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Some underlying medical conditions put Covid-19 patients at higher risk of severe outcomes, including death. But much remains unknown about exactly which conditions are involved and how much they increase risk.

To explore the connections between underlying conditions and Covid-19, my organization, FAIR Health, collaborated with the West Health Institute and surgeon Marty Makary of the Johns Hopkins University School of Medicine. Our study, published on Wednesday, sheds some light on the subject.

Using FAIR Health’s vast database of private health care claims, we studied 467,773 patients diagnosed with Covid-19 from April 1 through Aug. 31, looking for the risk factors that increased their odds of dying from Covid-19. Our goal was to inform public health policy, particularly protocols for distributing first-line vaccines or therapeutics.


We did the analyses for people of all ages, and again for those under age 70.

All ages

Across all age groups, Covid-19 patients had greater odds of dying if they had any of the 15 underlying health conditions, also known as comorbidities, shown in the chart below.


* not statistically significant Patrick Skerrett / STAT Source: FAIR Health

The comorbidities are ranked by odds ratio, a measure of the association between the comorbidity and mortality. (An odds ratio of 2 means double the risk compared with someone without the comorbidity.) The comorbidity with the highest odds ratio, 3.06, was developmental disorders, such as delays in development and disorders of speech and language, scholastic skills, and central auditory processing. All 15 odds ratios were statistically significant except for endometrial cancer. While patients with endometrial cancer had increased odds of dying, based on statistical analysis this could be due to chance. The uncertainty might result from the smaller sample size of this particular population.

Next came lung cancer, followed by intellectual disabilities and related conditions such as Down syndrome and other chromosomal anomalies; mild, moderate, severe, and profound intellectual disabilities; and congenital malformations such as certain disorders that cause microcephaly. Other researchers have seen similar associations for developmental disorders and intellectual disabilities and for lung cancer. Our findings echo a warning by the directors of the Intellectual and Developmental Disabilities Research Centers network that Covid-19 might have a disproportionate impact on individuals with intellectual and developmental disabilities.

There are several possible reasons why individuals with developmental disorders and intellectual disabilities might be more likely to die from Covid-19. They often have multiple chronic conditions, and another of our findings was that the odds of dying from Covid-19 rise as the number of comorbidities increase. Individuals with intellectual and developmental disabilities are also at greater risk of becoming infected with the virus that causes Covid-19, both because they are disproportionately represented as workers in essential service, and because many live in group residential settings.

Under age 70

Our initial analysis revealed that Covid-19-related death was highly associated with being age 70 and older. To see if the results differed if we excluded that patient age group, we evaluated the data for patients under age 70.

Among Covid-19 patients under age 70, the top 15 comorbidity risk factors were similar to those among all age groups, but with some differences. Spina bifida and other congenital anomalies of the nervous system, and spinal cord injury, were included only in the list for all age groups. Breast cancer and pressure and chronic ulcers were included only in the under-70 list.

Patrick Skerrett / STAT Source: FAIR Health

One striking difference between the two lists is that lung cancer, which ranked second in the all-age-groups list, ranked first in the under-70 list, with its odds ratio rising from 2.89 to 6.74. In fact, the risk of dying from Covid-19 was generally higher for a comorbidity for patients under age 70 than it was for patients of all ages. This is likely due to patients over age 70 — who have a higher probability of dying regardless of whether they had the comorbidity in question — being included in the all-ages analysis.

Other risk factors

Comorbidities aren’t the only risk factors for dying from Covid-19. Men are more likely to die from it than women and, as said earlier, older people are more likely to die from it than younger people. In our analyses, males were somewhat less likely than females to be diagnosed with Covid-19, with only 46% of all diagnoses in males. Yet 60% of deaths occurred among males.

Similarly, individuals age 70 and older accounted for just 4.8% of Covid-19 diagnoses, but accounted for 42.4% of all Covid-19 deaths.

Lack of comorbidities isn’t 100% protective

We also studied the just under half (48.3%) of Covid-19 patients who had no comorbidities. That was found to be partially protective against dying from Covid-19, but not completely. Among the Covid-19 patients in our study who died, 16.7% did not have underlying health conditions.

Public health message

Our goal in performing these analyses was to inform public health policy and, in particular, to provide actionable data to support policies on vaccine distribution and prioritization. We hope that our findings with respect to the high risk of Covid-19 mortality associated with developmental disorders and intellectual disabilities will provide valuable building blocks into the formation of such policies. And aside from the potential impact of our findings on vaccine-related protocols, they may also prove valuable in heightening the care and treatment of individuals with comorbidities that render them particularly vulnerable to adverse Covid-19 outcomes.

Robin Gelburd is the president of FAIR Health, a national, independent nonprofit organization dedicated to bringing transparency to health care costs and health insurance information.

  • Surprised not to see diabetes, immunocompromised state (weakened immune system) from solid organ transplant, obesity, pregnancy, sickle cell disease, smoking, coronary artery disease, cardiomyopathies or pulmonary hypertension on either list. CDC does list them. And why is Alzheimer’s listed twice?

    • Agree! Plus, where is the over 70 list? No mention that PPEs for staff at many facilities where many of the folks with the listed conditions reside were insufficient, likely leading to greater spread of Covid. Using odds ratios is also problematic without a discussion of how many people have the listed conditions. I haven’t looked it up, but I was not aware that spina bifida was currently a common condition.
      In my opinion, studies like this are a disservice. They are easily misinterpreted and should not be used for policy or resource allocation.

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