by Michelle Hampton, Associate Member, University of Cincinnati Law Review Vol. 93
I. Introduction
Health disparities are preventable outcomes and differences that some demographics and populations adversely experience, such as disease, injury, violence, or opportunities, more than others.[1] For example, despite significant advances in medical technology and healthcare, Black women continue to experience significantly worse maternal health outcomes compared to women of other races.[2] Thus, health disparities may be observed in the risks, prevalence, or problems resulting from specific behaviors, as well as the incidence, prevalence, and mortality from conditions, diseases, and/or disorders.[3] However, some disparities may be easier to observe when considering healthcare access, quality, and utilization.[4] Additionally, some disparities may be observed within healthcare facilities through the service and delivery of clinical care therein.[5] The U.S. Department of Health and Human Services (“HHS”) Office of Civil Rights (“OCR”) investigates HHS-funded programs and services to ensure nondiscrimination.[6] The OCR works to increase the number of people who have access to quality health care services.[7]
HHS OCR found that groups of people with specific racial and ethnic backgrounds, people with limited English proficiency, older adults, and people with various other disparities often experience issues with barriers and access to adequate health care.[8] HHS OCR helps to ensure that healthcare services and programs the government supports financially comply with applicable federal civil rights laws.[9] Title VI of the Civil Rights Act of 1964 (“Title VI”) prohibits discrimination based on race, color, and national origin in programs and activities receiving federal financial assistance.[10] The OCR conducts investigations to determine whether policies or practices have an unequal impact on persons and individuals.[11] The OCR safeguards particular persons and individuals so that they are not denied or deterred from obtaining benefits based on demographics or differences compared to another similarly situated individual.[12] If an individual believes that they have been discriminated against by a state or local government healthcare or social services agency, they can file a complaint with the OCR.[13]
This article will discuss the case of Collins v. Centers for Medicare and Medicaid Services, et al., which uncovers an issue of first impression where the court must analyze whether Title VI extends to a visitor of a federally funded healthcare institution.[14] Part II reviews the functions of the OCR within HHS for healthcare providers and institutions when facing an allegation of discriminatory treatment or conduct. Part II will also provide a cursory review of the facts involved in Collins v. Centers for Medicare and Medicaid Services, et al. Part III will discuss the potential outcomes of this decision and how the Court may be leaning in its ruling. Lastly, Part VI will conclude with a forecast regarding the future of healthcare for Black women and the unlikelihood of the future existence of the OCR within HHS.
II. Background
A. The U.S. Department of Health and Human Services Office of Civil Rights
The OCR within HHS conducts investigations to determine whether policies or practices have an unequal impact on similarly situated individuals due to acts of discrimination violating Title VI.[15] To initiate an investigation, an individual must file a complaint with the OCR.[16] A complaint filed with the OCR must: 1) be filed in writing through the means accepted by the OCR; 2) name the healthcare or social service provider involved and describes the acts or omissions believed to violate civil rights laws or regulations; and 3) be filed within 180-days of the individual’s knowledge of when the act or omission complained of occurred.[17] Once the complaint is received, the OCR determines if it has the legal authority to review and investigate the complaint.[18] The OCR retains authority to review complaints involving recipients of federal financial assistance from HHS.[19] Once a complaint is received by the OCR involving an HHS-funded institution or facility, an investigation will begin that involves interviewing witnesses, such as the complainant, obtaining documentation, and making visits to the appropriate sites or agencies involved in the complaint.[20]
At the end of the investigation, the OCR issues a letter presenting its decision on whether the individual’s rights have been violated.[21] If a decision is reached where an individual’s rights have indeed been violated, the healthcare provider or government agency that violated the individual’s rights is given a specific period to correct the violation or provide the OCR with a plan for corrective action.[22] If the provider is unwilling to take corrective action, the OCR will recommend initiating enforcement proceedings.[23] If such a violation by a provider continues without remedy, federal financial assistance may be terminated to the provider or agency.[24]
