Disparities in the financial burden of children's healthcare expenditures

OBJECTIVE: To examine whether income-related disparities in the burden of children's out-of-pocket health care expenditures have diminished with the expansions in public insurance for children in low-income families. DESIGN: We compared absolute financial burden (out-of-pocket expenditures per child) and relative financial burden (out-of-pocket expenditures per child as a proportion of family income) among children aged 0 to 18 years in 6 poverty level groups using the 1980 National Medical Care Utilization and Expenditure Survey and the 2000 Medical Expenditure Panel Survey. Regression models were used to assess whether disparities in financial burden diminished between 1980 and 2000. RESULTS: There were significant reductions (P<.01) in absolute burden over time for children above 200% of the federal poverty level. Relative financial burden decreased significantly (P<.01) for all of the income groups, ranging from a reduction of 36.49% for those below 100% of the federal poverty level (95% CI, -49.54% to -20.07%) to a reduction of 46.69% for those at or above 300% of the federal poverty level (95% CI, -54.43% to -37.62%). For low-income children, relative financial burden was 49.49% less with public insurance (95% CI, -66.24% to -24.35%) and 79.14% greater with private insurance (95% CI, 9.31% to 193.59%) than relative financial burden for low-income children without insurance. CONCLUSIONS: While the financial burden of children's out-of-pocket health care expenditures has decreased for all of the income groups over time, socioeconomic disparities persist. However, public insurance coverage appears to mitigate the financial burden for low-income children.     

Health care for children and youth in the United States: 2001 annual report on access, utilization, quality, and expenditures.

OBJECTIVES: To provide an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States and new information on parents' perceived quality of care for their children and to provide information on variation in hospitalizations for children from a 24-state hospital discharge data source. METHODS: The data on insurance coverage, utilization, expenditures, and perceived quality of care come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Nationwide Inpatient Sample, which is part of the Healthcare Cost and Utilization Project. Both data sets are maintained by the Agency for Healthcare Research and Quality. RESULTS: In 2000, 64.5% of children were privately insured, 21.6% were insured through public sources, and 13.9% were uninsured. Children aged 15-17 years were more likely to be uninsured than children 1-4 years old. Children without health insurance coverage were less likely to use health care services, and when they did, their rates of utilization and expenditures were lower than insured children. Publicly insured children were the most likely to use hospital inpatient and emergency department (ED) care. Being black or Hispanic and living in families with incomes below 200% of the poverty line were associated with lower utilization and expenditures. A small proportion of children account for the bulk of health care expenditures: approximately 80% of all children's health care expenditures are attributable to 20% of children who used medical services. Although most parents report that their experiences with health care for their children are good, there are significant variations by type of insurance coverage. There are substantial differences in average length of hospitalization across the United States, ranging from 2.9-4.1 days, and rates of hospital admission through the ED, which vary across states from 10%-25%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10- to 17-year age group, more than 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy. The top 10 most common conditions treated in the hospital account for 40%-60% of all hospital stays. CONCLUSION: Children's use of health care services varies considerably by the type of health insurance coverage, race/ethnicity, and family income. Quality of care, as measured by parents' experiences of care, also varies by type of coverage. There is substantial variation in use of hospital services across states.     

Health insurance and children with disabilities

Few people would disagree that children with disabilities need adequate health insurance. But what kind of health insurance coverage would be optimal for these children? Peter Szilagyi surveys the current state of insurance coverage for children with special health care needs and examines critical aspects of coverage with an eye to helping policy makers and clinicians improve systems of care for them. He also reviews the extent to which insurance enhances their access to and use of health care, the quality of care received, and their health outcomes. Szilagyi begins by noting that nearly 9 percent of children with disabilities are uninsured for all or part of a year and that coverage even for many such children with insurance is inadequate--either not meeting their needs or not adequately covering the costs of care. By one estimate, nearly two of every five special needs children are either uninsured or inadequately insured. The author finds strong evidence that health insurance improves access to health care. Children with disabilities who are insured are more likely than those who are uninsured to have a primary care provider, to be able to reach a specialist, and to have access to supporting services. They also have fewer unmet needs for medical and oral health care and receive care more quickly. The bulk of the evidence shows that insurance improves quality of care for children in general and for children with disabilities. Parents of insured children with chronic conditions are more satisfied with their children's primary care, medications, specialty care, and overall health care than are parents of their uninsured peers. A handful of studies of specific diseases have found insurance to be related to improvements in quality measures, such as more doctor visits and greater continuity of care. In conclusion, Szilagyi stresses the need to provide adequate health insurance to all children with disabilities and to develop a set of best practices in health insurance to cover important services needed by this population. To that end, implementation of the federal health care reform act, including the mandate for insurance coverage, is important. He also urges support for medical home and other quality initiatives and better ways to monitor quality and health outcomes to ensure that children with disabilities receive cost-effective and equitable care.     

