there is discrimination taking place, 
which quite likely there is. Again, as Senator Kaine said, if 
you don't have access to the Internet, it's more difficult to 
get on. If you're working full time, it's harder to just sit 
there and let the phone roll.
    But on the other hand, just like Frank Luntz did, it is 
important to actually look at the relative contribution of 
personal agency. ``I don't want it, I'm not going to show up 
for it.''
    It seems as if--let me ask you--if we look at health care 
workers, is there any data among health care workers who could 
receive the vaccine at work divided down by race or by 
socioeconomic class, et cetera, as to the relative rate of 
immunization?
    Dr. Wilkins. We do know that, from our Vanderbilt 
experience, that individuals who are working in the lower-wage-
earning positions, environmental services, food and nutrition, 
were less likely to be vaccinated. That's across the board, 
although we still did see lower vaccination rates among some of 
our nurses who were younger and white women.
    Senator Cassidy. Let me ask you, I presume Vanderbilt was 
giving those vaccinations for free?
    Dr. Wilkins. Of course.
    Senator Cassidy. They could receive the vaccine at work?
    Dr. Wilkins. Yes.
    Senator Cassidy. I assume it was well publicized that they 
could get it for free and receive it at work?
    Dr. Wilkins. Yes. I will point out, though, that there are 
some similar issues. Individuals who work for environmental 
services and food and nutrition are not sitting at desks and 
not able to actually sign up online the way that others of us 
have. So we did actually have to go onsite and do in-person 
town halls and support them in signing up. And we did find that 
actually bringing that information did make a difference. We 
did find that direct information, the opportunity for them to 
ask questions and get answers and talk about these myths that 
are widespread due to social media, addressing those actually 
increased the uptake of the vaccine among our health care 
workers.
    Senator Cassidy. That's exactly what Frank Luntz found with 
white Republicans. And I point that out because we fool 
ourselves if we say the only reason that people are not getting 
vaccinated is X, Y, and Z, without ignoring the role of 
personal agency. We've got to address it. Congratulations to 
Vanderbilt for addressing it, and that's where we should be 
going as a society, acknowledging personal agency and then 
giving the information. But I also note that it seems as if 
there still was a difference even after you did all that. 
Again, we have to kind of acknowledge the state of play.
    With that, I yield back. And thank you, Dr. Wilkins, for 
very informative answers.
    The Chair. Thank you, Senator Cassidy.
    I would ask any of our Members who wish to ask questions, 
either remotely or in person, if you could let our staffs know 
within the next several minutes so we can make sure we hold the 
Committee open for you.
    With that, Ms. Echo-Hawk, I want to go back to you. We have 
seen alarming evidence that rates of COVID-19 infection, 
hospitalization, and death are higher among American Indian, 
Alaskan Native, Native Hawaiian and Pacific Islander 
populations than white populations. And at the same time we 
know that tribal communities and community health centers, such 
as the Seattle Indian Health Board, are leading impactful 
vaccination campaigns to combat COVID-19 and reduce health 
inequities. These campaigns are really critical to defeating 
COVID-19, but much more needs to be done to ensure vaccine 
equity, and that's why I fought to make historic investments 
for tribal communities in the American Rescue Plan.
    Ms. Echo-Hawk, if you can share with us, as we continue to 
grapple with the pandemic, how are we going to ensure tribal 
communities have equitable access to and uptake of COVID-19 
vaccines?
    Ms. Echo-Hawk. Yes, thank you so much for that question. My 
organization has done, to date, the only national survey of 
American Indians' and Alaska Natives' willingness and what 
questions they need answered if they have any expressed 
hesitancies toward receiving the COVID vaccine. When we look at 
all the national polls and other evidence, it didn't include 
data related to American Indians and Alaska Natives. When we 
got at that information, what we found is 75 percent of Native 
people were willing and wanted to take the vaccine, and their 
main reason for doing that is they saw themselves as an 
individual who had a responsibility to their community, and 
that is a core public health practice, that we take care of our 
communities as individuals, doing that through masking, social 
distancing, and other public health practices. The Native 
community saw vaccinations as part of that.
    Using that survey, tribal nations nationwide have 
implemented incredible programs. So today here at my 
organization, I've already got a line starting out at the back 
of our agency waiting for vaccinations. We have people who are 
going out to homeless encampments working to get to those who 
are most marginalized, knowing that they may only vaccinate 15 
instead of the 100 they could do at our agency.
    But right now, as we think about equitable approaches, the 
one thing that tribal nations have done is exert our tribal 
sovereignty to define who are priority populations. So those 
homeless individuals who may be 18 years old, who may be 75 
years old, we know they are most at risk for hospitalization 
and death, and so we are out there getting them vaccinated.
    In addition, tribal nations, as a result of being able to 
determine who are their priority populations outside of the 
state mandates on priority populations, have done incredible 
things for the communities, not just the tribal nations. But we 
see ourselves as part of the communities in our states and in 
this Nation as a whole.
    In Oklahoma, there are tribes who will vaccinate any 
resident of Oklahoma within the tribal facilities, not just 
tribal members. The Seattle Indian Health Board a week ago 
vaccinated public school teachers, starting with special ed 
teachers, before the State of Washington did because there's a 
mandate starting to get them to head back into the schools and 
we recognized we needed to protect them. There are also other 
tribes across the Nation doing the exact same thing. These 
dollars that have been invested in our community are benefiting 
our communities and are addressing our health disparities, but 
they are also working to address the health disparities and the 
outcomes of COVID-19 for all communities.
    As we see these investments roll in and we see tribal 
nations take the responsibility of serving those most in need, 
we are seeing that impact all Americans, and there are so many 
lessons that could be learned on how we are rolling that out 
right now.
    The Chair. Thank you very much.
    Senator Baldwin has joined us. I will turn to her for 
questions.
    Senator Baldwin. Thank you so much.
