Inability to Access Needed Medical Care Among Asian American, Native Hawaiian, and Pacific Islander Medicaid Enrollees

Abstract

We examined self-reported inability to access to needed medical care and reasons for not accessing medical care among US-representative adult Medicaid enrollees, disaggregated across ten Asian American, Native Hawaiian, and Pacific Islander ethnic groups. Chinese (−4.54 percentage points [PP], p<0.001), Other Asian (−4.42 PP, p<0.001), and Native Hawaiian (−4.36 PP, p<0.001) enrollees were significantly less likely to report being unable to access needed medical care compared to non-Hispanic White enrollees. The most common reason reported was that a health plan would not approve, cover, or pay for care. Mitigating inequities may require different interventions specific to certain ethnic groups.

Introduction.

Asian American, Native Hawaiian, and Pacific Islander peoples, who make up 7% of the US population, face structural barriers to accessing necessary medical care, including higher rates of poverty, more experiences of racism, and limited availability of culturally and linguistically appropriate care (Adia et al., 2020; McMurtry et al., 2019; Shimkhada et al., 2021).

Though often aggregated into a single racial category, the Asian American, Native Hawaiian, and Pacific Islander population is diverse, and comprised of more than 50 ethnic groups (e.g., Chinese, Vietnamese, Guamanian) speaking more than 100 languages (Chin, 2017). As such, reporting health data that aggregates Asian American, Native Hawaiian, and Pacific Islander people of all ethnic groups may mask inequities. Recent studies suggest that the disaggregation of health data into ethnic groups can identify crucial inequities in health insurance coverage and access to care (Nguyen & Trivedi, 2019; Park et al., 2018). The California Health Interview Survey (CHIS), a population-based survey that has collected data disaggregated by ethnic groups, has often been used to identify inequities in health status, health conditions, and access to care for Asian American, Native Hawaiian, and Pacific Islander ethnic groups (Adia et al., 2020; Nguyen & Trivedi, 2019; Ponce, 2020; Shimkhada & Ponce, 2022). For example, studies using CHIS data indicate that compared to non-Hispanic White adults, Korean adults were significantly less likely to report a usual source of care and Chinese adults were significantly less likely to report having a doctor’s visit in the past year (Adia et al., 2020; Nguyen & Trivedi, 2019). Adults from other ethnic groups, such as Vietnamese adults, were significantly less likely to delay necessary care compared to non-Hispanic adults (Nguyen & Trivedi, 2019). It is unknown, however, whether differences by ethnic group among Californians contrast with national estimates. Further, while many studies have documented self-reported inequities in access to care for Asian American, Native Hawaiian, and Pacific Islander people, few have examined self-reported reasons for not accessing needed care.

Health insurance coverage has often been cited as one of the primary drivers of worse access to care among low-income Asian American, Native Hawaiian, and Pacific Islander people when compared to individuals from other racial and ethnic groups (Chang & Chan, 2016; Morisako et al., 2017). However, whether inequities in access to care persist among Asian American, Native Hawaiian, and Pacific Islander people with similar health insurance coverage – such as Medicaid – and whether variation exists by ethnic group is unclear. It is particularly crucial to understand inequities within the Medicaid program, which is a federal-state public health insurance program for low-income people in the United States. Among Asian American, Native Hawaiian, and Pacific Islander adult Medicaid enrollees, there is wide variation by ethnic group for reporting a usual source of care, a personal doctor, and timely access to primary and specialty care (Nguyen, Oh, et al., 2022; Oh et al., 2023). For example, compared to non-Hispanic White adult Medicaid enrollees, enrollees who are Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, multiethnic Asian, and other Pacific Islander were all significantly less likely to report timely access to specialty care (Oh et al., 2023). Evaluating variation in additional measures of access to care – such as self-reported inability to access needed medical care and reasons for not accessing medical care – remains an important gap in the literature that may be crucial for developing targeted interventions or policies that advance health equity for Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees (Adia et al., 2020; Morisako et al., 2017).

