health aff-2011-feng-1358-65

At the Intersection of Health, Health Care and Policy

doi: 10.1377/hlthaff.2011.0126

, 30, no.7 (2011):1358-1365Health AffairsDemographics And Possible Disparities In Options

Growth Of Racial And Ethnic Minorities In US Nursing Homes Driven ByZhanlian Feng, Mary L. Fennell, Denise A. Tyler, Melissa Clark and Vincent Mor

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By Zhanlian Feng, Mary L. Fennell, Denise A. Tyler, Melissa Clark, and Vincent Mor

THE CARE SPAN

Growth Of Racial And EthnicMinorities In US Nursing HomesDriven By Demographics AndPossible Disparities In Options

ABSTRACT Between 1999 and 2008, the number of elderly Hispanics andAsians living in US nursing homes grew by 54.9 percent and 54.1 percent,respectively, while the number of elderly black residents increased10.8 percent. During the same period, the number of white nursing homeresidents declined 10.2 percent. These shifts have been driven in part bychanging demographics, especially the fast growth of older minoritypopulations. However, the numbers of minority residents in nursinghomes increased more rapidly than the minority population overall, evenin areas with high concentrations of minority populations. Thus, theseresults may indicate unequal minority access to home and community-based alternatives, which are generally preferred for long-term care.When designing initiatives to balance institutional and noninstitutionallong-term care, policy makers should take steps to reduce racial andethnic disparities.

There are seventy-six million USbaby boomersthose born be-tween 1946 and 1964and the old-est of them turn sixty-five in 2011.During the next nineteen years,

each day will be the sixty-fifth birthday of about10,000 boomers.1 By 2030 the Census Bureauprojects that 20 percent of the US populationwill be sixty-five or older, up from 13 percenttoday.2

The numbers of elderly people in racial andethnic minority groups will grow particularlyfast. The number of older Hispanics, for in-stance, will increase from just under 1.8 millionin 2000 to more than 8.6 million by 2030, andthe number of older Asians, from 0.8 million to3.8 million.2 As the elderly population growsrapidly, the needs for long-term care are likelyto increase substantially.

The Changing Long-Term CareLandscapeIn the midst of demographic trends such asthese, the US long-term care landscape has beenundergoing a major transformation in recentyears, one marked by a shift away from nursinghome care and toward home and community-based services. The rubric of home and commu-nity-based services includes private programs aswell as a wide array of publicly supported pro-grams that provide eligible people with long-term services and supports.Most funds for these programs come from

what are known as Medicaid 1915(c) waivers,authorized in 1981 in the Social Security Act.States use the waivers to rebalance long-termcarethat is, to achieve a better balance betweeninstitutional and noninstitutional services andsupports, in both spending and use. The waiverspay for personal care and other supportive ser-vices that enable a subset of Medicaid benefici-

doi: 10.1377/hlthaff.2011.0126HEALTH AFFAIRS 30,NO. 7 (2011): 135813652011 Project HOPEThe People-to-People HealthFoundation, Inc.

Zhanlian Feng ([email protected]) is anassistant professor at theCenter for Gerontology andHealth Care Research atBrown University, inProvidence, Rhode Island.

Mary L. Fennell is a professorof sociology at BrownUniversity.

Denise A. Tyler is aninvestigator at the Center forGerontology and Health CareResearch, Brown University.

Melissa Clark is an associateprofessor of epidemiology atBrown University.

Vincent Mor is a professor ofhealth services, policy, andpractice at Brown University.

1358 Health Affairs JULY 2011 30:7

The Care Span


aries to live at home or in a residential settingother than a nursing home.3

Not only are home and community-based al-ternatives less expensive than institutional care,but they are also overwhelmingly preferred byolder adults with disabilities, who want to liveindependently in their homes and communitiesfor as long as possible.4,5 Nationally, the percent-age of Medicaid long-term care dollars spent onhome and community-based services has morethan doubled, from 19 percent in 1995 to 42 per-cent in 2008.6 The Affordable Care Act of 2010creates multiple new opportunities to furtherexpand home and community-based servicesand to accelerate the pace of rebalancing.7

