Medicaid Use among Older Low-Income Medicare Enrollees in California and Texas: A Tale of Two States.

CONTEXT: States face increasing Medicaid expenditures largely as a result of growing dual-eligible populations. In this article we examine self-reported community-based Medicaid participation among Medicare recipients 65 and older in California and Texas, with a particular focus on the older Mexican-origin population. METHODS: We use six waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) covering the period from 1993-94 to 2010-11. FINDINGS: The data reveal relatively high Medicaid participation rates by older individuals of Mexican origin, but significant differences between the two states. At baseline, 30% of older Mexican-origin Medicare beneficiaries in California reported receiving Medicaid compared to 41% in Texas. CONCLUSIONS: Despite California's more liberal eligibility criteria, community-dwelling Texans were more likely than Californians to report coverage at some point during the 17-year follow-up. Our data, as well as administrative data, reveal that California classifies nearly all of its community-dwelling Medicaid recipients as "full duals," meaning that they receive full benefits, whereas Texas is more likely to classify similarly poor and disabled individuals as "partial duals," meaning that they receive less coverage, thereby lowering overall program expenditures. Cost containment strategies that restrict access may be especially consequential for vulnerable Hispanic populations.

Reservation Lands as a Protective Social Factor: An Analysis of Psychological Distress among Two American Indian Tribes.

The unique physical, cultural, and ecological location of U.S. American Indian reservations simultaneously presents risks for mental health and offers sources of resilience to Native peoples. Using survey data from two American Indian tribes, we explore whether the length of one's life spent on a reservation is associated with lower odds of psychological distress. In both tribes, we find that individuals who live a vast majority of their lives on the reservation have lower odds of psychological distress than individuals who spent portions of their life off or near the reservation. These findings suggest a need to reframe the perception of life experience on tribal reservations but also call for a more nuanced investigation of the life experience of American Indians. This study illustrates the importance of deeply exploring the relationship that American Indians have with their tribal reservation lands.

Acculturation, Gender, and Active Life Expectancy in the Mexican-Origin Population.

OBJECTIVE: This study examines the potential effects of nativity and acculturation on active life expectancy (ALE) among Mexican-origin elders. METHOD: We employ 17 years of data from the Hispanic Established Population for the Epidemiologic Study of the Elderly to calculate ALE at age 65 with and without disabilities. RESULTS: Native-born males and foreign-born females spend a larger fraction of their elderly years with activities of daily living (ADL) disability. Conversely, both foreign-born males and females spend a larger fraction of their remaining years with instrumental activities of daily life (IADL) disability than the native-born. In descriptive analysis, women with low acculturation report higher ADL and IADL disability. Men manifest similar patterns for IADLs. DISCUSSION: Although foreign-born elders live slightly longer lives, they do so with more years spent in a disabled state. Given the rapid aging of the Mexican-origin population, the prevention and treatment of disabilities, particularly among the foreign born, should be a major public health priority.

Longer lives, sicker lives? Increased longevity and extended disability among Mexican-origin elders.

OBJECTIVES: (a) To identify factors associated with different patterns of functional decline in a longitudinal sample of older Mexican-origin individuals, and (b) to determine the proportions of life after age 65 characterized by serious functional impairment. METHODOLOGY: We use the Hispanic Established Populations for Epidemiologic Studies of the Elderly to examine changes in objective Performance Oriented Mobility Assessments in a cohort of 3,050 Mexican-origin elders initially interviewed in 1993/1994 and recontacted 6 times over 17 years. This sample combined with an additional cohort of 902 individuals 75 and older added at wave 4 in 2004/2005 (combined sample = 3,952) is used in life table analyses to estimate the number of years after 65 characterized by serious functional impairment. RESULTS: Three distinct patterns of functional decline emerge: (a) high initial functioning followed by decline, but not to the level of disability (48%); (b) moderate initial functioning followed by decline to the level of disability (37.5%); and (c) initial disability followed by continued poor functioning (14.5%). Life table analyses reveal that subjects spent over half of the period after 65 with serious functional limitations. Significant gender and nativity differentials emerge. DISCUSSION: Protracted morbidity that accompanies increases in life expectancy has serious implications for the physical, social, and economic well-being of older individuals and their families, as well as for health and long-term care policy.

Nativity status and sources of care assistance among elderly Mexican-origin adults.

Much like other racial/ethnic groups, Latinos are facing challenges to provide needed care to aging adults. Older Latinos underutilize nursing homes and home health care services and primarily rely on their families for assistance. While this general trend has been established, little attention has been paid to nativity differentials in patterns of caregiving for this segment of the aging population. The analyses are based on the latest wave (Wave 7) of the Hispanic Established Population for Epidemiologic Studies of the Elderly or H-EPESE (2010/2011) a sample of older Mexican-origin adults and their family caregivers living in the southwestern U.S. We examine 629 child caregiver/parent care recipient dyads using bivariate statistics and multinomial logistic regression analyses. The results reveal that while grown children of Mexican-origin elders play a critical role in providing instrumental and financial supports to their aging parents, the burden that the children of foreign-born parents bear is greater. Despite higher rates of disability, Mexican-born elders are more dependent on a child for help and far less likely to call upon other family members, relatives and community based-providers for help than the U.S. born. Given the recent and future growth of older Latinos, intervention strategies will need to focus on nativity status and acculturative processes in the context of caregiving and caregiver burden.

