GENERAL PEDIATRIC RESEARCH
Black and White Middle Class Children Who Have Private Health
Insurance in the United States
Michael Weitzman, MD*; Robert S. Byrd, MD, MPH‡; and Peggy Auinger, MS*
ABSTRACT. 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.
From the *Department of Pediatrics, University of Rochester School of
Medicine and Dentistry, Rochester, New York, and the ‡Department of
Pediatrics, University of California School of Medicine at Davis, Davis,
California.
This work was presented in part at the 37th Annual Meeting of the
Ambulatory Pediatric Association; May 1997; Washington, DC.
Received for publication Dec 26, 1998; accepted Feb 4, 1999.
Address correspondence to Michael Weitzman, MD, Department of Pediatrics, Rochester General Hospital, 1425 Portland Ave, Rochester, NY
14621. E-mail: [email protected]
PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Academy of Pediatrics.
ABBREVIATION. BPI, Behavior Problem Index.
S
ubstantial 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.
METHODS
Data were from the Child Health Supplement to the 1988
National Health Interview Survey. This is a cross-sectional, randomized household survey conducted by the Bureau of the
Census for the National Center for Health Statistics.21,22 In selected years, the most recent being 1988, a Child Health Supplement is added to obtain detailed information about the health
of and use of health services by the nation’s children. Information was obtained by face-to-face interviews with adult family
members on 1 randomly chosen child per household surveyed,
resulting in a sample of 17 110 children 0 to 17 years of age,
representative of all noninstitutionalized children and youth in
the United States in 1988.
The Census Bureau does not have an official definition of the
“middle class,” but it does rank households from lowest to
highest based on income and then divides them into equal
population groups, typically quintiles. The lowest quintile often
is used as a proxy measure of those in poverty and the highest
quintile as those who are most affluent.23 For the purposes of
these analyses, children were categorized as being middle class
if their families’ reported income was in the second, third, or
fourth quintile. In 1988, family incomes in the second quintile
PEDIATRICS Vol. 104 No. 1 July 1999
151
ranged from $15 103 to $26 182, in the third quintile from
$26 183 to $38 500, and in the fourth quintile from $38 501 to
$55 906. Therefore, children in middle class families, as defined
in these analyses, were in families whose incomes ranged from
$15 103 to $55 906 in 1988. The comparable range in 1995 was
$19 071 to $72 260. Because of concern that comparisons using
children in families whose incomes are in the second through
fourth quintiles might be biased because of the unequal distribution of black and white children across this income range, all
bivariate analyses were repeated after analyses were restricted
only to children in families whose incomes were in the third and
fourth quintiles.
Children were categorized as being covered by private health
insurance if the respondent answered yes to the question, “Is —
now covered by a health insurance plan that pays any part of a
hospital, doctor’s office or surgeon’s bill?” Although this question may be answered affirmatively by some children covered by
Medicaid, such misclassification is likely to be minimized with
the analyses limited to children whose family income is above
the poverty level. Demographic and family characteristics,
health status, behavior and school problems, and sources of
ambulatory care and utilization of health services of privately
insured, middle class black and white children and youth were
compared, as presented below.
Demographic and Family Characteristics
Characteristics investigated included family income and size;
region and degree of urbanization of residence24,25; maternal
educational level and age at the time of child’s birth; single- or
two-parent family; and index child’s age and gender. As is true
of all other variables in this dataset, children’s race was based on
parental report. Race and Hispanic ethnicity were asked separately. Hispanic children were not excluded from analyses, and
racial comparisons in this study are likely to be less pronounced
than in analyses confined to non-Hispanic children.
Health Status
The following aspects of children’s physical health were investigated: parental rating of children’s overall health; the percentage of children whose birth weights were low and very low
(2500 and 1500 g, respectively) or who were reported as having
asthma; the prevalence of chronic physical health conditions
(ascertained from affirmative responses to a checklist of 76
childhood health conditions that respondents were asked
whether the child had in the past 12 months— 68 of which were
considered chronic, consistent with earlier work using the survey)19,21,26,27; limitations of activities among children reported as
having any of these chronic conditions; and the number of days
spent in bed.
