The Unequal Cost of Social Distancing
Policies during a pandemic must protect vulnerable Americans who bear a disproportionate burden.
Reprinted with permission from Johns Hopkins University
Social distancing will save lives. Its economic costs are staggering. While frustrating but manageable for many people1, the economic fallout of social distancing is brutal for the poorest, most vulnerable and marginalized members of our society.
Even looking at the issue purely in terms of lives lost, injuries sustained and lifelong psychological damage, there are trade-offs that we feel have not been sufficiently acknowledged.
Unemployment will lead to increases in suicide, substance abuse, domestic violence, homelessness and food insecurity. Substance abuse itself — especially the opioid crisis — has already significantly reduced life expectancy in the U.S., and that has been during a time of relative prosperity. Under the current circumstances, it is entirely possible we will see such an impact again. Domestic violence is also deadly, more so now with abusers finding themselves frustrated and at home far more than normal.
Thousands of people will die from these causes, and many more will be severely injured and traumatized for life. While these issues can be universal, they fall hardest on the poorest, most vulnerable members of our population, who we know have been the first to lose their jobs and suffer the most from these terrible problems.
Thus, a grim trade-off is already being made between saving different lives: saving the lives of those who are most vulnerable to COVID-19 versus saving the lives of those who are most vulnerable to suicide, substance abuse and domestic violence. Moreover, these vulnerabilities mean social distancing may be unsustainable for large swaths of the poorest Americans. As decision-makers contemplate medium-term economic versus public health trade-offs, they must do so with an acknowledgement of the severely skewed nature of the costs of distancing.
Why Social Distancing Is So Costly to Vulnerable Households
It is well documented that economic downturns not only cause human suffering due to scarcity, but also lead to health problems and increases in mortality2. In short, the virus is lethal; but so is poverty3.
In the current climate, this burden is not equally shared. To get a sense of the problem, consider that many low-income workers live hand-to-mouth and are housing and food-insecure even when the economy is roaring4. Even before COVID-19 hit, only 61% of all American families had $400 of emergency savings5.
Many low-income workers are not salaried, but work hourly or are part of the “gig” economy. They are more likely to work in retail and service occupations, such as restaurants and salons, and cannot set up home offices to work remotely. In the short run, closure of businesses, lack of work for hourly or gig workers, and layoffs quickly deplete resources of low-income families, making it impossible to meet their most basic of needs. Due to school closures, even more workers are also forced to choose between taking care of their children and working (a trade-off already faced by so many working poor parents due to the high costs of child care). Without reliable internet, printers and tech-savvy parents, children in low-income families are unable to participate in online schooling to the same extent as their more advantaged peers.
Right now, we must recognize that we cannot expect the most marginalized among us to bear the greatest costs of social distancing for weeks or months on end.
The closer we look into the lives of what Michael Harrington famously called “the other America,” the magnitude of challenges low-income families face rises exponentially. For many, the #StayHome directive is not an option: “Home” is not a safe, comfortable place to be. For example, in Baltimore — like many other cities — many poor families live in cramped, low-quality, uncomfortable and even dangerous dwellings, making it more difficult to shelter in place6. Some of this housing also aggravates the asthma symptoms of their children, as mold and vermin infestation trigger episodes7. Multigenerational and complex households are also much more common among the poor: In Italy this proved to be a calamitous challenge8. People cannot enact self-quarantine protocols in crowded or dangerous settings, which creates more ideal conditions for transmission than might otherwise exist.
In many poor households, at least one member has either been a victim of abuse, has a history of violent behavior or suffers from addiction9. Outbreaks of violence or addictive behaviors occur in times of distress10. Indeed, there are already reports of spikes in child abuse and domestic violence, which means families stuck at home already face immediate physical danger. Abuse and violence also have long-run downstream effects on health, education and productivity11. Moreover, the very institutions designed to protect victims of abuse and violence — courts, social service agencies and law enforcement — are themselves shutting down or cutting back while they struggle to determine how to implement social distancing. There’s a serious risk that they will operate at significantly reduced capacity at a time when the need for their services is greater than ever.
