GENERAL PEDIATRIC RESEARCH Black and White Middle Class Children Who Have Private Health Insurance in the United States

Objective. To compare the health, behavior and school problems, and use of medical, mental health, and special education services of privately insured, middle class black and white children in the United States. Design/Methods. Analyses of the Child Health Supplement to the 1988 National Health Interview Survey, with a nationally representative sample of 17 110 children age 0–17 years. Results. Privately insured middle class black children had fewer chronic health conditions, but were less likely to be reported to be in excellent health (46.2% vs 57.3%) and more likely to have had asthma (8.5% vs 5.8%) or to have been of low birth weight (10.7% vs 5.6%). There were no differences in rates of having a usual source of routine care (92.2% vs 93.8%) or of being up to date with well-child care (79.3% vs 78.2%), but black children made fewer physician visits, were less likely to use physicians’ offices, were more likely to lack continuity of care, and were twice as likely to use emergency departments. These differences in use of medical services persisted in multivariate analyses and analyses restricted to more affluent children. Despite similar rates of behavior problems, black children were more likely to repeat a grade (20.0% vs 12.3%) and to have been suspended from school (11.3% vs 5.0%). Although significantly fewer black middle class children received mental health or special education services in bivariate analyses, no differences in receipt of these services were noted in multivariate analyses. All differences reported were significant. Conclusions. Among middle class children in the United States, black and white children have similar rates of health and behavior problems, but black children experience substantially increased rates of asthma, low birth weight, and school difficulties. Although not differing in the receipt of mental health or special education services, middle class black children, even in the presence of private health insurance, have markedly different sources and patterns of use of medical services. Pediatrics 1999;104:151–157; black and white children, middle class, private health insurance. ABBREVIATION. BPI, Behavior Problem Index. Substantial time and resources have been devoted to identifying, attempting to understand the causal mechanisms behind, and rectifying racial disparities in health in the United States.1–10 Much of our understanding of racial differences in children’s health and access to health services has been hindered by black race being confounded and often confused with low socioeconomic status,4,9,11,12 and we often fail to recognize that .50% of all black children in the United States do not live in poverty. In contrast to the extensive literature comparing the health and use of health services of poor and nonpoor children13–18 or of uninsured and insured children,19 virtually no literature has focused on these issues for middle class black and white children. The objectives of this study were to investigate and compare the health, behavior and school problems, sources of ambulatory care for, and use of medical, mental health, and special education services of middle class black and white children with private health insurance in the United States. These children were the focus because private insurance is the primary means of financing health care for children in this country,20 and we wished to examine the health and patterns of service use among children for whom there are no, or minimal, financial barriers to care.