The Moderating Effects of Ethnicity and Employment Type on Insurance Coverage

Abstract

Despite nearly universal insurance coverage for older Americans over the age of 65, the preretirement age cohort is susceptible to gaps in coverage. Related to the Patient Protection and Affordable Care Act (ACA), this study investigated heterogeneity in insurance status for preretirement Asian immigrants by examining the interacting effects of Asian ethnicity and employment type, which is a major factor that determines an individual’s insurance status in the U.S. Data from the 2009 California Health Interview Survey, which included 1,024 Asians between the ages of 50 and 64, were analyzed. Our findings indicate significant moderating effects of employment type and Asian ethnicity. However, regardless of employment type, Koreans had the highest rate of being uninsured. To effectively reach the ACA’s goal of reducing the number of uninsured individuals, targeted interventions specific to Asian subgroups are essential.

Keywords

ethnicity socioeconomic factors immigrants

The Patient Protection and Affordable Care Act (ACA, P.L. 111-148) was passed in 2011 and mandates individual-level health care coverage. The aim of the ACA is to reduce the number of uninsured by bridging the gap between employer-based coverage and public insurance programs. With recent economic downturns and high unemployment rates, the proportion of adults with employment-based coverage has declined in all ethnic groups (Denavas-Walt, Proctor, & Smith, 2012). In the United States, the preretirement age group is one of the most vulnerable to being uninsured, as these individuals do not yet qualify for publicly funded Medicare, and they may not be covered through employer-based programs (Baker & Sudano, 2005; Smolka, Purvis, & Figueiredo, 2007). Over the past decade, the number of uninsured, preretirement individuals aged between 50 and 64 years increased by 71% from 5.2 million in 2000 to 8.9 million in 2010 (Smolka, Multack, & Figueiredo, 2012).

The changing demographics of the United States highlight the need to examine public health concerns that are associated with the lack of health insurance among racial/ethnic minority groups, such as Asian immigrants. The prevalence of adults who are uninsured is greater among preretirement, foreign-born individuals than their U.S.-born counterparts. Immigrants are less likely to have employment-based private health insurance because they are more likely to have marginal employment that typically offers few benefits. Considering that there is a high rate of foreign-born individuals (63.5% in 2006) in the Asian American population (Huang & Carrasquillo, 2008), this study uses data from the California Health Interview Survey (CHIS) to examine the effects of Asian ethnicity and employment type on health insurance status among four subgroups of preretirement Asian immigrants.

Background

The number of Asians in the United States increased from 10.2 million in 2000 to 14.7 million in 2010, which represents a 43% increase within a single decade (Humes, Jones, & Ramirez, 2011). By 2050, the Asian population is projected to grow by 213% to 33.4 million people and will account for approximately 8% of the total U.S. population (U.S. Census Bureau, 2008). Despite the population trend, relatively little health services research has focused on Asian immigrants, especially the preretirement age group, and the subgroup differences within the diverse Asian population. These population trends underscore the need to examine the experiences of Asian adults, disaggregated by their ethnic background.

Nationally, 15.7% of adults lack insurance coverage, but this figure masks racial/ethnic differences (Denavas-Walt et al., 2012). Asian ethnic subgroups experience serious barriers to obtaining health insurance coverage and utilizing health services (Brown, Ojeda, Wyn, & Levan, 2000). In 2011, the uninsured rate for Asians was 16.8%, which was higher than non-Hispanic Whites (11.1%) but lower than Blacks (19.5%) and Hispanics (30.1%) (Denavas-Walt et al., 2012). These trends persist among the 8.9 million uninsured adults between the ages of 50 and 64, as Hispanics have the highest rate of being uninsured, and non-Hispanic Whites have the lowest rate of being uninsured (Smolka, Multack, & Figeriredo, 2012). Among Asians, data from the Census Bureau suggest that the rate of being uninsured increases in older age cohorts (U.S. Census Bureau, 2012).

Previous studies have found intragroup variations among Asian subgroups in terms of having health insurance (Brown et al., 2000; Ryu, Young, & Kwak, 2002; Alegría et al., 2005). The 2004-2006 Current Population Surveys found that 31% of Koreans and 21% of Vietnamese in the United States were uninsured, compared with only 12% of Japanese and Asian Indians (The Kaiser Family Foundation, 2010). Kao (2010) reported similar characteristics regarding Koreans and the Vietnamese, as they had the highest uninsured rates among Asian subgroups, as well as high proportions of foreign-born individuals and individuals with limited English proficiency.

