**3. Conceptual framework for understanding role of structural racism in inequities among long-term care facility residents**

To understand and address the effects of structural racism for LTCF residents, this chapter proposes a conceptual framework with elements from critical race theory, social determinants of health, and life course perspectives of inequity. **Figure 1** presents a graphical image of this conceptual model for understanding the role of structural racism in racial and ethnic disparities among LTCF residents. In this framework, structural racism directly contributes to increased racial and ethnic inequities among LTCF residents through LTCF-related policies and practices. It is also the root cause of economic and health disparities, which in turn cause racial and ethnic disparities among LTCF residents.

#### **3.1 Direct effects of structural racism**

The first tenet in our conceptual framework is that structural racism – the reinforcement of a racial hierarchy privileging "whiteness" and disadvantaging "color" through policy, systems, and institutional practices – is a direct cause of racial and ethnic inequities among LTCF residents. It is important to recognize that racism is so deeply embedded in the very fabric of U.S. society that the nation has, in a sense, become desensitized to it. Critical race theory responds to this need by shining a light on the role of race and structural racism in contemporary inequities [50].

To understand racial and ethnic disparities among LTCF residents, it is necessary to identify how structural racism directly affects their experiences. For example, the societal decisions to restrict public financing of LTCFs to Medicaid and to provide low levels of Medicaid reimbursement have created racial and ethnic disparities in access to quality LTCF care. Black, Latinx, American Indian/Alaska

#### **Figure 1.**

*Conceptual framework for understanding and addressing racial and ethnic inequities among long-term care facility residents.*

*Addressing Systemic Factors Related to Racial and Ethnic Disparities among Older Adults… DOI: http://dx.doi.org/10.5772/intechopen.99926*

Native, and multiracial people are more likely to have Medicaid coverage or be dual eligible for Medicare and Medicaid [51]. As a result, LTCFs that rely on Medicaid funding tend to have higher portions of residents of color [52]. These more Medicaid-dependent LTCFs tend to provide poorer quality of care than those with more generous funding streams [27, 33, 36]. Policy decisions restricting Medicaid reimbursement rates are not color blind; low rates of Medicaid reimbursement are correlated with higher levels of racism within a state [23]. Another example of structural factors associated with inequities in health services engagement and health outcomes for LTCF residents is federal regulations that fail to specify racial equity in their oversight of residents' quality of care and quality of life [53], in essence whitewashing the unique experiences and challenges of residents of color.

#### **3.2 Health disparities**

The second component of our conceptual framework relies on the Social Determinants of Health Framework. This framework recognizes that health is a social phenomenon across the life course, determined in part by social contexts and stratification [54]. When new residents are admitted into nursing homes, those from historically minority ethnic and racial groups tend to be younger, in poorer physical health with greater physical dependency, and have higher levels of cognitive impairment and care needs than newly admitted White residents [44]. These racial and ethnic disparities in health outcomes influence the level of care needs residents have once admitted and the quality of life they can experience.

Experiencing racism at the individual or personal level leads to worse physical and mental health outcomes for people of color [55]. However, the influence of racism systemically in the United States also leads to poorer health though its impact on economic stability, education, health care systems, and social and neighborhood environments [56]. The Social Determinants of Health Framework acknowledges that structural forces such as social policies, education and public health systems, social safety nets, politics, and societal values all affect health outcomes and health equity. Intermediary social determinants of health such as housing and neighborhood physical environment, financial resources, psychosocial stressors, and behavioral factors are caused by these structural factors.

There are abundant and interrelated examples of structural factors associated with the social determinants of health and racial and ethnic health disparities [56]. Access to quality health care in the United States requires insurance coverage or the financial means to pay for services. However, discriminatory hiring practices have disproportionately excluded people of color from higher paying jobs and jobs that provide health insurance. Furthermore, a confluence of policies and discriminatory practices from Jim Crow laws to the intentional exclusion of Black Americans from Social Security coverage in passage of the Social Security Act of 1935, as well as discriminatory hiring practices have resulted in economic inequities that span decades of unjust outcomes affecting generations of families [11, 56, 57]. Discriminatory practices in the criminal justice system and the War on Drugs have disproportionately targeted and incarcerated Black men [56], removing them from the paid workforce and economic opportunity. Income and wealth are important social determinants of health on their own and as factors associated with access to health care and healthy environments. Historical policies such as redlining and current discriminatory practices in rental and housing markets combined with economic disparities lead to racially segregated neighborhoods with communities of color being more likely to be placed near environmental health hazards or contain substandard housing [56, 58]. This also reduces opportunities for people of color to generate wealth through real estate [56]. The placement of health care services

in predominantly White communities has made geographic access to health care difficult for people of color. Within health care systems, people of color experience both interpersonal and institutional racism resulting in worse care and disparities in engagement with health services [56].