Behavior and School Problems
Extreme scores (top 10th percentile) on the 32-item Behavior
Problem Index (BPI) developed by Zill for children 4 years of age
and older and modeled after the Child Behavior Checklist of
Achenbach and Edelbrock28,29 were used to identify the percent
of children who had behavior problems. This index has been
used in several earlier studies,30 –35 and extreme scores on it have
been shown to correlate substantially with referrals to mental
health professionals.30 Whether the respondent believed that the
child needed psychological help in the past year also was determined, as was whether the child had ever repeated a grade or
been suspended from school.
Utilization of Medical, Mental Health, and Special
Education Services
Sources of routine and sick care and whether the child utilized the same source for routine and sick care (continuity of
routine and sick care) were assessed. Sources of care were categorized as 1) physicians’ office (doctors’ offices, private clinics,
and health maintenance organization/prepaid group plans); 2)
outpatient clinics (hospital, school, and migrant clinics); 3)
health centers (neighborhood and rural centers); and 4) emergency departments (hospital emergency departments and
walk-in emergency care centers). Also investigated were the
number of visits made to a physician, the number of hospitalizations in the past 12 months, and whether the child was up to
152
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date for well-child care,19 estimated by comparing the reported
number of routine physician visits with age-specific guidelines
established by the American Academy of Pediatrics.36 Also assessed was whether the child had ever seen a psychiatrist or
counselor or received special education services. No detailed
information regarding the specific nature of special education
services received was available, thus, it was not possible to
determine whether parents were referring to educational counseling, tutoring, or other school-based support services, or to
their children being placed in totally separate classes or educational tracks.
Statistical Analyses
x2 Tests were used to test for differences in weighted proportions. Logistic and linear regression modeling was conducted to
investigate the independent association of children’s race and
aspects of their physical health, behavior and school problems,
sources of ambulatory care, and utilization of services.
All analyses were conducted on an IBM-compatible PC. PC
SAS software was used for the initial analyses.37 SUDAAN software was used to obtain precise confidence intervals, accounting for the complex, two-stage survey design.38
RESULTS
Of the ;64 million children in the United States
in 1988, 48.3% (4.3 million) of black and 67% (32.5
million) of white children lived in families whose
incomes were in the second, third, and fourth quintiles of family incomes (P , .001). Of these middle
class children, 75.9% of black and 85.3% of white
youth had private health insurance (P , .001). All
subsequent results and all tabular presentations of
data refer to middle class children who were reported to have had private health insurance.
Demographic and Family Characteristics
Among middle class children who had private
health insurance, black children were less affluent
and more likely to live in single-parent households
(31.3% vs 12.4%; P , .001) of larger size (3.62 vs
3.34 family members per household; P 5 .003) with
mothers whose age at their birth was #16 years
(3.6% vs 1.4%; P , .01) (Table 1). Maternal educational status did not differ between groups.
Physical Health, Behavior, and School Problems
Black children were reported as having fewer
chronic health conditions, fewer days in bed because of illness, and comparable rates of limitations
of activity. However, they were less likely to be
reported to be in excellent health (46.2% vs 57.3%;
P , .001) (Table 2). They also were more likely to
have been born with a low birth weight (10.7% vs
5.6%; P , .001) and to have asthma (8.5% vs 5.8%;
P , .01).
Whereas there were no differences in rates of
scoring in the top 10th percentile on the BPI or in
being perceived by parents as needing psychological help in the past 12 months, black children were
almost twice as likely to have ever repeated any
grade (20.0% vs 12.3%; P , .001), and they were
more than twice as likely to have ever been suspended from school (11.3% vs 5.0%; P , .001).
Utilization of Medical, Mental Health, and Special
Education Services
Although comparable percentages were reported
as having a usual source of routine care, and there
TABLE 1.
Demographic and Family Characteristics of Black
and White Middle Class Children and Youth with Private Health
Insurance in the United States, Child Health Supplement to the
1988 National Health Interview Survey (N 5 8381)
Black % White %
(n 5 979) (n 5 7402)
Family income
Second quintile
Third quintile
Fourth quintile
Middle class, quintile unknown*
Region
Northeast
Midwest
South
West
Degree of urbanization
Urban
Suburban
Other
Maternal education
, High school
High school
. High school
Household composition
Single parent
Two parents
Maternal age at child’s birth
#16 y
.16 y
P
39.3
36.3
13.8
10.5
26.3
44.3
20.5
8.9
,.001
,.001
,.001
NS
15.4
18.0
58.5
8.1
20.2
30.6
30.4
18.8
,.05
,.001
,.001
,.001
34.4
16.8
48.9
10.4
25.5
64.1
,.001
,.001
,.01
13.1
47.9
39.0
11.6
48.3
40.1
.28
.87
.61
31.3
68.7
12.4
87.6
,.001
,.001
3.6
96.4
1.4
98.6
,.01
,.01
* Family reported that income was $$20 000, but failed to give
exact amount.