    This question is for Dr. Wilkins. Even before the pandemic, 
women of color, particularly Black women, faced significantly 
higher rates of maternal complications and deaths than white 
women. Experts are concerned that maternal health inequities 
will only worsen during this crisis due to the impact of COVID-
19 on communities of color.
    Last month I introduced the Perinatal Workforce Act, which 
would improve access to maternity care and grow and diversify 
that perinatal health workforce to better address some of the 
staggering maternal health inequities we face as a country. 
This bill is certainly a step in the right direction, but I'm 
worried about how the pandemic will only worsen this existing 
crisis.
    Dr. Wilkins, can you speak to two issues: one, the impact 
of the pandemic on maternal health disparities; and second, why 
it's important to prioritize the diversity of our health care 
workforce in responding to these crises and what we can do to 
mitigate the effects of the pandemic?
    Dr. Wilkins. Thank you, Senator. I share your concern about 
worsening disparities, especially related to maternal health. 
We certainly are seeing issues related to follow-up care for 
patients across the board, but certainly for individuals who 
are from racial and ethnic minority groups, especially Black 
women who are least likely at times to present for maternal 
care, prenatal care in a timely manner.
    I share those concerns, and it's probably going to worsen 
due to some of the issues related to access to telehealth, the 
challenges with having children at home and making sure that 
they are being educated remotely, the burdens that they're 
bearing, the loss of jobs. All of those things are actually 
increasing the amount of stress and burden on Black women.
    Those are issues that are not related, actually, to health 
care delivery that are increasing their risk for maternal 
mortality and morbidity.
    As far as the workforce is concerned, we need more 
diversity and more people of color in the health professions, 
from physicians to nurses to doulas, and making sure that when 
women are with child and in this environment, that they don't 
feel the toxicity of the environment, that they feel welcome, 
that their pain is acknowledged, that their symptoms are 
considered, that they feel welcome and that they belong.
    We need to ensure not just that we increase the number of 
individuals who are in traditional medical roles but in non-
traditional ones like doulas and birthing experts, as well as 
individuals who are supporting mothers breastfeeding.
    Senator Baldwin. Thank you.
    In 2019, before the pandemic, Milwaukee County, Wisconsin 
declared racism a public health crisis. They were the first in 
the Nation to do so. And since, others have followed suit. 
Central to this declaration was a commitment to taking action, 
which we saw during our response to COVID-19. From the 
beginning, the city included race and ethnicity as factors in 
its COVID-19 data, and as a result they were one of the first 
to recognize who was being most impacted by COVID-19, the 
city's Black community.
    Ms. Echo-Hawk, how does the recognition of racism as a 
public health crisis improve our understanding and response to 
crises like the COVID-19 pandemic, and what can state and local 
governments do to improve their data collection efforts?
    Ms. Echo-Hawk. Yes, such a great question. Thank you. These 
are absolutely integral things as we think about what it means 
to declare racism as a public health crisis. We recognize, and 
the research has shown us, that the impacts of racism impacted 
the overall health outcomes of racial and ethnic minorities. If 
we think about Milwaukee, I know there are incredibly high 
rates of infant and maternal mortality in the urban Indian 
community in Milwaukee, who are served by the Urban Indian 
Health Program located there. That is a direct result of not 
having access to transportation, access to safe and affordable 
housing, walkable spaces, all of the things that create the 
stress on a body that we know through the research that racism 
actually impacts the stress in your body, and it impacts 
whether or not you can carry a baby full term.
    It's in the recognition like that you're able to take a 
holistic view of health and look at what is impacting your most 
vulnerable populations. In taking that into consideration, 
you're able to identify policies and procedures that can allow 
for ensuring you're getting the resources to the right people.
    However, you can't do that without the data. So if you're 
not collecting the race and ethnicity data, what happens is 
these health disparities are effectively hidden and you're not 
able to direct the resources to the right people to make the 
right impactful changes that are needed in order to improve the 
health outcomes. I would love to see every city across the 
Nation declare racism a public health crisis so we can begin to 
take that holistic look at health and recognize that it's 
beyond just access to basic medical care. It's the holistic way 
that every one of us lives, breathes, where we pray, and where 
we spend time with our families. No matter where we are or what 
time of the day it is, it impacts our health overall.
    Senator Baldwin. Thank you.
    I yield back, Madam Chair.
    The Chair. Thank you very much.
    Senator Scott.
    Senator Scott. Without any question, the pandemic has 
brought real challenges and really illuminated a lot of 
disparities that we see in health care, whether those are 
chronic conditions like sickle cell anemia or, if it's focused 
on the pandemic, COVID-19. There's no doubt that we have to 
improve the delivery system for our Nation's most vulnerable.
    As we look toward solutions, not just combatting this 
pandemic but also addressing disparities in the long term, it 
seems clear to me that telehealth is a vital part of the new 
apparatus that's necessary. Mr. Woods, you and I had a 
discussion last year, if you recall, during the Aging Committee 
about the importance of telemedicine, and I took your words to 
heart, and we worked on bipartisan legislation called the 
Telehealth Modernization Act that will help stop that Medicare 
cliff from happening.
    Can you talk about the importance of such legislation, 
whether it's mine or others, that would help us focus attention 
on making permanent the telehealth delivery system? And I thank 
you for your leadership on this very important issue.
    Mr. Woods. Thank you, Senator, and thanks for your 
leadership on that. It's great to be able to come to do 
testimony and see legislation come out of that which is fully 
needed.
    Before COVID, we were running about 1,300 telehealth visits 
a month. That jumped up to about 130,000 in the middle of 
COVID, and now it's hovering around 60,000 to 70,000. We could 
not have served not just the population in general but the most 
vulnerable populations without that capability. And to your 
point, we're really concerned about the cliff because I don't 
think we can put the genie back in the bottle in terms of how 
we delivered care before. I spoke in my opening testimony about 
our hospital homes. We treated 50,000 people in their home, and 
it was the telehealth capability.
