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The author’s focus in this article is on racial disparities in medical care provision--that is, on differences in the services that clinically similar patients receive when they present to the health care system. Racial disparities in health status, which is not greatly influenced (on a population-wide basis) by medical care, are beyond his scope here. Disparities in medical care access-potential patients' ability, financial and otherwise, to gain entry to the health care system in the first place, are also outside his focus. The author begins this article by putting the problem of racial disparities in medical care provision within the larger context of disparities in health status and medical care access.

In Part I, the author concedes: (1) that medical care is almost certainly less important as a determinant of health than are social and environmental influences, and (2) that inequalities in Americans' ability to gain entry to the health care system probably play a larger role in medical treatment disparities than do racial differences in the care provided to people who succeed in gaining entry. He then briefly examines the moral politics behind the appearance of racial disparity in health care provision on the national policy agenda, ahead of disparities in health status and medical care access. In Part II, the author considers the links between clinical discretion and racial disparities in health care provision. He argues that pervasive uncertainty and disagreement, about both the efficacy of most medical interventions and the valuation of favorable and disappointing clinical outcomes, leave ample room for discretionary judgments that produce racial disparities. Neither existing institutional and legal tools, nor prevailing ethical norms, impose tight constraints on this discretion. As a result, provider (and patient) presuppositions, attitudes, and fears that engender racial disparities have wide space in which to operate. In Part III, the author refines this argument, pointing to a variety of extant organizational, financial, and legal arrangements that interact perniciously with psychological and social factors to potentiate racial disparities. Part IV considers the impact of the managed care revolution, contending that its cost containment strategies both contribute to racial differences in health care provision and creates opportunities for reducing some of these disparities. Part V closes with some recommendations as to how health care institutions and the law might respond pragmatically to racial disparities even as they pursue other important policy goals.

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1 Yale J. Health Pol'y. L. & Ethics 95-131 (2001)