HEALTH POLICY CENTER To What Extent Are Parents and Children Exposed to Bias and Unfair Treatment in Health Care? National Findings from 2022 Dulce Gonzalez, Michael Karpman, Genevieve M. Kenney, and Marla McDaniel July 2023 Adults' experiences of discrimination or unfair treatment based on race, ethnicity, and other personal characteristics are well documented (Bleich et al. 2019; Gonzalez et al. 2021; Hamel et al. 2020; IOM 2003; Nong et al. 2020). These experiences can adversely affect adults' health care access, health care quality, satisfaction with care, trust in the health care system, and treatment adherence (Agarwal et al. 2022; Armstrong et al. 2013; Bazargan, Cobb, and Assari 2021; Ben et al. 2017; Benjamins and Whitman 2014; Skopec, Gonzalez, and Kenney 2021). Less is known about the extent and impact of unfair treatment in health care on children and their parents, including during early childhood. Direct exposure to racism during childhood and indirect exposure mediated through a parent's or caregiver's experiences are associated with a range of adverse health effects, such as poor birth outcomes and worse child mental, socioemotional, and general health (Anderson et al. 2020; Heard-Garris et al. 2018; Priest et al. 2013). Prior research found that when older children are unfairly stopped by the police, their mothers' self-rated health deteriorates (Colen et al. 2019), suggesting that parental health and well-being may be adversely affected when they observe their children being treated unfairly. Unfair treatment in clinical settings may therefore affect the health and well-being of both parents and children by causing "psychological and physiological stress responses" (Sawyer et al. 2012), leading to disruptions in care and reductions in the quality of care, and fostering mistrust of health care providers during critical periods of childhood development. This study assesses unfair treatment in health care settings among parents and their children under age 19 using national data from the June 2022 round of the Urban Institute's Health Reform Monitoring Survey (see data and methods for information). We examine unfair treatment in health care settings related to race, ethnicity, country of origin, and primary language for parents and children. For parents, we also assess unfair treatment related to additional characteristics (insurance coverage type, weight, gender or gender identity, sexual orientation, income, and disability or health condition), consequences of unfair treatment, and concerns that they or family members will be treated unfairly in health care settings in the future. Our key findings include the following: ◼ Just over 1 in 8 parents (13 percent), including parents of young children, reported they were treated or judged unfairly in health care settings in the past 12 months because of their race or ethnicity, language, health insurance type, weight, income, disability, or other characteristics. » More than 1 in 5 Black parents (22 percent) reported unfair treatment, a rate that was 10 percentage points higher than that of parents who are white, Hispanic/Latinx, and additional races. ◼ Three percent of all parents, and 9 percent of Black parents, reported that their children were treated or judged unfairly in health care settings in the past 12 months because of the parent's or child's race, ethnicity, country of origin, or primary language. ◼ Just over 7 in 10 parents (71 percent) who experienced unfair treatment reported disruptions in their health care. About one-third (33 percent) took steps to express their dissatisfaction with how they were treated. ◼ Four in 10 Black parents (40 percent) and 3 in 10 Hispanic/Latinx parents (30 percent) reported being concerned they or a family member will be treated or judged unfairly in health care settings in the future because of their or a family member's race, ethnicity, or primary language. Our findings show that some parents, especially Black and Hispanic/Latinx parents, are treated unfairly because of their characteristics when they seek health care. Parents of children under age 3 are as likely as parents of older children to report unfair treatment. Changes in the health care system will be required to provide high-quality, respectful, culturally effective, and evidence-based care to all children and their parents, including Black parents and parents of color. Subsequent sections present the findings in more detail and discuss changes in policy and practice that may be needed to reduce racial and ethnic disparities in unfair treatment. Findings More than 1 in 8 parents, including parents of young children, reported they were treated or judged unfairly in health care settings in the past 12 months because of their race or ethnicity, language, health insurance type, weight, income, disability, or other characteristics. About 13 percent of parents reported they were treated or judged unfairly in