CONTENTS INTRODUCTION I. SEPARATE AND UNEQUAL: GOVERNMENT SPONSORED AND SUPPORTED RACIAL BIAS WITHIN THE U.S. HEALTH CARE SYSTEM II. RACIAL DISPARITIES IN ACCESS TO HEALTH CARE: STRUCTURAL AND INSTITUTIONAL RACIAL BIAS A. Structural Racial Bias 1. Racial Bias in the United States 2. Structural Racial Bias: Rationing Health Care Based on Ability to Pay B. Institutional Racial Bias: Hospital Closures III. RACIAL DISPARITIES IN HEALTH STATUS: INTERPERSONAL RACIAL BIAS IV. SOLUTIONS CONCLUSION For three hundred years, we've given them time. And Fve been tired so long, now I am sick and tired of being sick and tired, and we want a change. We want a change in this society in America because, you see, we can no longer ignore the facts. (1)
Fannie Lou Hamer
Since the end of the Civil War in 1865, the U.S. health care system has been structured to be racially separate and unequal. (2) Ninety-nine years later, the enactment of Title VI of the Civil Rights Act of 1964 (Title VI) was supposed to put an end to this racially separate and unequal health care system by mandating equal access to health care for all races. (3) However, fifty years later, African Americans continue to receive separate and unequal treatment compared to Caucasians, in hospitals, nursing homes, and physician offices. (4) As a result, racial disparities in health status and access to health care persist. Consequently, since 1964, research studies estimate that 4.2 million African Americans have died unnecessarily because of health disparities. (5) Beyond the costs of lost lives, the fiscal costs of racial disparities in health care from 2009 through 2018 is estimated to be approximately $337 billion, including $220 billion for Medicare, $27 billion for Medicaid, and $90 billion for private insurers and individual's out-of-pocket costs. (6)
These racial disparities in health status and access to health care are due to racial bias. (7) Dr. Camara Phyllis Jones defines racial bias as "a system of structuring opportunity and assigning value based on the social interpretation of how we look (which is what we call 'race'), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources." (8) Research has shown a link between experiencing racial bias and an increased likelihood of experiencing cardiovascular disease, infant mortality, and the onset of hypertension. (9) Moreover, racial bias prevents African Americans from obtaining the same educational, employment, and housing opportunities as Caucasians, thus limiting African Americans' ability to access health care. (10) Over three decades of empirical research studies show that racial bias prevents African Americans from receiving quality education, obtaining jobs, and accessing housing in safe, diverse, and environmentally-friendly neighborhoods. (11) Due to racial bias, African Americans attend substandard schools, are more likely to be unemployed or employed with no health insurance, and reside in houses with environmental hazards (that contain, for example, lead, vermin, or are situated near toxic waste dumps) located in unsafe neighborhoods. As a result of these hazards and because many lack health insurance, African Americans are left with little or no access to health care, resulting in reduced health care options.
African Americans' access to health care is further limited by racial bias within the health care system, which operates on three levels: structural, institutional, and interpersonal. As a result of structural racial bias, health care services in the United States are delivered based on ability to pay, leaving those who cannot pay (predominately minorities) without access to health care.* 12 Institutional racial biases contribute to the accumulation of health care facilities and physicians in wealthy, Caucasian neighborhoods, leaving those in poor, minority communities with no access to quality health care. (13) Finally, interpersonal racial biases in the form of explicit and implicit racial bias result in some health care providers failing to give African American patients the same life-saving treatment that is provided to Caucasians. (14)
To save African American lives and decrease the billions of dollars spent as a result of racial disparities in health status and access to health care, the U.S. government must stop funding and supporting racial bias. The 2014 Case Western Reserve University School of Law, Law-Medicine Symposium represents the first of many steps in this battle to eradicate racial bias in the U.S. health care system. The purpose of this interdisciplinary conference was to commemorate the fiftieth anniversary of Title VI by challenging the continuation of racial bias in the U.S health care system, which limits African Americans' access to health care and causes their unnecessary morbidity and mortality. This introduction summarizes not only the symposium articles contained in this issue, but also the key presentations given at the symposium.
