1. 1 Ensuring a Healthy Future for All Children in America Glenn Flores, MD Professor and Director, Division of General Pediatrics UT Southwestern & Children’s Medical Center Dallas

2. 2 Overview: 2 Goals of Today’s Presentation l Identify major inequities in health and healthcare of minority and immigrant children in America l Recommend policy solutions for eliminating these inequities and ensuring healthy future for all US children

3. 3 Background: Minority Children l Racial/ethnic minority children comprise 47% of US children, equivalent to 34 million l 2010 Census data indicate that minority children will outnumber white children by 2020 Census l Indeed, all growth in child population in America from 2000 to 2010 attributable to population increases in children who are Latino, API, multiracial, or “some other race” besides white l For first time in nation’s history, minorities comprise greater proportion of births (50.4%) than whites (49.6%)

4. 4 Background: Immigrant Children l Children living in immigrant families fastest-growing group of American children l One in four US children either first ‐ or second ‐ generation immigrant—equivalent to 17 million children l 61 million Americans (21%) speak language other than English at home, and 25 million (9%) have limited English proficiency (LEP) l Among schoolchildren, 11 million (20%) speak language other than English at home and 3 million (5%) LEP

5. 5 Major Disparities Exist in Health & Healthcare of Minority Children l Despite dramatic population growth of minority children, racial/ethnic disparities in children’s health and healthcare extensive, pervasive, and persistent l Recent comprehensive report by American Academy of Pediatrics documented children’s racial/ethnic disparities occur across spectrum of health and healthcare

6. 6 Noteworthy Health & Healthcare Disparities for Minority Children African-Americans l Overall death rate consistently higher vs. white children l Highest asthma prevalence, and substantially higher rates of asthma deaths, hospitalizations, and ED visits l Substantial HIV/AIDS disparities include largest percentages and numbers of new diagnoses in every age group l Autism diagnosed 1.4 years later vs. whites l Among children with kidney failure, much less likely than whites to be on kidney transplant waiting list or to receive kidney transplant

7. 7 Disparities: African-American Children l Among heart transplant patients, median age at heart transplant five years older than whites l More than twice as likely as whites to die in first 28 days and in first year of life

8. 8 Disparities: American Indian/ Alaska Native Children l Higher death rate than whites l Higher odds of being in poor or fair health l Firearm injury rate > 7 times higher than whites l Higher rates of overweight and obesity l Birth rate for female teens 2-3 times higher than for whites l Within six months of new depression episode, lower odds than whites of any mental-health visit or antidepressant prescription

9. 9 Disparities: Asian-Pacific Islander Children l More likely to have no usual source of healthcare and to have gone more than one year since last physician visit l Worst access to specialty care l Higher risks of injuries and lead intoxication l Among children with cancer, Pacific Islanders have greater risk of death and untimely treatment l Native Hawaiians have higher death rates than whites

10. 10 Disparities: Latino Children l Wide range of disparities in access to care and use of services, including greater odds of u Being uninsured u Having no regular healthcare provider u Going 1 year or more since last physician visit u Not being referred to specialist u Never/only sometimes getting medical care without long waits l Disparities in breastfeeding, injuries, violence victimization, and obesity l Double the odds of suboptimal condition of teeth

11. 11 Disparities: Latino Children l Higher risks of death for those with leukemia and after congenital heart surgery l Teen girls have birth rate 3 times higher than whites and highest of any racial/ethnic group l Highest youth rates of feeling sad or hopeless, making suicide plan in past year, and attempting suicide (especially for girls) l Major disparities in mental healthcare

12. 12 Major Disparities in Health and Healthcare of Immigrant Children l Immigrant children substantially more likely to be uninsured than citizen children u 45% of undocumented children in US uninsured, vs. 9% of US children overall u 25% of citizen children in mixed-immigrant families (with 1 immigrant parent) uninsured, vs. 8% of citizen children of US-born parents

13. 13 Adverse Consequences of Not Insuring Immigrant Children l Uninsured children significantly more likely than insured children to u Have worse health status, no regular physician, delayed immunizations, and more unmet needs u Make ED visits u Experience preventable hospitalizations u Die during hospitalizations