For many low-income parents and children, leaving the house to go to work or attend school provides a safe haven that can ease tensions in overcrowded homes12. Recreation centers, libraries and other community providers often make up the difference between what young people need and what their families provide. Many families also rely on service providers to help with addiction treatment and mental health. As these resources close or cut back service, more needs remain unmet. Beyond these short-term needs, there are added long-term costs to the disruptions in life caused by COVID-19. Low-income students already have unstable trajectories through post-secondary institutions when they are open, something only made worse by the shift to virtual learning. Gaps in their progress, the need to care for family and other needs can derail their educational careers, again with grave consequences for their future—and for the economy as a whole13. The consequences of social distancing for vulnerable people will be wide ranging, and the full impact will likely never be quantified.
The ROI of Medicaid
Delivering on multiple fronts in the middle of COVID-19.
By Anna Williams
The COVID-19 pandemic is taking a tremendous toll on large numbers of Americans — and the devastation isn’t limited to people’s health.
As of late August, 1.4 million American workers had filed for unemployment benefits — a number that could climb higher in the months to come. For many people, unemployment has meant not only the loss of a paycheck, but also the loss of health insurance, with many unable to afford coverage on their own.
With such a large number of Americans hit by these dual challenges, it’s clear that recovering from the COVID-19 crisis will require a multipronged solution: one that both helps battle the virus and provides economic relief to the newly unemployed.
Medicaid may be part of the answer. Containing the spread of COVID-19 requires comprehensive testing, treating and tracking — a strategy that only works if all Americans are able to engage in the health care system. And it’s not just about immediate care for COVID: People with existing health conditions, including diabetes and obesity, are at increased risk for severe illness from COVID-19. Shoring up Medicaid can help vulnerable Americans receive the care they need to properly manage such conditions, during the pandemic and going forward.
Medicaid provides more than health coverage. It can also serve as a much-needed jolt to the economy.
Research shows that state and federal support for the program acts as an economic stimulus. For example, a 2018 Louisiana State University study found that Louisiana’s decision to expand Medicaid led to the creation of more than 19,000 jobs and $177.8 million in state and local tax receipts. Louisiana isn’t alone. Similar economic boosts have been documented across the country, including in Arkansas, Colorado and Michigan. And on an individual level, research shows that Medicaid can help prevent medical bankruptcy and break the cycle of poverty. (See Q&A: “Pathway Out of Poverty”.)
During economic downturns, the social safety net is particularly powerful. A 2013 Johns Hopkins University study found that Medicaid successfully expanded during the Great Recession of 2007-2009 to meet the needs of Americans, with a rise in enrollment and an increase in spending from $327 billion in 2007 to $401 billion in 2010. The additional spending was also widely distributed, serving all major demographic groups, and families with and without children.
As more Americans confront their economic vulnerability during this crisis, there’s increasing recognition of the value in building a health care safety net. In a national Harris Poll commissioned by AmeriHealth Caritas in April 2020, a full 83% of respondents said they would sign up for Medicaid if they had no other option for health insurance.
With increasing numbers of Americans vulnerable to health care and economic challenges, a robust Medicaid system could help provide a degree of stability — and a path forward.
What Can We Realistically Expect People to Do?
Given the uneven burden, a concern is that long-term quarantine or social distancing measures are unsustainable, in part because the costs borne by disadvantaged segments of the population are too brutal. However, it is also clear that the consequences of business-as-usual are intolerable. Thus, two untenable views emerge. President Donald Trump argues for a potentially disastrous premature curtailment of social distancing. Many public health experts take a more nuanced view that advocates for some longer period of social distancing. When social and economic costs are acknowledged, however, these concerns are usually a footnote, not a priority. Whether or not we agree with this type of “cost-benefit” analysis of social distancing is likely to be beside the point14. Shuttering the economy indefinitely is unsustainable because the people bearing the biggest costs are unlikely to or unable to abide by the rules of social distancing.
Here, we can learn from previous research on behavior during epidemics. Risky sexual behavior continued through the AIDS epidemic15. We don’t need to look exclusively at epidemics to see this; people continue to smoke when they know about its risks16. More generally, people make choices that they know have negative future consequences, especially when the alternatives are worse. As social scientists, we spend a lot of time trying to understand why and under what circumstances people take risks or avoid them. However, the time to debate why is not now. Right now, we must recognize that we cannot expect the most marginalized among us to bear the greatest costs of social distancing for weeks or months on end. If we devise policy based on the assumption that families who cannot put food on the table will stay home indefinitely, we are fooling ourselves.
We must learn more about social costs and human behavior, including how willing and able different groups of people are to social distance.
