COVID-19 infections continue to rise in the United States. To date, over three million people have been infected with the virus, and nearly 140,000 people have died. Data shows that the racial and ethnic health disparities that persist in the nation’s health care system are making the pandemic especially lethal for communities of color. Furthermore, while the majority of these deaths have taken place within hospitals across the country, the second-most-common setting is nursing homes and long-term care facilities—indicating not only the disproportionate impact of COVID-19 among the aging population, but also the difficulty these facilities are having as they struggle to control the spread of COVID-19 among residents and staff.
In order to understand and address the gravity of these twin challenges, we have unpacked the most recent data on racial disparities, including in the nursing home setting. We also offer recommendations to better address COVID-19 health outcomes for all elderly, but particularly elderly people of color.
What We Know about Racial Disparities and COVID-19
The severe disparities in mortality, hospitalization, and infections between white people and people of color has been clearly documented—though data limitations prevent us from knowing the full scope of the problem. The COVID Racial Data Tracker tells us that Black people account for 23 percent of deaths where race is known, while making up just 13 percent of the population; these disparities exist at every age level. Non-Hispanic Black and Non-Hispanic American Indian or Alaska Native people have hospitalization rates about five times higher than non-Hispanic white people. In forty-two states, Hispanic/Latinx people represent a disproportionate number of infections.
When comparing the death rates for the Black and Hispanic/Latinx population to the white population, within groups around the same age, the disparities between the racial groups are clearer. (See Figure 1 for our calculations on the most recent death rates by race, age, and ethnicity.) Death rates are most starkly different among younger adults: of all Black people who have died, around 26 percent were younger than 65; of Latinx people who have died, just over 36 percent were younger than 65. Among white people who have died, only 10 percent were that young. Black and Hispanic/Latinx people who are 35 to 44 years old have died at nine times the rate of white people in that same age group.
Disparities are less pronounced for the oldest Americans (75 years old and up), which can be partly explained by the fact that the older population is disproportionately white. According to data from the National Center for Health Statistics, nearly 45 percent of white people who died of COVID-19 were over 85 years old, whereas approximately 20 percent of Black people and 18 percent of Hispanics/Latinx people were over 85. Still, after weighing for relative share of the population by age, Black and Hispanic/Latinx people in the 75 to 84 age group are three times and two times, respectively, more likely to die than white people in that age group. Death rates for Black people 85 and older are two times greater than white people in the same age group. And even though disparities are slightly less pronounced among the elderly, the largest total number of deaths are happening in the elderly population—as of July 1, 80 percent of COVID-19 deaths were among people over 65 years of age—meaning that understanding the challenges facing elderly people of color is critical.
Black and Hispanic/Latinx people in the 75 to 84 age group are three times and two times, respectively, more likely to die than white people in that age group.
The Special Challenge of the Nursing Home Setting
Every day brings new data indicating where mortality and infection rates are highest—nursing homes—although data availability is also limited. Data from the Centers for Medicare and Medicaid Services (CMS) show that about 27,000 COVID-19 deaths have occurred either in a nursing home or long-term care facility, but this reporting may be incomplete. The New York Times has compiled a database of nursing home deaths from federal, state, and local sources, and calculates that a full 54,000 deaths—43 percent of all deaths from COVID-19—occurred at a nursing facility. The scale of human tragedy happening in these facilities is perhaps most clear when put in the context of the size of the nursing home population. In New York, COVID-19 has killed 6 percent of nursing home residents; New Jersey lost 12 percent.
Nursing facilities were not entering this pandemic particularly well-prepared: about 40 percent of facilities already had deficiencies related to their ability to control infection. And there is a longstanding prevalence of nursing homes that do not meet professional staffing standards and have high turnover of staff, a trend that began well before the pandemic. But the pandemic has exacerbated these shortages and deficiencies, as nursing home staff become sick, take time off to care for family, or leave due to low wages and poor working conditions. Those challenges may be influencing the trajectory of outbreaks. In California, nursing homes with lower staffing levels (particularly registered nurse-to-resident levels) and those found to have failed to follow infection control protocols in the past were more likely to have COVID-19 infections. Looking at preliminary data from the CMS Nursing Home COVID-19 Public File, nursing homes with nursing and clinical staff shortages are slightly more likely to have a COVID-19 case or death within the facility.
In at least twenty-three states, a majority of COVID-19 deaths are linked to nursing homes.
While the data are still incomplete, recent reporting has shown that there are significant differences among states when it comes to shares of residents dying in nursing facilities. The New York Times reports that, in at least twenty-three states, a majority of COVID-19 deaths are linked to nursing homes. While 20 percent of deaths in New York were linked to nursing homes, New Hampshire saw 80 percent of their deaths occur among nursing home staff and residents. These differences may be partly due to the varying responses among states to mitigate the prevalence of COVID-19 within these facilities.
Nursing homes also entered the pandemic with existing systemic racial disparities. Nursing homes are highly segregated, and, historically, research has found racial disparities in care and health outcomes in these facilities, with homes serving more residents of color reporting lower staffing and nursing ratios, high numbers of deficiencies, and lower quality of care.
