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Annotated Bibliography

Laurie Dorywalski
University of Dayton School of Law 
Spring 1998


 This annotated bibliography attempts to demonstrate the current barriers to access of health care services and how this denial has affected the health of American children, especially those of ethnic American descent. Although Medicaid has been quite successful in improving the quality of health care provided to children, there are still many problems inherent with the current system which have adversely affected the quality of health care provided to ethnic Americans. Because the principle purpose of managed care is cost containment, the program attempts to maximize profit by eliminating excessive care. 

After reviewing this material and reading the attached articles, the reader should have a strong understanding of the current access barriers placed on health care by managed care organizations such as HMO's. The reader should have a clearer understanding of the implications of such a system which focuses primarily on cost containment. Groups, such as minorities and the undeserved, require much more intensive health care services due to their substandard living conditions and lack of preventive care. However, under the current system, they are oftentimes denied access to many needed health care services such as antibiotics and immunity shots. In addition, current medical professionals are unaware of these problems and do not have a good understanding of the needs of these groups. 

Minority children therefore are susceptible to various access barriers to necessary health care services. Minority and undeserved children have a greater tendency to contract more illnesses due to their living conditions. In addition, these children do not receive adequate immunity treatments as infants, thereby increasing their chances of getting sick. However, because the current system focuses on cost containment, these groups are oftentimes denied access to necessary medicines and treatments. 

Unless medical providers address the current problems and try to compile data concerning racial disparities, minority groups, especially children, will continue to face various access barriers to medical care. 

The following articles are included in this bibliography:

Access of Long-Term Care: Race As A Barrier, 19 J. Health Pol. Pol'y & L. 583 (1994). 

Discrimination: The Difference With AIDS, 6 J. Contem. Health L. & Pol'y 93 (1990).

Impact of Managed Care Organizations on Ethnic Americans and Undeserved Populations , 5(3) Health Care for the Poor and Undeserved, 224 (1994). 

"Race, Ethnicity, & Hospital Care: The Need for Racial and Ethnic Data", (June 1997) 30 J. Health Hospital Law, Issue 2, 125. 

Racist Health Care, 48 Fla.L.Rev.357 (1996). 

The Doctor Will See You Now: Medicaid Managed Care and Indigent Children, 21 Seton Hall Legis. J. 93 (1997). 

The Impact of Managed Care on Doctors Who Serve Poor and Minority Patients, 198 Harv. L. Rev. 1625 (May 1995). 

Toward a Healthy Future - Early and Periodic Screening, Diagnosis, and Treatment for Poor Children, National Health Law Program - Texas Rural Legal Aid (April 1995). 

Whitehall Boca v. Dept. of Health and Rehabilitative Services, 456 So.2d 928 (1984). 

Laurie Dorywalski is a second year law student at the University of Dayton School of Law. She graduated from Stetson University in Deland, Fla., in 1996 with a BS in Chemistry and a BA in History. Upon graduation from the University of School of Law, she would like to work for an administrative agency such as the EPA and eventually become an environmental prosecutor for the Attorney General's Office


Access to Long-Term Care: Race as a Barrier, 19 J. Health Pol. Pol'y & L, 583 (1994). 

This article addresses the problem of access to long term health care for minority patients and how societal attitudes about race have contributed to this disparity. By looking at studies conducted concerning the time elapsed between when a patient is medically ready for discharge and when he or she is actually discharged, the authors concluded that the longer delay for minority patients is a result of the unwillingness of nursing homes to accept minority applicants into their facilities. 

The authors used data from a study of patients awaiting alternative placement in North Carolina hospitals in 1991 which revealed a disparity in delay for whites verses non-whites. Nonwhite patients experienced much longer discharge delays than did non-whites regardless of a number of factors including age, sex, conditions, or levels of special care required. [FN 1] The authors surmise that nursing home facilities prefer white patients to patients of color. 

While there does seem to be some disparity among the admission of white patients verses minority patients to nursing home facilities, the authors of this article should examine information other than studies conducted in nursing homes in one state. There could other factors involved in the hypothesis that discrimination is a direct result of discharge delays among minority patients. 

FN 1. Robert Broyles, David Falcolm, Access to Long Term Care: Race As A Barrier, 19J. Health Pol. Pol'y & L, 583, 591 (1994). 

"Children's Health: Racial and Ethnic Differences in the Use of Prescription Medications", 95 Pediatrics 5 (May 1995). 

The author asserts that the use of prescription drugs mirrors other types of health care services in that minorities receive proportionately less than do white patients. She contributes this trend to various factors such as need, economic concerns, and structural organizations. Because few studies have been conducted on the relationship between the use of prescription drugs and minorities, the author examined data and statistical data from the Household Component of the 1987 NMES and attributes disparities to the poverty status and needs of minority children. 

