In decades past, Southern states frequently were associated with racial segregation.
However, a study published today in the journal Health Affairs sheds new light on the concept of segregation as it relates to a modern-day arena — nursing homes.
And this time, the South comes out clean.
Researchers at Temple University in Philadelphia, and Brown University in Providence, R.I., analyzed the quality and racial makeup of nursing homes.
What they found was distressing.
"We found that there were big differences between quality of nursing home care that blacks received as opposed to whites," said David Barton Smith, professor emeritus in the Fox School of Business at Temple University and lead author of the paper. "This was related largely to where they received their care."
Researchers looked at every nursing home across the United States and they assigned each metropolitan region a score reflecting the level of segregation among its nursing homes.
The Midwest was found to be the most segregated, with areas such as Cleveland, Milwaukee, Detroit, Chicago and Cincinnati ranking in the Top 10.
The South was actually the least segregated, with nursing homes there more likely to have racially mixed resident populations.
The nursing homes were then ranked along quality indicators such as patient-to-staff ratio and inspection deficiencies. Black nursing home residents were more likely to be in a facility with potentially hazardous deficiencies.
Study co-author Jacqueline Zinn, professor in the Fox School of Business at Temple University, notes that the differences in the care received by black nursing home residents and their white counterparts were not "within-home" differences.
"The care provided within the facility is consistent," she said. "It's just differences across [regions] with regard to the degree of segregation."
The issue of segregation in nursing homes may reflect a small piece of a larger issue, Smith said.
"Even though this is a small portion of the health-care system, it illustrates a deeper underlying problem and a real challenging one to try to deal with," he said.
But the need to deal with it appropriately may be growing.
The problem "matters to everybody because you have an entire generation of baby boomers that are suddenly discovering how difficult it is to get decent care to their parents, and they are thinking, 'what's going to happen to me?'" Smith said. "If we can make [the health system] work better for the minority population, we can learn how to make it better for everybody."
As for why this pattern has emerged, researchers say there could be many factors to blame.
Zinn said the choices of patients themselves may play a role in determining the racial makeup of specific areas.
"Most segregated institutions are in segregated communities," she said. "Whether or not that's self-selection is something that needs to be explored. When it comes to nursing homes, people want to stay close by friends and family."
Dr. Kevin Schulman, director for the Center for Clinical Genetics and Economics at Duke University in Durham, N.C., agrees. "The distribution of patients in nursing homes reflected the population of the community more generally," he said.