The Legacy of Institutionalization on Structural Ableism

Posted on March 31, 2026

By Carli Friedman, CQL Director of Research

Structural ableism is when systems, like laws, policies, and social norms, are set up in ways that harm and/or exclude disabled people. These systems did not just appear recently but instead have developed over time and become “normal” because they are so ingrained, resulting in inequities for disabled people.

Throughout history, the ways we think about disability and how disabled people are treated have been shaped by institutionalization. For example, in the 1800s institutionalization became increasingly common in the United States because disabled people were seen as a problem in need of fixing; the “solution” to dealing with this “problem” was segregating and institutionalizing people. Even centuries later, these ideas have continued, with stereotypes about disability still framing disabled people as having something wrong with them that needs intervention or fixing. Institutionalization has also shaped how Long-Term Services and Supports (LTSS) systems have developed and evolved, continuing to impact where people live and the quality of their outcomes and supports today.

For these reasons, in this study, my aim was to examine the legacy on historical institutionalization on practices today, including institutionalization of disabled people today and implicit disability bias today. To do so, I analyzed data about institutions and the number of people institutionalized in 1860 from the U.S. Census Bureau, Medicaid data about the number of people institutionalized in 2022, and state implicit attitude data from 750,000 people (2004-2022).

I found states that had more institutions per capita in 1860 continued to institutionalize more people in 2022; this finding was significant even when controlling for factors like state size, wealth, politics, disabled populations, and enslaved populations in 1860. States that institutionalized more disabled people in 1860 also institutionalized more people per capita in 2022.

Institutionalization in States in 1860 and 2022

In addition, states that had more institutions per capita in 1860 had more implicit bias today, even while controlling for the factors mentioned above.

Institutionalization in States in 1860 and Implicit Bias Today (2004-2022)

“Throughout history, institutionalization has done immense harm to the disability community. Despite this history, it is in no way in the past, and continues to shape systems and structures today via structural ableism. That is why the aim of this study was to examine the relationship between institutionalization and structural ableism, both in terms of who is institutionalized and implicit disability bias today. Our findings suggest that states which had more institutions in 1860 and institutionalized more disabled people in 1860, institutionalize more people today (2022). Centuries later, these states were also associated with worse implicit disability attitudes. Both being institutionalized and living in a state with higher levels of bias are associated with worse outcomes. As such, structural ableism is a threat to the health, quality of life, and equity of disabled people” (Friedman, 2026).

This article is a summary of the following journal manuscript: Friedman, C. (2026). Structural ableism and institutionalization of disabled people. Rehabilitation Psychology. https://doi.org/10.1037/rep0000658