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Perspective: Title VI, Healthcare Reform, and the Need for a State Antidiscrimination Law

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Abstract

“It might be that civil rights laws often go unenforced; it might be that current inequities spring from past prejudice and long standing economic differences that are not entirely reachable by law; or it might be that the law sometimes fails to reflect, and consequently fails to correct, the barriers faced by people of color.” – Derrick Bell1 Equal access to quality health care is a crucial issue that the United States (US) is facing. For too long, we have denied too many Americans equal access to quality health care based on race, ethnicity, and gender. Many factors contribute to disparities: cultural incompetence of health care providers, socioeconomic inequities, disparate impact of racially neutral practices and policies, inadequacy of civil rights laws and enforcement, and multiple forms of discrimination. These ­disparities exist in health status, access to health care services, participation in health research, and receipt of health care financing. This disparity in health care is doubly significant given the devastating racial disparity in health status that exists. The combination of racial disparity in health status, institutional racism in health care, inadequate legal protection, and the failure of health care reform to adequately address racial discrimination in health care points to a need for a major civil rights law for health care. Several federal laws address access to health care: Title XVIII (Medicare), Title XIX (Medicaid) of the Social Security Act, Title IX, and the Hill Burton Act. The only federal laws related to eliminating racial discrimination in health care delivery are Title VI of the Civil Rights Act and § 1557 of the Patient Protection and Affordable Care Act (hereinafter, “Affordable Care Act.” Racial inequality in health care persists in the United States despite laws against racial discrimination, in significant part because of the inadequacy of Title VI, and the Affordable Care Act has done little to correct the problem.

See Derrick AB, Jr. And we are not saved: the elusive quest for racial justice. New York: Basic Books; 1987) (hereinafter Not saved).

See, e.g., Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in Health Care Institute of Medicine, Committee on understanding and eliminating racial and ethnic disparities in health care, Board on Health Sciences Policy (2002) (hereinafter, “Unequal treatment”); The United States Commission on Civil Rights, The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination, and Ensuring Equality, Volume I, The Role of Governmental and Private Health Care Programs and Initiatives. 287 pp. No. 902-00062-2 (Sept., 1999) (Hereinafter, U.S. Commission on Civil Rights I).

See, e.g., Byrd WM, Clayton LA. An American health dilemma: a medical history of African Americans and the problem of race, beginnings to 1900 (2000) (Hereinafter, “An American health dilemma I”); Byrd WM, Clayton LA. An American health dilemma: a medical history of African Americans and the problem of race, 1900 to present (2002) (Hereinafter, “An American health dilemma II”); U.S. Commission on Civil Rights I, supra note 2.

See, e.g., U.S. Commission on Civil Rights I, supra note 2; U.S. Commission on Civil Rights II, supra note 2.

Social Security Amendments of 1965, Pub. L. No. 89–97, Titles XVIII, 79 Stat 286; the act does not contain any general anti-discrimination clauses although the implementing regulations require providers and facilities to abide by Title VI.

Id.

U.S.C. §§ 1681–88 (2002) (limited to sex discrimination in educational programs).

U.S.C. §§ 291–291o (2002) (requires uncompensated care and community service by facilities that receive funding under Hill-Burton Acts).

See, e.g., Smith DB. Health care divided: race and healing a nation. 1999; Smith DB. Addressing racial inequities in health care: civil rights monitoring and report cards. J Health Polit Policy Law. 1998;23:75; Randall VR. Racist health care: reforming an unjust health care system to meet the needs of African-Americans. Health Matrix. Spring 1993;3:127.

The Patient Protection and Affordable Care Act, PL 111–148, March 23, 2010, 124 Stat 119, § 1557 (2010).

See, e.g., Noah B. Racial disparities in the delivery of health care? San Diego L Rev. 1998;35:135; Hampton DK. Title VI: challenges by private parties to the location of health care facilities: toward a just and effective action. B C L Rev. 1996;37:517; Engelman-Lado ML. Breaking the barriers of access to health care: a discussion of the role of civil rights litigation and the relationship between burdens of proof and the experience of denial. Brook L Rev. 1994;60:239.