Occupation plays a major role in the disparities of health insurance coverage. According to Brown et al. (2000), most of the variation in uninsured rates among ethnic minorities is caused by differences in employment-based insurance. For example, almost two thirds of Korean workers were employed in small businesses, and fewer workers in these small firms have employer-based insurance compared to nearly all employees with employer-based insurance in large businesses (Davis & Branscome, 2011). While we know that occupation and ethnic groups are important, it is less clear how these factors work together to impact insurance status.

Theoretical Framework

Social determinants have been identified to differentiate a range of global health-related outcomes (Solar & Irwin, 2007). In particular, racial and socioeconomic disparities in health have been a focus of research (Link & Phelan, 1995; Sanchez-Vaznaugh, Kawachi, Subramanian, Sanchez, & Acevedo-Garcia, 2009). These disparities in health have been extended to Asians in the United States with differential risk to specific health outcomes (Trinh-Shevrin et al., 2007), as well as access to health care (Nguyen, 2012a, 2012b).

The stratification among Asian ethnic groups is important to note, considering the diversity within the Asian race (Mui, Nguyen, Kang, & Domanski, 2006). Generally, the differences in social positions among Asian ethnic groups are attributable to migration and other culturally based experiences (Mui et al., 2006; Trinh-Shevrin et al., 2007), but less research has examined the effects of the interaction between social determinants and health related outcomes.

Abel’s extension of Bourdieu’s conceptualization of social capital provides a framework to examine the interaction of sociocultural indicators (Abel, 2007, 2008). Abel’s theorization of the interrelationship between social capital and health status seeks to incorporate the interdependence between sociocultural and behavioral factors. In this model, social inequality affects behavioral transformation, which in turn results in health inequalities. Social inequality can take one of the three following interrelated forms of capital: social, economic, and cultural. Social capital provides access to support systems that can promote health. Cultural capital broadly encompasses the values, norms, and informational resources. Economic capital refers to the financial resources that facilitate the procurement of health-promoting options. Examples include the ability to pay for health care and goods and services that promote healthy lifestyle behaviors. Taken together, the three forms of capital interact and impact health outcomes.

This model has particular salience for older Asians. First, building from Bourdieu’s concept of cultural capital, the model is intended to describe the patterns for particular groups, rather than serving as broader comparisons across disparate groups. The model is ideally suited to examine Asian ethnic groups because it is assumed that there are differential allocations of social resources to particular subgroups. The diversity among Asian ethnic groups with regards to social and historical experiences has served to differentiate their social experiences. The historical exclusionary immigration policy and subsequent experiences of Asians in the United States (Nguyen, Shibusawa, & Chen, 2012) have resulted in historical social isolation, as well as differential access to social resources. Finally, the social position disruptions that are a result of immigration lead to the loss of social status, and this has broad social, economic, and cultural consequences (Portes & Rumbaut, 2006).

While prior research has examined the contribution of social or cultural factors on access to health care, little research has examined the joint effects of social and cultural factors. This research is imperative for preretirement Asian immigrants for whom cultural factors have been of traditional focus, while their social and economic experiences have been overlooked. In order to address this knowledge gap, this study aims to apply Abel’s (2007) model of capital in health promotion to examine the unique and joint effects of social and cultural capital indicators on having health insurance coverage among preretirement Asian immigrants. Particularly, this study aims to examine the relationship between Asian ethnic background (cultural capital) and employment type (social capital) and its effect on insurance status. It is hypothesized that the variation in health insurance coverage among preretirement Asian immigrant subgroups persists even when there are ethnic groups in the same employment type. For example, experience with the American health care system, both through historical experience as a U.S. colony and their high representation in the U.S. health care industry (Brush, Sochalski, & Berger, 2004), could explain the high rates of coverage for Filipino immigrants. The findings of this study will have significant implications for targeting health policy and practice interventions to increase insurance coverage for more vulnerable, Asian subgroups. This type of intervention will become increasingly important in relation to the implementation of the ACA in 2014.

