Abstract and Introduction
Approximately 27% of adults in the United States live with a disability,* some of whom qualify for Medicare benefits. Persons with disabilities are at increased risk for severe COVID-19–associated outcomes compared with the general population; however, existing studies have limited generalizability† or only pertain to a specific disability (e.g., intellectual). Older age is also associated with COVID-19–associated hospitalization and death, but the extent to which age might contribute to increased risk for severe COVID-19–associated outcomes among persons with disabilities is unknown. To describe the impact of COVID-19 on persons with disabilities and whether and how age contributes to disease rates, CDC assessed COVID-19 cases and hospitalizations during January 2020–November 2021, among Centers for Medicare & Medicaid Services (CMS) Medicare beneficiaries aged ≥18 years who were either eligible because of a disability (disability-eligible§) or only eligible because of age ≥65 years (age-eligible). COVID-19 incidence and hospitalization rates were higher in the disability-eligible group (10,978 and 3,148 per 100,000 population, respectively) throughout the study period compared with the age-eligible group (8,102 and 2,129 per 100,000 population, respectively). Both COVID-19 incidence and hospitalization rates increased with age in both disability- and age-eligible beneficiaries. American Indian or Alaska Native (AI/AN) persons had the highest disability-eligible (4,962 per 100,000) and age-eligible (5,024 per 100,000) hospitalization rates. Among all other racial and ethnic groups, hospitalization rates were higher among disability-eligible than among age-eligible patients. COVID-19 incidence and hospitalization rates among disability-eligible Medicare beneficiaries were disproportionally higher than rates among age-eligible beneficiaries. Collection of disability status as a core demographic variable in public health surveillance data and identification, as well as the addition of disability questions in other existing data sources can guide research and development of interventions for persons with disabilities. Efforts to increase access to and use of COVID-19 prevention and treatment strategies, including activities that support equitable vaccine access regardless of the substantial challenges that older adults and persons with disability face, are critical to reducing severe COVID-19–associated outcomes among these groups.
Medicare fee-for-service claims data, Medicare Advantage Plans encounter data, and Medicare enrollment information were used to identify the first diagnosis or hospitalization¶ for CMS Medicare beneficiaries with COVID-19 during January 2020–November 2021. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes B97.29 or U07.1 (starting in April 2020) were used to identify COVID-19 on a claim or encounter record from any health care setting (e.g., outpatient and inpatient hospital). To better evaluate the contribution of age to disease and hospitalization rates, COVID-19 cases and hospitalizations were stratified into two mutually exclusive groups: aged ≥65 years without disability (age-eligible) and aged ≥18 years with disability (disability-eligible); all disability-eligible adults were grouped together, irrespective of age. Approximately 44% of disability-eligible beneficiaries were also aged ≥65 years; these included persons with developmental, sensory, and mobility disabilities, as well as persons with other or uncategorized disabilities.
Monthly COVID-19 incidence and hospitalization rates were calculated using numbers of COVID-19 cases and hospitalizations among Medicare beneficiaries, divided by the Medicare population, or the population having hospital coverage for each month. Median length of hospital stay, underlying medical conditions, which were defined using measures of Chronic Condition Warehouse chronic disease indicators,** and hospitalization discharge status were compared by eligibility group. Deaths were defined as the number of patients listed as having died on the discharge date (in an inpatient or outpatient setting) or cases for which the inpatient discharge code indicated death. Because previous research suggests that vaccination coverage might differ between disability- and age-eligible groups, with persons with disabilities being less likely to be vaccinated, CMS guidance around analyzing and interpreting COVID-19 vaccine data was considered.†† In keeping with this guidance, COVID-19 vaccination was not included in the analysis, as vaccination records were incomplete or not reflective of vaccine doses administered. Rate differences between groups were tested using two-tailed t-tests for continuous variables and Pearson's chi-square tests for categorical variables; p-values <0.05 were considered statistically significant. Statistical analyses were performed using SAS Enterprise Guide (version 7.1; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§§
The study population comprised 68,911,412 Medicare beneficiaries, including 53,814,118 (78%) who were age-eligible and 15,097,294 (22%) who were disability-eligible. Compared with age-eligible beneficiaries, among whom overall cumulative COVID-19 incidence was 8,102 per 100,000 population, incidence was higher among disability-eligible beneficiaries (10,978 per 100,000) (p<0.001) (Table). The overall COVID-19–associated hospitalization rate was also significantly higher among disability-eligible beneficiaries (3,148 per 100,000) than among age-eligible beneficiaries (2,129 per 100,000) (p<0.001). COVID-19 incidence and hospitalization rates were higher among disability-eligible beneficiaries throughout the study period (Figure 1). Among disability-eligible beneficiaries, hospitalization rates among females and males (3,175 and 3,121 per 100,000, respectively) were significantly higher than those among age-eligible beneficiaries (1,951 and 2,350 per 100,000, respectively) (p<0.001) (Table). Hospitalization rates increased with increasing age in both groups and were also significantly higher among disability-eligible beneficiaries of all age groups (p<0.001). Among disability-eligible beneficiaries aged <65 years, the COVID-19–associated hospitalization rate (2,423 per 100,000) was significantly higher than the overall hospitalization rate in the age-eligible group (2,129 per 100,000) (p<0.001).
