How Insurance Works

Population Health Challenges for Latinos in the U.S.


[Alex Ortega] So, um, thank you.
Uh, Dr. Godwin, Hillary, my, my friend and colleague
for many years. Um, and one of the things
she mentioned in the, in my introduction is
about the way I, the, the, the language I use in
my articles. And, um, I think as health equity
researchers and advocates, it’s very important that we move away
from what sometimes the very bland language and research and, um, call out inequities when we observe them. And I tried to do that in my titles of
my manuscripts in the way I write up my manuscripts. Cause I think if you want
your work to have action, if they, if you want them to be able
to translate to action, I think you have to frame them in an
activist framework and use activist language. So that’s one of
the reasons why I do that. And I just started actually, I’ve
been doing it my entire career. I just started doing it
maybe about 10 years ago. Um, but before we start, um,
I wanna ask you guys, um, where are you from? So where are
you guys from? And not, don’t just say, you know, the University of
Washington, but where are you from? Where are you from? Yup.
Okay. You’re from Guadalajara. Alright. Hillary, where are you from? [Hilary Godwin] Oh, complicated. But I’m born in Michigan
and grew up in Southern Cal. Okay. So you’re from the Midwest.
Jeff, where are you from? Okay. Texas. Anybody else? Where are
you guys from? Where are you from? [inaudible] in the Philippines. You know,
so when I was, my dad, uh, was in the military and when I
was two weeks old, I was, um, they moved to the Philippines to a
station that, an air force base there. And I was, I, when I worked at UCLA, I had a staff that was mostly Filipino
and I used to tell them, you know, I was eating loopy a long before I was
eating burritos and they would always laugh and think I was
stupid. Um, no, but my, so my family’s from a little
town called Las Vegas, New Mexico. They like to say
they’re the first Las Vegas. Um, it’s a little mountain town
in Northern New Mexico. Uh, it’s probably, you know,
it’s 77% Latino. Uh, 52% speak Spanish. Um, about 20% have a, at least a
bachelor’s degree, a bachelor’s degree, uh, high rates of obese
and overweight. Uh, for only about 48% report
having a healthy diet, 90% report, drinking alcohol, um,
on somewhat of a regular basis. It’s a very high rate. There’s,
of course among adults, and the average household
income is about $34,000 a year. And so people, sometimes I get
asked, you know, why, what, why do you do health disparities research
and why are you focused on Latinos? And a lot of it comes from
just my, my family background. So my grandmother had 16, um, but eight of them died in
infancy. Uh, I have, you know, also in this town, there’s just no, this
town is riped with health disparities. Um, they have a lot of, uh,
substance and drug abuse. Um, and I have two uncles
who died of overdose. So I come from a family with a lot of
health disparities, a lot of diabetes, all of that cardiovascular disease.
Both my grandparents died of strokes. So it’s something that
I’m very familiar with. Now I’m going to put this,
I’m not going to walk around. I’m just going to put this
here for now. Alright, so you guys in this audio,
you, you all, you know, sounds like you guys are all health
professionals, nursing, public health, social, social work students. Um,
can, you probably have heard this, that the Latino population is dramatically
shifting, right? It’s growing. Um, so you can see just from 1970,
which was around when I was born, uh, you only had about, um, 9.6 million Latinos in the United States. Most of them were concentrated
in the West and Southwest. And now in 2018 with the latest
census, it’s closer to 60, 60. I’m sorry. Um, and by the way, feel free to stop me at any time. Um, so I’m gonna start off with just some
demographic stuff and then I’m going to get into some of my research, but feel free to stop me because
happy to clarify, happy to, to, to elaborate, happy
to go off on tangents. I’m happy to do all of that stuff. So,
um, when you look, when you look at, um, Latinos compared to other demographics
in the U in the United States, um, it’s a, it’s a, it’s a growing
population. So right now, um, Latinos make up about 18% of the U S
population and it’s expected by 20, 65, but that number will
go up to close to 25%. Um, and also, I think, yeah, no in
emerging population or Asians, Asian Americans in the us, but, um, Latinos now comprise or compose the
largest group of racial or ethnic minorities. And you know, you, we’ve hear a lot in the
literature now about, um, especially since the 2016 election, a lot about undocumented immigration. And the reality is that long before, uh, Donald Trump, I’m sorry to call him
out by name, but I’m not employed here. So I think I can do that. Um, well, you
know, um, came into office, you know, the, the, the, the number of undocumented immigrants
into the U S has been declining. And interestingly, uh, the average, the average stay in the United States for
undocumented immigrants is now around. It’s more than, so it’s
more than 10 years. So, um, 66% of unauthorized immigrants, uh, have been in the U S for more than 10
years. So this notion that, you know, that, um, that the undocumented, it’s
a recent phenomenon that they’re, you know, that they’re low acculturated and
all of that is somewhat outdated. In fact, I have a paper out of view
right now, um, that has shown that, uh, the undaunted,
you’re actually not, uh, have patterns of life duration and health
like you see with recent immigrants that they actually [inaudible] the, the, the average undocumented Latino
immigrants has helped behaviors. It’s very similar to Americans.