So how do racial disparities in COVID-19 infections and mortality play out in nursing homes that already display disparities in other outcomes? Early analysis from the New York Times showed that nursing homes serving significant populations of Black or Latinx residents were twice as likely to have at least one COVID-19 case than those where residents were primarily white. Similar analysis out of the University of Chicago also found a strong relationship between race and the probability of cases and death. (Neither analysis found that the government star quality rating was predictive).
These data and analyses are incomplete, however, as we still don’t have overall data by race and ethnicity in every state, and even states that provide demographic data have large numbers of cases with unreported demographic information. More specific to this question, we also do not have administrative data on the location of infections or deaths broken down by race and ethnicity.
The Root Causes of COVID-19 Vulnerabilities for Elderly People of Color
The particular lethality of this pandemic among elderly people of color results from the confluence of two damaging structural issues facing the nation: the low level of health care we give our most elderly, and the burden of racism that people of color must bear their entire lives.
Care Issues and Insurance Coverage among the Elderly
Before COVID-19, nursing homes were already experiencing challenges in controlling infections and the spread of viruses. According to Kaiser Health News, 63 percent of nursing homes were cited for control deficiencies as far back as 2016, raising serious questions about the quality of care in most of the country’s nursing homes and long-term care facilities. Kaiser Health News also says that these violations were more common in nursing homes with fewer nurses and aides than in facilities with more adequate staffing. In addition to staffing shortages, other issues cited were improper handwashing, poor hygiene, and issues with keeping common areas clean. Recent media reporting has also highlighted COVID-19 testing failures in nursing homes. These are some of the key reasons why COVID-19 has been able to thrive in nursing home environments.
Of the COVID-19 hospitalizations among Medicare enrollees alone, most were Black (465 per 100,000) or Hispanic (258 per 100,000).
It is also important to consider insurance status and certain social determinants of health for the elderly population, given that they are at greatest risk for contracting COVID-19. The most impoverished nursing home and long-term care residents are covered by Medicaid and Medicare. Medicaid is cited as being the largest single payer of nursing home care through state affiliates. Based on preliminary data released by the Centers for Medicare and Medicaid Services, people enrolled in both Medicaid and Medicare (also referred to as dual-eligible beneficiaries) have a higher rate of COVID-19 hospitalizations. Dual-eligible beneficiaries are more likely to be women and people of color, and typically have higher rates of chronic illness, need for long-term care, and are most likelihood of living in poverty. They are also more likely to experience disparities in health care access. Of the COVID-19 hospitalizations among Medicare enrollees alone, most were Black (465 per 100,000) or Hispanic (258 per 100,000). Aging people of color tend to not only be grappling with economic hardship, higher rates of chronic illness, and retirement insecurity, but they also suffer from the cumulative effects of racism, which long-standing research shows has an impact on their health and well-being.
Cumulative Effects of Structural Racism
Racism is an inescapable burden for people of color. Studies show that the cumulative effects of experiencing racism throughout the lifespan impacts the ability of people of color to be healthy—mentally, physically, and emotionally. The most dire impacts are seen in the health of Black Americans.
Black Americans experience more chronic illnesses and mental health challenges than white Americans. In fact, a study published in the journal Psychoneuroendocrinology found that racist experiences bring on an increase in inflammation in Black Americans. The increase in inflammation then leads to the onset of chronic illness, and at times premature death. Experiencing racism over long periods of time wears down the body’s defenses. It also takes a major toll on mental and emotional health, often serving as a source of toxic stress and trauma. While it has yet to be proven empirically that there is a relationship between racist experiences and the likelihood of contracting or dying from COVID-19, we know that racism does make Black Americans sick based on years of research and data on the connection that the experience of racism has with poorer health outcomes.
Where Do We Go From Here?
All nursing homes and long-term care facilities should operate under the highest safety standards for cleanliness and proper hygiene, and offer COVID-19 testing to all staff and residents at no cost. Personal protective equipment (PPE) must be guaranteed for all staff. Federal and state decision-makers can do more to help control the spread of COVID-19 within these facilities. Nursing homes and long-term care facilities must be properly resourced with funding and support. Minority-serving facilities, which tend to provide lower-quality care and grapple with the challenges that certain social factors pose for most of its residents, should be targeted and prioritized. These recommendations can help facilities ensure quality care and adequate staffing of skilled nurses and aides in order to be responsive to resident needs during the pandemic.
Given that so many deaths occur at nursing homes, and given what we know about racial disparities in COVID-19 mortality, a critical strategy to bring down mortality rates for Black Americans may lie in focusing interventions at these locations. We need to know more about disparities at these institutions, and design responses to protect these residents. In the meantime, focusing federal, state, and local policymakers on providing adequate (and protected and fairly compensated) staffing, infection control, PPE, and other precautions to often underresourced nursing homes and long-term care facilities is a good place to start those efforts.
Figure 1. Large Racial Gaps in COVID-19 Death Rates
COVID-19 deaths by age group were provided by the National Center for Health Statistics, updated as of July 8, 2020 to the reporting week of July 4, 2020. Death rates (COVID-19 deaths per 100,000 of populations of age/race groups) were calculated using Census Population Estimates for 2019. Ratio of death rates were calculated by dividing non-Hispanic Black death rates by non-Hispanic white death rates and dividing Hispanic/Latinx death rates by non-Hispanic white death rates.