THE CURRENT STATUS OF MINORITIES' ACCESS TO HEALTH
CARE
Annotated Bibliography
Spring 1997
Introduction
This annotated bibliography attempts to provide and overview
of the current status of minoritys' access to health care.
Specifically, this bibliography will show that ethnic
minorities have been and continue to be denied access to
adequate health care because of numerous barriers. These
barriers include institutional racism, lack of insurance,
lack of money, inadequate location of health care
facilities, poor relationships with non-minority physicians,
stereotypes, misconceptions, fear, abusive history, the lack
of enforcement of federal laws and lower socioeconomic
status. Although these barriers provide a comprehensive
analysis of the reasons that ethnic minorities face problems
in attaining health care, there remain additional barriers.
Upon completion of reading this bibliography, the reader
should have a general understanding of the numerous barriers
that ethnic minorities face in gaining access to health
care. Additionally, these articles should heighten an
individuals awareness of the social, economic and historical
roots of ethnic minoritys' denial of access of health care.
Furthermore, African Americans should also be aware of the
impact these barriers are having upon their health status
and be prepared to improve their situation.
The following articles are included in this bibliography
Access
to Medical Care for Black and White Americans: A Matter of
Continuing Concer
Black
and White Disparities in Health Care
Breaking
the Barriers of Access to Health Care: A Discussion of the
Role of Civil Rights Litigation and the Relationship Between
Burdens of Proof and the Experience of Denia l
Hispanics,
Health Care, and Title VI of the Civil Rights Act of 1964
Latina
and African American Women: Continuing Disparities in Health
Locational
and Population Factors in Health Care-Seeking Behavior in
Savannah, Georgia
Race,
Ethnicity, and Access to Ambulatory Care Among U.S.
Adolescent
Race/
Ethnicity and Socioeconomic Status: Measurement and
Methodological Issue
Racial
Inequalities in the use of Procedures for Patients with
Ischemic Heart Disease in Massachusett
Racism
and Health Care Access: A Dialogue with Childbearing Women
Racist
Health Care: Reforming an Unjust Health Care System to Meet
the Needs of African American
Relationship
Between Patient Race and the Intensity of Hospital Service
Segregation,
Poverty, and Empowerment: Health Consequences for African
American
Slavery,
Segregation and Racism: Trusting the Health Care System
Ain't Always Easy! An African American Perspective on
Bioethic
White
Doctors and Black Patients: Influence of Race on the
Doctor-Patient Relationship
Annotation
Lillie-Blanton, et. al., Latina
and African American Women: Continuing Disparities in
Health, International Journal of Health Services, vol. 23,
no. 3, pages 555-84, 1993.
The journal suggests that women of all races, creeds, and
color continue to face enormous obstacles as they attempt to
realize their promise of America. For women of color-- women
of various ethnicities-- the author suggests, the promise is
even more difficult because they are perceived as second
class citizens within their own racial and ethnic groups.
To help readers better understand the problems that women
of color face in health care, this article seeks to provide
information on racial/ethnic differences in women's social
condition, health status, exposure to occupational and
environmental risks, and use of health services. Other
factors that are considered are an individuals income and
class. This is done to attempt to provide the most
comprehensive information available for women of equal
financial status.
The author concluded that Latina and African American
women are more likely than Caucasian American women to
encounter negative social environments-- poverty and
hazardous work conditions-- that will significantly impact
their health. Moreover, the author found that racial
disparities in health care are not only a result of an
individuals negative social environments, but also a result
of barriers in access to quality health care. The author
noted that in order to rid society of the many disparities
in health care, there must be an attempt to reduce social
inequalities and enforce a policy of greater access to
facilities that manifest healthier environments and
lifestyles. To address many of these social inequalities,
the laws need to be changed from the ground up; community
based organizations should be used to directly reflect the
needs of minority women.[Back]
Council on Judicial Affairs, Black
and White Disparities in Health Care, JAMA, vol. 263, no.
