In this post, we investigate how the unique comorbidity profile among life settlements lives may impact outcomes due to COVID-19. Our analysis concluded that life settlements likely represents a higher risk comorbidity profile than either the U.S. adult or senior populations. Due to correlations with age, we could not conclude whether this increased vulnerability extends the vulnerability due to age alone as presented in our previous post on the topic.

Comorbidities can dramatically increase an individual’s mortality risk to COVID-19. The CDC lists that among the highest at risk are those with chronic lung disease, moderate to severe asthma, serious heart conditions, a weakened immune system, severe obesity, diabetes, chronic kidney disease undergoing dialysis, and liver disease (1) . Yet, the precise impact of comorbidities on COVID-19 outcomes is still unknown. It is not clear, for example, how the risk from type 1 diabetes differs from type 2 diabetes (2). Ongoing research on COVID-19 comorbidities will likely be useful to many in life settlements, life insurance, and related markets.

An early analysis from China (3) still offers some of the clearest results to date on comorbidities. The authors used data on 44,672 confirmed cases, representing 1,023 total deaths and an overall case fatality rate of 2.3% (4), to study the progression of the outbreak, its geographic spread, and the impact of age and comorbidities on case-fatality rate. The comorbidities included in the study were hypertension, diabetes, cardiovascular disease, chronic respiratory disease, and cancer. Smoking was not included in the study. Of the included comorbidities, cardiovascular disease had the greatest mortality risk (10.5% case-fatality rate). We note, however, that another paper based on outcomes in China identified malignant cancer as the comorbidity with the greatest mortality risk (5).

Using the results of this study, we estimated confidence intervals using a Poisson model for observed deaths and compared the prevalence of these comorbidities in life settlements to the U.S. adult and senior populations.

Table 1. Estimated Case-Fatality Rates by Comorbidity

We used Longevity Holdings’ life settlements dataset (6) to measure prevalence of each comorbidity in the study.  We included all insureds who are alive, are believed to have settled a life insurance policy, and were underwritten by ITM21st.  We worked with ITM21st’s Chief Underwriting Officer to identify the fields captured in ITM21st’s underwriting that correspond to each of seven “comorbidities” (the five comorbidities included in the study, plus gender and smoker).  More than 600 fields are included in ITM21st’s propriety underwriting model.  Finally, we compared these results to CDC and SEER data on U.S. adults and seniors.

Figure 1. Comorbidity Prevalence and Case-Fatality Rate

Table 2. Prevalence of Comorbidities Among U.S. Adults, U.S. Seniors, and Life Settlements

Three comorbidities (cardiovascular disease, hypertension, and male gender) are more prevalent in life settlements than among U.S. seniors.  Three comorbidities (diabetes, chronic respiratory disease, and smoker) are less prevalent in life settlements than among U.S. seniors.  We found cancer frequencies were about the same.  Only chronic respiratory disease and smoking were less prevalent in life settlements than among the broader U.S. adult population.

The net comorbidity profile of life settlements is likely higher than the broader senior population.  According to the study, cardiovascular disease represents the greatest risk among the comorbidities, and it is twice as common in life settlements as among U.S. seniors (38% vs. 19%).  Hypertension and male gender each have about 19% higher incidence rates in life settlements.  In comparison, the comorbidities of diabetes, chronic respiratory disease, and smoking have about 6%, 9%, and 5% lower incidence rates in life settlements.

Note that this study treated age and comorbidities as independent factors, probably due to limited data.  Yet, in our experience, there is usually an interactive effect.  In a previous post, we concluded that if one assumes life settlements and the broader U.S. populations experience similar incidence and fatality rates within age cohorts, then the mortality impact of COVID-19 will be 9-10 times greater in life settlements.  Our analysis here suggests that life settlements also represents a higher risk comorbidity profile.  However, due to correlation of comorbidities and age and potential interactive protective or anti-protective effects, we are unable to conclude whether the net effect of comorbidities and age is greater or less than the effect of age alone.

We compared life settlements to U.S. adult and senior populations on seven comorbidity dimensions.  This analysis suggests that life settlements lives are, on average, higher risk due to comorbidities.  These comorbidities will likely be an important factor in determining which subpopulations will be most impacted by the COVID-19 pandemic and should be monitored by anyone interested in life or longevity risk.

[1] https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html

[2] https://www.jdrf.org/coronavirus/

[3] The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) – China, 2020. Chinese Center for Disease Control and Prevention Weekly.

Available at http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51.

[4] It is important to distinguish between case-fatality and infection-fatality rates because these are often conflated.  Case-fatality rate (CFR) is the ratio of recorded deaths from the illness to total known cases among a population.  Infection-fatality rate (IFR), in comparison, is the ratio of all deaths from the illness to all infections among the population.  Neither the numerator nor the denominator of IFR can be directly measured, however it is likely lower than CFR due to mild cases that have not be diagnosed.  Recent antibody testing in New York City suggests the IFR may be between 0.5-1%, much lower than the CFR, which is currently measured at about 7.5%.  Further antibody testing and measures of all-cause mortality in the coming months will likely improve our understanding of COVID-19’s true IFR.

[5] Guan, Wei-jie et al., Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis, European Respiratory Journal, Vol 55 Issue 4.

Available at https://erj.ersjournals.com/content/early/2020/03/17/13993003.00547-2020

[6] Longevity Holdings is the parent company of ITM21st and Fasano Associates.