    As we look to affordability of health care going forward, 
these are the things we need to continue going forward past 
this pandemic. So your bill and what it includes, including 
looking at broadband access in rural communities and things of 
that nature, are really critical, and we applaud that, and 
we're the biggest advocate of that because we know it works as 
we've gone through this pandemic.
    Senator Scott. Mr. Woods, you just touched on a very 
important point, that point being broadband, because if you 
have telehealth available but you don't have a connection in 
your home, I'm not sure how available it really is. So the 
importance of us prioritizing, as part of an infrastructure 
conversation and a health care conversation, the broadband 
piece of the puzzle, I can't think of that as being less 
important than telehealth, because if you don't have the 
ability to have the connection, it just doesn't work. Am I 
missing anything there?
    Mr. Woods. I think you're spot on, Senator. If you think 
about just a rural hospital that's hours away from a major city 
that doesn't have access--for example, having physicians on 
staff that understood infectious diseases was really critical. 
We were able, because we have rural hospitals that are part of 
our system, able to use our doctors in Charlotte, for example, 
and beam into those hospitals several hours away. But that's 
not available to all the communities. A hospital is one thing, 
but it's not available. I think that should be a major national 
priority because that's also about collecting data. We've had a 
lot of conversations about data, and it's important to really 
know how access is occurring in the most vulnerable 
communities, rural or the urban poor.
    Senator Scott. Absolutely. Thank you for that very 
comprehensive answer.
    My last question, and since I'm running out of time I'll 
sort of abbreviate it. Clinical trial diversity is incredibly 
important for us to be able to measure the effectiveness of the 
drugs, whether it's the COVID-19 vaccine or any other drug, and 
that is an area where I believe we need to focus more of our 
attention on finding ways to diversify those who are willing to 
participate in some of the trials. I'm not sure if it's 
geographic location, factors like distrust based on the long 
storied history as it relates to trusting the government when 
it comes to vaccinations and health care.
    Mr. Woods, with your experience, can you tell me what steps 
providers, researchers, and other stakeholders are taking, and 
what steps should policymakers like myself look at taking in 
order to increase clinical trial diversity?
    Mr. Woods. Yes. I mean, the fundamental issue, and I think 
it's been referenced, is an issue of trust. Whether you're a 
white Republican or whether you're a person of color, there are 
some fundamental issues of trust that have to be addressed. 
We're speaking to Latinx people in their language so that we 
can explain that, for example, the Pfizer trials I think had 
about 40 percent of people of color in that trial, and we have 
to explain.
    I think part of the things that you, Senator, and your 
colleagues could do is continue to hold us accountable, but the 
FDA and others accountable, that in order to approve new 
treatments they have to have a certain percentage of people of 
color and Native communities also as part of those trials.
    Senator Scott. Excellent. Thank you very much, sir.
    I know I'm out of time. Thank you, Madam Chair, for the 
extra 45 seconds.
    The Chair. Thank you.
    Senator Rosen.
    Senator Rosen. Thank you, Chair Murray and Ranking Member 
Burr. This is a really important hearing, and I appreciate the 
witnesses for your important work.
    I want to build a little bit on what so many of my 
colleagues have already been talking about, the Latino 
community access. Our Latino community in Nevada has been the 
hardest hit by COVID-19. Latinos make up roughly 30 percent of 
our state's population, but they account for well over 36 
percent of the COVID-19 cases, nearly a quarter of the deaths.
    Fortunately, local partners in the community have really 
stepped up in a big way to assist the city of Las Vegas, and we 
recently partnered with the Mexican Consulate to host a vaccine 
clinic equipped with bilingual staff to vaccinate over 250 of 
our most vulnerable Latino community residents. I'm pleased 
that the Governor and so many elected officials have made it 
clear that COVID-19 vaccines will be free to all Nevadans who 
need them.
    This is building on Senator Scott's questions, and others. 
Dr. Wilkins, what more should we be doing to ensure that 
members of our Latino communities and all underrepresented 
communities, not just in Nevada but across the country, 
understand that the vaccines are safe, effective, and free? And 
how do we get that public health message out there for them? 
How do we do that?
    Dr. Wilkins. Thank you, Senator. I think the key really is 
that the actions have to be at the local level. We have to find 
ways to bring in the voices of individuals from local 
communities to help develop these strategies, the plans, and 
the messaging. We're still talking about very heterogeneous 
groups of people, and what works in one setting, system, town, 
state, might not work everywhere.
    You have to understand, as I'm sure you already know in 
your communities, what their needs are, what their priorities 
are, but also what are the community assets. I think that is 
something that we often miss. We keep talking about communities 
that are disinvested and deprived, but there are many assets 
and resources in communities that we have not been able to 
leverage, and bringing the voices of those in to tell us who 
are the trusted organizations, who are the trusted community 
leaders, who can actually deliver the message in a culturally 
appropriate, relevant way that addresses the concerns and the 
myths and the issues that are circulating, and how do we 
actually get vaccines and information to places where people 
already live, work, play and pray, I think that's really 
important.
    Of course, it has to be in languages that people speak and 
understand, and there are many different dialects even of 
Spanish. So understanding again what that looks like and how 
the messaging, the images on the brochures and the videos, what 
that should look like is very important.
    Senator Rosen. Yes, I agree with you. In Las Vegas, over 
180 students from our UNLB School of Public Health, they 
partnered with our health district to provide culturally 
competent contact tracing in 27 different languages. We have 
one of the fastest growing AAPI communities in the country, our 
Latino population in our state. So really working on this is 
critical to improving outcomes.
    I quickly want to move on to delayed care during COVID-19, 
which we also know is an issue even before the pandemic, 
particularly in our minority communities. They were already 
experiencing unequal levels of medical care, particularly in 
Nevada where there is a severe provider shortage. And now 
during COVID, I've heard from providers that patients were 
still afraid to come into the office to receive their cancer 
treatment, preventative health care like mammograms or prostate 
screenings and the like. In Nevada we already rank 47th in the 
Nation in percent of women who are up to date with mammograms, 
and we're 49th for people who are current with their colon 
cancer screenings, and 44th for women of color who are up to 
date on their cervical cancer screening.
