As many institutions across the country begin to wrestle with their own histories of racism, a group of researchers at UNC and peer universities are calling for what they say is an overdue examination of the nation’s long-term care system. These researchers point to historic policies and practices embedded in systemic racism that have created a harmful segregated system of care, particularly among nursing homes and among the direct health care workers they employ.
Over the last year, the COVID-19 pandemic has exacerbated the health and employment disparities that have long existed within these segregated systems and intensified their impact, particularly on Black nursing home residents and Black health care workers, said University Kenan Distinguished Professor Sheryl Zimmerman, director of aging research at the UNC School of Social Work, co-director of aging, disability and long-term care for the Cecil G. Sheps Center for Health Services Research and one of the co-authors of “Addressing systemic racism in nursing homes: A time for action.”
The article, recently published in the Journal of the American Medical Directors Association, was co-written with Distinguished Professor of Family Medicine Philip D. Sloane, co-director of the Shep’s program on aging, disability and long-term care. (Other co-authors included: Ruqaiijah Yearby from St. Louis University; R. Tamara Konetzka from University of Chicago; Yue Li from University of Rochester Medical Center in New York; and Robert Espinoza from PHI.)
According to the article, the researchers noted that the proportion of Black residents in nursing homes was found to increase the probability of a COVID-19 outbreak by 45% to 300%. In addition, in a recent analysis of data from more than 13,000 nursing homes, nursing homes with high proportions of Black residents had 3 times the COVID-19 infection rate and 3.3 times the COVID-19 mortality rate as nursing homes with the fewest Black residents.
At the same time, although research has shown that long-term care services are primarily provided by low-paid, racially diverse workers, Black employees in particular are underrepresented in professional and administrative roles in the health care field. In fact, the researchers noted, current policies and practices with roots in slavery continue to define personal care services, once assigned to enslaved individuals, as a low-wage occupation.
As a result, Black individuals employed in long-term care settings maintain a station at the bottom of the workplace hierarchy. The impact of this reality, the researchers noted, can be found in institutions “where low-paid people of color care for a primarily White clientele under the supervision of primarily White managers.”
“The lesson to learn is that we’ve built and perpetuated a tiered system of care for people of color and that racism and biases have had a very active role in it,” Zimmerman said. “As a result, this tiered system affects both the people who receive care and those who provide care.”
Racially segregated communities contribute to this problem, Zimmerman said. The racial makeup of nursing homes tends to mirror the racial makeup of nearby residential communities, the researchers noted. Nursing homes with a higher percentage of White residents tend to be situated in more affluent White communities, while nursing homes with the largest percentage of Black residents are located in neighborhoods that are also majority Black.
Moreover, data from the U.S. Centers for Medicare & Medicaid Services indicate that nursing homes with the lowest quality ratings are more than twice as likely to house 50% or more Black residents and much more likely to have more than half their residents receiving financial assistance via Medicaid. By comparison, the researchers noted, more White residents have access to private insurance or other financial resources to pay for long-term care services and as a result, are more likely to be recruited by higher quality nursing homes.
This disparity can also be attributed to historic systemic racism, the scholars noted. For example, the median wealth of White households is 10 times that of the average Black household. Research has shown that discriminatory policies and practices have denied Black residents the generational ability to accumulate wealth at the same rate as White residents. For many Black families, this barrier potentially impacts every facet of their life, including where they live, where they send their children to school, job opportunities, and ability to access health care, among other issues.
Further, the economic impact of systemic racism can also create challenges for people as they age, the scholars noted. Without generational wealth and adequate resources, Black residents have fewer choices available to them for long-term care services and are less likely to live in highly rated nursing home communities, which have reported particularly low COVID-19 infection rates. As a result, Black individuals who are high risk, older and disabled are disproportionately living in low-quality nursing homes and being cared for by low-wage workers of color who are also at higher risk for COVID.
Strengthening and improving the long-term care system will require transformative reform, the researchers agreed. The first step: accepting and acknowledging that systemic racism is behind the disparities in settings, care quality and outcomes. Centering the experiences of individuals who have been marginalized is also critical to understanding and addressing issues that impact people of color, the researchers noted.
Policymakers must also commit to investing financially in struggling communities, where many low quality nursing homes exist, the scholars added. They must also provide incentives to well-heeled nursing homes to recruit lower-income residents by raising the Medicaid reimbursements these institutions receive.
“We need to support low-performing nursing homes so they can improve their care, not fine them and take away the very resources they need to provide care,” Sloane said.
Meaningful reform will not happen without strengthening conditions for workers, the researchers concluded.
“There’s a mindset within the healthcare system that has ignored these incredible care workers who were already being devalued because of systemic racism,” Zimmerman added. “Now because of COVID and its effect on older adults, their importance is finally coming out of the shadows. We have to invest in communities and policy change to guarantee long-term care as a right as well as provide more opportunities for workers in terms of advancement and pay.”