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Latinx adults, especially immigrants, face higher uninsurance and lower awareness of the Affordable Care Act's (ACA) provisions and resources compared to other racial/ethnic groups. Television advertising of ACA health plans has directed many consumers to application assistance and enrollment, but little is known about how ads targeted Latinx consumers. We used Kantar Media/CMAG data from the Wesleyan Media Project to assess Spanish- vs. English-language ad targeting strategies and to assess which enrollment assistance resources (in person/telephone vs. online) were emphasized across three Open Enrollment Periods (OEP) (2013-14, 2014-15, 2015-16). We examined differences in advertisement sponsorship and volume of Spanish- versus English-language ads across the three OEPs. State-based Marketplaces sponsored 47% of Spanish-language airings; insurance companies sponsored 55% of English-language airings. The proportion of Spanish-language airings increased over time (8.8% in OEP1, 11.1% in OEP2, 12.0% in OEP3, p

Objectives We examined changes in health care access and utilization associated with the Patient Protection and Affordable Care Act (ACA) for different Asian American subgroups relative to non-Latino whites (whites). Research design Using 2003-2017 California Health Interview Survey data, we examined changes in 4 health care access measures and 2 utilization measures among whites and 7 Asian American subgroups. We estimated the unadjusted and adjusted percentage point changes on the absolute scale from the pre-ACA to post-ACA periods. Adjusted estimates were obtained from multivariable logistic regression models that controlled for predisposing, enabling, and need factors. We also estimated the pre-ACA to post-ACA changes between whites and Asian American subgroups using a difference-in-difference approach. Results After the ACA was implemented, uninsurance decreased among all Asian American subgroups, but improvements in disparities relative to whites in these measures were limited. In particular, Koreans had the largest absolute reduction in uninsurance (-16.8 percentage points) and were the only subgroup with a significant reduction in terms of disparities relative to whites (-10.1 percentage points). However, little or no improvement was observed in the other 3 access measures (having a usual source of care, delayed medical care in past year, or delayed prescription drug use in past year) and 2 utilization measures (having a physician visit or emergency department visit in past year). Conclusions Despite coverage gains among Asian American subgroups, especially Koreans, disparities in access and utilization persisted across all Asian American subgroups.

The burden of rising health care costs is being shifted to consumers, and 30 percent of health care costs are attributed to wasteful spending on low- or no-value services. Value-based insurance design (VBID) is intended to encourage the use of high-value services or discourage the use of low-value services by aligning cost with quality. During the summer and fall of 2016, this mixed-methods study used focus groups and a quantitative analysis of survey data to explore consumer decision making in Northern California. When presented with three common VBID approaches, the focus groups favored value-based benefit design the most (41 percent), followed by reference pricing (28 percent) and narrow networks (21 percent). When presented with VBID scenarios, participants were skeptical of the value-based trade-offs and reported seeking information they wanted instead of relying on information that health plans provide. Engaging consumers to successfully reduce waste through VBID will require clarifying trade-offs to support consumers' processes for arriving at high-value decisions as well as reaching out to consumers through trusted sources and networks.

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

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

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

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

Objectives We sought to determine the associations between maternal citizenship and health care access and utilization for US-born Latino youth and to determine whether maternal distress is a moderator of the associations. Methods Using 2010-2017 Integrated Public Use Microdata Series National Health Interview Survey data, multivariable logistic regressions were run to examine the associations among maternal citizenship and health care access and utilization for US-born Latino youth. Maternal citizenship and distress interactions were tested. Results Noncitizen mothers had higher odds of reporting uninsurance, lack of transportation for delaying care, and lower odds of health care utilization for their youth than citizen mothers. Compared with no distress, moderate and severe distress were positively associated with uninsurance, delayed medical care due to cost, lack of transportation, and having had an emergency department visit for their youth. Moderate distress was positively associated with youth having had a doctor's office visit. Noncitizen mothers with moderate distress were less likely to report their youth having had an emergency department visit than citizen mothers with moderate distress. Among severely distressed mothers, noncitizen mothers were more likely to report youth uninsurance and delayed care due to lack of transportation compared with citizen mothers. Conclusions Health care access and utilization among US-born Latino youth are influenced by maternal citizenship and distress. Maternal distress moderates the associations among maternal citizenship and youth's health care access and use. Almost one-third of all US-born youth in the United States are Latino and current federal and state noninclusive immigration policies and anti-Latino immigrant rhetoric may exacerbate health care disparities.