An example of the expanding supply of alter-natives to nursing homes is the rapid growth ofassisted living facilities.However, these facilitiescater primarily to relatively well-to-do peoplewith private health insurance, and they tend tobe concentrated in areaswhosepopulationshavehigh levels of education, income, and wealth inthe form of equity in the value of personallyowned housing.8 Such areas are typically sub-urban and predominantly inhabited by whites.Givenpersistent racial disparities in long-term

care access and quality,912 it is unlikely that allpopulation subgroupswill be equally able to reapthe benefits of public and private initiatives torebalance institutional and noninstitutionallong-term care. As recent studies of nursinghome closures have found, the numbers of clo-sures are higher in communities characterizedby high rates of poverty, higher proportions ofracial and ethnic minority residents, and veryfew new nursing home openings.13 The geo-graphic distribution of newer forms of long-termcare is still largely unknown; whether such ser-vices aremoving into communities that have lostnursing homes is unclear.Moreover, despite the steady growth of home

and community-based services, the majority ofMedicaid long-term care spending still goes to-ward nursing home care. Nursing homes havebeen, and will continue to be, an integral part ofthe long-term care continuum for meeting thecritical needs of older people who can no longerbe supported in their homes.Gaining a comprehensive understanding of

the changing demographic profile of the USnursing home population is both timely and vi-tal, to help policy makers understand and ad-dress potential disparities in long-term careamong population subgroups.

Study Data And MethodsDemographic shifts and the changing long-termcare landscape call for a more comprehensive

analysis of the nursing home population interms of its racial and ethnic mix, and how thismix has changed in recent years. Before the in-troduction of the nationwide Minimum DataSetpart of the process for clinical assessmentof all residents in nursing homes certified byMedicare or Medicaid, required under a 1987federal law14such analysis was difficult becauseof data limitations, particularly the exclusion orunderrepresentation of Hispanics, Asians, andother minority residents.Our analysis has two objectives. First, we in-

vestigate trends in the racial and ethnic compo-sition of the US nursing home population be-tween 1999 and 2008, using the MinimumData Set. Second, at a more local level, we exam-ine the association between changes in the racialand ethnic mix of nursing home residents andconcurrent demographic shifts among popula-tion subgroups within the Census Bureaus Met-ropolitan Statistical Areas over the study period.We briefly describe our study methods

including data, measures, and statistical analy-sisbelow. More details are available in the on-line Appendix.15

Minimum Data SetWeused the nationalMini-mum Data Set to obtain information on the raceand ethnicity of nursing home residents and tocalculate the annual number of Americans innursing homes. Census data and population es-timates allowed us to track demographic trendsamong population subgroups. All data covered aten-year period, 19992008.Under federal law,14 theMinimumData Set is a

form that must be completed when a new resi-dent is admitted to a nursing home, and at leastquarterly thereafter. It is currently used in allnursing homes certified by Medicare or Medic-aid and is the only uniform source of data avail-able on the race and ethnicity of nursing homeresidents. The form uses five mutually exclusivecategories: American Indian or Alaskan Native;Asian or Pacific Islander (hereafter referred to asAsian); black or African American, not of His-panic origin (hereafter black); Hispanic (regard-less of race); and white, not of Hispanic origin(hereafterwhite). In this analysiswe focuson thelatter four categories, given the extremely lownumbers of Native Americans and Alaskan Na-tives in nursing homes.We calculated the annual number of nursing

home residents by including all individuals re-siding in a nursing homeon the first Thursday inApril of each year. Therefore, the number in-cluded both long-term residents (those with alength-of-stay of at least ninety days) andshort-term patients receiving postacute care.In each year, the former group constituted morethan 80 percent of the total. We excluded resi-

JULY 2011 30:7 Health Affairs 1359


dents under age sixty-five and the few subjectswith missing information on race and ethnicity.Census Data And Population Estimates

Data on race, ethnicity, and age for the US pop-ulation as a whole came from the 2000 nationalcensus and annual population estimates forother years in the study period. In the 2000 cen-sus, people were allowed to use more than onerace category to identify themselves, and His-panic origin was also a separate option. Tomakedata comparable across sources and years, for200008 we used what are called bridged-racepostcensal population estimatesestimatesafter a census from the National Center forHealth Statistics. For 1999 we used intercensalestimates, made between two federal censuses.Both types of estimates follow definitions of raceand ethnicity that are consistent with the Mini-mum Data Set.16

