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."
A Small Piece of the Pie
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."
Too Close to Home
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.
As for quality of care, he added, "This study suggests that people need to pay better attention to quality metrics for homes and should consider homes further away from their neighborhood if the quality is higher."
Zinn added that part of the reason could also be historical. While government programs such as Medicaid cracked down on admissions discrimination in hospitals, the same regulatory strategies were never extended to nursing homes, she said.
Who Pays Matters
The study also demonstrated that blacks were more than twice as likely to be in nursing homes that housed predominantly Medicaid residents as opposed to private-pay residents.
According to the study, homes that had more Medicaid patients had more serious deficiencies.
Schulman said, "The lower level of resources available to care for African-American patients — based on inadequate public Medicaid payments — may contribute to the quality differences between facilities."
Potential solutions proposed in the study include higher payments to nursing homes with more Medicaid residents and tighter reinforcement of Title VI of the Civil Rights Act, which prohibits segregation in organizations receiving federal funds.
"There are lots of things that can be done in terms of just making the financial incentive work a little bit better," Smith said.
The study does need to be interpreted carefully. The researchers mention that the data being used only looked at nursing homes during the year 2000 and this should be kept in mind when looking at the individual regions with the most disparities.
But overall, the authors believe this study raises important awareness to the issue.
"This is an aging population. This problem is only going to get more serious as time goes on. Now is the time to start thinking of a remedy," Zinn said.