The impact of historical redlining on neurosurgeon distribution and reimbursement in modern neighborhoods

Abstract

Background: This study examines the lasting impact of historical redlining on contemporary neurosurgical care access, highlighting the need for equitable healthcare in historically marginalized communities.

Objective: To investigate how redlining affects neurosurgeon distribution and reimbursement in U.S. neighborhoods, analyzing implications for healthcare access.

Methods: An observational study was conducted using data from the Center for Medicare and Medicaid Services (CMS) National File, Home Owner's Loan Corporation (HOLC) neighborhood grades, and demographic data to evaluate neurosurgical representation across 91 U.S. cities, categorized by HOLC Grades (A, B, C, D) and gentrification status.

Results: Of the 257 neighborhoods, Grade A, B, C, and D neighborhoods comprised 5.40%, 18.80%, 45.8%, and 30.0% of the sample, respectively. Grade A, B, and C neighborhoods had more White and Asian residents and less Black residents compared to Grade D neighborhoods (p < 0.001). HOLC Grade A (OR = 4.37, 95%CI: 2.08, 9.16, p < 0.001), B (OR = 1.99, 95%CI: 1.18, 3.38, p = 0.011), and C (OR = 2.37, 95%CI: 1.57, 3.59, p < 0.001) neighborhoods were associated with a higher representation of neurosurgeons compared to Grade D neighborhoods. Reimbursement disparities were also apparent: neurosurgeons practicing in HOLC Grade D neighborhoods received significantly lower reimbursements than those in Grade A neighborhoods ($109,163.77 vs. $142,999.88, p < 0.001), Grade B neighborhoods ($109,163.77 vs. $131,459.02, p < 0.001), and Grade C neighborhoods ($109,163.77 vs. $129,070.733, p < 0.001).

Conclusion: Historical redlining continues to shape access to highly specialized healthcare such as neurosurgery. Efforts to address these disparities must consider historical context and strive to achieve more equitable access to specialized care.

Keywords: access; healthcare; neurosurgery; redlining; structural racism.

Figure 1

Homeowners’ Loan Corporation (HOLC) Map of Chicago: Displays a (HOLC) map of Chicago. A historic document illustrating the city’s division into distinct residential security grades. The color scheme denotes this division, with green representing Grade A neighborhoods, the most desirable areas for real estate investment. Blue represents Grade B, yellow represents Grade C, and red signifies Grade D neighborhoods, which denotes the redlined areas indicating high risk and disinvestment. Scans of historic HOLC maps are accessible in the public domain, sourced from the National Archives, offering valuable insights into historical urban development practices and their impact on communities.

Figure 2

Area description of a Homeowners’ Loan Corporation (HOLC) Grade D Community: Is a historical document prepared by the HOLC of a Grade D area within Chicago. It serves as a poignant illustration of the criteria HOLC employed to categorize neighborhoods. Notably, the figure draws attention to the occupations of residents, the presence of foreign.