Health Care in a Context of Civil Rights (1981) / Chapter Skim
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INTRODUCTION AND SUMMARY OF CONCLUSIONS
INTRODUCTION AND SUMMARY OF CONCLUSIONS
Pages 1-19
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The application of civil rights principles to the delivery of health services is taking place in the context of a changing environment of law as well as health care. In only a few decades, the United States has evolved from a society in which racial discrimination was tolerated and even mandated by legal institutions, to one in which the law forbids many forms of discrimination.
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Many aspects of civil rights law, even those as fundamental as the scope and applicability of various non-discrimination prohibitions, remain to be settled. The civil rights debates of the 1960s and 1970s about such concepts as equal access, equal opportunity, or equality of results in areas of education, employment, housing, and voting rights are likely to be replayed if more active civil rights enforcement develops in health.
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This report is based primarily on the committee's review of the relevant research and statistical literature on health care, its attempts to identify data sources and methodological approaches of potential usefulness, and its review of the responsibilities of the OCR and past civil rights enforcement activities. In some instances the committee sought and obtained, particularly from the National Center for Health Statistics, new analyses of existing data that
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Chapter 4 discusses the health care of handicapped persons, especially obstacles that bear on their ability to obtain needed care. Chapter 5 examines the legal approaches by which civil rights concerns can be addressed, including direct enforcement of civil rights laws by the OCR, the activities of health planning agencies, and the commitments made by institutions in obtaining Hill-Burton funds for facility construction.
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There are obvious racial differences in where people obtain medical care, both with regard to physician visits and hospital use. Blacks are less likely than whites to see private physicians, regardless of income level or type of insurance.
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Blacks and Nursing Homes The committee gave special attention to this topic because blacks use nursing homes at markedly lower rates than do whites. The committee believed that an assessment of the evidence that might explain this would not only be useful for its own sake, but also to illustrate the
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* Elderly blacks are more likely than elderly whites to reside as part of an extended family, which supports the hypothesis that family factors contribute to the relative absence of blacks in nursing homes.
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The evidence reviewed in Chapter 3 -- particularly concerning state variations in the underrepresentation of blacks in the Medicaid population of nursing homes and concerning patterns of racial segregation in nursing homes -- also suggests a basis for focusing civil rights compliance review activities.
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Data from the National Nursing Home Survey do not show a black/white differential in nursing home use below age 74; such findings may be used in establishing priorities for more detailed investigation of racial patterns in the use of nursing homes. Health Care of Handicapped Persons Although handicapped persons are covered by laws prohibiting discrimination in federal programs, few systematic data exist on the health care of handicapped persons that would allow for an assessment of the nature and severity of discrimination problems they face.
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First, is the care provided to handicapped persons equally effective, in relation to existing knowledge, as the care received by non-handicapped persons? Second, does the care of handicapped persons unnecessarily restrict their autonomy and independence?
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Handicapped persons are also likely to continue to face other obstacles that have an economic rationale, such as problems in obtaining health insurance, the waiting period of 29 months for disability coverage under Medicare, state variations in coverage under Medicaid, refusal of many providers to accept Medicaid, use of medical screens (to exclude potentially heavy users of services) in insurance and in prepaid health care settings, and nursing homes' discrimination against "heavy-care patients" when reimbursement levels are fixed.
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Existing data do not allow even a minimally adequate, empirical assessment of the problems experienced by handicapped persons in seeking or obtaining health care. Data problems may also impede coordination among various programs.
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Practices such as the use of medical screens, the use of physical or mental criteria in determining eligibility for programs such as the Crippled Children's Program, and discrimination against heavy-care patients in nursing homes may be inconsistent with Section 504, although the economic component of these practices should be given proper recognition in policy decisions intended to be remedies. It appears, however, that some of the most important difficulties in the health care of the handicapped persons cannot be addressed readily, if at all, under Section 504.
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Title VI of the Civil Rights Act of 1964 is clearly the most prominent civil rights statute of relevance to health, even though it does not specifically mention health. Title VI prohibits racial discrimination by providers who receive federal financial funds and requires agencies to terminate aid in the event of non-compliance.
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From its review of the law and past enforcement efforts, the committee concluded that such activities have been quite limited and that existing regulations are vague when applied to health care. Although more than 15 years have elapsed since the passage of the Civil Rights Act, there still remains little guidance as to its application in health care.
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Such data are prerequisites to enforcement activities under present legal obligations and to the continuing process of definition as to what disparities are to be regarded as unreasonable or illegitimate in terms of civil rights laws. The committee suggests that the OCR inventory available indicators and measures of civil rights compliance, including available and potential sources of data.
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Formal proposal in the Federal Register would not only make an important statement about the commitment of DHHS to the enforcement of civil rights, but would also provide the occasion for public comment by all concerned parties that would itself prompt further refinement of basic principles. Besides civil rights enforcement per se, the enforcement of clarified community service and equal access obligations of Hill-Burton facilities could have an important impact on alleviating some circumstances that have led to the unequal treatment of minorities by institutional health care providers.
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From page 18... ...
At the same time, the various impacts of government and private health programs on different members of the population are only beginning to be appreciated. In many areas, information is not yet being sought that will help define socially acceptable or legally unacceptable disparities in health services and health status in the United States.
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19 in testimony presented to the IOM committee by Dr.
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