Understanding uptake of COVID-19 testing, vaccination, and boosters among Spanish-speaking Latines in the United States: Qualitative insights from Spanish speakers and key informants

BACKGROUND

Latine communities in the United States have been disproportionately affected by COVID-19. It is critical to gain a better understanding of the sociocultural determinants that challenge and facilitate COVID-19 testing, vaccination, and booster uptake within these vulnerable communities to inform culturally congruent strategies and interventions.

METHODS

In summer 2022, our community-based participatory research partnership conducted 30 key informant interviews and 7 focus groups with 64 Spanish-speaking Latine participants in North Carolina. Interviewees consisted of representatives from health and service organizations, most of whom were engaged with direct service to Spanish speakers. Interviews were conducted in either English or Spanish, depending on the preference of the participant; all focus groups were conducted in Spanish. Interviews and focus groups were conducted in person or by videoconference.

RESULTS

Twenty themes emerged that we organize into four domains: general perceptions about COVID-19; barriers to COVID-19 testing, vaccination, and booster uptake; facilitators to COVID-19 testing, vaccination, and booster uptake; and recommendations to promote testing, vaccination, and booster uptake.

DISCUSSION

Results underscore important sociocultural determinants of ongoing COVID-19 testing, vaccination, and booster uptake to consider in developing interventions for Spanish-speaking Latines in the United States. Based on this formative work, our partnership developed Nuestra Comunidad Saludable (Our Healthy Community). We are implementing the intervention to test whether trained peer navigators can increase COVID-19 testing, vaccination, and booster uptake among Spanish-speaking Latines through blending in-person interactions and mHealth (mobile health) strategies using social media.

Heat stress survival and thermal tolerance of Australian stingless bees

Stingless bees (Meliponini) are important pollinators throughout the world's tropical and subtropical regions. Understanding their thermal tolerance is key to predicting their resilience to changing climates and increasingly frequent extreme heat events. We examined critical thermal maxima (CTmax), survival during 1-8 h heat periods, chill coma recovery and thermal preference for Australian meliponine species that occupy different climates across their ranges: Tetragonula carbonaria (tropical to temperate regions), T. hockingsi (tropical and subtropical regions only) and Austroplebeia australis (widely distributed including arid regions). We found interspecific differences in thermal tolerance consistent with differences in the climate variability observed in each species' range. Foragers of A. australis had a faster chill coma recovery (288 s) than foragers of T. hockingsi (1059 s) and T. carbonaria (872 s). Austroplebeia australis also had the highest CTmax of 44.5 °C, while the CTmax of the two Tetragonula species was ∼43.1 °C. After a 1-h heat exposure, T. carbonaria foragers experienced 95% mortality at 42 °C, and 100% at 45 °C. Surprisingly, larvae and pupae of both Tetragonula species were more resistant to heat exposure than foragers. Within an enclosed temperature gradient apparatus (17-38 °C), no clear preference was found for foragers; however, they were most frequently observed at ∼18 °C. Results indicate that in some regions of Australia, meliponines already experience periodic heat events exceeding their thermal maxima. Employing effective management strategies (such as nest site insulation and habitat preservation) may be crucial to colony survival under continued climate change.

Improving Consumer Understanding of Short-Term Health Insurance: An Experiment

Short-term health insurance policies-made available with longer durations during the Trump Administration-offer substantially fewer consumer protections than do Affordable Care Act ("ACA")-compliant policies. Federal regulations require short-term policies' sellers to disclose possible ACA noncompliance to prospective buyers. This controlled experiment finds, however, that the federally required disclosure does not substantially improve consumer understanding of these policies' coverage limitations. The experiment also finds that an enhanced disclosure greatly improves this understanding. Importantly, consumers' preferences for ACA-compliant policies also increased with their comprehension of the coverage differences. Thus, the study demonstrates not only that easily implemented changes in the federally required disclosure would improve consumer understanding of the coverage differences but also that the improved understanding matters to consumers. However, even the enhanced disclosure left many respondents mistaken about some key limitations of short-term policies, suggesting that policymakers should consider other strategies to protect buyers of short-term health insurance.

