Health insurance and access to care for families with young children in California, 2001-2005: differences by immigration status

American clusters: using machine learning to understand health and health care disparities in the United States

Health and health care access in the United States are plagued by high inequality. While machine learning (ML) is increasingly used in clinical settings to inform health care delivery decisions and predict health care utilization, using ML as a research tool to understand health care disparities in the United States and how these are connected to health outcomes, access to health care, and health system organization is less common. We utilized over 650 variables from 24 different databases aggregated by the Agency for Healthcare Research and Quality in their Social Determinants of Health (SDOH) database. We used k-means-a non-hierarchical ML clustering method-to cluster county-level data. Principal factor analysis created county-level index values for each SDOH domain and 2 health care domains: health care infrastructure and health care access. Logistic regression classification was used to identify the primary drivers of cluster classification. The most efficient cluster classification consists of 3 distinct clusters in the United States; the cluster having the highest life expectancy comprised only 10% of counties. The most efficient ML clusters do not identify the clusters with the widest health care disparities. ML clustering, using county-level data, shows that health care infrastructure and access are the primary drivers of cluster composition.

Factors in Immigrant Children's Use of Physician and Dentist Visits, Hospital Care, and Prescribed Medication in the United States

Applying the behavioral model of health services utilization to data from the United States, this study examined immigrant children's use of physician and dentist visits, hospital care, and prescribed medication. We employed data describing 9759 immigrant parents and children who participated in 2021's National Survey of Children's Health. Logistic regression results negatively linked physician visits to child health, child age, Asian children, fathers, lower parent education, lower family income, uninsured children, and parent's U.S. residence under 5 years. Dentist visits were positively associated with child age, girls, Hispanic children, parent education, family income, public/private health insurance coverage, and U.S.-born children, but such use was associated negatively with Asian children. Hospital use was positively associated with poor child health, Black children, children of "other" race/ethnicity, younger parent age, enrolled in health insurance, and parent's U.S. residence under 5 years. The use of prescribed medication was negatively associated with Asian children, younger child age, lower parent education, uninsured child, and lack of English proficiency. The paper's conclusion suggests policymakers expand Medicaid and CHIP eligibility among immigrant children and suggests community education to foster awareness of children's physical and oral health needs and of Medicaid, CHIP, and prescription assistance programs. The conclusion calls for healthcare providers and social workers to accommodate and respect immigrants' traditional health-related beliefs, showing cultural competence.

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.

A social determinants framework identifying state-level immigrant policies and their influence on health

BACKGROUND

Many conceptual frameworks that touch on immigration and health have been published over the past several years. Most discuss broad social trends or specific immigrant policies, but few address how the policy environment affects the context of settlement and incorporation. Research on the social determinants of health shows how policies across multiple sectors have an impact on health status and health services, but has not yet identified the policies most important for immigrants. Understanding the range and content of state-level policies that impact immigrant populations can focus health in all policies initiatives as well as contextualize future research on immigrant health.

METHODS

Our framework identifies state-level policies across five different domains that impact the health of immigrants and that vary across states, especially for those without legal status. Our scan shows that immigrants are exposed to different contexts, ranging from relatively inclusive to highly exclusive; a number of states have mixed trends that are more inclusive in some areas, but exclusive in others. Finally, we examine how the relative inclusiveness of state policies are associated with state-level demographic and political characteristics.

RESULTS

Contrary to the image that exclusive policies are a reaction to large immigrant populations that may compete for jobs and cultural space, we find that the higher the proportion of foreign born and Hispanics in the state, the more inclusive the set of policies; while the higher the proportion of Republican voters, the less inclusive.

CONCLUSIONS

Variation across immigrant policies is much larger than the variation in state demographic and political characteristics, suggesting that state-level policies need to be included as a possible independent, contextual effect, when assessing immigrant health outcomes. This policy framework can be particularly useful in bridging our understanding of how large macro processes are connected to the daily lives and health of immigrants.

