Nursing Homes for People of Color:
Still Segregated, Still Unequal

Bookmark and Share
Benzena Tucker (center) spent the last few years of her life in a public nursing home with peeling paint and overworked staff. She had no family and had been too ill to work for many years. At her side, are two volunteers, Wendy Josephs (l.) and Ricki Lewis (r.).

Benzena Tucker (center) spent the last few years of her life in a public nursing home with peeling paint and overworked staff. She had no family and had been too ill to work for many years. At her side, are two volunteers, Wendy Josephs (l.) and Ricki Lewis (r.) Benzena provided permission to publish this photo.

If Martin Luther King, Jr. was alive today, he would be 86. If he was like many elderly black Americans, he might well end up in a nursing home ranked lower in quality and with less well-trained nursing staff than a nursing home that many white Americans reside in. The facility would likely house a disproportionately larger proportion of people of color and on Medicaid than higher-quality nursing homes.

The disparities are easy to miss. After all, what happens in nursing homes stays in nursing homes, invisible to the rest of us. The only ones who see what’s going on are the patients, family and friends, and staff. If people report lousy conditions in the homes, nursing homes often vilify them. In fact, some would argue that the industry hides behind a smokescreen of patient privacy. Yes, there are inspections. Are they sufficient to drive equal care? Apparently not. Overall, the nursing home industry has changed little in terms of providing quality care for minority elders on par with what white elders get.

Documentation of inequality in long term care for minority elders dates back to enactment of Title VI of the Civil Rights Act and the passage of Medicare in 1966, which prohibited segregation in health facilities that accepted federal funds. In 1981, an Institute of Medicine report addressed the issue of segregated care in nursing homes. The hospital industry was forced to integrate to some degree at least, but nursing homes have been left largely alone.

Contrary to stereotypes, a large Commonwealth Fund analysis led by Vincent Mor, PhD, from the Department of Community Health at Brown University, found that segregation was lowest in the South and highest in the Midwest (Wisconsin, Missouri, Michigan, Indiana, and Ohio). The study found that Cleveland, Ohio, followed closely by Gary, Indiana, were the most segregated cities for nursing homes. Additionally, black elders tended to be in nursing homes in the lowest quarter of quality ratings. Blacks were 1.7 times as likely as white Americans to reside in a nursing home that was subsequently thrown out of the Medicare and Medicaid programs because of poor quality and 2.64 times as likely to be in a facility housing predominantly Medicaid residents. Elderly black Americans are not the only groups at increased risk of going to a poor-quality nursing home. So are elderly Hispanics and probably many other groups not cited here.

The proliferation of for-profit nursing homes in an industry that was once largely nonprofit has also had adverse impacts. In this study, for-profit nursing homes have been found to have lower RN staff intensity and lower RN skill mix than nonprofits, jeopardizing patient care. Poor people on Medicaid are going to for-profit nursing homes at far greater rates in many parts of the country.

This post is a snapshot of one part of long term care, which is an immense, complex topic.

Readers would be misguided if they thought that disparities are concentrated in the Midwest and do not persist elsewhere. These two anecdotes, though not data, are telling. Friends of mine recently watched in tears as a dear African American male friend landed for a long stay in a one-star nursing home in New Jersey. The nursing home housed people of color on Medicaid primarily. My friends were inconsolable when they returned from a visit, quick to call it a “crowded, smelly, dumping ground.” I learned of another story from an older African American woman from Queens NY, a New York City government retiree. I worked with her for many years. When she felt that she could no longer keep up her house, she could not find a satisfactory long term care residence to move into. She never left home: her health deteriorated and eventually, she died at home.

These stark realities are shameful. It’s 2015. We can quibble about statistics, question cause,effect, or association, but outrage, remedies, and stiff penalties and incentives for change are desperately needed.

Warning Signs

Bookmark and Share

“Warning Signs” is a new concept for Patient POV. In it, I plan to point to unanticipated changes in health care that warrant a closer look. In some cases, all we see is a snapshot of something awry in one locale, but the change is ominous, has the potential to spread, and the public ought to know about it. I hope to point to exemplary shifts in medicine as well.

In the past week, I found these warning signs particularly worrisome, and applaud the work done by other reporters and bloggers to document them:

  1. If you thought the peanut butter-salmonella scare sounded bad enough on its own, think again. The Center for Science in the Public Interest explains that even though the FDA Food Safety and Modernization Act was passed in 2011, FDA has not implemented measures essential for food safety. “Deadline after deadline has come and gone with the agency taking no action, leaving consumers vulnerable and industry without guidance. Peanut butter and other foods are no safer than they were at the beginning of the President’s term, when he rightfully expressed concern about the peanut butter in his daughter’s sandwiches.”
  2. Concerns over the future of Medicare have gotten lots of attention, but the future of Medicaid has gotten far less scrutiny, particularly for seniors and the disabled. An editorial in the Tampa Bay Tribune takes up Romney’s mean, lean plans for Medicaid and nursing home residents.” The editorialists point to the public’s confusion that nursing home care is solely a Medicare issue and that Medicaid is strictly for the poor.  “But Medicaid is the program that provides long-term care to the elderly and disabled…It was Ryan who authored the plan to convert Medicaid from a strong federal-state entitlement to a block grant program to the states that Romney has incorporated into his campaign. The plan, passed as a budget blueprint by the Republican-controlled House, would gut Medicaid’s safety net and focus instead on cutting funds. The nonprofit Center for Budget and Policy Priorities says Medicaid funding would decline by one-third by 2022 under Ryan’s plan.” Take a closer look.
  3. Electronic health records have enormous potential for improving patient care and tracking health outcomes, but abuses in Medicare billing, identified in a NY Times article, are worrisome. Readers will want to be aware of:
  • cloning, where a doctor copies information from a previous visit to a later one, or duplicates information from one record to another;
  • upcoding, which The Times defines as exaggerating “the intensity of care provided or the severity of a patient’s condition to justify higher billings.”

In response to this article, Attorney General Eric Holder Jr. and Health and Human Services Secretary Kathleen Sebelius sent a letter to five hospital associations, noting “troubling indications” and their intent to prosecute for billing for services never permitted.

4. Ever wonder, why, all of a sudden, you see higher out-of-pocket costs for doctors’ visits. Consider this: the Cleveland Plain Dealer describes how ordinary doctors’ offices have become “hospital departments,” and along with it, come new facility fees for simple primary care.  In one example at Cleveland Clinic’s MetroHealth Center, , a patient was charged a facility fee of $1,655, about four times the doctor’s bill, for 30 minutes in an exam room to have a suspicious lesion removed. The patient states: “There is a much bigger issue and that’s that people won’t get the care they need because they can’t afford these charges. It’s totally wrong.”

“Warning Signs” is new. Let me know if you like it, think of something that I missed, and most importantly, your POV.