Difficulties Navigating The Health Care System Are Causing Many Black And Brown Kids To Fall Through

A recent JAMA Pediatrics study confirmed what I see in practice as a pediatric primary care psychologist in Texas, one of four minority-majority states. The study reported alarming gaps between Black and Hispanic kids compared to white kids in attendance at primary care wellness visits—important appointments where children and parents can receive preventative and developmental services, timely immunizations, and answers to common questions. The cause of these disparities is not clear. The solution, however, may be.

The American Academy of Pediatrics recommends that kids and teens receive regular preventative wellness visits in primary care. In the study, only 53% of Black kids and 58% of Hispanic kids attended all their yearly recommended visits, compared to 68% of white kids. Attendance rates also differed by the families’ insurance status (31% for uninsured, 59% for publicly insured, 66% for privately insured).

These findings have major implications for kids’ health and wellness disparities based on race, ethnicity, and socioeconomic status.

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Black and Hispanic kids and those from low-income environments report higher levels of trauma-related mental health difficulties compared to white kids and those from higher-income environments. Also, the rate of suicide in Black kids younger than 13 years is about two times higher than in white kids. CDC data on Black kids show that between 2009 and 2019, there were substantial increases in suicidal ideation (13% vs. 17%), making a suicide plan (10% vs. 15%), and suicide attempts (8% vs. 12%).

Primary care wellness visits are the opportune time for pediatricians to identify these types of mental health concerns in kids early and connect them with mental health specialists. These visits are also ideal for identifying early developmental concerns since autism screening is part of the American Academy of Pediatrics’ preventative wellness visit schedule.

In addition to monitoring mental health and development, wellness visits are a time to monitor a child’s overall health (vision, hearing, weight, blood pressure), identify risk factors so diseases like asthma and Type 2 diabetes can be diagnosed at their earliest stages, and provide preventative care like vaccinations, and lifestyle guidance.

The more that kids attend their primary care wellness visits, the less likely they are to require acute care services, hospitalizations, and emergency room visits, which are costly to both families and society.

Researchers suggest that the racial/ethnic and economic disparities in primary care visit attendance may stem from factors not in the kids’ and families’ immediate control. These include racial bias and discrimination, a lack of diversity in health professionals affecting the patient-provider relationship, unaddressed social needs, and financial barriers.

A model called system navigation can help alleviate many of these barriers. System navigation incorporates non-clinician laypeople, such as navigators or community health workers (promotoras), into the primary care team to partner with and engage families in their health care. These individuals are trusted community members who share a common background and lived experiences with the families they serve.

Matching families and navigators by race/ethnicity, cultural, or some other lived experience can increase family engagement in their health care. Studies show that patients prefer providers who share the same race or ethnicity, yet the primary care physician workforce is less than 9% Hispanic and 5% Black, while U.S. children are 26% Hispanic and 14% Black.

When patients trust their providers, they are more likely to share their beliefs, preferences, past experiences, and current challenges. Navigators can help screen for social needs such as lack of transportation (the biggest predictor of no-shows) and, once they are aware of these needs, they can help address them. They can connect families to food pantries in the community, arrange transportation services, or help ensure families have insurance coverage.

Navigators can also help families better understand their doctor’s billing practices. Thanks to the preventive care provisions of the Affordable Care Act (ACA), Medicaid and most private insurance plans cover wellness check-ups for kids and teens. Still, many remain uninsured. The South and West regions include states with some of the highest rates of uninsured children, including Mississippi, Florida, Wyoming, and Texas—sadly, my state has the country’s highest rate of uninsured kids. And even families with insurance may still receive unexpected bills for wellness visits because of services provided during the visit that fall outside the list of ACA-mandated preventive care.

Evaluations across ambulatory medical settings show cost savings from navigation services, and these can benefit both patients and insurers. Savings are most profound when system navigation prevents unnecessary medical procedures and hospital and emergency room visits by proactively helping patients address health needs through primary care visit attendance. Because these are costs frequently borne by insurers, insurers have an incentive to invest in widespread system navigation.

So far, there is little research on whether non-clinician navigators can help close racial disparity gaps in primary care access for kids, but research on adult populations shows promising outcomes. One study found that low-income persons of color working with a navigator were three times more likely to have primary care access than those without a navigator and were significantly less likely to experience several barriers to care, such as not having insurance, not being able to pay for a visit, and not having transportation.

System navigation is not a panacea. Black and Hispanic families still face implicit and explicit bias and discrimination daily in health care settings and society through economic disadvantage, lack of safe and affordable housing, and education disparities. System navigation will not change racist and unfair systems, but it can help families navigate those systems.

Our primary care systems should be designed for all the kids and families they are intended to serve. Incorporating system navigators to support the needs of our most vulnerable families is a feasible step in the right direction.

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