Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults

Abstract

The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.

A systematic review of social determinants of health in pediatric organ transplant outcomes

“…Testing of such models, particularly with standardized variables, would require centers to collect comprehensive social data, which would allow for collapsing of data across both national and international centers for analyses 110 . Understanding of how SDoH and barriers to transplant impact specific patient populations would also ultimately inform interventions that are necessary to reduce disparities, including those aimed at reducing the impact of health disparities on transplant listing and transplant outcomes 111 …”

“…110 Understanding of how SDoH and barriers to transplant impact specific patient populations would also ultimately inform interventions that are necessary to reduce disparities, including those aimed at reducing the impact of health disparities on transplant listing and transplant outcomes. 111 When examining SDoH, it is critical to assess areas of clinical workflow that may contribute to systemic racism and health disparities. In healthcare, including transplant, certain practices (e.g., utilizing unstructured/non-validated assessments, having non-diverse transplant team members, and having team members of a racial or ethnic identity that does not match the community served) can often reinforce our implicit biases and therefore existing inequities.…”

Equity factors in pediatric transplant listing: Initial findings from a single center review

“…Our analyses of the association of SDoH variables indicates the importance of not looking at individual factors in a vacuum but rather the ways in which both institutional barriers and demographic factors can impact the transplant listing process. The intersectionality of these components are crucial for a better understanding of potential areas of bias (which may be multilayered and not as unilaterally defined) and how to promote greater equity at individual and community levels 12,13 . For example, in our dataset, it is possible that the higher odds of being declined for transplant listing as a Protestant is because of the racial diversity of this group, rather than the religious category by itself.…”

“…The intersectionality of these components are crucial for a better understanding of potential areas of bias (which may be multilayered and not as unilaterally defined) and how to promote greater equity at individual and community levels. 12,13 For example, in our dataset, it is possible that the higher odds of being declined for transplant listing as a Protestant is because of the racial diversity of this group, rather than the religious category by itself. Financial and resource barriers not only have the potential to impact the listing process but also have the potential to transplant outcomes in the longer term.…”

Immunosuppressive Agent Options for Primary Nephrotic Syndrome: A Review of Network Meta-Analyses and Cost-Effectiveness Analysis

“…The first is whether the positioning of traditionally used immunosuppressive drugs should be changed as new treatments are recommended, and the second question is whether B-cell/autoantibody-targeted therapies, as the centerpiece of the paradigm shift, can be expected to have therapeutic effects commensurate with the generally high cost. While renal healthcare for NS continues to evolve and research findings are being shared around the world, equal access to treatment is not guaranteed [ 39 ]. International guidelines from KDIGO have thus consistently been thoughtfully written with regional differences in economic characteristics in mind [ 1 , 26 ].…”