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Notes

  1. 1.

    Title VI of the 1964 Civil Rights Act, Pub. L. No. 99-352, 378 252 (codified at 42 U.S.C.) 2000d-200d-4 (1982).

  2. 2.

    Id.

  3. 3.

    Alexander v. Choate, 469 U.S. 287 (1985).

  4. 4.

    See, e.g., Smith T. Everyday indignities: race, retaliation and the promise of Title VII. Colum Hum Rights Law Rev. 2003;34:529; cf. Lynn V. Regents of University of California 656 F.2d 1337, 1343 n.5 (C.A.G. 1981).

  5. 5.

    See, e.g., Davis PC. Law as microaggression. Yale Law J. 1989:98:1559, 1576.

  6. 6.

    Cf., Belton R. Mixed-motive cases in employment discrimination law revisited: a brief updated view of the swamp. Mercer Law Rev. 2000;51:651, 662–63; Selmi M. Subtle discrimination: a matter of perspective rather than intent. Colum Hum Rights Law Rev. 2003;34(40):657, 667.

  7. 7.

    See, e.g., Bloche MG. Race and discretion in American medicine. Yale J Health Policy Law Ethics. 2001;1:95, 95–96; Bowser R. Racial profiling in health care: an institutional analysis of medical treatment disparities. Mich J Race Law. 2001;7:79, 80–91; Noah BA. Racial disparities in the delivery of health care.San Diego Law Rev. 1998;35:135, 137; Crossley M. Infected judgment: legal responses to physician bias. Villanova Law Rev. 2003;48:195.

  8. 8.

    See, e.g., Gornick ME. Vulnerable populations and medicare services: why do disparities exist? 2000;43.

  9. 9.

    See, e.g., Allen J. A possible remedy for unthinking discrimination. Brook Law Rev. 1995;61:1299.

  10. 10.

    See, e.g., Allen J. Unthinking discrimination, supra note 20.

  11. 11.

    Lawrence C. The Id, the ego, and equal protection: reckoning with unconscious racism. Stan Law Rev. 1987;39:317; Oppenheimer DB. Negligent discrimination. Univ Pa Law Rev. 1993;141:899, 967–72; Johnson SL. Unconscious racism and the criminal law. Cornell Law Rev. 1988;73:1016.

  12. 12.

    Lawrence C, The Id, supra note 22.

  13. 13.

    Williams DR. Race, health, and health care. St. Louis Univ Law J. Fall 2003;48:13; see Unequal Treatment, supra note 2.

  14. 14.

    Williams DR. Race, health, and health care, supra note 24; see Unequal treatment, supra note 2.

  15. 15.

    Williams DR. Race, health, and health care, supra note 24.

  16. 16.

    See, e.g., Fiske ST. Controlling other people: the impact of power on stereotyping. Am Psychologist. 1993; 48:621, 627; Fiske ST, Glick P. Ambivalence and stereotypes cause sexual harassment: a theory with implications for organizational change. J Soc Issues. Spring 1995;97:110–12.

  17. 17.

    Fiske ST. Stereotyping, prejudice and discrimination. In: Gilbert DT et al., editors. The handbook on social psychology. 4th ed. New York: McGraw-Hill; 1998. Vol. 2, p. 357.

  18. 18.

    See H.R. Doc. No. 318, 88th Cong., 2d Sess. (1964). See generally, Rice M, Jones W, Jr. Public policy compliance/enforcement and Black American health: Title VI of the Civil Rights Act of 1964. In: Jones W, Jr., Rice MF, editors. Health care issues in Black America: policies, problems and prospects. New York: Greenwood Press; 1987. pp. 100–17; Watson S. Reinvigorating Title VI: defending health care discrimination – it shouldn’t be so easy? Fordham L Rev. 1990;58:939, 943–48.

  19. 19.

    C.F.R. 80.3(b)(2) (1991) (Emphasis added).

  20. 20.

    C.F.R. 80.13(i) (1991).

