Compounding the racial discrimination experienced generally, is the institutional racism in health care that affects access to health care and the quality of health care received. Despite efforts to eliminate discrimination and reduce racial segregation over the past 30 years, there has been little change in the quality of or access to health care for many minorities. According to the US Commission on Civil Rights, "Failure to recognize and eliminate differences in health care delivery, financing, and research presents a discriminatory barrier that creates and perpetuates differences in health status." Racial discrimination in health care delivery, financing, and research continues to exist and racial barriers to quality health care manifests themselves in a number of ways including:

Lack of Economic Access to Health Care. Over 42 million Americans are uninsured with no economic access to health care. A disproportionate number of the uninsured are racial minorities.

Recent changes in the "safety net" has resulted in increased problems. Specifically, in 1996 welfare reform changed the structure of public assistance and, as a result, had a disparate impact on women and minorities. One of the direct effects of welfare reform has been a reduction in the use of medicaid by those who qualify, because of an unawareness of eligibility requirements, which has increased the number of uninsured. A second effect has been that the subsequent increased poverty among those in need of assistance has caused a worsening of health status and an increase in the need for health care services.

In fact, a disproportionate number of racial minorities have no insurance, are unemployed, are employed in jobs that do not provide health care insurance, disqualify for government assistance programs, or fail to participate because of administrative barriers. Gaps in health status, and the absence of relevant health information, are directly related to access to health care

Barriers to Hospitals and Health Care Institutions. The institutional/structural racism that exists in hospitals and health care institutions manifests itself in the (1) adoption, administration, and implementation of policies that restrict admission; (2) the closure, relocation or privatization of hospitals that primarily serve the minority community; and (3) the continued transfer of unwanted patients (known as "patient dumping") by hospitals and institutions. Such practices have a disproportionate effect on racial minorities banishing them to distinctly substandard institutions or to no care at all.

Barriers to Physicians and Other Providers. Areas that are heavily populated by minorities tend to be medically under-served Disproportionately few White physicians have their practices located in minority communities. Minority physicians are significantly more likely to practice in minority communities, making the education and training of minorities extremely important. Yet, minorities are seriously under represented in health care professions. The shortage of minority professionals affects not only access to health care but also input into the structure of the system. With so few minority health care professionals, the control of the health care system lies almost exclusively in White American hands. The result is an inadequate, if not ineffective and marginalized, voice on minority health care issues.

Racial Disparities in Medical Treatment. Differences in health status reflect, to a large degree, inequities in preventive care and treatment. For instance, African Americans are more likely to require health care services, but are less likely to receive them. In fact, racial disparity in treatment has been well documented in a number of studies, including studies done on AIDS, cardiology, cardiac surgery, kidney disease, organ transplantation, internal medicine, obstetrics, prescription drugs, treatment for mental illness, and hospital care. Differences also exist in the number of doctor�s office visits between whites and blacks, even when controlling for income, education, and insurance. Furthermore, researchers have concluded that doctors are less aggressive when treating minority patients. Thus, the most favored patient is "White, male between the ages of 25 to 44". In fact, at least one study indicated a combined affect of race and gender resulting in significantly different health care for African American women

Discriminatory Policies and Practices. Discriminatory policies and practices can take the form of medical redlining, excessive wait times, unequal access to emergency care, deposit requirements as a prerequisite to care, and lack of continuity of care, which all have a negative effect on the type of care received. Because discriminatory practices are often facially neutral, citing exact practices becomes a difficult task. There are many examples, however, of policies and practices that disproportionately affect racial and ethnic minorities, such as refusal to admit patients who do not have a physician with admitting privileges at that hospital, exclusion of medicaid patients from facilities, and failure to provide interpreters and translations of materials, to name a few." One significant example, is a federal Medicaid racially neutral policy which nonetheless results in fewer expenditures on minority populations for nursing home care even though they represent a larger portion of the Medicaid population and have more illness. It is the combination of over-representation and under-spending in Medicaid that exemplifies the kind of structural and institutional racial discrimination that persists in many areas of the health care system.

Lack of Language and Culturally Competent Care. In addition to recognizing the disparities in health status between White Americans and minority groups, we must recognize differences within groups as well. Ethnic and racial minority communities are comprised of diverse groups with diverse histories, languages, cultures, religions, beliefs, and traditions. This diversity is reflected in the health care they receive and the experiences they have with the health care industry. Without understanding and incorporating these differences, health care cannot be provided in a culturally competent manner. Culturally competent care is defined as care that is "sensitive to issues related to culture, race, gender, and sexual orientation." Cultural competency involves ensuring that all health care providers can function effectively in a culturally diverse setting; it involves understanding and respecting cultural differences. Nonetheless, there has been relatively little research done on the differences in accessing quality health care by racial/ethnic subgroups, and few data are available on many of these groups.

