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 Appendix An Selected Paragraphs from the United States Report Pursuant to Article 9 of the Convention

71. Although there has been significant progress in the improvement of race relations in the United States over the past half-century, serious obstacles remain to be overcome. Overt discrimination is far less pervasive than it was 30 years ago, yet more subtle forms of discrimination against minority individuals and groups persist in American society. In its contemporary dimensions discrimination takes a variety of forms, some more subtle and elusive than others. Among the principal causative factors are:

(k) Disadvantages for women and children of racial minorities. Often, the consequences of racism and racial discrimination are heightened for women and children. Whether in the criminal justice system, education, employment or health care, women and children suffer discrimination disproportionately. Startlingly high incarceration rates for minority women and children have placed them at a substantial social, economic and political disadvantage;

(l) Health care. Persons belonging to minority groups tend to have less adequate access to health insurance and health care. Historically, ethnic and racial minorities were excluded from obtaining private insurance, and although such discriminatory practices are now prohibited by law, statistics continue to reflect that persons belonging to minority groups, particularly the poor, are less likely to have adequate health insurance than White persons. Racial and ethnic minorities also appear to have suffered disproportionately the effects of major epidemics like AIDS. For example, in 1999, 54 per cent of new cases of HIV infection occurred among [African-Americans], even though they make up less than 15 per cent of the population;

(n) Discrimination against immigrants. Whether legal or illegal, recent immigrants often encounter discrimination in employment, education and housing as a result of persistent racism and  xenophobia. Some also contend that U.S. immigration law and policy is either implicitly or explicitly based on improper racial, ethnic and national criteria. Language barriers have also created difficulties of access, inter alia, to health care, education and voting rights for some.

136. The President has executive authority to direct the activities of federal agencies in furtherance of the Constitution and laws of the United States. In exercise of this authority, the President has issued executive orders that prohibit discrimination in federal programmes and that encourage diversity in the federal workplace to the extent that such actions are consistent with federal law. For example:        

(d) On 11 February 1994, in Executive Order 12898, President Clinton directed every federal agency to identify and consider adverse human health or environmental effects of its programmes, policies, and activities on minority and low-income populations. The Order also established a working group on environmental justice comprising the heads of the major executive agencies. The working group's task was to coordinate, provide guidance and serve as a clearinghouse for the federal agencies on their environmental justice strategies;

182. The President convened an Advisory Board of seven distinguished Americans to assist him with the Initiative. The Advisory Board worked with the President to engage the many diverse groups, communities, regions, and various industries in this country. The President asked the Advisory Board to join him in reaching out to local communities and listen to Americans from all different races and backgrounds, to achieve a better understanding of the state of race relations in the United States. The Advisory Board also studied critical substantive areas in which racial disparities are significant, including education, economic opportunity, housing, health care and the administration of justice. Once the year-long effort was completed, the Advisory Board submitted a report to President Clinton concerning its findings and recommendations for creative ways to resolve racial disparities.

376. Health and health care. Although the U.S. health care system provides the finest overall care in the world, the data show significant disparities with regard to certain health measures. For example:

 — Infant mortality rates are 2.5 times higher for African-Americans than for Whites, and 1.5 times higher for Native Americans. In 1997, the infant mortality rates for Whites was 6.0 deaths per 1,000 live births, compared to 13.7 deaths per 1,000 live births for [African-Americans];

— [African-American] men under age 65 have prostate cancer at nearly twice the rate of White men;

— The death rate from heart disease for [African-Americans] is 41 per cent higher than for Whites (147 deaths per 100,000, compared with 105 deaths);

— Diabetes is twice as likely to affect Hispanics and Native Americans as the general population. Diabetes rates are 70 per cent higher for [African-Americans] than for Whites;

— [African-American] children are three times more likely than White children to be hospitalized for asthma;

— The maternal mortality rate for Hispanic women is 23 per cent higher than the rate for non-Hispanic women. [African-American] women have a 5 per cent higher death rate in childbirth than non-Hispanic White women;