The author does a thorough job of examining not only data but also historical trends of discrimination in the health care industry. The article presented a different perspective on the effect of socioeconomic factors on the heath of minority children. 

Discrimination: The Difference With AIDS, 6 J. Contem. Health L. & Pol'y 93 (1990). 

The author begins this article by examining past discriminatory attitudes toward minorities and how those attitudes continue in the health care industry. According to his data, "black children have not shared equally in the overall health gains, and their death rates are much higher than those for white children". [FN1] Therefore, the author asserts that black children suffer the most from racial disparities including neglect and abuse, lack of immunization, lack of dental care, and malnutrition. Furthermore, black families are much less likely to have adequate health insurance. 

The author does a good job of addressing the impact current attitudes toward minorities have had on the quality of health care provided for minority children. He examines not only past practices but also current statistics and data. 

[FN1] Raymond C. O'Brien, Discrimination: The Difference with AIDS, 6 J. Contemp. Health L. & Pol'y 93, (1990). 

Impact of Managed Care Organizations on Ethnic Americans and Undeserved Populations, 5(3) Health Care for the Poor and Undeserved, 224 (1994). 

This article addresses the impact of managed care organizations on minorities and undeserved populations and discusses how rationing has detrimentally affected the quality of care provided for these groups. 

The author first looks at the fundamental premise of managed care which is to contain costs and then examines how the relationship between the patient and the physician has deteriorated as a result of this. Oftentimes, patients are unable to choose their physician and have to attend one with which they are uncomfortable. Utilization review, according to the author, will not abate many of the problems with the current system for various reasons. First, minorities have many untreated illnesses which require more intensive treatment. Due to cost containment measures they are many times unable to obtain the care they need. Secondly, the poor are traditionally in greater need of health care due to their living conditions. The problem with utilization review procedures is that they fail use data from white middle class individuals and therefore fail to properly reflect the current access problems among minorities. 

The author did a good job of examining racial trends in the current system. Therefore, although managed care organizations appear to be a feasible alternative to current fee for service facilities, they are inherently discriminatory towards not only minorities but also the poor. Therefore, although managed care appears to increase access, it essentially places many access barriers to health care. 

The Doctor Will See You Now: Medicaid Managed Care and Indigent Children, 21 Seton Hall Legis. J. 93 (1997). 

This article discusses the current problems with the Medicaid system and how it has failed to provide adequate medical treatment for American children, especially those in the African American Community. Foley begins the article discussing the achievements of the Medicaid system and how it has opened up health care services to poor children. She also acknowledges the increased access among poor children to health care services. However, Foley persuasively asserts that there are still many inherent problems with the Medicaid system. She contributes this problem to many factors. 

First, Foley asserts that the lack of uniformity among the states in their implementation of the Medicaid program leads to significant disparities in funding to individuals. Therefore, individuals who are similarly situated are treated differently depending on the program of the their state. 

Secondly, although the goal of the Medicaid program is to increase access, many groups such as the indigent and minorities receive substandard care and less care since there is a low participation rate among physicians in these areas. According to Foley, this negates the overall goal of the program since these groups are among those that they need the money the most. 

Foley then addresses the problems faced by many children who are unable to receive medical treatment. Her argument is based on the premise that poor children have a tendency to contract more sicknesses because of their inability to receive necessary medicine. Therefore, they are more likely to suffer from chronic sicknesses and need more care. Unfortunately, many children still do not have access to adequate health care services. This problem is magnified for minority children who receive even less medical care than white children. 

This article clearly defines the problems faced by many poor children, especially, minority children, who are denied access to much needed medical services. Although the author acknowledges the accomplishments of the Medicaid system, she addresses inherent problems that still exist in the program and how these problems affect groups such as the poor and the minorities. 

"Race, Ethnicity, & Hospital Care: The Need for Racial and Ethnic Data", (June 1997) 30 J. Health Hospital Law, Issue 2, 125. 

This article examines the problems of the current health system by analyzing how race and ethnicity are major determinants of the amount and quality of care a patient receives. The author asserts that these disparities are a result of discrimination. Ms. Watson examines how ethnic Americans have less access to hospitals and receive less care than do whites even when they are admitted with the same diagnosis, source of insurance, and socioeconomic class. Furthermore, she fears that the movement to managed care will only augment the current difficulties since minorities, who usually need more medical treatment than whites, will be denied various services die to efforts to contain costs. 