17, pages 2344-2346, 1990.
The authors of this journal found that there are
persistent differences in the quality of health care given
to American citizens. Moreover, despite improvements in
health care for African Americans over the last three
decades, African Americans have twice the mortality rate of
Caucasian Americans and have a significantly shorter lifer
expectancy, 6 years less. This disparity in health care
between African Americans and Caucasian Americans is
synonymous with the continuing disparities in income,
education, and other factors that relate to receiving
expensive medical services. Furthermore, studies have shown
that even when African Americans are given access to health
care, they are less likely than Caucasian Americans to
receive specific surgical therapies; also, this disparity is
not limited to African Americans. Specifically, the studies
have shown that African Americans' treatment is different
than Caucasian Americans' treatment in the areas of
cardiology and cardiac surgery, general internal medicine,
kidney transplantation, and obstetrics. Although there has
not been one single reason identified for the differences,
income has been the primary reason. Moreover, race and
income are the two most notable reasons for the disparity
because people believe that individuals with higher income
are better able to withstand the costs of medical
procedures. Some experts have stated they are more willing
to treat patients who are wealthier, more productively
employed, more assertive, more likely to respond to therapy,
and more of a value to society. Other factors, like
education and the skills that result from it, continue to
restrict African Americans from the ability to gain access
to the best medical treatment.
The author concluded that whether or not these
disparities are a result of race, education, or income, the
result should not be condoned. "Not only do the
disparities violate fundamental principles of fairness,
justice, and medical ethics, they may be part of the reason
for the poorer quality of health of blacks in the United
States." (1) [Back]
T. Laveist, Segregation,
Poverty, and Empowerment: Health Consequences for African
Americans, Milbank Quarterly, vol. 71, no. 1, pages 41-64,
1993.
The journal suggest that cities across the United States
have undergone substantial changes over the past two
decades. Several factors have influenced this change: the
development of a black political elite, sustained rates of
black poverty and intensified racial segregation. The author
notes that only over the course of the last twenty years,
however, have dramatic differences in the health status of
blacks and whites really emerged in research literature.
Specifically, this article relates its findings from its
studies of cities with a population of 50,000 people, where
at least 10 percent of which is black. As the study
expected, there was a substantial geographic variation in
black and white infant mortality rates. The study found that
racial residential segregation, black political empowerment,
and black and white poverty are the main characteristics
that distinguish cities with a high degree of
differentiation in the black and white mortality from cites
that do not such a differentiation.[Back]
D. Williams,
Race/ ethnicity and socioeconomic status: measurement and
methodological issues, International Journal of Health
Services, vol. 26, no. 3, pages 483-505.
The study was conducted to determine the adversarial
relationship between race/ethnicity and an individuals
socioeconomic status. Specifically, the study sought to
determine how the two variables relate to each other and
combine to affect variations in health status along racial
lines. The study reviewed a number of issues concerning the
interpretation of race in the United States that
significantly affects the quality of information available
on racial differences in health. Moreover, these issues
include the discrepancy between self-identification and
observer-reported race, the difficulties in categorizing
people of mixed races, changing racial classifications
categories and racial identification, and census
undercounting.
In reaching its conclusions about the relationship of an
individuals race/ethnicity to ones socioeconomic status, the
author first discusses the relationship between
race/ethnicity and socioeconomic status and shows how
socioeconomic status influences the health care that one
receives. Second, the author shows how ones socioeconomic
status fails to completely account for the variations in
health care. Finally, the author stresses the need of
researchers to give greater attention to alternate factors
that are linked to race that affect health care.
Specifically, these factors include racism, migration, and
the comprehensive assessment of socioeconomic status.[Back]
Wilbert M. Gesler and Melinda S. Meade, Locational
and Population Factor in Health Care-Seeking Behavior in
Savannah, Georgia, Health Services Research, vol. 23, no. 3,
1988.