    This really has long-term consequences for families, right? 
So how can we work to increase patient confidence and improve 
access to basic preventative care to those who already were 
marginalized and feel increased fear due to the pandemic?
    Dr. Wilkins. I do think this is where we should be 
leveraging community health workers, peer educators, peer 
navigators, individuals who have the ability to go out into 
communities, who have the time and resources and who are funded 
to make calls, to make visits, to actually understand what, 
beyond the fear of just going in, is preventing the individuals 
from seeking care. Is it transportation needs? Is it child care 
needs? What other resources do they need to actually be able to 
come in for that preventative care? And also what can we 
provide to them with respect to preventative care in their 
homes or in their communities?
    Senator Rosen. I think we can see what we might be able to 
connect with them initially on telehealth and then buildup that 
trust to bring them into the office for those tests, or 
wherever those tests are provided, do as much as we can there.
    Thank you. My time has expired.
    The Chair. Thank you so much.
    Senator Braun.
    Senator Braun. Thank you, Madam Chair.
    My question is for Mr. Woods. There have been a lot of 
questions asked already about what we can glean from the whole 
challenge with COVID. To me it's exposed and accentuated 
several weaknesses within the system. Heading up a major health 
care system, I'm going to focus more on two areas.
    No. 1, why it's taken so long for the industry to embrace 
technology in the full breadth of how you could lower costs, 
because the biggest issue in health care today is not only 
accessibility but it costs too much. I know in my own business 
I was able to use certain tools that embraced technology. We 
were doing telehealth for some of our employees 12, 13 years 
ago. And now all of a sudden, due to COVID, it seems like it's 
a revelation.
    I think leading a major health care system, being a CEO of 
it, tell me why it's taken so long for the industry in general, 
from records to treatments and so forth, to embrace technology, 
and then give me about a minute to a minute-and-a-half on that 
answer, and then I've got one other question after that.
    Mr. Woods. Thanks for the question, Senator. You know, 
actually, at Atrium Health, we invested in telehealth 
capabilities about 14 years ago. And what we asked ourselves is 
where is technology going? But at the time we made that 
investment, very significant infrastructure investments, 
including establishing all kinds of protocols with our 
physicians, there was no reimbursement for that.
    I think part of the challenge, if you look historically, 
especially for rural communities and things of that nature, 
it's just the affordability of really investing in that 
infrastructure. I think what we learned in COVID is that 
because of the CARES Act and all the dollars that were allowed 
to be used for telehealth, that changed pretty quickly 
overnight.
    I think it's a matter of really having the funding for the 
infrastructure required, and there's very significant 
infrastructure that's required. I think that's part of the 
answer. I think we, though, at Atrium, we recognized that even 
if we weren't going to be reimbursed, it was really the 
direction care was going in, and we continued to make 
investments in telehealth.
    I think really what COVID has showed us is that this 
technology has been pulled forward about 10 years, and I don't 
think the industry will go back. I think going forward we've 
learned that it has to be part of how we deliver care, to your 
point to make care more accessible but also more affordable.
    Senator Braun. I would just have one counterpoint to that. 
You talk about reimbursement, the rest of the economic spectrum 
as we invest in technology, we're not looking for a 
reimbursement or for somebody else to offset our cost. We don't 
have it. It would beg the question why, with all the wealth--in 
fact, health care is 20 percent of our economy--that you need 
reimbursement to invest, making yourself more efficient like 
all other sectors of the economy do.
    That leads to my second question. The biggest issue along 
with accessibility would be affordability. I didn't disagree 
with the underpinnings of the Affordable Care Act. In fact, I 
think that made sense. But it turned into--a better title would 
be the Unaffordable Care Act, and I think it's mostly due to 
the industry. You might be a leader, a trendsetter, but in 
general you have risen from just four or five decades ago when 
it was 5 percent of our GDP to where it's pushing 20 percent of 
our GDP.
    How are you leading the way to avoid more government 
involvement in telling you how to run your business, embracing 
things like full transparency, transparency between hospitals 
and insurance companies, so the main stakeholders out there who 
pay all the bills in health care would be all the businesses 
that are unrelated to health care and those of us, the CEOs 
that run it who have probably been too sheepish in using our 
leverage to get you to do what all the rest of us do, compete, 
be transparent, get rid of the barriers to entry, and it's a 
whole other question of how you start engaging the health care 
consumer financially in his or her own well-being.
    Mr. Woods. Senator, to clarify just one point in my former 
answer, we did invest before there was reimbursement. So I want 
to clarify that Atrium Health did not wait for reimbursement to 
do the right thing.
    Second, if you look at the transparency, we have fully 
embraced transparency and complied with the law that exists 
right now, and we fully continue to try to make that data more 
available in a way that can be interpretable. So we agree with 
that, as well.
    If you look at most hospitals, for lack of a better way of 
saying it, they are price takers, not price setters, right? 
Medicare and Medicaid typically comprise about 70 percent to 80 
percent of how we are reimbursed, and then the 20 percent is 
commercial insurance, up to 30 percent. So if you look at our 
margins at Atrium Health last year, it's less than 3 cents on 
the dollar at the end of the year in order to reimburse our 
communities. And this year with COVID, it was less than 1 cent 
on the dollar that we had to reinvest in the community because 
of all the expense with COVID.
    I think it's a multi-factorial issue. Health systems have 
to lean in, pharma has to lean in, industry has to lean in, and 
we need partnership with our legislators to really deal with 
the comprehensive and multi-factorial issues that surround 
affordable care.