The impact of Medicaid on children's healthcare and health

PURPOSE OF REVIEW: This article reviews the impact of the Medicaid program, including the proportion of children in America insured by Medicaid; the extent to which Medicaid-enrolled children have access to care; the use of services and the quality of care received by Medicaid enrollees, including evidence for disease reduction; and family satisfaction with the program. RECENT FINDINGS: More than a quarter of all children in the United States were insured through public programs, primarily Medicaid, in 2002. Public insurance programs are even more critical for low-income children: 69.5% of children in families with incomes below 100% of the federal poverty level are covered by public programs. The reach of Medicaid is extensive, although substantial numbers of eligible children remain uninsured. Although Medicaid-insured children still face access barriers, particularly for certain types of specialty care, parents of children with public insurance report high levels of satisfaction with their experience with well-child care. While the study findings are mixed, several recent studies show very favorable comparisons between the experience of privately insured children and that of publicly insured children. SUMMARY: Medicaid plays a critical role in providing health insurance coverage for children, particularly for very low-income families. Additional efforts are needed to fully enroll all eligible families and to assure full access to high-quality care.     

Access to health care for young adults with disabling chronic conditions

OBJECTIVE: To assess health insurance status and health care access of young adults with disabilities attributable to a chronic condition. DESIGN AND SETTING: We analyzed data from the National Health Interview Survey from 1999 to 2002. We present bivariate analysis and multiple logistic regression of reported health care access barriers in the United States stratified by health insurance status. PARTICIPANTS: The study population included 1109 survey respondents with and 22 481 without disabling chronic conditions, aged 19 to 29 years. MAIN OUTCOME MEASURES: Delayed or unmet health needs owing to cost, no contact with a health professional in the prior year, and no usual source of care. RESULTS: Thirty-five percent of respondents with and 15% without disabling chronic conditions reported an unmet health care need owing to cost (P< .001). Uninsurance rates for young adults with and without disabling chronic conditions were similar (26% vs 28%, respectively), and uninsurance was significantly associated with unmet health care needs. More than two thirds of uninsured respondents with a disabling chronic condition reported an unmet health need and 45% reported no usual source of care. After adjusting for sociodemographic factors, uninsured young adults with disabling chronic conditions had 8 times greater odds of reporting unmet health care needs and 6 times greater odds of having no usual source of care relative to insured respondents with disabling chronic conditions. CONCLUSIONS: Despite increasing attention to issues of health care transition for young adults with disabling chronic conditions, this study suggests that uninsurance is as common among these young adults as nondisabled peers and is significantly associated with health care access barriers in this population.     

A national profile of health care utilization and expenditures for children with special health care needs

OBJECTIVES: To provide the first nationally representative data on total health care expenses, out-of-pocket health care expenses, and information on the extent to which out-of-pocket expenses are financially burdensome for families of children with special health care needs (CSHCN). To also compare utilization and expenditure patterns for children with and without special health care needs. DESIGN: We used data from the 2000 Medical Expenditure Panel Survey (MEPS). We present univariate, bivariate, and multivariate statistics on utilization and expenditures adjusted for the complex sample design. PARTICIPANTS: The 2000 MEPS data set contains 6965 children younger than 18 years. Using the CSHCN definition adopted by the federal Maternal and Child Health Bureau and operationalized using the CSHCN Screener, 949 children (15.6%) were identified as children with special health care needs. MAIN OUTCOME MEASURES: Compared with other children, CSHCN had 3 times higher health care expenditures (2099 dollars vs 628 dollars; P<.01). The 15.6% of CSHCN accounted for 42.1% of total medical care costs (excluding dental costs) and 33.6% of total health care costs (including dental costs) attributed to children in 2000. Families of CSHCN were best protected against inpatient hospital care expenses and most exposed to dental care expenses. Families of CSHCN experiencing high out-of-pocket expenses (exceeding 5% of family income) were approximately 11 times more likely to be from households with incomes below 200% of the federal poverty level (odds ratio, 10.9; 95% confidence interval, 3.55-33.76) than to be from families with incomes at or above 400% of the federal poverty level. CONCLUSIONS: Families with CSHCN experience much higher expenditures, including out-of-pocket expenditures, than other children. Insurance plays an important protective role for families of CSHCN, but it still provides incomplete protection. Health policy changes that would extend the breadth and depth of insurance coverage are needed to ensure that all families of CSHCN are protected against burdensome expenses.     

