The Washington PostDemocracy Dies in Darkness

Income emerges as a major predictor of coronavirus infections, along with race

A covid-19 patient is attached to a ventilator at St. Joseph’s Medical Center in Yonkers, N.Y. (John Minchillo/AP)

Income is a potent force along with race in determining who among the nation’s vulnerable, older population has been infected with the novel coronavirus, according to a federal analysis that lays bare stark disparities in the pandemic’s toll.

The findings released Monday are based on billing records for people on Medicare who have contracted the virus. They echo the commonly understood pattern that black Americans are more likely to test positive for the virus and to be hospitalized for covid-19, the disease it causes, than other racial and ethnic groups. But they also point to the role of poverty as the pandemic has sped through U.S. communities in the winter and spring.

Individuals covered by Medicare, the vast federal insurance program for older Americans, who are poor enough to qualify for Medicaid, the public insurance safety net, were four times more likely to have been infected or hospitalized with the coronavirus than those on Medicare alone, according to billing records from more than 325,000 cases from January through mid-May.

For men, women and every racial, ethnic and age group of Medicare beneficiaries, the rate of coronavirus cases among those with incomes low enough to be on Medicaid is far higher than for everyone else in the analysis. Among those 65 and older, known in health-policy parlance as “dual eligibles,” 1,732 out of 100,000 people were infected, compared with 320 on Medicare alone, the data shows.

Such rates are “drastically higher,” said Seema Verma, administrator of the federal Centers for Medicare and Medicaid Services (CMS), which performed the analysis. The differences are a “clarion call,” Verma said, for changes that would focus on the health problems that come with poverty, including inadequate housing and access to nutritious food.

“At the end of the day,” Verma said on a conference call with journalists, the data analysis “reconfirms long-standing issues around disparities and vulnerable populations” — an issue that has traditionally been more of a priority for Democrats than for the Trump administration and other Republicans. She said the administration will press harder to pay doctors and other providers of care in ways that hold them responsible for making patients healthier, rather than the traditional “fee-for-service” method that simply rewards a high volume of patient visits.

Unlike previous government data about the pandemic — based on reports of tests, hospitalizations or deaths — the new analysis is based on the bills sent to Medicare, the federal insurance program that covers 62 million people who are 65 and older or have a disability.

The analysis looks in particular at the subset of people eligible for Medicaid, the public insurance for low-income Americans, as well as Medicare. Sometimes, people qualify for both because they always were poor, and sometimes they qualify because they have spent their savings — for instance, on expensive nursing-home care.

Verma did not address whether part of the high rates of infection and hospitalization among people in both programs is tied to living in nursing homes, which have been hit hard by the virus. Another CMS official said the analysis does not allow officials to determine the relative weight of poverty vs. living in long-term-care settings.

Officials called the analysis, the government’s first attempt to examine the way the virus has penetrated the nation’s older population, a snapshot. They noted the data is incomplete because doctors, hospitals and others are allowed up to a year to submit bills, known as claims, to the Medicare program, so the government is still awaiting an unknown number of claims for coronavirus treatment.

With the initial report released, the CMS plans to issue monthly updates. It also eventually will perform a similar analysis of coronavirus cases among low-income people on Medicaid, Verma said, but that program’s billing records are submitted to states and are more difficult for federal officials to collect.

Since early in the pandemic, medical practitioners and researchers have noticed that older Americans are especially vulnerable to covid-19. They are more likely to be hospitalized if they get infected and more likely to die.

The new findings show that nearly 110,000 Medicare patients for whom the government has bills were hospitalized for covid-19, about one-third of the cases in the analysis. Of the hospitalized patients, 28 percent died, the data shows.

Of the hospitalized patients in the analysis, about 81,000 are in the traditional version of Medicare, rather than in private Medicare managed-care plans. The government has spent $1.9 billion for the hospital stays of patients in that original version.

For the United States as a whole, there have been nearly 2.3 million cases of coronavirus infection since it began spreading in the winter and over 118,000 deaths. According to a report a week ago by the Centers for Disease Control and Prevention, nearly 400,000 coronavirus cases were reported through the end of May among Americans 60 and older.

The new data is consistent with that of the CDC report in finding pronounced racial and ethnic disparities in how likely individuals are to be infected or hospitalized. The new data found that, out of every 100,000 U.S. residents on Medicare, 731 black people were infected, compared with 380 Hispanics, 281 whites and 256 Asians.

Hospitalizations followed a similar pattern, with 332 out of 100,000 black people on Medicare requiring a hospital stay, compared with 124 Hispanics, 95 Asians and 88 whites.

The rate of hospitalization was nearly four times greater in rural areas than in urban ones, the data shows.

As earlier research has indicated, underlying health conditions play a substantial role in how susceptible people are to the virus — and how likely they are to need to go to a hospital.

By far, the highest rates of infection and hospitalization among people on Medicare are found in patients with end-stage kidney disease, the analysis found. Verma said it has been difficult for such patients to stay at home because they need to travel to dialysis centers.

The data also shows that nearly 80 percent of those hospitalized have high blood pressure, and 60 percent have high cholesterol. The rates for chronic kidney disease, anemia and diabetes are 50 percent each. Nearly half have heart disease.

Verma first said in April that her agency was preparing a demographic analysis of the pandemic, using diagnostic billing codes for testing or treatment of the coronavirus. She predicted at the time the analysis would be available in early May.

On Monday, she said the lag time in filing Medicare claims made it difficult to release an analysis before now.

Coronavirus: What you need to know

Vaccines: The CDC recommends that everyone age 5 and older get an updated covid booster shot. New federal data shows adults who received the updated shots cut their risk of being hospitalized with covid-19 by 50 percent. Here’s guidance on when you should get the omicron booster and how vaccine efficacy could be affected by your prior infections.

New covid variant: The XBB.1.5 variant is a highly transmissible descendant of omicron that is now estimated to cause about half of new infections in the country. We answered some frequently asked questions about the bivalent booster shots.

Guidance: CDC guidelines have been confusing — if you get covid, here’s how to tell when you’re no longer contagious. We’ve also created a guide to help you decide when to keep wearing face coverings.

Where do things stand? See the latest coronavirus numbers in the U.S. and across the world. In the U.S., pandemic trends have shifted and now White people are more likely to die from covid than Black people. Nearly nine out of 10 covid deaths are people over the age 65.

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