    Senator Braun. Thank you. You'd better get better at it, in 
my opinion, because you're losing the support of businesses and 
CEOs that would like to see our health care costs go down. So 
whatever is being done I don't think is going to escape the 
heavier hand of government unless you get a little better at 
it.
    Thank you.
    The Chair. Thank you.
    Senator Smith.
    Senator Smith. Thank you, Chair Murray and Ranking Member 
Burr.
    To all of our panelists, it's so great to be with you 
today. I have been jumping around between votes and hearings, 
like a lot of my colleagues, but I want to just start out by 
saying I appreciate the conversation around the importance of 
telehealth, and I appreciate very much the focus on equity in 
this Committee.
    I just want to note that nearly 37 percent of Black 
American households, 31 percent of Hispanic American 
households, and 35 percent of Americans living on tribal lands 
have no access to broadband or computer access in their home. 
So the opportunity that telehealth provides to improve access 
to care is again not widely shared, and this is something that 
we have to focus on.
    Ms. Echo-Hawk, I really appreciated the statement that you 
made at the beginning about the impact of these inequities and 
systemic racism in tribal nations, and also the impact on urban 
indigenous communities. It seems to me that in some sense with 
culture we have the opposite--I mean, with COVID we have the 
opposite of a virtuous circle or a healing circle. We have the 
impact of COVID on top of systemic and historic trauma and 
racism that has just been so compounded. And yet, I think there 
are some positive lessons to be learned from this, and I wanted 
to ask you about this example.
    Last Friday I had the opportunity to stop by the 
Minneapolis urban office of the Bois Forte of Ojibwe in 
Minnesota. Now, they have already vaccinated all of the 
eligible members in their tribal lands, and they are now coming 
down to the city, making stops with an ambulance that they were 
able to purchase with CARES Act funding, and they are doing 
incredible outreach and having real impact.
    My question for you is what can we learn from efforts like 
the Bois Forte and others in Minnesota around the country about 
why this is working to vaccinate people both in tribal land as 
well as urban communities?
    Ms. Echo-Hawk. Thank you so much for that question. They're 
doing an absolutely incredible job in Minnesota, across the 
state, and across the Nation as we look at tribal nations, 
again recognizing that as a result of exercising tribal 
sovereignty they have the ability to define who they vaccinate, 
and that just doesn't apply to their tribal members. They can 
vaccinate people within their communities, and that's what's 
happening.
    We were also able to get the high vaccination rates within 
our community by using trusted messengers, and also having an 
established health care system, the Indian health care system, 
that had already identified our most vulnerable community 
members. We had already established how we reached them and we 
just needed the resources. So the CARES Act funds and now the 
American Rescue Plan are going to be part of building forward 
those resources. It really illustrates the need to have trusted 
community messengers. Those are the ones the community will 
say, OK, you got vaccinated, that helps me overcome the 
questions I had about whether or not I should be doing that.
    It also allows us to ensure that for Native people--for 
example, today I sent my son off to a funeral I wasn't able to 
attend, because like many other Native people I've seen extreme 
numbers of deaths within my family and friend circle. We are 
also working to preserve our elders and our community members, 
those who, when we lose them, we've lost libraries of knowledge 
systems. So we recognize that those same things exist in other 
populations, which is why tribal nations have dedicated 
themselves to not only serving their people but the people 
around them.
    Senator Smith. Thank you. That is so good. I mean, that is 
a virtuous circle. It is appreciation of sovereignty. It is 
getting resources so that they can execute strong plans rooted 
in culture and community, and it works. I just want to note 
that the American Rescue Plan, which we have just passed, 
provides historic new levels of resources for tribal 
communities to begin to build back from the historic under-
investment that we have made, and I have hopes for that, and I 
look forward to working on that.
    Ms. Echo-Hawk. If I could say one thing with that rescue 
plan. As Indian Country, it has to be known that it is an 
incredible investment, but it cannot be seen as a one-time 
investment, because as it relates to investment in the Indian 
health care system, this has to be ongoing. It's just a start, 
and we look forward to working with all of you to continue that 
to ensure the funding of our systems.
    Senator Smith. It's such a great point. This is an issue, I 
think, with much of what's in the Rescue Plan. Another example 
is the child tax credit will benefit families across the 
country, but we cannot be in a situation where we're reducing 
child poverty by 50 percent and then have it jump back up 
again. We need a systemic change in the way we're doing this, 
so thank you for that.
    I am out of time, but I want to just thank Ms. Williams for 
your excellent discussion on what lies underneath this so-
called vaccine hesitancy in communities of color and how we can 
address it, and I think it ties in directly with this 
conversation we were just having right now.
    The Chair. Thank you.
    Senator Murkowski.
    Senator Murkowski. Thank you, Madam Chair.
    Thank you to all of our witnesses at this very important 
hearing this morning.
    Even prior to the pandemic last year, Alaska Natives have 
lived in fear of disease that might come to their remote 
communities. When the 1918 influenza pandemic hit Alaska, our 
Alaska Native populations were significantly impacted. They 
suffered one of the pandemic's worst death rates in the world 
at that time. The loss of entire families, the loss of 
practically entire villages resulted in generational trauma 
that really carries through today. There are those who still 
tell the stories of how the influenza wiped out their 
communities.
    During this past year, as we've looked at the disparities 
in mortality rates, we found that the mortality rates of 
American Indians and Alaska Native persons aged 20 to 29 years 
was 10.5 times higher compared to their non-Hispanic white 
counterparts. Those in the age 30 to 39 bracket had mortality 
rates of 11.6 times higher. Those aged 40 to 49 were 8.3 times 
higher compared to their non-Hispanic white counterparts.
    The question is we've seen this; we saw it 100 years ago. 
We have seen other areas where disease has come in where our 
Native peoples have perhaps been some of the most vulnerable. 
What investments do we need to make to close these gaps in 
mortality rates, especially as we're looking to our young 
people? There was a lot of focus initially, and we need to take 
care of our elders, we need to take care of our seniors, but it 
is also the young in our tribal communities.