The author attributes these disparities to many factors. First, minorities have difficulty receiving adequate health care since the majority of health care facilities are located in predominantly white neighborhoods. Secondly, many hospital procedures are directed toward white patients and therefore indirectly impact minority patients. Third, many minorities feel uncomfortable with seeking treatment in the current system since it is controlled primarily by whites. Moreover, the lack of minority health care professionals only intensifies this problem since many minorities have to attend white physicians. 

According to the author, these problems of access can be abated through increased education and awareness of racial barriers. Therefore, the author suggests that access barriers to health care will not be rectified until providers compile information regarding minority patients in an attempt to identify current problems. 

Noah, Barbara A. Racist Health Care, 48 Fla.L.Rev.357 (1996). 

This article discusses the problems with the current medical system and how the race of a patient may adversely impact the quality of health care provided to him or her. Noah looks to three particular areas where there are disparate impacts: (1) the implementation of Medicare; (2) the selection of recipients for cadarvic organ transplants; and (3) the representation of minorities in clinical research. 

The author first addressed racial disparities in the implementation of health care services and concluded that there were significant differences in both rates of utilization of these services and of mortality. According to HFCA studies, physicians have a tendency to pursue less aggressive therapies for African American patients who did seek medical care. 

Racial disparities appear also in the area of organ transplants according to the author. African Americans have to wait longer for transplants since UNOS relies heavily on UCL matching. Because the majority of donors are white, their organs do not match perfectly with those of the African American community. Noah asserts, however, that perfect matching is not necessary and that it instead reflects indirect discrimination. 

Finally, the author asserts that certain clinical practices reflect modern attitudes toward race. For example, new research is much more easily conducted on homogenous patients populations. However, the majority of tests conducted are on white patients and fail to take into account characteristics of many minorities groups. 

This essay then suggests ways in which medical educators, health care providers, and government agencies can work together to abate some of the apparent disparities in the utilization of medical care. According to the author, one of the best ways to reduce many of the disparities is through awareness. Medical schools should therefore educate students as to the severity of the problem and train them how to deal it. In addition, hospitals could establish review boards which would monitor any racial disparities in the administration of treatments. All these measures could be implemented with little cost to the market. 

The Impact of Managed Care on Doctors Who Serve Poor and Minority Patients, 198 Harv. L. Rev. 1625 (May 1995). 

This article addresses how the transformation of the medical industry from fee for service to managed care provides physicians with an incentive to serve white middle class patients as opposed to the minorities and undeserved. 

The author examines the obstacles minority physicians face in the managed care system and concludes that this will result in continued racial disparities. Because the future of the American health market appears to lie in managed care, doctors excluded from the managed care system may find themselves out of the health care industry altogether. Because minority physicians treat a higher percentage of minority patients than do white physicians, their lack of involvement in the current system will result in continued racial disparities. 

Toward a Healthy Future - Early and Periodic Screening, Diagnosis, and Treatment or Poor Children, National Health Law Program - Texas Rural Legal Aid (April 1995). 

This book discusses third party coverage of preventive health services for poor children and focuses on the need for Medicaid's Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). 

The author first addresses the need for screening. Since the number of children living in poverty are more likely than non-poor to get sick, they are in greater need to receive medical services. Therefore, it is important that these children be identified so that they can be provided the funding they need to seek care. 

The author then proceeds to narrow the concerns down to children most vulnerable: minority children, foster children, and adolescents. The number of children from these groups living in poverty is increasing rapidly. Most strikingly, of all the minority groups, African Americans are in the poorest health. 46% of all African American children under the age of 18 are poor, the percentage being 40% for Latino children. 

This article persuasively argues that preventive care could effectively improve the overall quality of health among children by decreasing the likelihood of future illnesses. The author suggests the coordination of agencies and related programs with other state agencies and local public health entities. 

Whitehall Boca v. Dept. of Health and Rehabilitative Services, 456 So.2d 928 (1984). 

This case involved a challenge to a proposed rule created by the Department of Health and Rehabilitative Services which required applicants for certificates of need for asylums to demonstrate that proposed services would benefit the entire district including low income persons and traditionally neglected groups such as minorities. 

Although the case involved procedure objections to the administrative procedures utilized by the department, the department's adoption of such a rule demonstrates the need for expanded access to health care services for minorities. The rules takes into account the medical needs for groups which have traditionally been denied access to health care and requires the department, when deciding on a application, to consider various factors such as the extent to which the undeserved use the applicant's services. Therefore, problems of access for the minority community continuing necessitating the need for rules such as the one adopted by the Department of Health and Rehabilitative Services. 

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Contact Information:
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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