Differences in Access to Care for Differences in Access to Care for Asian and White AdultsAsian and White Adults

Merrile Sing, Ph.D.Merrile Sing, Ph.D.September 8, 2008September 8, 2008

Policy ContextPolicy Context

Many Asians face significant linguistic and Many Asians face significant linguistic and cultural barrierscultural barriers

~ 25% of Asians live in linguistically isolated households ~ 25% of Asians live in linguistically isolated households (Census 2000)(Census 2000)

~ 63% of Asians are immigrants (Census 2000)~ 63% of Asians are immigrants (Census 2000)

Some Asian American subgroups are at greater Some Asian American subgroups are at greater risk than non-Hispanic Whites for certain risk than non-Hispanic Whites for certain diseases, such as diabetes, stomach and liver diseases, such as diabetes, stomach and liver cancer, hepatitis B, and tuberculosiscancer, hepatitis B, and tuberculosis

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Research ObjectivesResearch Objectives

To estimate adjusted differences in To estimate adjusted differences in access to care between non-access to care between non-Hispanic White and Asian adultsHispanic White and Asian adults

To identify factors that have the To identify factors that have the greatest marginal effects on greatest marginal effects on improving access to careimproving access to care

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Previous ResearchPrevious Research

Moy et al. (2008). “Moy et al. (2008). “Community Variation: Disparities Community Variation: Disparities in Health Care Quality Between Asian and White in Health Care Quality Between Asian and White Medicare Beneficiaries.”Medicare Beneficiaries.”

Miltiades and Wu (2008). Miltiades and Wu (2008). “Factors Affecting “Factors Affecting Physician Visits in Chinese and Chinese Immigrant Physician Visits in Chinese and Chinese Immigrant Samples.”Samples.”

Snyder et al. (2000). Snyder et al. (2000). “Access to Medical Care “Access to Medical Care Reported by Asians and Pacific Islanders in a West Reported by Asians and Pacific Islanders in a West Coast Physician Group Association”Coast Physician Group Association”

AHRQ (2007), AHRQ (2007), National Healthcare Disparities ReportNational Healthcare Disparities Report4

Study DesignStudy Design

Data are from the Medical Expenditure Panel Survey Data are from the Medical Expenditure Panel Survey (MEPS) & Area Resource File, 2002 - 2005(MEPS) & Area Resource File, 2002 - 2005– MEPS contains a nationally representative sample of MEPS contains a nationally representative sample of

households in the U.S. civilian, non-institutionalized households in the U.S. civilian, non-institutionalized populationpopulation

Sample includes non-Hispanic adults age 18 and older Sample includes non-Hispanic adults age 18 and older – There are 3,779 Asians and 52,498 WhitesThere are 3,779 Asians and 52,498 Whites

Andersen typology of access to care is usedAndersen typology of access to care is used

Outcome variables are binaryOutcome variables are binary– Usual source of care (excluding emergency room)Usual source of care (excluding emergency room)– At least one office visit during past yearAt least one office visit during past year

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Access to CareAccess to Care

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Andersen Typology:Andersen Typology:Control variablesControl variables

Access depends on:Access depends on:

– Predisposing characteristicsPredisposing characteristics

– Enabling ResourcesEnabling Resources

– Illness level or perceived needIllness level or perceived need

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Predisposing CharacteristicsPredisposing Characteristics

DDemographicemographic Age, sex, marital statusAge, sex, marital status

Social structureSocial structure EducationEducation AcculturationAcculturation

Difficulty speaking EnglishDifficulty speaking English In linguistically isolated familyIn linguistically isolated family Immigrant < 5 years in U.S.Immigrant < 5 years in U.S. Immigrant 5 – 14 years in U.S. Immigrant 5 – 14 years in U.S.

AttitudesAttitudes Overcome illness without medical professionalOvercome illness without medical professional More willing to take riskMore willing to take risk Always uses seat beltAlways uses seat belt

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Enabling ResourcesEnabling Resources

FamilyFamilyIncomeIncomeInsurance coverageInsurance coverage

CommunityCommunityUrban-rural (using Metropolitan Statistical Areas)Urban-rural (using Metropolitan Statistical Areas)Census Region (4)Census Region (4)Active non-federal MDs/ 1,000 population (county)Active non-federal MDs/ 1,000 population (county)Number of Federally Qualified Health Centers Number of Federally Qualified Health Centers

(county)(county)Percent Asian population in countyPercent Asian population in county

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Illness/Perceived NeedIllness/Perceived Need

– Self-rated general healthSelf-rated general health

– Poor mental health (Mental Component Poor mental health (Mental Component Summary)Summary)

– Number of chronic conditionsNumber of chronic conditions

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MethodsMethods

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Estimation MethodsEstimation Methods

Unadjusted differences in meansUnadjusted differences in means

Adjusted differences (multivariate Adjusted differences (multivariate logistic regressions)logistic regressions)

– Marginal effects estimated by method of Marginal effects estimated by method of recycled predictionsrecycled predictions

– Standard errors estimated using Standard errors estimated using balanced repeated replicatesbalanced repeated replicates

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Marginal effects onMarginal effects onAccess to careAccess to care

Which factors have the greatest marginal Which factors have the greatest marginal effects on improving access to care?effects on improving access to care?