— [African-Americans] experience disproportionately high mortality rates from certain causes, including heart disease and stroke, homicide and accidents, cancer, infant mortality, cirrhosis and diabetes;

— Native Americans are 579 per cent more likely to die from alcoholism, 475 per cent more likely to die from tuberculosis and 231 per cent more likely to die from diabetes than Americans as a whole;

— Individuals from minority racial and ethnic groups account for more than 50 per cent of all AIDS cases, although they represent only 25 per cent of the U.S. population;

— The rate of AIDS cases was 30.2 per 100,000 for Whites in 1993. It fell to 9.9 in 1998. The rate for [African-Americans] in  1993 was 162.2; 84.7 in 1998. The rate for Hispanics fell from 89.5 in 1993 to 37.8 in 1998.

377. Health care professionals. In 1996, about 740,000 medical doctors practiced in the United States (280 per 100,000 population). Minorities are likely to live in areas under-served by these and other medical professionals. Poor urban communities with high proportions of [African-Americans] and Hispanics averaged only 24 physicians per 100,000. Poor communities with low proportions of [African-Americans] and Hispanics averaged 69 doctors. This shortage is exacerbated by data that show [African-American] physicians are five times more likely than other doctors to treat [African-American] patients, and Hispanic doctors are 2.5 times more likely than other doctors to treat Hispanic patients. Minority doctors are also more likely to treat medicaid or uninsured patients than White doctors from the same area.

378. Health care facilities. There are about 6,200 hospitals in the United States providing more than one million beds. Before the 1960s, hospitals were voluntary organizations and did not face the same legal requirements as public institutions. In addition, hospital medical staffs were self-governing, which gave them freedom to select members, choose patients, and adopt their own payment policies. In many parts of the country, health care services and providers were segregated by race. Since passage of civil rights laws in the 1960s, these practices are no longer legal.

379. Health care financing. It is primarily through health insurance that Americans pay for their health care. Employer-provided health plans cover some of the costs of health care; others rely on private health insurers or managed care organizations, such as health maintenance organizations. Those without insurance must rely on financial assistance to obtain health coverage, and may qualify for public assistance, such as supplementary security insurance.

380. Public assistance for health care includes medicare (for the elderly) and medicaid (for the non-elderly poor). Medicare provides health insurance coverage for persons aged 65 years and older, and individuals with disabilities. Medicare provides health care coverage for more than 38 million people at a cost of about $200 billion. Medicaid provides coverage for low-income persons. It is administered by the states with matching funds from the Federal  Government. Medicaid covers 37 million people at a cost of about $164 billion. While medicaid rules and policies are set and monitored by federal and state agencies, the administration of the programmes is run by insurance companies.

381. Although medicare and medicaid provide more than 70 million people with health coverage, a large number of Americans remain uninsured and unable to access quality health care. Most of the uninsured are minorities and women with children, resulting in unequal access to health care. Almost 30 per cent of Hispanic children, and 18 per cent of [African-American] children are estimated to be without health insurance. Moreover, immigrants, those who are unemployed, work part-time, or are retired often have inadequate insurance.

382. Eliminating disparities in health care access. The U.S. Government has long sought to address the need for equal access to quality health care. During the past 35 years in particular, federal civil rights laws and policies have addressed the need to ensure equal access to health care and non-discrimination in health care programmes for racial and ethnic minorities. Congress has created several federal statutes designed to achieve equal protection of the laws through an emphasis on equality of access to institutions, including the nation's health care system. These statutes have helped establish the framework for the Federal Government's efforts to eliminate discrimination in the health care delivery system.

383. Two statutes are particularly relevant to health care: (a) the Hill-Burton Act, formally Title VI and XVI of the Public Health Service Act of 1964, Public Law No. 79-725, 60 Stat. 1040 (1946), codified as amended at 42 U.S.C. sec. 291-291-0 (1994) and Pub. L. No. 93-641, 88 Stat. 2225 (1974); and (b) Title VI of the Civil Rights Act of 1964, Pub. L. No. 88-352, Title VI, 78 Stat. 252 (codified as amended at 42 U.S.C. sec. 2000d-2000d-7 (1994)).

