Adverse Consequences of Food Insecurity Among U.S. Adults Beyond Health Outcomes.

INTRODUCTION: Food insecurity is associated with poorer health, but the adverse consequences of food insecurity may extend beyond just health outcomes. Thus, this study examined the association between food insecurity and health insurance coverage, access to care, healthcare utilization, and financial hardships among U.S. adults. METHODS: This study employed a retrospective longitudinal cohort study design using panel data from the 2016-2017 Medical Expenditure Panel Survey. Linear probability models were used to examine the association between food insecurity in 1 year and outcomes of interest (health insurance coverage, access to care, healthcare utilization, and financial hardships) in the subsequent year. Analysis was conducted in April 2023. RESULTS: Food insecurity was associated with higher uninsured rates and lower private coverage rates (3.5 [95% CI: 1.6-5.5] and -3.9 [95% CI: -6.2, -1.7] percentage points). Moreover, food insecurity was associated with lower access to care, including delay in receiving necessary medical care and delay in obtaining necessary prescription drugs (2.9 [95% CI: 1.0-4.8] and 4.1 [95% CI: 2.1-6.2]). Furthermore, food insecurity was associated with a higher rate of emergency room visits (2.8 [95% CI: 0.1-5.7]), whereas associations with inpatient, outpatient, and prescription drug use were not significant. Food insecurity was also associated with greater financial hardships, such as experiencing difficulties paying medical bills (9.6 [95% CI: 6.7-12.6]). CONCLUSIONS: These findings highlight the adverse consequences of food insecurity on access to and affordability of care for U.S. adults and families. Food insecurity can have far-reaching implications for the well-being of individuals and families.

Racial and ethnic disparities in telehealth use before and after California's stay-at-home order.

Introduction: Telehealth can potentially improve the quality of healthcare through increased access to primary care. While telehealth use increased during the COVID-19 pandemic, racial/ethnic disparities in the use of telemedicine persisted during this period. Little is known about the relationship between health coverage and patient race/ethnicity after the onset of the COVID-19 pandemic. Objective: This study examines how differences in patient race/ethnicity and health coverage are associated with the number of in-person vs. telehealth visits among patients with chronic conditions before and after California's stay-at-home order (SAHO) was issued on 19 March 2020. Methods: We used weekly patient visit data (in-person (N = 63, 491) and telehealth visits (N = 55, 472)) from seven primary care sites of an integrated, multi-specialty medical group in Los Angeles County that served a diverse patient population between January 2020 and December 2020 to examine differences in telehealth visits reported for Latino and non-Latino Asian, Black, and white patients with chronic conditions (type 2 diabetes, pre-diabetes, and hypertension). After adjusting for age and sex, we estimate differences by race/ethnicity and the type of insurance using an interrupted time series with a multivariate logistic regression model to study telehealth use by race/ethnicity and type of health coverage before and after the SAHO. A limitation of our research is the analysis of aggregated patient data, which limited the number of individual-level confounders in the regression analyses. Results: Our descriptive analysis shows that telehealth visits increased immediately after the SAHO for all race/ethnicity groups. Our adjusted analysis shows that the likelihood of having a telehealth visit was lower among uninsured patients and those with Medicaid or Medicare coverage compared to patients with private insurance. Latino and Asian patients had a lower probability of telehealth use compared with white patients. Discussion: To address access to chronic care management through telehealth, we suggest targeting efforts on uninsured adults and those with Medicare or Medicaid coverage, who may benefit from increased telehealth use to manage their chronic care.

Medicare Advantage enrollment by immigration and English proficiency status.

