Trends in racial/ethnic disparities in medical and oral health, access to care, and use of services in US children: has anything changed over the years?

Compared with white children, multiracial, API, Latino, and AIAN children were younger, and African-Americans slightly older (Table 1). Only 3% of white children live in households in which the highest educational attainment was not graduating high school, vs. over one-quarter of Latino children and over 10% of AIAN and African-American children. Latino, API, and AIAN children were significantly more likely than white children to reside in households in which English was not the primary language spoken at home. Compared with white households, AIAN, Latino, and African-American households are more likely to have >3 children, and all minority households are more likely to have >2 adults and adult unemployment.

Only 8% of white children are poor, compared with almost one-third of Latino and AIAN households, over one-quarter of African-American households, and 16% of multiracial households (Table 1). Over one half of Latino, African-American, and AIAN children live in low-income households (<200% of the FPT), compared with less than ¼ of white children. In contrast, over 1/3 of white and more than 40% of API households have a combined annual family income ≥ 400% of FPT, vs. 12-15% of Latino, African-American, and AIAN households, and about ¼ of multiracial households.

In bivariate analyses, minority children were significantly more likely than white children to not have excellent/very good health status (Table 2), with Latinos, African-Americans, APIs, and AIANs having a substantially higher prevalence of not excellent/very good health than whites. Almost ¼ of African-American, Latino, and AIAN children are obese, compared with 13% for white children and 10% for API children, and about 40% of African-American, Latino, and AIAN children are overweight, vs. 27% of white and 21% of API children. AIAN children had the highest prevalence of all racial/ethnic groups of needing more medical care than others; needing/getting special therapy; emotional, developmental, or behavioral problems needing treatment or counseling; and learning disabilities. Both AIAN and African-American children also had the highest prevalence of having limited abilities.

Disparities were noted in specific health conditions (Table 2). Asthma prevalence was highest among African-American, multiracial, and AIAN children, with about one in five African-American children afflicted with asthma. ADHD was highest among multiracial and AIAN children, at 12%, and particularly low among API children, at 2%, compared with 10% in white children. Depression/anxiety and diabetes were highest in AIANs and lowest in APIs. AIANs and African-Americans had a markedly higher prevalence of behavior problems than whites. The prevalence of developmental delay was highest for multiracial children and lowest for APIs. The prevalence of skin allergies was highest for African-American and multiracial children.

Suboptimal (not excellent/very good) teeth condition was noted in over half of Latinos, more than 1/3 of African-Americans, and almost 1/3 of AIANs and APIs, compared with only 20% in whites (Table 2). For the remaining measures, there either were no statistically significant intergroup differences, or the differences were statistically significant but slight.

Only six percent of white children are uninsured, compared with 19% of Latino, 13% of AIAN, and nine percent of African-American children (Table 3). Latinos, AIANs, and African-Americans are more likely than whites to be sporadically insured. Only 5% of white children lack a personal doctor or nurse, compared with 18% of AIANs, 14% of Latinos, 11% of African-Americans, and 7% of both multiracial children and APIs. Only 12% of white parents reported that their child’s PCP never or only sometimes spends enough time with them; this proportion was significantly higher for all minority groups, with Latinos (38%), African-Americans (31%), AIANs (30%), and APIs (28%) having a particularly high prevalence.

Only seven percent of white parents reported needing an interpreter to communicate with a PCP, compared with over 1/3 of Latino and almost ¼ of multiracial children (Table 3). AIANs, Latinos, African-Americans, and multiracial children were more likely than whites and APIs to have not received either all needed medical or dental care. Only 19% of whites experienced any problem obtaining specialty care, compared with 40% of AIANs, about one-third of African-Americans and Latinos, and over ¼ of APIs and multiracial children. Compared with other racial/ethnic groups, a higher proportion of Latinos and a lower proportion of African-Americans had no physician visit in the past year. About 1/3 of Latinos and over ¼ of APIs and multiracial children had no routine preventive dental visit in the past year, compared with ¼ or less for other racial/ethnic groups of children. Compared with white children, minority children were significantly less likely to receive specialty care. Lower proportions of APIs, Latinos, and African-Americans had received mental healthcare than AIANs, multiracial children, and whites.

