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Race Discriminaton, Poverty And Inaccessibility To Health Care And How It Effects African Americans

Annotated Bibliography

Kristin Marie Oberheu

2nd Year Law Student
The University Of Dayton School of Law
Health Care Law - Spring 1997

This annotated bibliography attempts to provide an overview of the unfortunate continuation of discrimination against African Americans in society today, health care problems associated with poverty among African Americans, and African Americans' inaccessibility to health care, and how these issues effect the quality and quantity of health care given to African Americans. Many different issues are presented in the articles that follow, including: the need for health care reform that increases health care financing to African Americans; the importance of preventive medicine and health education; attracting sufficient health care providers to the inner-cities; combating discrimination in the delivery of health care; developing new health care delivery systems responsive to the needs of inner-city residents; and many more.

After reviewing this bibliography and reading these articles, the reader can expect to have a better understanding that despite recent attempts to provide health care to more Americans, the African Americans remain under-served. In addition, these articles should also increase the readers awareness of the continued discrimination among African Americans in the health care industry, and encourage the reader to consider the efficiency of some proposed changes to our health care system that propose to improve the health care that African Americans receive.

Without providing inner-city African Americans with health insurance, health care facilities and physicians who understand the health needs, culture and langauge of African Americans, attempts to improve the health of African Americans and to reduce the cost of ever increasing health care expenses will continue to be unsuccessful.

 


This bibliography should be updated on an on-going basis as additional relevant information is accumulated.

 


The following articles are included in this bibliography:

Black-White Disparities In Health Care

Comment From The Assistant Secretary For Health

Does Clinton's Health Care Reform Proposal Ensure [E]qual[ity] Of Health Care For Ethnic Americans And The Poor?

Health Care In The Inner City: Asking The Right Question

Impact Of Managed Care Organizations On Ethnic Americans And Under-served Populations

Increasing The Pool Of Minority Providers

Managed Care: Implications For Under-represented Physicians

Meeting The Needs Of The Poor And Under-served Under Health Care Reform

Minority Physician Training: Critical For Improving Overall Health Of Nation

Racist Health Care: Reforming An Unjust Health Care System To Meet The Needs Of African-Americans

Searching For A Balance In Universal Health Care Reform: Protection For The Disenfranchised Consumer

Securing Health Or Just Health Care? The Effect Of The Health Care System On The Health Of America

Socio-economic Status And Risk For Substandard Medical Care

The Impact Of Managed Health Care On Doctors Who Serve Poor And Minority Patients


ANNOTATIONS

Sidney D. Watson, Health Care In The Inner City: Asking The Right Question, 71 N.C. L. Rev. 1647 (1993).

This article is part of a symposium entitled, The Urban Crisis: The Kerner Commission Report Revisited. It begins with a story of a pregnant minority woman who had no insurance, no money, no prenatal care, and whom the local private hospital did not want to admit. From this story, Watson introduces the reality that health care for the poor is neither equal nor quality.

Watson states that the poverty rate for African American families is three times the rate for white families.(1) Only about half of all African Americans have private health insurance; one in five have Medicaid or Medicare; and one in five have no health coverage.(2) The article demonstrates that African Americans, particularly poor, inner-city African Americans, have greater health care needs than whites. Although African American inner-city residents have many illnesses and need more medical care than other Americans, they have less access to health care. Federal budget cuts have forced many inner-city primary care clinics to close, and private hospitals have abandoned the inner city. The facilities that closed served twice as many African American patients and twice as many Medicaid patients as the hospitals that remained open.(3) The private hospitals that remained behind often limited the number of Medicaid patients treated, disproportionately excluding African American patients, who, as stated earlier, are five times as likely as whites to be covered by Medicaid.

Watson suggests that health care reformers need to address the larger question of how to improve American health generally and, specifically, the health of African Americans in the inner city. This would require: 1) health care financing; 2) attracting sufficient health care providers into the inner city; 3) combating discrimination in the delivery of health care; and 4) developing new health care delivery systems responsive to the needs of inner-city residents.(4)

Furthermore, Watson emphasizes that certain characteristics must be included in the reform package for improvements to occur, including: universal coverage for all residents; comprehensive coverage of preventive and primary health care; no serious financial barriers to participation; and provider reimbursement rates for any public system comparable to those of privately provided insurance.(5) Watson goes on to identify and discuss methods of attracting providers as well as to discuss the likelihood of civil rights enforcement of health care discrimination against inner-city African Americans.

Finally, the Watson concludes that increasing access to health care, by itself, will not improve the health status of inner-city African Americans. Other socio-economic strategies such as increase access to jobs, better schools, good housing, less crime, and more affordable transportation and food need to be implemented to ensure that the health of poor inner-city African Americans is improved. [Back


Note, The Impact Of Managed Care On Doctors Who Serve Poor And Minority Patients, 108 Harv. L. Rev. 1625 (1995).

This Note recognizes that the transformation of the medical industry from fee-for-service to managed care may lead to more substantial costs than anticipated. Specifically, since the goal of managed health care is to control costs, many qualified African American physicians who serve poor African American communities may be excluded from such plans as HMOs because these physicians usually serve a high percentage of sick patients who generally demand more intense and costly services than a healthier group of patients.(6) Furthermore, the Note supports that the exclusion of African American physicians from HMO plans is not only discriminatory against these physicians, but is also has a harmful consequence on the quality of health care provided to poor African American patients.(7) If African American physicians who serve poor African American communities are excluded from managed health care plans, non-African American physicians who are likely to be inexperienced in the special health care needs of African American patients may provide less effective care than would African American physicians with more experience serving poor African American patients. Also, non-African American physicians may be less familiar with the culture and language of poor African American patients making communication, and therefore dissemination of information, among physicians and patients difficult. In examining the above concerns, this Note is divided into three parts. Part I addresses how managed care that is unregulated might disproportionately burden African American physicians who serve poor African American communities.(8) The Note recognizes the relationship between African American physicians who serve poor African American populations and how these physicians help reduce the racial and financial barriers that confront the population that they serve.(9)

Part II of this note traces the consequences of the disproportionate exclusion of both African American physicians and non-African American physicians who serve poor African American patients from managed health care organizations.(10) The Note suggests that the exclusion of African American physicians from managed health care plans may drive many skilled African American physicians out of the health care profession altogether, which would adversely affect the quality of health care provided to poor African American patients. In particular, some of the excluded physicians' former patients may be forced to receive medical services at inconvenient locations from physicians who are encouraged to minimize costs, and therefore may provide inadequate health care services in addition to being less familiar with the culture, language, and health conditions of African American patients.(11)

Part III of this Note explores remedies that might prevent or decrease the consequences described in the first two Parts.(12) The Note calls for new laws to monitor the relationship between managed health care organizations and physicians in ways that respect the goals of managed health care, and at the same time, ensures adequate representation of African American physicians who serve poor African American communities.[Back


Lawrence O. Gostin, Securing Health Or Just Health Care? The Effect Of The Health Care System On The Health Of America, 39 St. Louis U. L.J. 7 (1994).

