Did you arrive here by via search engine?
Click here to view the original version of this article

Click to Print This Page
(This section will not print)

Preventing Racial Disparities in Health Status and Access to Health Care

Course Authors

Ruqaiijah A. Yearby, J.D.

Ruqaiijah Yearby, J.D., M.P.H., is Professor of Law and Associate Director of the Law-Medicine Center, Case Western Reserve University School of Law, Cleveland, Ohio.

Within the past 12 months, Ms. Yearby reports no commercial conflict of interest.

Albert Einstein College of Medicine, CCME staff, and interMDnet staff have nothing to disclose.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • Identify health care providers’ bias in the treatment of minorities;

  • Describe how health care providers’ bias causes racial disparities in access to health care and health status;

  • Discuss solutions for addressing health care providers’ bias.

 

"Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane," Dr. Rev. Martin Luther King Jr.(1)

The largest disparity in health status in the United States is between African-Americans and whites.(2) Some argue that biological differences between racial groups are the cause of these racial disparities. However, as proven by the Human Genome Project and noted by Nancy Krieger, the biological race theory is based on three flawed assumptions: that race is a valid biological category; that the genes which determine race are linked to the genes which affect health; and that the health of any community is mainly the consequence of the genetic constitutions of the individuals of which it is composed.(3) If race plays a role in racial disparities, it is because race is a powerful determinant of access to educational, housing, and employment opportunities.

Health care providers, regardless of race and ethnicity, also use race either explicitly and/or implicitly to determine who has access to health care services. Credible and robust research studies by social psychologists, medical researchers, and legal scholars have suggested that health care providers have explicit and/or implicit racial bias against African-Americans, which results in African-Americans' unequal access to health care and poor health status.(4)

This Cyberounds®discusses how health care providers' racial bias causes racial disparities in health status and access to health care, and then addresses strategies to overcome this bias.

Health Disparities Definition

Health disparities are defined as the differences in health between groups of people who have systematically experienced greater obstacles to health care services based on their racial group, socioeconomic status, or other characteristics historically linked to bias or exclusion.(5) Health care disparities affect both the quality and longevity of life. In the United States, as a result of racial disparities in access to health care, an estimated 83,570 African-Americans die each year.(6)

Racial Disparities in Access to Health Care

Although there have been many studies regarding racial disparities in access to health care, this Cyberounds® will review only a few. In the first study, published in 1996,(7) the investigators showed that physicians treated African-American Medicare patients less aggressively than white Medicare patients, who were more likely to be hospitalized for ischemic heart disease, have a mammography, and undergo coronary-artery bypass surgery, coronary angioplasty, and hip-fracture repair.(8) This was true even after controlling for income.

Likewise, a 1998 study found that African-Americans were less likely than whites to receive curative surgery for early-stage lung cancer, which is linked to increased mortality rates of African-Americans(9). The study showed that if African-American patients underwent surgery at a rate equal to whites, their survival rate would approach that of white patients.(10)

According to research also conducted in 1998 by a team from Harvard, African-American Medicare patients received poorer basic care than white Medicare patients who were treated for the same illnesses. (11) The study showed that only thirty-two percent of African-American Medicare patients with pneumonia were given antibiotics within six hours of admission, as compared to fifty-three percent of other Medicare patients with pneumonia.(12) Also, African-Americans with pneumonia were less likely to have blood cultures done during the first two days of hospitalization. The researchers noted that other studies had associated prompt administration of antibiotics and collection of blood cultures with lower death rates.(13)

African-American Medicare patients received poorer basic care than white Medicare patients.

