Portrait of mother and daughter wearing protective mask on the street

Q&A With Patricia Foxen

Dr. Foxen discusses the impact of the coronavirus pandemic on Latino communities, why life expectancy for Latinos is expected to drop by three years, and the challenges in collecting and tracking national and state COVID-19 data by race and ethnicity.

In recognition of National Minority Health Month, PRB is highlighting key health indicators for racial and ethnic minorities in the United States and inequities that continue to challenge the health and well-being of these communities.

Through her work at UnidosUS, PRB board member Dr. Patricia Foxen has researched numerous issues affecting the well-being and integration of Latino communities in the United States, including the psychosocial health of Latino children and youth. In this interview, Dr. Foxen discusses the impact of the coronavirus pandemic on Latino communities, why life expectancy for Latinos is expected to drop by three years, and the challenges in collecting and tracking national and state COVID-19 data by race and ethnicity.

Q. Before the coronavirus pandemic, what were the most important health issues for Latinos in the United States?
A. Latinos experience poorer health outcomes than non-Hispanic White Americans in several areas because of poverty-related social inequities, lower rates of health insurance coverage, and inadequate access to quality health care. Before the pandemic, for example, half of all Latinos were at risk of developing diabetes in their lifetime. Latinos with diabetes have worse outcomes than non-Hispanic Whites, including a higher risk of death from the disease. Latinos also have higher rates of chronic kidney and liver diseases and are more likely to be obese and have high blood pressure than non-Hispanic white Americans. Some subgroups of Latinos are also at higher risk for cervical and liver cancers.

Yet, Hispanic Americans also tend to live slightly longer than non-Hispanic white Americans and have lower mortality rates for leading causes of death such as heart disease and cancer. This phenomenon, often referred to as the Hispanic Paradox, has been linked to protective factors among Latino immigrants such as lower rates of smoking, strong family and community ties, and the younger median age of Latinos generally. Sadly, researchers have found that Latinos born in the United States have higher rates of obesity, smoking, cancer, and heart disease, as well as higher blood pressure than those who are immigrants, leading many to conclude that acculturation to the United States worsens people’s health.


Q. What would you say were the key underlying trends?
A. Several barriers contribute to Latinos’ poor health outcomes. A significant portion of Latinos work in low-income jobs that don’t offer health insurance or sufficient wages to cover health care costs out of pocket. Immigrant status is also important: Undocumented workers are prohibited by law from accessing most federally funded insurance programs, and even most authorized immigrants are barred from accessing federally funded programs for five years after obtaining legal status (states can decide whether to cover these health costs). Restrictive eligibility rules in many states with large Latino populations, such as Arizona, Texas, and Florida, limit access to health coverage for low-income Latinos.

The Affordable Care Act reduced racial/ethnic gaps in access but several policy changes between 2016 and 2020 deepened disparities. Anti-immigrant policies such as the public charge rule greatly increased fear among Latinos about the risks of enrolling in programs such as Medicaid and prevented many from accessing health and other related programs. Today, Hispanics are still three times more likely to be uninsured than non-Hispanic White Americans, meaning one in four Hispanics are not covered by health insurance.

Other issues such as the lack of culturally appropriate health services and outreach also affect access to adequate health care for Latinos. In addition, language and educational barriers can affect some Latinos’ ability to navigate health care systems and communicate with health care providers. Daily environments can also present health challenges, such as neighborhoods with limited access to healthy foods or space for physical activity, or exposure to environmental pollutants. The cumulative effect of these environmental and access factors contributes to many of the disparities we see.


Q. Health trends vary within the Latino population—for example, by ancestry or between U.S.- and foreign-born. What are some of those variations?
A. Latinos are extremely diverse in country of origin, class, race, generation, immigration status, and migration history. Despite their lower health coverage rates, immigrant Latinos tend to be somewhat healthier than U.S.-born Latinos, as seen, for example, in their significantly lower rates of cancer and other morbidities.