OBJECTIVES: Complex Medicare Advantage (MA) health plan choices may overwhelm immigrants, especially for those facing decision-making constraints due to limited English proficiency (LEP). We examined the trends and patterns of MA enrollment by immigration and English proficiency status. STUDY DESIGN: We employed a cross-sectional design using data from the 2008-2019 Medical Expenditure Panel Survey. METHODS: Our outcome was enrollment in an MA plan. Our primary independent variables were immigration and English proficiency status. We categorized the sample into 3 groups: LEP immigrants, non-LEP immigrants, and US-born residents. After adjusting for individual-level characteristics, we estimated the adjusted rates of MA enrollment for each group. RESULTS: Our adjusted analysis showed that MA enrollment was higher among immigrants than US-born residents, but the highest enrollment was found among LEP immigrants (LEP immigrants: 45.5%; 95% CI, 42.7%-48.2%; non-LEP immigrants: 42.1%; 95% CI, 39.4%-44.8%; US-born residents: 35.1%; 95% CI, 34.5%-35.6%). MA enrollment was higher among LEP immigrants with better health status (good self-reported health: 45.4%; 95% CI, 41.9%-48.8%; poor self-reported health: 41.4%; 95% CI, 37.7%-45.1%). However, we found small to no differences in the adjusted rates of MA enrollment between those with good vs poor self-reported health in both the non-LEP immigrants and US-born residents groups. We found no consistent enrollment patterns by socioeconomic status such as race/ethnicity, education, and income. CONCLUSIONS: Our findings suggest higher MA enrollment among immigrants, especially for LEP immigrants. Future research should study the care experience of immigrants in MA.

Adaptation of a community health outreach model during the COVID-19 pandemic: the case of the Mexican consulates in the United States of America.

The Ventanillas de Salud (VDS - "Health Windows") are a culturally sensitive outreach program within the 49 Mexican Consulates in the United States that provides information and health care navigation support to underserved and uninsured Mexican immigrants. During the COVID-19 pandemic the VDS rapidly transitioned to remote operations adding new services. Based on the EquIR implementation framework, this qualitative study investigates how adaptations to improve emergency preparedness were performed. We conducted motivational interviews with three actors - six VDS coordinators, eight partner organizations, and ten VDS users- in two VDS, Los Angeles and New York, to document specific needs of the target population and identify implementation processes to adapt and continue operating. The VDS adapted their model by adding new services for emerging needs, by switching service provision modalities, and by expanding the network of partner organizations. According to the VDS staff, these adaptations increased their topics, depth, reach, and diversified their users. Users had mostly positive opinions about the VDS adaptation, although they highlighted some heterogeneity across service provision. The VDS is a public health intervention able to serve a marginalized population and its implementation offers valuable lessons to complement health systems and to improve preparedness and resiliency for future crises.

Effects of Medicare eligibility and enrollment at age 65 among immigrants and US-born residents.

BACKGROUND: Understanding the impacts of Medicare coverage among immigrants is of high policy importance, but there is currently limited evidence. In this study, we examined the effects of near universal access to Medicare coverage at age 65 years between immigrants and US-born residents. METHODS: Using the 2007-2019 Medical Expenditure Panel Survey, we employed a regression discontinuity design, which exploits the eligibility for Medicare at age 65 years. Our outcomes were health insurance coverage, healthcare spending, access to and use of health care, and self-reported health status. RESULTS: Medicare eligibility at age 65 led to significant increases in Medicare coverage among immigrants and US-born residents (74.6 [95% CI: 71.6-77.5] and 81.6 [95% CI: 80.5-82.7] percentage points). Medicare enrollment at age 65 decreased total healthcare spending and out-of-pocket spending by $1579 (95% CI: -2092 to 1065) and $423 (95% CI: -544 to 303) for immigrants and $1186 (95% CI: -2359 to 13) and $450 (95% CI: -774 to 127) for US-born residents. After Medicare enrollment at age 65, immigrants reported only limited improvements in overall access to and use of health care, but they reported significant increases in the use of high-value care (11.5 [95% CI: 6.8-16.2], 8.3 [95% CI: 6.0-10.6], 8.4 [95% CI: 1.0-15.8], and 2.3 [95% CI: 0.9-3.7] percentage points increase for colorectal cancer screening, eye examination for diabetes, influenza vaccine, and cholesterol measurement) and improvements in self-reported health (5.9 [95% CI: 0.9-10.8] and 4.8 [95% CI: 0.5-9.0] percentage points increase for good perceived physical and mental health). Medicare enrollment also increased prescription drug spending by $705 (95% CI: 292-1117), despite the unchanged use of prescription drugs. For US-born residents, use of high-value care, self-reported health, and prescription drug use and spending did not change substantially after Medicare enrollment. CONCLUSION: Medicare has the potential to improve care among older adult immigrants.

Low-cost climate-change informational intervention reduces meat consumption among students for 3 years.