The authors examination of the location of health care
facilities is unique because it analyzes the importance of
the facility within downtown Savannah, Georgia. This is
unique because most reports regarding the location of a
health care facility reports how ineffective health care
facilities can be when they are located a great distance for
the people that it seeks to treat.
In their study, the authors sought to examine the factors
that influence an individuals use of health care facilities.
These factors included the distance to health care
facilities, differences among population subgroups in access
to health care, the relative locations of people and their
sources of health care, and citizens' activity places. The
study came up with five main conclusions: 1) distance alone
may have an important influence on the accessibility for of
health care for a number of people that live at varying
distances from the health care location; 2) the location of
the health care relative to the people who use them is
important; 3) the distance in travel to the health care
facilities was not as affected by race, sex or age as other
studies have shown; 4) each city has its own characteristics
and health care facilities and providers should understand
and observe these characteristics; and 5) the health care
facility and providers should better understand the daily
activity spaces of people to better understand and serve
them.
In all, the authors found that health care facilities,
like this one, that are located downtown better serve their
clientele because the distance from home is a determinative
factor in receiving health care. Specifically, the study
found that the limitations on inner city residents did not
allow them to travel far outside of their community to get
medical attention. While individuals who lived in the
suburbs or on the fringes of the city were able to commute
to get health care.[Back]
Mark B. Wenneker and Arnold M. Epstein, Racial
Inequalities in the use of Procedures for Patients with
Ischemic Heart Disease in Massachusetts, JAMA, vol. 261, no.
2, page 253.
The authors of this study found that among patients with
ischemic heart disease, Caucasian Americans were more likely
to receive treatment than their African American
counterparts. To develop their hypothesis, the authors
examined the interracial differences in the use of coronary
angiography, coronary artery bypass grafting, and coronary
angioplasty for both Caucasian and African American patients
in Massachusetts hospitals in 1985. Specifically, during the
course of the study the authors looked at the patients
payer, zip code, and admission type. The controlled study
found that Caucasian Americans were given significantly more
angiography and coronary artery bypass grafting procedures.
Caucasian Americans underwent 1/3 more coronary
catheterizations and more than twice as many coronary artery
bypass grafts and coronary angioplasties.
The authors noted that the procedures are expensive, but
also have a significant impact on the prolonged life of the
patient. As a result, African Americans and other indigent
populations were more likely to not receive treatment. Some
of the factors that the authors found that might have
influenced the study were the preconceived risk factors in
allowing African Americans to participate, the individuals
ability to pay, and the fact that African Americans are less
likely to seek medical treatment-- even when it is
necessary. In conclusion, the authors found that African
Americans are denied access to preventive health care on the
basis of race.[Back]
Marianne L. Engleman Lado, Breaking
the Barriers of Access to Health Care: A Discussion of the
Role of Civil Rights Litigation and the Relationship Between
Burdens of Proof and the Experience of Denial, 60 Brook. L.
Rev. 239 (1994).
The author suggests that the highest levels of security
and the benefits of medical research and technology are
reserved for the elite of American society. Moreover,
institutional racism, segregation and discriminatory
practices by health care providers of medical services
ensure that these benefits are not given to African
Americans. In the three part article, the author discusses
the barriers to health care, the role of civil rights
litigation in addressing all of the barriers to health care,
the relationship between the burdens of proof and the
experience of denial.
The author concluded that courts, as a whole, are not
dispensing impact oriented standards in a neutral way.
Moreover, the author believes that judges administer justice
in a biased manner that is often not favorable to African
Americans-- regardless of whether or not they are conscious
of it. The author stresses, however, that it is vital that
attorneys find ways to show the disparate effect that
current barriers possess in allowing for health care to the
indigent and African Americans. As advocates, the author
suggests that the most effective ways to show the courts the
negative effects of racism is through the use of
strengthening relationships with social scientists working
in areas like health planning and epidemiology who advocate
for the use of area specific surveys and in-depth
interviews.[Back]
Ralphael Metzger, Hispanics,
Health Care, and Title VI of the Civil Rights Act of 1964,
3-WTR Kan. J.L. & Pub. Pol'y 31 (Winter 1993/1994).
