III. INSTITUTIONAL RACISM AND AFRICAN-AMERICAN HEALTH STATUS
Racism is both overt and covert, it takes two closely-related forms: individual whites acting against individual blacks, and acts by the total white community against the black community. We called these ‘individual racism and institutional racism’. The first consists of overt acts by individuals, which causes death, injury or the violent destruction of property. The second type is less overt, or more subtle, less identifiable in terms of specific individuals committing the acts. But, it is no less destructive of human life. The second type originates in the operation of established and respected forces in the society, and thus receives far less public condemnation than the first type.
When white terrorists bombed a black church and killed 5 black children, that is an act of individual racism, widely deplored by most segments of the society. But, . . . [when] black babies die each year because of the lack of proper food, shelter, and medical facilities, and thousands more are destroyed and maimed physically, emotionally, and intellectually because of conditions of poverty and discrimination in the black community, that is the function of institutional racism. African-Americans are sicker than European-Americans. Knowing that African-Americans are sicker than European-Americans does not explain why. It certainly does not indicate the presence of institutional racism. To understand the role of institutional racism in health status requires an understanding of how health status is determined. Many things affect health status. An individual's personal lifestyle choices affect health status because they affect an individual's personal behavior and psycho-social health, which affect his or her physical health. Physical environment and biology also affect health status. Health care institutions affect health status because both personal behavior and human biology are affected by an individual's access to health care, and by the quality of health care the individual receives from health care institutions.
Class theory maintains that the primary factor affecting differences in health care status between racial groups is socioeconomic. According to the class theory, socioeconomic class affects life-style, psycho-social behavior, personal behavior, human biology, physical environment, access to health care, and the behavior of the system and its institutions toward the individual. According to the class theory, it is lack of money, not racism, that explains the disparity in health.
Certainly, access to health care services is related to ability to pay, and ability to pay is related to access to health insurance. It is estimated that 37 million Americans are uninsured. The spiraling costs of health care and health insurance make it impossible for many individuals to afford to purchase either privately. And yet, only about half of the poor meet government assistance programs' eligibility requirements. Many African-Americans are unemployed or employed in jobs that do not provide health care insurance. Many African-Americans are above the poverty line, disqualifying them for government assistance programs. Other African-Americans, approximately 25%, fall between the cracks, uninsured, without government assistance and without equitable access to health care. Consequently, many policy makers are suggesting health care reform proposals designed to minimize the effect ability (or inability) to pay has as a barrier to health care.
Even if any of the health care reform proposals are successful, the effect of socioeconomic class on health status will not be eliminated. In fact, its major effect will still exist, since socioeconomic class will continue to affect personal behavior and psycho-social health, physical environment, and human biology. Nevertheless, theoretically, access to health care will no longer be based on economics and ability to pay. If one accepts the class theory, then one must believe that establishing a universal health insurance will minimize the impact of class on health care access and should result in improved health for African-Americans.
The class theory, however, oversimplifies the issue and completely ignores the independent role of race in American society. Race influences not only life-style, personal behavior, psycho-social behavior, physical environment, and biology, but also socioeconomic status. Thus, race has a double influence.
Racism in America establishes separate and independent barriers to health care institutions and to medical care. Those who advocate for the class theory ignore the fact that removing economic barriers does not remove racial barriers. Racial barriers to health care are exhibited in two areas. First, institutional policies based on race establish barriers to access to health care to African-Americans. Second, practitioners provide disparate medical treatment to African-Americans based on their race which is not related to their socioeconomic class.
A. Racial Barriers to Access
It is hard to separate the effects of discrimination from those of concentration of Negroes in those areas where medical facilities are not easily accessible and in those income brackets that do not permit the purchase of medical facilities in the competitive market. Discrimination increases Negro sickness and death both directly and indirectly and manifests itself both consciously and unconsciously. Discrimination is involved when hospitals will not take in Negro patients; or when--if they do permit Negro patients--they restrict their numbers, give them the poorest quarters, and refuse to hire Negro doctors and nurses to attend them. . . . Ill health reduces the chance of economic advancement, which in turn operates to reduce the chance of getting adequate medical facilities or knowledge necessary for personal care.
