| Institutional Racism in U.S. Health Care
Compounding the racial discrimination experienced generally, is the
institutional racism in health care that affects access to health care
and the quality of health care received. Despite efforts to eliminate
discrimination and reduce racial segregation over the past 30 years,
there has been little change in the quality of or access to health care
for many minorities. According to the US Commission on Civil Rights,
"Failure to recognize and eliminate differences in health care
delivery, financing, and research presents a discriminatory barrier that
creates and perpetuates differences in health status." Racial
discrimination in health care delivery, financing, and research
continues to exist and racial barriers to quality health care
manifests themselves in a number of ways including:
Lack of Economic Access to Health Care. Over 42 million
Americans are uninsured with no economic access to health care. A
disproportionate number of the uninsured are racial minorities.
Recent changes in the "safety net" has resulted in
increased problems. Specifically, in 1996 welfare reform changed the
structure of public assistance and, as a result, had a disparate impact
on women and minorities. One of the direct effects of welfare reform has
been a reduction in the use of medicaid by those who qualify, because of
an unawareness of eligibility requirements, which has increased the
number of uninsured. A second effect has been that the subsequent
increased poverty among those in need of assistance has caused a
worsening of health status and an increase in the need for health care
services.
In fact, a disproportionate number of racial minorities have no
insurance, are unemployed, are employed in jobs that do not provide
health care insurance, disqualify for government assistance programs, or
fail to participate because of administrative barriers. Gaps in health
status, and the absence of relevant health information, are directly
related to access to health care
Barriers to Hospitals and Health Care Institutions. The
institutional/structural racism that exists in hospitals and health care
institutions manifests itself in the (1) adoption, administration, and
implementation of policies that restrict admission; (2) the closure, relocation
or privatization of hospitals that primarily serve the minority
community; and (3) the continued transfer of unwanted patients (known as
"patient dumping") by hospitals and institutions. Such
practices have a disproportionate effect on racial minorities banishing
them to distinctly substandard institutions or to no care at all.
Barriers to Physicians and Other Providers. Areas that are
heavily populated by minorities tend to be medically under-served
Disproportionately few White physicians have their practices located in
minority communities. Minority physicians are significantly more likely
to practice in minority communities, making the education and training
of minorities extremely important. Yet, minorities are seriously under
represented in health care professions. The shortage of minority
professionals affects not only access to health care but also input into
the structure of the system. With so few minority health care
professionals, the control of the health care system lies almost
exclusively in White American hands. The result is an inadequate, if not
ineffective and marginalized, voice on minority health care issues.
Racial Disparities in Medical Treatment. Differences in
health status reflect, to a large degree, inequities in preventive care
and treatment. For instance, African Americans are more likely to
require health care services, but are less likely to receive them. In
fact, racial disparity in treatment has been well documented in a number
of studies, including studies done on AIDS, cardiology, cardiac surgery,
kidney disease, organ transplantation, internal medicine, obstetrics,
prescription drugs, treatment for mental illness, and hospital
care. Differences also exist in the number of doctor’s office
visits between whites and blacks, even when controlling for income,
education, and insurance. Furthermore, researchers have concluded that
doctors are less aggressive when treating minority patients. Thus, the
most favored patient is "White, male between the ages of 25
to 44". In fact, at least one study indicated a combined affect of
race and gender resulting in significantly different health care for
African American women
Discriminatory Policies and Practices. Discriminatory policies
and practices can take the form of medical redlining, excessive wait
times, unequal access to emergency care, deposit requirements as a
prerequisite to care, and lack of continuity of care, which all have a
negative effect on the type of care received. Because discriminatory
practices are often facially neutral, citing exact practices becomes a
difficult task. There are many examples, however, of policies and
practices that disproportionately affect racial and ethnic minorities,
such as refusal to admit patients who do not have a physician with
admitting privileges at that hospital, exclusion of medicaid patients
from facilities, and failure to provide interpreters and translations of
materials, to name a few." One significant example, is a federal
Medicaid racially neutral policy which nonetheless results in fewer
expenditures on minority populations for nursing home care even though
they represent a larger portion of the Medicaid population and have more
illness. It is the combination of over-representation and under-spending
in Medicaid that exemplifies the kind of structural and institutional
racial discrimination that persists in many areas of the health care
system.
Lack of Language and Culturally Competent Care. In addition to
recognizing the disparities in health status between White Americans and
minority groups, we must recognize differences within groups as well.
Ethnic and racial minority communities are comprised of diverse groups
with diverse histories, languages, cultures, religions, beliefs, and
traditions. This diversity is reflected in the health care they receive
and the experiences they have with the health care industry. Without
understanding and incorporating these differences, health care cannot be
provided in a culturally competent manner. Culturally competent care is
defined as care that is "sensitive to issues related to culture,
race, gender, and sexual orientation." Cultural competency involves
ensuring that all health care providers can function effectively in a
culturally diverse setting; it involves understanding and respecting
cultural differences. Nonetheless, there has been relatively little
research done on the differences in accessing quality health care by
racial/ethnic subgroups, and few data are available on many of these
groups.