And, um, so the, I, you know, and they, and they, so this,
this, this notion that, um, you know, the notion of the healthy immigrant
effect for undocumented immigrants doesn’t really hold, although it does
for some women on some behaviors. And then the other thing I wanted to show
you here is that the immigration from Mexico has also decreased, which isn’t so surprising this now these
data do up to 2016 and if I had data that actually spread out to 2019, the
numbers would still be declining. Um, but, um, immigration from Latin America
has mainly been coming from other, other places than Mexico, where
early on it was mainly from Mexico. Now this is the [inaudible] of,
um, the population that was Latino. I’m Hispanic in 1980,
so a lot too long ago. I know some of you might
have been born back then, but this is what it looks
like. So I don’t know, concentrations of Latinos in
the West and the Southwest, which isn’t so surprising
because that used to be Mexico. Right? Um, in fact, you
know, people, so I’m, I showed you earlier that I was from
New Mexico that was once part of Mexico. Um, and people oftentimes ask me when my
family immigrated to the United States, and I always tell them, well, we didn’t
immigrate. You know, we were there. We were, or we recolonized,
um, after the Mexican war. And, uh, you can also see New Mexico, which is that really dark
blue area right there. Um, high proportions of, uh, of Latinos. Yes, go back 300 years. Now in 2014, the demography
has changed a bit. And so now you starting to
see Latino, it’s an areas, uh, where there were no Latinos in, you
know, 30 years ago, 40 years ago, and particularly in the
Northeast, um, in the, in the South there. But you also see Latinos growing up
in areas like Nebraska. You know, and I actually gave a talk a few months
ago in Lincoln and I was showing some similar and I said, and even in Nebraska,
you guys have Latinos, you know, and they were laughing about it. Um, so, but what, but one of the things is
that, you know, and also Washington, you know, Washington state up there,
you know, so now you have, I’ll go back. This is what it looked
like in 1980, 40 years ago. This is what it looks like now. So certainly seeing a lot more
Latinos in the United States now in terms of the heritage
groups. So Mexicans, not surprisingly because of the us
history make up the largest proportion of Latinos, all that, that that
is somewhat shifting, um, followed by Puerto Ricans. Um, and I do not believe the Pew data include
the 3.5 million Puerto Ricans who live on the Island. So this is just
Puerto Ricans on the mainland. Um, so if you include Puerto Ricans on
the Island who were also us citizens, that that percentage would be a bit
higher, um, followed by Cubans and um, Salvadorans. And then, you know, the notion that, uh, Latinos are all Spanish speaking
or that Spanish is the, the, the, the common factor that defines culture
or heritage for Latinos is quickly changing. And just as an anecdote,
so you know, I grew up at, you know, from New Mexico, but military
brat lived in the Philippines, lived in other places and my family,
my parents both spoke Spanish. My mother speaks Spanglish.
Really. My dad speaks Spanish. Um, but he can speak it, he
can’t write it, um, both there, but their parents were fluent and then
mostly in speaking but not writing. And then their parents were both
fluent and speaking and writing. So my family has served, certainly
acculturated over generations. Um, but this [inaudible] and so when I
was on the West coast, you know, this, which is, that’s a very common story
among Latinos on the West coast, especially in California and the Southwest
where many people my age and younger don’t speak Spanish well. And in 1992 I moved to
Pennsylvania for the first time. It was the first time I’d ever been
East of New Mexico and I lived in Philadelphia where I live now. Actually.
