Association of Maternal-Clinician Ethnic Concordance With Latinx Youth Receipt of Family-Centered Care.

Importance: Disparities in medical home provisions, including receipt of family-centered care (FCC), have persisted for Latinx youths in the US. Objective: To examine the association between maternal-clinician ethnic concordance and receipt of FCC among US-born Latinx youths. Design, Setting, and Participants: A cross-sectional secondary analysis of data from the Medical Expenditure Panel Survey from January 1, 2010, to December 31, 2017, was conducted. Data analysis was performed from January 6 to February 3, 2020. Latinx youths (age, ≤17 years) born in the US who had a usual source of care and used care in the past year, their Latina mothers (age, 18-64 years), and youths' health care clinician characteristics (eg, race, ethnicity, and sex) were evaluated using χ2 tests and propensity-score matching methods. Main Outcomes and Measures: Maternal reports on whether their youths' clinician listened carefully to the parent, explained things in a way the parent could understand, showed respect, and spent enough time with the patient. Results: There were 2515 US-born Latinx youths with linked maternal characteristics during the study period; 51.67% (95% CI, 48.87%-54.45%) of the youths were male, mean (SD) age was 8.48 (0.17) years (30.86% [95% CI, 28.39%-33.44%] were between ages 5 and 9 years), 61.53% (95% CI, 57.15%-65.74%) had public insurance coverage, and 39.89% (95% CI, 32.33%-47.89%) had mothers who were ethnically concordant with the youths' medical care clinician. We found that for youths with maternal-clinician ethnic concordance, the probabilities of reporting FCC were significantly higher than they would have been in the absence of concordance: that the medical care clinician listened carefully to the parent (average treatment effect on the treated [ATET], 5.44%; 95% CI, 2.14%-8.74%), explained things in a way the parent could understand (ATET, 4.82%; 95% CI, 1.60%-8.03%), showed respect for what the parent had to say (ATET, 5.51%; 95% CI, 2.58%-8.45%), and spent enough time with the patient (ATET, 5.28%; 95% CI, 1.68%-8.88%). Conclusions and Relevance: Given the increase of Latinx populations and the simultaneous shortage of underrepresented minority health care clinicians, the findings of this study suggest that increasing the number of clinicians from underrepresented minority backgrounds and ethnic-concordant parental-clinician relationships may help reduce disparities in receipt of medical home provision among US-born Latinx youths.

Allostatic Load Among U.S.- and Foreign-Born Whites, Blacks, and Latinx.

INTRODUCTION: The objective of this study is to examine how allostatic load, a multidimensional measure of the body's cumulative response to stressors experienced throughout the life course, has changed over time and by age among U.S.- and foreign-born Whites, Blacks, and Latinx. METHODS: Data were from 26,818 adult participants in the 2005-2018 National Health and Nutrition Examination Survey, a national repeated cross-sectional study. Allostatic load was measured based on 10 indicators of cardiovascular, metabolic, and immunologic risk. The analyses were conducted in March 2020. RESULTS: Allostatic load increased over time across all groups. The difference between the first and last survey cycle was greatest among U.S.-born Black women (from 2.74 in 2005-2006 to 3.02 in 2017-2018), U.S.-born Latino men (from 2.69 to 3.09) and foreign-born Latino men (from 2.58 to 2.87). Aging gradients in allostatic load were steepest among foreign-born Blacks of both genders and foreign-born Latina women and flattest among U.S.-born and foreign-born Whites. CONCLUSIONS: Chronic exposure to stressors leads to an erosion of health that is particularly severe among foreign-born Blacks and Latinx. Policies should seek to reduce exposure to structural and environmental risks and to ensure equitable opportunities to achieve optimal health among racial/ethnic minorities and immigrants.

Targeting of Enrollment Assistance Resources in Health Insurance Television Advertising: A Comparison of Spanish- Vs. English-Language Ads.

