How Has Access to Care for Medi-Cal Enrollees Fared Relative to Employer-Sponsored Insurance 4 Years After the Affordable Care Act Expansion?

BACKGROUND: The number of Californians covered by Medi-Cal increased more than 50% between 2013 and 2018, largely due to expansion under the Affordable Care Act (ACA). This rapid expansion of Medicaid rolls prompted concerns that Medi-Cal enrollees would face greater difficulty accessing health care. OBJECTIVE: Examine whether gaps in access to care between Medi-Cal and employer-sponsored insurance (ESI) present in 2013 (prior to ACA implementation) had changed by 2018 (several years post implementation). DESIGN: Secondary analysis of data from the 2013 and 2018 California Health Interview Survey. The sample included adults of ages 18-64 insured all year and covered by ESI or Medi-Cal at time of interview. Logistic regressions were used to examine variation across years in the association between access to care and insurance type. MAIN MEASURES: Five access to care outcomes were assessed: no usual source of care, not accepted as new patient in past year, insurance not accepted in past year, delayed medical care in past year, and difficulty getting timely appointment. The main predictors of interest were type of insurance (Medi-Cal or ESI) and survey year (2013 or 2018). KEY RESULTS: The association between insurance type and access to care changed significantly over time for three outcomes: not accepted as new patient in past year (OR = 0.55, 95% CI = 0.32-0.97), delayed medical care in past year (OR = 1.55, 95% CI = 1.06-2.25), and difficulty getting timely appointment (OR = 0.41, 95% CI = 0.23-0.74). Predicted probabilities indicate gaps between Medi-Cal and ESI narrowed for not accepted as new patient in past year and difficulty getting timely appointment, but widened for delayed medical care. CONCLUSIONS: Despite the rapid expansion in the number of Californians covered by Medi-Cal, most gaps in access to care between Medi-Cal and ESI enrollees improved or did not significantly change between 2013 and 2018.

Neighborhood, family and individual characteristics related to adolescent park-based physical activity.

BACKGROUND: Local parks are an important community resource that may influence levels of physical activity among youth. However, few population-based studies have investigated park-based physical activity among youth. PURPOSE: This study examines sociodemographic, family, and neighborhood characteristics associated with park-based physical activity among adolescents. METHODS: Data were from the 2007 California Health Interview Survey (CHIS), a population-based survey of California households, and were analyzed in 2012-2013 and 2015. This study examined individual (age, gender, race/ethnicity, and nativity), family (household income, parental education, and nativity), and neighborhood characteristics (urbanicity, perceived park availability, perceived park safety, neighborhood income, and racial composition) associated with engaging in park-based physical activity among adolescents. RESULTS: In California, 71% of adolescents reported being physically active the last time they visited a park. In adjusted multinomial logistic regression analyses, older adolescents and females were less likely to be physically active in parks. Adolescents with a park within walking distance of home and those with a safe park nearby were more likely to be physically active during a park visit. CONCLUSIONS: Park availability and perceptions of park safety are important predictors of engaging in park-based physical activity among adolescents. These findings provide information that can help inform interventions intended to increase physical activity among youth. Strategies that increase availability and safety of parks and other recreation spaces may be particularly effective.

School-based program options to promote physical activity: a response.

This commentary is a response to PM-14-1065R1 and addresses issues raised regarding research presented in PM-14-443.

How can schools help youth increase physical activity? An economic analysis comparing school-based programs.

OBJECTIVE: For optimal health, physical activity should be an integral and routine part of daily life. Youth spend a significant amount of time at school yet rarely achieve the recommended 60 min of moderate and vigorous physical activity in physical education (PE) classes or recess. This study assessed the following types of school-based opportunities to improve physical activity for youth: after-school programs, before-school programs, PE classes, extended-day PE, and short physical activity breaks during the school day. METHOD: An economic analysis conducted in 2013 compared school-based approaches to increasing physical activity. Analysis factors included costs, reach, effects on physical activity gains, cost-effectiveness, and other potentially augmenting benefits. RESULTS: Two programs were significantly superior in terms of reach and cost per student: (1) extending the school day with mandatory PE participation and (2) offering short (10-minute) physical activity breaks during regular classroom hours. After-school program costs per student are high and the programs have a smaller reach, but they offer benefits (such as childcare) that may justify their higher costs. Before-school programs did not appear feasible. CONCLUSION: Incorporating short physical activity breaks into the existing school day would be a cost-effective way to increase school-based activity. This type of program is inexpensive and has broad reach. Inserting activity breaks throughout the day is appropriate, especially when youth are otherwise largely sedentary.

