Ep 04: Is Our Care System Racially Segregated?

Research shows that Black nursing home residents are more often physically restrained and hospitalized than their peers and are less likely to have their pain treated. Black and Latinx people also make up a disproportionate number of cases and deaths from COVID-19. Why is that?

In this episode of A Question of Care™, Robert Espinoza sits down with Dr. Ruqaiijah Yearby, a professor at the Moritz College of Law at Ohio State University. They speak about systemic racism in long-term care, the unique challenges of Black older people, and what it would take to make aging a more positive experience for communities of color.

Robert Espinoza: How did the wealthiest country in the world get to a point where it can't support the health and long-term care needs of more than 54 million older adults? Welcome to A Question of Care™, a podcast that explores the many answers to this question through different viewpoints and topics. I'm your host, Robert Espinoza, a national expert and frequent speaker on aging, long-term care, and the workforce.

On this episode, our attention turns toward the impact of systemic racism on older people of color as they grapple with the complexities of the health care and long-term care systems. We’ll delve into the critical issues faced by this demographic, shedding light on their challenges and the solutions for much needed change. Joining us as our expert guide on this topic is none other than the esteemed Dr. Ruqaiijah Yearby.

Dr. Ruqaiijah Yearby: My name is Ruqaiijah Yearby, and I am the Kara J. Trott Professor in Health Law at the Moritz College of Law at The Ohio State University. I am also a co-founder and faculty affiliate of the Institute for Healing Justice and Equity.

Robert Espinoza: Much of Dr. Yearby's career has centered on racial disparities in healthcare and the role that systemic racism plays in the process. Systemic racism, sometimes referred to by experts as "structural racism," describes the pervasive and deeply embedded ways that racism exists within the policies, institutions, and culture of a society. As Dr. Yearby defines it…

Dr. Ruqaiijah Yearby: Systemic racism refers to a complex array of social structures, interpersonal interactions, and beliefs used to create a hierarchy that categorizes people into superior and inferior racial and ethnic groups. Traditionally, Black, Indigenous, and Latino Americans have been deemed as inferior ethnic groups compared to White Americans.

We can see this play out at different levels. We have cultural racism, which is the presence of societal beliefs and customs that promote the concept that White culture is superior. That often feeds into the other levels, including structural racism, which refers to the ways that laws are used to provide advantages to Whites while disadvantaging racial and ethnic minorities by limiting their equal access to key resources such as jobs, such as housing and healthcare.

And if you couple the belief that cultural racism, [that] White culture is superior, then it allows for laws to reinforce that through the denial of equal access to housing, health care, and unemployment.

Robert Espinoza: Ruqaiijah, can you offer a few examples of how systemic racism has harmed older people of color in particular?

Dr. Ruqaiijah Yearby: Well, when we look at structural racism on one level, on one category of systemic racism, we see it harming older people of color in the ways that we regulate and the ways that we fund long-term care, particularly the ways that business owners are allowed to not provide equal staffing, equal financing, and equal resources in nursing homes that provide care to predominantly Black and Latino individuals. We also see it in the ways that the laws do not require that we even know who owns nursing homes or long-term care facilities to be able to ensure that they're putting in the same amount of money in predominantly Black and Latino nursing homes that they do in White nursing homes. Furthermore, the law does not require the same amount of financing or anti-discrimination regulation when it comes to assisted living facilities.

And so what does that look like? That usually means that people of color who are in long-term [care] facilities do not receive adequate care. And as you know, that also means that people of color who work in these nursing homes don't receive adequate pay to take care of the residents in long-term [care] facilities, whether it be a nursing home or assisted living facility.

Robert Espinoza: Ruqaiijah, are there any stories that illustrate the impact that systemic racism has had on people of color accessing long-term care?

Dr. Ruqaiijah Yearby: I think the story that comes to mind is the case of Ms. Belle Carney, an African American woman with Alzheimer's disease. She sought admission to a nursing home in Tennessee, but she was never able to find it. This is a case from the 1990s where Tennessee basically allowed nursing homes to decide who they wanted to admit. And because she was a Medicaid recipient, the recipient of the nursing home would get paid less. And [as] a Black woman, she was not able to find nursing home care. She did bring a lawsuit with another woman challenging these policies, and what is exciting about the case is that, as a result of the case, Tennessee changed its admission policies to track the race of those seeking admission to nursing homes to see if they were being racially discriminated against.

Unfortunately, when it got to the federal courts, they did not rule on race-based denial of care. And so even though there was a great change in Tennessee, the rest of the country still has problems with the denial of people seeking nursing home care, particularly racial and ethnic minorities.

Robert Espinoza: As we discuss systemic racism and long-term care, it's also important that we talk about racism's impact on home care workers and nursing assistants. These are workers who support older adults and people with disabilities in their homes, nursing homes, assisted living, and other residential care settings.

