Examining Black-White Disparities in Experiencing Unmet Care Need Consequences across Community-Based Care Arrangements

Background and Purpose: At some point in our lives, approximately 70% of us will need support to help with daily care. Without adequate assistance we may experience unmet care need consequences (UCNC) – such as skipping meals, going without clean clothes, or taking the wrong medication. Evidence suggests that black older adults are more likely to experience UCNC compared to whites, but we do not know how black-white disparities in UCNC might differ across the long-term care continuum. This is the first study we know of to examine black-white disparities in the likelihood of experiencing UCNC across both informal and formal community-based long-term care arrangements.

Methods: We examine a nationally representative sample of older community-dwelling Medicare beneficiaries from the 2015 National Health and Aging Trends Study (N=4,983) to describe black-white disparities in UCNC among those receiving informal care only, formal home care, or non-nursing home residential care. Our dichotomous measure of UCNC is based on self-reported experiences of at least one consequence within the last month related to 9 self-care (e.g. wet or soiled clothes), mobility (e.g. stayed in bed) or household tasks (e.g. went without clean laundry). Weighted stepwise logistic regression models adjusting for demographic, economic, and health differences are used to examine the association between race and UCNC in 2015 and change in UCNC two years later (2017). An interaction term between race and care type in 2015 is added to cross-sectional and longitudinal models to examine racial disparities in UCNC across different care arrangements.

Results: In unadjusted models, black (12%) compared to white (8%) older adults were significantly more likely to experience an UCNC in 2015 (p<.001). The odds of black older adults experiencing a change in UCNC two years later was 1.34 times greater than whites (p<.05). In adjusted models, the increased likelihood of black older adults experiencing UCNC both cross-sectionally and over time was explained by black-white economic and health disparities. Race did not significantly moderate the association between care type and UCNC in the cross-sectional results, but in unadjusted and adjusted longitudinal models, there was a significant interaction effect. Black older adults (25%) were significantly more likely than whites (15%) to no longer experience an UCNC in 2017 when receiving formal home care; however, when living in residential care, black older adults (26%) were significantly more likely than whites (15%) to develop an UCNC two years later.

Conclusions and Implications: In support of prior work, the results indicate the importance of upstream factors (economic and health inequities) in addressing black-white disparities in UCNC. The results also generate new evidence suggesting black-white differences in experiencing UCNC over time based on type of care arrangement, with formal home care being particularly protective for black older adults to address unmet care needs, whereas living in residential care may increase the likelihood of experiencing UCNC for black compared to white older adults. The results of this study help target the advocacy efforts of social workers to advance health equity in later life.