Asthma-related school absenteeism and school concentration of low-income students in California.

INTRODUCTION: Asthma is one of the leading causes of school absenteeism. Previous studies have shown that school absenteeism is related to family income of individual students. However, there is little research examining whether school absenteeism is related to school-level concentration of low-income students, independent of family income. The objective of this study was to examine whether the proportion of low-income students at a school was related to school absenteeism due to asthma. METHODS: Using data from the 2007 California Health Interview Survey, a population-based survey of California households, we examined the association between attending schools with high concentrations of low-income students and missing school because of asthma, adjusting for demographic characteristics, asthma severity, and health insurance status. Schools with high concentrations of low-income students were identified on the basis of the percentage of students participating in the free and reduced-price meal program, data publicly available from the California Department of Education. RESULTS: Students attending schools with the highest concentrations of low-income students were more likely to miss school because of asthma. Students from low-income families, younger students, those with more frequent asthma symptoms, or those taking prescription asthma medications also were more likely to miss school because of asthma. CONCLUSION: The use of school-level interventions to decrease school absenteeism due to asthma should be explored, especially in schools with high concentrations of low-income students. Potential interventions could include school-based asthma education and disease management or indoor and outdoor air pollution control.

Income disparities in obesity trends among California adolescents.

OBJECTIVES: We assessed income-specific trends in obesity rates among a diverse population of California adolescents. METHODS: We used data from 17,535 adolescents who responded to the California Health Interview Survey between 2001 and 2007 to examine disparities in obesity prevalence by family income and gender. RESULTS: Between 2001 and 2007, obesity prevalence significantly increased among lower-income adolescents but showed no statistically significant differences among higher-income adolescents after adjustment for age, gender, and race/ethnicity. Although the overall disparity in obesity by family income doubled in this time period, trends were more consistent among male adolescents than among female adolescents. CONCLUSIONS: The magnitude of the income disparity in obesity prevalence among California adolescents more than doubled between 2001-2007. The overall leveling off of adolescent obesity prevalence rates could indicate that efforts to decrease childhood obesity are having an impact; however, our results suggest that efforts to prevent childhood obesity may be failing to help adolescents from lower-income families, particularly male adolescents.

Sociodemographic, family, and environmental factors associated with active commuting to school among US adolescents.

Active commuting (non-motorized transport) to school can be an important source of physical activity for children and adolescents. This research examined sociodemographic, family, and environmental characteristics associated with active commuting to or from school among 3,451 US adolescents aged 12-17 years, who responded to the 2005 California Health Interview Survey. Logistic regression results indicated that those more likely to actively commute were males, Latinos, from lower-income families, attending public school, living in urban areas, and living closer to school. Adolescents without an adult present after school and those whose parents know little about their whereabouts after school were also more likely to actively commute. Parental walking for transportation and perceptions of neighborhood safety were not associated with adolescent active commuting. Important family and individual correlates of walking or biking to school among adolescents were identified, even after adjusting for distance to school and urbanicity.

School lunch source and adolescent dietary behavior.

INTRODUCTION: As rates of childhood obesity rise, the nutritional content of lunches eaten at school is more heavily scrutinized. We examined the association between dietary behaviors and the number of days that adolescents bring lunch to school. METHODS: We analyzed cross-sectional data for 2,774 adolescents who responded to the 2005 California Health Interview Survey and reported dietary behaviors for a weekday. RESULTS: In bivariate analyses, adolescents who typically brought their lunch from home 5 days per week ate fast food on fewer occasions; consumed fewer servings of soda, fried potatoes, and high-sugar foods; and ate more fruit and vegetables compared with adolescents who never brought their lunch to school. In linear regressions controlling for demographics, body mass index, desire to change weight, parent education, and adult presence after school, students who typically brought their lunch to school 5 days per week ate fast food 0.35 fewer times and consumed 0.35 fewer servings of soda, 0.10 fewer servings of fried potatoes, 0.25 fewer servings of high-sugar foods, and 0.95 more servings of fruit and vegetables per day compared with students who never brought their lunch to school. CONCLUSION: These findings suggest that adolescents who bring lunch to school from home have more positive dietary behaviors than do adolescents who get their lunches from other sources. Improving the nutritional quality of foods offered from other sources, such as the National School Lunch Program and competitive foods, could help improve adolescent dietary behaviors.