Our study objectives were to examine differences in self-reported inability to access needed medical care and reasons for not accessing medical care, disaggregated across ten Asian American, Native Hawaiian, and Pacific Islander ethnic groups. To do so, we used a first-of-its-kind survey of Medicaid enrollees’ experiences of care. We present novel findings on self-reported inability to access needed care and reasons for not accessing care to unmask inequities among ten Asian American, Native Hawaiian, and Pacific Islander ethnic groups.

Methods.

We conducted a secondary analysis of the 2014–15 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems (NAM CAHPS), the most recent and only nationally-representative survey of adult Medicaid enrollees and one of the only federally-administered surveys that collected and made available data disaggregated by Asian American, Native Hawaiian, and Pacific Islander ethnic groups (Centers for Medicare & Medicaid Services, n.d.). The NAM CAHPS sample design created four unique, hierarchical beneficiary groupings: full dually eligible adults, adults with disabilities, adults enrolled in a managed care organization, and adults enrolled in a fee-for-service provider or in a primary care case management plan (Centers for Medicaid and CHIP Services, n.d.; Centers for Medicare & Medicaid Services, n.d.). The target population was adults (age 18 and older) who were enrolled in Medicaid in 2013 (Centers for Medicaid and CHIP Services, n.d.).

Study Population.

Our study population included adult Medicaid enrollees aged 18 years and older. We focus on enrollees from eight non-Hispanic Asian American and two non-Hispanic Native Hawaiian or Pacific Islander ethnic groups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Multiethnic Asian, Native Hawaiian, and Other Pacific Islander. Ethnic group was self-reported by survey respondents and respondents could select multiple ethnic groups. Multiethnic Asian category includes enrollees who identified as more than one Asian ethnic group (e.g., Vietnamese and Filipino) (Đoàn et al., n.d.; Nguyen, Oh, et al., 2022). Consistent with previous studies, we excluded enrollees from other racial or ethnic groups (e.g., Black, Hispanic/Latino enrollees) (Adia et al., 2020; Nguyen, Oh, et al., 2022; Nguyen & Trivedi, 2019).

Outcomes.

Our main outcome was self-reported inability to get needed medical care in the last six months. Respondents were asked, “In the last 6 months, were you unable to get medical care, tests, or treatments you or a doctor believed necessary?” and could respond yes or no. Respondents who were unable to access needed care reported reasons, including “couldn’t afford care,” “health plan wouldn’t approve, cover, or pay for care,” or other reason (Appendix Table 1).

We used weighted linear probability models to estimate differences between Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees compared to non-Hispanic White enrollees, first in the aggregate, then disaggregated into ten ethnic groups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Multiethnic Asian, Native Hawaiian, and Other Pacific Islander). Our models adjusted for age, sex, educational attainment, self-reported health status (excellent, very good, good, fair, poor), receipt of assistance completing the survey (reading questions, writing down answers, answering questions on the enrollee’s behalf, translated questions into the enrollee’s language, or other), Medicaid eligibility group (disability, dual eligible, -for-service primary care case management, or Medicaid managed care), and state Medicaid expansion status as of 2014. Covariates were informed by previous work and based on a priori conceptualization of factors that might influence inability to access needed medical care by Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees Analyses were conducted in Stata 15 (StataCorp LLC, College Station, TX). Survey weights were applied to all analyses. (Nguyen, Oh, et al., 2022; Oh et al., 2023). This study was not considered human subjects research, and therefore seeking approval or exemption from the Institutional Review Board was not necessary.

Results.

Our study sample included a total of 136,817 adult Medicaid enrollees, of which 8,817 were Asian American, 1,272 were Native Hawaiian and Pacific Islander, and 126,728 were non-Hispanic White. Respondent characteristics have previously been reported (Nguyen, Oh, et al., 2022; Oh et al., 2023).

