V. Reasons for Racial Disparities in Quality

Ruqaiijah Yearby, African Americans Can't Win, Break Even, or Get out of the System: The Persistence of “Unequal Treatment” in Nursing Home Care, 82 Temple Law Review 1177 (Spring-Summer 2010) (214 Footnotes).


Three reasons have been suggested to explain why racial disparities in the quality of nursing homes persist: socioeconomic status, geographical racial segregation, and racial bias.   I submit that each of these reasons is inextricably linked and due to structural, institutional, and interpersonal racial bias.

Operating at a societal level, structural bias privileges some groups, such as the rich Caucasians, while denying others access to health care,   while institutional bias operates through organizational structures and “establishes separate and independent barriers,” such as racial segregation, through the neutral denial of access to quality health care “that results from the normal operations of the institutions in a society.”   Finally, interpersonal bias is expressed in individual interactions.  

 A. Structural Bias: Socioeconomic Status

Structural bias in nursing home care allows those with privilege, such as the wealthy Caucasians, to obtain the best quality care available.   Those without *1192 privilege, such as poor minorities, are relegated to poor quality facilities. For example, although nursing homes remain the central institutional provider of care for the elderly and disabled, some elderly and disabled patients now reside in other long-term care facilities including assisted living facilities   and continuing care retirement communities.   The growth of private-pay assisted living developments and continuing care retirement communities in the 1990s, which served predominately Caucasian and relatively affluent clientele, decreased the number of Caucasians living in nursing homes.   Nursing homes were left serving poor minorities, who are more disabled, which is significant because usually these nursing homes are understaffed and provide fewer services.  

Studies show that quality nursing home care is linked to the availability of resources.   A nursing home's resources are primarily determined by its source of revenue, i.e. payment source.   Nursing homes that are primarily reliant on Medicaid payments have limited resources available because Medicaid generally pays below private-pay rates and is often below the actual cost of providing care.   The overreliance on Medicaid payments leaves these homes without resources to provide adequate staffing or high quality nursing home care.   Unfortunately, nursing homes that primarily rely on Medicaid payments disproportionately serve African American patients.  

Furthermore, as discussed in Section III.C, a 2004 study deemed facilities whose primary source of payment is Medicaid as “low-tiered facilities” because of their poor *1193 quality.   Due to limited resources, these homes often have markers of poor-quality care such as fewer nurses, more quality-of-care deficiencies, and higher incidences of pressure sores.   Research shows that “African Americans residing in nursing homes were nearly four times as likely to reside in a home with limited resources and historically poor performance than were white patients.”   In fact, one study found that higher Medicaid payment rates were associated with fewer occurrences of pressure sores and use of physical restraints.  

Nursing homes in resource-poor areas that disproportionately rely on Medicaid for revenue tend to provide poor care. Unfortunately, data shows that forty-one percent of African Americans admitted to nursing homes rely on Medicaid as a primary payer versus twenty-three percent of Caucasians.   African Americans are 2.64 times as likely as Caucasians to reside in nursing homes that house primarily Medicaid residents.   Thus, the structure of nursing home care privileges the wealthy and Caucasians by allowing them to reside in quality facilities, while the poor and minorities are relegated to substandard nursing homes. Due to this structural bias, nursing homes provide the most care to those that are privileged and wealthy, rather than providing the most services to those who are the most disabled, elderly African Americans.

 B. Institutional Bias: Residential Segregation

The institutional practices of nursing homes, such as concentrating good quality nursing homes in affluent neighborhoods, disproportionately disadvantage African Americans. The best quality nursing homes have been shown to reside in predominately Caucasian neighborhoods and have a predominately Caucasian population.   Unlike certificate of need programs that were used to regulate the location of hospitals, nursing homes have complete discretion in where to locate their facilities. Hence, nursing home owners have left predominately poor and minority neighborhoods without health care services to relocate to over-serviced affluent areas.   Regardless of the location of the facility, the nursing home remains racially *1194 segregated, which is linked to racial disparities in the provision of quality nursing home care.