Discrimination in health care has its foundation in the historical relationship between African-Americans and southern medical institutions. As slaves, African-Americans were perceived as property. While slave owners attempted to protect their own economic interests by providing minimal health care, most left the slaves to live or die as fate might befall them. After the Civil War, the Bureau of Refugees, Freedmen and Abandoned Lands (Freedman Bureau) was instituted to “furnish supplies and medical services” to the former slaves. However, the Freedman Bureau had very limited effect in providing services to former slaves. In fact, the Compromise of 1877 effectively ended the period of Radical Reconstruction which had been an attempt by the nation to make affirmative efforts in helping African-Americans.
During the Post-Reconstruction era, African-Americans were excluded from health care either by prohibition or discrimination.
[Even] where segregation and discrimination [were] not required by law they became deeply ingrained in the mores. Such behavior became part of the American Way of Life' . . . .
This “way of life” remained visible until the Civil Rights Movement of the 1960s. After the 1960s, health care institutions either fled predominant African-American communities or instituted policies which resulted in limited access for African-Americans. Discrimination can take two forms. Discrimination can be based on racist conduct that is intentional or it can be based on conduct which, although not intentional, nevertheless results in a disproportionate disparate impact on African-Americans. Much of the institutional racism has historically moved from intentional conduct to unintentional. While this classification may offer a distinction when assigning fault or culpability, the classification makes little difference to the African-American feeling the adverse affects of discrimination.
This legacy of a racist health care system persists today in African-Americans who are sicker than European-Americans and who continue to experience racial barriers to access. 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.
1. Barriers to Hospitals
The institutional racism that exists in many hospitals manifests itself in a number of ways including the adoption, administration and implementation of policies that restrict admission; the closure, relocation or privatization of hospitals that serve the African-American community; and the transfer of unwanted patients (known as “patient dumping”) by hospitals and institutions.
ADMISSION RESTRICTIONS. Many hospitals discriminate by using patient referral and acceptance practice standards that limit access. These practices restrict the admission of African-Americans to hospitals. Discriminatory admission practices include:
• Layoffs of recently hired African-American physicians - where those African-American physicians admit most of the African-American patients served by the hospital;
• Not having physicians on staff who can accept Medicaid patients; • Requiring pre-admission deposits as a condition of obtaining care; • Refusing to participate in programs to finance care for low-income patients not eligible for Medicaid; and, • Accepting only patients of physicians with staff privileges when the patients of such physicians do not reflect the racial composition of the local community. Such practices may have a devastating effect on African-Americans. The practices may banish African-Americans to distinctly substandard institutions treating mostly minority groups. They may completely prevent care where African-Americans have no access to other sources of care. COMMUNITY AVAILABILITY. Racial barriers to health care access are based, in large part, on the unavailability of services in a community. Increasingly, hospitals that serve the African-American community are either closing, relocating or becoming private. In a study done between 1937-1977, researchers showed that the likelihood of a hospital's closing was directly related to the percentage of African-Americans in the population. Throughout the 1980s many hospitals relocated from heavily African-American communities to predominantly European-American suburban communities.
This loss of services to the community resulted in reduced access to African-Americans. Geographic availability and proximity are important determinants to seeking health care services early. If African-Americans fail to seek early health care, they are more likely to be sicker when they do enter the system; and the cost for the patient to receive service and for the system to provide services at that point is likely to be greater than at an earlier state. Therefore, not only does the loss of services significantly increase health care costs to African-Americans, but also, it increases health care costs to the society in general.
Another devastating trend that affects the access of African-Americans to health care is the privatization of public hospitals. Quite a few hospitals (public and non-profit) have elected to restructure as private, for-profit corporations. As public hospitals, many were obligated to provide uncompensated care under the Hill-Burton Act. As private hospitals, these institutions are most likely to discontinue providing general health services to the indigent populations, and essential primary health care services to serve African-American communities.