Policies of Exclusion: Implications for the Health of Immigrants and Their Children

Public policies play a crucial role in shaping how immigrants adapt to life in the United States. Federal, state, and local laws and administrative practices impact immigrants' access to education, health insurance and medical care, cash assistance, food assistance, and other vital services. Additionally, immigration enforcement activities have substantial effects on immigrants' health and participation in public programs, as well as effects on immigrants' families. This review summarizes the growing literature on the consequences of public policies for immigrants' health. Some policies are inclusive and promote immigrants' adaptation to the United States, whereas other policies are exclusionary and restrict immigrants' access to public programs as well as educational and economic opportunities. We explore the strategies that researchers have employed to tease out these effects, the methodological challenges of undertaking such studies, their varying impacts on immigrant health, and steps that can be undertaken to improve the health of immigrants and their families.

Insurance Coverage and Well-Child Visits Improved for Youth Under the Affordable Care Act, but Latino Youth Still Lag Behind

OBJECTIVE

To examine whether there have been changes in insurance coverage and health care utilization for youth before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) and to assess whether racial and ethnic inequities have improved.

METHODS

Data are from 64,565 youth (ages 0-17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011-2013 vs years 2014-2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity.

RESULTS

The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve.

CONCLUSIONS

Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

Legal Status, Time in the USA, and the Well-Being of Latinos in Los Angeles

In the USA, undocumented Latino immigrants may have poorer health because of barriers to health care, stressors, and detrimental effects of immigration enforcement. Previous immigrant health research, however, suggests that recently arrived Latino immigrants have better health than US-born Latinos and their health deteriorates over time. Given the current environments that undocumented immigrants face, legal status is a structural factor that likely influences the patterns of immigrant health. Therefore, the aim of this study was to examine the extent to which physical and mental health differed by legal status and duration in the USA for the Latino population in Los Angeles County, California. We conducted analysis of Latino respondents (n = 1396) to the Los Angeles Family and Neighborhood Survey (L.A.FANS) Wave II. We examined self-reported health, depression measured by the Composite International Diagnostic Interview-Short Form, and blood pressure collected by trained interviewers. Respondents reported their legal status, time in the USA, and other sociodemographic characteristics. Regression models were used to test associations between each outcome and 1) legal status and 2) legal status by duration (≤ 15 and > 15 years) in the USA. Without taking duration into account, we found no significant differences in outcomes between undocumented, documented, or US-born Latinos. Taking duration into account, shorter duration undocumented immigrants had worse self-reported health than the US born. Undocumented immigrants, regardless of duration, had higher blood pressure than documented immigrants who had been in the USA for less time and the same level of blood pressure as the US born. In contrast, shorter duration documented immigrants had lower blood pressure compared to longer duration documented immigrants and US-born counterparts, and marginally lower blood pressure than shorter duration undocumented immigrants. The findings suggest that the "health advantage" generally presumed to exist among immigrants may not affect undocumented immigrants.

SEARCHING FOR THE FAMILY LEGAL STATUS OF MEXICAN-ORIGIN CHILDREN: A PRIMER ON DIFFERENT MEASUREMENT STRATEGIES

Interest in the consequences of family legal status for children has grown in response to immigration-related changes in the ethnic composition of American society. However, few population-based empirical studies devote attention to family legal status due to data limitations. Using restricted data from the California Health Interview Survey (2009), the primary objectives of this research are to identify and evaluate strategies for measuring this important determinant of life chances among Mexican-origin children. The results indicate that measurement strategies matter. Estimates of the size of status-specific segments of this population and their risks of living in poverty are sensitive to how family legal status is operationalized. These findings provide the foundation for a discussion of how various "combinatorial" measurement strategies may rely on untenable assumptions that can be avoided with less reductionist approaches.

Legal Status and Health Care: Mexican-Origin Children in California, 2001-2014

Using restricted data from the 2001-2014 California Health Interview Surveys, this research illuminates the role of legal status in health care among Mexican-origin children. The first objective is to provide a population-level overview of trends in health care access and utilization, along with the legal statuses of parents and children. The second objective is to examine the nature of associations between children's health care and legal status over time. We identify specific status-based distinctions that matter and investigate how their importance is changing. Despite the continuing significance of child nativity for health care, the descriptive analysis shows that the proportion of Mexican-origin children who are foreign born is declining. This trend suggests a potentially greater role of parental legal status in children's health care. Logistic regression analyses demonstrate that the importance of parental legal status varies with the health care indicator examined and the inclusion of child nativity in models. Moreover, variation in some aspects of children's health care coalesced more around parents' citizenship than documentation status in the past. With one exception, the salience of such distinctions has dissipated over time.