In this article, Gostin examines health care reform, and the economic impact that it has on the predominate players in the market: large employers, small businesses, insurers, and health care providers. Gostin argues that although the effects of reform on American businesses, including the business of health care, are legitimate concerns, there is little attention given to the effect of the health care system on the health of individuals and under-served populations, such as the African Americans. Therefore, Gostin emphasizes that promotion of the health of the population is the most important objective of health care reform, and that reasonable levels of government resource allocation are justified to achieve this purpose.(13) This article is divided into four parts. Part I analyzes why the prevention of illness and promotion of health provide the leading justification for the government to act for the welfare of the population.(14) This analysis focuses principally on the "foundational" importance of health for human happiness, the exercise of rights and privileges, and the formation of family and social relationships.(15) Gostin explains why health care, although important, is not the only determinant of health. Gostin notes that most morbidity and mortality in the United States is attributable to environmental conditions including heavily polluted areas, poor housing conditions, high populated areas for transmission of diseases such as AIDS, and human behavior such as one's drinking and smoking habit all of which are more evident in poor African American inner-cities, and would be more responsive to population-based interventions than to medical treatment.(16)

Part II explores the importance of universal access to health care in achieving the health of populations, especially poor inner-city African American residents.(17) The number of persons in the United States without health insurance or with inadequate insurance is extraordinarily high and increasing.(18) The article supports that inadequate access to health care services results in unnecessary sickness and death among large sectors of poor African Americans. Therefore, Gostin believes that universal access to health care is justified not only by greater vitality among the currently uninsured, but also by social and economic benefits for all of society.

Part III examines the importance of equitable access to health care.(19) Gostin explains how the distribution of health care services is highly inequitable, especially with African Americans who are in the lower socio-economic classes receiving substantially inferior care. Furthermore, inequity in the distribution of health care services not only lowers the quality of life among those receiving inferior services, but also renders them poorer and more dependent on society.(20)

Part IV inquires into the applicability of market theory and competition to health care services.(21) Gostin demonstrates how market theorists have the burden of showing why a theory developed for consumer goods and services generally is applicable to health services that are essential to humans. Gostin argues that this burden is particularly strong when the empirical evidence reveals that increased cost and inaccessibility have occurred in spite, and perhaps because, of competition in health care.(22) [Back


Vernellia R. Randall, Racist Health Care: Reforming An Unjust Health Care System To Meet The Needs Of African-Americans, 3 HEALTH MATRIX 127 (1993).

In this article, Professor Randall points out that most of the discussion on health care reform focuses on the need to control cost and to provide better access to people needing health care. Professor Randall argues, however, that the needs of African Americans is often overlooked. Professor Randall emphasizes that health care reform needs to take into special account African American health care because not only are African Americans sicker than European Americans, but they are dying at a significantly higher rate.(23)

After reading this article, the reader will have a heightened awareness that race does not only affect socio-economic status, biology, and physical environment, but that race also affects the way health care institutions provide services, access to care based on one's race, and the type and quality of health care treatment that is received.(24)

In a very comprehensive format, Professor Randall closely examines these issues in three parts. Part I evaluates the disparity between the health status of African Americans and European Americans.(25) Part II discusses the health care system and the clear evidence of institutional racism.(26)Part III explores several policy options for making the health care system more just.(27)

Professor Randall suggests several policy approaches towards a just health care system that focuses on eliminating the disparity in health care between African Americans and European Americans which includes: 1) expanding insurance coverage(28) ; 2) targeting special health services to African Americans(29) ; and 3) using Title VI of the Civil Rights Act of 1964 to eliminate racism in health care delivery and health care education.(30)

Furthermore, Professor Randall shares the difficulty in measuring one's health status due to its varying definitions, but emphasizes the importance in understanding the full extent of differences in health between African Americans and European Americans as essential to fully appreciating the need for reform in the health care system, and to understand the inadequacies in current reform approaches that do not recognize these differences. Without the health care system affording African Americans an opportunity to enjoy decent health, Professor Randall asserts that it is virtually impossible for African Americans to gain other attributes such as money and an education that are necessary to gain access to the American economic system. Therefore, "when African Americans are sick and poor, they are just enslaved as if the law made them so."(31)

Professor Randall also extensively examines how racism in America establishes separate and independent barriers to health care institutions and to medical care. To illustrate these problems, Professor Randall examines racial barriers to health care in two areas: 1) how institutional policies based on race establishes barriers to access to health care to African Americans; and 2) how practitioners provide disparate medical treatment to African Americans based on their race which is not related to their socioeconomic class.(32)

Racial barriers to access can be divided into three major groups: barriers to hospitals, barriers to nursing homes, and barriers to physicians and other providers.(33) While these issues will not be summarized herein, they are very informative and worthy of review. The basic premise, however, is that in order to improve the health of African Americans, it is not sufficient merely to remove barriers to access based on socio-economic status, but health care institutions must eliminate themselves of institutional racism. Therefore, Professor Randall concludes that in order to establish a successful health care reform plan, the plan needs to provide African Americans access to the health care they need, with a special focus on the needs of the African American population that differ from the needs of the European American. [Back


Vernellia R. Randall, Does Clinton's Health Care Reform Proposal Ensure [E]qual[ity] Of Health Care For Ethnic Americans And The Poor?, 60 Brook. L. Rev. 167 (1994).