health care settings because of one or more of the following reasons (table 1): their race, ethnicity, country of origin, or primary language (5 percent); type of health insurance coverage (5 percent); weight (5 percent); gender, gender identity, or sexual orientation (4 percent); income level (4 percent); disability or health condition 2 UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N (3 percent); or some other reason (1 percent).1 A similar share of parents of children under age 3 reported unfair treatment for one or more of these reasons (14 percent). Parents of children under age 3 who live with only one child reported similar rates of unfair treatment as other parents, suggesting young children are as likely as older children to experience indirect effects of unfair treatment toward their parents (data not shown). More than 1 in 5 Black parents (22 percent) reported unfair treatment, a rate that was 10 percentage points higher than that of parents who are white, Hispanic/Latinx, and additional races. Black parents were nearly twice as likely as white parents, Hispanic/Latinx parents, and parents of additional races to report unfair treatment (22 percent versus 12 percent; table 1). The most common reason Black parents reported they were treated unfairly was because of their race, ethnicity, country of origin, or primary language. Black parents were more than twice as likely as white parents, Hispanic/Latinx parents, and parents of additional races to report unfair treatment for these reasons (17 percent versus 1 percent, 7 percent, and 6 percent, respectively). Black parents were also more likely than white parents to report they were treated or judged unfairly because of their health insurance coverage type (9 versus 4 percent); weight (8 versus 5 percent); gender, gender identity, or sexual orientation (9 versus 4 percent); income level (6 versus 3 percent); or because of a disability or health condition (5 versus 3 percent). Most parents who reported unfair treatment indicated that a doctor, nurse, or other provider treated them unfairly (72 percent), and nearly half reported that a front office staff member treated them unfairly (45 percent; data not shown). About 29 percent of parents reported they were treated unfairly by both a provider and a front office staff member; 43 percent said that they were treated unfairly by a provider but not by a front office staff member; and 16 percent said they were treated unfairly by a front office staff member but not a provider (data not shown). UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N 3 TABLE 1 Share of Parents Reporting They Were Treated or Judged Unfairly in Health Care Settings in the past 12 Months, Overall and by Race/Ethnicity, June 2022 By All Parents' Race/Ethnicity Share of parents Parents of reporting they were children treated or judged All under age Hispanic/ Additional unfairly because of: parents 3 Black Latinx White races One or more reasons 13% 14% 22% 12%*** 12%*** 12%*** Race, ethnicity, country of origin, or primary language 5% 6% 17% 7%*** 1%***/^^^ 6%*** Health insurance coverage type 5% 4% 9% 4%** 4%** 6% Weight 5% 3% 8% 4%** 5%* 4%* Gender, gender identity, or sexual orientation 4% 6% 9% 2%*** 4%***/^ 5%*/^ Income level 4% 3% 6% 4% 3%* 3%* A disability or health condition 3% 3% 5% 2%*** 3%*/^^ 3% Some other reason 1% 2% 1% 0% 1%^^^ 0%^ Sample size 2,981 555 313 688 1,699 281 Source: Health Reform Monitoring Survey, June 2022. Notes: Parents are adults ages 18 to 64 who reported being the parent or guardian of a child under age 19 who lives with them. Parents who are Black, white, or additional races are not Hispanic/Latinx. Additional races include adults who are Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, some other race, or more than one race. Health care settings include a doctor's office, clinic, or hospital. Adults of additional races were more likely than white adults to report unfair treatment because of race, ethnicity, country of origin, or primary language (p < .05) and "some other reason" (p < .01). */**/***Estimate differs significantly from Black parents at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^Estimate differs significantly from Hispanic/Latinx parents at the 0.10/0.05/0.01 level, using two-tailed tests. Three percent of parents, including 9 percent of Black parents, reported that their children were treated or judged unfairly in health care settings in the past 12 months because of the parent's or child's race, ethnicity, country of origin, or primary language. Parents of color were more likely than white parents to report that any of their children were treated unfairly in health care settings because of their or their child's race, ethnicity, country of origin, or primary language (figure 1).2 Nine percent of Black parents reported their children were treated unfairly for these reasons, compared with 1 percent of white parents, 3 percent of Hispanic/Latinx parents, and 4 percent of parents of additional races. Among parents with only one child, parents of children under age 3 were as likely as parents of older children to report their child was treated or judged unfairly (data not shown). 