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The coronavirus disease COVID pandemic has focused attention on stark disparities in the US, with higher rates of infections and deaths among lower-income populations and here of color. Illness and death rates are not the only sources of health inequity in this country. There are also substantial differences in the care that patients with serious illnesses receive near the end of life that are based on race or socioeconomic status. Although pandemic-related efforts to improve equity rightfully focus on Workfirce death, in this and numerous other contexts, policy makers and clinicians should also work to eliminate disparities in end-of-life care.

Multiple dimensions of end-of-life care vary by socioeconomic status and race.

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Worjforce and Medicaid are key players in end-of-life care for low-income populations. One important difference between Medicare and Medicaid hospice is payment for nursing facility care. Other than hospice general inpatient care, which accounts for just 1. Although all Medicare beneficiaries can access the hospice benefit, for Medicaid, states can choose whether to include a hospice benefit at all.

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Even though most states cover hospice, several limit benefits to specific subpopulations in Medicaid, and others do not cover hospice or have eliminated hospice benefits in Life And Death Of The Medical Workforce past for budgetary reasons.

In addition, as laid bare during the pandemic, Medicaid chronically underfunds nursing home care, producing a crisis in quality, particularly in facilities primarily serving Black patients. Other groups of seriously ill patients are continue reading for federally subsidized insurance. One such group includes the 2 to 3 million adults with low income in states that did not expand Medicaid.

Another group includes undocumented immigrants, for whom the lack of insurance options, combined with cultural and language barriers, creates substantial barriers to end-of-life care. Nationally, 1 of 3 hospice programs limit or refuse to treat this population. Undocumented immigrants are also more likely to receive intermittent emergency care rather than the longitudinal care necessary for advanced care planning and good symptom management.

Poverty and geographical isolation are key contributors to poor access to end-of-life care services in tribal communities; this resembles broader disparities for rural patients of all races. Many tribal health organizations are also unable to satisfy the myriad Medicare and Medicaid requirements to provide hospice services, leaving patients reliant on outside hospice programs that frequently are insensitive to tribal culture and practices regarding end-of-life care.

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Beyond hospice, disparities also exist with respect to palliative care services. Palliative care, which can be provided to patients at all stages of serious illness without the 6-month life expectancy requirement for hospicecan improve patient quality of lifesymptom burdenand patient and caregiver satisfaction and can also lower health care use.

Another Family Culture to this pattern is that hospice and palliative care have traditionally focused on cancer, whereas other illnesses such as end-stage kidney disease —with substantially higher rates among racial minorities—can produce symptoms as severe as those of cancer, but patients with these conditions are less likely to receive key elements of high-quality end-of-life care. What can be done? First, financial access to care must be improved. Congress should reclassify hospice as an essential benefit required in state Medicaid programs, and states should eliminate prescription drug caps that impair adequate end-of-life symptom management.

A pathway to affordable coverage for undocumented immigrants to provide access to meaningful health care throughout the life cycle is also critical.]