Urban Wire It takes more than insurance to improve the health of low-income city residents
Lisa Dubay, Laura Skopec
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Throughout this week, Urban Institute scholars offer evidence-based ideas for policies that can make a difference for communities in Baltimore and beyond grappling with inequality and injustice.  Although this series covers a lot of issues, we by no means address all the challenges that matter.

Freddie Gray’s death while in police custody was ruled a homicide, a tragic but not uncommon cause of death in Sandtown-Winchester, Gray’s Baltimore neighborhood. But even if Gray had not died that day, his chances of leading a long and healthy life would still have been lower than the average Baltimore or Maryland resident.

In 2013, average life expectancy at birth in Sandtown-Winchester was 69.7 years, compared with 73.9 years in Baltimore, 79.6 years in Maryland, and 84.3 years in the wealthy DC suburb of Montgomery County. Between 2005 and 2009, there were an average of 63 deaths per year per 10,000 25-to-44-year-old Sandtown-Winchester residents; among Baltimore residents in the same age range, the average was 43.6.

The Baltimore Department of Health estimates that 50.8 percent of deaths in Sandtown-Winchester between 2005 and 2009 were preventable. Neighborhood residents die from virtually all the same causes as other Baltimore citizens, but in the city as a whole, that number was just 36.1 percent.

Insurance is part of the solution, but not the whole solution

Health insurance coverage is an important part of the solution. It improves access to care, financial well-being, and, ultimately, health outcomes and life expectancy for low-income adults.

But even though Maryland expanded coverage both before and since the enactment of the Affordable Care Act (ACA), insurance alone isn’t enough. In fact, between 2009 and 2013, 56.3 percent of Sandtown-Winchester residents were covered by public insurance, double the percentage of Maryland as a whole. So why aren’t they healthier?

Increasing access through community health services

Communities like Sandtown-Winchester have been plagued by provider shortages for primary care, mental health, and dental care. To confront these issues, the ACA provides increased financing for community health centers in medically underserved areas and integrates behavioral health—including substance use disorder services—into these programs.

Community health centers have had great results managing chronic conditions of their patients and providing access in areas where traditional providers are unavailable. Community health workers are also increasingly being used in underserved areas and have been found to be effective at improving health outcomes among disadvantaged groups. 

Going beyond health care and health services

But again, providing access to health care and services can only do so much.

The disparities between Sandtown-Winchester and the rest of Baltimore across all of the social determinants of health are stark. Thirty-one percent of Sandtown-Winchester residents live in poverty, compared with 19 percent of Baltimore as a whole. Thirty percent of its residents have less than a high school diploma. 

Economic opportunities are also poor: the ratio of businesses to population in Sandtown-Winchester is almost half that of the rest of the city. The neighborhood’s vacant building density is more than four times higher than in Baltimore as a whole, and the lead paint violation rate is more than three times higher.

Sandtown-Winchester has almost twice as many alcohol and tobacco stores per person as the rest of Baltimore, and the energy cutoff rate is more than twice as high. Its non-fatal shooting rate, homicide incidence rate, and juvenile arrest rate are almost twice as high as the rest of Baltimore. A 2011 ranking of 55 Baltimore communities rated it 55th in domestic violence and 54th in infant mortality.

To improve health and longevity, we need a comprehensive approach

Improving the health outcomes and the lives of residents of neighborhoods like Sandtown-Winchester will not be easy. To be effective, policies and investments must empower residents by offering them greater respect and the resources they need to improve their health,  housing, education, workforce training, and the economic development that goes on around them.

At the same time, the approach to law enforcement needs to be re-examined with input from the community.    

There are new models to learn from and innovative approaches being tested that should help find a safer, healthier path forward. 

Illustration by Adrienne Hapanowicz, Urban Institute

Research Areas Health and health care Race and equity
Tags Community-based care Social determinants of health Inequality and mobility Racial inequities in health
Policy Centers Health Policy Center