Immigrant children's reliance on public health insurance in the wake of immigration reform

Objectives. We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs.Methods. We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey.Results. Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured).Conclusions. In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.Recent attention has focused on immigrants’ use of public programs, especially health insurance programs, in the United States.^1–6 According to the 2000 census, 1 of every 5 children is a member of an immigrant family, and immigrants are increasingly dispersed across the country.⁷ Immigrant families are also complex in that parents and children may differ with respect to their immigration status. In 1998, 10% of children in the United States lived in “mixed-status” families composed of at least 1 noncitizen parent and at least 1 citizen child.⁸Because most children depend on their parents to obtain necessary benefits, including health insurance coverage, parental immigrant status may influence a child''s health insurance status and, ultimately, his or her health outcomes.⁹ As immigration rates continue to increase, these demographic shifts mean that the health of immigrant children will have a significant impact on the socioeconomic future of all Americans.Federal, state, and local policies can promote or hinder health insurance coverage for immigrants. The past 12 years have seen a pair of major policy changes designed to reduce immigrant enrollment in publicly funded health insurance programs. First, the Personal Responsibility Work Opportunity and Reconciliation Act of 1996 (commonly known as welfare reform) ruled that immigrants residing in the United States for less than 5 years were no longer eligible for any federally funded public benefits, including health insurance.¹⁰ In response, some states created public health insurance programs to cover immigrants with state funds.¹¹ Federal legislation to extend coverage to lawfully residing immigrant children continues to be debated.¹²Second, the “public charge” rule of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 was initially interpreted as requiring families to repay the US government for public benefits, including Medicaid, previously received at no cost.¹³ In response to collective advocacy efforts by health care providers and community-based organizations, the government specified in May 1999 that Medicaid benefits would be exempted from the public charge rule.¹⁴ In the wake of these rapid changes, there have been concerns about health care access for immigrant children, especially given that children require regular health supervision visits and immunizations to promote optimal health and well-being.^2,11,15–17Data from the mid-1990s have been used in most recent studies of health insurance coverage among immigrant children. One study involving data from the 1994 and 1996 versions of the Current Population Survey showed that 44.3% of immigrant children were privately insured, 34.1% were publicly insured, and 27.3% were uninsured.¹⁸ The majority of uninsured children had working parents whose employers failed to provide health insurance coverage or were members of families that did not meet Medicaid eligibility requirements for immigrants.¹⁸ Another study of low-income noncitizen adults and children showed that Medicaid participation rates dropped and that noncoverage rates increased between 1995 and 1998; these changes have been ascribed to confusion about eligibility rules for benefits related to welfare reform.¹⁵The most recent nationally representative analysis of which we are aware (from 1999) confirmed that foreign-born children (approximately 87% of whom were not US citizens⁷) were more likely to be uninsured than to have public health insurance coverage,¹⁹ but the data from that study were collected before the reversal of the public charge rule. In our study, we analyzed data from the 1997 through 2004 versions of the National Health Interview Survey (NHIS) in an effort to determine whether reversal of the public charge rule led to immigrant children becoming increasingly or decreasingly reliant on public health insurance programs.     

Parental Depressive Symptoms and Children’s School Attendance and Emergency Department Use: A Nationally Representative Study

We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997–2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7–2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4–3.0) and ADHD (3.8 %, 95 % CI 3.2–4.4) than among other children (1.6 %, 95 % CI 1.5–1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06–1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14–1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.     

A Novel Knowledge Representation Framework for the Statistical Validation of Quantitative Imaging Biomarkers

Quantitative imaging biomarkers are of particular interest in drug development for their potential to accelerate the drug development pipeline. The lack of consensus methods and carefully characterized performance hampers the widespread availability of these quantitative measures. A framework to support collaborative work on quantitative imaging biomarkers would entail advanced statistical techniques, the development of controlled vocabularies, and a service-oriented architecture for processing large image archives. Until now, this framework has not been developed. With the availability of tools for automatic ontology-based annotation of datasets, coupled with image archives, and a means for batch selection and processing of image and clinical data, imaging will go through a similar increase in capability analogous to what advanced genetic profiling techniques have brought to molecular biology. We report on our current progress on developing an informatics infrastructure to store, query, and retrieve imaging biomarker data across a wide range of resources in a semantically meaningful way that facilitates the collaborative development and validation of potential imaging biomarkers by many stakeholders. Specifically, we describe the semantic components of our system, QI-Bench, that are used to specify and support experimental activities for statistical validation in quantitative imaging     