As a group, though, Latinos are not uniform in their health patterns. For instance, Latinos tend to have lower rates of low-birthweight babies than non-Hispanic whites, but Puerto Ricans have twice as many low-birthweight babies than white Americans. Mexicans, on the other hand, have much lower rates for this indicator. These subgroup disparities exist for other health determinants. For example, Latinos of Mexican, Central, and South American descent are less likely to be insured than Puerto Ricans and Cubans, which likely reflects legal status as well. Sadly, it has been documented that Latina mothers are more likely to have low birthweight babies following traumatic anti-immigrant events, such as worksite raids or the 2016 presidential election.


Q. Now that we’re at the one-year mark of the pandemic, how has it affected the Latino community? What’s been the experience of groups within the community?
A. The coronavirus pandemic devastated Latino communities on several fronts: health, income, housing, and education. While Latinos make up 18% of the U.S. overall population, they represent 21% of COVID-19 cases and 12% of COVID-19 deaths; they are also roughly three times more likely to be hospitalized than non-Hispanic white Americans (after adjusting for age). Last summer COVID-19-associated hospitalization rates were nearly eight times higher for Hispanic children than white children. The age-adjusted death rate from COVID-19 for Latinos is estimated to be more than double that of white Americans, and mortality among younger Latinos is especially high relative to other groups. In California, for example, it’s estimated that Latinos ages 35 to 49 have died from COVID-19 at more than five and a half times the rate of white people in that age group. An even more shocking figure shows that Latino life expectancy has dropped by nearly three years during the pandemic (compared to one year for the overall U.S. population)—a loss that significantly erodes the life expectancy advantage mentioned earlier (Hispanic Paradox).

Latinos are more susceptible to contracting the coronavirus and to other risk factors for the disease it causes, COVID-19, because of preexisting structural inequalities and unjust socioeconomic conditions. They are largely overrepresented in “essential” jobs that put them at greater risk of exposure to infection but often don’t provided health or economic support for workers who have contracted the disease. Those who live in crowded housing conditions with multigenerational families also face an increased likelihood of exposure. And again, many undocumented workers have not been able to access health coverage even during this time of heightened risk.

Since the beginning of the pandemic, Latinos have consistently experienced significantly higher rates of employment income loss than non-Hispanic whites. By July 2020, 63.5% of Latinos had suffered income loss compared to 45.2% of non-Hispanic whites; these effects have lingered, with roughly 60% of Latinos still suffering income loss in February 2021. According to a recent report by UnidosUS, Latinas in particular have suffered extremely high pandemic unemployment rates, partly because of their overrepresentation in hard-hit industries and increased pandemic-related caregiving work at home.

Throughout the pandemic, Latinos have also experienced higher rates for indicators such as missed rent or mortgage payments, food insufficiency, lack of health coverage, and mental health issues such as anxiety and depression. These disparities point to the fact that so many Latinos continue to be shut out of the U.S. safety net, in particular those who live in poor and mixed-status families (and, often, their U.S.-born children).


Q. What differences are you seeing across geography and what do you think accounts for that?
A. To see differences across geographies, I encourage readers to look at our COVID-19 Dashboard, which provides some state-based data. Differences between states can be explained in several ways, for example variation in state policies toward immigrants likely effects some of the trends seen in the dashboard.


Q. How would you compare Latinos’ experiences to that of other racial/ethnic communities?
Each community has faced unique challenges during the pandemic. Among Native American communities, these challenges go back to our nation’s historical failure to fund adequate basic services as part of treaty obligations. The devastating impact of COVID-19 among some groups—the Navajo Nation, for example, has more per capita cases and deaths than any U.S. state—is directly related to extremely poor health conditions, understaffed hospitals, lack of running water, limited internet access, and other poverty-related issues.

African Americans, like Latinos and Native Americans, have had very high rates of COVID-19-related illness and death. Many of the causal factors are similar to those faced by Latinos: working essential jobs, inconsistent access to health care, and underlying health conditions and high stress levels—all of which reduce immunity. It is important to point out that the overall lack of data on non-white populations, particularly related to COVID-19, is indicative of how underserved these communities are more broadly.


