Questions have been raised since last Summer about New York’s published count of nursing home resident deaths. The State had claimed until this month that nursing home deaths stood at only 7,491, a relatively low rate compared to other states across the nation. This, despite Governor Cuomo’s health department directive issued on March 25th that required nursing homes to accept stable patients returning from hospitalizations, including those with positive COVID-19 test results. The order provided that, “No resident shall be denied re-admission or admission to the NH solely based on a confirmed or suspected diagnosis of COVID-19. NHs are prohibited from requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.”
The stated justification for the policy was that “There is an urgent need to expand hospital capacity in New York State to be able to meet the demand for patients with COVID-19 requiring acute care. “
The directive raised concerns among families of nursing home residents, nursing home operators, and others that despite required precautions, the presence of COVID positive residents could lead to additional infections and deaths. The Associated Press reported that more than 9,000 recovering COVID patients were released to nursing homes following the Health Department action.
The state’s methodology for counting COVID-related nursing home deaths caused a substantial undercount – raising questions about the Governor’s claims that the nursing home death rate was low, compared to other states. Unlike most other states, New York counted only deaths that took place at nursing homes, excluding those of nursing home residents who died elsewhere, such as in hospitals.
The Cuomo administration let the controversy drag on for months, only releasing a complete count after a damning report from the New York Attorney General’s office estimated that the count missed about 50% of deaths of nursing home residents, and a judge ordered the release of totals including nursing home residents’ COVID related deaths that took place outside the facility. The order was the result of a freedom of information request and subsequent litigation initiated by The Empire Center.
The complete count of deaths in the totals, finally released in February 2021, more than six months after the Empire Center’s request was made, showed that 13,297 residents of nursing homes had died in New York State, nearly twice the amount – 7,491 – that the state had reported in late January.
Even worse, the New York Post reported that a spokesperson for the Cuomo administration admitted in a private conference call that “the Cuomo administration had rebuffed a legislative request for the tally in August because “right around the same time, [then-President Donald Trump] turns this into a giant political football.'”
The Administration’s decision to stonewall the release of accurate COVID-related nursing home data raised the possibility that the data was withheld to hide the fact that Health Department’s March order to accept COVID positive patients led to many unnecessary nursing home deaths. But, does the data show that these deaths were out of line with those in other states?
The True Impact of the Health Department Directive Cannot Be Estimated from Available Data
At the outset, it must be acknowledged that we may never know how many people died from exposure to COVID from positive patients who returned from hospitals. And, knowing how many nursing home deaths did occur in New York does not tell us how many resulted from the Health Department’s directive. Even if we knew the number of deaths on a daily basis, without contact tracing information for each death, we could not be sure whether they resulted from the policy.
The regulation was intended to relieve pressure on hospitals that were heavily burdened by COVID patients at the time. Hospitalizations had peaked on April 15th at 18,500, but were still very high, nearly 16,000 on the day the Health Department guidance was issued. Hospital capacity, and personnel and personal protective equipment shortages were severe problems through the March to May period in 2020. If the Health Department policy may have increased nursing home resident deaths, had it not been imposed, other COVID deaths might have been higher.
Nursing Home Residents Nationally Have High Rates of COVID-19 Mortality
Nursing home residents are extraordinarily vulnerable to deaths from COVID. Nationally, 10.5% of nursing home residents have died from COVID-19, as of the end of January. For the rest of the nation’s population, COVID deaths are less than one tenth of one percent.
The high rate of deaths in nursing homes reflects the strong relationship between age and the likelihood of death from COVID-19. One tenth of those aged 30-39 who have been infected died. For those 65-74, 4.6% died, for 75-84, the death rate has been 11.3%, and for those 85 or older, the rate has been 22.2%. For nursing home residents nationally, 20% of infected residents have died from COVID-19.
How New York’s Nursing Home Deaths Compare with Other States
A Crude Comparison
A simple comparison of nursing home deaths between states involves measuring the percentage of nursing home residents who have died in each state. This basic measure has some weaknesses, though, because community rates of infection would be expected to affect rates in nursing homes. States that had higher rates of infection would be expected to have higher nursing home death rates.
Using this crude measure, it is not surprising that the Cuomo administration did not want to disclose the total number of nursing home residents who had died of COVID. While the partial count that the Administration provided showed that the State’s nursing home COVID-19 death rate was 8.3%, the fifteenth lowest in the nation when all deaths are counted the rate is 14.8%, the highest in the nation.
While we don’t know whether the Administration had access to the total number of COVID deaths among nursing home residents, including those who died in hospitals and other places, it is certain that Cuomo’s top officials would have been aware that the number would be substantially higher than the number that had been disclosed to the public and would undercut the Governor’s argument about the Health Department’s directive.
A Better Comparison
Because overall rates of COVID-19 infection vary from state to state, nursing home residents are likely to have varying levels of exposure and deaths depending upon the levels of community infection. Available data permits comparison of the COVID death rates for nursing home residents with people who aren’t residents.
Because nursing home residents are typically elderly and live in congregate settings, the rate of nursing home deaths overall is much higher than it is for people who don’t live in these settings. Nationally, the ratio of nursing home COVID deaths per resident compared to deaths per non-nursing home resident is 114.5 to 1.
In states where the ratio of nursing home deaths to non-nursing home deaths per resident is higher than the national rate, that indicates that for some reason, the COVID death rate for nursing home residents is higher than expected based on community COVID-19 death rates. If the State Health Department’s guidance increased the rate of COVID deaths for nursing home residents in New York State, we would expect that the ratio for New York would be higher than 114.5 to 1.
The data shows that the ratio of the nursing home COVID death rate in New York to the non-nursing home rate is higher than the nation’s – 131.1 to 1 – 14% higher than the national average, but is lower than 19 other states.
Differences in the ratio of nursing home COVID deaths to those outside them could result from a number of reasons including population differences, differences in average staffing levels, differences in state infection control protocols and others. For that reason, we cannot pinpoint the cause of differences in death rates compared to the rest of the population to New York’s policy on releasing recovering COVID-19 patients to nursing homes. But, the data does not show that the rate of nursing home deaths from COVID-19 in New York State has been significantly higher than the rest of the nation.
Although the State Health Department’s decision to require nursing homes to accept recovering COVID-19 patients introduced risk into those congregate settings, the decision did not result in death rates at nursing homes that were disproportionately high when compared with COVID-19 death rates for the rest of New York’s population. The risk of the return of COVID-19 positive residents is likely to have been offset by several factors. The first is the requirement for infection control measures that were imposed by the state Health Department. A second is that we now know that the risk of COVID infection is highest in pre-symptomatic and early symptomatic COVID carriers and decreases later.
The Cuomo administration’s cover-up of data showing the true number of deaths at nursing homes remains indefensible, especially given the fact that the decision was essentially political – to prevent a perceived adversary from examining the data.
Government officials often must make difficult decisions, some with significant consequences for the lives of residents. Most of these decisions involve big tradeoffs – what is gained in one respect is offset by losses in another. Here we know that the potential for benefits in reduced hospital overcrowding may have been offset by some loss of life in nursing homes. But, the available data does not provide evidence that the Health Department’s directive was associated with disproportionate COVID-19 death rates in nursing homes.