Racial disparities in access to Medicare home health care: The disparate impact of policy

The Balanced Budget Act of 1997 altered the reimbursement structure for patients in the fee-for-service Medicare home health program. Reimbursements were reduced to 1993 levels, encouraging agencies to alter the amount, duration or type of services provided to patients. This paper specifically summarizes findings related to utilization of home health care after implementation of the BBA and the disparate impact of these policy changes by race. The study consisted of a secondary analysis of Medicare Current Beneficiary Survey and matching claims data for the years 1996 and 1998 (N=2,407). African American and Hispanic home health care users experienced greater decreases in visits and reimbursements than white users in bivariate analyses. Although African American users continued to receive more visits and higher reimbursements on average than white users, multivariate models, controlling for predisposing, enabling and need variables, showed that African American users experienced a greater decrease in both visits and reimbursements between 1996 and 1998 compared to white users. African American users also saw greater decreases in skilled nursing and non-skilled visits compared to white users. Users of “other” race (including Hispanic of any race) received fewer services than white users in 1998 for total and skilled nursing visits. They also experienced the greatest decrease in skilled nursing visits. Decreases in total and skilled visits in particular are concerning given that these models controlled for health and functional status along with patient demographic characteristics. These results suggest that race may be an independent factor in the determination of service delivery post-BBA.