African Americans make up 12.4 percent of the population, but accounted for 23.8 percent of the nation's COVID-19 deaths, as of June 23. This disparity has gained considerable attention in light of the protests sweeping the country.
But the situation is more complicated than it seems. According to a working paper released by the National Bureau of Economic Research (NBER) last week, the racial disparity in COVID-19 deaths "does not appear to be due to differences in income, poverty rates, education, mix occupational or even access to health insurance. "
Instead, the document argues that "a significant part of the disparity may … be caused by the use of public transportation."
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Racial disparities in health outcomes are complicated. But they are not positive proof of a racist healthcare system, nor do they lend themselves to simple solutions, such as expanding public health insurance programs.
How can we explain the disproportionate impact that COVID-19 has had on black Americans? It is well established that COVID-19 is more deadly for people with chronic conditions than for those without it. Unfortunately, African Americans suffer from these conditions at higher rates than whites: 40 percent more for hypertension and 60 percent more for diabetes.
Some claim that lack of access to medical care is to blame. NBER newspaper author Virginia University economist John McLaren quotes a pastor in Washington, DC: "I have seen that diagnostic tests are not done … and hospitalizations are extremely shortened, or do not occur at all , due to insurance. "
However, when McLaren handles the numbers, he concludes that "access to health insurance is not a driver of the racial mortality disparity."
That finding is important, as it suggests that spending billions of dollars on expanding public health insurance programs like Medicaid would do little to fight COVID-19.
The study seems to indicate that making public transportation systems safe would go a long way in reducing the devastation that COVID-19 has caused, particularly for African Americans.
McLaren's conclusion that "a substantial fraction of the racial disparity in mortality is due to the use of public transportation" is also significant. It seems to indicate that making public transportation systems safe, perhaps religiously cleansing them or rigorously applying mask-wearing and social distancing protocols, would go a long way in reducing the devastation that COVID-19 has wrought, particularly on African Americans.
The link between public transportation and COVID deaths is remarkable. In Brooklyn, for example, 61 percent of people use public transportation to go to work; in Los Angeles, only 6 percent do. In April, Brooklyn had 1,628 COVID deaths per million, compared to just 72 deaths per million in Los Angeles. According to McLaren's mathematics, public transportation accounted for 59 percent of the difference in mortality between the two cities during that month.
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Investigators have been struggling to explain racial disparities in health care long before COVID-19 hit our shores. A landmark 2006 study divided the country into eight groups, or "Eight Americas," to better understand how various factors influenced life expectancy. The study authors found that "disparities in life expectancy cannot be explained solely by race, income, or access to and use of basic medical care."
For example, Hispanic Americans have higher rates of chronic disease and a lower socioeconomic status, on average, than whites. But they tend to live longer than their white peers. Researchers have attributed this "Hispanic paradox" to everything from lower smoking rates, to stronger family networks, to genetics.
Expanding government health insurance programs would not do much to change the genetic and social factors that influence these disparities. In any case, it would leave the beneficiaries of the programs in a worse situation. Doctors are less likely to accept Medicaid than any other form of insurance due to its low reimbursement rates. Studies have shown that the results for people on Medicaid, about 71 million today, are no better than people in a similar situation who remain uninsured.
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Conversely, markets can do more to "erase" racial disparities than any government program. The American market-based system has fueled medical innovation that has helped add five years to the life expectancy of the US between 1980 and 2010. The life expectancy of all Americans has increased since 2007, and the The gap between life expectancy for blacks and whites has narrowed.
The COVID-19 outbreak has not affected the country equally. But that is not evidence of institutional discrimination.
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