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Medicare for All: How to Reduce Inequality in the Long-Term Care Market


Ruqaiijah Yearby (@ruqaiijah) is Professor of law at Saint Louis University School of Law.

This post is part of our symposium on Medicare for All. You can find all the posts in the series here.


Medicare for All has the potential to address gaps in access to quality long-term care services for the elderly by mitigating some of the inequities in the market for long-term care. It could do this by increasing reimbursement rates for long-term care, fostering competition between long-term care providers, and improving federal enforcement of non-discrimination requirements.

In the long-term care services market, the issue is not private insurance versus single payer because the government already finances most long-term care services through Medicare and Medicaid (Medicaid is the primary payer for long-term services and supports ranging from institutional care to community-based services). Instead, the issue is who will provide the care: institutions or home- and community-based providers.

Historically, nursing homes have been the primary institutional providers of long-term care services for the elderly. Nursing homes are often private corporations that derive their revenue through a mix of private funding and public reimbursement. Since the 1800s, quality nursing home care has been segregated by socioeconomic status and race.  Several laws have been passed to equalize access to quality nursing home care for the poor and racial minorities, including Title VI of the Civil Rights Act of 1964 and the Medicare and Medicaid Acts of 1965. Nevertheless, nursing homes remain segregated based on socioeconomic status and race, and the nursing homes that serve poor and racial-minority elderly patients tend to provide worse quality care. This is in part because Medicaid, the payer of nursing home care for the poor and racial minorities, reimburses nursing homes at below the cost of actual care.

Medicaid to Medicare: Increased Reimbursement

Since Medicare reimbursements are higher than Medicaid reimbursements, Medicare for All proposals that call for Medicare to replace Medicaid have the potential to improve quality of care for the elderly needing long-term services by increasing reimbursement. However, increasing reimbursement alone does not lead to improved quality care for elderly patients. Research has shown that increased reimbursement to nursing homes boosts profits without producing observable improvements in quality and patient outcomes. Additionally, research has shown that increases in Medicaid reimbursement to promote staffing levels lead to increases in nursing and nursing aide staffing levels but have a limited effect on quality outcomes.

Therefore, it is important to link reimbursement increases to better quality and access to home and community-based services for the poor and racial minority elderly patients. Currently, elderly Medicaid patients’ access to home- and community-based long-term care services is more limited than their access to nursing home care. States are allowed to reimburse Medicaid patients for home- and community-based long-term care services if they receive approval from the federal government. Yet, as of 2017, over 707,700 people were on waiting lists for home- and community-based long-term care services

Medicare for All Proposals: Fostering Competition

Several proposals call for Medicaid to be replaced, including Senator Bernie Sanders’ Medicare for All Act of 2019, Senator Debbie Stabenow’s Medicare at 50 Act, and the State Public Option Act. All of these proposals would maintain the current dominance of institutional providers in the long-term care services market. The bills that champion the use of home- and community-based services are Representatives Rosa DeLauro and Jan Schakowsky’s Medicare for America Act of 2019 (MAMA) and Representative Pramila Jaypal’s Medicare for All Act of 2019 (MAA).

The MAMA gradually replaces Medicaid and within 90 days of enactment requires that all individuals on state waiting lists for Medicaid home and community-based services must be enrolled in these programs. It also provides support for workforce development for home- and community-based long-term care services through pay rates and worker rights for direct care workers.

The MAA immediately replaces Medicaid and prioritizes the delivery of long-term care through home- and community-based services over nursing home care. Moreover, the MAA calls for payments to long-term care providers that reflect the actual costs of care and ensure wages for employees, which guarantee mandatory safe registered nurse-to-patient ratios and optimal staffing levels for other health care workers. By prioritizing home and community-based long-term care services and linking reimbursement to costs and necessary staffing levels, the MAA has the potential to increase competition in the long-term care services market. Yet increased competition alone will not improve access to quality long-term care services for the poor and racial minorities.

Quality of Care: Improving Enforcement of Non-discrimination Requirements

In the early 2000s, the creation of assisted-living facilities that served rich and middle-class Whites increased competition in the long-term care services market but did not benefit the poor and racial minorities who were Medicaid patients. In 2004, a national study of nursing home quality deemed facilities whose primary source of payment was Medicaid as ‘low-tiered facilities’ because of their poor quality care and noted that African-Americans are approximately four times more likely than Whites to live in these ‘low-tiered facilities.’

There is ample evidence of racial disparities in nursing-home care. A recent study found that of nursing home patients at high risk for developing pressure sores, more African-American patients than Whites actually developed pressure sores. In 2011 and 2015, the same researchers found that African-American nursing home patients were readmitted to hospitals from nursing homes for potentially avoidable causes more often than White nursing home patients. Finally, a 2019 study found that African-Americans are still concentrated in a small number of nursing homes and that these nursing homes had worse performance on the quality measures of rehospitalization and successful discharge to the community.

Long-term care providers already must certify that they provide quality care without discrimination when they accept Medicare funding. But this is clearly underenforced: journalists have found that racial disparities can persist even where majority-White and majority-African-American nursing homes share the same owner and similar funding sources. Hence, the government must improve its enforcement of the non-discrimination requirements of Medicare to ensure that racial and economic disparities in the quality of long-term care services are addressed, regardless of which Medicare for All bill is enacted.

Specifically, if Medicare becomes the primary payer of long-term care services with the enactment of a Medicare for All bill, the government must use its increased market power to link the non-discrimination investigations required by Medicare to quality-of-care surveys and impose fines on long-term care service providers for disparities in care.

Medicare for All has the potential to reduce the racial and socioeconomic disparities in long-term care, but it will take more than public funding to achieve that. A Medicare for All proposal will only increase access to care for all elderly people if the government increases reimbursement rates for long-term care, fosters competition between services providers by prioritizing home-and community-based providers, and improves its enforcement of non-discrimination requirements.