As of September 13, U.S. nursing homes have reported over 230,000 confirmed Covid-19 cases and over 55,400 Covid-19 deaths according to preliminary data from the Centers for Medicare and Medicaid Services (CMS). Black, Latino, and Native American or Alaska Native people are overrepresented in overall U.S. case and death totals, and it appears that similar disparities persist in nursing homes.
A new study from researchers at the University of Rochester Medical Center and IMPAQ, a policy research and analytics firm, found that nursing homes with a disproportionate number of non-white residents had more new Covid-19 cases among residents and staff and more deaths among residents.
These disparities arise from the systemic racism that affects Black and indigenous communities and communities of color. Racist policies and institutions, for example redlining, school/workplace segregation and immigration policies that restrict individual rights, have prevented Black people, indigenous people, and people of color from accessing resources that promote health.
“Who gets to own a home? Who has access to better-paying jobs?” said Odichinma Akosionu, a fourth-year doctoral student in the health services, research policy, and administration program at the University of Minnesota. “That impacts their probability of being able to afford quality long-term services and support.”
Before the pandemic, Yue Li, a professor in the department of public health sciences at the University of Rochester Medical Center, and others had documented racial and ethnic disparities in health outcomes in nursing homes.
“It seems that Covid-19 is making these worse,” said Li.
For their recent analysis, published in the Journal of the American Geriatrics Society, Li and his colleagues looked at CMS data of 12,576 nursing homes across the country to see what racial/ethnic disparities appeared in Covid-19 case counts among staff and residents and Covid-19 deaths among residents during the week of May 25, the first week nursing homes could submit weekly counts to CMS.
On average, nursing homes with the lowest proportion of non-white residents reported 0.4 new cases per facility while those with the highest proportion of non-white residents reported 1.5.
“Nursing homes with a higher proportion of minority residents tend to have higher rates of Covid infections and deaths,” said Li.
While these averaged numbers might look small, Tetyana Shippee, an associate professor in the division of health policy and management at the University of Minnesota who wasn’t involved in the study, said that this is a substantial difference.
“It’s worse than disparities we’ve found before for other outcomes in nursing homes,” said Li. “If every week you see these disparities cumulatively, at the end of the fall the disparity is going to be scary.”
In nursing homes with a medium proportion of non-white residents (which the researchers defined as about 3-11% non-white residents), facilities had a 25% higher risk of having at least one new case compared to predominantly white nursing homes. In nursing homes that were 11-30% non-white, the risk was 44% higher. For facilities with the highest proportion of non-white residents (greater than 30%), that risk increased to 76%.
“That’s a staggering disparity,” said Shippee. “The numbers are pretty shocking.”
Li saw a similar trend among Covid-19 deaths, with the low proportion nursing home group reporting an average of 0.1 deaths per facility and the highest proportion group reporting 0.4.
A New York Times analysis of data from 22 states and Washington, D.C. also found stark racial and ethnic disparities related to Covid-19 in nursing homes. They analyzed case counts from federal, state, and academic sources as of May 16, and found that nursing homes where at least 25% of the residents were Black and Latino were twice as likely as predominantly white nursing homes to see Covid-19 cases. Even in nursing homes with high government ratings, facilities with majority Black and Latino residents were still more likely to be affected by the virus.
Both the Times and Li’s group found that disparities remained when transmission rates in surrounding counties, nursing home size, neighborhood population density, and number of residents on Medicare/Medicaid were taken into account.
As Li and his colleagues point out in their paper, nursing homes are still highly segregated. Nursing homes with more non-white residents are more likely to be in communities with a large non-white population, which historically have not received the same access as majority-white communities to quality healthcare and other resources, like education and well-paying jobs, that can affect health outcomes later in life.
“When you paint the entire picture,” said Akosionu, “systemic racism impacts the ability of communities of color to live and thrive.”
To address these disparities, Li said reporting Covid-19 data according to race and ethnicity is the first step. “It’s important to know the disparities exist and then try to understand what underlies them,” he said.
In the immediate future, this data can inform how personal protective equipment and testing resources are distributed among nursing homes. In the long-term, Shippee and her colleagues state that policymakers should re-examine how existing processes perpetuate racial health inequities.
“It’s not race,” said Shippee. “It’s the racism.”