Health Policy$ense

Does Access to an ICU Bed Depend on Income?

Fewer ICU Beds in Low-income Communities, Despite Greater Need

In Health Affairs, Genevieve Kanter and Peter Groeneveld find that Intensive care unit (ICU) beds are not equally distributed across the United States, and income is a strong predictor of access to an ICU. The implications for COVID-19 are troubling. So far, infection rates have been most severe in low-income communities, which also have higher rates of underlying health conditions that increase the odds of requiring intensive care. Without better coordination and redistribution of ICU resources, the negative consequences of the pandemic are likely to grow, with a growing gap between these resources and the communities that need them.

Building on prior research

Prior research has identified counties with no intensive care beds, highlighting a rural-urban divide. Kanter and Groeneveld build on this literature by considering the role of income and focusing on access for people over age 50, who are most likely to need an ICU bed during the COVID-19 pandemic. The authors also used Hospital Service Areas (HSAs) as the unit of geographic measurement, which more accurately capture where individuals are likely to be hospitalized based on their zip code.

Overall, the median number of ICU beds in an HSA was 5 per 10,000 people aged 50 and older, but the distribution was skewed, with 37% of HSAs having no ICU beds. The northeast and south generally had more ICU beds than the Midwest and West. 

The results by income are striking. About half of HSAs with median household incomes under $35,000 had no ICU beds, compared to 3% of HSAs with incomes over $90,000. About 60% of highest-income HSAs had four or more beds per 10,000 residents, compared to 46% for the lowest-income HSAs.

Consistent with prior literature, Kanter and Groeneveld found a rural-urban divide. Over half of rural, low-income communities had no ICU beds, compared to 31% of urban, low-income communities. Additionally, the effect of income on access to ICU beds is most severe in rural areas. After adjusting for other factors including race, the authors estimated that a $10,000 increase in median income corresponded with an 11.8% increase in age-adjusted ICU bed capacity in urban areas, compared to a 13.4% rise in rural areas.  

Implications for COVID-19

During the COVID-19 pandemic, equitable access of ICU beds is essential for reducing health disparities. However, the number of ICU beds available per 10,000 adults over the age of 50—the group at greatest risk for serious complications—varies dramatically by income, with compounding regional effects. The first wave of infections was concentrated in urban centers, such as New York City. However, Midwestern, Southern, and Western states are now seeing dramatic outbreaks in both rural and urban areas.

These disparities underscore the need for policies to reduce the potential impact of COVID-19. Hospitals facing financial pressures related to COVID-19 have little incentive to admit critically ill patients from underserved areas, who have worse rates of uninsurance and complex needs. Therefore, state and local authorities need to carefully and proactively coordinate the expansion of emergency ICU capacity, with an eye towards the underlying maldistribution.

Secondly, while emergency services tend to follow guidance to transport patients to the nearest hospital, that protocol may require revision in communities hardest hit by COVID-19. In many parts of the country, transporting critically ill patients to the nearest hospital may be suboptimal if more beds are available elsewhere. Finally, as federal and state legislators consider the scope and scale of emergency funding to health care providers, they should pay particular attention to hospitals lacking ICU resources, especially those caring for older populations.