Scholars have suggested that geographical racial segregation is the fundamental cause of racial disparities in nursing homes.   Nationally, the racial segregation of nursing homes varies; however, the Midwest has the highest degree of racial segregation.   African Americans are placed in racially segregated, poor quality nursing homes because that is all that is available in the neighborhoods in which they live.   In fact a study released in 2007 found that “[n]ursing homes remain relatively segregated, roughly mirroring the residential segregation within metropolitan areas,” which results in poor outcomes for African Americans residing in these segregated nursing homes.   Specifically, predominately African American nursing homes have worse care than predominately Caucasian nursing homes. For example, in Illinois no predominately African American nursing home received an excellent quality rating, whereas 29% of predominately Caucasian nursing homes were rated as excellent.   Thus, racial segregation in nursing homes is significant because it is linked to the quality of care provided in nursing homes.

Even if geographical racial segregation is one of the reasons for racial disparities in the provision of quality nursing home care, numerous legal and medical scholars, including Professors Steven Wallace and David Williams, have still shown that one of the fundamental reasons for the continuation of geographical racial segregation is racial bias.   Studies have shown that “explicit discrimination in housing persists” as “[t]here has been little change in [the] levels of segregation in the last 20 years.”   This racial *1195 segregation is not self-imposed by African Americans as they “reflect the highest support for residence in integrated neighborhoods.”   Racial bias is also a factor in residential segregation in nursing homes.

A study of racial segregation in nursing homes reviewed nursing home care in four states: Kansas, Mississippi, New York, and Ohio.   In Mississippi, New York, and Ohio, census data showed that the percentage of African Americans residing in predominately Caucasian neighborhoods was much higher than the population of African Americans residing in nursing homes in those neighborhoods.   The researchers found that the racial segregation in nursing homes in these three states was greater than the surrounding geographical racial segregation, and thus concluded that geographical segregation could not fully explain racial segregation in nursing homes in these states.   Additionally, research has shown that interpersonal racial bias in admission practices by nursing homes has kept nursing homes racially segregated.   Hence, regardless of when one views the problem of racial disparities in health care--at the point of selection of residence in the neighborhood or at the point of selection of residence in a nursing home--interpersonal racial bias is a barrier to African Americans gaining access to safe, quality health care.

 C. Interpersonal Bias

Notwithstanding structural and institutional bias, traditional interpersonal racial bias remains. Research suggests that some of the nursing home admission staff in predominately Caucasian neighborhoods use preferences to keep out African Americans. For example, in North Carolina, some nursing homes deny admission to African Americans because some Caucasian nursing home residents wanted to room with those of the same race.   In New York, studies show that some quality nursing homes deny admission to African Americans, relegating them to substandard nursing homes.   In Ohio a nursing home was alleged to deny admission to African Americans because of their race.   Additionally, some nursing home staff at Illinois's African American nursing homes spent less time daily with residents than staff at facilities where a majority of the residents were Caucasian.   In fact, Caucasian “seniors had qualitatively better nursing home options than black seniors--in some cases, even *1196 when facilities had the same owner.”   These occurrences are not explained by residential segregation or socioeconomic status.  

Furthermore, even though there was a disparity in spending on quality of care in nursing homes that rely primarily on private pay and those that rely on Medicaid, there remains a racial disparity in the quality of care provided by nursing homes that rely on Medicaid. The Reporter analyzed the ratings for Chicago homes whose primary payment source was Medicaid and found that racial disparities in quality persisted.   Specifically, the study found that “[a] quarter of white homes received an excellent rating, compared with none of the black homes. More than half of the black homes received the worst rating, while 8 percent of white homes earned the same score.”  

As the data shows, African American patients are overrepresented in poorer quality nursing homes as a result of racial bias. Structural and institutional bias relegates African Americans to racially segregated under-resourced nursing homes, and interpersonal bias leaves African Americans without equal access to quality nursing home services compared to Caucasians. Currently, the regulations governing the provision of quality nursing home care fail to address racial bias in any form.   Because the nursing home regulatory system not only fails to address the root cause of racial disparities in the provision of quality nursing home care--racial bias, but also is guilty of exhibiting the same bias, it will never alleviate the harm suffered by African Americans, i.e. unequal access to quality nursing home care. One glaring example of the failure of the nursing home regulatory system to improve the quality of care African Americans receive in nursing homes is the SFF initiative, which is discussed below.