Key Points Question Was the Patient Protection and Affordable Care Act Medicaid expansion associated with an increase in health insurance coverage among persons with a disability? Findings In this cross-sectional analysis of more than 2.5 million US adults aged 26 to 64 years with incomes up to 138% of the federal poverty level, Medicaid expansion was significantly associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. Meaning These findings suggest that Medicaid expansion was associated with improved health insurance coverage among persons with a disability., This cross-sectional analysis of data from more than 2.5 million Medicaid-eligible US adults in states that enacted and did not enact Medicaid expansion under the Patient Protection and Affordable Care Act evaluates the association of Medicaid expansion with health insurance coverage among persons with a disability., Importance Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability. Objective To determine the association of Medicaid expansion with health insurance coverage among persons with a disability. Design, Setting, and Participants Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019. Main Outcomes and Measures Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties). Results Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA’s Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% − 16.2% = −9.1%) and without a disability (21.2% − 34.9% = −13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference–estimated Medicaid coverage was −4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P

Limited provider participation within Medicaid and narrow provider networks on health insurance Marketplaces pose potential barriers to accessing and using the health care system for people with behavioral health needs. We compared employer-sponsored insurance, Medicaid, and Marketplace coverage for people with psychological distress across three domains of health care: access, utilization, and financial strain. We found evidence that adults with psychological distress reported greater difficulty accessing health care relative to those without such distress, regardless of insurance source. Among adults with psychological distress, Medicaid enrollees were more likely to use care and less likely to experience health-related financial strain than those enrolled in employer-sponsored insurance were. However, people with Marketplace coverage were more likely to experience barriers across all domains, relative to people with the other two coverage sources. Policy makers should be cognizant of the participation of providers within Medicaid and the Marketplaces and work to make network breadth more transparent.

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

Objective: We examined changes in insurance coverage and health care utilization associated with the Affordable Care Act (ACA) among subgroups of Asian youth relative to non-Latino white youth. Methods: Data were from the 2010-2017 American Community Survey and National Health Interview Survey. Difference-in-difference models were used to examine changes in insurance coverage and health care utilization associated with the ACA among subgroups of Asian youth relative to white youth and subgroups of Asian youth in households below 200% of the federal poverty level (FPL) relative to comparable white youth. Results: Since the implementation of the ACA, insurance coverage increased among all Asian subgroups and white youth. The magnitude of the increase in insurance coverage was larger among Asian subgroups than white youth. More pronounced increases were found among almost all Asian subgroups in households below 200% FPL. Changes in health care utilization were limited and varied by subgroup. Increases in well-child visits were observed only among Chinese and “other” Asian youth. Conclusions: Insurance coverage increased among Asian youth after the implementation of the ACA. Improvements in health care utilization were limited and differed by subgroups. Programs to improve health care utilization should be tailored to Asian youth according to subgroup.

Television advertising has been a primary method for marketing new health plans available under the Affordable Care Act (ACA) to consumers. Data from Kantar Media's Campaign Media Analysis Group were used to analyze advertising content during three ACA open enrollment periods (fall 2013 to spring 2016). Few advertisement airings featured people who were elderly, disabled, or receiving care in a medical setting, and over time airings increasingly featured children, young adults, and people exercising. The most common informational messages focused on plan choice and availability of low-cost plans, but messages shifted over open enrollment cycles to emphasize avoidance of tax penalties and availability of financial assistance. Over the three open enrollment periods, there was a sharp decline in explicit mentions of the ACA or Obamacare in advertisements. Overall, television advertisements have increasingly targeted young, healthy consumers, and informational appeals have shifted toward a focus on financial factors in persuading individuals to enroll in marketplace plans. These advertising approaches make sense in the context of pressures to market plans to appeal to a sufficiently large, diverse group. Importantly, dramatic declines over time in explicit mention of the law mean that citizens may fail to understand the connection between the actions of government and the benefits they are receiving.

