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Variation in COVID-19 Mortality in the US by Race and Ethnicity and Educational Attainment
Open accessAbstract
Importance: Racial and ethnic inequities in COVID-19 mortality have been well documented, but little prior research has assessed the combined roles of race and ethnicity and educational attainment. Objective: To measure inequality in COVID-19 mortality jointly by race and ethnicity and educational attainment. Design, Setting, and Participants: This cross-sectional study analyzed data on COVID-19 mortality from the 50 US states and the District of Columbia for the full calendar year 2020. It included all persons in the United States aged 25 years or older and analyzed them in subgroups jointly stratified by age, sex, race and ethnicity, and educational attainment. Main Outcomes and Measures: Population-based cumulative mortality rates attributed to COVID-19.F. Results: Among 219.1 million adults aged 25 years or older (113.3 million women [51.7%]; mean [SD] age, 51.3 [16.8] years), 376 125 COVID-19 deaths were reported. Age-adjusted cumulative mortality rates per 100 000 ranged from 54.4 (95% CI, 49.8-59.0 per 100 000 population) among Asian women with some college to 699.0 (95% CI, 612.9-785.0 per 100 000 population) among Native Hawaiian and Other Pacific Islander men with a high school degree or less. Racial and ethnic inequalities in COVID-19 mortality rates remained when comparing within educational attainment categories (median rate ratio reduction, 17% [IQR, 0%-25%] for education-stratified estimates vs unstratified, with non-Hispanic White individuals as the reference). If all groups had experienced the same mortality rates as college-educated non-Hispanic White individuals, there would have been 48% fewer COVID-19 deaths among adults aged 25 years or older overall, including 71% fewer deaths among racial and ethnic minority populations and 89% fewer deaths among racial and ethnic minority populations aged 25 to 64 years. Conclusions and Relevance: Public health research and practice should attend to the ways in which populations that share socioeconomic characteristics may still experience racial and ethnic inequity in the distribution of risk factors for SARS-CoV-2 exposure and infection fatality rates (eg, housing, occupation, and prior health status). This study suggests that a majority of deaths among racial and ethnic minority populations could have been averted had all groups experienced the same mortality rate as college-educated non-Hispanic White individuals, thus highlighting the importance of eliminating joint racial-socioeconomic health inequities.
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“These groups of workers have been at the greatest risk of serious illness and death from COVID-19.”
From The Lancet Commission on lessons for the future from the COVID-19 pandemic (2022) · cites this paper as [278]
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“22 This study is an exception, since most studies have analyzed the relationship between the socio-economic status of the area of residence and COVID-19 mortality.”
BackgroundVariations in COVID-19 Hospital Mortality by Patient Race/Ethnicity and Hospital Type in Illinois
Hua, M. J., & Feinglass, J. M. (2022) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-022-01279-6 · Cited by 3
Yuan, A. Y., Atanasov, V. A., Parra, P. N. B., Franchi, L., Whittle, J., Weston, B. W., Meurer, J., Luo, Q., & Black, B. S. (2023) · SSRN Electronic Journal · doi:10.2139/ssrn.4317312 · Cited by 3
Benavidez, G. A., & Zgodic, A. (2024) · Healthcare · doi:10.3390/healthcare12242543 · Cited by 2
“Feldman and Basset (2021) showed that if all racial and ethnic minoritized groups had died at the same rate as college-educated White people, there would have been 89% fewer deaths among those aged 25 to 64 in this population [4].”
Amele, S., Kibuchi, E., McCabe, R., Demou, E., Leyland, A. H., Hainey, K., Rudan, I., Kurdi, A. B., Simpson, C. R., Ritchie, L. D., et al. (2025) · European Journal of Public Health · doi:10.1093/eurpub/ckaf078 · Cited by 2
“Lastly, the relationship between ethnicity, SEP measures, and health inequalities in Scotland may differ from other countries, such as the United States, where SEP and ethnicity are more strongly correlated [36].”