were no differences in rates of being up to date with
well-child care or in the number of hospital episodes in the past 12 months, on every other measure, the two groups differed (Table 3). Black children lacked a source for sick care (6.6% vs 3.8%;
P , .01) or continuity of routine and sick care more
frequently (13.8% vs 7.5%; P , .001), used a physician’s office for routine (79.4% vs 92.8%; P ,
.001) or sick care (81.8% vs 92.0%; P , .001) less
frequently, and were more than twice as likely to
have used emergency departments for sick care
(5.4% vs 2.4%; P , .01). They also made fewer
ambulatory care visits, were less likely to receive
mental health services (3.6% vs 5.8%; P , .05), and
among children who repeated a grade or were suspended from school, they were substantially less
likely to have received special education (11.8% vs
18.8%; P , .05) or mental health services (4.0% vs
13.2%; P , .001).
Children Whose Family Incomes Were in the Third
and Fourth Quintiles
Analyses restricted to children whose family incomes were in the third and fourth quintiles revealed findings similar to those from analyses that
also included children of less affluent families having incomes in the second quintile. Although the
findings in the more restricted and smaller sample
did not reach statistical significance for some measures, the trend remained similar to that found in
the larger middle class sample. For example, black
children still were more likely to lack the same
source of care for routine and sick care (10.1% vs
6.5%; P 5 .06), more likely to use emergency departments as their source of sick care (4.2% vs
2.2%; P 5 .07); and less likely to receive mental
health (4.4% vs 5.9%; P 5 .22) or special education
services (2.8% vs 4.1%; P 5 .13). Among children
who experienced educational difficulties, black
TABLE 2.
Physical Health and Behavior and School Problems of Black and White Middle Class Children and Youth with Private
Health Insurance in the United States, Child Health Supplement to the 1988 National Health Interview Survey (N 5 8381)
Physical health
Health status
Excellent
Very good or good
Fair or poor
Low birth weight (,2500 g)
Very low birth weight (,1500 g)
Ever had frequent ear infections
Ever had asthma
Chronic health conditions
None
1
2
.2
Chronic health condition and limitations of activity
Major activity limited
School activity limited
Days in bed in last 12 mo
0
1–5
6–10
11–20
.20
Household member currently a smoker
Household members smoked since child born
Psychological and school functioning
Behavior Problem Index score $ 90 percentile
Felt to need psychological help in the past 12 mo
Repeated any grade
Ever suspended from school
Black % (n 5 979)
White % (n 5 7402)
P
46.2
51.3
2.5
10.7
1.4
16.9
8.5
57.3
41.0
1.7
5.6
0.6
27.9
5.8
,.001
,.001
.30
,.001
.08
,.001
.01
80.8
16.1
2.0
1.0
71.5
21.9
4.8
1.8
,.001
.001
,.001
.07
4.5
5.1
5.1
6.1
.45
.19
63.3
28.5
5.7
1.6
0.8
41.9
49.7
44.1
41.9
8.6
3.8
1.6
39.2
49.8
,.001
,.001
.002
,.001
.02
.29
.95
7.5
1.8
20.0
11.3
8.3
1.7
12.3
5.0
.51
.88
,.001
,.001
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153
TABLE 3.
Comparison of Sources of Care and Use of Medical, Mental Health, and Special Education Services by Black and White
Middle Class Children and Youth with Private Insurance in the United States, Child Health Supplement to the 1988 National Health
Interview Survey (N 5 8381)
Lack usual sources of care
Routine care
Sick care
Same source of care for routine and sick care
Usual place for routine care
Physician’s office
Outpatient’s clinic
Health center
Usual place for sick care
Physician’s office
Outpatient clinic
Health center
Emergency department
Number of physician visits in last 12 mo
0
1–5
6–10
11–20
.2
Not current with well-child care
,2 y
2–5 y
6–12 y
13–17 y
No. of short-stay hospital episodes in last 12 mo
0
1–5
.5
Ever seen psychiatrist or counselor
Received special education services for developmental delay,
learning disability, or emotional/behavioral problem
Repeated any grade or was ever suspended from school, and:
Received special education services
Ever seen psychiatrist or counselor
children in these quintiles also were less likely to
receive both special education (9.6% vs 19.4%; P ,
.05) and mental health (6.4% vs 14.5%; P , .06)
services.