In a study conducted in 1999, researchers evaluated the medical records of patients who underwent a coronary angiography during hospitalization to ascertain "whether there were differences by race and gender in the underutilization of [coronary artery bypass] surgery among patients for whom [this procedure] is the appropriate intervention." (14) They reported a significant racial disparity: African-American patients were only sixty-four percent as likely as white patients to receive surgery.(15)

In 2010, researchers showed that when receiving care in hospitals, African-American Medicare beneficiaries with diabetes received less than the medically necessary treatment compared to white Medicare beneficiaries.(16)

Finally, a 2013 clinical investigation demonstrated that African-Americans are more likely to die from coronary artery bypass grafting, abdominal aortic aneurysm repair, and resection for lung cancer than white patients.(17) These disparities in medical treatment and survival rates resulted from African-American's separate and unequal access to quality hospitals because even though African-Americans lived closer to high quality hospitals than whites they were more likely to undergo surgery at low-quality hospitals.(18) Many "decisions about where to go for major surgery [such as coronary artery bypass grafting, abdominal aortic aneurysm repair, and resection for lung cancer] are made by referring physicians, not by patients and their families," and the research clearly shows that the provision of primary care is racially separate and unequal, determining where patients have surgery.(19)

All of the studies discussed above, controlled for socioeconomic status, disease status, insurance status, and education level, suggest that the unequal treatment received by African-Americans, which causes racial disparities in health status, occurs as a result of their race. Race matters in health care because, as the groundbreaking 2003 Institute of Medicine Study, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare ("IOM study") asserts, racial bias is widespread in the health care delivery system, beginning "at the point of entry and continu[ing] throughout the secondary and tertiary pathways of the system."(20)

IOM Study

The Institute of Medicine (IOM) concluded that some health care providers, regardless of the providers' race or ethnicity, were racially biased against African-American patients, which, in turn, created a barrier to African-Americans' access to health care.(21) Not only did this racial bias prevent African-Americans from accessing health care services, it caused African-Americans to have poor health outcomes.

Racial bias is widespread in the health care delivery system.

The IOM study found evidence of poorer quality of care for minority patients in studies of cancer treatment, treatment of cardiovascular disease, and rates of referral for clinical tests, diabetes management, pain management, and other areas of care.(22)

Eleven years after the publication of the IOM study, racial bias continues to drive racial disparities in health status and access to health care. Racial bias in health care operates on three different levels: interpersonal, institutional, and structural. This Cyberounds® will only focus on interpersonal bias.

Interpersonal Racial Bias

Interpersonal bias is the explicit (conscious) and/or implicit (unconscious) use of prejudice in interactions between individuals.(23) Prejudice is a negative pre-judgment against a person or group.(24) An action based on racial prejudice is racial bias.(25) Interpersonal racial bias is defined as an explicit and/or implicit racially prejudicial action or comment by an individual which harms another person.(26) Interpersonal racial bias can occur between individuals of different races or between individuals of the same race.

According to psychiatrist Joel Kovel, there are two types of people who exhibit interpersonal racial bias: dominative and aversive racists.(27) A "dominative racist" is a person who is conscious of his or her prejudicial beliefs that members of one racial group (such as whites) are superior and acts based on these beliefs, while an "aversive racist" believes that everyone is equal but harbors contradicting, often unconscious, prejudicial beliefs that minorities (such as African-Americans) are inferior.(28) Over four decades of social psychology research suggests aversive racism has become the dominant form of interpersonal racial bias between African-Americans and whites in the United States.(29)

More recently, medical research studies have begun to study aversive racism in health care by measuring health care providers' implicit racial bias about African-Americans and the effect of these beliefs on health care providers' treatment decisions.(30) These studies show that instead of relying on individual factors and scientific facts, health care providers rely on their explicit and/or implicit racial biases.(31) This reliance results in the unequal treatment of African-Americans, which causes racial disparities in access to medical treatment and inequalities in mortality rates between African-Americans and whites.

Interpersonal Racial Bias and Racial Disparities

Empirical evidence of health care providers' implicit racial bias was first published in 1999 when Schulman et al.(32) investigated primary care physicians' perceptions of patients and found that a patient's race and sex affected the physician's decision to recommend medically appropriate cardiac catheterization. Specifically, African-Americans were less likely to be referred for cardiac catheterizations than whites, while African-American women were significantly less likely to be referred for treatment compared to white males.

