Children in big cities in the United States: Health and related needs and services

Objective. To examine how children in big cities in metropolitan areas with > 1 million people differ from other children in the United States in terms of health and related characteristics; and in these cities, what the role is of public sources (community health centers and hospital clinics) and private sources (private physicians and health maintenance organizations) in providing children's primary health care. Design. Analyses of data from the Child Health Supplement to the National Health Interview Survey. Setting and sample. Nationally representative random sample of 17,110 children aged 0-17 years in 1988. Main outcome measures. Children's demographic characteristics; health status; rates of chronic health conditions, behavior problems and school difficulties; and sources of primary care. Results. The approximately 10 million children in big cities are more racially and ethnically diverse and are more likely to be poor and to use hospital clinics and health centers, and less likely to use private physicians as compared with children elsewhere (p < 0.05 for each year). 21% of all children in these cities with a regular source of care use health centers and hospital clinics: 41% of poor, 33% near-poor, 27% uninsured, 33% with behavior problems, and 34% who repeated a grade are represented among their users. Selected unadjusted odds ratios comparing children who use health centers and hospital clinics with those who use private sources of care in these cities are: 4.6 for poverty, 2.0 for near-poverty, 3.4 for Black and 0.2 for White race, 1.6 for being uninsured, 6.3 for Medicaid, 2.1 for behavior problems, and 2.5 for having repeated a grade (p < 0.05 for each). Conclusions. These data demonstrate the concentration of high-risk children among the one in six children in the United Slates who reside in large cities, the increased risk of low income children in these cities for mental health and educational difficulties, the profoundly disproportionate representation of such children in hospital clinics and community health centers, and the critical role that hospital clinics and community health centers play in the provision of primary care services such children receive. These findings have significant implications for the growth of managed care programs and other aspects of health care reform currently evolving or being considered.