UMLS content views appropriate for NLP processing of the biomedical literature vs. clinical text

Identification of medical terms in free text is a first step in such Natural Language Processing (NLP) tasks as automatic indexing of biomedical literature and extraction of patients’ problem lists from the text of clinical notes. Many tools developed to perform these tasks use biomedical knowledge encoded in the Unified Medical Language System (UMLS) Metathesaurus. We continue our exploration of automatic approaches to creation of subsets (UMLS content views) which can support NLP processing of either the biomedical literature or clinical text. We found that suppression of highly ambiguous terms in the conservative AutoFilter content view can partially replace manual filtering for literature applications, and suppression of two character mappings in the same content view achieves 89.5% precision at 78.6% recall for clinical applications.     

Extracting Rx information from clinical narrative

Objective

The authors used the i2b2 Medication Extraction Challenge to evaluate their entity extraction methods, contribute to the generation of a publicly available collection of annotated clinical notes, and start developing methods for ontology-based reasoning using structured information generated from the unstructured clinical narrative.

Design

Extraction of salient features of medication orders from the text of de-identified hospital discharge summaries was addressed with a knowledge-based approach using simple rules and lookup lists. The entity recognition tool, MetaMap, was combined with dose, frequency, and duration modules specifically developed for the Challenge as well as a prototype module for reason identification.

Measurements

Evaluation metrics and corresponding results were provided by the Challenge organizers.

Results

The results indicate that robust rule-based tools achieve satisfactory results in extraction of simple elements of medication orders, but more sophisticated methods are needed for identification of reasons for the orders and durations.

Limitations

Owing to the time constraints and nature of the Challenge, some obvious follow-on analysis has not been completed yet.

Conclusions

The authors plan to integrate the new modules with MetaMap to enhance its accuracy. This integration effort will provide guidance in retargeting existing tools for better processing of clinical text.     

Taking the hassle out of wellness: Do peers and health matter?

Despite substantial financial incentives provided by the Affordable Care Act and employers, employee enrollment in wellness programs is low. This paper studies enrollment in a wellness program offered along an employer-provided health insurance plan. Two factors are considered in the choice of health plan with wellness: the effect of peer choices and family health on plan choice. Using exclusively obtained data of health insurance plan choice and utilization, this paper compares similar plans and focuses on a subsample of new employees. Result show that peers affect own choice of health insurance: a 10 percentage point rise in the share of colleagues enrolled in Aetna Wellness increases the probability of own enrollment in the plan by up to 3.9 percentage points. This result suggests that lack of experience with a wellness program are key to employee reluctance to enroll. Health effect on probability of enrollment in Aetna Wellness ranges from a 3 percentage point decline to a 3 percentage point rise depending on the measure, suggesting that while wellness programs appeal to low- to medium-intensity users of medical services, they do not appeal to individuals with more severe medical conditions which might benefit most from better coordinated medical care.     

Policy of prevention: Medical utilization under a wellness plan

Wellness programs constitute central components of disease prevention efforts under the Affordable Care Act and are likely to remain a component of employer provided health insurance. This paper evaluates the impact of such programs on medical utilization 4 to 7 years after enrollment in the plan. Using a unique suited data provided by a large private employer, I analyze medical expenditure and utilization for individuals enrolled in a wellness plan. The analysis compares expenditures and visits between wellness members and nonmembers who are matched through propensity score methods. The results show that although the wellness program increases utilization of preventive and outpatient care, by as much as 1.57 visits per year, there is no comparable decline in emergency or inpatient care, resulting in an overall increase in medical expenditure of around $507 per person per year. The increase in medical expenditure persists even 6 to 7 years of continued enrollment in wellness. I find some evidence of improved health, as diagnoses of diabetes decline 0.8 percentage points among wellness members. The results suggest that employer savings stemming from improved health and more judicious use of medical services are not likely to materialize in this wellness program.     