Liao, T. F. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192315803 · Cited by 2
A Syndemics Approach to NCAA Collegiate Sport Participation During COVID-19
Clarke, C. V., Pericak, K., Adamson, B., & Mahoney, K. (2023) · Global culture and sport series · doi:10.1007/978-3-031-14387-8_23 · Cited by 2
Understanding the Experiences of Latinx LGBTQ Texans at the Beginning of the COVID-19 Pandemic
Dorri, A. A., Loza, O., Bond, M. A., Ciszek, E. L., Elias-Curry, Y., Aguilar, S., Fliedner, P., Norwood, A., Stone, A. L., Cooper, M. B., et al. (2023) · Journal of Homosexuality · doi:10.1080/00918369.2023.2241597 · Cited by 2
“Research has found higher educational attainment is associated with lower risk of COVID-19 infection and severity of symptoms (Feldman & Bassett, 2021; Yoshikawa & Asaba, 2021).”
BackgroundChange and Continuity in Americans' Work Day Characteristics, 2019 to 2021
Flood, S., & Genadek, K. R. (2023) · Emerald Group Publishing Limited eBooks · doi:10.1108/s0147-912120230000051009 · Cited by 2
Yazdanpanah, F., Jackson, A. C., Sanaie, N., Sharifi, F., Shamshirgaran, S. M., & Bahramnezhad, F. (2024) · Health Science Reports · doi:10.1002/hsr2.2049 · Cited by 2
“21 The results of Ribeiro et al.'s 22 study showed that social discrimination such as a low education level, poverty, and unemployment increase the mortality rate in this vulnerable group.”
BackgroundMedia-Based Health Information Seeking Behaviors Among Latinx Populations in the United States
DuPont‐Reyes, M. J., Villatoro, A. P., & Tang, L. (2023) · Hispanic Journal of Behavioral Sciences · doi:10.1177/07399863241259292 · Cited by 2
“…America and the Caribbean—were particularly disproportionately impacted by slow dissemination, and high misinformation and disinformation, of potentially life-saving health communications (Bastick, 2022; El-Mohandes et al., 2020; Feldman & Bassett, 2021; Maleki et al., 2021; Olayo-Méndez, 2021).”
Kelly, M. S., Mohammed, A., Okin, D. A., Alba, G. A., Jesudasen, S. J., Flanagan, S., Dandawate, N. A., Gavralidis, A., Chang, L. L., Moin, E. E., et al. (2023) · Critical Care Explorations · doi:10.1097/cce.0000000000000927 · Cited by 2
“Yet, as race and ethnicity often intersect and covary with other social and demographic factors, it is challenging to elucidate which specific factors drive disparities (1, 6, 10, 16).”
BackgroundHealth Equity and Social Determinants of Health
Diallo, M. S. (2024) · Anesthesiology Clinics · doi:10.1016/j.anclin.2024.02.002 · Cited by 2
Hassan, A., Nassrallah, E. I., & Fisman, D. N. (2026) · medRxiv · doi:10.64898/2026.01.02.26343363 · Cited by 2
How epigenetic inheritance fails to explain the Black-White health gap
Charney, E., Darity, W., & Hubbard, L. (2025) · Social Science & Medicine · doi:10.1016/j.socscimed.2025.117697 · Cited by 1
The COVID-19 syndemic: a perfect storm for the life expectancy of the most disadvantaged Americans
Probst, C., Bright, S., Zhu, Y., Kilian, C., Buckley, C. M., Ye, Y., Mulia, N., Kerr, W. C., & Rehm, J. T. (2025) · International Journal of Epidemiology · doi:10.1093/ije/dyaf069 · Cited by 1
Educational Polarization in American Politics: More than Just a Diploma Divide
Zingher, J. N. (2026) · American Politics Research · doi:10.1177/1532673x261443524 · Cited by 1
“The results of this relationship between educational attainment and distrust in science were that the less educated, who were at higher risk of severe illness for many other reasons, bore the brunt of the pandemic (Case & Deaton, 2022; Feldman & Bassett, 2021).”