Microbial diversity in stingless bee gut is linked to host wing size and influenced by the environment

Stingless bees are important social corbiculate bees, fulfilling critical pollination roles in many ecosystems. However, their gut microbiota, particularly the fungal communities associated with them, remains inadequately characterised. This knowledge gap hinders our understanding of bee gut microbiomes and their impacts on the host fitness. We collected 121 samples from two species, Tetragonula carbonaria and Austroplebeia australis across 1200 km of eastern Australia. We characterised their gut microbiomes and investigated potential correlations between bee gut microbiomes and various geographical and morphological factors. We found their core microbiomes consisted of the abundant bacterial taxa Snodgrassella, Lactobacillus and Acetobacteraceae, and the fungal taxa Didymellaceae, Monocilium mucidum and Aureobasidium pullulans, but variances of their abundances among samples were large. Furthermore, gut bacterial richness of T. carbonaria was positively correlated to host forewing length, an established correlate to body size and fitness indicator in insects relating to flight capacity. This result indicates that larger body size/longer foraging distance of bees could associate with greater microbial diversity in gut. Additionally, both host species identity and management approach significantly influenced gut microbial diversity and composition, and similarity between colonies for both species decreased as the geographic distance between them increased. We also quantified the total bacterial and fungal abundance of the samples using qPCR analyses and found that bacterial abundance was higher in T. carbonaria compared to A. australis, and fungi were either lowly abundant or below the threshold of detection for both species. Overall, our study provides novel understanding of stingless bee gut microbiomes over a large geographic span and reveals that gut fungal communities likely not play an important role in host functions due to their low abundances.

Increasing COVID-19 testing and vaccination among Spanish speakers in the USA: protocol for the development and evaluation of the Nuestra Comunidad Saludable intervention using a group-randomised trial design

INTRODUCTION

Our community-based participatory research partnership aims to expand understanding of the social, ethical and behavioural implications of COVID-19 testing and vaccination to inform the development of an integrated intervention that harnesses community-based peer navigation and mHealth strategies to improve COVID-19 testing and vaccination; test the intervention; and develop and disseminate practice, research and policy recommendations to further increase COVID-19 testing and vaccination among Spanish-speaking Latine communities in the USA.

METHODS AND ANALYSIS

We will conduct 50 individual in-depth interviews with health providers, who have conducted COVID-19 testing and/or vaccination activities within Spanish-speaking communities, and with representatives from Latine-serving community-based organisations. We will also conduct six focus groups with 8-12 Spanish-speaking Latine community member participants each for a total number of about 60 focus group participants. Next, we will develop the Nuestra Comunidad Saludable intervention based on findings from interviews and focus groups and use a longitudinal group-randomised trial design with two arms (intervention and delayed intervention) to evaluate the impact of the intervention. We will recruit, enrol and collect baseline data from 20 community-based peer navigators (Navegantes) and their social network members (n=8 unique social network members per Navegante). Navegantes (coupled with their social networks) will be randomised to intervention or delayed intervention groups (10 Navegantes and 80 social network members per group).

ETHICS AND DISSEMINATION

Ethical approval for data collection was granted by the Wake Forest University School of Medicine Institutional Review Board. Following the description of study procedures, we will obtain consent from all study participants. Study findings will be disseminated through an empowerment theory-based community forum, peer-reviewed publications and presentations at scientific meetings, and reports and briefs for lay, community and practitioner audiences.

TRIAL REGISTRATION NUMBER

NCT05302908.

Pollen-insect interaction meta-networks identify key relationships for conservation in mosaic agricultural landscapes

Flower visitors use different parts of the landscape through the plants they visit, however these connections vary within and among land uses. Identifying which flower-visiting insects are carrying pollen, and from where in the landscape, can elucidate key pollen-insect interactions and identify the most important sites for maintaining community-level interactions across land uses. We developed a bipartite meta-network, linking pollen-insect interactions with the sites they occur in. We used this to identify which land-use types at the site- and landscape-scale (within 500 m of a site) are most important for conserving pollen-insect interactions. We compared pollen-insect interactions across four different land uses (remnant native forest, avocado orchard, dairy farm, rotational potato crop) within a mosaic agricultural landscape. We sampled insects using flight intercept traps, identified pollen carried on their bodies and quantified distinct pollen-insect interactions that were highly specialized to both natural and modified land uses. We found that sites in crops and dairy farms had higher richness of pollen-insect interactions and higher interaction strength than small forest patches and orchards. Further, many interactions involved pollinator groups such as flies, wasps, and beetles that are often under-represented in pollen-insect network studies, but were often connector species in our networks. These insect groups require greater attention to enable wholistic pollinator community conservation. Pollen samples were dominated by grass (Poaceae) pollen, indicating anemophilous plant species may provide important food resources for pollinators, particularly in modified land uses. Field-scale land use (within 100 m of a site) better predicted pollen-insect interaction richness, uniqueness, and strength than landscape-scale. Thus, management focused at smaller scales may provide more tractable outcomes for conserving or restoring pollen-insect interactions in modified landscapes. For instance, actions aimed at linking high-richness sites with those containing unique (i.e., rare) interactions by enhancing floral corridors along field boundaries and between different land uses may best aid interaction diversity and connectance. The ability to map interactions across sites using a meta-network approach is practical and can inform land-use planning, whereby conservation efforts can be targeted toward areas that host key interactions between plant and pollinator species.