The problem of limited resources is not new and has plagued the African-American community since slavery. Historically, African-American communities attempted to address the problem by establishing African-American hospitals. At one point there were more than 200 African-American hospitals in the United States. African-Americans relied on these institutions to “heal and save their lives.”
Now, these institutions are fighting for their own survival. By the 1960s, only 90 African-American hospitals remained. Between 1961 and 1988, 57 African-American hospitals closed and 14 others either merged, converted or consolidated. By 1991, only 12 hospitals continued to “struggle daily just to keep their doors open”. As a result of closures, relocations, and privatization, many African-Americans are left with limited, if any, access to hospitals.
PATIENT DUMPING. An African-American seeking care at a private hospital faces the possibility of being “dumped”, that is, the hospital may transfer an “undesirable” patient to a different facility. The transfer is medically appropriate only when the care required is not available at the transferring hospital. However, many transfers are for economic reasons, i.e., the patient was either uninsured or unable to make admission deposits. African-Americans are disproportionately affected by these practices.
In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act which became effective as Section 9121 of the Consolidated Omnibus Reconciliation Act (COBRA). The Act provides a cause of action against hospitals that “dump” patients with emergency conditions from their emergency rooms, or who “dump” pregnant patients in active labor. Several states have make “patient dumping” illegal.
However, limited enforcement of these legislative enactments makes patient dumping an ongoing problem. For instance, as of October 30, 1990, only 530 facilities had been investigated; only 139 facilities were found in violation of the statute; and only five facilities actually lost their Medicare contracts. A high percentage of African-Americans are uninsured or under-insured. Consequently, patient dumping continues to be an issue that plagues African-Americans. Furthermore, hospitals have developed methods to dump the patient without invoking the statute. For instance. the statute provides that hospitals receiving federal funding must accept any patient who “comes to an emergency room.” If hospitals reroute the patient before the patient arrives then the statute will not apply.
In Johnson, a parent called the paramedics after her baby went into cardiac arrest. The paramedics contacted University of Chicago hospital. The hospital told the paramedics to take the child to another hospital even though it was only five blocks away. The child was taken to a hospital without a pediatric intensive care unit and had to be transferred to another hospital. The child died after admission to the second hospital. The plaintiff sued on common law claims and for violation of COBRA. The district court dismissed and the Seventh Circuit upheld the dismissal of the COBRA claim. The Seventh Circuit noted that “In accordance with the plain meaning of the statutory language, we do not believe that the infant ever ‘came to’ the hospital or its emergency department. For purposes of COBRA, a hospital-operated telemetry system is distinct from that same hospital's emergency room.” The court went on to acknowledge that a “. . . hospital could conceivably use a telemetry system to dump patients”; nevertheless, the court held that the “statute does not expressly address the question of liability in such a situation.” Thus, the Seventh Circuit leaves the door open for other hospitals to continue dumping patients, most of whom will be African-Americans.
2. Barriers to Nursing Homes
Nursing homes are the most segregated publicly licensed health care facilities in the United States. Smith, in his study, concludes that racial discrimination is the major factor explaining that type of segregation. It has been suggested that any difference in African-American use of nursing homes can be explained by cultural biases against using nursing homes as care source for disabled or aged family members. However, in some areas (such as Delaware and Detroit Metropolitan) African-Americans make up a higher portion of nursing home residents than European-Americans. This suggests that African-Americans do not consistently decide against nursing homes.
Furthermore, even where racially neutral policies exist, institutional racism is still a factor. For instance, evidence about the use of nursing homes under Medicaid demonstrates that institutional racism has an impact even without regard to economic class. For instance, although African-Americans constitute only 12% of the nation's total population, the African-American poverty rate (31%) is three times greater than the European-American poverty rate (10%). However, African-Americans constitute only 29% of the Medicaid population and 23% of the elderly poor. Medicaid expenditures for African-Americans are only 18% of total expenditures. If, indeed, African-Americans are sicker, then Medicaid expenditures for African-Americans should at least be equal to, if not greater than, the percentage of Medicaid's African-American population. It is this combination of under-representation and under-spending in Medicaid that suggests racism.
