Economic burden of lives lost due to COVID-19 in California State

Aim: To examine the economic impact of lives lost due to the coronavirus pandemic across California and Los Angeles (LA) County. Patients & methods: Years of potential life lost (YPLL) and the value of statistical life (VSL) were calculated using mortality data from the California Department of Public Health, the LA County Department of Public Health and the Social Security Administration websites. Results: In California and LA County, the average YPLL per person were 14.3 and 14.7 and the VSLs were approximately US$219.9 billion and $82.7 billion, respectively. YPLL and VSL were greatest for Latinos aged 50–64. Conclusion: The economic burden of lives lost due to the coronavirus across California and LA County is substantial. Latinos aged 50–64 were most affected.


Data acquisition
Cumulative state-and county-level coronavirus mortality data were retrieved from the California Department of Public Health and the LA County Department of Public Health websites on 28 July 2021 and 30 July 2021, respectively [11,10] [12]. Period life expectancy was extracted from the most recent (2017) actuarial life tables from the Social Security Administration website [13]. Period life expectancy is defined as the average number of years of life remaining if a group of persons at that age were to experience the mortality rates for 2017 over the course of their remaining life [13]. Acquired data included the average number of years of life remaining for males and females from birth to 119 years of age. The actuarial life tables reflect values for the Social Security area population, which includes residents of the 50 states and the District of Columbia (adjusted for net census undercount); civilian residents of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Northern Mariana Islands; federal civilian employees and persons in the US Armed Forces abroad and their dependents; non-citizens living abroad who are insured for Social Security benefits; and all other US citizens abroad [13]. All extracted data were publicly available and did not require approval from the institutional review board.
The primary outcomes analyzed by this study were the YPLL and the VSL due to COVID-19 in California State and LA County, excluding Long Beach and Pasadena. The secondary outcomes were YPLL and VSL further stratified by race and ethnicity for California State only. The number of COVID-19 deaths in each age range was multiplied by the average period life expectancy for males and females at the midpoint of each age range to estimate the YPLL. The VSL for each age range was calculated by multiplying the YPLL by the population average value of statistical life year (VSLY). The VSLY was determined to be US$240,676 based on previously published literature and a VSLY methodology that incorporated age range by decile and income quintile [14]. This VSL could be used by policymakers to help estimate the economic burden of premature deaths due to the coronavirus pandemic and evaluate the cost-benefit ratio of different risk-reduction interventions. The YPLL and VSL values of each age range were summated to determine a total YPLL and VSL value. Total YPLL was then divided by the total number of deaths (including any unknown or missing deaths) to determine the average YPLL per person. Upper and lower limit YPLL and VSL sensitivity analyses for California State and LA County were calculated by replacing the midpoint value of the average period life expectancy with the upper and lower end of each respective age range [4].

Results
A total of 63,891 coronavirus deaths had been reported across the state of California as of 28 July       14.6%, 20.4% and 13.8%, respectively. By race and ethnicity, Latinos accounted for over half of the total YPLL and VSL, at 56.5% and 64.9%, respectively, followed by Whites, Asians and African Americans (  (Table 1). Fatalities from the 50-64 and 65-79 age ranges contributed to more than half of the total YPLL and VSL, at 36% and 32.7%, respectively (Figures 1 & 2).

