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Institutional Racism in US Health Care

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Vernellia Randall


Racial Discrimination in Health Care in the United States as a Violation Of the International Convention on the Elimination of All Forms of Racial Discrimination, [a1] 14 University of Florida Journal of Law and Public Policy 45-91 (Fall, 2002)

Compounding the racial discrimination experienced generally is the institutional racism in health care that affects minority access to health care and the quality of health care received.(59) Despite efforts over the past thirty *54 years to eliminate discrimination and reduce racial segregation, there has been little change in the quality of, or access to, health care for many minorities. According to the U.S. Commission on Civil Rights, "Despite the existence of civil rights legislation equal treatment and equal access are not a reality for racial/ethnic minorities and women in the current climate of the health care industry. Many barriers limit both the quality of health care and utilization for these groups, including ... discrimination."(60) Racial discrimination in health care delivery, financing, and research continues to exist, and racial barriers to quality health care manifest themselves in a number of ways.

A. Lack of Economic Access to Health Care

More than 38.4 million Americans are uninsured with no economic access to health care.(61) A disproportionate number of the uninsured are racial minorities.(62) As access to health insurance in the United States is most often tied to employment, racial stratification of the economy due to other forms of discrimination has resulted in a concentration of racial minorities in low wage jobs. These jobs are almost always without insurance benefits.(63) As a result, disproportionate numbers of the uninsured are racial minorities. Recent changes in the "safety net" have resulted in increased problems.(64) Specifically, welfare reform enacted in 1996 changed the structure of public assistance, resulting in a disparate impact on women and minorities.(65)

One of the direct effects of welfare reform has been a reduction in the use of medicaid by those who qualify due to an unawareness of eligibility *55 requirements, resulting in an increased number of uninsured.(66) 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.(67) In fact, a disproportionate number of racial minorities have no insurance, are unemployed, are employed in jobs that do not provide health care insurance, are disqualified for government assistance programs, or fail to participate because of administrative barriers.(68) Gaps in health status and the absence of relevant health information are directly related to access to health care.(69)

B. Barriers to Hospitals and Health Care Institutions

The institutional/structural racism that exists in hospitals and health care institutions manifests itself in (1) the adoption, administration, and implementation of policies that restrict admission;(70) (2) the closure, relocation, or privatization of hospitals that primarily serve the minority community;(71) and (3) the continued transfer of unwanted patients (known *56 as patient dumping) by hospitals and institutions.(72) Such practices have a disproportionate effect on racial minorities, banishing them to either distinctly substandard institutions or to no care at all.(73)

C. Barriers to Physicians and Other Providers

Areas that are heavily populated by minorities tend to be medically underserved.(74) Disproportionately few White physicians have their practices located in minority communities.(75) Minority physicians are significantly more likely to practice in minority communities, making the education and training of minorities extremely important.(76) Yet, due to discrimination in post-secondary education, racial biases in testing, and quality-of-life issues affecting school performance, minorities are seriously underrepresented in health care professions.(77) The shortage of minority professionals affects not only access to health care, but also access to the power and resources needed to structure the health care system, leaving its control almost exclusively in White hands.(78) The result is an inadequate, ineffective and marginalized voice on minority health care issues.

*57 D. 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.(79) Disparity in treatment has been well documented in a number of studies, including studies done on AIDS,(80) cardiology,(81) cardiac surgery,(82) kidney disease,(83) organ transplantation,(84) internal medicine,(85) obstetrics,(86) prescription drugs,(87) treatment for mental illness,(88) pain treatment,(89) and hospital care.(90) Certainly, difference in treatment can be based on a number of different factors, including clinical characteristics, income, and medical or biological differences. However, race plays an independent role.(91) There are marked differences in time spent, quality of care and quantity of doctor's office visits between Whites and African-Americans.(92) Whites are *58 more likely to receive more, and more thorough, diagnostic work and better treatment and care than people of color -- even when controlling for income, education, and insurance.(93) Differences also exist in the number of doctor's office visits between Whites and African- Americans, even when controlling for income, education, and insurance.(94) Furthermore, researchers have concluded that doctors are less aggressive when treating minority patients.(95) Thus, the most favored patient is "White, male between the ages of 25 and 44."(96) In fact, at least one study indicated a combined effect of race and gender resulting in significantly different health care for African-American women. (97)

