Posted September 26, 2007

Blacks more likely than whites to live in poor-quality nursing homes

In a country known for its equal opportunity and racial color-blindness, nursing home access and quality still need major improvement, Temple researchers have found.

According to a comprehensive study led by David Barton Smith, emeritus professor at the Fox School of Business, and Jacqueline Zinn, professor of healthcare management at the Fox School, commonly found nursing home segregation in the United States leads to racial disparities in the quality of care.

Smith, Zinn and their co-authors documented these long-suspected inequities in their study “Separate but Unequal: Racial Segregation and Disparities in Quality across U.S. Nursing Homes,” published in the September/

October issue of Health Affairs. The study, supported by the Commonwealth Fund and conducted with Brown University’s Zhanlian Feng, Mary L. Fennel and Vincent Mor, is the first to document the relationship between racial segregation and quality disparities in U.S. nursing homes.

David Barton Smith
Photo by George Bilyk

According to their findings, black Americans are four times more likely than white Americans to find themselves in poorly funded, understaffed nursing homes that offer substandard care. Nationwide, 40 percent of black nursing home residents live in lower-tier nursing homes, compared to just 9 percent of white nursing home residents. In fact, blacks are grossly overrepresented in lower-tier nursing homes in virtually every state in the country.

“This study shows us that racial segregation has a significant impact on the quality of care received by nursing home residents,” said Smith, lead author of the study.

Jackie Zinn
Submitted photo

How is it possible for such disparities to exist today? According to Zinn, “A recurring theme over the past 40 years has been the lack of data to document the extent of the problem.” In fact, the study reports that as recently as 1967, nursing homes merely had to post signs that certified that they did not discriminate in order to qualify for Medicare. No written admission or practice information was requested, and, according to the study, no federal civil right inspections were performed.

The problem is most acute in the Midwest. However, Pennsylvania (Harrisburg-Lebanon-Carlisle) included some of the especially segregated metropolitan statistical areas (MSAs). As of the year 2000, Harrisburg was listed in the top 10 in the nation for “Degree of Segregation among Black and White U.S. Nursing Home Residents,” according to data used in the study collected from the Centers for Medicare and Medicaid Services. Philadelphia (combined Phila PA/NJ primary MSA) ranked as the 26th most segregated MSA out of 147, and the Wilmington/Newark DE area ranked 84th.


In their analysis, the researchers looked at racial segregation in 147 MSAs, with 7,196 nursing homes caring for more than 800,000 residents. Researchers used the Dissimilarity Index, the most common measure of residential segregation, based on U.S. Census race categorizations. The index indicates the combined percentage of residents in both races who would have to be relocated for there to be an equal proportion of blacks and whites in the nursing home.

The researchers also found that:

• Blacks were nearly three times as likely as whites to be located in a nursing home housing predominantly Medicaid residents.

• Blacks were nearly twice as likely as whites to be located in a nursing home that was subsequently terminated from Medicare and Medicaid participation because of poor quality.

• Blacks were 1.41 times as likely as whites to be in a nursing home that had been cited with a deficiency causing actual harm or immediate jeopardy to residents.

• Blacks were 1.12 times as likely as whites to reside in a nursing home that was greatly understaffed.

• Lower-tier facilities are significantly more likely to serve residents with psychiatric conditions or those with a history of mental retardation.

As to the future, said Smith, “While it is important to eliminate disparities in care within nursing homes, to achieve full equity we must also eliminate the persistent segregation that puts minority Americans at higher risk for poor quality of care.”

Added Zinn, “The most important thing is awareness.”

—Written by Kady Adams

For the Fox School of Business

Smith and his co-investigators offered the following policy recommendations for reducing inequalities in nursing homes:
• Disproportionate-share payment adjustments to nursing homes with a higher proportion of Medicaid residents
• Equalization of Medicaid and private-pay payments
• Certificate-of-need and broader regional planning responsive to racial-disparity concerns
• Ongoing monitoring and more rigorous enforcement of Title VI in admission practices (Title VI of the 1964 Civil Rights Law prohibits segregation and other forms of discrimination in any organization receiving federal funds)