Dr. El

In the last few weeks, mass protests against racism have led to wider recognition of racial injustices in our country, with alterations in policing procedures, removal of Confederate statues and a rethinking of corporate norms. 

I’ve been reading about the systemic inequities in healthcare and reflecting on those in long-term care in particular. While I don’t have a prescription for correction, acknowledging problems can open the door to constructive discussions and creative solutions. As Deke Cateau stated in his guest column about diversity in LTC this week, “We must…have difficult and uncomfortable conversations that push us to change.”

This piece begins with racial disparities and describes other areas of unfairness I’ve noticed over the years. As the country reexamines long-held practices, perhaps LTC will reconsider its own policies, payment structures and assumptions.

  • One of the most obvious disparities in LTC is that those in management positions are more likely to be white and male, while over 90% of the nursing assistants are women1 and 59% of direct care workers are people of color.2 LTC leadership is missing out on diverse voices and unique perspectives. 
  • The average salary for a certified nursing aide is $27,9993 with 17% of CNAs living below the poverty level.4 This contributes to hiring challenges and understaffing, which leads to burnout, turnover and inadequate care. See this article for one potential remedial approach.
  • As noted in a 2019 LeadingAge report, there is insufficient funding for Medicaid patients, with most states having a reimbursement rate $16 per patient per day lower than the actual costs of care. According to this study in American Economic Review 2019, “moderate increases in Medicaid reimbursement rates lead to significant increases in the quality of care” primarily through an increase in the number of licensed practical and registered nurses.
  • Research shows that when proprietary homes take excessive profits, it’s to the detriment of care quality. The study authors recommend more careful monitoring of profit levels.
  • The lack of insurance coverage for homecare services can lead to unnecessary (and more expensive) nursing home placement. Skilled nursing facilities are valuable and viable as part of a continuum of care that allows seniors as much independence as possible. Entering a congregate setting should be based on care requirements and not because payments are misaligned with needs. As a country, we can absolutely figure this one out.
  • I’ve had many hundreds of conversations with distraught residents about the routine impoverishment of middle-class elders to pay for the same care being received by people with no savings, while wealthier people pass their fortunes to their children. All I can do is help them accept the reality and universality of the situation.

A few months ago, it seemed impossible to imagine the vast changes that have occurred in society, from quarantines to LGBT worker protections to routine telehealth. As we reflect on social injustices, our field has its own injustices to rectify. I imagine that if we held conferences devoted to addressing these issues, with the political will to follow through on recommendations, the smart, caring people of LTC would solve them all.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition andGold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her at EleanorFeldmanBarbera.com.