Multivariate Analyses
Table 5 demonstrates adjusted ORs for selected
measures of health, behavior and school problems,
and sources of care and use of services, controlling
for family income and size, source of routine care,
region, urbanization, gender, single- vs two-parent
household, and maternal age at child’s birth. Black
children in these quintiles still were less likely to
be reported as being in excellent health (OR: 0.7,
95% CI: 0.6 – 0.8), and they still were more likely to
have been born with a low birth weight (OR: 1.9,
95% CI: 1.3–2.8) and to have asthma (OR: 1.4, 95%
CI: 1.01–2.0; P , .05). Black children also remained
at increased risk for having ever been suspended
from school (OR: 2.2, 95% CI: 1.5–3.3) and tended
to have higher rates of repeating a grade (OR: 1.4,
95% CI: 0.98 –1.9; P 5 .07) in adjusted analyses.
In multivariate analyses, race no longer was associated with disparities in lack of a usual source of
sick care, but black children still were more likely
to lack continuity of routine and sick care. The
likelihood of black children overall ever having
received mental health or special education services, although still less than that of white chil154
SUPPLEMENT
Black %
(n 5 979)
White %
(n 5 7402)
P
7.8
6.6
13.8
6.2
3.8
7.5
.22
,.01
,.001
79.4
13.1
7.2
92.8
4.5
2.4
,.001
.001
,.001
81.8
8.9
3.9
5.4
92.0
4.1
1.6
2.4
,.001
,.001
,.05
,.01
29.5
62.7
5.7
1.8
0.4
20.7
9.0
21.6
20.5
23.8
17.8
67.6
10.3
3.0
1.2
21.8
8.8
23.7
24.0
22.3
,.001
,.05
,.001
.01
.001
.54
.94
.56
.23
.71
97.5
2.5
0.0
3.6
3.0
96.7
3.2
0.04
5.8
4.2
.20
.23
.11
,.05
.09
11.8
4.0
18.8
13.2
,.05
,.001
dren, was now of marginal statistical significance.
Similarly, among children who had ever repeated a
grade or had ever been suspended from school,
although no longer statistically significant, the
trend was still for black children to be less likely to
have received special education services or to have
seen a psychiatrist or counselor. Black children
still were found to use physicians’ offices for routine care half as often (OR: 0.4, 95% CI: 0.3– 0.5)
and emergency departments for sick care three
times as often as white children (OR: 3.2, 95% CI:
1.7–5.8). Not shown are data from a linear regression model indicating that black children still had
fewer physician visits than did white children (P ,
.001).
DISCUSSION
This study differs from other studies of children’s health and use of health services in that it
focuses on middle class black and white children
who have private health insurance. Black and
white children were found to have comparable
rates of being up to date with well-child care. In
contrast, they differed substantially on many measures of utilization of services, and most of these
differences persisted in multivariate analyses and
analyses restricted to more economically privileged
middle class children, as well as across the entire
middle class income range. Black children were
TABLE 4.
Physical Health, Behavior and School Problems, Sources of Care, and Use of Medical, Mental Health, and Special
Education Services by Black and White Children with Private Health Insurance and Family Incomes in the Third and Fourth Quintiles
Child Health Supplement to the 1988 National Health Interview Survey (N 5 5263)
Black %
(n 5 502)
Urban residence
Single-parent household
Maternal age at child’s birth #16 y
Physical health
Health status excellent
No chronic conditions
Low birth weight
Ever had asthma
Psychological and school functioning
Behavior Problem Index Score $90 percentile
Repeated any grade
Ever suspended from school
Medical and related service use
Lack usual source of
Routine care
Sick care
Same source routine and sick care
Usual place for routine care:
Physician’s office
Outpatient clinic
Health center
Usual place for sick is emergency department
Not current with well-child care
Ever seen psychiatrist or counselor
Received special education services for developmental delay,
learning disability, or emotional/behavioral problem
Repeated any grade or was ever suspended from school and
Received special education services
Ever seen psychiatrist or counselor
White %
(n 5 4761)
34.9
22.8
1.6
10.6*
9.5*
1.2
50.2
78.9
11.6
9.5
59.8*
71.2*
5.2*
5.9*
7.6
17.5
11.5
7.9
11.3*
5.0*
5.3
6.4
10.1
5.2
3.2*
6.5**
83.2
12.1
4.5
4.2
17.7
4.4
2.8
94.2*
3.8*
1.8*
2.2***
21.5*
5.9
4.1
9.6
6.4
19.4*
14.5**
* P , .05; ** P 5 .06; *** P 5 .07.