Physical activity among adolescents. When do parks matter?

BACKGROUND: The availability of places to engage in physical activity may influence physical activity levels. This study examined whether the relationship between physical activity and access to parks differs depending on adolescents' sociodemographic, housing, and neighborhood characteristics. METHODS: Data were analyzed from 4010 adolescents who responded to the 2003 California Health Interview Survey (CHIS). Analyses were conducted in 2005-2006. Five sets of logistic regressions were conducted to examine the relationship between physical activity and access to a safe park among adolescents living in (1) urban versus rural areas; (2) apartment buildings versus houses, (3) neighborhoods perceived as unsafe versus safe; (4) lower- versus higher-income families; and (5) adolescents who were Latino, African American, Asian, or white. Analyses also examined interactions between park access and these factors. RESULTS: Access to a safe park was positively associated with regular physical activity and negatively associated with inactivity for adolescents in urban areas, but not rural areas. Additionally, adolescents with access to a safe park were less likely to be inactive than those without access among those living in (1) apartment buildings, (2) unsafe neighborhoods, and (3) lower-income families. Park access was not associated with regular physical activity for these groups. The association between park access and physical activity varied by race/ethnicity. CONCLUSIONS: These findings suggest that the relationship between physical activity and access to parks differs depending on adolescents' sociodemographic, housing, and neighborhood characteristics, and that parks may be particularly important for promoting physical activity among urban adolescents.

Behavioral couples therapy for comorbid substance use disorders and combat-related posttraumatic stress disorder among male veterans: an initial evaluation.

Outcomes after behavioral couples therapy (BCT) were compared for 19 dually diagnosed veterans with combat-related PTSD and a substance use disorder (SUD, primarily alcohol dependence) and 19 veterans with SUD only. Clients with and without comorbid PTSD had very similar pre-treatment clinical profiles on dimensions of substance misuse, relationship functioning, and psychological symptoms. Further, both PTSD and non-PTSD clients showed good compliance with BCT, attending a high number of BCT sessions, taking Antabuse, and going to AA. Finally, both PTSD and non-PTSD groups improved from before BCT to immediately after and 12 months after BCT. Specific improvements noted were increased relationship satisfaction and reductions in drinking, negative consequences of drinking, male-to-female violence, and psychological distress symptoms. Extent and pattern of improvement over time were similar whether the client had PTSD or not. The present results suggest that BCT may have promise in treating clients with comorbid SUD and combat-related PTSD.

Civic Engagement Among California High School Teens.

This policy brief describes civic engagement among California adolescents in high school. Using data from the California Health Interview Survey (CHIS), the study found that the most common civic engagement activity among California high school teens is volunteering. Latino teens and those from low-income families have lower rates of civic engagement. Higher rates of civic engagement are associated with better health status, fewer days of missed school due to health, better grades, and greater perceived likelihood of attending college. Strategies to increase adolescent civic engagement could help promote healthy development. Policymakers, schools, and community organizations can promote civic engagement among all youth by expanding programs, encouraging youth participation in school and community organizations, and engaging youth who have not traditionally been included in civic activities.

Sugary Beverage Consumption Among California Children and Adolescents.

This policy brief examines patterns of sugary beverage consumption among children and adolescents in California. Using data from the California Health Interview Survey (CHIS), this study found that while sugary beverage consumption decreased among adolescents ages 12-17 between 2011-12 and 2013-14, it increased among children under age 12 between 2009 and 2013-14. The trend among children under age 12 may be attributed to a shift in sugary beverage consumption from soda to sports and energy drinks. Establishing and strengthening policies that focus on reducing consumption of sugary beverages could counter the increasing consumption trend among younger children as well as result in further reductions in consumption among teens.

Few California Children and Adolescents Meet Physical Activity Guidelines.

This policy brief describes physical activity among California children and adolescents. Using data from the California Health Interview Survey (CHIS), the study found that only 31 percent of children ages 5-11 and 18 percent of adolescents ages 12-17 meet the physical activity guidelines of engaging in at least one hour of physical activity every day. Neighborhood characteristics, including safety and proximity to parks, are related to physical activity levels among youth. Also, among older children, boys are more active than girls. Additional efforts by state and local policymakers, as well as communities, are needed to promote physical activity to increase the proportion of children and adolescents achieving recommended amounts of physical activity.

