Since the Civil War access to health care in the United States has been racially unequal. This racially unequal access to health care remains even after the passage of Title VI of the Civil Rights Act of 1964 ("Title VI") and the election of an African-American President. Both of these events held the promise of equality, yet the promise has never been fulfilled. Now, many hail the passage of the Patient Protection and Affordable Health Care Act ("ACA") as the biggest governmental step in equalizing access to health care because it has the potential to increase minority access to health insurance. However, access to health insurance means little when physicians continue to exhibit conscious and/or unconscious racial prejudice keeping them from adequately treating African-Americans (interpersonal racial bias); health care entities close and relocate leaving minority neighborhoods without medical facilities (institutional racial bias); and the health care system is based on ability to pay, not need, leaving those with poor health and no money, usually minorities, without access to health care (structural racial bias). Thus, in order to equalize access to health care, the government must acknowledge that racial bias (interpersonal, institutional, and structural) is the central cause of racial disparities in the United States, and implement institutional and structural changes to address racial bias in health care, such as integrating quality improvement programs and civil rights enforcement. Then, and only then, will the cycle of unequal treatment be broken.

The election of President Obama prompted many Americans to declare that the United States had entered into a ‘post-racial’ era in which racial bias no longer existed and African-Americans are treated equally. However, racial bias did not cease before or after the election of an African-American president. In fact, empirical evidence shows that African-Americans continue to be treated unequally because of racial bias in decisions regarding bankruptcy, residential zoning, mortgage lending, apartment rental, and housing rental. One of the most poignant examples of the continuation of racial bias in a “post-racial” era was a Cincinnati landlord’s posting of a “White Only” sign by a pool in the summer of 2011. The persistence of racial bias in a “post-racial” era is also evident in the health care system, where the unequal treatment of African-Americans because of their race is the main cause of the continuation of racial disparities in health care. Unequal treatment of African-Americans in health care is nothing new.

In 2002, the ground breaking Institute of Medicine Study, (“IOM study”) Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, noted that some health care providers, such as physicians, were influenced by a patient’s race, which, in turn, is a barrier to African-Americans’ access to health care. Not only has this racial bias prevented African-Americans from accessing health care services, it has caused African-Americans to have poor health outcomes. The IOM study also 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. Ten years after the publication of this sweeping study, access to health care remains unequal and, as a result, racial bias continues to drive racial disparities in health care. Racial bias in health care operates on three different levels: interpersonal, institutional, and structural.

Interpersonal bias is the conscious (explicit) and/or unconscious (implicit) use of prejudice in interactions between individuals. Interpersonal bias is best illustrated by physicians’ treatment decisions based on racial prejudice, which results in the unequal treatment of African-Americans. According to René Bowser’s seminal article, Racial Profiling in Health Care: An Institutional Analysis of Medical Treatment Disparities, these racial disparities in treatment often lead to racial disparities in mortality rates between African-Americans and Caucasians. Institutional bias operates through organizational structures within institutions, which “establish separate and independent barriers” to health care services. According to Professor Brietta Clark, institutional bias is best demonstrated by hospital closures in African-American communities. Finally, operating at a societal level, structural bias exists in the organizational structure of society, which “privile[ges] some groups…[while] denying others access to the resources of society,” which includes health care. An example of structural bias is the provision of health care based primarily on ability to pay, rather than on the needs of the patient.

Unfortunately, the government often ignores the significance of institutional and interpersonal biases in causing racial disparities in health care, and by extension, overall health, even though such biases are among the causes identified in numerous government reports, initiatives, and empirical research studies conducted over the past decade. The Patient Protection and Affordable Care Act (Patient Protection Act or the Act) exemplifies the government’s failure to acknowledge the interconnectedness of racial bias and racial disparities. Although the Patient Protection Act explicitly mentions disparities in health care and provides several mandates to address these disparities, it fails to acknowledge or target the root causes of racial disparities — racial bias. Therefore, this Article argues that the Patient Protection Act will not fully equalize access to health care for minorities. In fact, the Act may exacerbate the existing problem of racial disparities because it proposes individual and community based solutions that will not put an end to interpersonal, institutional, and structural racial bias, which cause racial disparities in health care.

The debate surrounding the Patient Protection Act has rarely focused on issues related to racial disparities. My article begins to fill this void. Part II provides a brief historical context for the Patient Protection Act by discussing previous legislation that addressed racial disparities in health care and governmental action to measure and eradicate racial disparities. Part III then reviews the root cause of racial disparities — racial bias — as evidenced by empirical data. Next, Part IV examines specific sections of the Patient Protection Act, which address racial disparities, and discusses the strengths and weakness of the Act. Finally, Part V suggests some solutions.


implicit racial bias, interpersonal racial bias, institutional bias, structural bias, post-racialism, health care reform, Patient Protection and Affordable Care Act, nursing home, hospital

Publication Date


Document Type


Place of Original Publication

Connecticut Law Review

Publication Information

Breaking The Cycle Of ‘Unequal Treatment’


44 Conn. L. Rev. 1281 (2012)


COinS Ruqaiijah Yearby Faculty Bio