After multivariable adjustment for eight covariates, multiple racial/ethnic disparities persisted in medical and oral health status (Table 4). Compared with whites, Latinos, African-Americans, and multiracial children were significantly more likely to be in suboptimal (not excellent/ very good) health and to be overweight/obese. African-Americans were more likely than whites to have limited abilities and digestive allergies. Multiracial children, African-Americans, and Latinos were more likely than whites to have asthma. Multiracial children were more likely than whites to have ADHD and depression/anxiety. Compared with whites, AIANs and African-Americans had higher odds of behavior problems, and African-Americans and multiracial children had higher odds of skin allergies. All minority groups except for multiracial children were more likely than whites to have teeth in suboptimal condition. Of note, there were several medical and oral health indicators for which minority children had reduced odds compared with white children, including 12 for APIs, six for African-Americans, and one for Latinos.

Multiple disparities also persisted in access to care and use of health services (Table 5). Compared with white children, AIANs, Latinos, and African-Americans were significantly more likely to be both uninsured and sporadically insured. AIANs had about four times the odds, and African-Americans, Latinos, and multiracial children about double the odds of whites of having no personal doctor or nurse. Parents in all minority groups were significantly more likely than whites to report the PCP never/sometimes spends enough time with the child. AIANs and multiracial children were twice as likely as whites to have not received all needed dental care. All minority groups except APIs were significantly more likely than whites to have had a problem obtaining specialty care. APIs, AIANs, and African-Americans were more likely to have received no specialty care in the past year. APIs had triple the odds and African-Americans double the odds of whites of receiving no mental healthcare in the past year. In contrast, there were only three indicators for which minority children had reduced odds compared with white children, including uninsurance and unmet dental needs for APIs, and physician visits in the past year for African-Americans.

All racial/ethnic minority groups of children, except for multiracial children, are significantly more likely than white children to have teeth in suboptimal condition. The reasons for these disparities are unclear, and merit further study. For AIAN children, suboptimal oral health may be a result of their higher odds of unmet dental needs, but other minority groups did not differ from whites in unmet dental needs. No minority group differed from whites in the adjusted odds of no routine preventive dental visit in the past year, but this indicator only applies to children who have ever made a dental visit, so oral health disparities might relate to a greater risk of having never made a dental visit or later initiation of the first dental visit. Disparities in satisfaction with and the quality of dental care for minority children have been reported [13], and may also play a role in oral health disparities.

Latinos, AIANs, and African-Americans are significantly more likely than whites to be uninsured and sporadically insured, and these disparities persisted between 2003-2007, except that lack of health insurance arose as a new disparity in 2007 for African-American children. Latinos and African-Americans continue to be disproportionately represented among uninsured American children, with the two groups accounting for 40% of US children, but 57% of uninsured US children [14]. Not enough is known about why AIAN children continue to be at high risk for being uninsured and sporadically insured. Evidence from a randomized, controlled trial indicates that community health workers can eliminate racial/ethnic disparities in uninsurance [15], suggesting that great use of community health workers may be needed to achieve equity in health insurance coverage.

Noteworthy disparities were identified in lacking a personal doctor or nurse (PDN), insufficient time with the child’s healthcare provider, and problems getting specialty care. All minority groups except for APIs have approximately double to triple the odds of having no PDN. Having a PDN―and the associated continuity of care― is a crucial component of the medical home, so many health and healthcare disparities identified in this study could relate to lack of a PDN and medical home. All minority groups had greater odds than whites of the PCP never/sometimes spending enough time with the child, which has the potential to result in poorer communication, lower patient/parent satisfaction, and possibly lower quality of care. Recently, it has been pointed out that racial/ethnic disparities in health and healthcare can be viewed as deficits in quality of care [16, 17], and a comprehensive strategy using a quality-improvement framework and tailored interventions has been shown to reduce disparities [18]. All minority groups, except for APIs, have significantly higher odds than whites of experiencing problems getting specialty care. This is especially concerning, because inadequate access to pediatric specialists can result in poorer quality of care and adverse outcomes. For example, among minority children with asthma, only 17% were being seen by a pediatric asthma or pulmonary subspecialist, subspecialty care was associated with five times the odds of having an asthma care plan, and having an asthma care plan was associated with a significantly lower likelihood of asthma exacerbations in the past year [19].