4 UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N FIGURE 1 Share of Parents Reporting One or More of Their Children Were Treated or Judged Unfairly in Health Care Settings in the past 12 Months Because of Their or the Child's Race, Ethnicity, Country of Origin, or Primary Language, Overall and by Parents' Race/Ethnicity, June 2022 9% 4%* 3% 3% 3%** 1%***/^^ All parents Parents of children Black Hispanic/Latinx White Additional races under age 3 By All Parents' Race/Ethnicity URBAN INSTITUTE Source: Health Reform Monitoring Survey, June 2022. Notes: Parents are adults ages 18 to 64 who reported being the parent or guardian of a child under age 19 who lives with them. Parents who are Black, white, or additional races are not Hispanic/Latinx. Additional races include adults who are Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, some other race, or more than one race. Health care settings include a doctor's office, clinic, or hospital. Estimates for adults of additional races differed significantly from white adults (p < .05). */**/***Estimate differs significantly from Black parents at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^Estimate differs significantly from Hispanic/Latinx parents at the 0.10/0.05/0.01 level, using two-tailed tests. More than 7 in 10 parents who experienced unfair treatment reported disruptions in their health care. About one-third of parents took steps to express their dissatisfaction with the way they were treated. Most parents (71 percent) who reported they were treated or judged unfairly in health care settings reported a disruption to their health care following those negative experiences (figure 2). Disruptions to care included looking for a new health care provider (48 percent), delaying (46 percent) or not getting (41 percent) needed care, and not following the doctor's or provider's recommendations (25 percent). One in three parents (33 percent) who reported unfair treatment took other actions to express dissatisfaction with how they were treated. Twenty-two percent spoke to the provider about how they were treated, 15 percent filed a complaint, and 14 percent wrote a review or shared their experience on social media. UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N 5 FIGURE 2 Disruptions to Health Care Receipt and Other Actions by Parents in Response to Unfair Treatment in Health Care Settings in the past 12 Months, June 2022 Any disruption to care 71% Looked for a new health care provider 48% Delayed needed care 46% Did not get needed care 41% Did not follow doctor or provider's recommendations 25% Any action taken to express dissatisfaction with unfair treatment 33% Spoke to the doctor or provider about way treated 22% Filed a complaint 15% Wrote a review or shared on social media 14% URBAN INSTITUTE Source: Health Reform Monitoring Survey, June 2022. Notes: Parents are adults ages 18 to 64 who reported being the parent or guardian of a child under age 19 who lives with them. Health care settings include a doctor's office, clinic, or hospital. Respondents could have reported more than one disruption to care or action taken in response to unfair treatment. Four in 10 Black parents and 3 in 10 Hispanic/Latinx parents reported being concerned they or a family member will be treated or judged unfairly in health care settings in the future because of their or a family member's race, ethnicity, or primary language. Nearly 1 in 5 parents (18 percent) reported they were very or somewhat concerned that they or a family member would experience unfair treatment in health care in the future because of their racial or ethnic background or primary language (figure 3). Black parents were most likely to report these concerns about future unfair treatment (40 percent), followed by Hispanic/Latinx parents (30 percent), parents of additional races (25 percent), and white parents (8 percent). 6 UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N FIGURE 3 Share of Parents Reporting They Are Very or Somewhat Concerned They or a Family Member Will Be Treated or Judged Unfairly in Health Care Settings in the Future Because of Their Race, Ethnicity, or Primary Language, Overall and by Race/Ethnicity, June 2022 40% 30%** 25%*** 18% 18% 8%***/^^^ Black Hispanic/ White Additional races Latinx All parents Parents of children By all parents' race/ethnicity under age 3 URBAN INSTITUTE Source: Health Reform Monitoring Survey, June 2022. Notes: Parents are adults ages 18 to 64 who reported being the parent or guardian of a child under age 19 who lives with them. Parents who are Black, white, or additional races are not Hispanic/Latinx. Additional races include adults who are Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, some other race, or more than one race. Health care settings include a doctor's office, clinic, or hospital. Estimates for adults of additional races differed significantly from white adults (p < .05). */**/***Estimate differs significantly from Black parents at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^Estimate differs significantly from Hispanic/Latinx parents at the 0.10/0.05/0.01 level, using two-tailed tests. Conclusion This study finds that 13 percent of parents reported they were treated or judged unfairly in health care settings in the past year because of characteristics such as their race, ethnicity, language, health insurance type, income, weight, or disability and that 3 percent reported their children were treated or judged unfairly because of their or the child's race, ethnicity, country of origin, or primary language. After experiencing unfair treatment in health care, most parents reported delaying or not getting needed care, which could have adverse implications for access to crucial services such as preventive screening and chronic condition management. Parents of children under age 3 were equally likely to report unfair treatment in health care as parents of older children. Even if children under age 3 were not the direct target of unfair treatment, very young children could experience adverse fallout if parents' UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N 7 health is negatively affected following these experiences, given the close linkage between parental and child health (Kamis 2021; Murphey et al. 2018; Wolicki et al. 2021). Black parents and their children were at the greatest risk of experiencing unfair treatment in health care settings. More than 1 in 5 Black parents reported that they had experienced unfair treatment in the prior year, compared with just under 1 in 8 parents in other racial/ethnic groups. Moreover, nine percent of Black parents reported that their child was treated or judged unfairly in the preceding year because of their or their child's race, ethnicity, country of origin, or primary language compared with 1 percent of white parents, 3 percent of Hispanic/Latinx parents, and 4 percent of parents of additional races. Black parents and other parents of color were also much more likely than white parents to express concerns that they or a family member will be treated or judged unfairly in health care settings: 4 in 10 Black parents, 3 in 10 Hispanic/Latinx parents, and 1 in 4 parents of additional races indicated that they had this worry compared with 1 in 12 white parents. Prior experiences with unfair treatment in health care settings and anticipation of unfair treatment in future encounters could create long-lasting adverse consequences for children and their parents (Gee, Walsemann, and Brondolo 2012; Gee et al. 2019; Graetz, Boen, and Esposito 2022). Children are attuned to concepts of fairness as young as age 2 (Li et al. 2016); early messaging to children of color that they and their parents are not on equal footing with white children and parents when seeking care warrants attention because of the multiple ways in which unfair treatment can undermine health, well- being, health care access, and trust in the health care system among children and their families (Armstrong et al. 2013; Skopec, Gonzalez, and Kenney 2021; Danielson 2022).3 Interrupting instances of unfair treatment will be especially important for closing health inequities for future generations. Children of color make up an increasingly large share of the child population in the US, and missed opportunities to disrupt unfair treatment and bias in health care for these children will reverberate for the nation's health far into the future (O'Hare and Mayol-Garcia 2023). Changes in the health care system will be required to provide high-quality, respectful, culturally effective, and evidence-based care to all children and their parents, including Black parents and parents of color. The root causes of worse health care experiences among parents and children of color are complex. They include racist beliefs and implicit biases held by health care providers and front office staff that lead to overt and indirect discrimination and as well as structural factors that constrain health insurance and health care options, such as residential segregation, wealth and income inequalities, and health care workforce and facility shortages in areas where people of color live (Lang et al. 2016; Johnson et al. 2017; Steil and Arcaya 2023; Yearby, Clark, and Figueroa 2022).4 The large disconnect between the overall racial and ethnic composition of physicians and other health care providers and the children and parents they are serving makes it much less likely that children of color will be treated by providers of their race and ethnicity compared with white children, which may also contribute to the racial and