Section I provides a brief history of how the U.S. health care system has been separate and unequal since the Civil War because of racial bias and remains so in spite of the passage of the Patient Protection and Affordable Care Act (ACA). Section II examines the effects of structural and institutional racial bias on African Americans' health status and access to quality health care, while Section III discusses the effects of interpersonal racial bias on African Americans' health status. Finally, Section IV provides solutions to put a definitive end to racial bias within the U.S. health care system.
SEPARATE AND UNEQUAL: GOVERNMENT SPONSORED AND SUPPORTED RACIAL BIAS WITHIN THE U.S. HEALTH CARE SYSTEM
At the end of the Civil War, Congress debated creating a universal health care system that would cover all U.S. citizens. (15) The proposal was emphatically vetoed based on arguments that the system would cover newly freed blacks. (16) The development of private health insurance ensured the defeat of racially integrated government health insurance, and the development of private hospitals guaranteed the racial segregation of patients. (17) Thus, Caucasians who could afford private health insurance were provided the best health care in private hospitals, while African Americans who could afford private health insurance and pay to stay in the same health care facilities as Caucasians were treated in separate and unequal health care facilities. (18) The influence of racial bias in the development of the U.S. health care system was so pervasive that the federal government not only funded, but also explicitly and implicitly supported separate and unequal health care services, in contravention of the laws prohibiting racial bias. (19)
For example, the Hospital Survey and Construction Act of 1946, better known as the Hill-Burton Act, allotted funding for the construction of hospitals and nursing homes and granted states the authority to regulate this construction. Hospitals used this funding to construct among other things, hospital buildings, nursing homes, and freestanding geriatric hospitals. (20) The Hill-Burton Act also provided assurances that adequate health care facilities be made available to all state residents without discrimination of color. (21) According to Dr. David Barton Smith's article, "The 'Golden Rules' for Eliminating Disparities: Title VI, Medicare, and the Implementation of the Affordable Care Act," these assurances were not worth the paper they were written on because "there was no procedure for checking on the validity of the 'assurances,' nor was there any authorized course of action for violations." (22) This nondiscrimination rule was further negated by section 622(f), which stated:
[S]uch hospital or addition to a hospital will be made available to all persons ... but an exception shall be made in cases where separate hospital facilities are provided for separate population groups, if the plan makes equitable provision on the basis of need for facilities and services of like quality for each such group. (23) Federal support and funding of separate and unequal health care facilities ensured that African Americans' tax money in at least fourteen states was used for the construction of health care facilities from which they were barred. (24)
The passage of Title VI was supposed to put an end to federally supported and funded racial bias within the health care system. However, Dr. Smith noted that in the first year and half year after the passage of Title VI, the government had not allocated any staff to enforce the law, nor were there any investigative tools (reporting requirements, subpoena powers, etc.) or the ability to impose credible sanctions, and it was unclear what constituted noncompliance. (25) Things changed with the passage of the Medicare and Medicaid Acts.
By linking Title VI to Medicare and Medicaid, the federal government was able to leverage the influx of cash to hospitals and convince them to integrate almost overnight. (26) The government also harnessed the power of the civil rights movement by using local civil rights groups and activists, many of them health care or government workers, to conduct Title VI inspections in hospitals that refused to integrate even with the promise of cash, or those hospitals that took the cash but did not integrate. (27) Many, but not all hospitals' certification in Medicare and Medicaid was guaranteed by local civil rights groups and activists after finding that the hospitals were compliant with Title VI. (28) Unfortunately, this was the extent of the victory under Title VI.
The U.S. Department of Health and Human Services (HHS), the agency responsible for enforcing Title VI, allowed hospitals to move out of predominately African American neighborhoods to predominately Caucasian neighborhoods. HHS ruled that physicians...