Nursing homes are only as safe as their communities

ABOUT 2.2 million Americans, or a little under 0.7 percent of the country’s population, live in nursing homes and other residential-care facilities for the elderly. Residents of these facilities, meanwhile, have by some estimates accounted for more than 40 percent of US deaths from Covid-19.

This “astounding share of deaths,” as conservative health-policy expert Avik Roy described it last month, has raised lots of questions about whether a different approach to managing the disease in the US might have been able to spare the lives of nursing-home residents while allowing for fewer restrictions on everyone else. I don’t exactly have answers to those questions, and in truth I don’t think anyone does yet. I have collected some numbers, though, that may help put the issue in context.

First, there’s nothing particularly surprising about nursing homes and their ilk accounting for a much larger share of Covid-19 deaths than they do of the population. The Centers for Disease Control and Prevention keeps track of deaths by location, and from 2014 through 2018 19.5 percent of US deaths from all causes and 20.9 percent of deaths from internal causes occurred in nursing homes and other longterm-care facilities. Since late January of this year, 24.1 percent of the deaths from Covid-19 for which the CDC has data on place of death have occurred there.

This is lower than the 40 percent-plus cited above because it does not count nursing home residents who die in hospitals. A lot of nursing home residents die in hospitals in normal years, with a large-scale study from the 2000s putting the share at about 20 percent, but with co vid-19t he percentage seems to be at least twice that. So yes, nursing homes do seem to have been inordinately affected. But they have also suffered heavily during past outbreaks of influenza and even the common cold, and though their share of US Covid-19 fatalities is high it hasn’t really been “astounding,” or markedly different from that seen in other countries.

Nursing homes and their ilk are especially vulnerable to infectious diseases such as Covid-19 because their residents are frail elderly people with weak immune systems who spend a lot of time indoors, often in shared bedrooms, and generally cannot avoid coming in close contact with their caregivers. These caregivers, meanwhile, are among the lowest-paid workers in the health-care sector—or any sector, for that matter.

Because pay is so low, caregivers for the elderly often live in overcrowded conditions and work multiple jobs. They’re also less likely to have health insurance or access to paid sick leave than other healthcare workers, and while the Families First Coronavirus Response Act passed by Congress in March addressed these issues somewhat, there were loopholes.

It shouldn’t be too surprising, then, that two recent studies of the characteristics of nursing homes hit hardest by Covid-19 found that the main things they had in common were (1) locations in communities with high incidence of the disease and (2) large size.