IV. Institutional Racism and Racial Discrimination in the U.s. Health Care System

 Compounding the racial discrimination experienced generally is the institutional racism in health care that affects minority access to health care and the quality of health care received. Despite efforts over the past thirty  years to eliminate discrimination and reduce racial segregation, there has been little change in the quality of, or access to, health care for many minorities. According to the U.S. Commission on Civil Rights, “Despite the existence of civil rights legislation equal treatment and equal access are not a reality for racial/ethnic minorities and women in the current climate of the health care industry. Many barriers limit both the quality of health care and utilization for these groups, including ... discrimination.” Racial discrimination in health care delivery, financing, and research continues to exist, and racial barriers to quality health care manifest themselves in a number of ways.


A. Lack of Economic Access to Health Care

 More than 38.4 million Americans are uninsured with no economic access to health care. A disproportionate number of the uninsured are racial minorities. As access to health insurance in the United States is most often tied to employment, racial stratification of the economy due to other forms of discrimination has resulted in a concentration of racial minorities in low wage jobs. These jobs are almost always without insurance benefits. As a result, disproportionate numbers of the uninsured are racial minorities. Recent changes in the “safety net” have resulted in increased problems. Specifically, welfare reform enacted in 1996 changed the structure of public assistance, resulting in 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 due to an unawareness of eligibility requirements, resulting in an increased 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, are disqualified 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.


B. Barriers to Hospitals and Health Care Institutions

 The institutional/structural racism that exists in hospitals and health care institutions manifests itself in (1) the 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 either distinctly substandard institutions or to no care at all.


C. Barriers to Physicians and Other Providers

 Areas that are heavily populated by minorities tend to be medically underserved. 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, due to discrimination in post-secondary education, racial biases in testing, and quality-of-life issues affecting school performance, minorities are seriously underrepresented in health care professions. The shortage of minority professionals affects not only access to health care, but also access to the power and resources needed to structure the health care system, leaving its control almost exclusively in White hands. The result is an inadequate, ineffective and marginalized voice on minority health care issues.


 D. 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. 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, pain treatment, and hospital care. Certainly, difference in treatment can be based on a number of different factors, including clinical characteristics, income, and medical or biological differences. However, race plays an independent role. There are marked differences in time spent, quality of care and quantity of doctor's office visits between Whites and African-Americans. Whites are  more likely to receive more, and more thorough, diagnostic work and better treatment and care than people of color — even when controlling for income, education, and insurance. Differences also exist in the number of doctor's office visits between Whites and African-Americans, 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 and 44.” In fact, at least one study indicated a combined effect of race and gender resulting in significantly different health care for African-American women.


E. 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 racially-neutral federal medicaid policy that limits the number of beds a nursing home can allocate to medicaid recipients. The policy encourages these facilities to move existing patients who have depleted their assets and are now newly eligible for medicaid into medicaid beds as they become available. It is mostly White women who have the assets to afford long-term care without  medicaid and who live long enough to deplete those assets. The effect of this policy is that fewer medicaid resources are spent on nursing for minority populations even though minorities represent a larger portion of the medicaid population and have more illness. The combination of minority overrepresentation and government under-spending in medicaid is yet another example of the kind of structural and institutional racial discrimination that persists in many areas of the health care system.


F. Lack of Language and Culturally Competent Care

 A key challenge has been to get the government to establish clear standards for culturally competent health care. 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. In addition to recognizing the disparities in health status between White Americans and minority groups, society must recognize differences within groups as well. Ethnic and racial minority communities include diverse groups with diverse histories, languages, cultures, religions, beliefs, and traditions. This diversity is reflected in the health care minorities 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. 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.

 One example of institutional barriers to culturally competent care is the prevalence of linguistic barriers that also affect the quality of health care services, particularly for Hispanics and Asian Americans. 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 those with limited proficiency in English. This failure includes not providing education or information at the appropriate literacy level. Furthermore, “English only” laws — laws that restrict access to public services to those with proficiency in English — also have an acute and racially disproportionate impact on minorities. The lack of an official government infrastructure (extending from the federal to the local level) to ensure standards of culturally competent care and equal access to services is inconsistent with Article 5 of CERD.


G. 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 by women as a whole. However, race discrimination and sex discrimination often intersect so as 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 health 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 minority 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 the medical concerns of minority women are not taken as seriously as those of minority men and are often dismissed as the result of emotional distress or as a psychosomatic condition. Further, some health issues of minority women, 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 the health concerns of minority women.

 Policies and practices that increase government surveillance and control of minority women are also a key factor in health status. Minority women are less likely to receive sympathetic intervention by law enforcement in cases of domestic violence. Women who, after calling upon police for help in such cases, become victims of both domestic violence and police violence. Family planning is another area where public policy has had a  negative impact on health status and life choices of minority women. Minority women do not have equal access to preventive medicine or the full range of birth control options available. Barriers include lack of family-planning services or facilities in their communities; lack of medicaid or other publicly-funded health insurance coverage of certain services, medications or procedures; and disproportionately higher prescriptions of medically risky or unnecessary procedures, such as contraceptive implants or forced sterilization. State and local policies are more likely to be discriminatory than federal policies. There are few standards for ensuring equal access and equal treatment at the state and local levels. With jurisdiction over health care issues increasingly devolving to the state and local levels, there is a critical need for a clear regulatory infrastructure that provides redress for these barriers and remedies and consequences for policies and practices with discriminatory outcomes.


H. 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 biological differences that affect the manifestations of certain illnesses and their treatments. Billions of dollars are spent each year on health research ($35.7 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% and .37%, respectively). In response to years of exclusion of women and minorities, several statutory requirements have been enacted to ensure that research protocols include a diverse population. However, the health condition of women and minorities will continue to suffer until they are included in all types of health research.


 I. 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 are often 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.


J. 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, which does not currently exist, managed care will, over time, tend to place increasingly stringent requirements on providers. Providers may fail to  develop more expensive but culturally-appropriate treatment modalities, and they may refuse or minimize the expenditures necessary to develop an 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 the Office of Civil Rights, leading commentators, and advocates for civil rights in health care services, financing, and treatment. However, little has been done to protect minorities from this risk of discrimination. The U.S. Commission on Civil Rights reported:

The Office of Civil Rights (OCR) also has not sufficiently prepared its investigative staff to identify and confront instances of discrimination by managed care organizations. 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 impact on minorities. For example, one of the most common ways in which Managed Care Organizations (MCOs) discriminate against minorities is in the MCOs' selection of available 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 containing only providers that accept medicaid, resulting in segregated provider lists.  Other methods MCOs have used to discriminate against medicaid patients include excluding sections of the inner city from the 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.