There have been multiple reports that COVID-19 is disproportionately impacting minorities. A Kaiser Family Foundation report found that African Americans accounted for a higher share of confirmed COVID-19 cases (in 20 of 31 states) and deaths (in 19 of 24 states) compared with their share of the total population. 

The study found similar patterns for Hispanic populations. The two most commonly cited reasons for these disparities are the disproportionate number of chronic diseases among minorities and their living situations. 

The disproportionate number of chronic diseases and comorbidities among minorities increases the risk of hospitalization and death, which could explain the racial differences in COVID-19 diagnoses and deaths. 

As Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Disease, stated at a recent White House Coronavirus Taskforce press briefing, “The things that get people into intensive care and require them to be put on a ventilator—something that often leads to death—are the very factors that are, unfortunately, disproportionately prevalent in the African American population.” 

The second common reason put forth to explain these disparities is that Hispanics and African Americans tend to live in more densely populated communities and households, which can facilitate viral spread. It is no surprise that one of the strongest predictors of an outbreak of COVID-19 cases in a nursing facility is the prevalence of COVID-19 in the community and the population density of the area in which a facility is located.

The Medicaid F​actor

While minority populations are traditionally underrepresented in long term care facilities, the number of residents who are African American or Hispanic has increased in recent years. 

Some have suggested that a higher percentage of African American residents in a nursing facility may be a proxy for fewer nursing facility resources, which would lead to lower-quality care. A 2007 study found that “residents in nursing homes with high concentrations of blacks had 20 percent higher odds of hospitalization than residents in nursing homes with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent for white residents and 22 percent for black residents.”

This explanation was supported by testimony from David Grabowski, PhD, Department of Health Care Policy at Harvard Medical School, to the U.S. Senate Finance Committee in 2019 in which he noted that Medicaid is a major driver of staffing levels and quality in nursing facilities. 

In May 2020, The New York Times reported on the relationship between nursing facility racial differences and COVID-19 cases. The reporters’ analysis found that more than 60 percent of nursing facilities where at least a quarter of the residents are black or Latino have reported at least one COVID-19 case, which was nearly double the rate of facilities where black and Latino people make up less than 5 percent of the facility population.

The differences were partly explained by facility location. The more urban a facility and the larger a facility, the greater the likelihood of COVID-19 cases. 

Not even quality metrics of nursing facilities correlate with COVID-19 outbreaks. The New York Times’ analysis found that “the federal government’s Five-Star rating system … was not a predictor. Even predominantly black and Latino nursing homes with high ratings were more likely to be affected by the coronavirus than were predominantly white nursing homes with low ratings ...”

The Community Fa​​ctor

These findings are similar to two separate studies comparing the characteristics of skilled nursing facilities with COVID-19 cases to those without. Vincent Mor, PhD, professor of health services, policy, and practice from Brown University School of Public Health, used real-time electronic medical record data to track the epidemiology of COVID-19 in nursing facilities across 30 states.

The research showed the major factors associated with facilities contracting COVID-19 cases were bed size and proximity to surrounding communities with COVID-19 cases. The prevalence of COVID-19 in the community was the strongest predictor. Less strong predictors included a facility having a higher proportion of African Americans.  

Mor concluded that COVID-19 outbreaks in nursing facilities are related to the amount of “traffic,” or people, coming in and out of a building. In higher-density communities with higher rates of COVID-19 among the general population, the increased risk of introducing COVID-19 into a nursing facility is due to people entering and exiting the facility, he found.

This was further supported by his finding that facilities with higher staffing levels were also more likely to have COVID-19 cases. In other words, higher numbers of people entering a skilled nursing facility increased the likelihood of introducing the virus into the facility.

So What Does Th​is All Mean? 

It’s clear that COVID-19 disproportionately impacts African Americans and Latinos in the general population and in long term care settings. As the research indicates, in urban and densely populated areas, facilities with a large number of beds and staff are more likely to have COVID-19 cases. Such nursing facilities tend to serve African Americans and Latinos because they are in black and brown communities and are chronically underfunded by Medicaid, the predominant form of coverage for these residents. 

In the short term, large facilities in more urban areas and in communities with high rates of COVID-19 must pay particular attention to the number of people entering a facility. Continued steps should be taken to screen individuals entering the building, regularly test staff for asymptomatic cases, and target interactions with residents to reduce person-to-person spread, with special attention paid to the number of different people interacting with each resident. 

In the longer term, state and federal policymakers should reform how long term care is financed. In particular, policymakers should examine Medicaid reimbursement and how financing may need to change as a facility cares for more people of color and individuals who rely on Medicaid.

What additional support will be needed for these facilities, or will they be left on their own? Continuing to ignore these systemic funding problems and kicking the can down the road is short-sighted and risks the health of those most vulnerable in the country. 

As more data become available, it is imperative that we collect ethnic information to help better evaluate racial disparities in long term care and look beyond simple comparisons of differences. 

Instead, we should carefully evaluate what may be contributing to the disparities and identify solutions. Otherwise, we risk implementing changes that do not actually improve the health outcomes of people of color in long term care facilities.  

David Gifford, MD, MPH, is chief medical officer and senior vice president, quality and regulatory affairs, of the American Health Care Association/National Center for Assisted Living.​​

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