October 1, 2020

CSAC has engaged with the Newsom Administration virtually around the clock over the last two weeks regarding the state’s proposal for a new health equity metric as part of the tiering system in place under the Blueprint for a Safer Economy. It was poster last night here and a detailed summary follows.

The final metric represents scores of hours of effort by the CSAC Officers, CSAC Executive Committee, the newly formed “CSAC Kitchen Cabinet” and CSAC Rural Caucus Working Group, affiliate public health partners CHEAC and HOAC, and CSAC staff to craft a substantially improved metric for counties. While the state ultimately held firm to their belief that the new health equity metric must be tied to the current Blueprint for a Safer Economy tiering system despite the many steps counties have already undertaken to reduce COVID-19 related health disparities for months, CSAC was able to guarantee the following:

1. A delayed implementation date of October 6;
2. An exemption for smaller counties from the numbers-based metric; and
3. Ensure that the new metric would not be used to move a county backwards, or into a higher, more restrictive tier.

It’s important to note that the relationship between the state and counties has strengthened during the development of this new metric. Through our collective efforts, the state came to understand the critical role counties must play in policy development and how that engagement ultimately results in improved outcomes. While the new health equity metric is still problematic, CSAC was able to fully engage the state on this issue and relay the message that counties care about underserved communities and have been working for months on these issues. CSAC will continue to press the Administration for continued consultation and engagement on key COVID-19 policies. We also wish to thank affiliate partners CHEAC and HOAC with their expertise and commitment to increasing health equity to the extent possible.

While the months ahead remain uncertain – flu season is right around the corner, multiple hometown businesses are closing their doors, unemployment and food insecurity remain high, and Boards are impacted by an increasingly impatient public – CSAC will continue to ensure that counties have a voice in the process.

Details: New Health Equity Metric
The new health equity metric contains three components and will be applied as a condition for moving tiers beginning October 6 for medium and large counties and October 12 for rural counties. The goal of the new metric is to reduce and possibly eliminate disparities in the levels of COVID-19 transmission among county residents. CDPH will provide small-team technical support to assist counties in meeting the new metric, but CSAC has noted that counties may also require resources to comply.

Component 1: Improving test positivity rates for the most disadvantaged communities within counties larger than 106,000 residents
This metric requires medium and large counties to ensure that the test positivity rates in their most disadvantaged neighborhoods, as defined as the lowest quartile of the U.S. Census Healthy Places Index for California (HPI), must meet the overall test positivity rate for the next lowest tier. This new metric will join the overall test positivity rate and case rate requirements within the Blueprint for a Safer California. More information regarding the actual calculation is forthcoming. Key points include: 

1. This health equity metric will not be used to move counties back to a more restrictive tier – only forward.
2. It does not apply to counties under 106,000 (see Component 2 for smaller counties)
3. The threshold for the next lowest tier must be met for two consecutive weeks to move forward

CSAC was also able to negotiate two modifications to the state’s original proposal to assist in movement to a less-restrictive tier, including:

Acceleration Possible: While a county must meet the health equity threshold for the next lowest tier to move forward, a county with a health equity positivity rate and overall county positivity rate meeting the threshold for two tiers down may move one tier down if the county’s overall case rates are slightly higher but showing a decreasing trend.

Softer Metric: Because continually reducing disparities is not a linear process, the state has agreed to a CSAC request to soften the thresholds for meeting tiers below purple as follows:

1. For counties entering the red tier, their lowest quartile HPI census tracts’ test positivity must also be ≤8%
2. For counties entering the orange tier, their lowest quartile HPI census tracts’ test positivity must be within 5% of the orange tier threshold, or <5.25%
3. For counties entering the yellow tier, their lowest quartile HPI census tracts must be within 10% of the yellow tier threshold, or <2.2%

Component 2: Closing disparities within all counties
Data on underserved communities varies across the state. Because Component 1 of the health equity metric uses the Healthy Places Index, it’s important to note that the test positivity rate for the lowest quartile cannot be reliably calculated due to the limited number of census tracts for smaller jurisdictions. For this reason, counties under 106,000 residents must only comply with Components 2 and 3, whereas larger counties must comply with all three components.

For Component 2, the state will require all counties to submit a plan for spending CDC funding on underserved communities by October 12. The plans must be submitted before a county can move to a less-restrictive tier.

The plan must include a definition of a county’s unique and disproportionately impacted populations, specify the case rate in these identified populations, and demonstrate how the county will deploy the same percentage of their share of the CDC ELC grant funding (Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases) from both CARES and the PPPHCE to combat COVID-19 among those populations.

Activities for expending ELC funding may include increasing testing and access to testing, disease investigation and contact tracing, isolation/quarantine support, and outreach and education efforts for populations and at-risk workers. The ELC allocations for each county are attached.

Component 3: Improving all county COVID-19 data reporting
The state will work with all counties to improve race/ethnicity data reporting for all COVID-19 cases. Currently, only about a third of cases reported to the state include this important data. The ELC grant funding mentioned above can be used for improving data reporting to reduce disparities, including epidemiologic support, data collection, data entry, and the purchase of data systems and technology. The state will monitor each county’s progress and continue publish county-level data on the overall completeness of race/ethnicity for all tests, cases, and deaths.