Availability Of Home Health Services In Minoritized Racial/Ethnic Group Areas Limited

Rural ZCTAs were markedly more likely than urban ZCTAs to lack home health service access in 2020 with 10.3% of all rural ZCTAs versus 2.2% of all urban ZCTAs being totally without service. However, these gaps were not uniformly distributed across the U.S. First, rural ZCTAs that lack service are disproportionately located in low population density states in the West and Southwest. Second, ZCTAs falling into the top 5 percent for concentration of AI/AN residents are disproportionately likely to be underserved.

Rural residents with reduced access to opportunities for care in the home may be disproportionately placed in institutional settings when compared to their urban peers with adverse effects for both their survival and costs to the healthcare system.15 ,16 However, the principal issue is one of equity: home health care is a Medicare benefit, but it is not equally available to all potential Medicare beneficiaries across the U.S.

Policy analysts have suggested that payments intended to foster the provision of care for rural residents should be targeted to specific areas of need rather than implemented for “rural” more broadly. 17 Rural Medicare add-on payments for home health care, one method for ensuring service availability, are scheduled to be phased out in 2022.18 The evidence regarding the effect of add-on payments is limited as the implementation of rural add-ons for payment coincided with more general reduction in base payment rates.20 Targeting add-on payments toward ZCTAs that lack service or are currently served by only a single provider, thus removing any beneficiary choice, could be considered.

CMS support for home health care has undergone significant changes in the past two years. In its 2020 and 2021 Reports to Congress, the Medicare Payment Advisory Commission (MedPAC) has voted to reduce Medicare Home Health base rates (by 7% for 2021 and by 5% 2022). In addition, CMS has instituted a diagnosis-based prospective payment model for HHC which sets pay rates for 432 patient groupings. Both changes occurred before the emergence of COVID-19 which may have long-term health impacts on those who experience the disease (“long haulers”). Our analysis was based on home health services availability as of October 2020, relatively early in the pandemic period. Reassessment of the geographic availability of home health care, subsequent to both payment changes and the workforce effects of the pandemic, is strongly recommended.

The apparent lack of home health service availability in ZCTAs with a high representation of AI/AN residents deserves further investigation. It is possible that these areas are receiving services from organizations not certified by CMS such as agencies within the Indian Health Service (IHS), but only a minority of IHS agencies (28.3%) report providing this type of care.19 However, support services, while valuable for older adults, are not the equivalent of nursing care which is a required element of CMS-verified home health care. From an equity perspective, attention is needed to ensure that AI/AN Medicare and Medicaid beneficiaries are not systematically deprived of access to an important Medicare benefit.