Study Measures To measure the racial andethnic composition of the nursing home popu-lation,weusedboth the absolutenumberand thepercentage share of residents in each racial andethnic group, both nationally and at the Metro-politan Statistical Area level. Although our re-sults do not report Native Americans or AlaskanNatives as a separate category, they were in-cluded in our calculations of the percentageshares of other racial and ethnic groups. Thegeneral population measures were determinedsimilarly, but for each racial and ethnic group,we calculated the number and percentage of peo-ple age sixty-five or older, as well as the totalpopulation.Statistical AnalysisWe tracked thenational

trend in the racial and ethnic composition ofnursing home residents, 19992008, and com-pared this trend with demographic changeswithin each racial and ethnic group over thesame period. To determine whether growth innursinghomeuse among a population subgroupwas faster, slower, or about the same comparedto overall growth in the total populationor togrowth in the number of people age sixty-five orolderin the same group, we calculated both theoverall andannualized rates of change from1999to 2008.For both 1999 and 2008, we compared the

percentage share of nursing home residentsper racial and ethnic group across MetropolitanStatistical Areas, which were grouped in quar-tiles by the percentage of population age sixty-five and older within each racial and ethnicgroup. Because minority populations are geo-graphically concentrated, we also performed de-tailed, area-specific analyses (similar to those atthe national level) in the ten Metropolitan Sta-tistical Areas that had the largest population ofeach minority racial and ethnic group.

LimitationsOur analysiswas based on annualsnapshots of the nursing home population, in-cluding everyone residing in a facility at a givenpoint in time. It is noteworthy that thenumber ofolder patients discharged fromhospitals to nurs-ing homes for short-stay, postacute care hasrisen substantially since the introduction ofthe Medicare prospective payment system forhospitals in 1983.17,18 Despite this trend, theproportion of long-stay residents in nursinghomes has remained quite stable (roughly80 percent).19,20

Therefore, our portrait of the racial and ethnicprofile of the nursing home population isunlikely to be affected by the churning ofshort-stay patients into and out of nursinghomes during the study period. Nevertheless,these dynamics in nursing home use do pointto the need for future research to track individ-uals as they transition through nursing homesand other care settings.

Study ResultsThe national nursing home population declinedby 6.1 percent from 1999 to 2008, or by an aver-age of 0.7 percent per year (Exhibit 1). This trendwas driven primarily by a decline of 10.2 percentamong white residents. In contrast, the totalnumbers of Hispanic and Asian residents grew54.9 percent and 54.1 percent, respectively. Thenumber of black residents also grew, although ata slowerpace. In relative terms, thepercentageofwhite residents in nursing homes also de-creased, while the percentages of blacks, His-panics, and Asians increased.Changing Demographics In Population

Subgroups From 1999 to 2008, the US popula-tion age sixty-five or older grew at a faster ratethan did the total population (Exhibit 1). Boththe total and older (age sixty-five or older) pop-ulations of blacks, Hispanics, and Asians grewmore rapidly than did those of whites. For in-stance, both the older Hispanic and Asian pop-ulationsexperiencedexplosivegrowth(58.2per-cent and 64.2 percent, respectively), comparedto just 6.7 percent forwhites.Growthof the olderblack population was less dramatic, at 16.2 per-cent, but still more than double the rate forwhites. The increase of nursing home residentsfrom all groups except whites was highly consis-tent with the groups population growth.Dynamics At The Metropolitan Statistical

Area Level Exhibit 2 shows racial and ethnicpercentages of nursing home residents at thelevel of Metropolitan Statistical Areas in 1999and 2008. For each racial and ethnic group,we calculated the percentage of the total popu-lation age sixty-five or older in each area and