Monthly COVID-19 incidence (A)* and hospitalization rate (B)†,§ among age- and disability-eligible¶ Medicare beneficiaries — United States, January 1, 2020–November 20, 2021
*COVID-19 cases per 100,000 population.
†COVID-19–associated hospitalizations per 100,000 population.
§The y-axis scales for panels A and B are different.
¶Age-eligible beneficiaries were aged ≥65 years and had no disability; disability-eligible beneficiaries were aged ≥18 years and had one or more disabilities.
By race and ethnicity, hospitalization rates were highest among AI/AN persons (both disability-eligible [4,962 per 100,000] and age-eligible [5,024 per 100,000]), followed by Black or African American (Black) persons, (disability-eligible = 4,323; age-eligible = 3,318). Hospitalization rates among disability-eligible beneficiaries were significantly higher than were those among age-eligible beneficiaries for all racial and ethnic groups other than AI/AN.
The median length of hospital stay for COVID-19 hospitalizations was 7 days for both disability- and age-eligible beneficiaries. Although place of residence before hospitalization was not identified, the largest proportion of patients were discharged to their home in both groups (58.0% of disability-eligible and 54.4% of age-eligible), followed by discharge to a skilled nursing facility (16.9% of disability-eligible and 17.6% of age-eligible) (Supplementary Table, https://stacks.cdc.gov/view/cdc/118094). Overall, the in-hospital mortality rate was lower among disability-eligible patients (16.5%) than among age-eligible patients (19.0%). However, the mortality rate among disability-eligible beneficiaries aged ≥65 years was 19.1%, similar to that among age-eligible beneficiaries (19.0%).
Among 18 underlying medical conditions¶¶ assessed among Medicare beneficiaries hospitalized with COVID-19, 91.4% of disability-eligible and 90.6% of age-eligible beneficiaries had two or more conditions (p<0.001). The prevalence of 16 of these conditions (including obesity, depression, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and anemia) were significantly higher in disability-eligible beneficiaries aged ≥65 years than in age-eligible beneficiaries (Figure 2).
Percentage of Medicare beneficiaries hospitalized with COVID-19 with 18* selected underlying medical conditions,† by age and disability eligibility§ — United States, January 1, 2020–November 20, 2021
Abbreviation: COPD = chronic obstructive pulmonary disease.
*Eighteen underlying medical conditions: Alzheimer disease and dementia, anemia, asthma, atrial fibrillation, cancer (breast, colorectal, leukemia and lymphoma, lung, and prostate), chronic kidney disease, COPD and bronchiectasis, depression, heart failure, hyperlipidemia, hypertension, ischemic heart disease, obesity, osteoporosis, peripheral vascular disease, rheumatoid and osteoarthritis, schizophrenia, and stroke.
†Data on underlying medical conditions were only available for full fee-for-service beneficiaries who had 12 months of Medicare Part A and B coverage (or coverage until time of death) and no Medicare Advantage Plans coverage during 2020. The chronic disease indicators presented in the figure are a subset of the conditions from the Chronic Conditions Data Warehouse. https://www2.ccwdata.org/web/guest/home/
§Age-eligible beneficiaries were aged ≥65 years and had no disability; disability-eligible beneficiaries were aged ≥18 years and had one or more disabilities.
Morbidity and Mortality Weekly Report. 2022;71(24):791-796. © 2022 Centers for Disease Control and Prevention (CDC)