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Decisions on how to classify a given death are made by local doctors or coroners, but based on World Health Organization guidelines followed by the U.S. and nearly every other country.
Among death certificates that list COVID-19 as a factor, 92% call it the primary factor.
Hospitals do get 20% more money for Medicare patients (under a bill signed by Trump), but there’s no evidence that has spurred fraud.
Speaking at one of his many recent Wisconsin rallies, President Donald Trump said skewed stats mean the COVID-19 pandemic is overblown.
The pandemic response under Trump has been a central issue of the presidential campaign, with Democratic nominee Joe Biden and an array of third-party groups hammering Trump in campaign ads for what he has — and hasn’t — done to address COVID-19.
Pushing back on this point in Waukesha on Oct. 24, 2020, Trump pointed to how the country is counting COVID-19 deaths and funding COVID-19 healthcare coverage.
"Some countries, they report differently. If somebody's sick with a heart problem, and they die of COVID, they say, ‘They died of a heart problem,’" Trump said. "If somebody's terminally ill with cancer (in the U.S.), and they have COVID, we report them (as a COVID death). And you know, doctors get more money and hospitals get more money. Think of this incentive. … Then you wonder, ‘Gee, I wonder why their cases are so low.’ (The U.S.) and their reporting systems are really not doing it right."
Trump’s contention is that we are counting deaths we shouldn’t actually attribute to COVID-19. And his implication — by mentioning the cost — is that this is being done to financially benefit the healthcare industry.
This gets at a core question for many COVID-19 skeptics — whether the widely-publicized tallies are deaths from COVID-19 or with COVID-19.
Let’s dig in.
Trump is right that a terminal cancer patient’s death could be counted as a COVID-19 death.
But experts say he’s wrong that there’s anything illogical about that. The decision how to report cause of death is made independently at the local level by a physician, medical examiner or coroner, then listed on each person’s death certificate.
The federal agency that oversees mortality data said what is listed as the "underlying" (i.e. primary) cause of death comes down to timing.
"If a terminal patient still had, say 6 months to live, but was infected by the virus and died, the certifier might determine that COVID-19 was the underlying cause of death because of the timing," Bob Anderson, chief of mortality statistics at the CDC’s National Center for Health Statistics, said in an email. "In the same way, if that same terminal cancer patient was in a car accident and died from that trauma, the car accident would be the underlying cause. If, on the other hand, death from terminal cancer was imminent or COVID-19 symptoms were mild, COVID-19 might be viewed only as a contributing factor —not the underlying cause — or, if the patient was asymptomatic, it might not be viewed as a factor at all — and therefore, not reported on the death certificate."
The approach to identifying an underlying cause is laid out by the World Health Organization, which says a "death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma)." The Center for Health Statistics says this guidance is "used in virtually all countries to code and classify causes of death."
In other words, Trump is wrong about U.S. stats being skewed because other countries take a different approach. And his hypothetical about how other countries would classify a person with heart disease who died of COVID-19 is wrong as well.
Among the COVID-19 deaths tallied by the Center for Health Statistics (based on death certificates), COVID-19 was the underlying cause in 92% of them. So roughly speaking, that’s the group that medical professionals determined on an individual basis died from COVID. The remaining 8% are closer to the dying with COVID category — though listing COVID-19 at all means officials believe it played a role in that person dying at that point.
In short, this distinction between dying from COVID or with COVID isn’t nearly enough to alter the scale of the national pandemic, which has killed more than 200,000 Americans.
We should note minimizing COVID by attacking the death figures is hardly a new tactic from Trump.
Trump said in a Sept. 1, 2020 interview on Fox News, "I saw a statistic come out the other day, talking about only 6% of the people actually died from COVID, which is a very interesting — that they died from other reasons."
Trump was referring to CDC data listing comorbidities that went viral due to widespread misinterpretation. The report lists other medical issues people had when they died of COVID-19 — and noted that 94% of people who died of COVID also had another medical issue.
PolitiFact National rated Trump’s claim Pants on Fire after detailing an array of expert input on the nature of this tally. Since Trump is applying similar logic in his latest claim, let’s review what experts told our fact-checkers at the time:
"The point that the CDC was trying to make was that a certain percentage of them had nothing else but just COVID-19," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, in a Sept. 1 interview with "Good Morning America." "That does not mean that someone who has hypertension or diabetes who dies of COVID didn’t die of COVID-19 — they did."
