Barriers to Healthcare Among Asian Americans

Abstract

The myth of the well-adjusted Asian American resulted from sample-biased research studies that concluded that Asian Americans are physically healthier and financially better off than Caucasians. The myth has been perpetuated by researchers who have often categorized Asian Americans as a single, undifferentiated group rather than as distinct ethnic groups. Consequently, data analysis techniques do not reveal distinctions that may exist had the researchers controlled for ethnic group variation. The authors discussed four major barriers—language and culture, health literacy, health insurance, and immigrant status—to healthcare that may influence within-group disparities among Asian Americans that may go unreported. The authors argue that healthcare policy makers and researchers should consider Asian Americans as members of discrete ethnic groups with unique healthcare needs. Recommendations for health policies and future research are provided.

KEYWORDS:

• Asian Americans
• access to healthcare
• health literacy
• immigrant health
• health disparities

Introduction

The utilization of healthcare services by any group is determined by calculating the ratio of the number of group members who receive healthcare services against the number of group members within the population at large (Snowden, Collinge, & Runkle, 1982). Parity of service use is achieved when the ratio of the group receiving the service is the same as the ratio for the members within the population at large. In the past few decades, research has documented the disparities in healthcare service use by race, whereby Caucasians consistently have greater access to healthcare and enjoy better health than their non-Caucasian counterparts. Although there are many racial and ethnic minority groups, much of the research has focused on differences between Caucasian Americans and African and Hispanic Americans.

Although research studies have explored important aspects of racial and ethnic health disparities, many of the studies categorized diverse subgroups under one racial category, thus ignoring important within–race group and–ethnic group variation. Asian Americans comprise multiple ethnic groups that have been found to underutilize healthcare services compared to their Caucasian counterparts (Snowden et al., 1982; Takada, Fort, & Lloyd, 1998). Existing research, however, has largely considered Asian Americans as one monolithic group that has been faring better than the general population, rather than as separate and unique groups with their own healthcare needs. Within-group diversity is not an exclusive characteristic of Asian Americans. In recent years, many researchers have begun to investigate the diversity within racial/ethnic groups that historically have been treated as homogeneous groups, such as Hispanic and African Americans.

The purpose of this article is to discuss barriers to healthcare for Asian Americans and to provide policy and research recommendations that will benefit people of all Asian American ethnic groups. The discussion will focus on major barriers to healthcare among Asian Americans groups, including language and culture, health literacy, insurance, and immigrant status. These barriers will be discussed against the backdrop of the Asian American myth, which puts forth that all people from Asian backgrounds are better off than are other groups with respect to their healthcare.

DIVERSITY AMONG ASIAN AMERICANS AND ITS RESEARCH IMPLICATIONS

Asian Americans are among of the fastest growing ethnic groups in the United States. According to the 2000 U.S. Census, approximately 13.1 million individuals (4.2% of the American population) self-identify as Asian American. The number of Asian Americans is expected to increase to 33.4 million (8% of the American population) by 2050 (U.S. Census Bureau, 2004a). Despite the rapid increase, there is a dearth of knowledge on the issues related to healthcare use among various Asian American ethnic groups.

Language has been a continuing issue in conducting research on Asian Americans. Due to their limited English-speaking skills, recent Asian immigrants may not be able to adequately answer survey questions and thus either refuse or are considered ineligible to participate in health research studies. As a result, much of the research on Asian Americans includes English-speaking and well-acculturated individuals, who have more education, better insurance, and higher incomes than the nonrespondents. Consequently, the existing national data sets are unrepresentative of all Asian Americans (Takada et al., 1998). The sampling bias, in turn, perpetuates the myth of the well-adjusted Asian American.

Due in part to the limitations of existing research, many Asian Americans ethnic groups have not been represented in existing research and have thus been deprived of potential help from the U.S. government (Fong & Mokuau, 1994). A bimodal pattern has emerged in which several ethnic Asian American groups are faring better than others. With respect to poverty, Japanese and Filipino Americans have much lower poverty rates than their Caucasian counterparts, while other Asian American groups such as Cambodians, Hmongs, Laotians, and Vietnamese Americans have much higher poverty rates (Niedzwiecki & Duong, 2004).