Latinx adults, especially immigrants, face higher uninsurance and lower awareness of the Affordable Care Act's (ACA) provisions and resources compared to other racial/ethnic groups. Television advertising of ACA health plans has directed many consumers to application assistance and enrollment, but little is known about how ads targeted Latinx consumers. We used Kantar Media/CMAG data from the Wesleyan Media Project to assess Spanish- vs. English-language ad targeting strategies and to assess which enrollment assistance resources (in person/telephone vs. online) were emphasized across three Open Enrollment Periods (OEP) (2013-14, 2014-15, 2015-16). We examined differences in advertisement sponsorship and volume of Spanish- versus English-language ads across the three OEPs. State-based Marketplaces sponsored 47% of Spanish-language airings; insurance companies sponsored 55% of English-language airings. The proportion of Spanish-language airings increased over time (8.8% in OEP1, 11.1% in OEP2, 12.0% in OEP3, p <.001). Spanish-language airings had 49% lower (95%CI: 0.50,0.53) and 2.20 times higher odds (95%CI: 2.17,2.24) of mentioning online and telephone/in-person enrollment assistance resources, respectively. While there was a significant decrease in mention of telephone/in-person assistance over time for English-language airings, these mentions increased significantly in Spanish-language airings. Future research should examine the impact of the drastic federal cuts to ACA outreach and marketing.

Association of Maternal Citizenship and State-Level Immigrant Policies With Health Insurance Coverage Among US-Born Latino Youths.

Importance: The association of state-level immigrant policies with uninsurance among Latino youths remains unknown. Objective: To assess the association of state-level immigrant integration and criminalization policies with health insurance coverage among US-born Latino youths by maternal citizenship. Design, Setting, and Participants: This cross-sectional study analyzed secondary data from the American Community Survey, January 1, 2016, to December 31, 2018, for US-born Latino youths (age, ≤17 years) and their mothers (age, 18-64 years) as well as state-level indicators of immigrant integration and criminalization policies (in all 50 states and the District of Columbia). Exposures: Immigrant integration and criminalization policies. Main Outcomes and Measures: The main outcome was maternal reports of youth uninsurance status at the time of the American Community Survey interview. Variation in youth uninsurance by maternal citizenship, state immigrant integration policy context, and state immigrant criminalization policy context were examined. All analyses were conducted with weighted survey data. Results: Of the 226 691 US-born Latino youths (115 431 [50.92%] male; mean [SD] age, 7.66 [4.92] years) included in the study, 36.64% (95% CI, 36.21%-36.92%) had noncitizen mothers. Overall, 7.09% (95% CI, 6.78%-7.41%) of noncitizen mothers reported that their youths were uninsured compared with 4.68% (95% CI, 4.49%-4.88%) of citizen mothers. Of uninsured youths who resided in states with a low level of immigrant integration policies, 9.10% (8.22%-10.06%) had noncitizen mothers and 4.75% (95% CI, 4.19%-5.37%) had citizen mothers; of uninsured youths who resided in states with high criminalization policies, 9.37% (95% CI, 8.90%-9.87%) had noncitizen mothers and 5.91% (95% CI, 5.64%-6.20%) had citizen mothers. In states with few immigrant integration policies, the probability of uninsurance among youths with noncitizen mothers was 3.3% (95% CI, 2.3%-4.4%) higher than that among youths with citizen mothers. Among youths with noncitizen mothers, the difference in the probability of uninsurance between those residing in states with a low level vs a high level of immigrant integration policies was 2.1% (95% CI, 0.6%-3.6%). Among youths residing in states with high levels of immigrant criminalization policies, those with noncitizen mothers had a 2.6% (95% CI, 1.9%-3.0%) higher probability of being uninsured compared with those whose mothers were citizens. Among youths with noncitizen mothers, the difference in the probability of uninsurance between those who resided in a state with a low level vs a state with a high level of immigrant criminalization policies was 1.7% (95% CI, 0.7%-2.7%). Conclusions and Relevance: The findings of this cross-sectional study suggest that among US-born Latino youths, disparities in uninsurance by maternal citizenship are associated with state-level immigrant integration and criminalization policies and that anti-immigrant policies may be associated with disparities in health care access for US-born Latino youths.