Physical performance and short-term mortality in very old Mexican Americans.

UNLABELLED: BACKGROUND/STUDY CONTEXT: Physical performance measures have been found to be strong predictors of adverse outcomes in aging populations. Few studies have examined the predictive ability of physical performance measures exclusively within populations of the very old. This study explores the predictive ability of the Short Physical Performance Battery (SPPB) and its three subcomponents-a timed walk, balance test, and repeated timed chair stands-on mortality in a sample of Mexican Americans aged 75 and older. METHODS: Logistic regression analyses were used with data from the Hispanic Established Population for the Epidemiological Study of the Elderly (Hispanic EPESE), to investigate the relationship between timed walk, balance test, repeated timed chair stands, and the SPPB and mortality over a 2½-year period. RESULTS: The authors find that being unable to complete the timed walk, the balance test, and repeated timed chair stands, or unable to complete any of the SPPB was significantly associated with mortality over 2½ years. CONCLUSION: These findings indicate that physical performance measures may be less predictive of short-term mortality in very old Mexican Americans than previously thought. More research is needed to understand this relationship.

After Babel: language and the fundamental challenges of comparative aging research.

The rapid growth in comparative survey research carried out in multiple countries, or among different language communities within a single nation, has given rise to a renewed concern with problems of translation. The fundamental problem facing the comparative survey researcher relates to the complexity and subjectivity of language, and the fact that complete equivalence of concepts in different linguistic, cultural, and social class contexts may be in principle impossible to achieve. Yet language remains the only medium through which information concerning subjective states, values, and beliefs can be collected. That language and the subjective constructs to which it refers are influenced by a wide range of cultural and social factors. This fact has particular relevance for comparative aging research since older individuals are often monolingual in their native languages and more tied to traditional cultures than younger individuals. This paper consists of a review of basic issues related to the nature of language and communication, and discusses the possibility of a truly scientific translation process. It outlines current best practices, and also raises questions related to the common practice of using information collected with translated survey instruments in ways that assume it reflects a comparable and quantifiable latent construct.

Beyond borders: comparative quantitative research on partner violence in the United States and Mexico.

We employ two surveys to identify similarities and differences in the risk of abuse among poor urban Mexican-origin women in the United States and Mexico. While the two surveys reveal basic structural similarity in the predictors of partner violence, the rate of violence among Mexican women is far lower than among either foreign-born or native-born Mexican origin women in the United States. While these differences may reflect reality, we argue that survey data must be interpreted cautiously and with an understanding of the cultural, economic, and political context in which the information is collected as well as methodological differences between the surveys.

Agency versus structure: genetics, group membership, and a new twist on an old debate.

The decoding of the human genome and advances in genetic medicine promise great advances in the prevention and treatment of disease. These powerful methodologies, though, raise serious intellectual, ethical, and practical questions when they are employed in explanations of complex higher-order behavioral and social outcomes. There can be little doubt that all human behavior reflects complex gene/environment interactions, but isolating the unique contributions of genes and environment in the explanation of overdetermined behavioral and social outcomes may not in principle be possible. When dealing with groups that differ significantly in histories of discrimination and exclusion biological explanations must be employed with caution even as they promise great strides in dealing with specific diseases.

A window of vulnerability: health insurance coverage among women 55 to 64 years of age.

INTRODUCTION: largely a consequence of historical gender differences in labor force attachment in the United States, many women rely on their spouse for health insurance coverage, particularly during late middle age. Prior research finds that this creates a window of vulnerability for women during late middle age who may lose their (older) spouse's employment-based coverage when he retires from the labor force and enrolls in Medicare. However, the few studies that have examined this window of vulnerability have been based primarily on white adults. METHODS: we used the 2004 and 2006 Annual Social and Economic Supplements to the Current Population Survey to examine whether the window of vulnerability exists among non-Hispanic Black, Mexican-origin, and non-Hispanic White women 55 to 64 years of age, and whether similar factors contribute to the vulnerability across these race/ethnic groups. RESULTS: women 55 to 64 years of age married to men 65 years or older had an elevated risk of lacking coverage at a time of life when health problems are common and expensive. Among non-Hispanic White women, their husband's exit from full-time employment accounted for the higher risk, whereas a more complex and systemic set of social factors contributed to the higher risk among non-Hispanic Black and Mexican-origin women. CONCLUSION: ensuring adequate and affordable health insurance coverage among women during late middle age may require additional health care reforms such as extending Medicare eligibility to younger adults or basing Medicare age eligibility on the age of the older partner within a married couple.

The rural-urban divide: health services utilization among older Mexicans in Mexico.