Other problems in carrying out research on Asian Americans are the methodological difficulties inherent in studying them. Included with these difficulties is the relatively small number of Asian Americans in some ethnic groups. Although they form one of the fastest growing populations in the United States, there are only small numbers of different ethnic Asian American groups who have been living in the United States for more than one or two generations. As such, it can be difficult for researchers to find ethnic enclaves of Asian Americans. Another reason for the limited knowledge of Asian American health is the diversity within each Asian American ethnic group. Researchers have identified between 27 and 32 unique Asian American groups in the United States that fall under the umbrella of “Asian/Pacific Islanders.” Consequently, due to the relatively small number of people in some of the other ethnic groups, differences in their language, and their wide geographic dispersion, it is extremely difficult to come up with a representative sample.

Because of the sampling issues, most of the help-seeking behavior and health service use studies on Asian Americans have been limited to either small and regional samples or service use data (Cheung & Snowden, 1990). To overcome the difficulties in sampling and recruitment, researchers often choose samples from one Asian American group (Kim, 2002). In turn, researchers may extrapolate from their findings to form a model they believe is representative of all Asian Americans. This limitation not only fails to flush out differences among the Asian American groups not being studied, but the one group under study is unlikely to be representative of its own ethnic Asian American population. Moreover, the extant studies on the health of Asian Americans have been limited unless the researchers intentionally invest in bilingual interviewers. While considering the fact that language proficiency is a proxy measure for acculturation, Asian Americans whose English skills are sufficient for research may have biased the results, thus indicating that all Asian Americans are better off than Caucasians and other racial and ethnic groups. Considering the above limitations, researchers who review Asian American healthcare issues need to exercise caution when pointing out the implications and limitations of the research.

BARRIERS TO HEALTHCARE

Language/Culture

Language has been identified as the most formidable barrier for Asian American immigrants in accessing healthcare (Mayeno & Hirota, 1994). Language is not only a measure of adjustment but also a means to adjust to a new environment. Many Asian Americans who are not proficient in English experience barriers in help-seeking, including making an appointment, locating a health facility, communicating with health professionals, and acquiring knowledge on illness. The language barrier is a particular obstacle for elderly Asian Americans, who are the least likely to be proficient in English (Jones, Chow, & Gatz, 2006).

The lack of language proficiency may bring about role disruptions in Asian American families. Children of recent immigrants tend to speak, read, and understand English better than their parents do and, as such, are often burdened with the duty of being the family translator when dealing with family illnesses (Lauderdale, Wen, Jacobs, & Kandula, 2006). This temporarily reversed family role creates awkward situations in the healthcare setting: no matter how fluent the children are in English, their role as children predominates and as such they may feel uncomfortable facilitating their elder family members' healthcare decisions.

Moreover, although interpreter services may be available and helpful, people with limited English-speaking skills tend to refrain from asking questions about their health. In fact, Green et al. (2005) found that Chinese and Vietnamese patients with limited English-speaking skills appeared to refrain from asking questions about their health, compared to their counterparts with better skills. Interpreter services do not necessarily mean that the immigrant patient will procure quality care, as many individuals who must rely on interpreters fear that the interpreter will not respect their confidentiality within the larger Asian American community.

The presence of an expert who understands Asian American culture and expressions of illness can help remove the barriers to healthcare. In fact, Asian Americans' perceptions of cultural, gender, and linguistic sensitivity have been found to predict more help-seeking behavior, even when controlling for insurance coverage (Fung & Wong, 2002). However, culturally responsive service can be a double-edged sword and, as such, cultural understanding is not a panacea for improving healthcare for Asian Americans. In an HIV/AIDS project in New York City, providers' cultural literacy ensured that they were being understood even without speaking. This comfort, however, can come with a fear of lack of confidentiality due to the tight social networks of Asian communities (Chin, Kang, Kim, Martinez, & Eckholdt, 2006).

Health Literacy

A related issue to language and culture is health literacy, which includes the ability not only to read health content but also to understand the content in the context of specific health situations. Such situations include understanding instructions on prescription drug labels, appointment slips, health education fliers, physician's directions and consent forms, and complex healthcare systems. The National Library of Medicine reports that the definition of health literacy is not simply the ability to read health literature but also the ability to use analytic and decision-making skills in healthcare situations (Sullivan & Glassman, 2007).

