Estimating Population Impact of State Triage Policies Restricting Healthcare Access for Older Adults with Chronic Conditions

Introduction

The COVID-19 pandemic in 2020 prompted states to modify existing or draft new pandemic preparedness plans in anticipation of resource scarcity. Some plans included written triage policies for allocating scarce hospital-based resources, like ventilators or intensive care unit admission.^1,2 For example, Montana’s triage scheme utilizes a scoring system that considers short- and long-term prognosis and presence of comorbidities to triage patients.³ State triage policies came under scrutiny from disability and aging rights groups, in addition to the U.S. Department of Health and Human Services Office of Civil Rights over discrimination on the basis of disability, advanced age, and race/ethnicity.⁴

The role of age, disability, and race in state triage policies have previously been described.^5–7 We systematically analyzed how state-promulgated plans factored chronic conditions into triage,⁸ but the population impact of these policies is unknown. Using the framework and primary data from our previous work, our objective was to quantify the impact of state triage schemes by estimating the number of older adults with chronic diseases living in states whose triage policies could have given them lower priority (“deprioritization”) during triage, or categorically excluded them from accessing scarce hospital resources. We hypothesized this number would be greater than one million.

Methods

Among the sixteen states with triage policies that incorporated chronic conditions to deprioritize or exclude patients from hospital resources or admission,⁸ we calculated the number of potential beneficiaries affected by those schemes.

We analyzed publicly available files of all 2018 Medicare enrollment and claims data (most recent data available) from the Centers for Medicare and Medicaid Services (CMS), as derived from the CMS Chronic Conditions Data Warehouse (CCW). Available data included: Medicare fee-for-service beneficiaries (hereafter “beneficiaries”), medical conditions, geographic location, enrollment characteristics, and sociodemographics.⁹

We calculated: 1) the total number of beneficiaries aged ≥65; 2) number of beneficiaries aged ≥65 with 2 or more chronic conditions; 3) number of beneficiaries aged ≥65 with specific chronic conditions overall and by state. Chronic conditions included in the CMS public files were chosen based on the U.S. Department of Human and Health Services’ Multiple Chronic Conditions Initiative.⁹

Results

We identified approximately 20 million CMS beneficiaries aged ≥65 across the U.S. with 2 or more chronic conditions. Of these, 5.6 million (28%) reside in states whose pandemic triage policies would deprioritize or exclude patients from accessing life-saving critical care resources based on advanced chronic conditions during the COVID-19 pandemic (Figure 1).

Figure 1.

Proportion of Medicare fee-for-service beneficiaries aged ≥ 65 with at least 2 chronic conditions¹, for whom access to care could be restricted by state pandemic triage policies

¹Chronic conditions from the Centers for Medicare and Medicaid Services publicly available 2018 enrollment and claims data include: Alcohol Abuse, Alzheimer’s Disease and Related Dementia, Arthritis (Osteoarthritis and Rheumatoid), Asthma, Atrial Fibrillation, Autism Spectrum Disorders, Cancer (Breast, Colorectal, Lung, and Prostate), Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Depression, Diabetes, Drug Abuse/Substance Abuse, Heart Failure, Hepatitis (Chronic Viral B & C), HIV/AIDS, Hyperlipidemia, Hypertension, Ischemic Heart Disease, Osteoporosis, Schizophrenia and Other Psychotic Disorders, Stroke

Conditions commonly listed in restricting states’ triage plans include: Alzheimer’s disease and related dementia, chronic obstructive pulmonary disease, cancer (breast, colorectal, lung, and prostate), chronic kidney disease, heart failure, and ischemic heart disease (Table 1).

Table 1.

Older adults who could be deprioritized or excluded during pandemic triage based on presence of specific chronic conditions

Conditions	States	Number of beneficiaries ≥ 65 potentially impacted
Alzheimer’s Disease and Related Dementia	KS, LA, MT, NV, NM, OK	205,022
Chronic Obstructive Pulmonary Disease	AR, MI, MN, LA, MT, NM, OK	333,293
Cancer (Breast, Colorectal, Lung, and Prostate)	AR, CA, KS, KY, LA, MI, MN, MT, NV, NM, OK, SC, VT, WA	657,624
Chronic Kidney Disease	AK, AR, IN, KS, MI, MT, OK, SC, WA	1,007,068
Heart Failure and Ischemic Heart Disease	AR, CA, IN, KS, LA, MI, MN, MT, NM, OK, SC, VT, WA	3,196,796

Abbreviations: AK, Alaska; AR, Arkansas; CA, California; IN, Indiana; KS, Kansas; LA, Louisiana; MI, Michigan; MN, Minnesota; MT, Montana; NM, New Mexico; NV, Nevada; OK, Oklahoma; SC, South Carolina; VT, Vermont; WA, Washington

Discussion

To our knowledge, this is the first attempt to estimate the potential impact of triage policies restricting access to care based on chronic conditions. One in four Medicare beneficiaries aged ≥65 with 2 or more chronic conditions reside in states whose pandemic triage policies would deprioritize or exclude them from receiving potentially life-sustaining resources under conditions of scarcity. These data suggest that millions of older Americans could be affected by written triage policies’ consideration of chronic conditions, reviving concerns about the lawful limits of healthcare triage schemes for whole classes of persons protected under federal law, including persons with disabilities and older adults.

Moreover, the data do not account for the kinds of common modifiers outlined in individual state policies intended to further specify the application of triage protocols. For example, only 6 states restrict access due to chronic obstructive pulmonary disease specifically, but the remaining 10 restricting states list home oxygen-dependence or specific pulmonary function abnormalities. In practice, this would expand the number of people with respiratory conditions impacted by these triage schemes. Likewise, prevalence of other diseases commonly listed in triage policies, such as cirrhosis, pulmonary hypertension, pulmonary fibrosis and cystic fibrosis, are not captured with these CMS data. Our data only capture a subset of all the conditions listed in state policies, likely representing a conservative estimate. Nevertheless, if all U.S. state triage policies were implemented, large swaths of older adults, people with disabilities, including a disproportionate number from racially minoritized groups who bear an excess burden of chronic disease,¹⁰ could be excluded from life-saving treatment during a crisis.

These results suggest that state governments and the Office for Civil Rights have reason to continue to examine state pandemic triage policies promulgated before and during the COVID-19 pandemic to ensure that large numbers of older Americans are not unjustly and unlawfully denied access to care during a future pandemic.