That same year researchers found that African-Americans were less likely than whites to be evaluated for renal transplantation and placed on a waiting list for transplantation after controlling for patient preferences, socioeconomic status, the type of dialysis facility patients used, perceptions of care, health status, the cause of renal failure and the presence or absence of coexisting illnesses.(33)

In 2000, Dr. Calman, a white physician serving African-American patients in New York, wrote about his battle to overcome his own and his colleagues' racial prejudices, which often prevented African-Americans from accessing quality health care.(34) Drs. van Ryn and Burke conducted a survey of physicians' perceptions of patients(35) which demonstrated that physicians rated African-American patients as less intelligent, less educated, and more likely to fail to comply with physicians' medical advice.(36) Physicians' perceptions of African-Americans were negative even when there was individual evidence that contradicted the physician's prejudicial beliefs.

Dr. van Ryn repeated this study (in 2006) using candidates for coronary bypass surgery. Again, the physicians surveyed exhibited prejudicial beliefs about African-Americans' intelligence and ability to comply with medical advice.(37) The physicians acted upon these prejudicial beliefs by recommending medically necessary coronary bypass surgery for African-American males less often than for white males.

Most recently, a 2008 study reported that physicians subconsciously favor white patients over African-American patients.(38) In this study, physicians' racial attitudes and stereotypes were assessed and then physicians were presented with descriptions of hypothetical cardiology patients differing in race. Although physicians reported not being explicitly racially biased, most physicians regardless of race or ethnicity held implicit negative attitudes about African-Americans, and thus were aversive racists.(39) This is significant because research has shown that the stronger the implicit bias, the less likely the physician was to recommend the appropriate medical treatment for African-American patients for heart attacks.(40)

Physicians subconsciously favor white patients over African-American patients.

In addition to the harm caused by unequal treatment due to implicit racial bias, African-Americans perceive this implicit bias and respond negatively.(41) African-Americans often sense providers' implicit racial bias against them, which negatively affects their health by serving as a barrier to accessing health care services. For example, African-Americans' perception of racial prejudice inside the health care delivery system results in African-Americans' non-adherence to treatment regimens, delays in seeking care, an interruption in continuity of care, and reduced health status.(42)

African-Americans react most negatively to physicians who were aversive racists (those individuals who exhibited low explicit prejudice, but high implicit prejudice), compared to physicians who were not racist (those that exhibited low explicit and implicit prejudice) or were 'dominative racists' (those who exhibited high explicit prejudice).(43) Patients perceived aversive racists as deceitful compared to dominative racists, who were clear and honest about their prejudicial beliefs. This perception may explain why African-Americans are less compliant with treatment recommendations made by physicians who they feel are aversive racists.

In the past, the United States government did not provide funding or support to address health disparities, but this changed with the passage of the Patient Protection and Affordable Health Care Act ("ACA" or "the Act").

Government Support for Change

Passed in 2010, the ACA ("Obamacare") has the potential to address provider racial bias.(44) Although the central focus of the ACA is to regulate the health insurance industry and increase access to health insurance for the uninsured, it also includes provisions to put an end to health disparities. Specifically, the Act provides measures for assessing health disparities in accessing health care and the provision of quality health care.

Section 6301 creates a Patient-Centered Research Institute that is required to identify a research agenda, which includes addressing health disparities. Sections 10302 and 10303 of the ACA mandate that the Secretary of the U.S. Department of Health and Human Services ("HHS") develop a national strategy to improve the quality of health to reduce health disparities. Section 10303 further provides for the creation of quality development measures that allow the assessment of health disparities. Medicare providers will also receive additional payment bonuses for rectifying health disparities by increasing staffing in long-term care facilities.

Section 3501 creates quality improvement programs that provide technical assistance grants to health care providers to address health disparities. The Act also suggests putting an end to disparities through the use of preventive care, health education programs, language services, community outreach, and cultural competency training. To this end, Section 10503 of Act expanded access to primary health care by investing eleven billion dollars into the Health Research Services Administrations Community Health Center Program.