"The numbers that you’ve been hearing, the 180,000-plus deaths, are real deaths from COVID-19. Let there not be any confusion about that."
So why do 94% of death certificates that mention COVID-19 also list other conditions?
When a coronavirus patient is admitted to the hospital, the virus is listed on their medical record. Since the coronavirus attacks the lungs, perhaps they develop respiratory failure, which would also be listed on their record. Unfortunately, they die after going into cardiac arrest, so doctors take note of that, too.
All three of those conditions would be listed on the patient’s death certificate, but COVID-19 started the process.
"The people dying were not going to die but for the acquisition of COVID," said Dr. Myron Cohen, director of the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill.
Lastly, let’s examine Trump’s claim that doctors and hospitals have an "incentive" to code a certain way because they get paid more.
It is true that hospitals get an extra 20% for Medicare patients being treated for COVID-19. This was part of a coronavirus relief bill Trump himself signed on March 27, 2020. Medicare (which covers about 40% of all hospital patients) provides a flat rate payment based on the patient’s diagnosis, and the CARES act included additional payment to address the complications and costs that typically accompany COVID-19 patients.
But Trump’s implication that something nefarious is connected to this is unsupported. We’ve seen no evidence health officials are misidentifying COVID patients for financial gain on any significant scale, and doing so for a Medicare patient would be prosecutable as fraud, experts say.
A similar claim questioning whether COVID counts are inflated because of the financial incentive was rated Half True by PolitiFact National in April. The fact-check noted the additional payments are real but there is no evidence of numbers being padded a result.
To the contrary, researchers have noted the U.S. is likely undercounting COVID-19 deaths due to lack of testing, since the number of people dying nationwide in 2020 is well above normal rates.
The CDC reported Oct. 23 that the U.S. has had 300,000 more deaths in 2020 than would be expected in a typical year, two-thirds of which can be attributed directly to COVID-19. Analyses by the Washington Post, Yale University and others said the remaining deaths are likely from two main sources: Deaths related to COVID-19 where COVID wasn’t listed on death certificates and "deaths at home or in nursing homes from heart attacks, diabetes, strokes and Alzheimer’s disease, among people afraid to seek care in hospitals or unable to get it," the Post reported
Trump said at a Waukesha rally the U.S. is "really not doing (COVID-19) reporting right" because deaths are being improperly counted and hospitals have an "incentive" to pad stats.
This is wrong on every point.
The U.S. is following the same COVID-19 death reporting guidelines as nearly every other country, which come from the World Health Organization. Under those guidelines, someone with heart disease, cancer or any other disease whose death is hastened by COVID-19 would be listed as COVID-19 death.
And while COVID-19 patients do generate slightly higher payments to hospitals if they’re covered by Medicare — due to a bill Trump himself signed — there’s no evidence this has led to any widespread fraud or incorrect reporting as Trump implies.
We rate this claim False.
Donald Trump, Waukesha rally, Oct. 24, 2020
Email exchange with press office, National Center for Health Statistics, Oct. 26, 2020
World Health Organization, INTERNATIONAL GUIDELINES FOR CERTIFICATION AND
CLASSIFICATION (CODING) OF COVID-19 AS CAUSE OF DEATH, April 16, 2020
CDC’s National Center for Health Statistics, Technical Notes: Provisional Death Counts for Coronavirus Disease (COVID-19), accessed Oct. 26, 2020
CDC, United States COVID-19 Cases and Deaths by State, accessed Oct. 26, 2020
CDC’s National Center for Health Statistics, Provisional Death Counts for Coronavirus Disease 2019 (COVID-19), accessed Oct. 26, 2020
PolitiFact, Trump repeats false claim about COVID-19 deaths on Fox News, Sept. 3, 2020
PolitiFact, Fact-check: Hospitals and COVID-19 payments, April 21, 2020
CDC’s National Center for Health Statistics, Excess Deaths Associated with COVID-19, accessed Oct. 26, 2020
Boston University School of Public Health, US COVID Deaths May Be Undercounted by 36 Percent, Oct. 1, 2020
Washington Post, The coronavirus pandemic has caused nearly 300,000 more deaths than expected in a typical year, Oct. 20, 2020
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