This study compared need for care, called negative care outcomes, of Missouri nursing facility residents by nursing facility primary reimbursement, ownership, geographical location and by resident race and presence of dementia. Impact of facility performance upon Medicaid residents' need for care was examined by comparison of facility expenditures and fund balance and resident length of stay.

Nineteen hundred eighty-eight (1988) data from 22,000 Medicaid residents were made available from the University of Missouri-Columbia, and 1988 facility cost reports were obtained from the Missouri Division of Medical Services. Analysis of these data have provided insight into basic areas of equal treatment of Medicaid residents in Missouri nursing facilities.

Black Medicaid residents in urban facilities were found to be segregated in profit and not-profit facilities with the least financial capabilities to properly care for them. This segregation also allows Medicaid residents with highest care needs to be placed in these subsidized facilities ($>$70% Medicaid reimbursed). Because these subsidized facilities typically spend more than their revenue primarily due to resident care needs, there are severe financial limits of resident care in subsidized facilities which are not evident in non-subsidized facilities.

This study directly compared Medicaid residents in facilities with dramatically different resources. Medicaid residents in urban private facilities are given a substantially better environment in facilities with higher revenues and with other residents requiring significantly less care than subsidized facilities. The class of residents which appears to be given the least chance to be admitted to facilities with highest revenues and lowest case mix are Black urban citizens. Considering the overall disadvantaged status of Black citizens in our society, it seems that the overwhelming percentage of Black residents in subsidized facilities fulfills reasonable preliminary criteria to determine discrimination exists within the Medicaid class of Missouri nursing facility residents. Most particularly racial discrimination exists without effective regulatory control to assure all Missouri nursing facility residents equal opportunity to receive quality care.