Medicare Beneficiaries of Color More Likely to Rely on Unpaid Informal Caregivers for Home Health

Many older Americans who require postacute services — for instance, care after a hospitalization or an injury — or help managing chronic health conditions use home health care services, which may include skilled nursing care, physical and occupational therapy, speech therapy, and in-home social services, such as providing a social worker to facilitate connections with helpful community resources.

Prior research shows that Black and Hispanic beneficiaries using home health services are more likely than white beneficiaries to have poor health outcomes, such as emergency department visits and hospitalizations. Research has shown an association between such adverse health outcomes and higher use of low-quality home health agencies, as well as an elevated risk of mortality for older adults who are taken care of by informal caregivers. These studies indicate that the source of home health care provided to older adults, especially minority populations, may significantly impact health outcomes.

We examined a nationally representative survey of noninstitutionalized (i.e., people who live in their homes rather than an institution) Medicare beneficiaries to assess the use of different types of home health care providers — that is, home health services and unpaid informal caregivers, who are often family members — by the race and ethnicity of beneficiaries.

We found that Medicare beneficiaries of color used more home health care services than white beneficiaries overall and that Medicare beneficiaries of color were more likely to rely on unpaid informal caregivers for their home health care needs than did white beneficiaries.

Among home health users, Black (non-Hispanic) and Hispanic Medicare beneficiaries reported, on average, that they received care from home health care providers more than seven months in a year, about half of that time from unpaid informal caregivers. Both Black (non-Hispanic) Medicare beneficiaries and Hispanic beneficiaries were more likely to report using unpaid informal caregivers than agency providers. White Medicare beneficiaries, alternatively, reported receiving in-home provider care for approximately five months per year, and almost equal use of unpaid informal caregivers and agency-sponsored providers.

Unpaid informal caregiving is often provided by family or friends. Lack of proper training for such caregiving can place a significant responsibility on the individuals receiving care and those caring for them. The greater overall use of such home health care services by Medicare beneficiaries of color suggests that these populations may face more challenges managing their health at home and potentially have worse outcomes, with a greater burden on friends and family.

A recent Fund-supported study interviewed Medicare beneficiaries with home health care needs and showed that access to consistent in-home services has been difficult to obtain because of lack of knowledge about Medicare coverage. The Medicare home health benefit is often misunderstood, and providers and home health agencies frequently communicate inaccurate information regarding the benefit to patients. Additionally, this benefit can be narrowly implemented (i.e., providing fewer hours of home health aide services than the benefit allows by law), potentially limiting the assistance granted by health insurance coverage. The financial strain of securing home health services and supports may be greater for Medicare beneficiaries of color: the median per capita savings among white Medicare beneficiaries is more than six times the savings accumulated among by Black or Hispanic beneficiaries. When beneficiaries do not have the resources to pay out-of-pocket for services, patients and families can be forced to pay for services themselves, as much as finances allow; fend for themselves; or go without needed care.

Ensuring that Medicare beneficiaries have equitable access to high-quality home health care providers merits greater attention. The Medicare home health benefit is not adequately addressing the needs of its beneficiaries in sufficiently lowering access barriers to the highest quality of in-home services and supports. It will be important to further explore the different types of in-home providers used across racial and ethnic groups in the Medicare population and the quality of care they can provide, as well as the reasons why certain groups have worse health outcomes than others. Medicare plays a pivotal role as a safety net for older U.S. adults. Targeting policies to reduce health disparities among the aging in Medicare could subsequently have a profound effect.