Chapter 4. Priority Populations (continued)

Asians

Previous NHDRs showed that Asians had similar or better quality of care than Whites but worse access to care than Whites for many measures that the report tracks. Findings based on core report measures of quality and access to health care that support estimates for either Asians or Asians and Pacific Islanders (APIs) in aggregate are shown below.

Figure 4.3. Asians compared with Whites on measures of quality and access

Better = Asians receive better quality of care or have better access to care than Whites.
Same = Asians and Whites receive about the same quality of care or access to care.
Worse = Asians receive poorer quality of care or have worse access to care than Whites.
Key: CRM = core report measures (Table 1.2).
Note: Data presented are the most recent available.

Table 4.5. Asians compared with Whites on measures of quality and access for most current data year: Specific measures

Figure 4.4. Change in Asian-White disparities over time

Improving >5% = Asian-White difference becoming smaller at an average annual rate greater than 5%.
Improving 1-5% = Asian-White difference becoming smaller at an average annual rate between 1% and 5%.
Same = Asian-White difference not changing.
Worsening 1-5% = Asian-White difference becoming larger at an average annual rate between 1% and 5%.
Worsening >5% = Asian-White difference becoming larger at an average annual rate greater than 5%.
Key: CRM = core report measures (Table 1.2).
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 36 core report measures could be tracked over time for Asians and Whites.

Table 4.6. Change in Asian-White disparities over time: Specific measures

Note: Measures in bold indicate improvement or worsening at a rate of greater than 5% per year.

Focus on Asian Subpopulations

The Asian population in the United States is highly heterogeneous. The term "Asian" refers to people who identify their country of origin as being located in East Asia, Southeast Asia, or the Indian subcontinent. These include people from Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.⁸ In 2008, Asians represented an estimated 4.5% of the U.S. population, or 13.5 million people.⁹ According to 2000 census data, approximately 23% of Asians identified themselves as Chinese, 20% Filipino, 16% Asian Indian, 10% Korean, and 9.7% Japanese.⁸

Research has shown that within-category variation (that is, variation between Asian subpopulations) is sometimes as large as the differences between Asians and Whites.^10,11 To show differences within racial groups, this year's NHDR includes information from the California Health Interview Survey (CHIS) on Asian subpopulations in California. The geographic distribution of Asian subpopulations allows for such comparisons in California using CHIS data.

In 2008, an estimated 4.6 million people, or about 34% of the Asian population in the United States, lived in California.⁹ The proportion of many Asian subpopulations residing in California is also greater than the proportion in the overall U.S. population. For example, the Vietnamese population is 1.3% of California's population compared with only 0.4% of the U.S. population, and the Filipino population is 2.7% of California's population compared with only 0.7% of the U.S. population. This finding is especially important when examining data for these relatively smaller groups, as most national data sources do not have sufficient data to report estimates for these groups. Selected CHIS measures are presented here, including colorectal cancer screening, influenza vaccinations, uninsurance, and provider-patient communication.

The data show that disparities for Asians exist, not only in comparison with Whites but also between Asian subgroups (Chinese, Filipino, Japanese, Korean, Vietnamese, and South Asian) and across Asian subgroups by income and insurance status. Differences in English proficiency and place of birth are also significant. The following section shows only some of the significant disparities for these groups in California from CHIS data. The selected measures in this section are limited to a subset of measures available to supplement the existing national measures used in the report.

Figure 4.5. Adults age 50 and over who received a sigmoidoscopy, colonoscopy, or fecal occult blood test in the past 5 years, by race, Asian subgroup, and income; by insurance status; by Asian subgroup, stratified by education; by English proficiency; and by place of birth, California only, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults age 50 and over in California.

Note: Data were statistically unreliable for poor Japanese, middle-income Vietnamese, poor, low-income, and middle-income South Asians, Filipino and Japanese with less than a high school education, and South Asians with less than a high school education and high school graduates.

• The percentage of adults age 50 and over who had colorectal cancer screening within the past 5 years was lower overall for Asians compared with non-Hispanic Whites in California (60.6% compared with 69.2%; Figure 4.5). This percentage was also lower for Chinese people (58.8%), Koreans (54.0%), and Vietnamese people (55.0%) compared with non-Hispanic Whites (69.2%).
• Among Asians, the percentage was lower for people with public insurance and people without insurance compared with people with private insurance (46.1% and 32.4%, respectively, compared with 63.7%).
• Among Asians, the percentage was lower for poor people and low-income people compared with high-income people (51.3% and 48.7%, respectively, compared with 68.0%). There were no statistically significant differences by racial subgroups within each income group.
• Among Asians, the percentage was lower for people with less than a high school education and high school graduates compared with people with at least some college education (48.7% and 52.9%, respectively, compared with 66.3%). There were no statistically significant differences by racial subgroups within each education group.
• Among Asians, the percentage of adults age 50 and over who had colorectal cancer screening within the past 5 years was lower for people who did not speak English well or did not speak English at all than for native English speakers (49.6% compared with 71.3%).
• Among Asians, the percentage of adults age 50 and over who had colorectal cancer screening within the past 5 years was lower for people who were not born in the United States than for people who were born in the United States (58.9% compared with 70.7%).

