In part one of the series, researchers analyzed the findings of nearly 150 recent studies examining racial differences in the quality of health care for children in the USA. They found that racialized children received worse care than White children across numerous pediatric specialties. These included emergency medicine, primary care, surgery, mental health care, and palliative care.
The researchers described how differences in health insurance, preference, geographic area or need, could not account for the disparities in health care.
In part two of the series, the authors call for systemic changes to make child health care in the USA more equitable.
“We must fundamentally rethink and redesign systems and policies, not only in health care but across the societal spectrum, to promote equitable, excellent health for all children,” said Dr. Natalie Slopen, of Harvard University, who led the research review.
A system of inequality
The fact that people in lower socioeconomic positions have worse health outcomes is well understood by health experts. Known as social determinants of health, non-medical factors that shape the conditions of our everyday life such as income, job security, discrimination, access to education, and even the neighborhoods we live in can affect our health in many ways.
The World Health Organization (WHO) says that, “social determinants can be more important than health care or lifestyle choices in influencing health,” and may account for 30-55% of health outcomes. The Centers for Disease Control (CDC) point out that obstacles to health include “poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”Â
The series authors point to multiple sectors in the US — including housing, employment, health insurance, immigration, and the legal system — in which racial minorities are disadvantaged, and outline how these disparities result in poorer health care for non-White children.
Unhealthy housing
Non-White people in the US are, to this day, still affected by historical housing practices related to racial segregation. One example of this is “redlining”, a discriminatory lending practice in which people from low-income neighborhoods were deliberately denied access to lending programs and mortgages regardless of individual creditworthiness. Redlining was legal and widespread in the US until 1968. “Redlined” neighborhoods, deemed risky investments where property values were likely to go down, were neighborhoods where Black people lived.
The racism inherent in social practices like redlining has had lasting effects. Racial minorities in the US are still less likely to own a home and more likely to live in poor neighborhoods than White people. Nearly a generation after the practice was banned, the proportion of Black people in formerly redlined neighborhoods remains nine times higher than in more affluent neighborhoods. In a 2023 report, the National Association of Realtors noted that home ownership among Black Americans lags significantly (44%) behind rates for White Americans, representing the largest Black-White homeownership rate gap in a decade.
In The Lancet review, the authors point out four main ways that living in neighborhoods with concentrated poverty affects child health:

- Housing stability – Living in unstable housing, characterized by moving frequently or falling behind on rent, is associated with increased risk of depression, druguse, and pregnancy among youth.
- Housing quality – Homes with environmental concerns such as dampness, poor ventilation, pest infestations, lead paint, and overcrowding are associated with health problems like asthma and poor cognitive development.
- Affordability – Families with unaffordable housing costs have less disposable income to buy healthy food, pay for medication, and otherwise promote their children’s health and development.
- Geographical Location – Children living in poor neighborhoods are more likely to experience community violence and have less access to crucial factors of health such as educational opportunities, clean air, and good nutrition.
To combat the negative effects of housing inequality, the authors recommend policy changes such as:
- Community investment initiatives to promote healthy food projects and green space improvement.
- Assistance for renters at risk of eviction (such as access to a mediator).
- Increasing the stock of affordable housing, for example, through tax credits to owners of rental properties.
- Laws protecting tenants and home buyers from discrimination.
- Expanding access to mortgages to help renters transition to home ownership


Inequalities in work and wealth
In the US, racial and ethnic minorities hold substantially less wealth than White people. While poverty rates for Black and Hispanic Americans improved slightly in 2019, according to the US Census Bureau, they are still far more likely to live below the poverty line than White or Asian Americans.


In 2022, 17% of Black and Hispanic people and 25% of American Indigenous people in the US were living below the poverty line, compared to just 8.6% of White people. This disparity is directly tied to poorer health because, as the review authors point out, children who grow up in low socioeconomic environments are more likely to have negative health outcomes such as low birthweight, asthma, depression, and antisocial behaviour.
Government assistance programs for low-income families, such as Temporary Assistance for Needy Families (TANF) are available in all 50 states, but the amount of assistance varies by state. The authors point out that Southern states with the highest populations of Black people often have the lowest TANF benefits.
