By Jose F. Figueroa, Rishi K. Wadhera, Dennis Lee, Robert W. Yeh, and Benjamin D. Sommers
Health Affairs, August 27, 2020 (published ahead of print)
Massachusetts has one of the highest cumulative incidence rates of coronavirus disease 2019 (COVID-19) cases in the US. Understanding which specific demographic, economic, and occupational factors have contributed to disparities of COVID-19 is critical to inform public health strategies. We performed a cross-sectional study of 351 Massachusetts towns/cities (01/01/2020–05/06/2020) and found that a 10 percentage point increase in the Black population was associated with a 312.3 increase in COVID-19 cases per 100,000, while a 10 percentage point increase in the Latino population was associated with an increase of 258.2 cases per 100,000. Independent predictors of higher COVID-19 rates included the proportion of foreign-born non-citizens living in a community, mean household size, and share of food service workers. After adjustment for these variables, the association between the Latino population and COVID-19 rates was attenuated. In contrast, the association between the Black population and COVID-19 rates persisted, and may be explained by other systemic inequities. Public health and policy efforts that improve care for foreign born non-citizens, address crowded housing, and protect food-service workers may help mitigate the spread of COVID-19 among minority communities. [Editor’s Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.]
Across Massachusetts’ cities and towns, Latino and Black communities are experiencing much higher rates of COVID-19 cases. Several factors measured in our data (foreign-born non-citizen status, household size, and job type) appear to explain the higher COVID-19 case rates among Latino communities in Massachusetts. It appears that these factors may not be the primary reason for higher case rates in Black communities.
While the extent of racial and ethnic disparities has already been documented, our study identifies important factors that are independently associated with higher COVID-19 case rates in the state. The proportion of foreign-born non-citizens was the strongest predictor of the burden of COVID-19 cases within a community, and in Massachusetts, this population includes sizable numbers of both Latin American (44.9%) and Asian individuals (30.7%). Furthermore, under the Trump Administration’s revised “Public Charge” Rule, which took effect in early 2020, lawfully present immigrants who use public benefits from local, state, or federal governments may be at risk of being denied permanent residency status. Although the U.S. Citizenship and Immigration Services website now encourages immigrants to seek care for COVID-19-like symptoms, enrollment in Medicaid at the time of COVID-19-related care may still be used in the Public Charge analysis. Recent studies suggest that immigrant families have strong incentives not to enroll in public health insurance like Medicaid and may avoid seeking medical care if they develop COVID-19-like symptoms and require testing. In the absence of a positive test, these individuals are less likely to isolate and quarantine, which may impede public health efforts to control the spread of COVID-19.
These issues are likely only magnified by the fact that immigrants tend to live in larger households, which we also found to be an independent predictor of COVID-19 case rates. Policy approaches that reduce barriers to accessing medical care for immigrant populations and that address crowded housing—particularly when individuals have tested positive and need to be isolated—could be important avenues for reducing disparities and slowing the spread of infection.
Our work also sheds important insights into the factors that may be contributing to the higher rates of COVID-19 cases among Latino communities. As noted above, many immigrants in the Latino community may be deferring necessary care for fear of risking citizenship under the Public Charge rule or possible deportation. In addition, Latino persons tend to be disproportionately employed in essential services that are public facing, particularly in the food service industry, which we found to be associated with higher COVID-19 rates. As the state moves to cautiously re-open more businesses, greater worker protections to reduce potential exposures may be needed in these jobs. Many low-income minority workers also do not have the luxury of working from home, and less than half of Latino workers in the U.S. have jobs with paid sick leave. While Congress recently expanded the availability of paid sick leave under the CARES Act in March 2020, the law exempted workers in large firms and health care organizations, which may leave many essential workers unprotected if they contract COVID-19.
Meanwhile, our results show large disparities in infection rates associated with Black communities, but these disparities do not appear to be primarily explained by the factors that we examined. Other factors not examined in this study may explain the disparate impact of COVID-19 in Black communities. Structural inequities, such as disproportionately high incarceration rates, residence in areas with a higher concentration of multiunit residential buildings, and de facto neighborhood segregation, which may lead to disparities in health care access and greater exposure to environmental hazards, may contribute to the spread of COVID-19 in these communities. Transportation use may also increase the risk of exposure to COVID-19, as Black workers are more likely to use public transit to commute to work.
Evidence emerging from other U.S. cities and states has similarly described that Black and Latino populations are being disproportionately affected by COVID-19. In addition, preliminary work from Massachusetts suggests that these populations also have substantially higher death rates. Our study expands upon these findings in several ways. We identify important factors (proportion of foreign-born non-citizens in a community, household size, food service occupation) that are strongly associated with the risk of developing COVID-19. In addition, we characterize the extent to which these factors, among others, may be contributing to the higher number of COVID-19 cases in Black and Latino communities. Because we evaluate each of these unique populations separately, we find that some factors, such as occupation in an essential service field, may not affect Black and Latino communities in a similar manner. Our findings provide important insights that may inform and help tailor public health and policy strategies to address the ongoing COVID-19 pandemic.
Across Massachusetts cities and towns, significant COVID-19 disparities are evident along multiple dimensions—particularly race/ethnicity, foreign-born non-citizen status, household size, and job type. Higher proportions of Black or Latino residents within a community was significantly associated with higher rates of COVID-19 cases. The factors examined in our study explained this relationship for Latino communities but did not appear to explain the higher rates among black communities. Further research into the social and economic factors underlying COVID-19-related disparities and new policies to address risk factors and institutional racism will be critical to controlling the epidemic and improving health equity.
By Don McCanne, M.D.
Besides removing financial barriers to care, one of the most important reasons to enact and implement single payer Medicare for All is to improve health equity. The current pandemic has provided an opportunity to demonstrate what role racial and ethnic disparities play in interfering with the establishment of health equity.
The issues are complex. In Massachusetts, although both Latino and Black populations have an increased prevalence of COVID-19 and deaths attributed to the disorder, associated aggravating factors varied between the populations, as explained in the Discussion above.
The first step is to recognize that neither of the two major candidates for president are offering health policy proposals that would adequately address the factors that result in health inequities (though one has suggested a few beneficial tweaks, however inadequate). We clearly need to enact and implement Medicare for All, but that alone is not enough. Policies to address structural racism are absolutely essential.
(How important is this issue? Although I am stepping out of line to reveal this at this time, the issue is important enough that the PNHP board is in the process of revising the mission statement of PNHP to include addressing the issue of racism. We have to do it.)
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