DMEJ

   Duke Medical Ethics Journal   

The Unequal Burden of COVID-19 on Minority Children

High Infection Rates, Limited Access to Healthcare, and Food Insecurity

By: Sophie Hurewitz

Defined as “the ways in which societies foster discrimination through mutually reinforcing inequitable systems,” structural racism manifests in our American cultural, political, economic, academic, biological, and interpersonal systems and norms (Egede and Walker, 2020; Lawrence and Keleher, 2004). Emerging research has revealed that racism is significantly associated with poorer mental and physical health (Egede and Walker, 2020). Amid the current pandemic, both mental health and physical health are of utmost importance.

In April 2020, the Centers for Disease Control and Prevention (CDC) began to collect national data on differences in the impact of COVID-19 by ethnicity, race, and socioeconomic status. Early data suggests significant ethnic, racial, and socioeconomic disparities in both rates of COVID-19 infection and COVID-19-associated mortality (Ambrose, 2020). Due to the increased COVID-19 burden on minority communities and individuals, minority children are more likely to be exposed to infection (Ambrose, 2020). An existing body of work has shown that minority children are also more likely than their White peers to suffer from underlying conditions like asthma and obesity; such conditions have been associated with higher risk of negative COVID-19 outcomes (Ambrose, 2020). Not only do minority children face a higher risk of COVID-19 infection during the pandemic, but they also may face additional pandemic-related obstacles, such as the inability to access high-quality healthcare and unreliable access to and benefits from food assistance programs.

Racial disparities in U.S. coronavirus testing rates, infections, and hospitalizations extend to our country’s children: numerous studies have highlighted disparities in COVID-19 infection rates by examining testing data. Compared to White children, both Black and Latinx children had significantly higher rates of COVID-19 positive test results during a testing period from March to April of 2020 (Bandi et al, 2020). These statistically significant findings remained even after adjusting for other demographic factors. Furthermore, a recent CDC report analyzed the rates of a rare, coronavirus-associated syndrome called Multisystem Inflammatory Syndrome in children (MIS-C), finding that nearly 75 percent of children diagnosed with MIS-C were Black or Latinx (Stobbe, 2020). Another CDC report examined data regarding COVID-related hospitalizations among children and found that Latinx children and Black children have been hospitalized at a rate eight times higher and five times higher than their White peers, respectively (Stobbe, 2020). Notably, these stark findings reflect only the segment of relatively well-positioned minority children that had both geographical and financial access to testing sites, healthcare clinics, and hospitals.

"the U.S. public healthcare system was ill-prepared for the impact of COVID-19 on communities already at the periphery of the national healthcare, social services, and nutrition support systems"

Among U.S. children, racial and ethnic minority children are significantly more likely to be uninsured. (Flores et al, 2016). In the U.S., Black and Latinx children comprise 53 percent of uninsured American children, despite making up only 48 percent of the total population of children (Flores et al, 2016). Uninsured children are likely to have decreased geographical and financial access to high-quality healthcare services, problems that are further exacerbated as the proportion of uninsured people in local communities increases (Pauly and Pagán, 2007). A large proportion of Black and Latinx children utilize hospital emergency rooms as a source of healthcare when doctor’s office visits are geographically inaccessible or financially infeasible (Stobbe, 2020). In the context of the COVID-19 pandemic, this relative lack of access to high-quality healthcare could lead to more severe illness, unwillingness of families to pursue necessary healthcare services, or a combination of the two (Stobbe, 2020). In short, the U.S. public healthcare system was ill-prepared for the impact of COVID-19 on communities already at the periphery of the national healthcare, social services, and nutrition support systems.

According to data from the Kaiser Family Foundation, about 157 million Americans and their families rely on employer-sponsored health coverage (Gavidia, 2020). However, even within the population that receives employer-sponsored coverage, there are vast disparities in the benefits that are received. For example, employees with higher-paying jobs reap more benefits from their health coverage than do those with lower incomes (Bittker, 2020). Furthermore, 2018 American Community Survey data revealed the racial disparities in the provision of employer-sponsored coverage. Approximately 66 percent of White employees and their families receive employer-sponsored health insurance, whereas only 46 percent of Black employees, 41 percent of Latinx employees, and 36 percent of American Indian and Alaska Natives employees receive employer-sponsored coverage (Bittker, 2020). The coronavirus pandemic and the associated increase in unemployment continues to weaken the already fractured and unequal provision of employer-sponsored health coverage to American families.