I had lived there around the nineties, moved away, and then
now I’m back again. Um, but it was striking to me that people
would challenge my Latino ethnicity. So I would tell you, people say, well,
where are you from? Because I did, I looked different, but they couldn’t
really placement. And they had a lot of, some people thought I was Italian,
but they really couldn’t. Maybe, maybe you’re Puerto Rican. I can’t
really figure it out. And um, I would tell them I’m
Latino, I’m Mexican heritage. And they would immediately say, no,
you’re not. You don’t speak Spanish. You don’t have an accent. And
it was very like, you know, for me it was kind of traumatic
because, you know, it’s like, why would you not think and why
do I have to defend my ethnicity? But that was just what they were used to. In terms of the emerging Latino
population in the Northeast at the time, most, most people were coming into to
the region were immigrants or they were, um, migrating from Puerto Rico and
Spanish was the primary language for most Latinos. It’s now changed
since I’ve moved back. It’s much more Latino than it had been. And there are a lot of
English speaking Latinos in, in Philadelphia and in Pennsylvania,
but you can also see that the, that Latinos in the in the U S are are
quickly acculturating at least in terms of language proficiency
speaking language at home. Um, so now I just wanna so
I’m going to get some, that’s just a little bit of background
and now I want to get a little bit into my work. Um, so before we get into, I’m going to talk mostly about
healthcare reform and population health, but I just wanted to give a little shout
out to a grant. I recently got from uh, NIH to study psychiatric and substance
use disorders post hurricane Maria in Puerto Rico. I’ve been doing work
in Puerto Rico for 21 years now. Um, and we have a cohort of about 3,300
Puerto Ricans who we surveyed. It’s a ha, it’s a probability sample,
household sampling, all that good stuff. Um, uh, Island wide of, um, that we surveyed about a year before
hurricane Maria hit the Island. And we just so happened to have
surveyed them on all their S on all the psychiatric and substance
use disorders in, um, in the disk. And, um, and now
so then the hurricane hit, which provided a unique opportunity to
look at the longitudinal development and exacerbation of psychiatric
disorders after a hurricane, after a major hurricane like Maria, which really doesn’t exist in the
literature. I mean, most of the, most of the post-disaster work that’s
been done has been after you know, post-disaster and then people
are asked to recall, um, their experiences or their psychopathology
before the hurricane. And as we know, there’s something in psychiatry called
telescoping, which is, you know, when you ask people after an event to
recall things before the event, before, before disaster, they will, they will attribute symptoms
to the event because that’s, that’s what they’re thinking about. And so that creates a lot of bias and
determining psychiatric disorders post post event. And we’re looking at
things like, um, resilience, uh, so those who didn’t have
psychiatric disorders before
the hurricane and continue not to have psychiatric
disorders after. Um, and then how they differ from those who
had psychiatric disorders and continued and those who didn’t. And then did.
And then we’re also asking, um, in addition to a bunch of other questions, we’re asking about the governmental
response and how the lack of, uh, the poor governmental response to
the event to the hurricane impacted psychopathology on the Island as well
as their experiences to the hurricane. So I think there’ll be some interesting
stuff that comes out of this study. We’re really looking forward to
it. We’re currently in the field. And the other thing about this
study is we’re able to follow, um, Puerto Rican too, moved off
the Island after the hurricane. So we’re actually doing household
interviews in New York and in Florida. I’m sending my staff in Puerto Rico
out to, uh, to do those investigations. Now let’s get into the ACA. So
the ACA is a hot topic right now. It has been for the last 10 years
ago. The ACA is 10 years old now, almost 10 years old. Um, I was talking to my undergraduates about
the ACA recently and they just looked at me like I was talking about ancient
history and they, and I said, well, how many of you, you know, were, were, were you in 2010 and they
were in elementary school. So just to give you a
little bit of context, so this paper came out in
2016 with my colleague, JIA Chen, the university of
Maryland. And we just wanted to know, it’s a simple question. So
how has the ACA impacted, uh, health care disparities? So have we seen a reduction
in healthcare disparities, particularly between non Latino whites
and non Latino blacks and Latinos. And, um, what we found in
this study is that, um, actually things have gotten
better with the ACA that, um, we’ve sought improvements in access to. So of course you’ve seen improvements
in insurance coverage. Um, we have seen improvements in, in, um, accessing care as well as
utilization of services, um, and that the disparities
have been attenuated. However, of the groups,
Latinos continued to fair work. So while they improved in access and
utilization and while the disparities got were attenuated, uh, Latinos continued to to fall way behind. And I’m just going to show you, I
wanted to show you, these are just, you guys can go to the paper to find
out the, you know, look at all the, the adjusted analyses if
you want to. Basically the, the patterns are the
same for the unadjusted. So I just figured it’d be
easier to demonstrate the
unadjusted analysis for you here. So what you can see here, so this
is the probability of being uninsured, pre-imposed the affordable care act.
