Racialized Geographies of Pain: Structural Barriers to Hospice Utilization for Prostate Cancer Decedents, 1999-2020

Background Despite a two-decade expansion of hospice care in the United States, racial disparities in end-of-life care for advanced prostate cancer remain entrenched and cannot be explained by socioeconomic status alone. Grounded in the theoretical framework of "racialized geographies of pain," this study investigates the structural barriers contributing to these disparities, specifically examining the "Urban-Insurance Paradox" where high resource availability does not translate to equitable care for Black men. Methods We analyzed a national cohort of 464,142 prostate cancer decedents using the Centers for Disease Control and Prevention (CDC) WONDER database (1999–2020). To address data suppression in minority groups, we employed a novel truncated Poisson Monte Carlo simulation. We utilized logistic regression to calculate adjusted odds ratios (aOR) for institutional death and Sankey flow analysis to visualize temporal transitions in the place of death. Additionally, we assessed the impact of Medicare Advantage (MA) penetration on racial gaps in care utilization using generalized linear models. Results We identified a distinct "Urban-Insurance Paradox": although 96.9% of Black decedents resided in medical resource-dense metropolitan areas with high MA penetration, their adjusted risk of institutional death remained significantly higher than White decedents (aOR=1.73). Sankey analysis indicated that the de-institutionalization process for Black men lagged approximately 10 years behind that of White men. Crucially, while MA market expansion facilitated racial convergence in the utilization of professional hospice facilities (narrowing the gap to 0.2%), it failed to disrupt the "Parallel Retention" of Black men in acute care settings, with the racial gap in institutional death rates locked at approximately 11 percentage points. Conclusions Market mechanisms alone are insufficient to penetrate deep-seated structural inertia. For Black men, high institutional reliance represents a rational adaptation to "hospice deserts" lacking community-based pain management infrastructure. De-institutionalization does not simply equate to "de-pain" but signifies a redistribution of structural risk from institutions to communities. Health policy must urgently shift towards place-based interventions, such as establishing "Pain Management Enterprise Zones," to address structural inequities embedded in spatial geographies.