E. 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.(98) 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.(99) One significant example is a racially-neutral federal medicaid policy that limits the number of beds a nursing home can allocate to medicaid recipients.(100) The policy encourages these facilities to move existing patients who have depleted their assets and are now newly eligible for medicaid into medicaid beds as they become available. It is mostly White women who have the assets to afford long-term care without *59 medicaid and who live long enough to deplete those assets.(101) The effect of this policy is that fewer medicaid resources are spent on nursing for minority populations even though minorities represent a larger portion of the medicaid population and have more illness. (102)The combination of minority overrepresentation and government under-spending in medicaid is yet another example of the kind of structural and institutional racial discrimination that persists in many areas of the health care system.

F. Lack of Language and Culturally Competent Care

A key challenge has been to get the government to establish clear standards for culturally competent health care.(103) Culturally competent care is defined as care that is "sensitive to issues related to culture, race, gender, and sexual orientation."(104) Cultural competency involves ensuring that all health care providers can function effectively in a culturally diverse setting; it involves understanding and respecting cultural differences.(105) In addition to recognizing the disparities in health status between White Americans and minority groups, society must recognize differences within groups as well.(106) Ethnic and racial minority communities include diverse groups with diverse histories, languages, cultures, religions, beliefs, and traditions. This diversity is reflected in the health care minorities receive and the experiences they have with the health care industry.(107) Without understanding and incorporating these differences, health care cannot be provided in a culturally competent manner.(108) Nonetheless, there has been relatively little research done on the differences in accessing quality health *60 care by racial/ethnic subgroups, and few data are available on many of these groups.

One example of institutional barriers to culturally competent care is the prevalence of linguistic barriers that also affect the quality of health care services, particularly for Hispanics and Asian Americans.(109) 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 those with limited proficiency in English.(110) This failure includes not providing education or information at the appropriate literacy level. Furthermore, "English only" laws -- laws that restrict access to public services to those with proficiency in English -- also have an acute and racially disproportionate impact on minorities.(111) The lack of an official government infrastructure (extending from the federal to the local level) to ensure standards of culturally competent care and equal access to services is inconsistent with Article 5 of CERD.(112)

G. 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.(113) These women share many of the problems experienced by minority groups in general, and by women as a whole. However, race discrimination and sex discrimination often intersect so as to magnify the difficulties minority women face in gaining equal access to quality health care.(114) In addition to barriers restricting access to health care for racial/ethnic minorities, there are barriers to health care that *61 predominantly affect minority women. There are also gender differences in medical use, provision of treatments, and inclusion in research.(115) This is partly the result of different expectations of medical care between men and women and of gender bias of health care providers.(116) Furthermore, the difficulty minority 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.(117)

An additional symptom of gender bias in the health care system that can affect outcomes is the way the medical concerns of minority women are not taken as seriously as those of minority men and are often dismissed as the result of emotional distress or as a psychosomatic condition.(118) Further, some health issues of minority women, 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 the health concerns of minority women.(119)

Policies and practices that increase government surveillance and control of minority women are also a key factor in health status. Minority women are less likely to receive sympathetic intervention by law enforcement in cases of domestic violence.(120) Women who, after calling upon police for help in such cases, become victims of both domestic violence and police violence. Family planning is another area where public policy has had a *62 negative impact on health status and life choices of minority women.(121) Minority women do not have equal access to preventive medicine or the full range of birth control options available. Barriers include lack of family-planning services or facilities in their communities; lack of medicaid or other publicly-funded health insurance coverage of certain services, medications or procedures; and disproportionately higher prescriptions of medically risky or unnecessary procedures, such as contraceptive implants or forced sterilization.(122) State and local policies are more likely to be discriminatory than federal policies. (123)There are few standards for ensuring equal access and equal treatment at the state and local levels.(124) With jurisdiction over health care issues increasingly devolving to the state and local levels, there is a critical need for a clear regulatory infrastructure that provides redress for these barriers and remedies and consequences for policies and practices with discriminatory outcomes.

