DOES CLINTON'S
HEALTH CARE REFORM
PROPOSAL ENSURE
[E]QUAL[ITY]
OF HEALTH CARE
FOR ETHNIC AMERICANS
AND THE POOR? Vernellia
R. Randall,
60 Brooklyn Law Review 167-235 ( 1994).
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)
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| 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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