Structural racism encompassing groups, not bigotry targeting individuals, drives much of the healthcare inequity in the U.S., according to a study in Health Affairs.
The specific racist structure that researchers with the University of Iowa cite involves residential “redlining,” a method the federal government used to guide banks away from approving home loans to minorities. The residual effects of that program are still being felt.
The expansion of Medicaid coverage under the Affordable Care Act (ACA) helped address the problem to some extent, but not all states elected to take advantage of that opportunity.
“Emerging evidence has begun to show that exposure to redlining (living in previously redlined neighborhoods) is consistently associated with poor health and higher mortality rates,” the study said.
Researchers used data from the U.S. Census Bureau’s annual American Community Survey of about 3.5 million individuals, looking at the five-year average uninsurance rate for 2009-13, and again for 2015-19. It did not include 2014, the year that states could choose to expand Medicaid coverage under the ACA.
The study looks at uninsurance rates for non-Hispanic Blacks, non-Hispanic whites and Hispanic non-elderly adults ages 18 to 64. Researchers considered states that expanded Medicaid as treatment states and those that did not as control states.
“In addition to stratifying the sample by race and ethnicity, we grouped census tracts into four categories on the basis of historical redlining patterns, with one indicating the least amount of redlining and four indicating the most,” the study said.
Medicaid expansion states contained 1,928 previously redlined neighborhoods, while states that did not expand the program comprised 1,793 such tracts. Before passage of the ACA, uninsurance rates were highest in the redline areas in both expansion and nonexpansion states.
Compared to change in nonexpansion states, uninsurance rates among non-elderly adults in formerly relined districts declined 5.7 percentage points more for non-Hispanic Black adults, 3.9 percentage points more for non-Hispanic white adults and 7.9 percentage points more for Hispanic adults. Medicaid expansion lowered uninsurance rates for these groups in the areas with the most severe redlining. However, within each redlined category, researchers found no statistical evidence that Medicaid expansion affected differences in uninsurance rates among different races or ethnicities.
“By reducing uninsurance rates in the most heavily redlined census tracts, Medicaid expansion may have helped reduce some of the negative consequences of structural racism and racial segregation,” the study found.
However, it added that “structural racism, not race, is the cause of health insurance disparities. When implementing and evaluating health policy reforms, policy makers should address not only individual-level factors but also contextual factors such as structural racism.”
The Home Owners’ Loan Corporation (HOLC), a federal agency created in the 1930s, determined what neighborhoods could be considered risky investments for mortgage lenders. HOLC used a grading system: from A, “always upper or upper-middle class white” and therefore desirable, down to D, “infiltrated with undesirable populations such as Jewish, Asian, Mexican, and Black families,” and therefore a very bad risk, according to the agency.
HOLC maps colored neighborhoods rated D different shades of red, and, following the government’s lead, banks either would refuse to grant mortgages in redlined neighborhoods or OK home loans only at exorbitant interest rates.
“Disproportionate access to credit for white middle- and upper-class families led to decades of wealth accumulation that was disproportionate to that of working-class and minoritized groups who lacked such access,” the study said, “Moreover, systematic disinvestment from minoritized communities prevented these communities’ residents from realizing the benefits of [post-World War II] economic prosperity experienced by white Americans.” Researchers note that home ownership represents the biggest source of wealth for most Americans.
The Civil Rights Act of 1968 abolished redlining, but researchers argued that the law, along with the ACA, could not sweep away the residual effects of generations of redlining, including the undergirding of healthcare inequities.