Access to medical care for children and adolescents in the United States

To evaluate access to health care for American children and adolescents, a telephone survey of a national random sample of households was conducted in which 2182 children 17 years or younger were studied. Approximately 10% had no medical insurance; 10% had no regular source of care; and 18% identified emergency rooms, community clinics, or hospital outpatient departments as their usual site of medical care. Children who were uninsured, poor, or nonwhite were less likely to have seen a physician in the past year (P less than .001), and uninsured children were less likely to have up-to-date immunizations. Logistic regression analyses revealed that poor, uninsured, or nonwhite children less frequently had a regular source of care; more frequently used emergency rooms, community clinics, and hospital outpatient departments as their regular providers; and more frequently encountered financial barriers to health care. Low-income or nonwhite children had much less access to care compared with children from more affluent or white families, independent of insurance status or health status.     

Access to care for children of the working poor

CONTEXT: Recent evidence suggests that children in working poor families lack health resources, placing them at risk for inadequate access to care. OBJECTIVES: To examine financial and nonfinancial access and utilization of health services among children in working poor families, and to compare these data with those of children from both nonworking poor and moderate to affluent families. DESIGN: A cross-sectional study of 13 785 children younger than 18 years. PARTICIPANTS: Subjects from the 1997 National Health Interview Survey. MAIN OUTCOME MEASURES: Prevalence and continuity of health insurance coverage, of delayed or missed care, and of unmet care needs; presence and type of usual source of care; and the amount of visits to physicians, emergency departments, and hospitals. RESULTS: Compared with children of nonworking poor parents and moderate to affluent children, more working poor children were uninsured (22% vs 12% and 5%, respectively; P<.01) and experienced disruptions in insurance coverage (P<.01). After adjusting for other covariates, disparities in insurance coverage and continuity persisted, as did delays in care and unmet care needs; these delays were far higher for the working poor. Although these children had access to a regular source of care and had utilization rates comparable with those of other poor children, they differed markedly from moderate to affluent children on structural access and utilization (adjusted odds ratios, 1.5-3.4). CONCLUSIONS: Children in working poor families experience far more barriers to care than other children. Health insurance expansions through the Children's Health Insurance Program and Medicaid, which reduce financial and nonfinancial barriers to care, may help correct these disparities.     

Community Health Centers: Medical Homes for Children?

ObjectiveTo explore medical home attributes of community health centers (CHCs) that provide care to low-income children nationwide compared to other providers for the poor.MethodsCross-sectional study of children aged 0 to 17 years in the Medical Expenditure Panel Survey (MEPS; 2003 to 2009) who resided in families living at <200% of the federal poverty level (FPL) and had visits to a primary care setting. CHC visits were defined as a visit to a neighborhood/family health center, rural health clinic, or community health center. Independent measures included provider type, age, gender, race/ethnicity, insurance, FPL, number of parents at home, language, maternal education, health status, and special health care need. Dependent measures included 4 medical home attributes: accessibility, and family-centered, comprehensive, and compassionate care.ResultsCHCs typically serve low-income children who are publicly insured or uninsured, come from racial/ethnic minority groups, and have poorer health status. Eighty percent to 90% of parents visiting both CHCs and other primary care providers rated high levels of family-centered, comprehensive, and compassionate care. However, CHCs had a 10% to 18% lower rating of accessibility (after-hours care, telephone access) even after controlling for sociodemographic characteristics. Racial/ethnic disparities existed at both settings, but these patterns did not differ between CHCs and other settings.ConclusionsOn the basis of parental reports, CHCs received similar ratings to other primary care providers for family-centered, comprehensive, and compassionate care, but lower ratings for accessibility. Further studies should examine strategies for practice transformation in CHCs to improve patient satisfaction and accessibility to optimize child health outcomes.     