Association of Medicaid expansion with health insurance coverage by marital status and sex.

OBJECTIVE: To determine the association of Medicaid expansion with health insurance coverage by marital status and sex. METHODS: A population-based, quasi-experimental policy analysis was undertaken of the implementation of the Patient Protection and Affordable Care Act's (ACA) Medicaid expansion provision on or after January 1, 2014. The 2010-16 American Community Survey provided data on 3,874,432 Medicaid-eligible adults aged 19-64 with incomes up to 138% of the federal poverty level. The outcome measures were no health insurance coverage and Medicaid coverage. The predictor variables were marital status and sex, with controls for family size, poverty status, race/ethnicity, education, employment status, immigration status, and metropolitan residence. RESULTS: In 2016, the uninsured rate for married men and women in a Medicaid expansion state was 21.2% and 17.1%, respectively, compared to 37.4% for married men and 35.8% for married women in a non-expansion state. The Medicaid coverage rate grew between 14.8% to 19.3% in Medicaid expansion states, which contrasts with less than a 5% growth in non-expansion states. Triple differences analysis suggests that, for women of all age groups, Medicaid expansion resulted in a 1.6 percentage point lower uninsured rate for married women compared to unmarried women. For men, there was not a statistically significant difference in the uninsured rate for married compared to unmarried men. For women of all age groups, there was a 2.6 percentage point higher Medicaid coverage rate for married compared to unmarried women. For men, there was a 1.8 percentage point higher Medicaid coverage rate for married compared to unmarried men. CONCLUSION: Medicaid expansion under the ACA differentially lowered uninsurance and improved Medicaid coverage for married persons, especially married women, more than unmarried persons.

State-Level Immigrant Prenatal Health Care Policy and Inequities in Health Insurance Among Children in Mixed-Status Families.

Children in immigrant families are twice as likely to be uninsured as their counterparts, and states may influence these inequities by facilitating or restricting immigrant families' access to coverage. Our objective was to measure differences in insurance by mother's documentation status among a nationally representative sample of US-born children in immigrant families and to examine the role of state-level immigrant health care policy-namely, state-level immigrant access to prenatal coverage. Compared with US-born children in immigrant families with citizen mothers, children with undocumented immigrant mothers had a 17.0 percentage point (P < .001) higher uninsurance rate (8.8 percentage points higher in adjusted models, P < .05). However, in states with nonrestrictive prenatal coverage for immigrants, there were no differences in children's insurance by mother's documentation status, while large inequities were observed within states with restrictive policies. Our findings demonstrate the potential for state-level immigrant health care policy to mitigate or exacerbate inequities in children's insurance.

Association of Medicaid Expansion With Health Insurance Coverage Among Persons With a Disability.

Importance: Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability. Objective: To determine the association of Medicaid expansion with health insurance coverage among persons with a disability. Design, Setting, and Participants: Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019. Main Outcomes and Measures: Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties). Results: Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA's Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% - 16.2% = -9.1%) and without a disability (21.2% - 34.9% = -13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference-estimated Medicaid coverage was -4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P < .001). Medicaid expansion was associated with a 3% higher private insurance rate for persons with a disability than for persons without a disability. Conclusions and Relevance: Medicaid expansion appeared to be associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. This study's findings suggest that the reduction in the uninsured rate and gains in Medicaid coverage were greater for persons without a disability than for persons with a disability.

Racial and Ethnic Disparities in Provider-Related Barriers to Health Care for Children in California After the ACA.

The aim of this study was to examine disparities in provider-related barriers to health care by race and ethnicity of children in California after the implementation of the Affordable Care Act (ACA). California Health Interview Survey child (0-11 years) survey data from 2014 to 2016 were used to conduct multivariable logistic regressions to estimate the odds of reporting any provider-related barrier, trouble finding a doctor, child's health insurance not accepted by provider, and child not being accepted as a new patient. Compared with parents of non-Latino white children, parents of non-Latino black, Latino, Asian, and other/multiracial children were not more likely to report experiencing any of the 4 provider-related barrier measures. The associations between children's race and ethnicity and parents' reports of provider-related barriers were nonsignificant. Findings demonstrate that there are no significant racial/ethnic differences in provider-related barriers to health care for children in California in the post-ACA era.

