Comparing health and health care use in Canada and the United States

Results from the Joint Canada/United States Survey of Health (2002-2003) reveal that health status is relatively similar in the two countries, but income-related health disparities exist. Americans in the poorest income quintile are more likely to have poor health than their Canadian counterparts; there were no differences between the rich. In general, Canadians were more like insured Americans regarding access to services, and Canadians experienced fewer unmet needs overall. Despite higher U.S. levels of spending on health care, residents in the two countries have similar health status and access to care, although there are higher levels of inequality in the United States.     

Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey

OBJECTIVE: To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors. DESIGN: Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care. RESULTS: The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings. CONCLUSIONS: For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.     

The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.     

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.     

Disability in two health care systems: access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities

BackgroundAn overarching question in health policy concerns whether the current mix of public and private health coverage in the United States can be, in one way or another, expanded to include all persons as it does in Canada. As typically high-end consumers of health care services, people with disabilities are key stakeholders to consider in this debate. The risk is that ways to cover more persons may be found only by sacrificing the quantity or quality of care on which people with disabilities so frequently depend. Yet, despite the many comparisons made of Canadian and U.S. health care, few focus directly on the needs of people with disabilities or the uninsured among them in the United States. This research is intended to address these gaps. Given this background, we compare the health care experiences of working-age uninsured and insured Americans with Canadian individuals (all of whom, insured) with a special focus on disability. Two questions for research guide our inquiry: (1) On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access, utilization, satisfaction with, or quality of health care services within or between the United States and Canada? (2) After controlling covariates, when examining each level of disability severity, are there any significant differences in these measures of access, utilization, satisfaction, or quality between U.S. insured and Canadian persons?MethodsCross-sectional data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed with particular attention to disability severity level (none, nonsevere, or severe) among three analytic groups of working age residents (insured Americans, uninsured Americans, and Canadians). Differences in three measures of access, one measure of satisfaction with care, one quality of care measure, and two varieties of physician contacts are compared. Multivariate methods are then used to compare the healthcare experiences of insured U.S. and Canadian persons on the basis of disability level while controlling covariates.ResultsIn covariate-controlled comparisons of insured Americans and Canadians, we find that people with disabilities report higher levels of unmet need than do their counterparts without disabilities, with no difference in this result between the nations. Our findings on access to medications and satisfaction with care among people with disabilities are similar, suggesting worse outcomes for people with disabilities, but few differences between insured U.S. and Canadian individuals. Generally, we find higher percentages who report having a regular physician, and higher contact rates with physicians among people with disabilities than among people without them in both countries. We find no evidence that total physician contacts are restricted in Canada relative to insured Americans at any of the disability levels. Yet we do find that quality ratings are lower among Canadian respondents than among insured Americans. However, bivariate estimates on access, satisfaction, quality, and physician contacts reveal particularly poor outcomes for uninsured persons with severe disabilities in the United States. For example, almost 40% do not report having a regular physician, 65% report that they need at least one medication that they cannot afford, 45% are not satisfied with the way their care is provided, 40% rate the overall quality of their care as fair or poor, and significant reductions in contacts with two types of physicians are evident within this group as well.ConclusionBased on these results, we find evidence of disparities in health care on the basis of disability in both Canada and the United States. However, despite the fact that Canada makes health insurance coverage available to all residents, we find few significant reductions in access, satisfaction or physician contacts among Canadians with disabilities relative to their insured American counterparts. These results place a spotlight on the experiences of uninsured persons with disabilities in America and suggest further avenues for research.     

Physical and mental health characteristics of U.S.- and foreign-born adults: United States, 1998-2003

OBJECTIVE: This report presents national prevalence estimates of selected measures of physical health status and limitations, health care access and utilization, and mental health status among the civilian noninstitutionalized population of U.S.- and foreign-born adults aged 18 years and over in four race-ethnicity groups in the United States. METHODS: The estimates in this report were derived from the Family Core and Sample Adult components of the 1998-2003 National Health Interview Surveys, conducted annually by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). Estimates were generated and comparisons conducted using the SUDAAN statistical package to account for the complex survey sample design. Data were age adjusted to the 2000 U.S. standard population. RESULTS: In general, the foreign-born population was younger, less likely to have a high school diploma, more likely to be poor, heavily concentrated in the central cities of metropolitan areas, and more likely to live in large families, compared with their U.S.-born counterparts. Hispanic immigrants were the least likely to have health insurance or to have a usual source of health care compared with other immigrant groups. Non-Hispanic black and Hispanic adults, regardless of nativity, were more likely to be obese than non-Hispanic white and non-Hispanic Asian adults. However, non-Hispanic black and Hispanic immigrant adults were significantly less likely to be obese than their U.S.-born counterparts. Hispanic immigrants were more likely to be obese the longer they lived in the United States. Foreign-born nonHispanic black and Hispanic immigrant adults experienced fewer symptoms of serious psychological distress compared with their U.S.-born counterparts. CONCLUSIONS: There are significant differences in physical health status and mental health status among U.S.-born and foreign-born adults. Foreign-born adults enjoy considerable advantages over their U.S.-born counterparts for many health measures despite limited access to health care and unfavorable sociodemographic characteristics. Differences in the impact of length of stay in the United States on immigrant health suggest that the role of acculturation in understanding immigrant health is complex and may differ for various race/ethnicity groups.     