ethnic disparities in unfair treatment observed among children and parents (Gonzalez et al. 2022; Salsberg et al. 2021). Mechanisms for accountability to prevent or address unfair treatment in health care could include creating feedback loops for health insurance plans to document instances of unfair treatment by 8 UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N providers through patient satisfaction surveys and related data collection efforts. Such efforts could document patient experiences and outcomes by race and ethnicity and establish criteria for determining whether providers and office staff members are qualified to provide culturally competent and effective evidence-based care as part of performance evaluations (Bleich, Zephyrin, and Blendon 2021).5 Although we cannot assess the health insurance coverage type for children in the survey, other data show that nearly 4 in 10 children in the US are covered by Medicaid/CHIP and that these programs disproportionately serve children who are Black, Hispanic, and Native American.6 As such, it is critical to consider ways to reduce unfair treatment in health care encounters with children covered under those programs. Prior research found that adults with Medicaid felt that they were treated unfairly at higher rates because of their insurance coverage compared with those with private insurance coverage (Gonzalez et al. 2022), which may derive partly from lower Medicaid payment rates and higher administrative burdens facing providers (Grimm 2023). In addition to increasing provider willingness to serve Medicaid patients overall, it will be important to leverage available tools in Medicaid and CHIP to ensure that children and parents of color consistently receive high-quality, evidence-based care as effective as that provided to white families. Overcoming existing barriers may require incentives that reward providers who excel at providing culturally competent, evidence-based care.7 Further research on interventions that can help reduce provider biases and discrimination in health care for parents and their children is needed. A better understanding of such interventions and mechanisms for spreading them will be critical to ensuring that parents of color and their children receive the quality care they deserve. Data and Methods Survey Data This analysis draws on data from the June 2022 round of the Urban Institute's Health Reform Monitoring Survey (HRMS). Launched in 2013, the HRMS is a nationally representative, internet-based survey of adults ages 18 to 64 that provides timely information on health insurance coverage, health care access and affordability, and other health topics. For each round of the HRMS, a stratified, random sample of nonelderly adults is drawn from Ipsos's KnowledgePanel, the nation's largest probability- based online research panel. Panel members are recruited from an address-based sampling frame covering approximately 97 percent of US households, including those without internet access. If needed, panel members are given internet access and web-enabled devices to facilitate their participation. The June 2022 round of the HRMS had a sample size of 9,494 adults, including oversamples of adults in low- and moderate-income households, nonwhite and Hispanic/Latinx adults, and young adults. Survey weights adjust for unequal selection probabilities and are poststratified to the characteristics of the national nonelderly adult population based on benchmarks from the Current Population Survey and the American Community Survey. Participants can take the survey in English or UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N 9 Spanish, and it takes a median time of 15 minutes to complete. The margin of sampling error, including the design effect, for the full sample of adults in the 2022 survey is plus or minus 1.2 percentage points for a 50 percent statistic at the 95 percent confidence level.8 Measures Our measure of unfair treatment in health care settings among parents is based on the following question: In the past 12 months, was there a time when you felt you were treated or judged unfairly at a doctor's office, clinic, or hospital because of any of the following reasons? (response options: yes or no) ◼ Your race ◼ Your ethnicity ◼ Your gender ◼ Your gender identity or sexual orientation ◼ Your country of origin or primary language ◼ Your health insurance coverage type ◼ A disability or health condition ◼ Your weight ◼ Your income level ◼ Some other reason (specify) Adults who reported they were treated or judged unfairly because of one or more reasons were also asked the following questions: Thinking of the last time you were treated or judged unfairly at a doctor's office, clinic, or hospital, did you take any of the following actions? (response options: yes or no) ◼ Looked for a new health care provider ◼ Delayed getting care you needed ◼ Did not get care you needed ◼ Spoke to the doctor or