Method

Study Design

This study used data derived from the 2009 CHIS. The CHIS is a cross-sectional study of California residents’ health and access to care using a random-digit-dial telephone survey and a two-stage sampling procedure. The 2009 data file was used for the large representation of preretirement Asian immigrants relative to other waves of the CHIS. The survey instrument was translated into several Asian languages, including Cantonese, Mandarin, Korean, and Vietnamese. The overall landline response rate was 21.1%. Ethnicity was categorized according to the UCLA Center for Health Policy Research criteria. Respondents who were foreign-born and identified as Chinese, Filipino, Korean, or Vietnamese alone between the ages of 50 and 64 were included in our study. This resulted in a study sample of 1,024 participants. The protocols for this study were reviewed and approved by the local institutional review board.

Measurement of Variables

Study Variables

Insurance status was the dependent variable for this study. Respondents who were uninsured at the time of the survey or at any point in the preceding 12 months were classified as being uninsured.

To explain the variation in insurance status, Asian ethnicity, which is an indicator of cultural capital, was divided into the following four categories: Chinese, Filipino, Korean, or Vietnamese. Applying the conceptualization that employment type facilitates access to different networks, employment type served as an indicator of social capital. Respondents were classified based on their self-reported employment. If a respondent had a spouse, a couple’s employment status was captured in this variable, while for those without a spouse, only a respondent’s employment information was used. The following three categories were used: (a) neither the respondent nor spouse is working, (b) neither the respondent nor spouse is working in the public or private sector, and at least one is self-employed or working in a family business, (c) either the respondent or spouse is working in the public or private sector. Additional covariates were examined by applying Abel’s model (2007, 2008).

Cultural Capital

The English proficiency variable was divided into the following two categories: poor English proficiency (the “not at all” and “not well” responses) and good English proficiency (the “well,” “very well,” and “speak only English” responses). The proportion of an immigrant’s life spent in the United States, which is a function of age at immigration and duration of residence in the United States and is provided in the CHIS data set, was another variable and was used as a proxy of acculturation. As less than 10 respondents indicated that they had lived greater than 80% of their life in the United States, we followed recommendations in the literature to address small cell sizes in large data sets (SAS Institute, 2005). Therefore, the percent of life lived in the United States was divided into four categories ranging from less than 20%, 20% to 39%, 40% to 59%, and 60% to 99%.

Economic Capital

Educational attainment was dichotomized in the following two categories: less than high school graduate and high school graduate. Poverty level, as provided by the CHIS, served as a continuous income control. Ranging from 0 to 24, the value corresponded to the respondents’ income relative to the poverty line, where a value of 1 equated to 100% of the Federal Poverty Line.

Social Capital

Marital status was divided into the following three categories: married, divorced/widowed/separated, and never married.

Other Covariates

Age (in years), gender, and self-rated health (excellent/very good/good vs. fair/poor) were used as covariates in the final models.

Analysis

Univariate analyses were conducted to develop a basic understanding of the factors that affect preretirement Asian immigrants. Subsequently, bivariate analyses were conducted to examine associations among the variables. To test for the omnibus interaction effects of employment type on the relationship between Asian ethnicity and having insurance coverage, hierarchical logistic regression was used (Jaccard, 2001). Two logistic regression models, both with and without six interaction terms, were tested, and the model fit was compared. Subsequently, to better understand the interaction effects, separate logistic regression models were conducted by employment type (Gomez, Miranda, & Polanco, 2011; Rothermann, 2007). Given the small sample sizes of Filipinos who were self-employed, they were excluded from the interaction analysis and subsequent analyses. This alteration did not result in a change in the model fit statistics, which supported their deletion (SAS Institute, 2005). Subsequently, Filipinos were omitted from the self-employed model to produce valid variance estimates.

All analyses were conducted using the SAS 9.3 software (SAS Institute, 2008). To account for the complex sampling methods used in CHIS, jackknife replication methods applying the survey-supplied replicate weights were used to obtain accurate, weighted variance estimates (Rust & Rao, 1996; SAS Institute, 2008).

Results

A description of the sample is presented in Table 1. The average age was 56.6 years. Greater than 13.8% of preretirement Asian immigrants did not have health insurance at some point during the past 12 months. While 12.4% of the sample had lived in the United States for less than 20% of their life, approximately 63% of the sample had lived greater than 40% of their life in the United States. Nearly 77% of the sample received income from public or private employment, while less than 10% were self-employed or worked in a family business.

Table 1.

Demographic Characteristics.