TABLE 5.
Adjusted ORs* for Selected Measures of Health, Behavior and School Problems, Sources of Care, and Health Services
Utilization by Privately Insured, Middle Class Black Children and Youth in the United States,** Child Health Supplement to the 1988
National Health Interview Survey (N 5 8381)
Excellent health
Ever had asthma
Low birth weight
Repeated any grade
Ever suspended from school
Lack
Usual source of sick care
Same source of care for routine and sick care
Physician’s office is usual place for routine care
Emergency department is usual place for sick care
Ever seen psychiatrist or counselor
Psychiatrist or counselor felt needed, but never seen
Ever seen psychiatrist or counselor, child has BPI $90th percentile***
Ever received special education services
Repeated any grade or ever suspended from school
Received special education services
Ever seen psychiatrist or counselor
OR
95% CI
P
0.7
1.4
1.9
1.4
2.2
0.6–0.8
1.01–2.0
1.3–2.8
0.96–1.9
1.5–3.3
,.001
,.05
,.001
.09
,.001
1.3
1.9
0.4
3.0
0.5
0.7
2.0
0.6
0.8–2.2
1.2–2.9
0.3–0.5
1.7–5.5
0.2–1.1
0.3–1.9
0.5–7.9
0.4–1.1
.34
.01
,.001
,.001
.10
.50
.30
.09
0.6
0.5
0.3–1.2
0.2–1.8
.12
.31
* Independent Variables tested include second (lower), third (middle), and fourth (upper) middle class income quintiles; age; source
of routine care (outpatient clinic, health center, emergency department, physician’s office); region (Midwest, South, West, Northeast);
urbanization (large or small city, suburban, rural); gender; household composition (single- or two-parent); maternal age at child’s birth
(#16 y or .16 y); and family size.
** Referent group: Privately insured, white middle class children.
more likely to lack a usual source for sick care and
continuity of routine and sick care, get their care
from outpatient clinics and health centers, and use
emergency rooms, and they made fewer physician
visits.
Privately insured middle class black children
were more likely to have been born with low birth
weight, a finding consistent with other studies
showing this same difference among infants born to
nonpoor parents.39,40 They also were more likely to
have asthma, a finding compatible with results of
other studies32,41– 43 that show that higher rates of
this condition among black children cannot be explained entirely by social or economic factors. In
contrast, black children were reported as having
fewer chronic health conditions overall and similar
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155
rates of limitations of activity because of these conditions, yet they were less likely to be perceived by
their parents as being in excellent health. Although
black children and white children had similar rates
of behavior problems, black children were twice as
likely to have repeated a grade or to have been
suspended from school. In multivariate analyses,
the association of children’s race and repeating a
grade was no longer statistically significant (OR:
1.4; P 5 .09), but black children were still more
than twice as likely to have been suspended from
school compared with their white peers. We are
unaware of any previous studies indicating this
heightened risk for black middle class children.
Other studies, although not focusing on middle
class children, also have found increased rates of
discontinuity of routine and sick care, increased
use of hospital outpatient departments and community health centers,1,2,18,44 and decreased numbers of ambulatory care visits by black children.13,45,46 Although it appears that the increased
rates of lacking continuity of care were attributable
to their increased use of community health centers
and hospital outpatient departments, this does not
appear to account for black children’s diminished
use of private physicians for routine care, their
increased reliance on emergency departments for
sick care, or their fewer ambulatory care visits,
because these differences persisted in multivariate
analyses that controlled for their source of routine
care. The data available provide no insights into
whether these differences are attributable to nonfinancial barriers to care,46,47 such as long waits and
diminished evening and weekend availability at
hospital outpatient departments and community
health centers; longer distance to or more difficult
access to private physicians’ offices; families feeling out of place in some practice settings; or overt
or covert discrimination.
