Objective: The relationship between socioeconomic status and its interaction with State Medicaid-expansion policies on COVID-19 outcomes across United States (US) counties are uncertain. To determine the association between median-household-income and its interaction with State Medicaid-expansion status on COVID-19 incidence and mortality in US counties Methods: Longitudinal, retrospective analysis of 3142 US counties (including District of Columbia) to study the relationship between County-level median-household-income (defined by US Census Bureau Small-Area-Income-and-Poverty-Estimates) and COVID-19 incidence and mortality per 100000 of the population in US counties from January 20, 2020 through December 6, 2020. County median-household-income was log-transformed and stratified by quartiles. Medicaid-expansion status was defined by US State Medicaid-expansion adoption as of first reported US COVID-19 infection, January 20, 2020. Multilevel mixed-effects generalized-linear-model with negative binomial distribution and log link function compared quartiles of median-household-income and COVID-19 incidence and mortality, reported as incidence-risk-ratio (IRR) and mortality-risk-ratio (MRR), respectively. Models adjusted for county socio-demographic and comorbidity conditions, population density, and hospitals, with a random intercept for states. Multiplicative interaction tested for Medicaid-expansion*income quartiles on COVID-19 incidence and mortality. Results: There was no significant difference in COVID-19 incidence across counties by income quartiles or by Medicaid expansion status. Conversely, significant differences exist between COVID-19 mortality by income quartiles and by Medicaid expansion status. The association between income quartiles and COVID-19 mortality was significant only in counties from non-Medicaid-expansion states but not significant in counties from Medicaid-expansion states (P<0.01 for interaction). For non-Medicaid-expansion states, counties in the lowest income quartile had a 41% increase in COVID-19 mortality compared to counties in the highest income quartile (MRR 1.41, 95% CI: 1.25-1.59). Conclusions and Relevance: Median-household-income was not related to COVID-19 incidence but negatively related to COVID-19 mortality in US counties of states without Medicaid-expansion. It was unrelated to COVID-19 mortality in counties of states that adopted Medicaid-expansion. These findings suggest that expanded healthcare coverage should be investigated further to attenuate the excessive COVID-19 mortality risk associated with low-income communities.

Objective To study the relationship between county-level COVID-19 outcomes (incidence and mortality) and county-level median household income and status of Medicaid expansion of US counties. Methods Retrospective analysis of 3142 US counties was conducted to study the relationship between County-level median-household-income and COVID-19 incidence and mortality per 100,000 people in US counties, January-20th-2021 through December-6th-2021. County median-household-income was log-transformed and stratified by quartiles. Multilevel-mixed-effects-generalized-linear-modeling adjusted for county socio-demographic and comorbidities and tested for Medicaid-expansion-times-income-quartile interaction on COVID-19 outcomes. Results There was no significant difference in COVID-19 incidence-rate across counties by income quartiles or by Medicaid expansion status. Conversely, for non-Medicaid-expansion states, counties in the lowest income quartile had a 41% increase in COVID-19 mortality-rate compared to counties in the highest income quartile. Mortality-rate was not related to income in counties from Medicaid-expansion states. Conclusions Median-household-income was not related to COVID-19 incidence-rate but negatively related to COVID-19 mortality-rate in US counties of states without Medicaid-expansion.