In part, this disparity in expenditure is based on the limited access that African-Americans on Medicaid have to nursing homes, both intermediate and skilled nursing facilities. Only 10% of Medicaid intermediate care patients are African-Americans. Similarly, only 9% of Medicaid skilled nursing care facilities' patients are African-Americans. This disparity may be due in part to a policy allowing limited bed certification. Under limited bed certification, nursing homes determine the number of beds that are certified to participate in Medicaid. Federal regulations permit a distinct part of intermediate care facilities to be certified. Some states will certify a limited number of beds. Thus, the certified portion of a facility need not contain all intermediate care facilities residents. Furthermore, some states will certify beds which are not in a separately administered unit of a facility, but are instead part of a wing or ward that also contains non-certified beds.
Limited bed certification programs allow nursing home operators to give preference to private pay patients by reserving for their exclusive use beds which are unavailable to Medicaid patients. It also allows the nursing home operators to change the bed certification, resulting in disruption of the care of Medicaid patients by displacing them after they have been admitted to a nursing home.
Displacement can occur in several ways. It occurs when a patient exhausts his or her financial resources. The patient needs to make a transition from private pay to Medicaid. At that point, a patient may be told that his or her bed is no longer available. Furthermore, displacement occurs when a patient with insurance (private, medicaid or medicare) is transferred from a skilled nursing facility to an intermediate care facility. If the insurance will not cover intermediate care, the patient may not have financial resources to continue obtaining nursing home care. Similarly, displacement can occur when a patient already on Medicaid and authorized to receive skilled nursing care is reclassified for intermediate care only.
A nursing home can manipulate the availability of nursing home beds by certifying (and decertifying) beds. This certification and decertification process limits access to minorities. Linton v. Carney effectively challenged the practice.
In Linton, Mrs. Linton was threatened with an involuntary transfer from the facility she occupied. The threatened transfer was due to a change in her classification status by the Tennessee Medicaid program. Although Mrs. Linton occupied a bed in the nursing home certified for her new classification, the nursing home threatened to decertify her bed. No other beds were available in the facility. Joining Mrs. Linton (as a plaintiff-intervenor) was Mrs. Carney. Mrs. Carney was an 89-year-old African-American who could not find an available nursing home in the state of Tennessee. The District Court found the limited bed certification policy to violate both Title VI of Civil Rights Act and the Medicaid statute.
The Linton court recognized that Title VI prohibits policies and practices with adverse disparate impact on ethnic and racial minorities. According to the court, the plaintiffs showed that the defendants' limited bed certification policy had a disparate impact on racial minorities. While the defendants argued the “self-selection preferences” of the minorities adequately explained the disparate impact , the court rejected that interpretation as “sufficient justification for minority under-representation in nursing homes.” Therefore, the defendants did not meet their burden of proof.
Linton demonstrates that health care programs can operate in a racist way despite the appearance of racial neutrality. Any reform to the health care system that does not specifically address race has the potential of being racist and discriminatory.
3. Barriers to Physicians and Other Providers
Another important aspect of access to care is the availability of health care providers who serve the African-American communities. It should go without saying that proximity increases utilization. At this point, data on the actual numbers of white physicians who have offices in the African-American community are not available. There are probably very few. Consequently, African-American physicians have been an important aspect of filling the availability gap. Without physicians and providers in their communities, African-Americans are likely to delay seeking health care. That delay can result in more severe illness, increased health care cost, increased mortality and increased costs to society.
Given the increased morbidity and mortality among African-Americans logically one would expect more health care providers in their communities not fewer, and more African-Americans in health care fields. Scrutiny of the physicians heading in the Yellow Pages of any major city, clearly indicates that many physicians do not physically serve the African-American community.
