Medicaid Expansion Improved Health Equity for Redlined Areas

In historically redlined areas, states that adopted Medicaid expansion saw lower uninsurance rates than nonexpansion states, a study published in Health Affairs uncovered.

Redlined areas were determined “hazardous” (Home Owners’ Loan Corporation grade D) for investments in the 1930s through a law that remained active until the late 1960s. The presence of non-White, low-income populations determined a neighborhood’s grade. As a result, these areas have had less wealth accumulation, perpetuating economic inequities due to race and class.

To this day, redlined areas are tied to lower rates of home ownership—a key factor in wealth accumulation—, lower access to healthcare, worse health outcomes, and higher mortality rates compared to non-redlined neighborhoods.

“Although measuring disaggregated health outcomes remains critical for advancing health equity, our findings support the growing evidence that health services and policy research focused solely on individual-level measures of disparities may be missing important contextual or community-level measures related to multiple forms of racism,” the researchers explained.

The researchers leveraged American Community Survey (ACS) data from 2009 to 2013 and from 2015 to 2019 to observe differences in uninsurance rates before and after Medicaid expansion took effect in 2014. They used Medicaid expansion data from KFF and redlined appraisal data from the Mapping Inequality project.

Over 11,640 census tracts were analyzed in this study, separated into four categories with category 4 having the most redlining. Of the historically redlined tracts that the study assessed, over 1,900 were in Medicaid expansion states while nearly 1,800 were in non-expansion states.

Prior to expansion, states that ultimately expanded their Medicaid programs had higher uninsurance rates in category 4 census tracts (30.0 percent). Before Medicaid expansion took effect, uninsurance rates were highest in census tracts with the most redlined districts across all races and ethnicities.

After Medicaid expansion, uninsurance rates for individuals in redlined areas declined in both nonexpansion and expansion states. In Medicaid expansion states, uninsurance dropped 6.2 percentage points in category 4 areas, with no statistically significant effect on categories 1 through 3.

The researchers determined how much uninsurance decreased in expansion and nonexpansion states before and after the Affordable Care Act’s implementation. Then, they compared the amount of the decrease and discovered that in Medicaid expansion states had a higher decline in uninsurance relative to nonexpansion states.

Hispanic adults living in category 4 areas of Medicaid expansion states had the biggest decline in uninsurance when compared to individuals in nonexpansion states. Uninsurance among Hispanic populations in category 4 areas in Medicaid expansion states was 7.9 percentage points lower than in nonexpansion states.

Meanwhile, non-Hispanic Black category 4 area residents in Medicaid expansion state areas saw a 5.7 percent lower uninsurance than similar populations expansion states. Non-Hispanic White adults in the same regions achieved an uninsurance rate 3.9 percentage points lower than in expansion states.

In nonexpansion states, the average uninsurance rate for non-Hispanic Black individuals living in highly redlined census tracts was 15.7 percent. For Hispanic individuals the average uninsurance rate in these areas was 23.4 percent. In heavily redlined census tracts, the average uninsurance rate was lowest for non-Hispanic White individuals (13.6 percent).

In census tracts that were not redlined, only non-Hispanic White nonelderly residents saw significant declines in uninsurance due to Medicaid expansion.

The study had some limitations, including the inability to detect differences in uninsurance rates within census tracts, the inability to look at the data by census tract, and the fact that these results are restricted to historically HOLC redlined districts which excluded Washington, DC.

“By reducing uninsurance rates in the most heavily redlined census tracts, Medicaid expansion may have helped reduce the burden of historical racial segregation. This benefit has not yet been realized in the most heavily redlined communities in nonexpansion states,” the researchers concluded. “The gap is especially detrimental for the pursuit of health equity in these states.”

Separate studies have demonstrated the effects of Medicaid expansion on coverage gains and uninsurance among underserved populations.