384. When it was first enacted in 1946, the Hill-Burton Act was designed as a means for facilitating hospital construction, especially in rural communities. In 1964, however, Congress reformulated Hill-Burton as a key provision in the Public Health Service Act to include the modernization of existing hospital facilities. In 1974 the Act was amended yet again, this time requiring that hospitals receiving funds provide a specified amount of service to those unable to pay.  Additionally, a facility receiving funds was to be made available to all members of the community in which it was located, regardless of race, colour, national origin or creed.

385. The Department of Health and Human Services (HHS) is the federal agency with primary responsibility for enforcing Title VI in the health care context, as well as other civil rights statutes and provisions addressing equal access to quality health care. HHS seeks to ensure compliance with the non-discrimination provisions of these laws by relying on implementing regulations, policy guidance, comprehensive full-scope compliance reviews, complaints investigations, mediation, settlement agreements, technical assistance, outreach and education programmes, as well as through enforcement actions.

386. The impact of medicare and medicaid, originally passed by Congress in 1965, has been enormous. In 1964, Whites were almost 50 per cent more likely than [African-Americans] to see a physician. By 1994 this ratio had been reversed: [African-Americans] were about 12 per cent more likely than Whites to have seen a doctor in the preceding two years. However, [African-Americans] continue to be twice as likely to use hospital outpatient services, while Whites are substantially more likely to visit a private physician.

387. President Clinton has committed the nation to an ambitious goal of eliminating by 2010 disparities in health status experienced by racial and ethnic groups in the United States. President Clinton targeted six health priority areas: infant mortality, breast and cervical cancer screening and management, cardiovascular disease, diabetes, child and adult immunization levels, and HIV/AIDS. As part of this effort, for example, the Center for Disease Control recently awarded $9.4 million to 32 community coalitions in 18 states to reduce the level of disparities in one or more of the priority areas.

388. Furthermore, in response to studies showing that language barriers in health care present serious problems for a large percentage of Americans with limited English proficiency (LEP), on 11 August 2000, President Clinton issued Executive Order 13166, “Improving access to services for persons with limited English proficiency”. The President ordered that “each Federal agency shall examine the services it provides and develop and implement a system by which LEP persons can meaningfully access those services consistent with,  and without unduly burdening, the fundamental mission of the agency. Each Federal agency shall also work to ensure that recipients of Federal financial assistance (recipients) provide meaningful access to their LEP applicants and beneficiaries. To assist the agencies with this endeavour, the Department of Justice has today issued a general guidance document (LEP Guidance), which sets forth the compliance standards that recipients must follow to ensure that the programmes and activities they normally provide in English are accessible to LEP persons and thus do not discriminate on the basis of national origin in violation of Title VI of the Civil Rights Act of 1964, as amended, and its implementing regulations.” As described in the LEP Guidance, recipients “must take reasonable steps to ensure meaningful access to their programmes and activities by LEP persons.”

390. On 11 February 1994, President Clinton issued Executive Order 12898 to all departments and agencies of the Federal Government directing them to take action to address environmental justice with respect to minority populations and low-income populations. Agencies were directed, among other things, to address disproportionate human health or environmental effects of programmes on such populations, to collect additional data on these subjects, and to coordinate their efforts through a newly established inter-agency working group.

391. While most environmental laws do not expressly address potential impacts on low-income and minority communities, Executive Order 12898 directs the Environmental Protection Agency (EPA) “[t]o the greatest extent practicable and permitted by law ... [to] make achieving environmental justice part of its mission by identifying and addressing, as appropriate, disproportionately high and adverse human health or environmental effects of its programmes, policies, and activities on minority populations and low-income populations.”

446. “Changing America: Indicators of Social and Economic Well-Being by Race and Hispanic Origin” documents current differences in key indicators of well-being: education, labour markets, economic status, health, crime and criminal justice, and housing and neighbourhoods. The information in this publication provides a factual base on which to build dialogue about race.

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