Variable	n	N	Weighted %
Mean age, years (SE)	56.6 (0.32)
Asian ethnicity
Chinese	270	153,971	30.6
Filipino	131	217,419	43.2
Korean	219	37,960	7.5
Vietnamese	454	94,417	18.7
Employment type
Unemployed	220	74,239	14.7
Self/Family	124	43,346	8.6
Public/Private	730	386,182	76.7
Percent of life in the United States
Less than 20%	123	62,311	12.4
20% to 39%	320	124,763	24.8
40% to 59%	470	210,562	41.8
60% to 99%	161	106,131	21.0
Insurance status
Insured	837	434,013	86.2
Uninsured	237	69,754	13.8

Uninsured rates

When the four ethnic groups were compared (Table 2), preretirement Vietnamese and Korean Americans had similar characteristics. However, more Koreans were self-employed or worked in family businesses (26%), had poor English proficiency (66.8%), and were uninsured (39.5%) than all other Asian ethnic groups. Conversely, more preretirement Vietnamese Americans suffered from poor health (52.4%), did not complete high school (51.4%), and were unemployed (25.5%) than other Asian ethnic groups.

Table 2.

Sociocultural Capital Differences by Asian Ethnicity.

Variable	Chinese	Filipino	Korean	Vietnamese
Health behavior
Uninsured %***	16.6	8.3	39.5	11.7
Cultural capital
English proficiency***
Good	50.6	95.1	33.2	39.1
Poor	49.4	4.9	66.8	60.9
Percent of life in the United States
Less than 20%	13.4	9.0	20.9	15.1
20% to 39%	23.8	25.6	24.4	24.5
40% to 59%	45.6	40.5	42.2	38.4
60% to 99%	17.2	24.9	12.5	22.0
Economic capital
Employment type***
No employer	13.4	10.2	19.2	25.5
Self/family	13.2	4.0	26.0	4.7
Public/private	73.4	85.8	54.8	69.8
Educational attainment**
Less than HS	33.6	23.2	31.8	51.4
HS graduate	66.4	76.8	68.2	48.6
Social capital
Marital status*
Married	81.8	68.1	90.8	76.3
Not currently married	18.2	31.9	9.2	23.7
Other covariates
Female**	53.2	73.7	69.5	56.9
Physical health (poor)***	29.4	14.9	48.1	52.4
Mean age, years (SE)	56.4 (.44)	57.2 (.65)	56.4 (.70)	55.5 (.47)

p < .05. **p < .01. ***p < .0001. HS = High School.

Extensive differences by employment type are noted in Table 3. The uninsured rate varied across groups, as 10.5% of respondents worked for a public/private employer, 24.9% were unemployed, and 25% were self-employed or worked in a family business. Greater than 60% of those employed by public or private employers, as well as those who were self-employed or employed by family-owned businesses, were females. Differences were also noted for marital status, as almost half of those not working were currently unmarried, while 19.6% of those who worked for a public or private employer, and 27.6% of those who were self-employed or in a family business were unmarried. Nearly 73% of respondents who were working for a public/private employer spoke English well, while a comparable percentage that lacked English proficiency were unemployed.

Table 3.

Sociocultural Capital Differences by Employment Type.

Variable	Not working	Self-employed/family business	Public/private employer
Health behavior
Uninsured %*	24.9	25.0	10.5
Cultural capital
Asian ethnicity**
Chinese	27.8	47.0	29.2
Filipino	30.0	20.0	48.3
Korean	9.8	22.7	5.4
Vietnamese	32.4	10.3	17.1
English proficiency**
Good	37.7	54.8	73.1
Poor	62.3	45.2	26.9
Percent of life in the United States
Less than 20%	14.2	18.3	11.3
20% to 39%	38.9	18.3	22.8
40% to 59%	27.6	42.4	44.5
60% to 99%	19.3	21.0	21.4
Economic capital
Educational attainment
Less than HS	41.5	33.7	30.4
HS graduate	58.5	66.3	69.6
Social capital
Marital status*
Married	52.2	72.4	80.4
Not currently married	47.8	27.6	19.6
Other covariates
Female	68.5	65.4	62.9
Physical health (poor)*	51.7	29.4	24.4
Mean age (SE)	59.1 (.79)	57.0 (.91)	56.0 (.39)

p < .01. **p < .0001. HS = High School.

Moderation analysis

The results of the main effect and interactive logistic regression models are presented in Table 4. In the main effect model, compared to Korean Americans, all other Asian groups were less likely to be uninsured. In terms of poverty level, the likelihood of being uninsured decreased as a function of income (OR = 0.62).