Asian Americans have been found to have limited health literacy and often to have erroneous beliefs regarding disease that in turn can prevent them from seeking healthcare services, thus leading to poorer health outcomes (Jones et al., 2006; Juon, Kim, Shankar, & Han, 2004). Additionally, if the prevalent belief based on studies with nonrepresentative samples is that Asians rarely have breast cancer, Asian immigrant women might not seek regular screenings. In the case of Korean Americans, Juon et al. (2004) found that only 14.8% of Korean immigrant women aged 65 and older had heard of mammography screenings, compared to 40.9% of Caucasian women of the same age. The first generation of Asian Americans, especially the elderly, tends to hold different beliefs on healthcare. For example, many seek healthcare only when their symptoms are severe enough as not to be resolved with standard preventive care (Han, Kang, Kim, Ryu, & Kim, 2007).

Health Insurance

Health insurance serves as a major gatekeeper to accessing care. Most industrialized countries place a high value on equality in their healthcare system, with cultural sensitivity being an important issue (Donnelly, 2006). In the United States, however, there is not as great a focus on parity in healthcare among all groups, as in other countries, thus leading to health disparities regarding which individuals and groups receive healthcare. Despite the public's view of Asian Americans as the financially well-to-do “model minority,” the poverty rate for Asian Americans as a group is actually higher than that of Caucasians (U.S. Census Bureau, 2004b).

Moreover, employment is not the best predictor of health insurance for Asian Americans. Although unemployment rates among Asian Americans are relatively low, many Asian Americans do not have health insurance. This is because many Asian Americans work for small businesses or have multiple low-wage jobs, which typically do not offer health insurance (Takada et al., 1998). In fact, whereas approximately 26% of all Americans are covered by employer-sponsored health insurance, only 6% of Asian Americans are covered by employer-sponsored health insurance (U.S. Census Bureau, 2007). Further, there is an insurance loophole into which many self-employed Asian Americans fall: they earn too much money to qualify for government-sponsored health insurance programs and yet too little to purchase private insurance. As such, Asian Americans from the lowest socioeconomic strata may have a better chance of being insured than do those with higher incomes. For example, Southeast Asian refugees who are relatively less well off than other Asian ethnic groups had greater access to health insurance coverage because, as refugees, they qualify for government-sponsored insurance (Mayeno & Hirota, 1994). Additionally, Asian Americans with certain demographic characteristics, specifically young, unmarried, non–English-speaking Chinese American females, were found to have healthcare access problems (Ying & Miller, 1992). In a recent national survey of Asian Americans, Alegría et al. (2006) found that 8.3% of Asian Americans received public health insurance, whereas the U.S. Census data demonstrated that 18.6% of Asian Americans received public health insurance (U.S. Census Bureau, 2007). The source of this discrepancy is not clear and requires further investigation.

There are also discrepancies between the national data set and local surveys. The National Latino and Asian American Survey, the most comprehensive and recent national study, concluded that 14.4% of Asian Americans are uninsured, with Vietnamese having the highest rate at 20.2% (Alegría et al., 2006). However, local surveys present a different picture. For instance, more than 50% of Korean Americans in Los Angeles and 41% in Chicago, 35% of Chinese Americans in Oakland, 37% of Southeast Asians in San Diego, 15% of Vietnamese Americans in San Francisco (Alegría et al., 2006), and 21% of Asian women in Southern California (Mayeno & Hirota, 1994) indicated that they did not have any health insurance.

Uninsured or inadequately insured Asian Americans may resort to less costly alternative medicine. Asian Americans are likely to be knowledgeable about alternative medicine as an option, substitute, or complementary treatment, and many have found it to be effective. For example, acupuncture and herbal medicine are still considered the best means to treat certain types of illnesses such as sprained ankles, nerve problems, or mental illnesses not recognized by Western medicine (Donnelly, 2006). Most forms of alternative medicine have been used for thousands years and have been found to relieve pain, treat illness, and save lives. Because alternative medicine can produce undesirable side effects or complications when combined with other treatments, the use of alternative medicine can become problematic when patients and their families use alternative medicine without telling their physicians. Further, research has not sufficiently addressed the interactions between alternative and Western medicine. Because some forms of alternative medicine are underregulated in the United States, the quality of treatment is potentially dubious. Accordingly, comprehensive community health education is needed for Asian American ethnic communities to understand that alternative medicine is not a substitute; rather, it should be used with caution. Overall, health insurance information on Asian Americans is not conclusive. Considering the significance of health insurance in healthcare access, these issues need to be investigated further to enhance access to healthcare for Asian Americans.

