Despite our significant progress in making health care services more equitable to all populations, older people and those residing in nursing homes and long-term care facilities are often overlooked in mainstream discussions about health care equity.  

One of the reasons contributing to their exclusion from these discussions is the current funding structure for their care. While Medicare provides reasonable reimbursement, its duration falls short, placing the major financial burden on Medicaid, which offers comparatively limited payment. Consequently, apart from a few fortunate individuals who can afford private care, most older adults have no viable alternatives. The demographic distribution within U.S. nursing homes does not mirror the overall population composition in the country, illustrating the manifestation of this effect. Research conducted by Feng et al. highlighted that from 1999 to 2008, the population of elderly Hispanics, Asians, and African Americans in nursing homes saw an increase of 54.9%, 54.1%, and 10.8%, respectively. On the other hand, the count of Caucasian senior citizens residing in these institutions dropped by 10.2% within the same timeframe. The data shows that the growth rate of minority residents in nursing homes outpaced the growth of the minority population in general, even in regions with a significant minority presence. This might suggest that minorities have unequal access to preferred alternatives for long-term care, such as home and community-based services.  

Under the Older Americans Act, every state administers a Long-Term Care Ombudsman Program (LTCOP) to aid residents and improve long-term care systems. Likewise, Protection and Advocacy (P&A) programs exist nationwide to uphold the rights of individuals with disabilities, providing advocacy and legal support, and functioning independently of service providers. Even with these programs in place, when we consider the challenges associated with aging, such as lack of personal advocacy, limited mobility, and cognitive decline, it becomes apparent that this demographic genuinely requires more robust representation. \

For example, the long-term care facilities were largely left out of the digital transformation efforts initiated by the Health Information Technology for Economic and Clinical Health (HITECH) Act. These facilities did not qualify for the meaningful use incentives, which could provide eligible health care professionals with up to $44,000 for adopting and utilizing electronic health record systems. As a result, this segment has significantly lagged in the digitization of the health care industry and missed the associated benefits. This oversight has far-reaching indirect impacts on various aspects that influence the patients’ quality of life. An illustrative example is the high turnover rate in the industry, which is exceeding 100% annually.  In 2017 and 2018, Registered Nurses (RNs) experienced the highest average turnover, with a rate of 140.7%. Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) also saw notable turnover rates at 114.1% and 129.1% respectively, though they were lower. Considering the severe toll of the COVID-19 pandemic on both residents and staff of nursing homes, we anticipate that the turnover rates will significantly increase in the post-pandemic period. 

Surprisingly, a recent study by my colleagues and I has shown that factors like pay are not the primary drivers of turnover. Rather, aspects such as scheduling flexibility and improved supervision carry greater importance. Empirical research indicates that scheduling software can play a vital role in reducing turnover rates. Yet implementation of such software would face significant challenges given that long term care facilities have been left behind in our national digitization efforts.

Read the full article about healthcare for older people by Niam Yaraghi at Brookings.