provider about the way you were treated ◼ Filed a complaint ◼ Did not follow the doctor's or provider's recommendations ◼ Wrote a review or shared on social media ◼ Other (specify) 10 UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N Thinking of the last time you were treated or judged unfairly at a doctor's office, clinic, or hospital, who treated or judged you unfairly? (respondents could select all that apply) ◼ A doctor, nurse, or other health care provider ◼ A front office staff member ◼ Someone else (specify) Our measure of unfair treatment in health care towards children is based on the following question: In the past 12 months, was there a time when you felt [your child under 19 living with you was/any of your children under 19 living with you were] treated or judged unfairly at a doctor's office, clinic, or hospital because of your or their… (response options: yes or no) ◼ race? ◼ ethnicity? ◼ primary language? ◼ country of origin? Finally, our measure of concern about future unfair treatment in health care is based on the following question: Thinking about the future, how concerned are you that you or a family member will be treated or judged unfairly at a doctor's office, clinic, or hospital because of your or their racial or ethnic background or primary language? ◼ Very concerned ◼ Somewhat concerned ◼ Not too concerned ◼ Not at all concerned Analysis For this analysis, parents are adults ages 18 to 64 who reported being the parent or guardian of a child under age 19 who lives with them. We estimate the share of parents ages 18 to 64 who reported they were treated or judged unfairly at a doctor's office, clinic, or hospital (hereafter referred to as "health care settings") in the past 12 months because of their race, ethnicity, or other characteristics. Next, we estimate the share of parents who reported that any of their children were treated or judged unfairly in the past 12 months because of the parent's or child's race, ethnicity, country of origin, or primary language. We also examine experiences of unfair treatment among parents of children under age 3. Finally, we examine disruptions in care stemming from perceived unfair treatment, actions parents took UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N 11 in response to that treatment, and parents' concern about future unfair treatment in health care settings because of a family member's race, ethnicity, or primary language. Limitations The HRMS has several limitations, including a low cumulative response rate, and nonresponse bias is likely only partially mitigated by the survey weights. However, studies assessing recruitment for the panel from which HRMS samples are drawn have found little evidence of nonresponse bias for core demographic and socioeconomic measures (Garrett, Dennis, and DiSogra 2010; Heeren et al. 2007). Further, HRMS estimates compare well against federal surveys with larger sample sizes, higher response rates, and stronger designs (Long et al. 2014). Because the HRMS is fielded in English and Spanish, we do not fully capture the experiences of households with adults who speak other languages. Notes 1 Rates of unfair treatment among parents were similar to those for nonparents (12 percent; data not shown). 2 We cannot determine the age of the child who was treated unfairly from the survey data. 3 Martha Hostetter and Sarah Klein, "How Pediatric Care Providers Are Identifying and Addressing the Impacts of Racism on Children," Commonwealth Fund, May 9, 2023, https://www.commonwealthfund.org/publications/2023/may/how-pediatric-providers-are-addressing-racist- policies-and-practices. 4 Hostetter and Klein, "How Pediatric Care Providers Are Identifying and Addressing the Impacts of Racism on Children." 5 Rick Evans, Shari Berman, Esther Burlingame, and Stephanie Fishkin, "It's Time to Take Patient Experience Measurement and Reporting to a New Level: Next Steps for Modernizing and Democratizing National Patient Surveys," Health Affairs Forefront (blog), March 16, 2020, https://www.healthaffairs.org/do/10.1377/forefront.20200309.359946/full/. 6 Kaiser Family Foundation, "Health Insurance Coverage of Children 0-18," State Health Facts, accessed May 31, 2023, https://www.kff.org/other/state-indicator/children-0- 18/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D; Kaiser Family Foundation, "Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity," State Health Facts, accessed May 31, 2023, https://www.kff.org/medicaid/state-indicator/nonelderly-medicaid-rate-by- raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%2 2%7D. 7 Vivek Garg, Amberly Molosky, Sandeep Palakodeti, and Sachin H. 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Casad, Sarah S. M. Townsend, and Wendy Berry Mendes. 2012. "Discrimination and the Stress Response: Psychological and Physiological Consequences of Anticipating Prejudice in Interethnic Interactions." American Journal of Public Health 102 (5): 1020–6. https://doi.org/10.2105/AJPH.2011.300620. Skopec, Laura, Dulce Gonzalez, and Genevieve M. Kenney. 