Jason Semprini (
Abdinasir K. Ali, University of Iowa.
Health Aff (Millwood). 2023 Oct;42(10):1439-1447. doi: 10.1377/hlthaff.2023.00400.
Medicaid expansion narrowed racial and ethnic disparities in health coverage, but few studies have explored differential impact by exposure to structural racism. We analyzed data on historical residential redlining in US metropolitan areas from the Mapping Inequality project, along with data on uninsurance from the American Community Survey, to test whether Medicaid expansion differentially reduced uninsurance rates among nonelderly adults exposed to historical redlining. Our difference-in-differences analysis compared uninsurance rates in Medicaid expansion and nonexpansion states both before (2009-13) and after (2015-19) the state option to expand Medicaid pursuant to the Affordable Care Act took effect in 2014. We found that Medicaid expansion had the greatest impact on lowering uninsurance rates in census tracts with the highest level of redlining. Within each redline category, there were no significant differences by race and ethnicity. Our results highlight the importance of considering contextual factors, such as structural racism, when evaluating health policies. States that opt not to expand Medicaid delay progress toward health equity in historically redlined communities.
医疗补助计划的扩大缩小了健康保险覆盖范围方面的种族和族裔差距，但很少有研究探讨结构性种族主义暴露的不同影响。我们分析了来自“不平等测绘”项目的美国大都市地区历史上的住房抵押贷款歧视数据，以及来自“美国社区调查”的数据，以检验医疗补助计划的扩大是否会降低历史上住房抵押贷款歧视暴露的非老年成年人的保险不足率。我们的差异分析比较了在平价医疗法案于 2014 年生效后，医疗补助计划扩大和不扩大的州在 2009-13 年（扩大之前）和 2015-19 年（扩大之后）的保险不足率。我们发现，在住房抵押贷款歧视程度最高的普查区内，医疗补助计划的扩大对降低保险不足率的影响最大。在每个红线类别内，种族和族裔之间没有显著差异。我们的结果强调了在评估卫生政策时考虑结构性种族主义等背景因素的重要性。选择不扩大医疗补助计划的州会延迟历史上住房抵押贷款歧视社区实现健康公平的进程。