Crossing the border for health care: access and primary care characteristics for young children of Latino farm workers along the US-Mexico border.

OBJECTIVES: To examine prevalence and correlates of cross-border health care for children of Latino farm workers in counties near the US-Mexico border and to compare access and primary care in the United States and Mexico. METHODS: Two hundred ninety-seven parents at Head Start centers in San Diego and Imperial counties were surveyed regarding percentage of health care received in Mexico and the United States, access, and primary care characteristics. RESULTS: More than half of all health care was reported as received in Mexico. Reasons for Mexican use revolved around cost, accessibility, and perceptions of effectiveness. Parents of insured children reported slightly more US care, yet even this group reported approximately half of health care in Mexico. Insurance status was related to having a regular source of care, while uninsured children reporting most care in Mexico were less likely than uninsured children in the United States to have had a routine health care visit. Primary care characteristics were related to insurance status and source of care. Uninsured children reporting most care in Mexico fared better in some aspects of primary care than uninsured children reporting most care in the United States and as well as children with insurance receiving care in the United States or Mexico. CONCLUSIONS: Children of farm workers living along the US-Mexico border, almost irrespective of insurance status, receive a large proportion of care in Mexico. Especially for uninsured children, parent reports of Mexican care characteristics compare favorably with that received in the United States. Mexican health care might be a buffer against vulnerability to poor health outcomes for these children.     

The impact of health insurance gaps on access to care among children with asthma in the United States.

BACKGROUND: Health insurance coverage is important to help assure children appropriate access to medical care and preventive services. Insurance gaps could be particularly problematic for children with asthma, since appropriate preventive care for these children depends on frequent, consistent contacts with health care providers. OBJECTIVE: The aim of this study was to determine the association between insurance gaps and access to care among a nationally representative sample of children with asthma. METHODS: The National Survey of Children's Health provided parent-report data for 8097 children with asthma. We identified children with continuous public or continuous private insurance and defined 3 groups with gaps in insurance coverage: those currently insured who had a lapse in coverage during the prior 12 months (gained insurance), those currently uninsured who had been insured at some time during the prior 12 months (lost insurance), and those with no health insurance at all during the prior 12 months (full-year uninsured). RESULTS: Thirteen percent of children had coverage gaps (7% gained insurance, 4% lost insurance, and 2% were full-year uninsured). Many children with gaps in coverage had unmet needs for care (7.4%, 12.8%, and 15.1% among the gained insurance, lost insurance, and full-year uninsured groups, respectively). In multivariate models, we found significant associations between insurance gaps and every indicator of poor access to care among this population. CONCLUSIONS: Many children with asthma have unmet health care needs and poor access to consistent primary care, and lack of continuous health insurance coverage may play an important role. Efforts are needed to ensure uninterrupted coverage for these children.     

Use of inhaled anti-inflammatory medication in children with asthma in managed care settings

BACKGROUND: Many factors affect use of inhaled therapy in asthma. Relatively little is known about current patterns of use of anti-inflammatory medication in children with asthma and whether variations occur with age and use of bronchodilator medication. OBJECTIVE: To study the factors associated with dispensing of anti-inflammatory (controller) asthma medication to children in 3 managed care organizations (MCOs). METHODS: Using automated databases, a 1-year cross-sectional study of children with asthma aged 3 to 15 years cared for in 3 MCOs was used to evaluate the association of age and other factors with controller medication use. RESULTS: A total of 13 352 children were studied. Significantly fewer children aged 3 to 5 years were dispensed any (> or =1) controller medication than older children (P<.001). Among children dispensed 6 or more beta-agonists, only 39% also received 5 or more controller dispensings, with adolescents significantly less likely than younger children to receive 5 or more controllers (33%; P<.001). Significant differences were seen among MCOs in proportions of patients dispensed controller medication. In a multiple logistic regression model, controlling for frequency of beta-agonist dispensing and MCO, significantly lower dispensing of any controller medication was seen for those aged 3 to 5 years (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9) and for girls (OR, 0.9; 95% CI, 0.8-0.96). In contrast, for repeated (> or =5) controller dispensing there were significantly fewer dispensings to adolescents (OR, 0.7; 95% CI, 0.6-0.9) and girls (OR, 0.8; 95% CI, 0.7-0.9). CONCLUSIONS: There may be differences in the use of preventive asthma medication in children that are affected by age, sex, and health care organization. Few children with frequent symptoms are using controllers regularly, as is recommended by national guidelines.     

