INTRODUCTION
The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), has caused significant morbidity and mortality worldwide.
Access to healthcare and testing are a key component of addressing COVID-19 in the
United States (US). Lack of insurance may hinder access to healthcare and testing,
and disproportionately impact underserved communities including the Hispanic/Latino
population.
1
Over 95% of individuals in the state of Rhode Island are insured due to Medicaid expansion.
2
Uninsured individuals are more likely to be undocumented, or have other barriers to
navigating the healthcare system.
METHODS
To determine the prevalence of COVID-19 in this at-risk population, we reviewed the
data from a major federally qualified health center (FQHC) in Providence, RI, which
consisted of 10 neighborhood clinics and approximately 60,000 patients, predominantly
Hispanic/Latino. Ninety-percent of households are under 200% federal poverty level
(FPL) and a significant proportion of our uninsured patients are undocumented immigrants.
We characterized patients by demographics and insurance status. We reported numbers
(percentages) for binary/categorical variables and medians (interquartile ranges,
IQR) for continuous variables. Chi-square tests and Wilcoxon rank-sum tests were applied
to compare the statistical significances. A 2-sided significance threshold was set
at P < 0.05. The Providence Community Health Centers Review Committee approved the
project. All analyses were run using STATA 13.1 (StataCorp, College Station, TX).
RESULTS
A total of 7226 symptomatic patients were tested through May 22, 2020; 66.3% were
female. Of these, insurance information was unavailable for 147 patients and these
were excluded from the analysis. Of the 7079 patients, for which insurance info was
available, 5703 had insurance (Medicare, Medicaid, private insurances, or other) and
1376 (19.4%) were uninsured. Among the uninsured, 68.1% were Hispanic/Latino. A total
of 1548 (27.1%) were positive for SARS-CoV-2 among those insured, and 510 (37.1%)
among the uninsured patients (P < 0.001). Among the Hispanic/Latino population, 46.7%
of the uninsured tested positive for SARS-CoV-2 compared with 31.1% of the insured
(P < 0.001). No significant prevalence differences between the non-Hispanic Black
and White populations (Table 1). During this time period in Rhode Island, a total
of 132,922 persons were tested for SARS-CoV-2 and 13,968 (10.5%) were positive.
3
The US positivity rate through the week of May 17, 2020, was 13.1% (8,762,465 tested
and 1,145,733 were positive).
4
Table 1
Characteristics and Results of SARS-CoV-2 Testing by Insurance Status
Insured (n = 5703)
Uninsured (n = 1376)
P value
Median age (IQR) (year)
38.7 (26.0–51.0)
37.1 (28.0–46.0)
Sex, no. (%)
Female
3868 (67.8)
828 (60.2)
SARS-CoV-2 test positive, no. (%)
All race/ethnicity
1548 (27.1)
510 (37.1)
< 0.001
Hispanic/Latino (any race)
1228 (31.1)
438 (46.7)
< 0.001
Black (non-Hispanic or ethnicity unknown)
108 (21.0)
14 (18.7)
0.761
White (non-Hispanic or ethnicity unknown)
40 (10.7)
5 (13.9)
0.575
Other race (non-Hispanic or ethnicity unknown)
24 (25.0)
1 (12.5)
0.676
Multiple races (non-Hispanic or ethnicity unknown)
13 (18.1)
2 (25.0)
0.640
Unknown or declined
135 (19.4)
33 (27.1)
0.068
DISCUSSION
Compared with those who were insured, those who were uninsured were 36.5% (95% CI
1.259–1.481, P < 0.001) more likely to test positive for SARS-CoV-2. Among Hispanic/Latino
population, the uninsured were 50.3% (95% CI 1.384–1.632, P < 0.001) more likely to
test positive compared with the insured. The SARS-CoV-2 prevalence rate was almost
three times higher than the state and national averages for those who were uninsured.
Most patients at our FQHC do not have insurance due to financial cost and legal status.
However, since the study cohort was based on our FQHC population, the results may
not represent the whole state or the US.
Our results indicate high SARS-CoV-2 prevalence among this at-risk population. Importantly,
the lack of insurance makes it extremely challenging for this population to access
healthcare in general. Improved access and payment structures for SARS-CoV-2 is needed
in this particular population to reduce the impact of COVID-19.