Although the ACA does not specifically address or mention providers' implicit racial bias, Section 1557 of the ACA notes that the requirements of nondiscrimination apply to the ACA.(45) Furthermore, many of the Sections of the ACA discussed above provide either funding for research to determine the cause of existing health disparities in access or programmatic support for health care providers to put an end to health disparities.

Hence, with government support and funding, the time is now for health care providers to become proactive in developing ways to address their implicit racial bias, a significant factor in racial disparities in access to health care and health status. Research suggests that making health care providers aware of their implicit racial bias, and how it can influence outcomes of medical encounters, can help motivate health care providers to correct their implicit bias.(46) Consequently, one way to eradicate provider racial bias is through a change in health care provider continuing medical education and medical school education.

Solutions

Although unconscious, implicit bias is malleable. Since 2001, psychology research studies have shown that implicit racial bias can be changed through re-education methods, such as showing pictures of African-Americans associated with good things and pictures of infamous whites.(47) For example, Drs. Dasgupta and Greenwald tested subjects' pro-white implicit bias before and after showing the subjects images of ten famous and highly regarded African-Americans, such as Dr. Rev. Martin Luther King, and ten images of infamous white Americans, such as Charles Manson. They found that viewing the images weakened the subjects' pro-white implicit bias.(48) This re-education should be integrated into continuing medical education and medical school education through state medical education, cultural competency training, and civil rights training. Additionally, to equalize health care, providers need to be trained in health equity.

Implicit racial bias can be changed through re-education methods.

Health Provider Training

In order to maintain a license to practice medicine, many states require health care providers to take continuing medical education ("CME"). Additionally, HHS has two different health care provider training initiatives. The first addresses cultural competency and the second focuses on civil rights laws. Neither state CME nor HHS' health care provider initiatives address providers' racial bias.

State CME CME is required to ensure that health care providers maintain competency in their field and learn about new and developing areas in their field of practice. Each state has different CME requirements.(49)

HHS Training: HHS' Office of Minority Health has created voluntary national culturally and linguistically appropriate services ("CLAS") standards that are intended to provide health equity and eliminate health care disparities.(50) The CLAS standards are achieved through cultural competency training, which includes equitable governance, diverse leadership and health care workforce, communication and language assistance programs and engagement by health care facilities and accountability.

HHS' Office of Civil Rights has partnered with the National Consortium for Multicultural Education for Health Professionals to create a medical school course concerning civil rights laws and health disparities.(51) In this course, providers are educated about unequal access to health care, racial disparities in health outcomes, and the legal ramifications for racial bias in health care.

Implicit Racial Bias Training: No state CME mentions a requirement to take implicit racial bias classes. Furthermore, although both HHS courses provide invaluable information and training, they fail to address providers' implicit racial bias and discuss re-training.

Thus, required re-training should be added to each state's CME and medical school cultural competency and civil rights curricula in order to educate health care providers about their implicit racial bias. Additionally, these programs should discuss how health care providers' racial biases affect their treatment recommendations and cause poor patient outcomes. The programs must also inform providers about how their bias affects their patients' interaction with the medical system. Finally, the training should include re-education exercises to change health care providers' implicit racial bias.

Health Equity

HHS has also developed the National Stakeholder Strategy for Achieving Health Equity ("Strategy").(52) The Strategy includes a set of common goals and objectives for the public and private sector to use in order to ensure that racial and ethnic minorities reach their full health potential. To attain health equity within the health care delivery system, it is imperative that health care providers treat all patients the same, regardless of race and ethnicity. Unfortunately, the Strategy does not address providers' implicit racial bias.

For example, one objective of the Strategy is to increase the number of racial and ethnic minority physicians treating minorities. This is significant because seventy-five percent of African-Americans' medical interactions are with physicians who are not African-American.(53) Studies have found that medical interactions between racially different patients and physicians are "characterized by less patient trust, less positive affect, fewer attempts at relationship building, and less joint decision-making."(54)

It has been shown that African-American patients, when compared to white patients, are less likely to receive encouragement to participate in medical decision-making and less likely to receive sufficient information from their physicians about their medical condition.(55) Increasing the diversity of physicians, therefore, will improve medical interactions between physicians and patients. Nevertheless, as discussed above, physicians of all races and ethnicities have been shown to be racially biased against African-American patients. Thus, health equity must also include training to overcome physicians' implicit racial bias.