Now I have to tell you, so these data, go for this paper. These data go up to
2014. So just as a footnote to this, so the, the, the law
was passed in 2010, um, but it wasn’t nationally implemented
until 2014 although some States in particular, California and other States started
implementing some provisions of the ACA, uh, before 2014. So this is going up to 2014
and I have some later data, some more current data
in a bit, I’ll show you. But what you’re seeing
here is that the, the, the trends of uninsurance are going
down, but that there are disparities. So, so what you’re seeing here is that,
so for all groups doing better, but for Latinos, they fare, they fare
much worse than the other groups. And this is looking at the probability
of delaying any necessary care. So again, it’s all, it’s good for all groups. Um, although for African Americans in this
case, they’re the ones who do worse. Uh, but Latinos are right behind them. And then the probability of
having any physician visit, all groups are doing better, but Latinos fare worse and, um, they continued to fare worse. So we were so, so then
we were interested, okay, well we know when we look at
Latinos as a monolithic group, um, they don’t do so well
compared to the other groups. But is that true for all Latino groups is. So we did another paper working
with the former PhD student of mine, Hector Alcala, who’s
now at Stony Brook. Um, we just started to desegregate the data
by heritage group and we looked at, um, Puerto Ricans, Mexicans, Cubans,
central Americans. And this, you know, there’s some morphous
at their Latino group. And what we found was
that, um, the, again, the ACA has reduced gaps in
access and utilization, um, but that most of the reductions
were experienced by Puerto Ricans, which isn’t so surprising because Puerto
Ricans are us citizens and then they don’t have the same issues around
citizenship and documentation status and eligibility that other Latinos,
particularly recent immigrants have. So in case you guys don’t know
this, so in most States, um, immigrants who’ve been in the United
States for less than five years are not eligible for any kind of federal benefit. And that’s a result actually of
the Clintons in the 1996 welfare, welfare reform act. Um, and that there, so there we found in this paper
that the remaining disparities, and I’m just going to show you
again the, I’m showing you the, um, some of the unadjusted analyses here, uh, trends were saying were similar
when we adjusted. And the, the take home message here is that
Mexicans and central Americans, uh, fare worse than the other groups. So in terms of looking at this is the, we flipped of this cause I thought
it was at the time it was easier to, to the the question and
the data is uninsured. We flipped it to talk about insured. But you can see that there are the trends
for insurance and coverage goes up for all groups. Um, but uh, there are disparities according to
heritage group where Mexicans and central Americans do worse. And the Puerto Ricans, um, do you do pretty well, again looking at any delay
in care. So trends are, are actually getting better. So there are fewer people
delaying necessary health care, but I mean it’s a little
bit noisy over there, but there are some disparities
and then this is for going care. So this is just not
getting any care at all. Same idea of trends are getting
better. So for, for Latinos in general, everything is getting
better after the ACA, but there are some disparities
according to group. And then this is looking at ed
visits. And this is interesting here. So while Puerto Ricans were doing better
on insurance coverage and all these other access and utilization
measures, they actually were more, much more likely to use
the emergency department. And we couldn’t really get into
the data as to cause the data. Don’t really allow us to
understand why that’s the case, but we can speculate and some
potential hypotheses. Um, you know, around the quality of care that
Puerto Ricans are receiving. Both, um, you know, in particularly in,
in New York and the Northeast, the systems of care might be of
lower quality, less accessible, um, particularly around
language concordance, uh, accessibility and providing
information to, uh, to patients about, um, what
services are available to them. Um, also we, uh, so you guys, again, I don’t want to say things that you
might already know about, but the ACA, something that we don’t talk a lot about
with the ACA is that much of the in, you know, the increase in enrollments
after the ACA hip come from Medicaid, Medicaid coverage. So,
particularly among the, the very poor and, uh, Puerto Ricans are much more likely
to be on Medicaid and we know that, um, than some of the other
groups. And we know that, um, from other studies we’ve done
that physicians post ACA or less, even though Medicaid is now in
reimbursing at higher rates post ACA, a lot of physicians still
won’t take Medicaid. So even though you have
insurance coverage now, doesn’t mean that you will have access, doesn’t mean that providers
will take your insurance. And that’s not only true for Medicaid, it’s also true for people on
the marketplace exchanges. We have shown that
another studies that um, physicians post ACA are
less likely to take, um, patients on Medicaid and our marketplace
exchanges versus those who are on implored employment-based
insurance or, um, those who had just bought a private
insurance plan off the marketplace. And it’s actually something we don’t
talk too much about because the media mostly focuses on, on a, on the marketplace exchanges.
And in fact, right now, I don’t know if you
guys know this, but, um, I think it’s something like 14
States, 12, 14 States are suing. Um, and there it’s in the courts right now
to try to get rid of the ACA with Texas, which has high proportion
of Latinos by the way. Um, and has the highest uninsured rate of any
state in the country is the lead state in this lawsuit. And States that have decided to expand
Medicaid are all now freaking out, but governors are freaking out because
those States that have decided to expand Medicaid, um, you know, the, the federal government’s picking
up most of the tab of Medicaid now. And so if you get rid of the ACA, the state’s going gonna have to pick
up that tab or get those people off the Medicaid roles. And as we know, once you provide people
with insurance coverage, uh, and then you try to take it
away, constituents aren’t
going to be very happy. So the States are now trying
to scramble to figure out, especially those States that expanded
Medicaid and try to fit to try to figure out, um, what they’re going to
do with the, with the Medicaid, also with the marketplace exchanges.
