As part of its investigations into inequities in the later years of life, the Globe Spotlight Team set out to test this simple but critical question: Is it harder for the poor to get a nursing home bed?
The answer that came back was unmistakable: Yes.
Team members, posing as women seeking care accommodations for a frail, elderly mother, sent e-mails to more than 200 of the state’s roughly 380 nursing homes, chosen randomly, over several weeks last December. The team e-mailed each nursing home twice under different names, one to two weeks apart. One set of e-mails described applicants with the means to pay their way; the others said they would have to rely on Medicaid, also known as MassHealth.
The replies etched a clear pattern. Nursing homes were more than twice as likely to say they had no room when responding to inquiries from families saying they planned to pay for care with Medicaid — the government health program relied on by low-income residents — rather than paying privately.
Often the difference wasn’t subtle. In some cases, employees from the same facility would tell the daughter of a purported Medicaid applicant that there was a waiting list, while telling the daughter of a private payer, who could be expected to pay the nursing home nearly twice as much, she would be happy to discuss the options.
Discrimination against applicants covered by Medicaid has existed for years in the nursing home industry, say advocates for the elderly, and it can be illegal.
Massachusetts adopted explicit protections in 1994, barring nursing homes from discriminating against "any Medicaid recipient or person eligible or soon-to-be-eligible to receive Medicaid benefits.'' The regulations also prohibit facilities from offering help “in the preparation of applications or in any facet of the admission process to private pay applicants in a manner greater than that rendered or offered to Medicaid recipients.”
And yet many nursing homes do appear biased against Medicaid patients.
“You have more choices if you have money. That’s the world we live in,” said attorney Steven Cohen, a partner at Pabian & Russell in Boston who specializes in long-term-care and estate planning.
Medicaid pays nursing homes an average $209 per day, far less than the $389 typically paid out-of-pocket by well-off senior citizens — a sizable difference for an industry plagued by ongoing financial struggles and closures — according to 2018 state data. The most exclusive nursing homes charge private-pay residents even more.
Bed availability at nursing homes legitimately varies daily as patients die or move out. And because the Globe’s matched e-mails were sent up to two weeks apart to avoid detection, it’s possible that room availability changed during that time at any single nursing home, unrelated to the applicant’s method of payment.
But the overall findings are telling in the aggregate. The nursing homes that responded more favorably to private-pay applicants were spread across the state, including in Concord, Bedford, East Bridgewater, and Webster.
The response rate to our e-mails was 65 percent, identical for our private pay and Medicaid solicitations.
Not every nursing home clearly reported whether it had openings. But among those that did, nursing homes were more than twice as likely to tell the private-pay applicants a bed was open: A total of 52 facilities told private-pay applicants that space was available, while 22 said they had no opening.
Meanwhile, our fictitious Medicaid patients were almost twice as likely to be told there was no room: A total of 49 facilities said they had no openings; 28 reported having an opening.
Loomis House, now called Day Brook Village, a nursing home on a leafy campus in Holyoke, told our private-pay “applicant” that it had an opening.
“If you would like to stop by, I would be happy to show you around our nursing center,’' an administrator wrote.
Two weeks later, the same administrator told the Medicaid applicant, “Sorry to say, we do not have any openings at this time. We currently have a waiting list of 21 people."
Lisa Gaudet, vice president of business development and marketing at Berkshire Healthcare, which includes Day Brook, said bed availability shifts daily. When the private-pay candidate e-mailed, the facility had five open beds and four pending referrals from hospitals. Two weeks later, Day Brook had just one available bed and five possible hospital transfers, she said. Hospital admissions often take priority because they are more urgent, she said.
Gaudet said the admissions coordinator did not recall why she mentioned the 21-person wait list in one instance but not the other.
Gaudet acknowledged staff might be more enthusiastic about a private-pay applicant but said that is not discriminatory. "MassHealth has not kept up with costs. When you’re building a business around MassHealth patients, you need to be looking at what other payers you can bring into the mix. You need to keep the doors open.''
At another nursing home, D’Youville Senior Care, a four-star nursing home in Lowell, one executive told a prospective private-paying resident to fill out the application “asap as sometimes things can open up.’’
