“Bring the Hoses to Where the Fire Is!”: Differential Impacts of Marginalization and Socioeconomic Status on COVID-19 Case Counts and Healthcare Costs

• Published in: Value in health Vol. 25; no. 8; pp. 1307 - 1316
• Main Authors: Cheung, Douglas C., Bremner, Karen E., Tsui, Teresa C.O., Croxford, Ruth, Lapointe-Shaw, Lauren, Giudice, Lisa Del, Mendlowitz, Andrew, Perlis, Nathan, Pataky, Reka E., Teckle, Paulos, Zeitouny, Seraphine, Wong, William W.L., Sander, Beate, Peacock, Stuart, Krahn, Murray D., Kulkarni, Girish S., Mulder, Carol
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-08-2022; International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc
• Subjects: Canada; costs and costs analyses; COVID-19; marginalization; socioeconomic status; Themed Section: COVID-19; universal healthcare; COVID-19; marginalization; universal healthcare; Canada; costs and costs analyses; socioeconomic status
• ISSN: 1098-3015; 1524-4733
• DOI: 10.1016/j.jval.2022.03.019

Local health leaders and the Director General of the World Health Organization alike have observed that COVID-19 “does not discriminate.” Nevertheless, the disproportionate representation of people of low socioeconomic status among those infected resembles discrimination. This population-based retrospective cohort study examined COVID-19 case counts and publicly funded healthcare costs in Ontario, Canada, with a focus on marginalization.
Individuals with their first positive severe acute respiratory syndrome coronavirus 2 test from January 1, 2020 to June 30, 2020, were linked to administrative databases and matched to negative/untested controls. Mean net (COVID-19–attributable) costs were estimated for 30 days before and after diagnosis, and differences among strata of age, sex, comorbidity, and measures of marginalization were assessed using analysis of variance tests.
We included 28 893 COVID-19 cases (mean age 54 years, 56% female). Most cases remained in the community (20 545, 71.1%) or in long-term care facilities (4478, 15.5%), whereas 944 (3.3%) and 2926 (10.1%) were hospitalized, with and without intensive care unit, respectively.
Case counts were skewed across marginalization strata with 2 to 7 times more cases in neighborhoods with low income, high material deprivation, and highest ethnic concentration.
Mean net costs after diagnosis were higher for males ($4752 vs $2520 for females) and for cases with higher comorbidity ($1394-$7751) (both P < .001) but were similar across levels of most marginalization dimensions (range $3232-$3737, all P ≥ .19).
This study suggests that allocating resources unequally to marginalized individuals may improve equality in outcomes. It highlights the importance of reducing risk of COVID-19 infection among marginalized individuals to reduce overall costs and increase system capacity.
•In many countries, individuals with low income, of ethnoracial minorities, and who live or work in crowded conditions have been disproportionately affected by COVID-19.•What was not known was whether these disparities extend to access to and cost of healthcare for COVID-19.•In the province of Ontario, Canada, 2 to 7 times more COVID-19 cases resided in neighborhoods characterized by marginalization (eg, low income or unstable housing) than less marginalized areas. This suggests that COVID-19 discriminates against people who lack socioeconomic supports in Ontario.•Average per-person net costs attributable to COVID-19 were similar across strata of most dimensions of marginalization, in the first 30 days after a positive COVID-19 test result. This suggests that healthcare provision for COVID-19 was equal among individuals, independent of socioeconomic status, and is consistent with Canadian values of ensuring universal healthcare coverage for all.•Nevertheless, the skewed distribution of case counts resulted in an unequal overall burden, suggesting that allocating resources unequally (to marginalized individuals) is a possible way to achieve equality in outcomes. This would support equity in COVID-19 management, a core, if elusive, value of universal healthcare systems.