and Health Care.
Although the U.S. health care system provides the finest overall care in
the world, the data show significant disparities with regard to certain
health measures. For example:
rates are 2.5 times higher for Blacks than for Whites, and 1.5 times
higher for Native Americans. In 1997, the infant mortality rates for
Whites was 6.0 deaths per 1000 live births, compared to 13.7 deaths per
1000 live births for Blacks.
Black men under
age 65 have prostate cancer at nearly twice the rate of White men;
The death rate
from heart disease for Blacks is 41percent higher than for Whites (147
deaths per 100,000, compared with 105 deaths).
twice as likely to affect Hispanics and Native Americans as the general
population. Diabetes rates are 70 percent higher for Blacks than for
are three times more likely than White children to be hospitalized for
mortality rate for Hispanic women is 23 percent higher than the rate for
non-Hispanic women. Black women have a five percent higher death rate in
childbirth than non-Hispanic White women.
experience disproportionately high mortality rates from certain causes,
including heart disease and stroke, homicide and accidents, cancer,
infant mortality, cirrhosis and diabetes.
Americans are 579 percent more likely to die from alcoholism, 475
percent more likely to die from tuberculosis and 231 percent more likely
to die from diabetes than Americans as a whole.
from minority racial and ethnic groups account for more than 50 percent
of all AIDS cases, although they represent only 25 percent of the U.S.
The rate of
AIDS cases was 30.2 per 100,000 for Whites in 1993. It fell to 9.9 in
1998. The rate for Blacks in 1993 was 162.2; 84.7 in 1998. The rate for
Hispanics fell from 89.5 in 1993 to 37.8 in 1998. Health Care
Professionals. In 1996, about 740,000 medical doctors practiced in the
United States (280 per 100,000 population). Minorities are likely to
live in areas under-served by these and other medical professionals.
Poor urban communities with high proportions of Blacks and Hispanics
averaged only 24 physicians per 100,000. Poor communities with low
proportions of Blacks and Hispanics averaged 69 doctors. This shortage
is exacerbated by data that show Black physicians are five times more
likely than other doctors to treat Black patients, and Hispanic doctors
are 2.5 times more likely than other doctors to treat Hispanic patients.
Minority doctors are also more likely to treat Medicaid or uninsured
patients than White doctors from the same area.
There are about 6,200 hospitals in the United States providing more than
one million beds. Before the 1960s, hospitals were voluntary
organizations and did not face the same legal requirements as public
institutions. In addition, hospital medical staffs were self-governing,
which gave them freedom to select members, choose patients, and adopt
their own payment policies. In many parts of the country, health care
services and providers were segregated by race. Since passage of civil
rights laws in the 1960s, these practices are no longer legal.
It is primarily through health insurance that Americans pay for their
health care. Employer-provided health plans cover some of the costs of
health care; others rely on private health insurers or managed care
organizations, such as health maintenance organizations. Those without
insurance must rely on financial assistance to obtain health coverage,
and may qualify for public assistance, such as supplementary security
assistance for health care includes Medicare (for the elderly) and
Medicaid (for the non-elderly poor). Medicare provides health insurance
coverage for persons aged 65 years and older, and individuals with
disabilities. Medicare provides health care coverage for more than 38
million people at a cost of about $200 billion. Medicaid provides
coverage for low-income persons. It is administered by the states with
matching funds from the Federal government. Medicaid covers 37 million
people at a cost of about $164 billion. While Medicaid rules and
policies are set and monitored by federal and state agencies, the
administration of the programs is run by insurance companies.
Medicare and Medicaid provide more than 70 million people with health
coverage, a large number of Americans remain uninsured and unable to
access quality health care. Most of the uninsured are minorities and
women with children, resulting in unequal access to health care. Almost
30 percent of Hispanic children, and 18 percent of Black children are
estimated to be without health insurance. Moreover, immigrants, those
who are unemployed, work part-time, or are retired often have inadequate
Disparities in Health Care Access.