Evidence on the impact of information campaigns on meat consumption patterns is limited. Here, using a dataset of more than 100,000 meal selections over 3 years, we examine the long-term effects of an informational intervention designed to increase awareness about the role of meat consumption in climate change. Students randomized to the treatment group reduced their meat consumption by 5.6 percentage points with no signs of reversal over 3 years. Calculations indicate a high return on investment even under conservative assumptions (~US$14 per metric ton CO2eq). Our findings show that informational interventions can be cost effective and generate long-lasting shifts towards more sustainable food options.

Undocumented Latino Immigrants and the Latino Health Paradox.

INTRODUCTION: Despite having worse healthcare access and other social disadvantages, immigrants have, on average, better health outcomes than U.S.-born individuals. For Latino immigrants, this is known as the Latino health paradox. It is unknown whether this phenomenon applies to undocumented immigrants. METHODS: This study used restricted California Health Interview Survey data from 2015 to 2020. Data were analyzed to test the relationships between citizenship/documentation status and physical and mental health among Latinos and U.S.-born Whites. Analyses were stratified by sex (male/female) and length of U.S. residence (<15 years/>= 15 years). RESULTS: Undocumented Latino immigrants had lower predicted probabilities of reporting any health condition, asthma, and serious psychological distress and had a higher probability of overweight/obesity than U.S.-born Whites. Despite having a higher probability of overweight/obesity, undocumented Latino immigrants did not have probabilities of reporting diabetes, high blood pressure, or heart disease different from those of U.S.-born Whites after adjusting for having a usual source of care. Undocumented Latina women had a lower predicted probability of reporting any health condition and a higher predicted probability of overweight/obesity than U.S.-born White women. Undocumented Latino men had a lower predicted probability of reporting serious psychological distress than U.S.-born White men. There were no differences in outcomes when comparing shorter- with longer-duration undocumented Latino immigrants. CONCLUSIONS: This study observed that the Latino health paradox may express patterns for undocumented Latino immigrants that are different from those for other Latino immigrant groups, emphasizing the importance of accounting for documentation status when conducting research on this population.

Little To No Correlation Found Between Immigrant Entry And COVID-19 Infection Rates In The United States.

The relationship between immigrant entry and COVID-19 spread in the United States has driven much political discussion and policy, including the implementation of Title 42 by the Centers for Disease Control and Prevention. To examine the relationship between COVID-19 spread and immigrant entry, we compared 2020-21 immigrant flows with local COVID-19 rates, using estimates of border crossings from the Border Patrol and visas issued through the Department of Labor's seasonal guest worker program. Our analysis capturing seasonal guest worker entry at the national level showed no statistically significant relationship with COVID-19 rates. Our analyses of Southwest border crossings showed a small, statistically significant relationship between immigrant flows and COVID-19 rates in border counties (0.14 percent increase in local cases per 100,000 residents for each additional 100 immigrants). However, this estimate is modest compared with the fact that half of all month-to-month changes in case rates were greater than 59 percent. Furthermore, the modest increase became nonsignificant with increasing local vaccination rates. Estimates also did not maintain their statistical significance when analyzed with some alternative approaches. Our findings support existing evidence that the short-term impacts of immigrant flow on local COVID-19 rates were minimal.

The impact of Medicaid funding structures on inequities in health care access for Latinos in New York, Florida, and Puerto Rico.

OBJECTIVE: To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant). DATA SOURCES: Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey. STUDY DESIGN: Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households. DATA COLLECTION: The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019. PRINCIPAL FINDINGS: Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]). CONCLUSIONS: Limited Medicaid eligibility (non-expansion of Florida's Medicaid program) and capped Medicaid funds (Puerto Rico's Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.

Avoiding Medicaid enrollment after the reversal of the changes in the public charge rule among Latino and Asian immigrants.