In unadjusted models, Asian American, Native Hawaiian, and Pacific Islander adult Medicaid enrollees (aggregated) were significantly less likely to report being unable to access needed medical care (−5.76 percentage points [PP], 95% CI: −7.06, −4.46) compared to non-Hispanic White enrollees (Table 1). Unadjusted, disaggregated analyses revealed that Chinese (−8.55 PP, 95% CI: −10.81, −6.10), Vietnamese (−6.63 PP, 95% CI: −9.65, −3.61), Other Asian (−6.37 PP, 95% CI: −9.21, −3.53), and Native Hawaiian (−5.27 PP, 95% CI: −9.06, −1.49) adult Medicaid enrollees were significantly less likely to report being unable to access needed medical care compared to non-Hispanic White enrollees.

Table 1.

Rates of Self-Reported Inability to Access Needed Medical Care and Unadjusted Differences by Asian American, Native Hawaiian, Pacific Islander and non-Hispanic White Racial or Ethnic Group Among Adult Medicaid Enrollees, 2014–15

	Unadjusted Rates, %	Unadjusted Differences (95% CI)
Non-Hispanic White (Ref)	15.78	Ref
Asian American, Native Hawaiian, and Pacific Islander (aggregate)	10.02***	−5.76 (−7.06, −4.46)***
Asian American	9.78***	−6.00 (−07.33, −4.67)***
Native Hawaiian and Other Pacific Islander	14.69	−1.09 (−6.96, 4.78)
Asian Indian	12.80	−2.98 (−6.49, 0.53)
Chinese	7.32***	−8.45 (−10.81, −6.10)***
Filipino	9.67**	−6.11 (−9.69, −2.52)**
Japanese	15.22	−0.56 (−13.48, 12.36)
Korean	10.89	−4.89 (−9.94, 0.16)
Vietnamese	9.14***	−6.63 (−9.65, −3.61)***
Other Asian	9.41***	−6.37 (−9.21, −3.53)***
Multiethnic Asian	16.04	0.26 (−8.13, 8.65)
Native Hawaiian	10.51**	−5.27 (−9.06, −1.49)**
Other Pacific Islander	16.94	1.16 (−7.56, 9.89)

Notes.

^*p<0.05,

^**p<0.01,

^***p<0.001.

Question asks “In the last 6 months, were you unable to get medical care, tests, or treatments you or a doctor believed necessary?” Statistical significance estimated using unadjusted linear probability models. All analyses apply survey weights.

Estimates attenuated upon adjusting for sociodemographic characteristics, health status, and state policies: in adjusted models, Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees (aggregated) were significantly less likely to report being unable to access needed medical care (−2.74 PP, 95% CI: −4.18, −1.30) compared to non-Hispanic White enrollees (15.76%) (Table 2). In adjusted models disaggregated by ethnic group, Chinese (−4.54 PP, 95% CI: 6.98, −2.11), Other Asian (−4.42 PP, 95% CI: −6.36, −1.43), and Native Hawaiian (−4.36 PP, 95% CI: −8.05, −0.67) enrollees were significantly less likely to report being unable to access needed medical care compared to non-Hispanic White enrollees. Full adjusted regression models are provided in Appendix Table 2.

Table 2.

Adjusted Differences by Asian American, Native Hawaiian, Pacific Islander and non-Hispanic White Racial or Ethnic Group Among Adult Medicaid Enrollees, 2014–15

	Adjusted Differences (95% CI)
Non-Hispanic White (Ref)	Ref
Asian American, Native Hawaiian, and Pacific Islander (aggregate)	−2.74 (−4.18, −1.30)***
Asian American	−2.84 (−4.32, −1.36)***
Native Hawaiian and Other Pacific Islander	−0.96 (−6.12, 4.19)
Asian Indian	−0.73 (−4.19, 2.73)
Chinese	−4.54 (−6.98, −2.11)***
Filipino	−2.29 (−5.92, 1.34)
Japanese	2.13 (−10.31, 14.57)
Korean	−2.09 (−7.38, 3.20)
Vietnamese	−3.14 (−6.36, 0.07)
Other Asian	−4.42 (−7.41, −1.43)**
Multiethnic Asian	2.39 (−5.73, 10.51)
Native Hawaiian	−4.36 (−8.05, −0.67)*
Other Pacific Islander	0.86 (−6.80, 8.52)

Notes.

^*p<0.05,

^**p<0.01,

^***p<0.001.