Using the Health Security Act (the Act) as a bases for analysis in this articale, Professor Randall examines the potential for health care reform to improve access to health care for ethnic Americans. After a comprehensive review of health care reform in its current form, Professor Randall concludes that the proposed health care reform will not be successful in remedying the problem of inadequate quality of health care and inaccessibility to health care services for ethnic Americans and the poor because: it maintains a structurally and ideologically inadequate system(34); it perpetuates a fragmented system with inadequate infrastructure(35) ; it maintains a culturally incompetent system based on illness care(36) ; it rations health care through a tiered system based on private interests(37) ; and it inadequately protects against health care discrimination.(38)

Professor Randall emphasizes that ethnic Americans need a health system that is structurally and ideologically focused on improving ethnic Americans health status. Professor Randall believes that the reformed health care system proposed by the Act is inadequate in this regard because: 1) its ethical foundations are incomplete and inadequate in that the Act does not recognize equality as an essential component, but centers on autonomy, regional independence and competition(39) ; 2) it focuses on states' rights which may allow the states to avoid designing programs that meet the needs of ethnic Americans as compared to the rest of the population, and not assure that ethnic Americans have access to culturally competent care(40) ; 3) it continues an employment-based health insurance system which does not address the problem that the distribution of jobs is based on race, and therefore, the Act carries over the racism that exists in the employment system into the health insurance system(41) ; 4) it expands the "private sector" role in health care delivery in an attempt to control the cost of health care by increasing competition in the health care industry which may have a negative affect on ethnic Americans because the private sector is not committed necessarily to assuring culturally appropriate care to high-risk communities which costs more to provide than to low-risk communities.(42)

Also, under the Act, states are allowed to offer financial incentives to ensure that private sectors enroll ethnic Americans, however, the private sector, whose interests are more financial than service-oriented, may take advantage of ethnic American communities and then leave.(43)

Furthermore, with the state's approval, a health care plan may limit enrollment because of the plan's capacity to deliver services or to maintain financial stability which given the poor health status of ethnic Americans, it is likely that this exception will allow plans to exclude many ethnic Americans including the uninsured, the homeless, the lower income, and the ethnic minority populations(44) ; and 5) it does not ensure representation of ethnic Americans in policy-level decisions because the Act prohibits the appointment of health care providers to either of its Boards which prevents the health care system from evolving into an equitable system as it is the ethnic American providers who are often the most knowledgeable about ethnic American communities' needs.(45)

Professor Randall therefore concludes that the Act is only a partial answer, and in many ways, an inadequate answer in the search for a successful health care reform, especially where ethnic Americans and the poor are concerned. [Back


Louise G. Trubek & Elizabeth A. Hoffmann, Searching For A Balance In Universal Health Care Reform: Protection For The Disenfranchised Consumer, 43 DePaul L. Rev. 1081 (1994).

In this article, Trubek & Hoffman focuse on President Clinton's universal health care coverage plan, the Health Security Act (the Act), that proposes to afford all Americans access to a basic package of quality health care services. Trubek & Hoffman assert, however, that universal coverage alone will not be sufficient to protect the disenfranchised consumer such as the poor African Americans who need special protection to ensure appropriate service.

Trubek & Hoffman who both advocate for poor African Americans, argue that any national health care reform must take special notice of the specific health concerns raised by each of these groups. Trubek & Hoffman believe that each group of disenfranchised consumers has certain unique health-related concerns that will most likely be overlooked in the implementation of a universal health care plan. This article illustrates that African Americans have health care needs that are different from those of white patients in several ways. First, African Americans experience health problems of different types and to a different extent than white people.(46)

Studies have revealed that African Americans have a shorter life expectancy due to higher rates of cancer, hypertension, infant mortality, alcohol and drug abuse, cardiovascular disease, and diabetes.(47) In addition to these differences, Trubek & Hoffman also argue that African Americans have different cultural, social, religious, and linguistic backgrounds that need to be considered when determining what services and treatments are most appropriate.(48) Moreover, Trubek & Hoffman stress that having providers who are from the communities that they are serving adds a higher level of cultural sensitivity, as well as a better understanding of issues specific to the community.

Trubek & Hoffman assert that having quality health care available is useless if the poor African Americans are unable to travel to the location of the care. For African Americans who live in inner-city communities, the problem is that health care facilities are not often located in these communities.(49) Rather, they are built in more affluent areas or just outside the city limits. Another problem is that poor, African American inner-city communities rarely attract permanent medical staffs to these area.(50) Therefore, to receive health care, poor African Americans must travel a great distance or they must wait until a visiting health care provider reaches their area.(51)

Thus, Trubek & Hoffman point out that poor African Americans are often forced to travel far from their communities to receive care which for many of these patients, the cost of such traveling is something they are not able to afford. Therefore, Trubek & Hoffman emphasize the importance that health care must be accessible within these poorer communities. Trubek & Hoffman further believe that health care that is located within a community not only remedies the problem of accessibility, but it also addresses the issue of understanding the patient in his or her socio-economic, community and family context.(52)

Thus, local health care providers may have a greater understanding of the relationship between poverty issues and health care issues. Trubek & Hoffman concludethat President Clinton's health care reform plan is a step in the right direction, however, the above mentioned issues need to be addressed in order to ensure that disenfranchised consumers such as the poor African Americans are protected and afforded the appropriate health services.[Back


Council Report, Black-White Disparities in Health Care, 263 JAMA 2344 (1990).

This council report reveals that there is still substantial differences that continue to exist in the quality of health among Americans. African Americans, for example, have higher mortality rates and shorter life expectancies than whites.(53) This report recognizes the underlying reasons for the disparities in the quality of health among Americans to be the differences in both need and access. Moreover, this report includes recent studies that have suggested that even when African Americans gain access to the health care system, they are less likely than whites to receive certain treatments.(54) These studies have examined treatments in several areas, including cardiology and cardiac surgery, kidney transplantation, general internal medicine, and obstetrics. The report emphasizes that whether the disparities in treatment decisions are caused by differences in income and education, socio-cultural factors, or failures by the medical profession, they should be considered unjustifiable and therefore must be eliminated.(55) In this report, the Council on Ethical and Judicial Affairs of the American Medical Association emphasizes the need for: 1) greater access to necessary health care for African Americans; 2) greater awareness among physicians of existing and potential disparities in treatment; and 3) the continued development of practice parameters, including criteria that would prevent or diminish racial disparities in health care decisions.(56) The report concludes by emphasizing that until these issues are addressed and changes are made to our health care system to ensure better health care to the African Americans, African Americans will remain to be under-served and discriminated against. [Back


Chris Raymond, Minority Physician Training: Critical For Improving Overall Health Of Nation, 261 JAMA 187 (1989).