With COVID-19 arose a level of unemployment not seen since the Great Depression (Fairlie et al, 2020). The U.S. unemployment rate jumped to almost 15 percent less than two months after the implementation of social distancing measures (Fairlie et al, 2020). COVID-related unemployment rates also reveal racial disparities: 17 percent of Black individuals experienced unemployment (Fairlie et al, 2020). Latinx individuals were disproportionately hard hit with unemployment reaching more than 18 percent (Fairlie et al, 2020). Increases in unemployment – and the historic rate of adults exiting the job market altogether (which is not reflected in top-line unemployment rates) – are dramatically increasing both the number of uninsured children and families and the number of individuals who rely on food assistance programs.

The percent of families reporting low food security increased by about 20 percent during the pandemic (Adams et al, 2020). The three largest federally-supported food assistance programs for children and families - TANF, SNAP, and WIC - are largely unable to adjust their eligibility models to meet these increased needs. The Temporary Assistance for Needy Families (TANF) program provides state-administered cash assistance to families with limited or no income (Center on Budget and Policy Priorities, 2020). Since 1997, more than two million families have lost TANF benefits as a result of unemployment or other work-based eligibility requirements that vary among states (Pavetti, 2020). The TANF work requirements have “fueled a rise in deep poverty,” especially for the Black and Latinx children that live in states with the most restrictive TANF programs (Pavetti, 2020).

According to the U.S. Department of Agriculture, similar work requirements exist for the Supplemental Nutrition Assistance Program (SNAP). Work requirements for SNAP eligibility include being registered for work, participating in SNAP Employment and Training programs, taking a suitable job if offered, and not voluntarily quitting a job or reducing hours (U.S. Department of Agriculture, 2019). Many states have implemented temporary administrative flexibility with respect to SNAP eligibility requirements in response to the pandemic (Center on Budget and Policy Priorities, 2020). However, not all states took advantage of coronavirus-specific legislation, and even in states that did, the relaxation of eligibility limitations is only temporary and there are additional restrictive clauses (Dunn et al, 2020). Although the Families First Coronavirus Response Act, signed into law in March 2020, allowed for SNAP to supply families with additional emergency benefits such as increased monthly cash allotments and loosened work requirements, children do not qualify for the modified SNAP program if they are served by other federal programs or are undocumented immigrants (Dunn et al, 2020).

Other programs supporting children and families are similarly limited in their ability to meet the needs of those who would most benefit, although the prolonged impact of COVID has, sadly, increased the numbers of families that may be eligible. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) served more than 3.5 million children, almost 2 million infants, and more than 1.5 million women in 2018 (U.S. Department of Agriculture, 2019). Pregnant, postpartum and breastfeeding women, infants, and children under age five are eligible to participate in WIC. When these requirements are not met, WIC restricts participation to those who fall at or below 185 percent of the U.S. Poverty Guidelines (U.S. Department of Agriculture, 2019). For a family of four, 185 percent of the federal poverty level is an annual income below $50,000 dollars (United Way of Connecticut, 2020). Many families experiencing COVID-related unemployment have recently fallen below this federal poverty cutoff for the first time.

"only through the reconfiguring of social initiatives and policies that we can begin the process of destroying the political, social, biological, and interpersonal manifestation of structural racism in our country and on our country’s children"

School-based nutrition programs may provide additional benefits to families that rely on TANF, SNAP, or WIC sponsored food assistance for their children. The meals and snacks provided by schools and childcare centers can fulfill up to two-thirds of a child’s daily nutritional needs and are typically healthier than the food available at home (Dunn et al, 2020). Yet, there are significant racial disparities regarding the enrollment and participation in school-sponsored food assistance programs. Approximately 8 percent of White students, but more than 45 percent of Black and Latinx children, attend “high poverty schools.” (Ambrose, 2020). Since 1998, high minority enrollments have also been associated with high proportions of participation in subsidized school lunch programs (Hamrick and Stage, 1998).

Pandemic-related school closures have been especially harmful to vulnerable children and families who rely on school-based nutrition programs such as free and reduced-price lunch programs. Children in households with incomes at or below 130 percent of the poverty level are eligible for free school meals and children in households with incomes between 130 and 185 percent of the poverty level are eligible for reduced-price school meals (Food Research & Action Center, n.d.). As a result of COVID-related unemployment, many minority children have recently become eligible for these federally funded school programs that can provide food worth up to 30 dollars per week (Dunn et al, 2020). However, participation can be difficult due to ineffective and inequitable food distribution models, food supply shortages, and the stigma associated with food assistance programs (Dunn et al, 2020). With each day that schools remain closed, minority children across the country are becoming increasingly food insecure.

