State Comparison of Covid-19 Lockdowns and Deaths at Long-Term Care Facilities

The ABC Cafe presents the work of Amelia Janaskie at the American Institute for Economic Research and her ground-breaking article “Covid, Lockdowns, & Long-Term Care: State Comparisons.”

After almost a year, we know that Covid-19 predominantly strikes the infirm and elderly. Nursing homes have been hit especially hard by it: nearly 106,000 Covid-19 deaths occurred in nursing homes thus far. 

In May, the Centers for Disease Control (CDC) requested nursing homes start reporting Covid-19 deaths. ANew York Times analysis found that nursing homes constitute only 5% of Covid-19 cases, yet make up 38% of deaths, underscoring the prevalence of it in nursing homes across the country.

Unsurprisingly, viruses, from the common flu to Covid-19, quickly spread in communal settings such as long-term care (LTC) facilities housing the elderly (or those with underlying conditions). Nursing home staff may introduce viruses into facilities or carry them from patient to patient, while residents may become infected through visitors or while receiving routine medical treatments in hospitals or clinics.

The scatterplot below shows the relationship between total Covid-19 deaths per state and total LTC population per state. The trendline shows a strong correlation between the two variables (R-squared = 0.68), suggesting that the level of deaths within a state may be related to the number of LTC residents. New York (above trendline) and California (below trendline) are outliers on the graph, both having large populations in LTCs and high total death counts.

The states with higher percentages of the state population in LTC facilities also tend to have higher proportions of LTC Covid-19 deaths: Iowa’s percentage of Covid-19 deaths in LTC is 46.15%, Minnesota 68.7%, North Dakota 71.04%, and South Dakota 39.9%. However, Wisconsin, which has a relatively high proportion of its population in LTC (at 1.17%), has a low percentage of deaths in LTC at 25.9%. Still, 77% of Wisconsin’s Covid deaths are occurring in the elderly population, but are not as frequent in nursing homes.

In contrast, most states with low percentages of the state population in LTC – Nevada, New Mexico, Texas, and Georgia – have low percentages of deaths in LTC. Delaware, however, is the exception with a low percent of LTC population (0.42%) and a high percent of deaths in LTC (58.56%). 

New Hampshire, Rhode Island, Connecticut, North Dakota, and Minnesota are the five states with the highest percentages of Covid-19 deaths in long term care (LTC). New Mexico, Tennessee, Wisconsin, Nevada, and Hawaii have the lowest percentages of deaths in LTC. The chart below identifies the states with the highest and lowest percentage of deaths in LTC. 

As for the case fatality rate (CFR) – defined as the number of deaths divided by the number of confirmed cases – states with higher CFRs tend to have a higher percentage of deaths in LTC. For example, Connecticut has the highest CFR of 7.44% and the third highest percent of deaths (71.11%) in LTC. However, there are outliers – New Mexico and Michigan – that have a high CFR and low portion of Covid-19 deaths in LTC. 

Another factor influencing the CFR in states is the percentage of the population over 65. Tennessee, for example, has both a low CFR and 27.11% of its Covid-19 deaths occurred in nursing homes. Yet, 93.7% of Covid-19 deaths occurred in individuals aged 65 years or older. 

While a significant portion of states’ Covid deaths may be related to the number of long-term care facilities, several other factors are still relevant as to why LTC recipients are most affected. 

Firstly, some states may have a high population of residents per nursing home. California, Florida and New York have the highest average number of residents per LTC, at 218, 230, and 256 respectively, which is well above the nationwide average of 156 people per LTC facility. By contrast, nine of the ten states (inc. Wash, DC) with the lowest LTC populations (excluding Missouri, for which data only focused on St Louis County) – Alaska, Washington, DC, Delaware, Hawaii, Montana, North and South Dakota, Wyoming and Vermont – are within the bottom 30% for both cases and deaths.

The relationship between LTC Covid deaths and LTC population also omits the quality of care provided in those LTCs. Presumably, facilities with fewer residents per caregiver will receive better care, and there is less possible transmission as staff may be less likely to spread the virus from person to person. On the flip side, more caregivers mean more people entering the facility, and increases the likelihood of Covid-19 being introduced to the LTC facility (regardless of specially-designated ‘covid wings’).

Another important factor is the amount of funding each care facility receives. Nursing homes with more funding are better equipped in acquiring necessary PPE supplies, providing sufficient Covid tests to residents and staff, paying higher wages, or employing staff who have acquired immunity from Covid-19.

Finally, differing family structures, values, and ability to provide at-home care (as well as level of care needed) may impact decisions to move family members into long-term care. The cost, proximity, and availability of care facilities versus alternatives such as travelling nurses or assisted living may also play a role.

Following from these differences, each state’s long-term care (LTC) facilities have been impacted differently, leading states and individual LTCs to adopt varying guidance on mitigating nursing home spread. Some state-level guidance is more detailed. For example, Georgia created a plan to prevent introduction of the virus to facilities by isolating patients returning to the LTC after they receive treatments in the hospital or other clinics (and who could have been exposed to the virus). Others, however, are more vague and less focused.

Regardless, it remains a fact that the case fatality rate is higher for older populations. And a large majority of the elderly do not live in long-term care facilities. About 4.5% of adults aged 65 years and older live in nursing homes, 2% in assisted living facilities and an indeterminate number on their own or within a multi-generational household.

As the Times points out, long-term care residents account for 38% of the deaths related to Covid-19, yet the whole LTC population comprises just 0.74% of the total US population. The relatively small proportion of the population in LTC and the disproportionately high number of Covid deaths in LTC demonstrate that protection ought to focus on where Covid-19 is the most fatal: nursing homes and long-term care facilities.

While nursing homes await the arrival of the vaccine within the next few weeks, the data still speaks to the importance of protecting the elderly in the meantime. The focused protection of nursing homes and promotion of low-risk individuals’ carrying out life as normal both lower the unintended consequences of the pandemic while still keeping people safe. 

A balanced and holistic approach, grounded in data and facts, not fear. This is how we can live rewarding, healthy lives.

Data collected from various sources: Centers for Disease Control and Prevention, Covid Tracking Project, and state-provided data.


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