In this article, Raymond focuses on the importance of educating more African American health professionals, especially in the clinical and research areas of medicine, as essential to improving the overall health of the American people. According to the National Science Foundation, 12, 480 US citizens earned doctorate science degrees in 1987; of these, 222 (1.8%) were African Americans; less than 3% of US physicians, less than 3% of dentists, and less than 2% of biomedical scientists.(57)

Raymond emphasizes that the need for more African Americans to enter the medical profession is crucial because African American are more likely to choose primary care specialties and set up practices in under-served inner-city areas, therefore improving access to medical care for the less advantaged African Americans.(58)

Raymond explains several obstacles that are most likely responsible for the low percentage of African Americans who serve in the medical profession which include: 1) African Americans are still not fully accepted by majority universities as seen by the unfortunate fact that we still have a multiracial culture, and therefore, in the majority of schools, African Americans have a feeling of alienation and isolation(59) ; 2) the lack of qualified young African American men due to the fact that today there are more young African American men in prison than there are in college;(60) Therefore, Raymond encourages that efforts be made to attract the interest and enhance the abilities of future African American physicians at as early of an age as possible by sponsoring programs to promote academic achievement, especially in science, in local public schools; 3) the lack of faculty role models;(61) and 4) financial obstacles;(62) The article reports that African Americans who have an interest in entering the medical profession are discouraged from doing so due to the ever increasing cost of medical school tuition.(63)

Therefore, Raymond suggests that attention needs to be focused on providing funding through scholarships and other programs to financially assist those who want to enter the medical profession, but do not because of financial reasons.

After reading this article, the reader should have a greater appreciation for the need to encourage and to assist African Americans to enter the medical profession. This need is very important because in turn, it will help better serve African Americans and the poor in inner-city communities as African American physicians are more likely to return to these communities and provide medical treatment to the under-served. As a result, African Americans and the poor will be given treatment by those that have a better understanding of their needs such as the difference in cultures and language, and health conditions that are more predominant among African Americans as compared to the white population.[Back]

 


Robert E. Windom, MD, Comment From The Assistant Secretary For Health, 261 JAMA 196 (1989).

In this comment, the Assistant Secretary for Health argues that although the health of the American people overall has improved significantly in this century, statistics show a continued negative disparity between the health status of African Americans and other minorities and that of the population as a whole.(64) To explain, an investigation was conducted to study the health problems of African Americans, and recommended actions were suggested to close the gap in health status between African Americans and whites. A few of the areas highlighted in this report are: 1) cancer- the death rate from cancer for African Americans is 1.3 times for whites.(65) The Office of Minority Health (OMH) reported some 80 cancer-related programs in progress that either specifically targeted minorities or were expected to benefit both minorities and the general population.(66) The report shows that the major focuses of these programs are access to and utilization of health services and prevention, including anti-smoking initiatives. 2) homicide and injuries- the age-adjusted death rate from homicide and legal intervention (killed by police) for African Americans is 5.8 times that for whites, while for accidental deaths the rate among African Americans is 1.2 times that for whites.(67) The report acknowledged programs that have been established in this area that work with local social service groups to combat the growing problem of violence and unnecessary injuries within African American communities. 3) acquired immunodeficiency syndrome- the report reveals that this is one of the most crucial health problem affecting the African American community today, and explains that although African Americans constitute about 12% of the US population, they make up 27% of all Americans with AIDS.(68) Moreover, 53% of AIDS cases among children under 13 years old in the US have occurred among African Americans.(69)

The report concludes that poverty, unemployment, poor general health, inadequate access to proper health care, lack of health insurance, and educational disadvantages are burdens that are unfortunately all too common in African American communities.(70) Therefore, this comment emphasizes the need to provide a way to build an infrastructure and capacity to address not only the above mentioned problems, but the larger systemic public health problems related to disease prevention and health education, access to the delivery of health care, and the supply of health care professionals to African American communities to improve the overall health of African Americans. [back]

 


Helen R. Burstin et al., Socioeconomic Status And Risk For Substandard Medical Care, 268 JAMA 2383 (1992).

This article discusses a study to assess the quality of medical care received by the uninsured, Ethnic American, and poor populations.(71) The researchers sought to detect whether a patient s socioeconomic status was associated with the patient s risk of incurring medical injuries caused by medical management or by substandard care, ie. negligence. The factors included to decide socioeconomic status were gender, race, income and insurance status. The researchers conducted their study among fifty-one hospitals in New York State, using 30,195 medical records.(72) Researchers used the medical records of hospitalized nonpsychiatric patients discharged from nonfederal acute care hospitals during 1984. Trained nurses and medical record analysts screened the medical records. If the records were positive for potential medical injuries caused by medical management or by substandard care, two physicians further reviewed them independently. These physicians were usually board-certified internists or surgeons. The researchers began with a hypothesis that controlling for the ability to pay for medical care, race would not be a major determinant of the quality of medical care received. Of the 31,195 medical records reviewed, the researchers identified 1,278 medical injuries caused by medical management and 306 medical injuries caused by substandard care.(73) From the results of the study the researchers concluded that significant individual risk factors resulted in medical injuries from medical management and substandard care, and some factors that have no effect on the quality of care received by patients.(74)

First the study showed no association between a patient s gender and medical injury.(75) Second, after controlling for other factors, neither race nor income seemed significant factors in receiving poor quality medical care.(76) Third, the uninsured were at a greater risk for suffering medical injury from receiving substandard care. (77) The researchers concluded that the lack of insurance is the major socioeconomic risk factor for medical injuries caused by substandard care, as opposed to race, income or gender.(78)

The article gives three possible explanations why uninsured patients receive substandard care: first, uninsured persons often suffer from poor outpatient diagnosis and treatment because of the barriers they encounter to ambulatory services in their community; second, because uninsured persons receive most of their primary care in a hospital s emergency room, due to the hectic pace of treatment and diagnosis there is a greater risk of substandard care; finally, hospitals often hesitate to admit persons without medical insurance.(79)

The article concludes that in light of evidence in which it appears that the uninsured are at a greater risk for receiving poor quality of medical care, that policy makers need to consider different options when it comes to financing health care. In its evaluation of race as a factor in receiving quality medical care, the Medical Practice Study should have gone further by assessing whether race was a factor in the quality of medical care received by privately insured patients. This would lead to an evaluation as to whether insured African-Americans as compared with other groups with insurance receive the same or equal quality of medical care. This assessment would have also led to an evaluation as to what effect racism toward African-Americans has on their ability to receive adequate access to America s health care system. [Back]

 


Howard E. Freeman et al., Americans Report On Their Access To Health Care, 8 Health Affairs 6 (1987).