OBJECTIVE: To estimate the avoidance of Medicaid enrollment among Latino and Asian immigrants due to fears about immigration status. In 2019, changes to the "public charge" rule made it difficult for immigrants to receive a green card or permanent residence visa, particularly for those who used health and nutrition benefits. Despite the Biden administration's reversal of these changes, fear and misinformation persist among immigrants. DATA SOURCES: Pooled data from the 2017 to 2020 California Health Interview Survey. STUDY DESIGN: We used adjusted predicted probability models to estimate differences in access to and use of health care and health insurance coverage among Latino and Asian immigrant adults with and without green cards, using US citizens as the reference. We estimated the avoidance of Medicaid enrollment among immigrants without a green card, the immigrant population subject to the public charge rule. DATA COLLECTION/EXTRACTION METHODS: Population stratified by race/ethnicity and green card status. PRINCIPAL FINDINGS: Latino immigrants without a green card were -23.1% (CI: -27.8, -18.4) less likely to be insured, -9.2% (CI: -12.8, -5.5) less likely to have Medicaid coverage, -9.3% (CI: -14.5, -4.1) less likely to have a usual source of care, and -8.4% (CI: -13.2, -0.3) less likely to have a physician visit relative to citizens. Asian immigrants without a green card were -11.7% (CI: -19.7, -3.72) less likely to be insured, -8.8% (CI: -11.6, -6.1) less likely to have Medicaid coverage, -11.6% (CI: -19.3, -3.9) less likely to have a usual source of care, and -11.0% (CI: -19.2, -2.3) less likely to have a physician visit. Between 107,956 and 192,905 Latino immigrants and 1294 and 4702 Asian immigrants in California likely avoided Medicaid enrollment due to fears about their immigration status. CONCLUSION: While our estimates are lower than those of previous studies, our findings highlight barriers to health care for immigrants despite the reversal of the changes in the public charge rule. Since the public charge rule was not abolished, immigrants with low incomes might choose not to seek health care, despite recent efforts in California to expand Medicaid coverage to all eligible immigrants regardless of documentation statuses.

Emergency Medical Service Use Among Latinos Aged 50 and Older in California Counties, Except Los Angeles, During the Early COVID-19 Pandemic Period.

The COVID-19 pandemic has disproportionately affected Latino adults aged 50 and older in California. Among adults aged 50-64, Latinos constitute approximately one-third (32%) of the population, but over half (52%) of COVID-19 cases, and more than two-thirds (64%) of COVID-related deaths as of June 2, 2021. These health disparities are also prevalent among Latinos 65 years and older who constitute 22% of the population, but 40% of confirmed COVID-19 cases and 50% of COVID-related deaths. Emergency medical services (EMS) are an essential component of the United States healthcare system and a vital sector in COVID-19 response efforts. Using data from the California Emergency Medical Services Information System (CEMSIS), this study examines racial and ethnic differences in respiratory distress related EMS calls among adults aged 50 and older in all counties except Los Angeles. This study compares the early pandemic period, January to June 2020, to the same time period in 2019. Between January and June 2019, Latinos aged 50 and older had statistically significantly lower odds of respiratory distress related EMS calls compared to Blacks, Asians, and Whites. During the early pandemic period, January to June 2020, Latinos aged 50 and older had statistically significantly lower odds of respiratory distress related EMS calls compared to Blacks but slightly higher odds compared to Whites. Differences by race/ethnicity and region were statistically significant. Understanding EMS health disparities is crucial to inform policies that create a more equitable prehospital care system for the heterogeneous population of middle aged and older adults.

Health Insurance Coverage In Mexico Among Return Migrants: Differences Between Voluntary Return Migrants And Deportees.

Between 2010 and 2019 the number of Mexican immigrants in the US declined by almost 780,000, or 7 percent. Repatriated migrants either return voluntarily to Mexico (returnees) or are forcibly removed from the US (deportees). As repatriated migrants navigate their return, access to health care in Mexico becomes a pressing need. Lack of a valid form of identification, limited awareness of services, and social stigma, among other factors, restrict health coverage in Mexico for return migrants. This study examined differences in health insurance coverage in Mexico between Mexican-born deportees and returnees from the US in a five-year period and a reference population of Mexican-born residents (nonmigrants and returnees who had been back in Mexico for five years or longer). Using data from Mexico's National Survey of Demographic Dynamics from 2014 and 2018, we found that 74.0 percent of voluntary returnees and 67.5 percent of deportees had health insurance, compared with 88.4 percent of the reference population, after adjustment for socioeconomic and demographic differences. Policy makers from federal, state, and local governments and community organizations need to improve the reintegration of repatriated migrants by reducing bureaucratic hurdles, preparing returnees and deportees for their return to Mexico, and strengthening health coverage options for return migrants.

