Racist redlining policies still have an impact on health

Can a policy that was outlawed more than 50 years ago still have an impact today? A recent study on health disparities among residents of formerly “redlined” communities shows the importance of taking a historical view of health equity issues.

What is redlining?

In the 1930s, the Federal Housing Administration (FHA) was created to offer government-backed mortgages and encourage homeownership. However, these benefits were not available to everyone. Only neighborhoods that the federal Home Owners’ Loan Corporation designated as desirable were eligible for these loans. The HOLC created color-coded maps, on which green stood for “best,” blue for “still desirable,” yellow for “definitely declining” and red for “hazardous.” Much of the designation was based on the neighborhood demographics; neighborhoods with predominantly African Americans, immigrants, and religious minorities were labeled as undesirable, making it more difficult for residents to buy homes and reinforcing residential segregation. From 1934 to 1962, 98% of loans insured by the FHA went to white Americans.

The maps became self-fulfilling prophesies, as “hazardous” neighborhoods — “redlined” ones — were starved of investment and deteriorated further in ways that most likely also fed white flight and rising racial segregation. 

The New York Times, 2017

Although housing discrimination was outlawed in 1968, discriminatory housing policies keep formerly redlined areas segregated and make it harder for residents in these neighborhoods to buy homes and build wealth. The demographic, environmental, and economic impacts of redlining and continued residential segregation are stark. Most neighborhoods formerly designated as “hazardous” are still predominately minority and lower-income. Homes in formerly redlined neighborhoods are chronically undervalued, reducing the wealth that homeowners in these neighborhoods can accumulate. And residents of formerly redlined areas are more likely to be exposed to extreme heat waves, air pollution, and other environmental hazards.

How redlining impacts health today

Similar patterns are seen when it comes to health disparities and redlining. Residents of formerly redlined neighborhoods are at increased risk of health issues like preterm birth, cancer, tuberculosis, and maternal depression.

In a recent study in the Annals of Surgery, clinician researchers and architects at the University of Michigan teamed up to examine whether patients who lived in formerly redlined neighborhoods had worse outcomes after one of five common surgeries. They found that the color-coding of HOLC maps corresponded almost exactly to patients’ risk of 30-day post-operative mortality, complications, and readmissions. For example, the rate of post-surgery mortality for patients in the “best” neighborhoods defined by the HOLC was 5.4%, 5.8% in “still desirable,” 6.1% in “definitely declining,” and 6.4% in “hazardous.”

The color-coding of of HOLC maps corresponded almost exactly to patients’ risk of 30-day post-operative mortality, complications, and readmissions.

Even when researchers controlled for a modern measure of neighborhood disadvantage including education, employment, housing quality, and poverty, patients in neighborhoods formerly labeled “hazardous” had significantly higher rates of post-operative mortality and complications.

This study adds to the evidence of the impact of structural racism on health. Despite the fact that redlining was outlawed decades ago, the impact of this policy must be taken into account when thinking about health disparities. This analysis suggests that factors not captured in current measures of neighborhood disadvantage, such as segregation and racism, can have an effect on recovery from surgeries. For policymakers looking to reduce racial health disparities, improvements in education and environment are not the only community conditions that need to change. We have to also address police violence, which has a strong impact on mental health, and discrimination in the lending and real estate industries that perpetuate residential segregation.

Hospital quality may also play a role. Although hospital factors were not taken into account for this study, we know that hospitals in communities of color are more likely to have poorer outcomes — our hospitals are separate but certainly not equal. Our health care system sets up safety net hospitals for failure, because they are paid less to care for patients with public insurance like Medicaid, and not paid at all to care for uninsured patients. This leaves safety net hospitals with fewer resources to improve their quality of care. 

The legacy of redlining continues to impact health outcomes, but there are little incentives for hospitals to change. We have to end our unequal reimbursement system, so that all hospitals are compensated equally for the patients they serve. At the same time, hospitals caring for communities of color need more support to provide quality of care on par with wealthier hospitals.