Table 4.

Moderation Analysis Using Hierarchical Logistic Regression of Uninsured Status.

	Main effects model OR (95% CI)	Interaction effect OR (95% CI)
Cultural capital
Asian ethnicity (reference-Korean)
Chinese	0.22 (0.10, 0.48)	0.30 (0.12, 0.79)
Filipino	0.10 (0.02, 0.44)	0.05 (0.01, 0.20)
Vietnamese	0.09 (0.03, 0.31)	0.15 (0.05, 0.45)
English proficiency (reference-good)
Poor	0.81 (0.30, 2.23)	1.31 (0.56, 3.11)
Percent of life in the United States (reference-less than 20%)
20% to 39%	1.44 (0.56, 3.65)	1.09 (0.45, 2.65)
40% to 59%	0.70 (0.29, 1.71)	0.48 (0.22, 1.04)
60% to 99%	0.30 (0.02, 4.90)	0.05 (0.01, 0.26)
Economic capital
Employment type (reference-public/private employer)
Unemployed	1.28 (0.50, 3.30)	1.55 (0.39, 6.11)
Self-employed/family business	2.13 (0.47, 9.69)	4.71 (1.60, 13.89)
Educational attainment (reference-College/postgraduate)
Less than high school	0.50 (0.25, 1.00)	0.52 (0.25, 1.06)
Poverty level	0.62 (0.46, 0.84)	0.58 (0.44, 0.76)
Social capital
Marital status (reference-not currently married)
Married	0.83 (0.42, 1.67)	0.87 (0.45, 1.68)
Other covariates
Age	1.03 (0.94, 1.13)	1.03 (0.96, 1.11)
Female	0.68 (0.40, 1.15)	0.61 (0.34, 1.07)
Physical health (poor)	0.75 (0.41, 1.38)	0.73 (0.39, 1.37)
Interaction term
Asian ethnicity × employment type (reference-Korean/public/private employer)
Chinese × not working		1.28 (0.19, 8.33)
Chinese × self-employed/family business		0.02 (0.003, 0.12)
Filipino × not working		2.51 (0.29, 21.55)
Vietnamese × not working		0.28 (0.04, 1.99)
Vietnamese × self-employed/family business		0.21 (0.03, 1.22)
Wald χ²	76.21** (df = 15)	124.64** (df = 20)

p < .05. **p < .0001.

Bold values represent odds ratios that are significant at p < .05.

In the next hierarchical step, product terms created from Asian ethnicity and employment type were added. The difference in the model Wald χ² values between the main effect and interaction models was statistically significant (χ²_{(df = 5)}= 48.43), thus indicating the presence of a significant omnibus interaction effect (Jaccard, 2001). Chinese immigrants working for themselves or in family businesses were less likely than the reference group to be uninsured (OR = 0.02).

Ethnicity and employment type

To better understand the significant interaction between Asian ethnicity and employment type, separate logistic regression models were tested by employment type. The results are presented in Table 5. Among Asian immigrants working in the public or private sectors, Chinese (OR = 0.30), Filipino (OR = 0.07), and Vietnamese Americans (OR = 0.14) were less likely than Korean Americans to be uninsured. Among preretirement Asian immigrants who were not working, Filipino (OR = 0.03) and Vietnamese Americans (OR = 0.03) were less likely than Koreans to be uninsured. Among those who were self-employed or working in a family business, Chinese (OR = 0.04) and Vietnamese (OR = 0.12) Americans were less likely than Korean Americans to be uninsured.

Table 5.

Moderating Effect on Being Uninsured: Subgroup Analysis by Employment Type.

