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Vernellia R. Randall
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On September 22, 1993, President Clinton appeared before the American people to discuss his plans to reform the health care system. On November 20, 1993, the Health Security Act (the 'Act' or 'HSA') was introduced into Congress.(1) The Act responded to concerns about the uninsured and underinsured, about uncompensated care and about cost containment.(2) An implicit assumption has been that economic access is the most significant barrier to health care; and, in fact, it may be. However, there are many other barriers to access(3) If equitable access means, or is defined as, the actual receipt of the quality and quantity of services needed, then access in America has been inequitable(4) Many individuals receive different health care (both quantity and quality) based on characteristics other than medical need. The care received by the wealthy is different than the care received by the poor; the care received by European American(5) is different than the care received by ethnic Americans(6) and the care received by men is different than the care received by women.

Has the HSA designed a system that removes or minimizes inequities? Or will it provide the wealthy with one level of care and the poor with another? Does the HSA fashion a system that distributes health care resources so that ethnic Americans receive the same quantity and quality of care as European Americans? Will the system envisioned result in improved health status for ethnic Americans?

It is important that ethnic Americans do not accept an inadequate solution as a compromise. Once a significant reform package passes Congress and becomes law, the issue of 'major' health care reform probably will not be addressed again for quite some time. Furthermore, as ethnic Americans begin to point out problems with the 'reformed' system, European Americans, particularly those with upper-middle income, are likely to feel resentful toward ethnic Americans. European Americans, having expended a significant amount of energy, time and political capital on reforming the health care system, are likely to consider ethnic American concerns as undocumented complaints.

Consequently, despite the rhetoric of economics, ethnic Americans must ultimately evaluate health care reform on the potential to improve health status. Improving health status depends on improving access to both equal and quality health care. Ultimately, then, health care reform must be evaluated on how effectively it removes (or at least, significantly reduces) barriers to [e]qual[ity] health care.

Using the Health Security Ac(7) as a bases for analysis, this article analyzes the potential for health care reform, in its current from, to improve access to health care for ethnic Americans(8) Unfortunately, the article concludes that health care reform will fail ethnic Americans and the poor because it maintains a structurally and ideologically flawed system(9) it perpetuates a fragmented system with inadequate infrastructure(10) it maintains a culturally incompetent system based on illness care(11) it rations health care through a tiered system based on private interests(12) and it inadequately protects against health care discrimination(13)


FN1. The Health Security Act was introduced into the House as H.R. 3600, 103d Cong., 1st Sess. (1993), and into the Senate as S. 1757, 103d Cong., 1st Sess. (1993) (hereinafter the HSA).

FN2. See e.g., 139 Cong. Rec. S12.288-01 (daily ed. Sept. 23, 1993) (statement of Senator Moseley-Braun, D.-Ill., reciting the need for the HSA, based on the thirty- eight million uninsured, the millions inadequately insured, the escalating cost of health insurance, and the escalating expenditures on health care).

FN3. The barriers to (e)qual(ity) health care for ethnic Americans include: inability to afford quality health care (economic barriers); lack of providers and facilities from which to obtain health care (infrastructure barriers); provision of services in a middle-class form (class barriers); inability to obtain care because of racism (racial barriers); provision of culturally incompetent care (cultural barriers); and inability to obtain health care because of communication problems (language barriers). See infra notes 113-19, 175-84, and accompanying text.

FN4. America has had a 'long tradition of inadequately-funded, inferior, and segregated services for low-income and minority patients . . . entrenched by widespread racial, gender, ethnic, and class bias in many parts of the system.' Rand E. Rosenblatt, On Access to Justice, Discrimination and Health Care Reform 3 (Feb. 14, 1994) (testimony before the Health and Environment Subcommittee of the House of Representatives) (on file with the Brooklyn Law Review).

FN5. 'European American' denotes individuals usually called 'white.' Historically, ethnic Americans have been designated with a hyphenated name: 'African-Americans,' 'Asian-Americans,' 'Native-Americans,' 'Hispanic- Americans.' The hyphenation implies that a second person would not recognize these individuals as Americans unless designated as such. On the other hand, 'white' persons need no designation because they are presumed to be Americans. Consequently, even linguistically, 'whites' maintain a position of power. See Charles P. Freund, Rhetorical Questions: The Power of, and Behind, a Name, Wash. Post, Feb. 7, 1989, at A23. It would be 'nice' if no designations were needed, but the reality of the situation requires us to discuss the needs of specific ethnic groups. The term 'European,' rather than 'Anglo-Saxon,' provides balance with the other designations; that is, it offers a designation which loosely identifies the geographic region from which the original ancestors migrated.

FN6. I reject the designation of 'minorities' because it connotes subordination. Thephrase 'ethnic Americans' is used to refer to African Americans, Asian/Pacific Islander Americans, Indian/Native/Eskimo Americans and Hispanic/Latino Americans. Ethnic Americans constitute a significant portion of the American population--24.36%. 1990 U.S. Census. Even within each ethnic group, however, there is significant diversity. For instance, Asian/Pacific Islanders speak over 100 different languages and dialects. Association of Asian Pacific Community Health Organizations, at 2 (unpublished manuscript, on file with author). They have a varied history of settlement in America, and represent 47 different ethnicities. Id. at 3. Such diversity exists to some extent among all ethnic Americans. Consequently, the categorizations in this paper are, at best, generalizations.

FN7. See infra part I.

FN8. This evaluation is based on the contents of the HSA, as submitted to Congress on November 20, 1993, and technically corrected on December 15, 1993. It does not attempt to evaluate the multiple changes (both major and minor) made to the HSA after that date.

FN9. See infra part II.

FN10. See infra part III.

FN11. See infra part IV.

FN12. See infra part V.

FN13. See infra part VI.


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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu


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