This article discusses the results of two telephone surveys conducted in 1982 and 1986, in which researchers surveyed Americans about various aspects of access to medical care, such as their accessibility to a primary care physician; their use of physicians and other health professionals; their health status; their use of hospitals; economic status regarding their ability to pay for medial care; and their level of satisfaction with the amount of medical care they received.(80) The article s primary focus is to inform the reader of the signs that show a deterioration in the access to medical care among the poor, uninsured, and Ethnic Americans. The 1986 survey consisted of interviews conducted with 10,130 people throughout the continental U.S., and the 1982 survey consisted of interviews conducted with 6,700 people.(81)

The article highlights the results of the two studies and discusses the following significant findings: (1) African-Americans, poor persons, and the uninsured experienced a decline in their access to physician care, particularly those individuals who suffered from poor health; (2) African-Americans, Hispanics, and the uninsured receive insufficient hospital care than might be needed considering these groups have higher levels of ill health; (3) key populations under use important medical services; (4) hospitalizations and per capita physician visits declined among all Americans; (5) the disparity in the receipt of health services between persons living in rural and urban areas appears to have been eliminated; and (6) most Americans are satisfied with their medical care.(82)

The article continues by addressing each of these finding in turn. Most of the article discusses the deteriorating access to medical care among African-Americans, poor persons, and the uninsured.

Low-income Americans. Between 1982 and 1986 the rates of physician visits for poor individuals in poor health declined by eight percent while the physician visit rates for nonpoor persons in poor health increased by forty-two percent.(83) In addition, by 1986 poor persons had twenty-seven percent fewer physician visits than nonpoor persons with the same health conditions.(84)

These results show a trend toward greater inequity in the accessibility of physician care among the poor. The only possible bright spot for the poor in the survey was an indication that a poor individual was more likely than a nonpoor individual to have been hospitalized at least once in a year. This finding seems appropriate, since a larger proportion of the poor are in ill health.

Access for Ethnic Americans. The article s authors started this section by emphasizing that an important measure of equity in the access to medical services is the frequency of the use of medical services by Ethnic Americans. The survey showed that Hispanics and European-Americans have about the same rates of physician visits.(85) However, as for physician visit rates for African- Americans the survey shows that there is a diminishing rate of access to medical services.(86) The survey showed that by 1986 there was a thirty-three percent difference in the physician visit rates between African-Americans in poor health and European-Americans in poor health, and the percentage was about the same for those in good health.(87) The article s authors found this aspect of the survey particularly troubling considering the evidence assembled by the National Institutes of Health showing that African-Americans have a much higher mortality rate than that of European-Americans.(88)

In addition, although a greater proportion of Hispanics are in ill health, there was a significant disparity in the receipt of hospital care for Hispanics compared with European-Americans. Finally, despite their poorer health status, African-Americans were less likely to be hospitalized.

Access for the uninsured. The article s authors started this section by emphasizing that an important factor in access to medical services is heath insurance. The author s also emphasized that a larger share of persons in poor or fair health exists among the uninsured than among those who are insured. Thus, the author s concluded the uninsured have greater need of medical services such as physicians visits and hospital care than persons who have health insurance, therefore, the authors expected the rates of the uninsured to exceed the rates of the insured.(89) Not surprisingly however, the survey revealed just the opposite effect. In both 1982 and 1986, not only were the uninsured less likely than the insured to be hospitalized, but the uninsured had fewer physician visits than insured persons.(90) By 1986, a nineteen percent disparity existed between the hospitalizations of uninsured persons and insured persons and a twenty-seven percent disparity existed between physician visits by uninsured persons and insured persons.(91)

Six percent of person surveyed, which represents 13.5 million Americans, stated that they had failed to obtain medical care when needed due to financial reasons.(92) The article also discussed the under use of medical care in the following ways: one in six persons, who had an identifiable chronic or serious illness, defined as illness such as cancer, heart disease, diabetes, and stroke, did not visit a physician at least once during the year; respondents who reported visiting a physician within the last year also reported that they had experienced serious medical symptoms, which doctors state usually warrant some medical attention, however, forty-one percent of these persons stated that they did not seek medical attention for the symptoms; a large proportion of pregnant women did not seek prenatal care during their first trimester; almost one-third of the African-Americans and Hispanics suffering from hypertension did not have their blood pressure checked at least once during the year; thirty-eight percent of those surveyed had not seen a dentist in a year and only half of the poor reported a dentist visit.(93)

From the survey the authors conclude that many individuals are suffering from serious and potentially life-threatening illness are not receiving the appropriate amount of medical care.(94) The reasons for this failure may be lack of public education or unrecognized economic or professional barriers to care. The authors found the deteriorating access to medical care for Ethnic Americans, the poor, and the uninsured to be the survey s most disturbing finding.(95) The authors observed that the survey results represent a reversal in the gains made by African-Americans and the poor since the 60's and the 70's, leading the nation further from achieving a more equitable access to medical care for all Americans.(96)

The survey results should send a message to policy makers that the nation needs health care reform. The reform must remove the economic barriers to receiving appropriate medical care. We must also aim the reform at improving public education and removing social and cultural barriers to medical services. [Back]

 


Risa Lavizzo-Mourey, MD, MBA, Meeting The Needs Of The Poor And Underserved Under Health Care Reform, 5 Journal of Health Care for the Poor and Underserved 240 (1994).

In this presentation Dr. Lavizzo-Mourney discusses six principles of President Clinton's health reform package, the American Heath Security Act and what these principles mean for the poor and underserved.(97) These principles included: security, simplicity, choice, savings, quality and responsibility. Before Dr. Lavizzo-Mourney began discussing these principles she gave a brief summary of the major problems of America's health care system such as: thirty-seven million Americans, almost eighteen percent do not have health insurance; approximately half the people without insurance are children; if people lose their jobs they also lose their health insurance; poor individuals fail to seek treatment when they are sick leading to an exacerbation of their health problems; fourteen percent of the gross national product goes to the heath care system, this higher than any other country in the world; the U.S. is twenty-first in infant mortality rates and twice as many African-American infants as European-American infants die; and people without health insurance are more likely than those who have health insurance to die prematurely.(98) Dr. Lavizzo-Mourney continues by stating that America's health care system is broken and to fix it everyone must work together. The article stresses that the President's proposal addresses many health care system problems and gives an overview of the proposal focusing on the aspects that will affect the poor and underserved. Dr. Lavizzo-Mourney then precedes to discuss the six principles individually.