So this is something to, to follow. This is actually recent. This
is a recent thing. Well let’s, I’ll get back to the data. So this is
looking at any physician visits. Um, you know, this, you can see there’s
some disparities. They’re not, they’re not great. The one
thing I, these are these, this is probability of
having any physician visits. So just so you guys understand the
data. So this is a prop. This is, these are probability data. And then
in the paper we wanted to look at, you know, does, um, citizenship
and Spanish language use, um, affect, uh, any variability. And of course we find that non-citizens
compared to a us born Latino, so this universe is just Latinos. Uh, they had lower odds of being insured, lower odds of visiting
the emergency department, lower odds of seeing a physician,
which probably isn’t too surprising. And then also a similar patterns
for Spanish language use. So we wanted to figure out,
all right, so we know these, these cases, we’ve seen these
trends for adults. So we’ve seen, you know, positive, um, positive effects on access
and utilization post ACA. But do these associations
hold for kids? Now, the ACA was not designed to target kids, but they’re indirectly
effected through their parents. So once their parents have Medicaid
and they’re on the [inaudible], they have a marketplace plan
or you know, the, their, their kids are much more likely to be
covered through Medicaid or through chip. Um, and so what I just
want to show you here, so this is just looking at the child
population by race and ethnicity. So, um, right now, uh, Latino children make up about 25%
of the total child population. So it’s about one in four
kids. The United States, um, are Latino, and that rate
is, that number is growing. So this is some pre
ACA data. Um, I’m just, I’m not going to spend too much time on
this because this was pre ACA, but, um, this was a paper that
[inaudible], uh, ghetto, uh, uh, former trainee of mine at UCLA.
She reported in medical care. So she just wanted to know, do Latino children have worst
experiences in care? So do their, the, the, the youth in the Latino youth and
families have worse experiences in care compared to other children
and not shocking. We not, we found that they had worst IX.
They reported worse experiences. Um, so they were less likely to report, uh, having family centered care on these
four components of family centered care. And this is another paper by another
trainee of mine, Brent lands earlier. He did something called, he did a decomposition method to
try to figure out how much of um, observable, uh, factors can explain to sparity
he’s in health care for kids. And um, you know, similar to the adult findings
that I showed earlier, Latino kids were less likely to
have a usual source of care than, than um, white and African
American kids. Uh, they were, uh, they were less likely
to have a preventive visit, preventive visits to see a doctor, um, and they were more likely
to have delayed care. And the disparities were largely explained
by socioeconomic status factors and health policy factors. So this is important because these
are mutable health policy factors are mutable. Um, so we can do things with health
policy to try to assuage, um, the disparities. Now, uh, similar to the previous studies
we wanted to know. So, okay, we see these monolithic, you know,
with Tinos as a homogenous group. Do we see the subgroup differences
just like their parents. We see similar patterns with
Mexicans, Mexicans fairing worse. Um, and these data, we didn’t have
central, uh, central Americans, uh, but we did have Mexicans, Puerto
Ricans, Cubans and others. So the Mexican kids did worse
just like their parents, um, which may not be so surprising
given, uh, immigration patterns, um, particularly before the ACA. And the one thing that I’d wanna point
out here is that in the multivariate analyses, these dis, these disparities as as is
the case for the adults, could not be explained
away by insurance coverage. So utilization disparities could not, it’s not just a matter
of not having insurance. So we even when you account for having
insurance and other important factors like family income and family education
level and geographic location, we still see these disparities.
And more importantly, we see these disparities
after accounting for need. And then this is a, another paper came out a couple of years
ago looking at experiences in care. And so we just wanted to
know, um, similar to, to, um, the adult literature. Do we see
differences in children’s experience, experiences in care
according to their parents, citizenship status and language
use? And probably not so shocking. We found that there were disparities, um, although there were no
disparities in access, there were disparities
in experiences. And um, one thing I have to say is that
in terms of the kids’ literature, most kids have insurance.
