Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Jan 4;4(1):e2034578.
doi: 10.1001/jamanetworkopen.2020.34578.

Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties

Tim F Liao  1 , Fernando De Maio  2   3
Affiliations

Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties

Tim F Liao et al. JAMA Netw Open. .

Erratum in

  • Errors in Tables 1 and 2.
    [No authors listed] [No authors listed] JAMA Netw Open. 2021 May 3;4(5):e2114136. doi: 10.1001/jamanetworkopen.2021.14136. JAMA Netw Open. 2021. PMID: 33999170 Free PMC article. No abstract available.

Abstract

Importance: It is now established that across the United States, minoritized populations have borne a disproportionate burden from coronavirus disease 2019 (COVID-19). However, little is known about the interaction among a county's racial/ethnic composition, its level of income inequality, political factors, and COVID-19 outcomes in the population.

Objective: To quantify the association of economic inequality, racial/ethnic composition, political factors, and state health care policy with the incidence and mortality burden associated with COVID-19.

Design, setting, and participants: This cross-sectional study used data from the 3142 counties in the 50 US states and for Washington, DC. Data on the first 200 days of the COVID-19 pandemic, from the first confirmed US case on January 22 to August 8, 2020, were gathered from the Centers for Disease Control and Prevention and USAFacts.org, the US Census Bureau, the American Community Survey, GitHub, the Kaiser Family Foundation, the Council of State Governments, and the National Governors Association.

Exposures: Racial/ethnic composition was determined as percentage of the population that is Black or Hispanic; income inequality, using the Gini index; politics, political affiliation and sex of the state governor, gubernatorial term limits, and percentage of the county's population that voted Republican in 2016; and state health care policy, participation in the expansion of Medicaid under the Affordable Care Act. Six additional covariates were assessed.

Main outcomes and measures: Cumulative COVID-19 incidence and mortality rates for US counties during the first 200 days of the pandemic. Main measures include percentage Black and Hispanic population composition, income inequality, and a set of additional covariates.

Results: This study included 3141 of 3142 US counties. The mean Black population was 9.365% (range, 0-86.593%); the mean Hispanic population was 9.754% (range, 0.648%-96.353%); the mean Gini ratio was 44.538 (range, 25.670-66.470); the proportion of counties within states that implemented Medicaid expansion was 0.577 (range, 0-1); the mean number of confirmed COVID-19 cases per 100 000 population was 1093.882 (range, 0-14 019.852); and the mean number of COVID-19-related deaths per 100 000 population was 26.173 (range, 0-413.858). A 1.0% increase in a county's income inequality corresponded to an adjusted risk ratio (RR) of 1.020 (95% CI, 1.012-1.027) for COVID-19 incidence and adjusted RR of 1.030 (95% CI, 1.012-1.047) for COVID-19 mortality. Inequality compounded the association of racial/ethnic composition through interaction, with higher income inequality raising the intercepts of the incidence curve RR by a factor of 1.041 (95% CI, 1.031-1.051) and that of the mortality curve RR by a factor of 1.068 (95% CI, 1.042-1.094) but slightly lowering their curvatures, especially for Hispanic composition. When state-level specificities were controlled, none of the state political factors were associated with COVID-19 incidence or mortality. However, a county in a state with Medicaid expansion implemented would see the incidence rate RR decreased by a multiplicative factor of 0.678 (95% CI, 0.501-0.918).

Conclusions and relevance: This county-level ecological analysis suggests that COVID-19 surveillance systems should account for county-level income inequality to better understand the social patterning of COVID-19 incidence and mortality. High levels of income inequality may harm population health irrespective of racial/ethnic composition.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Incidence Estimations by County-Level Racial/Ethnic Composition and Gini Index for Income Inequality
The Gini index ranges from 0, indicating perfect equality, to 100, indicating perfect inequality.
Figure 2.
Figure 2.. Mortality Predictions by County-Level Racial/Ethnic Composition and Gini Index for Income Inequality
The Gini index ranges from 0, indicating perfect equality, to 100, indicating perfect inequality.
See this image and copyright information in PMC

References

    1. Adhikari S, Pantaleo NP, Feldman JM, Ogedegbe O, Thorpe L, Troxel AB. Assessment of community-level disparities in coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas. JAMA Netw Open. 2020;3(7):e2016938. doi:10.1001/jamanetworkopen.2020.16938 - DOI - PMC - PubMed
    1. Millett GA, Jones AT, Benkeser D, et al. . Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37-44. doi:10.1016/j.annepidem.2020.05.003 - DOI - PMC - PubMed
    1. APM Research Lab The color of coronavirus: COVID-19 deaths by race and ethnicity in the US. Published September 10, 2020. Accessed November 12, 2020. https://www.apmresearchlab.org/covid/deaths-by-race
    1. Metzl JM, Maybank A, De Maio F. Responding to the COVID-19 pandemic: the need for a structurally competent health care system. JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289 - DOI - PubMed
    1. Khazanchi R, Evans CT, Marcelin JR. Racism, not race, drives inequity across the COVID-19 continuum. JAMA Netw Open. 2020;3(9):e2019933. doi:10.1001/jamanetworkopen.2020.19933 - DOI - PubMed