Vernellia R. Randall, Inequality in Health Care Is Killing African Americans, 36-FALL Human Rights 20 (Fall, 2009).
For blacks, health inequalities are the cumulative result of both past and current discrimination throughout U.S. culture. Due to discrimination and limited educational opportunities, blacks disproportionately work in low-pay, high-health-risk occupations (e.g., they are migrant farm workers, fast food workers, garment industry workers). Historic and present racism in land and planning policy also plays a critical role in minority health status. Even controlling for income, blacks are much more likely to have toxic materials (and other unhealthy substances) sited in their communities than whites. For example, overconcentration of alcohol and tobacco outlets and the legal and illegal dumping of pollutants pose serious health risks to minorities. Another significant factor affecting many blacks is the lack of grocery stores with fresh foods but the ready availability of fast foods with high salt and fat content. Exposure to these risks is not a matter of individual control or even individual choice. Health status disparities are a direct result of policies, practices, procedures, and laws--institutional discrimination--that protect white privilege at the expense of black health.
Black Americans are sicker than white Americans, and they are dying at a significantly higher rate. These are undisputed facts. Black men live on average six years less than white men. Black men have shorter life spans than men in Chile, Barbados, Bahamas, or Jamaica. Black women live on average four years less than white women. Black women have shorter life spans than women in Barbados, Panama, Bosnia, and the Bahamas. Infant mortality rates are two times higher for blacks. Some racist has commented that African Americans should be grateful for being in the United States; yet black Americans have more low birth weight infants than women in Rwanda, Ghana, and Uganda.
Social determinants of health are the primary factors in the health status inequality between blacks and whites. Social determinants of health are the social, economic, political and legal forces under which people live. These determinants include wealth/income, education, criminal justice, physical environment, health care, housing, employment, stress, and racism/discrimination.
In fact, for blacks, racism is a primary factor. Even when you control for economics, blacks have poorer health. That is, middle-class blacks suffer poorer health than middle-class whites. In fact, middle-class whites live ten years longer than middle-class blacks, while poor whites live only three years longer than poor blacks. Furthermore, the stress of living in a discriminatory society accounts for the racial health disparities.
Appropriate state and federal laws must be available to eliminate discriminatory practices in health care. On its face, Title VI (with its implementing regulations) should be an effective tool for eliminating racial discrimination. Unfortunately, the Supreme Court has held in Alexander v. Choate, 469 U.S. 287 (1985), that Title VI itself directly reached only instances of intentional discrimination. Because of the very specialized knowledge required in medical care, individuals can be totally unaware that the provider has injured them. Finally, the health care system, through managed care, has actually built in incentives that encourage unconscious discrimination. Thus, the crux of the problem, given managed care, the historical inequity in health care, and unthinking reckless discrimination, is that current laws do not address the current barriers faced by minorities. (Reckless discrimination occurs when an individual knows that there is a high risk of discrimination and the individual proceeds with the behavior. Negligent discrimination occurs when the individual knew or should have known their behavior would result in discrimination and failed to take appropriate action to prevent or minimize discrimination.)
Compounding the racial discrimination experienced generally is the institutional discrimination in health care affecting access to health care and the quality of health care received. Racial discrimination in health care delivery, financing, and research continues to exist. Racial barriers to quality health care manifest themselves in many ways, including (1) economic discrimination, which rations health care on ability to pay; (2) insufficient hospitals and health care institutions and clinics; (3) insufficient physicians and other providers; (4) racial discrimination in treatment and services; and (5) culturally incompetent care.
A Health Care Anti-Discrimination Act would
(1) recognize multiple forms of discrimination;
(2) authorize and fund testers;
(3) assure appropriate fines and regulatory enforcement;
(4) require racial/ethnic disaggregate data collection and reporting;
(5) provide a private and organizational Right of Action;
(6) cover prevailing party attorney fees;
(7) provide punitive damage, in part or in whole, to fund monitoring and assessment programs; and (
8) require a health scorecard/report for health agency, provider, or facility.
Unless specifically addressed, inequality in health care will most certainly remain and blacks will continue to die at a disproportionate rate.
Vernellia R. Randall is a professor at the School of Law at the University of Dayton.