The impacts of COVID-19 and the associated economic fallout are likely to hit Nevada’s low-income population especially hard.

“They are often uninsured or underinsured so that’s going to affect their ability to seek healthcare,” said Brian Labus, an assistant professor with the UNLV School of Public Health. “All sorts of chronic conditions are more common among people of low incomes, so they’re more likely to suffer from severe complications if they do get sick.”

Thanks to an emergency order signed by Gov. Steve Sisolak on Thursday, health insurers cannot charge their Nevada enrollees out-of-pocket costs for visits to the doctor or emergency room if the purpose of the visit is COVID-19 testing. The regulation also bars insurers from charging for the tests and requires them to provide information about the illness and care options to their clients.

Currently, there is no charge for testing in Clark County, according to Southern Nevada Health District spokeswoman Stephanie Bethel.

But Sisolak’s regulation doesn’t address the costs for those Nevadans without insurance.

The Kaiser Family Foundation estimates that as of 2018, roughly 339,000 Nevadans were uninsured.

A November report from the Georgetown University Health Policy Institute named Nevada as the state with the sixth-highest rate of uninsured children in the country, with an estimated 58,000 uninsured Nevada children.

The Southern Nevada Health District recommends that individuals with fever, coughing and shortness of breath seek medical care if they have traveled to a COVID-19 outbreak location or been in contact with an individual who has a confirmed case.

“They could go to an urgent care clinic or their primary care provider,” Bethel said, adding that affected individuals should call first to alert the provider.

Those sick enough to be hospitalized would remain in hospital isolation, and people with “mild symptoms or who are not sick enough to be hospitalized could be discharged to their own home and would have to self-isolate within their homes,” she added.

Both scenarios present a problem for lower-income individuals, particularly those living paycheck to paycheck. Access to a physician may be difficult for individuals with no regular work schedule, and they may be unable to skip work if it means loss of a paycheck.

“What a public health crisis like this reveals is the social health inequalities that we tolerate every day,” said Dr. Giridhar Mallya, senior policy officer with the Robert Wood Johnson Foundation, a New Jersey-based philanthropic organization that supports public health projects.

Mallya explained that any low-income workers who do get sick face the choice of staying home and losing pay or going to work and potentially exposing others to the virus. That choice is further complicated by the potential consequences of using accrued sick leave, such as the risk of illegal retaliation, including firing, by employers.

“One or two missed shifts could be the difference between paying rent on time or not and putting themselves at risk for eviction,” he said.

For workers whose employers don’t offer sick leave, the situation can be even more complex.

A January 2012 paper in the American Journal of Public Health indicates that during the 2009 H1N1 “swine flu” epidemic, a higher incidence of influenza-like illness was “related to workplace policies, such as lack of access to sick leave, and structural factors, such as number of children in the household.” The paper, based on survey responses, also found that “Hispanic ethnicity was related to a greater risk of (influenza-like illness) attributable to these social determinants, even after we controlled for income and education.”

Though she wants to emphasize a levelheaded reaction to COVID-19, Erika Washington, executive director of economic and family rights group Make It Work Nevada, said there are so many potentially harmful “what-if” scenarios facing Nevada’s low-income workers.

”I think there’d be a lot less panic if people felt like, ‘I have time off, and I have good insurance and I have protections in place to keep things from going from bad to worse,’” she said.

Washington pointed out that everything from finding childcare to the possibility of making rent with reduced work hours, even temporarily, would present a multitude of problems for low-income Nevadans, many of whom don’t have sufficient savings to cover an extended emergency.

“At the bare minimum right now there should be some protection that if people can’t get paid time off, that they at least have some type of job security,” she said. “Maybe you can afford to take two days off, but is that enough to get through the symptoms of coronavirus and get well enough to go back to work and not be contagious?”

Mallya said employers’ responses to the virus will be crucial for low-income workers, as individuals employed in food service and other public-interaction fields are particularly at risk of both becoming infected and spreading COVID-19.

That could cause problems for those businesses, from liability issues to insufficient workers or patrons to loss of income. Some businesses are responding to these concerns.

Darden Restaurants Inc., operator of chain restaurants including Olive Garden and Yard House, announced Monday that all of its hourly employees would qualify for paid sick leave.

“Businesspeople have some very hard decisions to make, but now is the time to make decisions with a long-term view and not a short-term one,” Mallya said.

Washington said she’d like to see Nevada expand the sick leave bill that was passed in 2019 by requiring employers to offer seven earned paid sick days a year.

The sick leave bill requires all Nevada employers with more than 50 employees to offer paid sick leave to qualifying employees. After facing pushback from lobbyists and Republicans in the Legislature who argued it would hurt small businesses, the bill was amended to exempt employers with less than 50 employees.

Because of the nature of COVID-19 and other such respiratory illnesses, crowded public spaces as well as contained ones become shared environments in which the virus can affect large numbers of people at once, Labus said.

Contained spaces that Southern Nevada’s low-income populations reply upon, like buses, then can become points of potential exposure.

Francis Julien, deputy CEO of the Regional Transportation Commission of Southern Nevada, said via email that the local bus system is taking additional precautions to protect its riders.

The RTC “has crews thoroughly cleaning the floors, windows, bus interior rails and the driver’s area and applying a disinfectant solution on every public transit vehicle each night,” she said. The disinfectant solution is an additional precaution.

The RTC is also reaching out to customers and posting rider alerts on buses with the COVID-19 prevention information provided by the health district.

In terms of governmental policy, Mallya said among possible immediate interventions he believes could be useful to low-income Americans are emergency-based sick leave for times of public health crises, an income stimulus effort like that accomplished during the Great Recession, beefing up of labor protections for low-wage workers and meal support for children whose school hours might be affected.

Labus said additional measures Southern Nevada could take to protect the most vulnerable from a public health perspective are hard to identify. Short of revising the health care system to ensure everyone has adequate access, he said simple things like providing hand sanitizer in common areas might be somewhat helpful.

And though pictures of empty shelves that once held toilet paper, water and other supplies at local businesses have been circulating on social media, Labus said such extensive disaster preparation by locals doesn’t change the most effective weapon in everyone’s arsenal against COVID-19.

“Luckily, the best intervention for coronavirus is one of the cheapest tools we have, which is simple soap and water,” Labus said. “You don’t need to stand in line at Costco and buy 500 rolls of toilet paper.”