Social Determinants of Health: The Effect of Race and Class on Health in Light of the COVID-19 Pandemic

Abstract

Class is a key determinant of how individuals and families are impacted by medical and economic issues in the United States; the prevalence of out-of-pocket payments, employer-sponsored private insurance, and barriers to Medicaid eligibility place a significant burden on healthcare access to lower-income Americans. Due to employer-based insurance as the primary form of healthcare coverage in the United States, the onset of the Coronavirus Disease 2019 (COVID-19) pandemic and related large-scale shutdowns led to massive job and thus coverage losses throughout the initial stages of the pandemic. The overlap between “essential workers” and the under-insured or uninsured leads to inadequate medical treatments and interventions that likely cannot be prevented without altering or redesigning the entire American health insurance system.

The COVID-19 Pandemic

In a healthcare system firmly dependent on out-of-pocket payments,¹ class and health are intrinsically linked. Low-income Americans are often burdened with the highest out-of-pocket costs, and disparities in access to healthcare have only widened in tandem with the United States’ wealth gap. The existing Medicaid system only covers Americans within a certain income range, sometimes leaving families uninsured, as even those who may be too wealthy to be covered by Medicaid can struggle to find affordable private coverage. Existing Medicare and Medicaid qualification depends on income limits; those too wealthy for Medicaid or Medicare can struggle to find affordable and expansive private coverage.

As a result, the United States’ reliance on employer-sponsored private insurance places those in this area between Medicare or Medicaid qualification and employer-based coverage at risk of being under insured. That trend has only accelerated since the COVID-19 pandemic suddenly and fundamentally altered the workforce, leaving many without healthcare coverage and a steady source of income, as those who do not have salaried employment are at a disadvantage in terms of coverage.² Although Medicaid and the Marketplace were able to offset some of the approximately three million Americans who lost health insurance during the first six months of the pandemic,³ the existing lack of coverage for low-income and unemployed Americans requires substantive, definitive action, as difficulty covering healthcare costs predates COVID-19.

These growing disparities must be taken as a signal to preemptively reform and expand healthcare access before the next epidemic or pandemic hits and further worsens public health outcomes. Lessons can be gleaned from how the onset of the COVID-19 pandemic drastically shifted employment and savings trends and left increasing amounts of Americans scrambling to cover the costs of medical treatment.

Class as a Determinant of Health

The need for lasting healthcare reform is necessitated by the wealth gap, which inherently restricts the accessibility of healthcare and thus medical treatment. As the wealthy become wealthier and the cost of living goes up at a rate that outpaces wages, the logistics of the low-income – or the waning middle class – paying for health insurance becomes more challenging. An unsustainable health and economic burden is placed on impoverished Americans. A multitude of factors combined to worsen outcomes for the lower class, who are more likely to not have sick leave, a steady source of income, or resources to fall back on, a phenomenon worsened by high costs and low wages.

Firstly, health insurance in the United States is tied to employment, and these benefits vary significantly depending on different jobs – as some corporations avoid providing substantive healthcare benefits, which are more costly, whereas some jobs do not have employer-sponsored coverage at all – meaning that those who did become infected during the initial stages of the pandemic in cases had to deal with worse coverage and higher co-payment rates.

Relatedly, essential workers were those most at-risk, not only in terms of exposure, but because these jobs typically don’t have the more comprehensive care sometimes associated with expansive employment-based insurance coverage. This phenomenon dates back to the Eisenhower presidency and the United States’ shift to employer-based health insurance, which was incentivized by making employee health insurance tax-free for companies that covered it.⁴ And ultimately, low-income Americans were more financially strained by the stay-at-home orders, as they often had little to no savings; many were also furloughed or fired as the pandemic advanced and simply struggled to pay medical bills later on.

Not only was healthcare accessibility altered from a health insurance perspective, but the pandemic significantly delayed healthcare delivery for the majority of Americans – this meant fewer routine checkups, non-COVID-19 vaccinations, and elective surgeries. Although the implementation of necessary shutdowns required putting off important treatments, overall, the pandemic also worsened the ability of millions of Americans to pay insurance premiums, co-pays, and deductibles, causing many to delay or avoid medical treatment entirely. In 2018, 55.1 percent of the U.S. population had employer-sponsored health insurance. Remarkably, 23.6 percent of all workers in the U.S. worked in the service sector,⁵ which was the worst-affected by the pandemic, a phenomenon which caused significant slashes in healthcare coverage. Many workers in already under-insured professions lost what coverage they had; loss of employment, especially early on in the pandemic, left many without job-linked healthcare and unable to cover costs associated with their personal health insurance plans. Thus, the pandemic exacerbated existing issues due to reliance on job-linked health insurance, leaving many workers and their families uniquely vulnerable.

The long-term impacts of healthcare inequality affect different groups in varying ways. Due to the higher poverty levels for people of color, the COVID-19 pandemic left them exposed as “essential workers,” which compounded with existing under-insurance and higher rates of chronic health conditions.⁶ Those in the service sector, who were disproportionately people of color and low-income,⁷ were more likely to continue working throughout the pandemic, putting them at risk of long COVID. These differences in employment, insurance, and even zip-code based on race and class led to the insulation of the effects of pandemic among certain ethnic communities.

Preparing for Future Pandemics

However, when it comes to increasing healthcare accessibility to ameliorate issues of uninsurance and under-insurance, some of the most effective solutions have been the straightforward ones: healthcare professionals personally helping patients identify the most cost-effective option for insurance, medicine, and transportation to appointments directly improves patient proactivity, health outcomes, and insurance rates.⁸ Short-term changes in that mold can better address temporary loss of coverage, like the kind experienced during the job loss associated with the COVID-19 pandemic. However, ensuring a health system where health insurance is never lost would require automatic government-based coverage, an endeavor which would necessitate the rearrangement of the existing employer-sponsored health insurance model.

About the Author

Queen Balina is a first-year student at Harvard College and Executive Content Editor for the Harvard Health Policy Review (and future resident of Currier House) intending to study Human Developmental and Regenerative Biology with a secondary in Global Health and Health Policy.

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