Access to Health Care and Hearing Evaluation in US Adults

Objectives:

To explore self-reported hearing testing access for adults in a nationally representative survey.

Methods:

Demographic and audiologic adult survey respondent variables in the National Health and Nutrition Examination Survey (NHANES) database 2011-2012 cohort were examined. Logistic regression was used to determine odds ratios (OR) and 95% confidence intervals (CI).

Results:

In all, 5864 adult respondents were analyzed. Two-thirds (65.6%) of respondents reported having hearing tested 10 or more years ago or never tested at all. Male gender (OR = 2.27; 95% CI, 1.31-3.94), having a health care visit less than 3 years ago (OR = 8.19; 95% CI, 2.09-32.2), and having health insurance (OR = 1.73; 95% CI, 1.08-2.77) were significantly associated with respondents reporting having a hearing test less than 10 years ago. Mexican American race (OR = 0.41; 95% CI, 0.20-0.83) and respondent age 40 to 59 (OR = 0.52; 95% CI, 0.33-0.81) were significantly associated with respondents reporting having a hearing test 10 or more years prior or never.

Conclusion:

A significant proportion of the adult population reports having hearing tested 10 or more years prior or never at all. Effort will be required to identify adults who have hearing loss and may benefit from auditory rehabilitation such as hearing aids or the cochlear implant.

Barriers to health care for undocumented immigrants: a literature review

With the unprecedented international migration seen in recent years, policies that limit health care access have become prevalent. Barriers to health care for undocumented immigrants go beyond policy and range from financial limitations, to discrimination and fear of deportation. This paper is aimed at reviewing the literature on barriers to health care for undocumented immigrants and identifying strategies that have or could be used to address these barriers. To address study questions, we conducted a literature review of published articles from the last 10 years in PubMed using three main concepts: immigrants, undocumented, and access to health care. The search yielded 341 articles of which 66 met study criteria. With regard to barriers, we identified barriers in the policy arena focused on issues related to law and policy including limitations to access and type of health care. These varied widely across countries but ultimately impacted the type and amount of health care any undocumented immigrant could receive. Within the health system, barriers included bureaucratic obstacles including paperwork and registration systems. The alternative care available (safety net) was generally limited and overwhelmed. Finally, there was evidence of widespread discriminatory practices within the health care system itself. The individual level focused on the immigrant’s fear of deportation, stigma, and lack of capital (both social and financial) to obtain services. Recommendations identified in the papers reviewed included advocating for policy change to increase access to health care for undocumented immigrants, providing novel insurance options, expanding safety net services, training providers to better care for immigrant populations, and educating undocumented immigrants on navigating the system. There are numerous barriers to health care for undocumented immigrants. These vary by country and frequently change. Despite concerns that access to health care attracts immigrants, data demonstrates that people generally do not migrate to obtain health care. Solutions are needed that provide for noncitizens’ health care.

Can we spin straw into gold? An evaluation of immigrant legal status imputation approaches

Researchers have developed logical, demographic, and statistical strategies for imputing immigrants' legal status, but these methods have never been empirically assessed. We used Monte Carlo simulations to test whether, and under what conditions, legal status imputation approaches yield unbiased estimates of the association of unauthorized status with health insurance coverage. We tested five methods under a range of missing data scenarios. Logical and demographic imputation methods yielded biased estimates across all missing data scenarios. Statistical imputation approaches yielded unbiased estimates only when unauthorized status was jointly observed with insurance coverage; when this condition was not met, these methods overestimated insurance coverage for unauthorized relative to legal immigrants. We next showed how bias can be reduced by incorporating prior information about unauthorized immigrants. Finally, we demonstrated the utility of the best-performing statistical method for increasing power. We used it to produce state/regional estimates of insurance coverage among unauthorized immigrants in the Current Population Survey, a data source that contains no direct measures of immigrants' legal status. We conclude that commonly employed legal status imputation approaches are likely to produce biased estimates, but data and statistical methods exist that could substantially reduce these biases.