  21. 21.

    U.S.C.A. 2000d-1 (1981); 4 2 U.S.C.A. 2000d-4 (1981).

  22. 22.

    C.F.R. 80.3(b) (6) (i) (1991).

  23. 23.

    C.F.R. 80.3(B)(1)(vii)(2) (1991).

  24. 24.

    C.F.R. 80.3(B)(1)(vii)(2) (1991).

  25. 25.

    C.F.R. 80.3(b)(1)(i) (1991).

  26. 26.

    C.F.R. 80.3(b)(1)-(3) (1991).

  27. 27.

    Id.

  28. 28.

    See Alexander v. Sandoval. 532 U.S. 275, 280 (2001)

  29. 29.

    See, e.g., Allen J. Unthinking Discrimination, supra note 20.

  30. 30.

    Cong. Rec. H2599, H2622 (daily ed. May 22, 1990) (statement of Rep. Hoyer); see also 135 Cong. Rec. S10765, S10802 (daily ed. Sept. 7, 1989) (statement of Sen. Heinz).

  31. 31.

    See, e.g., Watson S. Reinvigorating Title VI: defending health care discrimination – it shouldn’t be so easy? Fordham Law Rev. 1990;58:939; Randall VR. Racist health care: reforming an unjust health care system to meet the needs of African-Americans. Health Matrix. Spring 1993;3:127; Engelman-Lado ML. Breaking the barriers of access to health care: a discussion of the role of civil rights litigation and the relationship between burdens of proof and the experience of denial. Brook Law Rev. 1994;60:239; Hampton DK. Title VI challenges by private parties to the location of health care facilities: toward a just and effective action. B C Law Rev. 1996;37:517.

  32. 32.

    C.F.R. § 42.406(a) (1992); 45 C.F.R. § 80.6(b) (1991).

  33. 33.

    See, e.g., Watson S. Health care in the inner city: asking the right question. N C Law Rev. 1993;71:1647.

  34. 34.

    See, e.g., Smith DB. Health Care Divided, supra note 9.

  35. 35.

    See, e.g., 45 C.F.R. § 80.3(b) (1991); Watson S. Health care in the inner city, supra note 45.

  36. 36.

    See, e.g., Watson S. Health care in the inner city, supra note 45.

  37. 37.

    Id.

  38. 38.

    But see Lesley v. Chie, 250 F.3d 47, 53 (1st Cir. 2001); Howe v. Hull, 874 F. Supp. 779, 789 (N.D. Ohio 1994).

  39. 39.

    Affordable Care Act, supra note 10.

  40. 40.

    Id.

  41. 41.

    Id.

  42. 42.

    Id.

  43. 43.

    Id.

  44. 44.

    See, e.g., Watson SD. Reinvigorating Title VI: defending health care discrimination – it shouldn’t be so easy. Fordham Law Rev. 1990;58:939; Smith DB. Health care divided, supra note 9; Smith DB. Addressing racial inequities in health care: civil rights monitoring and report cards. J Health Polit Policy Law. 1998;23:75; Randall VR. Racist Health Care, supra note 5.

  45. 45.

    See, e.g., Noah BA. Racial disparities, supra note 5; Hampton DK. Title VI: challenges by private parties to the location of health care facilities: toward a just and effective action. Boston College Law Rev. 1996;37:517; Noah BA. Racist health care? San Diego Law Rev. 1998;35:135; Engelman-Lado ML. Breaking the barriers of access to health care: a discussion of the role of civil rights litigation and the relationship between burdens of proof and the experience of denial. Brooklyn Law Rev. 1994;60:239.

  46. 46.

    See, e.g., U.S. Commission on Civil Rights II, supra note 2, 275–276.

  47. 47.

    Selmi M. Response to professor wax discrimination as accident: old whine, new bottle. Ind Law J. Fall 1999;74:1233; see also Young-Bruehl E. The anatomy of prejudices. Cambridge, MA: Harvard; 1996. p. 73; Selmi M. Subtle discrimination: a matter of perspective rather than intent. Colum Hum Rights Law Rev. 2003;34:657.