	Not working family business	Self-employed/employer	Public/private
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Cultural capital
Asian ethnicity (reference-Korean)
Chinese	0.13 (0.004, 4.98)	0.04 (0.004, 0.35)	0.30 (0.10, 0.89)
Filipino	0.03 (0.002, 0.63)	0.07 (0.02, 0.31)
Vietnamese	0.03 (0.002, 0.42)	0.12 (0.03, 0.54)	0.14 (0.04, 0.50)
English proficiency (reference-Good)
Poor	6.25 (0.15, 254.27)	1.02 (0.19, 5.32)	0.94 (0.39, 2.30)
Percent of life in the United States (reference-less than 20%)
20% to 39%	1.44 (0.11, 19.10)	0.63(0.04, 10.49)	0.90 (0.33, 2.50)
40% to 59%	0.14 (0.01, 4.26)	0.33 (0.02, 6.59)	0.47 (0.19, 1.13)
60% to 99%	0.06 (<0.001, 14.29)	0.21 (0.01, 3.22)	0.01 (0.002, 0.05)
Economic capital
Educational attainment (reference-College/postgraduate)
Less than high school	0.68 (0.08, 5.47)	0.83 (0.12, 5.90)	0.63 (0.23, 1.69)
Poverty level	0.44 (0.19, 0.99)	0.55 (0.43, 0.71)	0.61 (0.42, 0.89)
Social capital
Marital status (reference-not currently married)
Married	1.08 (0.28, 4.23)	4.81 (0.45, 51.59)	0.69 (0.30, 1.69)
Other covariates
Age	1.03 (0.85, 1.26)	0.96 (0.80, 1.14)	1.03 (0.94, 1.12)
Female	4.16 (1.09, 15.87)	7.86 (1.62, 38.06)	0.30 (0.14, 0.63)
Physical health (poor)	0.48 (0.09, 2.74)	2.14 (0.32, 14.21)	0.58 (0.26, 1.29)
Wald χ²	22.40* (df = 13)	72.13** (df = 12)	75.96** (df = 13)

p < .05. ** p < .0001.

Bolded values represent odds ratios that are significant at p < .05.

Discussion

This study examined ethnic differences in health insurance coverage among preretirement, foreign-born Asians in the United States in relation to their social, economic, and cultural capital. Highlighting the importance of employment type as one of the major sources of social capital to explain the variation in health insurance status among foreign-born Asians, the results underscored disparities in insurance coverage among certain preretirement Asian immigrant subgroups, even when individuals in the same employment type were compared. The study’s findings highlight the importance of cultural, economic, and social capital in understanding insurance status among preretirement Asian immigrants.

The results of this study extend the understanding of the lack of insurance to preretirement Asian immigrants. In this sample, the overall rate of being uninsured among Asian immigrants was comparable to that of non-Hispanic Whites nationally (Smolka, Multack, & Figueiredo, 2012). The disaggregation of the uninsured rates reveals a different picture, as the uninsured rate was the lowest for Filipinos and the highest for Korean immigrants. The high rates of being uninsured among Koreans exceeded the national rate observed for all other racial/ethnic groups of the same age group (Smolka, Multack, & Figueiredo, 2012). Nationally, employer-sponsored insurance benefits account for most of the insurance coverage for adults aged 50 to 64 years (Smolka, Multack, & Figueiredo, 2012). In our study, self-employed, preretirement adults, and those who worked in family businesses were uninsured at the same rates as the unemployed. Ensuring compliance with the ACA for Asian immigrants working in self-employed or family-owned businesses is essential for this important, yet overlooked, at-risk group.

The finding that preretirement Korean immigrants reported the highest rates of being uninsured compared to other Asian subgroups is consistent with existing literature (Shin, Song, Kim, & Probst, 2005; Yoo & Kim, 2008). The low insured rate among Korean immigrants is closely associated with the high rates of self-employment or employment in a small business and the related high premiums for nongroup health insurance (Yoo & Kim, 2008). In our study, 26% of Korean Americans were self-employed or worked in family-owned businesses, which greatly exceeded the proportion for other Asian ethnic groups. Strikingly, however, Koreans had the lowest insurance rate compared with all other groups across employment sectors. Thus, employment factors alone do not completely explain the lower insurance rates among Koreans.

Cultural explanations are often used when differences among Asian ethnic groups arise. Culturally informed values, norms, and behaviors vary among Asian ethnic groups and warrant further attention to examine how they differentiate health behaviors (Nguyen, 2012a; Tran, Nguyen, Chan, & Nguyen, 2012). The combination of social experiences and culture has manifested itself through the extent that the values, attitudes, and health behaviors of various Asian ethnic groups are congruent with the values of the U.S. health care system (Chung & Bemak, 2002).

