# Where Inequities Emerge: Racial and Ethnic Differences Across the COVID-19 Hospitalization Continuum

## TL;DR

This study shows that racial disparities in severe COVID-19 outcomes were most evident at hospital admission among Medicaid patients, highlighting the need for early prevention and care.

## Contribution

The study identifies where racial inequities in severe COVID-19 outcomes are most pronounced, emphasizing the role of social determinants and the limitations of insurance coverage.

## Key findings

- Non-Hispanic Black patients were more likely to be hospitalized with COVID-19 than non-Hispanic White patients.
- In-hospital mortality was significantly higher for COVID-19 hospitalizations compared to non-COVID-19 hospitalizations.
- Racial disparities in mortality were not evident during inpatient care for COVID-19 hospitalizations.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Racial and ethnic inequities in severe COVID-19 outcomes persisted among Medicaid beneficiaries despite uniform insurance coverage.Disparities were most evident at hospital admission, underscoring upstream social and structural determinants that shape exposure risk and severity at presentation.

Racial and ethnic inequities in severe COVID-19 outcomes persisted among Medicaid beneficiaries despite uniform insurance coverage.

Disparities were most evident at hospital admission, underscoring upstream social and structural determinants that shape exposure risk and severity at presentation.

Public health significance—Why is this work of significance to public health?
By examining the hospitalization continuum (COVID-19 diagnosis at admission, excess in-hospital mortality, and mortality within COVID-19 hospitalizations), this study clarifies where inequities are most pronounced.Findings show that insurance coverage alone is insufficient to prevent inequities in severe infectious disease-related hospitalization burden and hospital outcomes.

By examining the hospitalization continuum (COVID-19 diagnosis at admission, excess in-hospital mortality, and mortality within COVID-19 hospitalizations), this study clarifies where inequities are most pronounced.

Findings show that insurance coverage alone is insufficient to prevent inequities in severe infectious disease-related hospitalization burden and hospital outcomes.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
Equity-focused strategies should prioritize prevention, early diagnosis, and timely outpatient evaluation and treatment access to reduce avoidable hospitalizations in Medicaid and similarly vulnerable populations.Continuum-based evaluation of inequities can guide more targeted preparedness and health system responses for the COVID-19 endemic phase and future public health emergencies.

Equity-focused strategies should prioritize prevention, early diagnosis, and timely outpatient evaluation and treatment access to reduce avoidable hospitalizations in Medicaid and similarly vulnerable populations.

Continuum-based evaluation of inequities can guide more targeted preparedness and health system responses for the COVID-19 endemic phase and future public health emergencies.

COVID-19 exposed longstanding racial and ethnic inequities among underserved populations. This retrospective cohort study examined inequities across stages of the hospitalization continuum—from COVID-19 diagnosis at admission to in-hospital mortality, including mortality patterns among COVID-19 hospitalizations—among Medicaid beneficiaries in Kentucky during 2020–2021. Statewide hospitalizations were analyzed using multivariable regression models, with propensity score matching (PSM) used as a confirmatory approach. Non-Hispanic Black patients were more likely than non-Hispanic White patients to be hospitalized with COVID-19 (adjusted odds ratio [aOR] = 1.41; 95% confidence interval [CI] = 1.26–1.59). Across the full cohort, COVID-19 hospitalizations were associated with substantially higher in-hospital mortality compared with non-COVID-19 hospitalizations (adjusted hazard ratio [aHR] = 2.38; 95% CI = 2.09–2.70). Additionally, hospitalizations among non-Hispanic Black patients had a modestly lower hazard of in-hospital mortality compared with non-Hispanic White patients (aHR = 0.81; 95% CI = 0.70–0.94). However, in analyses restricted to COVID-19 hospitalizations, adjusted estimates showed no Black–White differences in in-hospital mortality, with consistent findings from PSM analyses. These results indicate that racial inequities were more pronounced at hospital admission than during inpatient care, underscoring the importance of prevention, early diagnosis, and timely outpatient care as COVID-19 enters an endemic phase.