Changes in the Relationship Between Income and Life Expectancy Before and During the COVID-19 Pandemic, California, 2015-2021.

Importance: The COVID-19 pandemic caused a large decrease in US life expectancy in 2020, but whether a similar decrease occurred in 2021 and whether the relationship between income and life expectancy intensified during the pandemic are unclear. Objective: To measure changes in life expectancy in 2020 and 2021 and the relationship between income and life expectancy by race and ethnicity. Design, Setting, and Participants: Retrospective ecological analysis of deaths in California in 2015 to 2021 to calculate state- and census tract-level life expectancy. Tracts were grouped by median household income (MHI), obtained from the American Community Survey, and the slope of the life expectancy-income gradient was compared by year and by racial and ethnic composition. Exposures: California in 2015 to 2019 (before the COVID-19 pandemic) and 2020 to 2021 (during the COVID-19 pandemic). Main Outcomes and Measures: Life expectancy at birth. Results: California experienced 1 988 606 deaths during 2015 to 2021, including 654 887 in 2020 to 2021. State life expectancy declined from 81.40 years in 2019 to 79.20 years in 2020 and 78.37 years in 2021. MHI data were available for 7962 of 8057 census tracts (98.8%; n = 1 899 065 deaths). Mean MHI ranged from $21 279 to $232 261 between the lowest and highest percentiles. The slope of the relationship between life expectancy and MHI increased significantly, from 0.075 (95% CI, 0.07-0.08) years per percentile in 2019 to 0.103 (95% CI, 0.098-0.108; P < .001) years per percentile in 2020 and 0.107 (95% CI, 0.102-0.112; P < .001) years per percentile in 2021. The gap in life expectancy between the richest and poorest percentiles increased from 11.52 years in 2019 to 14.67 years in 2020 and 15.51 years in 2021. Among Hispanic and non-Hispanic Asian, Black, and White populations, life expectancy declined 5.74 years among the Hispanic population, 3.04 years among the non-Hispanic Asian population, 3.84 years among the non-Hispanic Black population, and 1.90 years among the non-Hispanic White population between 2019 and 2021. The income-life expectancy gradient in these groups increased significantly between 2019 and 2020 (0.038 [95% CI, 0.030-0.045; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI: 0.005-0.044; P = .02] years per percentile among Asian individuals; 0.015 [95% CI, 0.010-0.020; P < .001] years per percentile among Black individuals; and 0.011 [95% CI, 0.007-0.015; P < .001] years per percentile among White individuals) and between 2019 and 2021 (0.033 [95% CI, 0.026-0.040; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI, 0.010-0.038; P = .002] years among Asian individuals; 0.024 [95% CI, 0.011-0.037; P = .003] years per percentile among Black individuals; and 0.013 [95% CI, 0.008-0.018; P < .001] years per percentile among White individuals). The increase in the gradient was significantly greater among Hispanic vs White populations in 2020 and 2021 (P < .001 in both years) and among Black vs White populations in 2021 (P = .04). Conclusions and Relevance: This retrospective analysis of census tract-level income and mortality data in California from 2015 to 2021 demonstrated a decrease in life expectancy in both 2020 and 2021 and an increase in the life expectancy gap by income level relative to the prepandemic period that disproportionately affected some racial and ethnic minority populations. Inferences at the individual level are limited by the ecological nature of the study, and the generalizability of the findings outside of California are unknown.

Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income.

INTRODUCTION: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. METHODS: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. RESULTS: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. CONCLUSION: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Depression and Anxiety During the COVID-19 Pandemic in an Urban, Low-Income Public University Sample.

Mental health disparities in the aftermath of national disasters and the protective role of socioeconomic status are both well documented. We assessed the prevalence of depression and anxiety symptoms among underresourced public university students during the COVID-19 pandemic in New York City. Between April 8, 2020, and May 2, 2020, adult students (N = 1,821) across the CUNY system completed an online survey examining COVID-19-related stressors and mental health and sociodemographic factors. Using multivariable logistical regression to assess the association between COVID-19-related stressors and depression and anxiety symptoms, we found a high prevalence and severity of depression and anxiety symptoms. We also observed that more exposure to COVID-19-related stressors was associated with increased depressive (27.0%, 41.4%, and 63.1% for low-, medium-, and high-level stressors, respectively) and anxiety symptoms (19.3%, 34.6%, 52.2%). In addition, the degree of exposure to COVID-19-related stressors served as an important predictor of depression and anxiety symptoms. Compared to high levels of stressors, the odds of depression were 0.2, 95% CI [0.2, 0.3] for low- and 0.4, 95% CI [0.3, 0.5] for medium-level stressors; for anxiety, the odds were 0.2, 95% CI [0.2, 0.3] for low and 0.05, 95% CI [0.4, 0.6] for medium stressors. Finally, household savings of less than $5,000 increased the risk of anxiety but not depression symptoms, OR = 1.3, 95% CI [1.0,1.6]. Together, these findings tell a devastating story of psychological distress among students from lower socioeconomic groups living in the COVID-19 epicenter of the U.S. pandemic.

Employment and economic outcomes of persons with mental illness and disability: The impact of the Great Recession in the United States.

Objective: To examine variation in employment and economic outcomes before, during, and after the great recession by disability and mental health status. Methods: Using a sample of adults in the 1999 to 2016 National Health Interview Survey (N = 419,336), we examined changes in labor force and economic outcomes by mental health and physical disability status. We employed difference-in-differences analyses to determine whether the changes in these outcomes during and after the recession for each comparison group (those with moderate mental illness, serious psychiatric disability, or physical disability) were significantly different from the changes for persons with neither a mental illness nor a disability. Findings: While the recession impacted all groups, those with mental illnesses or physical disabilities were hardest hit. Persons with disabilities were disadvantaged on all outcomes at each period, but persons with mental illnesses were the most disadvantaged. Unemployment, poverty, and use of food stamps increased for all groups, but the increase was greatest for persons with mental health problems who also saw a more substantial decline in wage income. Conclusions and Implications for Practice: The effects of the recession persist well after the recovery period. Practitioners should be aware that although most persons with mental illnesses want to work, they face significant barriers to employment. Following economic shocks such as those brought on by the current coronavirus pandemic, interventions should focus on people who are the most vulnerable, especially those with mental health problems. Renewed focus on employment for people with mental disorders is important. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

COVID-19 and Kidney Disease Disparities in the United States.

Racial, ethnic, socioeconomic, age, and sex-related health disparities in kidney disease are prominent in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately affected marginalized populations. Older adults, people experiencing unstable housing, racial and ethnic minorities, and immigrants are potentially at increased risk for infection and severe complications from COVID-19. The direct and societal effects of the pandemic may increase risk of incident kidney disease and lead to worse outcomes for those with kidney disease. The rapid transition to telemedicine potentially limits access to care for older adults, immigrants, and people experiencing unstable housing. The economic impact of the pandemic has had a disproportionate effect on women, minorities, and immigrants, which may limit their ability to manage kidney disease and lead to complications or kidney disease progression. We describe the impact of COVID-19 on marginalized populations and highlight how the pandemic may exacerbate existing disparities in kidney disease.