H. 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 biological differences that affect the manifestations of certain illnesses and their treatments.(125) Billions of dollars are spent each year on health research ($35.7 billion in 1995).(126) 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% and .37%, respectively).(127) In response to years of exclusion of women and minorities, several statutory requirements have been enacted to ensure that research protocols include a diverse population.(128) However, the health condition of women and minorities will continue to suffer until they are included in all types of health research.(129)

*63 I. 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.(130) Disaggregated information on subgroups within the five racial and ethnic categories is not collected systematically.(131) Further, racial and ethnic classifications are often limited on surveys and other data collection instruments, and minorities are often misclassified on vital statistics records and other surveys and censuses.(132) 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.(133) The lack of data on different minority populations (such as Asian-Americans) makes it difficult to conduct research studies and comparative analyses.(134) 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.(135)

J. 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, which does not currently exist, managed care will, over time, tend to place increasingly stringent requirements on providers.(136) Providers may fail to *64 develop more expensive but culturally-appropriate treatment modalities, and they may refuse or minimize the expenditures necessary to develop an adequate infrastructure for minority communities.(137) The potential for discrimination, particularly racial/ethnic discrimination, to occur in the context of managed care is significant and is recognized as such by the Office of Civil Rights, leading commentators, and advocates for civil rights in health care services, financing, and treatment.(138) However, little has been done to protect minorities from this risk of discrimination. The U.S. Commission on Civil Rights reported:

The Office of Civil Rights (OCR) also has not sufficiently prepared its investigative staff to identify and confront instances of discrimination by managed care organizations. 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.(139)

Several managed-care practices can have a disparate impact on minorities. For example, one of the most common ways in which Managed Care Organizations (MCOs) discriminate against minorities is in the MCOs' selection of available providers.(140) 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.(141) In addition, some MCOs may be limiting the access of medicaid patients to the full array of providers by sending these patients provider lists containing only providers that accept medicaid, resulting in segregated provider lists.(142) *65 Other methods MCOs have used to discriminate against medicaid patients include excluding sections of the inner city from the 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.(143) 


Racial Disparity in Health Status
Institutional Racism in US Health Care
Inadequacy of Legal Efforts
US Violations of ICERD
Recommendations and Conclusions
Appendix A US Report
Appendix B White Shadow Report Excerpts
Appendix C: Concluding Remarks 1475th CERD Meeting
Appendix D Concluding Observations


59. [FN59]. See, e.g., Marianne Engelman Lado, Unfinished Agenda: the Need for Civil Rights Litigation to Address Race Discrimination and Inequalities in Health Care Delivery, 6 TEX. F. ON C.L. & C.R. 1 (2001); René Bowser, Racial Profiling in Health Care: An Institutional Analysis of Medical Treatment Disparities, 7 MICH. J. RACE & L. 79 (2001); 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); Vernellia R. Randall, Racist Health Care: Reforming an Unjust Health Care System to Meet The Needs of African-Americans, 3 HEALTH MATRIX 127 (1993).

60. [FN60]. U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 202.

61. [FN61]. Kaiser Commission on Key Facts, The Uninsured and Their Access to Health Care (Mar. 19, 2002), available at http://www.kff.org/ (last visited June 26, 2002).

62. [FN62]. See, e.g., Sidney D. Watson, Health Care in the Inner City: Asking the Right Question, 71 N.C. L. REV. 1647, 1648 (June 1993) (citing John C. Boger, Race and the American City: The Kerner Commission in Retrospect, An Introduction, 71 N.C. L. REV. 1289, 1329 (1993) (reporting that 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)).

63. [FN63]. Kaiser Commission on Key Facts, supra note 61.

