Disparities in Vulnerability to Severe Complications from COVID-19 in the United States

Emily E. Wiemers, Scott Abrahams, Marwa AlFakhri, V. Joseph Hotz, Robert F. Schoeni and Judith A. Seltzer

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  • Among middle-aged and older Americans, vulnerability to severe COVID-19 complications based on preexisting conditions is 2-3 times greater for those with low versus high income.
  • Vulnerability is about 40% higher for middle-aged and older adults with a high school degree or less than adults with a four-year college degree.
  • In every age group, Blacks are more vulnerable than Whites, but Hispanics are at lower risk based on fewer preexisting health conditions.
  • Blacks, less-educated adults, and low-income individuals face potentially devastating effects of the coronavirus in localities, industries, and occupations with high rates of exposure.
  • The presence of preexisting health conditions increases vulnerability to severe complications from COVID-19. In the United States, vulnerability based on preexisting health conditions collides with long-standing disparities in health and mortality by race-ethnicity and socioeconomic status, especially in midlife. Outcome disparities manifest as higher hospitalization rates for Blacks and Latinos and staggeringly high mortality rates for Blacks. Despite an understanding of these well-known disparities, we lack a means of translating this knowledge into predictions about the risks of serious complications from COVID-19 across race-ethnicity and socioeconomic status.

    Our paper provides the first nationally representative estimates of these risks based on the distribution of underlying health conditions in the population. It describes disparities in risks across race-ethnicity, education, and household income to provide insight into which Americans are more vulnerable to the devastating impact of the virus.

    Large Gaps in Vulnerability to COVID-19 across Race-Ethnicity, Education, and Income
    In every age group, non-Hispanic Blacks have a higher risk of severe complications than non-Hispanic Whites. Among all adults age 25+, the difference in relative vulnerability between non-Hispanic Blacks and Whites is muted because a larger proportion of NH Whites than NH Blacks are in the oldest age group, 65+.1,2 Hispanics are at a lower risk overall than NH Whites based on underlying health conditions.

    Among all adults age 25+, the underlying health conditions of those with a high school degree or less put them at a 1.6 times higher risk of severe complications from COVID-19 than those with a bachelor’s degree. Americans from the lowest household income quartile face nearly three times the risk of severe complications compared to those in the highest income quartile. See Figure 1.

    Disparities in Vulnerability to COVID-19 Appear in Midlife
    Substantial disparities in vulnerability, especially by race-ethnicity and income, emerge in midlife and remain present as populations age. Among adults age 45-64, NH Blacks are 86% more vulnerable that NH Whites, while Hispanics are 24% less vulnerable. Adults in midlife with only a high school degree are nearly 40% more vulnerable to severe complications than those with a college degree or more. Individuals in the lowest income quartile face over twice the risk of severe complications than those in the highest income quartile. See Figure 1.

    Figure 1. Adults with Low Education and Low Income Have the Highest Vulnerability to Severe Complications from COVID-19
    Data Source: Sample is 13,150 household heads and spouses (or cohabiting partners) from the Panel Study of Income Dynamics (PSID). The y-axis shows the median risk of hospitalization from severe complications from a respiratory infection relative to that of a 30-year-old woman with zero underlying health conditions and is calculated using the survey model from DeCaprio et al. (2020)3 applied to underlying health conditions reported in the PSID.*

    Recommendations for Policy and/or Practice
    Large gaps in vulnerability to severe complications from COVID-19 across race-ethnicity, education, and income emerge by midlife and remain high at older ages. States and municipalities should consider these risks, especially among NH Blacks, less-educated Americans, and those from low-income households, as they reopen businesses and public services.

    Data and Methods
    This study uses the Panel Study of Income Dynamics (PSID), a nationally representative dataset of adults in the United States, which includes measures of health, race-ethnicity, and socioeconomic status. We use the health conditions reported in the data to calculate an index of vulnerability to severe complications from respiratory illnesses for these adults.3 We then calculate the median vulnerability relative to a 30-year old with no health conditions across age group, race-ethnicity, education, and household income. For more details about the data and methods, the full paper is available here.


    1. Ford, T., Reber, S., & Reeves, R. (2020, June 16). Race gaps in COVID-19 deaths are even bigger than they appear. Brookings Institution. https://www.brookings.edu/blog/up-front/2020/06/16/race-gaps-in-covid-19-deaths-are-even-bigger-than-they-appear/.
    2. Oppel, R. A., Gebeloff, R., Lai, K. K. R., Wright, W., & Smith, M. (2020, July 5). The fullest look yet at the racial inequity of coronavirus. New York Times. https://www.nytimes.com/interactive/2020/07/05/us/coronavirus-latinos-african-americans-cdc-data.html.
    3. DeCaprio, D., Gartner, J., McCall, C. L., Burgess, T., Kothari, S., & Sayed, S. (2020). Building a COVID-19 vulnerability index. medRxiv.org. https://doi.org/10.1101/2020.03.16.20036723.

    This paper was prepared with support from the Aging Studies Institute at Syracuse University. Additional support was provided by the Duke Center for Population Health and Aging, which receives core support (P30AG034424) from the National Institute on Aging. Support was also received from the California Center for Population Research at the University of California, Los Angeles, which receives core support (P2C-HD041022) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The collection of data used in this study was partly supported by the National Institutes of Health under grant number R01 HD069609 and R01 AG040213, and the National Science Foundation under award numbers SES 1157698 and 1623684. The authors also thank Megan Ray for edits on an earlier version of this brief.

    About the Authors
    Emily E. Wiemers is an Associate Professor of Public Administration and International Affairs at the Syracuse University Maxwell School of Citizenship and Public Affairs and a Faculty Associate in the Aging Studies Institute (eewiemer@syr.edu). Scott Abrahams is a Ph.D. Candidate in the Department of Economics at Duke University. Marwa AlFakhri is a Ph.D. Candidate in Public Policy at the Sanford School of Public Policy at Duke University. V. Joseph Hotz is the Arts and Sciences Distinguished Professor of Economics at Duke University and a faculty research scholar of the Duke Population Research Institute. Robert F. Schoeni is a Research Professor at the Institute for Social Research and a Professor of Economics and Public Policy at the University of Michigan. Judith A. Seltzer is a Research Professor of Sociology and Research Affiliate of the California Center for Population Research at the University of California, Los Angeles.