Immigrant Status

Asian Americans comprise three distinct immigration groups: those who voluntarily chose to come to the new country, refugees who were forced to leave their homeland because of war or political persecution, and decedents of immigrants (Mayeno & Hirota, 1994). The data on actual health service use provide evidence of factors that impede Asian American immigrants from receiving healthcare. Moreover, immigration status has been an important criterion for many healthcare benefits, whereby undocumented immigrants encounter significantly more barriers than documented immigrants in receiving healthcare.

The Immigration Act of 1965 is considered a tipping point that led to the influx of Asian Americans into the United States (Reimers, 1985). Under the act, 170,000 immigrants from countries in the Eastern Hemisphere (for example, people from Asian countries) are granted residence, with no more than 20,000 per country. Prior to the immigration act, the McCarran-Walter Act of 1952 granted residence to only 2,990 Asian immigrants per year (Kutler, 2003). This dramatic change led to the influx of Asian Americans into the United States.

Many researchers found an inverse relationship between years of residence and health status among foreign-born Americans (Frisbie, Cho, & Hummer, 2001; Uretsky & Mathiesen, 2007). Two other hypotheses have been proposed to explain the effect of immigration on health. The “selective immigration hypothesis” holds that those who decided to embark on the adventure of immigrating to the United States aspire to be successful and as such are strongly motivated and mentally and physically in better shape than those who have been living in the country to which they immigrated. Consequently, the immigrant group does not use services because the members do not need them. This hypothesis argues that although the majority of Asian Americans come from economically less privileged countries, their health is much better than those who remained in their homeland. However, as they live longer in the host country, the positive effects wear off and the differences between immigrants and those who are native to the new country disappear. Empirical evidence suggests that Asian Americans, like other immigrant ethnic/racial groups, tend to have poorer health and frequent hospitalizations (Frisbie et al., 2001). In comparison, the “salmon bias hypothesis” focuses on the differences between returning and remaining immigrants. It argues that unhealthy, unemployed, and unsuccessful immigrants may choose to return to their country of origin (Uretsky & Mathiesen, 2007), thus leaving their healthier expatriates in the host country.

Illegal Asian immigrants experience other health access problems. Due to their illegal immigrant status, most of them are not allowed to hold jobs that offer health insurance or purchase health insurance policies and do not qualify for government-sponsored insurance. To date, most of the studies on health insurance coverage focus on Asian Americans who have legal residence, thus limiting our understanding of healthcare for Asian Americans residing in the United States illegally.

RECOMMENDATIONS FOR HEALTH AND SOCIAL POLICY AND FUTURE RESEARCH

In order to develop health and social policies that address the issue of underutilization of healthcare services among Asian Americans, health and social policy analysts must make a significant effort to take into account patient characteristics such as primary language, ethnicity (Ray-Mazumder, 2001), culture, health literacy, insurance coverage, and immigrant status. Policy analysts and health researchers need to familiarize themselves with the emotional, psychological, and physical aspects of Asian American cultures including the vast diversity between groups. Without knowing the origin and nature of health behavior, it is impossible to develop health policies that are relevant to the needs of the various Asian American groups. It is also imperative for health policy analysts to pay extra attention to the social and political environments of the immigrants' homeland and the changes in immigration laws. The legal status of an individual directly affects her or his employment opportunities, insurance coverage, and therefore health options. Developing greater sensitivity in these areas will lead to richer foundations on which to build research and health policy agendas to enhance healthcare for Asian Americans.

The presence of healthcare experts who are knowledgeable about Asian American culture and social conditions can help remove, or mitigate, the effects of the barriers to healthcare for Asian Americans. Asian Americans' perceptions of a health provider's cultural, gender, and linguistic sensitivity have been found to predict greater help-seeking behavior, even when controlling for insurance coverage (Fung & Wong, 2002). This example can be expanded to the societal level so that Asian Americans' perception of society's cultural and linguistic responsiveness would increase the opportunity and eventually the quality of healthcare for Asian Americans.

Healthcare issues for Asian Americans cannot be conceptualized without considering healthcare for all Americans. Legislative bodies in the United States have historically avoided addressing equal access to healthcare. Consequently, the United States has remained the only industrialized country without universal healthcare for its citizens. Healthcare has been left in the hands of others, which in turn results in unequal access to healthcare services. Providing culturally competent healthcare services and conducting comprehensive research studies on Asian American ethnic group members and healthcare programs that reach out to people with limited health literacy and resources will eliminate the myth of the well-adjusted Asian American and warrant equal access to healthcare. In the long run, “healthy Asian Americans” is a necessary condition to build a stronger healthcare system in the United States.