    It's kind of a broad question, and I will throw that out to 
those of you online and here in the room.
    Ms. Echo-Hawk. Thank you so much, Senator. As an individual 
who was born and raised in Alaska--I'm associated with Mentasta 
Village--I recognize I heard those stories. And I'm also the 
co-author on the paper which you just cited those statistics. 
And as I was part of writing that paper, I could hear those 
stories in my head, the ones that I had heard. And it is 
absolutely essential for us to recognize that these underlying 
health disparities are resulting in deaths, and people are 
dying every single day. And unless we begin to invest in these 
community resources, and for tribal communities specifically 
investing in tribal sovereignty and the rights of tribal 
nations through Indian health care systems, unless we do that 
to the full funding capacity which is needed, we're not going 
to see this end, and I don't want to see the next pandemic 
impact us in the exact same way. I don't want to have these 
same stories that my grandchildren are saying. Unfortunately, 
unless we continue to invest like we have done in this most 
recent package, we're going to see that continue.
    It also has to be community driven. We know how to serve 
our communities. We know what they need, and we don't need 
people coming to us because they think we have all the problems 
but instead acknowledging we have the answers, and when 
properly resourced, as we've seen with the high vaccination 
rates, and in particular Alaska has some of the highest 
vaccination rates overall, and we had Native communities there 
that are 80 to 90 percent fully vaccinated as a result of the 
Indian health care systems, tribal health care systems in 
Alaska. When we see and have those investments, these are the 
changes we can bring.
    Again, it can't be a one-time fix. It needs to be an 
ongoing conversation that fully funds for tribal communities 
the Indian health care system and respects tribal sovereignty 
and the need for economic vitality through other types of 
investments to ensure that our people no longer experience 
these terrible, terrible outcomes.
    Senator Murkowski. Ms. Echo-Hawk, maybe you can also join 
with response to this because another area that we are seeing 
statistics that just are not in line with where we want to be, 
the United States is the only well-resourced country with a 
rising maternal mortality rate, and indigenous moms are dying 
at a rate two to three times higher than non-Hispanic white 
mothers nationally. We found that the maternal death rate for 
Alaska Native women between 2009 and 2018 was significantly 
higher than that for women of other racial or ethnic 
backgrounds.
    As we're looking at these statistics and the vulnerability 
of our Native people in this COVID time, I think it's also 
important to look at where these other health disparities lie. 
For us as a nation to actually be going the wrong way with 
maternal mortality is just something that in my mind is almost 
unforgivable, inexcusable. And then to see again how that has 
disproportionately impacted our Native women is something that 
I would hope we'll have an opportunity to continue to work on. 
I know that I've got some good partners on this Committee to 
help me with that.
    I'm out of time, Madam Chair, but I want to make sure that 
these types of disparities, and again statistics that are going 
in exactly the wrong way, we have an opportunity to address.
    The Chair. Thank you, Senator Murkowski, and I'm delighted 
you brought that up. We'll continue to work with you on that. 
Critically important.
    Senator Hassan.
    Senator Hassan. Thank you, Madam Chair, and to our Ranking 
Member. And I'll just echo what you just said and what Senator 
Murkowski talked about. It's work we need to do, and I look 
forward to working with our colleagues on it.
    I want to thank all the witnesses for being part of this 
hearing today, and I want to start with a question to you, Dr. 
Wilkins. The pandemic has certainly magnified the disparities 
in access to care for people of color all across the country, 
not just in cities but also in rural areas, including many 
places across my home state of New Hampshire. Studies show that 
people of color in rural areas are less likely to have access 
to primary care, and they are therefore less likely to have a 
trusted medical professional in their community to rely on for 
information and care during this pandemic.
    We have to do more to ensure that people of color have 
access to primary care, which is obviously important during 
this pandemic, but it's also necessary for preventive 
screenings and early diagnosis of many life-threatening medical 
conditions.
    Dr. Wilkins, how can we ensure that people of color who 
live in rural areas have access to trusted primary care 
providers?
    Dr. Wilkins. Thank you, Senator. I think this is a really 
important point. We saw this very early on in the pandemic, 
that individuals who had symptoms and needed testing were being 
told to contact their health care provider.
    Senator Hassan. Right.
    Dr. Wilkins. Well, if you don't have one, then who are you 
contacting, and how does that work? The delays and the lack of 
access due to that I think are really important.
    But we don't have enough primary care providers. We need 
more, and we also need to acknowledge that you don't have to be 
a physician to be a primary care provider. So we need to make 
sure that nurse practitioners and physician assistants also 
have the opportunity to provide that preventative care, the 
preventative screening, and be a front door for access to care.
    Again, we have not taken full advantage of community health 
workers as an access point, as people who are great 
communicators and can actually link to and improve the uptake 
of care that we're not seeing in so many communities.
    There's been a lot of talk about telehealth, and I'll just 
point out that at Vanderbilt we also saw a dramatic increase, 
and I'm really proud of the great adoption of telehealth during 
the pandemic. But when we disaggregate that data again by race, 
ethnicity, language, and ZIP Code, the communities who are most 
likely to use telehealth are wealthy and well educated. So even 
though we saw some individuals in rural communities, some urban 
racial and ethnic minorities using telehealth, it was not at 
the same rate, and we need to be prepared for what telehealth 
looks like for everyone, because it is not all the same.
    Senator Hassan. We have to get connectivity to everybody, 
and it has to be what they can afford.
    Dr. Wilkins. I think it's beyond connectivity. People have 
devices. They use their smart phones. But having to type in all 
the information for insurance, and if you need an interpreter 
to be on the line, connecting a third person, lots of 
challenges with that. Are you in a room where you actually can 
be by yourself in a crowded home and have a private health care 
visit? There are lots of things that we have to consider there.
    Senator Hassan. That's very helpful. Thank you very much.
