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The unevenly distributed pain and suffering from the COVID-19 pandemic present a remarkable case study. Considering why the coronavirus has devastated some groups more than others offers a concrete example of abstract concepts like “structural discrimination” and “institutional racism,” an example measured in lives lost, families shattered, and unremitting anxiety. This essay highlights the experiences of Black people and disabled people, and how societal choices have caused them to experience the brunt of the pandemic. It focuses on prisons and nursing homes—institutions that emerged as COVID-19 hotspots –and on the Medicaid program.

Black and disabled people are disproportionately represented in prisons and jails. Nursing homes and other care facilities are full of people who need care or assistance because of physical or mental disabilities. It’s no accident that so many Black and disabled people are incarcerated and so many disabled people are in nursing homes or other institutions. These realities do not reflect some criminological or biological inevitability. Instead, who ends up in these pandemic hotspots reflects choices our society has made and the value we’ve placed on human lives. The disparate effects are traceable to political and policy decisions—from racially tinged political decisions to pursue a “war on drugs,” to states’ halting progress in increasing the availability of home and community-based services (HCBS) for people with disabilities, to the decisions by a dozen states to reject federal funding for covering more low-income residents. When we look closely, the virus’s rampage through institutions and communities reveals the truth that politics, not biology, determines who is especially vulnerable to poor health and premature death.

High rates of coronavirus illness and death among people with disabilities and Black people are not unconnected. Disability is generally more prevalent among Black Americans than among whites, Latinos, and Asians. The intersection of race and disability is under-studied, but extant research suggests that the higher prevalence reflects Black Americans’ increased likelihood of developing or acquiring disability through social and environmental causes. Negative attitudes towards and devaluation of the lives of Black people and disabled people are connected as well.

This essay explores how the vulnerability of those groups to COVID-19 has been made. It presents an array of choices—some stretching back decades and others more recent—that led to disproportionate representation of Black people and people with disabilities in both nursing homes (particularly those hardest hit by COVID-19) and in prisons and jails. In so doing it will highlight the importance of intersectionality of race and disability in these COVID-19 hotspots. It reviews how decisions regarding the Medicaid program, particularly some states’ choice not to expand Medicaid, have contributed to disparities in the burden of COVID-19 illness and death. The essay concludes by briefly suggesting how going-forward choices made during the pandemic implicate health justice. Keeping equity issues centered will be critical to pursuing policies that mitigate, rather than further entrench unjust health disparities.