Figure 4.6. Adults age 65 and over who received influenza vaccination in the past year, by race, Asian subgroup, and English proficiency, California only, 2003, 2005, and 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2003, 2005, and 2007.
Denominator: Civilian noninstitutionalized adults in California age 65 and over.
Note: Data were statistically unreliable for Korean and Vietnamese groups in 2003 and for South Asians.

• In California, the percentage of adults age 65 and over who received an influenza vaccination decreased overall (from 73.9% to 68.9%; Figure 4.6). The percentage was not significantly different from 2003 to 2007 for all groups except for adults who did not speak English well or did not speak English at all. This group experienced a decrease (from 85.3% to 75.2%).
• There were no statistically significant differences within Asian ethnic subgroups.

Figure 4.7. People under age 65 uninsured all year, by race and Asian subgroup, California only, 2001, 2003, 2005, and 2007; by Asian subgroup, stratified by income; by English proficiency; and by place of birth, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2001, 2003, 2005, and 2007.
Denominator: Civilian noninstitutionalized population under age 65 in California.
Note: Income data did not meet criteria for statistical reliability for middle-income Chinese people, Filipinos, and Japanese, Vietnamese, and South Asian groups. No data for Japanese people met criteria for statistical reliability.

• While the overall percentage of Californians uninsured all year decreased from 2001 to 2007 (from 12.4% to 11.2%), there were no significant changes for any Asian ethnic subgroup (Figure 4.7).
• In 2007, nearly twice as many Asian as White Californians were uninsured all year (10.8% of Asians compared with 5.8% of Whites). Among Asian ethnic subgroups, Koreans had the highest percentage of people uninsured all year: about five times as high as Whites (31.7% compared with 5.8%). Vietnamese people were uninsured at a rate about twice as high as Whites (12.3% compared with 5.8%).
• Among Asians, people with middle income experienced an increase in the percentage who were uninsured all year (from 12.2% to 19.0%), as did people who were born in the United States (from 3.3% to 6.2%) (data not shown).
• In 2007, among Asians, the percentage of people uninsured all year was higher for poor people (22.3%), low-income people (20.2%), and middle-income people (19.0%) than for high-income people (5.0%).
• Among Asians, the percentage uninsured all year was higher for people who spoke English well or very well (13.6%) and for people who did not speak English well or did not speak English at all (24.5%) than for native English speakers (3.8%).
• Among Asians, the percentage of people who were uninsured all year was higher for people who were not born in the United States than for people who were born in the United States (13.7% compared with 6.2%).

Figure 4.8. Adults age 18 and over who reported difficulty understanding their doctor during their last visit within the past 2 years, California only, by race, Asian subgroup, income, and insurance status, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults in California age 18 and over.
Note: Income groups are all Asian. Data did not meet criteria for statistical reliability for Filipino, Japanese, and Korean groups.

• Overall, Asians were more likely than Whites to have difficulty understanding their doctor (5.5% compared with 2.6%; Figure 4.8).
• Among Asian subgroups, Vietnamese people had a higher percentage of patients who had difficulty understanding their doctor than Whites (23% compared with 2.6%).
• Among Asians, poor people (11.8%), low-income people (8.4%), and middle-income people (8.2%) were more likely than high-income people (3.0%) to have difficulty understanding their doctor.
• Among Asians, those with public insurance were more likely to have difficulty understanding their doctor than those with private insurance (13.3% compared with 3.7%).

Figure 4.9. Adults age 18 and over who reported language as the reason they had difficulty understanding their doctor during their last visit within the past 2 years, California only, by race, Asian subgroup, income, and insurance status, 2007

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2007.
Denominator: Civilian noninstitutionalized adults in California age 18 and over.
Note: Income groups are all Asian. Data did not meet criteria for statistical reliability for Filipino, Japanese, Korean, low-income groups, and uninsured Asians.

• Asians had a higher percentage than non-Hispanic Whites of adults who reported language as the reason they had difficulty understanding their doctor during the last visit (2.7% compared with 1.5%; Figure 4.9).
• Among Asian subgroups, Vietnamese people had a higher percentage than Whites of adults who reported language as the reason they had difficulty understanding their doctor during the last visit (8.8% compared with 1.5%).
• Among Asians, poor people had a higher percentage than high-income people of adults who reported language as the reason they had difficulty understanding their doctor during the last visit (5.9% compared with 1.6%).
• Among Asians, people with public insurance had a higher percentage than people with private insurance of adults who reported language as the reason they had difficulty understanding their doctor during the last visit (6.4% compared with 1.6%). 

Native Hawaiians and Other Pacific Islanders

The ability to assess disparities among NHOPIs for the NHDR has been a challenge for two main reasons. First, the NHOPI racial category is relatively new to Federal data collection. Before 1997, NHOPIs were classified as part of the Asian and Pacific Islander racial category and could not be identified separately in most Federal data. In 1997, the Office of Management and Budget promulgated new standards for Federal data on race and ethnicity and mandated that information about NHOPIs be collected separately from information about Asians.⁷ However, these standards have not yet been incorporated into all databases. Second, when information about this population was collected, databases often included insufficient numbers of NHOPIs to allow reliable estimates to be made.