Self-reported hypertension prevalence and income among older adults in Canada and the United States

Hypertension is one of the most common chronic conditions worldwide. There is strong evidence that low socioeconomic status is associated with elevated rates of blood pressure-related cardiovascular disease. Few studies have examined the association between socioeconomic circumstances and hypertension among people aged 65 years and older. The purpose of this study was to examine the relationship between household income and self-reported hypertension prevalence among persons aged 65 and older in the United States and Canada. Data were obtained from the 2002–2003 Joint Canada/United States Survey of Health for 755 Canadian and 1151 US adults aged 65 and older. Aggregate hypertension prevalence rates in the United States and Canada were generally similar (53.8% versus 48.0%). We found a significant inverse linear relationship between household income and the hypertension prevalence rate in the United States, but no evidence of such a relationship in Canada. In Canada, unlike the United States, the burden of hypertension is approximately equal for socioeconomically advantaged and disadvantaged older adults. It is important to consider these findings in the context of long-term and broader institutional policies. Social disparities and barriers to health care access and primary prevention among non-elderly persons in the United States may play a role in the higher hypertension prevalence rate among low-income older adults.     

Physician use in Ontario and the United States: The impact of socioeconomic status and health status.

OBJECTIVES: This study compared physician use in Ontario and the midwestern and northeastern United States for persons of different socioeconomic status and health status. The distribution of health problems associated with the most recent physician visit also was compared. METHODS: The design of the study was cross sectional; data derived from the 1990 Ontario Health Survey and the 1990 US National Health Interview Survey were used in analyses. RESULTS: Overall, persons in Ontario averaged 19% more visits than US residents, but differences varied markedly across income and health status. At each level of health status, low- income Canadians had 25% to 33% more visits than their US counterparts. However, among higher income persons, those in excellent or very good health had 22% more visits than Americans, while those in good, fair, or poor health had 10% fewer visits than Americans. Higher visit rates in Ontario were not associated with a greater prevalence of low- priority visits. CONCLUSIONS: Under the Canadian single- payer system, medical care in Ontario has been redistributed to low-income persons and the elderly. Compared with the United States, there has been a lower intensity of medical care for the sick higher income population.     

Disability,self-rated health,and time seeking medical care

BackgroundPopulation-level estimates of patient-reported time seeking medical care in the United States by disability status are unknown.ObjectiveTo estimate the likelihood of seeking medical care on an average day and the number of minutes spent traveling to, waiting for, and receiving medical care among those receiving care, by disability status.MethodsData are analyzed from the nationally representative 2008, 2010, and 2012–2016 American Time Use Surveys. Weighted logistic and linear regression models evaluate the association between sensory, cognitive, physical, or multiple disabilities and time spent seeking medical care, net of age, sex, race/ethnicity, education, employment, nativity, marital status, parental status, income, metropolitan area, and self-rated health.ResultsThe presence of a disability positively associates with the likelihood of seeking medical care on an average day. Patients with disabilities spend more total time in medical care than patients without disabilities as a result of longer clinical and travel time. These differences cannot be explained by sociodemographic disparities or by poorer self-rated health.ConclusionsPatient time burden is exacerbated by the presence of a disability. It is important to consider disability status along with other social disparities when evaluating the delivery of timely and equitable care.     

Income-Related Health Inequalities in Canada and the United States: A Decomposition Analysis

