Persistent effects of historical redlining on present day hospital siting and size

Racial health disparities persist in hospital care access, quality, and outcomes. These disparities are geographically patterned but paradoxically hospital proximity is not protective. Historical governmental policies such as redlining may explain this paradox. Redlining, proxied by explicitly race-based maps drawn by the Home Owners' Loan Corporation (HOLC) in the 1930s, led to extensive depopulation, property devaluation, and political disempowerment in neighborhoods with significant proportions of Black residents in the latter half of the 20th centuries. Hospitals expanding in the post-World War II period due to the Hill-Burton Act may have taken advantage of these racialized economic and political gradients. Our study investigates whether historical HOLC redlining categories are associated with present day hospital location and size.

We used hospital locations from the 2023 Homeland Infrastructure Foundation-Level hospital dataset and redlining locations and categories from the Mapping Inequality dataset. We calculated expected counts of hospitals and total number of beds based on the proportion of land covered by each HOLC category. We compared observed counts of hospitals and beds using Pearson chi-squared tests.

Hospitals were significantly overrepresented in HOLC D red areas by 20.5 % and underrepresented in HOLC A green areas by 35.6 %. Hospital beds were overrepresented in D areas by 56.5 % and underrepresented by 44.7 % in A, 5.2 % in B, and 20.8 % in C.

We show that hospital locations are not evenly distributed throughout the US with regard to 1930s HOLC categories. The expansion of hospital capacity in the post-World War II period may have taken advantage of exploitative policies. Hospitals have the ability and opportunity to correct past injustices and improve health equity today by increasing investments in community benefits.