Minority children shoulder an unequal burden in the COVID-19 pandemic. Not only is the risk of COVID-19 infection higher in this population of children, but they may also face additional pandemic-related obstacles such as the inability to access high-quality healthcare and unreliable benefits from federal and school-based food assistance programs. The strengthening of community support systems, restructuring of employer-sponsored healthcare coverage mandates, and increased and sustained COVID-specific flexibility in eligibility requirements for federal and school-based services will significantly benefit minority children and families both during and after the pandemic. It is only through the reconfiguring of social initiatives and policies that we can begin the process of destroying the political, social, biological, and interpersonal manifestation of structural racism in our country and on our country’s children.

References

Adams, Elizabeth L., Laura J. Caccavale, Danyel Smith, and Melanie K. Bean. "Food insecurity, the home food environment, and parent feeding practices in the era of COVID‐19." Obesity 28, no. 11 (2020): 2056-2063.

Ambrose, Adrian Jacques H. "Inequities during COVID-19." Pediatrics 146, no. 2 (2020).

Bandi, Sindhura, Michael Z. Nevid, and Mahboobeh Mahdavinia. "African American children are at higher risk for COVID‐19 infection." Pediatric Allergy and Immunology (2020).

Bittker, Bobbi M. “Racial and Ethnic Disparities in Employer-Sponsored Health Coverage.” American Bar Association, September 8, 2020. https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/health-matters-in-elections/racial-and-ethnic-disparities-in-employer-sponsored-health-coverage/.

Center on Budget and Policy Priorities. “States Are Using Much-Needed Temporary Flexibility in SNAP to Respond to COVID-19 Challenges.” Center on Budget and Policy Priorities, December 8, 2020. https://www.cbpp.org/research/food-assistance/states-are-using-much-needed-temporary-flexibility-in-snap-to-respond-to.

Dunn, Caroline G., Erica Kenney, Sheila E. Fleischhacker, and Sara N. Bleich. "Feeding low-income children during the Covid-19 pandemic." New England Journal of Medicine 382, no. 18 (2020): e40

Egede, Leonard E., and Rebekah J. Walker. “Structural Racism, Social Risk Factors, and Covid-19 — A Dangerous Convergence for Black Americans.” New England Journal of Medicine 383, no. 12 (2020). https://doi.org/10.1056/nejmp2023616.

Fairlie, Robert W., Kenneth Couch, and Huanan Xu. The impacts of covid-19 on minority unemployment: First evidence from April 2020 CPS microdata. No. w27246. National Bureau of Economic Research, 2020.

Flores, Glenn, Hua Lin, Candy Walker, Michael Lee, Alberto Portillo, Monica Henry, Marco Fierro, and Kenneth Massey. "A cross-sectional study of parental awareness of and reasons for lack of health insurance among minority children, and the impact on health, access to care, and unmet needs." International Journal for Equity in Health 15, no. 1 (2016): 44.

Food Research & Action Center. “School Meal Eligibility and Reimbursements.” Food Research & Action Center, n.d. https://frac.org/school-meal-eligibility-reimbursements.

Gavidia, Matthew. “KFF Survey Finds Employer-Sponsored Health Insurance Premiums Rose 4% in 2020.” AJMC, October 9, 2020. https://www.ajmc.com/view/kff-survey-finds-employer-sponsored-health-insurance-premiums-rose-4-in-2020.

Hamrick, Florence A., and Frances K. Stage. "High minority enrollment, high school lunch-rates: Predisposition to college." The Review of Higher Education 21, no. 4 (1998): 343-357.

Lawrence, Keith, and Terry Keleher. "Structural racism." In Race and Public Policy Conference, Berkeley. Retrieved from http://www.intergroupresources.com/rc/Definitions% 20of% 20Racism. pdf. 2004.

Pauly, Mark V., and José A. Pagán. "Spillovers and vulnerability: the case of community uninsurance." Health Affairs 26, no. 5 (2007): 1304-1314.

Pavetti, LaDonna. "TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions, Do Little to Increase Work." (2018).

Stobbe, Mike. “US Reports Show Racial Disparities in Kids with COVID-19,” August 7, 2020. https://apnews.com/article/ap-top-news-understanding-the-outbreak-hispanics-health-lifestyle-277772d59418c8bc79e0aff3fef946e6.

U.S. Department of Agriculture. “SNAP Work Requirements.” USDA, 2019. https://www.fns.usda.gov/snap/work-requirements.

U.S. Department of Agriculture. “WIC Frequently Asked Questions (FAQs).” USDA, 2019. https://www.fns.usda.gov/wic/frequently-asked-questions.

United Way of Connecticut. “Federal Poverty Levels – 3/2020-3/2021 - United Way of Connecticut - 211 and ELibrary - Income Assistance.” United Way of Connecticut - 211 and eLibrary, March 25, 2020. https://uwc.211ct.org/federal-poverty-levels-4115-33116/.