This article was designed to analyze the use of Title VI
of the 1964 Civil Rights Act of 1964 in relation to the
adequacy of health care to Hispanics. As a whole, Hispanics
are a large and growing part of the American population.
Numerous studies have shown that Hispanics health status is
worse than its non-Hispanic counterparts. This statistic is
attributed to a lack of access to health care services. This
article develops the authors theory that Hispanics lack of
access to health care services is a direct result of the
numerous barriers to access that are related to language and
culture.
As part of their barriers hypothesis, the author states
that there are two reasons why Hispanics have such a low
access to health care services: culture and language. Of
these barriers, the author tends to believe that the
language barrier weighs more heavily in the balance.
Specifically, because there are so few Spanish speaking
physicians in the medical arena, Hispanics are less likely
to attempt to get medical services. Moreover, an individual
who does not have medical insurance is less likely to ask
questions on how to get insurance, and therefore will not
receive medical attention.
In conclusion, the author suggests that if regulations
like the Limited English Proficiency Regulation were passed,
Spanish speaking people would be better accommodated by
health care services. The regulation would require Spanish
speaking individuals to be employed by all organizations
that receive money from the Department of Health and Human
Services. Moreover, the law would "prohibit specific
practices resulting in a disparate impact on persons with
limited-English proficiency and [create] affirmative
obligations for covered entities, including the provision of
interpreters, the posting of signs, and the provisions of
informational literature." (2)
The article concludes by restating that public health
experts realize that linguistic accommodation would greatly
increase Hispanics access to health care.[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).
The author of this article argues that institutional
racism is the main cause of African Americans' poor health
status and serves as the primary barrier to adequate health
care. Moreover, until institutional racism is analyzed and
dealt with, African Americans will continue to receive
substandard health care.
The author begins her analysis by looking at the health
status of African American. In this endeavor, the author
weighs several factors: African American's dissatisfaction,
discomfort, disability, disease, low-birth weight, and death
rate. The author concluded that the above mentioned factors
show the disparity in health care services given to African
Americans and Caucasian Americans. Furthermore, the author
states that, "[i]f African-Americans are sicker as a
result of disparate treatment in the health care system,
then they are victims of unequal access to health
care." (3)
The author continues by looking at institutional racism
and its effect on the African American health status.
Realizing that African Americans are sicker than their
Caucasian counterparts, the author seeks to find out why
this is the case. The authors main theory is that barriers
to access to health care have adverse effects on African
Americans. Specifically, barriers to hospitals, nursing
homes, and barriers to physicians and other providers do not
allow African American the ability to get the care they
need-- or desire.
The author also states in her article that by analyzing
the current health care policy and looking at possible
solutions to the disparity we can effect some positive
change. The author calls the current policy a "Do
Nothing" policy in which African Americans are not able
to improve their health status. As an alternative, the
author suggests that the United States expand its insurance
coverage to cover all Americans, as many countries already
have. The author also looks at targeting health services to
the needs of African Americans. Although this would be a
cumbersome task, it would allow health care providers an
opportunity to confront problems that are specific to
African Americans. Finally, the author suggests that the
United States use Title VI to eliminate institutional
racism. Although the law was passed to confront racism, it
currently is unable to correct covert racism that has a
disparate effect on African Americans.
The author concludes by noting that African Americans'
poor health status is a direct result of institutional
racism. Only by purging the health care system of
institutional racism can African Americans improve their
health status.[Back]
Vernellia R. Randall, Slavery,
Segregation and Racism: Trusting the Health Care System
Ain't Always Easy! An African American Perspective on
Bioethics, 15 St. Louis U.Pub.L.rev. 191 (1996).