Q. What prompted UnidosUS to develop your Latinos in the Time of Coronavirus dashboard?
A. By April 2020 it was already clear that the pandemic was having a major detrimental impact on Latino communities. UnidosUS immediately went into full gear to address this massive challenge through advocacy and communications outreach, and by seeking to support our 300+ affiliates (mostly community-based organizations around the country that were at the front lines of the pandemic). We needed to make sure that stakeholders—from legislators and policymakers to community advocates and practitioners—had readily accessible data so they could see the full picture and act on it.

Having data to back up our own policy work was also critical. In July 2020 UnidosUS  released a white paper analyzing the pandemic’s devastating impact on Latino communities; as time moved on, we wanted to chart shifting trends and have data readily available for our continuing advocacy efforts. We worked with a team at PRB led by Mark Mather, Matthew Martinez, and Beth Jarosz to create “By the Numbers: Latinos in the Time of Coronavirus,” an interactive, user-friendly dashboard that provides the latest data on the effects of COVID-19, displaying trends nationally and in six states (Arizona, California, Colorado, Florida, Nevada, and Texas) that have large Latino populations and have been key to UnidosUS advocacy efforts throughout the pandemic.

The PRB team used data from the U.S. Census Bureau’s experimental Household Pulse Survey to display biweekly data with racial/ethnic comparisons for a series of indicators in areas such as health, nutrition, jobs, education, digital access, and other data points that are important for UnidosUS and our policy and advocacy partners in our broader COVID-19 response. We also thought it would be helpful to provide COVID-19 case and mortality projections for the six states to show how the pandemic may develop in the future based on different scenarios.


Q. What lessons can researchers and advocates learn from your experience tracking the pandemic’s impact on Latinos?
A. First and foremost, the dashboard clearly shows the range of racial/ethnic disparities that have existed for Latinos (and, at the national level, other race groups) since the start of the pandemic. By looking at the variables separately, and then considering them all together, we can paint a rather comprehensive picture of how all these different inequities have both contributed to, and continue to reflect, such comparably high rates of health and social and economic devastation in our communities.

Nationally, we can see that in February 2021—roughly a year after the onset of the pandemic in the United States—22.5% of Latinos still had no health insurance, compared to 8.2% of non-Hispanic whites. Food insecurity among Latinos has grown during the pandemic, and today 19% of Latinos say they have not had enough to eat in the past week (compared to 7.7% for non-Hispanic whites). As mentioned earlier, nearly 60% of Latinos reported losing employment income during the pandemic, compared with 42.5% for whites. And so on.

At the state-level, some states are faring much worse on some indicators. For example, 37.2% of Latinos in Texas do not have health insurance; and in Nevada, 65% of Latinos reported losing employment income.

By clearly highlighting racial and ethnic disparities, the dashboard has helped UnidosUS and other advocates make the case (both nationally and at the state level) for more inclusion of Latinos, essential workers and others in our society’s pandemic response and our social safety net more broadly. We frequently use these data in conversation with decisionmakers and are told that policymakers reference our dashboard as a resource.


Q. Data collection and reporting, especially by race/ethnicity, has been challenging during the pandemic. What data do you wish had been available?
A. One of the limitations of the otherwise extremely rich Pulse Survey was that it was an experimental online survey and didn’t always meet some of the Census Bureau’s statistical quality standards. For example, because the survey was administered online, it may have created built-in biases, particularly for data related to computer and internet access. Given that the digital divide was exposed as such a major vulnerability for communities of color during the pandemic, having more accurate data on this issue would have been invaluable. In addition, we suspect that aggressive immigration policies and environments have had an impact on some of the disparities we see for Latinos during the pandemic, but these disparities are difficult to quantify so often go missing from analyses.


Q. Looking ahead, how do you think the pandemic will change the way we track and report on health data? Are there any data gaps that would help us better understand health within the Latino population?
A. The COVID-19 pandemic has demonstrated the importance of being able to disaggregate health data by race and ethnicity. Understanding disparities in infection rates across different population subgroups and states is important to understand how the virus has spread and who is most vulnerable. Yet many states have not done a good job compiling and reporting COVID-19 cases by race/ethnicity. Understanding basic information about who is most at risk—and sharing that information with the public—is critical to reducing the impact of future crises.