The uneven impact of Medicaid expansion on rural and urban Black, Latino/a, and White mortality

Abstract

AbstractPurposeTo determine the differential impact of Medicaid expansion on all‐cause mortality between Black, Latino/a, and White populations in rural and urban areas, and assess how expansion impacted mortality disparities between these groups.MethodsWe employ a county‐level time‐varying heterogenous treatment effects difference‐in‐difference analysis of Medicaid expansion on all‐cause age‐adjusted mortality for those 64 years of age or younger from 2009 to 2019. For all counties within the 50 US States and the District of Columbia, we use restricted‐access vital statistics data to estimate Average Treatment Effect on the Treated (ATET) for all combinations of racial and ethnic group (Black, Latino/a, White), rurality (rural, urban), and sex. We then assess aggregate ATET, as well as how the ATET changed as time from expansion increased.FindingsMedicaid expansion led to a reduction in all‐cause age‐adjusted mortality for urban Black populations, but not rural Black populations. Urban White populations experienced mixed effects dependent on years after expansion. Latino/a populations saw no appreciable impact. While no effect was observed for rural Black and Latino/a populations, rural White all‐cause age‐adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural‐ and urban‐specific Black‐White mortality disparities but did not shrink the rural‐urban mortality gap.ConclusionsThe mortality‐reducing impact of Medicaid expansion has been uneven across racial and ethnic groups and rural‐urban status; suggesting that many populations—particularly rural individuals—are not seeing the same benefits as others. It is imperative that states work to ensure Medicaid expansion is being appropriately implemented in rural areas.