Due to these challenges, in previous NHDRs estimates for the NHOPI population could be generated for only a handful of measures. A lack of quality data on this population prevents the NHDR from detailing disparities for this group. This year, the NHDR features data from the Behavioral Risk Factor Surveillance System (BRFSS) to supplement the NHDR information for the NHOPI population. Preventive care and access to care measures were selected to highlight quality of care for people who identified themselves as NHOPI (including people of mixed race who identified primarily as NHOPI). This year, the measures include cholesterol screening, colorectal cancer screening, pneumonia admissions, and cost as a barrier to medical care.

Data from BRFSS do not replace the need for continued efforts to improve data collection and statistical methods to provide more information on health and health care of the NHOPI population. BRFSS may have larger samples of NHOPIs due to State efforts to improve sample sizes, but it is not necessarily a comprehensive survey of health and health care. Other surveys and data collection efforts, such as vital statistics and hospital administrative data, include more topics but do not identify NHOPIs or have large enough sample sizes to provide data for these populations.

For all national data sources, the relatively small population sizes of many Pacific Islander groups can cause these populations to be overlooked when categorized as NHOPIs. In addition, identifying individuals with chronic conditions or other health conditions within such small populations further reduces the sample sizes that exist. However, as data become available, this information will be included in future reports.

Preventive Care: Cholesterol Screening

In the State of Hawaii, where 54% of Native Hawaiians reside, cardiovascular disease is the leading cause of death.¹² Screening for risk factors for cardiovascular disease, such as high blood pressure and high cholesterol, is important in preventing disease. Cholesterol screening is shown below to highlight one aspect of cardiovascular disease prevention for Native Hawaiians.

Figure 4.10. Adults who did NOT receive a cholesterol check in the last 5 years, Hawaii only, 2005 and 2007

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2005 and 2007.
Note: These data are self-reported from a survey of adults in a household.

• In 2005 and 2007, the percentage of adults who did not receive a cholesterol check in the last 5 years was significantly higher for NHOPIs than for Whites (34.8% compared with 24.6% in 2005 and 28.7% compared with 22.1% in 2007) (Figure 4.10).

Preventive Care: Colorectal Cancer Screening

Ensuring that all populations have access to appropriate cancer screening services is a core element of reducing cancer health disparities.¹³ Screening for colorectal cancer—including fecal occult blood test, sigmoidoscopy, and colonoscopy—is an effective way to reduce new cases of late-stage disease and mortality caused by this cancer. Although colorectal screening for Native Hawaiians has increased in the past 6 years, rates have remained lower than the State average in Hawaii.¹⁴ Below are supplemental national BRFSS data for the NHOPI population.

Figure 4.11. Adults age 50 and over who did NOT receive a blood stool test in the past 2 years or sigmoidoscopy or colonoscopy ever, Hawaii only, 2008

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2008.
Note: These data are self-reported from a survey of adults in a household.

• The percentage of adults age 50 and over who did not receive colorectal cancer screening was higher for NHOPIs than for Whites (39.3% compared with 30.4%; Figure 4.11).

Treatment: Pneumonia

High rates of hospitalizations for pneumonia may indicate poor outpatient care and low vaccination rates. NHOPIs have more hospital admissions for bacterial pneumonia than Whites. The problem appears to be worse for Pacific Islanders other than Native Hawaiians.

Figure 4.12. Bacterial pneumonia admissions per 100,000 population, age 18 and over, Hawaii only, by race and racial subgroups, 2006

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases, 2006, and AHRQ Quality Indicators, version 3.1.
Note: Excludes sickle cell or hemoglobin-S conditions, transfers from other institutions, and obstetric admissions. Rates are adjusted by age and gender using the total U.S. population for 2000 as the standard population. Data for Blacks did not meet the criteria for statistical reliability, data quality, or confidentiality.

• In 2006, NHOPIs had a higher rate of hospital admission with bacterial pneumonia than Whites (323.4 per 100,000 population compared with 254.4 per 100,000 population; Figure 4.12).
• Other Pacific Islanders had a significantly higher rate of hospital admission with bacterial pneumonia than Whites (1,371.4 per 100,000 population compared with 254.4 per 100,000 population).
• There were no statistically significant differences between Native Hawaiians and Whites.

Access to Care: Medical Costs

High premiums and out-of-pocket payments can be significant barriers to accessing needed medical treatment and preventive care. Studies show that racial and ethnic minorities are more likely to face barriers due to cost of care than other groups.^15,16

Figure 4.13. Adults who needed to see a doctor in the past year but could not because of cost, Hawaii only, 2007 and 2008

Key: NHOPI = Native Hawaiian or Other Pacific Islander.
Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2007-2008.
Note: These data are self-reported from a survey of adults in a household.

• The percentage of adults who needed to see a doctor in the past year but could not because of cost was higher for NHOPIs than for Whites in both 2007 and 2008 (Figure 4.13).

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