Simply increasing the diversity of physicians is, however, not enough to equalize access to health care and ensure that racial minorities reach their full health potential. Health care providers who serve African-American often do not have the same board certification, hospital staffing relationships, and resources as health care providers who provide care to whites. (56) Even as HHS increases the number and diversity of health care providers within African-American communities, it is important that HHS ensures that the providers have the same board certification, hospital staffing relationships, and resources as those serving white patients. Then, and only then, will African-Americans have equal access to health care that ensures they reach their full health potential.

Conclusion


Our urgent responsibility is to assure adequate health care to all Americans, I think that none would deny that consideration of race or color has no place with regard to the ailing body or the healing hand, Anthony J. Celebrezze. (57)

As a result of racial disparities in health status and access to health care, an estimated 4.2 million African-Americans have died unnecessarily since the 1960s.(58) Racial disparities persist in the United States because we continue to ignore one of the root causes of the disparities: racial bias within the health care delivery system. Decades of medical research studies show that African-Americans continue to receive separate and unequal treatment compared to whites in hospitals, nursing homes and physician offices in part because of providers' racial bias. In order to begin to address racial bias in health care, health care providers need to be educated about their racial bias and the role their bias plays in treatment decisions, which affects their patients' health status.

Until this re-education of health care providers occurs, more African-Americans will unnecessarily die and racial disparities in access to health care and health status will persist unfettered.