While cultural factors are important, additional explanations are needed to understand how economically and socially influenced experiences shape health behaviors. The patterns of insurance coverage require further discussions about the effects of the cultural, economic, and social capital of Asian subgroups, both at the individual and group levels, in relation to their country of origin. An immigrant’s capital at the individual level tends to interact with the immigration history of the entire ethnic group in the host country, as well as the characteristics of their country of origin. Although the majority of Vietnamese Americans came to the United States after 1975 with refugee status, a large scale of the migration of Chinese and Filipino Americans dates back to the mid-1800s and early 1990s (Dinnerstein & Reimers, 1999; Tseng, 2009). With their longer history of immigration to the United States and increases in new immigrants after 1965, Chinese and Filipino Americans are the two largest Asian groups in the United States, making up 24.3% and 19.9% of the Asian population in the United States, respectively (Tseng, 2009). Evidence indicating the linkage between individual- and group-level characteristics among immigrants can be seen in studies that have found a close relationship between the number of coethnics in the community and an individual’s social capital (i.e., size of social ties and network) among minority individuals (Almeida, Kawachi, Molnar, & Subramanian, 2009). Although not directly tested in this study, the two more established immigrant groups (i.e., Chinese and Filipino) may have greater social capital at the group level in the United States, which allows individual ethnic members to have greater access to support for accessing health insurance. This may partially explain the differences across subgroups of foreign-born Asians.

In addition, to understand disparities in the insurance rate for Asian immigrants, premigratory social and economic experiences need to be examined, as these experiences shape individual immigrants’ health and economic behaviors in the host country. For example, high rates of self-employment are found among Korean immigrants who migrated to other immigrant-accepting countries, and the differences between ethnic groups remain significant after controlling for individual-level demographic and economic capital characteristics (Tubergen, 2005). In addition, immigrants from the Philippines, where the official language is English, have adjusted better than other Asian groups in the United States, as they display higher levels of acculturation in the United States (Tseng, 2009). Thus, the country of origin appears to, at least partially, affect an immigrant’s cultural capital (i.e., values, norms, informational resources) in the host country, as well as their economic and social capital. In the context of having health insurance among immigrants, cultural capital would affect an immigrant’s values and attitudes toward purchasing health insurance. The history of health insurance and the ways in which health insurance is financed are not common across different parts of the world. In the United States, the concept of health insurance began in the early 20th century and has evolved as a unique system that heavily relies on the private sector for nonelderly individuals without disabilities (Owen, 2009). Immigrants from countries with universal health care may not be familiar with the U.S. private health insurance systems, such as Health Maintenance Organizations and Preferred Provider Organizations (Searight, 2003). Moreover, some foreign-born Asians may not be familiar with the concept of having health insurance (Fitzpatrick & Freed, 2000; Ma, 2000).

From this context, the differences in the health insurance systems in Korea and the United States may explain the lower coverage rate among Korean immigrants in the United States. While health insurance is compulsory, universal, and relatively inexpensive under the national health insurance system in Korea (Ryu, Young, & Park, 2001; Jeong, 2011), the current U.S. health insurance is voluntary and relies primarily on the private market through one’s employer. Thus, the willingness to pay for high health insurance premiums among Korean immigrants may be lower, especially among those who experienced and were accustomed to the Korean health insurance system. In addition, Korean immigrants may have the option to continue to receive care in Korea, which functions as a disincentive to purchase health insurance in the U.S. market.

Conversely, in China, the government-run health services met major health care needs until the 1980s. However, the role of the Chinese government in health insurance has become minimal since then, and the nation’s health insurance coverage has been far from universal, covering only 55% of urban residents and 21% of rural residence in 2003 (Flaherty et al., 2007). In addition, the lower uninsured rates of Chinese Americans, even among those who were self-employed or in family businesses, are reflective of group attitudes towards access to health care that are borne out of a longer historical legacy in the United States, specifically in California (Tseng, 2009). The networks developed within Chinese American enclaves in California facilitate collective decision-making (Min & Moon, 2006), which can promote the procurement of health insurance. Thus, the longer history of immigration in the United States and the health insurance practice in their country of origin among Chinese immigrants may explain the lower uninsured rates among preretirement Chinese individuals in the United States.

Conversely, even though the history of immigration is relatively short among Vietnamese Americans, their uninsured rate was either comparable to that of other ethnic groups or was lower among Asian individuals sharing the same employment type. This may be due to their higher Medicaid rate (Ponce, 2009), which is related to their higher incidence of poor health and being in poverty, than the other groups examined in this study. This indicates the importance of examining postimmigration characteristics in the host country and how these characteristics interact with their country of origin, as well as different levels and types of capital after immigration.