The U.S. government has long sought to address the need for equal access
to quality health care. During the past 35 years in particular, federal
civil rights laws and policies have addressed the need to ensure equal
access to health care and nondiscrimination in health care programs for
racial and ethnic minorities. Congress has created several federal
statutes designed to achieve equal protection of the laws through an
emphasis on equality of access to institutions, including the nation's
health care system. These statutes have helped establish the framework
for the Federal government's efforts to eliminate discrimination in the
health care delivery system.
are particularly relevant to health care: (1) the Hill-Burton Act,
formally Title VI and XVI of the Public Health Service Act of 1964,
Public Law No. 79-725, 60 Stat. 1040 (1946), codified as amended at 42
U.S.C. sec. 291-291-o (1994) and Pub. L. No. 93-641, 88 Stat. 2225
(1974); and (2) Title VI of the Civil Rights Act of 1964, Pub. L. No.
88-352, Title VI, 78 Stat. 252 (codified as amended at 42 U.S.C. sec.
When it was
first enacted in 1946, the Hill-Burton Act was designed as a means for
facilitating hospital construction, especially in rural communities. In
1964, however, Congress reformulated Hill-Burton as a key provision in
the Public Health Service Act to include the modernization of existing
hospital facilities. In 1974 the Act was amended yet again, this time
requiring that hospitals receiving funds provide a specified amount of
service to those unable to pay. Additionally, a facility receiving funds
was to be made available to all members of the community in which it was
located, regardless of race, color, national origin or creed.
of Health and Human Services (HHS) is the federal agency with primary
responsibility for enforcing Title VI in the health care context, as
well as other civil rights statutes and provisions addressing equal
access to quality health care. HHS seeks to ensure compliance with the
nondiscrimination provisions of these laws by relying on implementing
regulations, policy guidance, comprehensive full-scope compliance
reviews, complaints investigations, mediation, settlement agreements,
technical assistance, outreach and education programs, as well as
through enforcement actions.
The impact of
Medicare and Medicaid, originally passed by Congress in 1965, has been
enormous. In 1964, Whites were almost 50 percent more likely than Blacks
to see a physician. By 1994 this ratio had been reversed: Blacks were
about 12 percent more likely than Whites to have seen a doctor in the
preceding two years. However, Blacks continue to be twice as likely to
use hospital outpatient services, while Whites are substantially more
likely to visit a private physician.
Clinton has committed the nation to an ambitious goal of eliminating by
2010 disparities in health status experienced by racial and ethnic
groups in the United States. President Clinton targeted six health
priority areas: infant mortality, breast and cervical cancer screening
and management, cardiovascular disease, diabetes, child and adult
immunization levels, and HIV/AIDS. As part of this effort, for example,
the Center for Disease Control recently awarded $9.4 million to
thirty-two community coalitions in eighteen States to reduce the level
of disparities in one or more of the priority areas.
in response to studies showing that language barriers in health care
present serious problems for a large percentage of Americans with
limited English proficiency (LEP), on August 11, 2000, President William
J. Clinton issued Executive Order 13166, "Improving access to
services for persons with limited English proficiency." The
President ordered that "each Federal agency shall examine the
services it provides and develop and implement a system by which LEP
persons can meaningfully access those services consistent with, and
without unduly burdening, the fundamental mission of the agency. Each
Federal agency shall also work to ensure that recipients of Federal
financial assistance (recipients) provide meaningful access to their LEP
applicants and beneficiaries. To assist the agencies with this endeavor,
the Department of Justice has today issued a general guidance document (LEP
Guidance), which sets forth the compliance standards that recipients
must follow to ensure that the programs and activities they normally
provide in English are accessible to LEP persons and thus do not
discriminate on the basis of national origin in violation of title VI of
the Civil Rights Act of 1964, as amended, and its implementing
regulations. As described in the LEP Guidance, recipients "must
take reasonable steps to ensure meaningful access to their programs and
activities by LEP persons."