Children With Special Health Care Needs: How Special Are Their Health Care Needs?

ObjectiveTo assess use and needs for general practitioner, specialist, emergency department, hospital inpatient, and hospital outpatient services for children with special health care needs (CSHCN). To assess the level of CSHCN's needs compared with other children.MethodsHealth service use and needs for children aged 4 to 15 years were assessed using the nationally representative Longitudinal Study of Australian Children survey with 25,011 observations. Odds ratios of service use and unmet needs for CSHCN compared to other children were estimated. CSHCN were further grouped as those 1) needing only additional medication, 2) needing only additional medical care, or 3) needing both as defined by the CSHCN screener questions.ResultsThe prevalence of those meeting criteria for CSHCN was 16.1%. In the past 12 months, 77.7% of CSHCN used any general practitioner care and 46.4%, 21.7%, 12.4%, and 15.0%, respectively, used specialty care, emergency department, hospital inpatient, and outpatient services. Approximately half of CSHCN were identified as having special needs due to needing additional medication. Their service use and unmet needs are only slightly elevated. Another group of CSHCN who need both more medication and medical care comprises less than one third of all CSHCN. These children have the highest odds of using specialty care (odds ratio 12.3, P < .001), and of having unmet specialty care need (odds ratio 7.4, P < .001) compared to children without special needs.ConclusionsOur findings highlight the importance of ensuring specialty care for CSHCN, especially the one third with most elevated needs. This estimate might guide future care planning.     

Which physicians are providing health care to America's children? Trends and changes during the past 20 years

BACKGROUND: Although pediatricians and family physicians are trained in the care of children, previous studies have revealed significant differences in the medical care and specialty referral patterns each provides. During the 1990s, several developments in the population and the health care system (eg, aging of the population and increases in Medicaid managed care) may have resulted in changes to the proportion of children seeking care from one or the other specialty. OBJECTIVE: To determine any changes in the proportion of office visits for children from birth through the age of 17 years provided by pediatricians or family physicians from 1980 to 2000. DESIGN: Analysis of the National Ambulatory Medical Care Survey data sets from 1980 to 2000. During our years of interest, the total number of visits sampled ranged from 2524 to 9151. Visits were analyzed for physician type and patient age. RESULTS: There have been marked changes in the proportion of office visits to general pediatricians vs family physicians during the 1990s. Overall, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to general pediatricians increased significantly, from 56.2% in 1990 to 64.2% in 2000 (P<.001). During the same period, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to family physicians declined significantly, from 33.7% in 1990 to 23.9% in 2000 (P<.001). Visits to pediatric specialists, as a proportion of all visits, increased significantly, from 1.6% in 1980 to 4.5% in 2000 (P<.001). CONCLUSIONS: Pediatricians are providing more primary care visits for children in the United States, and this trend has accelerated during the past 5 years. These findings have implications for the cost of care, the physician workforce, and the training of future physicians. It is unknown if these changes have had a positive or negative impact on the health of our nation's children.     