The author suggests that African Americans have a high
level of distrust for the health care system. This distrust
is a direct result of the United States' history of
nonconsensual experimentation and abuse of African
Americans. Moreover, fear has shaped the manner in which
African Americans perceive the health care industry, and
created a perspective of distrust. Consequently, African
Americans have a tendency to not peruse medical treatment,
participate in medical research, from signing living wills,
and from donating organs. In general, African American's
fear of the health care industry negatively affects the care
that they receive.
The author begins by showing that African Americans' fear
of the health care industry is real and entrenched in the
United States history. Moreover, African Americans were the
target of experimentation by the same health care industry
that attempts to console it now. The author shows that
nonconsensual experimentation was occurring during slavery
as well as afterwards. Another area that African Americans
were exploited was in the prison system-- African Americans
comprise forty-four percent of the prison population. Other
areas of the health care system's experimentation of African
Americans revolved around the sickle cell screening and the
family planning and involuntary sterilization procedures
undertaken by the health care industry.
The author concludes her article by showing that in
present day America African Americans are still bombarded by
unfair practices of the health care industry. Specifically,
the author show that in the areas of abortion, general
health status, the use of racial barriers to health care,
the racial disparities in medical treatment, genetic
testing, managed care, organ transplant, and reproductive
technology oppression still exists.
In all, the author shows that the continued destruction
of African Americans is a direct result of a failure to
recognize that individuals perspectives are shaped by
experience and history. Until that perspective is understood
and accepted, African Americans will continue to have a
great deal of distrust of the health care industry.[Back]
J. Yergan, et. al., Relationship
Between Patient Race and the Intensity of Hospital Services,
Med. Care, vol. 25, no. 7, page 592-603 (1987).
The authors undertook their survey to determine whether
or not the hospital services rendered to its patients varied
by racial group. In particular, the authors looked at the
quality and equity of the services given. As for the test
subjects, the authors analyzed the treatment of pneumonia
patients from 16 hospitals that were randomly chosen. During
the course of their observations, the authors looked t the
intensity of the diagnostic and therapeutic services given
to patients, and the death rate during their hospital stay.
The results of the survey were closely compared to the
status of the patients before they were treated to
excentuate the disparities in the treatment. The authors
observed that the nonwhite patients received fewer hospital
services than were expected based on their poor condition.
The authors concluded that race was the primary determinant
in the intensity of care given to patients.[Back]
T. Lieu, Race,
Ethnicity, and Access to Ambulatory Care Among U.S.
Adolescents, American Journal of Public Health, vol. 87, no.
7, pages 960-65 (1993).
The study conducted by the author is an attempt to
analyze the differences in access to health care for
Caucasian Americans, African Americans and Hispanic
Americans, and how those differences affect the availability
of insurance. The author conducted its survey by looking at
7465 youths 10 to 17 years of age of the various races. The
survey found that as a direct result of the differences and
use of children of various races, Hispanic Americans had the
highest percentage of lack of insurance (28%), African
Americans had the second highest percentage (16%) and
Caucasian American had the lowest rate of uninsurance (11%).
Ironically, despite the fact that Hispanic Americans and
African Americans have a worse health status, they have a
significantly lower rate of visits to see physicians. The
study found that health insurance as directly related to
greater access and use of health services. Logically,
individuals without insurance tend not to go out and get
medical help. More importantly, the study found that even
among Hispanic Americans and African Americans that had
heath insurance, there was still a disproportionately low
number of nonwhites receiving medical services. The study
concluded nonwhite adolescents are at an increased risk for
attaining adequate access to health care because they are
less likely to have insurance and therefore make fewer
visits to see the physician.[Back]
N. Murrell, Racism
and Health Care Access A Dialogue with Childbearing Women,
Health Care Women International, vol. 17, no. 2, pages
149-59 (1996).
The study sought to show that African American women have
a far greater complications during birth than their
Caucasian counterparts because of inherent racism. The study
showed that African American women are twice as likely as
their Caucasian American counterparts to have children that
have low birth weights and delivered before term.
