Abstract
IMPORTANCE: Alzheimer disease special care units (ASCUs) are associated with improved outcomes for residents with dementia, yet they are unavailable in most nursing homes. OBJECTIVES: To examine racial and ethnic disparities in the availability of ASCUs and whether more generous Medicaid payments are associated with reduced disparities. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used 2009-2019 Certification and Survey Provider Enhanced Reporting data and resident assessments from Medicare- and Medicaid-certified nursing homes in the US, as well as state Medicaid payment-to-cost ratios for 2019. Statistical analysis was performed from September to December 2024. EXPOSURE: The percentages of Black residents and Hispanic residents in a facility and the state mean nursing homes' ratio of Medicaid payment to estimated Medicaid cost of care. MAIN OUTCOMES AND MEASURES: The main outcome was whether a nursing home had an ASCU. Multivariable logistic regression was conducted on ASCUs, and then separate logistic regressions were performed for states with different quartiles of Medicaid payment-to-cost ratios. RESULTS: Most of the 13 229 nursing homes in the study were for profit (9561 [72.3%]) and were part of a chain (7775 [58.8%]). The overall mean (SD) Medicaid payment-to-cost ratio among all states was 0.87 (0.13) (range, 0.58-1.29). Each 1% increase in the percentage of Black residents was associated with a 0.1% decrease in the probability of having an ASCU. Compared with facilities with 0% to 0.8% of Black residents, the odds of having an ASCU were 37% lower in nursing homes with 4.3% to 15.2% Black residents (odds ratio [OR], 0.63; 95% CI, 0.53-0.74), and 45% lower in nursing homes with 15.2% or more of Black residents (OR, 0.55; 95% CI, 0.46-0.65). Compared with facilities with no Hispanic residents, the odds of having an ASCU were 27% lower in those with 3.7% or more of Hispanic residents (OR, 0.73; 95% CI, 0.62-0.86). In states with Medicaid payment-to-cost ratios between 0.58 and 0.81, nursing homes with 15.2% or more of Black residents were 68% less likely to have an ASCU (OR, 0.32; 95% CI, 0.21-0.50). This difference decreased to 45% in states with Medicaid payment-to-cost ratios between 0.82 and 0.94 (OR, 0.55; 95% CI, 0.44-0.69) and almost disappeared in states with Medicaid payment-to-cost ratios greater than 0.94 (OR, 0.86; 95% CI, 0.53-1.40). Higher Medicaid payment-to-cost ratios were not associated with reduced disparities among Hispanic residents. CONCLUSIONS AND RELEVANCE: This cohort study of nursing homes suggests that racial and ethnic disparities in ASCU availability narrowed in states where Medicaid payment rates cover a greater share of costs. Racial disparities in specialized dementia care may be mitigated and even eliminated by more generous Medicaid payments.