Parental report of health conditions and health care use among children with and without autism: National Survey of Children's Health

OBJECTIVE: To compare parent-reported prevalence of health conditions and health care use between children with and without autism. DESIGN: Cross-sectional analysis of the 2003 to 2004 National Survey of Children's Health. SETTING: Population-based sample across the United States. PARTICIPANTS: More than 100 000 parents. The main exposure was "autism" (not further defined), from response to the question: "Has a doctor or health professional ever told you that your child has autism?" MAIN OUTCOME MEASURES: Medical and mental health conditions and measures of health care use. RESULTS: Autism prevalence among children aged 3 to 17 years was 53 per 10 000 (95% confidence interval, 45-61 per 10,000), equating to a national estimate of 324 000 children (95% confidence interval, 274,000-375,000 children). Children with autism had a significantly (P<.001) higher prevalence of depression or anxiety problems (38.9% vs 4.2%) and behavioral or conduct problems (58.9% vs 5.2%) than children without autism. Respiratory, food, and skin allergies were reported by parents more often for children with autism, with food allergies having the strongest relative difference between the groups (odds ratio, 4.5; 95% confidence interval, 3.0-7.0). Children with autism had significantly (P<.001) higher mean physician visits over 12 months for preventive care, nonemergency care, and hospital emergency care, and were far more likely than children without autism to receive physical, occupational, or speech therapy (76.0% vs 6.3%), to need treatment or counseling for an emotional, developmental, or behavioral problem (75.4% vs 7.0%), and, among those taking a prescribed medication, to be using a medication long-term (51.4% vs 14.5%). CONCLUSION: We found markedly higher reports of concurrent conditions and health care use associated with childhood autism in this study.     

Health care for children and youth in the United States: 2002 report on trends in access, utilization, quality, and expenditures.

OBJECTIVE: To examine changes in insurance coverage, health care utilization, perceived quality of care, and expenditures for children and youth in the United States using data from 1987-2001. METHODS: Three national health care databases serve as the sources of data for this report. The Medical Expenditure Panel Survey (1996-2001) provides data on insurance coverage, utilization, expenditures, and perceived quality of care. The National Medical Expenditure Survey (1987) provides additional data on utilization and expenditures. The Nationwide Inpatient Sample (1995-2000) from the Healthcare Cost and Utilization Project provides information on hospitalizations. RESULTS: The percent of children uninsured for an entire year declined from 10.4% in 1996 to 7.7% in 1999. Most changes in children's health care occurred between 1987 and the late 1990s. Overall utilization of hospital-based services has declined significantly since 1987, especially for inpatient hospitalization. Several of the observed changes from 1987 varied significantly by type of health insurance coverage, poverty status, and geographic region. Quality of care data indicate some improvement between 2000 and 2001, which varies by insurance coverage. Overall, mean length of stay of hospitalizations did not change significantly from 1995 to 2000, but changes in the prevalence of hospitalizations and the length of stay associated with age-specific diagnoses were evident during this time period. CONCLUSIONS: Health care for children and youth has changed significantly since 1987, with most of the changes occurring between 1987 and 1996. Insurance coverage has improved, the site of care has shifted toward ambulatory sites, hospital utilization has declined, and expenditures on children as a proportion of total expenditures have decreased. Variation in these changes is evident by insurance status, poverty, and region.     

Racial and income disparities in childhood asthma in the United States.

OBJECTIVE: To examine racial and income disparities in asthma prevalence in US children, and disparities in morbidity and ambulatory health care use among children with asthma. METHODS: Using 1993-1996 National Health Interview Survey data, we measured asthma prevalence and morbidity in children aged 3 to 17 years (N = 14 211) stratifying by race and poverty status. Measures of morbidity included asthma-related activity limitation and number of bed days. We used the ratio of asthma-related doctor contacts to number of bed days in the past 2 weeks to measure health care use adjusted for severity of illness. RESULTS: An annual average of 7.4% of children aged 3 to 17 years had asthma. There were no significant differences in asthma prevalence between race and poverty groups. In contrast, asthma-related morbidity was higher among black and poor children. Black poor children were most likely to have activity limitations due to asthma: 49% were limited compared with about 20% of black nonpoor, white poor, and white nonpoor children. Among children with activity limitations, black children and white poor children were more likely to have severe limitations, and white nonpoor children were least likely. Finally, white nonpoor children had the highest level of ambulatory care use for asthma after accounting for disease severity, and black poor children had the lowest level. CONCLUSIONS: We found no significant racial or income disparities in asthma prevalence among children in the United States. However, black children and poor children are at higher risk for activity limitation, more severe activity limitation, and relative underuse of ambulatory health care. Black children living in poverty are at highest risk. Targeted interventions to reduce the burden of asthma morbidity in this population are likely to reduce disparities in asthma morbidity as well as reduce overall childhood asthma morbidity.