Exploring the Role of Depression as a Moderator of a Workplace Obesity Intervention for Latino Immigrant Farmworkers.

We explored if and how depression moderated the treatment effect of Pasos Saludables, a successful pilot workplace obesity intervention for Latino immigrant farmworkers. The original randomized controlled study assigned 254 participants 2:1 to a 10-session educational intervention versus control. We assessed the relationship between change in BMI (primary outcome) and interaction of treatment allocation and baseline risk for depression. Baseline CES-D scores indicated that 27.3% of participants were at risk for depression. The interaction between treatment allocation and baseline risk for depression was significant (p = 0.004). In adjusted models among women, intervention participants with no indication of depression at baseline reduced their BMI by 0.77 on average (95% CI - 1.25, - 0.30) compared to controls. The reduction im BMI between the intervention group at risk for depression at baseline and either control was not significantly different from zero. Findings from our post-hoc, exploratory study indicate that depression may inhibit significant weight loss.

Disparities in Pediatric Provider Availability by Insurance Type After the ACA in California.

OBJECTIVE: To examine insurance-based disparities in provider-related barriers to care among children in California in the wake of changes to the insurance market resulting from the Affordable Care Act. METHODS: Our sample included 6514 children (ages 0 to 11 years) from the 2014-2016 California Health Interview Survey. We examined parent reports in the past year of 1) having trouble finding a general provider for the child, 2) the child not being accepted by a provider as a new patient, 3) the child's health insurance not being accepted by a provider, or 4) any of the above. Multivariable models estimated the associations of insurance type-Medi-Cal (Medicaid), employer-sponsored insurance, or privately purchased coverage-and parent reports of these problems. RESULTS: Approximately 8% of parents had encountered at least one of these problems. Compared with parents of children with employer-sponsored insurance, parents of children with Medi-Cal or privately purchased coverage had over twice the odds of experiencing at least one of the barriers. Parents of children with Medi-Cal had over twice the odds of being told a provider would not accept their children's coverage or having trouble finding a general provider and 3times the odds of being told a provider would not accept their children as new patients. Parents of children with privately purchased coverage had over 3times the odds of being told a provider would not accept their children's coverage. CONCLUSIONS: Our study found significant disparities in provider-related barriers by insurance type among children in California.

Insurance Coverage and Utilization Improve for Latino Youth but Disparities by Heritage Group Persist Following the ACA.

OBJECTIVE: Latino youth experience worse access to and utilization of health care compared with non-Latino "white" youth, with inequities persisting following the implementation of the Affordable Care Act (ACA). To better understand these disparities, we examine changes in youth's access and utilization associated with the ACA for different Latino heritage groups relative to whites. STUDY DESIGN: We use 6 years (2011-2016) of National Health Interview Survey data to examine Latino youth's insurance coverage and health care utilization by heritage group, nativity, and parental language. The dependent measures of utilization included well-child, emergency department, and physician visits. We used multivariable logistic regression models to estimate the odds of each dependent measure and interacted heritage group and time period [2011-2013 (pre-ACA) versus 2014-2016 (post-ACA)] to examine how changes associated with the ACA varied by group. RESULTS: Insurance coverage and well-child visits improved among youth overall following implementation of the ACA. Although Mexican and Central or South American youth experienced the largest absolute increase in coverage, they still had high levels of uninsurance post-ACA (9.9% and 9.1%, respectively). Disparities in coverage between Puerto Rican and white youth improved, while disparities in well-child visits between Mexican and white youth worsened. Little to no movement was observed in disparities by nativity and parental language. CONCLUSIONS: Most disparities in insurance and utilization across Latino heritage groups and white youth persisted post-ACA despite significant gains within groups. Although disparities for Puerto Rican youth have improved, Mexican and Central or South American youth continue to experience disparities.