The original model of Social Determinants of Health took pains to distinguish the social causes of health from unjust societal factors [54]. More recently, scholars have acknowledged the prominent role of structural racism in health outcomes [12, 56, 57]. Yearby [12] has reconfigured the original model to remove this distinction and place structural racism as a prominent root cause of racial health disparities [12]. In her reconfiguration, structural discrimination is the force that shapes aspects of social policy and systems of public health, neighborhood environments, education, and the economy. Our model for understanding and addressing racial and ethnic inequities among LTCF residents incorporates this perspective placing structural racism as an indirect effect on disparities in LTCFs by creating the conditions that result in poorer health for LTCF residents.

#### **3.3 Economic disparities**

The third feature of our conceptual model relates to the economic inequities experienced by people of color across the life course [59, 60]. It has long been acknowledged that nursing homes that serve higher proportions of Medicaidpaying residents are more likely to serve Black residents and have poorer staffing ratios and more care deficiencies [38]. This is relevant to racial and ethnic disparities because, as discussed in Section 3.2, due to economic disparities in the United States, Black and Latinx residents are more likely than White residents to have limited financial means [59, 60]. Inequality in wealth and income makes people of color more likely to rely on Medicaid for LTCF funding. This inequality is caused by systemic barriers to higher paying jobs, professional networks, educational opportunities and ownership of valuable real estate. Economic inequities can also explain why White LTCF residents compared to residents of color are disproportionately opting out of care in nursing homes in favor of receiving care in assisting living [14]. Although the homelike setting of assisted living makes it appealing [61], the cost of assisted living and the need for private pay in many assisted living communities exclude people of color with limited savings.

#### **3.4 Life course perspective of disparities among LTCF residents**

The vast majority of LTCF residents are older adults. In nursing homes, most residents are age 75 or older and in assisted living/residential care communities, over half are at least 85 years old [10]. These older residents carry with them a lifetime of experiences, opportunities, and injustices. American-born residents who are 85 years old today grew up in the United States when racial discrimination was legal and codified in many state laws. Lynchings by White people targeted Black citizens in the south and Mexican nationals along the Texas-Mexico border [62]. Many older LTCF residents were in their 20s and 30s when the Civil Rights Act of 1964 was passed. Unequal opportunities and oppression of people of color continued throughout their lifetimes and persist today.

Taking a life course perspective on the accumulated effects of inequities adds perspective to disparities among LTCF residents. The Matthew effect explains that inequalities, once they occur, become a perpetual cycle, and in the absence of advocacy, widen the gap between the advantaged and disadvantaged [63]. The Matthew effect framework closely aligns with the theory of cumulative (dis) advantage/disadvantage [64], which has been used to examine inequities in a variety of domains

#### *Addressing Systemic Factors Related to Racial and Ethnic Disparities among Older Adults… DOI: http://dx.doi.org/10.5772/intechopen.99926*

including health, well-being, and aging [65, 66]. One approach to distinguishing the two frameworks is to consider the Matthew effect (or *mechanism*) as the macro-level process of increasing societal inequality while thinking of cumulative advantage or disadvantage as the accumulated effect of positive or negative circumstances on an individual [64]. Through life course perspectives of inequality, it becomes evident that by the time older adults enter LTCFs, their financial and health status has accrued over decades. Intervention to address structural racism and its effect on economic, education, and health care systems early in life is necessary. Nonetheless, it is never too late to redress inequities, and LTCF residents deserve interventions aimed at eliminating the racial and ethnic disparities they experience.

Individuals who have experienced an accumulation of advantages early in life may find the concept of Matthew effects unsettling [63]. These very people may be overrepresented in positions of power such as policy-makers and LTCF chief executive officers as a result of their early advantages. In spite of this, it is necessary for individuals in the position to make meaningful change in LTCF disparities to recognize the accumulating effects of structural racism across the life course. Without policies or interventions in place to address the vicious cycle of compounding advantage and disadvantage, social inequities will widen [63].