64. [FN64]. See, e.g., The Healthcare Safety Net: An Overview of Hospitals in Five Markets (Aug. 8, 2002), available at http://www.kff.org/ (last visited Dec. 13, 2002).

65. [FN65]. Kaiser Commission on Key Facts, Welfare and Work: How Do They Affect Parents' Health Care Coverage? (June 17, 2002), available at http:// www.kff.org/ (last visited June 26, 2002).

66. [FN66]. See, e.g., Mary Anne Bobinski & Phyllis Griffin Epps, Women, Poverty, Access to Health Care, And The Perils of Symbolic Reform, 5 J. GENDER RACE & JUST. 233 (2002).

67. [FN67]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 98- 105; Bobinski & Epps, supra note 66.

68. [FN68]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 98- 103.

69. [FN69]. The discrimination in the Idaho CHIP Program provides an excellent case study of the issues. The Idaho Community Action Network (ICAN), a grassroots, member based organization in the state of Idaho received numerous complaints from their members about the application process for the federal Child Health Insurance Program (CHIP). ICAN took testimony from members and reviewed the evidence. Although nearly all applicants were treated poorly, there was clearly a pattern of discrimination that needed further investigation. ICAN developed a project that tested the accessibility of the program in three Idaho cities. They sent White and Latino families to apply for the CHIP and documented how people were treated. The testing program uncovered clear evidence of discrimination; lack of translators; intrusive questions by eligibility and caseworkers; requirements of proof of citizenship for Latino applicants; and unduly long processing time for all applicants that was even longer for Latino applicants. Mounting a publicity and organizing campaign, ICAN forced the state to standardize application procedures and reduce the written application form for both medicaid and CHIP from twelve to four pages. White Privilege Shadow Report, supra note 30 (adapting passage from "Leading with Race" by Gary Delgado in Grass Roots Innovative Policy Program, Applied Research Center (2000)).

70. [FN70]. Michael Romano, In the Physician's Practice; Minority Docs Find Racism Continues to Infect Many American Hospitals 31 MOD. HEALTHCARE 12 (2001) (reporting that nearly one in three minority doctors could not obtain hospital admissions for their patients, higher than the estimated twenty-five percent rate among White physicians); Woodrow Jones, Jr. & Mitchell F. Rice, Black Health Care: An Overview, in HEALTH CARE ISSUES IN BLACK AMERICA: POLICIES, PROBLEMS AND PROSPECTS 3 (Woodrow Jones, Jr. & Mitchell F. Rice eds., 1987).

71. [FN71]. See, e.g., David R. Williams & Toni D. Rucker, Understanding and Addressing Racial Disparities in Health Care, 21(4) HEALTH CARE FINANCING REV. 75 (2000); David G. Whiteis, Hospital and Community Characteristics in Closures of Urban Hospitals, 1980-87, 107(4) PUB. HEALTH REP. 409 (1992); Mark Schlesinger, Paying the Price: Medical Care, Minorities, and the Newly Competitive Health Care System, in HEALTH POLICIES AND BLACK AMERICANS 270-79 (David Willis ed., 1989).

72. [FN72]. See generally Robert L. Schiff et al., Transfers to a Public Hospital: A Prospective Study of 467 Patients, 314 NEW ENG. J. MED. 552 (1986) (A study of transfers among 467 medical transfers to Cook County Hospital showed that 89% were African-Americans or Hispanics. The study concluded that most of the patients were transferred for economic reasons and without their consent); Judith Waxman & Molly McNulty, Access to Emergency Medical Care: Patients' Rights and Remedies, 22 CLEARINGHOUSE REV. 21-27 (1991); Debra Spencer, Is Racism Killing Us?, ESSENCE 32 (1993) (discussing discriminatory treatment of African-Americans in accessing medical treatment).

73. [FN73]. U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 63-64.