B. Case Overview: Collins v. Centers for Medicare and Medicaid Services, et al.
In Collins, Shawanda Collins’ mother, Veronica Lee Collins Dixon, was admitted to Aurora St. Luke’s Medical Center for several ailments that required medical treatment and attention.[25] While Veronica was receiving care, various members of the medical team and staff made false allegations against Shawanda to prevent her from visiting her mother.[26] Shawanda had expressed concerns regarding the medical treatment that her mother was receiving to the appropriate supervisor and requested that her mother be transferred to another hospital floor to be under the care of a different group of medical care providers.[27]
In response to this request, the medical staff falsely accused Shawanda of saying that she “was going to shoot up the hospital,” and further, falsely portrayed her as an “angry black woman” so that she would be prohibited from visiting her mother in the future.[28] Hospital security investigated these allegations and found them to be false, after which, medical staff members claimed they were afraid of Shawanda.[29] Aurora staff members claimed that Shawanda “threatened a nurse” and was escorted out of the hospital, but security found no surveillance video showing Shawanda being escorted out of the hospital.[30] Aurora staff also turned off the phone to Shawanda’s mother’s hospital room and did not allow Shawanda to visit or speak with her mother.[31] A medical provider on her mother’s medical team falsely noted in the chart that they had received “various permissions” from her mother’s authorized power of attorney, but her mother did not have a power of attorney.[32] Shawanda’s mother, Veronica Lee Collins Dixon, passed away after allegedly receiving deficient medical care at Aurora.[33]
Shawanda filed suit in federal court, pro se, with allegations of racial discrimination and violations of her mother’s rights.[34] Shawanda further claimed that Aurora has no record of ever being accredited by the Joint Commission and had been fraudulently submitting Medicare and Medicaid claims for years.[35] Shawanda also claimed that the Centers for Medicare and Medicaid Services and the Wisconsin Department of Health Services “failed in their duty to protect hospital patients from harm through processes, procedures, and instruction manuals.”[36] Shawanda asserted that these failures disproportionately affected African Americans.[37] The court identified that Shawanda is not a lawyer, and thus was likely the reason for some of the incorrect claims asserted in the complaint, and therefore provided her with additional time to amend her complaint.[38] Shawanda named additional defendants in her amended complaint and modified her claims.[39] However, the court determined that she, again, failed to state federal claims against any defendant and dismissed her amended complaint.[40]
On appeal, the United States Court of Appeals for the Seventh Circuit agreed with the district court that most of Shawanda’s claims failed.[41] Yet, it concluded that she sufficiently pled that Aurora unlawfully blocked her from the hospital because of her race.[42] The Seventh Circuit reasoned that the complaint adequately pleads that Aurora intentionally discriminated against her by shutting her out of a federally funded hospital because she is African American.[43] Ultimately, the Seventh Circuit decided to remand the matter, with an issue of first impression, back to the district court to determine whether Title VI extends to a visitor, like Shawanda, of a federally funded healthcare institution.[44]
III. Discussion
Congress enacted the Civil Rights Restoration Act of 1987 (“Restoration Act”), which clarified that a recipient of federal funds may not discriminate in any of its operations and provided explanatory terms and definitions for “program or activity” within the meaning of several civil rights laws, including Title VI.[45] Title VI should extend to visitors within a federally funded healthcare facility. Regardless of the situation or circumstance, a visitor to a healthcare facility could become a patient while visiting someone who is a patient of the facility. However, the definition of “operations” as utilized in the Restoration Act could be argued to mean many things because no explanatory terms or definitions outline what should be considered an “operation” within the Restoration Act. Moreover, suppose a federally funded healthcare institution is open to the public and actively accepting patients. In that case, the facility’s functionality could be deemed as the institution being able to fully “operate.” Therefore, prohibitions on discrimination identified under Title VI should apply to those, including patients and visitors, benefiting from the operation or functionality of the healthcare institution. However, instead of interpreting Congress’s intention behind the use of “operations,” the Seventh Circuit analyzed case law interpretations of what it means to be within the boundaries of the zone of interests as determined in Heart of Cardon.[46]
The zone of interests analysis asks whether a “particular class of persons has a right to sue under [a specific] substantive statute.”[47] Furthermore, by “using traditional tools of statutory interpretation,” a court must determine “whether a legislatively conferred cause of action encompasses a particular plaintiff’s claim.”[48] This analysis asks whether the statute arguably protects the interest a would-be plaintiff seeks to advance.[49] The zone of interests analysis may be broken down into two steps: 1) identify the purpose of a particular statutory provision and the interests that are argued to be protected by it; and 2) determine whether the interests claimed by the plaintiff are among those statutory interests.[50] This is the analysis that the Seventh Circuit has remanded to be reviewed by the U.S. District Court for the Eastern District of Wisconsin through briefs submitted from both parties.[51] The court is asking both parties to prepare briefs applying the test from Heart of Cardon regarding the zone of interests, to further their arguments in Collins.[52] The zone of interests, previously understood as protected under Title VI, applied solely to the recipient of federal funds through healthcare services and programs rendered to an individual.[53] As an issue of first impression, the court in Collins must review whether the zone of interests extends to Shawanda, as a visitor, not as a direct recipient of federal funds through healthcare services rendered.
