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To Address Health Disparities for Latino Youth, Promote Their Engagement in Health Care

      See Related Article on p. 513
      Latinos are the largest minority group in the United States, expected to make up 29% of the nation's population by 2060, but this growing population's access to health care is limited by disproportionate rates of uninsurance and underutilization of care [
      • Colby S.L.
      • Ortman J.M.
      Projections of the Size and Composition of the U.S. Population: 2014 to 2060.
      ,
      • Doty M.M.
      • Gunj M.Z.
      • Collins S.R.
      • et al.
      Latinos and Blacks have made major gains under the Affordable Care Act, but inequalities remain: The Commonwealth Fund.
      ,
      • Alcala H.
      • Chen J.
      • Langellier B.
      • et al.
      Impact of the Affordable Care Act on health care access and utilization among Latinos.
      ]. Latinos are also the youngest racial-ethnic group in the country: 32% of Latinos are less than 18 years old, and 26% are Millennials, between 18 and 33 years old [
      • Patten E.
      The nation's Latino population is defined by its youth: Nearly half of U.S.-born Latinos are younger than 18.
      ]. The adolescents and young adults in this large and heterogeneous group face numerous disparities in their health outcomes, including higher rates of obesity and worse reproductive and mental health outcomes, when compared with white peers [
      • Kann L.
      • McManus T.
      • Harris W.
      • et al.
      Youth risk behavior surveillance — United States, 2015.
      ,
      ]. Engaging these young people in routine preventative care is a critical step toward ameliorating these poor outcomes. While systems-level interventions to improve health care engagement (including expanding health insurance access) are clearly needed, the influence of family on health care engagement is less understood. In an article titled, “Parents' Traditional Cultural Values and Mexican-Origin Young Adults' Routine Health and Dental Care,” Updegraff et al. [
      • Updegraff K.A.
      • Kuo S.I.C.
      • McHale S.M.
      • et al.
      Parents' traditional cultural values and Mexican-origin young adults' routine health and dental care.
      ] explore how parents in Mexican-American families impact youths' access to and engagement in routine medical and dental care as they transition into young adulthood.
      This study is particularly valuable for its focus on Mexican-Americans, who make up about two thirds of the young Latinos in the United States [
      • Patten E.
      The nation's Latino population is defined by its youth: Nearly half of U.S.-born Latinos are younger than 18.
      ]. Most of the available data about health care access and health disparities pool Latino populations (i.e., Mexican, Cuban, Dominican, and so forth), neglecting their intergroup differences. However, it is clear that, beginning in childhood, health care access varies by Latino subgroup, with Mexican-American children having poorer health care access and utilization than white children or other Latino subgroups, including Cubans and Puerto Ricans [
      • Perez V.H.
      • Fang H.
      • Inkelas M.
      • et al.
      Access to and utilization of health care by subgroups of Latino children.
      ]. Subgroup differences extend into adulthood, varying by ethnic subgroup and type of care [
      • Weinick R.M.
      • Jacobs E.A.
      • Stone L.C.
      • et al.
      Hispanic healthcare disparities: Challenging the myth of a monolithic Hispanic population.
      ]. This work is particularly needed and innovative in its attempt to isolate the cultural and familial forces that influence these differences for Mexican-American youth.
      Updegraff et al. highlight the positive impact of maternal familism during adolescence on utilization of preventative care during young adulthood. The authors define familism as “an emphasis on the needs of the family over those of the individual members, family as providers of support, and the importance of fulfilling family obligations.” Maternal familism during adolescence was a better predictor of a Mexican-American young adult's engagement in primary health care than their health insurance status (log odds: 1.25 vs. .98), making it a powerful force in promoting health care engagement, particularly among those most at risk for underutilizing care [
      • Updegraff K.A.
      • Kuo S.I.C.
      • McHale S.M.
      • et al.
      Parents' traditional cultural values and Mexican-origin young adults' routine health and dental care.
      ,
      • Lau J.
      • Adams S.
      • Boscardin W.
      • et al.
      Young adults' health care utilization and expenditures prior to the Affordable Care Act.
      ]. The authors speculate that strong familism values may prompt mothers to act as role models for their children by demonstrating healthful behaviors and utilizing preventative services. Interventions that build on familism by partnering with families to recruit adolescents into care and promoting parental role modeling could have a lasting impact on primary care utilization for Mexican-Americans as they transition into young adulthood.
      Future research should explore the role of immigrant generation and acculturation on health care access and utilization for different Latino subpopulations. While much has been made of the “immigrant paradox” and the relative good health of first-generation immigrants, research suggests that parents rate the health of their first-generation immigrant children as poor [
      • Burgos A.E.
      • Schetzina K.E.
      • Dixon L.B.
      • et al.
      Importance of generational status in examining access to and utilization of health care services by Mexican American children.
      ,
      ]. In addition, first-generation Latino immigrants have lower rates of insurance than other racial-ethnic groups or later immigrant generations [
      • Doty M.M.
      • Gunj M.Z.
      • Collins S.R.
      • et al.
      Latinos and Blacks have made major gains under the Affordable Care Act, but inequalities remain: The Commonwealth Fund.
      ]. The relationship between immigrant generation and the health and health care access of different subgroups of Latinos, as well as the potential role of parents in influencing access to care for youth of different immigrant generations, require additional study.
      As the United States' health and immigration policies shift with changing administrations, there will be changes in insurance access for some Latino adolescents and young adults. As these changes occur, efforts to identify and target interventions to maintain participation of youth from different Latino subgroups in preventative health care are even more critical. As a whole, the Latino population has made great strides in accessing insurance through the Affordable Care Act (ACA). Since the ACA went into effect in 2010, the percentage of uninsured Latinos has dropped from 41.8% to 30.3%, with 4.0 million people gaining insurance coverage [
      Health Insurance Coverage and the Affordable Care Act
      U.S. Department of Health and Human services, Office of the Assistant Secretary for Planning and Evaluation.
      ]. In the general U.S. population, young adults (including Latinos) have particularly benefitted from the ACA's extension of dependent coverage on parental plans up to age 26 years [
      Health Insurance Coverage and the Affordable Care Act
      U.S. Department of Health and Human services, Office of the Assistant Secretary for Planning and Evaluation.
      ,
      ]. Although the ACA excluded insurance coverage for new immigrants and those without documentation, some states (such as California and New York) have waived the federal 5-year waiting period for new immigrants and have expanded Medicaid access to portions of these populations using local funds [

      Covered California: Eligibility and immigration. Available at: http://www.coveredca.com/individuals-and-families/getting-covered/immigrants/. Accessed February 20, 2017.

      ,
      ]. Finally, the Deferred Action for Childhood Arrivals (DACA) program allowed some young immigrants without documentation to access health insurance either through locally funded Medicaid expansions or through the work and educational pursuits permitted under DACA [
      ,

      National Immigrant Law Center. Frequently asked questions: Exclusion of youth granted “Deferred Action for Childhood Arrivals” from affordable health care. Available at: https://www.nilc.org/issues/health-care/acadacafaq/. Accessed January 10, 2017.

      ]. The new presidential administration has repeatedly stated that the repeal or dismantling of the ACA and DACA are high priority items [

      Trump Pence make American great again 2016: Positions. Available at: https://www.donaldjtrump.com/policies/. Accessed January 10, 2017.

      ], placing the insurance status of the Latinos and immigrants who obtain insurance through these programs in jeopardy.
      With the changes in health insurance access that will result from these policy shifts, the role of Mexican-American parents in seeking health care opportunities and promoting youth engagement in available care will become even more important. This study by Updegraff et al. is a model for how researchers can continue to improve health care engagement by studying the specific cultural factors that promote participation in care for different racial, ethnic, and immigrant generation groups. With such data, it will be possible to design and test interventions that use the innate strengths of marginalized communities to promote their health and maintain their access to and participation in preventative health services.

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