There are other limitations to these data. All data
were from parent report, with limited information
available about many important aspects of children’s insurance and health care. Potentially important unassessed factors include the comprehensiveness, cost-sharing (ie, copays or deductibles),
and limits of insurance coverage; content, comprehensiveness, and cultural appropriateness of care
received; variability of any of these characteristics
with degree of urbanization, specific city, state, or
region of the United States; and factors influencing
choice of sources of care. There also was no information available regarding family wealth (ie, financial assets), and resources such as home ownership,
cars, other material possessions and liquid savings
might influence the patterns of service use noted.
Also, the data are 10 years old, predating the rapid
introduction of managed care into many communities.
Despite the limitations, these data offer what we
believe is the first detailed picture of the health,
behavior and school problems, and use of medical,
mental health, and special education services of
black and white middle class children in the
United States. They demonstrate similar rates of
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health and behavior problems, but substantially increased rates of school difficulties among black
children. They also demonstrate no differences in
rates of having a usual source of routine care being
current with well-child care, or receiving mental
health or special education services. In contrast,
even in the presence of private health insurance,
middle class black children had markedly different
sources and patterns of ambulatory medical service
use. Although the findings do not identify the
mechanisms behind the differences, they clearly
demonstrate the increased risk and relative disadvantage that black race appears to portend for middle class children in the United States. These and
similar findings, we believe, are crucial to our efforts to ensure equal access to medical services for
all our children, irrespective of their income, insurance, or race.
REFERENCES
1. Blendon RJ, Aiken LH, Freeman HE, Corey CR. Access to medical
care for black and white Americans. JAMA. 1989;261:278 –281
2. Council on Ethical and Judicial Affairs. Black–white disparities in
health care. JAMA. 1990;263:2344 –2346
3. Strogatz D. Use of medical care for chest pain: differences between
blacks and whites. Am J Public Health. 1990;80:290 –294
4. Navarro V. Race or class versus race and class: mortality differentials
in the United States. Lancet. 1990;336:1238 –1240
5. Council on Scientific Affairs of the American Medical Association.
Hispanic health in the United States. JAMA. 1991;265:248 –252
6. Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Dept of
Health and Human Services, Public Health Service. DHHS publication no. (PHS)91-50212; 1991
7. Lieu TA, Newacheck PW, McManus MA. Race, ethnicity, and access
to ambulatory care among US adolescents. Am J Public Health. 1993;
83:960 –965
8. Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income
on mortality and use of services among Medicare Beneficiaries.
N Engl J Med. 1996;335:791–799
9. Geiger HJ. Race and health care—an American dilemma? N Engl
J Med. 1996;335:815– 816
10. Peterson ED, Shaw BS, DeLong ER, Pryor DB, Califf RM, Mark DB.
Racial variation in the use of coronary revascularization procedures.
N Engl J Med. 1997;336:480 – 486
11. Adler NE, Boyce T, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health: no easy solution. JAMA. 1993;269:
3140 –3145
12. Pappas G. Elucidating the relationships between race, socioeconomic
status, and health. Am J Public Health. 1994;84:892– 893
13. Kleinman JC, Gold M, Makuc D. Use of ambulatory care by the poor:
another look at equity. Med Care. 1981;19:1011–1029
14. Egbuonu BS, Starfield B. Child health and social status. Pediatrics.
1982;69:550 –557
15. Starfield B. Family income, ill health, and medical care of US children. J Public Health Policy. 1982;3:244 –259
16. Newacheck PW, Halfon N. Preventive care use by school-aged children. Differences by socioeconomic status. Pediatrics. 1988;82:
462– 468
17. Wise PH, Meyers A. Poverty and child health. Pediatr Clin North Am.
1988;35:1169 –1186
18. St. Peter RF, Newacheck PW, Halfon N. Access to care for poor
children: separate and unequal? JAMA. 1992;267:2760 –2764
19. Holl JL, Szilagyi PG, Rodewald LE, Byrd RS, Weitzman M. Profile of
uninsured children in the United States. Arch Pediatr Adolesc Med.