A recent advance in the automatic indexing of the biomedical literature

The volume of biomedical literature has experienced explosive growth in recent years. This is reflected in the corresponding increase in the size of MEDLINE^®, the largest bibliographic database of biomedical citations. Indexers at the US National Library of Medicine (NLM) need efficient tools to help them accommodate the ensuing workload. After reviewing issues in the automatic assignment of Medical Subject Headings (MeSH^® terms) to biomedical text, we focus more specifically on the new subheading attachment feature for NLM’s Medical Text Indexer (MTI). Natural Language Processing, statistical, and machine learning methods of producing automatic MeSH main heading/subheading pair recommendations were assessed independently and combined. The best combination achieves 48% precision and 30% recall. After validation by NLM indexers, a suitable combination of the methods presented in this paper was integrated into MTI as a subheading attachment feature producing MeSH indexing recommendations compliant with current state-of-the-art indexing practice.     

Quantitative Imaging Biomarker Ontology (QIBO) for Knowledge Representation of Biomedical Imaging Biomarkers

A widening array of novel imaging biomarkers is being developed using ever more powerful clinical and preclinical imaging modalities. These biomarkers have demonstrated effectiveness in quantifying biological processes as they occur in vivo and in the early prediction of therapeutic outcomes. However, quantitative imaging biomarker data and knowledge are not standardized, representing a critical barrier to accumulating medical knowledge based on quantitative imaging data. We use an ontology to represent, integrate, and harmonize heterogeneous knowledge across the domain of imaging biomarkers. This advances the goal of developing applications to (1) improve precision and recall of storage and retrieval of quantitative imaging-related data using standardized terminology; (2) streamline the discovery and development of novel imaging biomarkers by normalizing knowledge across heterogeneous resources; (3) effectively annotate imaging experiments thus aiding comprehension, re-use, and reproducibility; and (4) provide validation frameworks through rigorous specification as a basis for testable hypotheses and compliance tests. We have developed the Quantitative Imaging Biomarker Ontology (QIBO), which currently consists of 488 terms spanning the following upper classes: experimental subject, biological intervention, imaging agent, imaging instrument, image post-processing algorithm, biological target, indicated biology, and biomarker application. We have demonstrated that QIBO can be used to annotate imaging experiments with standardized terms in the ontology and to generate hypotheses for novel imaging biomarker–disease associations. Our results established the utility of QIBO in enabling integrated analysis of quantitative imaging data.     

Comparison of wideband steady‐state free precession and T2‐weighted fast spin echo in spine disorder assessment at 1.5 and 3 T

Wideband steady‐state free precession (WB‐SSFP) is a modification of balanced steady‐state free precession utilizing alternating repetition times to reduce susceptibility‐induced balanced steady‐state free precession limitations, allowing its use for high‐resolution myelographic‐contrast spinal imaging. Intertissue contrast and spatial resolution of complete‐spine‐coverage 3D WB‐SSFP were compared with those of 2D T₂‐weighted fast spin echo, currently the standard for spine T₂‐imaging. Six normal subjects were imaged at 1.5 and 3 T. The signal‐to‐noise ratio efficiency (SNR per unit‐time and unit‐volume) of several tissues was measured, along with four intertissue contrast‐to‐noise ratios; nerve‐ganglia:fat, intradural‐nerves:cerebrospinal fluid, nerve‐ganglia:muscle, and muscle:fat. Patients with degenerative and traumatic spine disorders were imaged at both MRI fields to demonstrate WB‐SSFP clinical advantages and disadvantages. At 3 T, WB‐SSFP provided spinal contrast‐to‐noise ratios 3.7–5.2 times that of fast spin echo. At 1.5 T, WB‐SSFP contrast‐to‐noise ratio was 3–3.5 times that of fast spin echo, excluding a 1.7 ratio for intradural‐nerves:cerebrospinal fluid. WB‐SSFP signal‐to‐noise ratio efficiency was also higher. Three‐dimensional WB‐SSFP disadvantages relative to 2D fast spin echo are reduced edema hyperintensity, reduced muscle signal, and higher motion sensitivity. WB‐SSFP's high resolution and contrast‐to‐noise ratio improved visualization of intradural nerve bundles, foraminal nerve roots, and extradural nerve bundles, improving detection of nerve compression in radiculopathy and spinal‐stenosis. WB‐SSFP's high resolution permitted reformatting into orthogonal planes, providing distinct advantages in gauging fine spine pathology. Magn Reson Med, 2012. © 2012 Wiley Periodicals, Inc.