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.
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.