State Preemption of Municipal Laws and Policies that Protect Immigrant Communities: Impact on Latine Health and Well-Being in North Carolina

BACKGROUND

Some U.S. municipalities have proclaimed themselves "sanctuary cities" and/or adopted laws and policies limiting local involvement in enforcement of federal immigration policies. Several states, however, have adopted laws that preempt municipal laws and policies designed to protect immigrants. We explored the consequences of House Bill (H.B.) 318, one such preemption law in North Carolina (NC), on the health and well-being of Latine immigrants.

METHODS

We conducted focus groups with Latine immigrants (n=49) and in-depth interviews with representatives from health, social service, and immigrant-serving organizations and local government (including law enforcement) (n=21) in NC municipalities that, before HB 318, adopted laws and policies supporting immigrants. Data were analyzed using constant comparison.

RESULTS

Twelve themes emerged, including the positive impacts of municipal sanctuary laws and policies are limited by preemption and other state and federal actions; laws and policies like HB 318 are confusing, have a chilling effect on health services use, and make life harder overall for Latine communities; intensified federal immigration enforcement has increased fear among Latine communities; Trump administration policies worsened anti-immigrant climates; and use of community identification cards and greater information dissemination and inter-organization coordination can lessen the consequences of preemption and other restrictive laws and policies.

CONCLUSION

State preemption of protective municipal laws and policies negatively and profoundly affects immigrant health and well-being. However, creative strategies have been implemented to respond to preemption. These findings provide critical data for decision-makers and community leaders regarding the detrimental impacts of preemption laws and mitigation of these impacts.

A "Surprise" Health Policy Legislative Victory

It was a happy surprise when, overcoming partisan divisions and interest-group lobbying, Congress enacted the No Surprises Act, which bans unfair out-of-network "balance billing." Although this is only a modest legislative victory, key efforts by the health policy community made a real difference in a time of legislative gridlock.

The impact that family members' health care experiences have on patients' trust in physicians

BACKGROUND

A family member's negative experiences with medical care have long-term effects on a patient's attitudes and emotions. However, the impact of family members' experiences on patients' trust in their own physicians and in physicians generally is poorly understood. This study aims to quantify these associations.

METHODS

A cross-sectional online survey involving adults with non-communicable diseases (cardiac disease, diabetes, cancer, depression, and rheumatic disease) was conducted in Japan during April 2020. The main exposure variable was dissatisfaction with the medical care that family members had received. The main outcomes were patients' (N = 661) own trust in their personal physicians and in physicians generally. The study adopted the Japanese version of the Abbreviated Wake Forest Physician Trust Scales. Both 5-item scales (general and individual physician trust) were translated and validated for the study. The total scores were transformed into a scale of 0-100 points. A series of linear mixed-effects models with consideration for clustering effect by prefectures were fit.

RESULTS

The results showed a lower rating for trust in physicians generally as compared to trust in the respondent's personal physician (mean 57.0 vs. 66.4 points; p < 0.001). Furthermore, dissatisfaction with a family member's medical care was associated with lower trust in physicians generally (mean difference - 9.58, 95 %CI -12.4 to -6.76). Interestingly, dissatisfaction with a family member's care was also associated with lower trust in the respondent's personal physician (mean difference - 3.19, 95 %CI -6.02 to -0.36), but the magnitude of this association was weaker. The lower trust in personal physicians may be mediated by reduced trust in physicians generally.

CONCLUSIONS

We suggest that physicians enquire about past patients' negative experiences, including dissatisfaction with family members' medical care, to repair hidden loss of trust, when they sense that patients doubt them or physicians generally.

State Preemption of Local Immigration "Sanctuary" Policies: Legal Considerations

States have enacted a wave of statutes over the past several years preempting local government law and policies that potentially promote public health in various ways. Among these local preemption measures are statutes in at least 9 states that outlaw municipal policies providing some form of "sanctuary" to immigrants. Such policies, and their preemption, have importance both for direct access to health services and for broader social determinants of health.This article gauges the coverage and potential impact of these state preemption laws based on key informant interviews nationally and a close legal analysis of relevant laws and policy documents. It distinguishes between preemption laws focused on law enforcement cooperation and those that also encompass a wider array of "welcoming" policies and initiatives. It also distinguishes between more passive forms of preemption that prohibit barring cooperation with federal immigration enforcement, and those statutes that more affirmatively require active measures to assist federal enforcement.Drawing these distinctions can help municipalities determine which immigrant-supportive measures are still permitted, and how best to mitigate the adverse public health effects of these preemption laws.