The authors call for targeted interventions to improve child health by lifting racial minorities out of poverty such as:
- Tax credits for low-income families
- Cash benefits for families contingent on specific behaviours such as buying nutritional foods or keeping health care appointments
- Reforms to current state safety net programs to ensure benefits are fairly distributed.
- Eliminating state-imposed sanctions that cut off resources to the entire family, including the child, if certain requirements are not met (e.g., school attendance, child immunizations, and drug testing)
- Occupational skills training for low-wage workers that provide opportunities for high-quality jobs
- Improving access to paid family and sick leave, which has been shown to improve well-child visits, dental care, influenza vaccination rates, and breastfeeding.
Unequal health insurance coverage
Approximately 40 million US children from low-income families are covered by subsidized health insurance through Medicaid or the Children’s Health Insurance Program (CHIP). These two programs cover 55-60% of Hispanic, Black, and American Indigenous children, compared with 29% of White children.
The review quotes numerous studies that show children covered by Medicaid or CHIP have, “improved access to medical, preventive, and dental care, greater use of preventive services, higher quality of well-child care, increased parental satisfaction, and reduced out-of-pocket costs.” Insured children are also less likely to be hospitalized and have more positive outcomes across their lifespan, such as higher educational attainment.
The Affordable Care Act, enacted in 2010, called for the expansion of Medicaid to cover millions of low-income Americans who were not previously eligible. Medicaid expansion has successfully increased the number of minority children covered by health insurance, but access is not equal in all states.
In June 2012, the US Supreme Court ruled that states could not be forced to expand their Medicaid programs. As of 2023, 11 states still refuse to adopt Medicaid expansion, despite the fact that the federal government pays 90% of the cost. These holdout states are predominantly in the southern US, a region that the authors note holds 56% of the country’s Black population. This disproportionately prevents racial minorities from qualifying for Medicaid coverage.
States also differ in terms of how they reimburse medical providers, which can limit access to specialists for Medicaid patients. The series authors recommend changes to federal policies that:
- Expand access to health insurance for more Americans, including universal coverage for children and pregnant people
- Decrease state-based disparities in health insurance eligibility
- Increase reimbursements for health care providers
Criminal injustice
The over-representation of racial minorities in the US juvenile and criminal legal system is a long-standing problem that has garnered international concern. “Children of racial and ethnic minority background[s] are greatly over-represented at all stages of the general and juvenile justice systems. The disproportion is most marked for black youth,” said Amnesty International in a 1998 report detailing human rights violations against children in the US justice system.Â
Black youth make up only 15 percent of the US population aged between 10 and 17, according to Amnesty International, but account for 30 percent of youth arrested. The Lancet series highlights more sobering US statistics: A third of Black men are imprisoned in their lifetime, one in 1000 Black men will be killed by police, and one in nine Black children have a parent currently incarcerated.
Disparate policing policies such as over policing of low-income neighborhoods, racial profiling, and police presence in schools puts children as young as 7 years at high risk of entering the juvenile legal system.
“Disproportionate police contact is associated with poor mental health (including depression and suicidality), risky sexual behaviours, substance use in adolescence, and ongoing adverse health effects into adulthood,” state the authors, adding that, “youth detention and incarceration is associated with worse health outcomes into adulthood, which might be due to the psychological and physical traumas endured.”
The series authors call for changes to the legal and criminal systems such as:
- Reforms to prison policy to increase parent-child contact, such as free telephone or video calls
- Addressing racial biases in policing and judicial processing
- Ensuring support for young people in schools, such as more mental health counselors rather than punitive school resource officers
- Minimum age laws to protect children younger than 14 years from arrest, and decarceration of young people with low-level offences
- Supporting prison conditions that promote healing and accountability rather than further traumatization, such as banning solitary confinement for young people and providing access to quality mental health care.
- Robust re-entry support for parents and young people returning to the community
Healthy immigration policies
Policies intended to deter immigration, such as separating parents from children at the border or restricting access to public benefits like publicly funded prenatal care and food assistance, have been associated with poor mental health and food insecurity for immigrant children, say the authors.