  48. 48.

    See, e.g., Allen J. A possible remedy for unthinking discrimination. Brook Law Rev. 1995;61:1299 (advocating strict liability for unconscious discrimination).

  49. 49.

    Cf. Cummins JD. Refashioning the disparate treatment and disparate impact doctrines in theory and in practice. How Law J. 1998;41:455, 468; but see Wax A. Discrimination as accident. Indiana Law J. Fall 1999;74:1129, 1206.

  50. 50.

    See, e.g., Dorn S, et al. Anti-discrimination provisions and health care access. Clearinghouse Rev. 1986;20:439, 441 and n.27; Desnick v. American broadcasting companies. 44 F.3d 1345, 1352. 1995.

  51. 51.

    See, e.g., Ayres I. Fair driving: gender and race discrimination in retail car negotiations. Harv Law Rev. 1991;104:817; Haydons SE. A measure of our progress: testing for race discrimination in public accommodations. UCLA Law Rev. April 1997;44:1207.

  52. 52.

    U.S.C. s 3604.

  53. 53.

    See, e.g., Haydons SE. A measure of our progress: testing for race discrimination in public accommodations. UCLA Law Rev. April 1997;44:1207; Havens Realty Corp. v. Coleman. 455 U.S. 363 (1982).

  54. 54.

    See, e.g., Yelnosky MJ. Filling an enforcement void: using testers to uncover and remedy discrimination in hiring for lower-skilled, entry-level jobs. Univ Mich J Law Reform. 1993;26:403.

  55. 55.

    See, e.g., Landever M. Note, tester standing in employment discrimination cases under 42 U.S.C. s 1981. Cleve St Law Rev. 1993;41:381.

  56. 56.

    Linda R.S. v. Richard D., 410 U.S. 614, 617 n.3 (1973) citing Hardin v. Kentucky Utilities Co., 390 U.S. 1, 6, 88 S.Ct. 651, 654, 19 L.Ed.2d 787 (1968).

  57. 57.

    See, e.g., Black D. Picking up the pieces after Alexander V. Sandoval: resurrecting a private cause of action for disparate impact. N C L Rev. Dec 2002;81:356.

  58. 58.

    Id.

  59. 59.

    Id.

  60. 60.

    See, e.g., Haydons SE. A measure of our progress: testing for race discrimination in public accommodations. UCLA Law Rev. April 1997;44:1207.

  61. 61.

    See, e.g., Fair Housing Council Finds Discrimination Against Hispanics in dc 66 NO. 40 Interpreter Releases 1154 (October 16, 1989).

  62. 62.

    See, e.g., Miller MD. Catalysts as prevailing parties under the equal access to justice act. Univ Chic Law Rev. Summer 2002;69:1347.

  63. 63.

    See, e.g., Civil Rights Act of 1964, Pub L No 88-352, 78 Stat 259, codified at 42 USC § 2000e-5(k) (1994); Civil Rights Attorney’s Fees Awards Act of 1976, Pub L No 94-559, 90 Stat 2641, codified at 42 USC § 1988(b) (1994 and Supp 2000); Equal Access to Justice Act, Pub L No 96-481, 94 Stat 2325 (1980), codified at 5 USC § 504, 28 USC § 2412 (1994 and 1998 Supp); 66 Stat 813 (1952), codified at 35 USC § 285 (1994).

  64. 64.

    See, e.g., Stanton v Southern Berkshire Regional School District, 197 F3d 574, 577 (1st Cir 1999); Marbley v Bane, 57 F3d 224, 234 (2d Cir 1995).

  65. 65.

    Pogorelec JP. Under what circumstances did congress intend to award punitive damages for victims of unlawful intentional discrimination under Title VII? Boston Coll Law Rev. Sept 1999;40:1269.

  66. 66.

    See, e.g., Pogorelec JP. Under what circumstances, supra note 70; H.R. Rep. No. 102-40(I). 1991;64–65, reprinted in USSCAN. 1991;549, 602–03.