Question asks “In the last 6 months, were you unable to get medical care, tests, or treatments you or a doctor believed necessary?” Estimates use linear probability models and adjusted models include the following covariates: age, sex, educational attainment, self-reported health status, receipt of assistance completing the survey (reading questions, writing down answers, answering questions on the enrollee’s behalf, translating questions into the enrollee’s language, or other), enrollee eligibility group (persons with disabilities, dual eligible, or other [fee-for-service primary care case management or Medicaid managed care]), and Medicaid expansion status. All analyses apply survey weights.

Reasons for not accessing needed care also varied by ethnic group: most enrollees reported that their health plan would not approve, cover, or pay for care (42.66% for Asian American Medicaid enrollees, 59.33% for Native Hawaiian and Pacific Islander Medicaid enrollees). Rates were highest for Other Pacific Islander (59.66%), Native Hawaiian (58.17%), and Korean (55.76%) enrollees (Table 3). Inability to afford care was less commonly reported for non-Hispanic White (12.21%) and Asian American, Native Hawaiian, and Pacific Islander enrollees (16.88% aggregated). Compared to enrollees from other ethnic groups, Asian Indian (22.28%), Vietnamese (19.09%), and multiethnic Asian (36.02%) enrollees reported relatively higher rates of not accessing needed medical care because they could not afford care.

Table 3.

Reasons for Not Accessing Needed Medical Care by Racial or Ethnic Group Among Adult Medicaid Enrollees, 2014–15

	Couldn’t Afford Care, %	Health Plan Wouldn’t Approve, Cover, or Pay for Care, %	Other Reason, %
Non-Hispanic White	12.21	49.05	27.29
Asian American, Native Hawaiian, and Pacific Islander (aggregate)	16.88	44.01	31.29
Asian American	16.92	42.66	32.92
Native Hawaiian and Other Pacific Islander	16.40	59.33	12.67
Asian Indian	22.28	46.73	27.29
Chinese	17.43	48.58	30.00
Filipino	10.11	31.08	25.84
Japanese	-	10.59	84.37
Korean	-	55.76	34.93
Vietnamese	19.09	42.23	21.16
Other Asian	12.52	47.28	29.64
Multiethnic Asian	36.02	15.45	26.33
Native Hawaiian	12.65	58.17	8.79
Other Pacific Islander	-	59.66	46.54

Notes. “Other reason” includes the following: “Doctor doesn’t speak my language,” “Couldn’t get transportation to doctor’s office,” “Couldn’t take time off work or get child care,” and “Didn’t know where to get care.” The sample size across ethnic groups was too small for these responses. All analyses apply survey weights.

Discussion.

Our findings indicate that among adults with Medicaid coverage, Asian American, Native Hawaiian, and Pacific Islander enrollees were less likely to report not accessing necessary medical care when compared to non-Hispanic White enrollees. Medicaid can be a powerful facilitator of accessing needed health services for low-income Asian American, Native Hawaiian, and Pacific Islander people, despite previously documented challenges in identifying a usual source of care, having a personal doctor, or reporting timely access to specialty care (Chang & Chan, 2016; Nguyen, Oh, et al., 2022; Oh et al., 2023). Further, our findings also identify variation in self-reported barriers to accessing needed care by ethnic group among Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees. Our results provide important baseline estimates for future iterations of the Nationwide Adult Medicaid CAHPS or other patient experience surveys.

Our work has several implications for Medicaid policy and health equity. Mitigating barriers to accessing needed care among Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees may require a combination of state- and plan-level strategies, and it is possible that initiatives may differ by ethnic group (Morisako et al., 2017). For enrollees from several ethnic groups – including Korean, Native Hawaiian, and Other Pacific Islander enrollees – the primary barrier to not accessing needed medical care was that a health plan would not approve, cover, or pay for care. Evaluating state-level utilization management and restructuring benefit design (e.g., services and medications covered) may mitigate inequities in not accessing needed care. Considering most care in the Medicaid program is delivered through Medicaid managed care organizations, efforts to address inadequate benefits may require coordination with managed care plans, particularly in states with higher Medicaid managed care penetration.