Family legal status and health: Measurement dilemmas in studies of Mexican-origin children

Family legal status is a potentially important source of variation in the health of Mexican-origin children. However, a comprehensive understanding of its role has been elusive due to data limitations and inconsistent measurement procedures. Using restricted data from the 2011-2012 California Health Interview Survey, we investigate the implications of measurement strategies for estimating the share of children in undocumented families and inferences about how legal status affects children's health. The results show that inferences are sensitive to how this "fundamental cause" is operationalized under various combinatorial approaches used in previous studies. We recommend alternative procedures with greater capacity to reveal how the statuses of both parents affect children's well-being. The results suggest that the legal statuses of both parents matter, but the status of mothers is especially important for assessments of child health. The investigation concludes with a discussion of possible explanations for these findings.

Committee opinion no. 627: health care for unauthorized immigrants

Unauthorized (undocumented) immigrants are less likely than other residents of the United States to have health insurance. The American College of Obstetricians and Gynecologists has long supported a basic health care package for all women living within the United States without regard to their country of origin or documentation. Providing access to quality health care for unauthorized immigrants and their children, who often were born in the United States and have U.S. citizenship, is essential to improving the nation's public health.

Implementing federal health reform in the States: who is included and excluded and what are their characteristics?

OBJECTIVE

To estimate the characteristics and number of nonelderly adults eligible and ineligible for Affordable Care Act (ACA) expansions.

DATA SOURCES AND SETTINGS

Two secondary data sources are used in this analysis: the 2008 Panel of the Survey of Income and Program Participation (SIPP) and the 2009 American Community Survey (ACS).

STUDY DESIGN

We use multiple imputation to incorporate model-based uncertainty into the prediction of immigration status into the ACS from the SIPP. Key variables include place of birth, year of entry to the U.S., and health insurance coverage.

DATA COLLECTION/EXTRACTING METHODS

No primary data are used in this study.

PRINCIPLE FINDINGS

We estimate that potentially 3.5 million nonelderly adults will be excluded from the ACA Medicaid Expansion and 2 million from the health insurance exchanges because of their immigration status. We also find significant differences in estimates of excluded nonelderly adults across states.

CONCLUSIONS

Over 15 percent of income-eligible uninsured nonelderly adults will be potentially excluded from the ACA coverage expansions due to their immigration status. Policy makers must be careful to exclude ineligible nonelderly adults before estimating the impact of the ACA on coverage rates.

Disparities in disability after traumatic brain injury among Hispanic children and adolescents

OBJECTIVE

To compare the extent of disability in multiple areas of functioning after mild, moderate, and severe traumatic brain injury (TBI) between Hispanic and non-Hispanic white (NHW) children.

METHODS

This was a prospective cohort study of children aged <18 years treated for a TBI between March 1, 2007, and September 30, 2008. Hispanic (n = 74) and NHW (n = 457) children were included in the study. Outcome measures were disability in health-related quality of life, adaptive skills, and participation in activities 3, 12, 24, and 36 months after injury compared with preinjury functioning. We compared change in outcome scores between Hispanic and NHW children at each follow-up time. All analyses were adjusted for age, gender, severity and intent of injury, insurance, family function at baseline, parental education, and income.

RESULTS

The health-related quality of life for all children was lower at all follow-up times compared with baseline. Although NHW children showed some improvement during the first 3 years after injury, Hispanic children remained significantly impaired. Significant differences were also observed in the domains of communication and self-care abilities after TBI. Differences between groups in scores for participation in activities were also present but were only significant 3 months after injury.

CONCLUSIONS

Hispanic children with TBI report larger and long-term reductions in their quality of life, participation in activities, communication, and self-care abilities compared with NHW children. The reasons for these differences need to be better understood and interventions implemented to improve the outcomes of these children.