Linguistic barriers also affect the quality of health care services, particularly for Hispanics and Asian Americans." Furthermore, the failure to use bilingual, professionally and culturally competent, and ethnically matched staff in patient/client contact positions results in lack of access, miscommunication and mistreatment for limited proficiency in English. This failure includes not providing education or information at the appropriate literacy level. Furthermore, if attempts to pass "English only" laws are successful, there will be an acute and racially disproportionate impact on minorities.

Disparate Impact of the Intersection of Race and Gender. The unique experiences of women of color have been largely ignored by the health care system. These women share many of the problems experienced by minority groups, in general, and women, as a whole. However, race discrimination and sex discrimination often intersect to magnify the difficulties minority women face in gaining equal access to quality health care. In addition to barriers restricting access to health care for racial/ethnic minorities, there are barriers to care that predominantly affect minority women. There are also gender differences in medical use, provision of treatments, and inclusion in research. This is partly the result of different expectations of medical care between men and women and of gender bias of health care providers. Furthermore, the difficulty minoirty women face accessing adequate health care, and all its components, is not limited to illnesses that affect both male and female populations. Rather, there is evidence that minority women often find it difficult to access quality health care related to gender-specific illnesses such as breast cancer.

An additional symptom of gender bias in the health care system that can affect outcomes is the way in which minority women�s medical concerns are not taken as seriously as minority men�s and are often dismissed as the result of emotional distress or as a psychosomatic condition. Further, some minority women�s health issues, such as violence against women, have been largely ignored by the medical community, and seen primarily as a social issue, not necessarily a health issue. Part of the problem is that medical professions have historically lacked a female perspective, in much the same way that the minority perspective is missing, therefore giving little attention to minority women�s health concerns.

Inadequate inclusion in Health Care Research. Despite volumes of literature suggesting the importance of race, ethnicity, and culture in health, health care, and treatment, there is relatively little information available on the racial, ethnic, and genetic differences that affect the manifestations of certain illnesses and their treatments. Billions of dollars are spent each year on health research ($35 billion in 1995). However, a strikingly minute percentage of those funds are allocated to research on issues of particular importance to women and minorities, and to research by women and minority scientists (21.5 percent and .37 percent, respectively). In response to years of exclusion of minorities and women, several statutory requirements have been enacted to ensure that research protocols include a diverse population The health condition of women and minorities will continue to suffer until they are included in all types of health research.

Lack of data and standardized collection methods. Current data collection efforts fail to capture the diversity of racial and ethnic communities in the United States. Disaggregated information on subgroups within the five racial and ethnic categories is not collected systematically. Further, racial and ethnic classifications are often limited on surveys and other data collection instruments, and minorities often are misclassified on vital statistics records and other surveys and censuses. It is important to collect the most complete data on racial and ethnic minorities, and subpopulations, to fully understand the health status, of all individuals, as well as to recognize the barriers they face in obtaining quality health care. The lack of data on different minority populations (such as Asian Americans) makes it difficult to conduct research studies and comparative analyses. Furthermore, the lack of a uniform data collection method makes obtaining an accurate and specific description of race discrimination in health care difficult. The existing data collection does not allow for regularly collecting race data on provider and institutional behavior.

Rationing Through Managed Care. The health care financing system has been steadily moving to managed care as a means of rationing health care. Without proper oversight, oversight that does not currently exist, managed care will, over time, tend to place increasingly stringent requirements on providers. They may fail to develop more expensive but culturally appropriate treatment modalities, and they may refuse or minimize the expenditures necessary to develop adequate infrastructure for minority communities. The potential for discrimination, particularly racial/ethnic discrimination to occur in the context of managed care is significant and is recognized as such by OCR and leading commentators and advocates for civil rights in health care services, financing, and treatment. However, little has been to protect minorities from this risk of discrimination.

"The Office of Civil Rights (OCR) also has not sufficiently prepared its investigative staff to identify and confront instances of discrimination by managed care organization. Despite indications of discrimination prohibited under title VI, OCR has not yet developed policy guidance specifically addressing title VI compliance in the managed care context. OCR headquarters indicate that OCR has known about the potentially discriminatory activities of managed care organizations since 1995, yet the office has been loath to encourage or support the regional investigators in identifying cases.

Several managed care practices can have a disparate effect on minorities. For example, one of the most common ways in which MCOs discriminate against minorities is in their selection of providers. A physician or other type of provider that serves mainly poor minorities may not be included in a managed care network because the provider�s patients might be labeled "too costly." Further, some plans target suburban areas for enrollment while ignoring inner-city areas, a process known as selective marketing. In addition, some MCOs may be limiting the access of medicaid patients to the full array of providers by sending these patients provider lists that contain only providers that accept medicaid, resulting in "segregated" provider lists. Other methods MCOs have used to discriminate against medicaid patients are excluding sections of the inner city from the MCO���s service area; applying a stricter definition of "medical necessity," the standard used to determine whether a patient will receive a particular test or treatment; and longer waiting times for new-patient or urgent-care appointments.