A. Denial of Equal Access

      African Americans are denied equal access to quality nursing home care by delay in transfer and denial of admission to quality nursing homes. Elderly patients gain admission to nursing homes through transfer from hospital care or from home. Frequently, elderly patients are transferred to a nursing home after a hospital stay. The decision to transfer a patient from a hospital to a nursing home is controlled by the patient's physician and the hospital's discharge staff. A transfer normally occurs once a physician determines that a patient is well enough to be released from the hospital, but not well enough to go home. A member of the hospital discharge staff contacts the nursing home seeking to transfer a patient. Minorities are customarily delayed in transfer to quality nursing homes. A delay in transfer is “the time elapsed between when a patient was medically ready for discharge to another form of care and when he or she actually was discharged.” Delays in transfer to nursing homes deny patiental access to medically necessary rehabilitative care. Research studies in several states have shown that African Americans experience transfer delays to quality nursing homes because those nursing homes deny admission to African Americans.

       *458 Since the 1980s, several state studies have shown that African Americans are delayed by at least ten days in a transfer from the hospital to a nursing home. This delay is because African Americans have “difficulty in finding alternative placement.” Statistical analysis of transfer data suggests that African Americans' failure to find a nursing home placement was not correlated with the patient's payment source, physical condition, demographic attributes, family cooperativeness, or behavioral issues. Race was the central factor in the transfer of patients from the hospital to a nursing home. According to the authors of the study, Professors David Falcone and Robert Broyles, the fact that race is the greatest predictor of delay in transfer and that there has been no change in this delay even once brought to the attention of those responsible for transfers, proves that racial discrimination is the cause of the delays. Further research shows that, because there are fewer African Americans in nursing homes than Whites, African American patients are delayed transfer to nursing homes until they can be placed in the same room with other African Americans or can be transferred to predominately African American nursing homes. Hence, racial discrimination is also present in the admission practices and policies of nursing homes, which remain unregulated by both the state and federal governments.

      States administering federal entitlement programs (Medicaid and Medicare) are supposed to regulate the admission processes of nursing homes. However, if states were to regulate admissions and increase racial integration, the costs of Medicaid would increase. Trying to keep down the costs of Medicaid, states grant nursing *459 homes great discretion in their admission practices and policies. Thus, in reality, the admissions decisions are left solely to the nursing home staff. Nursing homes have used this discretion to deny admissions to African American patients, as shown by several state studies.

      In 1988, Doctors William Weissert and Cynthia Cready found that there was a significant delay in transfer of African Americans from hospitals to nursing homes in North Carolina. This delay was because some White nursing home residents wanted to room with those of the same race. To comply with this request, nursing homes intentionally kept rooms and their facility segregated by denying admittance to African Americans. In 1984, a study of New York nursing homes showed that nursing homes that provided excellent quality of care demonstrated a pattern of admitting Whites over African Americans. Statistics showed that the population of quality nursing homes was one-third White, while one-half of the population of the substandard quality nursing homes was predominately African American. This disparity was attributed to “a combination of discrimination by nursing homes and steering by hospital discharge planners.”

      The New York State Advisory Committee to the U.S. Commission on Civil Rights (“Advisory Committee”) reviewed nursing home admission practices in New York eight years later and found that there were still significant racial inequities in admission between African Americans and Whites. The Advisory Committee's findings showed that White patients were three times more likely to get into a quality nursing home than minority patients. Of the characteristics used to decide whether to admit a patient, race remained the chief factor, even in nursing homes sponsored by religious organizations, which were more likely to admit those of a *460 different religious background than those of a different race. Based on this evidence, the Advisory Committee found that discriminatory admission practices had been institutionalized in the admission policies and procedures of New York nursing homes causing a disparate impact on African Americans. The inequities in admissions practices are significant because where a patient is admitted usually determines the quality of care that patient receives. Statistics from a study of New York nursing homes showed that nursing homes that provide substandard care are predominately African American.