More inclusive policies that increase eligibility for employment, education, and access to resources have been associated with better child health outcomes in the immigrant community. The authors point out that a mother’s eligibility for Deferred Action for Childhood Arrivals (DACA), which provides protection from deportation and permission to work for qualifying immigrants, was associated with decreases in adjustment and anxiety disorders among their children.
The authors’ recommendations for immigration policy reform include:
- Ensuring humane treatment of asylum seekers, including ending the practice of separating parents from children at the border
- Expanding eligibility for health insurance and safety net benefits (e.g., food assistance) to include immigrant children and pregnant people
- Ending practices that limit access to social safety net programs as a means of deterring immigration
Addressing the roots of unequal health
“From the very earliest moments of life, there are pervasive inequities in the quality of health care received by children in the USA.” Said lead researcher, Dr. Slopen. “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.”
The authors note that reducing health inequities will be no easy task. The changes they recommend require nothing less than a profound culture shift in American policy and politics.
“There are deeply entrenched racial disparities that span broad sectors of US society and transcend generations,” said series author Dr. Monique Jindal, of University of Illinois Chicago School of Medicine. “It is abundantly clear that to ensure every child in the USA 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.”
References
Amnesty International (1998). Betraying the young: children in the US justice system. Accessed Feb 19, 2024 at https://www.amnesty.org/en/wp-content/uploads/2021/06/amr510601998en.pdf
Centers for Disease Control and Prevention (2023). Social determinants of health. Accessed Feb 18, 2024 at https://www.cdc.gov/publichealthgateway/sdoh/index.html
Currie, J., & Chorniy, A. (2021). Medicaid and Child Health Insurance Program Improve Child Health and Reduce Poverty But Face Threats. Academic pediatrics, 21(8S), S146–S153. https://doi.org/10.1016/j.acap.2021.01.009
Jindal, M., Barnert, E., Chomilo, N., Gilpin Clark, S., Cohen, A., Crookes, D. M., Kershaw, K. N., Kozhimannil, K. B., Mistry, K. B., Shlafer, R. J., Slopen, N., Suglia, S. F., Nguemeni Tiako, M. J., & Heard-Garris, N. (2024). Policy solutions to eliminate racial and ethnic child health disparities in the USA. The Lancet. Child & adolescent health, 8(2), 159–174. https://doi.org/10.1016/S2352-4642(23)00262-6
KFF (2024). Health coverage by race and ethnicity, 2010-2022. Accessed Feb 19, 2024 at https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/#:~:text=Coverage%20by%20Race%20and%20Ethnicity%20as%20of%202022&text=(Figure%202).-,Nonelderly%20AIAN%20and%20Hispanic%20people%20had%20the%20highest%20uninsured%20rates,their%20White%20counterparts%20(6.6%25)
National Association of Realtors (2023). More Americans own their homes, but Black-White homeownership rate gap is biggest in a decade, NAR report finds. Accessed Feb 18, 2024 at https://www.nar.realtor/newsroom/more-americans-own-their-homes-but-black-white-homeownership-rate-gap-is-biggest-in-a-decade-nar#:~:text=While%20the%20U.S.%20homeownership%20rate,rate%20gap%20in%20a%20decade
Primary Care Development Corporation (2020). New findings: historic redlining drives health disparities for New Yorkers. Accessed Feb 18, 2024 at https://www.pcdc.org/news/new-findings-historic-redlining-drives-health-disparities-for-new-yorkers/?creative=678574028123&keyword=definition%20of%20redlining&matchtype=b&network=g&device=c&gad_source=1
Statista (2024). Poverty rate in the United States in 2022, by race and ethnicity. Accessed February 18, 2024 at https://www.statista.com/statistics/200476/us-poverty-rate-by-ethnic-group/#:~:text=In%202022%2C%2017.1%20percent%20of,8.6%20percent%20of%20white%20people.
United States Census Bureau (2020). Poverty rates for Blacks and Hispanics reached historic lows in 2019. Accessed Feb 19, 2024 at https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-and-hispanics-reached-historic-lows-in-2019.html#:~:text=Poverty%20rates%20declined%20between%202018,Hispanics%2C%20it%20was%2015.7%25.
World Health Organization. Social determinants of health. Accessed February 18, 2024 at https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