PPredisposing conditionsredisposing conditions with and without acculturation variableswith and without acculturation variables

Enabling resourcesEnabling resources

Perceived needPerceived need

All control variablesAll control variables

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UnadjustedUnadjusted

DifferencesDifferences

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Access to CareAccess to CareAdults Age 18+Adults Age 18+81 78

7063

0102030405060708090

Usualsource of

care

Officevisit

% o

f P

op

ula

tio

n

White Asian

15

**

* (**) Significantly different from White at 0.05 (0.01) level or better Source: MEPS 2002 – 2005, adults eligible for access supplement

**

AcculturationAcculturationImmigrantsImmigrants

1 1 3

15

28

40

05

1015202530354045

< 5 yrs inU.S.

5 - 14 yrsin U.S.

15+ yrs inU.S.

% o

f P

op

ula

tio

n

White Asian

16

**

* (**) Significantly different from White at 0.05 (0.01) level or betterSource: MEPS 2002 – 2005, Adults eligible for Access Supplement

**

**

AcculturationAcculturationEnglish LanguageEnglish Language

0.4 0.2

12

5

02468

101214

Difficultywith

English

Linguist.Isolatedfamily

% o

f P

op

ula

tio

n

White Asian

17

**

* (**) Significantly different from White at 0.05 (0.01) level or betterSource: MEPS 2002 – 2005, Adults eligible for Access Supplement

**

Factors Associated with Factors Associated with Access to CareAccess to Care

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Variables associated withVariables associated withUsual Source of CareUsual Source of Care

Marginal effectMarginal effect Asian - 0.039*Asian - 0.039* (0.019) (0.019) EnablingEnabling PredisposingPredisposing IncomeIncome immigrant < 5 yrs in U.S.immigrant < 5 yrs in U.S. Insurance status Insurance status immigrant 5 - 14 yrs in U.S.immigrant 5 - 14 yrs in U.S. MSAMSA Difficulty w/ EnglishDifficulty w/ English Census RegionCensus Region Asian * Difficulty w/English Asian * Difficulty w/English

family sizefamily sizePerceived needPerceived need age age number of chronic cond. number of chronic cond. gender gender self-rated health marital statusself-rated health marital status

attitudesattitudes

Year 2004 - Year 2005 -Year 2004 - Year 2005 - Source: MEPS 2002 - 2005Source: MEPS 2002 - 2005 19

Variables associated withVariables associated withOffice Visit(s)Office Visit(s)

Marginal effectMarginal effect Asian - 0.077**Asian - 0.077** (0.015) (0.015) EnablingEnabling PredisposingPredisposing IncomeIncome immigrant < 5 yrs in U.S.immigrant < 5 yrs in U.S. Insurance status Insurance status Difficulty w/ EnglishDifficulty w/ English MSAMSA Census RegionCensus Region educationeducation Active MDs/ 1000 pop.Active MDs/ 1000 pop. family size family size

ageagePerceived needPerceived need gender gender number of chronic cond.number of chronic cond. marital status marital status self-rated general health self-rated general health attitudes attitudes self-rated mental healthself-rated mental health

Year 2004 + Year 2004 + Source: MEPS 2002 - 2005Source: MEPS 2002 - 2005 20

Estimated Marginal Estimated Marginal EffectsEffects

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Marginal Effects on Marginal Effects on Access to CareAccess to Care

Unadjusted Unadjusted Usual Source of Care Office Visit(s) Usual Source of Care Office Visit(s)WhiteWhite 0.811 (0.004)0.811 (0.004) 0.784 (0.003) 0.784 (0.003)AsianAsian 0.701 (0.013)0.701 (0.013) 0.630 (0.011) 0.630 (0.011)Difference Difference -0.110 ** -0.110 ** - 0.154 ** - 0.154 **

Adjusted differences: Marginal effects controlling for:Adjusted differences: Marginal effects controlling for: Usual Source of Care Office Usual Source of Care Office

Visit(s)Visit(s) Predisposing (w/o acculturation) - 0.115 ** - 0.143 **Predisposing (w/o acculturation) - 0.115 ** - 0.143 ** Predisposing (w/ acculturation)Predisposing (w/ acculturation) - 0.055 **- 0.055 ** - 0.102 **- 0.102 ** EnablingEnabling - 0.078 **- 0.078 ** - 0.123 ** - 0.123 ** Perceived needPerceived need - 0.068 ** - 0.068 ** - 0.098 ** - 0.098 ** All variablesAll variables - 0.039 ** - 0.077 **- 0.039 ** - 0.077 **

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ConclusionsConclusions

Asian adults were less likely than Whites to have a usual Asian adults were less likely than Whites to have a usual source of care or an office visit, after controlling for source of care or an office visit, after controlling for predisposing and enabling characteristics and perceived predisposing and enabling characteristics and perceived needneed

Greatest Marginal Effects on Access to CareGreatest Marginal Effects on Access to Care

PredisposingPredisposing Enabling EnablingPerceivedPerceived

w/ acculturation Needw/ acculturation Need

Usual Source of CareUsual Source of Care √√

Office VisitOffice Visit √ √ 23

Policy RelevancePolicy Relevance

Findings suggest areas to focus on for improving Findings suggest areas to focus on for improving access to care for Asian adults:access to care for Asian adults:

– Translating general medical information and Translating general medical information and Medicaid applications into Asian languages may Medicaid applications into Asian languages may improve access to care for some Asiansimprove access to care for some Asians

– Educating providers about differences in Educating providers about differences in culture and disease incidence for Asians culture and disease incidence for Asians compared with non-Hispanic Whitescompared with non-Hispanic Whites

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