The U.S. health care system is characterized by differences in access to services by race. For example, in one study, Black patients reported significantly longer travel times to access health services than White patients. For others, critical health services might exist locally, but financial barriers may make them unreachable. As of 2021, roughly 1 in 10 ten Hispanic and American Indian/Alaska Native children were uninsured, even with boosts to public insurance coverage established under the 2020 Families First Coronavirus Response Act (for example, to prevent individuals from losing Medicaid coverage). For children, disruptions in health insurance are associated with fewer physician visits. In 2020 and 2021, nearly one third of Hispanic and Asian children went without any visits to a doctor or health care professional for preventative care. On average, fewer than one in four children missed such visits. Beyond costs, there are many other obstacles to health care access. For example, the parents of nearly one quarter of Black children report that either a lack of child care or transportation contributed to challenges for their children’s access to health care.

Gaps in access are particularly troubling given wide racial and ethnic health disparities in health outcomes, particularly in chronic disease. Black children, for example, have high rates of asthma (13%)—nearly double the national rate (7%). In recent years, the prevalence of Type 2 diabetes has risen sharply, with American Indian and Black girls now experiencing the highest rates.

School communities can make it easier for students across racial and ethnic groups to access health services by providing school-based services and ensuring that eligible children are enrolled in Medicaid. Schools with school nurses can screen for health challenges and support chronic disease management. More intensive models such as wellness centers and school-based health centers can go even further, offering primary care, counseling, and prescriptions, and other health services.

Educational attainment is strongly linked to decreased rates of morbidity and mortality and increased economic opportunity. Health challenges and unmet health needs can inhibit school participation, limiting students’ academic progress. Illness is the primary reason for student absence from school and racial and ethnic disparities in asthma, oral health, behavioral health, and acute illness contribute to disparities in chronic absenteeism. Prior to the COVID-19 pandemic, Black and American Indian children, as well as Pacific Islander children, experienced higher rates of chronic absenteeism than their peers. School districts with strong racial and income segregation comprise one quarter of districts with the highest rates of absence.

Youth incarceration is strongly linked to poor adult physical and mental health outcomes. In the last two decades, youth incarceration has declined sharply—by 77 percent from 2000 to 2020. However, racial inequity within the juvenile justice system remains stark, with Black youth over age 16 constituting 46 percent of detained youth, and 38 percent of committed youth, in residential placement.

Racial and ethnic disparities in the juvenile justice system are often attributed to differences in offending by race and the differential (or biased) treatment of youth of color by law enforcement and within the larger juvenile justice system. However, differences in youth offending rates across racial and ethnic groups have not been empirically linked to differences in juvenile justice outcomes (e.g., sentencing outcomes). Instead, research links racial differences in certain types of violent and nonviolent offending to differences in exposure to environmental risk factors for crimes. These risk factors include high concentrations of unemployment, poor housing conditions, exposure to violence, inadequately resourced educational institutions, and neighborhood poverty. Schools can play a critical role in providing resources to address these risk factors.

However, schools can also contribute to racial disparities in the juvenile justice system, depending on their response to student behavior. Punitive school responses to behavior—such as suspension, expulsion, and school policing—heighten students’ risk of contact with the juvenile justice system. Federal datasets indicate that children of color, particularly Black children, are disproportionately subject to punitive discipline and referrals to law enforcement. Unsafe school environments can also expose students to various forms of violence. Alternatively, healthy schools can respond to students’ social, emotional, and mental health needs with services and support—and contribute to broader community initiatives to reduce environmental risk factors—to prevent school violence and limit the need for punitive discipline.

Childhood exposure to lead, pesticides, and other pollutants is associated with a range of negative health and mental health outcomes, including asthma and cancer. A child’s degree of exposure is heavily influenced by where the child lives: For example, children of color suffer greater levels of exposure due to a combination of historic and ongoing residential segregation, land use decisions that place hazards closer to their communities, and concentrated substandard housing and infrastructure in communities of color. Schools are part of this equation, as children spend most of their waking hours within school buildings, and students of color and low-income students are often the least likely to have access to structurally sound and well-maintained schools.

Schools are well positioned to either further contribute to or reduce disparities in childhood exposure to hazards based on the condition of school’s infrastructure. However, the Government Accountability Office (GAO) and the American Society of Civil Engineers (ASCE) both report that the majority of American school buildings are increasingly in disrepair. Approximately 54 percent of schools need to update or repair multiple building systems. Healthy school environments in which students have access to clean water, good air quality and ventilation, and proper heating and cooling would decrease disparate childhood exposure to hazardous environments.

Income inequities by race and ethnicity within the United States are wide and persistent, and expose children of color to a range of deprivations, including inequities in access to food, housing, and clothing. In 2021, when child poverty reached record lows after federal COVID-19 interventions, 23 percent of Black households with children and 18 percent of Hispanic households with children nevertheless experienced food insecurity. Of students experiencing homelessness during the 2020-2021 school year, 39 percent were Hispanic (although Hispanic students comprise only 28% of the student population) and 24 percent were Black (Black students comprise only 15% of the student population).

Healthy schools can help children connect with school- and community-based supports to ensure their basic needs are met and can generally promote core social determinants of health. Community schools, for example, build partnerships with families and communities to establish schools as a core source of neighborhood support and provide integrated students supports, including housing assistance, job placement services, and nutrition programs. Schoolwide free meal programs support student participation in meals and improve nutrition by alleviating stigma and removing cost barriers. Schools that attend to students’ basic needs have the potential to lessen the impacts of broader income inequity on child well-being.

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Conclusion

Dismantling the various forms of racial inequity within the United States will require continuous effort from a broad coalition that spans public and private entities and cuts across nearly every institution—including education systems, human services, health systems, the criminal and juvenile justice systems, and more. For children and youth, schools can provide a foundation for healthy development and support that can reduce (or mitigate the influence of) the structural inequities that threaten their well-being. However, school conditions, cultures, and practices are also known sources of racial inequity that, without reforms, can exacerbate the broader societal challenges that children of color are forced to navigate. Deliberate investment and attention to creating healthy schools is a necessary strategy to battle racial inequity on behalf of children of color.

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This report was commissioned by Kaiser Permanente Thriving Schools. The authors thank Kaiser Permanente for their generous support. The views and opinions expressed in this publication are those of the authors. They do not necessarily reflect the opinions or positions of Kaiser Permanente.

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