So it’s something like, and this is nationally and these are,
I believe these word, uh, chest data. Um, in California in particular, California has very flexible
and progressive health policies, but even nationally, most
kids have health insurance. So you don’t see big disparities
in things like insurance coverage, but you do see experiences, um, differences in disparities and things
like having a regular provider, um, per number of provider visits, having access to preventive care and
all those things. And also when you, we looked at, so we, this
was just a simple question. Do they have different experiences
according to these factors than they do? And that’s a big problem, especially
in California, which, um, you know, has such a large Latino population
and uh, we see disparities and this is looking at
insurance coverage and uh, Latino youth centers. So
much like their parents. Um, so this is now now, so what I’ve shown you up to
now has been pre, pre ACA. So this is looking at pre and
post ACA. And so we see that, um, for all kids, I’m going to show you
some of this data here. So for all kids, insurance coverage has improved, but that we do see
disparities for Latino youth. So Latino youth did better but they stare. They still fare worse
than the other bruise. This is looking at well child visits.
Um, so this is having thing like, you know, immunizations, um, having
screenings and that sort of thing. Um, all groups did a little better. I mean you can see that these are
small differences. Um, you know, one of the things I have to remind people
about is that when you’re looking at differences of like 2%, but when
the denominators millions of kids, that’s actually a lot of kids. So that’s one thing to keep in
mind when you look at these. When these look at these bar charts, um, you can see here for a
had an ed visit for uh, in the past year, there was really no differences pre
and post ACA for Latino kids. Um, there was this, there was a slight
drop here for African American kids. Really no difference in having
a physician visit. And then, um, we had just this, like
the, the former analysis, we wanted to break it up by
heritage group. And low and behold, what did we see here? That the Mexican kids and the central
and South American kids do worse than the other groups. Although they have
improved over time, like everybody else, they still, um, lag behind. Okay. And then this is looking at well, child visits in the past month
and the same patterns, um, that Mexican kids in central and
South American kids don’t do so well. Ed visits now again, like the adults, this Puerto Rican kids are going
to the emergency department. And so there’s still an unanswered
question about why that’s the case. Um, why? So you see improvements and insurance
coverage and access and primary care utilization. But there’s still going to the emergency
department and there’s actually a fallacy in the health services literature
that primary care is a replacement for EDE. So if you get, give people primary care that’s going
to move them away from the emergency department. Now we know
for certain segments of the
population that just isn’t, so you give them primary care, they’re going to go to their primary
care and they’re still going to go to the emergency department either because it’s
about a perception of availability and accessibility or convenience. It’s because what they
understand and know about the, the health services system.
Just anecdotally with my
family, when I was a kid, my mother never made primary
care appointments. We got sick. She just rushed us to
the emergency department. Like the notion of you have a primary
care provider who’s kind of responsible for, you know, your, the health
of your kids and you know, it’s supposed to be comprehensive
and continuous and coordinated. Um, just was not something she
knew about. Thought about. What about any of that.
So the idea of, you know, of, of the hospital or the, as, as a center for care was really
through the emergency department. You had a question back there. [inaudible] [inaudible] my, so my family would
be Mexican heritage. Okay. Yeah. So my family were us
born a us born Mexican. Yeah. So they were born in
New Mexico, Las Vegas, the first Las Vegas. Um, all right. And then S you know, to
the real Willie knows big, big patterns here other than Mexicans.
Again, we’re looking at physician visits, which is a little different than
well child visits. They fair work. Now one thing I wanted to point out
here, so we have a recent paper out. It’s so recent that it doesn’t
even have a day or volume yet. It’s still in process. Um,
we wanted to know, so 28, uh, 2018 and his national health
interview survey data came out. That’s what we were using for
some of those prior analysis. So we were interested to know, you know, are we still seeing improvements for kids
and do Latino youth still lag behind? Um, like so this was what they
called the progress report. So we re we analyze the data, um, using the new, using the, the,
the newly released and this data. And what do you guys think? We found just, I’m not going to show you this slide yet.
What do you think? So this is, again, this is for kids. The kids data.
Anybody want to take a guess? So in terms of the trends, so remember
before, so using the earlier data, the 20th, the 2016 and
his data, we saw that the, the trends for all kids in terms
of insurance coverage and well, child visits improved. But then when you broke it down
by racial and ethnic groups, Latinos fared worse,
right? They lag behind. So now we have the new data. So
do you think the trends continued? Did they reverse? What do you think?
