Our findings of racial and ethnic disparities in Covid-19 provide important distinctions from previous reports in the US and other countries with ethnically diverse populations. To our knowledge, the largest national study of race/ethnicity and Covid-19 in the US to date included 580 individuals across 14 states, showing that black individuals represented 33% of Covid-19 hospitalizations despite only making up 18% of the total population studied.⁷ In the UK, which was the first country with an ethnically diverse population to experience a Covid-19 outbreak,²¹ a study of 17 million individuals showed that those from minority backgrounds had a substantially higher risk of in-hospital death from Covid-19, which was not fully explained by underlying health conditions or deprivation.²² While our study also found racial and ethnic disparities that were not fully explained by health status, we found that these disparities occurred primarily at stages prior to hospitalization (i.e., testing positive for Covid-19). We found no evidence of racial or ethnic disparities in 30-day mortality once models were restricted to those who tested positive for Covid-19.

We demonstrated that black and Hispanic individuals were more likely to test positive than their white counterparts even after accounting for underlying health conditions, other demographics, residence type, and site of care. Our finding may still be an underestimate of the US population risk as health disparities in VA tend to be smaller than in the private sector.²³ Based on experience with 1918 Spanish Flu and the 2009 H1N1 epidemic, public health experts have warned that racial and ethnic minority populations may be at higher risk during infectious disease outbreaks due to underlying health conditions, lower access to care, and socioeconomic conditions.^{24 25} Prior reports have highlighted that members of racial and ethnic minorities are more likely to live in densely populated areas or multi-generational households, and minority groups are overrepresented in jails, prisons, and detention centers, all of which lead to reduced capacity to implement physical distancing.^26-30 Similarly, black and Hispanic workers are more likely than their white counterparts to be workers in essential industries who continue to work outside the home despite outbreaks in their communities making them more prone to infection.^30-32

Testing rates for Covid-19 in the VA were higher among black and Hispanic individuals compared to white individuals. Local reporting from metropolitan areas with large minority populations, including New York City³³ and Chicago,³⁴ have highlighted the disproportionate impact of Covid-19 in minority communities. We showed that VA facilities in these cities and others around the country that conducted the highest number of Covid-19 tests also had the highest proportion of black individuals in care. There was a striking difference in the rate of Covid-19 testing by age across race/ethnicity groups, whereby higher rates of testing were observed for middle-aged, white individuals while testing rates steadily increased with age and was highest among those aged 80 or more years among black and Hispanic individuals. White individuals living in urban residences were more likely to be tested than those living in rural residences while the opposite was true among black and Hispanic individuals. Among all individuals tested, those living in urban residences were more likely to test positive for Covid-19 than those living in rural residences. Finally, women were more likely to be tested for Covid-19 than men, but men were twice as likely to test positive. This association strengthened after adjustment and in conditional analyses but should be considered preliminary given limited numbers of women in this analysis.