B. Denial of Equal Quality

      The quality of nursing home care is defined by the health of the residents and by the nursing home's compliance with quality of care regulations under the Medicare and Medicaid Acts. When comparing the quality of care African Americans receive in nursing homes with the quality of care Whites receive in that same nursing home, the inequities are significant. Additionally, racial inequities in the quality of care provided in predominately African American nursing homes compared to predominately White nursing homes are evidenced by a plethora of research studies over the last decade.

      A study of several states, including New York, Kansas, Mississippi, and Ohio found that when Whites and African Americans reside in the same facility the quality of care provided is different. African Americans traditionally receive poor quality care. For example, the standardized admission resident assessment tool (required by the government to be completed within fourteen days of a resident's admission) showed that late-stage pressure sores are more common to African Americans, while early stage pressure sores are more common to Whites. African Americans have higher rates of late-stage pressure sores because *461 they are commonly underdiagnosed. Thus, Whites receive treatment before the pressure sore becomes too severe, while African Americans and other minorities suffer without treatment until the pressure sore becomes severe.

      In addition to these racial inequities in care when Whites and African Americans reside in the same facility, there are significant inequities when the races reside in different nursing homes. According to national data compiled from Medicare forms, African Americans reside in nursing homes with “lower ratings of cleanliness/maintenance and lighting.” Moreover, African Americans are twice as likely to be admitted to primarily Medicaid paying nursing homes, which are then twenty-four percent more likely to have deficiencies. The facilities whose primary source of payment is Medicaid are traditionally of poor quality and predominately house African Americans.

      In a recent national study of nursing home quality, researchers deemed facilities whose primary source of payment is Medicaid as “low-tiered facilities.” The researchers called Medicaid-only facilities low-tiered facilities because of their poor quality. Forty-one percent of predominately African American nursing homes are low-tiered facilities. This study showed further that nine percent of Whites reside in low-tiered facilities compared to forty percent of African Americans that reside in low-tiered facilities. African Americans are three to five times more likely to be in low-tiered facilities than Whites. The placement of a majority of African Americans in low-tiered facilities is significant because these nursing homes are more likely to be terminated from the Medicaid/Medicare program because of quality of care deficiencies. These low-tiered facilities have fewer nurses, more quality of care deficiencies, higher incidences of pressure sores, use physical restraints more, and have *462 inadequate pain control and use of antipsychotic medications. Hence, the admission of African Americans to low-tiered facilities has subjected them to substandard nursing home care. This national data is further supported by a study conducted in St. Louis, which showed that St. Louis nursing homes were racially segregated and those predominately African American had more deficiencies, i.e., violations of Medicare and Medicaid regulations.

      Overall, a review of the empirical data provides a dismal picture of the accessibility of quality nursing home care available to elderly African Americans. African Americans are delayed access to medically necessary rehabilitative care because nursing homes are unwilling to admit them for treatment. Even when African Americans finally gain access to nursing homes the quality of care is substandard. A number of barriers exist preventing African Americans from accessing quality health care: cultural differences, geographical racial segregation, socioeconomic status, and racial discrimination. Each factor may play a role in explaining this conundrum, but the abovementioned research studies and government reports show that African Americans face delays in transfer and denial of admission to quality nursing homes even when cultural differences, geographical racial segregation, and socioeconomic status are controlled. The only factor that remains predictive of the inequity in accessing quality care is race.