The surge of the Omicron variant in the United States sickened millions, hospitalized young people at record rates, killed Americans at a far higher rate relative to other high-income countries, and led to widespread work absences and social disruptions.

Household Pulse Survey (HPS) data reveal stark inequities in COVID-19-related outcomes by income. Among working-aged Americans, those with 2019 household incomes less than $25,000 were 3.5 times as likely to report missing an entire week of work mainly due to their own or loved ones’ COVID-19 symptoms, relative to those earning $100,000 or more (Figure). The United States does not collect national COVID-19 surveillance data by income or occupation, so the HPS data are among the best sources for evaluating disparities, although the survey response rate is low.

When low-income workers miss work due to COVID-19, they not only face the risk of severe illness—their families also report not being able to afford enough food to eat. After the expiration of the federal sick leave program, few low- income workers have access to paid sick leave to support them in self-isolating while infectious, reducing viral spread in the community, and leading a healthy recovery. Only 35% of low-wage workers have paid sick leave while 95% of high-wage workers do.

Inequities shaped by policy choices

Since the early months of the pandemic, low-income, front-line workers have faced elevated risk of exposure to and death from the airborne virus.

Two years into the pandemic, the lowest-income workers have had the least access to vaccines and boosters (Figure 1). Roughly 4 in 10 working-age Americans have either never been fully vaccinated (Figure 2) or have not gotten a recommended booster (Figure 3). The US federal government spoke of the importance of vaccines and boosters but did not take adequate steps to create access for low-income workers. Workers who were boosted were least likely to miss work due to COVID-19 symptoms, while two doses were less protective (Figures 4 and 5).

The United States has large vaccine inequities, no federal workplace safety standard in place to protect workers, and fewer than 10 of 50 US states had mask mandates during the Omicron surge. In contrast, other high-income countries responded quickly to the Omicron variant with widespread vaccine delivery. Of the 27 European countries, 23 implemented universal mask policies.

Other countries have consistently provided free rapid tests and high-quality masks to contain the virus. As the US federal government recently implemented a one-time free test and mask program at the end of the Omicron surge, there remains a need for clear plans to provide these materials on an ongoing basis, including at the start of future surges.

Additional surges are likely due to new variants, seasonality, and waning immunity. The United States can act now to reduce the toll of COVID-19 on low-income workers and their families, on employers, and on society, much as other high-income countries have done. Each of the following policies and approaches are well-aligned with the pandemic plan that President Biden released when he entered office.

Clear communications and data

The first principles of public health crisis communications are for high-level leaders to “be first” and “be right,” and to clearly communicate threats without minimizing or exaggerating. The Biden administration can be forthright that the recurring death and disruption of COVID-19 surges are serious concerns that warrant immediate policy interventions.

To inform an equitable policy response, the government needs comprehensive data on all Americans and communities most at risk. Policymakers, the Supreme Courtand researchers may use COVID-19 surveillance data on occupations with high exposure to COVID-19 to help provide further information about the virus and how to respond most effectively.

Vaccine mandates

Vaccine mandates are key to increasing the reach of vaccination as a tool for both reducing severe disease and limiting hospital overflows and economic and social disruption. The Biden administration can work closely with governors and mayors to implement vaccine mandates for all workers and workplaces.

Data-driven mask policies

COVID-19 spreads through the air, and mask policies that help people mask together are one of the most effective policies for reducing the spread of COVID-19. Data-driven mask policies are linked to local transmission rates and can turn off when cases are low and can turn on when cases begin to surge. New variants are likely, and having mask policies that automatically turn on could be especially important for more lethal or vaccine-evading variants.

High-quality masks and tests for low-income workers

President Biden’s January 2021 pandemic plan included using the Defense Production Act to scale up manufacture of high-quality masks and rapid tests to make them widely available, with a focus on front-line workers. However, this plan has yet to go into effect. Businesses and local governments would also benefit from access to high-quality masks and tests to help workers stay healthy, happy, and safe at work.

Improved workplace protections

Workplace transmission remains an important driver of the pandemic. While the Supreme Court blocked the Occupational Health and Safety Administration (OSHA)’s emergency temporary standard requiring unvaccinated workers to be masked and tested weekly, the majority of justices noted that OSHA could issue a worker protection standard targeted to higher risk workplaces. OSHA should do thisrequiring improved protections from exposure to airborne viruses in workplaces where the risks are highest.

Paid leave

As low-income workers face repeated infections and absences from work that often lead to food insufficiency, paid leave is more important than ever. Congress can help reduce food insufficiency among workers and their families by incorporating paid leave into Build Back Better legislation in a way that ensures the lowest-income workers are covered. Paid leave will also reduce onward transmission of COVID-19 to colleagues and customers by allowing infected workers to isolate at home.

The way forward

Disasters and diseases often exacerbate inequities. Leadership on good policies can reduce the toll for everyone and especially the most vulnerable. In the prolonged COVID-19 pandemic, policies that center equity can reduce harms for low-income workers, their families, their businesses, and ultimately the whole of our society.