74. [FN74]. See, e.g., id. at 55-60; David A. Kindig et al., Trends in Physician Availability, in 10 URBAN AREAS FROM 1963 TO 1980, 24 INQUIRY 136, 140 (1987) (reporting that in 10 cities the number of office-based primary care physicians in poor, inner-city areas declined 45% from 1963 to 1980 while there was only a 27% decline in non-poverty areas of the cities).

75. [FN75]. See, e.g., Watson, supra note 62.

76. [FN76]. See E. Moy & B.A. Bartman, Physician Race and Care of Minority and Medically Indigent Patients, 273 JAMA 1515 (1995) (asserting that in poor, urban areas of the U.S. with high proportions of African-Americans and Hispanics that there are only 24 physicians per 100,000 people compared to a national average of nearly 200 physicians per 100,000 people; showing that nearly 40% of all minority medical school graduates will practice medicine in underserved areas compared to 10% of their non-minority colleagues).

77. [FN77]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 55.

78. [FN78]. See, e.g., id. at 56-60.

79. [FN79]. See, e.g., id. at 78-82; Randall, Slavery, supra note 59; Randall, Racist Health Care, supra note 59.

80. [FN80]. See, e.g., Daniel J. DeNoon, AIDS Care Not Color Blind, AIDS WEEKLY, Sept. 11, 1995, at 2.

81. [FN81]. See, e.g., Kevin A. Schulman et. al., The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization, 340 NEW ENG. J. MED. 618 (1999).

82. [FN82]. See, e.g., Charles Maynard et al., Blacks in the Coronary Artery Surgery Study (CASS): Race and Clinical Decision Making 76 AM. J. PUB. HEALTH 1446 (1986).

83. [FN83]. See, e.g., P.W. Eggers, Effect of Transplantation on the Medicare End-Stage Renal Disease Program, 318 NEW ENG. J. MED. 223 (1988).

84. [FN84]. See, e.g., Robert S. Gaston et al., Racial Equity in Renal Transplantation, 270 JAMA 1352 (1993).

85. [FN85]. See, e.g., John Yergan et al., Relationship between Patient Race and the Intensity of Hospital Services, 25 MED. CARE 592 (1987).

86. [FN86]. See, e.g., Mark B. Wenneker & Arnold M. Epstein, Racial Inequalities in the Use of Procedures for Patients with Ischemic Heart Disease in Massachusetts, 261 JAMA 253, 253-57 (1989).

87. [FN87]. See, e.g., Beth A. Hahn, Children's Health: Racial and Ethnic Differences in the Use of Prescription Medications, 95 PEDIATRICS 727 (1995).

88. [FN88]. See, e.g., Jay C. Wade, Institutional Racism: An Analysis of the Mental Health System, 63 AM. J. ORTHOPSYCHIATRY 536 (1993).

89. [FN89]. Charles S. Cleeland et al., Pain and Treatment of Pain in Minority Patients with Cancer, 127 ANNALS INTERNAL MED. 813 (1997); Vence L. Bonham, Race, Ethnicity, and Pain Treatment: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatment, 29 J.L. MED. & ETHICS 9 (2001).

90. [FN90]. See, e.g., Charles L. Bennett, Racial Differences in Care Among Hospitalized Patients with Pneumocystis Carinii Pneumonia in Chicago, New York, Los Angeles, Miami, and Raleigh-Durham, 55 ARCHIVES INTERNAL MED. 1586 (1995).

91. [FN91]. See, e.g., Marian E. Gornick et al., Effects of Race and Income on Mortality and Use of Services Among Medicare Beneficiaries, 335 NEW ENG. J. MED. 791 (1996).

92. [FN92]. U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 82-83.

93. [FN93]. IOM REPORT, supra note 2.

94. [FN94]. See, e.g., id.

95. [FN95]. See, e.g., id.

96. [FN96]. Randall, Racist Health Care, supra note 59, at 160-62.

97. [FN97]. See, e.g., IOM REPORT, supra note 2.

98. [FN98]. See, e.g., id.

99. [FN99]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 74- 78; Sidney D. Watson, Reinvigorating Title VI: Defending Health Care Discrimination -- It Shouldn't Be So Easy, 58 FORDHAM L. REV. 939, 941-42 (1990).