2021. "Most Adults Who Feel Treated or Judged Unfairly by Health Care Providers Report Adverse Consequences." Washington, DC: Urban Institute. Steil, Justin, and Mariana Arcaya. 2023. "Residential Segregation and Health: History, Harms, and Next Steps." Health Affairs Health Policy Brief. 14 UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N Wolicki, Sarah Beth, Rebecca H. Bitsko, Robyn A. Cree, Melissa L. Danielson, Jean Y. Ko, Lee Warner and Lara R. Robinson. 2021. "Mental Health of Parents and Primary Caregivers by Sex and Associated Child Health Indicators." Adversity and Resilience Science 2: 125–139. https://doi.org/10.1007/s42844-021-00037-7. Yearby, Ruqaiijah, Brietta Clark, and José F. Figueroa. 2022. "Structural Racism In Historical And Modern US Health Care Policy." Health Affairs 41 (2): 187–194. https://doi.org/10.1377/hlthaff.2021.01466. About the Authors Dulce Gonzalez is a research associate in the Health Policy Center at the Urban Institute. She forms part of a team working on the Urban Institute's Well-Being and Basic Needs Survey. Gonzalez conducts quantitative and qualitative research focused primarily on the social safety net, immigration, and barriers to health care access. Her work has also focused on the impact of the COVID-19 pandemic on nonelderly adults and their families. Before joining Urban, Gonzalez worked at the Georgetown University Center for Children and Families and the nonprofit organization Maternal and Child Health Access. Gonzalez holds a BA in economics from California State University, Long Beach, and a master's degree in public policy from Georgetown University. Michael Karpman is a principal research associate in the Health Policy Center. His work focuses on the implications of the Affordable Care Act, including quantitative analysis related to health insurance coverage, access to and affordability of health care, use of health care services, and health status. His work includes overseeing and analyzing data from the Urban Institute's Health Reform Monitoring Survey and Well-Being and Basic Needs Survey. Before joining Urban in 2013, Karpman was a senior associate at the National League of Cities Institute for Youth, Education, and Families. He received his MPP from Georgetown University. Genevieve M. Kenney is a vice president and senior fellow in the Health Policy Center. She is a nationally renowned expert on Medicaid, the Children's Health Insurance Program (CHIP), and health insurance coverage; health care access and quality; and health outcomes for low-income adults, children, and families. She has played a lead role in several Medicaid and CHIP evaluations, including multiple congressionally mandated CHIP evaluations, and has conducted state-level evaluations of the implementation of managed care and other service delivery reform initiatives and policy changes in Medicaid and CHIP. Currently, she is leading a project focused on health equity that involves working with a community advisory board and is assessing Medicaid policies related to postpartum coverage and the unwinding of the Medicaid continuous coverage requirement. She received a master's degree in statistics and a doctoral degree in economics from the University of Michigan. Marla McDaniel is a senior fellow in the Center on Labor, Human Services, and Population at the Urban Institute whose research examines racial and ethnic disparities; low-income children, youth, and families; and the programs and policy environments that touch families' lives. She is interested in the relationships between inequities across multiple domains-including health, education, and employment-and their compounding effects on overall health and well-being. McDaniel holds a BA in psychology from Swarthmore College and a PhD in human development and social policy from Northwestern University. UNFAIR TREATMENT IN HEALTH CARE AMONG PARENTS AND THEIR CHILDRE N 15 Acknowledgments This brief was funded by the David and Lucile Packard Foundation. Funding from the Robert Wood Johnson Foundation supported the 2022 Health Reform Monitoring Survey. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. We thank Jennifer Haley and Carla Willis for their comments on this brief and Sarah LaCorte for assistance with editing. ABOUT THE URBAN INSTITUTE The Urban Institute is a nonprofit research organization that provides data and evidence to help advance upward mobility and equity. We are a trusted source for changemakers who seek to strengthen decisionmaking, create inclusive economic growth, and improve the well-being of families and communities. For more than 50 years, Urban has delivered facts that inspire solutions-and this 500 L'Enfant Plaza SW remains our charge today. Washington, DC 20024 Copyright © July 2023. Urban Institute. 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