Public views about COVID-19 'Immunity Passports'

IMPORTANCE

Discovery of effective vaccines and increased confidence that infection confers extended protection against coronavirus disease (COVID-19) have renewed discussion of using immunity certificates or 'passports' to selectively reduce ongoing public health restrictions.

OBJECTIVE

To determine public views regarding government and private conferral of immunity privileges.

DESIGN AND SETTING

National on-line survey fielded in June 2020. Participants were randomly asked about either government 'passports' or private 'certificates' for COVID-19 immunity.

PARTICIPANTS

Adults from a standing panel maintained for academic research, selected to approximate national demographics.

MAIN OUTCOMES/MEASURES

Level of support/opposition to immunity privileges, and whether views vary based on: government vs. private adoption; demographics; political affiliation or views; or various COVID19-related attitudes and experiences.

RESULTS

Of 1315 respondents, 45.2% supported immunity privileges, with slightly more favoring private certificates than government passports (48.1% vs 42.6%, p = 0.04). Support was greater for using passports or certificates to enable returns to high-risk jobs or attendance at large recreational events than for returning to work generally. Levels of support did not vary significantly according to age groups, socioeconomic or employment status, urbanicity, political affiliation or views, or whether the respondent had chronic disease(s). However, estimates from adjusted analyses showed less support among women (odds ratio, 0.64; 95% confidence interval, 0.51 to 0.80), and among Hispanics (0.56; 0.40 to 0.78) and other minorities (0.58; 0.40 to 0.85) compared with whites, but not among blacks (0.83; 0.60 to 1.15). Support was much higher among those who personally wanted a passport or certificate (75.6% vs 24.4%) and much lower among those who believed this would harm the social fabric of their community (22.9% vs 77.1%).

CONCLUSIONS AND RELEVANCE

Public views are divided on both government or private uses of immunity certificates, but, prior to any efforts to politicize the issues, these views did not vary along usual political lines or by characteristics that indicate individual vulnerability to infection. Social consensus on the desirability of an immunity privileges programs may be difficult to achieve.

Temporal changes in the microbiome of stingless bee foragers following colony relocation

Maintaining beneficial interactions with microbial symbionts is vital for animal health. Yet, for social insects, the stability of microbial associations within and between cohorts is largely unknown. We investigated temporal changes in the microbiomes of nine stingless bee (Tetragonula carbonaria) colonies at seven timepoints across a 10-month period when moved between two climatically and florally different sites. Bacterial 16S rRNA gene and fungal ITS amplicon sequencing confirmed that microbiomes varied considerably between colonies initially at site one. However, following relocation, considerable changes occurred in bacterial community composition within each colony, and the microbiome composition became more similar across colonies. Notably, Snodgrassella disappeared and Zymobacter appeared as relatively abundant taxa. Remarkably, bacterial communities within colonies continued to shift over time but remained similar across colonies, becoming dominated by Acinetobacter six months after returning to the original site. Our results indicate that the stingless bee microbiome can undergo major changes in response to the environment, and that these changes can be long-lasting. Such legacy effects have not been reported for corbiculate bees. Further understanding the microbial ecology of stingless bees will aid future management of colonies used in agricultural production.

Bee Visitation and Fruit Quality in Berries Under Protected Cropping Vary Along the Length of Polytunnels

Wild and managed bees provide effective crop pollination services worldwide. Protected cropping conditions are thought to alter the ambient environmental conditions in which pollinators forage for flowers, yet few studies have compared conditions at the edges and center of growing tunnels. We measured environmental variables (temperature, relative humidity, wind speed, white light, and UV light) and surveyed activity of the managed honey bee, Apis mellifera L.; wild stingless bee, Tetragonula carbonaria Smith; and wild sweat bee, Homalictus urbanus Smith, along the length of 32 multiple open-ended polyethylene growing tunnels. These were spaced across 12 blocks at two commercial berry farms, in Coffs Harbour, New South Wales and Walkamin, North Queensland, Australia. Berry yield, fresh weight, and other quality metrics were recorded at discrete increments along the length of the tunnels. We found a higher abundance and greater number of flower visits by stingless bees and honey bees at the end of tunnels, and less frequent visits to flowers toward the middle of tunnels. The center of tunnels experienced higher temperatures and reduced wind speed. In raspberry, fruit shape was improved with greater pollinator abundance and was susceptible to higher temperatures. In blueberry, per plant yield and mean berry weight were positively associated with pollinator abundance and were lower at the center of tunnels than at the edge. Fruit quality (crumbliness) in raspberries was improved with a greater number of visits by sweat bees, who were not as susceptible to climatic conditions within tunnels. Understanding bee foraging behavior and changes to yield under protected cropping conditions is critical to inform the appropriate design of polytunnels, aid pollinator management within them, and increase economic gains in commercial berry crops.

