LTC Bullet:  LTC Racism 

Wednesday, September 19, 2007 


LTC Comment:  Do America's nursing homes discriminate against blacks as a new study suggests?  The complicated truth after the ***news.*** 

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LTC Comment:  A national media hullabaloo exploded last week over an article in an academic journal.  A piece in Health Affairs seemed to suggest that U.S. nursing homes practice widespread racial segregation and discrimination.  A cry of outrage and self-defense arose from the nursing home profession.   

What is the truth and the larger meaning? 

First, we'll cite, link to, and provide excerpts from the Health Affairs article.  Then we'll give you a sample of the reaction from four nursing home representatives.  Finally, we'll explain what these findings and allegations really mean and why it matters to every American, regardless of race, or any other demographic characteristic. 


Excerpts from:   

David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor, "Separate and Unequal:  Racial Segregation and Disparities in Quality Across U.S. Nursing Homes:  Residential segregation in U.S. cities disproportionately places blacks in poorer-performing nursing homes," Health Affairs, Vol. 26, No. 5, September/October 2007, footnotes omitted,$doPp/cdb28.    

"This paper addresses two questions:  (1) What degree of racial segregation persists among U.S. nursing homes?  (2) Does racial segregation result in blacks' and whites' having access to nursing homes of differing levels of quality?"  (p. 1450) 

"We found that in 2000, blacks were concentrated in a small percentage of nursing homes, with more than 50 percent of black residents in for-profit homes concentrated in less than 10 percent of for-profit facilities and more than 70 percent of those in nonprofit homes concentrated in just under 10 percent of nonprofit facilities." (pps. 1451-2) 

"We found that nursing home care was relatively segregated in 2000, with two-thirds of all black residents living in just 10 percent of all facilities.  Furthermore, within most MSAs [metropolitan statistical areas], blacks were significantly more likely to be served by facilities in the bottom quartile of many structural and performance measures of quality." (pps. 1453-4)


LTC Comment:  That sounds a like a searing indictment of America's nursing homes.  How did the LTC profession respond?  Following are quotes from representatives of four nursing home associations. 

"Medicaid payments don't sufficiently cover the basic cost of providing services to most residents, says Alan Rosenbloom, the president of the Alliance for Quality Nursing Home Care.  'This study reflects disparities in the quality of care for African American seniors and that is simply wrong,' Rosenbloom says.  'Nursing homes may simply reflect the racial composition of the neighborhood,' he says." 

Quoted in "Nursing home industry still segregated, new report says, by Kathleen Fackelmann. USA Today. Sep 11, 2007, read it here.  

"'Florida nursing homes don't discriminate on race, and the study is wrong to suggest they do,' said Ed Towey, of the Florida Health Care Association.  He did agree with the study finding that nursing homes with high percentages of Medicaid patients have less money to care for their residents." 

Quoted in "Blacks more likely in worst nursing homes," by Phil Galewitz.  Palm Beach Post. Sep 12, 2007: Read it here

"'There is no denying that St. Louis is a racially, socially and economically polarized community, nor that nursing homes here reflect those conditions,' said Jon Dolan, executive director of the Missouri Health Care Association.  'I think what you're seeing is reflections of society, rather than bad nursing homes for black folks,' Dolan said.  'What you're seeing is our challenges.  About 63 percent of people in nursing homes in Missouri are on Medicaid,' Dolan said."  

Quoted in "Nursing home differences lead to care disparities for blacks," by Tina Hesman Saey. St. Louis Post-Dispatch. Sep 12, 2007:  Read it here.

"Steve Morrisette, president of the Virginia Health Care Association said, 'People select a nursing home based on what's convenient for them and their family and what they perceive to be adequate care, good-quality care.  'I do agree with the recommendation if you can get Medicaid to pay more of its fair share, I think we would improve the system across the board for everybody,' he said."  