100. [FN100]. 42 U.S.C. 1395 (2002) (federal medicare statute recognizing "distinct part" certification); 42 U.S.C. 1396a(a)(28) (2002) (applying "distinct part" certification to medicaid SNF certification); see Linton v. Carney, 779 F. Supp. 925, 931 (M.D. Tenn. 1990) (finding that "Tennessee will, at the provider's instructions, certify a limited component of beds in a facility which provides the same ICF level of care in all beds ....").

101. [FN101]. Randall, Racist Health Care, supra note 59, at 154-58.

102. [FN102]. Heather K. Aeschleman, The White World of Nursing Homes: The Myriad Barriers to Access Facing Today's Elderly Minorities, 8 ELDER L.J. 367 (2000); see generally Steven P. Wallace et al., The Consequences of Color- blind Health Policy for Older Racial and Ethnic Minorities, 9 STAN. L. & POL'Y REV. 329, 335 (1998).

103. [FN103]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 52- 54

104. [FN104]. Vernellia 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, 205-12 (1994).

105. [FN105]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 52- 54.

106. [FN106]. See, e.g., id. at 33-36, 39-40, 42-45.

107. [FN107]. See generally The Commonwealth Fund, Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans, available at http://www.cmwf.org (last visited June 26, 2001).

108. [FN108]. See generally Jean Lau Chin, Culturally Competent Health Care, 115 PUB. HEALTH REP. 25, 28 (2000) (noting that the "prevalence of negative stereotypes about Black and Hispanic groups ... have resulted in discriminatory practices in health care service delivery"); David R. Levy, White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship, 75 PEDIATRICS 639, 640-41 (1985) (describing several "common myth[s] leading to negative stereotyping of blacks").

109. [FN109]. See, e.g., id. at 53.

110. [FN110]. See generally Pancho H. Chang & Julia Puebla Fortier, Language Barriers to Health Care: An Overview, 9 J. HEALTH CARE FOR POOR & UNDERSERVED S5-S20 (1998); MAREASA R. ISAACS & MARVA P. BENJAMIN, TOWARDS A CULTURALLY COMPETENT SYSTEM OF CARE, VOLUME II (1991); Robert Wood Johnson Foundation, How Language Barriers Hinder Access and Delivery of Quality Care (noting that twenty percent of Spanish-speaking Latinos surveyed reported not seeking medical treatment due to language barriers), available at www.rwjf.org (last visited June 26, 2001).

111. [FN111]. See generally Kiyoko Kamio Knapp, Language Minorities: Forgotten Victims of Discrimination?, 11 GEO. IMMIGR. L.J. 747 (1997); Hearing Before the Senate Comm. on Governmental Affairs, 104th Cong. (1995) [hereinafter Narasaki Testimony] (testimony of Karen Narasaki, Executive Director of National Asian Pacific American Legal Consortium) available in LEXIS, News Library, Curnws File.

112. [FN112]. Supra note 111.

113. [FN113]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 47- 50; Lisa C. Ikemoto, The Fuzzy Logic of Race and Gender in the Mismeasure of Asian American Women's Health Needs, 65 U. CIN. L. REV. 799 (1997).

114. [FN114]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 47- 50.

115. [FN115]. See, e.g., id.

116. [FN116]. See, e.g., Diane E. Hoffmann & Anita J. Tarzian, The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain, 29 J.L. MED. & ETHICS 13 (2001); Michelle Oberman & Margie Schaps, Women's Health and Managed Care, 65 TENN. L. REV. 555 (1998); Carol Jonann Bess, Gender Bias in Health Care: A Life or Death Issue for Women with Coronary Heart Disease, 6 HASTINGS WOMEN'S L.J. 41 (1995).

117. [FN117]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 47- 50; National Minority Cancer Awareness Week -- April 17-23, 2000, 49(15) MORBIDITY & MORTALITY WKLY. REP. 330 (2000), 2000 WL 13925103.