14. 14 Adverse Consequences of Not Insuring Immigrant Children l It costs all Americans more when we don’t insure immigrant children u These children frequently end up getting much more expensive ED care, rather than outpatient care, and are hospitalized for preventable conditions u High costs of uncompensated care for this frequently preventable, expensive acute care passed on as tax on privately insured, and increased property taxes to pay for care in public hospitals

15. 15 Language Barriers to Healthcare for Immigrant Children l Despite large number of LEP Americans, and federal policy, known as Title VI, mandating adequate language assistance for LEP patients, many LEP children and families do not receive professional medical interpretation, but rather must resort to using ad hoc interpreters, such as family members, friends, or strangers from waiting room, or having no interpreter u One study revealed no interpreter use for 46% of LEP patients, and 39% of interpreters used had no training

16. 16 Language Barriers to Healthcare for Immigrant Children l Multiple studies document that language barriers can have profound negative impact on access to care, health status, use of health services, patient-physician communication, satisfaction with care, and patient safety, and can result in serious injury or death

17. 17 Case: “Juan” Juan was a 6-month-old presenting to the ED with vomiting and diarrhea. The triage history given by mom was interpreted by Juan’s 12-year-old sister. The sister stated that the patient had 4 dirty diapers and 3 vomiting episodes that day. Juan was triaged to a non-urgent level of care in which documentation stated he had vomited 7 times that day with no diarrhea. He was discharged shortly thereafter with a diagnosis of vomiting and instructions in English only for “pedialyte by mouth.”

18. 18 Juan l 3 days later, Juan returned to ED u In severe distress u With new onset of bloody stools l Juan admitted to hospital l Juan died 6 hours later of septic shock

19. 19 Language Barriers to Healthcare for Immigrant Children l But only 13 states and DC provide Medicaid and CHIP reimbursement for interpreter services u Most states with largest numbers of LEP patients, including California, New York, and Texas, do not

20. 20 Policy Solutions: Ensuring Healthy Future for All US Children l Data on race/ethnicity, primary language spoken at home, and parental English proficiency should be collected on every pediatric patient u So that disparities can be identified, monitored, and targeted as part of quality-improvement efforts l Children’s health and healthcare disparities should be monitored and publicly disclosed annually at federal, state, local, health-plan, and institutional levels

21. 21 Policy Solutions: Ensuring Healthy Future for All US Children l Provide continuous health-insurance coverage to ALL children, including immigrants u Undocumented immigrant children ineligible to obtain health insurance under ACA and Senate “Gang of 8” Bill u Automated enrollment/renewal and express-lane eligibility should be standard in Medicaid and CHIP u Proven effective community-based outreach and enrollment strategies, such as community workers and Parent Mentors, should be adopted on large scale by Medicaid and CHIP u Continuous coverage of children should be fundamental element of healthcare reform

22. 22 Policy Solutions: Ensuring Healthy Future for All US Children l All children should have u Access to needed specialty care and mental healthcare u Medical and dental homes, which can be provided through  Continued support and expansion of federally qualified health centers and other safety-net providers  Providing incentives and loan repayment programs for primary-care providers based on number of patients receiving care in medical and dental homes

23. 23 Policy Solutions: Ensuring Healthy Future for All US Children l No child should be denied healthcare or suffer injury or death due to language barriers u OMB report estimated it would cost average of only $4.04 more per physician visit, or only 0.5% increase in our nation’s healthcare expenditures, to provide all LEP patients with appropriate language services u The time has come for our nation to provide third-party reimbursement for medical interpreter services—not just in Medicaid and CHIP, but through private payers as well, and this should be high priority in immigration reform

24. 24 Policy Solutions: Ensuring Healthy Future for All US Children l Need to legislate innovative solutions to eliminate disparities for minority and immigrant children u Healthcare Empowerment Zones (providing resources, special programs, and community-based participatory approaches) should be funded and established in regions with greatest disparities u Funds should be provided for innovative, community- based interventions targeting elimination of children’s disparities, and successful interventions should be incorporated into Medicaid and CHIP as best practices  As controlled clinical trials document that such interventions eliminate disparities and save money