Walking Among California Adults.

This policy brief describes two types of walking among California adults: walking for transportation and walking for leisure. Using data from the 2013-14 California Health Interview Survey, the study found that the prevalence of both types of walking has increased since 2003. The prevalence of walking for both transportation and leisure varies with age, income, race/ethnicity, and neighborhood safety and cohesion. Additional efforts by state and local policymakers, as well as by communities, are needed to reduce disparities and promote walking among adults.

Disparities in Health Care Access and Health Among Lesbians, Gay Men, and Bisexuals in California.

This policy brief examines differences in health care access, health behaviors, and health outcomes by sexual orientation among California adults. Using data from the California Health Interview Survey, the study finds that although lesbian, gay, and bisexual women and men have similar or better rates of insurance coverage compared to straight women and men, they are more likely to experience delays in getting needed health care. Lesbians, bisexual women, and bisexual men have higher rates of smoking and binge drinking than straight women and men; however, gay men are less likely to consume sugary beverages and to be physically inactive. Lesbians and bisexuals had poorer health status and higher rates of disability than straight adults. Future research is needed to explain these disparities, as well as to identify health care and structural interventions that will improve access to care and health outcomes for this population.

Exploring the differences between pet and non-pet owners: Implications for human-animal interaction research and policy.

There is conflicting evidence about whether living with pets results in better mental and physical health outcomes, with the majority of the empirical research evidence being inconclusive due to methodological limitations. We briefly review the research evidence, including the hypothesized mechanisms through which pet ownership may influence health outcomes. This study examines how pet and non-pet owners differ across a variety of socio-demographic and health measures, which has implications for the proper interpretation of a large number of correlational studies that attempt to draw causal attributions. We use a large, population-based survey from California administered in 2003 (n = 42,044) and find that pet owners and non-pet owners differ across many traits, including gender, age, race/ethnicity, living arrangements, and income. We include a discussion about how the factors associated with the selection into the pet ownership group are related to a range of mental and physical health outcomes. Finally, we provide guidance on how to properly model the effects of pet ownership on health to accurately estimate this relationship in the general population.

Association of California Immigrants' Avoidance of Public Programs Due to Immigration Concerns With Delayed Access to Health Care.

This cross-sectional study examines the association of avoidance of public programs among California immigrants with delayed access to health care services and prescriptions owing to concerns about how their interaction with these services may affect their immigration status.

Prediabetes in California: Nearly Half of California Adults on Path to Diabetes.

In California, more than 13 million adults (46 percent of all adults in the state) are estimated to have prediabetes or undiagnosed diabetes. An additional 2.5 million adults have diagnosed diabetes. Altogether, 15.5 million adults (55 percent of all California adults) have prediabetes or diabetes. Although rates of prediabetes increase with age, rates are also high among young adults, with one-third of those ages 18-39 having prediabetes. In addition, rates of prediabetes are disproportionately high among young adults of color, with more than one-third of Latino, Pacific Islander, American Indian, African-American, and multiracial Californians ages 18-39 estimated to have prediabetes. Policy efforts should focus on reducing the burden of prediabetes and diabetes through support for prevention and treatment.

Lunchtime School Water Availability and Water Consumption Among California Adolescents.

PURPOSE: To examine the potential impact of California SB 1413, which required school districts to provide free, fresh drinking water during mealtimes in food service areas by July 1, 2011, on greater water consumption among California adolescents. METHODS: Data were drawn from the 2012 and 2013 state-representative California Health Interview Survey. A total of 2,665 adolescents aged 12-17 years were interviewed regarding their water consumption and availability of free water during lunchtime at their school. RESULTS: Three-fourths reported that their school provided free water at lunchtime, mainly via fountains. In a multivariate model that controlled for age, gender, income, race/ethnicity, body mass index, and school type, adolescents in schools that provided free water consumed significantly more water than adolescents who reported that water was not available, bivariate (standard error) = .67 (.28), p = .02. School water access did not significantly vary across the 2 years. CONCLUSIONS: Lunchtime school water availability was related to water consumption, but a quarter of adolescents reported that their school did not provide free water at lunch. Future research should explore what supports and inducements might facilitate provision of drinking water during school mealtimes.