Furthermore, despite being 12% of the population, African-Americans are seriously under-represented in health care professions. Only 3% of the physicians in the United States are African-Americans; only 2.5% of the dentists in the United States are African-Americans; and only 3.6% of the United States pharmacists are African-Americans. While this lack of representation is particularly significant for African-American communities which rely on African-American physicians for care, it also impacts the entire community. Shortage of adequate care results in sicker individuals and an increase in overall health care costs. If African-Americans are sicker, they need more physicians, not fewer. Yet, we see the same limited availability of providers, as of hospitals, to service African-American communities.
The shortage of African-American professionals further affects health care availability by limiting African-American input into the health care system. While the control of health care distribution is ultimately in the hands of the individual physician, that control is influenced and limited by law, hospital practices and policies, and the medical organization of the physician's practice. With so few African-American health care professionals, the control of the health care system lies almost exclusively in European-American hands.
The result is an inadequate, if not ineffective, voice on African-American health care issues. This lack of African-American voice leads to increased ignorance on the part of European-Americans regarding issues pertaining to African-American health. When health care issues are defined, the policy makers' ignorance results in their overlooking African-Americans' health concerns.
B. Racial Disparities in Medical Treatment
Racial barriers to access is only one aspect of institutional racism. Another aspect of institutional racism is the occurrence of racial disparities in type of services ordered and in the provision of medical treatment itself, well-documented in studies done in cardiology, cardiac surgery, kidney disease, organ transplantation, internal medicine and obstetrics.
Cardiology and Cardiac Surgery. African-Americans and European-Americans have similar rates of hospitalization for circulatory system disease. Yet, studies have found that European-Americans are one-third more likely to undergo coronary angiography and two to three times more likely to undergo bypass surgery.
Kidney Disease and Kidney Transplantation. The aggressive treatment of long-term kidney disease is based in part on race. Studies indicate that European-Americans are 5% to 15% more likely to receive aggressive treatment. In fact, the most favored patient for long term hemodialysis is a European-American male between the ages of 25 to 44. A European-American on dialysis is two-thirds more likely to receive a kidney transplant than a non-European-American. While the likelihood of receiving a kidney transplant is related to income, the effects of income and race are independent from each other, meaning that middle-income African-Americans are less likely to receive a kidney transplant than middle-income European-Americans.
Internal Medical Treatment. The patient's race has been correlated with the intensity of medical treatment. For example, when hospitalized with pneumonia, African-Americans were less likely than European-Americans to receive intensive care. This disparity in medical treatment persisted even after controlling for clinical characteristics and income.
Obstetrical Treatment. African-Americans were more likely to be classified as “clinic” patients despite comparable ability to pay for care. Private patients were more likely than clinic patients to have caesarean sections. This is true even though clinic patients were in poorer health and were more likely to have low birth weight babies.
These studies all raise the issue that African-Americans receive health care treatment different from the “preferred” patient the European-American male. Whether this difference is based on individual prejudices or medical school training, it is evidence of institutional racism that cannot be tolerated. Any patient seeking care from a physician should be able to be assured of the most appropriate medical treatment available. Irrespective of race, each of us should be assured that the physician will act in our best interest. Every person should be assured that the physician will not let personal prejudice or medical prejudice influence our medical treatment. As the situation exists, an African-American does not have those assurances.
Race affects access to care independent of socioeconomic class. Race also affects medical treatment independent of socioeconomic class. While the disparities in treatment decisions reflect clinical characteristics, income, medical or biological differences, they also reflect racial bias. To improve the health of African-Americans, it is not sufficient merely to remove barriers to access based on socioeconomic class. Health care institutions must rid themselves of institutional racism.
Medicine has found cures and controls for many afflictions, improving the health of all Americans--African-Americans, Asian-Americans, Hispanic-Americans, Native-Americans and European-Americans. However, the health institutions have failed to extend the same magnitude of improvement in health among European-Americans to African-Americans and other minority populations. Health institutions have failed to eliminate the racial distribution of health care. They also continue to perpetuate distinctions. Such a situation is intolerable. Of all the influences on African-Americans health, the influence of health care institutions, though relatively small, should nevertheless be free of racial prejudice and discrimination.