Hospice Care Gap: Racial Disparities Persist Even When Care Is Nearby

For older Americans dying of cancer, hospice care can transform the end of life. It reduces aggressive interventions in the final weeks, shifts the focus to comfort, and supports families through an emotionally devastating period. Yet a new study published in BMC Medicine suggests that the barriers keeping many patients from this care are not the ones policymakers have traditionally focused on. Even when a hospice is just a short drive away, Black, Hispanic, and Asian patients with poor-prognosis cancer remain significantly less likely to enroll than their White counterparts. The finding challenges the long-standing assumption that geography is the dominant obstacle to end-of-life care and points instead to a tangled web of structural and sociodemographic forces.

The research, led by Gabrielle Y. Park, A. James O’Malley, Jamaica R. M. Robinson, and Inas S. Khayal, drew on data from Medicare fee-for-service beneficiaries who died with poor-prognosis cancers in the United States during 2018. The team examined the relationship between hospice availability and hospice utilization, using a logistic mixed-effect regression model to account for a battery of individual and contextual variables: age, sex, race and ethnicity, driving distance to the nearest hospice, rurality, neighborhood income, and the racial composition of the patient’s neighborhood. By modeling these factors simultaneously, the researchers could isolate which ones truly moved the needle on enrollment decisions and, crucially, whether the effect of one factor depended on the levels of others.

The results painted a stark demographic picture. Beneficiaries who were female, older, and living in urban ZIP codes had higher odds of enrolling in hospice than their male, younger, and rural counterparts. These gradients align with patterns seen in earlier work on end-of-life care, where rural isolation and the greater intensity of treatment among younger patients have both been linked to lower hospice uptake. But the most consequential finding concerned race. Black, Hispanic, and Asian beneficiaries all had lower odds of hospice use than White beneficiaries, even after the model adjusted for distance to care, rurality, income, and the other measured characteristics.

What makes the study particularly revealing is its treatment of context. The researchers found statistically significant interactions between beneficiary race and two neighborhood-level factors: income and racial composition. In practical terms, this means the effect of living in a wealthier or demographically different neighborhood was not uniform across racial groups. The same environmental condition that might facilitate hospice enrollment for one population could fail to do so, or even work differently, for another. This heterogeneity is exactly the kind of signal that single-factor analyses miss, and it suggests that the pathways leading patients toward or away from hospice are shaped by how individual identity and community context combine, not by either alone.

Distance, by contrast, behaved differently than many would expect. When the team stratified their analyses by race and ethnic subgroups and by ranges of driving distance to a hospice, proximity did not meaningfully modify the effects of the other predictors. In other words, being physically close to hospice services did not erase or substantially reshape the disparities observed across racial and ethnic groups. The study’s title captures this paradox bluntly: patients can be close but unreachable. A hospice a few miles away is of little use if referral practices, communication patterns, cultural expectations, trust, or insurance and administrative hurdles stand between the patient and the service.

The technical machinery behind these conclusions is worth unpacking. A logistic mixed-effect regression is well suited to this kind of question because it models a binary outcome, here hospice enrollment versus non-enrollment, as a function of multiple predictors while incorporating random effects that account for clustering in the data, such as patients nested within regions or health care markets. Stratifying the analysis by distance ranges allowed the investigators to test whether the familiar drivers of hospice use operated differently at ten miles versus fifty. The finding that they largely did not is a methodologically grounded rebuke to the intuition that access is primarily a matter of miles.

The authors argue that these results demand a different conceptual framework altogether. Rather than treating hospice utilization as the product of isolated variables, they propose a pathway-based model grounded in systems thinking, an approach that captures how, when, and through what interactions multiple factors emerge and influence hospice decision-making over time. Under this view, a patient’s journey toward hospice is not a single decision at a single moment but a sequence of encounters: conversations with oncologists, family deliberations, prior experiences with the health care system, community norms, and the behavior of referring clinicians. Disparities can arise at any link in that chain, and intervening on distance alone leaves the rest of the pathway intact.

Such a framework also offers clearer targets for intervention. If the analysis shows that neighborhood racial composition interacts with patient race in shaping enrollment, then outreach programs, clinician training, and community partnerships may need to be tailored rather than uniform. If the effect of neighborhood income differs across groups, then policies that subsidize or expand hospice capacity in low-income areas may not automatically reach the patients who would benefit most. The systems perspective encourages researchers and policymakers to map the entire decision pathway and identify where the flow of patients toward comfort care is constricted, rather than assuming that widening the pipe at the geographic end will fix the flow overall.

The stakes are considerable. Hospice care is associated with reduced use of aggressive care at the end of life, including fewer intensive care unit admissions and invasive procedures in the final days, and it is widely regarded as a marker of high-quality end-of-life care. Persistent lower utilization among Black, Hispanic, and Asian patients therefore represents not just a statistical disparity but a difference in how Americans experience dying, in the burden placed on grieving families, and in the costs borne by the Medicare program. Because the study population consisted entirely of decedents, the researchers note that individual consent to participate was not applicable, and the work was approved by the Dartmouth Committee for the Protection of Human Subjects.

The study was supported by an American Cancer Society Award, and the authors report no competing interests. Its publication in an open-access journal means the full analysis is available to clinicians, health services researchers, and community advocates alike. What it offers them is a reframing: the question is no longer simply whether a hospice exists within driving distance, but why so many patients who live close to one never walk through its door. Answering that question, the authors contend, will require understanding hospice enrollment as a dynamic system of interacting factors, and designing interventions that reach patients wherever in that system the barrier actually lies.

Subject of Research: Racial and ethnic disparities in hospice utilization among older adults with poor-prognosis cancer in the United States

Article Title: Close but unreachable: racial disparities in hospice utilization beyond geographic proximity among older adult patients with cancer

Article References: Close but unreachable: racial disparities in hospice utilization beyond geographic proximity among older adult patients with cancer. (n.d.). https://doi.org/10.1186/s12916-026-05249-1

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05249-1

Keywords: hospice care, end-of-life care, health disparities, cancer, Medicare, geographic access, racial disparities, palliative care, health services research, systems thinking, logistic regression, BMC Medicine