How Medicaid expansion has helped redlined neighborhoods in Iowa, across US, get insured

Medicaid expansion helped remedy the effects of historical redlining for people living in those communities, according to a new study from the University of Iowa.

Published this week in the journal Health Affairs, the new study found states that expanded Medicaid saw a significant drop in uninsured rates in neighborhoods that historically had high levels of residential redlining, which was specifically designed to segregate Black families and other ethnic minorities from suburban neighborhoods in metropolitan cities.

The study's researchers argue that their findings show that Medicaid expansion has helped reduce the burden of historical racial segregation felt by these communities decades later.

"We can attribute about 5-6% less uninsurance in these higher redlined areas directly because of the decision to expand Medicaid," said Jason Semprini, author of the study and a postdoctoral scholar at the University of Iowa College of Public Health. "If these other states would have expanded Medicaid, they would have likely seen a very similar change."

The study was conducted by researchers from the University of Iowa and the University of South Carolina.

What is redlining?

Redlining refers to the historical government-sponsored practice that excluded Black residents from buying homes by ranking the loan worthiness of certain neighborhoods, marking primarily Black neighborhoods in red ink to signify they were more "risky" to mortgage lenders. That prevented many Black families from buying homes.

The practice, which came about during the 1930s as part of President Franklin Roosevelt's New Deal, had a lasting impact. Residents of these neighborhoods had a higher prevalence of poverty and poorer health outcomes because of their reduced access to health care, food and other necessities.

But the study found the expansion of state-based Medicaid programs may have helped alleviate the effects of that racial discrimination by reducing uninsured rates in the most heavily redlined census tracts.

How has Medicaid expansion reduced redlining's impact?

States that expanded Medicaid saw uninsured rates among adults decline an average 6.2 percent points in metropolitan communities with the highest levels of historical residential redlining, compared with non-expansion states.

Hispanic adults saw the greatest decline, falling an average 7.9 percentage points after 2014, while uninsured rates among Black adults fell 5.7 percentage points.

Semprini said the impact on uninsured rates was not just felt on Black and brown adults, but white residents of those neighborhoods as well. Among white adults, the uninsured rate fell 3.9 percent.

"While we found that the biggest impacts were in these communities that were previously redlined, but within these redlined communities, we didn't see any difference by race or ethnicity," he said. "Structural racism affects everyone. Structural racism led to disinvestment in these communities."

Does the Medicaid expansion's impact go beyond Iowa communities?

The impact Medicaid expansion had in Iowa is similar to the national average, Semprini said.

The average uninsurance rate in the highest redlined communities in the state's metropolitan areas before expansion was 26%. After expansion, that fell to 16%, which included a 5% decline that researchers directly attribute to increased access to Medicaid.

In states that did not expand Medicaid, the average uninsured rate was 21.6 percent in communities with the highest level of redlining. Those rates were 23.4 percent for Hispanic adults, 15.7 percent for Black adults and 13.6 percent for non-Hispanic White adults.

How did researchers determine the impact of Medicaid expansion?

Dozens of states, including Iowa, implemented and adopted Medicaid expansion under the Affordable Care Act when it was implemented in 2014, allowing more low-income residents to qualify for coverage under the program.

To study its impact, researchers compared five-year uninsured rates in expansion and nonexpansion states and its relation to redlined communities using Census data of major metropolitan areas across the country.

Semprini said researchers found the greatest impact from Medicaid expansion in areas with the highest prevalence of historical redlining. Those neighborhoods with lower instances of this real estate segregation did not see as dramatic a change in uninsured rates.

Though Medicaid expansion helped alleviate some of the negative consequences that resulted from historical redlining, Semprini said more work needs to be done in order to help those residents see continued improvement.

"Insurance is critical to accessing the health care system, to getting the care that they need and maybe more preventative care," Semprini said. "But at the same time, without more investment — whether its health care, financial or education — those areas are still going to be experiencing the negative consequences of disinvestment from structural redlining."

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mramm@registermedia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm