Héctor E. Alcalá

Impact of the Affordable Care Act on Health Care Access and Utilization Among Latinos

Introduction: In the United States, Latinos have poorer access to and utilization of health care than non-Latino whites. The Patient Protection and Affordable Care Act (ACA) may reduce these disparities. The ACAs impact among Latino subgroups is unknown. Methods: Using the 2011 to 2015 National Health Interview Survey, we examined access to and utilization of health care by Latino subgroups (18–64 years old). Subgroups were defined by Latino heritage group, citizenship status, and language use. Measures of access and utilization included insurance status, delaying medical care, forgoing medical care, visiting the emergency department, and visiting a physician. Logistic regression models were used to estimate the odds of the outcomes. Time period and subgroup interaction terms were used to test the effects of the ACA. Results: Mexicans and Central Americans had lower odds of being insured than did non-Latino whites. After ACA implementation, most reductions in disparities occurred between Puerto Ricans and non-Latino whites. Limited impact of the ACA was observed by language and citizenship status. Conclusions: The ACA has reduced gaps in access to and utilization of health care for some Latino population subgroups. Remaining disparities necessitate policy solutions that move beyond the ACA, particularly for groups excluded from coverage options, such as noncitizens.

Adverse Childhood Experiences and Use of Cigarettes and Smokeless Tobacco Products.

Adverse childhood experiences (ACEs) have been linked to increased use of tobacco productsxa0later in life. However, studies to datexa0have ignored smokeless tobacco products. To address this, data from the 2011 Behavioral Risk Factor Surveillance System, which interviewed adults 18xa0years and over (Nxa0=xa0102,716) were analyzed. Logistic regression models were fit to estimate odds ratiosxa0of ever smoking, current smoking and current smokeless tobacco use in relation to ACEs. Results showed that less than 4xa0% of respondents currently used smokeless tobacco products, while 44.95 and 18.57xa0% reported ever and current smoking, respectively. Physical abuse (OR 1.40; 95xa0% CI 1.14, 1.72), emotional abuse (OR 1.41; 95xa0% CI 1.19, 1.67), sexual abuse (OR 0.70; 95xa0% CI 0.51, 0.95), living with a drug user (OR 1.50; 95xa0% CI 1.17, 1.93), living with someone who was jailed (OR 1.50; 95xa0% CI 1.11, 2.02) and having parents who were separated or divorced (OR 1.31; 95xa0% CI 1.09, 1.57) were associated with smokeless tobacco use in unadjusted models. After accounting for confounders, physical abuse (OR 1.43; 95xa0% CI 1.16, 1.78), emotional abuse (OR 1.32; 95xa0% CI 1.10, 1.57), living with a problem drinker (OR 1.30; 95xa0% CI 1.08, 1.58), living with a drug user (OR 1.31; 95xa0% CI 1.00, 1.72) and living with adults who treated each other violently (OR 1.30; 95xa0% CI 1.05, 1.62) were associated with smokeless tobacco use. Living with someone who was mentally ill (OR 0.70; 95xa0% CI 0.53, 0.92) was associated with smokeless tobacco use after accounting for confounders and all ACEs. Results indicated that some childhood adversities are associated with use of smokeless tobacco products. Special attention is needed to prevent tobacco usexa0of different types among those experiencing ACEs.

Cancer Disparities in Rural Appalachia: Incidence, Early Detection, and Survivorship

PURPOSEnTo document cancer-related health disparities in Appalachia.nnnMETHODSnThe current study investigated disparities in cancer incidence, mortality, and staging between rural Appalachians and those living outside of rural Appalachia. To accomplish this, mortality data for the United States from 1969 to 2011 were obtained from the National Center for Health Statistics (NCHS) using SEER* Stat. These data were used to compare trends in mortality between rural Appalachians, urban Appalachians, rural non-Appalachians, and urban non-Appalachians. Cancer incidence trends, staging, and survivorship data were compared across regions using the SEER-18 Program, which represented 28% of the US population and includes 2 Appalachian states: Georgia and Kentucky.nnnRESULTSnCancer mortality rates declined in all regions, but disparities remained such that rural Appalachia has the highest incidence, while urban non-Appalachia has the lowest. In all but 1 state, rural Appalachians had higher cancer mortality rates than urban non-Appalachians. Cancer incidence declined for all regions except rural Appalachia. Rural Appalachians had lower rates of early stage breast cancer diagnoses than their urban non-Appalachian counterparts. Finally, rural Appalachians had lower 3- and 5-year survival rates than their urban non-Appalachian counterparts.nnnCONCLUSIONSnRural Appalachians are faced with poorer cancer-related health outcomes across the continuum of cancer care. A systematic effort is needed to reduce the burden of cancer for rural Appalachia. Additional research should explore reasons for the disparities that were observed.

Adverse Childhood Experiences and Cervical Cancer Screening

BACKGROUNDnAdverse childhood experiences (ACEs) have been associated with an increased risk of a variety of diseases, including cancer. However, research has largely ignored how ACEs impact cancer screening, a potential intermediate outcome. As such, the present study examined the association between ACEs and ever and recent use of Papanicolaou (Pap) test, among women aged 21 and older.nnnMATERIALS AND METHODSnAnalyses used the 2009 Tennessee Behavioral Risk Factor Surveillance System (nu2009=u20091527) to model odds of ever and recently (within the last 3 years) engaging in Pap tests screening from nine different adversities. Bivariate and multivariate logistic regression models were run to accomplish this.nnnRESULTSnIn bivariate and multivariate models, living in a household in which adults treated each other violently increased odds of ever receiving a Pap test. In bivariate models, physical and sexual abuse was associated with decreased odds of receiving a recent Pap test. After accounting for confounders, only the latter association remained significant.nnnCONCLUSIONSnResults highlight a potential mechanism by which early childhood experiences can impact the development of cervical cancer. Providers of care should consider modifications to their screening practices, including screening for child abuse, to better serve all women.

E-cigarette use and disparities by race, citizenship status and language among adolescents.

INTRODUCTIONnE-cigarette use among adolescents is on the rise in the U.S. However, limited attention has been given to examining the role of race, citizenship status and language spoken at home in shaping e-cigarette use behavior.nnnMETHODSnData are from the 2014 Adolescent California Health Interview Survey, which interviewed 1052 adolescents ages 12-17. Lifetime e-cigarette use was examined by sociodemographic characteristics. Separate logistic regression models predicted odds of ever-smoking e-cigarettes from race, citizenship status and language spoken at home. Sociodemographic characteristics were then added to these models as control variables and a model with all three predictors and controls was run. Similar models were run with conventional smoking as an outcome.nnnRESULTSn10.3% of adolescents ever used e-cigarettes. E-cigarette use was higher among ever-smokers of conventional cigarettes, individuals above 200% of the Federal Poverty Level, US citizens and those who spoke English-only at home. Multivariate analyses demonstrated that citizenship status and language spoken at home were associated with lifetime e-cigarette use, after accounting for control variables. Only citizenship status was associated with e-cigarette use, when controls variables race and language spoken at home were all in the same model.nnnCONCLUSIONSnEver use of e-cigarettes in this study was higher than previously reported national estimates. Action is needed to curb the use of e-cigarettes among adolescents. Differences in lifetime e-cigarette use by citizenship status and language spoken at home suggest that less acculturated individuals use e-cigarettes at lower rates.

Deconstructing family meals: Do family structure, gender and employment status influence the odds of having a family meal?

OBJECTIVESnWe assessed the odds of having a family dinner by parental gender, family structure and parental employment.nnnMETHODSnThis study used data from the American Time Use Survey (ATUS) (2006-2008). Multivariate analyses assessed the odds of two outcomes among parents: 1) eating at all with children and 2) having a family dinner.nnnRESULTSnSingle men had lower odds of eating at all with children and eating a family dinner in comparison to partnered/married males. Partnered/married women had increased odds of eating at all with children and eating a family dinner compared to their partnered/married male counterparts. While single women had increased odds of eating at all with children compared to partnered/married males, no difference was detected in the odds of having a family dinner. Among dual-headed households, women had lower odds of eating a family dinner when both parents were employed compared a dual-headed household with employed male/non-employed female. There were no differences among men regardless of their employment status or that of their partner/spouse.nnnCONCLUSIONSnFamily structure, parental gender and employment status all influence the odds of having a family dinner. Future research on family meals should consider all of these factors to better understand trends and disparities across household compositions.