    Ms. Williams, I want to turn to you for a question. Earlier 
this month I wrote to the Departments of Justice and Health and 
Human Services pushing for improvements in vaccine access for 
individuals with disabilities. I was pleased to receive a 
response that highlighted plans to investigate claims of 
discrimination and provide technical assistance to states and 
individual vaccination sites.
    However, I know that information about such resources is 
often not accessible to those who need it most, and I know you 
discussed this a bit in your answer to a couple of other 
questions earlier. But, Ms. Williams, what further steps should 
the Federal Government take to ensure that all vaccination 
sites and registration portals are fully accessible for 
individuals with disabilities?
    Ms. Williams. I'm really glad that you've asked this 
question. Something I think we need to consider, particularly 
as Members of Congress look for another response bill to this 
crisis, is we need to ensure that state and Federal responses 
to the pandemic really account for the needs of individuals 
with developmental disabilities and the needs of folks who 
aren't getting equitable access to vaccines across the Nation.
    As I noted in my testimony, they are some of the folks who 
are most impacted by this crisis, and we actually have entities 
throughout our communities, entities like state councils on 
developmental disabilities, university centers on developmental 
disabilities, and protection and advocacy agencies that are 
able to go into institutions and ensure that folks are getting 
equitable access to care and equitable access to vaccinations. 
They are equipped and have, over the last year, rapidly stood 
up virtual platforms that really do serve the needs and the 
voices of individuals who have been impacted by this crisis.
    As we think about future responses, I would ask that you 
all consider including additional support activities authorized 
under the Developmental Disabilities Act and the Bill of Rights 
to ensure that these entities that exist across our Nation in 
support of people with disabilities, that they can continue to 
serve them at this moment of crisis.
    Senator Hassan. Well, thank you very much.
    I know, Madam Chair, I am over time. I will just say it's 
also going to be important that we provide people with 
disabilities the kind of information they need so they can 
report violations, and that they can do that in a 
straightforward way.
    The other point I would make that follows up on Senator 
Murkowski's point and that of Senator Baldwin and others about 
the maternal health disparities we're seeing is given how big 
these disparities are, and given a relative dearth of 
information about the impact of vaccines on pregnant people, we 
need to make sure that we are addressing those disparities and 
getting vaccines to people for whom it is safe and answering 
their questions about the impact on pregnancy.
    Thank you.
    The Chair. Thank you.
    Senator Lujan.
    Senator Lujan. Thank you so much, Chair Murray.
    I come from a state with large Native American and Hispanic 
communities. And while all communities of color have been hit 
hardest by the COVID-19 pandemic, I want to ask some questions 
specifically in the Native American and the Hispanic community 
populations.
    The racial and ethnic groups for which the CDC reports 
COVID-19 health outcomes, the American Indian and Alaska Native 
populations face the highest death rate. Hispanics and Latinos 
are 1.3 times more likely to contract COVID-19, twice as likely 
to be hospitalized, and more than three times more likely to 
die from COVID-19. Data is a double-edged sword. When used 
correctly it can be an invaluable tool in focusing resources 
and addressing trends as they emerge. But data can also be used 
to further marginalize communities through exclusion.
    Ms. Echo-Hawk, yes or no? As a public health expert, are 
you confident the nationally reported data accurately reflects 
rates of COVID-19 infection among tribal communities?
    Ms. Echo-Hawk. No, it absolutely does not, and my 
organization recently released a report titled ``Data 
Genocide'' that ranks every single state on their ability and 
how they're reporting race and ethnicity of American Indians 
and Alaska Natives, and what we found is this Nation is 
failing.
    Senator Lujan. I appreciate that. You anticipated my next 
question, which is about over-or under-reporting, and I 
appreciate your clarification. I don't know if you want to add 
something about that?
    Ms. Echo-Hawk. Yes, absolutely. So we know there is a 
chronic under-reporting of race and ethnicity. The current data 
infrastructure is not allowing for race and ethnicity to be 
collected. In addition, for American Indians and Alaska 
Natives, when our race and ethnicity is not collected and then 
it is used for funding allocations, like what was done in the 
CARES Act package, what happens is the resources don't go to 
our smaller communities and do not properly reflect the needs 
of our communities as a result of that data.
    With the non-collection of our data, it's actually a 
failing of our treaty and trust responsibilities that then 
Congress is tasked with making sure that happens, and you're 
not able to do that without the right data. We are seeing an 
effort right now that I'm actively a part of with the Council 
for State and Territorial Epidemiologists. We're working to get 
funding to ensure we can build out the public health 
surveillance systems nationwide to properly reflect race and 
ethnicity for not only American Indians and Alaska Natives but 
for all people of color, and to assure accountability of the 
states to do that reporting.
    Senator Lujan. Chair Murray, last Congress Senator Tina 
Smith carried legislation in the Senate, I carried it in the 
House to address this issue, and we look forward to working 
with you and others on this specific area.
    Ms. Echo-Hawk, looking beyond the pandemic, what is the 
connection between improved data collection methodologies and 
improved health outcomes in Native, Hispanic, and Black 
communities?
    Ms. Echo-Hawk. We absolutely need that data in order to 
understand where to direct the proper resources. When we have 
the right information, we have the ability to understand where 
to go with that, and that includes not only the gaps, and I 
know we like to focus on the gaps, but it also has to include 
the strengths and the resiliencies. It is through those 
strengths and resiliencies we identify the protective factors 
that allow us to improve the health outcomes. And without all 
of those together, we are not going to be able to address these 
health disparities. It is going to take a concerted effort from 
the states and the Federal Government to ensure that actually 
happens.
    Senator Lujan. Dr. Wilkins, we're now finally seeing more 
awareness, at least I'd like to say that. That's my 
observation. I hope the data supports it. We're getting more 
support to Hispanics, Native American and Black communities in 
regards to the disparities that exist with access to care. How 
can we all work together to ensure that these partnerships are 
real, that they grow, and that they're sustainable after COVID?
