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From neonatal and primary care to emergency medicine and surgery, the quality of health care received by racial and minority ethnic children in the U.S. is almost universally worse compared to their white peers, according to new findings from scientists at Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago and several other institutions.
The findings reveal extensive inequities in care across pediatric specialties, including neonatal care, emergency medicine and palliative care. Overcoming these pervasive health care inequities — borne of structural racism — requires policy changes in multiple sectors of wider society, including housing, health insurance and the criminal justice system, the study authors said.
The findings were published Jan. 17 in The Lancet Child & Adolescent Health journal in a two-paper series.
“We now have more evidence than ever that pediatric care in the U.S. is not only disparate, but inequitable for a large group of children,” said senior author for both papers in the series Dr. Nia Heard-Garris, assistant professor of advanced general pediatric and primary care at Northwestern University Feinberg School of Medicine and a physician at Lurie Children’s. “Policies that advance health justice and reach across institutions, communities and populations are urgently needed.”
The authors outline several implications of their findings for health care practice and policy, including that hospital and other health care systems should investigate and address sources of structural racism within their existing policies and guidelines, and that senior managers of health care systems and providers must take steps to eliminate race-based pediatric care. They also highlight that policy changes to end racial segregation of pediatric care and enhance the diversity of the medical workforce are needed.
The overall trend indicated more care for white patients even when not justified on medical grounds.
“There are deeply entrenched racial disparities that span broad sectors of U.S. society and transcend generations,” said policy series author Dr. Monique Jindal, of University of Illinois Chicago School of Medicine. “These lead to, among other disadvantages, stark inequities in health care for children from minoritized racial and ethnic groups. It is abundantly clear that to ensure every child in the U.S. receives the best possible health care, there is a critical need for far-reaching policy changes that directly address deep-rooted structural racism at its core.”
By limiting the review to studies that controlled for health insurance status, the authors identified differences in care quality that are not due to a lack of access to health services.
Evidence from the past five years indicates infants from minoritized racial and ethnic groups, particularly Black and Hispanic children, consistently receive lower-quality neonatal care than white infants. In primary care, there is poorer quality communication between health care providers and children, youth and families from minoritized racial and ethnic groups, contributing to persistent inequalities, according to the findings.
Disparities also exist in end-of-life care, the study found. Black, Hispanic and Asian-American children who receive palliative care are more likely to die in the hospital compared to white children. Hispanic children also are more likely to receive medically intense care during their last days of life.
Strongest evidence of disparities was in pain management
Differences in wait times, triage assessment and the evaluation of suspected child abuse for children from minoritized racial and ethnic groups were also found for emergency medicine. The strongest evidence of disparities was in pain management with children from minoritized racial and ethnic groups being less likely than their white peers to receive painkillers for a broken arm or leg, appendicitis or migraine. The overall trend indicated more care for white patients — such as more painkillers, antibiotics, IV fluids and diagnostic imaging — even when not justified on medical grounds.
Disparities exist in the diagnosis of developmental disabilities, with Black and Asian children less likely to be diagnosed before preschool or kindergarten as compared to white children, while Latino children with special health care needs receive fewer specialist services than their white peers. There also are inequities in mental health care services, with lower rates of adequate care for major depressive disorder and ADHD among Black, Hispanic and other children from minoritized racial and ethnic groups compared with white children.
“From the very earliest moments of life, there are pervasive inequities in the quality of health care received by children in the U.S.,” said Dr. Natalie Slopen, of Harvard University, who led the research review. “Racism profoundly impacts not only children’s health but also people’s health on into adulthood, emphasizing the vital importance of tackling disparities in the care received by children.”
Structural and systemic obstacles to equitable pediatric care
Existing policies and practices at the local, state and federal levels in the U.S. create and perpetuate structural racism, leading to pediatric health disparities among minoritized racial and ethnic groups. These pose significant obstacles to achieving child health equity and highlight the need for policy solutions that directly address entrenched structural racism.
Housing and neighborhood policies play a major role in health disparities, as housing instability, poor quality, unaffordability, and neighborhood characteristics significantly influence children’s health outcomes. Racial disparities in housing — which are deeply rooted in historical policies — persist and impact health outcomes, indicating a need for comprehensive strategies to improve social and economic conditions in segregated neighborhoods.
Economic and employment policies underscore the impact of low socioeconomic status on children’s health, with racial income gaps persisting and anti-poverty programs needing an anti-racist approach. Disparities in health insurance access persist, especially for children from minoritized racial and ethnic groups, highlighting the importance of expanding Medicaid and Children’s Health Insurance Program (CHIP) coverage to achieve equity in pediatric health.
The criminal justice system’s disproportionate impact on Black people is linked to numerous ill health effects, emphasizing the need for policies that prevent young people from going to prison and mitigating the effects on children with parents in prison. Immigration policies also have a significant effect on children’s health by determining access to public benefits, with policies enhancing eligibility linked to better pediatric health outcomes.
Policy reform for healthier children
Based on their analysis, the authors make wide-ranging recommendations for policy changes to counteract pervasive disparities in pediatric care in the U.S. “We must fundamentally rethink and redesign systems and policies, not only in healthcare but across the societal spectrum, to promote equitable, excellent health for all children,” said Dr. Slopen
The authors point to numerous changes that could be implemented in broad sectors of society, including measures to improve the social and economic conditions of segregated neighborhoods, which can benefit child health. Investments in communities can improve access to resources and opportunities and have been linked to reduced depression and obesity and increased physical activity. Other measures — such as eviction prevention policies — could also ultimately benefit the health of children from racial and minority ethnic backgrounds.
Universal access to health insurance and standardizing administrative policies would ultimately deliver greater pediatric health equity. However, there are several areas within health insurance policy that could improve health equity for children more immediately. These include expanding Medicaid/CHIP continuous eligibility beyond 12 months, increasing Medicaid/CHIP provider reimbursement rates, and focusing on social determinants of health.
Enacting policies that set age boundaries to ensure no children are placed in adult prisons can mitigate the heightened risk they face of physical and sexual assault and psychological trauma. In general, policies must reflect that the youth justice system should be used only as a last resort. When it comes to immigration policies, those that increase eligibility for employment, education and access to resources are also linked with better pediatric health outcomes.
The authors also say further research is needed to better characterize the experiences of Asian-American and Native-American pediatric patients, and children classified as belonging to multiple racial or ethnic groups. Future work should also investigate the intersection of race and ethnicity with other socio-demographic features, such as gender identity, sexual orientation and family immigration history.
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