Well, I kind of told you the title here, but, well, they actually,
so they reversed. So I told, I said this is a problem when I
use act like activist titles in my, put my papers and I kind of
give away the punch line. Um, so this is what happened. So you can see 2011 2013 is pre ACA. 2014 2015 is right when
the ACA was implemented. It was implemented in 2014 and then 2016
2018 so you see improvements when you to get the total, that’s the first line. So when you have 6.6%
uh, currently uninsured, that that got better in, um, 2014, 2015 went down to 4.8% and then ticked
up in 2018 and actually that difference between 4.8 and five one 5.1%
might seem non-significant. It’s 300,000 kids. So we have around three and that the
total number of uninsured kids nationally is around 3.7 million. A lot of kids that’s bigger than
something like 41 or 42 States. It’s bigger than the size
of 40 S 40 something States. Interestingly, here, you see, what do you see for the Latino
kids at the bottom there? There they continued to improve,
right? So while all the other kids, white kids and black kids reversed,
the Latino kids continued to improve. They still like behind
right? And part of it, because they had so much
more to come from, right? So their insurance rates before the
ACA were really, really horrible. So they were, they were
lagging way behind. So now they’re just kind of
kicking up and then look at this. So we know that health insurance is just
one piece of the access to care puzzle. So what do we see here with the well
child visits, they actually got better, right? For all groups. So
why do you think that’s so, so you see CEC insurance coverage getting
worse overall and for white and black kids, but for all kids,
well, child visits improved. Does he have any ideas? Well, the
ACA, I’ll give you a little hint. The ACA has some essential preventive
require some essential preventive visits for kids. So things like immunizations and so we
speculate we can’t test with the data, but we speculate that these kids are
really going in for immunizations where they don’t need insurance
coverage. And that’s, that’s a big component of the ACA.
Another thing that we don’t talk about, and you know, we talk about, cause we’re public health professionals
and nursing professionals and social work professionals, but
in terms of the lay media, they focus just pretty much on
the marketplace exchanges and um, and the premiums of the
marketplace exchanges in some
and a little bit about the deductibles. The ACA is so much more than the
marketplace exchanges, right? It’s Medicaid, it’s population health, it’s improving healthcare systems and
accountable care organizations and community engagement and all these
great things that we talk about at the university and that they do in
practice in public health. But the, but the media never
really talk about that. Okay. Um, let me just once, all right,
so I just want to check the time here. So this is a paper that just recently
came out in the medical care. So, um, we had a paper that came out in 2007
that used California health interview survey. Um, excuse me, just as a footnote. The California health interview survey
is a large statewide population based representative survey.
Now done country ever. It’s done yearly. They interview
about 20,000 people every year. Um, it’s a telephone survey. They get decent
response rates for telephone survey. It’s not great, but it’s pretty good. And then they have weights to
make it representative. Um, in 2007, we just had a simple
question. Uh, we’re using, uh, and by the way, so just, just as the
California health university survey, Cisse is the only large population based
study in the United States that has measures of documentation status. So if you want to have
unbiased probability result
probability statistics on the undocumented, you have to go to chess
and it’s only in California. Um, and we just wanted to know, do you
know, how do you know we were hearing, this is back in 2007 when the
undocumented was still a very, it was, I’m undocumented. Immigration is still
a very polarizing political topic. Um, we just wanted to then
there was in the, in the, in, in the media you were
hearing a lot about the, the, the undocumented immigrants were the
result of safety net hospitals and clinics closing throughout the United States
because they were burdening the healthcare system and you know, but then of
course, if you go to the literature, there was no evidence for that, but that was part of the
popular political dogma, which was that, that the
undocumented we’re causing, we’re causing our hospitals
and our clinics to close. So we just wanted to know if
that was the case. And of course, in the 2007 study, we found actually they
don’t use really any health care. And, and about 50, 40 to 50% of them have some form of
insurance coverage. Some of them are, you know, some of it’s through the state,
some of it’s through employer base, but they had insurance covers. So this
notion that the undocumented come in, undocumented immigrants come
in and they just, you know, are a burden on the system and
they don’t pay. And then, and then, and then when we do
qualitative assessments, we’ve talked to two clinics to clinic
administrators. They say, you know, all the immigrants who come in then,
you know, undocumented immigrants, if they’re uninsured, they’re the ones who are much more
willing to come and ready to pay. They want it, they want to pay. Um, so that was some interesting
stuff that came out of that work. So we just wanted to re
analyze the data. And, um, lo and behold, we find that
the undocumented still,
you know, they have works, um, uh, access and utilization of
care, which is not so surprising. Um, and these are
adjusted analysis. So, uh, I’m not gonna go through each point, but the patterns are basically for each
indicator when looking at having a usual source of care, the doctor, um, not
accept being, not your insurance, not being accepted by a doctor. Um, having any ed visit and he doctor visit
in the past 12 months and the number of times, uh, dr [inaudible] in the past