Objectives. We examined income-related inequalities in self-reported health in the United States and Canada and the extent to which they are associated with individual-level risk factors and health care system characteristics.Methods. We estimated income inequalities with concentration indexes and curves derived from comparable survey data from the 2002 to 2003 Joint Canada–US Survey of Health. Inequalities were then decomposed by regression and decomposition analysis to distinguish the contributions of various factors.Results. The distribution of income accounted for close to half of income-related health inequalities in both the United States and Canada. Health care system factors (e.g., unmet needs and health insurance status) and risk factors (e.g., physical inactivity and obesity) contributed more to income-related health inequalities in the United States than to those in Canada.Conclusions. Individual-level health risk factors and health care system characteristics have similar associations with health status in both countries, but they both are far more prevalent and much more concentrated among lower-income groups in the United States than in Canada.Increasing evidence indicates that the roots of health inequalities lie in an array of social, economic, and political attributes of nation-states.^1–4 Nations differ both in their average levels of population health and in the extent to which health is distributed unequally by socioeconomic status. Income-related inequalities in mortality, which are relatively stable in Canada,⁵ have been increasing steadily in the United States. In the early 1980s, the life expectancy gap in the United States between the poorest and most affluent decile was 2.8 years. By the late 1990s, this gap had increased to 4.5 years.⁶ The socioeconomic distribution of infant mortality in the two countries is also different, with declines across socioeconomic groups in Canada over recent decades,⁵ but widening gaps in the United States that are attributable to relatively higher declines for the affluent.⁷What are the underlying causes of these disparities? Are determinants of population health distributed differently by income in these neighboring countries? Or is the association between these determinants and health stronger in the United States than in Canada? We aimed to identify the potential influence of health care and other policies on income-related inequalities in health by decomposing those inequalities in both the United States and Canada into relative contributions from a set of known determinants of health.     

The burden of rheumatoid arthritis and access to treatment: uptake of new therapies

This paper presents data on international differences in use of TNF inhibitors. It is part of a study on burden and cost of RA, access to new therapies and the role of HTA in determining access and cost-effectiveness. United States has the fastest most extensive use of the new drugs, about three times the average in the western European countries and Canada. Eastern and central European countries as well as Australia, South Africa and Turkey lag far behind. However, some smaller European countries, most notably Norway and Sweden have use of the new drugs not far behind the United States. While the income level of the country, and thus the health care expenditures per capita is a major factor for determining use in low and middle income countries, there are still considerable differences among countries with similar high total health care expenditures. Differences in prices are considerable between the US and Europe due to the changes in exchange rates between the US dollar and the Euro, but high and low use is not systematically related to differences in price.

     

Socioeconomic status and health-related quality of life among elderly people: results from the Joint Canada/United States Survey of Health

The objective of this study was to assess the independent effect of income on health-related quality of life (HRQL) among older adults in Canada and the United States. Data were obtained from the 2002-2003 Joint Canada/United States Survey of Health. The sample consisted of 755 Canadians and 1,151 Americans aged 65 years or older. HRQL was measured with the multidimensional Health Utilities Index Mark 3 (HUI3). The results indicated that in the elderly population, HRQL was significantly associated with household income in the United States but not in Canada, controlling for sociodemographic and health indicators. Various explanations for the positive linear relationship between HRQL and income in the elderly population are discussed, including the roles of access to health care and socioeconomic inequalities in the United States and Canada.     

The impact of workplace policies and other social factors on self-reported influenza-like illness incidence during the 2009 H1N1 pandemic

Objectives. We assessed the impact of social determinants of potential exposure to H1N1—which are unequally distributed by race/ethnicity in the United States—on incidence of influenza-like illness (ILI) during the 2009 H1N1 pandemic.Methods. In January 2010 we surveyed a nationally representative sample (n = 2079) of US adults from the Knowledge Networks online research panel, with Hispanic and African American oversamples. The completion rate was 56%.Results. Path analysis examining ILI incidence, race, and social determinants of potential exposure to H1N1 demonstrated that higher ILI incidence was related to workplace policies, such as lack of access to sick leave, and structural factors, such as number of children in the household. Hispanic ethnicity was related to a greater risk of ILI attributable to these social determinants, even after we controlled for income and education.Conclusions. The absence of certain workplace policies, such as paid sick leave, confers a population-attributable risk of 5 million additional cases of ILI in the general population and 1.2 million cases among Hispanics. Federal mandates for sick leave could have significant health impacts by reducing morbidity from ILI, especially in Hispanics.During the 2009 H1N1 pandemic, racial/ethnic disparities in hospitalization and mortality rates were reported in the United States.1–8 Non-Hispanic Blacks and Hispanics were overrepresented among hospitalized cases compared with non-Hispanic Whites.3,7 It is unclear whether these disparities were attributable to unequal levels of incidence resulting from disparities in exposure by race/ethnicity, unequal levels of underlying chronic conditions, or unequal access to health care leading to differences in timely care-seeking behaviors.We assessed the impact of social determinants of potential exposure to the virus, which are unequally distributed by race/ethnicity in the United States, on influenza-like illness (ILI) incidence.     

Effects of length of stay and language proficiency on health care experiences among immigrants in Canada and the United States

This study sought to examine the influence of length of stay and language proficiency on immigrants' access to and utilization of care in Canada and the United States (U.S,). Data came from the 2007-2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n = 12,870 in Canada and n = 7440 in the U.S.). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the U.S. among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country's official language(s), respectively. There was one exception to this pattern in the U.S.: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population.     

