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

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.