Another executive told the Medicaid applicant to fill out an application as well but was less encouraging, saying the woman would have to be approved for Medicaid in advance to even be considered.
Asked for an explanation, a D’Youville spokesman, Michael Ferrick, said “the response to the private pay inquiry and Medicaid inquiry came from two different individuals. This explains subtle differences in each of their helpful and compassionate responses." He added, "Appropriately, it was indicated to both applicants that there was no availability and they would be placed on a wait list.”
At another facility, Belmont Manor told our Medicaid applicant no rooms were available. An executive warned: “[I]t is always hard to [b]e able to say how long, but at this time, there are a lot waiting.”
Yet, that same executive seemed eager to help our private-pay client two weeks later: “I would like to talk with you about your Mother’s needs. Please call me, or send me your telephone number so I can call you. Look forward to hearing from you.” No talk of waiting or long queues.
When asked for an explanation, Belmont Manor co-owner Stewart Karger issued a one-line response by e-mail: “Belmont Manor follows all state and federal regulations regarding admissions.”
The reactions to our test e-mails at times appeared subtly more encouraging to the private-pay applicant.
The Sachem Center for Health & Rehabilitation, in East Bridgewater, offered these responses:
To the Medicaid applicant: “I unfortunately do not have any female availability at this time.”
To the private-pay applicant: “I would be happy to schedule a phone call with you to discuss this.”
The Sachem Center declined to comment.
One former nursing home administrator, who requested anonymity because she was not authorized by the facilities to describe their practices, said industry preference in favor of private pay residents is not surprising and not unusual. Medicaid’s low reimbursement rates and bureaucratic requirements are challenging, said the woman, who worked for various Massachusetts nursing homes for 40 years.
“A Medicaid application has to be filled out and it can take up to three months for approval,’' she said. “What if the patient does not get approved for Medicaid? You can’t send them home because they wouldn’t be safe at home. You are between a rock and a hard place.''
Some nursing homes take Medicaid patients without hesitation. But if an elderly person wants to get into “a really good place that is full 99 percent of the time, then your chances are very slim" if you’re on Medicaid, she said. “One particular place, we never took Medicaid patients. We would say there is ‘no available bed’ or ‘we have nothing right now. We will let [you know] if something opens up.’’'
“You have to meet expenses,’' she said.
Nursing homes are not forced to participate in Medicaid. Some facilities, such as the Pond Home in Wrentham, accept only private-pay residents. But once a nursing home takes taxpayer funding and accepts one Medicaid patient, it has to follow the rules and cannot discriminate. Despite state antidiscrimination regulations, though, advocates for the elderly and those who work in the nursing home industry said bias against applicants on Medicaid is an open secret.
Most Massachusetts nursing homes are dependent on money from Medicaid — the program pays for 70 percent of nursing home stays — so these facilities cannot reject those applicants entirely and survive. By law, they are allowed to inquire about an applicant’s finances and are not required to admit someone who does not have a current — or future — means to pay.
Some nursing home residents pay privately for a while before exhausting their resources and applying for Medicaid. Others, in what some industry specialists call a controversial practice, qualify for Medicaid through various strategies, including transferring money and property into irrevocable trusts. Though such trusts may be less common in recent years due to more aggressive government scrutiny, some families still take advantage of these methods so they can leave assets to children, long-term care experts say.
It is illegal for nursing homes that accept Medicaid to evict a private-paying resident who runs out of money and then qualifies for Medicaid.
With few solutions in sight at the national or state level, lawyers and consultants tell families they have a better chance of being admitted to their top-choice facility if they aren’t applying as a Medicaid recipient.
“I tell people ‘You should expect to pay privately for some period of time,’" said Cohen, the long-term-care and estate planning specialist.
Liz Kowalczyk and Mark Arsenault of the Globe staff can be reached at firstname.lastname@example.org and email@example.com. Andrew Ryan and Rebecca Ostriker of the Globe staff also contributed to this story.
The entire Last Words series can be found at www.bostonglobe.com/lastwords.