For 18 health and three use-of-services indicators, minority children had significantly lower odds than white children. The reasons behind these “reverse differences” are not entirely clear. It is possible that certain reverse differences—such as reduced odds of ADHD and of depression/anxiety among API and African-American children—may reflect underdiagnosis of these conditions due to the higher odds of the PCP never/sometimes spending enough time with the child and reduced access to specialty care and mental healthcare. For example, one study revealed that African-American children are less likely than white children to receive ADHD evaluation, diagnoses, and treatment [20]. In contrast, it is possible that other such reverse differences—such as reduced odds of overweight/obesity in APIs—may accurately reflect racial/ethnic variations in the prevalence of certain conditions. One systematic review, for example, concluded that Asian-Americans of all ages have a lower prevalence of obesity than all other racial/ethnic groups [21]. Reverse differences in use of services, such as lower odds vs. whites of having no physician visit in the past year for African-Americans or of not receiving all dental care for APIs, might potentially reflect better access to certain categories of healthcare for these racial/ethnic minority groups. Additional research clearly is needed on the reasons for such reverse differences and potential lessons that might be learned on how to enhance the health and healthcare of all children.

Many substantial and noteworthy disparities varied by racial/ethnic group (Tables 4, 5, 7), and awareness of these particular disparities, almost all of which persisted over time, would seem to be crucial in their prevention and monitoring, as well as the development and implementation of interventions to reduce or eliminate these disparities. Latino children have especially high odds of suboptimal health status and teeth condition, overweight, lack of health insurance, and sporadic health insurance. African-American children have particularly high odds of overweight, limited abilities, asthma, behavior problems, skin allergies, having no personal doctor or nurse, the PCP never/sometimes spending enough time with the child, and problems getting specialty care. API children have especially high odds of the PCP never spending enough time with the child, receiving no specialty care, and receiving no mental healthcare. AIAN children have particularly high odds of behavior problems, no health insurance, no personal doctor or nurse, unmet dental needs, and problems getting specialty care. Multiracial children have especially high odds of asthma, ADHD, depression/anxiety, and unmet dental needs.

Between 2003 and 2007, some noteworthy progress was made in reducing and eliminating certain racial/ethnic disparities in children’s health and healthcare. A significant reduction occurred over time in the total number of disparities in medical and dental services, which dropped from 11 to two. Two specific disparities improved over time. In addition, 26 specific disparities were eliminated over time. Of note, there was elimination of disparities which existed in 2003 for all minority groups in having no physician visit in the past year and for four of five minority groups in having no routine preventive dental visit in the past year. This is the first study, to our knowledge, to report such positive secular trends in children’s disparities. The reasons for these trends are unclear, and warrant further study, with particular attention to such possibilities as greater parental awareness of the importance of routine medical and dental care, heightened attention to these disparities among health systems and clinicians, or changing school regulations for annual physical exams and vaccinations.

In contrast, no significant change over time was seen in the number of indicators for which at least one minority group experienced disparities, either overall, or in any of the three subcategories. Furthermore, neither the total number of specific disparities, nor the numbers of specific disparities in the medical/oral health and access to medical and dental care categories changed significantly over time. In addition, three disparities worsened and 10 new disparities arose over time. These findings indicate that much work remains to be done to eliminate racial/ethnic disparities and achieve equity in children’s medical and oral health and healthcare.

The study findings underscore the importance of examining secular trends in disparities. For example, multiracial children experienced five new disparities over time during the study interval, while at the same time eight of their disparities were eliminated. These results suggest that the addition and elimination of disparities may be a continuously evolving process in a constant state of flux for certain groups, perhaps reflecting and acting in concert with changes in social determinants of medical and oral health and healthcare (such as poverty and educational opportunity), as well as changes in the healthcare system. For example, given that racial/ethnic minority children are disproportionately represented among the uninsured, changes over time in federal and regional poverty, temporary caps or freezes in state Medicaid and CHIP, out-of-pocket expenses, and the proportion of pediatric providers accepting current or new Medicaid- or CHIP-covered pediatric patients could account for new disparities or the elimination of previous disparities in health and dental insurance coverage, health status, access to care, and use of services.