Discussion
This study estimated the VSL lost and the YPLL in California State and LA County, excluding Long Beach and Pasadena, from the beginning of the pandemic (1 March 2020) through July 2021. Across California, the monetary value of lives lost exceeded US$219.9 billion, with LA County accounting for roughly US$82.7 billion, as of 28 July  2021. Among all California counties, LA County was disproportionately impacted, with nearly five-times as many deaths as the next highest county [15]. These findings may reflect a combination of factors, including population density, poverty, race and ethnicity, homelessness and high household densities in LA County compared with other areas of the state [16]. Analysis by age range determined that older individuals accounted for most of the monetary cost of lives lost due to this pandemic, in spite of the fact that older populations tend to have fewer years of life remaining. These findings are consistent with prior literature demonstrating that older individuals over 50, and especially over 60, face elevated mortality risk due to COVID-19 [17]. Sub-analysis by race and ethnicity further indicated that certain racial and ethnic minority groups were more heavily impacted by the COVID-19 pandemic. Latinos comprise 39.4% of the population of California State but accounted for the greatest economic burden of lives lost (56.5% and 64.9% of YPLL and VSL respectively) [9]. They had the highest total YPLL and VSL, at 516,288 and $124.3 billion, respectively. Similarly, African Americans make up only 6.5% of California's population yet had a higher total YPLL (62,010) than Asians and Whites, who account for 15.5% and 36.5% of California's population, respectively [18]. These differences may be due to a combination of environmental and health factors. Individuals of color are more likely to have poor access to healthcare and underlying health conditions, such as asthma, diabetes and hypertension, which increase their risk of COVID-19 complications and fatality [19]. Compared with Whites and Asians, Latinos and African Americans are more likely to live in more crowded households with insufficient space for social distancing and self-isolation [20]. Furthermore, individuals of color are more likely to work in service and public-facing jobs that do not offer the ability to telework, thereby increasing their vulnerability and susceptibility to COVID-19 infection [19]. Latinos and African Americans are also more likely to live in poverty [21]. Prior literature has identified an association between low socioeconomic status, crowded households and an inability to telework and a disproportionate COVID-19 positivity and mortality rate among communities of color in California [22,23]. Specifically, prior literature has shown an increased rate of hospitalizations among individuals of color due to COVID-19, even after adjusting for comorbidities, highlighting the impact of social inequality during this pandemic [23]. With nearly 40 million residents, California has the largest population of any US state; it is also among the youngest and most diverse, with more Latino than White residents since 2014 [21]. California also accounts for 15% of the US economy [24]. In this context, the magnitude of the financial burden of COVID-19 mortality in California, as well its disproportionate impact on non-White communities, is particularly significant and concerning.
The results of the present study are consistent with similar disparities analyzed in New York, Ohio and Illinois. In New York and Ohio, older individuals bore the greatest economic burden of life lost, with individuals over the age of 60 experiencing the greatest impact [4,25]. In Chicago, Illinois, and in Cook County in general, Black and Hispanic residents experienced a disproportionate COVID-19 burden and premature loss of life [26,27]. In Cook County specifically, Latinos had a YPLL rate 4.8-times greater than Asians, the least affected group [26]. In Chicago, geospatial analysis identified COVID-19 mortality hot spots in neighborhoods of color and low socioeconomic status as well as higher rates of chronic comorbidities [27]. While the current data cannot be directly extrapolated to other states, the current findings are worrisome for similar trends across the USA.
The current study has several limitations. Most notably, the values included here were current as of July 2021; they do not reflect the full extent of the pandemic, as new fatality reports are confirmed and updated daily, particularly in the setting of new and more transmissible variants [28]. Furthermore, the COVID-19 pandemic has led to an excess of non-COVID deaths, related to factors such as delays in or avoidance of medical care, drug use and mental health crises [29,30]. As a result, the calculated YPLL and VSLs are surely an underestimation of the current economic losses and loss of life experienced across California and LA County due to COVID-19. Additionally, some data were incomplete at the time of analysis: 566 fatality reports listed an unknown or 'missing' age (Tables 2 & 3), precluding calculation and inclusion of YPLL and VSL in the analyses. Another important limitation is the lack of data stratified by both age and sex. As a result, the authors used an average of the male and female period life expectancy when determining YPLL.
VSLY also has important limitations. The VSLY utilized in this paper assumed an age-and income-adjusted but otherwise standard VSL, regardless of factors such as community preferences, values and work-related risk exposures [14,31]. Although the present approach is consistent with prior research [25], and no universally accepted mathematical model of VSLY exists, alternate models of VSLY may incorporate additional variables and arrive at different valuations [31,32] Consequently, the results of this study should be understood as estimates of the financial value of COVID-19 risk reductions across groups, with the trends toward racial and ethnic disparities observed here likely to be more meaningful than precise values. Furthermore, while it is possible that other methodologies would yield less-pronounced racial and ethnic disparities, the current findings may, in fact, be more likely to underestimate the disparities in VSL across racial and ethnic groups, due to the higher COVID-19 exposure risks associated with many low-income jobs, which are often disproportionately held by non-White workers [3]. Finally, it has been argued that VSLY-based cost-benefit analyses should be used with caution in analyses of social distancing measures for COVID-19 [14]. However, a superior metric has not been proposed [14]. Because VSLY remains a broadly understood and accepted tool for evaluating the costs and cost-benefit of risk-reduction interventions [31], the authors feel it is an appropriate and useful strategy for evaluating the financial costs associated with COVID-related deaths.

Conclusion
The economic burden of lives lost due to the coronavirus pandemic across California and LA County, excluding Long Beach and Pasadena, is substantial. Among the various age groups, ages 50-64 bore the greatest burden of statistical value of lives lost and estimated YPLL. By race and ethnicity, Latinos experienced the greatest economic burden of lives lost. This study may help inform important policy decisions and community interventions to promote health equity amid an ongoing COVID-19 pandemic, minimize further loss of life and help plan for a post-pandemic future in California State.

Summary points
• Estimated years of potential life lost (YPLL) and value of statistical life (VSL) are two measures used to evaluate the impact of excess mortality due to COVID-19. • The estimated YPLL and the VSL across California and Los Angeles (LA) County due to the coronavirus pandemic are substantial. • Across California, the economic burden of lives lost has exceeded US$220 billion, with LA County accounting for US$83 billion, as of July 2021. • The total YPLL across California and LA County was an estimated 913,682 and 343,186, respectively.
• Those aged 50-64 bore the greatest burden of the VSL and the estimated YPLL.
• Latinos accounted for the greatest economic burden of lives lost, with a total YPLL of 516,288 and a total VSL of US$124 billion. • African Americans were disproportionately impacted by COVID-19, with a higher total YPLL than Asians and Whites. Financial & competing interests disclosure