Date of Award

Spring 2009

Document Type


Degree Name

Doctor of Philosophy (PhD)


Public Administration and Urban Policy

Committee Director

John C. Morris

Committee Member

William Leavitt

Committee Member

Randy Gainey


While over one million elderly reside in U.S. nursing homes, little attention has been given to the factors that influence state nursing home regulation and how state regulations differ from the federal regulations. The focus of nursing home research literature has been on factors that impact quality of care at the individual patient and organizational level. The state comparative literature, which examines the differences between state policy choices, focuses on fiscal nursing home policymaking. An important gap exists in the literature in that state decision-making regarding nursing home quality of care policy has not been explored.

This study of U.S. nursing home quality of care regulation examines the factors that affect whether or not state nursing home regulations exceed the federal regulations. Most of the variables utilized in the current study were not significant in predicting whether or not states exceed the federal quality of care regulations. There does appear to be some demographic, socioeconomic and political influence. States with higher Medicaid payments per elder were more likely to exceed the federal regulations. States with Democratic governors were less likely to exceed the federal regulations, however, this was in the opposite direction than expected. States with traditionalistic political cultures may also be less likely to exceed to federal regulations for quality of care.

Once other state-level factors were controlled for, Medicaid payment and political culture were no longer significant predictors of whether or not states exceed the federal quality of care regulations. Party control of the legislature emerged as significant with the odds of states with Democratic legislatures being 13 times more likely to exceed the federal regulations than Republican-controlled legislatures. Percent minority population also emerged as significant with a one percent increase in minority population decreasing the odds of exceeding the federal regulations by 7.5%. The variables and theory needed to explain differences in state nursing home policy may be different from other policy areas in terms of what factors affect policy outcomes. This study shows that a purely quantitative approach to state comparative studies may not be the best approach in all cases and interviews with key nursing home stakeholders should be pursued to further inform the decision-making processes regarding nursing home regulation.


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