Linguistic barriers also affect the quality of health care services,
particularly for Hispanics and Asian Americans." Furthermore, the
failure to use bilingual, professionally and culturally competent, and
ethnically matched staff in patient/client contact positions results in
lack of access, miscommunication and mistreatment for limited
proficiency in English. This failure includes not providing education or
information at the appropriate literacy level. Furthermore, if attempts
to pass "English only" laws are successful, there will be an
acute and racially disproportionate impact on minorities.
Disparate Impact of the Intersection of Race and Gender. The
unique experiences of women of color have been largely ignored by the
health care system. These women share many of the problems experienced
by minority groups, in general, and women, as a whole. However, race
discrimination and sex discrimination often intersect to magnify the
difficulties minority women face in gaining equal access to quality
health care. In addition to barriers restricting access to health care
for racial/ethnic minorities, there are barriers to care that
predominantly affect minority women. There are also gender differences
in medical use, provision of treatments, and inclusion in research. This
is partly the result of different expectations of medical care between
men and women and of gender bias of health care providers. Furthermore,
the difficulty minoirty women face accessing adequate health care, and
all its components, is not limited to illnesses that affect both male
and female populations. Rather, there is evidence that minority women
often find it difficult to access quality health care related to
gender-specific illnesses such as breast cancer.
An additional symptom of gender bias in the health care system that
can affect outcomes is the way in which minority women’s medical
concerns are not taken as seriously as minority men’s and are often
dismissed as the result of emotional distress or as a psychosomatic
condition. Further, some minority women’s health issues, such as
violence against women, have been largely ignored by the medical
community, and seen primarily as a social issue, not necessarily a
health issue. Part of the problem is that medical professions have
historically lacked a female perspective, in much the same way that the
minority perspective is missing, therefore giving little attention to
minority women’s health concerns.
Inadequate inclusion in Health Care Research. Despite volumes
of literature suggesting the importance of race, ethnicity, and culture
in health, health care, and treatment, there is relatively little
information available on the racial, ethnic, and genetic differences
that affect the manifestations of certain illnesses and their
treatments. Billions of dollars are spent each year on health research
($35 billion in 1995). However, a strikingly minute percentage of those
funds are allocated to research on issues of particular importance to
women and minorities, and to research by women and minority scientists
(21.5 percent and .37 percent, respectively). In response to years of
exclusion of minorities and women, several statutory requirements have
been enacted to ensure that research protocols include a diverse
population The health condition of women and minorities will continue to
suffer until they are included in all types of health research.
Lack of data and standardized collection methods. Current data
collection efforts fail to capture the diversity of racial and ethnic
communities in the United States. Disaggregated information on subgroups
within the five racial and ethnic categories is not collected
systematically. Further, racial and ethnic classifications are often
limited on surveys and other data collection instruments, and minorities
often are misclassified on vital statistics records and other surveys
and censuses. It is important to collect the most complete data on
racial and ethnic minorities, and subpopulations, to fully understand
the health status, of all individuals, as well as to recognize the
barriers they face in obtaining quality health care. The lack of data on
different minority populations (such as Asian Americans) makes it
difficult to conduct research studies and comparative analyses.
Furthermore, the lack of a uniform data collection method makes
obtaining an accurate and specific description of race discrimination in
health care difficult. The existing data collection does not allow for
regularly collecting race data on provider and institutional behavior.
Rationing Through Managed Care. The health care financing
system has been steadily moving to managed care as a means of rationing
health care. Without proper oversight, oversight that does not currently
exist, managed care will, over time, tend to place increasingly
stringent requirements on providers. They may fail to develop more
expensive but culturally appropriate treatment modalities, and they may
refuse or minimize the expenditures necessary to develop adequate
infrastructure for minority communities. The potential for
discrimination, particularly racial/ethnic discrimination to occur in
the context of managed care is significant and is recognized as such by
OCR and leading commentators and advocates for civil rights in health
care services, financing, and treatment. However, little has been to
protect minorities from this risk of discrimination.
"The Office of Civil Rights (OCR) also has not sufficiently
prepared its investigative staff to identify and confront instances
of discrimination by managed care organization. Despite indications
of discrimination prohibited under title VI, OCR has not yet
developed policy guidance specifically addressing title VI
compliance in the managed care context. OCR headquarters indicate
that OCR has known about the potentially discriminatory activities
of managed care organizations since 1995, yet the office has been
loath to encourage or support the regional investigators in
identifying cases."
Several managed care practices can have a disparate effect on
minorities. For example, one of the most common ways in which MCOs
discriminate against minorities is in their selection of providers. A
physician or other type of provider that serves mainly poor minorities
may not be included in a managed care network because the provider’s
patients might be labeled "too costly." Further, some plans
target suburban areas for enrollment while ignoring inner-city areas, a
process known as selective marketing. In addition, some MCOs may be
limiting the access of medicaid patients to the full array of providers
by sending these patients provider lists that contain only providers
that accept medicaid, resulting in "segregated" provider
lists. Other methods MCOs have used to discriminate against medicaid
patients are excluding sections of the inner city from the MCO’s
service area; applying a stricter definition of "medical
necessity," the standard used to determine whether a patient will
receive a particular test or treatment; and longer waiting times for
new-patient or urgent-care appointments. |