Key drivers of financial performance of insurers in the Affordable Care Act market exchange

While most publicly-traded insurers have experienced losses and exited the Affordable Care Act individual insurance market exchange, insurers specializing in Medicaid managed care have been profitable in this market. Accessing individual market data, this study compares the financial performance of 20 state insurers owned by two publicly-traded companies that historically focused on insuring Medicaid members compared to 40 insurers owned by other publicly-traded companies. Medicaid-focused insurers incurred a significantly lower medical loss ratio of 83.3% compared to the medical loss ratio of 93.7% of other publicly-traded insurers, and they earned a significantly higher profit margin of 4.6% compared to the operating loss of 6.5% incurred by other publicly-traded insurers. This superior financial performance of Medicaid-focused insurers could be due to one or a combination of: their care management experience with the Medicaid population, other cost reducing strategies such as provider contracting, or the enrollment of a healthier than average population.

The Health of the Small-Group Insurance Market

ISSUE

There has been relatively little discussion about the small-group employer insurance market since the implementation of reforms under the Affordable Care Act. It is important to understand the condition of this market before the impact of recent regulatory changes from the Trump administration.

GOAL

To understand how the ACA’s market reforms have affected prices, enrollment, and competition in the small-group market.

METHODS

Analysis of financial data filed by small-group insurers with the federal government, along with relevant published literature.

FINDINGS AND CONCLUSIONS

Enrollment has declined in the small-group market, although this is largely a continuation of a trend in place prior to the ACA. Substantially more small-business owners and workers now have coverage than prior to the ACA because many have been able to take advantage of subsidized individual plans through the marketplaces. For those who remain in the small-group market, price increases have been similar to those in the large-group market. The ACA has not reduced the cost of small-group insurance, but has made it more accessible and comprehensive without harming the market. It will be important to continue monitoring the small-group market to ensure that recent regulatory changes do not worsen market conditions.

Financial Performance of Health Insurers: State-Run Versus Federal-Run Exchanges

Many insurers incurred financial losses in individual markets for health insurance during 2014, the first year of Affordable Care Act mandated changes. This analysis looks at key financial ratios of insurers to compare profitability in 2014 and 2013, identify factors driving financial performance, and contrast the financial performance of health insurers operating in state-run exchanges versus the federal exchange. Overall, the median loss of sampled insurers was -3.9%, no greater than their loss in 2013. Reduced administrative costs offset increases in medical losses. Insurers performed better in states with state-run exchanges than insurers in states using the federal exchange in 2014. Medical loss ratios are the underlying driver more than administrative costs in the difference in performance between states with federal versus state-run exchanges. Policy makers looking to improve the financial performance of the individual market should focus on features that differentiate the markets associated with state-run versus federal exchanges.

How Have Health Insurers Performed Financially Under the ACA' Market Rules?

ISSUE

The Affordable Care Act (ACA) transformed the market for individual health insurance, so it is not surprising that insurers' transition was not entirely smooth. Insurers, with no previous experience under these market conditions, were uncertain how to price their products. As a result, they incurred significant losses. Based on this experience, some insurers have decided to leave the ACA’s subsidized market, although others appear to be thriving.

GOALS

Examine the financial performance of health insurers selling through the ACA's marketplace exchanges in 2015--the market’s most difficult year to date.

METHOD

Analysis of financial data for 2015 reported by insurers from 48 states and D.C. to the Centers for Medicare and Medicaid Services.

FINDINGS AND CONCLUSIONS

Although health insurers were profitable across all lines of business, they suffered a 10 percent loss in 2015 on their health plans sold through the ACA's exchanges. The top quarter of the ACA exchange market was comfortably profitable, while the bottom quarter did much worse than the ACA market average. This indicates that some insurers were able to adapt to the ACA's new market rules much better than others, suggesting the ACA's new market structure is sustainable, if supported properly by administrative policy.