Ali, M., Brady, M., Campbell, P., Rooney, S., Williams, L. J., Paul, L., Mason, H., Manoukian, S., Chung, C. S., Barber, M., et al. (2025) · Health and Social Care Delivery Research · doi:10.3310/gjma0602 · Cited by 1
Ocak, G., Khairoun, M., Thans, M. V. S., Meeder, D., Moeniralam, H. S., Dekker, F. W., Verhaar, M. C., Bos, W. J. W., & Kaasjager, K. A. H. (2023) · PLoS ONE · doi:10.1371/journal.pone.0284036 · Cited by 1
Wang, S., Jang, Q., Wang, H., Yang, Y., Ruan, M., Yu, J., Li, X., & Luo, D. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1293318 · Cited by 1
Psychiatric Epidemiology During the COVID-19 Pandemic
Eisenberg‐Guyot, J., Presskreischer, R., & Pamplin, J. R. (2024) · Current Epidemiology Reports · doi:10.1007/s40471-024-00342-6 · Cited by 2
“Racialized, working class, and otherwise marginalized people have faced disproportionate COVID-19 morbidity and mortality, due to, among other factors, their inequitable healthcare access and segregation into hazardous essential occupations, overcrowded housing, and jails and prisons [5–9].”
Kimani, M. E., & Sarr, M. (2024) · PLoS ONE · doi:10.1371/journal.pone.0303667 · Cited by 1
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Song, Y., Baranova, A. V., Cao, H., Yue, W., & Zhang, F. (2025) · Human Genomics · doi:10.1186/s40246-025-00731-y · Cited by 1
“From prevalence to mortality, the epidemiology of COVID-19 is also affected by the socio-economic or psychological status of exposed individuals [13, 14].”
Baron, R. J. (2022) · Journal of Hospital Medicine · doi:10.1002/jhm.2776
Ehrenreich, J. H. (2022) · SpringerBriefs in psychology · doi:10.1007/978-3-031-04964-4_9
Bridging the Vaccination Gap: Policy Opportunity
Juanchich, M., Sayer, H., Oakley, C. M., Goffe, L., Booker, C. L., de Bruin, W. B., Meyer, C., Chadborn, T., Sirota, M., Vallée-Tourangeau, G., et al. (2022) · doi:10.5871/c19-recovery/m-j-h-s-c-o-c-b-w-b-c-m-t-c-m-s-g-v-t-d-h-r-w
The Economy at the Time of COVID-19: Theoretical and Political Debates in the USA
Bracarense, N. (2022) · Springer eBooks · doi:10.1007/978-3-031-05811-0_7
Escobar, N., & Joseph, K.-A. P. (2022) · Annals of Surgical Oncology · doi:10.1245/s10434-022-12540-x
Ensuring Progress Toward Racial Equity in Pulse Oximetry
Adams, A., & Cho, H. J. (2022) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2022.4854
Schulder, T., Rudenstine, S., Ettman, C. K., & Galea, S. (2023) · Psychology Health & Medicine · doi:10.1080/13548506.2023.2177684
Pandemic and Race: Un(fore)seen Circumstances, Same Old Biopolitics of Extraction and Use?
Žekevičius, A. (2022) · Athena filosofijos studijos · doi:10.53631/athena.2022.17.10
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Metadata
- Authors
- Feldman, J. M., & Bassett, M. T.
- Affiliations
- Harvard University (US)
- Corresponding author
- Feldman, Justin M.
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2021-11-23
- Volume
- 4
- Issue
- 11
- Pages
- e2135967
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC8611482
- OpenAlex
- W3215441144
- Cited by
- 120
- References
- 19
- Citations by year
- 2026: 5 · 2025: 14 · 2024: 25 · 2023: 42 · 2022: 34
- FWCI
- 9.76
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Topics
- Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
- Social Sciences › Health › Health disparities and outcomes
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Keywords
- COVID-19 mortality, racial and ethnic disparities, educational attainment, health disparities, SARS-CoV-2, Asian Americans, Hispanic Americans, African Americans, socioeconomic status, United States adults, COVID-19 pandemic, health inequalities reduction, infection fatality rate
- MeSH terms
- Academic Success, COVID-19, Health Inequities, Ethnic and Racial Minorities, Adult, Aged, Cross-Sectional Studies, Ethnicity, Female, Humans, Male, Middle Aged, Minority Groups, United States, Health Status Disparities
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