Income, Language, and Citizenship Status: Factors Affecting the Health Care Access and Utilization of Chinese Americans
Jang, Michael, Lee, Evelyn, Woo, Kent, Health and Social Work
Two decades of empirical research have demonstrated that numerous demographic and socioeconomic factors are related to health care access and use. Having health insurance is one of the more striking correlates to health-related behaviors and services (Feinstein, 1993; Hayward, Bernard, Freeman, & Corey, 1991; House, Kessler, & Herzog, 1990; Lambrew, DeFriese, Carey, Ricketts, & Biddle, 1996; Mandelblatt, Andrews, Kerner, Zauber, & Burnett, 1991; Stein, Fox, & Murata, 1991). The Office of Technology Assessment (U.S. Congress, 1992) conducted a thorough literature review regarding how the health insurance coverage affects utilization and health status. That review showed that, controlling for other factors, people without health insurance generally receive poorer health care services. More specialized studies have shown how health insurance affects physician recommendations (Mort, Edwards, Emmons, Convery, & Blumenthal, 1996), personal health status (Hahn & Flood, 1995), physician rather than hospital utilization (Hafner-Eaton, 1994), follow-up medical care (Kerr & Sui, 1993), and differential health care access by specified ethnic groups (Trevino, Trevino, Medina, Ramirez, & Ramirez, 1996).
Most studies examining access to health care by race or ethnicity concentrate on four general categories: white, African American (black), Hispanic, and "other" (Frazier, Jiles, & Mayberry, 1996; Manton, Patrick, & Johnson, 1987; Polednak, 1986; Trevino et al., 1996). Relatively little research has been conducted concerning health care access and health insurance in the Asian community, particularly for Chinese people living in the United States. Limited research has shown that socioeconomic factors such as lack of health insurance, inadequate formal education, and limited English language fluency have a strong effect on the Chinese population's use of health care services (Mayeno & Hirota, 1994). One study indicated that 23 percent of nonelderly Asian and Pacific Islanders and "others" living in California were not insured (Brown, Valdez, Morgenstern, Wang, & Mann, 1991). The 1989 Behavioral Risk Factor Survey of Chinese in California (Centers for Disease Control [CDC], 1992) revealed that over half of the respondents' annual household incomes were below $10,000 and that 35 percent of Chinese people in Oakland, California, were without health insurance coverage. Education and English language fluency can also strongly affect health care access in the Asian and Pacific Islander population. The CDC survey of Chinese in California indicated that 58 percent of Chinese people living in Oakland had an eighth-grade education or less. According to a survey in Chicago's Chinatown, 23 percent of respondents could read "a little" or "none" even in their native language (Yu, Huber, Wong, Tseng, & Liu, 1990). And the National Comparative Study of Minority Health Care (Commonwealth Fund, 1995) found that 22 percent of Asian Americans needed an interpreter when seeking health care services.
Most studies that examine "Asian" health care access aggregate all Asian and Pacific Islander subgroups together and do not specifically analyze the Chinese community. Asians as a group have typically not been disaggregated in previous studies. Using data that fail to make adequate distinctions among sociodemographic factors, particularly ethnic and cultural variables, greatly limits both public health research and service provision. As stated in the Behavioral Risk Factor Survey of Chinese (CDC, 1992), "differences reported in that survey underscored the need for tailored data collection approaches - such as characterizing ethnicity, nativity, income, insurance status, and language fluency - to accurately determine the health status of Asians and Pacific Islanders and other racial or ethnic groups" (p. 267). It is because of the need for more specific health-related data on San Francisco's Chinese community that this health study was undertaken. …