New York City, New York; Seattle, Washington; Phoenix, Arizona; and Miami, Florida—these are the well-known hotspots for the coronavirus disease 2019 (COVID-19) pandemic. Although attention has focused on cities, many rural and suburban areas across the country have experienced similar infection and mortality rates.
The virus does not respect geographic boundaries, but racial and socioeconomic inequities in COVID-19 follow persistent patterns. Across cities, suburbs, and the countryside, the pandemic has hit hardest in racially and economically segregated areas with limited economic opportunity, large immigrant communities, overcrowded housing, air pollution, and insufficient access to health care.
These place-based inequities are not new—but the COVID-19 pandemic has thrown them into sharp relief.
Decades of research have identified the harms of residential segregation, a form of institutional racism that one researcher called a “fundamental cause of racial disparities in health.” Racial segregation shapes health by determining access to education and economic opportunity, quality housing, and health care. These same factors elevate the risk of COVID-19 and its most serious consequences.
Adding to prepandemic neighborhood inequities, recent studies show more limited testing access in communities of color, and safety-net hospitals have experienced understaffing, lack of adequate personal protective equipment, and limited access to advanced treatments. All told, these factors likely contribute to lower survival rates in safety-net hospitals than in hospitals in higher-income neighborhoods.
But these are not solely city-based problems. Research shows that many of these place-based challenges are being replicated in low-income suburbs. Over the past 20 years, suburbs have seen rapid growth in poverty and barriers to health care. COVID-19 has been spreading in the suburbs. For example, in suburban Riverside, California, where poverty doubled over the past decade, the COVID-19 infection rates are similar to those of nearby Los Angeles, and the county has the second highest number of deaths in the state. The suburbs also have experienced similar racial and ethnic disparities as urban areas, and Hispanic residents and Black residents in Riverside are 2.4 times and 1.4 times more likely to be infected, respectively, than White residents.
Although rural places avoided high infection rates in the spring, they have experienced increasing incidence since then. High poverty rates, health care workforce shortages, inability to work from home, and lower insurance rates than in urban or suburban areas all combine to create conditions for substantial community spread of COVID-19 and mortality.
Kern County, California, which is primarily a rural county with large agriculture and petroleum industries, has one of the state’s highest infection rates. Replicating racial and ethnic inequities in urban areas, county infection rates are more than 3.8 times higher for Hispanic residents than for White residents. All local hospitals reached capacity by late July, and the county had to bring in traveling nurses because too few nurses live locally. Agricultural work, a key industry in many rural areas, elevates risk of infection due to difficulties in physical distancing, insufficient personal protective equipment, and limited job protections. In addition, many farm workers are noncitizens and may fear accessing testing and treatment services because of the public charge rule, a policy implemented during the early days of the COVID-19 pandemic that penalizes immigrants for using public services, including Medicaid.
Another hard-hit rural area is the Navajo Nation, which has experienced some of the highest per-capita COVID-19 rates in the US. Structural conditions play a key role, including cramped multigenerational housing, lack of running water for 30% of the population, lack of employment opportunities, high rates of underlying comorbidities, and long-term underfunding of the Indian Health Service.
Although local factors influence disparities, state factors also affect COVID-19 inequities. Much of the focus has been on how states have differed with respect to shutdowns and physical distancing policies, but prepandemic policies and practices are also central to how COVID-19 affects different states.
It is too early to know what effects—if any—Medicaid expansion and health insurance generally have on COVID-19 outcomes. But research on other diseases demonstrates that uninsured individuals are less likely than those with insurance to have a usual place of care or receive treatment for major health conditions. In states that expanded Medicaid, studies have found increased access to care and improved management for chronic diseases such as diabetes, heart disease, and respiratory conditions, which are all associated with elevate risk of COVID-19.
Insurance barriers may also make it more likely that mild cases of COVID-19 go undetected if patients avoid medical care or do not receive appropriate guidance on isolation and quarantine. Although uninsured patients can access free COVID-19 testing under federal legislation, the system of reimbursement is complex, treatment costs may not be covered, and many patients are likely unaware of this law.
The immigration policy climate in the individual states also likely influences rates of COVID-19 and the death rates. Although immigration laws are set federally, the climate and messaging toward immigrant communities vary greatly across states, as does the extent of collaboration with immigrant enforcement and state actions to fill safety-net gaps for immigrants. An estimated 5.5 million undocumented immigrants are essential workers, exposing themselves to elevated infection risk. Federal policy excludes undocumented immigrants from receiving disaster response funds or unemployment insurance. However, some states, such as California and New York, have created state-level unemployment programs and established relief funds for undocumented residents.
A Call for Policy Change
The COVID-19 pandemic offers the opportunity for—and in fact demands—a concerted effort to address long-standing structural inequities and racial injustice in housing, employment, immigration policy, and health care. Given the current lack of a unified federal response, states and local governments also must enact short-term strategies and policies that help address immediate inequities in testing, treatment, and care.
Even though it is now known which communities are most likely to experience disproportionate infection and mortality rates for COVID-19, many states and localities have not proactively targeted testing sites or shifted resources to hospitals serving those communities. To avoid overwhelming safety-net hospitals and ensure that all patients receive quality care, local leaders should determine transfer plans between hospitals before surges occur. In rural and suburban areas, states must step in to ensure access to testing and care if no safety-net institutions exist. The remaining states that have not expanded Medicaid should do so, or at the very least apply for federal waivers to provide emergency Medicaid for patients hospitalized for COVID-19. Under the Families First Coronavirus Response Act, states can offer coverage of COVID-19–related costs for individuals without insurance. And though outside the states’ purview, the federal government should permanently revoke using health insurance and health status as part of the public charge rule.
Further research is needed to help state and local governments understand why these populations and geographic areas are at greatest risk of infection, hospitalization, and death—and which policy levers will be most effective at eliminating disparities. Where you live has always mattered for health, but in the current COVID-19 pandemic, the stakes are even higher. The time for policy makers to act is now.
Open Access: This is an open access article distributed under the terms of the CC-BY License.
Corresponding Author: Benjamin D. Sommers, MD, PhD, Harvard T. H. Chan School of Public Health, Department of Health Policy and Management, 677 Huntington Ave, Kresge 406, Boston, Massachusetts 02115 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Schnake-Mahl reported receiving personal fees from Cityblock Health. Dr Sommers reported receiving personal fees from the Health Research & Educational Trust, the Massachusetts Medical Society, the Urban Institute, AcademyHealth, the American Economics Journal, and the Illinois Department of Healthcare and Family Services; and recieving grants from Baylor Scott & White.
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Schnake-Mahl AS, Sommers BD. Places and the Pandemic—Barriers and Opportunities to Address Geographic Inequity. JAMA Health Forum. 2020;1(9):e201135. doi:10.1001/jamahealthforum.2020.1135