Addressing Racial Disparities in the Long-Term Care System: Using Law to Create Public Health Solutions
Ruqaiijah Yearby, J.D., M.P.H. Assistant Professor, Institute for Health Law Loyola University Chicago School of Law
INTRODUCTION
Studies have shown that in 1950 before the end of Jim Crow, the life expectancy rates of 65 year old African-Americans and Whites was the same. Since 1950, African-Americans’ life expectancy has continued to decline even after the advent of Title VI, which granted them “equal” access to health care services. African-Americans lack of equal access to quality health often leads to a greater use of services for untreated chronic conditions than Whites.
INTRODUCTION (Cont.)
A recent study showed that under Medicare, African-Americans have greater access to services to care for untreated conditions than Whites. These services include amputations from diabetes, removal of testes from prostate cancer, removal of tissue from late stage pressure sores, and implantation of shunts for renal disease.
INTRODUCTION (Cont.)
Elderly African-Americans are generally more disabled than Whites and requires them to obtain more assistance conducting activities of daily living, such as dressing, eating, and showering. Assistance for these activities is provided by the long-term care system. Empirical studies of the long-term care system show that there are significant racial disparities in quality of care provided by the long-term care system, particularly in the care provided by nursing homes.
Road Map
I.
Racial Disparities in Nursing Homes (“NH”) Reasons for Racial Disparities Legal Resources Public Health Solutions
II. III. IV.
I. Racial Disparities in NH
Research
studies show that when compared to Whites African-Americans:
Face longer delays in transfer to nursing homes; Are denied access to quality nursing homes; and Are more likely to be placed in substandard quality nursing homes.
I. Racial Disparities in NH: Delay in Transfer
A delay in transfer is “the time between when a patient is medically ready for discharge to another form of care and when he or she actually is discharged.”
I. Racial Disparities in NH: Delay in Transfer (cont.)
FINDINGS Since the 1980s, several state studies have shown that African-Americans are delayed by an average of 10.7 days in a transfer from the hospital to a nursing home. This delay is because AfricanAmericans have “difficulty in finding alternative placement.”
I. Racial Disparities in NH: Denial of Admission
States administering federal entitlement programs (Medicaid and Medicare) are supposed to regulate the admission process of nursing homes. Trying to keep down the costs of Medicaid, States grant nursing homes great discretion in their admission practices and policies.
I. Racial Disparities in NH: Denial of Admission (cont.)
FINDINGS A 1984 study of New York showed that nursing homes, which provided excellent quality of care demonstrated a pattern of admitting Whites over African-Americans. Eight years later, a study of New York nursing homes found that White patients were three times more likely to get into a quality nursing home than minority patients.
I. Racial Disparities in NH: Substandard Quality of Care
A substandard nursing home is one that has violated one of the Medicare or Medicaid regulations regarding resident behavior and facility practices, quality of life, or quality of care that caused actual or serious actual harm to one or more nursing home residents.
See 42 C.F.R. § 488.301 (2005) (Definitions of Survey, Certification, and Enforcement).
I. Racial Disparities in NH: Substandard Quality of Care (cont.)
FINDINGS The number of Medicare deficiencies was two times higher in predominately AfricanAmerican nursing homes versus predominately White nursing homes. These inequities in quality are found not only in the difference in quality of nursing homes African-Americans are admitted to versus the nursing homes Whites are admitted to, but also in the differences in the quality of care received when they reside in the same nursing home.
CHICAGO NURSING HOME STUDY*
Number of Complaints of Violations of Medicare and Medicaid Quality of Care Regulations by Racial Characteristics of Zip Codes
*Study entitled, “Assessing Racial Disparities in the Quality of Nursing Home Care,” and conducted by: Ruqaiijah Yearby, Alexandra Pae Song, Margaret Eaglin, Claire Dobbins, Elissa J. Bassler, Margaret Beaman.
II. Reasons for Racial Disparities
Cultural
Difference Racial Segregation Status
Geographic
Socioeconomic Insurance
Racial
Status
Discrimination
III. Legal Resources
TITLE VI Section 601 and regulations: No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance, i.e. Medicare and Medicaid. Medicare & Medicaid: These federal programs pay for a majority of nursing home care provided in the United States. Nursing homes seeking participation in Medicare and/or Medicaid have to certify that they do not discriminate based on race and that they are providing quality care to every patient residing in the home.
IV. Public Health Solutions
Collect Admission and Transfer Data using Race Link Survey Data with Racial Mix of Nursing Home Residents
Impose Fines for Racial Disparities in Quality of Care Evaluate Effect of Efforts in Addressing Racial Disparities