Almost half of American children live in low-income households and poverty has been linked to a variety of adverse health outcomes that can persist throughout life1. One potential source of income-related health disparities is physical access to hospital care, which is itself dependent on both the geographic distribution of poverty and the geographic distribution of hospitals. For over two decades, poverty in America has been displaced from cities and gradually relocated to formerly affluent suburbs2. Over the same period, pediatric hospital care has become increasingly concentrated, with declining services in suburban hospitals and in non-academic hospitals serving the poor3,4.

Many children must travel significant distances to reach an emergency department5 or inpatient unit6 with pediatric capability, and even common pediatric conditions are increasingly cared for within a select subset of pediatric centers.4,7 Moreover, the high inter-hospital transfer rate for children with general pediatric conditions suggests that proximity to a hospital with designated pediatric beds does not ensure proximity to needed care.8, 9, 10, 11 As the number of pediatric-capable hospitals declines, physical access to care decreases. If this decline is uneven, geographical disparities in access to care can result.

We hypothesize that hospitals serving poorer populations are less able to maintain pediatric services than hospitals serving affluent populations, resulting in greater distances to care for poor children. We additionally hypothesized that these differences should be greatest in rural and suburban regions, where populations are less concentrated. To test these hypotheses, we first determined the pediatric capability of hospitals nearest all census block groups within 17 U.S. states and then compared those capabilities according to community affluence. We then estimated travel distances from each block to the nearest hospital offering pediatric inpatient care and compared those distances according to community affluence. For comparison, we undertook a similar analyses of adult care as well as subgroup analysis for urban, suburban, and rural regions.