1995;149:398 – 406
20. Sheils JF, Wolfe PR. The role of private health insurance in children’s
health care. Future Child. 1992;2:115–133
21. Adams PF, Hardy AM. Current estimates from the National Health
Interview Survey: United States, 1988. Vital Health Stat. 1989;173:
1–11, 133–144
22. Bloom B. Health Insurance and Medical Care. Health of Our Nation’s
Children, United States, 1988. Hyattsville, MD: National Center for
Health Statistics. Advance data from Vital Health Stat. No. 188; 1990
23. US Bureau of the Census. Middle Class and Income Inequality. Current Population Reports, Series P60. Washington, DC: US Bureau of
the Census; 1997. http://www.census.gov/hhes/income/midclass/
midclsan.html
24. Massey JT. Design and Estimation for the National Health Interview
Survey, 1985–94. Data Evaluation and Methods Research. Vital
Health Stat–Series 2;1989;110:1–33
25. Collins JG, Hendershot GE. Health Characteristics of Large Metropolitan Statistical Areas: United States, 1988 – 89. Vital Health
Stat–Series 10; 1993;187:1–97. Data from the National Health Survey. US Bureau of the Census. Statistical Abstracts of the United
States: 1993 (113th ed). Washington, DC: Government Printing
Office; 1993
26. Newacheck PW, Stoddard JJ, McManus P. Ethnocultural variations in
the prevalence and impact of childhood chronic conditions. Pediatrics. 1993;91:1031–1039
27. Weitzman M, Byrd RS, Auinger P. Children in big cities in the United
States: health and related needs and services. Ambulatory Child
Health. 1996;1:347–359
28. Peterson JL, Zill N. Marital disruption, parent– child relationships,
and behavior problems in children. J Marriage Fam. 1986;48:295–307
29. Achenbach TM, Edelbrock C. Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Queen City
Printers; 1983
30. Gortmaker SL, Walker DK, Weitzman M, Sobol AM. Chronic conditions, socioeconomic risks, and behavioral problems in children and
adolescents. Pediatrics. 1990;85:267–276
31. Byrd RS, Weitzman M. Predictors of early grade retention among
children in the United States. Pediatrics. 1994;93:481– 487
32. Weitzman M, Gortmaker SL, Sobol AM, Perrin JM. Recent trends in
the prevalence and severity of childhood asthma. JAMA. 1992;268:
2673–2677
33. McCormick MC, Gortmaker SL, Sobol AM. Very low birthweight
children: behavior problems and school difficulty in a national sample. J Pediatr. 1990;117:687– 693
34. Weitzman M, Gortmaker SL, Sobol AM. Maternal smoking and be-
havior problems of children. Pediatrics. 1992;90:342–349
35. Byrd RS, Weitzman M, Auinger P. Behavior problems, age-for-grade
and grade retention among children in the United States. Pediatrics.
In press
36. American Academy of Pediatrics. Guidelines for Health Supervision
II. Elk Grove Village, IL American Academy of Pediatrics; 1988
37. SAS Institute Inc. SAS/STAT User’s Guide: Statistics. Release 6.03
ed. Cary, NC: SAS Institute Inc; 1988
38. Shah BV, Barnwell BG, Hunt N, LaVange LM. SUDAAN User’s Manual Release 6.40. Research Triangle Park, NC: Research Triangle
Institute; 1995
39. Barfield WD, Wise PH, Rust FP, Rust KJ, Gould JB, Gortmaker SL.
Racial disparities in outcomes of military and civilian births in California. Arch Pediatr Adolesc Med. 1996;150:1062–1067
40. Schoendorf KC, Hogue CJR, Kleinman JC, Rowley D. Mortality among
infants of black as compared with white college-educated parents.
N Engl J Med. 1992;326:1522–1526
41. Weitzman M, Gortmaker S, Sobol A. Racial, social, and environmental risks for childhood asthma. Am J Dis Child. 1990;144:1189 –1194
42. Cunningham J, Dockery DW, Speizer FE. Race, asthma, and persistent
wheeze in Philadelphia school children. Am J Public Health. 1996;
86:1406 –1409
43. Gergen P. Social class and asthma— distinguishing between the disease and the diagnosis. Am J Public Health. 1996;86:1361–1362
44. Hahn BA. Children’s health. Racial and ethnic differences in the use
of prescription medications. Pediatrics. 1995;95:727–732
45. Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF. Access
to medical care for children and adolescents in the United States.
Pediatrics. 1990;86:666 – 673
46. Orr ST, Miller CA, James SA. Differences in use of health services by
children according to race: relative importance of cultural and system-related factors. Med Care. 1984;22:848 – 853
47. Margolis PA, Carey T, Lannon CM, Earp JL, Leninger L. The rest of the
access-to-care puzzle: addressing structural and personal barriers to
health care for socially disadvantaged children. Arch Pediatr Adolesc
Med. 1995;149:541–545
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