African-Americans make up 12.4 percent of the population but have 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 appears. According to a working paper published by the National Bureau of Economic Research (NBER) last week, the racial disparity in COVID-19 deaths "does not seem to be due to differences in income, poverty rates, education, occupational mix or even access to health care insurance."
Instead, the paper argues, "A significant portion of the disparity can ... be sourced to the use of public transit."
Racial disparities in health outcomes are complicated. But they're not proof positive of a racist health care system – nor do they lend themselves to simple solutions, like expanding public health insurance programs.
How can we explain the disproportionate impact COVID-19 has had on black Americans? It's well established that COVID-19 is deadlier for people with chronic conditions than for those without. Unfortunately, African Americans suffer from these conditions at higher rates than whites – 40 percent higher in the case of hypertension, and 60 percent higher in the case of diabetes.
Some claim that a lack of access to health care is to blame. The NBER paper's author, University of Virginia economist John McLaren, quotes a Washington, D.C., pastor: “I have seen diagnostic tests not performed ... and hospitalizations cut extremely short – or not happen at all – because of insurance."
Yet, when McLaren runs the numbers, he concludes that "access to health care insurance is not a driver of the racial mortality disparity."
That finding is important, as it suggests that spending billions of dollars expanding public health insurance programs like Medicaid would do little in the fight against COVID-19.
The study seems to indicate that making public transportation systems safe would go a long way toward reducing the devastation COVID-19 has wrought, particularly on African-Americans.
McLaren's conclusion that a "substantial fraction of the racial disparity in mortality is due to the use of public transit" is also significant. It seems to indicate that making public transportation systems safe – perhaps by cleaning them religiously or rigorously enforcing mask-wearing and social distancing protocols – would go a long way toward reducing the devastation COVID-19 has wrought, particularly on African-Americans.
The link between public transport and COVID deaths is remarkable. In Brooklyn, for instance, 61 percent of people use public transportation to get to work; in Los Angeles, just 6 percent do. In April, Brooklyn had 1,628 COVID deaths per million, compared to just 72 deaths per million in Los Angeles. By McLaren's math, public transportation accounted for 59 percent of the difference in mortality between the two cities during that month.
Researchers have been struggling to explain racial disparities in health care long before COVID-19 arrived on our shores. A landmark 2006 study broke the country down into eight groups, or "Eight Americas," to better understand how various factors influenced life expectancy. The study's authors found that "disparities in life expectancy cannot be explained by race, income or basic health-care access and utilization alone."
For example, Hispanic Americans have higher rates of chronic disease and 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 rates of smoking, to stronger family networks, to genetics.
Expanding government health insurance programs wouldn't do much to change the genetic and social factors that influence these disparities. If anything, it would leave the programs' beneficiaries worse off. Doctors are less likely to accept Medicaid than any other form of insurance because of its low reimbursement rates. Studies have shown that outcomes for people who receive Medicaid, about 71 million today, are no better than similarly situated people who remain uninsured.
By contrast, markets can do more to "erase" racial disparities than any government program. America's market-based system has driven the medical innovation that has helped add five years to U.S. life expectancy between 1980 and 2010. Life expectancy for all Americans has increased since 2007, and the gap between life expectancy for blacks and whites has narrowed.
The COVID-19 outbreak has not hit the country equally. But that's hardly evidence of institutional discrimination.