Ku L, Brantley E. Widening Social and Health Inequalities During the COVID-19 Pandemic. JAMA Health Forum. Published online June 10, 2020. doi:10.1001/jamahealthforum.2020.0721
The COVID-19 pandemic and efforts to flatten the curve have shaken the nation’s health, social, and economic systems and widened health and social disparities. For example, age-adjusted COVID-19 mortality rates are far higher for African American and Latino patients than white patients.1 But recent data show that economic and social disparities have also widened in relation to racial/ethnic, educational, and immigration status.
According to the Bureau of Labor Statistics (BLS), between February 2020 —before the COVID-19 period—and April 2020, the overall unemployment rate surged from 3.5% in February to 14.7% in April, an 11.2-percentage-point increase.2 But unemployment rose even more quickly for some groups. Our analysis shows that unemployment among Latinos climbed 14.5 percentage points, from 4.4% to 18.9%. Both white and African American adults experienced 11-percentage-point increases, but unemployment in the black community was consistently higher than in the white community (16.7% vs 13.5% in April). Unemployment rates among Asian Americans almost sextupled, from 2.5% to 14.5%.
Two additional factors drove disparities: immigration and educational status. Much larger increases occurred among those with less education; unemployment soared from 5.7% to 21.2% in April for those with less than a high school education, vs from 1.9% to 8.4% for college graduates. Unemployment among foreign-born adults rose 12.9 percentage points, from 3.6% in February to 16.5% in April, while rising 10.2 percentage points to 14.0% for US-born adults. One reason for these disparities is that minority, immigrant, and less-educated workers were more likely to be employed in service industries (eg, restaurants) that were more likely to shut down.
Official unemployment rates tell just part of the story. The unemployment rate excludes those who are not counted in the civilian labor force because they are not actively looking for work, such as homemakers, students, or retirees. The BLS data show that 8.4 million more adults were counted as being out of the labor force between February and April, a 4.9% drop-off. Many were not actively seeking work because they were following stay-at-home orders, had been laid off but believed jobs were unavailable in their fields because of widespread business closures, or were caring for a child whose school had closed or a sick relative. Large reductions in labor force participation occurred for those with less than a high school degree (11.5% reduction), immigrants (8.5%), and African Americans (7.0%). Although these discouraged workers are not counted as unemployed by the BLS, they have nonetheless lost jobs and experience more hardships.
Disparities are widening on other measures of economic hardships. A new rapid response survey, the Household Pulse Survey, is being fielded by the Census Bureau on a weekly basis. Our analysis found that for the April 23 to May 5 period, 47% of US adults reported someone in their household lost employment income since March 13.3 Employment income loss was widespread, but African Americans, Latinos, and Asians had somewhat higher rates (52%, 58%, and 50%, respectively) than white adults (42%). Income loss was more common among those with less than a high school degree (55%) than for college graduates (38%). Those in fair or poor health were somewhat more likely to lose income than those in excellent health.
One-tenth (9.8%) of adults reported their households sometimes or often did not have enough food to eat in the last 7 days. The level of food insufficiency was much higher for African Americans (20.4%) and Latinos (15.4%) vs whites (6.4%). Food insufficiency was 3 times higher (14.5%) for those who lost employment income than for those who did not (5.7%) and was 7 times higher for those with less than a high school degree (22.4%) than for college graduates (3.0%).
About 42% of adults reported that they had delayed getting medical care in the last 4 weeks due to COVID-19. However, delays had less association with social disparities. For example, 40% of white individuals delayed medical care, compared with 37% of black individuals and 35% of Latinos. Nor were health care delays strongly associated with education or loss of employment income. At least initially, delays in medical care may be broad-based responses to avoidance of unnecessary care and fear of contracting COVID-19 in medical facilities.4
To assist those who have lost their jobs and income, the United States offers safety net programs, such as unemployment insurance, Medicaid, and the Supplemental Nutrition Assistance Program (SNAP). But not everyone who needs assistance receives it. An April report found that only 29% of unemployed adults actually received unemployment benefits; those living in southern and great plains states were less likely to get them.5 Overwhelmed application systems and complex eligibility restrictions both contribute to limited effectiveness.
Immigrants, even those who are lawfully present, are often ineligible for benefits such as SNAP and Medicaid. For example, the public charge regulation issued by the Department of Homeland Security would penalize immigrants who use Medicaid or SNAP, lowering participation.6 Immigrants are often ineligible for relief offered in the CARES Act, such as recovery rebates and added unemployment benefits.7 Those with limited education often face barriers applying for benefits; they may have limited internet access or have more difficulty navigating paperwork requirements. Those with low education are also less likely to meet requirements for work history and minimum earnings levels under traditional unemployment than workers of higher socioeconomic status; temporary changes in the CARES act only partially addressed this.8
Recent legislation, such as the Families First Coronavirus Response Act and the CARES Act, shored up unemployment assistance and Medicaid (and SNAP to a lesser extent), but key provisions are temporary and may expire while the levels of hardship remain stubbornly high. The House-passed HEROES Act would bolster safety net programs and add additional economic stimulus but faces an uncertain future due to opposition by the Senate and the president.9 To mitigate the enormous harm of the COVID-19 pandemic, policy makers should develop robust safety net programs to help those who experience the greatest harms and continue to monitor social and health conditions to assess whether overall hardships and disparities are being reduced.
Since this brief was accepted, a new BLS report indicated that the overall US unemployment rate declined slightly from 14.7% in April to 13.3% in May. The BLS also acknowledged a misclassification error and stated actual unemployment rates ought to have been approximately 5% higher in April and 3% higher in May. Nonetheless, the disparity trends described above continued over the February to May period. Between April and May, white unemployment rates declined but rose for African Americans and Asian Americans.
Corresponding Author: Leighton Ku, PhD, MPH, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave NW, 6th Floor, Washington, DC 20010 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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