Quoted in "Richmond-Petersburg area is 12th in import of disparities, study says," by Tammie Smith. Richmond Times-Dispatch. Sep 12, 2007:  Read it here


LTC Comment:  See a trend here?  The real problem is Medicaid and its low reimbursement levels which undercut access and quality.  Medicaid hurts poor people most because they have no choices besides public assistance.  But Medicaid also hurts middle class and affluent people whose wealth has been expropriated by heirs and their Medicaid-planner accomplices. 

The Health Affairs article recognizes as much: 

"Disparities in payment between Medicaid and private payers make the financial viability of a nursing home dependent on the proportion of private-pay patients it is able to attract.  Homes unable to attract sufficient private-pay patients will tend to have lower nurse staffing levels and more-serious inspection deficiencies.  This will result in lower occupancy levels and, if the operators of a home are unable to take effective corrective action, a 'death spiral,' forcing the eventual closure of the home."  (p. 1456) 

LTC Comment:  Medicaid has squeezed nursing homes mercilessly between the rock of inadequate reimbursement and the hard place of mandated quality.  Something had to give.  In wealthier demographic areas, enough full-private-pay residents make it economically feasible to provide high quality care to everyone in the facility, including Medicaid patients.  But in poorer demographics, with too many residents reimbursed at Medicaid's starvation levels, everyone suffers, including the few private payers remaining in such facilities. 

That's why racial discrimination in LTC occurs.  Don't blame the nursing homes.  The vast majority of them are just doing the best they can in spite of a totally inadequate financing system.   

So, who IS responsible?  Blame the system that makes Medicaid the primary financing system for most nursing home care.  That's what discourages responsible long-term care planning and deters private financing alternatives that could improve access and quality for everyone. 

But most of all, blame the professional poverty-makers who profit personally by putting too many people on Medicaid who should, could, and would have paid their own way in the absence Medicaid's easy and elastic eligibility rules. 

That's where LTC racism really occurs.  Poor people, including poor blacks, have nowhere to turn but to Medicaid.  In fact, the program is supposed to be their safety net. 

But, instead, the system allows affluent people to self-impoverish and divert scarce public welfare funds to their own advantage.  Medicaid planners assure their upper-middle-class clients they'll get good care because they can buy their way into the best nursing homes with "key money." 

Thus, the well-to-do, mostly whites, get great care even when on Medicaid, but the poor, often blacks, end up in the worst nursing homes, most heavily dependent on Medicaid. 

What needs to be done?  Certainly not what the Health Affairs article suggests: 

"What can be done to cut this knot?  A multi-prong effort in four areas could help:  (1) disproportionate-share payment adjustments to nursing homes with a higher proportion of Medicaid residents; (2) equalization of Medicaid and private-pay payments; (3) certificate-of-need and broader regional planning responsive to racial-disparity concerns; and (4) ongoing monitoring and more rigorous enforcement of Title VI in admission practices."  (p. 1456-7)  

LTC Comment:  Hello!  There is no extra government money lying around to increase Medicaid reimbursements.  Why do you think they remain so inadequate?  Capping supply with CONs only distorts the system in other ways.  Tougher enforcement doesn't work.  You can't get blood out of a turnip. 

Rather, the solution is to target Medicaid to people truly in need.  Stop Medicaid planning and drastically reduce the excessive home equity exemption.  That will increase private-pay census in nursing homes.  More people will use reverse mortgages to fund LTC.  More people will buy private insurance for LTC.  Nursing homes will have extra money to spend on staff and facilities.  Access and quality will increase dramatically for everyone when Medicaid can afford to pay higher rates for a smaller number of truly needy dependents.  As quality is equalized between mostly Medicaid and mostly private pay facilities, racial segregation will decline.  Nursing homes in affluent areas will be able to accept more Medicaid, i.e. genuinely poor, residents.  Nursing homes in poor areas will provide better care thus attracting more private payers.  Everyone wins. 

So what's really going on here is less LTC racism and more the result of 40-plus years of well-intentioned, but perversely counterproductive public policy.  The bad news is the current system is a hopeless mess.  The good news is it's easy to fix.  And fixing it will redound to the benefit of everyone, rich and poor, regardless of race.