Associations Between Insurance, Race and Ethnicity, and COVID-19 Hospitalization Beyond Underlying Health Conditions: A Retrospective Cohort Study

•In healthy young adults, severe COVID-19 is associated with public/no insurance.•Severe COVID-19 risk is higher in young adults of color regardless of health status.•Social determinants of health likely drive elevated risk of severe COVID-19. People of lower socioeconomic position and people of color experience higher risks of severe COVID-19, but understanding of these associations beyond the effect of underlying health conditions is limited. Moreover, few studies have focused on young adults, who have had the highest incidence of COVID-19 during much of the pandemic. We conducted a retrospective cohort study using electronic health record data from the University of Washington Medicine healthcare system. Our study population included individuals aged 18–39 years who tested positive for SARS-CoV-2 from February 2020 to March 2021. Using regression modeling, we estimated adjusted risk ratios and adjusted risk differences of COVID-19 hospitalization by socioeconomic position (measured by health insurance status) and race and ethnicity. We adjusted for any underlying health condition to examine these associations beyond the effect of underlying health conditions. Among 3,101 individuals, the uninsured/publicly insured had a 1.9-fold higher risk of hospitalization (adjusted risk ratio=1.9, 95% CI=1.0, 3.6) and 9 additional hospitalizations per 1,000 SARS-CoV-2–positive persons (adjusted risk difference=9, 95% CI= −1, 20) than the privately insured. Hispanic or Latine, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic Native Hawaiian or Pacific Islander patients had a 1.5-, 2.7-, 1.4-, and 2.1-fold higher risk of hospitalization (adjusted risk ratio=1.5, 95% CI=0.7, 3.1; 2.7, 95% CI=1.1, 6.5; 1.4, 95% CI=0.6, 3.3; and 2.1, 95% CI=0.5, 9.1), respectively, than non-Hispanic White patients. Although they should be interpreted cautiously given low precision, our findings suggest that the increased risk of COVID-19 hospitalization among young adults of lower socioeconomic position and young adults of color may be driven by forces other than underlying health conditions, including social determinants of health.