Historically, this workforce has been predominantly made up of women, people of color, and immigrants, and their jobs and livelihoods have long been hurt by racist policies in the U.S. A recent article written by Dr. Yearby titled "The Social Determinants of Health, Health Disparities and Health Justice," focused on these particular issues, tracking current day racial disparities for this workforce to racist policy back to slavery.

Dr. Ruqaiijah Yearby: Because when we think of slavery, we think part of it is that they were forced to provide care to people in their homes. After slavery, laws limited the ability of racial and ethnic minorities, particularly Black individuals, from working outside of these occupations. And so they continue to be forced to work in these occupations of giving direct care to people in their homes.

Even when those laws were rolled back, when you see many of the bills passed during the New Deal era, which was also the Jim Crow era, they did not apply to direct care workers, people providing care to people in their homes. What this means is that the workers did not qualify for minimum wage. They do not get overtime. They are often also not protected by health and safety protections. So many of the workers suffer injuries in people's homes. They're not covered by any [workers'] compensation. They still are paid beyond minimum wage. This is because many of these occupations were not covered, but that goes back to the racist practices during slavery.

Robert Espinoza: A few years ago, you and I and a few other experts collaborated on an article for the Journal of the American Medical Directors Association titled "Addressing Systemic Racism in Nursing Homes." We wrote this article during the height of the COVID-19 pandemic, which was disproportionately impacting people of color, older people, people with disabilities, and people with severe illness.

I want to explore a few points in this article because I get asked about it often, and I think it's made quite an impact. The first is a study that the article cited. The study found that when risk factors for illness, hospitalization, and death were investigated, the proportion of Black residents in a nursing home was found to increase the probability of a COVID-19 outbreak by anywhere from 45% to 300%. Why have Black people borne the brunt of this pandemic?

Dr. Ruqaiijah Yearby: Well, it's because of longstanding systemic racism, particularly structural racism, which again goes back to the underfunding of resources for people of color, particularly Black individuals in long-term care.

So many of the long-term care facilities are understaffed. They do not adopt effective infection control. And so when you talk about COVID-19 spreading, it will be rampant among these facilities where you don't have enough staff or infection control. You also see Black individuals, Latinos, and immigrants bearing the brunt because many of them were essential workers. And so some people got to stay at home, and those were disproportionately White individuals who could work from home, whereas Black individuals, Latinos, and immigrants had to continue to go to work. But we're not provided with PPE, masks, infection control. We're not always able to stay six feet apart. And so you see high rates of COVID-19 infection among these individuals and communities.

Robert Espinoza: The article also describes how access to long-term care and its quality is "fundamentally tied to geography." For communities of color, this often means that where you live, whether it's by zip code or by a neighborhood, will usually determine how you live, especially when you're older and you need paid support. How did this country create a racially segregated long-term care system?

Dr. Ruqaiijah Yearby: It did so the same way that it created racially segregated neighborhoods, right? Long-term care facilities are viewed as a person's house. And so we've allowed some of the same racist policies in terms of segregation. In fact, when the majority of funding was put into place in the 1940s to fund the creation of the long-term care system that we have now, it explicitly allowed for a separate and unequal system. And so many states created long-term care facilities that did not include Black, Latino, or Asian individuals. And that continues today, even though Title VI of the Civil Rights Act of 1964 was passed to ensure that individuals would not be discriminated against when applying to enter long-term care facilities.

You have a quote by government officials saying that they did not want to apply Title VI to long-term care facilities because they did not want to force White individuals to live next to Black individuals. So, to force them to have to live in a long-term care facility with a Black individual, and unfortunately, that continues today. We've never made it fair regarding admission policies within long-term care facilities. And so many facilities remain racially segregated.

Robert Espinoza: In addition to that segregation, the article also talks about how Black residents are being treated, and then there are a number of startling findings in this regard. They find that when compared with White residents, Black residents are more often physically restrained, more frequently develop pressure ulcers, less often receive influenza vaccines, less often have pain treated, are more frequently hospitalized, and report a lower quality of life. What's behind these gross inequities?

Dr. Ruqaiijah Yearby: A little bit of cultural racism and structural racism, right? So cultural racism–it's a belief that Black patients don't feel the same as White patients, that they have a higher threshold, that they seek drugs. So, we don't want to treat their pain when they acknowledge the pain. Structural racism: I talked about it in terms of the ways that laws are used to advantage Whites, but it's also about policies.

And so when we go back to training nurses and doctors around pressure ulcers, they often are not trained on how they show up on dark skin. And so many times, you have staff who can't even identify when people with dark skin have pressure ulcers. And so you don't get them being identified in dark-skinned patients until it's become too late.

And so we need to change not only the culturally racist beliefs that Black patients or racial and ethnic minorities experience pain differently, but we also need to train people on different colors of skin so they understand that they are having a pressure ulcer sooner rather than later.

Robert Espinoza: Ruqaiijah, I want to shift the conversation to interventions and solutions. What types of anti-racist policies should this country adopt to support people of color in the long-term care system?