The Care Span



divided the areas into quartiles, by group. Thepercentage of nursing home residents for eachminority group was substantially higher in Met-ropolitan Statistical Areas that had a higher per-centage of people age sixty-five or older withinthe same minority group.For blacks in 1999, for instance, the average

share of nursing home residents was more thannine times higher in the highest quartile than inthe lowest13.7 percent versus 1.5 percent(Exhibit 2). The differences were even largerfor Hispanics and Asians in 1999. That is, inMetropolitan Statistical Areas where a minoritypopulation was older, there weremoremembersof the minority group in nursing homes. In con-trast, no such association was observed amongwhites. Similar results were seen in 2008.Comparing data between the columns in

Exhibit 2 reveals that the average percentageof minority nursing home residents increasedfrom 1999 to 2008 across all Metropolitan Stat-istical Area quartiles. This was in contrast to adeclining percentage of white residents overall.Furthermore, the annualized rate of growth ofthe nursing home population and that of thepopulation age sixty-five or older in each minor-ity group tracked each other quite closely acrossthe areas (see Appendix Figure 1).15

Lastly, we identified for each minority groupthe ten Metropolitan Statistical Areas that havethe largest numbers of people from that group.

Exhibit 1

Racial And Ethnic Composition Of The US Nursing Home Population, The US Population Age Sixty-Five Or Older, And The Total US Population, 1999 And2008

1999 2008 Change in number, 1999 to 2008

Number Percent Number Percent Percent change Percent annualized changeUS nursing home residents

White 1,119,047 86.7 1,005,320 82.9 10.2 1.2Black 124,111 9.6 137,519 11.3 10.8 1.2Hispanic 29,826 2.3 46,201 3.8 54.9 5.0Asian 12,344 1.0 19,021 1.6 54.1 4.9Total 1,291,241 100 1,212,912 100 6.1 0.7

US population age 65 or older

White 29,388,315 84.5 31,371,464 80.9 6.7 0.7Black 2,808,789 8.1 3,263,766 8.4 16.2 1.7Hispanic 1,658,811 4.8 2,624,027 6.8 58.2 5.2Asian 811,977 2.3 1,333,381 3.4 64.2 5.7Total 34,797,841 100 38,799,891 100 11.5 1.2

Total US population

White 197,154,118 70.7 201,775,403 66.3 2.3 0.3Black 34,722,236 12.4 38,452,228 12.6 10.7 1.1Hispanic 33,937,795 12.2 46,978,568 15.4 38.4 3.7Asian 10,957,343 3.9 14,590,362 4.8 33.2 3.2Total 279,040,168 100 304,374,846 100 9.1 1.0

SOURCES Nursing home residents: Note 14 in text. US population: Note 16 in text. NOTE Percentages do not sum to 100 because the totals also include the small number ofpeople from other racial or ethnic groups.

Exhibit 2

Nursing Home Residents By Race Or Ethnicity And Percentage Of Total Population AgeSixty-Five Or Older, 1999 And 2008

Percent share of residents

MSA quartiles, by percent of population age 65 orolder within each group

1999mean SD

2008mean SD

White

1 (lowest) 85:0 17:0 83:7 15:12 86:0 11:9 86:1 15:03 88:2 10:0 82:9 14:04 (highest) 86:7 14:6 82:5 17:1Black

1 (lowest) 1:5 3:2 2:1 4:52 8:1 8:4 8:7 9:03 12:3 11:5 14:0 12:64 (highest) 13:7 9:9 15:6 10:8Hispanic

1 (lowest) 0:4 0:5 0:9 1:42 1:3 1:9 2:1 3:43 2:9 4:1 3:6 5:04 (highest) 8:1 17:6 11:0 20:0Asian

1 (lowest) 0:1 0:1 0:3 0:42 0:2 0:2 0:4 0:73 0:3 0:5 1:0 2:44 (highest) 2:5 9:1 2:9 9:7

SOURCES Nursing home residents: Note 14 in text. US population: Note 16 in text. NOTES N = 323.MSA is Metropolitan Statistical Area. SD is standard deviation.



With rare exceptions, both the minority popula-tion age sixty-five or older and the population ofminority nursing home residents grew at a con-siderably faster rate than the overall minoritypopulation between 1999 and 2008, no matterwhich minority group was considered (see Ap-pendix Table 1).15 The growthwasmost dramaticin areas with the largest Hispanic or Asian pop-ulations. These local patterns are consistentwithresults at the national level (Exhibit 1).

DiscussionOur analysis is the first to use the national Mini-mumData Set14 to track themost recent trends inthe racial and ethnic composition of the nursinghome population, along with concurrent demo-graphic shifts at both the national and Metro-politan Statistical Area levels. The results indi-cate that nationally, both the absolute numbersand the relative shares of minority residents inUS nursing homes increased steadily between1999 and2008, in contrast to declining numbersand percentages of white residents.Hispanics andAsianswere the fastest-growing

minority groups amongnursinghome residents,followed by blacks. Similar trends and patternswere observed at a more local level across majorUS metropolitan areas. These findings portraythe changing face of the nursing home popula-tion, and they signal an important shift in theuseof long-term care options among racial and eth-nic groups in the US population.These results should be interpreted in light of

two ongoing trends. First, changing demo-graphics appear to be a major driver of recentshifts in the racial and ethnic profile of the nurs-ing home population. Second, the evolving long-term care landscape, shaped by both marketforces and public policy efforts to rebalancelong-term care, may also be involved in the ob-served shifts. Minority elders may well facegreater barriers than white elders in access tohome and community-based alternatives tonursing home care.Is Demography Destiny? Our analysis re-

veals that between 1999 and2008, both thenum-bers of minority nursing home residents andminority older populations have grown rapidlyand that these two parallel trends were corre-lated. Furthermore, thenumbers ofminority res-idents in nursing homes increased more rapidlythan did either the minority population as awhole or the minority older population in virtu-ally all Metropolitan Statistical Areas with highconcentrations of minority populations over thestudy period. Thus, recent shifts in the racial andethnic mix of nursing home residents overallhave been driven in part by changing demo-

graphics, especially the fast growth of olderminority populations.The rapidly growing number of older people

who will need long-term care, regardless of set-ting, will increasingly challenge the countrysphysical and economic resources. There is trou-bling evidence that the disabled proportion ofthe US elderly population grew between 2000and 2005,21 reversing a previously well-docu-mented and long-term trend of declining disabil-ity among the elderly.22

The prevalence of chronic disease amongyounger populations is also on the rise, whichleads to projections of increased morbidity anddisability among elderly people of the future.23

Depending on trends in old-age disability, theavailability of informal support networks, andongoing efforts to rebalance long-term care,the recent downward shift in rates of nursinghome use,24,25 primarily among elderly whites,may well be halted or reversed in the future.Although not examined in this analysis, therapid growth in the use of nursing homes byracial and ethnicminority populationsmay haveresulted from ongoing changes in family struc-tures that have led to the declining availability oftraditional, family-based care options.2628

If current trends continue, racial and ethnicminoritiesespecially older Hispanics andAsianswill become an even larger share ofthe nursing home population. Ultimately, thatpopulation will mirror the racial and ethnicmakeup of the elderly US population. This pros-pect raises concerns about whether nursinghomes will be able to provide the culturally sen-sitive and competent care required to meet theneeds of residents from diverse ethnic and cul-tural backgrounds.Are Disparities In Long-Term Care Chang-

ing?Historically, disparities in access to nursinghomes and other formal long-term care servicesmay have contributed to the lower rates of use ofsuch services by elderly members of minoritygroups, compared to elderly whites.2931 But asnursing home occupancy rates have declined inmost markets, and assisted living and otherhome and community-based options have pro-liferated, access to nursing home care may nolonger be a problem for elderly minorities.10,32

Our finding of steady increases in the share ofolder blacks, Hispanics, and Asians in nursinghomes in recent years lends support to this in-terpretation. The apparent increase in minorityaccess to nursing home beds appears to indicateshrinking levels of disparity in long-term care.However, long-stay residentsmakeupmore than80 percent of the nursing home population, andnursing homes are widely perceived as an unfav-orable optionand indeed used as the last re-