The zone of interests and its protections outlined in Title VI should be extended to visitors who find themselves in a federally funded healthcare institution that is fully functional and operational and actively accepting patients. However, with changes in government administration, changes with HHS and the OCR, and the overturn of the Chevron Doctrine, likely, the district court will wrongly reason that the zone of interests boundary to prohibit discrimination in federally funded healthcare institutions under Title VI does not extend to visitors who have been racially discriminated against in such facilities.[54] But this article shall remain hopeful that the court will determine instead that the zone of interest, as identified in Heart of Cardon, under Title VI should apply to visitors who have been discriminated against based on racial discrimination.
Unfortunately, as the new administration wages on, it is difficult to determine if the federal government will ever acknowledge that racial discrimination exists. The government has removed almost all of the information related to the OCR within HHS. Thus, even if the court remained undecided on this issue of first impression, it would not be able to turn to HHS for its interpretation of “operation” due to the reversal of Chevron deference and the sweeping dismantling and winding down of departments and agencies under the new administration.
Again, looking ahead with optimism for the court to render a fair and accurate decision and reviewing the zone of interests under Heart of Cardon, it may be argued that Collins meets the test’s standards. In reviewing the first element of the test, Title VI clearly illustrates protections for discriminatory treatment in facilities or institutions that receive federal funds and further clarifies its definition and reach of protections through the Restoration Act. Shawanda Collins, identifying as a Black woman, qualifies for protection under this provision within the test’s first prong, identifying a zone of interest. The interests protected by this provision are equitable access to quality health care and healthcare facilities by all individuals, regardless of race or ethnicity.
Looking to the second element, when considering the totality of the circumstances, the fundamental issue claimed by Shawanda Collins was that she experienced disparate treatment based on Aurora’s discriminatory treatment against her as a visitor and allegedly against her mother as a patient based on their racial identity – Black or African American.[55] Shawanda’s claim is on point and satisfies the second element of the zone of interests prong that identifies a key component of a statutory interest intended to be protected by Congress. An additional argument to be raised to substantiate Shawanda’s claims further is for the court to interpret legislative intent within the meaning of “operation” in the Restoration Act. The court needs to identify whether “operation” is as simple as having a building or institution open and operational, which works in favor of Shawanda as a visitor, or whether “operation” shall be interpreted as the intentional use of resources within a federally funded healthcare institution.
IV. Conclusion
Considering the instability of current political changes and climate, this could not be a more uncertain time to have such an issue of first impression that hinges on several surrounding, competing, and politically charged factors. Empowering Black women to advocate for themselves within the healthcare system is crucial to overcoming disparities.[56] This should extend to all minorities, especially Black women, as both a visitor and a patient within a federally funded healthcare institution. Under the letter of the law and potentially under a different administration, the U.S. District Court for the Eastern Division of Wisconsin would be able to thoroughly analyze the issue and provide sound precedent for similar matters to come with such a landmark decision in expanding racial discriminatory protections to visitors of healthcare facilities. Nonetheless, this article remains hopeful that the U.S. District Court for the Eastern District of Wisconsin will interpret the law to rule in favor of Shawanda Collins.[57]
[1] What is Health Equity?, Ctr. for Disease Control (June 11, 2024), https://www.cdc.gov/health-equity/what-is/index.html.
