Black and Latinx nursing homes residents have been hit with a double whammy: They have historically resided in lower-quality nursing homes, and now their nursing homes are more likely to have cases and deaths from COVID-19.
There are long-standing racial and ethnic disparities in nursing home quality. Black and Latinx people are more likely than whites to reside in nursing homes that are understaffed, perform poorly on standard quality measures, and have high hospitalization rates. These nursing homes are also more reliant on Medicaid’s low reimbursement rates, leaving little slack to invest in quality improvement.
These disparities rarely arise from discrimination within nursing homes — that is, black and white residents in the same facility receive the same quality of care. Rather, they arise from differences between nursing homes. Nursing homes serving a high number of black and Latinx residents have lower quality.
Nursing home segregation reflects residential segregation — those serving a high number of black and Latinx residents tend to be located in neighborhoods where people of color live. These neighborhoods, in turn, often lack adequate health infrastructure, community-based health resources, and the influence and power to demand improvement. Disparities in nursing home care are systemic and must be addressed by investing in communities of color and the nursing homes located there.
But this year, a new crisis has emerged — COVID-19, with alarming rates of cases and deaths in nursing homes. In Pennsylvania, like in many other states, over half of COVID-related deaths are associated with nursing homes. And within this tragedy lies a more disturbing truth — black and Latinx residents have borne the brunt of these deaths.
There are many potential reasons for the unequal impact of COVID-19 in vulnerable communities. Black and Latinx people are disproportionately represented among essential workers who are unable to work from home, more likely to rely on public transportation to get to work, less likely to have paid sick leave, and more likely to live in settings that make social distancing difficult. The potential for transmission of the coronavirus is high in many vulnerable communities.
But nursing homes present additional challenges. In a recent testimony before the U.S. Senate Special Committee on Aging, one of us presented an analysis showing that the racial composition of a nursing home is a strong predictor of COVID-19 cases and deaths, more important than the nursing home’s quality, staffing, or deficiency ratings. Because racial composition of nursing homes reflects neighborhood composition, and the prevalence of the virus is high in black and Latinx neighborhoods, the virus is more likely to affect nursing homes in black and Latinx neighborhoods. Even after nursing homes banned visitors, staff must continue to go in and out of nursing homes. Nursing homes in these neighborhoods are simply more vulnerable to COVID-19.
To make matters worse, these nursing homes that rely on Medicaid have little financial reserve to respond to a crisis like the pandemic. Without funds for personal protective equipment and testing, without the capacity to keep staff on site to prevent community spread, and without the ability to pay staff for sick leave, these nursing homes didn’t stand a chance.
Thus, the double whammy: Black and Latinx nursing home residents have historically resided in lower-quality nursing homes. And now, with COVID-19, the nursing homes in their neighborhoods are bearing a disproportionate burden of this crisis, regardless of their quality.
To date, the little federal assistance to nursing homes has been unevenly distributed, inadequate, and will provide only temporary relief. This lack of assistance has been particularly detrimental to nursing homes with the greatest need, those with the lowest financial reserve.
The little federal assistance to nursing homes has been unevenly distributed, inadequate, and will provide only temporary relief.
In place of federal assistance, the Centers for Medicare and Medicaid Services has recently announced plans to increase inspections and fines to low-quality nursing homes. This plan is misguided and punitive, targeting nursing homes in vulnerable communities. It will divert money from nursing homes hardest hit by the pandemic, those with the greatest need for financial assistance. It will further deepen the current disparities in COVID-related deaths.
A more equitable solution is to target federal assistance to nursing homes with a high proportion of black and Latinx residents, those typically reliant on Medicaid that face greater challenges in obtaining personal protective equipment and testing. We must ensure that nursing homes in communities of color — those hardest hit by COVID-19 — have adequate resources to prevent the spread of the coronavirus.
It is time to directly address the long-standing inequities in financing of nursing homes. Otherwise, policymakers risk exacerbating the racial and ethnic disparities that have long plagued these homes and their most vulnerable residents.
R. Tamara Konetzka is a professor of public health sciences at the University of Chicago. Rachel M. Werner is the executive director of the Leonard Davis Institute of Health Economics and a professor of medicine at the University of Pennsylvania. @rm_werner