Footnotes

1Dr. Rev. Martin Luther King, Jr., in a speech at the Second National Convention of the Medical Committee for Human Rights, Chicago, IL, March 25, 1966.
2David Satcher et al., What If We Were Equal? A Comparison Of The Black-White Mortality Gap In 1960 and 2000, 24 HEALTH AFF. 459, 459 (2005).
3Mary Bassett & Nancy Krieger, The Health of Black Folk: Disease, Class, and Ideology in Science, 38 MONTHLY REV. 74, 75Ac€??oe9 (1986).
4Ruqaiijah Yearby, Breaking the Cycle of 'Unequal treatment"?? with Health Care Reform: Acknowledging and Addressing the Continuation of Racial Bias, 44 CONN. L. REV. 1281 (2012); Janice Sabin et al., Physicians' Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender, 20 J. HEALTH CARE POOR & UNDERSERVED 896, 907 (2009); H. Jack Geiger, Health Disparities: What Do We Know? What Do We Need to Know? What Should We Do?, in GENDER, RACE, CLASS, AND HEALTH, at 261, 261-288 (2006).
5NatIonal Partnership for Action to End Health Disparities, Health Equity & Disparities, http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34 (last visited July 17, 2014).
6David Satcher et al., What If We Were Equal? A Comparison Of The Black-White Mortality Gap In 1960 and 2000, 24 HEALTH AFF. 459, 459 (2005).
7Marian E. Gornick et al., Effects of Race and Income on Mortality and Use of Services Among Medicare Beneficiaries, 335 NEW ENG. J. MED. 791, 791-792 (1996).
8Id. at 793-794.
9Peter B. Bach et al., Racial Differences in the Treatment of Early-Stage Lung Cancer, 341 NEJM. 1198, 1198-1202 (1999).
10Id. at 1202.
11 John Z. Ayanian et al., Quality of Care by Race and Gender for Congestive Heart Failure and Pneumonia, 37 MED. CARE 1260, 1260–61 and 1265 (1999).
12 Id. at 1265.
13 Id.; see also Manreet Kanwar et al., Misdiagnosis of Community-Acquired Pneumonia and Inappropriate Utilization of Antibiotics: Side Effects of the 4-h Antibiotic Administration Rule, 131 CHEST 1865, 1865 (2007); Mark L. Metersky et al., Predicting Bacteremia in Patients with Community-Acquired Pneumonia, 169 AM. J. RESPIRATORY & CRITICAL CARE MED. 342, 342 (2004).
14 Edward L. Hannan et al., Access to Coronary Artery Bypass Surgery by Race/Ethnicity and Gender Among Patients Who Are Appropriate for Surgery, 37 MED. CARE 68, 69 (1999).
15 Id. at 73.
16 Julie P.W. Bynum, et al, Measuring Racial Disparities in the Quality of Ambulatory Diabetes Care, 48 MED. CAR. 1057, 1059 (2010).
17 Justin Dimick, Black Patients More likely than Whites to Undergo Surgery at Low-Quality Hospitals in Segregated Regions, 32 HEALTH AFF. 1046, 1047 (2013).
18 Id. at 1048.
19 Id. at 1051.
20 Sara Rosenbaum & Joel Teitelbaum, Civil Rights Enforcement in the Modern Healthcare System: Reinvigorating the Role of the Federal Government in the Aftermath of Alexander v. Sandoval, 3 YALE J. HEALTH POL’Y L. & ETHICS 215, 218 (2003).
21 INST. OF MED., UNEQUAL TREATMENT: CONFRONTING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE at 5–9, 11–12 (Brian D. Smedley et al. eds., 2003).
22 Id. at 53–55, 57–59, 60–64.
23 See Andrew Grant-Thomas & john a. powell, Toward a Structural Racism Framework, POVERTY & RACE 3, 3–6 (2006).
24 Jay Newman, Prejudice as Prejudgment, 90 ETHICS 47, 47–9 (1979).
25 Beverley Daniels Tatum, Defining Racism: ??oeCan We Talk?,??? in RACE, CLASS, AND GENDER IN THE UNITED STATES 124, 127 (Paula S. Rothenberg ed., 2004).
26 Ruqaiijah Yearby, Breaking the Cycle of ??oeUnequal treatment??? with Health Care Reform: Acknowledging and Addressing the Continuation of Racial Bias, 44 CONN. L. REV. 1281, 1296 (2012).
27 Joe Kovel, WHITE RACISM: A PSYCHOHISTORY 31–2 (Columbia University Press,1984).
28 See id. at 32.
29 See Samuel L. Gaertner & John F. Dovidio, Understanding and Addressing Contemporary Racism: From Aversive Racism to the Common Ingroup Identity Model, 61 J. SOC. ISSUES 615, 618-23 (2005).
30 Janice Sabin et al., Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender, 20 J. HEALTH CARE POOR & UNDERSERVED 896, 897–98, 906–07 (2009); Michelle van Ryn & Jane Burke, The Effect of Patient Race and Socio-Economic Status on Physicians’ Perception of Patients, 50 SOC. SCI. & MED. 813, 813–14 (2000).
