UCLA

Background: The first community health centers (CHCs) were created to address the lack of health care services in segregated Black communities, but little research has empirically investigated the relationship between CHC access, medical underservice, and racial residential segregation.Objective: Using Black feminist thought, Critical Race Theory, and the Public Health Critical Race Praxis, this study examined how the residential segregation of Black Americans was associated with medical underservice and CHC expansion between fiscal years 2011 and 2019 among 3 populations: 1) US metropolitan counties; 2) Cook County, IL municipalities; and 3) Chicago census tracts (i.e., neighborhoods). Data: I linked CHC and medically underserved area/population (MUA/P) data from the Health Resources and Services Administration (2010-2019) to demographic, population health, and housing data from multiple sources including the: American Community Survey (2011-2015), Home Mortgage Disclosure Act (2010) and Home Owners’ Loan Corporation (HOLC) (1940). Measures: CHC expansion was first measured as a binary indicator of whether an area had at least 1 new CHC between FYs 2011 and 2019, and then as the number of new CHCs an area gained. MUA/P designation was a binary indicator of whether an area had at least 1 MUA/P designation between FYs 2011 and 2019. Segregation was measured using the dissimilarity and isolation indices for US counties and the index of concentration at the extremes for Cook County municipalities. For Chicago census tracts I measured contemporary redlining using racialized neighborhood credit refusal (an indication of whether a tract has a high proportion of denied mortgage loans and a majority Black population) and historical redlining using perceived mortgage foreclosure risk (a grade from A to D assigned by the HOLC). Analysis: The descriptive analysis compared the characteristics of CHC expansion and nonexpansion areas and geographic variation CHC expansion, MUA/P designations, and segregation. I estimated multivariate logistic and negative binomial models and compared estimates from the national and local samples. Results: Between FYs 2010 and 2019, the number of CHCs among US metropolitan counties in the sample increased from 3,687 to 10,305. Counties with higher Black-White dissimilarity and Black isolation were more likely to gain a new CHC and had a larger number of new CHCs. MUA/P designation only mediated the association between CHC expansion and isolation. At the local level, among Cook County municipalities, the concentration of Black and White residents was not significantly associated with CHC expansion or MUA/P designation between FYs 2011 and 2019. Among Chicago neighborhoods, there was a positive association between MUA/P eligibility and MUA/P designation and the association was moderated by contemporary redlining. Conclusion: The Patient Protection and Affordable Care Act of 2010 created the Community Health Center Fund, a multibillion-dollar investment in CHC expansion. Although the number of CHCs increased drastically, the results from this study suggest racialized geographic inequities in CHC expansion and MUA/P designations existed during the first 9 years of the fund.