    Dr. Wilkins. Thank you for the question. I do think that we 
need to make sure that we continue to emphasize that the 
community has assets, and they're often not recognized. So when 
we build these partnerships, we often see there's the 
opportunity to get vaccines out or deliver a certain message. 
But the only reason that can happen is because these 
communities do have assets, resources. They have trust. They 
are deemed as trustworthy. And we need to invest in those 
relationships long term. If there is not a commitment to a 
long-term partnership, then we'll continue to have these 
opportunities where we're just doing one-offs and not taking 
full advantage of the resources, intellect, and people who can 
actually solve these problems.
    Senator Lujan. Mr. Woods, we know that patients who are 
able to receive culturally competent behavioral health care 
have improved outcomes. What is one lesson we should learn from 
your work at Atrium Health to recruit and retain diverse health 
care providers who are able to provide high-quality care to 
their patients?
    Mr. Woods. There are a number of factors. I mean, we do 
cultural competency training every year, and you can't just do 
it one time and then not continue. I think in a typical year, I 
think we have 300 different languages and patients that we have 
to take care of. When you're talking to somebody in their own 
language, their blood pressure goes down because they feel like 
they're in a place that understands them.
    But I think the other thing, Senator, is we have to take a 
long view here. We have to really start in Title 1 schools to 
grow more physicians and clinicians that are Black and brown 
that go into the pipeline. We just combined with Wake Forest 
University in building a new medical school in Charlotte, and 
that medical school is going to be focused on making sure that 
we're reaching out to young bright minds that look like the 
community they serve so that they can go back into those 
communities.
    Senator Lujan. Thank you, Chair Murray, for this important 
hearing. I appreciate the time today.
    The Chair. Thank you.
    Senator Burr.
    Senator Burr. Senator Murray, I've only got one question 
left, but I know we've got Members who are frozen on the floor, 
frozen in other committees. I know you'll do a unanimous 
consent, but I encourage all the Members to ask questions, 
written questions, and I would urge our witnesses to please 
answer those as expeditiously as you can.
    Gene, let me come to you just real quick. You talked 
briefly about the public-private partnerships that Atrium had 
and has ongoing. Can you expand a little bit on those and what 
the difference is it's made to the health community of 
Charlotte and the community herein?
    Mr. Woods. Thank you, Senator. We just could not as 
effectively have dealt with this pandemic without those 
partnerships. When I refer to the mass vaccination events that 
we did, and my good friend is the CEO of Honeywell and lives in 
the neighborhood, and we took a walk and said how do we get 
shots in arms faster? Honeywell has tremendous logistical 
capabilities throughout the world, really. So we blended those 
capabilities with the ones that we have at Atrium and really 
were able to effectively, for example, pull off some of the 
largest, most successful mass vaccination events. We did the 
same thing for masking. We're working together.
    There's a group here in Charlotte that's led by Brian 
Moynihan, the CEO of Bank of America, and we're working with 
business communities and the government to deal with things 
like pre-K education.
    I think the problems, the issues that we deal with as a 
society are too big for any one sector to deal with alone. I 
think it's those partnerships that actually, quite frankly, 
have been strengthened in the middle of this pandemic that I'm 
looking to continue to maintain well past that, because it's 
only when, as I said in my testimony, when government, when 
health systems and businesses and citizens work together that 
we can solve these most intractable issues that we've faced for 
too long.
    Senator Burr. Gene, thank you for that.
    I'd point out to the Chair that partnerships have been 
essential not only to the delivery of vaccines, it was 
essential to the development of a vaccine. Today we see Big 
Pharma companies that don't have a vaccine manufacturing for 
another company; that's unheard of historically. This shouldn't 
be the exception. It should help to shape how we look at this 
from a policy standpoint and statute, to continue to allow 
flexibility out there.
    The decision was made very early on, I'm sure with 
objection, that we leave it up to states and Governors to 
decide where the deployment of vaccines went. I still think 
that was much better than us deciding in Washington here's the 
location it's going to go to. When Governors chose the wrong 
place, it was Vanderbilt or it was Gene Woods or it was 
somebody that said to the state people we need different, we 
need more, we need something that doesn't look traditional 
because we're not reaching a population, and locally those 
changes were made. We haven't made them everywhere in the U.S., 
but as long as we keep in mind that as we write policies the 
flexibility has to be there so people can change the 
architecture based upon the geographical location, based upon 
the disease, based upon the target for that disease, then I 
think we're going to be just fine.
    I thank the Chair.
    The Chair. Thank you.
    In September 2020, I published a report titled ``COVID-19 
and Achieving Health Equity.'' Congressional action is 
necessary to address racism and inequality in the U.S. health 
care system. That report outlined how the health care system 
has failed communities of color due to entrenched bias, 
discrimination and racism, and laid out a series of 
recommendations for Congressional action, and I ask unanimous 
consent to enter that report in the record.
    So ordered.
    [The following information can be found on pages 67 through 
112 in Additional Material:]
    The Chair. Thank you. That will end our hearing today, and 
I'd like to thank all of our colleagues, and I'd really like to 
thank all of our witnesses--Dr. Wilkins, Ms. Echo-Hawk, Ms. 
Williams, and Mr. Woods--for having such a substantive 
conversation on how damaging longstanding health inequities 
have been, including during this COVID-19 pandemic, and what we 
can do about it, and I look forward to continuing to discuss 
these issues and, more importantly, to taking long overdue 
action to address them.
    With that, for any Senators who wish to ask additional 
questions, questions for the record will be due in 10 business 
days, on Thursday, April 8th, at 5 p.m.
    This hearing record will remain open until then for Members 
who wish to submit additional materials for the record.
    With that, thank you again to all of our witnesses, and 
this Committee stands adjourned.

                          ADDITIONAL MATERIAL
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    [Whereupon, at 12:05 p.m., the hearing was adjourned.]

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