LTC Bullet: LTC Racism
September 19, 2007
Comment: Do America's
nursing homes discriminate against blacks as a new study suggests? The complicated truth after the ***news.***
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BULLET: LTC RACISM
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
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
we'll explain what these findings and allegations really mean and why it
matters to every American, regardless of race, or any other demographic
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
segregation in U.S. cities disproportionately places blacks in
poorer-performing nursing homes," Health Affairs, Vol. 26,
No. 5, September/October 2007, footnotes omitted, http://e.ccialerts.com/a/hBG5wQpAIyhSgAJJpA8AJW$doPp/cdb28.
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?"
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.
found that nursing home care was relatively segregated in 2000, with
two-thirds of all black residents living in just 10 percent of all
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.
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
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."
in "Nursing home industry still segregated, new report says, by
Kathleen Fackelmann. USA Today. Sep 11, 2007, read it here.
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
in "Blacks more likely in worst nursing homes," by Phil
Galewitz. Palm Beach
Post. Sep 12, 2007: Read it here.
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."
in "Nursing home differences lead to care disparities for
blacks," by Tina Hesman Saey. St. Louis Post-Dispatch. Sep
12, 2007: Read it here.
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
in "Richmond-Petersburg area is 12th in import of disparities,
study says," by Tammie Smith. Richmond Times-Dispatch. Sep
12, 2007: Read it here.
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.
Health Affairs article recognizes as much:
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."
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.
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.
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
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
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.
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."
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.
needs to be done? Certainly
not what the Health Affairs article suggests:
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.
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.
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
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.