USA - No Country for Old People [In These Times]

America's healthcare crisis hits minority seniors - and things are getting worse

MELVINTEEN DANIELS MAY HAVE BEEN in the autumn of her life, but it shouldn't have ended the way it did. At a county-run Pennsylvania nursing home, she perished from neglect, her body ravaged by malnourishment and blood infection, according to court documents. Her skin was marred by a pressure ulcer that had grown to about 11-inches wide.

Last summer, a federal appeals court judge allowed Daniels' family to go forward with a civil lawsuit, which was, like thousands of other nursing home neglect cases, settled out of court. But the Daniels case was unusual for its legal rationale: By invoking an obscure civil rights statute in the 1987 Federal Nursing Home Reform Act, the suit uniquely linked the concept of civil rights with the care of the elderly. Daniels' death foreshadows a coming crisis in the healthcare system: As a massive number of older Americans - the "gray wave" - are absorbed into long-term care programs, can the system deliver what our elders need and deserve at the most vulnerable stage in their lives?

By 2030, the baby boom will be hurtling toward a senior bust Nearly one out of every five Americans will be 65 or older, resulting in national demographics similar to those that currently exist in Florida. Despite the soaring need for long-term care that such an aging population is likely to require - a 2008 study projected about half a million new nursing home beds would be needed by 2020 - the number of nursing home beds has actually shrunk by 5 percent over the past decade. Meanwhile, as America's population of olà people becomes more ethnically and racially diverse, elderly people of color are likely to suffer disproportionately from the shortage of nursing home care.

Amid the structural challenges of the impending gray wave, newly emboldened Republican lawmakers want to gut the Medicare and Medicaid systems that support nursing homes and other longterm care services. Such cuts are likely to result in even greater racial and class inequities in long-term care.

As the budget standoff escalated in Washington this summer, keystone health programs - despite their vital role as safety net programs in a weak economy- became a whipping post for deficit hawks, particularly in light of the uproar over the new healthcare reform legislation. Now that both parties are embroiled in a race to cut the deficit, supposedly to shore up the country's long-term finances, both Medicare and Medicaid have been hauled onto the table in the political horse trade. Some possible "cost-saving" measures include converting Medicaid to a flat-funded block grant program or restricting Medicare coverage based on the patient's income. In the bipartisan deficitslashing frenzy, healthcare cuts might also be compounded by the downsizing of Social Security and other federal programs that millions of poor and elderly rely on for survival.

Nursing home white flight

Stories like Daniels' are rare, but such tragedies expose grim patterns of neglect woven into the country's seniorcare infrastructure. The key factors determining the quality of nursing care tend to be outside of seniors' (or their families') control. For a senior living on a fixed income, the likelihood of winding up in a home where she can't stand the food, is given the wrong medications or has to sleep in a wet bed at night may ultimately hinge on how much her family can pay. That has a lot to do with her race and where she Uves.

A 2007 study by researchers at Brown and Temple Universities found that blacks were 40 percent more likely to live in a facility cited by federal regulators for posing an immediate health hazard, and 70 percent more likely to live in a facility that ultimately lost its Medicare and Medicaid certification. A new follow-up analysis shows that, from 1999 through 2008, poor quality of care contributed to a rash of closures of nursing facilities across the country, resulting in a net loss of nursing home beds.

It all adds up to a "tiered system of nursing home care that concentrates blacks in marginal-quality nursing homes," said Zhanlian Feng, one of the study's lead researchers. "If you look at the distribution of patients across poor versus higher quality homes ... minorities go to poor homes, whites go to relatively better homes." He added that when the care deteriorates to a crisis point - for instance, a crippling lawsuit - "the closure of a bunch of homes in these troubled communities most likely will exacerbate these kinds of persistent disparities."

The problem isn't with individual facilities but with the socioeconomic inequalities of which inadequate facilities are symptomatic. People in marginalized communities are less healthy overall due to a lack of medical insurance, higher poverty and other hardships throughout their fives. They are also less capable of buying their way out of deteriorating public facilities, a transition that more affluent seniors are making by moving away from nursing home care to less institutionalized settings like assisted living facilities. Another study from Brown published this summer suggests that, after years of being underrepresented in the nursing home population, black and Latino elderly are seeking nursing home care at unprecedented rates, while whites are moving out - mirroring patterns of suburban white flight that deepened housing segregation.

"So now, you just have more money flowing away from the nursing homes," says Ruqaiijah Yearby, a professor at Case Western Reserve University School of Law, "which says to me that the poorest and most disenfranchised, such as impoverished blacks, are going to be left in these nursing homes."

No place like home

For hundreds of thousands of frail and ill seniors, a nursing home may be the most affordable option available through Medicaid and Medicare. But in recent years, the pressures of rising healthcare costs have converged with a turn toward more flexible, communitybased programs, such as alternative care systems that are less restrictive and antiseptic than a typical nursing facility. In newer care models, a home nursing aide or an adult day-care center might effectively provide the services of a conventional nursing staff, but also allow a grandmother to keep her pets, celebrate her birthdays with family and eat home-cooked meals.

Some community organizations have been able to serve local low-income seniors under the Program of All-inclusive Care for the Elderly (PACE). The joint federal/state program lets care providers use Medicare and Medicaid dollars for community-based health and support services for seniors eligible for regular nursing care.

First piloted in San Francisco'sChinatown in the 1970s, the PACE model was designed to meet the long-term care needs of aging Chinese Americans, for whom nursing homes were a culturally alien concept. Centered around "interdisciplinary" teams that include social workers,' physicians, dieticians and physical therapists, the program fosters personal planning of care using local resources, so seniors can remain at home for as long as possible. Research comparing regular nursing home care with various PACE programs shows the new model tends to be more costefficient in the long run.

"Care and services should be organized around each person's needs and what is most important to them to maintain their quality of life, not around a list of services that are reimbursable under Medicaid and Medicare," says Robert Greenwood, vice president of public affairs at the National PACE Association.

Pending reform measures may reroute federal money toward leaner home- and community-based services. Still, according to research by the Center for Health Care Strategies, home and community-based care will face funding and management challenges as the need for services intensifies. Even if marginal reforms are enacted, longterm obstacles include high initial costs as well as sparse local healthcare infrastructures, which limit options for care close to home. Real systemic change may sadly have to wait until those barriers crash with the rising gray wave.

For now, finding the right kind of care for seniors is often left to trial and error. But as Washington scrambles to find solutions, the experiences of todays elders leave us with some surprisingly simple wisdom: Being cared for shouldn't mean being helpless, and being independent shouldn't mean having to be alone.

Home health aide Wendys Cerrato deans Robert Granville after shaving him in his Miami home in Dec. 2009. His limited mobility prevents him from living independently.

For a senior living on a fixed income, the likelihood of winding up in a home where she can't stand the food and is given the wrong medications may ultimately hinge on how much her family can pay.

MICHELLE CHEN (3), an In These Times contributing editor, co-produces Asia Pacific Forum, a weekly radio program about the Asian diaspora.

Copyright: (c) 2011 Institute for Public Affairs, Inc.

Source: Proquest LLC

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