12 months, the undocumented fair, worse than the other groups. And this was the first time using
probability studying where we actually, we were able to look at
physical and behavioral health
and without going through each one of these, I mean, so these, we’re looking at chronic diseases like
obesity, overweight, high blood pressure, um, heart disease, um, and then whether
or not they had psychological distress, they needed help for emotional problems
of Racine, a mental health professional. Um, the undocumented did, did
better on all these indicators, meaning that they had fewer physical and
behavioral health problems than other immigrants. So, and then,
and then we asked. So, and then among those who a behavioral problem, they were also less likely to be
able to get help for those problems. So they didn’t have health insurance
that would cover it and um, they didn’t enter into treatment and
they didn’t get help because of the behavioral health problems. I was going to say one other
thing about this. So, uh, so an interesting interesting observation
here is that they have better physical and behavioral health,
which isn’t so surprising. It’s a healthy immigrant effect
really. Although recall the, the Pew data I showed you earlier where
66% of undocumented Latinos are now in the U S for 10 years or longer. So there’s that spin on it that
we still have to kind of explore, but they were less likely to rate
their health as excellent or very good. So they were healthier in terms
of physical and mental health, but they didn’t rate their health
as well as the other groups. And so in the paper we
speculate as to why. So now let’s, I have a few minutes remaining and I want
to make sure I released some time for Q and. A, but I just want to get
briefly into some policy dilemmas. So my colleagues, uh, Hector Rodriguez, who actually at one point was on the
faculty here at university of Washington and, uh, he’s now at Berkeley
and Arturo Vargas, Buster manta, he’s a colleague of mine at UCLA. Uh, we wrote a few years ago on policy
dilemmas for Latino healthcare and implementation of the affordable care act. So one of the things I’m sure I alluded
to earlier is that we’re starting to see a growth, um, significant growth across
the country of Latinos, but particularly in States that have not
expanded Medicaid as part of the ACA. Um, and this is problematic for
a lot of, is this is problematic, not just for Latinos. It’s problematic
for everybody in the state who’s, who’s, who’s working poor. Uh, but there’s,
what we’re seeing is a growth, especially in Texas. I mean, Texas is
really, should be ashamed of itself. Uh, you know, for, for doing what it’s
doing right now on the courts, given their population demographics,
their high uninsured rates, um, the vast number of Latinos
who live in that state, et cetera. And also, I mean, you know, you
see it in the South, you see it, you see it in the Midwest,
Cal. And also, um, you know, being able to offer benefits
to undocumented immigrants. California is, uh, one of the first States to
start experimenting with
providing health benefits to undocumented immigrants. They
actually had put a waiver, a federal waiver in to try to allow,
uh, undocumented immigrants to, to participate in the marketplace
exchanges, but without subsidies. Um, and this was right
before the 2016 election. Uh, and once the election didn’t
go the way they people, the California was hoping it would go,
they’d then just scratch the whole thing. But now they do allow youth and young
adults who are undocumented to benefit from our California health
benefits from, for medical. That’s the state Medicaid program. And then I, I don’t know
if you guys heard of, I mean the few months ago this was a,
it’s actually, I think, I don’t know, I don’t know where the
status of it is now. I’m probably been stayed in the
courts, but the government has a, the U S government, the executive
branch has tried to change, uh, the implementation and
definition of public charge. So public charges when you are, uh, liable to become a public charge is
the term used in the United States to classify prospective immigrants
who are denied entry to the, to their disabilities or
lack of economic resources. And it really hasn’t been enforced widely. And historically it’s been around I think
on the book since the 18 hundreds. Um, and now, uh, the, the Trump administration would like
to provide the public charge and also include public assistance
including Medicaid and snap, um, which would largely
impact, uh, youth and families. And they could, it also, the could be used against providing
benefits to youth who are here legally authorized or who are us citizens.
So that’s quite alarming. And I showed you here, this was from, um, the center on budget and
policy priorities. They,
you know, that how many, um, kids would be disenrolled, uh, who would lose their health benefits as
a result of changing the definition of public charge. And then of course,
you know, it’s, this is just the, I wrote an article in the Philadelphia
Inquirer couple of years ago about, you know, children in cages and we’ve
all seen this. And this is, you know, some horror, horrific, uh, part of our, kind of our history of our
history in the country. Um, and then the impact that that has, um, on the health of families and also on
being able to engage families into health care. And then finally,
I’ll just say, you know, the Latino population is here. So, you
know, it’s kinda like, it reminds me, you know, when I, when I was in college,
there was a phrase, we would go work, we’re queer, we’re here, get over it,
you know, and population is here. Uh, get over it. You know, we have to deal
with it. You know, we as a society, we need to, to make sure
that Latinos are healthy, um, that they’re integrated into society,
um, that they’re respected and, um, that we treat them with dignity and
that we value health as a human. Right. And with that, I will open up to questions [Applause].


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