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Population

Deadly divides: Socio-geographic disparities of persistently high mortality during the era of Medicaid expansion in the United States Alexandra Ro*, Alexandra Ro, Regina S. Baker, Matthew M. Brooks, J. Tom Mueller,

Prior research has documented geographic disparities in persistently high mortality (PHM) across U.S. counties. However, less is known about how these disparities have recently evolved relative to regions – especially in the South and the Deep South – and sociodemographic factors, such as the impacts of Medicaid expansion and individual-level characteristics. Using 2009-2022 county-level data, we conceptualize multiple measures of PHM and examine patterned geographic disparities. Descriptive analyses reveal that PHM counties are disproportionately clustered in the South, with nearly half of those counties in the Deep South. Their socioeconomic characteristics rank unfavorably compared to other southern counties and PHM counties in other regions. Notably, large shares of PHM counties are concentrated in southern states that did not adopt Medicaid expansion, and sizable shares exist in expansion southern states. When observing patterns by sex, large shares of PHM counties for men and women continue to be in some southern states that did not adopt Medicaid expansion and some expansion southern states, with the proportion of PHM being relatively higher among men than among women. In terms of racialized groups, large shares of PHM counties for non-Hispanic White residents are in a mix of southern states that did not adopt Medicaid expansion and expansion southern states; in comparison, large shares of PHM counties for non-Hispanic Black residents are mostly in southern states that did not adopt Medicaid expansion. In terms of age, large shares of PHM counties for children, young adults, and older working-age adults are in southern states that did not adopt Medicaid expansion while large shares of PHM counties for younger working-age adults are in southern states that did not adopt Medicaid expansion and expansion southern states. Our findings provide contemporary evidence of how socio-geographic contexts continue to uniquely shape patterns of high mortality persistence.