Security and Simplicity. Under the proposal the poor and the underserved will have cradle-to-grave coverage for medical services and health insurance would be available to all persons regardless of their employment status. (99) The plan would remove the barriers encountered by persons seeking insurance who have preexisting medical conditions. The proposal would simplify the heath care system by eliminating most of the paperwork.

Choice. The plan will increase choice of physicians for the poor and uninsured by increasing the number of practitioners in underserved areas, such as the inner city and rural areas.(100) The proposal seeks to increase the practitioner numbers by doing the following: provide health insurance to everyone so that providers practicing in underserved areas will receive payment for their medical services; offer loan forgiveness and tax incentives for practitioners who service underserved areas; give an incentive to young practitioners to practice in underserved areas by expanding the National Health Service Corps; improve the infrastructure to support and retain practitioners in underserved communities; because Ethnic Americans are more likely to provide care for Ethnic American communities, we need to develop and start a plan that would at least double the number of Ethnic Americans to medical and nursing schools; eliminate Medicaid by creating one universal health insurance system, this would eliminate the distinction between Medicaid patients and everyone else; and give a bonus to health insurance plans that care for poor people.(101) Dr. Lavizzo-Mourney emphasizes that these changes would allow the poor and the underserved to have meaningful choices when seeking medical care services.

Savings. Dr. Lavizzo-Mourney stresses that health care coverage must be more affordable. Under the plan sixty-five percent of people will pay the same or less for more health care coverage, twenty percent of people will pay the same for the same coverage, and fifteen percent will pay more for the less health care coverage than they currently receive.(102) While this latter group may be getting an unfair deal, this group is mostly composed of young and healthy individuals who have benefited under the current system by receiving lower health ratings because they are unlikely to get sick.

Quality. Dr. Lavizzo-Mourney states that four attributes are equated with quality of medical care, such as: health care access; satisfaction; appropriateness of care; and outcomes of care.(103) To ensure quality in medical care services there needs to be an ongoing assessment of patient satisfaction with their health care services. To have high quality medical care the patient must have access to medical services; providers should treat the patient with dignity; the treatment received should be appropriate for the patient s condition; and usually the patient should ultimately have an improvement in their health status.(104)

Responsibility. As to responsibility Dr. Lavizzo-Mourney stresses that everyone must pay their fair share when it comes to paying for health care services, including the government, employers, and individuals.(105) Under the plan employers would pay eighty percent of the health insurance premiums for their employees and the employees would pay the remaining twenty percent, including a copayment for receiving certain specialized services.(106) The government would pay for Medicare, health insurance for the poor, the unemployed and provide discounts for small business and others.(107) Under the plan everyone except the very poor would have to pay for medical services.(108) Dr. Lavizzo-Mourney emphasizes that responsibility also includes a commitment to achieving parity in health status. To reduce the disparities in health status between the poor and the underserved and other Americans, we must reform the health care system to include universal access, comprehensive coverage and an emphasis on prevention.

Dr. Lavizzo-Mourney concludes the article by emphasizing that these six principles must serve as a beacon in setting up any health care reform and that health care reformers must not compromise these principles. Dr. Lavizzo-Mourney ended the article by emphatically stating that all Americans need health care reform now, particularly the poor and the underserved.

The American Health Security Act, if implemented would likely lead to a removal of the economic barriers to receiving medical care. In addition, it would allow the poor and the underserved to have greater access to medical care such as physician visits and prescriptive medical treatment. The heath care reform package would allow physicians to spend more time with their patients, which can only lead to better and more informed medical treatment. The proposal would prevent physicians from discriminating against patients who receive Medicaid. It would not allow manage care plans to limit the patient's choice of physicians. By creating meaningful choice for the poor and the underserved, the plan would place these groups on an equal footing with persons who currently have choice. The plan would also greatly benefit African-Americans who represent a disproportionate share of the poor population by giving them greater access to medical care services. [Back]

 


Dodd Wilson, MD, Increasing The Pool Of Minority Providers, 5 Journal of Health Care for the Poor and Underserved 260 (1994).

In this presentation, Dr. Wilson discusses the University of Arkansas' programs for the recruitment and retention of Ethnic American medical students, particularly African-American medical students.(109) Dr. Wilson begins his presentation by noting that America s poverty population is at its highest level since 1962, with thirty-three percent of African-Americans, twenty-nine percent of Hispanics, and approximately ten percent of European-Americans living in poverty. (110) Dr. Wilson continues by discussing how the University serves as a safety net for many poor persons in Arkansas. The University services the poor though its hospital in which thirty percent of the patients have no means of paying for the medical services they receive.(111)

To have universal access to good-quality medical care we need racial and cultural diversity in the medical community; thus Dr. Wilson asserts that medical schools must educate more Ethnic Americans, especially African-Americans.(112) The presentation goes on to discuss how the University of Arkansas is meeting this challenge. The University began by creating a Minority Student Affairs Office, which is not only dedicated to the recruitment and retention of Ethnic American medical students, but to the identification of qualified Ethnic Americans for house-staff positions.(113)

The University s goal is to have the same percentage of African-Americans in their medical schools as they have in the state s population, about seventeen percent, thus the school has started to recruit African-American students while they are still in junior high school.(114)

To recruit more Ethnic Americans the University has started a six-week summer science program for Ethnic American students in which students learn studying and reading skills, and meet Ethnic American physicians in the community.(115) The University is also attempting to build a relationship with African-American physicians in the community, who can serve as surrogate faculty and mentors for African-American medical students.(116) Dr. Wilson continues his presentation by discussing the University s measures to retain Ethnic American medical students. To improve the retention rate of Ethnic American medical students the University has done the following: implemented lenient first-year rules in which a student need only pass half of his or her credit hours and achieve a D average to remain in school; try to get all students to participate in a study group; established a medical board-preparation course; and established a one day course on cultural diversity that all students must take.(117)

In addition, the University started a prematriculation course in which thirty at-risk students of all races and backgrounds come to the University and take summer courses before they start medical school.(118) The recruitment and retention of Ethnic American medical students today, will lead to an increase in the pool of Ethnic American providers in the future. By recruiting students during junior high school is likely to lead to more African-Americans pursuing medical careers. Since African-Americans are more likely to return to their community to practice medicine by increasing the number of African-American physicians we will increase African-Americans access to medical services. [Back]

 


Ronald Horn, MD, Managed Care: Implications For Underrepresented Physicians, 5 Journal Of Health Care for the Poor and Underserved 154 (1994).