118. [FN118]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra not 2, at 47- 50.

119. [FN119]. See, e.g., id. at 47-55, 60-63, 89-91.

120. [FN120]. Lisa M. Martinson, An Analysis of Racism and Resources for African-American Female Victims of Domestic Violence in Wisconsin, 16 WIS. WOMEN'S L.J. 259 (2001); Paula C. Johnson, Danger in the Diaspora: Law, Culture and Violence Against Women of African Descent in the United States and South Africa, 1 J. GENDER RACE & JUST. 471, 514-24 (1998); R. EMERSON DOBASH & RUSSELL P. DOBASH, WOMEN, VIOLENCE AND SOCIAL CHANGE 146-212 (1992); Miriam H. Ruttenberg, A Feminist Critique of Mandatory Arrest: An Analysis of Race and Gender in Domestic Violence Policy, 2 AM. U. J. GENDER & L 171 (1994).

121. [FN121]. See, e.g., Charlotte Rutherford, Reproductive Freedoms and African American Women, 4 YALE J.L. & FEMINISM 255 (1992).

122. [FN122]. See, e.g., James D. Shelton et al., Medical Barriers to Access to Family Planning, 340 LANCET 1334-35 (1992).

123. [FN123]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS II, supra note 4.

124. [FN124]. See, e.g., id.

125. [FN125]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 109- 117.

126. [FN126]. See, e.g., id. at 109.

127. [FN127]. See, e.g., id.

128. [FN128]. Pub. L. No. 103-43, 107 Stat. 122 (1993); see, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 109.

129. [FN129]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 110.

130. [FN130]. See, e.g., David R. Williams, Race/Ethnicity and Socioeconomic Status: Measurement and Methodological Issues, 26(3) INT'L J. HEALTH SERVICES 483-505 (1996); Sidney D. Watson, Race, Ethnicity and Quality of Care: Inequalities and Incentives, 27 AM. J.L. & MED. 203, 221-24 (2001).

131. [FN131]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 50- 52.

132. [FN132]. Williams, supra note 130.

133. [FN133]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 50- 52.

134. [FN134]. Williams, supra note 130.

135. [FN135]. See Madison-Hughes v. Shalala, 80 F.3d 1121, 1123 (6th Cir. 1996) (dismissing for lack of subject matter jurisdiction); U.S. Commission on Civil Rights, Federal Title VI Enforcement to Ensure Nondiscrimination in Federally Assisted Programs, (Washington, D.C., 1996), at 246; Marianne Engelman Lado, Unfinished Agenda: the Need for Civil Rights Litigation to Address Race Discrimination and Inequalities in Health Care Delivery, 6 TEX. F. ON C.L. & C.R. 1 (2001).

136. [FN136]. See, e.g., Vernellia R. Randall, Impact of Managed Care Organizations on Ethnic Americans and Under Served Populations, 5(3) J. HEALTH CARE FOR POOR UNDERSERVED 224 (1994); Vernellia R. Randall, Managed Care, Utilization Review,and Financial Risk Shifting: Compensating Patients for Health Care Cost Containment Injuries, 17 PUGET SOUND L. REV. 1, 3 (1993).

137. [FN137]. See, e.g., supra note 136.

138. [FN138]. See, e.g., id.; see U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2; Frank M. McClellan, Is Managed Care Good For What Ails You? Ruminations on Race, Age And Class, 44 VILL. L. REV. 227 (1999).

139. [FN139]. U.S. Commission on Civil Rights, supra note 135.

140. [FN140]. See, e.g., Randall, Impact of Managed Care, supra note 136; Randall, Managed Care, supra note 136; see U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2; The Impact of Managed Care on Doctors Who Serve Poor and Minority Patients, 108 HARV. L. REV. 1625 (1995).

141. [FN141]. See, e.g., supra note 140.

142. [FN142]. See, e.g., id.

143. [FN143]. See, e.g., U.S. COMMISSION ON CIVIL RIGHTS I, supra note 2, at 88- 92.


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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu


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