[2] Black Maternal Health Disparities: Understanding and Resources, Univ. of Cincinnati Health (Apr. 25, 2024) https://www.uchealth.com/en/media-room/articles/black-maternal-health-disparities-understanding-and-resources.
[3] Jennifer Alvidrez et al, The National Institute on Minority Health and Health Disparities Research Framework, Am. J. of Pub. Health (Jan. 2019), https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2018.304883.
[4] Id.
[5] Id.
[6] Health Disparities Nondiscriminatory Quality Healthcare Services, U.S. Dep’t of Health and Human Serv. (July 13, 2013), https://www.hhs.gov/civil-rights/for-individuals/special-topics/health-disparities/index.html.
[7] Id.
[8] Id.
[9] Id.
[10] Title VI of the Civil Rights Act of 1964, C.R. Div. U.S. Dep’t of Just. (Mar. 24, 2025), https://www.justice.gov/crt/fcs/TitleVI.
[11] National Origin Discrimination, U.S. Dep’t of Health and Human Serv. (Aug. 10, 2016), https://www.hhs.gov/civil-rights/for-individuals/special-topics/national-origin/index.html.
[12] Id.
[13] Id.
[14] Collins v. Centers for Medicare and Medicaid Servs., No. 24-2557, 2025 WL 599630,*2 (7th Cir. Feb. 25, 2025).
[15] National Origin Discrimination, supra note 11.
[16] How to File a Civil Rights Complaint, U.S. Dep’t of Health and Human Serv. (Apr. 10, 2025), https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html.
[17] Id.
[18] What to Expect, U.S. Dep’t of Health and Human Serv. (June 16, 2017), https://www.hhs.gov/civil-rights/filing-a-complaint/what-to-expect/index.html.
[19] Id.
[20] Id.
[21] Id.
[22] Id.
[23] Id.
[24] Id.
[25] Collins v. United States, No. 24-CV-0490-BHL, 2024 WL 3916237, *2 (E.D. Wis. Aug 23, 2024), aff’d in part, vacated in part sub nom. Collins v. Centers for Medicare & Medicaid Servs., No-24-2557, 2025 WL 599630 (7th Cir. Feb 25, 2025).
[26] Id.
[27] Id.
[28] Id.
[29] Id.
[30] Id.
[31] Id.
[32] Id.
[33] Collins v. Advoc. Aurora Health Inc., No. 24-CV-0490-BHL, 2024 WL 2293017, *2 (E.D. Wis. May 21, 2024).
[34] Collins v. Centers for Medicare and Medicaid Servs., No. 24-2557, 2025 WL 599630, *1 (7th Cir. Feb. 25, 2025).
[35] Id.
[36] Id.
[37] Id.
[38] Id.
[39] Id.
[40] Id. at *5.
[41] Id.
[42] Id. at *1.
[43] Id. at *2.
[44] Id. at *2.
[45] Id.
[46] T.S. by & through T.M.S. v. Heart of CarDon, LLC, 43 F.4th 737, 738 (7th Cir. 2022).
[47] Id. at 741.
[48] Id.
[49] Id.
[50] Id.
[51] Collins v. Centers for Medicare and Medicaid Servs., No. 24-2557, 2025 WL 599630, *3 (7th Cir. Feb. 25, 2025).
[52] Id.
[53] T.S. by and through T.M.S., 43 F.4th at 738.
[54] Loper Bright Enterprises v. Raimondo, 603 U.S. 369, 412 (2024).
[55] Collins v. Centers for Medicare and Medicaid Servs., No. 24-2557, 2025 WL 599630, *1 (7th Cir. Feb. 25, 2025).
[56] Black Maternal Health Disparities: Understanding and Resources, supra note 2.
[57] The views and opinions expressed in this blog are the personal views of the author and not those of any employer or other affiliates or affiliations of the author.
Cover Photo by Amanda Wolbert on Unsplash.