Social cohesion and the smoking behaviors of adults living with children

INTRODUCTIONnThe smoking behavior of adults can negatively impact children through exposure to environmental tobacco smoke and by modeling this unhealthy behavior. Little research has examined the role of the social environment in smoking behaviors of adults living with children. The present study specifically analyzed the relationship between social cohesion and smoking behaviors of adults living with children.nnnMETHODSnData from the 2009 California Health Interview Survey, a random-digit dial cross-sectional survey of California Adults, were used. Adults living with children reported their levels of social cohesion and smoking behaviors (N=13,978). Logistic regression models were used to predict odds of being a current smoker or living in a household in which smoking was allowed, from social cohesion.nnnRESULTSnOverall, 13% of the sample was current smokers and 3.74% lived in households in which smoking was allowed. Logistic regression models showed that each one-unit increase in social cohesion is associated with reduced odds of being a current smoker (AOR=0.92; 95% CI=0.85-0.99) and reduced odds of living in a household in which smoking is allowed (AOR=0.84; 95% CI=0.75-0.93), after controlling for sociodemographic characteristics.nnnCONCLUSIONSnAmong adults living with children, higher social cohesion is associated with a lower likelihood of both being and smoker and living in a home where smoking is allowed. Thus, future research is needed to better understand mechanisms that explain the relationship between social cohesion and smoking-related behavior in order to prevent smoking-related health consequences and smoking initiation among children and adults.

Access to Care and Cardiovascular Disease Prevention: A Cross-Sectional Study in 2 Latino Communities.

AbstractCardiovascular disease (CVD) is the leading killer of Americans. CVD is understudied among Latinos, who have high levels of CVD risk factors. This study aimed to determine whether access to health care (ie, insurance status and having a usual source of care) is associated with 4 CVD prevention factors (ie, health care utilization, CVD screening, information received from health care providers, and lifestyle factors) among Latino adults and to evaluate whether the associations depended on CVD clinical risk/disease.Data were collected as part of a community-engaged food environment intervention study in East Los Angeles and Boyle Heights, CA. Logistic regressions were fitted with insurance status and usual source of care as predictors of the 4 CVD prevention factors while controlling for demographics. Analyses were repeated with interactions between self-reported CVD clinical risk/disease and access to care measures.Access to health care significantly increased the odds of CVD prevention. Having a usual source of care was associated with all factors of prevention, whereas being insured was only associated with some factors of prevention. CVD clinical risk/disease did not moderate any associations.Although efforts to reduce CVD risk among Latinos through the Affordable Care Act could be impactful, they might have limited impact in curbing CVD among Latinos, via the laws expansion of insurance coverage. CVD prevention efforts must expand beyond the provision of insurance to effectively lower CVD rates.

Differential mental health impact of cancer across racial/ethnic groups: findings from a population-based study in California

BackgroundLittle research has examined the interactive effect of cancer status and race/ethnicity on mental health. As such, the present study examined the mental health of adults, 18 and over, diagnosed with cancer. This study examined the extent to which a cancer diagnosis is related to poorer mental health because it erodes finances and the extent to which the mental health impact of cancer differs across racial/ethnic groups. Furthermore, this study aimed to test the stress process model, which posits that the proliferation of stress can lead to mental illness and this process can differ across racial/ethnic groups.MethodsData from the 2005 Adult California Health Interview Survey was used (Nu2009=u200942,879). The Kessler 6, a validated measure of psychological distress, was used to measure mental health, with higher scores suggesting poorer mental health. Scores on the Kessler 6 ranged from 0 to 24. Linear regression models estimating psychological distress tested each aim. The mediating effect of income and the race by cancer interaction were tested.ResultsAfter controlling for gender, age, insurance status, education and race/ethnicity, cancer was associated with higher Kessler 6 scores. About 6% of this effect was mediated by household income (tu2009=u20094.547; SEu2009=u20090.011; pu2009<u20090.001). The mental health impact of cancer was significantly worse for Latinos and Blacks than for non-Hispanic Whites.ConclusionsThe mental health impact of cancer is not uniform across groups. Future work should explore reasons for these disparities. Efforts to increase access to mental health services among minorities with cancer are needed.

Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act

Background: Millions of adults have gained insurance through the Affordable Care Act (ACA). However, disparities in access to care persist. Objective: This study examined differences in access to primary and specialty care among patients insured by private individual market insurance plans (both on-exchange and off-exchange) and Medicaid compared with those with employer-sponsored insurance. Research Design: Using data from the 2014 and 2015 California Health Interview Survey, logistic regression analyses were used to calculate the odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor’s appointment in a timely manner, with insurance type serving as the independent variable. Interaction terms examined if the expiration of the ACA’s optional Medicaid primary care fee increase in 2014 modified any of these associations. Results: Findings showed poorer access to providers among those insured through Medicaid and the individual market (whether purchased through the state’s health insurance exchange or off-exchange) relative to employer-based insurance. Poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. In addition, findings showed that reduction of Medicaid fees coincided with reduced ability to see primary care providers. However, a similar trend was seen among those with employer-based coverage, which suggests that this change may not be attributable to reductions in Medicaid fees. Conclusion: Despite ACA-related gains in insurance coverage, those with on-exchange and off-exchange individual private insurance plans and Medicaid encounter more barriers to care than those with employer-based insurance.