Health Policy Challenges Posed By Shifting Demographics And Health Trends Among Immigrants To The United States.

Since the 1960s the immigrant population in the United States has increased fourfold, reaching 44.7 million, or 13.7 percent of the US population, in 2018. The shifting immigrant demography presents several challenges for US health policy makers. We examine recent trends in immigrant health and health care after the Great Recession and the nationwide implementation of the Affordable Care Act. Recent immigrants are more likely to have lower incidence of chronic health conditions than other groups in the US, although these differences vary along the citizenship and documentation status continuum. Health care inequities among immigrants and US-born residents increased after the Great Recession and later diminished after the Affordable Care Act took effect. Unremitting inequities remain, however, particularly among noncitizen immigrants. The number of aging immigrants is growing, which will present a challenge to the expansion of coverage to this population. Health care and immigration policy changes are needed to integrate immigrants successfully into the US health care system.

Cardiovascular disease behavioral risk factors among Latinos by citizenship and documentation status.

BACKGROUND: Studies have observed that recent Latino immigrants tend to have a physical health advantage compared to immigrants who have been in the US for many years or Latinos who are born in the United States. An explanation of this phenomenon is that recent immigrants have positive health behaviors that protect them from chronic disease risk. This study aims to determine if trends in positive cardiovascular disease (CVD) risk behaviors extend to Latino immigrants in California according to citizenship and documentation status. METHODS: We examined CVD behavioral risk factors by citizenship/documentation statuses among Latinos and non-Latino US-born whites in the 2011-2015 waves of the California Health Interview Survey. Adjusted multivariable logistic regressions estimated the odds for CVD behavioral risk factors, and analyses were stratified by sex. RESULTS: In adjusted analyses, using US-born Latinos as the reference group, undocumented Latino immigrants had the lowest odds of current smoking, binge drinking, and frequency of fast food consumption. There were no differences across the groups for fruit/vegetable intake and walking for leisure. Among those with high blood pressure, undocumented immigrants were least likely to be on medication. Undocumented immigrant women had better patterns of CVD behavioral risk factors on some measures compared with other Latino citizenship and documentation groups. CONCLUSIONS: This study observes that the healthy Latino immigrant advantage seems to apply to undocumented female immigrants, but it does not necessarily extend to undocumented male immigrants who had similar behavioral risk profiles to US-born Latinos.

Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act.

We examine changes in health insurance coverage and access to and utilization of health care before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) among the U.S. adult immigrant population. Data from the 2011-2016 National Health Interview Survey are used to compare adult respondents in 2011-2013 (before the ACA implementation) and 2014-2016 (after the ACA implementation). Multivariable logistic regression analyses are used to compare changes over time. This study shows that the ACA has closed the coverage gap that previously existed between U.S. citizens and non-citizen immigrants. We find that naturalized citizens, non-citizens with more than 5 years of U.S. residency, and non-citizens with 5 years or less of U.S. residency reduced their probability of being uninsured by 5.81, 9.13, and 8.23%, respectively, in the first 3 years of the ACA. Improvements in other measures of access and utilization were also observed.

Comparing costs of a senior wellness care redesign in group and independent physician practices of an accountable care organization.

Primary care redesign for older adult patients is currently ongoing in countries with aging populations. One of the main challenges of this type of transformations is how to estimate implementation costs in different types of health care delivery organizations. This study compares start-up and incremental expenses of implementing a primary care redesign across 2 organization types: integrated group (n = 31) practices and independent practice association (IPA) sites (n = 213). Administrators involved with implementing the redesign completed a cost capture template to quantifying expenses. The potential impact of measurement error, recollection bias, and implementation models across sites and geographic regions was examined in sensitivity analyses. Marginal start-up and incremental expenses were higher for Group sites ($122-$328) compared to IPA sites ($31-$227). Group and IPA sites, however, implemented the redesign with different intensities. According to our analyses, if IPA sites implemented the redesign with the same intensity as Group sites, marginal costs would have been $5 to $13 higher for IPA sites than for Group sites. This study shows how a flexible approach to estimate the cost of a wellness care redesign is needed when the intensity of the transformation differs across 2 different types of health care organizations.