The Care Span



sortfor long-term care, compared to home andcommunity-based alternatives. Thus, the resultsreported here may suggest not a lessening but ashifting of disparities, with minorities stillunderrepresented in preferred sites of care.In fact, at amore local level, our analysis shows

that acrossmetropolitan areas, the relative shareof racial or ethnic minority nursing home resi-dents was correlated with the percentage of el-derly in the same minority group, but no suchcorrelation existed for whites. This suggests thatcompared to minority elders, white elders mayhave more varied choices of care in their com-munities andmay have been better able to affordalternatives to nursing homes such as assistedliving facilities, largely used by people with pri-vate insurance. Racial and ethnic minorities, incontrast, are more likely to live in socioeconom-ically disadvantaged areas with limited alterna-tives to nursing homes.8,33

If increased use of nursing homes by minorityelders has resulted inpart froma lack of access tohome and community-based alternatives, then arenewed concern about access disparities arises.As racial and ethnicminority elderly populationsgrow rapidly, their demand for nursing homecare will increase further. Yet between 1999and2008, nearly 16 percent of all nursinghomescertified by Medicare or Medicaid closed, result-ing in a net loss of more than 5 percent of beds.13

More important, these closures were concen-trated in minority and poor communities.These disconcerting facts suggest that dispar-

ities in access may be further exacerbated inthose communities. It is also important to notethatwhenminority elders dousenursinghomes,they are more likely to end up in lower-qualityfacilities characterized by fewer resources,greater reliance on Medicaid, poorer service,and worse care than available in nursing homesin more affluent communities.11,12,33

Policy ChallengesThe results of our analysis can be used to informcurrent policy efforts intended to rebalance long-term care. We contend that the increased pres-ence of elderly people from racial and ethnicminority groups in nursing homes and the si-multaneous exodus of whites are indicative ofpotential disparities in access to home and com-munity-based alternatives. Policymakers shouldbear in mind that although home and commu-nity-based services are preferred by older peopleneeding long-term care, such services are

unlikely to be equally available, accessible, andaffordable for all subgroups of the population oracross all communities. Ultimately, poor minor-ity elders may be increasingly relegated to nurs-ing homes, while whites with more financial re-sources are able to use various home andcommunity-based alternatives.Data on nursing home residents are regularly

gathered through mandated inspections of thefacilities and assessments of the residents. Butaside from accounts that track Medicaid spend-ing on home and community-based services,there is no standardized national data set onhome and community-based providers and theclients they serve.Without such information, it isdifficult to examine the full range of long-termcare options available in local communities, andit is impossible todetermine levels of carequalitydelivered by these different service providers.Policy efforts to rebalance our long-term care

system should be based on full information onthe changing long-term care market. Althoughideally such a system of data collection wouldhave been developed long ago, it is reasonableto suggest that states now make a coordinatedeffort to gather information on all home andcommunity-based services that require licens-ingincluding home health services, assistedliving facilities, and adult day care providerswhen they receive or renew a license.

ConclusionRecent shifts in the racial and ethnic composi-tion of the US nursing home population indicatethat a confluence of market forces and policyinitiativesmayhave unintentionally perpetuatedlong-existing disparities among racial and eth-nic population subgroups in access to nursinghomes and home and community-based alterna-tives to them. New disparities may also havearisen.Policymakersmust pay particular attention to

enduring and emerging disparities in long-termcare, especially in light of rapid changes in bothpopulation demographics and the long-termcare landscape. They should also strive to buildequity into current efforts to rebalance long-term care.10 Given the geographic concentrationof racial and ethnic minority populations andnursing home residents from those groups, ef-forts to reduce disparities should target bothcommunities and facilities with high concentra-tions of minority residents.



Results from an earlier version of thispaper were presented at theAcademyHealth Annual ResearchMeeting, Boston, Massachusetts,

June 2729, 2010; and at theInternational Conference on Aging in theAmericas: Issues of Disability,Caregiving, and Long-term Care Policy,

at the University of Texas, Austin,September 1517, 2010. This work wassupported in part by a National Instituteon Aging grant (P01AG027296).

NOTES

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2 Census Bureau. Projected popula-tion by single year of age, sex, race,and Hispanic origin for the UnitedStates: July 1, 2000 to July 1, 2050[Internet].Washington (DC): CensusBureau; 2008 [cited 2011 Apr 26].Available from: http://www.census.gov/population/www/projections/downloadablefiles.html

3 Smith DB, Feng Z. The accumulatedchallenges of long-term care. HealthAff (Millwood). 2010;29(1):2934.

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5 Reinhard SC. Diversion, transitionprograms target nursing homesstatus quo. Health Aff (Millwood).2010;29(1):448.