The Relation Between Health Insurance and Health Care Disparities Among Adults With Disabilities

Objectives. We examined disparities among US adults with disabilities and the degree to which health insurance attenuates disparities by race, ethnicity, and socioeconomic status (SES).Methods. We pooled data from the 2001–2007 Medical Expenditure Panel Survey on individuals with disabilities aged 18 to 64 years. We modeled measures of access and use as functions of predisposing, enabling, need, and contextual factors. We then included health insurance and examined the extent to which it reduced observed differences by race, ethnicity, and SES.Results. We found evidence of disparities in access and use among adults with disabilities. Adjusting for health insurance reduced these disparities most consistently for emergency department use. Uninsured individuals experienced substantially poorer access across most measures, including reporting a usual source of care and experiencing delays in or being unable to obtain care.Conclusions. Although health insurance is an important enabling resource among adults with disabilities, its effect on reducing differences by race, ethnicity, and SES on health care access and use was limited. Research exploring the effects of factors such as patient–provider interactions is warranted.Continuing its emphasis on reductions in health care disparities, Healthy People 2020 identifies the elimination of health disparities as 1 of 4 overarching goals.1 Congress has charged the Agency for Healthcare Research and Quality (AHRQ) with tracking disparities in health care access and quality among racial, ethnic, and socioeconomic groups, as well as for priority populations. In April 2012, AHRQ released its ninth report, finding that, although there was evidence of improvements in quality of care, health care access and quality are suboptimal, particularly for individuals who are racial/ethnic minorities or of lower socioeconomic status (SES).2An estimated 1 in 5 noninstitutionalized individuals in the United States experiences a disability.3 Although individuals with disabilities have been identified as a priority population by Congress,2 examining disparities among those with disabilities has garnered less attention. There is evidence that individuals with disabilities receive fewer preventive and treatment services than individuals without disabilities.4–7 Individuals with disabilities are more likely to report cost as a barrier to care,4,8 to report higher out-of-pocket costs,9 and to report unmet need for medical care.8Individuals with disabilities are disproportionately racial/ethnic minority and of lower SES. Rates of disability are higher for Blacks (22.2%) than for Hispanics (17.8%) and Whites (17.4%).3 Using data from the American Community Survey, Erickson and Lee10 found prevalence of disability to decline with increasing income. Disability is also associated with educational attainment. Substantially more people without a disability (30.8%) had a bachelor’s degree or higher than people with a disability (12.5%). Limited work has focused on disparities by race and SES on health care access and use among individuals with disabilities.11Health insurance provides an essential link to health services and outcomes,12,13 attenuating but not eliminating disparities by race and SES in the general population.14 Data from the 2010 American Community Survey indicate that, nationally, 82.1% of working-age individuals with disabilities had health insurance, compared with 78.2% among working-age individuals without disabilities.15 Nationally, 17.9% of working-age adults with disabilities were uninsured, but there was substantial state variability. Adults with disabilities are much more likely to have public, relative to private, coverage—50.5% public and 43% private coverage nationally in 2010 (some individuals have both public and private coverage). Research has rarely examined the extent to which health insurance coverage reduces potential disparities by race, ethnicity, and SES among individuals with disabilities. Thus, we extended the research on disparities among individuals with disabilities by examining whether minority and lower-SES adults with disabilities experience disparate access to and use of health care services.     

Equity of primary care service delivery for low income “sicker” adults across 10 OECD countries

Background

Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally.

Methods

The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent.

Results

Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands.

Conclusion

Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

     

Racial/ethnic health disparities among children with special health care needs in Boston,Massachusetts

BackgroundLittle is known about the factors that contribute to racial/ethnic disparities among children with special health care needs (CSHCN).ObjectiveTo quantify the contributions of determinants of racial/ethnic disparities in health and health care among CSHCN in Boston, Massachusetts.MethodsA sample of 326 Black, Latino, and white CSHCN was drawn from the Boston Survey of Children's Health, a city-wide representative sample of children. The study implemented Oaxaca–Blinder-style decomposition techniques to examine the relative contributions of health resources and child-, family-, and neighborhood-level factors to disparities in four outcomes: health status, barriers to medical care, oral health status, and utilization of preventive dental care.ResultsWhite CSHCN had a greater likelihood of having very good/excellent health and oral health and were less likely to experience barriers to care than Black CSHCN. Compositional differences on predictors explained 63%, 98%, and 80% of these gradients, respectively. Group variation in household income, family structure, neighborhood support, and exposure to adverse childhood experiences accounted for significant portions of the Black–white gaps in health and access. White CSHCN were also more likely to have very good/excellent health and oral health compared to Latino CSHCN. Differences on predictors accounted for about 86% and 80% of these gaps, respectively. Household income, adverse childhood experiences, and household language emerged as significant determinants of Latino–white disparities.ConclusionsRacial/ethnic health disparities among CSHCN are explained by relatively few determinants. Several of the contributing factors that emerged from the analysis and could be targeted by public health and policy interventions.