CONTEXT: Mexico. PURPOSE: Using the health care service utilization model as a framework, this paper will analyze the differences in health care service use among older Mexicans living in urban and rural areas in Mexico. METHODS: The Mexican Health and Aging Survey (MHAS) data were used to test the applicability of Andersen's "model of health services" of predisposing (ie, age, sex, etc.), enabling (education, insurance coverage, etc.) and need factors (diabetes, hypertension, etc.) to predict ever being in the hospital and physician visits in the past year by place of residence (urban, rural, semi-rural). FINDINGS: Results showed that older Mexicans living in the most rural areas (populations of 2,500 or fewer) were significantly less likely to have been hospitalized in the previous year and visited the physician less often (P < .0001) than their urban counterparts. The significant difference in hospitalization between rural and urban residing older Mexicans was largely accounted for by having health care coverage. Certain need factors such as diabetes, previous heart attack, hypertension, depression, and functional limitations predicted frequency of physician visits and hospitalization, but they did not explain variations between rural and urban older Mexicans. CONCLUSIONS: Not having insurance coverage was associated with a lower likelihood of spending an overnight visit in the hospital and visiting a physician for older Mexicans. This lower utilization may be due to barriers to access rather than better health.

Shorter stay, longer life: age at migration and mortality among the older Mexican-origin population.

OBJECTIVE: In this article, we investigate the association between age at migration and mortality during a 13-year period in a sample of Mexican American immigrants 65 and older at baseline. METHOD: We employ the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-PESE) to control for mortality-related health and social factors. RESULTS: Our analyses show that the immigrant generation does not represent a homogeneous mortality risk category. Individuals who migrated to the United States in mature adulthood have a considerably lower risk of death than individuals who migrated in childhood or midlife. Chronic conditions or functional capacity do not account for these differences. CONCLUSION: Our findings suggest that standard risk pools may differ significantly on the basis of genetic and unmeasured life-course factors. A better understanding of the late-life immigrant mortality advantage has important implications for more effective and targeted social and medical interventions.

The long-term health consequences of relationship violence in adulthood: an examination of low-income women from Boston, Chicago, and San Antonio.

OBJECTIVES: We examined the long-term health consequences of relationship violence in adulthood. METHODS: Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables. RESULTS: Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health. CONCLUSIONS: Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.

Employment, marriage, and inequality in health insurance for Mexican-origin women.

In the United States, a woman health insurance coverage is largely determined by her employment and marital roles. This research evaluates competing hypotheses regarding how the combination of employment and marital roles shapes insurance coverage among Mexican-origin, non-Hispanic white, and African American women. We use data from the 2004 and 2006 March Supplements to the Current Population Surveys. Results show that these roles largely substitute for each other among non-Hispanic white and African American women, although marriage generally increases the odds of coverage slightly more than employment among non-Hispanic white women. In contrast, these roles cumulatively increase those odds among Mexican-origin women. Yet neither employment, nor marriage, nor their combination assures their coverage. Married Mexican-origin women are particularly disadvantaged. As women increasingly spend a smaller fraction of their lives in marriage, and as relatively few women are in benefits-rich occupations, stable and equitable coverage may require a universal health insurance system.

Subjective control and health among Mexican-origin elders in Mexico and the United States: structural considerations in comparative research.

OBJECTIVES: This study examines the joint impact of psychological and structural factors on Mexican and Mexican American elders' sense of personal control over important aspects of their lives and health in Mexico and the United States. METHODS: We employ the Mexican Health and Aging Study (MHAS) and the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) to explore patterns of association among structural factors, personal characteristics, indicators of material and physical vulnerability, and expressed locus of control. RESULTS: The results suggest that an older individual's sense of personal control over important aspects of his or her life, including health, reflects real material and social resources in addition to individual predispositions. In Mexico, only the most privileged segment of the population has health insurance, and coverage increases one's sense of personal control. In the United States, on the other hand, Medicare guarantees basic coverage to the vast majority of Mexican Americans over 65, reducing its impact on one's sense of control. DISCUSSION: Psychological characteristics affect older individuals' sense of personal control over aspects of their health, but the effects are mediated by the economic and health services context in which they are expressed.

Relationship violence and frequency of intoxication among low-income urban women.

Using data from the Welfare, Children, and Families project (1999), a probability sample of 2,280 low-income women with children living in low-income neighborhoods in Boston, Chicago, and San Antonio, we examine the effects of relationship violence before age 18 and in the past year on frequency of adult intoxication. Results obtained from a series of ordered logistic regression models suggest that sexual coercion before age 18 and minor and severe physical assault in the past year are independently associated with greater frequency of intoxication, net of a range of sociodemographic controls. The study's limitations are noted.

Structural and cultural factors in successful aging among older Hispanics.

Successful or healthful aging are terms that draw attention to life course issues related to individual, physical, and psychologic development and maturation, but they also draw attention to the material basis of successful aging and the social structures that determine one's place in the social hierarchy. This article focuses on barriers to optimal aging for Hispanics, especially those of Mexican origin, and argues that cultural factors and social class are closely associated. The reduction of health disparities and equity in medical and long-term care requires an understanding of both cultural and material sources of differential health levels.