6 Kaiser Commission on Medicaid andthe Uninsured. Medicaid home andcommunity-based service programs:data update [Internet]. Washington(DC): Kaiser Family Foundation;2011 Feb [cited 2011 May 23].Available from: http://www.kff.org/medicaid/upload/7720-04.pdf

7 Shugarman LR. Health care reformand long-term care: the whole isgreater than the sum of its parts.Public Policy & Aging Report. 2010;20(2):37.

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9 Wallace SP, Levy-Storms L, KingtonRS, Andersen RM. The persistence ofrace and ethnicity in the use of long-term care. J Gerontol B Psychol SciSoc Sci. 1998;53(2):S10412.

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15 To access the Appendix, click on theAppendix link in the box to the rightof the article online.

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30 Mui AC, Choi NG, Monk A. Long-term care and ethnicity. Westport(CT): Auburn House; 1998.

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The Care Span



ABOUT THE AUTHORS: ZHANLIAN FENG, MARY L. FENNELL,DENISE A. TYLER, MELISSA CLARK & VINCENT MOR

Zhanlian Feng is anassistant professorat the Center forGerontology andHealth CareResearch, BrownUniversity.

In Health Affairs this month,Zhanlian Feng and coauthorsallat Brown Universitydocument arising proportion of racial andethnic minorities in the US nursinghome population. The fact that theincrease is greater than simpledemographics would suggest, theyargue, means that policyadjustments should ensure equalaccess to all types of long-term careoptions, including home andcommunity-based services andsupports.Feng is an assistant professor of

health services, policy, and practiceat the Center for Gerontology andHealth Care Research at BrownUniversity. His current researchinterests include racial segregationand disparities in nursing homes,and the growth of institutionalelder care in Chinese cities. Fengreceived his masters and doctoraldegrees in sociology from BrownUniversity.

Mary L. Fennell is aprofessor ofsociology at BrownUniversity.

Mary Fennell has been aprofessor of sociology and

community health at BrownUniversity and senior investigatorwith the Center for Gerontologyand Health Care Research since1995. She has also served on thefaculties of Pennsylvania StateUniversity and the University ofIllinois at Chicago. Together withcoauthors Feng and Vincent Mor,Fennell is currently researchingpatterns of racial and ethnicsegregation in nursing homes andthe effects of nursing homeclosures. She holds both mastersand doctoral degrees in sociologyfrom Stanford University.

Denise A. Tyler isan investigator atthe Center forGerontology andHealth CareResearch

Denise Tyler has been a researchfaculty member at the Center forGerontology and Health CareResearch since 2008. She is alsomanager of the Shaping Long-TermCare in America Project, funded bythe National Institute on Aging.She received her masters anddoctoral degrees in social policyfrom the Heller School for SocialPolicy and Management, BrandeisUniversity.

Melissa Clark is anassociate professorof epidemiology atBrown University.

Melissa Clark is an associateprofessor in Browns Departmentof Epidemiology and the Center forPopulation Health and ClinicalEpidemiology. A surveymethodologist whose work focuseson barriers and facilitators tohealth and well-being among theaging and in underservedpopulations, Clark received bothmasters and doctoral degrees inpublic health from the Universityof Illinois at Chicago.

Vincent Mor is aprofessor of healthservices, policy, andpractice at BrownUniversity.

Vincent Mor is the Florence PirceGrant Professor of Health Services,Policy, and Practice at the BrownSchool of Medicine. He has beenon the faculty of BrownsDepartment of Community Healthsince 1981, serving as its chairfrom 1996 until 2010, and hasdirected the universitys Center forGerontology and Health CareResearch for ten years. An authorof the Minimum Data Set used inthe present study, Mor is principalinvestigator of the Shaping Long-Term Care in America Project. Heholds a masters degree inrehabilitation administration fromNortheastern University and adoctorate in social policy fromBrandeis.



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