To better analyze the problem, the author conducted a
survey to study African American women both prenatally and
after labor. As part of the survey, the authors conducted
one to two hour interviews with the women in the study and
discussed their access to health care, treatment,
differences in care, stereotypes and their experiences with
racism. The results revealed some important findings: 1) a
pervasiveness of negative stereotypes about African American
women; 2) when health care was given, it indifferent,
inaccessible and undignified; 3) the women experienced a
general feeling of racism directed towards them. The author
concluded by stating that African American womens'
perception of their access to health care encompasses
social, political and economic factors that mandate need for
further investigation.[Back]
Robert J. Blendon, et. al.,Access
to Medical Care for Black and White American: A Matter of
Continuing Concern, JAMA, vol. 261, no. 2, page 278.
In their article, the authors found that a national
survey revealed that African Americans of all income levels
have a significant deficit in health care access when
compared to Caucasian Americans. The study also indicated
that African Americans underused their medical resources
when in need of medical attention. Furthermore, the study
found, African Americans are less likely to be satisfied
with their medical treatment when they are ill, more
dissatisfied with the care that they receive when they are
hospitalized, and more likely to believe that their hospital
stay was too short.
The study was quick to point out that African American's
access to health care has improved over the last three
decades-- "[i]n 1963 the, the proportion of blacks who
saw a physician was 18% lower than for whites; by 1982 this
gap had been almost eliminated." (4)
Moreover, African Americans' improvements in health care
over the years also improved general health outcomes--
infant mortality declined by over 50% during that time
period. The authors found, however, that researchers were
quick to point out all of the advances that African
Americans have made in terms of their access to health care
should not lead to believing that the problem has been
eradicated-- African Americans have a 1 1/2 higher death
rate, as compared to Caucasian Americans, and the infant
mortality rate for African Americans is twice as high for
that of Caucasian Americans.
In conclusion, the authors found that the 1986 national
study found that there continued to be a lack of equality in
access to health care. As a result, there were a large
number of unmet medical needs for African Americans as a
whole. Although the lower economic status of African
Americans contributes to the lack of access to medical
services, the study showed that even African Americans who
were above the poverty line have less access to health care
when compared to their Caucasian American counterparts. In
all, the authors concluded that in spite of all of the
advances that African Americans have made over the last
three decades in improving their access to health care,
there is still a long way to go until parity is
reached.[Back]
David R. Levy, White
Doctors and Black Patient: Influence of Race on the
Doctor-Patient Relationship, Pediatrics, vol. 75, page 639-
643, 1985.
The author found that the communication between a
physician and his patient-- a relationship that is not given
a great deal of attention during medical school-- is very
important for the patients satisfaction and care. Moreover,
in a large number of situations, the attending physician is
middle class and Caucasian, and the patient is lower class
and African American. Interestingly, the author found that
racial differences, without any type of class differences,
has a negative effect of the physician-patient relationship.
Through the course of the article the author made several
recommendations to improve the relationship between the
physician and the patient. These recommendations include:
having good manners, understanding, do not stereotype the
people you help, reassess ones criteria for diagnosing the
pathology in black patients, and try and learn more about
the black experience. All of these recommendations are an
attempt to help African Americans receive greater access to
health care in America.[Back]
1. Council on Judicial Affairs, Black
and White Disparities in Health Care, JAMA, vol. 263, no.
17, pages 2344-2346, 1990.
2. Ralphael Metzger, Hispanics, Health
Care, and Title VI of the Civil Rights Act of 1964, 3-WTR
Kan. J.L. & Pub. Pol'y 31 (Winter 1993/1994).
3. Vernellia R. Randall, Racist Health
Care: Reforming an Unjust Health Care System to Meet the
Needs of African Americans, 3 Health Matrix 127 (1993).
4. Robert J. Blendon, et. al., Access
to Medical Care for Black and White Americans: A Matter of
Continuing Concern, JAMA, vol. 261, no. 2, page 278.
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