Policy implications

Health insurance status (i.e., being insured or not) does not guarantee health service utilization. High deductibles and out-of-pocket expenditures prohibit many Asian immigrants from accessing health services for nonemergency conditions, even among the insured (Yoo & Kim, 2008). However, disparities in insurance status increase Asian individuals’ risk for adverse health outcomes (Juon, Kim, & Choi, 2000; Kim, Kim, Juon, & Hill, 2000). With the pending implementation of the ACA, an understanding of the interrelationships of social, cultural, and economic factors with the procurement of insurance is essential to ensure that vulnerable immigrant groups are in compliance with legal mandates in a changing health care environment.

The specification of cultural and economic contributions to insurance coverage has implications for understanding Asian immigrants’ health behaviors amidst social policy changes. While the eligibility criteria for Medicare and Medicaid will remain the same for immigrants, the ACA is expected to extend health insurance coverage among legally admitted individuals with moderate income who are not eligible for Medicare, medicaid, and employment-based health insurance because of their age, immigrant status, or employment status. Permanent resident immigrants will be subject to the same mandates and will receive the same benefits as U.S. citizens upon arrival, and the ACA prohibits denial of coverage based on preexisting health conditions (The Kaiser Family Foundation, 2010; National Immigration Law Center, 2010). The pending health care mandates are germane to older Asian immigrants, which is a group that is at-risk for being uninsured and is socially marginalized. While the extent of the implementation of the ACA is unclear, New York and West Virginia, among others, are implementing state-level system redesigns to extend insurance coverage while managing costs. These redesigns build off of efforts in California to extend coverage through the Medi-Cal program (Ponce, 2009). Future research, particularly at the national level, could replicate the current study to examine whether the coverage gap between newer and longer term immigrants, as well as the gap between different ethnic groups, decreases following the implementation of the ACA in 2014.

Study Limitations

This study’s findings are constrained by several limitations. The CHIS used in this study employed a cross-sectional design, which cannot draw longitudinal conclusions in relation to the length of residence in the United States. Because the CHIS was conducted in California, the data have limitations of generalization and selection bias, which raise a question about the representativeness of the population studied. Consequently, the CHIS data may underestimate the proportion of preretirement Asian immigrants who are uninsured compared to nationally representative data. Despite these limitations, the present study demonstrates the importance of examining moderating relationships between ethnicity and employment type in relation to being uninsured to better target more vulnerable subgroups, especially within an evolving health care environment.

Conclusion

This research demonstrates that Asian ethnicity and employment type are fundamental factors affecting health insurance coverage among preretirement Asian immigrants, and are interrelated in how they affect health behaviors among preretirement Asian immigrants. Moving forward, a deeper conceptual understanding of the interaction of cultural, economic, and social capital influences on health behavior is necessary to develop culturally sensitive, health-promoting activities. Given the diversity across Asian ethnic groups, and the different values and attitudes that are embedded within each group, ethnic-specific knowledge is needed to tailor health behavior interventions to meet the diverse needs of Asian immigrants. In particular, community health interventions that target culturally based values and attitudes are needed to promote population health. Recent changes in health care policy at the state and federal levels can reduce disparities in coverage, but future efforts to remedy disparities in health care coverage will require a multifaceted approach that incorporates targeted health promotion efforts for each Asian subgroup to increase health literacy.

Footnotes

Author’s Notes

The protocols in this study were reviewed by the local IRB. As the data does not involve private information about living individuals, the IRB determined the project is not considered research with human subjects and did not require further review.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: A research project funded by the Research Challenge Fund at New York University and the John A. Hartford Scholars Program in Geriatric Social Work, administered by the Gerontological Society of America.

Author Biographies

Duy Nguyen is an Assistant Professor with the Silver School of Social Work at New York University and a Faculty Fellow at the McSilver Institute for Poverty Policy and Research. A Hartford Geriatric Social Work Faculty Scholar, his research focuses on health and mental health service utilization among older immigrants. Sunha Choi is an Assistant Professor with the College of Social Work at the University of Tennessee at Knoxville. She is a Hartford Geriatric Social Work Faculty Scholar and her research has focused on discrepancies in formal health and mental health service utilization among older minorities. So Young Park is a doctoral candidate at New York University’s Silver School of Social Work. She previously worked in a hospital as a medical social worker and was involved in a variety of research projects such as chronic disease prevention, child abuse, and health-related quality of life. Her current research interests include mental health, access to health care, and other health disparities among Asian Americans.

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