The study findings have several implications for clinical practice, research, and policy. The lack of significant change over time in the total number of specific disparities and of indicators for which at least one racial/ethnic group experience disparities, together with the appearance of 10 new disparities, suggest that racial/ethnic data (as self-identified by the parent) routinely should be collected on all children by health systems, practices, Medicaid, CHIP, managed-care organizations, and private insurers, so that racial/ethnic disparities can be identified, monitored, and targeted as part of quality-improvement efforts. This recommendation is consistent with two recent reports by the Institute of Medicine [17, 22], proposals by disparities experts [23, 24], and Section 4302 of the Affordable Care Act [25, 26]. The persistence and new occurrence over time of racial/ethnic disparities in children’s health and healthcare also indicate that disparities monitoring and public disclosure at least annually should be considered by Medicaid, CHIP, states, counties, health plans, hospitals, and clinics [27]. In addition, the large number of pediatric disparities identified in this analysis indicates that there is an urgent need to expand the number of children’s disparities assessed in periodic disparities reports; for example, only six pediatric disparities indicators were examined in the most recent Agency for Healthcare Research and Quality’s National Healthcare Disparities Report [28], a number which easily could be augmented by incorporating some or all of the 34 indices examined in our study.

Although racial/ethnic minorities comprise 45% of US children, they account for 62% of our nation’s uninsured children [14]. Study findings documenting that Latinos, AIANs, and African-Americans are significantly more likely to be uninsured and sporadically insured than white children underscore the need to provide continuous health-insurance coverage to all children in America. The results showing that multiple disparities exist and have persisted in lack of a personal doctor or nurse and in unmet dental needs highlight the necessity of developing effective interventions and policies for ensuring that every child has a medical and dental home. The prevalence and persistence of children’s disparities also suggests that it may be useful to frame disparities as a quality-of-care issues, as has been pointed out by experts [16] and in a recent IOM report [17]. Although it has been shown that children who need and receive care from a specialist have significantly fewer ED visits and hospitalizations and a greater likelihood of care that is consistent with national practice guidelines than children who do not receive specialty care [29, 30], our study finding revealed that minority children are significantly more likely that white children to have problems getting specialty care, indicating that interventions and polices are needed to ensure that all children have access to and receive needed specialty care.

The study findings of multiple disparities in children’s health and healthcare and their persistence over time also suggest a need to diversify the healthcare workforce, to conduct more research on children’s disparities, and to develop and implement innovative solutions to eliminate children’s disparities. Even after adjusting for income, communities with high proportions of minorities are four times more likely than other communities to have physician shortages, but underrepresented minority (URM) pediatricians and other physicians are significantly more likely than their non-URM counterparts to care for minority, publicly insured, and uninsured patients [31, 32], indicating that diversifying the healthcare workforce might be a powerful mechanism for reducing children’s disparities. A more diverse pediatric workforce might prove particularly useful in addressing disparities identified in this study that might be particularly responsive to greater workforce diversity, including having a personal doctor or nurse, the PCP spending enough time with the child (especially where language barriers are prevalent), receiving all needed medical and dental care, and improving access to specialist and mental healthcare (Table 5). The study results, together with a recent systematic review [4], indicate that more research funding and studies are needed on children’s disparities; for example, only five of 103 studies in the IOM’s report on healthcare disparities specifically addressed children’s disparities [33]. In particular, our study findings suggest that it would be beneficial to fund more research on why there are so many disparities in the medical and oral health and healthcare of children, and the reasons for the persistence of these disparities over time. The study findings—which dramatically underscore the multiplicity, spectrum, depth, and persistence of children’s disparities—also highlight the need for innovative, evidence-based solutions to eliminate these disparities. These might include using geographic information systems and other health-information technologies to identify and target communities experiencing the most substantial disparities, and establishing healthcare empowerment zones—providing needed resources, tailored programs, and community-base participatory processes—in areas of need, which have been shown to be effective [34]. Finally, randomized, controlled trials document that racial/ethnic disparities in children’s health and healthcare can be eliminated, using innovative, family-centered, community-based interventions [12, 15], suggesting that more federal and state funding is needed for such interventions, and successful interventions should be incorporated into Medicaid and CHIP programs as best practices.