People typically need some form of elder care as they age. All too frequently the quality and location of that care is segregated along economic and racial lines. Nursing homes have especially evidenced this trend over the past four decades. The proportion of white elderly in care facilities has steadily declined as the minority proportion steadily increases.
In general, residential care facilities in the United States are shrinking in size and popularity as their residents are becoming proportionately more Black, more Hispanic, more Asian, and less white. For example: between 1999 and 2008, the number of elderly African American nursing home residents increased 10.8 percent. During the same period, the number of White nursing home residents declined 10.2 percent.
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The nationwide trend, reflected in metropolitan areas from New York to Los Angeles, results from changing demographics and disparities in what people can afford. To fully appreciate the shift and its significance we must first briefly examine elder care in the United States.
Presently 34.7 million adults (16% of population) are caregivers to the elderly. Women account for 66% of caregivers and while men may be sharing in caregiving tasks more than before, women still shoulder the major burden of care. The potential care-recipient population continues to expand rapidly. There are 76 million US baby boomers—those born between 1946 and 1964—and the oldest of them turned sixty-five in 2011. During the next nineteen years roughly 10,000 people each day will turn 65.
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By 2030 the Census Bureau projects that 20 percent of the US population will be sixty-five or older, up from 13 percent today.As the population ages the ethnic composition is shifting. Between 2000 and 2030, there will be a substantial shift with the older African American population expanding by 168% and the older White population increasing by 90%. A growing African American elderly population will likely exacerbate existing racial disparities. Therefore, it is critical to improve our understanding of the extent, causes and implications of uneven racial distribution across the spectrum of long-term care.
Among the U.S. adult population approximately one-fifth (21%) of African-Americans provide care to an elderly family member or loved one in a home setting, but this is changing. With more Black women obtaining collegiate and/or professional degrees then pursuing professional careers there are fewer caregivers within the community. According to the 2010 census 21.4% of African American women held college degrees or higher. In general this is a great achievement and a positive step forward but in terms of elder care this creates a void of caregivers in our communities.
Cost is another factor in the racial segregation of elder care. The three most common long term care options are: nursing homes, assisted living facilities and home care. Some or all of these options may not be equally available, accessible or affordable to everybody. Annually, the national average cost for a private nursing home is $92,000, assisted living $42,000 and home care $41,000. These cost traditionally play a role in the decision to care for African American elders in the home by family members.
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Nursing homes previously catered to a predominantly white population. African Americans who resided in long term care accommodations tended to be concentrated in a few predominantly African-American facilities located in rural, non-poor, African American communities.
This is changing. The proportion of African Americans in long-term residential care facilities has increased steadily over the past four decades. In 1963, an estimated 27 white and 10 minority elderly persons per 1000 persons in the general population resided in nursing homes, yielding a minority–white ratio of 37%. In 1969 this ratio stood at 46%; by 1977 it had risen to 60%, and by 1989 it was 65%. The racial gap in use of long-term care is therefore narrowing.
A cursory look at the numbers would suggest that elderly Blacks, Hispanics and Asians are gaining greater access to nursing home care. But the growing proportion of minorities in nursing homes is coming about partly because they do not have the same access to more desirable forms of care as wealthier whites do.
In nursing homes, where African Americans are most prevalent, typically the majority of facility revenues come from Medicaid. The reliance of nursing homes on Medicaid reimbursement ensures access for poor elderly African Americans. Whites, having greater economic resources, are utilizing better more preferable alternatives, like assisted living or home care.Nursing homes in predominately minority areas are often of lower quality and are more likely to close, while assisted living facilities are more likely to be built in areas where residents have high incomes. Recently built assisted living facilities are marketed toward middle- and upper-income people. When you overlay economics with age you tend to find the majority of people who can afford these facilities are white. The result being medically able whites abandon nursing homes for assisted living facilities and home care, their beds are then backfilled by Blacks. This results in a disparity that manifests not only economically but also racially.
In fact, the numbers of minority residents in nursing homes increased proportionately more rapidly than the minority population overall, even in areas with high concentrations of minorities. These results may indicate unequal minority access to home care and assisted living alternatives, which are generally preferred for long-term care.
Moreover, despite the steady growth of private pay home care and assisted living facilities, the majority of Medicaid long-term care spending still goes toward nursing home care. Said another way, since a high percentage of minorities rely on Medicaid to pay for care, they are being directed to nursing homes when the elderly population who can afford to pay out-of-pocket for services are choosing alternatives such as assisted living facilities or home care.
Lastly, another potential explanation of the observed racial separation is exclusionary practices. Many long-term care facilities have preserved the ability to control who gets admitted through control of payer mix, case mix, duration of stay and race. This is significant because, in general, African American elderly are less wealthy, in poorer health and have more chronic and disabling conditions compared with white elderly.
What To Do?
As we move forward we may suggest to policy makers, health care providers and payor sources that a “rebalancing” may be needed. For example, Medicaid funding options may need continued expansion from nursing homes to other forms of care and should increasingly include assisted living facilities and home care. As it is, whites are clearly more likely to use these more desirable alternatives.
More emphasis and funding may be required to promote minority elders’ use of them, too, if a more race neutral elder care future is desired. Otherwise, questions about the nature and quality of long-term care received by minority groups will eventually need to be addressed.
After years of consulting, providing professional advice and caring for the elderly, Derrick Y. McDaniel, a recognized expert in the eldercare industry, an attorney and former NYU professor, has composed a resource tool to help everyone who cares for their aging loved ones. Eldercare, The Essential Guide to Caring for Your Loved One and Yourself is a book that answers all the tough care giving questions that most people do not know to ask. Visit MrEldercare101.com for more information.