Going Forward: Research and Policy
There is broad support for policies aimed at mitigating the economic fallout of COVID-19. [In March], the federal government passed a massive stimulus bill with broad bipartisan support. The bill included provisions to help low-income families, such as direct payments to individuals and expanded unemployment insurance. This bill at best buys struggling families, and thus the country, some time. The hope is that we use the time wisely since it does not buy us an indefinite amount of time to shut down the economy. At some point we need to resume normal activity.
While more help from the federal government is certainly necessary, state and local governments need to step up as well. Many states are taking actions to increase the capacity of their health systems; they must also work to expand services for vulnerable populations. Nine states have reopened health insurance exchanges, and many school districts are providing free meals for children and families. These are steps in the right direction.
With each passing day, there are aggregate economic effects that become difficult to bounce back from. Moreover, with each passing day, the burdens placed on families rise. As this pandemic goes on, the likelihood of the people who suffer the highest costs of social distancing remaining compliant with public health guidance will go down. This is not sustainable, nor is it an acceptable sacrifice to expect people to make.
We must immediately start testing systematically sampled subsets of the population to understand basic information like infection and mortality rates. Right now, efforts to stem the global COVID-19 pandemic are stymied because this information is either nonexistent or difficult to interpret due to lack of systematic randomized testing. Eventually, when COVID-19 is better understood, such information may lead to targeted interventions with lower economic costs. Instead, we are forced to institute radical, blanket measures to stem the spread of the virus, imposing staggering costs on those least able to incur them.
In addition to the urgent need for policy responses, research must be done so that this disorganized, lethal response does not happen again. Beyond learning how to prepare for the direct health consequences of a pandemic, we must learn more about social costs and human behavior, including how willing and able different groups of people are to social distance. It is important to understand how people at low risk of harm from COVID-19, but high risk of harm from social distancing, weigh these trade-offs in this uncertain situation. We must also examine the relative effectiveness of our social safety net during this time: Which policies were the most protective, and which were inefficient? Many of our traditional anti-poverty programs won’t help under social distancing. For example, EBT benefits are useless if people with resources are buying in bulk, therefore hoarding the food low-income parents need. Providing housing vouchers is less likely to relieve housing burdens when landlords can’t meet inspectors or prospective tenants to begin the leasing process. Some special education services cannot be delivered outside of the classroom and in homes without technology. We need to understand far more about the intermediaries who were crucial to the efforts that did mitigate costs, such as the social workers and teachers who creatively risked their own health to deliver therapy and services in the homes of our poorest families.
There are enormous opportunities now, not to mention a duty, to do better not only next time a disaster hits, but all the time, and especially in the wake of this crisis, which will require significant repair. We now have an extraordinary opportunity to learn lessons that will help us craft better policy moving forward.
- Though for some more privileged people, it has been romanticized as an opportunity to spend more time with family, simplify life, engage in hobbies, binge watch TV shows, get ahead at work, and so on.
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- Chetty, Raj, et al. “The Association Between Income and Life Expectancy in the United States, 2001-2014.” JAMA, vol. 315, no. 16, 2016.
- Babic, Mary, et al. “From Paycheck to Pantry: Hunger in Working America” Feeding America 2014.; Braga, Breno, Steven Brown, and Signe-Mary McKernan. “Working to Make Ends Meet During Good Economic Times” Urban Institute 2019.; Economic Research Service “Food and Nutrition Assistance” USDA ERS. 2018. https://www.ers.usda.gov/data-products/ag-and-food-statistics-charting-the-essentials/food-security-and-nutrition-assistance/
- Board of Governors of the Federal Reserve “Report on the Economic Well-Being of U.S. Households in 2018-2019” 2019. https://www.federalreserve.gov/publications/2019-economic-well-being-of-us-households-in-2018-dealing-with-unexpected-expenses.htm
- Deluca, Stefanie, Holly Wood and Peter Rosenblatt. “Why Poor Families Move (and Where They Go): Reactive Mobility and Residential Decisions.” City and Community vol. 18 no. 2. 2019.
- Pacheco, Christina et al. “Homes of Low Income Minority Families with Asthmatic Children have Increased Condition Issues” Allergy Asthma Proceedings, vol. 35, no. 6. 2014.
- Dowd, Jennifer et al. “Demographic Science Aids in Understanding the Spread and Fatality Rates of COVID-19” Oxford Working Paper 2020.
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