Health Care Access and Physical and Behavioral Health Among Undocumented Latinos in California.

BACKGROUND: This paper provides statewide estimates on health care access and utilization patterns and physical and behavioral health by citizenship and documentation status among Latinos in California. METHODS: This study used data from the 2011-2015 California Health Interview Survey to examine health care access and utilization and physical and behavioral health among a representative sample of all nonelderly Latino and US-born non-Latino white adults (N=51,386). Multivariable regressions estimated the associations between the dependent measures and citizenship/documentation status among Latinos (US-born, naturalized citizen, green card holder, and undocumented). RESULTS: Adjusted results from multivariable analyses observed worse access and utilization patterns among immigrant Latinos compared with US-born Latinos, with undocumented immigrants using significantly less health care. Undocumented Latinos had lower odds of self-reporting excellent/very good health status compared with US-born Latinos, despite them having lower odds of having several physical and behavioral health outcomes (overweight/obesity, physician-diagnosed hypertension, asthma, self-reported psychological distress, and need for behavioral health services). Among those reporting a need for behavioral health services, access was also worse for undocumented Latinos when compared with US-born Latinos. CONCLUSIONS: Patterns of poor health care access and utilization and better physical and behavioral health are observed across the continuum of documentation status, with undocumented immigrants having the worst access and utilization patterns and less disease. Despite fewer reported diagnoses and better mental health, undocumented Latinos reported poorer health status than their US-born counterparts.

Coverage Gains After the Affordable Care Act Among the Uninsured in Minnesota.

OBJECTIVES: We determined whether and how Minnesotans who were uninsured in 2013 gained health insurance coverage in 2014, 1 year after the Affordable Care Act (ACA) expanded Medicaid coverage and enrollment. METHODS: Insurance status and enrollment experiences came from the Minnesota Health Insurance Transitions Study (MH-HITS), a follow-up telephone survey of children and adults in Minnesota who had no health insurance in the fall of 2013. RESULTS: ACA had a tempered success in Minnesota. Outreach and enrollment efforts were effective; one half of those previously uninsured gained coverage, although many reported difficulty signing up (nearly 62%). Of the previously uninsured who gained coverage, 44% obtained their coverage through MNsure, Minnesota's insurance marketplace. Most of those who remained uninsured heard of MNsure and went to the Web site. Many still struggled with the enrollment process or reported being deterred by the cost of coverage. CONCLUSIONS: Targeting outreach, simplifying the enrollment process, focusing on affordability, and continuing funding for in-person assistance will be important in the future.

Propensity score matching to measure the effect of survey mode on reports of racial and ethnic discrimination in health care.

OBJECTIVE: To examine the effect of survey mode (mail vs. telephone) on the likelihood of reporting health care-related discrimination based on race, ethnicity, or nationality. METHODS: We use data from a mixed-mode, mail and telephone survey of public health care program enrollees (N=2807), including Somali, Hmong, African American, American Indian, and Latino populations. Self-reported discrimination was measured as the experience of unfair treatment by health care providers due to race, ethnicity, or nationality. We use propensity score matching to create exchangeable groups of phone and mail respondents based on the probability of completing the survey by phone. RESULTS: Overall, 33.1% of respondents reported having experienced discrimination in health care, but only 23.6% of telephone respondents reported discrimination compared with 36.8% of mail respondents. After matching phone and mail respondents based on probability of responding by telephone, all observable significant differences between respondents that were brought about by differential self-selection into mode were erased, allowing us to estimate the effect of survey mode on report of discrimination. Even after matching, the mode effect remains, where report of health care discrimination for telephone respondents would have been 12.6 percentage points higher had they responded by mail (22.6% vs. 35.2%). CONCLUSIONS: Survey mode has a significant effect on report of discrimination. Respondents may be more willing to disclose experiences of discrimination in a mail survey than to a telephone interviewer. Findings have substantial policy and clinical significance as variation in report of discrimination based on mode may lead to underestimation of the extent of the problem.