The Role of Courts in Shaping Health Equity

United States' courts have played a limited, yet key, role in shaping health equity in three areas of law: racial discrimination, disability discrimination, and constitutional rights. Executive and administrative action has been much more instrumental than judicial decisions in advancing racial equality in health care. Courts have been reluctant to intervene on racial justice because overt discrimination has largely disappeared, and the Supreme Court has interpreted civil rights laws in a fashion that restricts judicial authority to address more subtle or diffused forms of disparate impact. In contrast, courts have been more active in limiting disability discrimination by expanding the conditions that are considered disabling and by articulating and applying the operative concepts "reasonable accommodation" and "other qualified" in the context of both treatment and insurance coverage decisions. Finally, regarding constitutional rights, courts have had limited opportunity to intervene because, outside of specially protected arenas such as reproduction, constitutional law gives government wide discretion to define health and safety goals and methods. Thus, courts have had only a limited role in shaping health equity in the United States. It remains to be seen whether this will change under the Affordable Care Act or whatever health reform measure might replace it.

Activation of endoplasmic reticulum stress response by enhanced polyamine catabolism is important in the mediation of cisplatin-induced acute kidney injury

Cisplatin-induced nephrotoxicity limits its use in many cancer patients. The expression of enzymes involved in polyamine catabolism, spermidine/spermine N1-acetyltransferase (SSAT) and spermine oxidase (SMOX) increase in the kidneys of mice treated with cisplatin. We hypothesized that enhanced polyamine catabolism contributes to tissue damage in cisplatin acute kidney injury (AKI). Using gene knockout and chemical inhibitors, the role of polyamine catabolism in cisplatin AKI was examined. Deficiency of SSAT, SMOX or neutralization of the toxic products of polyamine degradation, H2O2 and aminopropanal, significantly diminished the severity of cisplatin AKI. In vitro studies demonstrated that the induction of SSAT and elevated polyamine catabolism in cells increases the phosphorylation of eukaryotic translation initiation factor 2α (eIF2α) and enhances the expression of binding immunoglobulin protein BiP/GRP78) and CCAAT-enhancer-binding protein homologous protein (CHOP/GADD153). The increased expression of these endoplasmic reticulum stress response (ERSR) markers was accompanied by the activation of caspase-3. These results suggest that enhanced polyamine degradation in cisplatin AKI may lead to tubular damage through the induction of ERSR and the consequent onset of apoptosis. In support of the above, we show that the ablation of the SSAT or SMOX gene, as well as the neutralization of polyamine catabolism products modulate the onset of ERSR (e.g. lower BiP and CHOP) and apoptosis (e.g. reduced activated caspase-3). These studies indicate that enhanced polyamine catabolism and its toxic products are important mediators of ERSR and critical to the pathogenesis of cisplatin AKI.

Providing Health Information to Latino Farmworkers: The Case of the Affordable Care Act

OBJECTIVE

Providing health program information to vulnerable communities, such as Latino farmworkers, is difficult. This analysis describes the manner in which farmworkers receive information about the Affordable Care Act, comparing farmworkers with other Latinos.

METHODS

Interviews were conducted with 100 Latino farmworkers and 100 urban Latino North Carolina residents in 2015.

RESULTS

Most farmworkers had received health information from a community organization. Trusted sources for health information were health care providers and community organizations. Sources that would influence decisions to enroll were Latino nurses and doctors, religious leaders, and family members. Traditional media, including oral presentation and printed material at the doctor's office, were preferred by the majority of farmworkers and non-farmworkers. Farmworkers used traditional electronic media: radio, television, and telephone. More non-farmworkers used current electronic media: e-mail and Internet.

CONCLUSIONS

Latino farmworkers and non-farmworkers prefer traditional media in the context of a health care setting. They are willing to try contemporary electronic media for this information.

The Affordable Care Act's Day(s) in Court

This article reviews the primary avenues of judicial challenge to the ACA, focusing on those that have reached, or have the potential to reach, the Supreme Court. The review demonstrates how deep-seated public policy opposition can be expressed through litigation.

Influence of thermal stimulation during the late phase of incubation on hatching results and post-hatch broiler performance under commercial conditions

Two experiments, which differed in breeder age, strain and season, were conducted to study the influence of low-intensity, short-duration thermal stimuli during the late phase of incubation on hatchability and performance. The first experiment conducted in April-June used eggs from Cobb × Ross broiler breeders at 35-41 weeks of age and the second experiment performed in February-April used eggs from Hubbard × Cobb broiler breeders at 49-53 weeks of age. Eggs in the test group had the same physical environment as eggs in the control group except that incubation temperature was increased by 1˚C for 2 h/d above the control group from 18 to 20 d of incubation (DI). The results demonstrated that thermal stimulation of 1˚C for 2 h/d above control incubation temperature during 18-21DI did not have any adverse effects on hatch and post-hatch performance of broilers. In both experiments, treatment did not significantly alter the secondary sex ratio in hatched chickens, but hatch residue showed that the proportion of unhatched male embryos was significantly lower in the test groups than in the control groups. In the first experiment, thermal stimulation improved feed conversion by 1.82% compared with the control.