31 Janice Sabin et al., Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender, 20 J. HEALTH CARE POOR & UNDERSERVED 896, 898 and 906-8 (2009); Michelle van Ryn et al., Physicians’ Perceptions of Patients’ Social and Behavioral Characteristics and Race Disparities in Treatment Recommendations for Men with Coronary Artery Disease, 96 AM. J. PUB. HEALTH 351, 351–54 (2006); Michelle van Ryn & Jane Burke, The Effect of Patient Race and Socio-Economic Status on Physicians’ Perception of Patients, 50 SOC. SCI. & MED. 813, 813–14 (2000).
32 Kevin A. Schulman et al., The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catherization, 340 NEJM 618, 622–24, 624 tbl.4 (1999).
33 John Ayanian, The Effect of Patients’ Preferences on Racial Differences in Access to Renal Transplantation, 341 NEJM 1661, 1661 and 1663 (1999).
34 Neil S. Calman, Out of the Shadow: A White Inner-City Doctor Wrestles with Racial Prejudice, 19 HEALTH AFF. 170, 172–74 (2000).
35 Michelle van Ryn & Jane Burke, The Effect of Patient Race and Socio-Economic Status on Physicians’ Perception of Patients, 50 SOC. SCI. & MED. 813, 813–14 (2000).
36 Id. at 821.
37 Michelle van Ryn et al., Physicians’ Perceptions of Patients’ Social and Behavioral Characteristics and Race Disparities in Treatment Recommendations for Men with Coronary Artery Disease, 96 AM. J. PUB. HEALTH 351, 351–54 (2006).
38 Alexander R. Green et al., Implicit Bias Among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients, 22 J. GEN. INTERNAL MED. 1231, 1235–36 (2007).
39 Id. at 1234 tbl.1,1235–36.
40 Id. at 1235.
41 Louis A. Penner et al., Aversive Racism and Medical Interactions with Black Patients: A Field Study, 46 J. EXPERIMENTAL SOC. PSYCHOL. 436, 438 (2010).
42 Janice Sabin et al., Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender, 20 J. HEALTH CARE POOR & UNDERSERVED 896, 907 (2009).
43 Louis A. Penner et al., Aversive Racism and Medical Interactions with Black Patients: A Field Study, 46 J. EXPERIMENTAL SOC. PSYCHOL. 436, 436-38 (2010).
44 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1, 124 Stat. 119, 119 (2010).
45 42 U.S.C.A. § 18116 (2010).
46 John F. Dovidio, et al., Disparities and Distrust: The Implications of Psychological Processes for Understanding Racial Disparities in Health and Health Care, 67 SOC. SCI. & MED. 478, 483 (2008).
47 Irene V. Blair, The Malleability of Automatic Stereotypes and Prejudices, 6 PERS. SOC. PSYCHOL. REV. 242-61 (2002); Nilanjana Dasgupta & Anthony G. Greenwald, On the Malleability of automatic attitudes: Combatting Automatic Prejudice With Images Of Admired and Disliked Individuals, 81 J. OF PERS. AND SOC. PSYCHOL. 800-814 (2001); and Laurie A. Rudman, et al, ??oeUnlearning??? Automatic Biases: The Malleability Of Implicit Prejudice And Stereotypes, 81 J. OF PERS. AND SOC. PSYCHOL. 856-68 (2001).
48 Nilanjana Dasgupta & Anthony G. Greenwald, On the Malleability of automatic attitudes: Combatting Automatic Prejudice With Images Of Admired and Disliked Individuals, 81 J. OF PERS. AND SOC. PSYCHOL. 800, 812-4 (2001).
49 State CME Requirements, http://www.medscape.org/public/staterequirements (last visited July 17, 2014).
50 Office of Minority Health, The National CLAS Standards, http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 (last visited July 17, 2014).
51 Stopping the Discrimination Before it Starts: The Impact of Civil Rights Laws on Health Care Disparities- A Medical School Curriculum, http://www.hhs.gov/ocr/civilrights/resources/training/pptworkshop.pdf (last visited July 17, 2014).
52 HHS, National Partnership for Action to End Health Disparities, http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286 (last visited July 17, 2014)
53 Louis A. Penner et al., Aversive Racism and Medical Interactions with Black Patients: A Field Study, 46 J. EXPERIMENTAL SOC. PSYCHOL. 436, 436 (2010).
54 John F. Dovidio et al., Disparities and Distrust: The Implications of Psychological Processes for Understanding Racial Disparities in Health and Health Care, 67 SOC. SCI. & MED. 478, 480–82 (2008).
55 Id.
56 Peter Bach, Primary Care Physicians Who Treat Blacks and Whites, 351 NEJM 575, 582 (2004).
57 Anthony J. Celebrezze, Secretary of HHS, Speech on March 9, 1964, in THE U.S. COMMISSION ON CIVIL RIGHTS, REPORT ON EQUAL OPPORTUNITY IN HOSPITALS AND HEALTH CARE FACILITIES 6 (1965).
58 David Satcher et al., What If We Were Equal? A Comparison Of The Black-White Mortality Gap In 1960 and 2000, 24 HEALTH AFF. 459, 459 (2005).