(Withdrawn) Applying a Disability Equity Framework to State Crisis Standards of Care Plans

Background and Purpose: Crisis Standards of Care Plans (CSOC) are designed to guide an equitable distribution of scarce healthcare resources during a public health emergency (Cleveland Manchanda et al., 2020; Ne’eman et al., 2021). States developed many CSOC plans in response to the H1N1 pandemic in 2009 and they have gained increased attention during the COVID-19 pandemic (Cleveland Manchanda et al., 2020; Ne’eman et al., 2021). Much of this attention came from disability advocates who highlighted the implicit biases in allocation criteria (Center for Public Representation [CPR], 2020).

This study applied a CSOC evaluation framework developed by the CPR in collaboration with other disability organizations to state CSOC plans at two distinct stages of the COVID-19 pandemic to examine whether state plans had become more responsive to the needs of people with disabilities.

Methods: CSOC plans were identified from prior reviews conducted by Cleveland Manchanda et al., (2020), Ne’eman et al., (2021), and disability advocacy organizations (CPR, 2020), supplemented with a Google search and review of states’ department of health websites. We only included CSOC plans with specific criteria for making determinations about allocation of healthcare resources. Data extraction occurred in two phases. The first round of data extraction included CSOC plans published prior to June 1, 2020 to capture the status of state CSOC plans early in the COVID-19 response. The second round included CSOC plans published or updated from June 2020 to March 2022 to understand the impact of disability advocacy and COVID-related learning as the pandemic progressed.

Data were extracted using a framework analysis (Srivastava & Thomson, 2009) with the evaluation criteria developed by CPR and other advocacy organizations as a priori codes. These criteria included explicit statements regarding equity, protections for people with disabilities and other marginalized groups, and modifications to the plan to account for baseline differences in functioning, among other factors.

Results: Twenty-four states had CSOC plans with specific allocation criteria published before June 1, 2020. Fifteen states had CSOC plans that were either initially published or updated from June 1, 2020 to March 1, 2022. Plans in both rounds of data extraction were more likely to include high-level protections for people with disabilities (ex. naming equity as a principle of the plan, stating that disability could not be considered in allocating resources) than they were to provide specific protections (ex. modifications to scoring criteria, protections for patients with personal ventilators). Protections for patients with disabilities were more common in plans published after June 1, 2020.

Conclusions and Implications: The increase in protections for people with disabilities in CSOC plans published later in the COVID-19 pandemic suggests that work by disability advocates may have successfully increased awareness of discrimination in the public health response. Despite these improvements, work remains to ensure that responses to future emergencies are equitable, and that CSOC plans are applicable to a variety of public health crisis scenarios.