  67. 67.

    As of 2003, 12 states had split-recovery statutes. The 12 states are: Alaska, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Missouri, New York, Oregon, and Utah.

  68. 68.

    See, e.g., Klaben MJ. Split-recovery statutes: the interplay of the takings and excessive fines clauses. Cornell Law Rev. 1994;80:104, 105. Stepanian LM II. Comment, the feasibility of full state extraction of punitive damages awards. Duquenese Law Rev. 1994;32:301, 317.

  69. 69.

    See, e.g., Williams DR. Race/ethnicity and socioeconomic status: measurement and methodological issues. Int J Health Serv. 1996;26(3):483–505; Watson SD. Race, ethnicity and quality of care: inequalities and incentives. Am J Law Med. 2001;27:203.

  70. 70.

    See, e.g., U.S. Commission on Civil Rights I, supra note 2, 50–52.

  71. 71.

    See, e.g., Williams DR. Race/ethnicity and socioeconomic status: measurement and methodological issues. Int J Health Serv. 1996;26(3):483–505.

  72. 72.

    See, e.g., U.S. Commission on Civil Rights I, supra note 2, 50–52.

  73. 73.

    Williams DR. Race/ethnicity and socioeconomic status: measurement and methodological issues. Int J Health Serv. 1996;26(3):483–505.

  74. 74.

    See Madison-Hughes v. Shalala, 80 F.3d 1121, at 1123 (6th Cir. 1996); 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, 1. 6 Tex. F. on C.L. and C.R. 1 (Summer 2001).

  75. 75.

    Bagley C. A plea for ignoring race and including insured status in American research reports on social science and medicine. Soc Sci Med. 1995;40:1017–1019.

  76. 76.

    Williams DR. Race and health, supra note 2, 322–333.

  77. 77.

    Id.

  78. 78.

    Randall VR. Racist Health Care, supra note 13, 127–194

  79. 79.

    Williams DR. Race and health, supra note 2, 322–333.

  80. 80.

    Id.

  81. 81.

    See, e.g., Smith DB. Addressing racial inequities in health care: civil rights monitoring and report cards. J Health Polit Policy Law. Feb 1998;23:75.

  82. 82.

    Smith DB. Health care divided, supra note 9; Geiger HJ. Race and health care – an American Dilemma. New Eng. J Med. 1996;335:815, 816; Bowser R. Racial profiling in health care: an institutional analysis of medical treatment disparities. Mich. J Race Law. Fall 2001;7:79.

  83. 83.

    See, e.g., Smith DB. Addressing racial inequities in health care: civil rights monitoring and report cards. J Health Polit Policy Law. Feb 1998;23:75.

  84. 84.

    See, e.g., Smith DB. Health care divided, supra note 9 at 326; Nat’l Comm. Quality Assurance, Health Plan and Employer Data Information Set (version 3.0 1998); Enthoven AC, Vorhaus CB. A vision of quality in health care delivery. Health Aff. May/June 1997; Bowser R. Racial profiling in health care: an institutional analysis of medical treatment disparities. Mich J Race Law. Fall 2001;7:79.

  85. 85.

    See, e.g., Watson SD. Book Review Essay. In: Smith DB, editor. Health care divided: race and healing a nation. Ann Arbor: University of Michigan Press; 1999, 386 pp, $39.50., 21 J. Legal Med. Dec 2000;601.

  86. 86.

    Id.

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  1. The University of Dayton School of Law, Dayton, Ohio, USA

    Vernellia R. Randall (Professor of Law)

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  1. Medicine at UCLA, and, The Minority Health Institute, Inc., The David Geffen School of, Clairton Place 3425, Los Angeles, 91436, California, USA

    Richard Allen Williams

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Randall, V.R. (2011). Perspective: Title VI, Healthcare Reform, and the Need for a State Antidiscrimination Law. In: Williams, R. (eds) Healthcare Disparities at the Crossroads with Healthcare Reform. Springer, Boston, MA. https://doi.org/10.1007/978-1-4419-7136-4_16

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