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

PURPOSE: To 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. METHODS: We 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. FINDINGS: Medicaid 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. CONCLUSIONS: The 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.

Are Rural Areas Holdouts in the Second Demographic Transition? Evidence From Canada and the United States.

A central premise of the first demographic transition theory is that demographic change would occur more slowly in rural than urban areas. Few studies, however, have investigated whether rural areas remain holdouts during the second demographic transition. To address this gap, this study (1) examines trends among rural and urban families in Canada and the United States over a 30-year period and (2) determines whether compositional differences in demographic, socioeconomic, and religious factors explain current differences between rural and urban families. We find that rural Canadian women continue to have, on average, 0.6 more children than urban women. However, rural families do not trail behind urban families on any other indicator of family change. In fact, rural women in both countries are now significantly more likely to cohabit and roughly 10 percentage points more likely to have children outside of marriage than urban women. These differences are largely explained by lower levels of education and income among rural American women and fewer immigrants in rural Canada. Examining family change through a rural-urban lens fills important empirical gaps and yields novel insights into current debates on the fundamental causes of ongoing family change in high-income countries.

Persistent disparities in affordable rental housing among America's ethnoracial groups.

Housing and residential outcomes in the United States are significantly stratified by ethnoracial group, but the extent to which disparities exist in affordable renting over time is less clear. In this study, I explore affordable housing disparities among White, Black, Hispanic, and Asian renters and test hypotheses regarding variation by education, local ethnoracial composition, and chosen measurement of affordability. Chiefly, I find that White households have higher rates of affordable housing than Black and Hispanic households with disparities remaining nearly identical between 2005 and 2019 and become larger when considering household's ability to afford other basic needs. Nevertheless, returns to education are not uniformly larger for White renters, in that Black and Asian renters experience larger marginal increases in residual income based affordable housing at higher levels of education. The effects of county ethnoracial composition effects are consistent with all groups-including White households-experiencing declining affordability when living in counties with large coethnic populations.

Cost of Living Variation, Nonmetropolitan America, and Implications for the Supplemental Poverty Measure.

Poverty scholarship in the United States is increasingly reliant upon the Supplemental Poverty Measure (SPM) as opposed to the Official Poverty Measure of the United States for research and policy analysis. However, the SPM still faces several critiques from scholars focused on poverty in nonmetropolitan areas. Key among these critiques is the geographic adjustment for cost of living employed in the SPM, which is based solely upon median rental costs and pools together all nonmetropolitan counties within each state. Here, we evaluate the current geographic adjustment of the SPM using both microdata and aggregate data from the American Community Survey for 2014-2018. By comparing housing costs, tenure, and commuting, we determine that median rent is likely an appropriate basis for geographic adjustment. However, by demonstrating the wide variability between median rents of nonmetropolitan counties within the same state, we show that the current operationalization of this geographic adjustment could be improved through the use of more-specific categories such as metropolitan adjacency or Rural Urban Continuum Codes.

Unequal From the Start? Poverty Across Immigrant Generations of Hispanic Children.

Recent cohorts of U.S. children increasingly consist of immigrants or the immediate descendants of immigrants, a demographic shift that has been implicated in high rates of child poverty. Analyzing data from the 2014-2018 Current Population Survey and using the U.S. Census Bureau's Supplemental Poverty Measure, we describe differences in child poverty rates across immigrant generations and assess how these disparities are rooted in generational differences in the prevalence and impact of key poverty risk factors. Our estimates show that poverty rates among Hispanic children are very high, particularly among first-generation children and second-generation children with two foreign-born parents. Low family employment is the most significant risk factor for poverty, but the prevalence of this risk varies little across immigrant generations. Differences in parental education account for the greatest share of observed intergenerational disparities in child poverty. Supplemental comparisons with third+-generation non-Hispanic White children underscore the disadvantages faced by all Hispanic children, highlighting the continued salience of race and ethnicity within the U.S. stratification system. Understanding the role of immigrant generation vis-à-vis other dimensions of inequality has significant policy implications given that America's population continues to grow more diverse along multiple social axes.

Rural-urban differences in the labor-force impacts of COVID-19 in the United States.

COVID-19 has had dramatic impacts on economic outcomes across the United States, yet most research on the pandemic's labor-market impacts has had a national or urban focus. We overcome this limitation using data from the U.S. Current Population Survey's COVID-19 supplement to study pandemic-related labor-force outcomes in rural and urban areas from May 2020 through February 2021. We find the pandemic has generally had more severe labor-force impacts on urban adults than their rural counterparts. Urban adults were more often unable to work, go unpaid for missed hours, and be unable to look for work due to COVID-19. However, rural workers were less likely to work remotely than urban workers. These differences persist even when adjusting for adults' socioeconomic characteristics and state-level factors. Our results suggest rural-urban differences in the nature of work during the pandemic cannot be explained by well-known demographic and political differences between rural and urban America.

County Reclassifications and Rural-Urban Mortality Disparities in the United States (1970-2018).

Objectives. To demonstrate how inferences about rural-urban disparities in age-adjusted mortality are affected by the reclassification of rural and urban counties in the United States from 1970 to 2018.Methods. We compared estimates of rural-urban mortality disparities over time, produced through a time-varying classification of rural and urban counties, with counterfactual estimates of rural-urban disparities, assuming no changes in rural-urban classification since 1970. We evaluated mortality rates by decade of reclassification to assess selectivity in reclassification.Results. We found that reclassification amplified rural-urban mortality disparities and accounted for more than 25% of the rural disadvantage observed from 1970 to 2018. Mortality rates were lower in counties that reclassified from rural to urban than in counties that remained rural.Conclusions. Estimates of changing rural-urban mortality differentials are significantly influenced by rural-urban reclassification. On average, counties that have remained classified as rural over time have elevated mortality. Longitudinal research on rural-urban health disparities must consider the methodological and substantive implications of reclassification.Public Health Implications. Attention to rural-urban reclassification is necessary when evaluating or justifying policy interventions focusing on geographic health disparities.