How Has the Affordable Care Act Affected Health Insurers' Financial Performance?

Starting in 2014, the Affordable Care Act transformed the market for individual health insurance by changing how insurance is sold and by subsidizing coverage for millions of new purchasers. Insurers, who had no previous experience under these market conditions, competed actively but faced uncertainty in how to price their products. This issue brief uses newly available data to understand how health insurers fared financially during the ACA's first year of full reforms. Overall, health insurers' financial performance began to show some strain in 2014, but the ACA's reinsurance program substantially buffered the negative effects for most insurers. Although a quarter of insurers did substantially worse than others, experience under the new market rules could improve the accuracy of pricing decisions in subsequent years.

Promoting Value for Consumers: Comparing Individual Health Insurance Markets Inside and Outside the ACA's Exchanges

The new health insurance exchanges are the core of the Affordable Care Act's (ACA) insurance reforms, but insurance markets beyond the exchanges also are affected by the reforms. This issue brief compares the markets for individual coverage on and off of the exchanges, using insurers' most recent projections for ACA-compliant policies. In 2016, insurers expect that less than one-fifth of ACA-compliant coverage will be sold outside of the exchanges. Insurers that sell mostly through exchanges devote a greater portion of their premium dollars to medical care than do insurers selling only off of the exchanges, because exchange insurers project lower administrative costs and lower profit margins. Premium increases on exchange plans are less than those for off-exchange plans, in large part because exchange enrollment is projected to shift to closed-network plans. Finally, initial concerns that insurers might seek to segregate higher-risk subscribers on the exchanges have not been realized.

Comparing Individual Health Coverage On and Off the Affordable Care Act's Insurance Exchanges

The new health insurance exchanges are the core of the Affordable Care Act's (ACA) reforms, but how the law improves the nonsubsidized portion of the individual market is also important. This issue brief compares products sold on and off the exchanges to gain insight into how the ACA's market reforms are functioning. Initial concerns that insurers might seek to enroll lower-risk customers outside the exchanges have not been realized. Instead, more-generous benefit plans, which appeal to people with health problems, constitute a greater portion of plans sold off-exchange than those sold on-exchange. Although insur­ers that sell mostly on the exchanges incur an additional fee, they still devote a greater portion of their premium dollars to medical care. Their projected admin­istrative costs and profit margins are lower than are those of insurers selling only off the exchanges.

How Insurers Competed in the Affordable Care Act's First Year

Prior to the Affordable Care Act (ACA), most states' individual health insurance markets were dominated by one or two insurance carriers that had little incentive to compete by providing efficient services. Instead, they competed mainly by screening and selecting people based on their risk of incurring high medical costs. One of the ACA's goals is to encourage carriers to participate in the health insurance marketplaces and to shift the focus from competing based on risk selection to processes that increase consumer value, like improving efficiency of services and quality of care. Focusing on six states--Arkansas, California, Connecticut, Maryland, Montana, and Texas--this brief looks at how carriers are competing in the new marketplaces, namely through cost-sharing and composition of provider networks.

IN VITRO CHEMOTHERAPY PROFILING OF WELL-DIFFERENTIATED MIDGUT NEUROENDOCRINE TUMORS (NETS) BASED ON INDIVIDUAL PATIENT TUMOR BIOMARKERS ANALYSIS

BACKGROUND

Midgut neuroendocrine tumors (NETs) are rare malignancies with indolent clinical courses. In general, they are well-differentiated with most tumor cells in the G0 phase of the cell cycle, consistent with the poor response rate of NETs to chemotherapy in vivo. We hypothesize that insults, such as surgery, can drive NET cells from G0 into S phase and that biomarker analysis of individual patient tumors harvested and grown in the lab will provide useful practical guide for future intra and post-operative adjuvant therapy.

METHODS

97 well-differentiated midgut NET patients underwent cytoreductive surgery at our institution between May/2012 and October/2012. 148 surgical specimens were collected and submitted to a single commercial lab for processing. Primary tumors, lymph nodes and liver metastases were harvested and cultured. Their ribonucleic acids (RNA) were then extracted to analyze the expressivity, a total of 88 different biomarkers. Based on our patients' specific tumor biomarker expressivity and known correlations between 36 anti-neoplastic agents with their linked biomarkers, recommendations were reported as clinically beneficial or non-beneficial.

RESULTS

A total of 148 specimens from 97 patients were tested. In four of the 97 patients, no clinically beneficial chemotherapy agent could be identified. Among the remaining 93 patients, the top three agents that are most likely to be clinically beneficial are: fluorouracil, cisplatin and carboplatin. These were reported to be clinically beneficial in 135/148 (91.2%), 103/148 (69.6%), and 103/148 (69.6%) patients respectively.