In his presentation on managed care, Dr. Horn identifies recent trends in the health care system, discusses their impact on underrepresented physicians and offers recommendations on how to deal with these changes in the health care system.(119) The major change in the health care system is toward more managed care systems. Managed care will affect the underrepresented physician in the following ways: primary care physician numbers will increases; to influence more residents and medical students to choose primary care there will be increases in their salaries and reimbursements; managed care programs will heavily recruit primary care physicians; to address cost containment, improve quality of medical care and provide universal access, in the future health care plans will combine health care and insurance; eliminate cost-shifting, simplified and uniform billing forms and procedures; to survive private practice physicians will need to join forces to create bidding groups for large contracts from managed care programs; small practices will find it hard to compete with group practices because of physical, economic and political reasons; managed care systems will allow that only board-certified physicians competed for or enroll in manage care plans; and many physicians will retire or change careers rather than deal with the uncertainty of managed care.(120)

The primary impact of managed care on underrepresented physicians may be that they are left out of the new health care plans completely.(121) Currently underrepresented physicians -women and Ethnic Americans- make up a large percentage of primary care physicians, however, the number of Ethnic Americans entering the primary care field has been decreasing slightly since 1988.(122) In addition, Ethnic American medical school graduates usually say that they intend to practice in underserved areas, thus when insures examine computer printouts to decide the cost-effectiveness of primary care physicians, many underrepresented physician practices will not be cost-effective.(123) Underrepresented physician practices are not cost-effective because of the type of patients they care for, young children, women, the elderly and others with chronic aliments.(124)

When compared with better-served groups, the underserved groups are sicker, often delay treatment longer, seek care in emergency rooms, and are more often hospitalized.(125) Being left out of the new health care plans due to cost-effectiveness is particularly troubling for Ethnic Americans, especially African-Americans because they suffer and die of cancer, heart disease, drug dependency, diabetes, homicide, and infant mortality at far greater rates than European-Americans.(126) In addition, among urban African-Americans, especially African-American women, AIDS and HIV-related diseases have emerged as a serious health problem.(127) The impact of manage care will do a great disservice to urban primary care physicians and their patients, and it will penalize the physicians who have made a commitment to providing medical services to the poor and underserved.(128)

Dr. Horn continues his presentation by offering s recommendations on how to deal with these changes in the health care system. Dr. Horn offers the following: increase recruitment and retention of Ethnic Americans and women in medical schools; increase recruitment of underrepresented physicians to faculty positions at medical schools and residency programs; underrepresented physicians must become involved in the management of managed control systems; and underrepresented physicians must become board-certified in their medical field.(129)

In concluding his presentation Dr. Horn asserting that underrepresented physicians will bear most of the burdens of managed care, and that managed care is focused on the bottom line not bedside manner.(130) Underrepresented physicians and their patients must reassess their relationship, their priorities, and their involvement in the health care system to survive in the managed care system.(131)

The trend in America s health care system toward managed care is not likely to be reversed. Therefore, Ethnic Americans must deal with this system and the changes it will bring. If Ethnic Americans do not deal with these changes appropriately, they are likely to have devastating effects on their communities as to access to medical services and quality of care. [Back]

 


Vernellia R. Randall, Impact Of Managed Care Organizations On Ethnic Americans and Underserved Populations, 5 Journal Of Health Care for the Poor and Underserved 224 (1994).

In this presentation Professor Randall discusses the effects of managed care on Ethnic Americans and the underrserved.(132) The primary goal of health care reform is cost-containment. Managed care organizations use strict utilization review and financial risk-shifting to effectuate this goal. Managed care organizations operate on an assumption that they can reduce health care expenditures by reducing the significant overutilization that currently exists in the health care system.(133) Professor Randall asserts that the manner in which managed care organizations operate may cause harmful effects on Ethnic American and poor populations. Managed care organizations implement this cost containment by creating partnerships with health care providers such as physicians. Under this partnership managed care organizations use financial incentives to encourage providers to serve as gatekeepers.(134) The gatekeeper s duty is to prevent the overutilization of medical services by limiting a patient's access to medical services. This aspect of health care reform does not consider that Ethnic Americans and the poor have a tendency to underuse medical services rather than overuse medical services. In addition, because Ethnic Americans and the poor tend to have poor health status, they are in need of more medical services not less. Professor Randall continues her presentation by discussing the traditional relationship between the patient and the health care provider; and how health insurance became a component of employee compensation.

Professor Randall continues by discussing how utilization review and financial risk-shifting will effect Ethnic Americans. Under the managed care system the third-party payer, such as an employer pays for medical services rendered to the patient by the physician, however, the third-party payer will only pay for medical services provided under the guidelines and standards set by the third-party payer.(135)

Although the physician must still provide appropriate medical treatment to the patient, he or she must also balance the patient s medical care needs with the third-party payer s needs for cost-containment. Under a utilization review the third-party payer using set guidelines and standards decide what medical service is necessary; and if the payer decides that the service is not necessary the provider will not be paid for medical services rendered to the patient. A utilization review uses statistical norms, practice parameters, and other population data to decide whether a particular medical service is necessary.(136)

Most of the data used in an utlization review comes from middle-class, European- American, healthy males, and such data when applied to Ethnic Americans and the poor are inadequate and unreliable.(137) Managed care organization s utilization process inadequately addresses the medical needs of Ethnic Americans and the underserved for the following reasons: due to their poor health status Ethnic Americans and the underserved often require more medical treatment that the guidelines and standards state are necessary; Ethnic Americans and the underserved are likely to have limited access adequate housing, food and clothing; thus, their illnesses are likely to be longer and more severe; and persons conducting the review often lack the cultural background that would enable them consider the patient s poverty, race, class and prior health care when making a recommendation regarding the patient s treatment.(138)

To effectuate the ending of overutilization, managed care organizations engage in financial risk-shifting in which medical service providers are given rewards when they control medical costs and penalties when they do not. A predetermined fixed dollar amount may serve as a reward, and excluding a physician from the organization may serve as a penalty.(139) Third-party payers use the following means to transfer financial risk to physicians: capitation, withholding, discounted fee for service, per diem payments, case mechanisms and capitated payments.

