The Real COVID Numbers Should Factor Out Nursing Homes

The New York Times headline screams: “U.S. Deaths Near 100,000, Incalculable Loss.” It should have read “Nursing Home Deaths Near 50,000, Unfathomable Negligence.” Both headlines are true, but only the imagined one is about a loss that could have been mitigated by proper policies and with well-understood protective measures. We know far less about what could have been done differently to avoid the fate of the other 50,000 or so people who succumbed to COVID-19, caused by the SARS-CoV-2 virus. So, the Times was alerting us to nothing useful.

It is becoming more universally known that governors in several states, most notably the Democratic governor of New York, Andrew Cuomo, mandated that nursing homes accept residents being released from the hospital after being diagnosed with COVID-19. Combined, the top seven states (New Jersey, New York, Massachusetts, Pennsylvania, Michigan, Illinois, and Connecticut) account for half the deaths in long-term care facilities (LTCFs), which account for nearly half of the total U.S. COVID-19 deaths.

Historians and public health experts in the future will try to sort out to what extent the governors’ policies were responsible. It is clear that the resident population in LTCFs have a much higher incidence of comorbidities (conditions making them more susceptible to disease and death) and are far older than the general population (an appropriate allusion to prison these days). LTCFs are also generally ill-equipped to handle contagious diseases, and in far too many cases, are not maintained or sanitized as they should be. We will leave that debate to others for now.

But the refashioned headline does imply that there are really two statistical universes when it comes to COVID-19 mortality tracking: LTCFs and everywhere else. That means the relevant number for the average U.S. resident is the 50,000 or so deaths outside of the LTCF universe.

Examining that universe leads to different implications than would be reached using the gross number alluded to by the Times. As of May 22, the American Heart Association reports 94,708 deaths from COVID-19. Looking deeper into the data by state and combining it with data from Freeop.org about nursing home fatalities by state, the data allows us by subtraction to examine the impact of the virus on the general population. (For the 11 states not reporting on nursing homes, we applied the average of the others.)

It turns out that 34 states plus D.C. and Puerto Rico each had fewer than 500 fatalities from the virus over the course of three months; of those, 17 states have reported fewer than 100 deaths. In those 36 jurisdictions, it is unlikely that the healthcare system was ever threatened (although in some rural settings distance to care is a challenge, and Puerto Rico may be chronically underserved). 

It is also doubtful that the more severe restrictions imposed, especially lockdowns, were necessary given the small number of serious cases. The basic distancing, group limitations, hygiene, and masking protocols arguably would have been totally sufficient. Businesses without tightly packed workers could have continued with minor accommodations.

Then there is a middle tier of 10 states with deaths ranging between 500 and 1,600. Only the “top” six states had mortality over 2,000, with New York far ahead at nearly 25,000. It should have been obvious early on, even with only the initial fraction of cases and deaths, that the more draconian public health measures should be implemented first in the six or 16 most affected states. Those measures easily could have been held off in the remaining locations pending actual results.

This data was available in a timely fashion, so resorting to a “one-size-fits-all” approach was inappropriate. But the political pressure grew from those unwilling to accept the “flatten the curve” imperative as being sufficient and who believed that preventing every possible death was worth any price in economic harm. Also, the experts seem to have gotten sidetracked believing the novelty of this virus extended to methods of transmission, which now does not appear to be the case. 

What is novel, in fact, is the long incubation period and the ability of pre-symptomatic and asymptomatic individuals to infect others. In a sense, the experts panicked and advised almost universal draconian measures, while inexplicably overlooking the value of masks to prevent infected individuals from spreading the virus before they knew they had it.

The current fashion is to criticize loudly the people attempting to manage this pandemic. As expected, much of this is based on pure opinion and outright speculation. There is usually an underlying assumption that, had other people been involved from the outset, the decisions and results would have been different and better without the benefit of hindsight or knowledge gained over the course of the pandemic. That, of course, is impossible to know.

Any objective observer (the species seems to be endangered) must acknowledge that the scientific knowledge was rapidly evolving, and the public reporting was contradictory and often wrong. This then stoked a fear factor that had political consequences and strongly influenced policymakers. For all the reasons above, there is no compelling basis to argue that another set of people would have reacted in a significantly different way.

The oversight of not separating statistics about LTCFs from the totals, however, has had enormous economic consequences. Limiting restrictions (at least until actual experience could provide a clearer road map) in places with low general population death rates (not skewed by LTCF mortality) would have made far more sense and caused far less pain. Lack of scientific knowledge is not a viable explanation for this shortcoming. 

Sadly, the press is unlikely even to recognize the underlying nuances of the data and we can expect more of the Times’ kind of shock reporting rather than the careful analysis once embraced by career journalists.

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About Andrew I. Fillat

Andrew I. Fillat spent his career in technology venture capital and information technology companies. He is also the co-inventor of relational databases as a graduate student at M.I.T.

Photo: 4X-image/Getty Images

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