For Asian Indian, multiethnic Asian, and Vietnamese enrollees, a common barrier to not accessing needed care was the inability to afford care. One approach for state Medicaid programs or Medicaid managed care plans to mitigate these inequities is to reduce cost sharing requirements (e.g., copays, coinsurance) which, for Medicaid enrollees, may pose substantial financial burdens. Future work may need to more granularly examine the types of health care services – such as prescription drugs, inpatient hospitalizations, or other visits – that have higher financial burden for adult Medicaid enrollees, and whether there is variation by Asian American, Native Hawaiian, or Pacific Islander ethnic group.

More broadly, initiatives aimed at enhancing the availability of patient navigators and racially- or linguistically-concordant health care providers may facilitate access to care, and address language and cultural barriers faced by Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees. For example, some interventions are increasingly invested in community health workers who are tasked with targeting specific groups of interest like Asian American, Native Hawaiian, and Pacific Islander people. Ensuring that outreach from Medicaid agencies to Asian American, Native Hawaiian, and Pacific Islander enrollees is culturally and linguistically appropriate may also be crucial. Continued collection of disaggregated Asian American, Native Hawaiian, and Pacific Islander ethnic group data that is consistent with the Affordable Care Act Section 4302 suggestions on minimum categories of collecting race and ethnicity is crucial for identifying inequities (Evaluation, 2011).

Our study builds upon previous work examining inequities in access to care among adult Medicaid enrollees in three ways: first, some previous analyses using CAHPS survey data have identified differences between non-Hispanic White and Asian American, Native Hawaiian, and Pacific Islander enrollees (aggregated), but did not disaggregate by ethnic group (Barnett et al., 2018; Nguyen, Wilson, et al., 2022). Our study disaggregates outcomes for ten Asian American, Native Hawaiian, and Pacific Islander ethnic groups and identified substantial variation in outcomes. Second, our data includes a nationally representative sample of Medicaid enrollees, thereby mitigating the potential impact of health insurance coverage types (e.g., private health insurance, Medicare, Medicaid, uninsured) as a driver of differential access to care. Our analysis also extends previous work that has examined inequities in experiences of care using a sample of Medicaid managed care enrollees by including other Medicaid population groups (e.g., individuals with fee-for-service primary care case management, individuals with disabilities, and individuals who are dually eligible for Medicare and Medicaid) (Nguyen, Wilson, et al., 2022). Third, few national surveys have collected data on ethnic group and self-reported reasons for not accessing needed care, limiting the availability of nationally-representative estimates. As such, our findings provide novel evidence about the primary reasons adult Medicaid enrollees from different Asian American, Native Hawaiian, and Pacific Islander ethnic groups are unable to access needed care.

Limitations.

Our study has several limitations. First, we could not assess the urgency or type of care that enrollees were unable to access. Additional research is needed on type of care enrollees were unable to access, as well as how self-reported inability to access necessary medical care correlates to measures of utilization. Second, survey participation was based on 2013 Medicaid eligibility and may not reflect experiences today; however, our findings present baseline estimates to inform future work, and this survey remains the only nationally-representative survey of adult Medicaid enrollee experiences with disaggregated Asian American, Native Hawaiian, and Pacific Islander ethnic group data. Third, smaller sample sizes for some ethnic groups limited the examination of reasons for not accessing care. Future research is needed to better understand these other reasons, such as qualitative interviews.

Conclusion.

Despite previously reported inequities in access to care, Asian American, Native Hawaiian, and Pacific Islander Medicaid enrollees were significantly less likely to report being unable to access necessary medical care when compared to non-Hispanic White enrollees, suggesting that Medicaid can facilitate crucial access to low-income Asian American, Native Hawaiian, and Pacific Islander people. Importantly, there was variation in our outcomes by ethnic group. As such, our results underscore the importance of collecting and reporting health and social needs data disaggregated by ethnic group to measure, monitor, and address racial inequities in the Medicaid program (Morey et al., 2022; Nguyen, Lew, et al., 2022; Ponce, 2020; Shimkhada et al., 2021).