CONCLUSIONS

Midgut NETs are slow growing tumors which are chemotherapeutically inert owing to the fact that most of the tumor cells are in G0 cell cycle. Surgical insult drives NET cells into active synthetic phase where they begin to express biomarkers specific to their tumor cells. Analysis of these biomarkers guides further potential beneficial therapy based on the current known associations among biomarkers and chemotherapy agents. These results must then be compared and confirmed against a direct in-vitro chemo sensitivity assessment conducted simultaneously on the same patients.

The impact of local immigration enforcement policies on the health of immigrant hispanics/latinos in the United States

OBJECTIVES

We sought to understand how local immigration enforcement policies affect the utilization of health services among immigrant Hispanics/Latinos in North Carolina.

METHODS

In 2012, we analyzed vital records data to determine whether local implementation of section 287(g) of the Immigration and Nationality Act and the Secure Communities program, which authorizes local law enforcement agencies to enforce federal immigration laws, affected the prenatal care utilization of Hispanics/Latinas. We also conducted 6 focus groups and 17 interviews with Hispanic/Latino persons across North Carolina to explore the impact of immigration policies on their utilization of health services.

RESULTS

We found no significant differences in utilization of prenatal care before and after implementation of section 287(g), but we did find that, in individual-level analysis, Hispanic/Latina mothers sought prenatal care later and had inadequate care when compared with non-Hispanic/Latina mothers. Participants reported profound mistrust of health services, avoiding health services, and sacrificing their health and the health of their family members.

CONCLUSIONS

Fear of immigration enforcement policies is generalized across counties. Interventions are needed to increase immigrant Hispanics/Latinos' understanding of their rights and eligibility to utilize health services. Policy-level initiatives are also needed (e.g., driver's licenses) to help undocumented persons access and utilize these services.

The federal medical loss ratio rule: implications for consumers in year 3

For the past three years, the Affordable Care Act has required health insurers to pay out a minimum percentage of premiums in medical claims or quality improvement expenses--known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2013 were $325 million, less than one-third the amount paid out in 2011, indicating much greater compliance with the MLR rule. Insurers' spending on quality improvement remained low, at less than 1 percent of premiums. Insurers' administrative and sales costs, such as brokers' fees, and profit margins have reduced slightly but remain fairly steady. In the first three years under this regulation, total consumer benefits related to the medical loss ratio--both rebates and reduced overhead--amounted to over $5 billion. This was achieved without a great exodus of insurers from the market.

What's behind health insurance rate increases? an examination of what insurers reported to the federal government in 2013-2014

The Affordable Care Act requires health insurers to justify rate increases that are 10 percent or more for nongrandfathered plans in the individual and small-group markets. Analyzing these filings for renewals taking effect from mid-2013 through mid-2014, this brief finds that the average rate increase submitted for review was 13 percent. Insurers attributed the great bulk of these larger rate increases to routine factors such as trends in medical costs. Most insurers did not attribute any portion of these medical cost trends to factors related to the Affordable Care Act. The ACA-related factors mentioned most often were nonmedical: the new federal taxes on insurers, and the fee for the transitional reinsurance program. On average, insurers that quantified any ACA impact attributed about a third of their larger rate increases to these new ACA assessments.

Obamacare: what the Affordable Care Act means for patients and physicians

The Affordable Care Act's core achievement is to make all Americans insurable, by requiring insurers to accept all applicants at rates based on population averages regardless of health status. The act also increases coverage by allowing states to expand Medicaid (the social healthcare program for families and people with low income and resources) to cover everyone near the poverty line, and by subsidizing private insurance for people who are not poor but who do not have workplace coverage. The act allows most people to keep the same kind of insurance that they currently have, and it does not change how private insurance pays physicians and hospitals. Although the act falls short of achieving truly universal coverage, nine million uninsured people have received coverage so far. Market reforms have not hurt the insurance industry's profitability, prices for individual insurance have been lower than expected, and government costs so far have been less than initially projected. The act expands several ongoing pilot programs in Medicare that reform how doctors and hospitals are paid, but it does not directly change how private insurers pay healthcare providers. Nevertheless, it has set into motion market dynamics that are affecting medical practice, such as limiting insurance networks to fewer providers and requiring patients to pay for more treatment costs out of pocket. In response, many hospitals and physicians are forming closer and larger affiliations. Further time and study are needed to learn whether these evolutionary changes will achieve their goals without harming the doctor-patient relationship.