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

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

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

Objectives. We examined reports of insurance-based discrimination and its association with insurance type and access to care in the early years of the Patient Protection and Affordable Care Act. Methods. We used data from the 2013 Minnesota Health Access Survey to identify 4123 Minnesota adults aged 18 to 64 years who reported about their experiences of insurance-based discrimination. We modeled the association between discrimination and insurance type and predicted odds of having reduced access to care among those reporting discrimination, controlling for sociodemographic factors. Data were weighted to represent the state’s population. Results. Reports of insurance-based discrimination were higher among uninsured (25%) and publicly insured (21%) adults than among privately insured adults (3%), which held in the regression analysis. Those reporting discrimination had higher odds of lacking a usual source of care, lacking confidence in getting care, forgoing care because of cost, and experiencing provider-level barriers than those who did not. Conclusions. Further research and policy interventions are needed to address insurance-based discrimination in health care settings.

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

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

Objectives Tuberculosis (TB) is a significant public health issue, claiming 1.4 million lives worldwide in 2011. Using data from the 2009-2010 National Health Interview Survey, we examine variation in 'having heard of TB' (HTB) by global region of birth and health insurance status. Methods Cross-sectional analysis with bivariate comparisons and multivariate logistic regression to evaluate how adults differed in reported HTB, controlling for global region of birth. Results HTB rates ranged from 63.4% of adults born in Asia to 88.6% born in Europe. Uninsured immigrants had the lowest rate of HTB, ranging from a low of 50.1% of uninsured adults born in Asia to 77.6% born in Europe and 90.8% of US-born uninsured adults. Longer length of time in the United States (>5 years) was significantly associated with increased likelihood of HTB, as did being of Asian race/ethnicity and being male. Those with private health insurance coverage had the highest rates of HTB. Conclusions To reduce persistent TB, public health program directors and policy makers must 1) recognize the variation in HTB by global region of birth and prioritize areas with the lowest HTB rates, and 2) reduce barriers to health insurance coverage by eliminating the 5-year ban for public program coverage for new immigrants.

Fewer than half of all U.S. states provide dental care for non-elderly adult Medicaid enrollees. Although the Affordable Care Act (ACA) expands Medicaid eligibility for adults, states are not required to offer dental care to adults. We project the effect of the ACA on patient-identified barriers to dental care based on a framework developed using data from a 2008 survey of Minnesota Medicaid enrollees with and without an annual dental visit. The rate of annual visits (55%) was below that of all Minnesotans (79%) with 40% reporting difficulties accessing services. We found no racial/ethnic disparities in annual dental visits among adult Medicaid enrollees. Adult Medicaid recipients with no annual visit reported individual (51%), provider (27%), and system-level (22%) barriers. Hmong, Somali, and American Indian adults were more likely than others to report barriers to receiving dental care. We project that the ACA will not reduce barriers to dental care for adult Medicaid enrollees.

Limited English proficiency (LEP) is a common barrier that negatively affects access to health care and quality of care. Prior studies have examined interpreter services as a means of ameliorating LEP, but have focused on Spanish-language services, largely overlooking comparisons with other, less-established ethnic groups. Furthermore, few if any studies have assessed the quality of interpreter services provided. Data come from 2,489 Hispanic/Latino, Hmong, and Somali enrollees of public health insurance programs in Minnesota. We employ weighted, regression-adjusted comparisons of enrollee-reported need and availability of interpreters, access to professional and consistent interpreters, and problems with quality of interpreter-assisted communication. Compared with Latinos, Hmong and Somali enrollees reported greater needs and more communication problems, Somali enrollees reported lower availability, and Hmong enrollees reported lower access to professional interpreters. Further training of interpreters for relatively less-established ethnic groups is needed to increase availability of professional, high-quality communication among publicly insured ethnic minorities.

The authors examined the feasibility and preliminary outcomes of Project Wings Girls’ Groups, a school-based mental health promotion program designed to improve well-being in Latina adolescents, as observed in outcomes, including perceived stress, depressive symptoms, coping, and connectedness. This pilot randomized controlled trial compared outcomes over 9 months postintervention for 42 9th and 10th grade adolescents attending two urban high schools. Girls were randomized to Project Wings Girls’ Groups, a 16-session facilitated curriculum, including sharing circles, mind–body exercises, and coping skills building or the attention control (i.e., similar format but focused on general health topics). Feasibility of retention and long-term follow-up data collection was demonstrated, with lessons learned for future study. Although not statistically powered, this trial demonstrated findings in the expected direction, including reduced perceived stress and depression and increased connectedness. A trial with sufficient power is warranted to examine Project Wings’ effects on mental health problems among Latina adolescents.