The major drawback of utilization review and financial risk-shifting, is that they distort the doctor-patient relationship by putting the focus on what medical services will the physician be paid for rendering, rather than what medical services are necessary for the patient. This distortion combined with the expansion of managed care organizations has serious implications for Ethnic Americans and the underserved. For example, Ethnic Americans and the underserved often do not fall within third-party payer treatment guidelines and standards, thus physicians are not likely to adequately treat these populations. Professor Randall concludes that the expansion of managed care will change the perceptions expectations of society, physicians, patients and third-party payers regarding what medical treatment is appropriate and necessary; and that these altered perceptions and expectations may be contrary to the needs of Ethnic Americans and the underserved.(140)

Managed care may ultimately widen the disparity in health status and medical treatment between European-Americans and Ethnic Americans. To counter this effect managed care organizations should use culturally sensitive data when creating medical treatment guidelines and standards. If this change is not made then Ethnic Americans and the underserved will not benefit from health care reform. [Back]

 


Footnotes

1. Sidney D. Watson, Health Care In The Inner City: Asking The Right Question, 71 N.C. L. Rev. 1647, 1647 (1993).

2. Id.

3. Id. at 1648.

4. Id. at 1652.

5. Id. at 1654-55.

6. The Impact Of Managed Care On Doctors Who Serve Poor And Minority Patients, 108 Harv. L. Rev. 1625, 1625 (1995).

7. Id. at 1626.

8. Id.

9. Id.

10 Id. at 1634.

11. Id. at 1635.

12. Id. at 1636.

13. Lawrence O. Gostin, Securing Health Or Just Health Care? The Effect Of The Health Care System On The Health Of America, 39 St. Louis U. L.J. 7, 9 (1994).

14. Id. at 11.

15. Id. at 11-13.

16. Id. at 21.

17. Id.

18. Id.

19. Id. at 27.

20. Id. at 28.

21. Id. at 34.

22. Id. at 36.

23. Vernellia R. Randall, Racist Health Care: Reforming An Unjust Health Care System To Meet The Needs Of African-Americans, 3 HEALTH MATRIX 127, 138 (1993).

24. Id. at 131.

25. Id.

26. Id. at 141.

27. Id. at 162.

28. Id. at 169.

29. Id. at 181.

30. Id. at 184.

31. Id. at 141.

32. Id. at 144.

33. Id. at 148.

34. Vernellia R. Randall, Does Clinton's Health Care Reform Proposal Ensure [E]qual[ity] of Health Care For Ethnic Americans and The Poor?, 60 Brook. L. Rev. 167, 177 (1994).

35. Id. at 192.

36. Id. at 205.

37. Id. at 212.

38. Id. at 226.

39. Id. at 178.

40. Id. at 182-83.

41. Id. at 184.

42. Id. at 187.

43. Id. at 189.

44. Id. at 190.

45. Id. at 191.

46. Louise G. Trubek & Elizabeth A. Hoffman, Searching For A Balance In Universal Health Care Reform: Protection For The Disenfranchised Consumer, 43 DePaul L. Rev. 1081, 1091 (1994).

47. Id. at 1092.

48. Id.

49. Id. at 1093.

50. Id.

51. Id.

52. Id. at 1094.

53. Council Report, Black-White Disparities In Health Care, 261 JAMA 2344 (1990).

54. Id.

55. Id.

56. Id. at 2346.

57. Chris Raymond, Minority Physician Training: Critical For Improving Overall Health Of Nation, 261 JAMA 187 (1989).

58. Id. at 193.

59. Id. at 187.

60. Id.

61. Id. at 188.

62. Id. at 193.

63. Id.

64. Robert E. Windom, MD, Comment From The Assistant Secretary For Health, 261 JAMA 196 (1989).

65. Id.

66. Id.

67. Id. at 198.

68. Id. at 199.

69. Id.

70. Id. at 200.

71. Helen R. Burstin et al., Socioeconomic Status And Risk For Substandard Medical Care, 268 JAMA 2383 (1992).

72. Id.

73. Id. at 2384, 2385.

74. Id. at 2386.

75. Id.

76. Id.

77. Id.

78. Id.

79. Id. at 2387.

80. Howard E. Freeman et al., Americans Report On Their Access To Health Care, 8 Health Affairs 6 (1987).

81. Id. at 8.

82. Id.

83. Id. at 10.

84. Id.

85. Id. at 12.

86. Id.

87. Id.

88. Id.

89. Id. at 13.

90. Id.

91. Id.

92. Id.

93. Id. at 14, 15.

94. Id. at 17.

95. Id.

96. Id.

97. Risa Lavizzo-Mourey, MD, MBA, Meeting The Needs Of The Poor And Underserved Under Health Care Reform, 5 Journal of Health Care for the Poor and Underserved 240, 242 (1994).

98. Id. at 241.

99. Id.

100. Id. at 243.

101. Id. at 244.

102. Id. at 243.

103. Id. at 244.

104. Id.

105. Id.

106. Id. at 244.

107. Id. at 245.

108. Id.

109. Dodd Wilson, MD, Increasing The Pool Of Minority Providers, 5 Journal of Health Care for the Poor and Underserved 260 (1994).

110. Id.

111. Id.

112. Id. at 262.

113. Id.

114. Id.

115. Id. at 263.

116. Id.

117. Id. at 274.

118. Id.

119. Ronald Horn, MD, Managed Care: Implications For Underrepresented Physicians, 5 Journal Of Health Care for the Poor and Underserved 154 (1994).

120. Id. at 155.

121. Id.

122. Id.

123. Id. at 156.

124. d.

125. Id.

126. Id.

127. Id.

128. Id.

129. Id.

130. Id. at 167.

131. Id.

132. Vernellia R. Randall, RN, Impact Of Managed Care Organizations On Ethnic Americans And Underserved Populations, 5 Journal Of Health Care for the Poor and Underserved 224 (1994).

133. Id. at 225.

134. Id. at 226.

135. Id. at 230.

136. Id.

137. Id.

138. Id. at 231.

139. Id. at 232.

140. Id. at 235.

 

 
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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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 03/10/2010

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