August 29, 2011 -- New York -- The number of older Americans living in nursing homes continues to fall, and the proportion of residents who are black, Hispanic or Asian has climbed sharply. But don’t expect cheers from the Brown University researchers who’ve tracked this major shift in long-term care.
The back story here is that for years advocates have urged the federal government to strengthen alternatives so that fewer old people have to live, and die, in nursing homes. Nobody really wants to be there — seniors historically have said they prefer to remain at home as long as possible. But the system was long out of kilter: Medicaid would pay for nursing home care, but was much stingier about underwriting home care, assisted living and other options.
This led to an extended attempt at “rebalancing” — funneling more Medicaid money into home and community programs and less into institutionalization. And it’s working. Though Medicaid still devoted only 42 percent of its spending on long-term care to home and community programs in 2008, that’s more than double the proportion in 1995.
“It’s been a gradual 20- to 30-year effort, and the pace is getting faster,” said Zhanlian Feng of the Center for Gerontology and Health Care Research at Brown University.
That’s one reason the nation’s nursing home population fell from 1.6 million elderly residents in the 1990 to 1.2 million in 2008.
At the same time, the nursing home population is growing more ethnically and racially diverse. “Thirty years ago, reports from the Institute on Medicine and from civil rights groups raised a lot of concern about lack of access to nursing homes” for minority elders, Dr. Feng said. But over the decade from 1999 to 2008, the number of black residents in nursing homes grew by 10.8 percent, and the Asian and Hispanic populations climbed by more than 50 percent.
Good news, right? Maybe not. “On the surface, it looks like we’ve achieved parity,” Dr. Feng told me in an interview. “But this is disparity in disguise.”
He and his colleagues, analyzing federal data on residents in nursing homes that receive Medicare and Medicaid (virtually all of them), just published their findings in the journal Health Affairs. They’ve turned up some disturbing developments.
“Whites are aging as well, but you’re not seeing more of them in nursing homes,” Dr. Feng said. “Their numbers are declining.” The proportion of white residents fell 10.2 percent over the decade, while the growth in minority nursing home residents outpaced the growth in the nation’s minority population in general.
What’s happening? “Minorities don’t have as many choices as white elders,” said Dr. Feng.
Take assisted living facilities, which have siphoned off more than a million residents who might earlier have entered nursing homes. Assisted living facilities are expensive, generally private-pay and located in affluent communities.
“On average, whites have more income and education and can better afford these options,” Dr. Feng said. “They don’t have to go to nursing homes, or they’re better able to delay going.”
With greater scrutiny, then, this demographic trend represents a less happy reality. Just as minority seniors are pouring into nursing homes, whites are turning to more attractive choices and staying out.
Because there’s much less data on who, exactly, relies on home and community services, compared with who enters nursing homes, Dr. Feng is couching this explanation as a hypothesis.
He notes that the statistics may also reflect cultural changes. Immigrant communities that care for parents in multigenerational households may be less able to maintain that practice as they acculturate. “A lot of things are happening to undermine those traditional family options,” he said. He’s seen a similar shift in his native China, a topic I’ll return to in a subsequent post.
Over all, he sees a good news-bad news story, in which minority seniors get stuck in the institutions that whites have the means to avoid. “I’m struck by this persistent disparity,” Dr. Feng said. “It looks like we’re making some progress, but not really. The disparities are still there and are deeply rooted in history, geography, segregation and socioeconomic differences.”
Copyright Paul Span -- New York Times 2011