CONTEXT An evaluation of the Minnesota Community Application Agent (MNCAA) Program was conducted for the MN Minnesota Department of Human Services and funded by the Health Resources and Services Administration's State Health Access Program grant. OBJECTIVE The MNCAA evaluation assessed effectiveness in reaching disparate populations, explored overall program value, and sought lessons applicable to the Navigator programs required under the Affordable Care Act. DESIGN Mixed-methods approach using quantitative analysis of tracking and payment data and interviews with key informants to elicit "lessons learned" about the MNCAA program. SETTING The MNCAA program offers incentive payments and technical assistance to community partner organizations that assist individuals in applying for public health care coverage. PARTICIPANTS A total of 140 unique community organizations participated in the MNCAA program in 2008 to 2012. Outreach staff and directors from participating MNCAAs and state/local government officials were interviewed. MAIN OUTCOME MEASURE(S) The article highlights a strategy for targeting outreach to individuals eligible for Medicaid coverage or subsidies under the Affordable Care Act by presenting evaluation findings from a unique outreach program to increase access to care for vulnerable populations in Minnesota. RESULTS Almost two-thirds of applicants were successfully enrolled but lengthy waiting periods persisted. Seventy percent of applications came from health care organizations. Only 13% of applicants assisted by MNCAAs were new to public health care programs. Most MNCAAs believed that the incentive payment-$25 per successful enrollee-was insufficient. CONCLUSIONS Significant expertise in enrolling individuals in public health care programs exists within a core group of community organizations. Incentives to leverage the capacity of community organizations must be accompanied by recruiting and training. Outreach providers and navigators also need timely access to client information. More investment in financial incentives will be required.

Purpose – To synthesize the literature on coping among adolescents of color in the U.S., we examine normative and circumstantial stressors, describe coping strategies, and summarize the literature on coping for the promotion of well-being among adolescents of color, including descriptive and intervention studies. Methods/approach – We conducted an extensive review of the literature in four scientific databases (medline, CINAHL, ERIC, and PyschInfo) between July 2010 and June 2011 (key words: (minority) adolescent(s) (of color), cope/coping, stress (ors), and adaptation/psychological). Studies included in our review were peer-reviewed articles published between 2000 and June 2011 that presented original data on the coping strategies and outcomes of adolescents of color (e.g., studies including a majority from underrepresented racial/ethnic communities) between the ages of 12 and 18. Findings – We identified a total of 91 articles for inclusion, including 83 descriptive and 8 intervention studies. We use a matrix approach to compare descriptive studies by their purpose, study design, sample, targeted stressors, and outcomes. We then discuss the eight interventions we identified, highlighting the targeted population, intervention protocol/adaptation, feasibility/acceptability, and study outcomes. Implications – The breadth and depth of research on coping among adolescents of color has improved significantly over the past decade, yet our review reveals several areas where further exploration is needed, including research on intra-group differences, validation of coping measures in diverse groups, measurement of the effectiveness of coping strategies over time, and most importantly, the translation of available knowledge on effective coping into culturally relevant, multifaceted interventions for adolescents and their families.

Latino girls (Latinas) experience disproportionate rates of emotional distress, including suicidal ideation, which may be indicative of inadequate coping abilities. Prevention of mental health problems, a U.S. public health priority, is particularly critical for Latina adolescents due to lack of access to mental health treatments. The purpose of this study was to examine the feasibility of Project Wings, a 14-session stress management/coping intervention. Latinas in school (ages 15−21) met weekly for 2-hr with two bilingual experienced facilitators to participate in sharing circles, relaxation exercise, and skill building. Intervention participation and post-intervention focus group data were analyzed. Fall semester intervention ( n = 10) occurred during school (72% attendance rate); spring semester intervention ( n = 11) was after school (84% attendance rate). Focus group data confirmed acceptability. Latina adolescents will participate in a school-based, group-based stress management/coping intervention. The findings offer insights about intervention recruitment and retention that are specifically relevant to school nurses. Future research includes intervention testing using a randomized study design.