Dr. Ruqaiijah Yearby: So, I have been working with a group of individuals, Professors Lindsay Wiley, Seema Mohapatra, Brietta Clark, and Emily Benfer, on the Health Justice model. And what this does is move us past health equity [to] looking at how to address inequities experienced by communities through community-led and systems-led intervention.

And so, what this includes [are] three components. One: truth and reconciliation. I think in our article, what we tried to identify is that we have to be truthful about the continuation of racism and long-term care and employment that is harming individuals. And to do so, we also need to make space for the individuals to talk about their experiences. During COVID-19, many nursing home workers, direct care workers, and patients experienced a lot of harm because of the lack of support they got from the government. And so we need to talk about that and rectify it.

The second is that the government needs to change the laws and policies so that there are structural changes. One of the key things that we talked about in our article and that you talked about in your group is that direct care workers still do not receive equal living wages, paid sick leave, and all the things they need. Some states have tried to move forward with giving power to those workers in Washington, and others have negotiated with unions of direct care workers. We need to make that a standard.

And finally, communities need to drive the change. And so if we want to improve health care for racial and ethnic minorities, then they need to be the ones at the table helping to design this because they are the ones who know the problems, right? And so if we want to improve our long-term care system, it shouldn't just be to push more people into nursing homes. It should be listening to people who want to stay at home. What do they need to be able to stay at home? What do the workers need to be able to give them the best care within their homes? And so, that's what we need to do.

Robert Espinoza: More broadly, what would it take to make aging a more positive experience for communities of color?

Dr. Ruqaiijah Yearby: Several things. I think one is that we cannot just try to fix the problem at the point that people are elderly, right? It's a long-term issue. And so that means that we need to ensure that throughout the lifespan, racial and ethnic minorities have equal access to healthcare so that by the time they age, they don't experience so much disability and harm, right? They don't need so much help. We need to ensure that they, throughout their lifespan, are getting equal wages so that by the time they retire, they have money to put forward to long-term care.

And finally, we need to invest in a long-term care system. We cannot just expect that people somehow are going to be able to pay for it all on their own and that people who are giving care to people who are in the long-term care system can afford to not have health insurance, can afford to not make living wages, can afford to not have paid sick leave.

So, we have to invest in the long-term care system just as we have begun to invest in the infrastructure in this country. We need to get more young people to become workers in this area. But to do that, we have to invest a lot of money.

Robert Espinoza: Thank you, Ruqaiijah. I want to end on a hopeful note. What gives you hope these days as it relates to racial justice?

Dr. Ruqaiijah Yearby: What gives me hope is that finally, we have an acknowledgment at the federal level about the harm that has been done. Seeing President Biden issuing a number of executive orders and focusing on racial justice is exciting to me. But they are doing so in a way that is bringing everybody in because everybody has been harmed by racial injustice. It's not just Asians, Blacks, Indigenous, Latino Americans. It's also White Americans. And it's not just individuals from the race focus, right? It's also about Black individuals with disabilities not being able to get equal access to the care that they need in long-term [care] facilities.

And so I am hopeful that we can work together to improve this country. But to do so, we have to rectify past harms.

Robert Espinoza: Though my conversation with Dr. Yearby ends on a positive note, there is profoundly concerning evidence all around us that racism has no intention of stopping. In fact, it might be on the rise. In late June of this year, a conservative Supreme Court gutted affirmative action in college admissions, which had intended for decades to promote racial and ethnic diversity in colleges and universities and to provide more opportunities to students of color who had historically been underrepresented in higher education.

Consider also that Florida's public schools will now teach that slavery in this country was of "personal benefit to some enslaved people, a decision that The Washington Post described as "obscene revisionism."

Frighteningly, the White supremacist movement continues to grow, especially over digital media. They are guided by ideas such as the genetic superiority of a supposed White race and the fear that immigrants of color are threatening the economy and the culture of White America, among other egregious beliefs. And it isn't just White supremacists who hold these beliefs. According to 2019* data from the Pew Research Center, 32 percent of White adults in the U.S. believe that greater attention to the history of slavery and racism is wrong. That's one in three White adults in this country.

Yet perhaps these developments emphasize how we should prioritize racial justice, both to turn the tide on growing racist sentiment in this country and to support older people of color at a time when they want to enjoy their lives and their families as much as possible. Our latter years should be filled with joy, not hardship, community, not discrimination, and fairness, not inequitable treatment. However, we are nowhere near this reality, especially if you're an older person of color.

Thank you to my guest, Dr. Ruqaiijah Yearby, and to you, our listeners. If you enjoyed this episode of A Question of Care, please share it on your social channels and stay tuned for future episodes. This podcast was produced by me, Robert Espinoza, in partnership with Modry Media. Please make sure to rate and review the podcast wherever you're listening.

This transcript has been slightly edited from the original episodes to improve readability and accessibility—while preserving the guest's authentic voice and conversational style.

*Correction: This data is from 2021.